A Hidden Crisis: HIV in the Two-Spirit Community

From the Margin to the Center

The growing epidemic of HIV among Native Americans and Alaskan Natives (NA/AN) is reason for concern. Roughly 5.2 million people in the U.S. identified as NA/AN in the 2010 U.S. census. While the Native community in the U.S. accounts for less than 1% of reported HIV cases, they have the third highest rate of HIV infection, after African Americans and Latinos. They also have the shortest life expectancy after an AIDS diagnosis of any race or ethnicity.

As indigenous people, once we are gone, we are gone. Take for example the Onondaga Nation in upstate New York. There are only 2,000 Onondaga left in the world, with 700 living on their traditional land. In 2008, they had three new HIV cases. Some may say "That's only three people," but that is over nine times the rate of HIV infection in the overall U.S. population. When considered in the scale of the Native population, HIV is taking an enormous toll.

According to the CDC, men who have sex with men (MSM) and MSM/IDU (intravenous drug users) accounted for 62% of all new diagnoses of HIV among Native Americans. Though useful for tracking behaviors that lead to increased risk, these labels don't help us understand why people of different identities engage in risky behavior or tell us how to treat people with HIV in a culturally sensitive and supportive way.

Two-Spirit Identity

There were once about 400 distinct indigenous Nations in North America. Of that number, 170 have documented multiple-gender traditions. At the Third Annual International Gay and Lesbian Native Gathering in 1990, activists created the term "Two-Spirit" to encompass these multiple traditions. They wanted a term that "reflected the combination of masculinity and femininity which was attributed to males in a feminine role and females in a masculine role" in many indigenous cultures. Our male-embodied Two-Spirit people (what the CDC call MSM) bear the brunt of the HIV crisis.

The Two-Spirit tradition is primarily a matter of gender, not sexual orientation. Within traditional Native communities, women farmed, gathered food, and cooked, while men hunted. Although there was division of labor along gender lines, there was no hierarchy based on gender -- a community could not survive without both of the equal halves of a whole. The Native commitment to gender equality opened the door for multiple genders, without the idea that a man was taking on a lesser gender by placing himself in a women's role, or vice versa.

Traditional Roles of Two-Spirit People

The Native commitment to gender equality opened the door for multiple genders, without the idea that a man was taking on a lesser gender by placing himself in a women's role, or vice versa.

People of Two-Spirit gender functioned as craftspeople, shamans, medicine-givers, mediators, and social workers. In many Native communities, men's and women's styles of speech were distinct -- sometimes even different dialects were spoken. Two-Spirit people knew how to speak in both the men's and women's ways. Many nations had a division of labor, women gathered and men hunted. As a result, there were men's camps and women's camps. Women were not allowed in the men's camp and vice versa. Since it was believed that Two-Spirit people had both men's and women's spirits, they were the only ones allowed to go between the two camps. They brokered marriages, mediated divorces, settled arguments, and fostered open lines of communication between the sexes.

Two-Spirit people challenged the rigid views of colonizers and missionaries -- not just of a binary gender system, but their entire binary system of "this or that." The Two-Spirit's mere existence threatened the colonizers' core beliefs, and the backlash was violent. Captain Vasco Nunez de Balboa, a Spanish conquistador, unleashed violent dogs on the male-bodied Two-Spirit people from what is now Panama. Word of this brutal treatment spread quickly from Nation to Nation. Many Nations decided to take actions to protect their Two-Spirit people. Some Nations hid them by asking them to replace their dress, a mixture of men and women's clothing, with the attire of their biological sex. After years of colonization, some of those Nations converted to Western religions that did not accept their community structures and forgot, or even denied, ever having a tradition that celebrated Two-Spirit people.

Colonization and Challenges to HIV Prevention

HIV prevention among NA/AN is filled with challenges. The historical trauma suffered by Native peoples has led to increased rates of alcoholism and drug abuse, which contribute to partner violence and make HIV prevention difficult. The stigma now associated with sexuality and gender in Native communities, along with the close-knit nature of these communities, can make it difficult to confidentially discuss and confront HIV.

A Hidden Crisis: HIV in the Two-Spirit Community

In 2011 the CDC released the National Intimate Partner and Sexual Violence Survey. One of the most staggering findings was that nearly half of the men who identified as Native reported rape, physical violence, or stalking by an intimate partner. HIV and other sexually transmitted infections (STIs) are more likely to be transmitted during sexual violence because of physical trauma. Intimate partner violence also causes power inequality in relationships, making it difficult to negotiate condom use. This staggering amount of intimate partner violence is fueling the HIV epidemic among Native communities.

Alcoholism leads people to engage in risky sex and can lead to intravenous drug use. These are the most common HIV transmission modes among Native people, who have the highest rates of drug use among all racial groups. In 2011, intravenous drug use accounted for 37% of HIV transmissions among Native women and 11% among men. This is almost double that of other races. Another factor fueling the spread of HIV in Native communities is the high rates of STIs, since they increase the risk of HIV infection. Native people have the second highest rates of gonorrhea, chlamydia, and syphilis among all racial groups.

Homophobia can be especially harmful, since it discourages people from seeking services out of fear of being targeted. Urban Natives have access to more services and to the LGBT community, but those who live on reservations are isolated. Local tribal health care centers offer HIV testing, but some people refuse testing out of fear. As a result, they may unknowingly be infecting others. Other issues, such as language and culture, gender identity, and culturally based holistic treatment are also important to address when providing HIV care.

As a colonized population, Native peoples have a long history of mistrust of the government, medical institutions, and service organizations. They have endured significant traumas, such as removal from homelands, divided nations, loss of language and culture through forced enrollment of children in boarding schools, rape, disease, etc. This history continues to influence today's generation.

A Hidden Crisis: HIV in the Two-Spirit Community

Recent Efforts to Combat HIV

The Indian Health Service, a federally-funded health program, recently created a website to inform people about HIV within Native communities. It includes educational information, the ability to search for local service providers, and statistics from a 2006 CDC report on HIV in Native peoples. While the site is a great resource, the out-of-date information highlights the shortcomings of dealing with the epidemic in this community.

Last March, the CDC published a comprehensive report titled HIV Among American Indians and Alaskan Natives. In 2007, National Native HIV/AIDS Awareness Day began an annual tradition of promoting HIV testing. The following year, The Indian Health Service began a nationwide campaign to promote routine testing of all Native populations. Slogans like "Native Tested Proud" and "Know Your Body, Know Your Status" encourage all Native people to get tested, regardless of gender identity or behavioral risk factors.

The U.S. Office of Minority Health, in partnership with the Indian Health Service released "The Circle of Life" curriculum for Native youth in December 2012. It emphasizes the importance of mental, physical, spiritual, and emotional wellness to prevent HIV infection.

Honoring Our Traditions

While many Native people have forgotten the "old" ways, there are groups of elders and activists who have quietly kept the Two-Spirit tradition alive. In some Nations, Two-Spirit people are again fulfilling some of their traditional roles and regaining the honor and respect of their communities.

A Hidden Crisis: HIV in the Two-Spirit Community

Not long ago, the Two-Spirit identity was not embraced by either the LGBT community or the Native community. This meant that no data were collected on the Two-Spirit community. With no data, it was nearly impossible to obtain any funding because leaders could not document what they knew was going on in their community. Fortunately, there are now two sets of data on Two-Spirit health.

One of these is the New York State Department of Health's needs assessment, "Reclaiming Our Voices: Two Spirit Health & Human Service Needs in New York State." The other is Dr. Karina Walters' five-year, multi-site health survey of Two-Spirit Native Americans, "The Honor Project," funded by the National Institute of Mental Health. The Honor Project has found that about a third of transgender Two-Spirit people and MSM reported they were living with HIV. These rates of infection are similar to those in sub-Saharan Africa, as well as to those among U.S. African American MSM, a community with a verified AIDS crisis.

The National American Indian and Alaska Native Addiction Technology Transfer Center assisted with the dissemination of the training, "Two-Spirit Then and Now: Reclaiming Our Place of Honor." This training helps mental health, substance abuse, and HIV care providers work more effectively with Two-Spirit people. Both Native and non-Native participants are given an opportunity to discuss how historical trauma led to the displacement of Two-Spirit people from their communities, and its impact on their mental health, health disparities, and recovery support needs. For more information, email training@ne2ss.org.

Since September 2012, the Substance Abuse and Mental Health Services Administration's Native American Center for Excellence has been hosting monthly Two-Spirit webinars. In "Depression and Suicide in The Two-Spirit Community," presenter Karina Walters acknowledged the difficulties that affect the mental health of Two-Spirit people and showed that strong family support networks are key to combating HIV in Native communities. For info on upcoming webinars, email info@nacesap.org, and visit nace.samhsa.gov/TTA/TrainingDocs.aspx to view past webinars.

Two-Spirit Gatherings

There are now 16 Two-Spirit organizations in the U.S. They know that a holistic and culturally appropriate approach to wellness is paramount, including a person's physical, mental, emotional, and spiritual self. Many of these Two-Spirit organizations hold regular gatherings, and the International Two-Spirit Gathering has been held yearly since 1990. Here people can explore, heal, experience, and share within a setting that is affirming of their Two-Spirit identity and traditions. The NorthEast Two-Spirit Society is hosting the 25th International Two-Spirit Gathering at Wading River, Long Island, from September 18 to 23, 2013. The theme for this year's Gathering is "Celebrating 25 Years of Resilience, Healing & Restoring Honor." For more information, email the planning committee at gathering@ne2ss.org.


Three decades after the AIDS epidemic began, Two-Spirit programs are providing culturally sensitive services with little to no funding and have set a high standard of service provision to an almost invisible population. These programs are necessary to begin our healing. The Two-Spirit tradition is a rich one that deserves closer examination. LGBT activists fighting for equality for all should remember that there was a time when people who engaged in same-sex relationships or who did not conform to binary gender systems were accepted and honored for their special qualities.

Two-Spirit people are a part of the fabric of this land, and we stand here today as a testament of our collective strength. By honoring the traditional place of Two-Spirit people in our communities, we have great potential for expanding HIV prevention and treatment.

Harlan Pruden is Director and Co-Founder of NorthEast Two-Spirit Society and is a member of the Goodfish Lake Band of the Saddle Lake Indian Reservation.

Tim Nuttle (Cherokee) is a volunteer and supporter of the NorthEast Two-Spirit Society.

Shannon Finucane is a Jeannette K. Watson Fellow and Public Policy Intern at GMHC.