Interesting... From the comments:
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I read an article about the sex reassignment surgeries in Iran a few years ago. The word does not mean the same thing there as it means here in the west. I'm sure the western style operations are available for the wealthy, but often sex change only means the removal of male genitalia with no hormone treatment. This explains why statistically Iranian surgeons outperform everyone else so massively in this field. Also, the patients are often gay men who are more or less forced to undergo the operation by their families, against their own wishes. Castrated and forced to live as a woman in Iran? A living nightmare if there ever was one.
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Hey Dana, there's another chapter for a book in here, about equating "no penis" with "being female."