Nevena, a trans woman undergoing hormone therapy in Serbia. All photos by Nemanja Knežević
Serbia's cheap medical tourism industry has attracted trans people from across the world—but local trans people find themselves left out in the cold.
When Serbian president Slobodan Milošević was finally deposed on October 5, 2000, it wasn't NATO bombs that forced him out—it was the electorate who dragged the alleged war criminal out of office, enraged by his refusal to step down after being defeated at the polls several weeks earlier. For a second, it appeared as though Serbia had developed a newfound and seemingly irrepressible hunger for democracy after decades of authoritarian rule.
Sensing change in the air, local LGBT groups made their first attempt at staging a Pride parade the following year, under the banner, "There's room for everybody." The response couldn't have been more nightmarish. A lynch mob of football hooligans, nationalists, and Christian extremists took to Belgrade's streets chanting, "Kill, kill, kill a faggot," and mauling anyone that they suspected of being gay. Little has changed in the 16 years since, and recent parades have only gone peacefully thanks to a combination of EU pressure and military-scale police operations.
Despite this climate of heinous intolerance, Belgrade has somehow become a global hub for gender reassignment surgery. The Transgender Law Center reports that surgery in the US can cost between $5,000 to $50,000; in Serbia, you would expect to pay between $4,335 and $10,839. Around a hundred trans people travel to the Serbian capital every year, drawn by the irresistable combination of low prices and high levels of expertise.
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A hundred patients might not seem like a particularly noteworthy figure, but this isn't a common form of surgery. According to the Washington Post, only around 100 to 500 people are operated on yearly in the US. Only 143 operations took place in the UK in 2009. In global terms, Serbia's medical industry punches far above its weight, and its reputation is so renowned that Cher's son Chaz Bono even declared that he wanted to go to Belgrade for gender reassignment surgery a few years ago.
"If we're going to talk about medical tourism, don't forget that every other form of operation is cheaper here than in the rest of the world," Dr Miroslav Djordjević says from his desk in a cramped examination room at the University Children's Hospital. One of Serbia's leading gender reassignment surgeons, he leads the Belgrade Center for Genital Reconstructive Surgery. "If you want to operate [on] your gallbladder, that's a cheap operation here—15 times cheaper than in America—but nobody comes here for that. The reason they come here is because of the quality that we offer, the operating techniques that we pioneered and advanced to the point where patients say, 'I want to go to Belgrade.'"
Dr Miroslav Djordjević leads the Belgrade Center for Genital Reconstructive Surgery. All photos by Nemanja Knežević
Besides the cheap medical bills, Belgrade's doctors are best known for their mastery of female-to-male surgeries, which are more complicated (and as a result, less widely available) than its inverse operation. Djordjević claims that the degree of medical expertise is so high that surgeons here have condensed what would be several lengthy operations into a single six-hour procedure, sparing patients the physical and mental stress of being operated on multiple times. Djordjević regularly flies out to perform operations in hospitals as far afield as Japan and the US, and estimates that trans men make up 80 percent of his foreign patients.
"I decided to go to Belgrade for several reasons: first, Miro is a urologist and most of the other surgeons are plastic surgeons," one of Djordjević's US patients told me over email. "What I needed was the ability to urinate from my penis, not just something that was aesthetically pleasing. I made contact with four doctors, three in the USA and one in Belgrade."
He only received one direct response from a US surgeon; the others directed him to their online application processes. The Belgrade Center responded immediately. "Miro and I made arrangements to meet in the USA. He saw me and he spent close to four hours with me, reviewing my history and answering my questions. He saw me as an individual, he spoke and treated me with the utmost respect."
He was known to pull patients off the operating table mid-operation, because these were private procedures done in state clinics outside of working hours...
The global medical tourism trade has a slight cowboy reputation—everybody seems to know somebody who knows somebody whose aunt flew out to Thailand for a boob job, only to return with what appeared to be the contents of two cans of Spam soldered to her back. Djordjević says that what sets the Belgrade team apart, aside from their "enthusiasm" and intrinsic "humanitarianism," is the strict regulatory procedures that they have in place.
A patient can't simply wire the cash and book a procedure—they first need to complete a year of preliminary mental assessment, in which they are examined by both psychologists and endocrinologists, followed by six to 12 months of hormone therapy before they are finally led into the operating theatre. Foreign patients must prove that they've gone through equivalent testing in their home country.
"For us, patients aren't simply a source of revenue that'll be operated today and forgotten tomorrow," Djordjević says. "We stay in contact with them and insist that they stay in contact with us so we can follow them and get reliable information to draw conclusions on our results, successes, or failures. And that's the difference between us and one of the 50 hospitals in Thailand that perform this sort of surgery."
Milan Djurić, a trans queer man who campaigned for Serbian government to subsidize gender reassignment surgery.
Serbia's emergence as a hub for these procedures is entirely down to the work of a single urologist called Dr Sava Perović, who was renowned across Yugoslavia for correcting genital deformities in children. As in all rigidly-minded socialist societies, doctors were held in particular esteem, and appearances on the radio and in newspapers made Perović a celebrity of sorts.
According to Djordjević, who trained under the late surgeon, it was this reputation that brought Perović his first trans patient. "The first patient, unable to go on, burst into the infirmary one day and said, 'I have a problem, I'm a woman and I don't want this thing I have,'" Djordjević recalls, gesticulating downwards towards his lap.
This incident perked Perović's interest, inspiring him to research gender dysphoria before carrying out his first gender reassignment procedure in 1989. He continued operating until his death five years ago, training every single local surgeon performing these procedures today and single-handedly building this branch of Serbia's medical industry from scratch. In the intervening years since, nearly 300 patients from the former Yugoslav republics, in addition to roughly a thousand foreigners, have visited operating rooms in Belgrade.
There was great resistance to us doing these operations, especially at state clinics.
If you speak to one of the city's surgeons or their assistants, it won't be long before you're treated to a protracted sermon framing their work as a moral mission and themselves as great philanthropists. As one patient case coordinator told me via email: "This is not a national phenomenon. It is a personal one generated by a few men doing wonderful things for people... at tremendous personal sacrifice." The late Perović is referenced with the sort of gushing reverence typically reserved for saints. And while he and his pupils have no doubt transformed hundreds of lives for the better, one trans individual familiar with the doctor described him as "narcissistic" and suffering from a "Freudian God complex." They agreed to speak under condition of anonymity.
"Sava Perović started doing these operations in the 80s, and during the 90s a team formed around him that operated in completely criminal circumstances," they say. "They earned huge money off of trans individuals, charging them up to five, six, seven thousand Deutsche marks [roughly $8,200-$11,500 in 1993], except that Sava would always change that figure—one day he'd tell you one price, a different day another. He was known to pull patients off the operating table mid-operation, because these were private procedures done in state clinics outside of working hours, and they couldn't let their colleagues see what they were doing. It was all done under the counter and the state tolerated it."
Djordjević at his desk.
When I presented these allegations to Djordjević, he told me: "There was great resistance to us doing these operations, especially at state clinics. I don't have details of what was paid, how much and to whom. And I can't comment on that. From 2007 we brought in more defined regulations and now it's tidier, defined by law. I couldn't comment on other people's experiences."
Determining the validity of these claims is difficult. As one trans person went to Belgrade for surgery explains, any former patient would be reluctant to discuss the subject because "they'd rather forget the past." But anyone familiar with 90s Serbia won't find the allegations particularly outlandish. Politically isolated by economic sanctions and stuck in the transitional phase from socialism to capitalism in the midst of a civil war, the country transformed into a full-blown mafia state. Rule of law crumbled. The black market was the only economy that thrived, and certain individuals made themselves unimaginably rich via cigarette and gasoline rackets, while members of the state apparatus were even allegedly involved in heroin trafficking. If nothing else, unlicensed medical procedures definitely fit with the economic climate of the decade.
For a long time, these operations were prohibitively expensive for those who lived in Serbia, a country where roughly 20 percent of people are out of work. But thanks to the relentless campaigning of local NGO Gayten-LGBT, a new law came into being in 2012. It declared that every trans citizen who passes the required psychological checks is entitled to state funding covering 65 percent of their operation. Djordjević tells me that the government has paid for 16 individuals to undergo gender reassignment surgery since.
However, some argue that this creates a purely cosmetic sense of progress. "The fact that the state subsidizes 'sex change' procedures is a great step forward that we have worked hard for," says Milan Djurić, who heads up Gayten-LGBT and identifies as trans and queer. "What's been missing all this time, especially up until four or five years ago, is that state institutions and the medical industry don't discuss the whole array of issues and problems that trans people face—the suicide rate is staggeringly high, as is homelessness, poverty, unemployment...
"There's an entire corpus of issues that go unaddressed... It's great that the state has finally listened up and done something, but so much more needs to be done."
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Trans identity lies on a broad spectrum, and plenty of people who don't identify with their biological gender feel no need to tinker with their genitals. In Serbia, those who don't find themselves in existential limbo because they are unable to legally change their gender without a note from a doctor, something most refuse to issue until after surgery. In fact, there is no legal framework to regulate the bureaucratic process of transitioning, with trans individuals left at the mercy of whichever public official happens to be dealing with their case.
"I have other troubles now. I face problems in medical institutions and with the police because my appearance doesn't match what's written in my identification," explains Nevena, a trans woman currently receiving hormone therapy. "I look like a woman but in my documents my gender is listed as male. That creates a lot of problems: It confuses people, and it's also why I can't find stable employment, because employers won't hire [trans] people, often out of fear."
Serbian trans people may find it easier than ever to fund their surgery, but little has been done to improve their legal standing. The national constitution, for example, only recognises a heteronormative model of marriage; if a married individual legally changes their gender, their parental rights or inheritance and visitation rights as a spouse remain undefined. In the country's rural backwaters, Djurić tells me that many trans patients are unable to receive state aid because local doctors are often ignorant of gender dysphoria or actively refuse to recognize it as a medical condition.
But in a strange way, it's almost fitting that Serbia has become a global hotspot for gender reassignment surgery. Back when it was known as Yugoslavia, freedom of expression was constrained—as it was in many communist societies. Technical subjects like the sciences and engineering were aggressively nurtured, almost as a form of overcompensation. Serbian society may remain as intolerant as ever, but you get the feeling that the no-nonsense people who work in science-based pursuits like medicine are best equipped to separate their work from bigotry and ideology. As Djordjevic tells me, "We can't change someone's genetic code with an operation; what we change is their genitals."
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