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Even when the gender identity problem isn't just a "delusion", surgery will usually just replace one problem with another. It's simply not possible to make a fully anatomically/physiologically male person fully female, or vice versa, and believing otherwise is always a delusion. Some people who appear anatomically normal really do have a problem -- in some cases it can't be detected/identified by current medical science, but in other cases (like chromosomal mosaicism) it can be. But having a body that's not fully normal for either gender, is just as troubling to a sane person as having a clear and lifelong sense of belonging to the opposite gender from one's perfectly normal anatomy. Most of the cases where surgery has a positive effect are those where the person was anatomically ambiguous to begin with, or at least so overwhelmingly aesthetically wrong-looking that it was impossible to move through society normally. I remember an article in Time or Newsweek many years back which included an adolescent male-to-female transsexual who had not yet had surgery (and as I recall had also only very recently started taking hormones, to stave off the irreversible changes that puberty would bring). This child was attending a small private Christian school, and had the full support of his/her parents -- definitely not a case of a self-absorbed kid swept up by a trendy fad. The photos of this "boy" were amazing -- absolutely drop-dead gorgeous blonde and *all* girl in appearance. There was just NO way any creature like this could function normally in society as a heterosexual male -- at best s/he would have gone through life with people constantly staring and wondering if s/he was really a woman pretending to be a man. Chastity Bono, on the other hand, looks like a perfectly normal overweigth female, when she isn't posing to try to look like a man. This photo is an example: