Busan, South Korea: As Dr. Kim Seok-Kwun begins surgery to create a functioning penis for a Buddhist monk who was born female, he is well aware of the unease his work creates in this deeply conservative country. The devout Protestant known as the "father of South Korean transgender people" once wrestled with similar feelings.
"I've decided to defy God's will," Kim, 61, said in an interview before the monk's recent successful surgery to become a man. "At first, I agonized over whether I should do these operations because I wondered if I was defying God. I was overcome with a sense of shame. But my patients desperately wanted these surgeries. Without them, they'd kill themselves."
Kim is a pioneer in slowly changing views on sexuality and gender in South Korea, where many have long considered even discussions of sexuality a taboo. He has conducted about 320 sex change operations over the past 28 years, widely believed to be the most by any single doctor in the country.
Kim said the monk, who underwent 11 hours of surgery, did not want to be interviewed for fear of offending Buddhist believers at his temple. The doctor said the monk has been taking hormone therapy and has been living as a man for a long time.
When Kim first started doing the surgeries in the 1980s, his pastor objected. Friends and fellow doctors joked that he was going to hell if he didn't stop. He now feels a great sense of achievement for helping people who feel trapped in the wrong body. He believes he's correcting what he calls God's mistakes.
"Some people are born without genitals or with cleft lips or with no ears or with their fingers stuck together. Why does God create people like this? Aren't these God's mistakes?" Kim said. "And isn't a mismatched sexual identity a mistake, too?"
A strong bias against sexual minorities persists in South Korea, the result of lingering Confucian beliefs that children should never damage the bodies they received from their parents; a large, vocal conservative Christian community; and past military-backed dictatorships that ignored minority voices.
Sex change operations "are a blasphemy against God and make the world a more miserable place," said the Rev. Hong Jae Chul, president of the Seoul-based Christian Council of Korea. He called Kim's remarks "cursed and deplorable."
Kim, a plastic surgeon at Dong-A University Hospital in the southeastern port city of Busan, specializes in fixing facial deformities. He began doing sex change operations in 1986 after several men wearing women's clothing visited him separately and asked him to construct vaginas for them. The first visitor had already had his penis removed, Kim said.
Kim initially turned them away because he knew nothing about sex change surgery. But he kept thinking about their pleas, studied foreign publications and began performing the surgeries a year later.
His best known patient is South Korea's most famous transsexual entertainer, Harisu, who had Kim officiate at her 2007 wedding to a male singer.
Harisu, who only uses a single name, said in an interview at a Seoul coffee shop that the pain she felt after her 1995 male-to-female surgery "was like a hammer hitting your genitals." But days later, when she left the hospital, she felt reborn, comparing her transformation to the Disney film "The Little Mermaid," where a mermaid gives up her fish tail in exchange for human legs and eventual happiness.
Many of Kim's earliest patients were in their 40s and 50s. Sometimes parents showed up just before surgeries, furious and threatening to disown their children.
Today, most of his sex-change patients are in their early 20s, and sometimes their parents agree to pay for the surgery. Male-to-female procedures cost 11 million to 15 million won ($10,210 to $13,920), and the more difficult female-to-male procedures cost 31 million won ($28,760).
The changes in his clientele reflect changes in South Koreans' views of sexual minorities.
Several gay-themed movies and TV dramas have become hits. An actor once banned from show business because of his homosexuality is working again. A well-known male movie director symbolically tied the knot with his male partner last year in what was the first high-profile ceremony of its kind in South Korea, which still doesn't legally recognize same-sex marriage.
At the same time, activists say transsexuals remain likely to face harassment, abuse or insults, and many suffer from depression and have attempted suicide. The conservative government of President Park Geun-hye, which took office in early 2013, said it would create a broad anti-discrimination law, but there's been no major progress.
In 2012, vehement protests by conservative activists and Christian groups forced a TV channel to scrap a talk show program featuring transgender people after airing its first segment.
Transgender people who want to legally change their gender also face obstacles in South Korea. The Supreme Court suggests that judges allow such changes only for those who have undergone sex change operations, have lost reproductive capability, are not married and have no underage children.
The lack of any binding rules has led transsexuals to flock to judges rumored to be less strict about approving gender change requests, according to Hahn Chae Yoon, leader of the Korean Sexual-Minority Culture and Rights Center in Seoul.
Last year a Seoul court approved gender change requests for five people even though they hadn't yet completed their female-to-male procedures, something previously deemed necessary. Since then, about 30 other people in similar situations have been allowed by the court to legally change their sex, according to court officials.
Kim requires his candidates for surgery to get testimony from at least two psychiatrists showing a diagnosis of gender identity disorder. They're asked to live for more than one year in the other gender's clothing and hairstyle and to get parental approval. Of his 320 sex change operations, about 210 are male-to-female, the rest female to male.
Many patients see the operation as a matter of life or death. Before her surgery, Harisu, the transsexual entertainer, signed a document acknowledging that she knew she could die during surgery, though Kim said none of his sex-change operations have gone so horribly wrong.
"If I had lived as a man without undergoing a sex change operation, I might be dead already," Harisu said. "I was already a woman except for my genitals. I didn't want to live an awkward life with those genitals ... I'm a woman, so I wanted to live as a woman."