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A "neoclitoris" that allows sensation can be created from parts of the penis. In female to male surgery, the breasts, uterus and ovaries are removed (in two separate procedures).

A "neophallus" can be constructed using tissue from the forearm or other parts of the body that allows sexual sensation, an expensive procedure.

Extending the urethra to allow standing urination has proved to be perhaps the most difficult part of the process, Bowers said. Women wishing to live as men often have mastectomies.

Men transitioning to women can have plastic surgery to "feminize" their appearance, including work on their eyes, noses, brows, chins and hairlines. Bowers and Ettner said a woman who chooses the full range of surgical procedures available would spend $75,000 or more to transition to a male.

And if there were, there is no agreement on what "trangender" means. The number worldwide is estimated to be two to five times larger." At least one other researcher says there are many more.