American Indians differ in their degree of acculturation. In part, American Indians’ acculturation is muddy because what actually constitutes an Indian is unclear and controversial. This controversy is heightened by several factors, for example, in the USA: (a) the United States Census relies on self-report of racial identity, (b) Congress has formulated a legal definition in which an individual must have an Indian blood quantum of at least 25 %, and (c) some tribes have developed their own criteria and specify either tribal enrollment or blood quantum levels (Sue and Sue 2013). Garret and Pichette (2000) identify levels of cultural orientation to explain the degree to which AIANs identify with native culture (see Table 7.2). In addition, urban dwellers do not have access to tribal governmental services and political decision-makers or to public housing as their counterparts on-reservations. Urban American Indians may find it difficult to exercise their rights as citizens of Native Nations and may be disenfranchised and lose their voice in tribal governance (Weaver 2012).

In Canada, AP (including Inuit and Metis) are not afforded the same privileges as other Canadians. “In 1998, a United Nation Human Rights Committee ruled that the treatment of AP within Canada stood in violation of international law and was the most pressing human rights issue facing Canadians” (Meyer-Cook and Labelle 2003, p. 36). Both the historical and current treatments of AIAN and First Nations in North America are discriminatory and oppressive. The circumstances faced by AIANs and First Nations are similar to the challenges and oppression faced by more than three million indigenous people globally. The concerns for indigenous peoples globally culminated in the United Nations Declaration on the Rights of Indigenous Peoples (“the Declaration”), which is a framework of rights for indigenous peoples for states. Each Nation that adopts the Declaration is independently responsible for enacting domestic legislation and polices that comply with Declaration standards (Rowland 2013), though the Declaration is not legally binding for Nations that adopt it.

Cultural determinants of AIAN resistance and resilience include identity, spirituality, and traditional health practices, the very aspects of Native culture targeted by colonial persecution (Walters and Simoni 2002). For two-spirit persons in Canada, the binary concept of gender conformity that prevailed in colonial days was contrary to that of gender variance. Canadian two-spirit persons who thought in more circular ways resulted in outlawing and discrediting of any processes that that could not easily be co-opted to advance a larger agenda of profit by Europeans (Meyer-Cook and Labelle 2003). In fact, for two-spirit persons, enculturation (the process by which individuals learn or re-immerse themselves in their cultural heritage, norms, and behaviors within a contemporary context) in the form of “retraditionalization” may be a powerful process because of the denigration of their formally elevated status in many tribal communities (Fieland et al. 2007). Meyer-Cook and Labelle (2003) suggest that for two-spirit persons to achieve a sound identity, they need to simultaneously follow two tracks of identity formation: first as Native people or people of a minority group and second as people who are differently gendered.

As a population, health statistics for American Indians reveal significant adverse outcomes (Roubideaux et al. 2004). As compared to the general US population, American Indians have alcoholism mortality rates that are more than twice as high, significantly higher obesity and diabetes rates, injury-related deaths (e.g., homicides, motor vehicle crashes, suicides), disproportionate rates of depression, and deaths from injuries and violence account for 75 % of all deaths (Centers for Disease Control [CDC] 2007; U.S. Department of Health and Human Services 2007), lower earnings, lower educational level, and higher poverty rates, violence, and depression (CDC 2011). These factors are co-occurring, which means that AIANs are simultaneously at risk for all of them, creating a potentially severe network of social and psychological risks that affect their mental well-being (Native Vision Project 2012). Rates for older AIAN or two-spirit elders are not disaggregated among the data. The Alaska Department of Labor estimates that Alaska Natives (AN) account for about 7135 ANs over age 65 and 8040 between the ages of 55 and 64, with the most rapid increase in elders between 70 and 74, followed by those 85 and older. There is a higher prevalence of chronic illnesses such as cancer and heart and lung diseases, which can lead to a higher incidence of functional disability, and a corresponding need for long-term care (Branch 2005). Table 7.3 provides priority health needs as identified by Alaska Native elders.

Currently, older single-race AIAN adults account for 0.87 % of the total US population and multiple-race AIAN for 1.53 % of the US population (Ogunwole 2006). Compared to the general population, older AIANs are less educated, have a higher divorce rate (24.0 % vs. 19.9 %), and a higher percentage has never married (11 % compared to 6.5 % of the general population) (Tamborini 2007). Several factors contribute to the vulnerability of older AIANs: lower educational attainment, lower household income, greater poverty, less insurance coverage, and higher limited English proficiency. Furthermore, vulnerability might be affected by multiple contributing factors, not by a single factor (Kim et al. 2012). AIANs aged 62 and older self-reports of health status reveals that almost 46 % are in fair to poor health, compared with 33.6 % of the general population. AIANs have higher rates of work limitations at 34.3 %, compared to 15.2 for the general population (Dunaway-Knight et al. 2012). In addition, the percent of AIANs who will receive Social Security disability benefits at some point in their lives is higher than the general population (16.0 % vs. 10.8 %) (Social Security Administration 2011). Typically, the age at which a person is considered elderly in American society is 65; however, there is no such consensus among tribal nations. The Older Americans Act gives discretion to individual tribes to make this determination. The health status of AP of Canada, especially elders, is similar to that of AIANs and is substantially lower than that of average Canadians. Moreover, compared to other Canadians, AP have poorer social and economic indicators, face critical housing shortages, higher rates of unemployment, lack of access to basic health services, and lower levels of education attainment (Lafontaine 2006).

First Nations elders, including Aboriginal, Metis, and Inuit seniors, have received limited attention by researchers because as a population, Aboriginals are younger than the non-Aboriginal population (Beatty and Berdahl 2011), and a lack of epidemiological data results in pan-Aboriginal (i.e., between assimilation and traditional) evidence and approximations (Lafontaine 2006). The dire straits of Aboriginal elders is summed up thusly: they “are among the most neglected social class because of their increasing multiple physical and mental health problems and increasingly poor socioeconomic supports have forced them into even more challenging and dependent situations at an age when they should expect to be well treated and taken care of properly by both their families and governments” (Beatty and Berdahl 2011, p. 1). Metis report poorer health status than the non-Aboriginal population (Janz et al. 2009; Wilson et al. 2011) and are more likely than First Nations elders to report fair to poor health (Wilson et al. 2010, 2011). One in five Metis has arthritis or rheumatism compared to one in ten in the general Canadian population. In addition, Metis have higher rates of high blood pressure, asthma, diabetes (30 % of men vs. 14 % of non-Aboriginal men; 32 % of women vs. 11 % of non-Aboriginal women), and heart problems. First Nation elders have higher rates of disability due to injury and/or chronic disease, with 58.5 % over age 60 compared to 46.5 % of Canadian seniors (Lafontaine 2006). Aboriginal elders are more likely than non-Aboriginal elders to report daily smoking and heavy drinking; however, one in two reports not drinking at all, with the majority either never smoking or having quit smoking (Turcotte and Schellenberg 2007).

Similar to research findings in minority groups in the USA, Beatty and Berdahl (2011) identify social and economic status as the two most important determinants of health among Aboriginal elders. The prevalence of low income is higher among Aboriginal elders than non-Aboriginal elders, and Aboriginal elders are often less able to pay for private or co-funded services. Economic differences are more pronounced among First Nations who come from reservations and cannot fulfill the residency requirements and are placed at the end of long waiting lists. With the increase in the number of people receiving homecare among those without alternative income to supplement higher costs, health care beyond post-acute care is unaffordable and inaccessible to Aboriginal elders. A related issue is the underutilization of services by Aboriginal elders in cities and on-reservations. Barriers to service utilization include culture, language, affordability, jurisdiction, and problems navigating the health services system, barriers exacerbated by limited knowledge of and access to policymakers and service providers. Although some policies have helped improve competency skills and communications between service providers and minority elders, limited efforts have been made to address institutional structures, racism in gerontological settings, and access to care facilities for Aboriginal elders (Beatty and Berdahl 2011). Table 7.4 identifies health and service needs of First Nations Canadian elders.

Among other problems, Aboriginal elders encounter educational and literacy barriers, poor housing conditions, homelessness in urban areas, and elder abuse. In Canada, housing on reservations is among the poorest in the country, which means that many elders with disabilities and chronic conditions live in overcrowded and deficient homes (Health Canada 2009). Currently, federal funding policies do not allow for building of long-term care facilities on reservations (Beatty and Berdhal 2011). As a vulnerable population, medically compromised and dependent Aboriginal elders are often targets of abuse (Podneik 2008). Elder abuse occurs most frequently as physical, psychological/emotional, financial abuse, and neglect whether the elder is at home or in semi-private and public institutions. Often, elders’ and families’ preferences for self-determination of care are disregarded. Aboriginal elders living in Toronto identified major issues facing them including, social isolation, lack of transportation services, lack of assisted living services, lack of family peer support, lack of senior housing, poor proximity to housing services, lack of activities programming, lack of physical fitness resources, and lack of alcohol and drug abuse counseling (McCaskill et al. 2011).

Indigenous peoples have an identity that is rooted in a particular land of origin. Cultural identity is intimately connected with and defined by traditional territories. Indigenous cultural beliefs and values (e.g., harmony, respect, generosity, courage, wisdom, humility, honesty) and spiritual practices (e.g., natural world) are inextricably linked to the land. Even when Native Peoples are displaced from their territories, with ethnic mixing, and sporadic contact with tribal homelands, the tie to core indigenous values persists (Hendry 2003; Weaver 2012). For AIAN and First Nations, family or tribe is of fundamental importance because it provides a sense of belonging and security, an extension of the tribe (Sue and Sue 2013). This sense demonstrates the persistence and resilience of the community despite change (Weaver 2012). Different families and tribes have their own cultural assets. The cultural values and behaviors presented in the remainder of this section are generalizations and their applicability should be assessed for particular clients or patients and their families. The authors acknowledge distinctiveness within and between indigenous persons in the USA and Canada, and the intent is not to obscure such distinctiveness.

Native Peoples traditionally have respected the unique individual differences (personal differences) among people. This respect is demonstrated through staying out of the affairs of others and expressing personal opinions only when asked. An expectation is that this courtesy will be returned. Another traditional behavior is quietness. The act of silence serves multiple purposes in Native life. Historically, silence contributed to survival. When angry or uncomfortable, many Native Peoples remain silent. Silence is a deeply embedded form of Native interpersonal etiquette, and Patience is a closely related value to silence. Patience is based on the belief that all things unfold in time. The practice of patience demonstrates respect for individuals, facilitates group consensus, and permits “the second thought” (deliberation) (http://​www.​nwindian.​evergreen.​edu/​cirriculum/​ValuesBehaviors.​prf). In traditional Native Peoples’ life, work is always directed toward a distinct purpose and is taken on when it needs to be done. Work is linked to accumulating only that which is needed, which reflects the nonmaterialistic orientation of many Native Peoples. Mutualism, as a value, attitude, and behavior, permeates everything in the traditional Native social fabric. It promotes a sense of belonging and solidarity with group members cooperating to gain group security and consensus. The traditional manner in which most Native Peoples prefer to communicate is affective (nonverbal orientation) rather than verbal. That is, they prefer listening rather than speaking. Talk, like work, must have a purpose, and talking for talking’s sake is rarely practiced. Words have a primordial power, and when there is a reason for their expression, it is generally done carefully. Closely linked to nonverbal orientation are the highly developed and valued skills of seeing and listening. Hearing, observing, and memorizing were highly developed skills because all aspects of Native culture were transferred orally through storytelling (http://​www.​nwindian.​evergreen.​edu/​curriculum/​ValuesBehaviors.​pdf).

For Native Peoples, traditionally life unfolds when it is time. Time orientation is flexible and generally not structured into compartments. Similarly, Native Peoples have an orientation to the present and to immediate tasks at hand. What is occurring in the present takes precedence over vague future rewards. Emphasis is placed on being-rather-than-becoming (however, this value has shifted significantly over the past five decades toward a more futuristic approach). Both time orientation and orientation to the present tie into the Native value of practicality, with a focus on approaches that are concrete and experiential. At the core of traditional Native culture is a holistic orientation in which every aspect of life is based on an integrated orientation to the whole. A holistic perspective is essential in Native culture and is seen in aspects ranging from healing to social organization. Likewise, spirituality is integrated into every part of the sociocultural fabric of traditional Native Peoples’ life. Spirituality is considered a natural component of everything. Lastly, caution is exercised in unfamiliar personal encounters and situations. Caution is manifested as quiet behavior and placidity. In many cases, being cautious is the result of fear of how their thoughts and behavior will be perceived by those with who they are unfamiliar or in a new situation with which they have no experience (http://​www.​nwindian.​evergreen.​edu/​curriculum/​ValuesBehaviors.​pdf).

AIAN and Aboriginal or First Nations of Canada have distinct tribal values, beliefs, and behaviors; however, as Native Peoples of North America, these groups share some common cultural practices. The extent to which two-spirit persons incorporate some or all of these practices into life is dependent upon their level of acculturation, assimilation, or pantraditional experience. The following section describes two-spirit persons of North America.

For traditional American Indians , the terms gender roles and sexual orientation are false conceptualizations because AIANs never analyzed human sexuality in such dichotomous and categorical ways. Rather, a continuum of human sexuality and gender behavior is appropriate for different people. That is, people do what they do best (Pope 2012). From a community perspective, the major focus was on the fulfillment of social or ceremonial roles and responsibilities as a more important defining feature of gender than sexual behavior or identity (Fieland et al. 2007). American Indians have always held intersex, androgynous people, feminine males, and masculine females in high esteem. Gender is viewed as biological, whereas gender status is more culturally defined. Thus, one’s gender status may be either man (masculine), woman (feminine), or not-man/not-woman. In this model, not-man is not the same as woman, and not-woman is not the same as man. Clearly, by definition women are not men; however, other social groups within a society may consist of males whose gender status is that of not-men but who are also defined as not-women. These multiple genders are part of gender role construction in American Indian societies, and service providers for such cultures must be cognizant of this contextual ambiguity (Pope 2012).

Instead of seeing two-spirit persons as transsexuals who attempt to make themselves “the opposite sex,” it is more accurate to understand them as individuals who take on a gender that is different from both women and men. In essence, two-spirits “will do at least some women’s work and mix together much of the behavior, dress, and social roles of women and men” (Williams 1986, p. 344). Early on the term “berdaches” was used before the term two-spirit. Berdaches refer to that scared person accepted in the native world who is said to be both female and male (two-spirited) and believed to have mystical powers (Warren 1998). The term two-spirit originated in Winnipeg, Canada, in 1990 during the third annual Intertribal Native American First Nation Gay and Lesbian conference. Two-spirit was originally chosen to distance Native First Nations people from non-Native as well as from the words “berdache” and “gay” (http://​www.​rainbowresourcec​entre.​org). In 1991, the term berdache was replaced with the word two-spirit because of various negative connotations (e.g., male slaves or prostitutes) (see Williams 1986 for additional information). According to Laframboise and Anhorn (2008), the term two-spirit is preferred because it emerged from Native American people, whereas the term berdache was imposed upon Native People by the colonial explorers. Table 7.5 contains various terms that have been used to describe two-spirit American Indians. One of the reasons that two-spirits received respect was out of fear because they were considered to be touched by the spirits and to have powers on the level of a shaman. Two-spirits were highly regarded as artisans, craftspeople, child-rearers, couples counselors, and tribal arbiters.

Two-spirits are considered to be a “third gender,” and female two-spirits are considered to be a “fourth gender” (similar to the way that both female and male homosexuals are considered to be gay, while females are also considered to be lesbian) (http://​androgyne.​0catch.​com/​2spiritx.​htm). Rather than emphasizing the homosexuality of two-spirits, American Indian focuses on their spiritual gifts (Williams 1986). Laframboise and Anhorn (2008) make a key distinction about terms regarding gender-variant people, indicating that two-spirit is different from sexual orientation because such words did not exist in Native languages. As terminology referring to LGBT persons has evolved over time, gender, which “is an obligatory grammatical category in the English/French and Latin languages”… and as a linguistic term “… has no connection with biological sex or social identity of an individual” (p. 2). The relevance of the issue is where gender intersects with the Native Peoples of North America because two-spirit does not refer to people with homosexual tendencies; rather, on different genders being manifested and not on sexual preferences or practices (Lafranmoise and Anhorn). See Discussion Box 7.1 for ways in which two-spirits are honored.

It is important to point out that the term two-spirited has multiple meanings within several different contexts. For example, Aboriginal people who identify as gay or lesbian use the term because it is more culturally relevant to their identities. Aboriginal people who are transgender might also use the term two-spirit, an umbrella term for Aboriginal persons who live between socially defined male and female gender roles (Balsam et al. 2004), or they may use terms of their own Aboriginal languages (Scheim et al. 2013). Elders within Aboriginal culture teach that two-spirited people have a special place in their communities. Aboriginal culture is recognized for balance and harmony, and no one element or force dominates the others. The term two-spirit originates from the First Nations’ recognition of the traditions and sacredness of people who maintain a balance by housing both female and male spirits (Wahsquonaikezhik et al. 1976). Two-spirit persons are considered a vital and necessary part of the natural world and of the community as a whole because they possess an ability to see an issue from both perspectives and can understand and help solve problems that women and men may have individually or between each other (McLeod-Shabogesic 1995).

Not all AIAN or First Nations who are LGBT identify as two-spirited. Those who choose to use the term two-spirit do so to reflect their sexual and gender identity and its connectedness with spirituality and traditional worldviews (Walters et al. 2006). At times, First Nation LGBT persons may choose to use the word lesbian or gay in order to be understood in Western culture. C. Thomas Edwards (1998) is cited in We Are Part of a Tradition and explains that American Indians do not buy into homophobia because it is a focus on sexual behavior rather than the intricate roles two-spirit persons play. In the context of gender, two-spirit people also associate with the term bi-gender, which involves having a separate male persona and a separate female one. Granted, these terms are not exactly alike; nevertheless, they are closely related in both experiences and representation of that person (http://​www.​rainbowresourcec​entre.​org). Laframboise and Anhorn (2008) suggest that it is the inner calling of contemporary two-spirited people that mix their understanding of sexuality with the perception that homosexuality was well accepted in pre-colonization instead of recognizing that these homosexual behaviors were accepted under the role of gender identity. Thus, “the modern movement of reclaiming Two-Spirit Traditions incorporates sexual orientation and sexual identity” (p. 3).

Ristock et al. (2011) interviewed Aboriginal two-spirit/LGBT persons ages 19–61 regarding migration, mobility, and health and found that most moved from First Nations communities and/or small or rural towns to metropolitan areas because doing so allowed them to find a personal identity either with their sexuality and/or gender identity and/or Aboriginal identity. Other reasons for the move were to explore the anonymity that a big city can offer when it comes to exploring the “gay lifestyle,” finding others like them, for gender reassignment, and to begin a healing journey from incest and violence, they may have encountered as children. Those not actively involved in the LGBT community felt an affirmation of their identity just knowing that a large LGBT community in the city existed. Some distinction was made by two-spirit persons about the importance of having their own space because of the domination in the LGBT community by White people. A culturally specific space also allowed a place to have ceremonies.

Individually and collectively, AIANs and AP have worse health outcomes than other ethnic minority groups and non-Hispanic Whites (NHWs). Health disparities and chronic health conditions exist with marked variation across Indian Health Service (IHS) areas and within tribes in the USA (Wright 2009) and likewise for indigenous elders in Canada (Beatty and Berdahl 2011). The disparities are especially problematic for low-income elders in indigenous communities. Older AIANs and AP have greater numbers of chronic conditions, higher rates of disease comorbidity, and higher rates of disability than do other populations of elders (Beatty and Berdahl 2011; Satter et al. 2010). Although research has focused on the physical health status of older AIANs and AP, studies pertaining to their access to healthcare service are sparse, and their mental health status has been less often documented (Kim et al. 2012). Research suggests that older AIANs experience greater emotional and/or mental health problems compared to their peers of other racial and ethnic groups (Kim et al. 2011; Satter et al. 2010). Arguably, the impact of structural oppression including homophobia, heterosexism, and racism is likely to play a role in the physical and mental health of Aboriginal two-spirit/LGBT persons (Canadian Rainbow Health Coalition 2004; Taylor and Ristock 2011; Ristock et al. 2011). In response to the limited research on healthcare access and service, Kim et al. (2012) examined older AIANs’ physical and mental health status and related healthcare use in comparison with NHWs and found that older AIANs reported poorer physical and mental health than NHWs, were less likely to see a medical doctor and to have a usual source of medical care, and were more likely to delay getting needed medical care and report difficulty understanding the doctor at their last visit. However, this study did not indicate if any of the participants were two-spirit persons.

Two-spirit persons do not have more propensity or pathology of mental illness than the general population. However, their prolonged exposure to hostile or intolerant environments can cause significant stress on LGBT persons, and having to manage stigma has far-reaching effects on their health status (Brotman et al. 2003). Although information in this section is presented on the health status of AIANs and AP with reference to two-spirit elders as applicable, the authors agree with the position of Scheim et al. (2013) that AIAN and “Aboriginal gender-diverse peoples’ experiences and health statuses cannot be understood by simply summing together what is known from research on broader (AIAN), Aboriginal, or gender-diverse populations. Nevertheless, health inequities documented in studies using one or the other of these identity categories provide an important context for understanding the well-being of (AIAN) and Aboriginal gender-diverse peoples” (p. 109). Scheim et al. (2013) conducted a study to describe barriers to well-being in a sample of Aboriginal gender-diverse peoples in Ontario, Canada (see Research Box 7.1).