Cultural and Language Discrimination in Healthcare as Experienced by Basque Women and Gender Non-Normative Individuals in the Basque Country

Abstract

Basque women and gender non-normative individuals are a part of an Indigenous and ethnic minority culture, thus more likely to be exposed to discrimination and sub-optimal healthcare services. This study explores their experiences with healthcare and identifies the barriers and facilitators to implement culturally safe healthcare practices in the Basque Country. We used a critical ethnographic approach to conduct 37 semi-structured interviews, 36 hours of health clinic observations, and 4 focus groups. Using a thematic analytic approach, we find that euskalfobia in the healthcare system presents a major barrier to culturally safe healthcare through the normalization of euskarafobia, systematic invisibilizing of Basque language and culture, and the devaluing of cultural healing practices. Language and culturally concordant care, acknowledgment of cultural healing practices, and training regarding the concept of cultural safety at an individual and institutional level can facilitate the implementation of cultural safety in the Basque context.

Background

Globally, Indigenous and ethnic minority women face discrimination in their exposure to social determinants of health and their access to high-quality healthcare (Curtis et al., 2019). Gender non-normative individuals within these communities also report experiencing discrimination and violence, leading to poor health outcomes (Chan et al., 2023). This contributes to greater disparities, such as higher rates of poor mental health and lower self-rated physical and mental well-being (Teti et al., 2021). While these groups are highly diverse in terms of language, culture, migration status, and origin, they share common challenges rooted in the legacy of colonialism (United Nations, 2018).

Europe is home to over 100 ethnic minority groups (Cole, 2011), which form many of Europe’s “stateless nations” (Friend, 2012), including the Basque Country. Basque people, over 3.1 million (Gaindegia, 2020), are divided in two nation-states (Spain and France). Basques are an Indigenous group, with their own language and culture that date back thousands of years (Gupta, 2005; Reyner, 2013). Like other Indigenous and ethnic minority populations, Basques have faced centuries of consistent and prolonged oppression (Irujo & Miglio, 2013). During the 14th–17th centuries, oppression manifested through witch-hunt and dispossession of communal land and Indigenous knowledge (Federici, 2004). During the French Revolution, minority languages were associated with “ideological backwardness, narrow-minded provincialism, and fanatical politics” (Urla, 2012). Under the Spanish dictatorship (1939–1978), strict anti-Basque policies were enforced, with Basque speakers being punished and humiliated for their cultural and language practices. French and Spanish elites both considered the Basque language insignificant, while nation-states saw regional languages and identities, like Basque, as threats to national unity (Irujo & Miglio, 2013).

Despite sustained repression, primarily through the educational system and the imposition of monolingual Spanish and French political systems, the Basque language and culture have endured (Irujo & Miglio, 2013). The current healthcare system reflects this imposition, and bilingual professionals who speak Basque are rare (Committee of Experts of the European Charter for Regional or Minority Languages, 2024; Montes Lasarte et al., 2021). Thus, Basques are rarely able to communicate with healthcare workers in their preferred language (Petralanda Mendiola, 2018), a disadvantage when understanding choices and making healthcare decisions. More than a system of communication, language is a means to establish trusting relationships, thus important within the healing process. Research emphasizes the positive effects maintaining and reviving Indigenous languages have in the physical and collective health of Indigenous communities (Hodge & Nandy, 2011; Nez Henderson et al., 2005; Oster et al., 2014).

Basques’ distinctive culture and language (Euskara) reinforce their collective identity (Zabala et al., 2020). Basque speakers (Euskaldunak) whose preferred language is Euskara constitute 15.3% of the Basque Country’s population, with 29.6% of Basque Country residents having some Euskara knowledge, but only 12.6% practice it outside the home environment (Sociolinguistic Cluster, 2020). Therefore, Basques are a linguistic and ethnic minority, whose language and cultural identity are in a disadvantaged position in comparison to the two dominant cultures (Spanish and French) within the Basque Country (Zabala et al., 2020).

Language is the most prominent aspect of Basque cultural transmission (Bullen, 2003). Historically, Basque women have played a crucial role in preserving and transmitting language, customs, and traditions (Bullen, 2003). While resistance to recognize this role remains, contemporary Basque women have gained increased visibility in cultural life. However, those who adopt non-traditional gender roles still face negative personal and social repercussions. Social constructs of language, nation, and gender are frequently used to establish boundaries and shape personal identities (Echeverria, 2003).

Many minority language speakers and non-hegemonic cultures are denied access to quality healthcare services due to the power differentials that exist between minority and dominant cultures. According to Roche (2019), language oppression, as a form of domination, is comparable to oppression related to race, national origin, or ethnicity. Curtis et al. (2019) state that in addition to the power differential arising from language and culture, other contributing factors include an overall lack of awareness and training of healthcare workers regarding the importance of culture and language associated with a particular group, placing provider–patient therapeutic relationships at risk of intended or unintended bias.

The concept of cultural safety has been promoted by Maori nurses working in Aotearoa within a colonial context (Papps & Ramsden, 1996). Cultural safety is the practice of proactively considering patients’ social, economic, and political situations, and power relations in healthcare, while acknowledging that lack of such consideration can intensify institutional discrimination and replicate traumatic experiences in historically oppressed populations (Ramsden, 1993). Cultural safety derives from critical social theory and asserts that established methods such as “cultural awareness” or “cultural competence,” currently applied in healthcare, neglect to address power relationships, which are historically unbalanced between migrant, Indigenous, and/or ethnic minority groups and healthcare providers and services (Evans et al., 2019). As such, Indigenous and ethnic minority groups are often perceived as the “other” rather than as an ally whose knowledge and values can contribute evenly to a relationship, or to service the healthcare systems. Cultural safety focuses on relationships of both mutual reciprocal trust and respect (Evans et al., 2019). Therefore, healthcare providers must acknowledge that an individual’s dignity must be recognized and highlighted, address their own biases, and engage in reflexivity (Curtis et al., 2019). Implementation of safe and quality care requires healthcare workers to work toward both cultural safety and critical consciousness, and healthcare organizations and authorities must be accountable for delivering culturally safe healthcare (Curtis et al., 2019).

Understanding the healthcare experiences of Basque women and gender non-normative individuals (BWNN) in the Basque Country, particularly in relation to cultural safety, can improve nursing practice, guide health policy, and deepen the understanding of cultural safety for Indigenous, ethnic minority women, and gender non-normative individuals. This research aims to explore the healthcare experiences of BWNN and identify the barriers and facilitators to implementing cultural safety in the Basque healthcare system.

Intersectionality Theory

Intersectionality theory is broadly used in social science and health research (Njeze et al., 2020). Black feminist, Latina, post-colonial, Indigenous, and queer academics and activists have generated knowledge addressing the interconnected identities and processes that form human experiences for decades (Bunjun, 2010; Collins, 1990; Valdes, 1997; Van Herk et al., 2010).

Intersectionality is also an extensively utilized theoretical framework in women and gender studies. The core principles of intersectionality emphasize that systems of power, such as race, class, ethnicity, gender, and other forms of hierarchy, are interrelated and co-construct one another. Intersectionality focuses on how these intersecting systems of power influence and reinforce interconnected social inequalities. These overlapping power dynamics create complex and interdependent forms of oppression, shaping the lived experiences of individuals and communities based on their unique social positions within these structures (Collins, 2019).

Intersectionality, aimed to contest and transform power dynamics, examines the experiences of marginalized women which can lead to the promotion of cost-effective health interventions and health policy (Ghasemi et al., 2021). Intersectionality is essential to public health and healthcare because rather than ignoring the complex interactions that are instrumental to comprehend social disparities, it welcomes this complexity (Bowleg, 2012). We conducted our analysis with intersectionality theory in mind, focusing on examining displayed systemic structures of oppression and how they are experienced by BWNN within the health system.

Method

We used a critical ethnographic approach to describe the cultural and sociopolitical factors that shape the experiences of BWNN with healthcare. Critical ethnography emphasizes raising awareness in the aspiration to produce social change (Polit & Beck, 2012). It focuses on the social, cultural, political, and historical contexts, while providing a holistic approach to exploring the connections between various forms of power and the evidence supporting empowerment-based practices (Al-Hamad et al., 2022). This approach promotes a critical analysis of power differentials and inequalities as well as continuing communication with communities experiencing discrimination and oppression (Al-Hamad et al., 2022).

Critical ethnography and intersectionality each have strengths, and their combination creates synergies. Building on these synergies, we use critical ethnography and intersectionality to explore the experiences of BWNN in healthcare settings. Both approaches examine marginalized populations, analyzing how their daily experiences of inequality and exclusion are shaped by intersecting systems of oppression, power dynamics, and cultural influences. Adopting an intersectional perspective deepens our understanding of how overlapping systems of power—such as social class, ethnicity, and gender—interact to produce unique forms of disadvantage for BWNN, influencing their daily life experiences and broader social organizational practices (Hankivsky et al., 2014). These contributions of intersectionality align with the principles of critical ethnography, which not only advocate for empowerment and social change but also expose the underlying and often hidden mechanisms of power and control (Madison, 2020). Therefore, by integrating intersectionality as a theoretical framework and employing critical ethnography as a method to operationalize it, we emphasize the need to challenge and dismantle the oppressive norms currently affecting BWNN.

Through critical ethnography, we seek to capture the lived realities of BWNN by engaging directly with their experiences and observing the ways institutional practices and policies affect their lives. Intersectionality provides a framework to analyze how power systems intersect and overlap creating unique experiences of discrimination for BWNN. By combining these approaches, our research aims to uncover the complex layers of marginalization within the Basque healthcare system, while amplifying the voices of BWNN to promote more equitable practices and policies.

Setting

This study was conducted in Nafarroa, a Basque province, where Law 18/1986 regulates the populations’ linguistic rights, dividing it in three linguistic zones called “Basque-speaking area,” “mixed zone” and “non-Basque-speaking area” (Irujo & Urrutia, 2008). Basques are distributed in seven provinces, three in the French state and four in the Spanish state, ruled by distinct administrative entities (Urla, 2012), and three different entities that manage healthcare. Osasunbidea is the organization that manages the healthcare system in Nafarroa.

Ethical Considerations

Pseudonyms were used to protect participant identities. Formal written consent was obtained by our principal researcher from all participants prior to their involvement. This study was conducted in partnership with a governmental health department and its corresponding ethics committee and approved by the institutional review board of a collaborating university.

Participants and Recruitment

Our research team included five women: four nurses two Euskaldun (Basque-speaking), one Latina, and one White of Eastern European descent and one Black American sociologist. Observations, individual interviews, and focus groups were conducted in Basque by the principal researcher. Prior to initiating the recruitment process, we established relationships with community members, Basque women’s and feminist organizations, Basque LGBT+ associations, institutional organizations, and Basque language groups. We distributed a flyer, in Basque, with the approval of the corresponding health department and the management teams of six public healthcare clinics across the province. It was also sent to local feminist, LGTBI, and women’s groups, and Basque cultural associations through WhatsApp with a brief message explaining the purpose of the study and the eligibility criteria (i.e., self-identified as Basque woman or gender non-normative individuals, 18 years and older, who speaks and understands Basque, and had used the healthcare system at least three times within the last year as a patient or as a caregiver). The term gender non-normative individual is used within Basque institutions and was agreed upon with members of the Basque LGTBI community to identify individuals whose identity is different from the gender assigned to them at birth, including trans and non-binary individuals. Individuals who expressed interest were asked to contact the principal researcher. We used purposive and snowball sampling, recruiting from November 2022 through April 2024.

Research occurred in public healthcare clinics, in cultural centers, on Zoom, and in private settings, depending on participants’ preferences. We observed six public healthcare clinics, both in rural and urban areas, throughout Nafarroa. Two focus groups took place at a cultural association, one in the library of an Ikastola (school) and another in a participant’s home.

The study’s 37 participants included 35 who self-identified as women, one who identified as non-binary, and one who preferred not to respond. Participants ranged from 22 to 84 years of age (median of 49.6 years). Twenty-eight participants identified as heterosexual, seven as bisexual, one as non-heterosexual, and one did not respond. For racial and ethnic identity, 29 participants identified as Euskaldun (Basque-speaking person), 4 identified as Euskaldun and Nafar (native inhabitant or person who identifies their origins to Nafarroa), 1 identified as Nafar, 1 identified as Nafar, Euskaldun, and Spanish, 1 identified as multiracial, and 1 did not respond. Participants’ formal educational levels ranged from 8 to 12th grade (n = 5), technical school (n = 8), 3-year university degree (n = 3), 4- to 5-year university degree (n = 13), post-graduate degree (n = 2), other (n = 5), and one did not respond. For employment status, 19 participants were employed, 7 were retired, 3 were self-employed, 3 were unemployed, 2 were on disability, and 2 did not specify.

Data Collection and Analysis

We developed one semi-structured interview guide and one focus group guide. The interview guide addressed the socio-cultural background of the participants, caring experiences, healthcare experiences, cultural and gender identity, and their preferred care options. The focus group was used as a method of member checking as well as assessing if participants had experienced fear during the healthcare encounter. We also used a Qualtrics socio-demographic questionnaire to gather participants’ information on age, ethnicity, employment, and educational status.

We conducted a total of 37 in-depth interviews, in Basque, both via Zoom and in person, between November 2022 and April 2024. The interviews lasted between 23 and 80 minutes. We deidentified the collected data to guarantee confidentiality. We transcribed the data verbatim using Aditu Elhuyar, a transcription software, and a transcriptionist. Once the interviews were transcribed, a translator translated the data from Basque to English, and the principal researcher revised all transcripts to ensure accuracy.

Since data collection and analysis occurred concurrently, emergent categories and themes guided the ensuing recruitment and data collection decisions. After the analysis of the first eight interviews, we decided to recruit more participants from areas where Basque language is used less as well as participants with diverse sexual and gender identities to obtain broader information regarding the healthcare experiences of BWNN and improve the application of intersectionality to the study. Participant recruitment concluded when saturation was reached, emerging codes and categories became repetitive and could be included in previously identified themes.

Upon completing all individual interviews, we invited all participants to join one of four focus groups. A total of 24 participants accepted the invitation, 12 were unable to participate due to scheduling conflicts and personal reasons, and one participant sadly passed away before the focus groups. We held the focus groups in all three classified Basque linguistic zones of Nafarroa. Two focus groups took place in urban areas where Basque is considered semi-official. Another was held in a region where Basque has official status, and one in an area where Basque is not recognized as an official language. The in-person focus groups lasted between 58 and 85 minutes and were transcribed and translated as per previous procedure.

Aligned with critical ethnography, we conducted 36 hours of non-participant observations in six healthcare settings, two in each linguistic zone. These observations took place after we contacted managers within each of the facilities and obtained permission from the Department of Health. The observations were carried out in open public areas, such as admission and waiting rooms and focused on cultural, language, and gender-related expressions and interactions. We observed interactions between healthcare workers and patients, cultural expressions within the healthcare centers (including music, decoration, healthcare promotion flyers, and reading material), and language used within the facilities. Each observation session lasted approximately 120 minutes and was conducted three times in each facility between December 2023 and March 2024. We took field notes during the observations and throughout the study, which we later integrated into the data analyses.

We followed a multi-step process to become thoroughly familiar with the data. A reflective thematic analysis was conducted following the approach described by Braun and Clarke (2021). The process began with familiarizing with the data by reading the transcripts thoroughly. We classified and indexed the data into more manageable units for easier review and classified our field notes in a similar way. We used ATLAS.ti software to identify patterns and analyze relationships within the data. We created initial codes, which were grouped into code families. We then examined these codes for repetition, analogies, and differences to identify themes emerging from the data. Extensive memo writing afforded a deep analysis of emerging themes. Throughout the coding process, we engaged in peer debriefing and consultation to identify the main themes and subthemes and to consider alternative data interpretation. As themes emerged, analysis triangulation was used by converging data obtained from individual interviews, focus groups, field notes, and observations to form thematic statements (Grove & Gray, 2019; Polit & Beck, 2012).

Researcher Positionality

Our principal researcher is a Basque working-class feminist activist with both strong ties to local and national feminist, cultural, and language associations and over a decade of experience working as a nurse in the community. Our study approach was shaped by her understanding of BWNN’s historical gender and cultural oppression and her positionality within the Basque community. Throughout the research, we consistently engaged in reflexivity, critically examining our power and privilege and the impact of our positionality on the research process.

Findings

We will describe euskalfobia, meaning the overall rejection to Basque culture (Elhuyar, n.d), in the healthcare system as an overarching theme and normalization of euskarafobia, invisibilizing the Basque language and culture, and devaluing of cultural healing practices as underlying themes. Euskalfobia is not an isolated phenomenon but part of a broader global pattern of cultural suppression and resistance. These forms of rejection mirror colonial and nationalist strategies that seek to marginalize minority identities. Employing critical ethnography deepened the understanding of Euskalfobia within the healthcare system. As evidenced in the findings, this methodology also illuminated the connections between hegemonic and ideological discourses that shape social structures and influence the daily experiences and actions of research participants (Cook, 2005).

Most participants reported experiencing different forms of euskalfobia from the highest organizational level to the lowest operational level of the healthcare system, creating unique experiences of discrimination for BWNN.

Normalization of Euskarafobia

Euskarafobia is a term describing a negative attitude or rejection toward the Basque language (Elhuyar, n.d.). According to Arbelaitz Mitxelena (2022), as a linguistic community, euskarafobia describes a conscious and political attitude that marginalizes a vulnerable minority in society. This is not a unique oppression against Basques; it happens when multiple languages coexist within the same geography. Persecution is often tied to a lack of sovereignty, and major empires have historically exercised brutal violence against marginalized groups Arbelaitz Mitxelena (2022).

Data revealed an overall atmosphere of normalized oppression toward Basque language and culture within the healthcare system and beyond; that is, experiences occurring outside the healthcare system were transferred into it. Participants of different ages and regions had stories of being mistreated and threatened with physical violence for speaking Basque within the school system or on the street.

Bianditz, a 22-year-old woman, works as a supervisor at a children’s play center and collaborates with high school students to promote after-school activities in Euskara. She lives in a city in the southern part of the province, where most of the population speaks Erdara (non-Basque language). Her experiences with the healthcare system have primarily involved visits to the gynecologist, for routine check-ups or for acute concerns. She reports that these experiences have been negative, as she feels her concerns were not taken seriously. Discussing language and cultural issues in the healthcare system, Bianditz notes that “many people are against Euskara” in her area. She described, during a focus group, a recent event where her acquaintances were threatened with physical violence for speaking Euskara in public, leading Bianditz to admit that she often tries to conceal her Euskaldun identity for fear of being mistreated or prejudged.

A few weeks ago, two acquaintances walked down the street and, said “agur” [Good-bye, in Euskara] to each other, and a group went after them to beat them up. With situations like that … I rarely speak Euskara to a doctor or in a supermarket, because I don’t dare unless there’s somebody I know.

Bianditz’s experience is shaped by intersectional oppression. As a young woman, she is describing not being taken seriously which is commonly experienced by women during healthcare encounters. Being Euskaldun and living in an area where her language and culture are rejected enhance this experience of marginalization, as she encounters euskarafobia daily and potentially during healthcare encounters. The healthcare system is not exempt of prejudice and often reproduces systemically embedded oppressive structures of power such as patriarchy and cultural/linguistic supremacy. Bianditz’s fear of being mistreated due to her ethnicity conveys that healthcare workers may, consciously or unconsciously, reproduce society’s prejudices. Thus, her ability to receive optimal healthcare services is limited and it raises concern regarding how structural oppression operates within institutions.

Participants also reported several instances where they were mistreated or discriminated against for using their language or identifying as Euskaldun. They described experiencing prejudiced attitudes and comments from healthcare workers for speaking Euskara with their children. Iholdi, a 52-year-old woman who works as a teacher, lives in the northern part of the province, a predominantly Euskaldun municipality. She has had multiple interactions with the healthcare system, both as a patient during her pregnancies and childbirth and as a caregiver for family members. She recalls an incident at the hospital where a doctor was treating her son, and she had to translate because her son did not understand Spanish. The doctor expressed disapproval of her son’s inability to speak Spanish, and Iholdi felt as though her son was being portrayed as uneducated and her abilities as a mother were being questioned, creating tension during the healthcare encounter.

And we went there, and a woman (doctor) said, “open your mouth” and “open your mouth” (Euskara) I said to (son), and so she started … “How old is this child?” and “5” and … “It’s time for him to learn to speak Spanish.” And I told her, “Well, I don’t know…” “And in school do they not learn Spanish?” “No,” I told her, that they spoke only in Euskara, but I told her to relax. That he would learn Spanish, that I also always studied in Euskara and that I knew Spanish perfectly, as I was speaking.” … “She went into my personal life and was basically saying that my son was “uneducated” because he did not know Spanish. (Underlines represent Spanish language quotes)

Iholdi finds herself in a vulnerable position due to her concern for her child’s illness and need for healthcare services. This vulnerability is heightened when she perceives rejection toward her identity and culture. She anticipates and fears euskarafobia, having come to normalize it as part of her interactions with Erdaldun healthcare workers. Her concern shifts to how intense this rejection will be in each encounter.

Imagine how far I’ve gone, I mean, almost to settle if they don’t give us a bad look or a look of disdain, to settle with that. Sometimes they treat you badly because you are speaking Euskara with your son who does not understand Spanish. But what the fuck is that?

During one of the focus groups, as we were reflecting about these experiences and what participants feel as they experience euskarafobia, Iholdi identifies this feeling as fear:

And concerning the language … I mean, I’d certainly call it fear. Afraid to say the first word in Euskara. Afraid of their reaction, because the last time was horrible, not because they spoke Erdara, no, but because my son did not know Erdara …

Iholdi’s experience is shaped by overlapping factors of gender, ethnicity, and power relations within the healthcare system. She is simultaneously encountering gender scrutiny as a mother, linguistic discrimination as an Euskaldun, and institutional prejudice in a healthcare system dominated by Erdaldun norms. Iholdi’s experience illustrates how numerous experiences of subordination intersect to create magnified discrimination (Hay et al., 2019) for BWNN.

Normalization of Euskarafobia increases existing power relations between healthcare workers and patients, leading to high tension and frustration during healthcare encounters. Participants’ experiences demonstrate the lack of cultural safety in healthcare, where linguistic and cultural discrimination enhances their vulnerability and leads to feelings of judgment. To implement cultural safety in the Basque healthcare setting, systemic oppression, as well as its historical roots, must be addressed at all levels.

On the other hand, most participants agree that language and cultural concordance is necessary and positive in their healthcare experience. Participants refer feeling closeness, joy, openness, and tranquility when language and cultural concordance occurs. Nahia, a 39-year-old woman who lives in a small village in eastern Nafarroa, is a teacher and recalls how having Euskaldun healthcare workers care for her during childbirth was key to a positive experience.

… during my pregnancy for example, well, I was lucky because the midwives were Euskaldun and that changed everything for me … being there, in that environment, talking in Euskara and without being judged … It might be the sweetest memory I have from childbirth; I felt like at home.

Nahia’s feeling of being “like at home” indicates a profound sense of comfort and security during her birthing experience, which is crucial given the stress many birthing individuals encounter during childbirth. Her experience highlights a deep sense of well-being and connection, which extends beyond sharing her language and culture with the healthcare worker; it encompasses a sense of belonging and safety that underscores the idea of being in place (Rhodus & Rowles, 2023).

Language and cultural concordance can reduce the likelihood of ethnic discrimination and bias, while increasing patient satisfaction during healthcare encounters. Therefore, language and cultural concordance could mitigate the negative effects of cultural and linguistic discrimination and play a crucial role in facilitating the implementation of cultural safety in the Basque setting.

Invisibilizing the Basque Language and Culture in the Healthcare System

When we asked participants how they perceived the value of their culture and language within the healthcare system, most participants agreed that their language and culture were either undervalued or not valued at all. This sentiment was consistent throughout Nafarroa, regardless of the official status of the Basque language in different regions. Several factors contribute to this sense of undervaluation: the scarcity of healthcare workers who recognize the Basque language and identity, the absence of Basque cultural expressions—such as Basque music or symbols—within healthcare settings, and legislation that imposes geographical restrictions on the linguistic rights of Basque speakers (Irujo & Urrutia, 2008). Together, these conditions create the foundation for invisibilizing the Basque language and culture within the healthcare setting. The following narratives illustrate this lack of recognition and invisibilization.

Eihara, a 48-year-old woman, is a Basque language teacher currently on medical leave, recovering from a surgery which increased her recent exposure to the healthcare system. She lives in a city in the southern part of the province, where the Basque-speaking population is a minority and linguistic rights of Basque speakers are not legally recognized. This restriction means that no healthcare providers are required to speak or understand Euskara. Eihara identifies the practical repercussions of this law affecting her experience within the healthcare system. She refers to requesting her appointment reminders to be sent to her in Euskara as the only sign of the presence of her language or culture within the healthcare system:

Of course, here I cannot, directly … go to the health center or hospital speaking Euskara … I asked for them [reminders] to be in Euskara but …, then I go with the letter to the nurse and the nurse does not understand anything, and once they told me, “I don’t know in what language you have this, do you want me to change it to Spanish?” And I told them, “No, no … that’s Euskara and I asked for that change.” And there, for example, I felt, well, on the one hand, good, because I set my identity on the table and, … On the other hand, bad, you say, well I have to give an explanation … because I receive a letter in my own language, and I also have to make a double effort, on the one hand for having to request the change and on the other hand, because I had to ask them to leave it like that, that I don’t want it to be in another language.

Eihara is aware of the limitations and restrictions she faces during healthcare encounters, as a conversation with her doctor in her own language is not an option. However, she presents the letter as a means of asserting her identity and making it visible. This denial, in turn, restricts her linguistic rights and enhances her experience of discrimination.

Aloña, a 52-year-old woman, is on disability due to a chronic illness and is a frequent user of the healthcare system. She lives in a small village in the northern part of the province in a municipality where over 70% of the population are Basque speakers. She has regular follow-up visits with her primary care provider in her hometown and with specialists in the city. She believes her language and culture are not valued and explains how she rarely encounters providers who are Euskaldun. Aloña attributes this to a structural problem related to the deliberate decision of the healthcare system to not require healthcare workers to speak her language.

So well, from 0 to 10 I would say 0. Yes, that’s how I live it, because I can see that among all the doctors that treat me, it’s a big coincidence to have an Euskaldun one … I mean, in the health system that I use, none of the doctors … would be able to treat me in Euskara.

For Aloña, the limited opportunity to speak her language during healthcare encounters produces a general sentiment of hopelessness, anger, and frustration:

So, it’s a bit hopeless. So, at the same time, you go for some results or to run some tests or for I don’t know what and well, with that hopelessness you set all that aside. Your anger or your happiness, or it doesn’t matter, I live all that from hopelessness. Yes, I feel there are no options.

Aloña faces significant disadvantages during her interactions with the healthcare system. Relying on these services to maintain her health, she feels she has no option but to endure the marginalization imposed by the healthcare system replicating euskalfobia by not requiring healthcare workers to have a knowledge of Basque language and culture.

Auza is a self-employed 40-year-old non-binary individual. They live in a small town in the northern part of the province where most of the population is Euskaldun. They are currently seeking gender-affirming care with initial encounters with their primary care provider and multiple follow-up appointments with specialists. Their experience has been especially challenging due to the limited number of specialists in gender-affirming care, which reduces the likelihood of finding Euskaldun providers in this field. Although Auza has conveyed to the healthcare system that being able to express themselves in Euskara is a necessity, all their specialists have been Erdaldun. For Auza, the most difficult part of their experience has been to realize how their language and culture are invisible to the healthcare providers caring for them. Auza understands that this invisibility is a result of structures of oppression manifested through the power relations between them and healthcare workers during their encounters, which allow healthcare workers to be active or passive participants of this structural oppression: “For me the biggest difficulty is the people or the system that don’t see what being Euskaldun is.” For Auza, there is a persistent attempt by Erdaldun healthcare workers to deny the existence of their culture and language, whether consciously or unconsciously. Auza feels this lack of acknowledgment undermines their ability to be themselves. The negative impact of this denial is even more pronounced when a power relation exists, which occurs during the healthcare encounter: “From a position of power, it is in their interest to make it disappear, or they don’t want this reality to exist, so they will do whatever using their power.” Auza believes that a healthcare worker’s lack of knowledge of their language and culture goes beyond merely having to communicate in a language they are not fluent in; it also signifies a deliberate attempt at cultural erasure.

So, what happens to me over and over in the health system is, that if the person that takes care of me doesn’t know Euskara, I need to adapt to their situation, because they can’t adapt to mine. Because my situation [being Euskaldun] doesn’t exist in their world. So then, in that difficulty … I can’t be myself and I show a part of what I am. And with that, if it needs to be done, you go ahead, but sure, for me, it’s not going to be satisfying.

Auza describes this experience of invisibility as oppressive and restricting. Not being able to express themselves in their language results in not being able to make their identity visible, which leads to an unpleasant and unsatisfying healthcare experience.

Participants’ experiences reveal how multiple overlapping power dynamics at a micro level (patient–provider interaction, healthcare inequality, and discrimination) intersect with macro-level structures (patriarchy, ableism, transphobia, homophobia, and colonialism) (Bowleg, 2012) to produce experiences of discrimination for BWNN. These interactions take place in an environment of connected systems and structures of power such as laws, policies, state governments, and the healthcare system (Hankivsky, 2014). In this case, invisibilization of Basque language and culture occurs at multiple levels of the healthcare system. This includes legislation that restricts the linguistic rights of Euskaldun patients, a public healthcare system that does not require workers to be knowledgeable about Basque language and culture, and Erdaldun healthcare workers who reinforce these discriminatory policies during medical encounters.

During the observations, we perceived the dominance of Spanish language and culture throughout all healthcare centers, regardless of the official presence of Basque language and culture. Euskara, when present, is secondary, mostly in posters and signs related to province-wide campaigns. Signs originating from healthcare centers, particularly those intended to communicate with patients in reception areas or consultation offices, are typically only in Spanish. We observed very few culturally significant signs, pictures, or decorations related to Basque culture or language (e.g., farmhouses, sheepherding, sports, dances, and carnivals). Only one center in the “Basque-speaking” region displayed Basque culture—a collection of photos showing local people from different historical periods. Additionally, in several healthcare centers, the background music played was mostly in English or Spanish.

Observations reinforced participants’ perceptions that the Basque language and culture have decreased visibility. These findings coincide with other Indigenous communities whose cultural norms and expressions are considered invisible, neglected, and unknown to the majority of healthcare workers (Mehus et al., 2019; Ness & Munkejord, 2022). This invisibility reflects a form of euskalfobia that lays the groundwork for cultural erasure, particularly in the Basque culture, where the focus has been on language eradication. Language eradication parallels dehumanization; just as dehumanization can lead to genocide, the degradation of a language—and its speakers—can result in “linguicide” (Irujo & Miglio, 2013).

As we listened to healthcare workers and patients speaking, we noticed that Euskara was more common in the rural northern part of the province, coinciding with majority Euskaldun population municipalities. However, even there, Spanish dominated, even among Euskaldun workers. We also observed Euskaldun patients switching to Spanish when communicating with monolingual Spanish-speaking healthcare workers. In the healthcare centers in the central and southern areas of the province, we rarely heard patients or healthcare workers speaking Euskara. The decreasing visibility of the Basque language and cultural expressions coincide with the official status of the language having decreased recognition and the Euskaldun population being a minority. Structural violence of linguistic erasure is gradual, as it fosters assimilation not only by prohibiting certain languages but also by making preferred options impractical while rendering undesirable options convenient and rewarding (Roche, 2019).

To implement cultural safety in the Basque healthcare system, it is essential to recognize the existence of the Indigenous ethnic minority and their right to culturally safe healthcare. The invisibility and discrimination of the Basque language and culture within the healthcare system present significant barriers to achieving this goal.

Devaluing of Cultural Healing Practices

Another important cultural component of health for BWNN is the use of healing practices. Most participants acknowledged the existence of cultural healing practices transmitted throughout generations. However, participants perceive that this knowledge is being threatened by the current healthcare system’s rejection of these practices. Auza, whom we met earlier, notes that devaluing of cultural healing practices is yet another facet of cultural erasure experienced through various levels of oppression throughout history.

That knowledge has been there until recently, and now few people know it. It’s disappearing for a reason; it’s not considered in the system because of something. But if there are things that work, why are they not in the system? … Well, if there is some knowledge of this kind, of a culture that is now oppressed, imagine what would happen in an era where it was even more oppressed. Probably, they made that wisdom disappear on purpose. Because it’s a strategy to make that culture disappear.

By questioning the exclusion of these practices from the healthcare system, Auza directs attention to the power structures that prioritize Western medicine while attempting to erase healing traditions rooted in Indigenous knowledge. Auza’s insight agrees with research that understands devaluation of cultural healing practices as an example of how healthcare systems are complicit in medical colonialism which has systematically interrupted Indigenous knowledge transmission through cultural erasure (Pilarinos et al., 2023).

Most participants admit using cultural healing practices and, on many occasions, prefer them over Westernized medicine. Participants however are reluctant to share this information with their healthcare providers for fear of being judged or scolded, as they perceive promotion of Western medicine as the only option to healing. This leads to miscommunication and lack of transparency during the healthcare encounter as well as the avoidance of using the healthcare system.

Maddi is a 39-year-old woman living in a small town in the northern region of the province, where the majority of the population is Euskaldun. She works as an education support specialist. Although she has used the healthcare system sporadically over the years, Maddi and her family prioritize using cultural healing practices when available. For Maddi, it is common to initially address health issues through these cultural practices and combine them with Western medicine as needed:

I remember one time; my fistula was up on my back … and I went to the doctor in an emergency, and I told them I was using San Juan ointment … Because I first use those things I have handy, and those are the things I have handy, right? And then if I see they’re not working, … I go to the health center. And I didn’t really like their reaction, right? They told me “Well, if you want, keep using it,” but like that, as if it worked for nothing, right? So that last time, when my fistula came out again, I went to the doctor, and I was using the San Juan ointment, but I didn’t tell them. In the end, why am I going to tell them?

A lack of training and knowledge about cultural healing practices lead many practitioners to advise against their use, to dismiss them, or to fail to recognize their therapeutic effects. In Maddi’s experience, gender dynamics, cultural erasure, and systemic bias within the healthcare system overlap and contribute to an environment of distrust that could contribute to negative health outcomes.

Amalur, a 57-year-old woman, was born and raised in a large town in the center of Nafarroa, where she still lives. This area falls within the “mixed zone” of the province, where Basque language has limited legal recognition. She works part-time as a porter at a cultural center and part-time in a school dining room. She has had various experiences with the healthcare system, both as a caregiver for her parents and children, and occasionally as a patient. Amalur notes that cultural healing practices, common in her region, are considered an important part of local traditions. For Amalur, cultural healing practices are closely related to community knowledge transmission and community interdependence. She shares an experience where a neighbor, whom she didn’t know personally, visited her home to offer local remedies for her osteoarthritis, which he had learned about from the community.

One day this retired man came here, to my home, … I did not know him, I just knew who he was, and “damn, I have heard that you have osteoarthritis, and look …” He brought me herbs and a paper saying how to make the cream. “I mean, I heard about your problem so here you are.” I mean, how we take care of each other, right?

Amalur emphasizes that the significance of cultural healing practices goes beyond their medicinal properties. They represent shared knowledge within the community, emphasize the collective aspect of healing, and highlight the importance of community members caring for one another, a key part of their cultural identity.

Most participants support and respect the use of cultural healing practices and advocate for their inclusion as an option within the healthcare system. Many suggest that the system should offer a combination of treatments, allowing access to different healing practices without placing the financial burden on patients.

Laiene, a 43-year-old woman who works as a teacher and lives in a predominantly Euskaldun area in western Nafarroa, was raised using cultural healing practices alongside Western medicine. She believes the healthcare system lacks a holistic approach, a gap that could be addressed by integrating these cultural practices.

Well, I think public health ought to also be maybe a bridge, right? … I think it should be more integrated, including the health system, right? Well, with those herbs, the same, I don’t know if that person is with the therapist, I don’t know, right? In a more comprehensive way this holism of the person, right? and that knowledge of culture too, I think are very useful, right?

Overall, the devaluing of cultural healing practices by healthcare workers and the healthcare system leads to a lack of trust and poor communication during healthcare encounters. Participants see this devaluation as a sign of disdain toward their culture and collective knowledge. They associated this rejection with the absence of a holistic approach in Western medicine, which does not fully meet their healthcare needs. The devaluation of cultural healing practices is not isolated but is tied to broader systems of marginalization that affect how participants access and experience healthcare. A gradual understanding of cultural healing practices through healthcare worker training and research could be a key step toward implementing cultural safety in healthcare for BWNN.

Discussion

During interactions with healthcare workers and clinic leadership prior to starting data collection, several providers expressed the belief that BWNN did not face discrimination. However, our findings reveal that BWNN not only experience discrimination based on gender, ethnicity, and other factors but that these systems of power overlap and intersect with multilevel oppressive structures. These structures are reproduced through normalization of euskarafobia, invisibilizing Basque language and culture and devaluing cultural healing practices within the healthcare system, creating a unique negative experience for BWNN. Marginalization of linguistic minorities leads to members of these communities experiencing discrimination, linguistic oppression, and assimilation (Roberts et al., 2007).

Since critical ethnography seeks to empower those impacted by social policies and ideologies (Cook, 2005), its use in this study enhanced the understanding of BWNN experiences. This research underscores the significance of applying critical methodologies to examine the barriers and facilitators influencing the implementation of cultural safety in healthcare. Power unbalance between patients and healthcare workers is manifested throughout health literature (Green et al., 2018; Noyes, 2022; Ocloo et al., 2020; Odero et al., 2020). This study made visible the interrelatedness of privilege and oppression within the experiences of BWNN in healthcare, and the importance of assessing the interrelation and generation of situations of marginalization or privilege for the researched community (Hay et al., 2019). BWNN experience marginalization within the healthcare system due to their position as Indigenous and ethnic minority people, who are also in a position of vulnerability as patients or caregivers, which coincides with other historically oppressed communities’ experiences, explained by intersectionality theory (Crenshaw, 1991; Hankivsky, 2014).

The implementation of cultural safety can enhance BWNN’s experiences by considering their specific socio-economic and political contexts, as well as the power dynamics in healthcare (Ramsden, 1993). In this study, barriers and facilitators to culturally safe care, that is, quality care as perceived by the participants and their communities (Harding et al., 2021), have been identified based on the unique experiences of BWNN. Invisibilizing Basque language and culture is a major barrier to implement cultural safety in the Basque healthcare setting. Implementation of cultural safety requires structural changes within all levels of the healthcare system including coordinated pathways of care, organizational changes and healthcare professional training (Laverty et al., 2017), acknowledgment of the existence of an Indigenous ethnic minority, and promotion of the understanding of their right to receive culturally safe care.

The findings of this study highlight the systemic existence of euskarafobia which make it difficult for staff and management to recognize and acknowledge discrimination incidences, resulting in a generalized belief that they do not occur. BWNN participants connect the normalization of euskarafobia in healthcare with the historical oppression of the Basque community. To implement cultural safety in the Basque setting, the historical roots of euskarafobia need to be addressed. It is necessary to identify the power structures that enable its promotion, and a systemic approach to expand healthcare workers’ awareness of this unconscious bias by identifying it, preventing it, and creating structures to eliminate it (Ness & Munkejord, 2022).

Findings demonstrate how discrimination experienced and normalized outside of the healthcare setting is replicated within it. These results align with the concept of cumulative discrimination which indicates that when an individual or community has lived countless forms of marginalization throughout history, preceding experiences may condition current events (Ness & Munkejord, 2022). Participants refer experiences of being dismissed as uneducated and ignorant by healthcare workers, leading participants to avoid healthcare services for fear of being judged or mistreated during the healthcare encounter. This finding aligns with other studies examining the experiences of ethnic minority groups, whose health concerns are frequently dismissed and devalued by providers lacking cultural knowledge, leading to a reluctance to seek care (Fante-Coleman et al., 2022).

Participants perceived that healthcare workers’ devaluing and dismissing cultural healing practices was related to an overall devaluation of participants’ cultural beliefs. This aligns with the experiences of other Indigenous communities who feel that their beliefs are being ignored, which intensifies mistrust in Westernized healthcare (Pilarinos et al., 2023). This study also shows that most BWNN participants use cultural healing practices in search of a holistic approach to health based on community kingship. Research proposes blending Westernized and cultural healing practices by including both sources of knowledge in the development of a healthcare system that will benefit all communities (Marsh et al., 2015). The gradual introduction of cultural healing practices into the healthcare system in combination with Westernized medicine practice is considered by participants as an optimal and comprehensive approach.

Although language and cultural concordance is not guaranteed within the Basque healthcare system, this study shows that when language and cultural concordance occurs, increased trust, sense of belonging, and satisfaction is perceived. Studies emphasize the importance of language concordance to improve health outcomes (Hsueh et al., 2021; Seale et al., 2022). Policy initiatives in the Basque Country have aimed to establish healthcare circuits that provide comprehensive language and cultural concordant care to Basque patients, ensuring equal access to quality healthcare services in all official languages (Montes-Lasarte, 2015). However, implementation has faced resistance, and limited access remains a challenge in regions where Basque speakers are a minority. This could potentially force Basque-speaking practitioners and patients to commute, perpetuating disparities in accessibility.

Limitations

Limitations of this study include data collection in Euskara and data analysis in English. As every language provides unique perspective and understanding, there is a possibility that essential parts of data might have been lost through translation. We mitigated this by reading the transcripts in Euskara and the English translation. This study was conducted in only one of the seven Basque provinces; therefore, results may not be generalizable to other Basque regions. Although the study included BWNN, the study sample mostly included heterosexual cis-gender women, which led to an underrepresentation of sexual and gender minorities.

Conclusions

This qualitative study explored the experiences of BWNN with healthcare in the Basque Country, contributing to fill a gap in research in this area within the European setting. This study highlights harmful prejudice and discrimination experienced by BWNN in the healthcare setting due to their preferred language and marginalized position as members of an Indigenous ethnic minority community, which could lead to negative health outcomes. However, findings also provide guidance to practices, including language and cultural concordance, acknowledgment of cultural healing practices, and training regarding the concept of cultural safety at an individual and institutional level which may act as facilitators to the implementation of cultural safety in the Basque Country.