TEHRAN, Iran—When Shadi Amin was growing up in pre-revolutionary Iran, she began experiencing sexual feelings toward other girls. “I thought there was something wrong with me,” she says. “I thought, maybe I should change something.” By “something,” Amin was referring not to her identity or lifestyle, but to her gender. “If I was that young girl living in Iran today, I would have considered having a sex change operation,” even though she has never identified with being male.

Most people who experience same-sex attraction would not immediately think to undergo sex reassignment surgery. But in Iran, the options between a homosexual existence and a transsexual existence offer little real choice. Homosexuality, under certain circumstances, is punishable by death. Transsexuality, on the other hand, is considered a legitimate health problem by the dominant legal, religious, and medical communities, for which the sanctioned...

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