John Mark Karr, 41, had his sideburns and hair under his chin removed with lasers at the Siam Swan Cosmetic Clinic and its branches in downtown Bangkok during four sessions from March to July, said Dr. Setthakarn Attakonpan.

US teacher John Mark Karr (C) seen sitting with US security officers prior to boarding a plane for the US in Bangkok, 20 August 2006. Authorities held the suspect in the killing of six-year-old JonBenet Ramsey at a Los Angeles prison before a hearing for his extradition to Colorado to face charges. [AFP]

"He wanted to prepare himself to do a sex-change operation," said Setthakarn, a dermatologist who saw Karr during the first session.

Karr also had a consultation at the Pratunam Polyclinic in downtown Bangkok, said Dr. Thep Vechavisit, a doctor who specializes in sex-change surgery. He declined to provide additional details, but confirmed Sunday that Karr was "one of my patients."

The clinic, which co-sponsors a popular transsexual beauty contest, advertises a large menu of plastic surgery procedures in the English-language Bangkok Post. Breast implants go for US$1,125 (euro879) , liposuction costs US$625 (euro488) and sex-change surgery is US$1,625 (euro1,269) - a bargain compared to US prices, where male-to-female reassignment surgery typically runs in the tens of thousands of dollars.

A staffer at the clinic in the dingy office off a busy street said Karr had consulted the doctor about sex-change surgery. She declined to give her name because she was not authorized to speak to the media.

Karr arrived in Los Angeles late Sunday following his arrest in Bangkok last week. He faces charges of first-degree murder, kidnapping and child sexual assault in connection with the 1996 killing of the 6-year-old child beauty queen who was found dead in her basement.

He told authorities he was with JonBenet when she died and that her death was an accident.

While globe-trotting as an English teacher abroad, Karr exchanged e-mails with US journalism professor Michael Tracey over four years. Excerpts published in the US newspaper, the Rocky Mountain News, touched on gender issues.

Karr said his father was a "strong influence but rarely around," and responded to Tracey's question about whether his "fascination with little girls - which clearly has a strong erotic component - is a way of going back."

"Maybe I am not going back but have simply stayed consistent," Karr responded. "My peer group has not changed since I was a little boy, and girls were the people I was with always. Referring to them as a peer group is somewhat incorrect, but might also be the very definition of what they continue to be in my life."

Bangkok is well-known for its large, open transgender population and is a haven for many foreigners in search of acceptance and gender reassignment surgery.

Thep said he performs about one sex-change surgery a week. Each procedure takes about two to three hours and patients are typically able to return to their hotels a day after the operation. He said most patients have been living as women - dressing and taking hormones - for years before appearing at the clinic.

He said mostly Thais and other Asians, especially Vietnamese and Japanese, come to him for gender reassignment surgery. Occasionally, he also gets foreigners from America or Europe.

"I'm pretty popular," he said in his cramped office, stuffed with boxes of papers and photos of before-and-after breast enlargement photos - the most sought-after procedure. He has been performing sex-change surgeries for 10 of the 20 years he has worked as a plastic surgeon.