Desperately Seeking Subjects: Methodological Advances and Lessons Learned from the HONOR Project

Background: American Indian and Alaska Native (AIAN) lesbian, gay, bisexual, transgendered individuals (two-spirits) are an understudied and underserved group, at risk for multiple health and mental health problems. The HONOR Project was a 5-year mixed methods, community based participatory and social epidemiological health study (R01MH65871) designed to: test a culturally-based theoretical model of stress and coping; develop innovative trauma measures specific to this population; examine sexual networks for this population; and design and test a modified respondent driven sampling strategy to approximate a representative sample of two spirits.

Methods: With funding from the National Institute of Mental Health six national urban American Indian agencies partnered with University of Washington's Indigenous Wellness Research Institute to: Conduct 65 qualitative interviews with two spirit leaders to identify health and sexual risk and protective behaviors; conduct structured survey interviews with 447 American Indian adults to test an indigenist stress coping model and establish preliminary baseline prevalence rates for HIV and other health outcomes; develop and test new measures related to two-spirit specific traumatic stress and discrimination and collect some of the first data on sexual networks and respodnent driven sampling methods for this population.

Results: Preliminary empirical findings support the indigenist stress-coping model. Specifically, results indicated that identity moderated the influence of discrimination distress and historical trauma loss on self-rated health and smoking behaviors. Findings suggest that historical trauma loss and discrimination may be a risk factor for embodiment of physical pain and impairment and for fair or poor self-rated health among those with poor identity integration. Additionally, given high rates of concurrency in this population, results indicate that sexual risk interventions should target gay Native men and bisexual Native women for HIV and Hep C prevention efforts. The sexual network findings provide some of the first insights into sexual networks and concurrency among two spirit populations, a group that has been virtually ignored in HIV prevention efforts. Data provides the first glimpse into lives and networks of two spirit communities. Clearly two spirit men and women both deserve attention in HIV prevention efforts at individual, dyadic and population levels. Finally, this presentation will discuss the design and CBPR methods developed for this study with a particular emphasis on lessons learned related to the selected sampling and sexual network strategies, cultural protocols, and potential methodological advances.

Conclusions: This study yielded distinctive empirical and methodological contributions including: theorizing the role of trauma on sexual and health risk among two spirits; using a culturally-based theoretical model and empirical measures that capture specific culturally-based factors (e.g., historical trauma); testing an innovative sampling strategy for hidden populations; providing the first ever sexual network data of two spirit populations; and incorporating an interdisciplinary and intertribal team approach with six American Indian agencies.