By now, about 30,000 Americans have undergone sex-change surgery, according to the International Foundation for Gender Education, an advocacy group in Waltham, Mass.

Some may cross-dress, and some may actually seek sex-change surgery.

He said that many transgender people cannot afford sex-change surgery or therapy, and often do not consider it necessary.

Two transgender people have won an appeal in Australia's highest court giving them legal recognition as men despite not completing sex-change surgeries.

Last February, the lieutenant went on sick leave to begin the "real-life test," a yearlong experiment in living openly as a woman, which doctors require before approving sex-change surgery.

But he is now facing dismissal after his plans to have sex-change surgery became public.

As the policy stands now, Mr. Carannante says, only people who have undergone sex-change surgery are able to alter the gender designation on birth certificates.

Cachita returned to Cuba for a family visit soon after her first of a series of sex-change surgeries.

But until the 1960's sex-change surgery was rarely performed in this country, and treatment was largely unavailable.