Patients must have a note from the psychiatrist or clinical psychologist.
Two months prior to the surgery, patients are required to see a psychiatrist in Thailand to confirm eligibility for sex reassignment surgery.
Kathoeys began to gain prominence in the cinema of Thailand during the late 1980s.
Through beauty pageants, Thailand has been able to promote the country's cosmetic surgery industry, which has had a massive increase in medical tourism for sex reassignment surgery.
According to the Miss Tiffany's Universe website, the live broadcast attracts record of 15 million viewers.
The winner of the pageant receives a tiara, sash, car, grand price of 100,000 baht (3,000 USD) - equivalent to a yearly wage for a factory worker living in Thailand.
In 1993, Thailand's teacher training colleges implemented a semi-formal ban on allowing homosexual (which included kathoey) students enrolling in courses leading to qualification for positions in kindergartens and primary schools.