He arrives for work at 7:15 on a cold, gloomy Thursday morning, wearing a brown Stetson, a down jacket, jeans and black boots.
He'd more easily be taken for a rancher than America's dean of sex-change surgeons.
But pulling on operating room scrubs, Dr. Stanley Biber is in his element. He's utterly relaxed about this morning's surgery, a delicate affair that will take three hours to complete.
"We worry more about what's going to happen to the Broncos," says Biber, who does two or three sex-change operations a week. He's completed more than 3,000 male-to-female procedures in the last 25 years and figures he still performs about half the operations in the world.
"I'm getting to be the old man in the field," says Biber, who admits to being about 70. But he shows few signs of slowing down.
The doctor spends several mornings a week in the lone operating room at Trinidad's 70-bed Mt. San Rafael Hospital, working with a small, close-knit team of surgical technicians and nurses.
Later, he sees patients at his office in an old stone bank building downtown, and some afternoons he heads to the courthouse to fulfill his duties as a Las Animas County commissioner. Weekends are spent working on his farm or on one of his cattle ranches.
Trinidad's most famous resident has no plans to retire.
"As long as my hand's steady and my mind's clear, I'm going to continue to do transsexuals," he says.
Biber built his practice in this coal-mining town nestled in the eastern foothills of the Rocky Mountains where the Purgatoire River reaches the Great Plains. As the mines have shut one by one, the population of Trinidad--193 miles south of Denver--has fallen to about 8,400.
Some places might resent being known as the "Sex-Change Capital of the World," but Trinidad's residents are used to it.
Down at the Dairy Queen, Delfina Vialpando takes a break to ponder Biber's legacy to the community.
"When I broke my arm a long time ago, he's the one who fixed it," she says. "It's a normal thing now. Everybody's OK with it, I think."
In a nearby booth, Louis Volturo extends his right index finger, severed two years ago in a butcher-shop accident.
"He put my finger back on," Volturo says, his wife Sheila nodding agreement. "I owe him my life, I guess."
Although they once had reservations about Biber's sex-change practice, the Volturos say they're used to the idea. "If it helps people, more power to them," Louis Volturo says. "They're lucky if they have somebody to help them."
Biber's latest patient is Henryetta (formerly Henry, "call me Etta"), a 22-year Army veteran who retired with the rank of sergeant first-class. At 43, she is slight, with permed, red-highlighted hair and blue eyes behind large-framed glasses. Growing up, "No one ever came up to me and called me a sissy," she says. "I was never that kind of a person."
But she always felt feminine on the inside. Ten years ago, while stationed in Germany and living in an off-base apartment, she started cross-dressing after hours.
Until recently, Henryetta says, she'd never been romantically involved with anyone.
"I did not go out on dates. I've never been married. I just didn't participate," she says. "I lived in my own world. . . . There are a lot of things I missed."
She moved to Oklahoma City after her discharge in August, 1993, and began hormone treatments to prepare for sex-change surgery. She also adopted a new name and gender identity.
As the hormones lightened her beard, raised her voice and caused breasts to develop, Henryetta delighted in her new self.
"There are still little euphoric highs," she says. "Like when you're in the store shopping and someone comes up and says, 'May I help you, ma'am?' "
Biber requires that his patients follow standard guidelines for sex-change surgery. Henryetta, for example, lived full-time as a woman, began attending group therapy and underwent a second psychological evaluation. (Therapy is required to ensure that people are really ready to take the big step.)
Meanwhile, she made arrangements with Biber, who had operated on several of her friends with good results.
Insurance doesn't cover the surgery, so surgeon's fees, hospital charges, counseling and hormone therapy are all paid for out of pocket--about $30,000, Henryetta says. About $11,000 of that goes to Biber and the hospital.
On the eve of the surgery, Henryetta insists that she is comfortable with her decision.
During the procedure, the surgeon will remove the penile tissue and testes and use the excess skin to fashion a vagina, virtually indistinguishable from that of a biological woman. Patients can have sex and even reach orgasm because the nerve connections remain intact.
"I don't consider this a mutilation," Henryetta says. "This is more like a hysterectomy to me. It's an operation that's necessary and required."
But it was tough when Henryetta, an only child, told her parents of her decision. Her mother took it hard.
"She looked at me and said, 'I gave birth to a son. You will always be my son and there will be no change in my mind.' "
But Henryetta's father has called to wish her well, and both parents still love her, she says. "My parents taught me to be anything that I wanted to be when I was growing up."
Stanley Biber came to town in 1954 after commanding a MASH unit in Korea. He worked at a clinic, intending to stay for a year. Charmed by the town, he never left. For years he ran a general medical practice while serving as the town's only surgeon.
He raised his nine children here. His oldest, 46, is a urologist; his youngest, 8, is a third-grader.
He performed his first sex-change surgery--a man-to-woman operation--in 1969 after being approached by an acquaintance who was a social worker.
"One day she comes in and sits down at my desk and says, 'Can you do my surgery?' " Biber recalls. "I said 'What kind of surgery?' She said, 'I'm a transsexual.' I said, 'What's that?' "
Biber found a surgeon at Johns Hopkins University who agreed to send some hand drawings of a technique that was primitive by today's standards.
The operation turned out well, and Biber soon was getting cases referred by word-of-mouth.
But he says he was ostracized by other doctors for doing sex changes. Transsexuals, they insisted, were suffering from psychiatric problems best treated non-surgically.
Since then, scientists have recognized gender dysphoria syndrome as a legitimate disorder and posited several theories about its cause. Currently, they suspect a genetic abnormality.
Biber sought from the start to reassure his neighbors.
"We educated the public here," he says. "The best thing I ever did was get together with the Ministerial Alliance--I gave them three lectures."
Biber gets more respect from colleagues these days, and the $800,000 to $1 million a year his patients bring the nonprofit hospital helps it stay open.
Biber has refined the procedure five or six times over the years. He says his work is so good that one former patient is married to a gynecologist who doesn't suspect a thing.
In addition to his 3,000 male-to-female transformations, Biber has also performed about 250 female-to-male operations, which are less common because the results are still unsatisfactory.
Biber screens patients to make sure they don't make a decision they'll regret. Most are in their late 20s, but he once operated on an 84-year-old because "she wanted to die as a female," he says.
"It's such a hard life that they've lived," he says. "We try not to rip them off. The poor people--they don't have a lot of money."
Outside the OR, Biber greets a wan-looking Henryetta, who hasn't gotten much sleep. They pose for a picture and he pats her gently on the arm.
After being anesthetized, she is prepped for surgery, her feet fitted into stirrups attached to the operating table.
The team works with relaxed concentration. Biber wields his scalpel steadily and confidently, providing a running commentary for the benefit of a visiting nurse.
In the "destructive" phase of the operation, he "skins" the penis, retaining the skin and discarding the spongy inner tissue. Then he removes the testes before using his gloved fingers to create space for the vagina, gently pushing aside connective tissue.
Biber stretches the inverted penile skin around a form, pulls it down and inserts it into the new cavity, first making an incision for the urethral opening. Later, he'll use excess flaps of skin to create the labia. (Many patients opt to return six months later for further plastic surgery to improve the appearance of the labia.) When the sutures heal and the hair grows back the result will look natural, he says.
Biber finishes by shaving some cartilage from the front of the patient's trachea to make a more feminine-looking Adam's apple.
After Biber's assistants close the incision, the patient is wheeled to recovery.
Three weeks later back in Oklahoma City, Henryetta pronounces herself satisfied with the outcome of the surgery.
"Everything that I had anticipated and was expecting is exactly the way it is, and now I'm legal."
One of the first things she did was change the name on her driver's license.
"The clerk reached over and patted me on the hand and said, 'You can live your life the way you want.' "
Holly Carr, a volunteer with the International Foundation for Gender Education in Waltham, Mass., estimates that 30,000 people worldwide have had sex-change surgery. Another 50,000 probably would have the surgery if they had access to it, she says.
Apart from Trinidad, sex-change operations are commonly performed in such far-flung places as Neenah, Wis., Montreal, Brussels and London.
Biber, Carr says, greatly improved the standards of sex-change surgery.
"He was the first to do a good job at it," she says. "Some of Biber's people were really enthusiastic. I think he did a really neat job, compared to his predecessors."
Surveys of Biber's former patients show most are satisfied with the results, says Marsha Botzer, a Seattle therapist and founder of the Ingersoll Center, which offers counseling to trans-gender and transsexual people.
"We've completed 200 case histories, and out of that we have a 93% positive response on the surgery itself," she says. "It's almost embarrassingly positive.
"He's a great guy," says Botzer, who's known Biber for 12 years. "He seems to be honestly concerned with his patients. He's someone who gets great satisfaction when people are happy."
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Biber's Base Dr. Stanley Biber operated in the 70-bed Mt. San Rafael Hospital in Trinidad, Colo., sometimes known as the "Sex-Change Capital of the World."