Building a Model for Gender Affirming Care at Cowlitz Indian Tribe

Editor’s note: Support for this reporting came from the Poynter Institute with funds from the Gill Foundation. Read other stories in this series here, here and here.

The colonial legacies of assimilation policies and heteropatriarchal notions of gender and sexuality continue to reverberate through Indigenous communities, but many Native nations, like the Cowlitz Indian Tribe, are working to maintain traditional values that predate the harm caused by those legacies.

One way the Cowlitz are doing this is by protecting all of their citizens through approaches that reflect long-held cultural understandings of the gender spectrum, as demonstrated by the holistic gender-affirming care offered through their Health and Human Services department.

The Cowlitz Health and Human Services department includes 11 programs and employs about 200 employees, making it the largest department of the Cowlitz Indian Tribe’s government. The department has five office locations across Washington state in Vancouver, Butte, DuPont, Toledo, and Tukwila, where it provides behavioral health services like substance use disorder support, mental health and Medicaid medication-assisted treatment, an elders program, an Indian Child Welfare Act program, a victim services program called Pathways to Healing, an employment support program that helps Cowlitz citizens and other enrolled Native people with disabilities find employment services, and a child care development program that provides child care vouchers.

Underpinning the Cowlitz’s commitment to serving its people is the honoring of gender diversity.

“It really is about looking at the whole person and always making sure that we are providing the services that the whole person needs in a place that is safe and is judgment free and is really patient centered and led,” Debbie Hassler, the Deputy Director of our Health and Human Services Department told Cronogomet + ICT. “That means making sure that our advocates and our Pathways to Healing program understand maybe some of the nuances or uniquenesses in providing advocacy services to people who are trans or are in same-sex relationships, because sometimes those needs, or those resources, or how we help people be safe, are different.

Making everyone feel welcome

Hassler, Cowlitz, has been the deputy director of the Health and Human Services department for the past two years but has worked for her nation in different roles for almost 20 years. Hassler said that making sure the facilities are a welcoming and safe place from the moment people enter the building is a major priority for the entire department. Every facility entrance has artwork created by Marysa Sylvester, Tulalip and Quileute Tribes.

“To really make sure that we could message to individuals that they are welcome here and will be safe here,” Hassler said of the department’s goal.

Each location also has gender-neutral restrooms. The department recently received feedback from a young adult about signage asking people not to flush “feminine hygiene products” in the women’s restroom. The person pointed out that not all people who menstruate are women. In response, the department switched to more inclusive signage in the restrooms for “menstruation products.”

“For me as the deputy director, it’s like all the little things that we can do add up to, I think, making some real significant impacts in our community, [which] is pretty great,” Hassler said.

Hassler added that not everybody outside of Health and Human Services understood the importance of changing the language, which prompted important conversations that turned into more awareness and a better understanding of gender-diverse people within their own community.

The Cowlitz Health and Human Services department makes sure that its clinicians and providers are knowledgeable and well trained in the needs of the community, including gender-diverse patients.

“Being able to be a health and human service department, we really are able to marry those social health or human service kind of resources into integrated care,” Hassler said.

Whether in regards to gender-diverse issues, access to Plan B or other issues, Hassler said the department is able to honor the Cowlitz Indian Tribe’s cultural values through its integrated care model. Cowlitz citizens are spread out because it doesn’t have a reservation, so the nation has facilities all over the state to best serve its community members.

In order to make sure that every employee continues to honor Cowlitz cultural values, staff members all receive eight hours of cultural education training that details Cowlitz history, the legacy of violence and forced assimilation, the effects of federal Indian policies, tribal sovereignty, and Two-Spirit relatives’ place and reverence in community.

Hassler said the elders, spiritual people and culture keepers that Cowlitz citizens depend on are often members of the Two-Spirit and LGBTQIA+ community and that it’s important honor them and acknowledge that.

“Every person in our community has a role to play,” Hassler said.

The department also received training from Tavis Taylor, an internal medicine physician who has provided trans care since 2011 and teaches trans care to medical providers, including University of Washington Family Practice and Internal Medicine Residents. A portion of Taylor’s three-part series on providing gender-affirming care describes case studies that demonstrate how the care has had positive impacts for patients.

According to Hassel, the department’s medical director, Dr. Lynelle Noisy Hawk, Oglala-Hunkpapa Lakota, supports these trainings and believes continuing education in gender-affirming care is a priority for the department’s providers.

“We’re really excited that we have a person who feels comfortable and confident to be able to do that and really look at all of our community members and patients as unique people,” Hassler said. “If there’s a way that we can individualize the care that we’re providing people, whether it’s because they’re needing gender-affirming care, or maybe they need something else, being able to provide and have the resources and flexibility of the Cowlitz Indian Tribe to be able to make those individual treatment plan decisions has been something that I think we’re pretty proud of.”

Gender-affirming care, a phrase that many people in what’s now referred to as the United States have become familiar with, describes a range of healthcare services that support trans and nonbinary people. But it has long been a familiar concept to Indigenous peoples across Turtle Island, as people along the gender spectrum often held roles of importance and respect in many Native cultures prior to the perpetuation of the gender binary through colonization.

Hassler said her department provides all services related to gender-affirming care that patients have needed so far. This includes helping them decide on an individualized treatment plan that can include treatments such as hormone replacement therapy, referrals to specialists for surgical treatments if the patient expresses interest and other services.

If they are pediatric patients, the patient is referred to pediatric gender-affirming care teams for specialized support. There is also a therapeutic intervention youth group for kids 13-16 years old that meets once a year depending on interest. The group has presenters who talk through issues like understanding signs and red flags of abuse of people who identify as Two-Spirit and resources for help.

Family planning services for same sex and other families on the gender spectrum are also provided, including contraceptive counseling, referring patients for IVF/IUI services and offering resources for patients interested in adoption or becoming foster parents. Additionally, a new family nurse practitioner is joining the staff in January 2025 who has obstetrics experience and an interest in gender-diverse care. She will be working with clinical admin staff and clinical providers to explore additional family planning services.

The Cowlitz Health and Human Services Department also provides mental health support to patients regardless of gender identification, including gender-affirming counseling.

Future plans

The department has also taken sexual orientation and gender identity training through Paths (Re)membered. Itai Jeffries, Yesah, director of the Paths (Re)membered Project, facilitated the training and was also a keynote speaker at the Cowlitz Behavioral Health Conference in August along with Harlan Pruden, First Nations Cree, co-founder of the Two-Spirit Dry Lab, a quantitative research group, and an Indigenous Knowledge Translation Lead at Chee Mamuk, an Indigenous Health Program at the British Columbia Centre for Disease Control.

“We’re really excited about the content of this conference, and a large part of that was our Two-Spirit, LGBT focus,” Hassler said.

At the conference, behavioral health providers spoke about the importance of training and best practices when providing services or resources to citizens who are Two-Spirit and LGBTQIA+, and every breakout session had a speaker who was Two-Spirit or a workshop that addressed issues specific to Two-Spirit people in some capacity.

Indian Health Service will not support funding for the conference next year, so Hassler is unsure if the conference will be held again.

Future collaborations with Paths (Re)membered include Paths (Re)membered staff filming material around gender-affirming care at the Cowlitz tribal clinic to be used in the department’s promotional marketing or informational videos.

After a conversation with Pruden about the language Cowlitz people would have used to identify somebody in their community who was Two-Spirit, Hassler talked to the Cowlitz linguist.

“I want to know how Cowlitz would have identified a Two-Spirit person in our community,” Hassler said. “What was our word for that?”

Hassler is hoping to be able to share what she learns by June for Pride month in conjunction with the nation’s language program.

Lori Morris, the department’s referred care program manager, would also like to have a dedicated gender-affirming care team in the department, which would include a medical provider, a behavioral health clinician, a member of executive leadership and ancillary staff, according to Hassler.

Hassler is amazed by the department’s growth over the last 20 years and everything the Cowlitz nation has been able to accomplish. She believes the model should be celebrated. The department has even become a resource for other programs like the Northwest Portland Area Indian Health Board, which reached out to inquire about Cowlitz’s programs.

“I’m real proud of us as an employer,” Hassler said. “I’m proud of us because we do some cool things, but as a tribal member I’m really excited that we’re building all of this for my kids’ kids, and their kids and their kids. I just think it’s just so important.”