11 Determinants of Health Among Two-Spirit American Indians and Alaska Natives Karen C. Fieland, Karina L. Walters, and Jane M. Simoni 1 Introduction In comparison to other racial/ethnic groups, American Indians and Alaska Natives (AIANs or “Natives”) suffer from glaring disparities in health-related resources and outcomes. Specifically, morbidity due to violence and substance use is higher and overall mortality is greater (Indian Health Service [IHS], 2001). AIANs who identify as gay, lesbian, bisexual, or transgender (GLBT) or with the modern roughly equiva- lent Native term “two-spirit” (hereafter collectively referred to as “two- spirits”) face additional stressors associated with negotiating their dual oppressed statuses. They often confront heterosexism from Natives and racism from GLBTs. Not surprisingly, two-spirits are thought to be at even greater risk for adverse health outcomes than other Natives (Walters, 1997; Walters et al., 2001). Preliminary empirical evidence supports the notion that two-spirits experience disproportionately greater anti-gay as well as anti-Native violence, including sexual and physical assault during childhood and adulthood (Walters et al., 2001; Simoni et al., 2004a) and historical trauma (Balsam et al., 2004)—expe- riences that are typically linked to adverse health and psychosocial functioning. Despite the considerable heterogeneity both within and across the more than 562 federally recognized tribes in the United States, the universal experience of colonization has created a shared history for two-spirit people, shaping distinctive conditions of health risk and resilience. The health problems of AIANs in general and two-spirits in partic- ular are not simply an artifact of Native genetics, culture, or way of life. 11 Two-Spirit Health Determinants 269 Rather, historical and contemporary trauma in concert with sociode- mographic vulnerabilities have interacted to undermine the physical and mental health of indigenous populations (Walters & Simoni, 2002). Precisely how these factors affect the health of two-spirits has yet to be empirically evaluated. Indeed, public health research and practice has given scant attention to AIAN populations and has virtually ignored two-spirits: There are no comprehensive reviews of two-spirit health or health-related issues and few empirical studies of even modest scope. The major aim of this chapter is to stimulate work in the area of two- spirit health by providing a foundation for the conceptualization of two-spirit health risks and resilience. We review the available litera- ture, highlight major gaps in the knowledge base, and provide directions for future research. We first provide an overview of the his- torical experience of two-spirit people and of the literature on Native health, including morbidity and mortality statistics. We then present the “indigenist” stress-coping model of Walters et al. (2002) as a framework by which to conceptualize how historical, structural, inter- personal, and cultural factors affect two-spirit health outcomes. Research related to some of these health-determining factors is then reviewed. Given the dearth of studies focusing on two-spirits, we refer mainly to studies of AIANs and other people of color as well as GLBT populations, which are almost exclusively non-Native. We conclude with a list of “decolonizing” strategies for future research on two-spirit health. 2 Two-Spirits: Historical Overview Native worldviews generally do not involve strict binary categories reflected in the Western weltanshauung, according to which male is con- trasted with female, gay with straight. Instead, they include a fluid con- ception of self, community, time, and space that permeates cultural norms and linguistic understanding of the self in relation to ancestors, contemporary community, and future generations (Walters et al., 2001). Appreciation of this nonlinear perspective is critical to understanding Native concepts of gender and sexuality, which lack meaningful equivalents in the West (Tafoya, 1992). Historically, Native societies incorporated gender roles beyond male and female. Individuals embracing “third” or “fourth” genders may have dressed; assumed social, spiritual, and cultural roles; or engaged in sexual and other behaviors not typically associated with members of their biologic sex. From the community’s perspective, the fulfillment of social or ceremonial roles and responsibilities was a more important defining feature of gender than sexual behavior or identity. Although often referred to as “two-spirits” today, there were tribe-specific terms for these individuals, including heemaneh (among the Cheyenne), Miati (Hidatsa), Winkte (Oglala Lakota), and Agokwe (Ojibway) for men and Tw!inna’ek (Klamath), suku (Maidu), Brumaiwi (Couer d’Alene), and Kwido’ or kweedo’ (Tewa) for women. 270 K.C. Fieland et al. Two-spirit men generally had sexual liaisons and partnerships with men and women. These ranged from brief sexual encounters to cul- turally sanctioned marriages to other males, which could be polyga- mous, monogamous, or part of a series of marriages (Lang, 1998). For example, among the Aleuts, marriages between a man and a shupan were commonplace, although typically the shupan would be a “wife” who was second to a biologic woman (Lang, 1998). Among the Nevada Shoshoni, a marriage between a tangowaiipü (two-spirit woman) and a Shoshoni woman also would be sanctioned, although the moroni noho (two-spirit women) of the Paiute people typically remained single. Two-spirit marriages or partnerships were viewed as unions with a third-gendered person; therefore, they were not viewed as “homo- sexual” but, rather, as “hetero-gendered” (Lang, 1998). Although there were exceptions, many of the individuals who embodied “alternative” gender roles or sexual identities were inte- grated within their community, often occupying highly respected social and ceremonial roles (Medicine, 1988; Brown, 1997; Little Crow et al., 1997). In her review of more than 125 tribal cultures, Lang (1998) noted that two-spirit men were generally held in high esteem and thought to be endowed with spiritual or medicinal powers. The Western lens through which early anthropologists judged Native gender roles and sexuality was fraught with ethnocentric biases, leading to their confounding gender roles with sexual orientation. Early anthropologic reports employed the term berdache to describe Native people whose gender role varied from Western conventions. The term is offensive to AIANs because of its colonial origins and purely sexual connotations: it is a non-Native word of Arabic origin (i.e., berdaj), which refers to male slaves who served as anally receptive prostitutes (Jacobs et al., 1997; Thomas & Jacobs, 1999). More contem- porary anthropologists created the terms “women-men” to describe men who assumed gender roles and behaved in ways more commonly associated with women and “men-women” to describe women who assumed gender roles and behaved in ways more commonly associ- ated with men (Lang, 1998). Western colonization and Christianization of Native cultures included attacks on traditional Native conceptions of gender and sexual identity. Missionaries in boarding schools and government agents on reservations enforced conformity to the European and Christian binary, anatomically based gender system that dictated “proper” dress, appearance, and social and work roles. This colonizing process succeeded in undermining traditional ceremonial and social roles for two-spirits in many tribal communities. The cultural genocide (i.e., ethnocide) resulting from Christianization (Tinker, 1993) replaced traditionally accepting and inclusive tribal traditions toward two- spirits with systems of oppression and shaming condemnation, giving rise to internalized heterosexism and homophobia in Native commu- nities. A movement toward retraditionalization has begun to reverse this destructive process. Begun during the Red Power movement of the 1970s, retraditionalization involves reembracing traditional practices and is the impetus for such programs as language revitalization. 11 Two-Spirit Health Determinants 271 The conflation of gender and sexual orientation resulting from Western misinterpretations of Native traditions was partially corrected by introduction of the pan-Indian term “two-spirit.” Adopted in 1990 at the third annual spiritual gathering of GLBT Natives, the term derives from the northern Algonquin word niizh manitoag, meaning “two spirits,” and refers to the inclusion of both feminine and mascu- line components in one individual (Anguksuar, 1997). The creation of a two-spirit identity, according to Native activists, is an attempt to rein- form, recreate, and retraditionalize the contemporary Native GLBT experience according to affirming historical practices (Walters et al., 2001). It is inclusive of different tribal histories, ceremonial and social statuses, and contemporary gender and sexual identities, allowing AIANs to align with ancestral traditions while simultaneously enact- ing political resistance to Eurocentric hegemony in non-Native GLBT communities (Walters et al., 2001). The term “two-spirit” is not easily translated into indigenous lan- guages (e.g., in Navajo it means literally “being possessed”). Neither is the term uniformly employed or widely accepted among Natives. To some AIANs, the term refers to a person with a GLBT orientation. To others, it denotes an individual with tribally specific spiritual, social, and cultural roles that are not defined