Creating a safe and inclusive space for transgender and two-spirit people

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Dr. James Makokis went into medicine to make a difference in the lives of people. As a Nehiyô two-spirit physician, he is determined to bring the humanity back to medicine. He practices family medicine in Kinokamasihk Cree Nation in northeastern Alberta and has a transgender-health-focused practice in south Edmonton. He spoke to VPSA members and other VCH medical staff during a recent Zoom session about decolonizing medicine and offering safe and inclusive medical care for transgender and two-spirit people.

Dr. Makokis and his husband, Anthony Johnson, are widely recognized as the winners of the 2019 Amazing Race Canada. Participating as Team Ahkameyimok (Never Give Up in the Cree Language), they were the first two-spirit Indigenous married couple in the world to win the series.

“We wanted to participate in the race because it was an opportunity to educate people on many issues,” recalled Dr. Makokis. “Everywhere we went for the show, we acknowledged the territory on whose land we were. We wore red for the murdered and missing Indigenous women and girls. And, we had the Pride rainbow. Our story made international news. It was important for young people to see such diversity.”

He recalled that growing up the messages we received on TV were ones of heterosexism and cis gender normativity. There was a lack of cultural or ethnic diversity and ableism was the norm. Dr. Makokis remarked that this is true still for most medical leaders.

“Racism exists within the medical system,” he said. “Diversity, equity, and inclusion are critical issues, and we need diversity at the table if we’re going to address issues such as systemic racism.”

First Nations have an ancient understanding and acceptance of gender and sexually diverse people. While the term two spirit is an English expression, it refers to First Nations people taking an active step to reclaiming traditional roles known before colonization. It is an intersection of sexuality, gender, and culture.

“Often two-spirit people were—and still are—thought to be born with additional gifts,” said Dr. Makokis, who went on to give historical examples of two-spirit people. He described the Nehiyô governance structure and its disruption during colonization. The effects of this on two-spirit people were devastating and have created barriers to accessing safe and inclusive health care.

“Over 50 per cent of Indigenous trans people have attempted suicide,” said Dr. Makokis. “I got into transgender medicine because I was told it would help save lives. We need trauma-informed processes, and we need to reduce barriers for our patients to feel safe.”

Dr. Makokis started working at Enoch Health Services six years ago. It is an on-reserve health centre that is difficult to access without a car. Still, transgender patients come from throughout Alberta and even from international destinations.

“That so many people come despite the barriers shows there are major health barriers for trans people,” noted Dr. Makokis.

Barriers to medical care for transgender people and those transitioning include a lack of knowledge among physicians. We are not always aware of gender diversity, terminology, gender diversity safe care, or referral pathways. There is fear because we are not taught this.

“Creating a safe space at Enoch meant speaking with and educating all staff,” said Dr. Makokis. “It’s important not to make assumptions based on a patient’s appearance, so we use gender neutral language. Proper alerts are created in medical chars (preferred pronouns and names) and we use their preferred pronouns. All patients are treated with respect.”

Dr. Makokis reviewed the process he used to use when meeting with patients and how that has evolved. Forms are now sent ahead of time to patients and HRT can begin immediately upon meeting.

“Patients often cry after receiving their first set of hormones because they’ve waited so long,” said Dr. Makokis. “It’s one of the most rewarding parts of my practice.”

His take-home message is if a patient tells you they are transgender, they are transgender until proven otherwise. During their second visit, he talks with a patient about their gender and sexual history to establish the diagnosis. He emphasized that he has only had one patient in six years who did not meet the criteria for gender dysphoria. He and the patient will also discuss their social readiness to assist with the transition.

Dr. Makokis took the time to discuss pediatrics and puberty-suspending medications before giving an overview of allyship and ways we can demonstrate support in our lives and in our work. He welcomed questions and comments from the session attendants.

“Providing transgender health care is decolonizing medicine and saves lives,” he concluded.

VPSA members interested in transgender health-care professional development can attend the World Professional Association for Transgender Health that will be held in Montreal this September. Dr. Makokis also recommends reading Transgender Primary Medical Care: Suggested Guidelines for Clinicians in British Columbia and Shelbourne Health Centre’s Protocols for Hormone Therapy for Trans Clients.

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