by Maria K Todd, MHA PhD

Founder and Executive Director
The Center for Health Tourism Research

For years, the small town of Trinidad Colorado was known as the "sex-reassignment capital of the world". Dr. Marci Bowers didn't make Trinidad Colorado the sex-change capital of the world, but she built a destination brand for it and brought tremendous economic impact to the community because of it. She established a professional brand, a destination brand, and her work benefited the little town of about 10,000 residents in the Purgatoire River Valley.

Gender-reassignment patients didn’t fly in and out overnight except for perhaps a physician consultation. When they arrived to have their procedures, they remained for weeks. Restaurants, gift shops, hotels and guest houses, Mt. San Rafael Hospital a 25-bed rural Critical Access Hospital, even the local pharmacy benefited economically from the destination development in such an unlikely place. 

Across the United States, destinations like Trinidad might be assumed as ultra conservative and perhaps even judgmental. But here, people respect others' privacy and maintain a live-and-let-live philosophy all over town as they have for years.

How the Story Began

In the 1950s, a Des Moines Iowa-born, Army surgeon moved to Trinidad and established his medical practice there. He was one of the first doctors in the United States to perform sex changes and for years was one of only a handful to offer them. He became one of the country's most prolific providers of the operation, which, it was estimated, he performed more than 4,000 times beginning in 1969.  During the 1970's, 80's and early 90's, Trinidad, Colo., where Dr. Biber practiced, was an unlikely mecca for men and women who sought to change their sex. Featured frequently on television and in newspapers, the doctor's work earned the town of about 10,000 people a reputation as "the sex-change capital of the world."

Many people and businesses of the town and surrounding community benefited from this destination brand.  They embraced Dr. Biber and his work. They acknowledged the quality of his work and shared the pride in the service he performed to humanity. The former coal-mining town was struggling economically when the doctor moved there.

Biber worked as a general practitioner, performing tonsillectomies, delivering babies and setting bones, sometimes reading X-rays at his kitchen table when patients called on him at night. He originally came to the town because local coal miners working in the region needed care.

After graduating from high school at 16, he enrolled in a yeshiva in Chicago, intending to become a rabbi. He interrupted his studies to work for the Office of Strategic Services, forerunner of the Central Intelligence Agency, during World War II. After the war, he enrolled at the University of Iowa, where he earned a medical degree in 1948. After a residency in the Panama Canal Zone, Dr. Biber joined the Army, where he was the chief surgeon of a MASH unit in the Korean War. He finished his service at what is now Fort Carson, in Colorado, and in 1954 took a job at a United Mine Workers clinic in Trinidad. He only planned to stay a year or two.  He began working at the only hospital then, Mount San Rafael.

In 1969, a friend went to his office. She was a social worker who admired Dr. Biber's skill in repairing the harelips of children she had referred to him. She asked if he would perform an operation on her. She declared she was a transsexual - a man living as a woman.  Few surgeons in the United States had ever seen a sex-change operation, much less performed one. But Dr. Biber was young and sure of his surgical prowess.  The procedure had not developed to the popularity it enjoys now. Back then, the news was about George Jorgensen who became Christine Jorgensen in Denmark, in 1952 was pretty much the most one could find on the topic.  Working from a set of hand-drawn diagrams he obtained from the Johns Hopkins University hospital, he performed the operation.

Word got around, and soon other transsexuals visited Trinidad and Dr. Biber. Worried about the court of public opinion and his patients' right to privacy, he stored the charts of his sex-change patients in the hospital safe.

Turning point towards establishment of a medical tourism destination brand

Eventually realizing that he needed the hospital's support, and the town's as well, Dr. Biber gave a series of lectures to local leaders on what is now called gender dysphoria, the feeling that one is trapped in a body of the wrong sex. Though he was sometimes a target of demonstrations by conservative groups over the years, he won over enough people in Trinidad that his work became an accepted part of life there.

Most of Dr. Biber's patients were men seeking to become women, though he also performed female-to-male sex changes. His patients came from all over the world and from all walks of life. There were three brothers who became three sisters. There were an 84-year-old train engineer, a 250-pound linebacker and an American Indian medicine man, all of whom emerged as women. How they chose to make their revelations of their surgery was their business. They were the early social marketing influencers of the doctor's brand and the destination's brand.  By the mid-1990's, an increasing number of surgeons in the United States and abroad were providing sex-change operations. In 2003, after his age made malpractice insurance prohibitive, Dr. Biber stopped performing surgery altogether. He passed away in 2006. He was a humble servant to his community caring for local residents the same as those who traveled to consult with him or undergo a procedure until his passing.

His practice was been taken over by a protégée, Dr. Marci Bowers, who herself made the transition from male to female several years before. Bowers work attracted journalists and reporters producing documentaries, magazine articles, TV shows to learn more about neocolporrhaphy or vaginoplasty surgeries which are the definitive Male-to-female gender reassignment surgery (GRS) procedures. She is an excellent surgeon and a master of public relations within the specialty. Unfortunately, her business strategy and approach was different than Biber's and the hospital leadership was not aligned with the publicity and marketing strategy.

The history of GRS goes back to 1933 when people traveled to Berlin, Germany, the effective birthplace of the modern Transgender movement. The procedures were the culmination of twenty years of research by Drs. Steinach and Hirschfeld began transgender research in the early 1910’s, experimenting with animal castration, gonadal transplantation and elucidation of the chemical composition of sex hormones. Their early research enabled the eventual discovery of DES, the world’s first synthetic estrogen. People traveled from far and wide to consult with Seinach and Hirschfeld. They also consulted with a psychiatrist who was a protégée of the research laboratory destroyed by Hitler, who moved to the USA to establish the  world’s first clinical psychiatric clinic compassionately attuned to the medical and psychological needs of early Transsexuals in their bid for gender identity in New York.

In 1958, Dr, Georges Burou assumed notoriety as the inventor of the modern vaginoplasty with his description of the ‘Penile Inversion Technique’ for MTF Sex Reassignment Surgery (SRS). Practicing in another unlikely medical tourism destination - Casablanca, Dr. Burou, a French born Gynecologist, established the surgical prototype for later procedures adapted across the world and US.  Later designated Genital or Gender Reassignment Surgery (GRS) or even Gender Confirming Surgery (GCS), SRS/GRS has evolved over the past 5 decades with ever more attention to female sexual and aesthetic expectations. So while Thailand may currently attempt to pass itself off as the branded destination for SRS and GRS procedures, while they do a fantastic job they are by no means where medical tourism for gender reassignment began.

Will they assume the branded designation as a medical tourism destination for GRS and SRS? Perhaps. While Dr Bowers talent and dedication is world renowned, San Francisco is one of the most expensive destinations in the world. Her new practice is located in Burlingame a slightly less expensive suburb, almost adjacent to the San Francisco airport. She currently performs surgery at Mills-Peninsula Hospital (where I've been a patient due to a complication of epidemic keratoconjunctivitis while traveling home from a medical tourism discovery fam tour in Korea.)

Physician and hospital integration and alignment are necessary to build a medical tourism destination and product

The hospital viewed the whole medical tourism concept and attention as an intrusion, an inconvenience and a royal pain. The executives viewed crews dragging cameras, wires and microphones through the 24-bed hospital disruptive to patient care. They argued that it cost the hospital money. While it may have added to cost, it probably also contributed significantly to bottom line revenues that most Critical Access Hospitals would give their eye teeth for.  The hospital killed the golden goose when it established an unusual policy. Media must get hospital permission 60 days in advance before visiting and pay for access.  It was that policy, Bowers said, that drove her away. In 2010, the thriving medical tourism destination known as the sex change capital of the world and that produced a consistent stream of 100 or so surgeries per year to make up about 5% of the hospital's net revenues ceased abruptly as Bowers moved her practice to San Francisco.


Today, the hospital sports a pitiful 2.5/5 star rating when searched on Google. The hospital has hired a gynecologist and starting offering cardiac diagnostic tests. None of those differentiate the town as the medical tourism destination it had been since 1969. The Victorian guest house with 5 rooms that once specialized in aftercare for post-operative patients shut down operations. Its owner is now a manager of a wine shop there. The wine shop's owner, a transplanted New Yorker who moved there to live as a transgender woman.

In San Francisco, where Bowers relocated after her departure from Trinidad, her packages include a 3-night hospital stay and an additional 3-night post operative stay at two select level hotels. Select level hotels are those that may offer breakfast and a more apartment like atmosphere than a standard hotel room, but don't usually offer full time restaurant operations, etc.  While most patients are mobile and unlikely to experience complications, the post operative course includes the placement of a Foley catheter bag that remains in for at least 3 days after discharge. That puts a natural damper on sightseeing and other destination activities until it is removed.

Is San Francisco as exciting as Thailand as a medical tourism destination choice for GRS and SRS? That's a personal decision. Is her practice as economically significant to the town of Burlingame as it was to Trinidad? Not hardly. Can she make Burlingame or San Francisco a medical tourism destination of distinction for GRS and SRS? It would take years to do so, local tourism authority support and alignment and - in my opinion, an important decision and significant effort by the hospital to establish itself as a medical tourism destination facility of renown.

I commend Dr. Bowers for her courage to relocate and continue her important work as a clinician. I am pleased to designate her as an Approved Provider. Learn more about what she does at Her website, like her work, is exemplary.

What's next for Trinidad in the way of healthcare?

As for Trindad and the Mount San Rafael critical access hospital, our best wishes for its current strategy and sustainability. Its decision to revert back to focus on the essential medical services to the people of Trinidad and Las Animas County as a Critical Access Hospital (CAH) is a great case study. The hospital’s status as a CAH allows it to receive cost-based reimbursement, subject to certain federal requirements.   It’s also licensed as a Provider-Based Rural Health Clinic (PBRHC), which helps it recruit and retain physicians through improved reimbursement from Medicare and Medicaid, for Trinidad's only hospital within miles of other options.

Mount San Raphael's hospital and clinic employ 216 people, who receive pay and benefits worth about $16.6 million. Total clinic encounters for the year run about 31,500, while Emergency Room visits number about 10,000. Another 28,000 outpatient encounters round out the picture. On the expense side, hospital and clinic operational expenses run about $28 million per year, or about $75,000 per day.

A Critical Access Hospital (CAH) must furnish 24-hour emergency care services 7 days a week, using either on-site or on-call staff, with specific on-site response timeframes for on-call staff. They must ™ maintain no more than 25 inpatient beds that may also be used for swing bed services. These swing beds are often used as skilled nursing facility beds.  CAHs may also operate a distinct part rehabilitation and/or psychiatric unit, each with up to 10 beds.  They must be located in a rural area or be treated as rural under a special provision that allows qualified hospital providers in urban areas to be treated as rural. The CAH must have an annual average length of stay of 96 hours or less per patient for acute care (excluding swing bed services and beds that are within distinct part units [DPUs]). This requirement cannot be assessed on initial certification but applies subsequent to CAH certification. Payment rules require a physician to certify that an individual may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH, so as far as medical tourism cases are concerned, the CAH is an excellent setting for minor procedures, outpatient procedures and short stay procedures. They must be located more than a 35-mile drive from any hospital or other CAH, or alternatively, be located more than a 15-mile drive from any hospital or other CAH in an area with mountainous terrain or only secondary roads. They must also be designated as a “necessary provider” of health care services to residents in the area.

Critical Access Hospitals across the United States face serious challenges to remain afloat. Healthcare reform has driven many larger, competing hospitals to acquire the CAHs in their region and reduce them to outpatient or outreach feeder hospitals to the bigger inpatient center. That action often crushes the economic impact of the hospital as one of the largest employers in the community, often the site of the best paying skilled and unskilled jobs, and learning and internship opportunities.  Declines in overall reimbursement, not just at the CAH level, have placed tremendous pressures on all health facilities across the USA to do more with less.

CAHs and their towns can develop into medical tourism niche destinations, known for a particular acumen in a specialty, when a branded physician the likes of Marci Bowers joins the medical staff.  The niche doesn't have to be socially controversial either. It can be a destination development strategy that pulls in local assets such as the new local coal mine, which might lend itself to a center of excellence if it could attract a renowned pulmonolgist. It could evolve as a seasonal sports medicine destination if it chose to develop a golf swing analysis clinic at the Cougar Canyon Golf Course in collaboration with a golf pro, an orthopedic or physiatry specialist, and an exercise physiologist aided by video analysis technology. Any of those options can infill critical revenue streams not only for the hospital, but for the entire community.

When a hospital is dealing with limited revenues from state and federal programs and commercial payer contracts with HMOs and PPOs that set fee schedules for Medicare patients at 101% of reasonable costs.  They are not subject to the Inpatient Prospective Payment System (IPPS) or the Hospital Outpatient Prospective Payment System (OPPS). Commercial payers often tie their reimbursement rates to Medicare, when it suits them. But when a Medicare patient comes, they face an inpatient deductible of $1288 for each benefit period, with a $0 coinsurance. On the physician and outpatient side, patients are responsible to pay a cost share of 20% of the outpatient allowable fee schedule set by Medicare after they satisfy a $166 annual deductible. On the contrary, when a commercial payer ties the rate to Medicare's fee schedule, but sets deductibles at $6500 per year before paying a penny, if the CAH doesn't collect all that's due from both insurer and patient, it suffers an "effective discount rate" that could cause the hospital to realize about 40% -55% less than what Medicare pays if the local commercially-insured residents can't afford to pay what they owe.  Not for profit hospitals owe a duty for charitable service. But if there's no margin, there's no mission.

A prepaid, paid in full at the time of admission, fully-inclusive case rate for a medical tourism elective surgery or episode of care is a strategy that can help the CAH hospital make ends meet, hire more staff, offer better pay, develop additional service lines to meet community needs and add prestige to its brand. But as the late George Carlin said "Ya gotta wanna." It's unfortunate for many of the other businesses and their would be employees that the Mount San Raphael critical access hospital has decided to exercise its prerogative for another strategy. No more cameras cluttering the halls.



Maria Todd is a trusted adviser and expert specialist to hospitals, clinics, governments, healthcare business owners, investors, and independent professionals. Clients call on her to help them do a better job of marketing, branding, or contracting with insurers and employers, and to grow their business.

Maria is the CEO of Mercury Healthcare International, in Denver, Colorado and the founder of Mercury Health Travel, the leader of the Health Tourism Practice Group of Mercury Advisory Group, the Executive Director of the Center for Health Tourism Strategy, its research and education resource center, and a Board Member and Advisor at Higowell, the world's first health tourism operations platform. She has been recognized as an Academician with the Ukrainian Academy of Rehabilitation and Human Health and is a member of the Scientific Committee of Termatalia in Spain. She is also a Board Member at Global Health Connections, a nonprofit organization associated with the University of Colorado MBA-HA program. She is the author of 15 internationally-published business improvement books in healthcare administration and health tourism. 

Invite Dr Todd to speak at your next event.  She presents a compelling workshop of interest to tourism and economic development officials, foreign investors, healthcare strategists, and suppliers on Opportunities for Economic Development through Inbound Medical Tourism Sector Development.