The COVID-19 pandemic has impacted social and structural health inequities for Indigenous[1] women, Two-Spirit[2] Peoples, and people with marginalized and minoritized sexual and or gender identities, including, lesbian, gay, bisexual, pansexual, asexual, transgender, non-binary, gender fluid, and queer+. Indigenous cisgender and transgender women continue to face multiple layers of ongoing discrimination, criminalization and intergenerational trauma (1). Ongoing colonial violence and gender-based violence continues to impact the health and well-being of Indigenous women, Two-Spirt Peoples, sex workers, and women living with HIV (2–6). Historical and ongoing colonial violence has impacted Indigenous health and Indigenous women Two-Spirit Peoples, women living with HIV, and sex workers face multiple barriers to accessing reliable healthcare services (7) and people with marginalized and minoritized gender identities face increased barriers to accessing healthcare on the ancestral, occupied territories of the Musqueam, Squamish, and Tsleil-Waututh Peoples in what is now referred to as Vancouver (8, 9). Barriers that impact health access are rooted in racism and discrimination. In Canada, racism remains a key determinant of health and significantly impacts Indigenous Peoples access to non-Indigenous-led health services and is well documented in reports such as the British Columbia (BC) Commissioned In Plain Sight report (7, 10, 11). The impacts of the COVID-19 pandemic have left gaps in knowledge that are not only essential to address now but also in preparation for future pandemic planning in the health system. Structural health inequities, including, access to healthcare services and community-based services (10, 12–15), gender-based violence (16, 17), and mental health disparities (14, 18, 19) have been impacted by the COVID-19 pandemic (20), yet little is known about marginalized Indigenous cisgender and transgender women and Two-Spirit Peoples access to routine healthcare services during the pandemic.
The COVID-19 pandemic further magnified existing health inequities that disproportionately impacts the health and well-being of Indigenous women and Two-Spirit Peoples (6, 10, 21). Sex workers and women living with HIV have been affected by the COVID-19 pandemic facing loss of income and lack of access to outreach services as well as stigmatization and harassment by governments and police (22, 23). Gendered impacts of COVID-19 include increased economic insecurity, unplanned pregnancy, lack of access to health services, domestic violence, lack of women’s voice and agency, and mental health issues (6, 12, 15, 24). The impacts are particularly felt by racialized groups that are marginalized by social and structural inequities, including Indigenous women and Two-Spirit Peoples. Due to COVID-19 pandemic lockdowns, mandated social distancing, and fear of the virus, there has been a significant increase in psychological and emotional stress (6, 18, 25–27). Marginalized Indigenous women and Two-Spirit Peoples face intersecting and compounding forms of oppression, and we hypothesize that psychological and emotional stress may further impact healthcare access and utilization. Considering how the intersection of gender and Indigeneity impact access to healthcare, gender diverse[3] and Two-Spirit populations face mental, physical, and sexual health disparities (28) as well as high rates of racism, stigma, and discrimination from healthcare providers that impact their access to healthcare services (24, 29, 30). Sex workers and women living with HIV who identify as a minority gender face increased barriers to accessing healthcare in Vancouver, BC (9, 31). The COVID-19 pandemic has impacted gender diverse populations access to healthcare services and gender-affirming care, including higher rates of violence and victimization (24). Our understanding of access to healthcare and the impacts of the COVID-19 pandemic among Two-Spirit and gender diverse Indigenous Peoples remains limited. Responsive and culturally appropriate research is needed to address the lack of understanding of the health inequities that Two-Spirit and gender diverse Indigenous Peoples face, as well as the reclamation of their healing.
There is conclusive global evidence demonstrating that Indigenous Peoples have worse access to quality healthcare than other populations around the world and Indigenous Peoples face unique barriers to accessing health care services (32–34). It is important to note that research on the health differences between Indigenous and non-Indigenous Peoples does not mean that Indigenous Peoples are inherently more likely to be sick but rather they are experiencing the ongoing impacts of colonial violence, for example, residential schools, the sixties scoop, intergenerational trauma, and ongoing racism (35). Previous and ongoing work clearly articulate the deeply harmful roles of colonialism and racism in continuing to systemically exclude Indigenous Peoples from accessing equitable and culturally safe healthcare. These acts of colonialism have ensured and continue to ensure that Indigenous Peoples are intentionally excluded from accessing equitable healthcare. The impacts of colonial violence on the health of Indigenous Peoples have been severe, leading to health issues that were not present prior to colonization, for example, mental health issues (7), tuberculosis (36), diabetes (37), cancer (38), and violence (22). The widespread racism and violence against Indigenous Peoples in Canadian systems of care led to the In Plain Sight inquiry. The In Plain Sight report highlights racism as a social determinant of health and Indigenous specific racism as a significant barrier to accessing health services, including accessing a doctor, nurse, and clinic. Racism crucially impacts the health and well-being of Indigenous Peoples in BC (7, 10). Compared to non-Indigenous people, Indigenous Peoples in BC face lower rates of continuity of care and healthcare access (10). Limited action has been taken towards addressing these health inequities that are clearly outlined in the In Plain Sight (10), The Truth and Reconciliation (TRC) (39), and the National Inquiry into Missing and Murdered Indigenous women, girls, Two-Spirit and LGBTQQIA + reports (40). It is critical to draw on the guidence of these foundational reports to investigate access to routine healthcare and build upon these reports by looking at access among marginalized Indigenous cisgender and transgender women and Two-Spirit Peoples (8).
Indigenous women, Two-Spirit Peoples, sex workers, women living with HIV, and people with marginalized and minoritized gender identities live in the intersections of multiple forms of structural violence (5, 9, 41). As a result of the intersectional stigma (i.e., the convergence of multiple stigmatized identities among a group or person) and violence, health and health service inequities are produced and reproduced (5, 10, 31, 42). Previous research has emphasized the roles of social determinants of health such as violence and cultural safety and access to healthcare services and supports among Indigenous women, Two-Spirit Peoples, sex workers and women living with HIV (7, 31, 43–45). Marginalized Indigenous women and Two-Spirit Peoples are targets of colonial violence and acts of genocide that are supported by colonial structures (40). Despite Indigenous women accounting for approximately 4% of the population, Indigenous women are overrepresented among women experiencing gender-based violence, with Indigenous women accounting for 75% of the overall population of women experiencing violence (46–49). Indigenous women and Two-Spirit People who are pregnant face severe amounts of racism and violence in the medical system, including threats and actions of child apprehension (5, 50), birth alerts (51), racism (10), and reproductive violence through forced sterilization which impacts trust in the medical system for Indigenous women and Two-Spirit Peoples who are pregnant or caring for a child (51). Racism and violence are known to undermine the health and safety of Indigenous peoples and undermine their access to care (5). For example, while Indigenous Peoples make up 14% of the population in Winnipeg, Canada, one-fifth of homicides were Indigenous women in 2022 (52). Previous studies describe high prevalence of violence perpetrated across community, intimate partner and community contexts among sex workers (31, 53, 54), with a disproportionate burden among Indigenous sex workers and Two-Spirit Peoples in Canada (31, 53, 55). Women living with HIV and sex workers also face several barriers to accessing healthcare services including violence (42, 56). Sex workers face disproportionate health and social inequities, for example, high rates of HIV and STI’s, violence, and criminalization (56). Sex workers and women living with HIV face several sources of structural violence, including lifetime exposure to violence, intimate partner violence, gender-based violence, and police harassment that impacts their access to healthcare services (22, 31, 57). A growing body of evidence has highlighted how culturally safe and trauma-informed healthcare services may reduce barriers to healthcare services among racialized and minoritized populations (7, 58, 59). The In Plain Sight and National Inquiry into Missing and Murdered Indigenous women, girls, Two-Spirit and LGBTQQIA + reports call us to address barriers to access to health services and the urgent need for culturally safe care (10, 40).
There is a need to understand how the COVID-19 pandemic has impacted social and structural health inequities for marginalized Indigenous cisgender and transgender women and Two-Spirit Peoples. Historical and ongoing colonial violence has impacted Indigenous health and marginalized Indigenous women and Two-Spirit Peoples face multiple barriers to accessing reliable healthcare services (7). The impacts of the COVID-19 pandemic have left gaps in knowledge that are not only essential to address now but also in preparation for future pandemic planning in the health system. The aim of this study was to evaluate access to culturally safe health services, experiences of violence, changes in mental health and changes in routine healthcare access during the COVID-19 pandemic. We hypothesized that these factors would be associated with experiencing difficulty accessing routine healthcare in a cohort of marginalized Indigenous cisgender and transgender women and Two-Spirit Peoples in Metro Vancouver, Canada during the COVID-19 pandemic.