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MTF: Genital

Requirements - Prior to Surgery

Medical History - Please indicate any major medical problems and any previous surgery as well as any current medications. Use the Medical History form, available here in PDF Format or RTF Format. If you have any heart problems, you must provide a letter of surgical clearance from a cardiologist. You may also be required to provide additional labwork or testing prior to surgery. If you are diabetic, you must provide additional labwork within 30 days of surgery. Please contact the office if you have heart problems, diabetes, or any other significant medical conditions, within 6 months of surgery to obtain instructions for possible additional medical requirements.

Genital Hair Removal - This area seems to generate controversy. Hair grows in cycles of 13 weeks so generally cannot be cleared at the time of surgery although we do clear follicles from the scrotal area and perform extensive intra-operative electrolysis at the time of surgery. If you wish to have a truly hair-free vagina, pre-operative hair removal is highly recommended. Laser is less expensive overall and generally effective for this purpose, but best with darker hair, where the pigment absorbs the laser energy best. Electrolysis is the traditional method if laser is not available to you. The recommended locations are:

  1. The Scrotal Sac (most important). Follicles will be scraped and zapped during surgery, but hair growth cycles prevent us from getting all of the dormant hair.
  2. The central 2/3 of the scrotum is most important. Leave some along the sides for scar cover-up. You may wish to taper the bottom portion down to a point 1" above the anus.
  3. The Penile Shaft (important)

In my opinion, it is the penile shaft and the scrotal areas that are most important as these are uniformly utilized to create the female vagina. Remember to plan ahead, you will need multiple treatments over a 5-6 month period (usually 3-5 clearings for laser, 5-8 for electrolysis) to ensure effective and permanent hair removal. Please stop hair removal treatments at least two weeks prior to your SRS to permit the area to heal and recover....

Also remember that no matter how well the surgery goes, there will be two scars running along each large labia. These are nicely covered by hair - so the hair on the outer scrotum and higher than the shaft should be left intact for maximum coverage.

We've come up with a sketch of the recommended areas to remove hair from.

Looking for someone to do the genital hair removal? We've compiled a list here.

Psychiatric Evaluations - Per the WPATH Standards of Care, two (2) Letters of Recommendation must be provided, usually by a psychologist or psychiatrist working in the field of transgender healthcare. We're slowly building a list of mental health professionals who work with the transgender population. If you are having trouble finding someone in your area, or if you are a therapist and would like to be added to our in-office list, please email or call Robin.

Dr. Bowers requires one letter from any PhD or MD therapist/psychiatrist, and a second letter from any licensed therapist. Both letters must follow the format outlined in the WPATH Standards of Care, and one letter must be dated within one year of surgery. Specifically, both letters must include the following information:

  1. The patient's general identifying characteristics;
  2. The initial and evolving gender, sexual, and other psychiatric diagnoses;
  3. The duration of their professional relationship including the type of pyschotherapy or evaluation that the patient underwent;
  4. The eligibility criteria that have been met and the mental health professional's rationale for hormone therapy or surgery;
  5. The degree to which the patient has followed the Standards of Care to date and the likelihood of future compliance;
  6. Whether the author of the report is part of a gender team;
  7. That the sender welcomes a phone call to verify the fact that the mental health professional actually wrote the letter as described in this document.

The readiness and eligibility criteria are outlined below:

Eligibility Criteria. These minimum eligibility criteria for various genital surgeries equally apply to biologic males and females seeking genital surgery. They are:

  1. Legal age of majority in the patient's nation;
  2. Usually 12 months of continuous hormonal therapy for those without a medical contraindication.
  3. 12 months of successful continuous full time real-life experience. Periods of returning to the original gender may indicate ambivalence about proceeding and generally should not be used to fulfill this criterion;
  4. If required by the mental health professional, regular responsible participation in psychotherapy throughout the real-life experience at a frequency determined jointly by the patient and the mental health professional. Psychotherapy per se is not an absolute eligibility criterion for surgery;
  5. Demonstrable knowledge of the cost, required lengths of hospitalizations, likely complications, and post surgical rehabilitation requirements of various surgical approaches;
  6. Awareness of different competent surgeons.

Readiness Criteria. The readiness criteria include:

  1. Demonstrable progress in consolidating one's gender identity;
  2. Demonstrable progress in dealing with work, family, and interpersonal issues resulting in a significantly better state of mental health; this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis, suicidality, for instance).

In general, despite her misgivings about the Standards of Care, Dr. Bowers is required by the hospital and insurers to require two letters of approval (except patients who can document a real life experience of 5 years or more, in which case just one letter is required). Our rigid adherence to a standard of care allows Dr. Bowers to retain insurance for this important, but still rare, practice of medicine. Please be sure your letters of recommendation are received by Dr. Bowers no less than 30 days prior to your surgery date.

Suitability for Surgery - Please note that the final determination indicating acceptance for surgery is made by Dr.Bowers, usually no later than the day prior to surgery. Consultation prior to setting a surgery date is offered if you are in the area at a cost of $175. Acceptance criteria include: (a) Weight less than 210 pounds (unless height/weight proportional) (If you are over 210 pounds (regardless of proportion or level of fitness) you *must* let Dr. Bowers know in advance; she will contact you to determine if surgery should be postponed. Surgery simply takes longer in heavier patients and puts you at greater risk for complications, If you arrive greater than this weight, you risk postponement, or you will be charged a $750 surcharge to cover the longer length of surgery.) (b) Non-smoker (unless specifically exempted by Dr. Bowers). For smokers, tissue healing is truly poorer and the risk of surgical complications greater.

HIV Status - Please send an HIV result from an accredited laboratory performed no sooner than 12 weeks prior to surgery. HIV- Status, however, is not a pre-requisite for acceptance for surgery. (contact Dr. Bowers specifically regarding her criteria). HIV testing is currently required only for MTF vaginoplasty, unless risk factors apply. We leave this up to you.

Skin Grafting - The need for non-scrotal skin grafting to create the neovagina is necessary in no more than 5% of cases. However, this determination does need to be made at the time of the clinical evaluation and is an additional $2500. Skin from the scrotal sacs is preferred as the graft-donor site and allows us to almost always have enough skin to achieve suitable vaginal length. Grafted skin from the lower abdomen, buttocks, or Repliform® subject to additional fee.

If you do consider yourself to be on the unusually small size, or have specific requirements or expectations for post-surgical depth please include that information in your medical history and consider a consultation with Dr. Bowers.

You will need to arrive in San Mateo two-three days prior to surgery with a pre-operative consultation performed at that time. This will need to be arranged with Dr. Bowers' office. There is no charge for this visit.

Want to schedule surgery? Please use this Application Form in PDF Format or RTF Format when sending in a deposit for SRS.

Have a date set? Please submit your Medical History using this form, in PDF Format or RTF Format at least one month prior to your surgery.

Already started your countdown? We've put together a GRS Checklist for you to make sure you've got everything, in PDF Format or RTF Format.

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