Sitting on the floor of a teepee, in a circle of patients, friends and relatives, doctor James Makokis cried as he remembered his father struggling to accept him when he came out as gay at the age of 17.

Speaking to about two dozen people, including transgender teenagers and their parents, Makokis explained how his uncles helped his father come to terms with his sexuality.

“It was kind of difficult for him to understand that,” his voice breaking as his husband Anthony Johnson comforted him in the garden of their home near Edmonton, capital city of Canada’s Alberta province.

Makokis, now 37, is a First Nations family doctor from Saddle Lake Cree Nation who identifies as “two-spirit” — an umbrella term used by indigenous people in North America who identify with both masculinity and femininity and which harks back to pre-colonial third-gender roles. Although his mother accepted him as gay, Makokis moved from his small rural community northeast of Edmonton to the city to finish his last year of school.

“Reflecting now as a physician, I had all the characteristics of depression,” Makokis said. “It was really important that I physically move away to be in a place like Edmonton that is more diverse.”

After training as a doctor in the provinces of Ontario and British Columbia, Makokis wanted to support other indigenous LGBT+ people, particularly those identifying as “two-spirit,” many of whom feel their traditional acceptance in native communities has been lost.

He decided to focus on treating trans patients, advising them on transition, prescribing hormones, and teaching indigenous culture to young people who make up about 5 percent of his estimated 300 patients.

“I thought if I practiced trans medicine I will be working to address this issue of homophobia, transphobia that has come to exist in our nations now and help to empower two-spirit people to belong again,” Makokis said.

This cultural education includes hosting LGBT-inclusive native ceremonies with his husband in “sweat lodges,” which are typically low, dome-shaped huts made of natural materials.

During a traditional Cree “sweat,” a spiritual purification and rejuvenation ceremony, women sit on one side of the lodge and men on the other. But at a “two-spirit sweat” people were invited to sit freely as elders drummed, sang traditional songs and prayed in their native Plains Cree dialect while water was poured onto red-hot rocks in the dark.

Afterwards in the nearby teepee, Makokis, Johnson and the other attendees took turns sharing stories of coming to understand the meaning of two-spirit and finding a community to support them.

There is no survey data on the number of LGBT+ or two-spirit people in Canada. Sean Waite and Nicole Denier, assistant professors of sociology at Western University and University of Alberta respectively, estimate the number of indigenous LGBT+ people as between 39,000 and 100,000.

Canada’s 2016 census counted nearly 1.7 million indigenous people, or 4.9 percent of the population of 35.2 million.

Two-spirit people describe their identity in a multitude of ways, from being able to access the masculine and feminine within them, to walking in both male and female worlds.

The term was widely adopted after being coined in 1990 at a Native American/First Nations gay and lesbian conference in Winnipeg, Canada, according to Kylan Mattias de Vries, chair of Gender, Sexuality, and Women’s Studies at Southern Oregon University.

It replaced “berdache,” a colonial-era word, and aimed to reflect diverse gender identities that have always existed in indigenous communities across North America, according to de Vries, where some third-gender roles carried ceremonial and spiritual significance.

In Cree culture, Makokis said, a two-spirit person is a “chameleon,” carrying out whatever job needs doing, regardless of whether it is considered men’s or women’s work.

Sabine Lang, an anthropologist at the Roemer and Pelizaeus Museum in Germany, said the colonization of North America and government-sponsored religious “Indian Residential Schools” that housed 150,000 children between the 1840s and 1990s in Canada had a “devastating effect” on the acceptance of two-spirit people.

“Some people in Native American communities today will deny that there were ever such people in their communities despite anthropological evidence,” said Lang.

Data is scant on the discrimination and mental stress faced by LGBT+ and two-spirit people in Canada, including on teenagers. However, a 2018 survey of about 26,000 LGBT+ 13-to-24-year-old Americans by the Trevor Project, which supports young people, found indigenous trans youth were the group most at risk of suicide, with 37 percent saying they had attempted suicide in the prior year.

Purpose on Earth

Makokis acknowledged the mental toll of being two-spirit, but said there were also positives, such as having unique perspectives and the ability to fill multiple roles in the community. He remembered how he decided that he wanted to become a doctor at the age of 4.

“In Cree thought or belief, we believe that children will announce at least four different times what their purpose is here on Earth — and usually before the age of 4,” he said. “So it’s kinda cool that that happened.”

He recalled his first shift working on a maternity ward, waiting to be called to a delivery before he realized the nurses were deliberately excluding him.

“As I was walking in the room, one of the nurses ... pulled my braid so hard that my head jerked and said, ‘You can’t go in that room,’ and, ‘Who do you think you are?’ I think every indigenous learner will experience racism in some form,” he said.

In 2016 only 9.6 percent of First Nations Canadians had a university degree compared to 28.5 percent among the total population, according to government census data.

“One of the responsibilities that comes with being an indigenous person, who has gone to school in a Western university setting, is not to forget and leave your ingenuity behind as you walk through the doors of the ivory towers,” Makokis said.

He decided that specializing in trans medicine was one way to do this, as well as to help address the mental struggles faced by his patients.

“Patients immediately respond to having access to quality care that’s safe and that they feel comfortable with,” he said.

Various studies show that gender transition tends to improve the wellbeing of trans people, and between 0.3-3.8 percent of adults who undergo medical transition regret it, according to Cornell University’s “What We Know” project, which collates research on public policy issues.

Long-term data on children and young people are “sparse,” Johanna Olson-Kennedy, the medical director of the trans youth clinic at the Children’s Hospital Los Angeles, said in a 2016 research summary.