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Assessing Health Provider Perspectives Regarding Barriers American Indian/Alaska Native Transgender and Two-Spirit Youth Face Accessing Healthcare

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American Indian/Alaska Native (AI/AN) youth disproportionately face barriers accessing healthcare compared with non-AI/AN youth. AI/AN youth who also identify as transgender or Two-Spirit (2S) face higher rates of mental health issues and suicidality, along with increased rates of disease, due to health inequity and historical trauma.


This project evaluated health provider knowledge of context surrounding gender and sexuality in AI/AN communities. It assessed provider perspectives of provider-side and patient-side barriers accessing care to develop suggestions for improvement.


Semi-structured interviews (SSI) and focus group discussions (FGD) were held among healthcare providers across four sites in the Pacific Northwest. Questions were developed using a community-based participatory research conceptual model, considering the impacts of context, partnerships, and community knowledge. A grounded theory approach was used to analyze transcripts. This project received exemption from the University of Washington IRB and approval from each tribal ethical/research committee.


Twenty healthcare providers from varied geographic settings, provider types, and ethnic backgrounds participated in this study. Knowledge regarding contexts surrounding gender in AI/AN communities varied. Long-standing effects of settler colonialism, trauma, and systemic issues presented as overarching concepts. Participants also shared a number of patient and provider-side barriers impacting care and suggested solutions to reduce these barriers.


Patient and provider-side barriers inhibit AI/AN transgender and 2S youth access to healthcare. Historical trauma and community resilience play a role in health for these youth. Understanding history, the intersection of identities, and community strengths can help with the development of solutions to provide high quality care to AI/AN transgender or 2S youth.

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  1. LGBTQ2S: Lesbian, Gay, Bisexual, Transgender, Queer/questioning, Two-Spirit

  2. Native and AI/AN are used interchangeably throughout this work


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I would like to thank the Coast Salish peoples, the traditional owners of the land on which this project was completed, a resilient group of people who honor and bring light to their ancestral heritage. Thank you to all the individuals who participated in this project with enthusiasm. Your dedication to your patients and the American Indian and Alaska Native transgender and Two-Spirit community inspire me. This project would not be possible without the support of my thesis committee members, Dr. Tessa Evans-Campbell and Dr. Duran, my faculty advisor, Dr. Alison Roxby, and the Department of Global Health at the University of Washington.

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Correspondence to Alessandra Angelino.

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Ethical Approval

This study received exemption through the University of Washington IRB, Human Subjects Committee D (STUDY00006752). All procedures performed involving human participants were in accordance with the ethical standards of the University of Washington and each participating tribal clinic, and with the 1964 Helsinki declaration and its later amendments and comparable ethical standards.

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Angelino, A., Evans-Campbell, T. & Duran, B. Assessing Health Provider Perspectives Regarding Barriers American Indian/Alaska Native Transgender and Two-Spirit Youth Face Accessing Healthcare. J. Racial and Ethnic Health Disparities 7, 630–642 (2020).

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