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. 2025 Nov 24;34(6):e70144. doi: 10.1002/jgc4.70144

Achieving cultural safety in genetic counseling for Aboriginal and Torres Strait Islander people in Australia

Bethany Wadling 1,2,3,✉, Clara Gaff 4,5, Johanna Barclay 1,6, Alex Brown 1,6
PMCID: PMC12641591  PMID: 41277711

Abstract

Globally, Indigenous people, including Aboriginal and Torres Strait Islander people in Australia, experience significantly poorer health outcomes than their non‐Indigenous counterparts. In part, this can be attributed to the ongoing impacts of colonization, marginalization, and systemic discrimination. In the genomic healthcare era, Indigenous people remain underrepresented in public genetic health services, raising concerns about cultural competency and inclusivity within the genetic counseling profession. Without culturally safe and accessible genetic services, the disparities in Indigenous people's health could widen. This paper explores cultural safety within the context of genetic counseling for Aboriginal and Torres Strait Islander people in Australia. It outlines the historical, social, and cultural factors influencing engagement with healthcare, including the ongoing impacts of colonization, intergenerational trauma, and institutional racism, and discusses how these continue to shape experiences of care today. Drawing on the core competencies defined by the Human Genetics Society of Australasia (HGSA), the paper highlights how relationship building, reflective practice, client‐centered counseling, and advocacy can be applied to foster culturally safe and responsive practice. Ultimately, providing culturally safe genetic counseling requires moving beyond cultural awareness and competency toward practices that empower Aboriginal and Torres Strait Islander clients, families, and communities. This includes recognizing collective decision‐making processes, kinship systems, and the importance of trust and respect in clinical encounters. By embedding cultural safety at both individual and institutional levels, genetic counselors can contribute meaningfully to reducing health inequities and ensuring equitable participation in genomic healthcare for Aboriginal and Torres Strait Islander people.

Keywords: Aboriginal and Torres Strait Islander communities, cultural safety, genetic counseling

1. INTRODUCTION

Across the world, Indigenous people have poorer health than their non‐indigenous counterparts. In part, this can be attributed to Indigenous peoples' experience of social, cultural, geographic, nutritional, and psychological change, all of which can have a profound impact on individual health outcomes (Valeggia & Snodgrass, 2015). Internationally, efforts are being made to improve health outcomes for Indigenous people including the Reducing Inequalities in Health framework in Aotearoa New Zealand (Ministry of Health New Zealand, 2002) and the Center for Indigenous Innovation and Health in North America (Office of Minority Health, 2025). Both programs aim to address the socioeconomic, ethnic, gender, and geographic inequalities in their specific contexts, and how these contribute to poorer health. In Australia, Aboriginal and Torres Strait Islander people represent 3.8% of the population (Australian Bureau of Statistics, 2021). Like other Indigenous Populations worldwide, it has been well documented that Aboriginal and Torres Strait Islander people experience a greater burden of disease and die younger than non‐Indigenous Australians (Elsum et al., 2020). While the National Agreement on Closing the Gap seeks to overcome these health inequities (National Indigenous Australians Agency, 2021), in the genomic era there are concerns that this gap will widen further if Aboriginal and Torres Strait Islander people do not have adequate access to genetic health services (Dalach et al., 2021).

Across Australia, there is significant under‐scheduling of appointments in public genetic clinics for Aboriginal and Torres Strait Islander people (Luke et al., 2022). While appointment under‐scheduling may reflect referral bias, inequitable access or general lack of awareness of genetics in primary healthcare, there are also concerns about cultural competency and safety in genetic health services (Dalach et al., 2021).

Genetic counselors (GCs) play a critical role in the provision of genomic healthcare, communicating complex information and offering support to individuals and families to understand and adapt to a genetic diagnosis (Williams, 2020). Genetic counselors of Aboriginal and Torres Strait Islander descent can assist Aboriginal and Torres Strait Islander people feel more comfortable and supported in genetic health services (Dalach et al., 2021), yet in 2024, only one (0.4%) of the 252 genetic counselors across Australia and New Zealand responding to a survey investigating diversity, inclusion, and capacity of GCs in the region identified as Aboriginal (Kanga‐Parabia et al., 2024). Hence, it is imperative that the broader genetic counseling community build cultural competency to provide culturally safe practice that supports and empowers Aboriginal and Torres Strait Islander people.

To date, there is limited literature that addresses cultural safety and the provision of genetic counseling in cross‐cultural contexts, specifically Indigenous communities. This paper serves as a starting point, highlighting some of the cultural safety considerations that must be taken into account when caring for Indigenous people accessing genetic services. Keeping in mind the uniqueness of Indigenous cultures across the world, this paper will primarily discuss the experience of and considerations for Aboriginal and Torres Strait Islander people in Australia.

2. DEFINING CULTURAL SAFETY

There is growing recognition that to address the inequities that exist in Indigenous people's health, cultural awareness, cultural competency, and cultural safety must be achieved (Curtis et al., 2019). Cultural awareness is a basic understanding that there is diversity in cultures across populations. Cultural competency however extends beyond individual skills or knowledge to influence the way that a system or service operate across cultures (Bainbridge et al., 2015). In Australia, health professionals working in government roles, including GCs in public clinical genetics services, are required to complete mandatory cultural competency training. This training has been shown to enhance clinicians' knowledge and attitudes about cultural differences. One‐off training however is insufficient to create a culturally competent workforce (Australian Institute of Health and Welfare, 2023; Jongen et al., 2018).

While cultural awareness and cultural competency are important, it has been postulated that a move to cultural safety is a more complete and beneficial framework for addressing health inequities (Curtis et al., 2019). The term cultural safety was first described by Dr. Irihapeti Ramsden and Māori nurses in the 1990s as providing “a focus for the delivery of quality care through changes in thinking about power relationships and patients' rights” (Papps & Ramsden, 1996). The notion of cultural safety acknowledges the barriers to clinical care that arise with inherent power imbalances that exist between health practitioners and their patients. Rather than health practitioners focusing on learning the cultural customs of different ethnic groups, practitioners are encouraged to be aware of cultural differences, the impacts of colonization and the importance of decolonizing practices, as well as power dynamics that exist in relationships and the importance of reflective practice. Clients themselves are then the ones to determine whether a clinical experience is culturally safe. Contrasting cultural awareness and competency, cultural safety requires health providers to question their own biases, attitudes, assumptions, stereotypes, and prejudices that may be contributing to a lower quality of healthcare for some patients (Curtis et al., 2019).

3. UNDERSTANDING AND RESPECTING THE CULTURAL CONTEXT OF ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLE

For many Aboriginal and Torres Strait Islander people, a lack of engagement with genetic health services and healthcare services more broadly is rooted deep in a historical context of colonization, marginalization, discrimination, and racism (Kowal, 2015). When British settlers arrived in Australia in 1788, they dispossessed Aboriginal and Torres Strait Islander people of their land, resources, and autonomy. The flow‐on effects of this included the displacement of many Aboriginal and Torres Strait Islander Communities who lost their connection to Country, language, and cultural knowledge. Aboriginal and Torres Strait Islander people were then forced to assimilate into Western culture, which included the expectation they adhere to Western legal, health, and social systems, ones that differ from their own traditional customs (Griffiths et al., 2016).

Further damaging the relationship between Aboriginal and Torres Strait Islander people and non‐Indigenous Australians was the forcible removal of many Aboriginal and Torres Strait Islander children from their families and Communities by the Australian government from the late 19th century until the 1970s (National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families (Australia) & Wilson, 1997). Often referred to as the ‘stolen generation’, this policy further denigrated Aboriginal and Torres Strait Islander people's culture, autonomy, and trust. The effects of the stolen generation are still felt by many Aboriginal and Torres Strait Islander people today, many of whom experience intergenerational trauma. The profound impacts of intergenerational trauma continue to affect not only the mental and physical well‐being of Aboriginal and Torres Strait Islander people but also drive distrust in institutions, including the healthcare system (Bretherton & Mellor, 2006; Menzies, 2019).

For many Aboriginal and Torres Strait Islander people, another driver of mistrust and skepticism toward institutions is the experience of institutional racism. This discrimination is often covert and in a healthcare context, can include lack of cultural safety, implicit bias in treatment, and limited access to quality care for minority communities (Bourke et al., 2018). Institutional discrimination was a significant factor in reducing the likelihood of Indigenous people accessing essential services in areas such as healthcare (House of Representatives Select Committee on Intergenerational Welfare Dependence, 2019: 34) and a significant driver in perpetuating health disparities between Aboriginal and Torres Strait Islander people and non‐Indigenous Australians (Bourke et al., 2018; Menzies, 2019).

4. CONSIDERATIONS FOR CULTURALLY SAFE GENETIC COUNSELING

With the cultural and historical contexts as previously described in mind, it is clear that we as healthcare professionals must rebuild trust and relationships between Indigenous peoples and the institutions responsible for supporting their health and social needs. For GCs practicing in Australia, there are 13 core competency standards, endorsed by the Human Genetics Society of Australasia (HGSA) that represent a set of core skills for GCs to have and to apply to any area of genetic counseling. While these competencies will develop and be practiced differently depending on a GC's level of knowledge and experience, at its core GCs should feel capable and empowered to practice in accordance with these guidelines (Human Genetics Society of Austrlasia, 2022). Many of these core competencies can be utilized to support GCs in employing culturally safe and appropriate genetic counseling for Aboriginal and Torres Strait Islander people accessing these services.

4.1. Building trust and relationships

Relationship building and client‐centered counseling are two core competencies listed by the HGSA that speak to GCs' ability to promote the establishment of an effective therapeutic relationship. This may include the use of verbal and nonverbal communication to establish rapport, define boundaries, and promote trust with their clients (Human Genetics Society of Austrlasia, 2022). As with any client, adopting a person‐centered approach to genetic counseling is crucial when engaging with Aboriginal and Torres Strait Islander people. Focusing on individual stories and perspectives and incorporating the individuals' beliefs, preferences, and cultural values fosters trust and supports the development of a therapeutic relationship (De Zilva et al., 2022). Given the history of mistrust in the healthcare system for many Aboriginal and Torres Strait Islander people, establishing a strong therapeutic relationship built on genuine respect for each client, clear communication, empathy, and cultural understanding are all complementary skills that foster trust between the GC and client.

While typically genetic counseling has been viewed as a finite interaction between the GC and client, it should be considered that when engaging with Aboriginal and Torres Strait Islander people, continuity of care is also critical for building trust. Where possible, maintaining a therapeutic relationship between the GC and client across multiple appointments is important. However, GCs may also consider what other support people may be appropriate to foster an ongoing relationship. This could, for example, be engagement with a primary health care physician or Aboriginal Liaison who can offer ongoing support for Aboriginal and Torres Strait Islander people. It should be noted, however, that the decision regarding who is involved in care is a matter for discussion with the client and ultimately their personal choice.

Finally, reflective practice is a critical tool for identifying and addressing individual biases, assumptions, and behaviors that may perpetuate inequities or hinder effective relationships with individuals from diverse cultural backgrounds, including Aboriginal and Torres Strait Islander people (Fook & Gardner, 2007). Reflective practice is another core competency for GCs as determined by the HGSA and expects GCs will “employ reflection to recognise personal competency and skills, as well as areas for development, to inform future practice” (Human Genetics Society of Austrlasia, 2022), a skill conducive to the ongoing development of establishing culturally safe practice.

4.2. Involving community and family

Acknowledging the central role of family and community for Aboriginal and Torres Strait Islander people is paramount in achieving cultural safety. This approach to genetic counseling recognizes the cultural values of collectivism, interconnectedness, and respect for elders and traditional knowledge.

Kinship systems are culturally constructed systems in Aboriginal Communities that have existed for many generations. Through culturally defined kin relations, each person is born into a kinship system which traces connections to both familial and nonbiological connections. Unlike Western culture, terms like “brother” and “sister” are used to describe these connections but do not necessitate or reflect blood relations. In utilizing the core competencies of both client‐centered counseling and risk assessment (Human Genetics Society of Austrlasia, 2022), understanding kinship as a collectivist system provides further context for the impact of decision‐making and shared responsibility among the community. Acknowledging both biological and nonbiological relationships and the importance of each is paramount in engaging with Aboriginal and Torres Strait Islander people throughout the genetic counseling process (Sorby et al., 2024).

Collective decision‐making is common in many Aboriginal and Torres Strait Islander Communities, where health decisions are not made in isolation but involve input and consent from family and sometimes the broader community. It is crucial Aboriginal and Torres Strait Islander people are given the opportunity to seek advice and support from their family to ensure that any decision aligns with their cultural values, priorities, and obligations. This may include the opportunity for multiple people to attend a genetic counseling appointment or allowing patients the time and space to discuss the option of genetic testing with family and Community. The provision of culturally appropriate resources to empower Aboriginal and Torres Strait Islander people with information they can share and consider with their family and Community should also be considered (De Zilva et al., 2022). When appropriate, involve community leaders, Elders, or traditional healers who may have a role in health decisions or provide additional support to the individual and their family.

4.3. Creating safe environments

Culturally safe spaces are environments in which individuals from diverse cultural backgrounds feel respected, valued, and empowered to express their identities without fear of discrimination, judgment, or marginalization. For Aboriginal and Torres Strait Islander people, culturally safe spaces in healthcare, including genetic counseling, are particularly important as they address the historical and systemic barriers that have led to distrust and inequitable access to services.

In both public and private settings, the incorporation of Aboriginal and Torres Strait Islander flags, artwork, or cultural symbols signifies respect and inclusivity and can help to make Aboriginal and Torres Strait Islander people “feel more at home” (Hayman et al., 2009). It is imperative to note that culturally welcoming spaces should not be tokenistic and do not in isolation promote cultural safety (Mbuzi et al., 2017).

4.4. Summary

While not an exhaustive list, Table 1 seeks to summarize some of the genetic counseling skills that can be utilized by GCs to employ culturally safe genetic counseling as highlighted above.

TABLE 1.

Summary of skills that might be utilized when engaging with Aboriginal and Torres Strait Islander People in genetic counseling.

Consideration for cultural safe genetic counseling Genetic counseling competency Example of culturally safe application
Building trust and relationships

  • Relationship building

  • Client‐centered counseling

  • Communication

  • Reflective practice

  • Use of verbal and nonverbal communication that is respectful and promotes trust

  • Outlining of what client may expect from a genetic counseling appointment

  • Acknowledging historical mistrust for Aboriginal and Torres Strait Islander people when engaging with healthcare system and how this might influence GC's interaction with clients and client's interaction with GC

  • Identifying and addressing personal biases or assumptions that may affect care

  • Using reflection to evaluate and improve communication and relationship‐building strategies

  • Committing to ongoing learning to better support clients from diverse backgrounds
Involving Community and family

  • Client‐centered counseling

  • Risk assessment

  • Case management

  • Coordinate care with Aboriginal Liaison Officers, local GPs, and community services with client consent

  • Explore family and kinship networks as defined by the client

  • Document nonbiological relations

  • Utilize culturally appropriate resources to explain genetic concepts
Creating safe environments

  • Service delivery

  • Incorporation of Aboriginal and Torres Strait Islander flags, artwork, or cultural symbols signify respect and inclusivity

  • Provide outreach or telehealth options
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5. CONCLUSION

While efforts to improve the health of Indigenous people across the world are vital, it is important to consider the cultural context of individuals. For Aboriginal and Torres Strait Islander people in Australia, there are significant barriers to accessing culturally safe genetic counseling rooted in the impacts of colonization, systemic racism, and intergenerational trauma. Addressing these inequities requires more than cultural awareness, it demands a sustained commitment to cultural safety, trust‐building, advocating for systemic change, and community engagement. The core competencies listed by the HGSA mean GCs have and can continue to develop skills that foster inclusivity, respect, and empower clients to make decisions about their health. This includes recognizing diverse kinship systems, supporting collective decision‐making, and ensuring Indigenous voices are not only heard but centered in the design and delivery of services.

AUTHOR CONTRIBUTIONS

Johanna Barclay conceptualized the idea. Bethany Wadling drafted the manuscript. Clara Gaff and Alex Brown reviewed the manuscript and approved the final version.

CONFLICT OF INTEREST STATEMENT

None of the authors declares any conflicts of interest.

ACKNOWLEDGMENTS

The authors acknowledge the use of artificial intelligence (AI) tools in the preparation of this manuscript, specifically for editing. All content has been critically reviewed and revised by the authors to ensure accuracy, originality, and alignment with the objectives of the manuscript.

Wadling, B. , Gaff, C. , Barclay, J. , & Brown, A. (2025). Achieving cultural safety in genetic counseling for Aboriginal and Torres Strait Islander people in Australia. Journal of Genetic Counseling, 34, e70144. 10.1002/jgc4.70144

DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

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