Abstract Gender dysphoria is discomfort living as a male or as a female. When sufficiently distressing it leads to the request for ‘sex change’. The age range of patients is adolescence to mid-life, and three-quarters are born male. Clinical practice should proceed from reversible steps to the more irreversible. Clothing change and name change precede hormone administration, which may precede surgery. The safest clinical process is the ‘Real Life Experience’. This is the trial period, of at least 1 year, of full cross-gender living prior to eligibility for surgical interventions. During this time some patients may revert to the original gender role. For those who complete the sex reassignment process, the reported quality of life is generally superior to that experienced in the pre-transition life period.