There have been anecdotal reports of human rights violations among sexual and gender minorities in Nepal [5-7]. Violence towards Metis (cross-dressing effeminate males) by law enforcement officers, including rape, has been reported, and metis may be potentially targeted because of their feminine gender presentation [5]. These reports, however, have usually been secondary accounts of sporadic incidents, and systematic assessments of the range of human rights violations faced by sexual and gender minorities are lacking.

After obtaining written informed consent from each of the participants, written summaries of international human rights documents including the international covenant on civil and political rights and the international covenant on social, economic and cultural rights were provided to the participants in Nepali. We also provided them a summary and tentative list of potential human rights violations developed by our community partners to initiate discussion. The participants were entrusted with generating and ranking a participant-generated list of human rights violations relevant to sexual and gender minorities in Nepal based on their experiences. Two study investigators acted as facilitators for the discussion (SS and MB), while a third facilitator (SP) maintained a running list of specific rights violations generated in the discussion. As participants shared their experiences, the initial list was updated and refined. All participants were given the opportunity to contribute, with follow up comments and conversation encouraged until saturation of ideas and specific descriptions of violations had been achieved. After generating a complete list on a whiteboard, the participants reviewed the violations in a group and assigned categories such as those experienced at the household level, neighborhood level, schools, public places, health care settings and violations at the hands of authorities. Apart from these specific domains, the participants elaborated on additional domains and physical and mental health issues associated with rights violations or as a consequence of these violations.

Lastly, each participant independently and blinded to the choices of others in the group assigned numerical rankings to their top 3 choices of categories of human rights violations perceived to be of greatest importance to their daily lives. The individual rankings were tallied over all participants in the group to identify the top three categories i.e. those ranked by the highest number of participants, based on the preferred ranking by the most number of participants. In the event of a tie the choices selected in the next highest category were evaluated as a tie-breaker. The top three choices were reviewed by the group to ensure that the rankings reflected their priorities.

These discussions were conducted in morning sessions lasting approximately four hours. Identical procedures were followed on each of the three days. Each focus group discussion was followed by a debriefing session among the investigator team in the afternoon to ensure that those examples of rights violations that had not been discussed earlier were explored on the next day. Care was taken to avoid contamination of ideas from the previous discussion by ensuring that each participant had an opportunity to report experiences relevant to all the domains. The facilitators guided the discussed and clarified concepts as an iterative and interactive process. None of the participants received any remuneration. The participants were identified by numeric identifiers only and no identifiable information was recorded. All discussions were conducted in Nepali. The sessions were not audio recorded to protect the participants. Two additional experienced note takers (n=6 note takers) made daily notes in Nepali and translated them into English. SS and MB used content analyses in examining the data [12]. Themes derived from the focus group discussions were grouped into categories: 1) a general category denoting broad description of participant generated listing of human rights violations; 2) location-specific categories including within-household, in educational settings, at the workplace, in public places representing the life-course of these participants from more private to more public settings and; 3) context specific categories including violations at the hands of the authorities and violations due to the lack of adequate legal protections.

The findings should be interpreted in the context of international human rights norms. Nepal has ratified the Convention on Civil and Political Rights, and is also a party to the International Covenant on Economic, Social and Cultural Rights [13,14]. Participant-reported human rights violations such as discrimination against sexual and gender minorities by non-state actors, are not explicitly guaranteed under the traditional concept of international human rights norms for which state actors are held responsible. However, the state has an obligation to protect people from violence, including those committed by non-state actors. These acts of discrimination should also be interpreted in the broader context of human duties as reflected in the preamble to the International Covenant on Civil and Political Rights- “Realizing that the individual, having duties to other individuals and to the community to which he belongs, is under a responsibility to strive for the promotion and observance of the rights recognized in the present Covenant”[13]. Such a broad context of international human rights norms allows one to arrive at a comprehensive understanding of the spectrum of human rights violations experienced by sexual and gender minorities in Kathmandu.

These findings also need to be interpreted in the context of local laws in Nepal. Nepal’s existing civil code of law (Mulki Ain) defines rape as “vaginal penetration”, thus providing very little legal recourse for men who have sex with men who experience acts of rape [15]. The legal ambiguity around the prohibition of “unnatural sex” was being used to imprison men who have sex with men in Nepal. In 2007 the Supreme Court of Nepal ended the legal ambiguity by calling sexual and gender minorities’ natural people, therefore ending the potential for the use of the “unnatural sex” clause to be used against sexual and gender minorities [16]. It also issued a decree to issue citizenship certificates with appropriate categorization of gender identity, including a self-identified “third gender.” Although various ministries have expressed support for implementing this third gender category on the national citizenship identification card, the practical realization of these rights has remained difficult due to the lack of implementation and accountability [17]. More recently in 2011 the census in Nepal allowed citizens to identify as male, female, or third gender [17]. The impact of the census was limited, however, because it failed to record third gender citizens along with other meaningful data sets, and there were widespread reports of discrimination during the enumeration. Nonetheless, these changes in the legal environment may have created more awareness which might be partly responsible for the forthright descriptions of personal experiences seen in our study.

These findings should also be interpreted in the context of diverse socio-cultural landscape of Nepal. Some have argued that participant-reported abuse or violence within the family noted in this study fall outside the scope of human rights. Because Nepal is a relatively conservative society, traditional marriage between a man and a woman and subsequent child-raising are still considered essential for maintaining one’s social standing in Nepal, which was until a few years ago an official Hindu state. Any deviation from heterosexuality, explained one of our participants, may be viewed as a Western influence. The exclusion of sexual and gender minorities from cultural events could also reflect an effort on the part of the majority to preserve the traditional “social order” and a form of structural violence. This exclusion appears to hamper the ability of sexual and gender minorities to fully exercise their right to social participation. This social arrangement may ultimately serve to justify or legitimize acts of violence against sexual and gender minorities, and also confer social acceptability on these acts.

Our study also reinforces the synergistic and dual role of social, economic and cultural rights and civil and political rights in the life of sexual and gender minorities in Nepal. The human rights violations identified here encompass various dimensions of social, economic and cultural rights such as the right to food, water and shelter and social inclusion. The participants who identify as third gender reported that the lack of legal recognition on government issued citizenship identification cards has created numerous problems for third gender people. Without proper identification they cannot apply for travel document or open bank accounts [17]. The preferences for legal rights along with changes in their social and cultural life may reflect their desire to ensure that legal rights are an instrument to improve their social, cultural and economic life.

Our results bear similarities and differences with the experiences of sexual and gender minorities in other parts of the world [18]. Difficulty in accessing health care appears to be a common theme for men who have sex with men, around the world [12]. Several participants expressed their reluctance to seek health care because of their experiences at the hands of health professionals, which may further compound their physical and mental health issues. Men who have sex with men in Nepal reported several violations occurring at the household level but, unlike among men who have sex with men in much of sub-Saharan Africa, where men who have sex with men behavior is criminalized, blackmail by families did not appear to be a major issue in our small sample [12]. Sexual and gender minorities in the current study in Nepal cited exclusion from religious ceremonies or cultural functions, paralleling the experience of MSM in Baltimore who report exclusion from church groups. One should be careful in distinguishing the experiences of men who have sex with men who do not identify as third gender with those of people who do identify as third gender, although some studies may have evaluated them together. Some participants in our study, particularly third genders expressed concerns about their physical appearance which made them vulnerable to human rights violations. This is similar to the evidence from other settings such as Brazil that feminine appearing men who have sex with men may be at higher risk of violence due to their distinctive physical difference and expressed gender identity [19].