Living a Dual Life : Multiplicity of Sexual Risks among Men who have Sex with Men ‘ and ’ Women in Bhutan

Among bisexual MSM also called “men-on-the-down-low”, sexuality driven risks stimulate spectrum of vulnerabilities for both genders. Pressure to marry may drive a greater proportion of MSM to have female partners, indicating the potential for bridging HIV transmission. However, these interactions are poorly understood and measurement of potential risk to MSM and their female partners is inconsistent especially in conservative societies like Bhutan, where sex is tabooed and homosexuality is restricted even in programmatic discussions.


Background ISSN: 2454-499X
Study aims to describe the overlapping male and female partnerships of MSM-SW in the view of multiplicity of risk for HIV.Basic data used in this paper has been collected as a part of Mapping and Size Estimation of MSM in Bhutan during 2012 conducted by National HIV/AIDS and STI Control Program, Royal Government of Bhutan with support from UNDP.Bivariate and Multivariate techniques were applied on the data and the analysis was carried out in three stages.Bisexuality among down-low men in Bhutan is rampant as nearly three-fourths of MSM having sex with a male in the last 6 months also reported sex with a female partner during the same period.Among those who didn't use condom in last homosexual encounter, over two-fifths reported condom use in the last sex with female partner.However, considerably lower prevalence of consistent condom use (30%) among those having sex with multiple female partners in the last 6 months is a marker of multiplicity of the STI/HIV risk.MSM "on-the-down-low" are vulnerable to STI/HIV not only due to their MSM behavior but overlapping risk of unprotected sex with multiple female partners enhancing the multiplicity of risk.Role of MSM-SW in HIV transmission is a more complex issue than depictions of men as sexual predators and women as uninformed victims.MSM programs should envisage beyond homosexuality and address bisexuality regardless of their sexual identity as threat clouding prevention efforts by increasing thrust of programs designed for MSM adopting network-based approach.
The most generic definition of the term "down-low" is "to keep something private".The term is used to describe the behavior of men who have sex with other men (MSM) as well as women and who do not identify themselves as bisexual.Down-low has most often been associated with African American men.This theoretical conception draws attention to the concept of a transmission bridge between bisexual men and heterosexual women [1].This phenomenon makes the researchers think out of box and draw their attention to questions like: Are bisexually active men more likely than other groups of men to be HIV (Human Immunodeficiency Virus) infected?Do men on the down low engage in fewer or more sexual risk behaviors than men who are not on the down low? and finally, what effect this behavior has on the vulnerabilities of female partners of these men?
The phenomenon of Men on the "down-low" has gained considerable attention from both mainstream media and public health official of west in the past few years but remains quite disregarded in east, not because it does not exist but due to the phenomenon being clouded by the overtly stress on the MSM activity of these men.The leading cause of HIV infection for both black men and women was sex with a man [2].The behaviors associated with being on the down-low are not specific to black men, where the phenomenon was primarily observed, and men of other races and ethnicities also engage in homosexual sex and do not disclose their homosexual behavior to female partners.As a result, heterosexual transmission of HIV is a growing problem for women, but many women do not know how their partners acquired HIV.The current risk classification hierarchies in most countries rely on self-reported risk behaviors at the time of HIV testing but the validity of these self-reported risk behaviors are not assessed [3].
Several investigators have raised the possibility that men who have sex with men and women may serve as a "bridge" for infection between these groups.Despite these concerns, the behavior and characteristics of HIV-infected MSM/W has received relatively little attention [4].
In Bhutan, till date 272 people are living with HIV.Although Bhutan is a low prevalence country there are several factors that are likely to contribute to higher risk and vulnerability for HIV such as sixty percent of the country's population is below 25 years of age.The increasing numbers of MSM and associated high risk behavior are emerging as a major driver of epidemic in Bhutan and the down low phenomenon is fast catching up in the East and Bhutan is no different [5].Not much is known about the existence, number, the extent of their sexual behaviors and its impact on the STI/HIV epidemic in the country, the limited literature shows that number of accessible MSM in the country is increasing.
Homosexuality is a taboo subject in Bhutan and thus invisibility of Most at Risk Populations remains the core challenge in mitigating the epidemic.Penal Code 2004 Code 213 criminalizes sodomy or any other sexual conduct that is against the "order of nature".Penalties include a prison sentence of up to one year.In part because there is no evidence that Penal Code 2004 Code has ever been enforced, a recent UNDP report categorizes Bhutan's legal system as "moderately prohibitive" [6].Given prevailing conservative beliefs in Bhutan with regard to human sexuality, it is reasonable to expect that MSM face barriers to accessing sexual health services in Bhutan [6,7].At time of writing, there were criminal sanctions for consensual sex between male adults [6].Bhutan's HIV response continues to be led by the 2004 Royal Decree on HIV Prevention.In 2005, the Fifth King, His Majesty Jigme Khesar Namgyel Wangchuck, advocated for abstinence and urged Bhutan's youth to "use their strength of character to reject undesirable activities" [8].
It is quite evident from the recent advancements that although homosexuality is a taboo subject in Bhutan, but younger generations are thought to be more accepting [7].Little is known about the nature of same-sex sexual activity in Bhutan and even the educated are ignorant about the fact that there is a gay population in Bhutan.Anecdotes exist of sex between men occurring in army barracks, prison cells, and monk dormitories [7,9].Till date, there is very little published information about the MSM population in Bhutan [10].There are no known community-based responses to HIV among MSM in Bhutan and known national MSM networks are non-existent in country [11].A recent behavioral assessment in two major towns found evidence of high-risk behavior among key affected populations, including MSM [9,12].
Further, in the conservative society of Bhutan, where enormous stigma is attached to sex and sexuality, the homosexuality attracts harsher and even violent societal resistance and familial unacceptance.Literature shows that although almost all MSM tend to indulge in relationships with multiple male partners and active anal sex, due to the stigma attached to being an MSM, this population keep their identity concealed and in order to do so they adopt a dual life leading to bisexuality.Bisexuality enables these men to lead a dual life of secrecy, without the knowledge of their female partner and many times their family.These men live a life of straight men.Commercial and non-commercial sexual ties with male as well as with females results in an elevated risk of HIV transmission.Under these circumstances this group acts as a potential bridge transmitting the infection from homosexual network to heterosexual networks through their female partners including wives and girl friends.
Findings from a study conducted in Mumbai, India substantiate the above statements.It reveals that almost all men included in the study reported sex with women; additionally, 13% also reported having sex with other men, 13% reported sex with Hijras (male-to-female transgenders), and 11% had sex with all 3 genders.Men who had sex with men and/or Hijras as well as women, reported having greater numbers of partners, including female sex workers (FSW), and were more likely to engage in insertive anal and oral sex with women.The prevalence of HIV was higher among men having sex with Hijras (14%) or with all 3 genders (13%) than among men having sex with men and women (8%).A high proportion of men who attend STI (Sexually Transmitted Infection) clinics in Mumbai are behaviorally bi-or tri-sexual and have multiple partners with whom they engage in risky sex [13].
Such overlapping of homosexual and heterosexual intercourse and sexual risk behaviors among MSM translates into a range of STI/HIV vulnerabilities for both their male as well as female partner's health.These multiple sexual risks stimulate variety of repercussions on the well being of both the genders.Yet, majority of the Targeted Interventions (TIs) and Prevention Programs principally focus on cutting male-to-male HIV transmission and risk reduction in homosexual sex disregarding the risk that women partner of these MSM face due to heterosexual intercourses.Under this backdrop it becomes essential to gain more clarity on the role that MSM play in shaping the STI/ HIV vulnerability of their female partners, i.e. commercial (female sex workers), casual (girl friends) and regular (wives).
It may be well argued now that among bisexual MSM also called "men-on-the-down-low", sexuality driven risks bring about wide array of vulnerabilities for both genders.Pressure to marry may drive a greater proportion of MSM to have female partners, indicating the potential for bridging HIV transmission.However, in context of south-east Asia and Bhutan in particular, these interactions are poorly understood and measurement of potential risk to MSM and their female partners is inconsistent especially in conservative societies like Bhutan where sex is tabooed and homosexuality is not given social sanction.This paper attempts to map the overlapping sexual risks among MSM that elevates their women partners' vulnerability to STI/ HIV.Study aims to describe the overlapping male and female partnerships of MSM-SW in the view of multiplicity of risk for HIV.Basic data used in this paper has been collected as a part of Mapping and Size Estimation of MSM from 7 districts in Bhutan during 2012 conducted by National HIV/AIDS and STI Control Programme, Royal Government of Bhutan.Time location cluster approach was applied for the study.This study used participatory approach in which the community members took part in the entire process of field work.Involvement of members from MARP community made the process more inclusive, empowering and useful in enhancing the quality of the data.Local and qualified community members from the MARPs were trained to function as field researchers.The data was collected through canvassing structured questionnaire as a part of behavioral study with the help of a well trained team consisting of social scientists, as well as members of the community.To enable maximum reach to the population, social mapping of key populations was done by adopting a "geographical approach" in which "population of target group", "risk activities" was defined clearly, and then locations where these activities took place were identified to capture hidden population.To get a comprehensive picture of vulnerabilities and also understand the core issues that were critical for the groups, a semi-structured survey instrument was used to collect information on the self-reported sexual behavior and partnership.An informed oral consent was obtained from all the MSM respondents recruited for the survey.The data used in this study has been collected from 7 districts namely, Chukha, Samdrup Jongkhar, Bumthang, Wangdue, Punakha, Sarpang-gelephu, Thimphu in Bhutan during 2012.The total of 293 MSM were interviewed for the collection of behavioral data in these seven districts.The quantitative data collected from the field was cleaned and analyzed using SPSS.

Data and Methods
The proposal of the study was approved by the Ethical Review Committee of Department of health, Government of Bhutan.
To get insights into the bisexuality driven overlapping sexual risks influencing STI/ HIV vulnerability of female partners of these men, the analysis was carried out in three stages by applying Bivariate and Multivariate techniques.The section I of the analysis dealt with sexual behavior in homosexual relations.Section II discussed about the bisexuality of MSM and the risk taking behavior with heterosexual partners.Section III highlighted the possible correlations in homo and heterosexual risky behaviors with an aim to find out the possible pathways through which homosexual practices shaped heterosexual practices.We have applied Logistic regression giving adjusted effect of different predictors included in the model.

Analysis Plan
Based on the demographic and socio-economic data collected from MSM, a profile of the population has been identified.The profile of the study population enables to understand the behavioral aspects more clearly, especially when dealing with such high risk and sensitive population.According to the age distribution, it is seen that majority of MSM belong to age groups 20-29 and 30 and above.However, there isn't much difference in proportion of MSM in both these categories as 48 percent and 45 percent MSM fall in each category respectively (Table 1).Further, only 19 (6.5%) out of 293 respondents were from age group below 20.Educational attainment of these MSM portrays that, more than half (56%) had completed 10 or more years of schooling.On the other hand, little less than one-fifth had no formal schooling.Another 15 percent reported to have 6-10 years of schooling and one-tenth reported up to 5 years of education.The marital status is very important in case of MSM population because of their sexual orientation and stigma attached to it.It is seen that nearly two-thirds of MSM in Bhutan is currently married and hence they have adopted bisexuality as their sexual orientation, which may enhance the HIV vulnerability for themselves as well as their spouses.Migratory status of MSM reveals that they are majorly (90%) migrants.

No. of MSM (unweighted)
An analysis of initiation of homosexuality reveals initiation of anal activity at almost the internationally accepted age of adulthood with 21.3 being the mean age at first anal sex for this group of MSM.This finding is reinforced by the distribution of mean age at first anal sex in various background categories, which lies almost around the mean age with no specifically prominent outlier.The mean duration of involvement in the anal sex is 6.4 years.This duration is less for those MSM who have more than 10 years of education (5.2), who are un-married (4.1) and are natives (5.3).The mean duration is remarkably high among illiterate MSM (11.0) and those who are ever married (8.8) as shown in Table 2.
Homosexuality, homosexual behavior and profiling of risky behavior Further, analysis of partnership with male partner in terms of mean number of partners during last 6 months revels that mean number of non-commercial partner in last 6 months is 2.9.The mean is higher for those who are in age group 20-29, highlighting the fact that the partner exchange rate among this population is high.Number of non-commercial partners is also high among those who are illiterate, are never married and are migrant as compared to their counterparts.It was surprisingly also high for the MSM with 6-10 years of education.The coital frequency among this population was assessed by gathering information about the number of intercourses with a 30 days recall period and results show that over one-fourth of MSM reported to have coitus frequency of 3 to 9 times in last 30 days prior to the survey.Further, two-thirds, of the respondents reported the coital frequency of 1-2 times in last 30 days with their male partner.On the other hand, it is important to note here that one in ten MSM reported coital frequency of more than 10 times in last 30 days with the male sexual partner.
Further, in order to get insights into the risky behavior in these homosexual partnerships, we analyzed multi-partner behavior in terms of no. of male sexual partners the respondent had sex with in last 6 months prior to the survey.We also analyzed use of condom and lubricant in the last sex.It is evident from Table 3 that among those who reported to have sex with any male noncommercial partner in the last six months 43.5 percent of them have had 1-2 partners, 33 percent have had sex with 3-5 partners and 24 percent have had sex with 6 or more partners.The multi-partner behavior seems to be more pronounced among older MSM since larger proportion of them aged 30 years and above reported 6 or more partners, whereas, 71 percent of MSM below the age of 20 reported only 1-2 partners in last 6 months.One-third ever married MSM had 6 or more male sexual partners in the last 6 months as compared to 18% never married MSM.Similarly, relatively larger proportion of ever married MSM reported 1-2 non-commercial partners in the last 6 months than their never married counterparts.Journal of AIDS and HIV Infections It is evident from table 3 that 83 percent MSM used a condom and 19 percent used lubricant in their last non-commercial MSM activity.It is worth mentioning that on both the indicators of safe sexual encounters in case of MSM i.e., use of condom in the last sex and use of lubricant in the last sex, practice do not vary significantly across different categories of background characteristics, except for age group 20-29, which portrays comparatively lower use of condom as well as lubricants among MSM with noncommercial partner.One possible reason may be less exposure and access to condom and lubricants among MSM in the middle age group, which may also be the age when they enter the professional and family life.
The main drivers of HIV epidemic today are High Risk Group (HRG) population transmitting virus through heterosexual route.The channels of virus transmission include FSW and MSM transmitting to their male clients and those clients infecting their female partners are well versed but interactions between HIV epidemics in MSM and heterosexual populations are not well understood [14].For most of MSM, social and cultural pressure enforces bisexuality and demand from family and society forces them into the institution of compulsory marriage making the sexuality of these men complex and taxing for the health of both the partners and also for the STI/HIV prevention efforts.To understand the complexity of issues and tease out the factors affecting the behaviors, it is important to first understand the extent of bisexuality and risk behavior in the heterosexual encounters.The results from the present study reveals that down-low is not uncommon as a very high prevalence of bisexuality is observed in this group with 93 percent of MSM reporting to ever have had sex with women.At the same time, it is observed that there is a high partner mixing and change even with the female partners among these men.The mean number of female partners in the last 6 months was 3.7, which is quite high considering the fact that these men identify themselves as MSM (Table 4).

Bisexuality among MSM and profiling of risky behavior in heterosexual sex
Further, in order to study the extent of bisexuality against the background characteristics, it was seen that the proportion of MSM who reported to ever had sex with women is higher among MSM aged 30 or above, have at least 5 years of education, married, migrants and those who reported to have coital frequency of 1-2 encounters with non-commercial male partner in last 30 days.
Logistic regression revels that MSM between the ages of 20-29 are 10.7 (p<0.05)times more likely to ever have had sex with a woman.Further those who are educated for upto 5 years are 3.3 (p<0.01)times more likely to have had sex with women.Migration is also playing a significant role in determining the relationship with women as those MSM who are natives are 97% (p<0.05) less likely to have sex with female.The findings reinforce the fact that bisexuality in this group is pronounced.Not only bisexuality, multi partner behavior is also marked and the mean number of female partner is very high.These female partners can be both intimate partners or commercial partners or the mix of both.In any case, the chances of transmission of virus to low risk female population cannot be overlooked.Also, it is seen that the men having higher no. of MSM non-commercial intercourse are exhibiting higher no. of female partners, an issue requiring immediate attention of interventionists (Table 5).It is evident that among those who reported to have ever had sex with a female partner showed a uniform distribution in the categories based on the number of partners in last 6 months.The percentage of MSM reporting to have <2 partners or 2-3 partners or 4 and above partners was nearly one-third in each category.However, the pattern of variation in proportion of MSM having sex with number of female partners shows a positive association by their age when <2 partners are concerned but the opposite is true when 4 and above partners were concerned.More than two-fifths of never married MSM had 4 and above female sexual partners in the last six months prior to the survey as compared to 31% MSM.

Ever had sex with a female Mean number of female sexual partners
Regarding the safe sexual practices, it is observed that condom use in their last sex with a female partner is low (64 %) among the MSM (Table 5).However, this proportion is significantly higher in case of unmarried MSM (79%) as against married MSM (58%).There is inverse relationship between proportion of MSM using condom in their last sexual encounter with a female partner and their current age.Percentage of MSM using condom in last sex with female partner is 75 percent among those below age 20 which declines to 56 percent among those aged 30 and above.Interface of these two observations portrays that there is low condom use in the last sexual encounter with spouse and hence the exiting sexual practices and condom use among MSM in Bhutan have a potential to enhance HIV vulnerability among general population in the country.At the same time, MSM community should be motivated enough to use protection while having sexual encounter with spouse or living partner.
Bisexuality driven overlapping sexual risks influencing heterosexual women's vulnerability to STI/ HIV Bisexuality may or may not be portrayed out of choice for this socially marginalized group.Indulgence in heterosexual commercial sex mostly can be reasoned as a byproduct of risk taking attitude and sexual experimentation and fantasies.Non-commercial sex many times can be forced or socially demanded.Many MSM may have been forced into a marriage with a girl, forced into sex without condoms for babies which results in many women being infected due to the husbands sexual practices with other multiple men [15].Many factors including the extent of homosexual behavior may be operating beneath the behavior that a MSM may be generating towards his women partner.In the light of above argument, to achieve the third objective a bivariate analysis of condom use with non-commercial male partner was done against condom use with female partners.MSM who reported condom use with non-commercial male partner in last sex exhibited a positive relationship with condom use with female partner also.90 percent MSM who used condom with non-commercial male partner also reported to use condom with female partner.Also a large proportion of MSM (57%) reported not to use condom with either non-commercial male or any female partner.Interestingly, among those who reported not to use condom with commercial male partner, more than two-fifths reported to use condom with their female partner.The condom use practice of this group is further analyzed using consistent condom use with female partner.Table 6 also reveals that among those MSM who reported condom use in last sex with male partner, nearly half reported using condom with female partner most of the time and 30 percent reported using condom all the time.On the other hand, among those MSM who did not use condom in the last sex with the male partner, around 43 percent reported never using condom with female partner.Journal of AIDS and HIV Infections

Discussion and Conclusions
The results from the present study reveal that down-low is not uncommon, although, it is hidden in the society.The fact that it is often unrevealed and stigmatized makes it more arduous to the programmers and public health practitioners to deal with.Our data support other studies across the world that has observed that a large proportion of MSM are married.Social pressures may lead many MSM to marry and have children despite their sexual preference for men.A very large proportion of MSM reporting being sexually active with females underlines the rampant bisexuality and sexual overlap among MSM of Bhutan.Further, almost half of MSM below age 20 and two-fifths among age 20-29 reported to have sex with 4 or more female partners in the last 6 months.Even among married this prevalence is 30 percent.These findings clearly bring out the level of vulnerabilities the female partners of these MSM face.These women are an important part of the entire convoluted web of HIV and STI vulnerability and mostly are at the receiving end in this complex transmission mesh.In order to work for this group, interventions need to overcome the hurdle of reaching the wives of these MSM who are mostly unaware of their husbands' bisexuality.
It is also important to throw light on the very low prevalence of condom use with female partners in comparison to male partners of MSM.Interestingly, protected sex is low with female partners in comparison to male partners.It is lowest among married MSM and those aged 30 and above.Nearly three-fifths of MSM who didn't use condom in their last sex with non-commercial male partner also reported to have unprotected sex the last time they had sex with a female partner, which may enhance the effect of overlapping sex on women's vulnerability.Of course, practice of safe sex is occasional in homosexual encounters.Among those who didn't use condom in last homosexual encounter, over two-fifths reported condom use in the last sexual intercourse with female partner.However, considerably lower prevalence of consistent condom use among those having sex with multiple female partners in the last 6 months is a marker of multiplicity of the STI/HIV risk.This may largely be attributed to the social pressure that these men may face of marrying women as part of social obligation and societal norms demanded or even forced by family.Non-use of condom with wives may be due to the demand of children in the marital bonds as in conservative societies like Bhutan condom is mostly seen as a means of family planning rather than a measure to save one from any infection.MSM "on-the-downlow" are vulnerable to STI/HIV not only due to their MSM behavior but overlapping risk due to unprotected sex with multiple female partners.This multiplicity forms an important cofactor, which needs increasing thrust of programs designed for MSM adopting network-based approach.Role of MSM-SW in HIV transmission is a more complex issue than depictions of men as sexual predators and women as uninformed victims.Targeted Interventions on MSM should envisage beyond homosexuality and address bisexuality regardless of their sexual identity as threat clouding prevention efforts.

Limitations of the study
This study is cross-sectional and do not examine reported behavior over time.The study uses a wide window of time to define bisexual behavior that may have bearing on the extent of bisexuality and its contribution in epidemic.

Table 2 :
Sexual history and current profile of MSM, Bhutan, 2011-12

Table 3 :
Profile of risky behavior in Homosexual relationships among MSM, Bhutan, 2011-12

Table 4 :
Percent distribution of MSM having sexual relationship with female by relational intensity with male partners and some selected background characteristics, Bhutan, 2011-12

Table 5
reveals the percent distribution of MSM by their number of female sexual partners in the last six months prior to the survey and use of condom in their last sexual encounter with a female partner by some selected background characteristics.

Table 5 :
Profile of risky behavior in Heterosexual relationships among MSM, Bhutan, 2011-12

Table 6 :
Condom use behavior among MSM with different partner types, Bhutan, 2011-12