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Caring for Underserved 2STIGD Folks

The following section outlines the most up to date practices in delivering gender-affirming and culturally sensitive health care to Two-Spirit, trans, Indigiqueer, and gender-diverse (2STIGD) folks from underserved communities.

Colorful Pattern

Disability and Neurodivergence

Disability and neurodivergence is a large intersection that can include physical and intellectual disabilities, as well as PTSD, ADHD, Autism, and other diagnosed conditions. Disabled and Neurodivergent People have a longstanding history of trauma and mistreatment from the medical care system. Far too often, Disabled and Neurodivergent folks are invalidated or ignored when seeking help from PCPs, which is called medical gaslighting. Unfortunately, this means that most Disabled and Neurodivergent patients have likely experienced some level of harm or trauma from the medical care system and it’s important to proceed with that awareness and understanding, using a careful, trauma informed approach.

Disabled People will have different needs based on income, sociocultural factors, access to health care, and gender identity. Ableism has one of the biggest impacts on Disabled People's health outcomes, often causing additional intersecting struggles. The social determinants of health impact many Disabled People, including discrimination, inaccessibility, stigma, and barriers to health care. Some barriers include the lack of adequate health insurance coverage, personal and cultural barriers, and a general lack of knowledge among PCPs about disability. These barriers, and others, often lead Disabled People to postpone seeking health care, or avoid the healthcare system altogether.  Even though there is a difference between disability and health status, our healthcare system is rooted in systemic issues that increase the likelihood of Disabled People experiencing poor health outcomes compared to their able-bodied peers. It’s also important to note that a patient's age plays an important role in accessing health care services; for older Disabled People, there is a higher rate of unmet health care needs due to ageism and discrimination. When it comes to accessing gender-affirming care, Disabled and Neurodivergent patients who are also Two-Spirit, trans, Indigiqueer, and gender-diverse (2STIGD) can face barriers to accessing services in situations where PCPs negate access based on a belief that the patient does not have the capacity to consent, ignoring their desires to medically and/or socially transition. This is another form of gatekeeping which is rooted in ableism.

Before making a referral, ensure that they will be safe, affirming, and accommodating, to Disabled and Neurodivergent folks. For example, consider calling ahead to ask what kinds of services or equipment are available to accommodate your patient, as some spaces may contribute to medical trauma and harm. In situations where there are limited options for referrals and you have accessibility concerns, communicate these openly with the patient, inviting the patient to be a part of the process of how best to proceed.

 

Finally, should a patient highlight that a service is inaccessible, whether within your own practice or outside of it, your attitude is vitally important. Thank them for pointing it out, and carefully consider how you can address this concern for the future when it is in your power to change. If the concern is outside of your control, take time to come up with a plan for how to assist patients in the future, whether referring them to a place that is more accessible for them , or supporting them in some other way.

When working with Disabled and Neurodivergent Patients Consider The Following

  • If a patient has self-identified as Disabled and or Neurodivergent, ask what it means to them and what kinds of needs or challenges they may have, rather than making assumptions about their individual experience.

  • Discuss available services/technology that can make appointments accessible for the patient (i.e screen readers, examining table size, accessible pathways with adequate space for mobility aids).

  • 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.

  • Keep in mind that clear and transparent communication is very important, for example; consider offering to send any notes taken during appointments, communicating using visuals, audio recordings of appointments, and sending them home with physical resources or a way to access them online/in store, etc.

  • Above all, listen to what the patient needs.

Debunking Myths About Autism

Much of our current medical research prioritizes the needs of white cisgender males of European descent, and the diagnostic criteria for Autism is no different. Limited research of traits and symptoms of Autism has resulted in many AFAB folks and trans and non-binary AMAB folks being severely underdiagnosed and misdiagnosed as their symptoms are often missed in childhood. Additionally, the way these individuals tend to be socialized is heavily influenced and impacted by heteronormativity and cisnormativity, which in turn increases their likelihood to be diagnosed incorrectly as their symptoms may present differently. With increased research in diverse populations, we are beginning to understand the many different ways neurodivergence can present, and what supports are needed for Autistic adults

Autism or ASD is best understood on a spectrum of needs, abilities and experiences. In the past, folks began referring to autistic people as being either low or high functioning based on a research study in the 1980s. The study differentiated between those with or without an intellectual disability as determined by an IQ test. Functioning labels have since been identified as problematic, as they are not only extremely harmful and damaging but they also do not accurately represent the autistic experience. Autism is a developmental disability and it is not mutually exclusive to intellectual disabilities. Similarly in the past, ‘levels’ were used to describe the ‘severity’ of someone’s autism including terms such as Aspergers syndrome. There is no such thing as mild or severe autism. That language is outdated and no longer accepted. Rather than focusing on an ableist view of ‘how well someone is functioning,’ it is more respectful and accurate to view the person as a whole, autonomous individual with accessibility needs that will vary from person to person. Everyone’s experience with autism is different and can also vary based on other intersecting identities (socioeconomic status, gender, culture, mental health, etc.) in addition to the environment in which they were socialized. 

 

Autism is not curable and does not need to be ‘fixed.’ ABA - a type of behavior therapy aimed at minimizing symptoms and traits in Autistic kids has been identified as more harmful than helpful. Anne Borden, cofounder of Autistics for Autistics, says “ABA is fundamentally flawed and problematic” and many folks in the Autistic community have even referred to ABA as abusive. Borden calls ABA “compliance training” and explains that this type of treatment teaches children to ignore their intuition and damages their understanding of boundaries and consent which can impact their future judgement and relationships. Borden also suggests that they may suffer lasting trauma as a result of ABA. The journal Advances in Autism validates this claim through a study published in 2018. They found that “nearly half of children and adults exposed to ABA had post-traumatic stress disorder (PTSD).” Additionally, ABA tends to reduce only the outward appearance of autism. For the individual experiencing this therapy, it deeply damages their self-esteem and sense of self as they’re trained to act neurotypical and hide who they are. This internalization can lead to symptoms of severe anxiety along with many other long-lasting negative health outcomes.

 

When looking for further information, seek out Autistic individuals who choose to share their experiences rather than  an organization that may or may not be operated by Autistic people themselves. There is a lot of misinformation about autism so it’s important to be very conscious of where and who the information is coming from. Autism Speaks for example is an organization that perpetuates harmful information about Autistic people and is widely discredited by the community.​

Autism and Gender Diversity

There is a strong correlation between autism and gender diversity, as 2STIGD individuals are three to six times more likely to be Autistic than cisgender individuals. Additionally, gender-diverse individuals are more likely to suspect they have undiagnosed autism or have autistic traits. The reason for this strong intersection between autism (and neurodivergence more broadly) and gender diversity is still unclear due to a lack of research. However, many feel that it is connected to the way that autistic individuals interact with social norms and social communication. As much of our current understanding of gender is socially constructed, it can be understood that Autistic individuals would not naturally conform to these ideas of cisnormativity.

 

In addition to being gender-diverse, it was found that “nearly 70 percent of Autistic gender-diverse adolescents say they need medical gender-related care [...] and 32 percent say their gender identity has been questioned because of their autism diagnosis." As Autistic individuals have also been noted to have an increased risk of depression and other psychiatric conditions, PCPs should be conscious of the health impacts that can result from multiple layers of marginalization and to work with the patient to determine how best to support their mental health as necessary. That said, it is very important to keep in mind that these comorbidities do not mean that one should be denied care, or that an individual’s gender identity is invalid. 

 

Just as neurotypical 2STIGD patients are at an increased risk of depression or anxiety due to the weight of today’s cisnormative society, there are also negative mental health outcomes for Autistic 2STIGD patients. For Autistic folks, navigating a world that is inaccessible, and masking as a means to survive can be incredibly exhausting and can take a toll on a patient’s overall health and sense of self. Especially in the case of 2STIGD Autistic patients, those experiences are compounded by the negative health outcomes that 2STIGD patients face more broadly. It is important for PCPs to be aware of the relationship between autism, gender, sociocultural factors, and mental health when working with 2STIGD individuals. 

Person-First or Identity-First Language? 

Is it more respectful to say “Disabled person” or “person with a disability?” The short answer is both, and as such PCPs should always adjust their language based on how the patient speaks about their disability. For autism in particular, there have been efforts within the community to move away from person-first language as the standard practice and instead use identity-first language, as “many self-advocates prefer terminology such as ‘Autistic,’ ‘Autistic person,’ or ‘Autistic individual’ because we understand autism as an inherent part of an individual’s identity.” In all cases however, deference should always be given to the individual.

2STIGD People of Colour

Studies have shown that there are greater health disparities among 2STIGD who are also POC (People of Colour), compared to their white counterparts. Using the theory of intersectionality, it can be understood that 2STIGD People of Colour can face systemic oppression in a compounded way due to their “double minority status.” They are confronted not only with the discrimination and violence imposed by cisheteronormativity, but also with racism. 2STIGD People of Colour also often deal with the intersecting burden of economic oppression and financial barriers to health care. They also may be less likely to be insured and therefore are less likely to receive appropriate care when needed. 2STIGD folks accessing care are often put into positions where they need to educate their provider on the care they need. Additionally, People of Color manage the added burden of educating their provider on care that is culturally safe and responsive to their needs. The links between these identities must be understood in order to understand the social determinants that lead to poor health outcomes among this population.

Resources

BIPOC Women’s Health Network

How to Make Your Practice Inclusive for 2SLGBTQ+ BIPOC Folx

Anti-Asian Racism & The Healthcare System

Substance Use Disorder (SUD) 

Anyone experiencing mental health challenges, regardless of their age or identity, is at an increased risk of self-medicating in the form of substance use and addiction. As 2STIGD individuals often experience stigmatization and discrimination, they are at an increased risk of mental health challenges, which in turn increases the risk of substance use and addiction. In fact, according to a 2019 national survey of mental health among 2SLGBTQIAA+ youth, “approximately 60-75% of adolescents with mental illness have a co-occurring substance use disorder.” Recent data shows that youth who identify as a sexual minority are about twice as likely to use substances compared to heterosexual youth. Additionally, those who identify as a gender minority face exceptionally high levels of stigmatization and discrimination, which correlates to higher rates of mental health challenges and suicidality; one research study identified that the risk of substance use among these youth is 2.5 to 4 times higher, relative to their cisgender peers. It is important to remember that being a part of the 2STIGD community is not inherently a risk factor for substance use, but rather, “the heightened risk comes from the stigma and discrimination they face as a result of their sexual orientation and/or gender identity.”

 

In treatment centers for Opioid Use Disorder (OUD) and other substance use disorders, some have “no-needle” policies or rules about self-administration of medications, however it is vital that 2STIGD patients continue GAHT during this time, as suddenly stopping the medication can cause negative side effects such as depression and suicidal thoughts. When a referral is being made for a patient undergoing GAHT, be sure to call ahead and ask treatment programs how they address this. For referrals within New Brunswick, see New Brunswick Addiction Centers.     

 

“Opioid agonists, including treatments such as methadone and buprenorphine, have known interactions with certain ART (Antiretroviral) medications, particularly efavirenz, and with hormone-modulating medications, such as spironolactone.” Known or perceived medication interactions may deter some patients from potentially life-saving treatment for OUD. “Co-prescription of these medications is safe and feasible with appropriate monitoring and follow up.” Ensure however, that patients are always given fully informed consent on these medication interactions.

Immigrants, Refugees, Migrant Workers and Undocumented Individuals

Immigrants, Refugees, Migrant Workers and Undocumented (IRMU) individuals often have overlapping barriers to care as POC. Although not all IRMU folks are People of Colour, they may face similar and additional compounded difficulty when accessing health care and facing discrimination related to their status in Canada. IRMU individuals may also commonly deal with economic oppression and other barriers to accessing support services such as a lack of language translation. Undocumented individuals in particular are one of the most underserved populations as a lack of immigration status leads to a fear of accessing services, as this poses a risk of being reported to immigration authorities and even deportation. Undocumented folks are a vulnerable population as they have limited access to health care, social services, and employment protections. This may increse their likelyhood of working in informal sectors which have less systemic support and protections, including childcare, housekeeping, agriculture, construction and sex work. IRMU individuals who are also 2STIGD face additional layers to their already marginalized identity, impacting not only their access to safe and culturally-sensitive gender-affirming care, but also to their ability to have immigration documents which accurately reflect their gender identity. 

 

Refugee claims may be made for many reasons, including those on the basis of facing violence due to the individuals’ sexual orientation, gender identity and expression, sex characteristics, HIV+ status, and more. This happens in instances where their home country cannot or will not protect them, or for other reasons. They may often deal with additional mental health challenges related to the trauma/violence of transphobia and homophobia and the discrimination and stigmatization they faced in the country they are seeking assylum from. It is important for PCPs to be aware that this is a reality for many and these relationships must be handled with care to achieve positive health outcomes.

Application for Canadian Citizenship: Adults - Subsection 5(1) CIT 0002 - Appendix C outlines the process of changing your gender marker for those born outside of Canada. Many countries may require the gender marker to be changed on the original birth certificate first before any Canadian citizenship documents can be changed. Alternatively, patients may only need to access the original copy of their birth certificate in order to proceed. This adds a complex layer of difficulty as not everyone will have access to their original birth certificate for a number of reasons including a country being in conflict, and there may be barriers to changing original documentation based on a country’s beliefs on 2STIGD individuals and their rights. It's important for PCP’s to be aware of how name changes and gender markers involve many additional barriers for folks born outside of Canada.

Specific considerations for accessing health care must be made due to their citizenship/imigration status as access will vary extensively. For refugees and patients seeking asylum in Canada, they are eligible for health coverage under the Interim Federal Health Program (IFHP) even before their case is decided. The coverage is equivalent to New Brunswick Medicare and includes all health needs, including prescription drugs. For more information on this program, visit the Interim Federal Health Program. For folks who may not have access to health coverage (considering undocumented individuals and migrant workers) cost may be one of the biggest barriers. Community health centers and hospitals will see patients who are undocumented or otherwise do not have access to New Brunswick health care. However, patients get billed directly for those health care costs and can vary depending on the service (bloodwork, prescriptions, etc).  

Intersex
Considerations

Disclosure: The following information was obtained from The Fenway Institute’s National LGBTQIA+ Health Education Center and incorporated into this education package with their permission. Seeing as the Fenway Institute is an American organization, all information has been fact checked for accuracy within the Canadian context. 

 

Intersex is an umbrella term that refers to those with a wide range of natural variation in sex characteristics and development that falls outside traditional conceptions of female or male. Although biological sex has traditionally been seen as binary (female or male) in many cultures, the reality is more complex. Variations may occur in the chromosomes, external genitalia, gonads (testes or ovaries), hormone production, hormone responsiveness, internal reproductive organs, or any combination of these, among others. People are born with these variations or develop them at a young age. The word Intersex also invokes a community. Intersex people are diverse, coming from all socioeconomic backgrounds, races, ethnicities, genders, sexual orientations, faiths, and political ideologies. 

 

Language related to Intersex health is complex. Currently, the medical field uses the terms “differences of sex development” (DSD) as well as Intersex. The term “diverse sex development” has also been cited in the literature. The DSD acronym originally referred to disorders of sex development, however Intersex community members have made it clear that the term disorders is pathologizing and demeaning. The outdated terms hermaphrodite, pseudohermaphrodite, and ambiguous genitalia are experienced as stigmatizing and hurtful; these terms should be avoided unless an Intersex person asks you to use them. PCPs should also avoid terms that describe a person’s anatomy as defective or abnormal.


While some people in the community use the terms Intersex or difference of sex development, other people in the community prefer to use the specific name of their diagnosis. For PCPs, the best practice is always to mirror the term(s) patients use, or ask patients what they prefer.

Caring for Intersex Patients

Like Two-Spirit, trans, Indigiqueer, and gender-diverse people (2STIGD), Intersex people may have a gender identity that does not correspond with their sex assigned at birth or gender of raising. In addition, because Intersex people have sex characteristics that transcend typical notions of female and male bodies, they may experience barriers similar to 2STIGD people in accessing affirming health care that respects their bodies, gender identities, and physical needs.

 

While some intersex variations are noted prenatally or at birth, many intersex traits do not become apparent until puberty or later in life. Below are common points at which an intersex variation may be identified:

  • During a prenatal ultrasound

  • At the time of child’s birth, if genital variation is identified

  • During care related to an inguinal mass/hernia that leads to the discovery of internal testes

  • At time of puberty, if pubertal changes do not occur, or if there are unexpected physical changes (e.g., virilization of an individual assigned female sex at birth)

  • Incidentally during a laparoscopy for another medical concern

  • During evaluation of an adult for infertility

 

While PCPs are not expected to be intersex specialists, they still require education in the basics of intersex care. PCPs can provide affirming and compassionate care for intersex patients and their families. To practice affirming care in interactions with intersex patients, it is important for PCPs to listen with sensitivity to their patients and acknowledge that:

  • Sex development, like gender identity, exists on a continuum

  • Human fetal development is complex - variations in sex characteristics are an expected and natural outcome of sex development

  • An individual born with variations in their sex characteristics may or may not identify as Intersex or as part of the 2SLGBTQIAA+ community

Gender-Affirming Care for Aging 2SLGBTQIAA+ Folks

Disclosure: The following information was adapted from The City of Toronto’s Leading & Learning WITH PRIDE: A Revitalized Tool Kit on Supporting 2SLGBTQI+ Seniors and incorporated into this education package with their permission. 

 

2SLGBTQIAA+ elders, seniors, and older persons in Canada have faced systemic discrimination and oppression based on their sexual orientation, gender identity, and gender expression. As a result, many continue to face unique challenges as they age and often experience barriers to access across healthcare, long-term care, retirement, homecare, and social service environments. 2SLGBTQIAA+ elders, seniors, and older adults experience stigma and discrimination at all points of the healthcare continuum, negatively affecting physical and psychological health and wellbeing. Gaining an understanding of the issues and experiences of 2SLGBTQIAA+ elders, seniors, and older adults is critical to informing government, service providers and community organizations on how to provide appropriate policies, programs and services, and positive, caring environments for aging 2SLGBTQIAA+ people.

                        

Respectful, inclusive, and affirming care acknowledges the diverse experiences of 2SLGBTQIAA+ elders, seniors, and older adults and addresses their physical, psychological, emotional, social, and spiritual needs. Keep in mind that 2SLGBTQIAA+ elders, seniors, and older adults are an incredibly diverse group. As such, the common experiences, needs, and challenges examined in this section may not apply to everyone you work with. Additionally, while research on 2SLGBTQIAA+ elders, seniors, and older adults is gradually increasing, it is still limited, particularly for those identifying as 2STIGD. These gaps in evidence reflect that our knowledge and understanding of 2SLGBTQIAA+ elders, seniors, and older adults and their needs are incomplete and still developing.

Terminology

The language we use to describe ourselves and others matters. It matters because terms related to our social identities can help us feel seen and understood, especially when pieces of our identity might not be readily visible to others or made invisible by stigma, discrimination, and oppression. In this section you will notice that instead of using the acronym 2STIGD, that we have opted to use the larger umbrella term 2SLGBTQIAA+. The reason for this is to more accurately reflect the evolution of terminology. 

 

Although the language and terminology related to 2SLGBTQIAA+ communities is understood to be fluid, the way in which language evolves over time is particularly important to note when it comes to 2SLGBTQIAA+ elders, seniors, and older persons. Some words that may have been appropriate in the past can become dated and offensive. Other words that were once derogatory can be reclaimed and used by 2SLGBTQIAA+  people in empowering way. For example, some older people may refer to themselves using terms such as transsexual, crossdresser, or homosexual. 


For 2SLGBTQIAA+ elders, seniors, and older persons, providing respectful, inclusive and affirming care often starts with the use of appropriate language and terms. As with all 2SLGBTQIAA+ people, PCPs should use the language and terminology that each individual patient prefers to be referred to.

Resource 

Fruit Machine, a documentary by Sarah Fodey recounting the personal stories of survivors of the LGBT Purge.

Context

The last 50 years have seen immense progress for 2SLGBTQIAA+ liberation movements worldwide. However, many elders, seniors, and older adults grew up in places and times where stigma, discrimination, and oppression against  2SLGBTQIAA+ communities were rampant and normalized.

 

Many 2SLGBTQIAA+ elders, seniors, and older adults grew up during periods where gender and sexual diversity was criminalized and pathologized. In fact, homosexuality was only partially decriminalized in Canada in 1969 and up until 1973, was included in the Diagnostic and Statistical Manual of Mental Disorders. As a result, many 2SLGBTQIAA+ elders, seniors, and older adults have been subjected to police brutality and incredibly harmful, scientifically discredited conversion therapies focused on changing their sexual orientation, gender identity, and/or gender expression. Many of these so-called ‘treatments’ have continued into the present day. 2SLGBTQIAA+ elders, seniors, and older adults may have come of age during the 1969 Stonewall Riots or the 1981 Toronto Bathhouse Raids. Many have lost partners, friends, chosen family, and entire communities during the AIDS crisis. Some may have lost their jobs during the ‘LGBT Purge,’ a process through which the Canadian government systematically surveilled, interrogated, abused, and fired 2SLGBTQIAA+ people serving in the Canadian Armed Forces and the Royal Canadian Mounted Police between the 1950s and mid-1990s.

However, it is important to avoid thinking of 2SLGBTQIAA+ elders, seniors, and older adults only through the narrow lens of victimhood. Despite the challenges they may have faced, 2SLGBTQIAA+ elders, seniors, and older adults belong to diverse, vibrant, and resilient communities with rich histories full of activism, advocacy, and joy. Understanding significant 2SLGBTQIAA+  historical events can help contextualize the current needs of 2SLGBTQIAA+ elders, seniors, and older adults and contribute to your knowledge and skills in inclusive and affirming care.

Social Isolation and Mental Health

Social isolation, meaning infrequent or poor quality contact with others, can be a significant concern for 2SLGBTQIAA+ elders, seniors, and older persons. The factors contributing to social isolation among 2SLGBTQIAA+ elders, seniors, and older persons are numerous, but may include any of the following:

  • More likely to live alone

  • Less likely to have spouses, life partners, or children

  • Less likely to have other familial supports, sometimes due to rejection from their family of origin

  • There may be limited opportunities for community connection

  • Programs and services geared towards 2SLGBTQIAA+ elders, seniors, and older persons are generally limited

  • Hesitancy to form new connections due to past and/or anticipated experiences of stigma and discrimination

  • May have lost partners, friends, chosen family, or entire communities to AIDS or due to homophobic, biphobic, and transphobic violence.

 

It is important to note that social isolation among 2SLGBTQIAA+ elders, seniors, and older persons is not inevitable and not all 2SLGBTQIAA+ elders, seniors, and older persons are socially isolated. Protective factors like connection to community and social support networks can shield against isolation and promote resilience. Without access to these critical supports, social isolation can result in a number of physical and mental health challenges. These may include:

  • Loneliness

  • Chronic Pain

  • Low Physical Activity

  • Falls and Hospitalization

  • Depressive Disorders

  • Anxiety Disorders

  • Substance Use

  • Suicidality

 

In addition to these isolation-related challenges, 2SLGBTQIAA+ elders, seniors, and older persons may experience increased mental health issues. These may include:

  • Poor Self-Rated Mental Health

  • Self-Harm

  • Suicidal Ideation and Attempts

  • Anxiety Disorders

  • Depressive Disorders

  • Other Mood Disorders

  • Substance Use


As always, it is important to recognize the oppressive social contexts in which 2SLGBTQIAA+ elders, seniors, and older persons grew up and acknowledge how repeated exposure to stigma and discrimination can impact mental health over the life course. Of note, Two-Spirit, Indigiqueer, and Indigineous LGBTQIAA+ Elders, seniors, and older persons may experience heightened mental health challenges as a result of the violence and abuse in Canadian Residential Schools and during the 60s Scoop.

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