I am transgendered - many friends have said I am transsexual in that they think I am more female than male, and may have a point. However - and this is the main point - I do not see my self as a woman and would never consider surgery. I came to this conclusion many years ago. I often imagine myself as woman though and love wearing the clothes and making up - and even doing what I think are female things - BUT the moment I look at real women reality hits - it's a very sharp reminder - if you have the courage to admit it to yourself.
I have seen many transition and go through the surgery and say how happy they are, but they can't get jobs, they lose their families yet they still say they are happy! The only TS I know whose transition was justified to me was one who was born sexually ambiguous and forced to live as a man by his father. When his father died he became a woman, which he really was in the first place, and is truly happy.
In Canada, Europe and the UK, to get SRS free on the health service you have to live as a women for a year, and be seen to integrate successfully into female society. You also have to support yourself economically in the same period and show yourself not to be a potential drain on society. You come under the supervision of a real psychologist for that time and he/she will assess you not only for readiness and commitment but also whether other factors are present such as depression, bi-polar that could skew the assessment. There are good reasons for failure.
This really works - there was a TV program in the UK where a TS was followed by the cameras throughout his year. It was rough and the man had to face up to a reality pretty quickly. The psychologist's bar was very high.
In the US nothing like this happens. The TG goes to a support group who convinces him that he is a TS and tells him what he wants to hear. He goes to a local counselor (usually no more than a Social Worker) who tells him he's TS and should have the operation and gives him sessions (which he pays for) to convince him he's ready. At no point is a psychologist involved or anyone who is willing to tell him what he doesn't want to hear - that he is mostly delusional and needs to sort out other issues first. I am convinced that most TGs have other issues going on as well as their cross-dressing.
I have told many TSs in the US about the year in Europe and the UK only to have it, and me, very aggressively ridiculed, which tells its own story.