You may know them as the winner of Season 7 of “The Amazing Race Canada”, but if that isn’t impressive enough, Dr. James Makokis is also a Two-Spirit family physician from the Saddle Lake Cree Nation, and a world-renown expert on Indigenous LGBTQ2S+ healthcare.
Dr. James Makokis
Makokis grew up with big dreams but equally significant challenges. Despite not seeing Indigenous Peoples or Two-Spirit people represented in medicine, they found ample inspiration in family and community from an early age.
“Growing up, there were not any doctors working in my community that were from my community. I didn’t have that to look to. What I did have to look to were my mother and aunts who went back later in life to pursue graduate studies,” Makokis told Forbes Healthcare.
Along with providing a positive example, Makokis’s family and community also provided nourishment for their dreams.
“Without the support of my parents, family, and community, I would not have made it to medical school.”
Mission accomplished. Today, Makokis is an Associate Clinical Professor in the Faculty of Medicine at the University of Alberta who cares for Indigiqueer patients and advocates for Indigenous Two-Spirit and transgender health nationally and internationally. For their impactful work, Makokis was named to The Medical Post’s 2021 Power List.
Makokis spoke to Forbes Healthcare about their journey to medicine, work in Two-Spirit health, advice for aspiring Two-Spirit physicians, the need for more Indigiqueer representation in medicine, and the unique health challenges faced by Indigiqueer communities.
Dr. James Makokis
Forbes Healthcare: First, can you tell us more about yourself and your journey to medicine?
James Makokis: I wanted to be a doctor since I was at least three years old. In the Cree or Nehiyô childbearing belief system, our elders tell us that children are gifts from the spirit world who come as stars and rays of light. It is the function of our healthy communities to raise that child up and nurture their utmost potential, because that makes our nation stronger. The elders say that children will demonstrate or announce their gifts of what they came here to do on this earth, usually around three or four years of age. It is then up to adults to nurture those gifts. As a little boy growing up on my reserve, I demonstrated my gifts to my parents, and they supported me in my schooling. Without the support of my parents, family, and community, I would not have made it to medical school.
Getting to medical school was a long and arduous journey because I was coming to terms and accepting my own Two-Spiritedness. I came out at the age of seventeen in my first year of college. Like many other Two-Spirit youth, there is almost a second adolescence that you have, which is the first one where you have space to express being attracted to who you are attracted to and being who you really are. Unfortunately, for Two-Spirit and transgender youth, many of these spaces are often in clubs and environments that can be saturated with drugs and alcohol. That affected my academics because I was more involved in exploring who I was in places that were not conducive or not always healthy. At one point, I realized I might not get into medicine with the way things were going. It was shocking and scary because I worked my whole life for that. So I decided to do an additional year of university and then a Master of Public Health to increase my GPA and demonstrate a commitment to my academics. I then got into medical school on my first try in 2006 at the University of Ottawa Medical School. I was part of the second cohort of an Aboriginal medical program which was established to address institutional barriers that Indigenous people face to accessing medicine. I graduated in 2010 and went on to do my Aboriginal family medicine residency training at the University of British Columbia in Victoria, on Vancouver Island, which I completed in 2012. Since 2012, I have been practicing as a family physician.
FH: What does being a Cree Two-Spirit physician mean to you and how does it influence the way you care for your patients?
JM: I am first and foremost a Nehiyô Two-Spirit person and citizen of my Indigenous nation. Then I am a physician. That is how I practice medicine. What that means is that if someone comes to me with a health concern, I look at it through both lenses. I listen and evaluate as a diagnostician, as we are trained to be. If I feel I have come to the answer, I will tell them what it is. But if I am able to, I also let them know how we can address the issue with Cree healing practices. I lay out the opportunities with western medicine and also encourage the use of both western and Cree medicines that are available to them. What that does is uplift autonomy—the power to have a choice—which for Indigenous Peoples who are historically and contemporarily oppressed, doesn’t happen often. I want to give that power back. If I know the medicine, I will even go with them to pick and harvest it. Everyone used to know our medicines and how to look after ourselves. And yes, we had specialists, but we all used to have that basic knowledge that has been significantly impacted by colonial violence. When we share this knowledge, it is empowering, improves trust in me as a doctor, and helps patients know how to take care of themselves. If they only want Cree medicine, I also support that and I, as the doctor, will order the diagnostics to follow their treatment progress, just as I would for western medicine. That is the importance of having Indigenous Peoples from our communities who are working with elders and knowledge holders and supporting them to go into medicine so they can practice the way our elders envisioned.
FH: How have you personally navigated the largely white, male-dominated world of medicine?
JM: Medical school was one of the most difficult and challenging experiences I have ever had to go through. It was also one of the most violent. The only way I was able to cope and protect myself while I was in it was with the help and support of my family, elders who nurtured and taught me, and my community. It was especially difficult when eight of my relatives passed away during medical school, and I had to take time away from intensive learning to go home and grieve, and participate in the ceremonial burial processes. Being in a constant state of grieving affected my ability to learn, and to help me, my parents would fly my sister and me home and prepare ceremony, such as a sweat lodge, to help us recharge, feel supported, and encouraged again. Our elders always encouraged us not to give up and to keep going, saying, “Don’t give up my grandchild, you can do it… come back and help us.”
I believe that being an Indigenous medical learner is different because it is never just about ourselves. The years spent in education away from family, language, and elders are always for our nations to become stronger. Many people I went to school with may have gone into medicine for altruistic reasons, but for us, it is for our people and our nations. It is because of their support that I was able to get through the cisgendered, white male-dominated field of medicine, which is often violent towards us. Every year, I would Kihkosimowin (fast), participate in ceremonies, record elders’ teachings and songs so that I could listen to them and continue my own learning to help me navigate through the difficult field of medicine. This gave me the strength to continue and be present, knowing they were always with me, and that our ancestors were always with me. I felt their presence when I was writing exams or working 24-hour shifts. I knew that I was never alone, and that everything my grandparents had to suffer through and the strength they had to endure residential school violence was with me.
FH: Why is Indigiqueer representation in medicine important?
JM: When I think about Indigiqueer representation in medicine, I recall a Pacific Indigenous health conference where I was a speaker in 2012. It was held in Alice Springs, Australia, and during my presentation on Two-Spirit health, I noticed that it was the first time the topic had ever been presented at the conference. The room was packed, and I estimate that about 90% of the medical learners present were Two-Spirit or Indigiqueer. It was amazing because, historically, we know that Two-Spirit people worked in health, medicine, and healing before colonization. In spite of everything that happened to us, we are still finding ways to work as healers, and I saw that reflected in the crowd that day. It is important for young people to see themselves represented in these professions where we have never seen ourselves before.
For example, I can only think of a few Indigenous doctors in Canada who have braids. I started to grow my hair out in 2005 knowing I was going into medicine. When I walked down the hallways of medical schools, they were largely dominated by white males, and there were few to no Indigenous people. So, I thought of my own nephew, who is turning nine this year and who has long braids, and I wanted him to see that there is space for him too. I wanted to change the perception of non-Indigenous people that Indigenous people can become doctors while being fully who we are in all our power and authenticity. We don’t have to assimilate, and we can come out stronger. Our strength, pride, identity, and culture allow us to be successful.
FH: What advice would you give to Indigiqueer youth who are interested in medicine?
JM: Please apply. You can do it. There is space for you. Reach out to other Indigenous and Indigiqueer doctors to help support and mentor you. It is important to have mentors to encourage you along the way. It is important to have the support of BIPOC physicians around you because racism, transphobia, and homophobia are still realities in medicine, and the field continues to be violent towards BIPOC and LGBTQ2S+ peoples. Connect with mentors who can help you navigate these spaces and advocate for you so that all Indigiqueer physicians can be their fabulous selves, representing on rounds, and wearing the coolest styles. You can be successful and do whatever it is you want to do and put your mind to doing.
FH: What are some of the unique health challenges facing Two-Spirit and Indigiqueer communities?
JM: When we look at where our communities are in terms of decolonization or, as my husband says, restoring harmony, we can best see our progress reflected in how we treat our Two-Spirit and transgender relatives, as well as women. If our Two-Spirit and transgender relatives are welcome in ceremony for who they are and don’t have to change, then we know we have made significant progress in creating safe spaces. If we see homophobia, misogyny, toxic masculinity, and transphobia, we know there is work to do.
Unfortunately, in many of our communities, the impact of Christianity has been very violent to transgender and Two-Spirit peoples. The rates of transgender and Two-Spirit Indigenous youth suicide reflect this. If there is a transgender or Two-Spirit young person in our community, the stats tell us they can have up to a 50% chance of attempting suicide. For Two-Spirit and Indigenous transgender youth, the suicide rate is likely one of the highest of any population in the world.
This is one of the important areas and opportunities within both medicine and our communities to reclaim and celebrate our relatives for their gender and sexual diversity and uniqueness, which we have always done before colonization. That’s why I got into gender-diverse and transgender medicine because I wanted to provide gender-affirming care, which is life-saving. It is one of the most rewarding parts of my career, but also one of the most life-saving. I also wanted to advocate for the recreation of inclusive spaces, including ceremonially inclusive spaces where Two-Spirit and transgender relatives can fully participate in our ceremonies, which are supposed to be the healthiest parts of our Nations and where our people go to get help. If we continue to exclude our Two-Spirit and transgender relatives, we are not decolonizing and returning to our original teachings. We can only do that when we are fully inclusive.
FH: On a systemic level, what can the field of medicine do to provide better care for Two-Spirit and Indigiqueer communities and respond to their unique challenges?
JM: Medicine can be hugely improved by embedding transgender and gender-affirming care in medical education, so we learn about transgender health as a normalized aspect of our curriculum. When I went to medical school, we had about one hour of transgender health teaching. It was really about the social aspects but not about providing medical care, whether it’s hormone replacement therapy, gender-affirming surgeries, assessing gender dysphoria, or introducing transgender people as a normalized aspect of everyday patient encounters. When I think about my transgender patients, 100% of them have experienced transphobia within the healthcare system. Some of these experiences may have been extremely violent, such as getting kicked out of doctors’ offices, while others involve the subtle nuances of unconscious bias, such as not being addressed by their pronouns. These experiences underscore my feeling that by the time medical students graduate, transgender health should be completely normalized to the point that when they start practicing, it is nothing new to them, and they don’t perpetuate the discrimination and violence that transgender people endure.
FH: What advice would you give a non-Indigenous healthcare provider who wants to learn and do better by their Indigiqueer patients on the clinical level?
JM: There are many professional development opportunities for physicians to learn. One example is the World Professional Association for Transgender Health, which has biannual conferences that provide continuing medical education on these topics. Their global education initiative provides both beginner and advanced level training for physicians to learn how to provide clinical care for gender diverse people, improving confidence in providing hormone replacement therapy, for instance.
Another thing physicians can do is spend time with other physicians who provide gender affirming care. I encourage physicians to come and spend time with me in my practice if they have fears or knowledge gaps. Within a couple of days, they often realize they can do this. They realize it’s no different than monitoring hormone levels in post-menopausal women or someone on androgen therapy for hypogonadism, just in a different context. Once they realize their perceived limitations are not difficult to overcome, they can provide that care in their own practices. This helps all gender diverse people have access to a safe provider, so they don’t have to continue searching for someone in the medical system who is safe. So far, I have trained about 10 physicians, and in this small way, I hope to increase physician capacity to address this huge shortage.
We also need to stop calling Indigenous medicine alternative medicine because it is actually the original medicine. For the past 400-500 years, our medicine has been systematically dismantled by colonialism, which has contributed to significant Indigenous health disparities. Prior to colonization, our medicine allowed our people to live long, healthy, and able lives. They were routine centenarians without western medicine. So clinicians must support, elevate, and uplift Indigenous medicine in parallel with western medicine.
FH: What is your vision for the future of Indigiqueer healthcare?
JM: I hope to see many more Indigiqueer physicians in all areas of medicine. I hope to see Indiqueer and Two-Spirit people reclaiming their roles as medicine people, healers, midwives, plant medicine holders, and knowledge holders working in our communities in parallel with Indigiqueer physicians, serving all aspects of Indigenous society. When I see the celebration of Indigiqueer children from a young age, and full support for them through their rights of passage into adulthood, having families, and being able to be authentically who they are, that would be a tremendous accomplishment for all of our peoples. This would signal a return to the inclusivity of our nations and a turn towards the health and well-being of our people. We are only as healthy and advanced as a society as we treat the most oppressed members of our society, which at this time are our transgender and gender diverse relatives. In our lifetime, we need to change that and celebrate the gifts of all of our people, no matter who they love or what their gender is.
FH: Who are some of your role models in Two-Spirit health and how have they made an impact on you?
JM: When I was growing up in the 1980s, listening to Madonna as a young Two-Spirit boy in rural Alberta, there were very few out Two-Spirit people to look up to. But I do remember there was Richard Jenkins, who was out as a Two-Spirit Métis man. He was a role model for me growing up and went on to develop and found the 2 Spirits in Motion Society. He was instrumental in the Two-Spirit movement in North America, helping to start learning those teachings from elders that had gone underground for a long time due to the colonial transphobia imposed on our traditional teachings. He uncovered them and did a lot of that foundational work. He is a Two-Spirit elder who has always been an advocate. People like him were brave at a time when it was so difficult to be themselves and live in their authenticity so that we, as a younger generation, could have it easier and be who we are. So, I acknowledge him as a trailblazer.
FH: What are some of the grounded solutions you are working on to address Two-Spirit and Indigenous transgender community health?
JM: As Cree people, we have always had interventions throughout the lifetime that were integrated into our health systems. These interventions included pre-pregnancy ceremonies, birthing ceremonies, celebrating when babies took their first steps, or giving Cree names or spirit names. These practices demonstrated to our youth that we saw them and recognized their existence. As they transitioned into adulthood, we would send them out into the bush to fast for four days and nights without food or water. This would connect them with all of creation and their ancestors, so they would know that they are never alone and are connected to the Mamawtawsit (Great Mystery). Through this, they would learn resilience, honesty, kindness, and truth, which are the values we call natural law. Every single person in our nation had the opportunity to go through these ceremonies in their life. However, colonial violence, child welfare systems, boarding schools, the outlawing of our ceremonies, and the desecration of our food systems have disrupted these practices.
As physicians, we need to rebuild our own medical systems, and that means making the opportunity for young people, especially Two-Spirit and transgender youth who need it even more, to practice these sacred ceremonies. We have realized that no one is going to do this for us, so we have to do this for our own Two-Spirit and transgender youth. For the past three years, with a Canadian Institute of Health grant, we have been working on a program called “Okimaw Kihew Mihkwanahk,” led by Dr. Lana Whiskeyjack (Saddle Lake Cree Nation) and her husband James Lamouche. This program’s aim is to make rights of passage ceremonies accessible to Two-Spirit and transgender youth. Next year, our young Two-Spirit and transgender youth will have the opportunity, if they choose, to go and participate in their rights of passage. This is what I mean when I say we need to revive our traditional medical systems and all our ceremonies. Everyone needs the opportunity to participate in all of our ceremonies. We are celebrating Two-Spirit and transgender youth coming into their own as adults, which is protective, so they can be the best, boldest, and brightest versions of themselves and be celebrated by their communities.
This is something I hope other Indigenous communities look at doing because it promotes health, prevents suicide, and addresses health in the holistic way that we have always done. We also need allies to help support this work. Finally, we need our land back to do these ceremonies in the spaces we have always done them in without fear of arrest or the government preventing our sovereignty over our lands and bodies.