One early campaigner for transsexual rights is Maryam Hatoon Molkara, who was formerly a man known as Fereydoon. Before the revolution, she had longed to become a woman but could not afford surgery. Furthermore, she wanted religious authorization. Since 1975, she had been writing letters to Ayatollah Khomeini, who was to become the leader of the revolution and was in exile. After the revolution, she was fired, forcedly injected with male hormone, and institutionalized. She was later released with help from her connection, and she kept lobbying many other leaders. Later she went to see Khomeini, who had returned to Iran. At first she was stopped and beaten by his guards, but eventually Khomeini gave her a letter to authorize her gender reassignment operation. The letter is later known as the fatwa that authorizes such operations in Iran.
A small number of Iranian clerics have advised that homosexual men and women undergo gender reassignment in order for them to be able to live "normal lives".
Hojatoleslam Kariminia, a mid-level cleric who is in favor of transgender rights, has stated that he wishes "to suggest that the right of transsexuals to change their gender is a human right" and that he is attempting to "introduce transsexuals to the people through my work and in fact remove the stigma or the insults that sometimes attach to these people."
UNHCR's 2001 report says that sex reassignment surgery is performed frequently and openly in Iran, and that homosexual and crossdressing people would be safe as long as they keep a low profile. However, the Safra Project's 2004 report considers UNHCR's report over-optimistic. The Safra Project's report suggests that UNHCR underestimated legal pressure over LGBT.
The report further states that currently, it is not possible for transgender individuals to choose not to undergo surgery - if they are approved for gender reassignment, they are expected to undergo treatment immediately. Those who wish to remain "non-operative" (as well as those who crossdress and/or identify as genderqueer) are considered their biological gender, and as such they are likely to face harassment as being homosexuals and subject to the same laws barring homosexual acts.