Rethinking Gender Diversity Terminology: A Call to Include Native Two-Spirit and LGBTQ+ Youth

The term Two Spirit refers to AI/AN individuals with sexual orientations or gender identities typically excluded from binary, westernized identification. Two Spirit encompasses sexual, cultural, gender, and spiritual identity and moves beyond binary terminology focused on sex assigned at birth. In this way, some individuals may have fluid and nonlinear identities, and an individual who is Two Spirit may identify as nonbinary, agender, genderqueer, or transgender.²  It is important to note that Two Spirit is not synonymous with a Native individual who is LGBTQ+. We again acknowledge that terminology is fluid and varies by Native culture and geography.

Before colonization, gender diversity was celebrated within AI/AN communities. Two Spirit and gender diverse individuals held esteemed roles as leaders, healers, and decision-makers.²  The process of settler colonialism eliminated the historic celebration of gender diversity across all Native communities, though each community was impacted in distinct ways.^3,4  Within the United States, genocide, forced seizure of land, and the placement of AI/AN children in boarding schools eradicated Native culture and connections to community. As a result, 2SLGBTQ+ AI/AN individuals were forced to assimilate and repress both their Native and gender diverse identities.³  Thus began the process of historical and intergenerational traumas, setting the stage for discrimination and health disparities experienced by AI/AN and 2SLGBTQ+ communities.

Although data regarding health for Native 2SLGBTQ+ are limited because of lack of inclusion or misclassification,⁵  outcomes parallel those among non-Native GDY. 2SLGBTQ+ youth experience increased rates of poor mental and physical health resulting from the long-term impacts of historical trauma, including barriers to healthcare.^6–8  Common barriers to care for 2SLGBTQ+ youth include socioeconomic obstacles, restrictive legislation, distance to healthcare facilities (especially for patients in rural locations), and lack of health insurance and family support.⁹  Lack of provider understanding of AI/AN perspective and culture, or discomfort with terminology and practices surrounding gender-affirming care, also contribute.⁹  Considerations regarding autonomy and sexual and reproductive health are critical. For instance, the history of forced sterilizations and paternalistic medical care against AI/AN individuals may influence decision-making (ie, surrounding long-acting reversible contraception (LARC), emergency contraception, and sexual health).¹⁰ 

In the face of inequity, Native 2SLGBTQ+ youth and adolescents have demonstrated remarkable resilience. GDY and adolescents remain hopeful about the future and report positive markers of mental health (improved pride, self-esteem, reduced mood symptoms) when supported by family and community.¹¹  They report pride behind their identities as AI/AN and gender diverse.¹¹  Such connections to AI/AN traditions and values are integral in overcoming trauma and are important for pediatric providers to recognize. By viewing youth and adolescents comprehensively, providers can celebrate their multiple unique identities. Addressing the connection between community, culture, and health in clinical settings can also improve outcomes. Studies demonstrate that providers who ask patients culturally informed questions report helping their patients at higher rates than those that who do not know how to ask.¹² 

Providers and researchers play integral roles in supporting the well-being of Native 2SLGBTQ+ youth. Taking steps to educate providers and staff surrounding both AI/AN history and cultures as well as gender-affirming practices are critical. Understanding historical context allows providers to honor the strengths and resilience of AI/AN youth, adolescents, and communities, and better advocate for their needs. Clinicians who celebrate gender-diversity and recognize the role of reconnection to tradition in healing can better connect with Native patients and their families. For non-Native LGBTQ+ patients, stories of gender diverse Native individuals demonstrate that gender diversity is not a trend, combatting common misinformation. Culturally informed resources, such as the “Celebrating Our Magic” Toolkit and Paths (Re)Membered Project, may also help with education for providers, patients, and families.^11,13,14 Figure 1 and Table 1 highlight some key takeaways from these resources.

Beyond affirming environments and care, providers should promote the inclusion of AI/AN 2SLGBTQ+ youth and adolescents in research. Highlighting their experiences can increase medical knowledge and yield data to support programming focused on 2SLGBTQ+ youth and adolescents. Best practices include engaging AI/AN individuals in community-based participatory research and elevating the strengths of existing programming in Native communities. Inclusion of 2SLGBTQ+ youth and adolescents in this space is also critical to center and elevate their voices in the gender diversity space.

Increasing awareness of the strengths and needs in this community can also be accomplished through medical education. Medical school, medical residency, and health services curricula ought to incorporate historical contexts, the connection between historical trauma and health disparities, and inherent strengths among Native communities. Similarly, Two Spirit identity and historical contexts of gender diversity should also be included in lessons related to gender-affirming care.

On an advocacy level, providers can support legislation focused on protecting rights and access to care for all GDY. Providers can also share the history of gender diversity in the policy space to dispel myths related to gender diversity being a trend. Including stories about Two Spirit and Native LGBTQ+ patients and including 2SLGBTQ+ individuals themselves in policy making can ensure that their voices are present and needs highlighted. In the same way, providers can advocate against the cultural appropriation of the term Two Spirit by non-Native peoples.

Current legislative trends necessitate that pediatrics providers understand the history of gender diversity, so they can best care and advocate for all GDY. If we leave AI/AN youth and adolescents out of the picture, we cannot truly promote and create equity for GDY.

We thank Itai Jeffries (they/them) (Yèsah) for their review of this commentary and their inspirational and impactful work advocating for Native 2SLGBTQ+ youth, adolescents, and adults.

2SLGBTQ+

Two Spirit and Lesbian, Gay, Bisexual, Transgender, and Queer

AI/AN

American Indian and Alaska Native

GDY

gender diverse youth