Native American Two Spirit and LGBTQ health: A systematic review of the literature

Figures & data

Table 1. Demographic information for retrieved and included articles.

Title	Author	Year Published	%2SLGBTQ	% LGBQ	%2S (SO)	%2S (GI)	%Bisexual	%T	%AIAN	Setting	Country	Rural/urban* (R/U)
A cautionary tale: Risk reduction strategies among urban American Indians/Alaska Native men who have sex with men. **	Pearson, C.R., Walters, K.L., Simoni, J.M., Beltran, R. & Nelson, M.K.	2013		100% MSM					100%	Multiple locations	USA	U
A qualitative study of transgender individuals' experiences in residential addiction treatment settings: stigma and inclusivity.	Lyons, T., Shannon, K., Pierre, L., Small, W., Krusi, A., & Kerr, T.	2015	100%			29%		64%	93%	Office Space	Canada	U
Aboriginal Two-Spirit and LGBTQ migration, mobility, and health research project: Final report	Ristock, J., Zoccole, A. & Passante, L.	2010	100%	46%	42%	8%	29%	33%	100%	Nonprofit or Community Organization	Canada	U
Abuse, mastery and health among lesbian, bisexual and Two-Spirit American Indian and Alaska Native women. **	Lehavot, K., Walters, K.L., & Simoni, J.M.	2009	100%	83%	17%		45%		100%	Multiple locations	USA	U
Access to Care: Exploring the health and well-being of gay, lesbian, bisexual, and Two-Spirit people in Canada. **	Ryan, B., Brotman, S., & Rowe, B.	2000	100%	48%	20%				20%	Multiple locations	Canada	U
Alcohol misuse and associations with childhood maltreatment and out-of-home placement among urban Two-Spirit American Indian and Alaska Native people.	Yuan, N.P., Duran, B.M., Walters, K.L., Pearson, C.R., & Evans-Campbell, T.A.	2014	100%		100%				100%	Multiple locations	USA	U
American Indian gay, bisexual and Two-Spirit men: a rapid assessment of HIV/AIDS risk factors, barriers to prevention and culturally sensitive intervention.	Burks, D.J., Robbins, R., & Durtschi, J.P.	2011	100%	100% MSM					100%	Public Space	Oklahoma City, USA	U
Barriers to well-being for aboriginal gender-diverse people: Results from the Trans PULSE project in Ontario, Canada. **	Scheim, A.I., Jackson, R., James, L., Dopler, T.S., Pyne, J., Bauer, G.R.	2013	100%		44%			100%	100%	Office Space	Canada	U
Coaching mental health peer advocates for rural LGBTQ people.	Willging, C.E., Israel, T., Ley, D., Trott, E.M., DeMaria, C, Joplin, A., & Smiley, V.	2016	83%				33%	17%	33%	Office Space	New Mexico, USA	R
Culture, trauma, and wellness: A comparison of heterosexual and lesbian, gay, bisexual, and Two-Spirit Native Americans. **	Balsam, K.F., Huang, B., Fieland, K.C., Simoni, J.M., & Walters, K.L.	2004	14%		14%		2%		100%	Nonprofit or Community Organization	USA	U
Determinants of health among Two-Spirit American Indians and Alaska Natives	Fieland, K.C., Walters, K.L., & Simoni, J.M.		100%		100%				100%	NA	USA	RU
Discriminatory distress, HIV risk behavior, and community participation among American Indian/Alaska Native men who have sex with men.	Town, M.A, Walters, K.L., & Orellana, E.R.	2018	100%	100% MSM					100%	Multiple locations	USA	U
HIV vaccine acceptability and culturally appropriate dissemination among sexually diverse Aboriginal peoples in Canada.	Newman, P.A., Woodford, M.R., & Logie, C.	2012	48%	39%	26%		9%		100%	Nonprofit or Community Organization	Canada	U
Indian boarding school experience, substance use, and mental health among urban Two-Spirit American Indian/Alaska natives.	Evans-Campbell, T., Walters, K.L., Pearson, C.R., & Campbell, C.D.	2012	100%		100%			8%	100%	Multiple locations	USA	U
“My Spirit in my heart": identity experiences and challenges among American Indian Two-Spirit women **	Walters, K.L., Evans-Campbell, T., Simoni, J.M., Ronquillo, T., & Bhuyan, R.	2006	100%		100%				100%	Multiple locations	USA	U
Racial Discrimination and Racial Identity Attitudes in Relation to Self-Rated Health and Physical Pain and Impairment Among Two-Spirit American Indians/Alaska Natives	Chae, D.H. & Walters, K.L.	2009	100%	76%	16%		29%	29%	100%	Multiple locations	USA	U
Racial discrimination's influence on smoking rates among American Indian Alaska Native Two-Spirit individuals: Does pain play a role?	Johnson-Jennings, M.D., Belcourt, A., Town, M., Walls, M.L., & Walters, K.L.	2014	100%	45%	16%		29%		100%	Multiple locations	USA	U
Reclaiming space-regaining health: The health care experiences of Two-Spirit people in Canada.	Brotman, S., Ryan, B., Jalbert, Y., & Rowe, B.	2008	58%		50%				100%	Multiple locations	Quebec, Central Canada	U
Risk Factors for HIV Disease Progression in a Rural Southwest American Indian Population.	Iralu, J., Duran, B., Pearson, C.R., Jiang, Y., Foley, K., & Harrison, M.	2010						14%	100%	Clinic	New Mexico, USA	R
Sexual orientation bias experiences and service needs of gay, lesbian, bisexual, transgendered, and Two-Spirited American Indians **	Walters, K.L., Horwath, P.F., & Simoni, J.M.	2001	39%		1 focus group				87%	Nonprofit or Community Organization	USA	U
Sexual orientation, sexual behaviors, and pregnancy among American Indian adolescents **	Saewyc, E.M., Skay, C.L., Bearingern L.H., Blum, R.WM., Resnick, M.D.	1998	16% (LG/Unsure)						100%	School	USA	R
Sexual partner concurrency and sexual risk among gay, lesbian, bisexual, and transgender American Indian/ Alaska natives **	Cassels, S., Pearson, C.R., Walters, K., Simonia, J.M., & Morris, M.	2010	100%	46%	16%		27%	8%	100%	Multiple locations	USA	U
Sexual practices and condom use among a sample of Northern and Indigenous adolescents in Northern Canada: cross-sectional survey results.	Logie, C.H., Lys, C.L., Fujioka, J., MacNeill, N., Mackay, K., & Yasseen III, A.S.	2018		14%				1.2%	73%	School	NWT, Canada	R
Syndemic Factors Associated with Safer Sex Efficacy Among Northern and Indigenous Adolescents in Arctic Canada	Logie, C.H., Lys, C.L., Mackay, K., MacNeill, N., Pauchulo, A., & Yasseen III, A.S.	2019	14%					2%	73%	School	NWT, Canada	Not specified
The process of developing a community-based research agenda with lesbian, gay, bisexual, transgender and queer youth in the Northwest Territories, Canada.	Logie, C. & Lys, C.	2015	44%							Pride	Yellowknife, Canada	R
They tell us 'we don’t belong in the world and we shouldn’t take up a place': HIV discourse within Two-Spirit communities.	Arguello, T.M. & Walters, K.	2018	100%		100%				100%	Multiple locations	USA	U
Urban lesbian and gay American Indian identity: Implications for mental health service delivery. **	Walters, K.L.	1997	100%						100%	NA	USA	U
Victimization, Substance Use, and HIV Risk Behaviors Among Gay/Bisexual/Two-Spirit and Heterosexual American Indian Men in New York City.	Simoni, J.M., Walters, K.L., Balsam, K.F., & Meyers, S.B.	2006	28%		24%		4%		100%	Nonprofit or Community Organization	NYC, USA	U

Table 2. Summary of methods and results for retrieved and included articles.

Title	Setting	Sampling method	Sample size	Population age	Focus	Research framework	CBPR (Y/N)	Quan/Qual?
A cautionary tale: Risk reduction strategies among urban American Indians/Alaska Native men who have sex with men.	Multi-site	targeted; partial-network; respondent-driven	174	Adult	HIV/AIDS; Sexual Health	Subset of cross-sectional survey Honor Project	N	Quantitative
Major findings
94.8% reported some risk reduction strategy, including: – no anal sex (23%) – 100% condom use (23%) – seroconcordant monogamous partnership (8%) Participants in serodiscordant partnerships were: – less likely to reveal HIV status (χ^2 = 20.0) – more likely to ever have an STI (χ^2 = 4.7) – more likely to have traded sex for money or drugs (χ^2 = 14.5) – more likely to be HIV+ (χ^2 = 20.0)
A qualitative study of transgender individuals' experiences in residential addiction treatment settings: stigma and inclusivity.	Office Space	Targeted; respondent-driven	14	Adult	Health Equity	Semi-structured interviews Participant transcript analysis	N	Qualitative
Major findings
Trans residents experienced: –  (1) enacted stigma (social rejection and violence) –  (2) transphobia and felt stigma –  (1) “trans friendly” and inclusive treatment Stigma was related to leaving treatment early. Inclusion was related to completed treatment.
Aboriginal Two-Spirit and LGBTQ migration, mobility, and health research project: Final report	Community Organization	Partial-network; respondent-driven	24	Adult	General Health	Semi-structured interviews Focus Groups	Y	Qualitative
Major findings
Themes: – Migration/Movement to city for acceptance, to reservation/rural area for family/community – Negative impacts: assault, homelessness, drug use, survival sex work, HIV, poverty, loneliness, isolation, suicidality – Positive impacts: Positive peer froup, escaping abuse/discrimination, sense of resilience, Recommendations: – Need for intersectional groups/support – Need for services for new Native LGBTQ residents
Abuse, mastery and health among lesbian, bisexual and Two-Spirit American Indian and Alaska Native women.	Multi-site	targeted; partial-network; respondent-driven	152	Adult	Mental Health; Violence Prevention	Subset of Cross-sectional Survey Honor Project	N	Quantitative
Major findings
Of Two Spirit & LGBTQ Women: – 78% had experienced physical assault – 85% had experienced sexual assault Assault had a negative effect on mental health (ANOVA F (2, 151)  3.08, p<.05) Mastery mediated the outcome of mental health as it relates to: – childhood trauma (z = 2.18, p<.05) – partner violence (z = 1.94, p<.05) – physical assault (z = 2.0, p<.05)
Access to Care: Exploring the health and well-being of gay, lesbian, bisexual, and Two-Spirit people in Canada.	Multi-site	Targeted	61	Adult	Health Equity	Semi-structured interviews Focus Groups	N	Qualitative
Major findings
Themes: Barriers to Connection – – Unsafe to come out – Perceived conflict between gay and indigenous identity Barriers to Healthcare – – Providers don’t talk about sex – Power differential between practitioners and recipients; – Organizational indifference to 2SLGBTQ needs Tips for Successful Navigation: – Selecting affirming provider
Alcohol misuse and associations with childhood maltreatment and out-of-home placement among urban Two-Spirit American Indian and Alaska Native people.	Multi-site	targeted; partial-network; respondent-driven	294	Adult	Substance Use	Subset of Cross-sectional Survey Honor Project	N	Quantitative
Major findings
High rates of past-year alcohol dependence (50.8% men, 48.7% women) Boarding school attendance and foster care placement predicted past-year alcohol dependence in men Foster care placement predicted less past-year alcohol dependence in women
American Indian gay, bisexual and Two-Spirit men: a rapid assessment of HIV/AIDS risk factors, barriers to prevention and culturally-sensitive intervention.	Public Space	Network Sampling	42	Adult	HIV/AIDS	Subset of: Semi-structured interviews; Participatory design	Y	Qualitative
Major findings
Themes: – Participants have moderately good knowledge of HIV-related risk behaviors – Mistrust of service organizations – Condoms under-utilised – Good knowledge of testing and resource locations – Limited hours/availability of HIV testing is a barrier – Culturally specific treatment efforts more effective
Barriers to well-being for aboriginal gender-diverse people: Results from the Trans PULSE project in Ontario, Canada	Office Space	respondent-driven	32	Adolescent, Adult	Violence Prevention; Health Equity	Subset of Cross-sectional survey	Y	Quantitative
Major findings
43% had experienced physical or sexual assault 76% had considered suicide and 48% had attempted suicide 20% had supportive adult parents/relatives 61% had unmet healthcare need 71% had unmet gender-affirming hormone need
Coaching mental health peer advocates for rural LGBTQ people.	Office Space	Respondent-driven	6 (4 peer advocates and 2 coaches)	Adult	Mental Health	Semi-structured interviews	N	Qualitative
Major findings
Themes: – LGBTQ cultural competency crucial to effective peer advocacy – Lack of infrastructure and safe meeting places in rural areas
Culture, trauma, and wellness: A comparison of heterosexual and lesbian, gay, bisexual, and Two-Spirit Native Americans.	Community Organization	Targeted, network, respondent-driven	179	Adult	Metal Health; Substance use	Semi-structured interviews	N	Quantitative
Major findings
When compared to heterosexuals, Two Spirit participants reported: – Higher rates of childhood physical abuse (χ^2 = 4.86) – Higher rates of sexual assault (χ^2 = 1.53) – Higher rates of historical trauma events – Higher use of mental health services (χ^2 = 10.83) – More likely to drink to improve social skills (χ^2= −2.32) or manage mood (χ^2= −3.04)
Determinants of health among Two-Spirit American Indians and Alaska Natives	NA	NA	NA	NA	General Health	Literature Review/Overview	NA	Qualitative
Major findings
Two Spirit people may experience intergenerational trauma, heterosexism in Native communities, and racism in GLBT communities, making them multiply at risk. Providers and researchers can improve work with Two Spirit people by using an Indigenist stress-coping model and strengths-based perspective as a research framework. Enculturation and connection to traditional, elevated status of Two Spirit people in Native communities may help protect against risk factors for Two Spirit people.
Discriminatory distress, HIV risk behavior, and community participation among American Indian/Alaska Native men who have sex with men.	Multi-site	targeted; partial-network; respondent-driven	183	Adult	HIV/AIDS; Sexual Health	Subset of cross-sectional survey Honor Project	N	Quantitative
Major findings
Unprotected anal intercourse was positively associated with: – Two Spirit discriminatory distress (95% CI) – Less engagement with LGBT online forums (p<.05) – Less attendance of Two Spirit events (p<.01)
HIV vaccine acceptability and culturally appropriate dissemination among sexually diverse Aboriginal peoples in Canada.	Community Organization	Targeted	23	Adult	HIV/AIDS	Focus groups Semi-structured guide	N	Qualitative
Major findings
Barriers to HIV Vaccine Uptake: Limited awareness – Historically accurate mistrust of government and healthcare system Perceived conflict between traditional western meds – Vaccine cost – Sexual prejudice and AIDS stigma
Indian boarding school experience, substance use, and mental health among urban Two-Spirit American Indian/Alaska natives.	Multi-site	targeted; partial-network; respondent-driven	447	Adult	Mental Health; Substance Use	Cross-sectional survey Honor Project	N	Quantitative
Major findings
Former boarding school attendees reported: – Higher rates of substance use disorder (x^2 = 4.97) – Higher rates of suicidality (x^2 = 6.39) and attempted suicide (x^2 = 8.85) – Children of boarding school attendees reported: Higher rates of anxiety (χ^2 = 6.69) – Higher rates of PTSD (χ^2 = 6.2) – Higher rates of suicidality (χ^2 = 6.2)
“My Spirit in my heart”: identity experiences and challenges among American Indian Two-Spirit women	Multi-site	targeted; partial-network; respondent-driven	5	Adult	General Health	Subset Analysis of Cross-sectional Survey Honor Project	N	Qualitative
Major findings
Themes: – Two Spirit identity goes beyond sexuality or gender identity to include spiritual and advocacy aspects. – Two Spirit identity means serving the people. – As a collective identity, Two Spirit allows for resistance and mobilization within the indigenous community. – Tension between trying to fit into white LGBTQ community and indigenous community can lead to experiences of disconnection.
Racial Discrimination and Racial Identity Attitudes in Relation to Self-Rated Health and Physical Pain and Impairment Among Two-Spirit American Indians/Alaska Natives	Multi-site	targeted; partial-network; respondent-driven	447	Adult	Health Equity	Cross-sectional survey Honor Project	N	Quantitative
Major findings
Discrimination was associated with increased physical pain and impairment (CI = 1.13) Self-actualization lowered odds of physical pain and impairment (CI = 0.35) and protected against influence of discrimination on self-rated health (p=.02)
Racial discrimination's influence on smoking rates among American Indian Alaska Native Two-Spirit individuals: Does pain play a role?	Multi-site	targeted; partial-network; respondent-driven	447	Adult	Health equity, substance use	Cross-sectional survey Honor Project	N	Quantitative
Major findings
45% of participants reported smoking 57% reported pain Pain mediates the association between racial discrimination and smoking. (Sobel test = 2.15; p<.05)
Reclaiming space-regaining health: The health care experiences of Two-Spirit people in Canada.	Multi-site	Targeted	12	Not specified	Health Equity	Subset Analysis of Focus groups Semi-structured Guides	N	Qualitative
Major findings
Claiming a Two-Spirit identity can have a positive impact on health and well-being The lack of gay- or trans-positive support systems or resources in their communities an act as barriers to accessing health services Aboriginal spaces can be a dangerous space to come out as a result of the closeness of the community Even in urban spaces, Two-Spirit resources rare The coming-out process for Two-Spirit individuals can be particularly difficult because of their position as an ethnic and sexual minority
Risk Factors for HIV Disease Progression in a Rural Southwest American Indian Population	Clinic	Targeted (automatic enrollment)	36	Adult	HIV/AIDS	Cross-sectional	N	Quantitative
Major findings
Lower mean CD4 counts associated with being incarcerated in the past 12 months (M = 286.4 vs. not incarcerated, M = 442.8) and use of traditional medicine (M = 280.2 vs. no use, M = 430.3) Higher log M viral loads associated with income below $1000 (M = 5.90 vs. >$1000, M = 3.336), being incarcerated in the past 12 months (M = 6.69 vs. not incarcerated, M = 3.87), and 12-month provider-assessed alcohol abuse (M = 6.05 vs. no alcohol abuse, M = 3.49) Less-than-excellent adherence associated with higher viral loads (M = 7.02) than excellent adherence (M = 2.59) as determined by providers
Sexual orientation bias experiences and service needs of gay, lesbian, bisexual, transgendered, and Two-Spirited American Indians	Office Space	Targeted	31/34	Adult	Health Equity	Survey and focus groups; cross-sectional	N	Both
Major findings
100% experienced verbal insults, 79% had been threatened with attack, and 57% had been chased or followed 43–79% of assailants for all bias experiences were American Indian With American Indian GLBTT-S, 50% of providers felt very comfortable, 46% comfortable, and 5% uncomfortable – More negative attitudes toward gay men than lesbians (M = 14.27 vs. M = 11.18) – Reduced heterosexist attitudes associated with having GLT friends (M = 28.80 vs. M = 47.00) For informing the community about GLBTT-S issues: 90% said word of mouth, educational talks, and center newsletter; 81% suggested television and radio; 77% recommended pamphlets Top 3 Sources of Bias: HIV/AIDs epidemic, alcohol or other drug problems, and homophobia within the AI community Top Barriers to Healthcare Access: availability of financial resources, invisibility, negative/unaffirming experiences with uneducated providers
Sexual orientation, sexual behaviors, and pregnancy among American Indian adolescents	School	Targeted	3748	Adolescent	Sexual Health	Cross-sectional Survey Secondary Analysis	N	Quantitative
Major findings
Gay/bisexual boys and unsure boys: – less likely to use contraceptives (35.5& and 37.5% vs. 28% for heterosexual, x^2=10.70) – higher rates of abuse (history of physical abuse (x^2=16.91)), sexual abuse (x^2=26.92), and running away(x^2=23.91)) Lesbian/bisexual and unsure girls: – less likely ot use contraception (x^2=27.16) – unsure girls: 66.2% used ineffective contraception vs. 51.7 and 54.5% for lesbian/bisexual and heterosexual (x^2=16.06)
Sexual partner concurrency and sexual risk among gay, lesbian, bisexual, and transgender American Indian/Alaska natives	Multi-site	subset analysis: venue-based; convenience; RDS	330	Adult	Sexual Health	Subset of Cross-sectional Survey Honor Project	N	Quantitative
Major findings
38% reported trading sex, highest for MSM (51%) and WSWM (38%) 55–63% of men versus 84–85% women reported at least 1 of their 3 last partners was a steady partner Men more likely to repost an one time partner (34–37% vs. 12–25% for women) MSM and WSWM were most likely to report partnerships with a duration of less than 1 month (41% and 34%) 9% of all reported always using condoms – anal sex condom usage higher (13–22%) than for vaginal sex (0–14%) – Concurrency: – cumulative prevalence without time restriction: 59% (higher for MSM) – Median duration of overlap: 4 months, 28% reported 1 month or less – 72% of those with at least 1 concurrency reported unprotected sex with at least 1 partner – Higher among: males (M = 1.33 vs. females, M = 0.88), HIV+ (M = 1.62 vs. HIV-, M = 0.98), respondents with greater than 10 lifetime partners (M = 1.27 vs. less than 10, M = 0.74)
Sexual practices and condom use among a sample of Northern and Indigenous adolescents in Northern Canada: cross-sectional survey results.	School	Targeted	607	Adolescent	Sexual Health	Cross-sectional survey	N	Quantitative
Major findings
47% of those sexually active (22.9% for girls, 15.4% for boys) reported consistent condom use in the past 3 months For girls, sexual activity associated with age (uRR = 1.23), STI knowledge (uRR = 1.13), and alcohol/drug use (uRR = 6.55). For boys, sexual activity associated with age (uRR = 1.62) and alcohol/drug use (uRR = 5.76)
Syndemic Factors Associated with Safer Sex Efficacy Among Northern and Indigenous Adolescents in Arctic Canada	School	Targeted	610	Adolescent	Sexual Health	Cross-sectional survey	N	Quantitative
Major findings
23.6% reported food insecurity and 18.2% reported intimate partner violence (IPV) Food insecurity (β − 2.02; 95%CI − 2.79, − 1.24) and IPV (β − 1.23; 95%CI − 2.19, − 0.26) negatively associated with safer sex efficacy Currently dating associated with higher safer sex efficacy (β 1.00; 95% CI 0.19, 1.80) Higher safer sex efficacy associated with consistent condom usage among women (β 1.40[0.19, 2.61], p = 0.024) and men (β 2.14[0.14, 4.14], p = 0.036)
The process of developing a community-based research agenda with lesbian, gay, bisexual, transgender and queer youth in the Northwest Territories, Canada.	Pride	Convenience sampling for youth, Targeted for stakeholders	27	Adolescent, Adult	Health Equity	Focus groups; interdisciplinary team	Y	Qualitative
Major findings
Stigma highly felt by youth in secondary schools, gender non-conforming and transgender youth, and young gay men Need for LGBTQ issues to be integrated into youth programs Need for flexibility in the delivery of health services to LGBTQ youth
They tell us 'we don’t belong in the world and we shouldn’t take up a place': HIV discourse within Two-Spirit communities.	Multi-site	Targeted	6	Adult	HIV/AIDS	Subset of Cross-sectional Survey Honor Project Discourse Analysis	N	Qualitative
Major findings
4 functions of HIV in discourse: – Shadow presence – Professional identity – Way to connect with and claim community and culture – Health priority
Urban lesbian and gay American Indian identity: Implications for mental health service delivery.	NA	NA	NA	Not specified	Mental Health	Literature Review	N	Qualitative
Major findings
Invisibility experienced by gay/lesbian AI - denial of existence within the ethnic community so forced to choose between being gay or being AI. Cultural values - conflict between gay/lesbian cultural values and AI values (kinship networks) Potential conflict between cooperation and anonymity as valued in their community vs their individualistic coming out process
Victimization, Substance Use, and HIV Risk Behaviors Among Gay/Bisexual/Two-Spirit and Heterosexual American Indian Men in New York City	Community Organization	Targeted	71	Adult	HIV/AIDS; Violence Prevention; Substance Use	Subset of Cross-sectional Survey Honor Project	N	Quantitative
Major findings
20% of respondents reported some kind of victimization 2S men reported more lifetime HIV risk behaviors than straight men (5.90 versus 3.84) 2S men reported high numbers of sexual partner risk factors (3.75 vs. 0.32) 10% 2S and 6% heterosexual respondents HIV positive, indicating underreporting of HIV/AIDS in AIAN populations may be possible Victimization associated with: – Number of sexual partner risk factors (r = 0.76) – Frequency of failures to use a condom because of alcohol or other drug influence (r = 0.37) Lifetime HIV risk behaviors associated with victimization (r = 051)

Figure 1. PRISMA diagram depicting article inclusion and exclusion.

Figure 2. Volume of research in Two Spirit and Native LGBTQ health over time from 1980 to 2019.