Stigma and discrimination against transgender men in Bhutan.

BACKGROUND: While transgender people worldwide face high rates of stigma and discrimination, there are few studies of transgender men (also "trans men") in Asia. We measured the prevalence of, and factors associated with, stigma and discrimination faced by trans men in Bhutan to bring visibility to their experiences and inform health and social policy changes. METHODS: This cross-sectional survey was conducted in nine regions in Bhutan from November 2019 to January 2020. A total of 124 trans men were recruited using a hybrid venue-based and peer-referral approach. Data were collected using an interviewer-administered questionnaire. Multivariate logistic regression characterized associations with experiencing stigma and discrimination when accessing health services. FINDINGS: Participants were young (48.0% 18-24 years) and 48.4% had migrated from a rural to an urban area. The majority (95.2%) experienced stigma because people knew or thought they were trans men. Associations with frequent experiences of stigma were living with their partner as a couple (adjusted odds ratio [AOR] 3.07, 95% CI 1.27-7.44) and being unemployed or a student (3.22, 1.44-7.19). Nearly half (47.6%) said they experienced discrimination when accessing health care because people knew or thought they were a trans man; this experience was associated with migration (2.42, 1.08-5.39) and having >15 trans men in their social network (3.73, 1.69-8.26). Most (94.4%) experienced verbal violence, 10.5% experienced physical violence, and 4.8% experienced sexual violence. INTERPRETATION: Our study found high rates of stigma, discrimination, and interpersonal violence due to being a trans man in Bhutan. Findings highlight the urgent need for strengthening laws and regulations to protect the rights of transgender persons, particularly when accessing health services, recognizing partnerships, and preventing violence in public spaces.

Population size estimation of transgender women and men in Bhutan.

INTRODUCTION: Transgender persons experience health disparities and are marginalized in many societies worldwide. Even their numbers are unknown in many countries. We conducted the first effort to estimate the population size of transgender women (TGW) and transgender men (TGM) in Bhutan from November 2019 to January 2020. METHODS: Community-based surveys of TGW and TGM integrated several methods to estimate the size of hidden populations, including key informant mapping, wisdom-of-the-crowd, the service multiplier, and the unique object multiplier. Results of the several methods were synthesized using a Bayesian approach. RESULTS: Surveys included 34 TGW and 124 TGM. TGW was persons assigned to the male sex at birth and currently self-identified as "trans women" (91%), "women" (6%), or another gender (3%). TGM were persons assigned female sex at birth and self-identified as "trans men" (100%). Bayesian synthesis of the multiple methods estimated 84 TGW (credible interval 61-110) and 166 TGM (credible interval 124-211) in Bhutan. CONCLUSIONS: Our study documented that TGW and TGM are part of Bhutanese society, with TGW constituting 0.03% of adult women and TGM 0.06% of adult men. Estimates can help advocate for resources and programs to address the health and well-being of these communities.

Characteristics and Population Size Estimation of Female Sex Workers in Bhutan.

BACKGROUND: Knowing the number of persons at risk for sexually transmitted diseases (STDs) and their risk behaviors are needed to allocate limited resources, set targets for prevention and care activities, gauge the reach of programs, and assess their impact. Female sex workers (FSWs) are a population at high risk for STD worldwide; little is known about FSW in Bhutan. METHODS: We conducted a community-based survey and population size exercise of FSW in Bhutan. The survey used a hybrid venue-based/peer-referral sampling method. Population size estimation methods were key informant mapping, census and enumeration, unique object multiplier, and capture-recapture. RESULTS: Of 517 women surveyed, 67.5% provided sex for money in the last year. Compared with FSWs at venues, FSWs referred by peers were more likely to have sex with alcohol (80.1% vs. 51.5%, P < 0.001) and more paying partners (mean, 3.5 vs. 2.0; P = 0.001), and less likely to have tested for an STD (28.3% vs. 51.0%, P < 0.001) or have outreach worker contact (27.6% vs. 41.5%, P = 0.007). The estimated number of FSWs in the 9 districts was 353 (95% confidence interval, 345-362). Extrapolation to the whole country projected 597 (417-777) FSWs nationally. CONCLUSIONS: Our estimate of the number of FSW in Bhutan corresponds to 0.71% of adult urban women, a figure in line with other countries in South and Southeast Asia. Our data highlight the need for outreach beyond venues where women are employed to reach FSW at higher risk for STD but who have less access to interventions.