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. 2023 Jul 20;18(7):e0287745. doi: 10.1371/journal.pone.0287745

Stigma and discrimination against transgender men in Bhutan

Vinita Saxena 1,*, Audrey Xu 2, Kinley Kinley 3, Tashi Tsheten 4, Tenzin Gyeltshen 5, Tashi Tobgay 6, Tae Young Zajkowski 7, Willi McFarland 8, Lekey Khandu 9
Editor: Ricardo de Mattos Russo Rafael10
PMCID: PMC10358905  PMID: 37471374

Abstract

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.

Introduction

Stigma, discrimination, and violence have been documented among sexual and gender minority people in many parts of the world, ranging from daily micro-aggressions to verbal abuse, physical assault, rape, and death [1]. Discrimination against transgender persons results in denial of academic and other economic opportunities [2]. Transgender men (also “trans men”) are people whose sex is assigned female at birth but self-identify as men. Trans men also encounter abuse and harassment due to laws that aim to regulate public behavior and decency, including combating cross-dressing or imitation of the other sex [3].

Experiences of stigma, discrimination, and violence may prevent trans men’s access to health and social welfare services. Compared to cisgender men, trans men in the United States are less likely to have health insurance and a usual source of health care [4]. Compared to cisgender men, they also experience a higher prevalence of health conditions such as emphysema, liver disease, ulcer, sleep disorders, and poor mental health [5]. The stigma and discrimination against transgender people can lead to hesitation in seeking health and social services, resulting in unmet physical and mental health needs. Unmet mental health needs in turn can lead to high rates of depression and suicide among trans men [6].

According to UNAIDS and the laws in Bhutan, there is no criminalization of transgender people, sex work, or same-sex sexual acts in private [7]. Bhutan’s constitution protects transgender persons for acts such as rape, domestic violence, and sexual harassment in the workplace regardless of gender. However, laws do not explicitly protect LGBTQ+ individuals from discrimination on the basis of sexual orientation, gender identity, or gender expression. In addition, there are no legal explicit legal rights for transgender people to access gender-affirming care, marry, or change government identity documents. Pride Bhutan and Queer Voices of Bhutan, two civil society organizations advocating for LGBTQ+ rights, are not legally registered organizations [8]. It should be recognized that the legal and cultural situation in Bhutan is rapidly changing [9].

Unfortunately, there is very little scientific research published on trans men worldwide, and even less on trans men in Asia [10–13]. Further, to our knowledge, no studies in Asia have measured the prevalence of experiences of stigma, discrimination, and violence experienced by trans men. Therefore, we took the opportunity to ask questions in these domains in the first survey conducted for trans men in Bhutan.

The goals of the current report are to document the presence of stigma and discrimination experienced by trans men in Bhutan and identify factors associated with this stigma and discrimination. We further undertake to present the prevalence of different types of interpersonal violence experienced by trans men, including verbal, physical, and sexual violence. Such data can advocate for policies and practices to support transgender persons in Bhutan and establish a baseline from which to gauge future progress in eliminating stigma, discrimination, and violence toward this vulnerable population.

Materials and methods

Overall study design and source population

This study was a cross-sectional survey of trans men conducted in Bhutan from November 2019 to January 2020. Participants were eligible if they were 18 years or older and assigned female sex at birth and self-identified as a gender other than female regardless of hormone use, gender-affirming procedures, sexual orientation, and public gender presentation.

Study locations included nine of Bhutan’s 20 districts (dzongkhag), namely Thimphu, Chhukha (Phuentsholing), Wangdue Phodrang, Sarpang, Paro, Samdrup-Jongkhar, Mongar, Punakha, and Bumthang. The study area covered 64% of the nation’s population and 82% of the urban population. The largest and most urban districts are the capital Thimphu and Chhukha (Phuentsholing), the latter bordering India. These nine districts are located in the three major regions of Bhutan: central, southern border, and the east.

Survey design and procedures

Details of the sampling and recruitment have been previously described [14] and are summarized here. First, community outreach workers recruited eligible trans men in their social networks to participate and instructed them to refer other eligible trans men from their networks. Second, peer outreach workers also recruited participants from online and physical spaces frequented by LGBTQ+ populations in Bhutan. This resulted in a study sample that was a hybrid of venue, online, and peer-referral recruitment methods. The dates when participants were enrolled are the same as the dates of the survey implementation. Eligible trans men who provided verbal informed consent participated in a structured face-to-face interview. The authors had no access to any information that could identify individuals during or after data collection, and the survey was anonymously conducted. As compensation, participants received cell phone airtime cards of ngultrum 500 (USD $6.79) for survey completion and ngultrum 200 (USD $2.72) for each peer referral.

Measures

The structured questionnaire was brief and collected demographic information, use of services, and indicator questions on experiences of stigma and discrimination. These indicators are comparable with frameworks and definitions previously used for measuring stigma and discrimination among transgender populations [15]. Translated from the Dzongkha language, the question about stigma was generally asking about experience as a trans man, namely, “Have you experienced stigma because people knew or thought you are a trans man?” The question about discrimination referred to experience with accessing healthcare, namely, “Have you experienced discrimination when accessing health services because people knew or thought you are a trans man?” The answer choices for these two questions ranged from “often,” “sometimes,” and “never.” Participants were also asked if they experienced violence (verbal, physical, sexual) due to being trans men. Occupations labeled as “entertainment” included employment in bars, karaoke clubs, and “drayangs” where dances are performed for customers. These occupations do not explicitly include sex work, although such venues are often locations where sex workers find clients [16]. The questionnaire also included questions on the level of outness about being transgender and the participants’ social network size of other trans men.

Statistical analysis

Descriptive analysis characterized the demographic profile of the study population and the prevalence of experiences of stigma, discrimination, and violence. We further examined correlates of stigma and discrimination. For correlates of stigma experience, we dichotomized the outcome to be “often” vs. “sometimes/never” due to any experience reported by the vast majority of respondents (i.e., “often” or “sometimes” was reported by 95.2%). For correlates of discrimination when accessing health care, we dichotomized the outcome as “often/sometimes” vs. “never” due to a more balanced distribution of having experienced any such discrimination (i.e., “often” or “sometimes” was reported by 47.6%). We first performed bivariate analysis using the chi-square test to identify potential associations with experiences of stigma and discrimination. Multivariate logistic regression analysis was conducted to characterize independent associations with stigma and discrimination, considering the inclusion of variables associated with these outcomes at p<0.2 in bivariate analysis. Final models retained those variables with p<0.1, while considering only those with p<0.05 as significant. The final models are adjusted for the other variables included. Of note, age, education, and other demographic variables were not associated with stigma or discrimination, nor did they confound any of the associations with the variables included in the final model. Statistical analysis was conducted using StataSE 17.

Ethics

This study was approved by the Research Ethics Board of Health (REBH) in Bhutan (Ref. No. REBH/Approval/2019/051). Oral consent was obtained from participants.

Results

Table 1 provides descriptive statistics of this population. A total of 124 trans men were recruited. Participants were young, 48.0% aged 18–24 years, ranging from 18 to 37 years overall. All participants were assigned female sex at birth and currently identified as trans men. Historical terms for transgender persons in Dzongkha, the official language of Bhutan, were generally not used by participants of this study. Most participants (99.2%) were heterosexual, and all participants were born in Bhutan. The majority of participants (98.4%) had an education of middle secondary school and above, and 68.3% had an education level of high school and above. Among participants, 35.5% were living with a partner as if married, and 62.9% were single and never married. One-third (33.9%) held salaried jobs, one-third (33.9%) were students, 28.2% were unemployed, and 4.0% worked in entertainment jobs. Participants’ current residences were 65.3% urban and 34.7% non-urban with nearly half (48.4%) having migrated from non-urban to urban areas.

Table 1. Demographic characteristics of trans men in Bhutan, 2020 (N = 124).

Characteristics N %
Age group (years)
    18–24 59 48.0
    25–37 64 52.0
Sex assigned at birth
    Male 0 0
    Female 124 100
    Intersex, other, don’t know 0 0
Gender Identity
    Male 0 0
    Female 0 0
    Trans woman 0 0
    Trans man 124 100
    Don’t know, other 0 0
Sexual identity
    Straight, heterosexual 123 99.2
    Gay 0 0
    Bisexual 0 0
    Lesbian 0 0
    Transmen 1 0.8
    Other 0 0
Ethnicity
    Bhutanese 124 100
    Non-Bhutanese 0 0
Education
    No education 0 0
    Primary 2 1.6
    Middle secondary school (grade 7–10) 37 30.1
    Higher secondary school (grade 11–12) 79 64.2
    University 5 4.1
Marital status
    Living together, not officially married 44 35.5
    Single never married 78 62.9
    Divorced 2 1.6
    Widowed 0 0
    Other 0 0
Occupation
    Salaried 42 33.9
    Entertainment 5 4.0
    Student 42 33.9
    Unemployed 35 28.2
Region of birth
    Urban 23 18.6
    Non-urban 101 81.5
Current residence
    Urban 81 65.3
    Non-urban 43 34.7
Migration
    Non-urban to urban 60 48.4
    Urban to non-urban 2 1.6
    No migration 62 50.0
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*Categories do not always add up to the total due to missing data; percentages shown are among respondents.

Table 2 describes the stigma and discrimination experiences of trans men. The majority (85.5%) stated that many people know they are trans men. Concerning social networks, 51.2% knew more than 15 other trans men. More than half (58.9%) of participants reported often experiencing stigma due to being a trans man, while 3.2% reported never experiencing such stigma. In terms of experiencing discrimination when accessing health services because people thought or knew they were a trans man, 5.7% reported often, 41.9% sometimes, and 45.2% never experienced such discrimination. Most participants (94.4%) experienced verbal violence, 10.5% experienced physical violence, and 4.8% experienced sexual violence due to being a trans man.

Table 2. Stigma and discrimination experiences of trans men in Bhutan, 2020 (N = 124).

Question N* %
Do people know you are a trans man?
    No one knows this about me 1 0.8
    Only a few friends/families know 15 12.1
    Many people know 106 85.5
    Don’t know 2 1.6
How many other trans men do you know?
    1–15 60 48.8
    >15 63 51.2
Have you experienced stigma because people knew or thought you are a trans man?
    Often 73 58.9
    Sometimes 45 36.3
    Never 4 3.2
    Don’t know 2 1.6
Have you experienced discrimination when accessing health services because people knew or thought you are a trans man?
    Often 7 5.7
    Sometimes 52 41.9
    Never 56 45.2
    Don’t know 9 7.3
Have you experienced violence because people knew or thought you are a trans man? (Multiple responses allowed)
    None 7 5.6
    Verbal 117 94.4
    Physical 13 10.5
    Sexual 6 4.8
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*Categories do not always add up to the total due to missing data; percentages shown are among respondents.

Table 3 shows the prevalence of stigma and discrimination by different characteristics of trans men. Often experiencing trans-related stigma was significantly higher for individuals who were living with a partner as if married (77.3%, p = 0.002) compared to individuals who are single. By occupation, often experiencing stigma was higher among those who worked in entertainment (80.0%), were students (69.1%), or were unemployed (68.6%, p = 0.009). Often experiencing stigma was more frequent among trans men whose current residence was in an urban area (66.7%, p = 0.015). Experiencing any discrimination was higher among trans men who were living with a partner (65.9%, p = 0.002), with current urban residence (55.6%, p = 0.015), who migrated (61.3%, p = 0.002), and who knew more than 15 trans men (65.1%, p<0.001).

Table 3. Associations with stigma and discrimination among trans men in Bhutan, 2020 (N = 124).

  Often experienced stigma,
N = 73 (58.9%)		 Any discrimination in accessing health services, N = 59 (47.6%)
Variables p-value p-value
Age group (years) 0.353 0.948
    18–24 32 (54.2) 28 (47.5)
    25–37 40 (62.5) 30 (46.9)
Education 0.472 0.354
    Middle secondary and below 21 (53.9) 16 (41.0)
    Secondary school and above 51 (60.7) 42 (50.0)
Marital Status 0.002 0.002
    Living together, not officially married 34 (77.3) 29 (65.9)
    Single (includes divorced) 39 (48.8) 30 (37.5)
Occupation 0.009 0.263
    Salaried 16 (38.1) 15 (35.7)
     Entertainment 4 (80.0) 2 (40.0)
    Student 29 (69.1) 23 (54.8)
    Unemployed 24 (68.6) 19 (54.3)
Region of birth 0.104 0.369
    Urban 17 (73.9) 9 (39.1)
    Non-urban 56 (55.5) 50 (49.5)
Current residence 0.015 0.015
    Urban 54 (66.7) 45 (55.6)
    Non-urban 19 (44.2) 14 (32.6)
Migration 0.362 0.002
    Urban/non-urban migration 39 (62.9) 38 (61.3)
    No migration 34 (54.8) 21 (33.9)
Do people know you are a trans man? 0.191 0.172
    No one knows this about me 0 (0.0) 0 (0.0)
    Only a few friends/families know 8 (53.3) 10 (66.7)
    Many people know 65 (61.3) 49 (46.2)
How many other trans men do you know? 0.338
    1–15 33 (55.0) 18 (30.0) <0.001
    >15 40 (63.5) 41 (65.1)
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*Categories do not always add up to the total due to missing data, percentages are among respondents.

Table 4 shows independent associations for often experiencing stigma and experiencing any discrimination among trans men in Bhutan. Those who were living with a partner as married had 3.07 times the odds of often experiencing stigma as compared to those who did not live with a partner (95% CI 1.27–7.44). Those who were students or unemployed had 3.22 times the odds of often experiencing stigma as compared to those with paying jobs (95% CI 1.44–7.19). Trans men who had migrated experienced 2.42 times the odds of experiencing any discrimination in accessing health care compared to those who had not migrated (95% CI 1.08–5.39). Those who knew more than 15 trans men had 3.73 times the odds of experiencing any discrimination when accessing health services compared to those who knew fewer trans men (95% CI 1.69–8.26).

Table 4. Multivariate analysis: Independent associations with stigma and discrimination experiences of trans men in Bhutan, 2020 (N = 124).

Outcome Predictors Adjusted* odds ratio (95% confidence interval) p-value
Often experienced stigma Living with partner
Student/unemployed
Current urban residence		 3.07 (1.27–7.44)
3.22 (1.44–7.19)
2.19 (0.96–4.99)		 0.013
0.004
0.064
Experienced any discrimination in accessing healthcare Living with partner
Any urban/non-urban migration
Trans men’s social network >15		 2.11 (0.91–4.89)
2.42 (1.08–5.39)
3.73 (1.69–8.26)		 0.081
0.031
0.001
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*Adjusted for the other variables listed in each model.

Discussion

Our study measured very high levels of stigma, discrimination, and violence due to being trans male in Bhutan. Our data corroborate high levels of stigma and discrimination suggested by the few available studies of trans men worldwide [10–13,17]. Many of these studies were qualitative and therefore direct comparison to the prevalence found in our data is not possible. Nonetheless, a consistent pattern of high prevalence of stigma and discrimination is evident. For example, experiences of stigma were common in a study of trans men in Puerto Rico, with components described as structural, interpersonal, and individual [10]. Similarly, in Nigeria, trans men expressed frequent stigma when accessing HIV services for being transgender [11]. In this Nigerian trans male population, respondents specifically mentioned struggling with gender identity disclosure, facing reduced sensitivity when interacting with healthcare providers, and not receiving gender-inclusive HIV services [11]. Participants in a study with trans men in Uganda reported stigma related to disclosing their gender identity and HIV status, including at healthcare facilities, leading to decreased access to services [12]. A study in the United States found that trans men were less likely to seek medical care due to discrimination [13]. At least one quantitative study, from Peru, reported higher levels of discrimination experienced by trans men from healthcare providers (69.0%) than we found in Bhutan (47.6%) [17]. To our knowledge, our study is the first to measure stigma and discrimination among trans men in Asia. Also, to our knowledge, it is the largest study of trans men in Asia, with 124 participants.

Although the sample size was small in absolute terms, we were able to identify significant correlates of stigma and discrimination. For example, living with a partner was associated with higher odds of experiencing stigma and discrimination. As same-sex marriage is not yet officially recognized in Bhutan, marriage for transgender persons remains unclear. We therefore take the response of “living together” when asked about their marital status as a proxy for being married. We hypothesize that the association with stigma and discrimination may be due to the increased visibility a co-habiting couple may face in public. Current urban residence was also associated with experiencing higher levels of stigma and migrating to an urban area was associated with increased discrimination. We hypothesize a similar reason may explain these findings in that trans men in an urban area may be living more openly as transgender and therefore more easily targeted by stigma and discrimination. The finding that having more trans men in their social network being associated with increased discrimination may also support this increased visibility hypothesis; that is, being part of the community may entail higher visibility as transgender. Moreover, the questions themselves were phrased with the implication that the experienced occurred because people knew or thought they were trans men. However, because this study is cross-sectional, there may be a reversal of this cause and effect. That is, trans men experiencing stigma and discrimination may move to urban areas for greater anonymity, and they may live with their partner and seek out other trans men for increased safety or support after having faced stigma and discrimination. Our finding that trans men who were students or unemployed did not report higher levels of discrimination was unexpected because discrimination from academic and employment opportunities have been noted in previous studies of transgender persons [18,19].

Experiencing stigma and discrimination due to being trans men can also cause multiple adverse mental health effects. One study found that interpersonal stigma, which includes interpersonal violence and everyday stigma, was associated with poor mental health [20]. These researchers also found that experiencing everyday discrimination was associated with depression, anxiety, post-traumatic stress disorder, and self-injury in trans men. A Canadian study that investigated the mental health of transgender youth, including transmasculine youth, posited that high rates of mental health problems might be attributed to stigma and related social and familial struggles [21]. Another study in New Zealand found trans men had higher prevalence of anxiety and depression diagnoses than trans women [22]. The researchers attributed the findings to trans men experiencing additional stressors, including higher reported rates of sexual abuse, domestic violence, and discrimination when accessing healthcare and employment services. Trans men might also use substances as a way of coping with the stigma and discrimination they experience. One study found that 27.6% of trans men reported substance use as a coping technique for experiencing stigma [23]. Experiences of stigma and discrimination by transgender persons could also lead to eating disorders. A study of sexual and gender minority populations found transgender and gender non-conforming adults more likely to report current or past eating disorders compared to gay men [24]. Of note, other evidence finds trans men with protective factors to potentially mitigate mental health disorders. Such protective factors for trans men are being in a committed relationship, older age, increased resilience, and family connectedness [20–21]. Fostering these protective factors could provide increased support and benefit to trans men facing multiple levels of stigma and discrimination.

This study has limitations that must be noted. First, as mentioned above, the cross-sectional design does not allow for determining the temporal cause-and-effect relationships between correlations. Second, because the survey was brief, it included only a few questions on experiences of stigma and discrimination providing limited context and detail. We acknowledge the need for primary theoretical research on the context and measurement of stigma and discrimination for sexual and gender minority populations in Bhutan. Third, the representativeness of our sample is not known. We note that the young age of the sample is consistent with Bhutan’s age structure [25]. However, the proportions in our sample that are urban and with secondary education appear higher than among the general population. Whether this is true of all trans men or only for those whom we could reach and who were willing to participate in our study is not known. We highlight factors of our study that may strengthen inference. Recruitment was not conducted through clinics or services, as is often the case for studies of trans men [22,26,27]. Moreover, recruitment included hybrid methods that helped further diversify the sample by reaching trans men who are less visible (i.e., through peer referral) as well as those who may be less connected to peers (i.e., through online and physical venues). Although the sample size is small, 124 participants, it should be noted that this is estimated to constitute a large proportion of the reachable transgender population estimated at 0.06% of adult men in Bhutan [14]. Finally, we also note that our survey is one of the largest of trans men to date. We know of only one online-recruited survey of greater sample size [28] and one other peer-referral plus venue-based recruited survey of equal size [29], both predominantly of trans men living in the United States.

In summary, our data point to very high rates of stigma and discrimination experienced by trans men in Bhutan, in line with many other parts of the world [10–13]. These experiences appear associated with factors that increase their visibility in public where they may face multiple contexts for stigma and discrimination, including when seeking health services. Our data speak to the need to strengthen anti-discrimination legislation to include gender identity and sexual orientation and recognize committed partnerships. While dismaying to see such high levels of physical and emotional violence directed at this community, we believe documentation of their high prevalence can help advocate for these policies and laws to protect Bhutanese trans men to make their lives healthier and happier.

Data Availability

Data cannot be shared publicly because we and our IRB have ethical concerns with releasing our study data publicly due to the small numbers of transgender persons in Bhutan, the high likelihood that sharing the primary data may expose individual participants, and the possible harm that might befall participants if exposed. We appreciate that deidentification of a dataset usually means that participants cannot be identified individually. However, in the setting of our study and our sample size, even a deidentified dataset presents a high risk of revealing a participant’s identity. Such data would effectively expose participants or could be perceived by the participants as being exposed. This type of scenario occurs in too many instances to safely make public the primary data. Requests for data will have to be considered on a case-by-case basis with extreme caution in what can be released to avoid exposing participants. Address requests for data access to the chairperson of the Research Ethics Board of Bhutan, Dr. Nezang Wangmo (or their successor) at: REBH, Ministry of Health, Royal Government of Bhutan, PO Box 726, Thimphu, Bhutan. Attention: REBH Secretary, Tel +975-2-322602, msgurung@health.gov.bt or tashidema@health.gov.bt.

Funding Statement

This study was funded by the Royal Government of Bhutan Ministry of Health (REBH/Approval/2019/051), which supported LK, KK, TTb, TTs, and TG. Support for VS, AX, TYZ, and WM was provided by The National Institute of Mental Health (R25 MH119858). The funders had no role in study design, data collection, analysis, decision to publish, or preparation of the manuscript.

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Decision Letter 0

Ricardo de Mattos Russo Rafael

20 Apr 2023

PONE-D-23-07072Experiences of Stigma and Discrimination Against Transgender Men in BhutanPLOS ONE

Dear Dr. Saxena,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Ricardo de Mattos Russo Rafael, Ph.D.

Academic Editor

PLOS ONE

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Additional Editor Comments (if provided):

Dear authors,

Firstly, congratulations on your manuscript. After a thorough analysis of the material, the reviewers have provided important and commendable feedback on the study. However, despite the excellent execution mentioned by the reviewers, the final decision is "minor revision".

For the publication of this manuscript, it is essential to clarify the theoretical and conceptual aspects indicated in the reviewers' evaluation and, above all, to complement the description of the control variables used in the multiple regression. There is still doubt about the measurement of the variable "stigma experience," which I consider essential to be clarified, as well as improvements in the text that will certainly add value to the study.

Even though I understand the difficulties in disclosing the database, it is essential that the authors review the guidelines of Plos One. In addition to not identifying the participants, in some cases, it is possible to hide potential variables that may reveal identities. However, note that it is not acceptable for the authors to be solely responsible for ensuring data access by the journal's guidelines.

Upon resubmitting your revised manuscript, please upload the minimal underlying data set of your study as Supporting Information files or to a stable, public repository, and include the relevant URLs, DOIs, or accession numbers in your revised cover letter. For a list of acceptable repositories, please refer to http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please refer to our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. I reiterate that it is not acceptable for the authors to be solely responsible for ensuring data access. Therefore, if it is impossible to meet the above guidelines, it is essential that the authors fulfill this request.

Best Regards,

Ricardo de Mattos Russo Rafael, PhD

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review your manuscript. This highly important and well-conducted study addresses an understudied population: Asian transgender men. I have just a few suggestions aimed at improving the manuscript’s quality.

INTRODUCTION: Is it possible to include one brief paragraph describing the reality for LGBTQ+ persons in Bhutan? Is it legal to be openly queer? Does Bhutan recognize same-sex marriage? LGBTQ+ people can adopt kids, have legal recognition as a couple etc? Do trans persons have easy access to hormone therapy, sex reassignment surgery, changing name/gender in official documents etc.?

METHODS, measures: Why did the authors dichotomize ‘stigma experience’ and ‘discrimination’ in a different way (“often” vs. “sometimes/never” // “often/sometimes” vs. “never”)

RESULTS: what does it mean to have an occupation in “entertainment”? Does it include sex work?

RESULTS, table 4: Multivariate analysis was controlled by which variables?

DISCUSSION, first paragraph: There is no need to cite (again) your results.

DISCUSSION, first paragraph: “Our data corroborate high levels of stigma and discrimination suggested by the few available studies of trans men worldwide.” Please cite those studies after this sentence.

DISCUSSION, first paragraph: "Respondents specifically mentioned (…)” Respondents of which study? Please cite again.

DISCUSSION, first paragraph: “At least one quantitative study, from Peru, reported higher levels of discrimination experienced by healthcare providers (…)” The sentence is confusing; this Peruvian study was conducted with transgender men who were healthcare providers?

DISCUSSION, second paragraph: This sentence is also confusing, I’m not sure what the authors wanted to state here: “The finding that trans men who were students or unemployed did not report higher discrimination was unexpected as discrimination from academic and employment opportunities have been previously noted in studies of transgender persons.”

I look forward to seeing the manuscript published!

Reviewer #2: The manuscript presents the results of a pioneering study conducted among transgender men in Bhutan. All methodological procedures are appropriate for the population and sample. However, there is a conceptual imprecision, as the terms "stigma" and "discrimination" are used as categorical variables without clear definitions. The text does not specify what the authors mean when they ask "have you ever experienced stigma" - is this about experiences in general, as a transgender man? Additionally, in the next question, the term "experience discrimination" is used in the context of health services, which is clearer to readers than "experience stigma." The latter is typically used in passive voice to describe a feeling or perception of being stigmatized. Therefore, I kindly urge the authors to provide proper definitions and contextualization for these terms. Any translation issues should also be addressed.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Monica Malta

Reviewer #2: Yes: Helena Maria Scherlowski Leal David

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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PLoS One. 2023 Jul 20;18(7):e0287745. doi: 10.1371/journal.pone.0287745.r002

Author response to Decision Letter 0

1 Jun 2023

Dear Dr. Ricardo de Mattos Russo Rafael,

We are thrilled that you and the reviewers found merit in our study with trans men in Bhutan and that PLOS ONE will consider the publication, pending satisfactory revisions. We have carefully considered all of the reviewers’ and editor’s comments and have done our best to address them. The following is a point-by-point response to the issues raised and revisions to the manuscript.

Dear authors,

Firstly, congratulations on your manuscript. After a thorough analysis of the material, the reviewers have provided important and commendable feedback on the study. However, despite the excellent execution mentioned by the reviewers, the final decision is "minor revision".

Response: Thank you for the encouraging words and the decision of “minor revision”.

For the publication of this manuscript, it is essential to clarify the theoretical and conceptual aspects indicated in the reviewers' evaluation and, above all, to complement the description of the control variables used in the multiple regression. There is still doubt about the measurement of the variable "stigma experience," which I consider essential to be clarified, as well as improvements in the text that will certainly add value to the study.

Response: We appreciate the comment and the complexity of measuring stigma. Added complexities include how such measures are translated into Dzongkha and interpreted by respondents. This area is well worth primary, qualitative, theoretical research in the context of Bhutan. However, as a rapid survey that was the first of its kind, our measure should be considered a broad indicator that aligns with self-perceived/evaluated stigma. We have clarified in the text of the revised manuscript in the Methods section providing the translation into English from Dzongkha. We also add the related limitations to the Discussion section and the need for more in-depth, contextual research. We point to references in the literature stigma frameworks with which we feel our indicator aligns.

With respect to the control variables in the multivariate regression, please see our comments below in response to reviewer #1.

Even though I understand the difficulties in disclosing the database, it is essential that the authors review the guidelines of Plos One. In addition to not identifying the participants, in some cases, it is possible to hide potential variables that may reveal identities. However, note that it is not acceptable for the authors to be solely responsible for ensuring data access by the journal's guidelines. Upon resubmitting your revised manuscript, please upload the minimal underlying data set of your study as Supporting Information files or to a stable, public repository, and include the relevant URLs, DOIs, or accession numbers in your revised cover letter. For a list of acceptable repositories, please refer to http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized. Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please refer to our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. I reiterate that it is not acceptable for the authors to be solely responsible for ensuring data access. Therefore, if it is impossible to meet the above guidelines, it is essential that the authors fulfill this request.

Response: We have re-read the policy; we agree with the principles of openly verifiable data that is not the decision of the investigators. Unfortunately, the protocol approved by Bhutan’s IRB explicitly says only the investigators or their designated supervisees are permitted access to the full data. In addition, the approved informed consent explicitly indicated who would have access to the data and this was what participants agreed to. For readers who want to know the numbers behind means, medians, and associations, we are available to provide those statistics and numbers without the possibility of identifying individuals. We appreciate that PLOS ONE prioritizes the safety of research participants and the ethical guidelines of the country of the data’s origin.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

Response: As noted above, we understand and do agree with the importance and principles of open data policies and that only rare exceptions are made. Please see the above response to the editor.

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review your manuscript. This highly important and well-conducted study addresses an understudied population: Asian transgender men. I have just a few suggestions aimed at improving the manuscript’s quality.

Response: We are glad that you recognize the importance of this population and that the health needs of trans men are understudied.

INTRODUCTION: Is it possible to include one brief paragraph describing the reality for LGBTQ+ persons in Bhutan? Is it legal to be openly queer? Does Bhutan recognize same-sex marriage? LGBTQ+ people can adopt kids, have legal recognition as a couple etc? Do trans persons have easy access to hormone therapy, sex reassignment surgery, changing name/gender in official documents etc.?

Response: We have updated the background text to include the requested context. According the UNAIDS and Bhutan’s legal codes, there is no criminalization of transgender people, sex work, or same-sex sexual acts in private [11]. Bhutan’s constitution protects transgender persons for acts such as rape, domestic violence, and sexual harassment in the workplace regardless of gender. However, laws do not explicitly protect LGBTQ+ individuals from discrimination on the basis of sexual orientation, gender identity, and gender expression. In addition, there are no explicit legal rights for transgender persons to access gender-affirming care, marry, or change government identity documents. Pride Bhutan and Queer Voices of Bhutan, two civil society organizations advocating for LGBTQ+ rights, are not legally registered organizations [12]. It should be recognized that the legal and cultural situation in Bhutan is rapidly changing [ref].

METHODS, measures: Why did the authors dichotomize ‘stigma experience’ and ‘discrimination’ in a different way (“often” vs. “sometimes/never” // “often/sometimes” vs. “never”)

Response: We clarify in the revised text the reason for these different dichotomizations. The different dichotomizations were based on the different distributions of these variables. “Often” reporting stigma was common, while any stigma experience was reported by greater than 95% of trans men, therefore there were too few to model correlations with reporting “any” vs. “never”. In contrast, the frequency of “often” experiencing discrimination was rare and too infrequent to model, while any experience (often or sometimes) was more balanced and therefore permitted modeling correlations.

RESULTS: what does it mean to have an occupation in “entertainment”? Does it include sex work?

Response: We added clarification of “entertainment” as an occupation in the revised Methods. The occupations labeled as “entertainment” included employment in bars, karaoke clubs, and “drayangs” where dances are performed for customers [16]. These occupations do not explicitly include sex work, although some persons working in such venues might engage in sex work or transactional sex on the side. In the study, few (4.0%) trans men worked in such venues. Although we note that bivariate analysis indicated this type of employment was apparently associated with a higher experience of stigma, the finding did not hold in multivariate analysis.

RESULTS, table 4: Multivariate analysis was controlled by which variables?

Response: We have clarified in the revised Methods and Table 4 which variables were controlled for. Namely, the adjusted ORs are controlled for by the other variables listed for the models. Notably, age, education, and other demographic variables were not associated with stigma or discrimination, nor did they confound the other associations included in the final models. The revised Methods section further clarifies the selection of variables for inclusion in the final multivariate analysis.

DISCUSSION, first paragraph: There is no need to cite (again) your results.

Response: Thank you, the redundancy has been eliminated.

DISCUSSION, first paragraph: “Our data corroborate high levels of stigma and discrimination suggested by the few available studies of trans men worldwide.” Please cite those studies after this sentence.

Response: We appreciate your attention to detail. These studies have been added (citations 10-13,17)

DISCUSSION, first paragraph: "Respondents specifically mentioned (…)” Respondents of which study? Please cite again.

Response: Thank you, this unclear detail has been corrected. Citation 11 has been added to the statement.

DISCUSSION, first paragraph: “At least one quantitative study, from Peru, reported higher levels of discrimination experienced by healthcare providers (…)” The sentence is confusing; this Peruvian study was conducted with transgender men who were healthcare providers?

Response: This was discrimination faced by trans men from healthcare workers. This has been corrected.

DISCUSSION, second paragraph: This sentence is also confusing, I’m not sure what the authors wanted to state here: “The finding that trans men who were students or unemployed did not report higher discrimination was unexpected as discrimination from academic and employment opportunities have been previously noted in studies of transgender persons.”

Response: Thank you, we have rewritten the sentence to be clearer.

I look forward to seeing the manuscript published!

Response: We agree!

Reviewer #2: The manuscript presents the results of a pioneering study conducted among transgender men in Bhutan. All methodological procedures are appropriate for the population and sample.

Response: We appreciate the recognition of the importance of the study and the appropriateness of the methods for this population and context.

However, there is a conceptual imprecision, as the terms "stigma" and "discrimination" are used as categorical variables without clear definitions. The text does not specify what the authors mean when they ask "have you ever experienced stigma" - is this about experiences in general, as a transgender man? Additionally, in the next question, the term "experience discrimination" is used in the context of health services, which is clearer to readers than "experience stigma." The latter is typically used in passive voice to describe a feeling or perception of being stigmatized. Therefore, I kindly urge the authors to provide proper definitions and contextualization for these terms. Any translation issues should also be addressed.

Response: We agree with these distinctions and have revised the text accordingly:

Translated from the Dzongkha language, the question about stigma was generally asking about experience as a trans man, namely, “Have you experienced stigma because people knew or thought you are a trans man?” The question about discrimination referred to experience with accessing healthcare, namely, “Have you experienced discrimination when accessing health services because people knew or thought you are a trans man?”

As noted above and in the limitations, our measures of these perceptions and experiences are brief indicators and we concur with the need for primary theoretical research in this area.

We have also carefully reviewed the journal requirements and formatting as directed. In the course of revision, we also identified and corrected minor typos. With these changes, we feel the manuscript has been greatly improved. We thank the reviewers for their time and attention and hope for a favorable response from PLOS ONE.

Sincerely,

Vinita Saxena on behalf of the authors

Attachment

Submitted filename: PLOS Bhutan Stigma Trans Men Response Letter 2023-05-30.docx

Click here for additional data file. (28.6KB, docx)

Decision Letter 1

Ricardo de Mattos Russo Rafael

13 Jun 2023

Stigma and Discrimination Against Transgender Men in Bhutan

PONE-D-23-07072R1

Dear Dr. Saxena,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Ricardo de Mattos Russo Rafael, Ph.D.

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: All the conceptual issues and imprecisions were adequately addressed by the authors, and the manuscript is ready to be published.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Monica Malta

Reviewer #2: Yes: Helena Maria Scherlowski Leal David

**********

Acceptance letter

Ricardo de Mattos Russo Rafael

12 Jul 2023

PONE-D-23-07072R1

Stigma and Discrimination Against Transgender Men in Bhutan

Dear Dr. Saxena:

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Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    Attachment

    Submitted filename: PLOS Bhutan Stigma Trans Men Response Letter 2023-05-30.docx

    Click here for additional data file. (28.6KB, docx)

    Data Availability Statement

    Data cannot be shared publicly because we and our IRB have ethical concerns with releasing our study data publicly due to the small numbers of transgender persons in Bhutan, the high likelihood that sharing the primary data may expose individual participants, and the possible harm that might befall participants if exposed. We appreciate that deidentification of a dataset usually means that participants cannot be identified individually. However, in the setting of our study and our sample size, even a deidentified dataset presents a high risk of revealing a participant’s identity. Such data would effectively expose participants or could be perceived by the participants as being exposed. This type of scenario occurs in too many instances to safely make public the primary data. Requests for data will have to be considered on a case-by-case basis with extreme caution in what can be released to avoid exposing participants. Address requests for data access to the chairperson of the Research Ethics Board of Bhutan, Dr. Nezang Wangmo (or their successor) at: REBH, Ministry of Health, Royal Government of Bhutan, PO Box 726, Thimphu, Bhutan. Attention: REBH Secretary, Tel +975-2-322602, msgurung@health.gov.bt or tashidema@health.gov.bt.

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