BELGRADE, Serbia — Twenty years ago, newspapers here jeered that transsexuality was an act against God. Today, people are coming from around the world to Serbia for sex change operations, which are now subsidized for Serbs by national health insurance.
“It is surprising that a conservative, patriarchal country is becoming a center for sex change operations, but social attitudes are slowly shifting,” said Cristian, a transgender activist from Belgrade who was unwilling to give his last name.
Nearly 100 foreigners and Serbs have undergone sex reassignment surgery in the past year, and the numbers are growing, according to the Belgrade Center for Genital Reconstructive Surgery, with candidates coming from France, Russia and Iran, and from as far away as the United States, South Africa, Singapore and Australia.
Serbia is becoming a transgender surgery hub, experts say, in part because genital reassignment surgery is costly, controversial and complicated and is shunned in many other countries in the region, including Austria, Hungary, Romania, Bulgaria and Greece and the other countries of the former Yugoslavia, according to Dr. Miroslav Djordjevic, a professor of urology who leads the Belgrade Center.
Even in medically advanced Western European countries like France, some surgeons complain that they cannot get proper training or that they are even rebuked by colleagues for performing sex reassignment, prompting many transgender people to go to Belgium for treatment. In Britain, where the procedure costs about $15,000 and is covered by the National Health Service, 143 such operations were performed in 2009, according to British news reports.
Dr. Marci Bowers, a gynecologist in San Mateo, Calif., who has performed 1,100 sex reassignment operations over the past 10 years and is herself transgender, noted that in the United States, a global center for sex changes, only about five surgeons were performing the operation regularly. She said that social conservatism and a lack of surgical skills in many countries, combined with surgeons’ fears of potentially catastrophic complications, were promoting the growth of transgender tourism.
Foreign patients say they are attracted to Serbia by the price tag of about $10,000 — compared with $50,000 or more at some clinics in the United States for the more expensive female-to-male procedure. Cher’s transgender son, Chaz Bono, recently told the radio personality Howard Stern that he hoped to come to Belgrade for the surgery.
Sociologists say the more accepting attitude toward transgender people in Serbia signals the first glimmers of a shift in a country where conservative currents still run deep.
“We are the children of two parents: one is the Orthodox Church, the other is communism,” said Dr. Dusan Stanojevic, a pioneer of sex reassignment surgery here.
He said transsexuality was so taboo in the former Yugoslavia that it was not even mentioned in medical textbooks. But a surgeon, Dr. Sava Perovic, began performing the operations in 1989 after being approached by a man suffering from gender identity disorder.
Word quickly spread and Dr. Perovic, who has since died, attracted a legion of patients, as well as fellow surgeons drawn by the challenge of an exceptionally difficult procedure. More than 20 years later, sex reassignment surgery has become a surprising niche here, with four medical centers specializing in the procedure.
In Serbia, the surgery is performed in a single six-hour procedure, saving the patient from the trauma of multiple operations. Complications can include postoperative regret, functionality problems or infection.
To qualify for the surgery, a patient needs two letters of recommendation from psychiatric specialists attesting that he or she is suffering from gender identity disorder, in which a man or woman identifies better with the opposite sex. At least one year of counseling and one year of hormone therapy are required before the surgery.
Daniel, a 25-year-old lawyer from St. Petersburg, Russia, came to Belgrade in May for the surgery after he said he failed to find a suitable surgeon in his country. The surgery and treatment have been so successful that Daniel, who lifts weights regularly and likes to sport facial stubble, betrays few signs that he was once female.
Asking that his last name not be used for fear of being hounded back home, Daniel said he had known since he was 10 that he was male in a female body. When he was 18, he said, he told his family that he was a lesbian, even as he realized that physically becoming a man was his ultimate goal. He said his grandparents, both physicians, refused to accept it, saying he had a disorder of the brain.
“I came out twice, first as a lesbian, then as transsexual. That made it easier,” he said a day after having the surgery. “Russia is extremely homophobic, and coming to Serbia was easier for me.”
Serbia, which became a candidate for European Union membership in March, will hold a gay pride parade this year, activists say. The move is significant, because last year the government canceled a planned gay pride parade after the previous year’s was disrupted by violent clashes during which protesters threw gasoline bombs at armed police officers while chanting, “Death to homosexuals!”
Advocates said they were determined to show that the country was overcoming past prejudices nearly 12 years after Slobodan Milosevic was overthrown. The subtle change in attitude, they added, is also reflected in popular culture.
Last year, a surprise film hit in Serbia was a dark comedy called “The Parade,” in a which a gay veterinarian and his homophobic friend, an ex-paramilitary man, travel across the former Yugoslavia in a pink Mini and recruit war veterans to act as security guards for a gay pride parade in Belgrade. The film, which adroitly plays on stereotypes only to puncture them with an underlying message of tolerance, was among the highest-grossing films in the country’s history.
Cristian, the transgender activist, said he and his wife seldom encountered discrimination, even though in the past he had been taunted and had even received death threats for being different.
For all the challenges of being transgender, Cristian said, being brought up in Serbia in the 1990s had bred a certain resilience. “When bombs are falling from the sky and people are at war,” he said, “sexual identity is not your main concern.”