Dr-Patient confidentiality kinda ends regarding this issue and the Feds, somehow they find out on occasion. I don't know how the feds find out but there is a history of people getting orchi's (or who had orchi's done in the past) and having their documents changed back. An Orchi is committed, and honestly I have no problem with it being used consider the costs of SRS. Somehow somebody always tips them off, if its not the performing surgeon (often accidentally, or through detailing the procedure used on the documents), its somebody else. Its actually kind of sad.
Licenses can be changed without issue, but that will change December 31, 2009.
There is difference of what is perceived in the transgender community and how the legal and regulatory system treats us.
Trust me, I wish how this was enforced differently. But the reality is alot changed under the Bush administration for the worse. It used to be you could change your SS card without SRS before the Bush administration. They ended imposing the draconian passport rules that said only SRS (and a narrow definition of such) can change gender markers.
The thing is where they might get in trouble is if traveling to a foreign country and going through an invasive search.
Pre-Bush adminstration an Orchi would have been enough. But they really have been going out of their way to screw transgender people and make things much more difficult.
The truth is if Doctors are willing to sign off on an SRS document after doing an Orchi, it may be the doctors who work with transgender patients have caught on and are sensitive to the changes in the law, not that the lawyer got around the rules. It is ultimately the Doctors letter that determines whether things go forward or not. It may be the doctor performing the orchi knew of the situation right now in the states and is willing to keep things quiet and sign off on an SRS procedure with regards to the letter, even though it was an orchi.
When the Bush Admin changed the SS rules, a ton of TS who had orchi's were outed, because the documents did not say SRS/GRS had been completed, and that an orchi was not enough. This may be a case of doctors catching on to how the Bush administration and the courts are handling things.
The problem is if somebody tips off the feds, and it has happened. People can be very cruel.
A good judge can also help also. The court order is key.