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Indigenous Gender Diversity 

The following section outlines the most up to date practices in delivering gender-affirming and culturally sensitive healthcare to Two-Spirit, Indigiqueer, and Indigenous trans or gender-diverse folks. This section is comprised of both visual and written material, and should be completed in the following order: 

Watch Trans Care BC's educational video on Indigenous Gender  Diversity here.

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Read and review the written guidelines and information outlined below. 

2

We would like to highlight the importance of cultural competency, not just for PCPs, but for all individuals working and volunteering within the health care system. We would encourage you to share these resources with all involved, as all staff and volunteers will be working in some capacity with Indigenous patients.

What Land Am I On?

Acknowledging the land we reside on is a way to honor and respect the Indigenous Peoples who have occupied and cared for the land since time immemorial. It allows us to reflect on a shared history and understand our current roles, responsibilities and relationships both to each other and the land, as settlers, or traditional occupants of this land.

 

As a part of 2SQTP-NB/P2SQT-NB training we encourage Trainees (if you have not already done so) to start developing this awareness journey by going here to find out more about the Indigenous land you occupy and the original and longstanding caretakers of that land. 

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Colonialism and the Gender Binary

“Two-Spirit is a cultural identity specific to Indigenous people, with a rich history. While trans is considered a more Western term that some gender-diverse Indigenous peoples use as well.” - Trans Care BC

Colonization distorted and fragmented ideas of gender in Indigenous communities. Traditionally, children were raised in more fluid ways that allowed them to explore their gender identity on their own. The gender binary was enforced through colonial methods like residential schools as an attempt to erase Indigenous gender diversity, gender expression and Two-Spirit roles. As such, Two-Spirit People’s health must be understood within the dual contexts of colonial oppression rooted in heteropatriarchy, as well as the resurgence of Two-Spirit People’s gender roles and sexuality. This understanding is integral to improving the overall health, wellbeing, and care of Two-Spirit People. During the late 1800s in the area that is now called New Mexico, We’wha was a Lhamana (Zuni Two-Spirit) whose community tended to separate appearance and tasks by gender; however, We’wha dressed and performed tasks associated with both men and women. They were accepted and respected in their community as both a weaver and potter, as well as a hunter and spiritual leader, and are known for having been one of the earlier “Two-Spirit heroes who helped light the way.”

The effects of colonization are apparent in all aspects of Indigenous peoples’ health and well-being, affecting not only their physical health, but also their mental, emotional, and spiritual wellness. It is well established that Indigenous Peoples in so-called Canada experience a disproportionate burden of poor health outcomes compared to non-Indigenous folks. In large part, these health disparities have been a result of government policies that were put in place to eradicate the Indigenous population and assimilate them into Euro-Canadian ways of life, leading to physical and emotional harms to children, loss of culture and language, and the disconnect of family structures and community. Many of the negative health outcomes that are disproportionately experienced by Indigenous peoples have therefore been attributed to the lasting and ongoing effects of colonialism, including the Indian Act, the reserve system, and the residential school system. To promote equity in health care for Indigenous peoples, PCPs must have an understanding of the social determinants of health and health care inequities for Indigenous peoples. 

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In 1884, amendments to the Indian Act, including the creation of Indian residential schools, were adopted. Duncan Campbell Scott, the Deputy Minister of Canada in 1920, was quoted on record for saying “I want to get rid of the Indian problem… Our objective is to continue until there is not a single Indian in Canada that has not been absorbed into the body politic and there is no Indian question, and no Indian Department.” Scott was responsible for the 1920 amendment of the Indian Act that mandated the attendance to residential schools of all children under the age of 15. The schools in Canada were predominantly funded and operated by the Government of Canada and Roman Catholic, Anglican, Methodist, Presbyterian and United churches. 

 

An estimated 150,000 First Nation, Metis and Inuit children attended these schools. During their time at the schools, they were physically, sexually, emotionally, and spiritually abused. Thousands of children died at these schools, and many escaped but never made it home. Thousands survived, carrying with them the lasting effects of their experiences. This trauma is carried down through generations in families and communities, and dramatically impacts the overall health and wellbeing of Indigenous Peoples today. In Indian day schools, the same kinds of abuse happened, but in those circumstances, the children were allowed to go home at the end of the day. 

 

This is still within living memory as the last residential school closed in 1997. Thousands of survivors are alive today and are able to tell their stories. It is thanks to their bravery that justice and reparations can be made for the thousands of survivors and their families who are impacted by the irreparable harm caused by the Indian residential school system.


The Truth and Reconciliation Commision of Canada outlines a report on the stories of over 6000 survivors and the impacts of the Indian residential school (IRS) system in Canada. The TRC also reports on links to the child welfare system, referring to it as a continuation of the IRS system in which children are removed from their homes and disconnected from their culture, language, family, and community. There are now three times more Indigenous children in the child welfare system than there had been even at the height of residential schools. It is important to consider the impacts the IRS system has on the current overrepresentation of Indigenous children in the welfare system, and to understand and contextualize the ongoing removal of First Nations, Metis and Inuit children from their homes and communities.

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Intergenerational trauma is a direct result of colonization, attempted genocide and forced assimilation. Indigenous Peoples now face disproportionate structural disadvantages which lead to barriers in the education system and employment, mental health concerns, reliance on social assistance programs, substance use, survival sex work, etc. It is not a health care provider's place to judge anyone based on the systems of oppression they have lived through; instead, a truly trauma-informed PCP takes into account the history and lived realities of Indigenous patients and proceeds with care, using a non-judgemental approach. It is because of the historic mistreatment and attempted genocide and assimilation of Indigenous Peoples in Canada that culturally-focused care is critical to repairing the harm done and building relationships of trust with Two-Spirit, Indigiqueer, trans and gender-diverse Indigenous People.

Colonialism & Health Care

The health care system in particular has a long history of violence against Indigenous Peoples. As was the case with various public services (including health, educational, and social services), colonialism systemically limited access on the premise that Indigenous Peoples deserved less, and therefore fewer resources would be allocated to Indigenous Peoples and communities. Furthermore, resource allocation was done with the intention of assimilating, segregating, and eradicating the Indigenous population. As a measure of control, health care provided to Indigenous Peoples has been limited, underfunded, and at times, deliberately harmful. 

 

This systemic racism within the health care system continues today, as Indigenous Peoples, both on an individual level and as a group, “continue to be seen as those who don't really belong; as drains on the system; whose care is never quite as urgent; and, in general, less deserving of the same level of treatment as non-Indigenous patients [...] and are often blamed for their ailments and medical needs.” Indigenous patients regularly deal with racism, discrimination, mistreatment, and microaggressions when accessing care. Other barriers to health care include but are not limited to; language barriers, transportation, and difficulty navigating funding and support services. 


When engaging with Indigenous patients, it is important for PCPs to understand the ongoing effects of colonialism and how the attempted assimilation and genocide of Indigenous people continues today (e.g., forced sterilization, lack of access to clean water, and land theft and destruction). Indigenous health care and wellbeing should be approached collaboratively and holistically by addressing the social determinants that impact the overall health and wellbeing of Indigenous Peoples, including but not limited to: poverty, barriers to safe housing, social injustice, and systemic racism.

Indigenous Folks in Rural, Remote, or Reserve Communities

When reserves were created, they were often placed “out of the way” and today many of them remain physically isolated from central community support services This impacts both the services that are readily accessible (the magnitude of infrastructure deficits have been described as “particularly striking”), as well as revenue opportunities for the communities, meaning that individuals need to leave their communities to be able to better access services and/or employment. Similarly, for many rural Indigenous folks living on reserve, there is a lack of services available for gender-affirming care that do not require significant travel. 

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When booking appointments: 

  • consider booking them on the same day as other appointments to limit any travel-related concerns

  • host appointments virtually if possible

  • work with patients to assist with travel (see NIHB Program for possible supports)

  • Remember that for Indigenous folks who may have moved out of their communities to access gender-affirming care, school or other support services, they may struggle with culture shock


While this is not a “one size fits all” approach, it is important to keep these things in mind when working with Two-Spirit, Indigiqueer, and Indigenous trans or gender-diverse patients.

Microaggressions are words or actions that come from implicit biases. It can be described as subtle or unintentional discrimination of a marginalized group, and can impact patients’ level of emotional safety. For Indigenous Peoples, this can involve things like: being asked to explain topics about Indigenous history, cultures or political events (unprompted), or receiving inappropriate questions about their identity that are unrelated to their direct care, etc. 

 

Some things to remember:

  • Know that you will at times make mistakes with pronunciation and pronouns, and your patient may correct you, or you may realize the mistake yourself. When this happens, thank the patient if they have corrected you, repeat what you had said with the correct pronunciation (to the best of your ability) or pronoun, and move on. For more detail on how to respond to a mispronunciation or misgendering error, please see Misgendering 101 and Original Voices.

  • Avoid making assumptions about a patient’s identity or lived experience.

  • Only ask questions that are relevant to the patient’s direct care.

Microaggressions

Clinical vs. Relational Approach

Due to the deep rooted systemic racism that has existed historically and continues to exist between health care systems and Indigenous Peoples, it is important to be sensitive to Indigenous Peoples’ potential hesitancy with PCPs, Western medicine, and distrust in the healthcare system as a whole. There can be a lot of vulnerability involved for Indigenous patients to trust non-Indigenous PCPs. Treat the relationship with care and cultivate trust and safety. 

 

Involvement in culture and ceremony may play a huge role for some individuals and for others it may not. Some may need medical care such as GAHT/surgeries, and for others, social and cultural transition is the end goal and can look like: the roles someone may play in their community, where they sit in the sweat lodge, or the way they express their gender through clothing, gender-affirming garments, etc.

 

Some ways to practice a relational approach to working with Indigenous Peoples:

  • Act with humility: Be honest about gaps in knowledge and do not make assumptions.

  • Use the Informed Consent Model and make your intentions clear. It’s important for care providers to be transparent about options and next steps to nurture a relationship of trust and respect with the patient. This is especially important in regards to prescription medication, as patients may be hesitant to trust western medicine, or may prefer other options. 

  • Encourage follow-ups and referrals and try to avoid delays whenever possible, as this has been and continues to be weaponized against Indigenous folks seeking medical care.

  • Use accessible language (avoid overuse of medical jargon).

  • Let the patient know that having a support person attending appointments is an option, though this may or may not be necessary for the patient.

  • Invite them to tell you how they experience themselves and listen to what they need rather than making assumptions or dismissing their concerns. This will help you to avoid gaslighting. 

  • Above all, keep in mind that many of your patients will have had previous negative experiences with the health care system, and it will take time for you to gain trust.

 

Cultivate relationships by getting involved

  • Get to know other service providers who work with Two-Spirit, Indigiqueer, and Indigenous trans or gender-diverse People.

  • Seek partnerships with Indigenous health programs, organizations and communities in your area.

  • Encourage your employer, staff, or colleagues to seek further training opportunities on working with Indigenous Peoples, either in-person or online, as well as seeking them out yourself.

 

If you’re making a referral:

  • Think beyond the Western idea of service providers (i.e., traditional healers, cultural ceremony, experts in community, etc.). For many Two-Spirit, Indigiqueer, and Indigenous trans or gender-diverse People, their gender journey is interconnected with their cultural and spiritual identity. Therefore, some people find cultural and spiritual guidance invaluable during their journey, whether they are transitioning socially, accessing gender-affirming medical care, or preparing for and healing from a surgery.

When you are unsure if a care provider or service is competent working with Two-Spirit, Indigiqueer, and Indigenous trans or gender-diverse People - call ahead. Consider asking them what policies are in place to help Two-Spirit, Indigiqueer, and Indigenous trans or gender-diverse People feel safe.

Providing Competent, Culturally Sensitive Care is an Ongoing Journey

As is often the case when working with anyone whose experience differs from yours, or even at times when you have a shared experience, mistakes and misunderstandings will occur, and there will always be room for personal growth. Continuing to challenge your own internal biases, accepting correction, and working to do better in the future will continue to positively impact your relationships with your patients, contribute toward a more trusting environment, and result in favorable health outcomes for 2STIGD patients.

Questions to Ask Yourself and Reflect On
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  1. What role do I play in reconciliation?

  2. Are the services I provide and the spaces that I provide them culturally safe, responsive and accessible to Two-Spirit, Indigiqueer, and Indigenous trans or gender-diverse patients?

  3. Am I thinking critically about my positionality and unconscious biases and the ways they impact care delivery?

  4. Has my practice or workplace made efforts to learn about the lived experience of the Indigenous Peoples in the area? (i.e., relationship building, training, shared resources, team conversations, etc.)

  5. What are three ways I can make my clinical space safer for Indigenous folks in the short term?

  6. What are three ways I can make my clinical space safer for Indigenous folks in the long term?

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