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.

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.

Doctors perform a gender reassignment surgery in Beijing. [China Daily]

"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.