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Hayhoe said she does not expect a flood of applications or approvals for the surgery because many won’t seek it or won’t qualify under guidelines that she described as conservative. Herman, a scholar of public policy who focuses on gender identity and transgender people at The Williams Institute, a think-tank on LGBT issues at the University of California, Los Angeles, said the best national survey found that about 42 percent of respondents had any surgery, including some of the procedures the department defines as cosmetic.

One of the new guidelines is that the inmate must have at least two years left in prison.

Guidelines to decide whether transgender prison inmates in California can undergo sex reassignment surgery took effect Tuesday, making it the first U. The guidelines are believed to be the first in the nation by a prison system, said Joyce Hayhoe, a spokeswoman for the federal court-appointed official who controls California’s prison medical care.

California last summer agreed to regularly provide and pay for treatments including hormones as well as surgery to alter the biological sex of its prisoners.

They were developed in cooperation with the California Department of Corrections and Rehabilitation, which oversees inmates’ mental health care.

There are currently 375 men and 26 women in the prison system receiving hormone therapy that gives them the characteristics of the opposite sex.

The eight-page document (PDF) calls for inmates who request the surgery and meet the basic criteria to be referred for evaluation to a committee of two medical doctors, two psychiatrists and two psychologists, which would make a recommendation to another higher-level committee of medical professionals.

The policy prohibits procedures which are considered merely cosmetic, including hair removal, face lifts, breast augmentations or other implants, which Hayhoe said will help hold down the cost to taxpayers.

That became a factor in the case of Michelle-Lael Norsworthy, who was released from prison one day before a federal appeals court was to hear her request in August for the state prison system to pay for her sex reassignment surgery.

But the same month, the corrections department announced it would pay for the surgery for Shiloh Heavenly Quine, who is serving a life sentence for a Los Angeles County murder. A federal judge in Sacramento is considering the third case, that of Mia Rosati, after the 9th U. Circuit Court of Appeals ruled in June that the state may be violating her rights by denying her sex reassignment surgery.She also is serving a life sentence for murder from Los Angeles County.