Surgery, however, is the last major step in a very complicated and long process. The first step is gender dysphoria therapy. The person meets with a therapist to make sure there are no major disturbances, other than the conflict of dysphoria. The second step is hormonal treatment. Females receive testosterone therapy to develop more body hair and to enlarge the clitoris in preparation for surgery.
Males receive estrogen therapy to enlarge the breasts.
The third step is living as a member of the preferred gender for one year. This is the time when the person works to alter mannerisms, voice inflection and body movement. The fourth step is sex reassignment surgery. For males who want to be female, this involves removal of the testes, construction of a clitoris from the former penis, construction of vaginal lips from excess skin and construction of an artificial vagina. For females who want to be males, the clitoris is fashioned into a penis that has a removable or permanent prosthesis for creating erections.