What Health Providers Can Learn:
There are two-education steps to a healthy patient relationship with 2-Spirit People.
July 1, 2004 to December 31, 2005

1. Overview:

The medical education literature recognizes that in order to meet the needs of historically marginalized communities, educators must develop curriculum to improve medical students' knowledge of how to provide sensitive and appropriate care to these peoples (Shroeder et al. 1989; Kern et al. 1998; Wasylenki et al., 2000; Pickerel 2001). Theses educators, however, have not developed a curricular response to the health issues, barriers, and realities of the gay, lesbian, bisexual, and transgendered/transexual (GLBT) community. As a result, GLBT peoples' access to health care continues to be compromised by homophobia and heterosexism that affects their dignity, trust of health care professionals, equal access to health knowledge, and ability to achieve and maintain good health.

The medical education literature also recognizes that cultural differences affect doctor-patient communications, use of health services, and health status (Bayne-Smith, 1996; Flores 2000). A subfield of this literature recognizes that First Nations experience the greatest disparities in health status and access to health care (Korenbrot et al. 2003; Wittig 2004). Factors that contribute to this disparity are traceable to colonialism, Christian missionization, the theft of traditional cultures, and concomitant low self-esteem, reflected in the indicators of poverty, inadequate housing, high rates of substance abuse, high suicide rates, high unemployment, high risk behaviour, and violence (Waldram 1994; Wotherspoon 1994; Wright et al. 1997; Brotman et al. 2002). In addition, Aboriginal people often possess an historic distrust of state-delivered health care that was rarely delivered using the best practices of the day. Racism and cultural insensitivity in today's mainstream health services continue to compound this distrust.

Training doctors to understand Aboriginal and other cultural scenarios can eliminate ethnic disparities in health use and health status. A recent study, however, found that no Canadian medical schools taught a course on cultural issues (Flores et al. 2000). Instead, it found that Canadian medical schools address culture in a few lectures contained within a larger course. It also found that within this small allotment of time, only 27% of Canadian medical schools addressed Aboriginal health issues (Flores et al. 2000). The authors were astonished to find that although greater cultural understanding can reduce health disparities between communities and improve doctor-patient communication, that no Canadian medical school had made any curricular modifications to meet this fact.

Two-Spirited People's access to health care is uniquely problematized by the combination of homophobia, heterosexism, racism, cultural insensitivity, and a legacy of distrust towards health care professionals. One result is the diminished health status of our membership. Two-Spirited peoples' health issues are not limited to HIV/AIDS but also include diabetes, substance abuse related illnesses, high STDs, and injuries from accidents and violence. Another factor that affects our members' health is discrimination within their home communities. Two-spirited people do not generally trust the confidentiality of on-reserve health services and due to discrimination in rural environments, often leave for cities where they find anonymity but experience cultural trauma and isolation (Brotman et al. 2002). In 1989, we formed 2-Spirited People of the 1st Nations to help dislocated and disadvantaged 2-Spirited people build a cultural support system and reclaim our identity as 2-Sprited - an Aboriginal tradition independent from the western history of GLBT culture.

2-Spirited People of the 1st Nations early identified our members' problematic access to health care. In response, we steadily enlarged our capacity and partnered with various provincial and federal health care funders to provide Hepatitis and HIV clinics, conduct a needle exchange program, and develop a culturally appropriate palliative care program. We have also conducted rigorous community-based social science research that has influenced health policy in Canada. The environment of mainstream health services, however, still needs reform. The problem is two-fold. Not only do mainstream services maintain homophobic and heterosexist environments, but our members take a passive response to these barriers, do not demand an equitable understanding of their realities, and generally avoid these services when they need them.

We are pleased that CRHC has set a goal to improve GLBT and 2-Spirited peoples' access to care through the education of health care professionals and the enlargement of the capacity of communities. Medical schools in Canada have recently undergone a major pedagogical transformation and moved away from didactic, lecture room-based learning to "problem-based" and "community-oriented" learning. The opportunity to integrate knowledge of our health issues in this pedagogical approach is good (Schmidt et al. 1989; Normile 2002; Langan 2002; Wasylenki et al. 2000). To date, however, no medical school has included a 2-Sprited health scenario in its problem-based learning or expressed an interest in extending its community-oriented learning to our community. This gap can be remedied.

2. Main objective

We propose to develop a medical school curriculum on 2-Spirited health to be part of a larger course devoted to GLBT health. The curriculum will offer text and video-based materials and opportunities for medical students to learn within our community.

In the development of this proposal, we spoke with a Canadian medical school curriculum designer who stated that a 2-Spirited curriculum would provide a "rich experience" for medical students and contain many principles transferable to other areas of a doctor's career. He expected that medical school directors would be receptive to this proposed leaning opportunity. Our shared goal is to help doctors become better doctors.

3.1 Specific objective 1

To develop partnerships with Canadian medical schools and implement a 2-Sprited health curriculum that will be part of a full course devoted to GLBT health.

We have begun this process through informal discussions with medical professionals.

3.2 Specific objective 2

The objective of our curriculum is to increase the capacity of medical students to address the health and well-being of 2-Spirited peoples. In the development of this curriculum we will identify and share the knowledge, skills, and attitudes essential to the education of medical students. The project will be first implemented in the greater Toronto area then expanded to schools across Canada (see section 4 below).

The curriculum will begin with text-based studies of our traditional culture from a small but emerging literature (Williams 1984; Brown 1997; Crow et. al., 1997; Jacobs et al. 1997; Jacobs et al. 1997;). We propose to augment these texts with members' auto-ethnographies of our 2-Sprited traditions to be recorded on videotape. The curriculum can then extend to text-based studies on current Aboriginal health and the health issues of 2-Spirited Peoples (Wotherspoon 1994; Waldram 1994; Kaufman et. al1996; Silverman et al. 2001; Browne et al. 2001; Walters et al. 2001; Craib et. al. 2003). We propose to augment this literature with videographies of members' recent experiences with health care services. The videos will be designed in conjunction with medical educators so as to be most useful in "problem-based" classroom scenarios. The literature concurs that "teaching through stories" is a valuable teaching strategy in community-based medical learning (Sorrell 2002).

Third, we propose to invite medical students into our community to learn first-hand about our cultural and sexual perspectives. Students can observe our Hepatitis and HIV clinics along with our other programs. We also propose to develop seminars in which our members can share their health care experiences with medical students. Students may be required to journalize or diarize their experiences as part of a self-reflecting teaching strategy (Kern et. al. 1998; Redmond 2002).

By providing medical students with our membership's direct perspective on culture, traditions, health issues, and health access, our members will have an important impact on the education of medical students (Wasylenki et. al. 2000).

The final part of the curriculum is to have the medical students who entered our community participate in a post-placement seminar with other medical students and share their experience, discuss the knowledge acquired, and be self-reflective about their assumptions. Student self-reflection is critical to acquiring the skills, knowledge, and attitudes required to better serve our community (Kern et. al. 1998; Redmond 2002). Through a post-placement seminar, the medical students can share their leaning with student who did not enter our community (or choose to enter a different GLBT community).

3.3 Specific objective 3

The purpose of the curriculum is not only to address the education of medical students, but also to address the problems that affect the health of 2-Spririted people. To ensure that we understand the health barriers and health access needs of our members, we will conduct focus groups and short surveys among our members. This social science research will be conducted using best current practices.

The data will provide a picture of members' current problems with access to health care. Clarifying our memberships problems will help us best address their needs and build our internal capacity. Clear identification of their access barriers will also enable us to focus our curriculum design (Kern et. al. 1998). The ultimate purpose is to address the access problems that affect the ability of our members to attain and maintain good health.

3.4 Specific objective 4

To build the capacity of 2-Spirited peoples to become active partners in their own health care. We propose to hold seminars with our members to discuss their health access issues and "workshop" ways in which they may empower themselves to receive respect and better health care. Improved contact between medical schools and our members during the course of this project can help members become self-reflective and more aware of how they can expect doctors to serve them better.

4. Targeted Players

Initially, the targeted players are students enrolled in Toronto medical schools and the membership of 2-Spirited Peoples of the 1st Nations. Our member survey and focus groups will help us target areas of medical practice for particular curricular attention. After we have assessed our program we will construct a model that can be replicated in medical schools and other 2-Spirited communities across Canada. Our problem-based and community-oriented learning curriculum is designed so that it not only influences the education of a few medical students but that the student's learning is shared among their cohorts. The skills and attitudes that medical student can learn are transferable to other medical scenarios that they may encounter in their careers.

5. Territory

The literature and video components of our curriculum can be applied in any Canadian medical school. Initially the applied community-oriented component will be limited to the Toronto area. Once we have had the time to assess and improve this component, we propose to develop a model that may be applied by any 2-Spirited community across Canada.

6. How our proposal meets the CHRC's project goals

The CHRC and 2-Sprited Peoples of the 1st Nations have identified a common goal to educate health care professionals about our health, sexuality, and culture. The medical community has also identified this need and invited our leaders to lecture to medical students from time to time. This current system, however, is ad hoc and inadequate. We share the CHRC's commitment to end ad hoc educational programming and embed a full and appropriate GLBT/2-Spirited health study in the curriculum of medical students. Our project can dovetail with another GLBT organization's curriculum proposal and our unique cultural factors will add a critical dimension to the curriculum.

We have the capacity to undertake this project and are committed to the promotion of a more sensitive health care system and improving the health status of our members.

7. Duration of the project

The duration of the project will be from July 1, 2004 to December 31, 2005.

8. A work plan for the project

  • Literature review
  • Conduct survey with 2 spirit members and Toronto based medical school for the pilot
  • Video production
  • current health scenarios
  • cultural problem based videos
  • Identify 2-Spirit health issues
  • Discussion group(s) with 2 spirit members
  • Develop curriculum
  • Work with GLBT health to incorporate 2-Spirit health curriculum
  • Collaborate with GLBT health to introduce curriculum and explain to medical professionals
  • Evaluate pilot curriculum and ensure appropriateness for other medical schools in Canada

9. A budget

10. References

Bayne-Smith, Marcia, ed. (1996). Race, Gender, and Health. London: Sage Publications. Brotman, Shari, Bill Ryan, Yves Jalbert, and Bill Rowe (2002). "Reclaiming Space - Regaining Health: The Health Care experiences of Two-Spirited People in Canada", Journal of Gay and Lesbian Social Services 14.1: 67-87.

Brown, L.B. (1997). "Women and men, not men and not-women, lesbian and gay gender alternatives", Journal of Gay & Lesbian Social Services 6.2: 5-20.

Browne, Annette J., and Jo-Anne Fiske (2001). "First Nation Women's Encounters with Mainstream Health Care Services", Western Journal of Nursing Research 23.2: 126-147.

Craib, Kevin J.P. et. al. (2003). "Risk factors for elevated HIV incidence among Aboriginal injection drug users in Vancouver", Canadian Medical Association Journal 168.1: 19-24.

Crowe, J.A. Wright, and L.B. Brown (1997). "Gender selection in two American Indian tribes", Journal of Gay and Lesbian Social Services 6.2: 21-8.

Flores, G, D. Gee, and B. Kastner (2000). "The teaching of cultural issues in U.S. and Canadian medical schools", Academic Medicine 75.5: 451-5.

Jacobs, M.A., L.B. Brown (1997). "American Indian lesbians and gays: An exploratory study", Journal of Gay and Lesbian Social Services 6.2: 29-41.

Jacobs, S.E. , W. Thomas, and S; Lang (1997). Two-Spirit People: Native American gender identity, sexuality and spirituality. Chicago: University of Illinois Press.

Kauffman, Jo Ann, and Yvette K. Joseph-Fox (1996). "American Indian and Alaska Native Women", in Marcia Bayne-Smith, ed., Race, Gender, and Health. London: Sage Publications.

Kern, David E., Patricia A. Thomas, Donna M. Howard, Eric Base (1998). Curriculum Development for Medical Education: A Six-Step Approach. Baltimore: John Hopkins University Press.

Langan, Joanne C. "Choosing Contracting for Community-based Sites", Community-based Nursing Curriculum: A Faculty Guide. Philadelphia: Davis Company: 3-16.

Normile, Loretta Brush (2002). "Teaching Students in a Community HIV/AIDS Network", Community-based Nursing Curriculum: A Faculty Guide. Philadelphia: Davis Company: 139-47.

Redmond, Georgine (2002). "Teaching and Learning Activities in Community-based Settings", Community-based Nursing Curriculum: A Faculty Guide. Philadelphia: Davis Company: 41-52.

Schmidt, H.G., M. Lipkin, M.W. de Vries, J.M. Greep, eds. (1989). New Directions for Medical Education: Problem-based learning and Community-oriented Medical Education. New York: Spinger-Verlag.

Schroeder, S.A., Z.S. Jones, and J.A. Showstack (1989). "Academic medicine as a public trust", Academic Medicine 262: 803-812.

Silverman, B.E., W.M. Goodine, M.G Ladouceur, and J. Quinn (2001), "Learning needs of nurses working in Canada's First Nation communities and hospitals", Journal of Continuing Education in Nursing 32.1.

Sorrell, Jeanne M (2002). "Teaching through Stories: An Approach to Student-centred Learning", Community-based Nursing Curriculum: A Faculty Guide. Philadelphia: Davis Company: 27-39.

Waldram, J. (1994). :Cultural and socio-economic factors in the delivery of health care services to Aboriginal People", in B.S. Bolaria and R. Bolaria, eds. Racial Minorities, Medicine, and Health. Halifax: Fernwood Press: 323-339.

Walters, Karina L., Jane M. Simoni, Pamela F. Horwath (2001). "Sexual Orientation Bias Experiences and Services Needs of Gay, Lesbian, Bisexual, Transgendered, and Two-Spirited American Indians", Journal of Gay & Lesbian Social Services 13.1/2.

Waslenki, Donald, Niall Byrne, and Barbara McRobb (2000). "Community Oriented Medical Education: The Toronto Experience", in Delese Wear and Janet Bickel, eds.,Education for Professionalism: Creating a Culture of Humanism in Medical Education. Iowa City: University of Iowa Press.

Williams, W.L. (1984). The Spirit and the Flesh: Sexual Diversity in American Indian Culture. Boston: Beacon Press.

Wotherspoon, T. (1994). "Colonization, self-determination and the health of Canada's First Nations Peoples", in B.S. Bolaria and R. Bolaria, eds. Racial Minorities, Medicine, and Health. Halifax: Fernwood Press: 247-268.