What Health Providers Can Learn: There are two-education steps to a healthy patient relationship with 2-Spirit People

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

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

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

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

We are pleased that CRHC has set a goal to improve GLBT and 2-Spirited peoples’ access to care through the education of health care professionals and the enlargement of the capacity of communities.

Medical schools in Canada have recently undergone a major pedagogical transformation and moved away from didactic, lecture room-based learning to “problem-based” and “community-oriented” learning. The opportunity to integrate knowledge of our health issues in this pedagogical approach is good (Schmidt et al. 1989; Normile 2002; Langan 2002; Wasylenki et al. 2000). To date, however, no medical school has included a 2-Sprited health scenario in its problem-based learning or expressed an interest in extending its community-oriented learning to our community. This gap can be remedied.

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

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

3.1 Specific objective 1

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

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

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

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

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

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

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

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

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

3.4 Specific objective 4

4. Targeted Players

5. Territory

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

7. Duration of the project

8. A work plan for the project

9. A budget

10. References