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Barriers to well-being for Aboriginal
gender-diverse people: results from the
Trans PULSE Project in Ontario, Canada
Ayden I. Scheim, Randy Jackson, Liz James, T. Sharp Dopler, Jake Pyne and Greta R. Bauer
Ayden I. Scheim is a PhD
Student and Greta R. Bauer is
an Associate Professor, both
are based at Department of
Epidemiology and Biostatistics,
Schulich School of Medicine &
Dentistry, The University of
Western Ontario, London,
Canada.
Randy Jackson is a PhD
Candidate and Jake Pyne is a
PhD Student, both are based
at School of Social Work,
McMaster University, Hamilton,
Canada.
Liz James is with the Trans
PULSE Project, based in
Vancouver, Canada.
T. Sharp Dopler is a Regional
Outreach/Support Services
Worker, at Ontario Aboriginal
HIV/AIDS Strategy, Ottawa,
Canada.
Abstract
Purpose – Despite health inequities experienced by Aboriginal and transgender (trans) communities, little
research has explored the well-being of Aboriginal trans (gender-diverse) people. This paper aims to
describe barriers to well-being in a sample of Aboriginal gender-diverse people in Ontario, Canada.
Design/methodology/approach – In 2009-2010, 433 trans people in Canada’s most populous province
participated in a multi-mode health survey. In all, 32 participants identified as First Nations, Me
´
tis, or Inuit
(Aboriginal); unweighted frequencies were calculated to describe their characteristics.
Findings – Participants expressed diverse gender identities; 44 per cent identified with the pan-Aboriginal
term two-spirit. High levels of poverty (47 per cent), homelessness or underhousing (34 per cent), and ever
having to move due to being trans (67 per cent) were reported. In all, 61 per cent reported at least
one past-year unmet health care need. Most participants had experienced violence due to being trans
(73 per cent) and had ever seriously considered suicide (76 per cent). One-fifth had been incarcerated while
presenting in their felt gender. Aboriginal spirituality was practiced by 44 per cent, and 19 per cent had seen
an Aboriginal Elder for mental health support.
Research limitations/implications – Action is needed to address the social determinants of health
among Aboriginal gender-diverse people. Using principles of self-determination, there is a need to increase
access to health and community supports, including integration of traditional culture and healing practices.
Larger study samples and qualitative research are required.
Originality/value – These first published data regarding the health of Aboriginal gender-diverse
Ontarians illustrate both their heterogeneity and all-too-common experiences of individual and systemic
discrimination, and barriers to care. Results highlight potential impacts of colonialism and social exclusion,
and suggest priorities for ameliorative action.
Keywords Ethnicity, Health, Transgender, Aboriginal, Transsexual, Two-spirit
Paper type Research paper
Background
Aboriginal peoples in Canada include First Nation (status or non-status), Inuit, and Me
´
tis
peoples (Adelson, 2005). In English-speaking western cultures, individuals who do not conform
to the Eurocentric belief that gender is binary and stable are commonly described as trans,
including those who are transgender (an umbrella term for those who do not conform to societal
gender expectations) or transsexual (a more specific term for those who identify with a sex other
than that assigned at birth) (Bauer et al., 2012). Aboriginal people who are trans might also
describe themselves using the term two-spirit, an umbrella term for Aboriginal individuals who
live between socially defined male and female gender roles (Balsam et al., 2004). They may also
use terms from their own Aboriginal languages, such as ogokwe-nini in Ojibwe or a’yahkwew in
Cree, reflecting the many culturally-distinct concepts of gender diversity, and traditional spiritual
roles of gender-diverse persons as seers, healers, and medicine people (Anguksuar, 1997).
rAyden I. Scheim, Randy Jackson,
Liz James, T. Sharp Dopler, Jake
Pyne, Greta R. Bauer.Published by
Emerald Group Publishing Limited.
This article is published under the
Creative Commons Attribution (CC
BY 3.0) licence. Anyone may
reproduce, distribute, translate and
create derivative works of this article
(for both commercial & non-
commercial purposes), subject to full
attribution to the original publication
and authors. The full terms of this
licence may be seen at http://
creativecommons.org/licences/by/
3.0/legalcode
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VOL. 6 NO. 4 2013, pp. 108-120, Emerald Group Publishing Limited, ISSN 1757-0980 DOI 10.1108/EIHSC-08-2013-0010
Owing to cultural and linguistic diversity across Aboriginal groups in Ontario, there is no single
agreed-upon term to describe Aboriginal trans people, and therefore we have opted to use the
term gender-diverse.
As posited by intersectionality theory (Hancock, 2007), Aboriginal gender-diverse peoples’
experiences and health statuses cannot be understood by simply summing together what
we know from research on broader Aboriginal or gender-diverse populations. Nevertheless,
the health inequities documented in studies using one or the other of these identity categories
provide important context for understanding the well-being of Aboriginal gender-diverse
peoples. Aboriginal people in Canada face inequalities in access to health care, and are
disproportionately impacted by chronic and infectious diseases such as diabetes and HIV/AIDS
(Adelson, 2005). Trans and gender-diverse populations also experience elevated levels of
conditions attributed to social exclusion, such as depression (Rotondi et al., 2011) and HIV
(Baral et al., 2013), and face systemic barriers to accessing respectful and competent health
care (Bauer et al., 2009; Grant et al., 2011).
For Aboriginal and other Indigenous peoples, patterns in the prevalence of disease mirror
broader patterns of social and economic inequity. Colonization is viewed as a key determinant
of health for Aboriginal communities (Czyzewski, 2011; King et al., 2009; Reading and Wien,
2008). Aboriginal people have been displaced from their lands, separated from their cultural
traditions and languages, and forcibly removed from their families and communities through
residential schools and the child welfare system (Blackstock, 2007). Evidence also suggests that
gender-diverse and two-spirit people were particular targets of violence in Canada’s history of
colonization, due to the challenge they posed to European Christian worldviews (Tinker, 1993).
This legacy of colonial violence is reinforced by ongoing structural violence and inequity,
including inadequate housing, education, and food security, as well as frequent exposure to
violence (Adelson, 2005). Thus, health inequities in Aboriginal communities are understood,
in part, as a consequence of historical and intergenerational trauma and deprivation (Evans-
Campbell et al., 2012). Moreover, Aboriginal gender-diverse people encounter both institutional
and interpersonal racism (Marcellin et al., 2014), homophobia, and transphobia.
Walters and Simoni’s (2002) indigenist stress-coping model posits that such life stressors are
largely responsible for negative health outcomes among Aboriginal people. They also suggest
that Aboriginal cultural resources (e.g. spirituality, ceremony, and traditional health practices)
can be mobilized to moderate the negative health impacts of life stressors. Moreover, Aboriginal
health scholars argue that eliminating the disproportionate burden of life stress for Aboriginal
peoples requires addressing colonialism as the fundamental determinant of health, through
self-determination of Aboriginal peoples over their lands, institutions, and health care systems
(Czyzewski, 2011; Fieland et al., 2007). For Aboriginal gender-diverse peoples, decolonization
also involves the reclamation, and incorporation into contemporary Aboriginal life, of traditional
knowledges that value gender diversity (Maracle, 2000).
The literature focused on the health of Aboriginal gender-diverse people is sparse. This is
due to a lack of studies focused specifically on the experiences of this group. Moreover,
in studies of broader populations, most health research has not included or adequately
captured gender-diverse identities (Bauer, 2012), and Aboriginal participants comprise a small
proportion of most transgender health study samples (in the absence of targeted recruitment or
oversampling). However, a small number of studies have had samples sufficiently large to
analyze, or have focused specifically on Aboriginal gender-diverse peoples. In a large US
transgender survey, 5 per cent of respondents were American Indian or Alaska Native (n ¼ 350),
and they had lower incomes than non-Native participants overall (National Transgender
Discrimination Survey, 2012), higher levels of lifetime suicidality than all other ethnoracial
groups, and higher prevalence of HIV than white, Asian-American, and multiracial participants
(Grant et al., 2011). American-Indian participants comprised 4 per cent (n ¼ 152) of another
large US survey sample, and reported higher levels of gender-based harassment than all other
ethnoracial groups (Beemyn and Rankin, 2011). Two studies have focused on migration to urban
centres among Aboriginal two-spirit and gender-diverse peoples in Ontario and Manitoba
(neighbouring Canadian provinces) (Teengs and Travers, 2006; Ristock et al., 2010). Participants
reported that migration increased their access to gender-diverse communities and services,
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but that they also encountered racism, violence, homelessness, health challenges, and a lack of
accessible services. Finally, in a study of safety concerns among 27 Aboriginal gender-diverse
people in Winnipeg, Manitoba, participants reported experiencing violence in multiple life
domains, and high levels of mental distress, substance dependence, self-harm, and suicidality
across their lifetimes. Participants varied widely in their experiences of family support or rejection
of their gender identities; some indicated that Aboriginal communities were quite supportive,
while others identified religiosity as a barrier to social inclusion (Taylor, 2009). Need has
been identified for increased awareness of the history of gender diversity in Aboriginal nations,
to support inclusion and celebration of gender-diverse people by Elders, Chiefs, and communities
(Stratton, 2008; Brotman et al., 2002).
To provide an evidence base for efforts to improve the health and human rights of trans and
gender-diverse people in Ontario, the Trans PULSE community-based research project was
initiated. The Trans PULSE Project survey and sampling strategy aimed to reflect the broad
range of trans and gender-diverse communities in Ontario (Bauer et al., 2012). This paper seeks
to describe the 32 Aboriginal survey respondents, and to identify implications for health care,
social services, and research in Ontario.
Methods
Study sample
The Trans PULSE Project survey was funded by the Canadian Institutes of Health Research.
In 2009 and 2010, 433 people participated in an onli ne or paper survey. Eligible participants
self-identified as trans or as having trans experience, were 16 years of age or above, and were living,
working, or receiving healthcare in Ontario. Recruitment was conducted using respondent-driven
sampling, a form of chain-referral in which participants subsequently recruit their peers, with
tracking of recruitment patterns (Heckathorn, 1997). Methods are described in greater detail
elsewhere (Bauer et al.,2012).Participantscouldremainanonymous,andwereoffereda$20
honorarium (gift card or donation toatransortwo-spirit-relatedcharity). Of 433 participants, 32
self-identified as First Nations, Me
´
tis, or Inuit, and were included in this analysis. Ethics approval was
obtained from The University of Western Ontario and Wilfrid Laurier University. As the study was not
designed to specifically focus on Aboriginal participants, Aboriginal-specific ethical review was
not obtained. In keeping with the community-based research principles of the project, and reflecting
our commitment to meaningful engagement and leadership of Aboriginal peoples in research,
this paper was conceptuali zed, collaboratively written, and edited by a team including Aboriginal
and non-Aboriginal authors representing a range of gender identities.
Measures
All mea sures were based on self-report, an d participants were free to skip any items.
A copy of the survey is available online (http://transpulseproject.ca/resources/trans-pulse-
survey/). As part of the su rvey development process, measu res were reviewed and rev ised
by Aboriginal researchers and gender-diverse community members (including authors L.J.
and R.J.).
Characteristics
Socio-demographic measures included Aboriginal identity (including those of mixed ethno-racial
backgrounds), having an Indian Status card, gender identity, intersex status, sexual orientation,
gender transition status, age, education, income, household poverty, employment, and current
residence (region, urbanity, and whether they lived on a First Nations reserve). Participants were
asked if they had an Indian Status card as part of an item about the sex designated on one’s
government-issued identification. Gender spectrum was categorized as male-to-female (MTF)
or feminine or female-to-male (FTM) or masculine based on assigned sex at birth; participants
did not necessarily identify as MTF, FTM, female, or male. Household poverty was coded based
on the 2008 Statistics Canada formula for low-income cut-off (Statistics Canada, 2009), using
the mid-points of the household income categories. Region of residence and rurality were coded
based on the first letter and first number of participants’ postal codes.
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Life experiences
Participants were asked about current homelessness or unstable housing, lifetime homelessness
while presenting in their felt gender, past-year food security, HIV status, lifetime Hepatitis C
diagnosis, history of incarceration in their felt gender, history of migration due to trans status,
experiences of transphobic violence, and both lifetime and past-year suicidality. Participants were
coded as currently homeless or under-housed if they reported being homeless; living in a motel,
boarding house, or rehab facility; couch-surfing or squatting; or having difficulty meeting housing
costs while living below the low-income cut-off.
Health service access
Measures of health service access included having a regular family doctor, reported past-year
need and unmet need for health care, ever having seen an Elder for mental health support, and
HIV testing history.
Family, community, and spiritual supports
Participants were asked about their current religion or spirituality; degree of religiosity or
spirituality; the level of support for their gender identity or expression from parents, siblings,
and extended family.
Data analysis
Unweighted frequencies and proportions were calculated using SAS Version 9.3 (SAS Institute
Inc, 2012). Proportions excluded respondents who did not complete the item. Although
previous Trans PULSE results have been weighted to represent the networked Ontario trans
population using respondent-driven sampling analytic methods, results presented herein are
unweighted due to the small sample size and corresponding lack of precision (i.e. wide
confidence intervals) in weighted estimates.
Results
In all, 7 per cent of Trans PULSE survey participants (n ¼ 32) identified as First Nations (n ¼ 14),
Me
´
tis (n ¼ 17), or Inuit (n ¼ 1). Socio-demographic characteristics are presented in Table I.
Most (n ¼ 28, 90 per cent) spoke English as a first language. One participant spoke
Anishinaabemowin (Ojibwe) as a first language, and four additional participants (13 per cent)
spoke Ojibwe or Cree as a second or third language. In all, 37 per cent (n ¼ 11, including six First
Nations and five Me
´
tis participants) reported having an Indian Status card. Me
´
tis identity cards
were not directly inquired about, but Me
´
tis participants may have meant to indicate recognition
from a Me
´
tis organization. Aboriginal participants were also approximately evenly split between
MTF (n ¼ 18, 56 per cent) and FTM (n ¼ 14, 44 per cent) gender spectra. While many participants
selected more than one term to describe their gender identity, two-spirit was the term most
commonly endorsed (n ¼ 14, 44 per cent).
The majority of Aboriginal participants were under 35 years of age (n ¼ 18, 58 per cent), and 26 per
cent (n ¼ 8) were under 25. Three-quarters (n ¼ 24) had at least some post-secondary education,
while 19 per cent (n ¼ 6) had not graduated from high school. Almost half (n ¼ 15, 47 per cent)
were living in poverty. A small number of participants lived in rural areas (n ¼ 3, 11 per cent), and
45 per cent (n ¼ 13) lived in metropolitan Toronto, the largest urban area in the province. None
reported living on a reserve at the time data were collected.
Life experiences of Aboriginal participants are presented in Table II. Approximately one-third of
Aboriginal participants were homeless or unstably housed (n ¼ 10, 34 per cent), and 29 per cent
(n ¼ 8) did not have enough food in the past year. One participant indicated that they were living
with HIV, and another had been diagnosed with Hepatitis C. In all, 20 per cent (n ¼ 6) had been
in jail while presenting in their felt gender, of whom two had been in jail in the past year. In all,
67 per cent (n ¼ 20) had to move at least once in their lifetimes due to being trans.
Most (73 per cent) had experienced some form of violence due to transphobia, including
43 per cent (n ¼ 13) who reported experiencing physical and/or sexual violence. Lifetime
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Table I
Characteristics of Aboriginal gender-diverse participants (n ¼ 32): Ontario, Canada
n%
Aboriginal identity
First Nations 14 44
Me
´
tis 17 53
Inuit 1 3
First language (n ¼ 31)
Anishinaabemowin (Ojibwe) 1 3
English 28 90
French 1 3
German 1 3
Has Indian (or Me
´
tis) Status card (n ¼ 30) 11 37
Gender spectrum
Male-to-female or feminine 18 56
Female-to-male or masculine 14 44
Gender identity
a
Two-spirit 14 44
Boy or man 8 25
Girl or woman 9 28
FTM 8 25
MTF 6 19
Trans boy or man 9 28
Trans girl or woman 10 31
Intersex 8 25
Cross-dresser 1 3
Genderqueer 6 19
Bigender 1 3
Medically recognized intersex condition
Yes 5 16
Unsure 9 28
No 18 56
Sexual orientation (n ¼ 31)
a
Two-spirit 14 45
Bisexual or pansexual 12 39
Gay 5 16
Lesbian 2 6
Queer 13 42
Straight or heterosexual 6 19
Asexual 2 6
Unsure or questioning 4 13
Social transition status (n ¼ 31)
Full-time in felt gender 23 74
Part-time in felt gender 6 19
Not living in felt gender 2 6
Medical transition status
Complete 13 41
In process 10 31
Planning but not begun 4 13
Not planning 0 0
Concept does not apply 3 9
Not sure if they will transition 2 6
Age (n ¼ 31)
16-24 8 26
25-34 10 32
35-44 7 22
45-54 5 16
55-64 1 3
Education
Did not finish high school 6 19
High school diploma 2 6
Some post-secondary 13 41
Graduated from post-secondary school 11 34
(continued)
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VOL. 6 NO. 4 2013
suicidality was high, with 76 per cent having ever seriously considered suicide (n ¼ 22) and
48 per cent (n ¼ 14) having attempted suicide at least once.
Health service access data are presented in Table III. Most (77 per cent, n ¼ 24) had a regular
family doctor. However, 61 per cent (n ¼ 19) reported at least one past-year unmet health care
need. Substantial proportions reported that they needed, but were unable to obtain, each of the
following types of service: shelters, hormone therapy, trans-related surgery, trans-related mental
health, sexual health, and addictions. However, most reported needs were met for general
health services, emergency care, and HIV or sexually transmitted infections testing. More than
half had been tested for HIV in the past year (n ¼ 17, 55 per cent).
Finally, information about family, community, and spiritual sources of support is presented in
Table IV. Aboriginal spirituality was the most frequently endorsed religious or spiritual affiliation
(n ¼ 14, 44 per cent), and 56 per cent (n ¼ 18) reported that they were fairly to extremely religious
or spiritual. Approximately one-fifth had ever seen an Elder for mental health support. A range of
family and community support for gender identity and expression was indicated.
Discussion
Participants reported a wide range of gender and sexual identities; while two-spirit was most common,
fewer than half identified with the term. This suggests that two-spirit may not be an appropriate
umbrella term for Aboriginal gender -diverse people. While some identify with both Aboriginal-specific
terms (e.g. two-spirit) and Euro-Canadian terms (e.g. transgender ), others may only use one of these,
depending on how they understand their gender(s) and their sense of connection to Aboriginal cultures
and communities. Others yet may identify exclusively as transitioned men or women.
Most participants had low personal incomes and were not employed full-time. This reflects low
incomes (Bauer et al., 2012), employment barriers, and trans-related discrimination (Bauer et al.,
2011) experienced by trans Ontarians. For Aboriginal gender-diverse people, this may also relate
to impacts of colonization and systemic racism on economic and employment opportunities
(Reading and Wien, 2008). That one-fifth of Aboriginal gender-diverse participants had ever
Table I
n%
Household poverty
In poverty (below low income cut-off) 15 47
Not in poverty 17 53
Personal annual income (n ¼ 29)
o$15,000 16 55
$15,000 to $29,999 2 7
$30,000 to $49,000 5 17
$50,000 to $79,000 5 17
$80,000 or over 1 3
Current employment (n ¼ 30)
Full-time 11 37
Part-time 6 20
Unemployed/disability/on leave 7 23
Student or retired 6 20
Region of Ontario (n ¼ 29)
Eastern 3 10
Central 6 21
Metropolitan Toronto 13 45
Southwestern 3 10
Northern 4 14
Rural residence (n ¼ 27) 3 11
Currently lives on reserve
No 32 0
Notes: Proportions are rounded and may not add up to 100 per cent.
a
Participants could select all that
apply; proportions will not add up to 100 per cent
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been incarcerated while presenting in their felt gender may demonstrate the impacts of social
exclusion and the over-incarceration of Aboriginal peoples in Canada (Office of the Correctional
Investigator, 2012; Scheim et al., 2013).
No participants lived on a First Nation reserve at the time of data collection. This may reflect
a combination of factors, including that Aboriginal peoples increasingly live in urban centres
(Environics Institute, 2010), migration by individuals who previously lived on reserve, Me
´
tis
or Inuit identity (i.e. non-reserve populations of Aboriginal peoples), or barriers to survey
recruitment or participation. Over 50 per cent of participants did not have an Indian Status card.
Under the Indian Act, only status First Nations are eligible for federal government recognition as
Status Indians. Although formal requirements for identity recognition present an obstacle, Me
´
tis
people can obtain identity cards through local or national Me
´
tis organizations. We recognize the
determination of status for Aboriginal peoples as a colonial project which, nevertheless, has
important consequences for access to rights and services (e.g. health care and education) owed
to Aboriginal peoples (de Leeuw and Greenwood, 2011).
Our participants reflected the younger age distributions of Ontario’s Aboriginal (Reading and Wien,
2008) and gender-diverse (Bauer et al., 2012) communities. This suggests that our findings
are particularly relevant for organizations working with gender-diverse and Aboriginal youth.
The vulnerability of both Aboriginal (Adelson, 2005) and gender-diverse youth to suicidality (Liu and
Mustanski, 2012) was reflected in our findings. Almost half of participants had attempted suicide
at least once. Initiatives to increase parental support (and other forms of social support) for
Aboriginal gender-diverse youth are necessary, as only one-fifth of participants had parents who
were strongly supportive of their gender identity. Parental support is a protective factor for mental
health and housing stability among trans and gender-diverse youth (Travers et al., 2012).
Table II
Life experiences of Aboriginal gender-diverse participants (n ¼ 32): Ontario,
Canada
n%
Currently homeless or unstably housed (n ¼ 29) 10 34
Ever homeless while presenting in felt gender (n ¼ 29) 11 38
Household did not have enough to eat in past year (n ¼ 28) 8 29
HIV Status (n ¼ 29)
HIV-positive 13
HIV-negative 23 79
Don’t know 5 17
Ever diagnosed with Hepatitis C (n ¼ 31) 1 3
Ever spent time in jail presenting in felt gender (n ¼ 29)
Yes, in a provincial jail 3 10
Yes, in a federal prison 1 3
Yes, both provincial and federal 2 7
No 23 79
Spent time in jail in the past year, presenting in felt gender (n ¼ 29) 2 7
Ever had to move because of trans status (n ¼ 30) 20 67
Had to move away from friends/family because trans (n ¼ 29) 16 55
Moved to a different city or town for own safety because trans (n ¼ 27) 10 37
Moved to a different city or town to be closer to trans-related services (n ¼ 29) 9 31
Ever been asked or told to leave parent’s or guardian’s house for being trans (n ¼ 28) 6 21
Experienced violence due to being trans (n ¼ 30)
None 8 27
Verbal harassment or threats only 9 30
Physical and/or sexual violence 13 43
Suicidality (n ¼ 29)
Ever seriously considered suicide 22 76
Ever attempted suicide 14 48
Seriously considered suicide in past year 8 28
Attempted suicide in past year 4 14
Note: Proportions are rounded and may not add up to 100 per cent
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Due to being trans, 67 per cent of Aboriginal gender-diverse participants had ever had to
move and 43 per cent had experienced physical or sexual violence. This underscores the need
for action to increase acceptance of gender diversity, prevent transphobic violence in
communities across the province, provide greater support for survivors of transphobic violence,
and increase the number of localized trans-specific services (including outreach to reserve
communities).
Unmet need was reported for almost all types of health services we inquired about. Unmet need
may be due to Aboriginal and gender-specific barriers (e.g. a lack of culturally competent
services, gender-segregated services that exclude trans people), or due to more general factors
(e.g. cost, distance, wait lists), which may nevertheless have a disproportionate impact on
Aboriginal gender-diverse people. The highest level of unmet need was reported for transition-
related surgery, but sex-reassignment surgeries were re-instated under Ontario’s public health
insurance plan one to two years before surveys were completed, so access may have now
improved. However, the requirement for comprehensive mental health assessment at a single
Toronto site still presents barriers for many. Unmet need for addictions services was also high,
Table III
Health service access among Aboriginal gender-diverse participants (n ¼ 31):
Ontario, Canada
n%
Has a regular family doctor 24 77
Any unmet need for health care in past year 19 61
Unmet need for health care in past year
Addictions services
Needed 7 23
Able to obtain
a
2 29
Sexual health services
Needed 10 32
Able to obtain
a
7 70
General health services
Needed 28 90
Able to obtain
a
26 93
Emergency services
Needed 13 42
Able to obtain
a
11 85
Hormone therapy
Needed 22 71
Able to obtain
a
14 64
Trans-related surgery
Needed 12 39
Able to obtain
a
3 25
HIV or sexually transmitted infection testing
Needed 13 42
Able to obtain
a
13 100
Shelters
Needed 8 26
Able to obtain
a
5 63
Mental health services (trans-related)
Needed 12 39
Able to obtain
a
7 58
Mental health services (not trans-related)
Needed 9 29
Able to obtain
a
7 78
Ever been tested for HIV
Yes, in the past year 17 55
Yes, but not in the past year 9 29
Never 5 16
Notes:
a
Of those who needed the specified service. Proportions are rounded and may not add up to 100
per cent
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and suggests that despite the existence of LGBT and Aboriginal-specific addictions services in
Ontario, the needs of Aboriginal gender-diverse people are not being met by existing services.
While participants did not report unmet need for HIV or sexually transmitted infections testing,
the professional experience of those working with Aboriginal gender-diverse Ontarians through
the Ontario Aboriginal HIV/AIDS Strategy suggest that barriers to testing remain a challenge
(TS Dopler, 24 July 2013, personal communication). Moreover, our measure was contingent on
participants’ perceptions of need, which may not reflect actual HIV risk. Previously published
evidence from Trans PULSE suggests that Aboriginal people do not differ significantly from
other trans and gender-diverse Ontarians with respect to HIV-related sexual risk behaviour
(Bauer et al., 2012). While Aboriginal participants appeared to have a higher prevalence of HIV,
this must be cautiously interpreted in light of the small sample, and the lack of available data
regarding HIV seroprevalence among trans people in Ontario.
In addition to barriers and challenges, some participants reported family and community support
for their gender identities, and high levels of spirituality. Supportive Aboriginal communities and
positive integration of Aboriginal identity and culture may buffer the impacts of life stressors,
including impacts of colonialism (Chae and Walters, 2009). It is important for health policy and
practice to build on these strengths. For example, about one-fifth had ever seen an Elder for
mental health support. Other participants may have experienced barriers to accessing Elders,
such as cost (for travel, honorarium, and gifts), distance, or a lack of access to local Elders
knowledgeable about gender diversity. Traditional culture, ceremonies, and healing practices
may play an important role in health promotion for Aboriginal peoples (Currie et al., 2013;
Table IV
Family, community and spiritual supports among Aboriginal gender-diverse
participants (n ¼ 32): Ontario, Canada
n%
Current religion or spirituality
a
Aboriginal spirituality 14 44
Agnostic or no religion 11 34
Buddhist 2 6
Catholic 4 13
Christian 6 19
Hindu 1 3
Jewish 1 3
Muslim 2 6
Wiccan/Pagan 2 6
Degree of religiosity or spirituality
Not at all, a bit, or somewhat 14 44
Fairly, quite, extremely 18 56
Ever seen an Elder for mental health support (n ¼ 31) 6 19
Are parents supportive of gender identity or expression? (n ¼ 25)
Very 5 20
Somewhat 8 32
Not at all or not very 8 32
n/a 4 16
Are siblings supportive of gender identity or expression? (n ¼ 25)
Very 9 36
Somewhat 5 20
Not at all or not very 8 32
n/a 3 12
Is extended family supportive of gender identity or expression? (n ¼ 25)
Very 6 24
Somewhat 9 36
Not at all or not very 4 16
n/a 6 24
Notes:
a
Participants could select all that apply; proportions will not add up to 100 per cent. Proportions are
rounded and may not add up to 100 per cent
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Dell et al., 2011). With respect for principles of self-determination, we believe that Aboriginal
cultural resources should be integrated into community-led health and social services for
Aboriginal gender-diverse people.
To the best of our knowledge, the current study represents the largest research sample of
Aboriginal gender-diverse persons in Canada. While the proportion of Aboriginal participants
in Trans PULSE was larger than the proportion of Ontarians overall who are Aboriginal (7 vs
2 per cent; Statistics Canada, 2012), we caution that results cannot be generalized to the
Aboriginal gender-diverse population of Ontario, given the small sample size, our corresponding
inability to use weighted RDS statistical procedures to produce population estimates with any
precision, and the networked (non-random) nature of our sample.
In conclusion, our findings draw attention to social and economic exclusion, barriers to health
service access, and high burdens of violence and suicidality among Aboriginal gender-diverse
people, and to culturally specific coping factors that may promote well-being. These results
suggest that increased access to health and social services is required for Aboriginal gender-
diverse people in Ontario, in addition to further research that could help to identify strategies
for improving well-being. We concur with Blackstock (2009) that quantitative methods are not
inherently antithetical to Aboriginal or Indigenous research, but that Aboriginal research
(in contrast to research about Aboriginal persons) should be grounded in Aboriginal epistemologies,
worldviews, and community-identified policy change needs. The current study was grounded
in principles of (trans) community control and accountability, but would not be considered
Aboriginal research, as conceptualized here. Thus, Aboriginal research with gender-diverse
persons is needed, particularly research that uses Indigenous approaches and responds
to community-identified priorities. Methodologically, this may involve larger samples for quantitative
studies, and qualitative research to understand lived experiences. Such research could more fully
define determinants of health for Aboriginal gender-diverse peoples and their impacts, including
historical determinants or traumas such as residential schools; explore cultural understandings of
gender diversity in ways that allow Aboriginal communities to rebuild from colonial assaults; and
provide information to reduce the multiple and interlocking barriers to health services.
Finally, we believe that it is imperative for health and social service providers and researchers
to consider decolonizing social, economic, and political changes as crucial interventions to
eliminate the health inequities experienced by Aboriginal peoples of all genders in Canada
(Czyzewski, 2011).
Acnowledgement
The research presented here was supported by an operating grant from the Canadian Institutes of
Health Research, Institute of Gender and Health (Funding Reference No. MOP-106478). Partners
in Trans PULSE included the Sherbourne Health Centre (Toronto), The 519 Church Street
Community Centre (Toronto), The University of Western Ontario (London), Wilfrid Laurier University
(Waterloo), and Rainbow Health Ontario. The Trans PULSE Steering Committee members were
Greta Bauer, Robb Travers, Rebecca Hammond, Anjali K, Matthias Kaay, Jake Pyne, Nik Redman,
Kyle Scanlon (deceased), and Anna Travers. The authors wish to acknowledge the contributions
of the 16 Community Engagement Team members and other Trans PULSE contributors who
worked to develop and promote the survey, and the 433 survey participants.
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About the authors
Ayden I. Scheim is a PhD Student in the Department of Epidemiology and Biostatistics within the
Schulich School of Medicine and Dentistry at The University of Western Ontario. His research
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includes quantitative, qualitative, and mixed-methods community-based projects focusing on
HIV prevention and the overall health of transgender communities, gay and bisexual men, and
people who use drugs. Ayden I. Scheim is the corresponding author and can be contacted at:
ayden.scheim@schulich.uwo.ca
Randy Jackson is a PhD Candidate and a Pre-Doctoral Fellow cross-affiliated in the School of
Social Work and the Department of Heath, Aging and Society at McMaster University.
Randy’s research focuses on HIV/AIDS in Aboriginal communities in Canada. Key areas of
interest include experiences of depression, stigma, HIV testing, Aboriginal youth leadership
in HIV prevention, community-based research, arts-based approaches in research, and
Indigenous methodologies.
Liz James is an MTF post op transsexual woman who is a two spirit Native American, with
family on both sides of the border. She is a University of British Columbia undergraduate, with a
counselling background, and a talented visual artist, craftsperson, and freelance writer. Liz has
been involved with the struggle for equal civil rights for trans peoples since 1989, as a trans
activist with organizations including the Trans PULSE Community Engagement Team. Liz wields
her father’s Iywasa (sacred War club); her family fought in the War of 1812. She eventually hopes
to obtain a Civil Law degree, as the battle for trans civil rights requires a different type of weapon.
T. Sharp Dopler is an O utreach/ Suppo rt Servic es Worker who has worked in t he Ottawa office
of the Ontario Aboriginal HIV/AIDS Strategy since 2006. Sharp is a Bear clan of Sauk/Fox,
Cherokee and Irish descent. Sharp has an extensive background in working at a grassroots
level in the field of violence against women, as well as educating people about HIV and safer
sex. Sharp has an MA in Canadian Studies and also has a range of experience doing research
and writing.
Jake Pyne is a Community-Based Researcher and a PhD Student in the McMaster School of
Social Work. Jake’s community work has focused on improving access to health and social
services for trans and gender non-conforming people. His research work explores societal
responses to gender non-conformity, with a specific focus on what different theories and
knowledge systems foreclose and make possible for gender non-conforming children. Jake is
a Co-Investigator on the Trans PULSE study.
Dr Greta R. Bauer is an Associate Professor in the Department of Epidemiology and Biostatistics
within the Schulich School of Medicine and Dentistry at The University of Western Ontario.
Dr Bauer’s primary research interests are in sexually transmitted infections and the broader
health of sexual and gender minority communities . Coming from an inte rdisciplinary
background, her work has spanned the biological, behavioural and social, with a strong
emphasis on quantitative research methodology.
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