For 40 years Iran has performed more gender transition surgeries than many other nations, largely a result of pressuring gay and gender-nonconforming citizens to undergo unwanted operations or risk the death penalty.

Now, faced with an economy crippled by war and sanctions, the Islamic republic is promoting its expertise to a global audience, hoping to attract transgender foreigners with the promise of inexpensive surgeries packaged with luxury hotel stays and sightseeing tours.

Desperate for foreign investment, Iran’s theocratic government has set a goal of generating more than $7 billion from medical tourism annually, according to Iranian state news media, about seven times as much as it earned last year. That objective has resulted in the proliferation of medical tourism companies, marketing not just nose jobs and hair transplants, but vaginoplasties, mastectomies and penis constructions through glossy English-language websites.

“We handle everything from start to finish, providing the best medical services to ensure a stress-free experience,” said Farideh Najafi, the manager of two medical tourism companies, MabnaTrip and MedPalTrip. “This includes booking hotels, hospitals, transportation and more,” she said.

Iran is one of the few places in the Muslim world that allows transgender people to seek gender-affirming care, and even subsidizes it. For many foreigners traveling to Iran for transition surgery, and indeed for many transgender Iranians, these operations can feel lifesaving. But the country’s reputation as a pioneer in the field belies the abusive history of the operations and the grim reality for most L.G.B.T.Q. people there.

In Iran, gay men and lesbians can be punished by public flogging and the death penalty. As a result, the United Nations Human Rights Council found, many gay and lesbian Iranians who are not trans are “pressured into undergoing gender reassignment surgery without their free consent.”

Still, the country’s cut-rate prices are drawing transgender individuals from as far away as Australia, the United States, Britain and Europe, according to medical tour operators and surgeons. Many more patients, they say, come from neighboring countries, like Iraq, where such treatments are strictly forbidden.

“In the United States, the cost of surgery is around $45,000, and in Thailand, it’s approximately $30,000,” according to the website of one operator, IranMedTour. “However, the cost of gender confirmation surgery in Iran is lower, with prices less than $12,000.” Other companies, advertise procedures at government hospitals for as low as $4,500.

Sam, 32, a trans man from Orange County, Calif., is currently in Tehran to pursue a hysterectomy and metoidioplasty, a kind of penis-construction surgery. Requesting anonymity to discuss a sensitive medical procedure, he said he was drawn to Iran because he believed the doctors there were “more confident” than those in the United States.

“The goal of these medical tours is probably to portray Iran as a paradise for trans people, which it isn’t,” said Saman Arastu, a transgender Iranian man and actor who chose to undergo so-called top and bottom surgeries. “In my opinion, these are nothing but a show. The situation for trans people is dire.”

While precise figures are unknown, a report by the Home Office of Britain from 2022 found that roughly 4,000 people underwent transition surgery each year in Iran, a figure higher than the combined annual totals in Britain and France. Experts say a vast majority of patients come from inside Iran.

Iran’s experience with transition surgery stems from a fatwa issued in the 1980s by the Ayatollah Ruhollah Khomeini, the founding supreme leader of the Islamic republic, who declared that transgender individuals could gain legal recognition of the gender with which they identified, but only on the condition that they underwent transition surgery.

On the surface that policy inverts what many in the West expect from Iran, where gender norms are so strictly enforced that until recently women were punished for not wearing hijabs in public.

But transgender Iranians and experts say the government’s embrace of surgery in no way correlates to advocacy for trans people.

Iranians who do not adhere to traditional norms of masculinity and femininity — including trans people who do not want surgery — are subject to violence, extortion or are pressured into operations.

“For the Islamic republic, being trans means you have to go through this surgery — from male to female, female to male,” said Zara Saeidzadeh of Orebro University in Sweden, a gender scholar who has spent a decade researching trans identity, with a focus on Iran. “If you identify as trans but don’t want to do any form of body modification, then you’re breaking the rules and you are going to be stigmatized and your life is threatened.”

Raha Ajoudani, a 20-year-old trans woman and activist, made the opposite journey that many foreign tourists are making. She fled to Germany from Iran in 2024 to avoid a forced transition surgery and to escape state persecution for her activism. Ms. Ajoudani said that she was detained twice by the authorities in 2022, after an ex-boyfriend collaborated with the Iranian Ministry of Intelligence, to facilitate her arrest. Her family, she added, is routinely hounded to get her to stop her activism.

“I never wanted to undergo gender reassignment surgery,” Ms. Ajoudani said. “I’ve defined myself outside of this binary. I didn’t want to live according to the governmental definition of cultural expectations of being a woman or a man, nor did I submit to Khomeini’s fatwa.”

Surgery is not a guarantee of acceptance or safety. Transgender people in Iran face murder and other forms of violence and harassment.

The tour companies include language to assuage foreigners of those fears in their advertising materials.

Amid glossy before-and-after photo illustrations of idealized pectorals and breasts, and copy that promises “budget-friendly” procedures, rapid visa approvals and help achieving “a strong feeling of happiness and relief,” the tour companies are also selling patients on what one calls Iran’s “relatively progressive stance on transgender rights.”

Ms. Najafi, the tour manager, conceded that some foreigners feared running afoul of the authorities or the locals, but said that patients traveling with her company had “never had any security issues.”

Transition surgeries are complex operations with a questionable record of safety in Iran. Some activists have likened the country’s gender clinics to “butcher” shops.

Saghi Ghahraman, who led the Iranian Queer Organization, said that while they believed treatment standards had improved, the change had come at a cost, as many gay people felt forced into operations that were like “experiments.”

A U.N. report on transition surgeries in Iran from 2015 described botched procedures that led to complications like “severe bleeding, severe infection, scarring, chronic pain and abnormally shaped or located sexual organs.”

Adding to the risks are some tour companies’ promises of rapid procedures, which experts said should involve months of planning. Some market stay timelines as short as one week.

Dr. Shahryar Cohanzad, a urologist in Tehran who has performed around 300 transition surgeries, said the companies’ aim to perform as many procedures as quickly as possible was unsafe.

“From what I know after 35 years of performing surgeries, it’s critical for the surgeon to spend as much time as possible with the patient,” he said.

Eric, a 45-year-old trans man living in Canada who requested anonymity to protect himself and his family from reprisals, said he had sought treatment in Iran because it was cheap. But he acknowledged the tension in seeking treatment in a place where others have it forced on them.

“I have heard a lot, especially among trans women, that because they are gay, and they cannot be gay in Iran, they try to do the surgery,” said Eric. “I’m really sad that gays and lesbians are not recognized in Iran, but on the other hand I’m happy for trans people because they can do what they’re willing to do.”