The Serbian surgeon that pioneered transgender sex reassignment surgery

In the last couple of months there were intense discussions about the connection between “intersex medicine“ and “transgender medicine“ today and in the past. Numerous surgeons are still claiming that the “brain sex” is the reason for the now elective sex reassignment surgeries that they’ve created by practicing genital surgery on various people with disorders of sexual development.

I translated for my readers one of the rare interviews with Dr Savo Perović, the sex reassignment surgery pioneer surgeon in my motherland Yugoslavia, who, by the end of the 80’s created and performed the penile inversion “sex change“ surgery, as well as two types of “phalloplasty” surgeries that are done to this day. He is literally the guy who invented these elective surgeries and introduced them to the world we know today.
It is also important to me to point out that the introduction of these surgeries to the whole medical world, happened in the context of the fallout of Yugoslavia, and in the context of Serbia being under years of sanctions after the recent Balkan wars.
The political and scientific elite in our country, elevated this surgeon trying to gain recognition for Serbia as a new country.

The interview I translated here, “With a scalpel through the world“, was done by a journalist Ljupka Kovačević and was published in the 5th edition of a magazine called “The Planet“ in January 2004. At the time Dr Savo Perović was 65 years old, and he died 6 years later. Dr Savo Perović was working with his assistant assistant Dr Miroslav Đorđević, who is one of the medical men who continued Savo Perović’s legacy and made the SRS into a profitable business in Serbia.

With a scalpel through the world

The urologist, whose specialty is genital surgery, became known for amazing procedures in 1977. Since then, he presents his works and achievements every year at gatherings of urologists and surgeons around the world. His surgeries are transmitted by satellite directly from the operating room.

Famous world surgeons invite Dr. Perović for professional cooperation in order to get acquainted with his unique methods. The biggest names in world surgery, such as Rudolf Hohenfellner from Mainz, Hans Marburger from Innsbruck, Hari Shankar Asopa from India and many others, compare him with Christian Bernard (who performed the world's first human-to-human heart transplant operation), saying that such a surgeon appears very rarely.

Many surgeons are wary of “gender reassignment” surgeries, but Professor Dr. Savo Perović is among the best in the world exactly in these procedures and the only surgeon of that profile in our country. He spent more than 30 years in operating rooms, performing countless procedures, from removing congenital anomalies of urogenital organs in children and adults, to transsexual - that is, procedures that lead to the “sex change”. Thus, at the beginning of the nineties of 20th century, at the invitation of the Medical Faculty in Hanover, he presented his method of transforming a man into a woman. In world medicine, sex change interventions are very frequent; they were introduced in our country as well, but only on the initiative of a double specialist, doctor of medical sciences Dr Savo Perović.

At the time of enrolling in his studies, his brother decided on the professional orientation of our interviewee - "I will be a doctor for animals, and you will be a doctor for people" - and Savo obeyed his brother. He graduated from the Faculty of Medicine in Belgrade on time with a high grade point average of 9.4 and was a student of the generation. What attracted him to medicine was the "craft" part:

“I was attracted to surgical disciplines, I loved exercises in pathology, dexterity and precision with which incisions are made, then forensic medicine ... I saw that it was kind of natural to me and I turned to it later. Before I finished my internship, I was admitted to the Children's University Clinic in Tiršova Street and entered surgery directly. I worked, studied and perfected my knowledge day and night. Many dawns found me over notes or in the operating room. Curiosity in researching ways to help people and discovering new achievements in medicine had to be underpinned by knowledge and responsibility. This is the only way to become a professional and top expert in our work." - said Dr. Perović.

Principles of surgery

The work performed by our interviewee can in no way be treated like any other work, because in addition to responsibility and courage, it also includes great expertise, which is acquired through continuous practice. Dr. Perović compares his job with that of a pilot:

“Here, a person really has to be talented, brave and self-critical at the same time, because everything depends on him. When I give lectures all over the world, I emphasize that a surgeon must have dexterity, he must not have, as we say, "two left hands", but even that is not enough. A skill is worth nothing without the constant and persistent work with which that skill is developed.”

Dr. Sava Perović is a specialist in surgery and urology. As a scholarship holder of the German government, he spent a year in Germany and that was extremely important - he learned the language, made friends, learned a lot from the field that interests him, but also showed something to his colleagues there. In his international career, the meeting with the famous urologist Rudolf Hohenfellner in Mainz was decisive.

“I had my first operation abroad in 1979 in Mainz. It was a congenital anomaly on the male sexual organ. They did not know how to eliminate it, I gave them a proposal, and they adopted it and accepted that I should do it. The operation was successful and from that moment all the doors were open for me. After that, the operations were serialized. Every month, I went to Germany and performed surgeries; even the first video satellite transmission of my operation went from Mainz, on the route Mainz - Hanover - Tokyo. Colleagues from these centers asked questions while I was operating and it was the first such satellite contact in 1987. Success in Germany was not a gift - I was one of the few experts when they considered their own student, who spoke their language very well and that they highly appreciated. That cooperation continues today. I emphasize that where I go almost every weekend and where I operate on patients around the world, are not private but university clinics, and these are demonstrational operations in the field of plastic and reconstructive surgery of the urogenital system. All these operations are done on congenital or acquired anomalies in the urogenital system. In fact, I solve the problem by forming a completely new organ from non-existent organs or partially existing organs, whether they are congenital acquired organs or accidentally damaged organs” - explains Dr. Perović.

Courage as applied talent

In the strong world competition in all areas of surgery, Dr. Savo Perović won his place even when it comes to complex “sex change” procedures. The beginning of such operations dates back to 1989, when a patient appeared with a desire to have his genitals removed. Until then, Dr. Perović often dealt with genital surgery and gained exceptional experience in surgery cases in disorders of sexual development, and DSD (intersex) is a congenital disease.

“When a human is born with traits of both sexes, with a mixture of genitals, it is necessary to do quite complicated surgical procedures and decide whether we will perform the operation in the direction of masculinity or in the direction of a woman (1). This is decided on the basis of the predominant phenotypical characteristics of one or the other sex. I refused that first patient three times, and then the primarius Dr. Zoran Rakić, who dealt with the problems of transsexualism, sent me a letter in which he explained to me that transsexualism is a real medical disease and that it was about gender identity disorder. That patient was a male person with a female brain and the changes happened in the cerebral cortex. I was looking for solutions in the literature and since I didn't find anything, I decided to do that operation based on my knowledge. It was successful, and then I started doing a series of such operations in our country, so I published my new operative technique in the world's leading journal for plastic and reconstructive surgery. Since then, foreigners started coming to our clinic for me to operate on them, and invitations to world clinics have followed. At that time, wars broke out in our country, there were sanctions and everything that happened to us, but I still found a way to get visas and continue with operations” - says Dr. Perović.

When it comes to sex reassignment surgery, the public is divided, but experts and the person who requests gender reassignment, if it is an adult, or parents, if it is a minor, still have the final say. When asked how he fights the patriarchal mentality in our country and how much medical ethics and patriarchal mentality go along, Dr. Perović answers:

“That's a big problem. When it comes to children, there were cases that a six-month-old baby is 46xy, which means one hundred percent genetic male, but he has anatomical features that are more inclined towards female genitalia. We are medically opting for a woman, but we had great problems convincing the parents of the justification for such a procedure. They wanted a male child at all costs. This was the case in 70 percent of cases! Then tragedies happen! Parents are not aware of the consequences that a child will bear when he grows up, when he becomes a man, but never a real man. You can never create a functional male sexual organ that will develop and respond to a hormonal stimulus. Such men today come in a psychosis and seek "alterations". Recently I started a project in cooperation with my colleague Professor Marko Bumbaširević, a famous micro-surgeon, and we do micro-surgical methods of making genitals, removing tissue either from the forearm (if it is well developed) or from the back - explains Dr. Perović. Along with the change of sex, one should definitely make a complete change of personality. That is why the sex change is done while the patient is a newborn, until the community finds out what sex that baby is. But when it comes to adults, psychological trauma is not negligible. We have seen that physical appearance, phenotype appearance, can be successfully changed. However, is there a way to change the soul, because it is also an integral part of a person?”

Dr Perović says that after almost thirty years in operating theaters, the way to change the soul was not found.

“It's almost impossible. On the current level of medicine, some biochemical research is being done to find the cause of it and to act on that part of the human being, but it is still not successful. At the last world meeting, which I attended, which was dedicated to transsexualism, also known as gender identity disorder, a whole team of experts from psychiatrists and psychologists, surgeons of social workers, participated. Without a multidisciplinary approach, there is no treatment for such patients and that works in the West, unfortunately not in our country” - said the interviewee of the Planet.

The biggest recognition - Europe in Serbia

Thanks to such surgical interventions, our country has gained a great reputation in the world. Serbia was one of the few countries where this top surgery was performed. Dr. Sava Perović received five top awards for new operative techniques that he presented in the world. He is an honorary member of the German Association of Urology, then the Hungarian and Romanian Association of Urology, because his work has contributed to the development of urology in these countries. The honors for success were decided by high officials of these countries and awarded to an extremely small number of people. Dr. Perović is a member of the European Association for Genitourinary Reconstructive Surgery, which is a significant and great recognition, he is a member of the World Health Organization Committee, which means that he belongs to a team of experts who set standards for diagnosis and treatment of patients requiring urological reconstructive surgery. Recognitions are constantly arriving, which speaks of inexhaustible creativity and the desire for constant shifting of existing borders in the field that is Dr. Perović's profession and a hobby.

The latest recognition is also the highest recognition for Serbian surgery. It represents the accession of our country to Europe. Namely, a center is opening in the Children's University Clinic in Tiršova Street, where specialists - urologists from all over the world, who meet certain conditions, will acquire knowledge in urological reconstructive surgery and receive diplomas signed by Dr. Sava Perović. Thus, a team of our experts, led by Dr. Perović, will be able to transfer their knowledge to younger colleagues. Finally, surgery, as our interviewee says, is not taught in our forties, but in our twenty-fifth year. “For a young surgeon who is just starting his career, the operating room is everything". As of next year, Belgrade is one of the European cities marked as the leading centers of surgery.

“The first group of urologists is coming to Belgrade from March 1 to 6, 2004, and so every month one group will spend a week in our Center. Preparations for the work of such a Center are very serious, but the most difficult thing was the fight for Europe to accept us. We have received credentials, our diplomas will be recognized without any diploma nostrification. And without these diplomas and without my signature, urologists will not be able to become specialists in andrology. This is absolutely the first time that something like this has happened in Serbian surgery” - Dr. Perović proudly points out.

I operate - so I exist

It should also be said that Dr. Sava Perović publishes his scientific papers in many professional medical journals around the world, and he also entered the German urological textbook, intended for the whole world. He is considered the most competent and best surgeon of today. He was recently elected a corresponding member of Serbian Academy of Sciences and Art (SANU), and that means a lot to him:

“I decided to live in this country and for me the greatest recognition is to become an academic. The recognitions I received around the world were also recognitions for my country, even during the war, but these recognitions in Serbia are my favorite, although I can't say that I don't face malice and jelousy. I don't know why that is so” - says Dr. Perović.

When someone is dedicated to their work, little else in life brings the excitement of that intensity. Dr. Perović entered the world of surgery at the age of twenty-four and is still held by the same strength, creativity and enthusiasm. It's like he's still twenty-four years old.

“If a man decided to become a surgeon, he voluntarily decided to go to a life time prison. The price of such a decision is paid by the family and the surgeon himself. You work constantly and you don't have time for other things in life. And when I finish the operation, I can't rest, because I have to write it all down and analyze it, otherwise everything is forgotten. Some time ago, with my colleague Miroslav Djordjević, I was in Hungary. We performed one operation which all the world experts invited by the Hungarians refused to do. I accepted to do it without any hesitation, and thanks to my knowledge, experience and great "training", everything went well. It was a congenital anomaly and I managed to transport the sexual organ from the place where it was, to the place where it should be and to preserve all its functions. I am not saying that it was not difficult, admits Dr. Perović and continues. I enjoy operations, I have no anxiety, but what burdens me is the knowledge that for me as a Serb, the operation must succeed, because if it fails, no one will call me another time. That luxury of failure, I must not allow myself. So I anxiously wait for each postoperative course and only when I see that everything is fine, then I am calm and I can move on. That uncertainty is the biggest burden ... But music relaxes me, I also like to operate with music ... I loved Bijelo dugme, and now I often listen to CD of Kemal Monteno and friends ... Those songs remind me of good old times, the times of old Yugoslavia. Unfortunately, I can't read almost anything else from the professional literature. I can't even see my family properly. Luckily, my wife has an understanding for the work I do. Both she and our two children are really responsible for my success, because without harmony in the family, even if my family weren't as they are, I doubt that I would have achieved this much” - reveals Dr. Perović.

He doesn't talk much about his further plans, he mentions China and South Korea, and he has just received calls from universities in Bangkok and Thailand, where he will perform operations in the field of "his" surgery. However, in the end, he could not help but discover which country and which people he was fascinated by.

"With my assistant Dr. Miroslav Đorđević, in 1995, I was a guest of the humanitarian mission for two weeks, as part of the American team, in Saigon, Vietnam. It was a great adventure with many dangers, but also a great challenge. For two weeks I performed various operations and I helped those poor but wonderful people. After the operation the people were kissing my feet, it is something that is never forgotten", - Dr. Savo Perović, a man who traveled almost the whole world with a scalpel, ends his story.

(1) Dr Perović did compare “masculinity“ and “a woman“ in this interview


Additional links:

Bel Medic Akademik Sava Perovic (Serbian language)

Dr Radoš Đinović - successor of dr Sava Perović (Serbian language)

Interview with Professor Miroslav Đorđević about the future of transgender surgery and project of penile transplantation in transmen (English language)

MLD Phalloplasty in Serbia - example of Miroslav Đorđević’s work (English language)

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