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In Iran, homosexuality is a crime, punishable with death for men and lashings for women. But Iran is also the only Muslim country in the Persian Gulf region that gives trans citizens the right to have their gender identity recognized by the law. In fact, the Islamic Republic of Iran not only allows sex reassignment, but also subsidizes it.

Before the 1979 Islamic revolution in Iran there was no official government policy on transgender people. After the revolution, under the new religious government, transsexuals were placed in the same category as homosexuals, condemned by Islamic leaders and considered illegal.

Things changed largely due to the efforts of Maryam Khatoon Molkara. Molkara was fired from her job, forcible injected with male hormones and put in a psychiatric institution during the 1979 revolution. But thanks to her high-level contacts among Irans influential clerics, she was able to get released. Afterwards, she worked with several religious leader to advocate for trans rights and eventually managed to wrangle a meeting with Ayatollah Khomeini, the supreme leader of Iran at the time. Molkara and her group were able to eventually convince Khamenei to pass a fatwa in 1986 declaring gender-confirmation surgery and hormone-replacement therapy religiously acceptable medical procedures.

The Iranian governmentsees trans individuals as people with psychosexual problems, and so provide them with a medical solutionEssentially, Molkara, the Iranian religious leaders she worked, and the Iranian government had reframed the question of trans people. Trans people were no longer discussed as or thought of as deviants, but as having a medical illness (gender identity disorder) with a cure (sex reassignment surgery).

The Iranian government doesnt recognize being trans as a category per se, rather they see trans individuals as people with psychosexual problems, and so provide them with a medical solution, says Kevin Schumacher, a Middle East and North Africa expert with OutRight Action International, a global LGBTIQ-rights organization. The policy is based on Islamic notions that gender is binary and that social responsibilities should be split between men and women. If youre born a man and your body is a female then in order to protect you and the wellbeing of society, says Schumacher says, the government is responsible for fixing the issue.

For Sarah, life in Iran was divided into two very distinct parts: before and after she had gender confirmation surgery.

As a young child growing up in the late 1980s in Tehran, Sarah (who, because she is not openly trans, did not want to publish her full name) was uncomfortable wearing the clothes and playing the games traditionally associated with being a boy, and felt she did not belong at the all-boys school to which her parents sent her. You are alone against all the social norms that dictate what you should do, what you should wear, how you should live, she says.

She was a good student, but in high school, when puberty hit and gender roles grew starker, Sarah began to have difficulty coping with schoolwork and dropped out. I had to deal with sexual harassment from my classmates and from other people in society on a daily basis, from everyone that thought that [I] was a girlish boy, a sissy boy, she says. My life as a teenager was total hell.

Despite the official policy about trans individuals, trans issues are not openly discussed in Iran. And because the government heavily censors material available on the internet (a 2013 analysis found that nearly half of the 500 most popular sites on the internet are blacklisted in Iran) Sarah couldnt research what it means to be transgender or connect with others in the community.

Meanwhile, she felt guilty about her inability to fit in. Everybody expected me to behave like a man and be like a man and I hated to be like that, she says. I wondered why I couldnt be like other people. Why I couldnt meet the social expectations.

At 16, she decided to make a change. If Im not a woman, if Im not a man, I thought at least I should be a productive person and live ahappy life, she says. So she enrolled in university in Tehran, and began to study languages and translation skills. Even though she continued to live as a man, she grew more confident in her gender identity thanks to the more tolerant atmosphere at the university, and from her academic successesthough she was still years away from realizing she was trans.

Officially, an Iranian can be diagnosed as having gender identity disorder only after a complex series of medical tests and legal procedures including obtaining a court order, multiple visits to a psychiatrist, and physical and psychological examinations at the states Legal Medicine Organization. Even if you somehow figure out how to navigate this processand Sarah did notit can take over a year, according to a report compiled by OutRight Action International, a global LGBTIQ-rights organization.

When people do approach doctors in Iran about being transgender, the experience is not always pleasant or helpful. Amir, a 26-year-old trans man from Shiraz, Iran, told OutRight that when he approached a medical professional about his condition, the doctor tried to intimidate him:

It all started when I was eight or nine years old. My parents took me to see a doctor because I kept saying I was a boy. The doctors never talked to me. They just told horrible and terrifying stories to shut me up. They said things like you will die if you undergo [sex reassignment surgery], or many girls who wanted to become boys died during the surgery

All of them treated me like I was delusional. They would tell me: Its not possible, you were born like this. But I knew I had to do this operation and change my sex. I was convinced there was a way and I was just looking for some kind of confirmation, from someone, who would tell me yes, its possible! Instead, one of the doctors gave me pills, and another other one injections. [Another] told me to get out and close the door behind [me], as if I was a dirty and untouchable person.

If an Iranian is officially diagnosed with gender identity disorder, the government issues the authorization for them to legally start the sex reassignment process, and at the end of that process the court issues a new identity card, with a new gender listed. In other words, while Iran does not mandate that all trans individuals have the surgery, it is not possible to change your gender marker on official documents without undergoing the surgery.

Over the last decade, with high-profile clerics and academic centers advocating for trans rights, social awareness on the issue has grown, says Schumacher. In 2007, Molkara established the Iranian Society to Support Individuals with Gender Identity Disorder, the first legally registered trans advocacy group. In 2008, the BBC reported that Iran was second only to Thailand in the number of sex-change operations performed, and the countrys surgery industry still attracts patients from all over the Middle East and Eastern Europe. Between 2006 and 2014, nearly 1,400 people applied for permission for the process according to government figures published in Iranian media.

There are even Iranian movies about accepting trans identities: 2012s Facing Mirrors was something of a social turning point, giving local journalists a chance to address the issue publicly. The films release was even covered by state-run television and radio channels.

I was so scared of the ramifications of what I was going to do, because I thought I [would] lose everyone and everything that I had fought for.Nevertheless, stigmas remain, reinforced by the notion perpetuated by the government that being trans is a medical problem. Outrights report found that trans individuals are often subjected to bullying, domestic violence, and social discrimination. In some cases, family members disown trans relatives. Openly trans people often cant get jobs, and when employers find out an employee is trans they are often fired. Trans individuals cant rent houses or apartments easily and find it hard to get married because families dont welcome the idea of having a trans son- or daughter-in-law.

All of which is why when Sarah finally realized that she was trans, when she was in her early 20s and already graduated from college, she did not feel comfortable coming out in public. Only my family members and few of my close friends knew about it, she says. I had to hide everything.

Making the decision to go through with gender-confirmation surgery was fraught with uncertainty. On one hand I really wanted to do that and be free and liberated from all the problems of my past, says Sarah. On the other hand I was so scared of the ramifications of what I was going to do, because I thought I [would] lose everyone and everything that I had fought for. My university degree, my job, everything. I saw myself having to stand against the entire world.

Practically, she did not have the means to go through with the surgery and live independently. According to OutRights report, the cost of the gender-confirmation surgery in Iran is $13,000 and hormone-replacement therapy costs $20-$40 a monthand the average Iranians monthly income is about $400.

The government does offer some limited financial support for gender-confirmation surgery, hormone-replacement therapy, and psychosocial counseling. But funds are limited and government officials decide on a case-by-case basis which individuals qualify. In 2012, the government announced that health insurance companies must cover the full cost of sex-change operations, according to a BBC report. But OutRight has found that insurance companies still often decline to cover some forms of transition-related care, on the basis that they are cosmetic and not medical.

The government pays a lot of lip service but the actual services that they provide are extremely limited, says Schumacher. You talk to many people and they tell you that they have been waiting for many years, hoping to receive some government assistance for these medical bills, but they are still waiting.

For those who dont get the surgery, life in Iran is exceedingly difficult.

Sharia-based laws mandate segregation of men and women in schools and public transport, and Iranian law requires men and women to wear gender-appropriate clothing in public spaces. Women are expected by law to wear a hijab, which means they must dress modestly and cover their head, arms, and legs. Traditionally, this is interpreted as a long jacket, called a manteau, accompanied by a headscarf. Failure to conform to this is a crime and could result in arrest or assault at the hands of vigilantes.

If their appearance is not completely male or female, they are even stopped in the streets by the moral police in Iran, says Saghi Ghahreman, president of the Iranian Queer Organization based in Canada. These are the undercover agents deployed by the police to patrol public spaces looking for men and women dressed or behaving in a manner deemed un-Islamic, The Guardian reported in 2016. The moral police crack down on loose-fitting headscarves, tight overcoats, shortened trousers for women and necklaces and shorts for men.The laws are often extended to cover new fashions. For instance in 2010 Iran banned ponytails, mullets, and long, gelled hair for men; in 2015 the country cracked down on homosexual and devil worshiping hairstyles along with tattoos, sunbed treatments, and plucked eyebrows for men.

Hasti, a 30-year-old Iranian trans woman from Khansar, told OutRight that she was frequently harassed by Iranian police for her feminine appearance and makeup. The [police] would lift up my dress, look at my ID card and ask me if I was a man or a woman, she said. In the end they would force me to sign a pledge letter [to promise that I would no longer dress as a woman] and then release me.

Because women are expected to get married at a young age and produce children, trans people who have not gone through the surgery are sometimes forced into marriage.

Worse, a trans person who is not legally recognized can be accused of homosexuality and face the death penalty. In fact, in some cases gay people in Iran decide to undergo the surgery because the alternative is death. The sex change operation is most of the time forced on trans people by the culture and by the government, says Ghahreman.

Sarah spent six years preparing mentally and financially to go through with the surgery. She describes that period as one of the darkest phases of her life. I was so depressed and anxious about everything, she says. At that time almost all the transgender people I saw in Iranian society were involved in prostitution, were isolated, were ostracized by the society and their family. I didnt see any successful transgender people. I was afraid if I did it myself, my life would turn into a kind of new misery.

The sex change operation is most of the time forced on trans people by the culture and by the governmentBut she stuck with the plan: she worked in a managerial job, living and dressing like a man, while saving for the surgery. When she had enough money, she decided to travel to Thailand for the surgery; despite the high number of gender confirmation surgeries performed in Iran, the quality of the work is poor. The operations are done by surgeons that are not professionally trained, says Ghahreman. Almost all of the trans people who have operations in Iran are suffering from many side effects that disable their body. Every trans person I have met in the past 10 years, they have a lot of pain because of the surgery and they cannot have normal or pleasurable intercourse.

When she was 28, Sarah had sex reassignment surgery. I turned into a whole new version of myself which I loved so much, she says, likening the process to dying and being reborn. I felt more liberated than what I was in the past. Because in the past I was imprisoned within the framework of my body and my former identity. After the surgery, I got liberated from all those things. For me, anything was better, anything. At least after the surgery I got to enjoy some basic rights that I didnt enjoy before the surgery.

Afterwards, she was surprised to find that almost everyone was very welcoming and very supportive. Sarah had worried government officials would harass her during the legal process after the surgery, but everyone treated me like a saint, she says. They adore me so much and they admire me so much for doing such a courageous thingthey respect me on a whole different level. I didnt even expect thatto be respected by people for being a transgender. But it all happened after the surgery. And, all of a sudden, she could wear the clothes she wanted, change her name, and live the lifestyle of her choice.

I felt I was a monkey at the zoo Not everyone has such a positive experience with Iranian officials. Assal, a trans woman who travelled back from Iran after undergoing the surgery in Thailand told OutRight she was harassed by Iranian border police agents who passed around her medical documents to each other and laughed at her. I felt I was a monkey at the zoo, she told OutRight.

And despite the support, Sarah never came out officially. Instead, she began to live as a woman in Iran. The people who know me from the past, they know that I am a transgender, but the people who know me after the surgery, they have no idea of who I was, she says. They just think that I am a straight woman.

Sarah stayed in Iran for six years after surgery. Now 36, she lives in Canada and works as a freelance journalist and translator. But she returns to the country of her birth frequently, and helped found an organization for trans rights there with Maryam Khatoon Molkara. The culture needs to change, says Sarah. The society needs to change its mindset towards people who not like the mainstream. It doesnt matter if they are gay, bisexual, or trans.

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Everyone treated me like a saintIn Iran, there's only one way to survive as a transgender person - Quartz