Rather than continue to live with this sort of ongoing discord, which can be enormously painful, the person elects a course of physical transformation. The choice for sex reassignment can hardly be undertaken lightly. Most of the experienced and ethical surgeons in the field are members of the Harry Benjamin International Gender Dysphoria Association, and follow the Association's Standards of Care . The Standards require that a prospective candidate for SRS spend time in psychotherapy with a therapist who holds a graduate degree in a clinical behavioral science, and is additionally trained in sex and gender issues. After the therapist and client agree that transformation seems like the most reasonable course to follow, the client must have a medical work-up and, if there are no physical contraindications, can begin taking hormones under the care of an endocrinologist.
Hormones also affect the individual's psychology, sometimes profoundly.
SRS has an array of additional complications for the successful candidate, which I needn't cover in this column. It is painful, time-consuming, and to some extent dangerous, and it costs many people their families, friends, and careers. I see no reason to doubt the assertions of people who accomplish such an ordeal successfully, that they were born into the wrong sexual bodies for their psychological genders. Why the lady didn't tell you about her transformation right away is a question you'd best put to her. A number of the new women I have met simply regard themselves as female and see no reason to set up doubts in other people's minds before those people get to know them for who they are.