The reasons for not having surgery or delaying it could be: Job Security, children, Grand Children, health, relationships, fears, and age. Though, some have received surgery well into their 70's.

Its not everyone who's lucky enough to transition on the job. If you're in a Goverment Job, Health care or a Fortune 500 company then you're lucky. If not, can you really afford to leave before you retire if you've been on the job for 30 years? If you have family responsibilities its not likely.

If you have health problems such as heart, lung or circulation disease or cancer, you would have a harder time getting surgery or hormones.

You're afraid of traumatizing young children or grandchildren. You fear persecution or lossing loved ones or a spouse. These are all legitimate concerns but what do you do in the meantime while you resolve these problems.

Meanwhile you are hurting inside being eaten up by a brain and emotions that don't match, you have anxiety, distress and confusion. Remember, its not only pre-ops who have thoughts of suicide. Non-ops have them as well.

There really are alternatives to SRS and most of them can be done without really major problems. First of course you should see a Gender Professional. This person can be the guide to understanding yourself and helping to remove any clouds in your mind. If medications or hormones are needed they can write a referral for you. If you decide later to get an Orchiectomy or SRS they can write the letters you need for you. Finally they can help you find a way to help you explain to a partner how serious your condition can be. Perhaps they can monitor that meeting for you.

Cross-living of some kind or length of time is essential. I'm not just talking crossdressing here. You need to live the role itself whether its for one day a week at home or seven. Of course this means telling the wife and any older children. Again, ask your therapist for help here because your sanity may be at stake. An Orchiectomy can provide some relief. Your local uroligist/surgeon can do this for you with a letter from your therapist. Removing the source of Testosterone can be benificial.

Some doctors may reccomend you take supplemental hormones such as low doses of Estogen. An Orchiectomy is the removal of the testes. This does not necessarily mean you will loose all erections though. Join a support group if you can, or start one. At most places you can dress at the meeting place.

The above steps can't replace SRS but they can provide you some relief. Cross-living by itself can give you some joy.