Yang Sisi feels he is different. He has been aware of it for many years and knows in his heart there is only one solution: an operation to make him a woman.

The 35-year-old wants to be among the rare few that undergo gender reassignment surgery every year in China, a traditionally low-key group, bar the odd beauty pageant and grand public wedding.

But the group has found itself thrust into the spotlight as authorities attempt to improve the procedure for transsexuals, moves that have met with a mixed response due to fears that newly proposed government regulations could hinder, rather than help.

Doctors perform a gender reassignment surgery in Beijing.

It was revealed last month officials at the Ministry of Health plan to set clear criteria for people who qualify for the surgery, as well as the hospitals and staff allowed to carry it out. Some in the transgender community, however, have raised concerns the new rules could be too strict.

"The idea of guidelines is a good thing, sex change operations would be legalized," said Yang. "But it cannot be so strict as it makes it harder, or even impossible, for people to have the surgery."

His fears center on the fact that, if the rules are approved, patients will have to prove they have had the desire to swap their gender for at least five years, and have lived full-time as their chosen gender for two years.

"How do you prove you have wanted to change sex for five years straight?" asked Yang, who was born in a poor peasant family in northwest China but now performs in a "she-male" show in Shanghai. "Does it start from when a person applies for the surgery? If so, five years is too long for someone to wait.

"Every person who applies for the surgery knows clearly what he or she wants. A sex change is a personal issue, so why should it be made so difficult?

"I have been saving my money for a long time, waiting desperately for my chance. But in the end I may be forced to go abroad for the surgery, like Thailand."

Transgender operations have been available in China since the 1980s and, although there are no official figures, to date it is believed around 500 have undergone the operation. The numbers are said to be low mainly because of the massive expense.

Han Bingbing, 34, is a post-op transsexual. She spent almost 200,000 yuan ($29,000) on several procedures to make her "an ordinary girl" in 1999 and sees the proposed rule changes as a mixed blessing.

The draft guidelines state candidates must be at least 20 years old and have already told their immediate family of their decision to swap sexes.

"I would not be able to have the surgery if there was such a guideline in 1999," said Han, who hails from Inner Mongolia. "My mother died when I was seven and I was not able to speak to my father about my feelings until I returned to my hometown after the operation.

"He was outraged and heartbroken. Even now I can see how sad it still makes him.

"Most transsexuals are not on good terms with their family. That is the reality. They sometimes change their names and move far away. What happens if their family refuses to let them have the surgery?"

Dr Li Jianning, an orthopedic surgeon with the No 3 Hospital of the Peking University in Beijing, said candidates would probably be forced to prove their "five-year desire" with the help of friends, family or a professional psychologist.

Despite unrest among the transgender community, many in the medical profession have welcomed the Ministry of Health proposals.

Dr Chen Huanran, one of China's top orthopedic surgeons and a sex change specialist, said he feels changes to the law have been "a long time coming" and added that, because of a lack of adequate government supervision, unsuitable hospitals were now freely allowed to carry out gender reassignment operations, usually unsuccessfully, leading to many lawsuits and ruined lives.

If the new rules are approved, clinics and hospitals will have to set up an ethics committee to evaluate all applications, as well as have a plastic surgery department that has operated for more than 10 years.

Only surgeons with more than five years' experience or training in sex change operations will be permitted to perform the procedures.

"Stringent criteria will protect the interests of both patient and surgeon," said Chen, who completed almost 200 sex swap operations between 1990 and 2003. "There is a story behind almost each stipulation. Candidates must prove a five-year desire to stop them regretting their transition later.

"International studies show people can live to regret the change, with some even going so far as to have the surgery reversed and return to their original gender. Parts of the surgery are irreversible, so it should be considered rationally. And that takes time."

He said getting consent from parents could also prevent the harassment faced by surgeons from family members unhappy at their relative's sex switch.

Psychology, before and after the operation, plays a massive part in the sex change process, with opinions often split over whether transgender candidates are really "born in the wrong body" or are suffering from some kind of mental illness.

The reasons behind feelings of mind-body incompatibility remain unclear, but experts say transsexuals can turn to self-harm or even suicide if they cannot find a way to live as the opposite sex.

"Transsexuals are not freaks. We are born this way. Only through a sex change operation can we be saved and become the people we really are," said Yang.

But Zhai Xiaomei, a bioethicist at the Peking Union Medical College in Beijing, disagreed and warned: "Surgery should be a last resort. Doctors should tell patients about other options first, such as hormone therapy.

"They should also explain to patients about the risks of the operation and the underlying social barriers after it, such as employment discrimination, and administrative recognition and approval."

Under the proposed rules candidates will have to undergo at least one year of "successful" psychological therapy before they get the go-ahead, potentially posing another financial headache.

The average cost of a sex change operation is already around 50,000 yuan, not including any extra plastic surgery or facial remolding. But the average wage for those Chinese living in urban areas was just 16,943 yuan last year, according to government figures, while for rural residents it was just 6,481 yuan.

Han said her sex change was not covered by her medical insurance, adding there is also no avenue for a transsexuals to borrow money from a bank or charity fund.

"Many transsexuals, like myself, have to work in she-male shows to make enough money quickly for the expensive surgery," she said.

Despite praise for the draft guidelines, Chen said there was still much room for improvement as they only address the physical side of the sexual transition and fail to take on the problem of discrimination.

"Even though transsexuals are the absolute minority in society, their rights and interests should not be neglected," said Chen, who stopped performing gender reassignment surgery because of the high legal risks and the fact most of his patients went on to live "such miserable lives". He now trains other surgeons in the field.

"What's the point of the surgery if the lives of the patients become even worse after it? It's too painful to watch them live miserable lives and not be able to do anything."

To make sure his patients were able to find jobs, he said he set his own "unreasonable criteria" for candidates: Men had to have a college degree, while women had to prove they would be able to earn a living after the surgery.

"Many people, including transsexuals, criticized me for such criteria. But I had no discrimination against anyone, my sole purpose was to make sure that they would be able to get a job and live a normal life afterwards," he said. "Compared with medical problems, post-operation support to transsexuals is equally important. Only when a transsexual enjoys equal rights and is accepted by the society, can we say his or her surgery is successful."

Han agreed and said the rules, if not improved before implementation, will make little impact.

"I talked with some of my sisters (people who have undergone male-to-female operations) about the guideline. Their reaction was, 'Does it matter?' I don't think the draft can help solve our practical problems, like discrimination and employment difficulties," she said.

China has no laws stipulating the new gender of a transsexual should be recognized, but the Ministry of Health has asked local public security bureaus to change the ID cards of patients if they can provide the necessary medical documents.

"We are lucky compared with transsexuals in other countries where gender on ID cards is based on birth certificates," said Han. "But a new ID card does not mean we are accepted. Compared to deciding to go ahead with the operation, being accepted by society is far more difficult."

Han, a former teacher at a dance school in Beijing, was fired shortly after her father learned she was a post-op transsexual. He complained to her boss, who was unaware of her past. "They were worried I might be a bad influence on the kids," she said.

She revealed that about 80 percent of Chinese transsexuals are forced to turn to she-male shows or even prostitution in order to make a living, adding: "Finding a decent job is almost impossible." In 2001, Han studied clothes design and now runs her own fashion studio.