Part 2 of 2.  Read part 1.

Dr. Jamie Koufman was at the top.

In 25 years in Winston-Salem, Koufman had established a reputation as an aggressive, innovative throat surgeon and a renowned specialist in laryngology. Wake Forest University Baptist Medical Center had established a Center for Voice and Swallowing Disorders under Koufman's direction.

But Koufman, known for perfectionism and an outspoken manner, was uneasy. Deciding to act on a belief that he was a woman trapped in a man's body filled him with a nagging fear. People had been fired or had their professional reputations destroyed because they were transsexuals.

In January 2003, Koufman made a typically brash decision. He called Daniel and Laura Hart McKinny, a filmmaking couple at the N.C. School of the Arts, and asked them if they would make a documentary about him as he made his transition from male to female. The McKinnys were intrigued at the idea of filming a story in which the ending was unknown - would he actually go through with it? - and agreed.

For Koufman, doing a film was a natural.

"One of the reasons I was doing a documentary was I was afraid I might be fired. So, that way, if I went from being this great person to a devil in six months, I would have some documentation," Koufman said.

Koufman showed bravado and fear when asked last summer why she thought that her sex-change operation had brought her few, if any, professional consequences.

"I think they were scared of me, that they would face a massive lawsuit. There were reasons it didn't happen to me," she said, before quickly backing off.

"I shouldn't say that. I should give them the benefit of the doubt. I would say that I was an important person in the medical community, and people just didn't care."

Koufman's decision took a few people by surprise, said Stan Shapshay, a professor in the otolaryngology department at Boston University School of Medicine. Shapshay and Koufman were medical residents together and have been friends ever since.

"I think there's certainly people out there who are less accepting and view this whole transition with some suspicion in that maybe there is some instability and this would affect Dr. Koufman's ability to function, but I'd say they are in the minority. I'd say we all have great respect for Dr. Koufman's abilities. People who are her friends are happy that she has made the choices she had to make," Shapshay said.

Sally Shumaker, then the associate dean of faculty affairs at the Wake Forest medical school, had been in her job for two weeks in the winter of 2003 when Koufman told her about what was happening.

Shumaker was aware of Koufman's international reputation as a surgeon.

"I also wanted to learn as much as I could about transitions, sex changes, and how we could make this environment as comfortable as possible for her to make this change," she said.

The administration never officially discussed Koufman's decision, Shumaker said.

Today, Koufman called the administrators visionary for how they handled her change. She said she believes that they wanted to show the world that the medical center is liberal and fair enough to handle this type of experience.

Koufman said she is glad that she did the documentary, even though she ultimately didn't need it for job protection. She hopes that the film, which will be shown Saturday night as part of the RiverRun International Film Festival, helps more people understand transsexuals and what they go through.

"When they see what it really is, someone who has the money and everything else, it is still brutally difficult. When you see me in this documentary, you will not see all pretty stuff. You'll see parts that are difficult, on the edge of giving up," she said. "Pretty beaten up emotionally and physically - and I have a lot of resilience - and it was very difficult at times."

Learning a new life

By July 2003, Koufman had a woman's face and wore her hair in a short, fashionable bob. The parts that weren't feminine - she still had male genitals - would be fixed by more surgery in the next year.

She returned to work at the medical center after her usual monthlong sabbatical. She always took the month of June off. In 2003, she had used the time to have the facial-feminization surgery.

She would have to live as a woman for a full year before she could have the final surgery to alter her genitalia.

Even though she had long dreamed of being a woman, she felt like a neophyte that first summer. She had cross-dressed throughout her life, but she had never had to assemble a female wardrobe for work, or put on makeup that would carry her through a professional day.

She would have to learn to be a grownup all over again.

One of the first things she did after she recovered was shop.

"Which place didn't I go to? I went to the Gap. I went to Old Navy, Dillard's," she said. "I must have spent $3,000, $4,000, and I wasn't buying expensive stuff."

She had to think about how she walked, even though she was used to high heels from her cross-dressing.

She made some mistakes. A black bra - instead of a camisole or nude underwear - worn under a thin black blouse brought complaints from other people at the medical center that she was dressing inappropriately.

The complaints made it clear that people were watching her.

"People didn't believe it. People were afraid; people were angry. People said things like 'I can't deal with this,'" Koufman said.

Of all the people affected by her change, Koufman said, her patients seemed the least upset. Only one patient, Koufman said, left because of the sex change. Other patients among the thousands who have seen Koufman may have quietly stopped because of the change, or because she was out of work for five out of 18 months in 2003 and 2004 as she underwent her surgeries and recuperation.

Koufman had created a two-page disclosure letter that explained what she had done and why. She handed it out to hundreds of patients every month.

When patients came to see her, a nurse gave them the letter to read before they saw Koufman.

"Then when I went in, I'd say to the patient, 'Are we OK, do we have to talk about this?'" Koufman said. "My perspective was, look, people don't come to see me for anything having to do with my personal life, and I realize that, but they do have a right to know why I look different."

The letter gave the patient information about how to contact Shumaker with questions.

Shumaker said she received just one inquiry.

Some patients had questions, Koufman said, but not many. There was one group that reacted more than others - the clergymen whom she treats.

"When a patient came to me, a religious person, and said, 'God doesn't make mistakes and you were made a man.' I said, 'God doesn't make mistakes and God made me transsexual.' And that seemed actually to satisfy," Koufman said. "I think a lot of clergy have taken the position God has a special plan for you, and I believe that is the case."

Mixed problems

There are some reactions by some people that Koufman has not been able to avoid. She does not like to talk about the feelings or reactions of family members, but she admits that they were devastated by her decision and remain extremely uncomfortable.

"Both of my kids still have some problems with this. They can't say, 'Hey, my mom and dad are going to join us for dinner.' What are they going to say, 'My mom and my transsexual-now-a-woman dad is.' Who wants to explain that all day?" Koufman said. "It's hard for them. They lost their father."

Her ex-wife, Marsha, has agonized over what the decision has done to her two sons. Marsha Koufman declined to be interviewed for this story.

And though Jamie Koufman has found a measure of peace and almost total self-acceptance through the change, she now laughs, somewhat ruefully, when talking about her hopes for looking like a "taller, sleeker Britney Spears" after her transition.

"I'm a little pissed that I didn't get to be that drop-dead gorgeous 18-year-old who comes flying out of the mall in little minishorts with a flip of the hair and every male of every species in a three-mile radius stops in his tracks. I missed that phase, sorry to say."

In an ironic twist for a specialist in voice disorders, Koufman also has had to realize that she will always be unhappy with her voice. There are few surgeries that she endorses to feminize the voice, though she is working to develop some. Today, Koufman's voice, while feminine, is husky; she said she's taken voice lessons to make it more acceptable.

She also lost some of the anonymity that she had outside of the medical center.

"If I show up, 30 people will say, 'That's the doctor who had the sex change.' It's almost a type of celebrity, which is of course not necessarily the kind you want," she said last August.

But Koufman is not hiding from publicity. Besides the film to debut this week at RiverRun, she is moving into becoming more of an advocate in the transgender community.

Surgery and its aftermath

Koufman had already gone through most of her transition - learning how to live as a woman, telling people she was a woman, and finding out about some of the more annoying aspects of being female - before she had the final surgery that truly made her a female.

She had the genital-reassignment surgery on June 8 of last year in Trinidad, Colo., after carefully researching the centers and doctors offering the procedure. It was of shorter duration and easier than the facial-feminization surgery. She spent three days in the hospital, then went to a local hotel set up for people recovering from such surgery.

When Koufman was alone, she got a full-length mirror and finally saw what she had waited a lifetime to achieve.

"I tried on a pair of stretch capri pants so I could admire my new crotch contour,'' she said.

On the way home, things became more difficult. Koufman was miserable during her layover in Chicago.

"My hormones were all screwed up," she said. "I cried the whole time we were in O'Hare."

Things were still difficult when she got home and an unexpected problem arose. The medicine that she had been taking for a urinary-tract infection after her surgery made her tendons more vulnerable. Koufman ended up tearing the Achilles tendon - the area between her foot and calf - on her left leg. She spent the first several weeks in a cast and using crutches and a mechanical Hovercraft to get around the medical center.

She also found out how time-consuming womanhood can be. She was spending as much as two hours a day - made a little longer because of the cast on her leg - doing her hair and makeup and getting dressed. For the first six months, she also had to spend 30 to 60 minutes a day on exercises that would ensure her new female genitalia healed properly.

But she said she felt free and happy.

"With gender-reassignment surgery my transition, which has been a deeply introspective and personal journey for me, comes to its conclusion. I've done it. My gender is forever changed. I am ready to go on with my life," she said. "This transformation has been so profound that I cannot help but feel that it is about more than gender."

Politics and advocacy

A few months after her surgery, Koufman created a Web site, http://www.inbroaddaylight.net/, and she has become a sort of folk hero in the transgender community.

She gets e-mails from all over from people asking for emotional support and medical advice.

"In view of the fact that even though I'm a stranger, I'm not a stranger. I mean, I get a lot of letters - they're like fan mail, I guess - from the Web site. But they say, 'I will never be able to do what you've done,' and it's still good to see it. That's a hard message," she said. "You get some of these angry, like, 'You know, who do you think you are just because you have a bunch of money you can do this and the rest of us poor transsexuals can't afford to do what you've done,' and that hurts, too."

Koufman also is admired among transsexuals for her willingness to talk.

"What Jamie's doing has a tremendous potential to help as well," said W. Meredith Bacon, a political-science professor at the University of Minnesota at Omaha. Bacon is one of the few academics in the country who studies transsexuals' behavior - specifically, who they are and what their political concerns are. "She is an invaluable member of the transsexual community. She is respected and looked up to as somebody who took control of her own life, as somebody who was honest about who she was when it came time to make a decision."

Koufman said she also counsels people who are close to home, including some colleagues at the medical center who believe that they are transsexual.

She has been speaking out about the transsexual experience. She appeared in The Vagina Monologues at the Arts Council Theatre in Winston-Salem last month. The monologues are a series of skits and speeches designed to increase understanding of women and to raise awareness about violence against women. Koufman was a co-producer of the show and was invited by other transsexuals to participate in a skit written for transsexual women.

She said she has made many friends among transsexual women, and flew to Colorado to help one through genital-reassignment surgery. Since her surgery, Koufman, who likes to cook, said she has people over to dinner, goes out to brunch, watches movies and relaxes more at home with friends.

"I think what I discovered is that the guy I was was driven to do things, to buy things. I cut back on my practice. I don't see as many patients. I spend more time with people. I don't make as much money. My patients are happier. I connect with more people, and I have made more friends in the past two years than I have in the rest of my life."

Colleagues said they have noticed the difference.

"I think there's been a 180-degree change in Dr. Koufman. I worked with Dr. Koufman for nine years, and Dr. Koufman is world-famous because of the voice center. Before, Dr. Koufman was all business," said Janet Fox, the patient-care team manager for the otolaryngology operating room.

Koufman is more personable now, with her staff and with her patients, Fox said. She asks her staff how things are going in their personal lives and touches them more in caring gestures.

"It's almost as if Dr. Koufman is a totally new person now. And we're just crazy about her. We just love her to death," Fox said.

A woman's life

At the end of her long journey, Koufman said she has no regrets.

"Basically, I'm happy. I needed to do this," she said. "I'm just as assertive as I ever was, but I'm not as aggressive. I'm much more at peace with who I am, I'm a much more gentle person."

And she remains hopeful that her family will come on board.

"When you're in your 50s and you transition, you have a whole bunch of people who have to come with you. It's not like I'm a little young thing," she said. "Just like Winston-Salem is different and will be different in two years, so will my relationships. There's a lot of family stuff that hasn't evolved yet, and that's difficult. My family still hasn't reconciled who I am and where I am yet."

There is something else she lost. People outside the hospital seemed to treat her differently.

Koufman said she saw the change almost as soon as she began looking and dressing like a woman. Taxi drivers in Washington, where she has a clinic, were not as respectful. It was harder to get the attention of a maitre d' in a restaurant.

Koufman recalls a day when a company representative went to speak to people in the otolaryngology offices. The representative had set up a lunch, and people who worked in the office were walking into the room to eat and to hear his sales pitch.

"He was new, and every time one of the residents - you know, squeaky shiny clean doctors in greens and a white coat - every ti