Holistic Health of Two Spirit People in Canada: A Call for Nursing Action

Abstract

Purpose: In response to item 7.1 from the Missing and Murdered Indigenous Women and Girls Report (2019), calling on health service providers to recognize the importance in inclusive services with and for Indigenous peoples including Two Spirit, lesbian, bisexual, transgender, queer, questioning, intersex, and asexual (2SLGBTQQIA) peoples, we undertook a review of the literature to identify the gaps in understanding and to better situate the health and resiliencies of Two Spirit people in Canada. Method: We conducted a review of 13 articles related to the health and wellness of the Canadian Two Spirit community. Overall, there was a dearth of Two Spirit specific health-related information. Results: Identified themes were grounded in the holistic Medicine Wheel teachings. These themes directly parallel holistic nursing in their demonstration that health is complex, and that there are many facets that make up an individuals’ health. Conclusion: Assessing the impact that colonization has had on the intersections of gender, race, sexuality, class, culture, and spirituality, Two Spirit people face unique health concerns. Considering the intersections of identity and structural barriers in place for this community, more research led by and in collaboration with the Two Spirit community is needed.

Calls for Justice

3.1 We call upon all governments to ensure that the rights to health and wellness of Indigenous Peoples, and specifically of Indigenous women, girls, and 2SLGBTQQIA people, are recognized and protected on an equitable basis.

7.1 We call upon all governments and health service providers to recognize that Indigenous Peoples – First Nations, Inuit, and Métis, including 2SLGBTQQIA people – are the experts in caring for and healing themselves, and that health and wellness services are most effective when they are designed and delivered by the Indigenous Peoples they are supposed to serve, in a manner consistent with and grounded in the practices, world views, cultures, languages, and values of the diverse Inuit, Métis, and First Nations communities they serve

- National Inquriy into Missing and Murdered Indigenous Women and Girls, Reclaiming Power and Place, 2019

The term “Two Spirit” is a self-determined indication of gender and sexual identity within Indigenous communities. The term was invoked by Indigenous community members in 1990 at the 3rd annual International Two Spirit Gathering in Manitoba, Canada (OUTSaskatoon, 2020b; Robinson, 2017). Although the term Two Spirit has roots in Canada, it is increasingly used by Indigenous communities across North America (Hunt, 2016). Through extensive interviews with Two Spirit people, Two Spirit scholar, Wilson (1996) shows that terms such as lesbian, gay, and bisexual are housed within a Western, colonialist framework and do not fully indicate the unique and complex expressions of gender within Indigenous cultures. By affirming the “interrelatedness of all aspects of identity, including sexuality, gender, culture, community, and spirituality” the concept of Two Spirit gives space to identify in a way that is meaningful for the individual, outside of Settler¹ understandings of sex, gender, and sexuality (Wilson, 1996, pp. 304–305) .

Acting as a culturally-situated umbrella term, Two Spirit may not mean the same to each person based on their Indigenous heritage, as it can refer both to one's gender expression and sexual and romantic orientations (Hunt, 2016; Robinson, 2017). In some Indigenous communities, Two Spirit people were believed to be the bridge between “male and female, the spiritual and the material, between Indigenous American and non-Indigenous American” (Wilson, 1996, p. 305). Two Spirit people often had important roles within their communities, such as Cheifs and knowledge keepers, and they were respected and valued members of their communities (OUTSaskatoon, 2020b; Wilson, 1996). Some tribes recognized up to six different genders (OUTSaskatoon, 2020b), and there are at least 168 terms in Indigenous languages to describe someone outside of the gender binary of man or woman (Robinson, 2020). Likewise, not all queer Indigenous people use the term Two Spirit, as some choose to use Western terms such as lesbian, gay, trans, or bisexual. Others use the term Indigi-queer, or choose to identify in their native language. For example in the Cree language Ayaahkwew refers to someone that is non-binary or gender fluid, Iskwehikan is a trans woman or someone that is trans-femme and Napehikan is a trans man or someone that is trans-masc (OUTSaskatoon, 2020a). It is vital for Western health practitioners to seek out understanding around Two Spirit identity so that they can work to create holistic and safe spaces for Two Spirit people and their health care needs.

In Canada, phrasing of “missing and murdered Indigenous women and girls” (MMIWG) refers both to vast incidences of violence against Indigenous women and girls and to the human rights movement that has arisen in response to this violence (Brant, 2020). Discrepencies in the number of MMIWG in Canada exist ranging from approximately 1,200 to over 4,000 (Brant, 2020), discrepancies that are due both to the lack of reporting of violence against Indigenous women, girls, and Two Spirit people, and a failure to identify victims as Indigenous (Brant, 2020). In 2016 Canada launched the National Inquiry into Missing and Murdered Indigenous Women and Girls (MMIWG) (in order to address and understand violence against Indigenous women, girls, and Two Spirit people (Centennial College, n.d.). In Canada, violence against Indigenous women, girls, and Two Spirit people is rooted in colonization² as the intersections of racism and patriarchy devalued the roles of these groups and subject them to colonial rule (Centennial College, n.d.). The inquiry listened to the experiences and testimonies of more than 2,380 people from across the country over a period of two years (National Inquiry into MMIWG, 2019). The final, two volume report, Reclaiming Power and Place, spans more than a thousand pages and shares 231 Calls for Justice aimed at governments, various institutions, and the general public (National Inquiry into MMIWG, 2019).

Significantly, Reclaiming Power and Place includes the stories and experiences of Two Spirit, lesbian, bisexual, transgender, queer, questioning, intersex, and asexual (2SLGBTQQIA) people, identifying 32 Calls for Justice that are specific to these communities. It is particularly important for healthcare professions, including nurses, to take seriously both the testimonies of those who shared their stories and the identified steps forward in the work of reconciliation and decolonization. As such, Calls for Justice 3.1 and 7.1 call on health and service providers to recognize the importance in providing services with and for Indigenous peoples including 2SLGBTQQIA peoples. In response to these and the many other Calls for Justice that are relevant to nursing and other healthcare professions, we undertook a review of the literature to both identify the gaps in understanding of holistic wellness of Two Spirit people and to better situate their health and resiliencies in a Canadian context. Through surveying available literature, we make visible a community that is largely invisible within the healthcare sector, thus calling for increased engagement, understanding, and awareness.

Despite there being a rich and growing history of Two Spirit identities, healthcare systems and research initiatives have done a poor job of addressing the health and wellness of Two Spirit people (Hunt, 2016; Robinson, 2017; Wechsler, 2016). Recently the Canadian House of Commons’ Standing Committee on Health (2019) released a document titled The Health of LGBTQIA2 Communities in Canada. This document highlights the numerous health inequities faced by lesbian, gay, bisexual, trans, queer, intersex, asecual and two-spirit (LGBTQIA2) people in Canada and provides strong recommendations for increased research and programing for LGBTQIA2 communities (Standing Committee on Health, 2019). Specific recommendations for the Indigenous LGBTQIA2 community include federal support for a national network of Two Spirit people and organizations, and that all work be committed to reconciliation and decolonization (OUTSaskatoon, 2019). However, the final report included only a small section that focused on Two Spirit and Indigenous LGBTQIA2 people, demonstrating that often, researchers and policymakers assume that people who identify as LGBTQIA2 have similar challenges or experiences within healthcare.

The intersections of gender, sexuality, culture, race, class, and trauma, health and wellness experiences differ for Indigenous 2SLGBTQQIA people who experience both heteropatriarchy and colonial oppression within health systems (Hunt, 2016). Because of these intersections, it is important to examine the unique experiences of Two Spirit and Indigi-queer people and to work toward decolonization through supporting traditional knowledge, values, practices, and beliefs (Robinson, 2020). Working towards decolonization is especially important within healthcare systems, as these settings can be places where people experience re-traumatization (Fleishman et al., 2019). To provide safe and decolonized care for Two Spirit and Indigi-queer people, action is needed by all people working in health care institutions.

It is well documented that the experience of living through and during the effects of colonization is a determinant of health. Ongoing effects of colonization create barriers to health for many Indigenous Peoples in Canada (Hunt, 2016; Scheim et al., 2013). Understanding the impact colonization has on the present day health of Indigenous Peoples is an important aspect in understanding the current health of the Two Spirit community, as much traditional knowledge including spiritual practices, language, and ways of life were lost to colonization (Beavis et al., 2015). The historical trauma the community has experienced and the current racism and discrimination that communities continue to experience can have direct impacts on health (Paradies, 2016). These health impacts can include depression, high-risk behaviors (Paradies, 2016), and substance use (Brave Heart, 2003).

For Two Spirit people the effects of colonization and residential schools include the enforcement of a gender binary that was not necessarily part of Indigenous communities prior to colonization. This experience erased the historic roles, responsibilities, and experiences of Two Spirit people, and perpetuated homophobia and transphobia within Indigenous communities as well as within Western society (Hunt, 2016; Ristock et al., 2019; Scheim et al., 2013).

Due to these intersections of identity, being both Indigenous and 2SLGBTQQIA, we cannot assume that the experiences of Two Spirit people are the same as those within the 2SLGBTQQIA or generally within Indigenous populations. As we build knowledge about the health and well-being of Two Spirit people both within the 2SLGBTQQIA communities and within the larger society, we must recognize their unique experiences, acknowledge the continued impacts of colonization, including the intersections of homophobia, transphobia, and racism, and take seriously the Calls to Action and the Calls for Justice which mobilize us to improve access to care within healthcare settings.

Methods

Through review of the literature, we aim to answer the question: What information is currently available pertaining to the health of Canadian Two Spirit people? By reviewing the literature surrounding the health and well-being of Two Spirit and Indigenous queer people, we aim to continue dialog around the health of Two Spirit people, uncover research gaps, and develop understandings of overall strengths of Two Spirit people. This review is part of a Canadian Institute of Health Research (CIHR) funded research initiative that began as an invited research summit for Indigenous scholars from across Canada. The findings from this review will support a gathering with Two Spirit community members from across the province of Saskatchewan, where we will be able to gather experiential input into health outcomes and needs of Two Spirit people.

Our original review of academic literature found minimal selection of information related specifically to the health of the Two Spirit community, leading us to include grey literature such as government reports, newspaper articles, and other community-based publications within our search. We reviewed articles within the last ten years (2010–2020) associated with Two Spirit health in Canada. The databases searched were Indigenous Studies Portal (iPortal), CINAHL, MEDLINE and Web of Science. The search terms used were “Two Spirit,” “Two-Spirit,” “2S,” or “Indigiqueer” and “health,” “wellbeing,” and “wellness.” We included articles if they were completed in the Canadian context and included anything related to health. We excluded literature that did not exclusively mention Two Spirit specific health related information, and any literature reviews or poster presentation abstracts. Additionally, we searched for grey literature, including reports and newspaper articles. We used the World Health Organization's (WHO) (2021) definition of health - “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” (para 1). This broad definition of health incorporates a holistic view and can value the ideologies within Indigenous Medicine Wheel teachings (emotional, spiritual, physical and mental) and the social determinants of health. We included sources if they focused on the 2SLGBTQQIA community and indicated Two Spirit specific data. Exclusion criteria involved any articles that were not in English. The initial literature search found 124 articles, 25 duplicates were removed, leaving us with 99 abstracts and titles to review. Following abstract and title review, we were left with 28 articles that were included in the full text review. Following a full text review, we included six academic sources from the literature review. Five sources were found through internet searches of grey literature: one government report, one monograph, and three newspaper articles. Ultimately, there are still very few studies that look exclusively at the health of Canadian Two Spirit Peoples, a factor which is often acknowledged in the literature (Hunt, 2016; Issa, 2019; Ristock et al., 2019; Scheim et al., 2013; Waite et al., 2019; Wechsler, 2016). Notably, we did not find any research speaking specifically to nurses about holistic care of Two Spirit people in Canada.

After we identified available research, we completed the analysis using NVivo to organize data and open coding guided by Braun and Clark's reflexive thematic analysis (2006, 2021). A reflexive thematic analysis was critical as it considers the researcher's subjectivity as a resource for analysis (Braun & Clarke, 2006, 2020). Critical reflexive practice was important for the research team as members identify in diverse ways and include people who identify as cis-gender, Two Spirit, queer, transgender, Indigenous, and White Settlers. The primary data coder (KM) is a cisgender, White settler. All members of the research team provided input and guidance on early and final drafts of the article. Working through the analysis phases involved open coding, identifying themes, developing and reviewing themes, and making connections and naming themes (Braun & Clarke, 2006, 2021).

Assessing the impact that colonization has had on the intersections of gender, race, sexuality, class, culture, and spirituality, the Two Spirit communities face unique health concerns compared with other members of the 2SLGBTQQIA community and Indigenous peoples. Because of the overlapping identities, an intersectional lens shaped this exploration of the literature. Intersectionality calls us to critically examine the structures and institutions that privilege some while oppressing others, based on multiple overlapping identities (Crenshaw, 2016; Van Herk et al., 2011). By using an intersectional lens, we aim to illustrate the multiple intersecting identities that Two Spirit people embody as they are both Indigenous and 2SLGBTQQIA. As well, because intersectionality values individual's lived experiences and their stories to be significant (Hankivsky et al., 2017) we felt it important to use grey literature highlithing the voices of the Two Spirit community.

Holistic Health

Addressing health in a holistic way involves looking at the person as a whole and including assessments of physical, mental, emotional and spiritual forms of health (O’Brien King & Gates, 2007). This view parallels the teachings of some Indigenous medicine wheel models where the goal is to find balance in all four directions (Garner et al., 2011). Holistic health acknowledges the entanglements between mind, body and spirit and the importance of viewing health from a whole person perspective (Zamanzadeh et al., 2015). When working with the Two Spirit community, approaching understandings of health in a holistic manner may allow connection to Indigenous teachings to the medicine wheel, and allows movement beyond paternalistic biomedical models that view health as the absence of disease.

Results

Following the review of the literature, identified themes were grounded in the Medicine Wheel teachings based on mental health, spiritual health, physical health and emotional health. These themes directly parallel holistic nursing in their demonstration that health is complex, and that there are many different facets that make up an individuals’ whole health (Frisch & Rabinowitsch, 2019). We found a significant entanglement within the themes where, for example, what one experiences regarding their physical health can affect their mental health – or their spiritual health affects emotional health. Although each theme is separate and individual, many pieces within each category influence a person's whole health.

Mental Health

Mental health is a broadly defined concept that includes many facets of wellness. For this review, we define mental health as “a state of wellbeing” characterized by connection, enjoyment and a sense of self and purpose (Canadian Mental Health Association [CMHA], 2020, p. para 4). From the literature, mental health themes were focused on deficits and strengths that were experienced based on intersections of identity. Mental health challenges faced by the Two Spirit community included suicide, substance use and depression. The mental health strengths and resiliencies that were supported by the Two Spirit community include sharing and hearing stories and connection to spirituality, which is discussed in more detail in a later section.

Suicide

Being Indigenous and part of the 2SLGBTQQIA community are considered non-modifiable risk factors for suicidality (Government of British Columbia, 2008; National Aboriginal Health Organization, 2012). Non-modifiable risk factor are things that are not able to be changed, for example, someone's age or race (Government of British Columbia, 2008). Consistent with the invisibility of Two Spirit experiences within healthcare research, often the Two Spirit community is not addressed in frameworks for prevention of suicide, and statistics may not fully identify Indigenous people who do die by suicide (Issa, 2019; Wechsler, 2016). Looking at the root causes, the increase in suicidality among the Two Spirit community is likely connected to homophobia, transphobia, isolation, and lack of connection (Ferlatte et al., 2020; Hunt, 2016; National Aboriginal Health Organization, 2012), as well as their experiences of homelessness, violence (Issa, 2019; Wechsler, 2016), or past trauma (Ferlatte, Oliffe, Salway, et al., 2019).

Depression, Anxiety, and Substance Use

Members of the Two Spirit community often list substance use as a top concern among community members (Hunt, 2016; Issa, 2019). Two Spirit people are more likely to experience depression and anxiety and be driven to use substances as a coping mechanism (Hunt, 2016). Increased substance use among people who are Two Spirit may be related to their lack of place upon often having to move from their home communities due to experiencing homophobia (Ristock et al., 2019) and lack of access to addictions care (Lyons et al., 2016; Scheim et al., 2013). Many studies have demonstrated that the use of substances may be a downstream effect of a lack of mental health services and general unmet mental health concerns considering experiences of social exclusion, racism, homophobia, transphobia, classism, and intergenerational trauma (Ferlatte, Oliffe, Louie et al., 2019; Hunt, 2016; Robinson, 2017). Knowledge that we are not meeting Two Spirit mental health needs are evident and yet little has been done to create culturally relevant mental health services that consider the intersecting identities of Two Spirit people in Canada.

Mental Health Strengths and Resiliencies

Although it may seem counterintuitive, some Two Spirit people feel as though their experience with multiple forms of oppression has made them more resilient (Jimmy, 2019). Resiliency is the “ability to adapt to adversity, trauma, tragedy, or significant sources of stress” (Hunt, 2016, p. 21). Spirituality – discussed below in greater detail - helps to shape resiliency (Robinson, 2017). Expressions of identity through art is also common within the Two Spirit community, and provides a way for people to express their stories, experiences and identities outside of the confines of normative communication and research strategies (Hunt, 2016). Hearing the stories of others, and sharing one's own stories is thought to be helpful and empowering for Two Spirit people as it highlights the importance of being in community (Jimmy, 2019). Often academic research frames Indigenous health from a deficit perspective. Acknowledging resilience and building on strength can build on existing Two Spirit wellness and should be considered in future and ongoing research with and for Two Spirit people.

Spiritual Health

A study of barriers to well-being for Indigenous gender-diverse people found that over half of the Indigenous participants reported being fair to extremely religious or spiritual, highlighting the importance that spirituality or religion may play in the lives of some Indigenous peoples (Scheim et al., 2013). Spirituality can vary depending on the individual and community. Spirituality can include things such as ceremony, counseling, learning traditional roles, connections to the land, traditional language, traditional teachings, connection to an Elder, and connection to the Medicine Wheel (Ferlatte, Oliffe, Louie et al., 2019; Hunt, 2016; Issa, 2019; National Aboriginal Health Organization, 2012; Robinson, 2017; Scheim et al., 2013).

Connection to Indigenous traditions and culture can have very positive effects on the health of the Two Spirit community in decreasing depression (Issa, 2019; Scheim et al., 2013), decreasing suicidality (National Aboriginal Health Organization, 2012) and building resilience (Ferlatte, Oliffe, Louie et al., 2019; Jimmy, 2019; Robinson, 2017). Ultimately, connection to culture is an essential part of health promotion (Scheim et al., 2013; Wechsler, 2016). For example, when discussing their history of suicidality 2SLGBTQQIA participants explored how use of traditional practices such as smudging, cleansed their body and spirit and helped remove thoughts of suicide (Ferlatte, Oliffe, Louie et al., 2019). In the same study, a Two Spirit participant described the experience of reconnecting with their traditions as being reborn (Ferlatte, Oliffe, Louie et al., 2019). It is evident that strategies intent upon supporting the health and well-being of Two Spirit people would do well to include access to spiritual and culturally specific supports while recognizing that spiritual and cultural supports can and will vary across different Indigenous people as individuals and as communities.

Barriers to Spirituality

The positive impacts of spirituality within Indigenous communities are inversely impacted by colonization. For many Indigenous people, colonization resulted in a shift from Indigenous spirituality to religion, particularly Catholicism, and this shift has had detrimental effects. As contemporary Indigenous people seek to learn and grow within Indigenous spiritualities, they face continued barriers due to neocolonialism, a lack of availability of Elders, and in some cases, Elders who are not knowledgeable about Two Spirit identities (Scheim et al., 2013). Because of the wide-reaching effects of colonization, Elders may unknowingly perpetuate homophobic and transphobic beliefs stemming from residential schools (National Aboriginal Health Organization, 2012).

Christian beliefs rooted in a binary understanding of sex and gender perpetuate the experiences of homophobia and transphobia, admonishing more fluid and flexible understandings of gender as existed within Indigenous communities (Ferlatte, Oliffe, Salway et al., 2019; National Aboriginal Health Organization, 2012). Consequently, for Two Spirit people, residential schools denied Two Spirit identities and erased traditional Indigenous teachings around gender diversity (Robinson, 2020). Literature and lived experience both support that micro and macro systems exist that create barriers to holistic spiritual wellness for Two Spirit people.

Physical Health

Physical health is multifaceted and can be explored in several different ways. For this review, physical health consists mainly of things that are medically diagnosable internally (i.e. HIV) or things that affect the external shell of the body (i.e. violence).

HIV

Currently, there are no known rates of HIV transmission and prevalence within the Two Spirit community, an absence which is itself a matter of concern (Hunt, 2016). Generally speaking, Indigenous communities are at a higher risk of HIV than non-Indigenous Canadians (Scheim et al., 2013) and a positive HIV status may add another intersecting identity that causes barriers within communities and institutional settings (Ferlatte et al., 2020; Standing Committee on Health, 2019). The Two Spirit community may be at an increased risk of HIV considering their increased mental health challenges, increased substance use, and exclusion from housing and support services (Lyons et al., 2016; Ristock et al., 2019). Increased tracking and demographic data are needed in order to better assess the impacts of HIV on the Two Spirit community.

Violence

As the National Inquiry into MMIWG has demonstrated, rates of violence, particularly sexual violence, against Indigenous people are staggering (National Inquiry into MMIWG, 2019). Extending the findings of the MMIWG Final Report, physical and sexual violence are commonly reported among Indigenous and Two Spirit communities (Hunt, 2016; Robinson, 2017; Scheim et al., 2013). This violence occurs both in their home communities (Ferlatte, Oliffe, Salway et al., 2019; Hunt, 2016) and larger urban centers (Ristock et al., 2019). Findings indicate that Two Spirit people are more likely to experience violence than non-Two Spirit Indigenous people (Klassen, 2014; National Aboriginal Health Organization, 2012). Compared to heterosexual Indigenous women and non-Indigenous members of the 2SLGBTQQIA community, Two Spirit women are more likely to experience both sexual and physical violence (Hunt, 2016; Klassen, 2014). These high incidences of violence are due to structural racism, continued impacts of residential schools and colonization, transphobia, homophobia, social exclusion (Lyons et al., 2016; Ristock et al., 2019; Scheim et al., 2013), and conditions related to poverty (Ristock et al., 2019; Robinson, 2017).

Emotional Health

When we speak of emotional health, we are inspired by the Canadian AIDS treatment information exchange (CATIE)'s definition, that supports a holistic perspective of emotional health. CATIE (n.d.) defines emotional health as a feeling of balance in the different aspects of one's life, and indicates that when we feel emotionally healthy, we can more easily find and establish a balance between all elements (CAITE, n.d.). We found that the most critical aspects of one's mental health were the ABCs – acceptance, belonging, and community, factors which are centrally linked to the health and well-being of 2SLGBTQQIA people and so often form the cornerstones of support services for these communities. As well, we identified barriers and supports, as indicated within the literature.

Barriers

For the Two Spirit community, acceptance and belonging have been challenged by racism, homophobia, and transphobia within Indigenous communities and general society (Hunt, 2016). Isolation due to lack of belonging in both Indigenous and non-Indigenous communities can increase suicidality and experiences of violence (Hunt, 2016). Invisibility within research, data, and media can also contribute to failed feelings of acceptance and belonging (Hunt, 2016; Issa, 2019; Lyons et al., 2016; Ristock et al., 2019; Scheim et al., 2013; Waite et al., 2019; Wechsler, 2016). Invisibility, isolation, and acceptance are affected by racism, homophobia and transphobia creating additional barriers for the Two Spirit community when achieving emotional health.

Supports

Relationships are an essential aspect of Indigenous traditions (Jimmy, 2019) and supportive relationships within a community can benefit one's health through enabling feelings of acceptance and belonging (Ferlatte, Oliffe, Louie et al., 2019; Jimmy, 2019). Recognizing the value of inclusion and belonging, studies have shown that amongst the general Indigenous population, youth suicides decrease when community connection is strong (Hunt, 2016). Furthermore, having supportive families is correlated with better mental health and stable housing (Scheim et al., 2013). As Two Spirit people occupy multiple identities, they sometimes experience social exclusion and lateral stigma in both queer and Indigenous contexts, making it difficult to access community (Ferlatte, Oliffe, Louie et al., 2019; Ferlatte, Oliffe, Salway et al., 2019; Ristock et al., 2019). Of even greater difficulty is the lack of access to Two Spirit specific community settings, however some have found other ways to meet such as through social media (Hunt, 2016). In future, it would be helpful for organizations to consider developing Two Spirit peer support roles and groups for people to easily connect with similar communities (Ferlatte, Oliffe, Louie et al., 2019). Overall literature and research that define and discuss the emotional health of Two Spirit people was difficult to find and remains poorly addressed in nursing knowledge and bodies of scholarly work.

Summary

One's health is made up of several complex and overlapping aspects: mental, spiritual, physical and emotional. For the Two Spirit community, each aspect comes with supportive factors and barriers to achieving holistic health. The Two Spirit community is often made to be invisible due to the many intersecting factors of race, gender, sexuality, class and culture. Spirituality and connection to culture are aspects of health that are positive and build resilience within the community. Nurses in practice, education, and research can be active leaders in working with and for Two Spirit people and communities to start to address the barriers identified to holistic Two Spirit wellness.

Discussion

We opened this review with two of the Calls for Justice from the MMIWG Inquiry: 3.1 and 7.1, both of which highlight the importance of focusing on the health of Indigenous Peoples and of achieving justice through listening to and following the lead of Indigenous Peoples. The Calls for Justice also provide a way to frame how health care members can take action to support Two Spirit wellness through acts of reconciliation and the decolonization of our health care systems. Nurses are centralized team members to many health care institutions and can use their skills in advocacy and as change agents to work along side Two Spirit people in Canada and to close health care gaps and enhance the holistic wellness of Two Spiritpeople. As such, our discussion both responds to the literature and aligns with these particular Calls for Justice in foregrounding key areas on which to focus our efforts within the field of holistic nursing education. In particular, the literature demonstrates that improvements to the health and well-being of Two Spirit people rely precisely upon increasing visibility of this group, both within research and educational settings as well as ensuring that any increases in visibility and attention are couched in the self determination of Two Spirit people. Following from these two findings, we identify evidence-informed steps to be taken within nursing practice, education, and research.

A Call to Increase the Visibility of Two Spirit People in Healthcare

Our review makes explicit that Two Spirit people are invisible within healthcare fields and research landscapes. The Two Spirit community exists at the intersections of the 2SLGBTQQIA community and the Indigenous community and this intersecting identity lends toward their invisibility and absence of uptake within recommendations and strategies aimed at increasing health and well-being. Furthermore, this invisibility compounds the lack of national statistics and interventions specific to the Two Spirit community. As the literature demonstrates, Indigenous members of the 2SLGBTQQIA community experience heightened risks and impacts on well-being. These heightened risks are exemplified in the increases of violence, poverty, substance use, and depression. Because of this, equitable protections include actions that increase visibility, such as amplifying voices of Indigenous LGBTQ2IA people in research, healthcare and education. Increased visiliby and awareness of Two Spirit people will respond directly to Call for Justice 3.1 which calls on governments to “ensure that the rights to health and wellness of Indigenous Peoples, and specifically of Indigenous women, girls, and 2SLGBTQQIA people, are recognized and protected on an equitable basis” (National Inquiry into MMIWG, 2019, p. 180).

A Call to Recognize and Support the Self-Determination of Two Spirit Peoples

In order to wholly support Indigenous communities to deliver effective care, we must understand the importance of building community, fostering spiritual aspects of health, and providing access to cultural supports and services. Shifts in healthcare services from Western colonist perspectives and paternalistic programs, must make space for Indigenous Ways of Knowing to be acknowledged, practiced, and respected. Reconciliation must focus on programing that supports Indigenous led health programs, integrating Indigenous practices alongside Western medicine.

Call for Justice 7.1 asks governments and health service providers to “recognize that Indigenous Peoples – First Nations, Inuit, and Métis, including 2SLGBTQQIA people – are the experts in caring for and healing themselves” (National Inquiry into MMIWG, 2019, p. 188). Furthermore, and in line with our review of the literature, the efficacy of health services will increase when they come from within the communities they aim to serve, formulated in a holistic manner that is consistent with the “practices, world views, cultures, languages, and values of the diverse Inuit, Métis, and First Nations communities” (National Inquiry into MMIWG, 2019, p. 188).

Within the nursing profession, this requires nurses to reflect, demand, and seek action at the practice, education, and research levels. We acknowledge that these are not simple tasks, and shifting the culture comes with many barriers and challenges. We also acknowledge that these discussions are not wholly inclusive of everything nurses are able to do. Regardless, we believe that it is our ethical and moral obligation to start somewhere.

Steps Toward Improving Nursing Practice

It is essential that nurses are educated on 2SLGBTQQIA and Indigenous populations. As both 2SLGBTQQIA and Indigenous education for HCPs is lacking (Murphy, 2019), Two Spirit specific knowledge and focus within healthcare education programs is likely also significantly lacking. Nurses must take on the responsibility of understanding the impacts that privilege and oppression have within our own practice and the profession as a whole (Van Herk et al., 2011). Cultural education can take many forms, and there are many existing iterations of culturally-informed education and training. Cultural competence education includes learning about different cultures and valuing diversity within patients and workspaces (Margolies & Brown, 2019). Cultural humility when working with populations builds upon cultural competence and suggests the development of self-reflection and an understanding of the power imbalances that contribute to different experiences within healthcare

Through cultural humility the aim is for developing relationships that are balanced, equitable, and patient-centered (Foronda et al., 2016). Cultural humility is not a task-focused skill to check off, it is a lifelong process and practice grounded in openness, self-awareness, and being egoless, supportive, and self-reflective (Foronda et al., 2016). Cultural humility fosters resilience, empowerment, and care that is patient-centered (Foronda et al., 2016). Fostering cultural humility within nursing practice calls on the importance of listening to the experiences of the Indigenous 2SLGBTQQIA community and amplifying their voices to truly listen to what is needed, and what our role is as nurses. Trauma-informed care often starts by acknowledging that experiences of trauma are highly prevalent within members of society, and that health care services can often be re-traumatizing (Fleishman et al., 2019). Although literature surrounding the efficacy of trauma-informed care is limited, early reports suggest that trauma-informed care is generally effective in some populations, and more effective in specific populations – including those who experience post-traumatic stress disorder (Barajas & Martinez, 2020). Incorporating trauma-informed care into nursing practice includes introducing our name and role, explaining procedures, gaining consent before touching, and avoiding medical jargon (Fleishman et al., 2019).

Within nursing practice, we can advocate for community programing that supports Two Spirit and Indigenous 2SLGBTQQIA people to have safe spaces and access to care. This may include shifting forms of practice to be inclusive of multiple identities like Two Spirit, or any of the gender and sexual identities with which people identify. Across North America, there are groups working to improve the visibility, health, and lives of the Two Spirit community and sowe can consider aligning ourselves with grassroot organizations that are already doing the work and see the ways that we are able to further support health at our base practice level, and into policy and institutional levels.

As nurses, we are also able to use our trusted position within society to advocate for the importance of access to Indigenous specific healthcare resources for members of the 2SLGBTQQIA community. From the reviewed literature, it was clear that spiritual health services that were Two Spirit inclusive were important for maintaining and regaining health within this community. Ensuring there is access to these supports is imperative in promoting holistic health within the community. This access can be supported through making connections with the community, speaking with grassroots organizations and, depending on what sites we are practicing in, speaking with management and administrators to ensure that diverse spiritual guides are available within a healthcare setting.

Steps Toward Improving Nursing Education

Indigenous people are underrepresented in nursing, currently making up less than 1% of the Canadian nursing workforce (Harder et al., 2018; Vukic et al., 2012), which may parallel the challenges many Indigenous Peoples face in health care access and receiving culturally appropriate care (Cameron et al., 2014). Literature on representation of Two Spirit nursing or nursing students was not found, which emphasizes the current invisibility of Two Spirit voices in health care, and health care education. Indigenous nursing students reported inadequate supports financially and socially, and experiences racism which affected their experiences with their nursing education (Vukic et al., 2012). Within nursing curriculum there may also be a lack of Indigenous ways of knowing (Vukic et al., 2012). Indigenous students identified supportive factors, as having peers that are Indigenous to support each other through the process and belonging within a group (Vukic et al., 2012). These findings highlight that Indigenous representation within nursing education and practice matters. It is essential that we aim to improve retention for Indigenous nurses.

Addressing racism and discrimination through nursing education is a step to take towards retention within the profession. Within nursing education, curriculums may focus on neutrality and the memorization of skills, opposed to critical education on oppression and structural violence (McGibbon & Lukeman, 2019). Additionally, the field of nursing education may be hindered in its ability to achieve this due to focus on efficiency, large class sizes, and focus on teaching towards the National Council Licensure Exam (NCLEX) (McGibbon & Lukeman, 2019).

Within nursing education, learning about critical theory like anti-racism and intersectionality may provide opportunities for students to understand the power relationships that broadly impact all aspects of health (McGibbon & Lukeman, 2019). Teaching and understanding critical perspectives within nursing, may allow for a deeper understanding and actioning of social justice (McGibbon & Lukeman, 2019). Social justice is a broad concept, focusing on equity among all members of society (Canadian Nurses Association [CNA], 2010). The nursing curriculum is an excellent opportunity to educate nurses on the value of practicing from a social justice framework (Buck-Mcfadyen & Macdonnell, 2017). Intersectionality allows for exploration of ways in which some identities are privileged where others face extreme barriers. Within nursing education, an understanding of intersectionality can provide nurses with the opportunity to critically reflect on their own identities and how the power we hold as nurses may impact the care we give (Van Herk et al., 2011). Mandatory anti-racism training for all health care educators, as well as health care students can be a starting point in addressing inequities for Two Spirit people.

To increase health equity, nursing students must understand the long-lasting impacts of colonization. These teachings could include discussions of the experiences of Indigenous communities, existing power structures and opportunities for self-reflection on oppression and privileges within their own practice (Beavis et al., 2015). It is essential that teachings on colonization include Two Spirit and Indigenous community members, in order that students comprehend the impacts of gender and sexuality and how these impact Two Spirit people (Beavis et al., 2015; Harder et al., 2018). When students learn about colonization and power structures, they are able to provide better care and to better advocate for their patients (Beavis et al., 2015). By understanding colonization and intersectionality and by acknowledging the additional barriers that the intersections of race, culture, gender and sexuality create for the Two Spirit community, nurses can work to increase the health equity for these populations.

Decolonizing nursing curriculum is a complex task that requires both addressing and understanding the ways that colonization affected, and is currently affecting Indigenous people (Harder et al., 2018). Harder et al. (2018), offer an approach of “two-eyed seeing” where we incorporate and value worldviews and knowledge from both Indigenous and Western paradigms. Two-eyed seeing refutes essentialism, which is imperative when working with Indigenous communities, specifically Two Spirit people, as there are many ways to exist within these identities (Harder et al., 2018). There is a lack of research that looks at the best ways to Indigenize curriculum, but some suggestions include assignments that focus on Indigenous knowledge, guest lectures from people in the Indigenous community, including Elders and nurses, and incorporating the Truth and Reconciliation Calls to Action (Harder et al., 2018), and the MMIWG Calls for Justice into curriculums.

Steps Toward Improving Nursing Research

From the literature reviewed, it is clear that more research is needed related to the holistic health of the Two Spirit community. Of note, Indigenous peoples are considered one of the most researched human groups, however, historically, many research projects were exploitative and continue to include power imbalances within the research relationship (Mirjam, 2019). Research projects that are led by the community, for the community, are essential building building on existing strengths and resiliencies of Indigenous community. Decolonizing and Indigenizing research opens up discussions related to positionality, power relations, and the role of settlers when using Indigenous research methodologies (Mirjam, 2019). Like education, working with Indigenous knowledge keepers, community members, and Two Spirit Elders can help facilitate community connections and knowledge when engaging in research with Two Spirit communities.

All Nursing colleges and universities should adopt OCAP principles as mandatory certification for all faculty and students. OCAP principles of Ownership, Control, Access and Possession embody how researchers must work with Indigenous populations (First Nations Information Governance Centre (FNIGC), 2021). The OCAP principles empower First Nations to make decisions on how they want their information to be gathered, used, and distributed (FNIGC, 2021). These principles highlight the control over all aspects of research that communities are involved in, and ensures access and control to the data that they provide (FNIGC, 2021).

When nurses use the OCAP principles, they are respecting Indigenous knowledge, autonomy and sovereignty, and are ensuring that work with Indigenous populations is ethical (FNIGC, 2021). Barriers exist within institutional boundaries in adopting OCAP principles because of traditional views on academic and research success that centre western perspectives of knowledge and knowing. Universities and colleges need to reframe scholarship in order to allow partnerships to work in a good way, for the benefit of the people and the community, and to not prioritize institutional gain. Engaging with the community and involving them in every step of the research process is imperative when researching with the Two Spirit community.

Limitations

Our findings indicate several limitations to finding comprehensive information about the health and wellness of the Two Spirit community. First, there was a general dearth of research done with or about this community. Second, throughout the literature, there may have been times where Two Spirit was included in the acronym, but it was not clear whether or not there were Two Spirit participants recruited, or any data collected from members of the Two Spirit community. And finally, some health literature was framed in a way that could be pathologizing and may not wholly incorporate a strengths-based approach. As a result, this research implicates health care providers at three levels, including nursing practice, education, and research, as demonstrated above.

Conclusion

Nursing has been largely silent on addressing inequities in the health of Two Spirit people as evidenced by the lack of research, practice, and educational content specific to Two Spirit health. Through using holistic approaches to health and assessing the impact that colonization has had on the intersections of gender, race, sexuality, class, culture, and spirituality, nurses can contribute to enhancing Two Spirit wellness through collaborative and community-led initiatives.

Two Spirit people have unique health needs that are specific to their Two Spirit identity and cannot be generalized or assumed to be homogonous to other members of the 2SLGBTQQIA community or other Indigenous peoples or communities. The Two Spirit community has been left out of many nursing and allied health research and now is the time to work with Two Spirit people and their communities in considering the intersections of identity and structural barriers that impact this community. More research led by and in collaboration with the Two Spirit community is needed.

Biography

Melissa Dykhuizen, MN, RN, is faculty in the School of Nursing at Saskatchewan Polytechnic and undergraduate adjunct professor at the University of Regina in the Saskatchewan Collaborative Bachelor of Science in Nursing Program. She is also a doctoral candidate in nursing through the University of Saskatchewan, focusing on transgender men's experiences of cervical cancer screening.

Kerry Marshall, MN, RN is a UBC School of Nursing PhD student interested in reproductive rights; harm reduction; social justice; and public, community, and 2SLGBTQ health.

Rachel Loewen Walker, PhD, MA is the Ariel F Sallows Chair in Human Rights with the College of Law at the University of Saskatchewan. She teaches in gender, sexuality, and social justice and is the director of the SSHRC-funded Social Innovation Lab on Gender, Culture, and Sexuality.

Jack Saddleback is a proud Nehiyaw (Cree) Two Spirit / IndigiQueer, trans, gay man from the Samson Cree Nation in Maskwacis, Alberta, and is OUTSaskatoon’s Cultural & SHOUT Project Coordinator. He is a staunch advocate for Two Spirit topics, mental health, Indigenous engagement, equitable policies, and social stewardship. He is currently studying sociology at the University of Saskatchewan.