There are a lot of different aspects to being male or female.
HRT can change some of them but there is still a lot of work to do even after HRT has done its "magic."
That patient of six years may have found the road to female to be too difficult.
In some ways it is easy for me being short of stature and having a voice that didn't change much with puberty. Still, it a lot of work to be respected as a female.