Gender Bias and Discrimination in Healthcare as Experienced by Basque Women and Gender Non-normative Individuals in the Basque Country

Abstract

The Basque Country is one of Europe’s many stateless nations and home to the Basque Indigenous population. As members of an Indigenous and ethnic minority culture, Basque women and gender non-normative individuals risk suboptimal healthcare services and outcomes because of gender bias and discrimination. This study explores their experiences with healthcare services and identifies the ways in which gender bias and discrimination serve as a barrier to cultural safety in the Basque Country. We used critical ethnography and triangulated data from 37 semi-structured interviews, health clinic observations, 4 focus groups, and document analysis. Thematic analysis was used to identify overarching themes from transcripts and field notes. Participants reported numerous instances of discrimination that hinder the implementation of cultural safety. We found that gender bias and discrimination are central to the healthcare experiences of Basque women and gender non-normative individuals. These issues manifest in various ways, including knowledge transmission gap regarding women’s health, discrimination based on sexual and/or gender identity, and obstetric and gynecologic violence. Meanwhile, patient autonomy during healthcare encounters is a key facilitator. Training in self-reflection, bias awareness, and gender-affirming can reduce discrimination. Findings also highlight clinical knowledge gaps and the need to integrate cultural safety into nursing education and practice.

Background

Indigenous and ethnic minority groups, particularly women within these groups, face a considerable disadvantage in healthcare experiences and outcomes when compared to non-minority populations (Toh & Shorey, 2023). Women’s healthcare experiences are significantly conditioned by their origin, culture, geographic background, and access to healthcare (Huffstetler et al., 2021). Gender non-normative individuals who are members of Indigenous and ethnic minority groups also report increased discrimination and violence compared to their non-minority counterparts (Chan et al., 2023). Gender inequality in healthcare occurs in a variety of forms, such as differential exposure to disease, discriminatory beliefs, and biases in health systems, which are added to social expectations transforming into health risk (Shannon et al., 2019). Basque women and gender non-normative individuals (BWNN) as members of an Indigenous and ethnic minority group, are uniquely positioned to experience discrimination within healthcare settings (Elizegi Narbarte et al., 2025). Research shows that no studies have examined BWNM’s experience in healthcare (Narbarte et al., 2025).

The Basque Country, one of Europe’s stateless nations (Friend, 2012), is administratively divided between two nation states, Spain and France. Both Basque people as a whole and Basque women in particular have experienced centuries of oppression, manifested through diverse political, cultural, and economic forms (Irujo & Miglio, 2013). Between the 14th and 17th centuries, European commoners faced the dispossession of communal lands, branding, and widespread witch hunts, during which more than 80% of those accused and executed for witchcraft were women (Federici, 2004). These persecutions were not isolated acts of superstition but mechanisms to dismantle women-centered forms of knowledge and community organization that challenged the emerging patriarchal and capitalist order (Federici, 2004). The Basque region was deeply affected by this process (Fernández de Pinedo & Otsoa de Alda, 2008), as witch hunts served to delegitimize women’s authority in areas such as healing, spirituality, and social leadership (Nausia Pimoulier, 2012). Such repression, carried out by dominant power structures—particularly the Church and the developing nation-states—laid the groundwork for the long-term subordination of Basque women. Despite this historical marginalization, Basque women have played a crucial, though often overlooked, role in sustaining Basque culture, language, and traditional healing knowledge (Bullen, 2003). In recent years, women have reclaimed public visibility by challenging restrictive gender norms, engaging in cultural practices that were once inaccessible to them, and organizing collectively around political and social issues (Echeverria, 2003). These efforts have been supported and amplified by a strong, organized feminist movement (Osa Galdona, 2024).

Building on centuries of resistance and activism, BWNN’s ongoing efforts to challenge systemic inequalities provide a crucial perspective for understanding and implementing cultural safety in the Basque healthcare setting. Cultural safety aims to promote both systemic and individual change by increasing healthcare workers’ awareness of their own identities and how these affect care for ethnic minority patients (Curtis et al., 2019). It addresses the impacts of colonialism in the healthcare system, emphasizes respect for patients’ cultural identities, and promotes a holistic, collaborative environment where individuals feel safe, heard, and treated with dignity (Curtis et al., 2019).

Therefore, analyzing the experiences of BWNN with healthcare in the Basque Country can help fill a significant research gap and inform nursing practice and healthcare, propose health policies, and develop a better understanding of cultural safety for Indigenous and ethnic minority women and gender non-normative individuals. This study aims to explore the healthcare experiences of BWNN, with a focus on culture and gender, and to identify the barriers and facilitators to implementing cultural safety within the Basque healthcare system.

Method

Study Design

We used a critical ethnographic approach to describe the experiences of BWNN with healthcare in the Basque Country. Critical ethnography is grounded in an ethical commitment to examining and addressing processes of injustice, with the aim of promoting greater freedom and equity. By moving beyond surface-level observations, critical ethnography seeks to challenge the status quo and address the underlying structures of power and control that shape social realities (Madison, 2020). It attends to the interactions of social, cultural, political, and historical factors, offering a comprehensive framework to examine power dynamics and support empowerment-based practices (Al-Hamad et al., 2022). This perspective encourages sustained critical reflection on inequalities and power imbalances, alongside ongoing engagement with communities affected by marginalization and oppression (Al-Hamad et al., 2022).

Through this methodology, we sought to understand the lived experiences of BWNN by engaging with their perspectives and critically examining how institutional structures and policies shape their everyday lives. As a qualitative approach, critical ethnography challenges dominant power relations and inequities in order to promote social change (Palmer & Caldas, 2016), enabling a deeper analysis of how individual experiences are connected to broader systems of power (Al-Hamad et al., 2022). Critical ethnography allowed a closer understanding of the experiences of BWNN while conducting a critical analysis intended to discover how these perceptions relate to larger power structures.

Theoretical Framework

This study is guided by the cultural safety framework to address health inequities experienced by BWNN. Cultural safety, originally developed as a concept by Māori nurses and midwives within a colonial context and later expanded into a framework, promotes healthcare that reflects the perspectives of Indigenous and ethnic minority groups (Papps & Ramsden, 1996). Cultural safety is grounded in critical social theory and emerged in response to the limitations of earlier approaches such as cultural awareness, cultural sensitivity, and cultural competence (Evans et al., 2019). These preceding frameworks have primarily focused on increasing healthcare workers’ knowledge of Indigenous and ethnic minority cultures, placing responsibility on providers while overlooking structural and historical factors. In contrast, cultural safety explicitly addresses power imbalances in healthcare relationships, particularly those shaped by colonialism and ongoing inequities between healthcare systems and migrant, Indigenous, and ethnic minority groups. By centering power dynamics and institutional structures, it offers a more critical approach to understanding and improving healthcare interactions (Curtis et al., 2019).

The framework encourages healthcare workers to reflect on their own culture and biases while fostering reciprocal, respectful relationships with patients and accountability within healthcare organizations (Curtis et al., 2019; Schill & Caxaj, 2019). Cultural safety is a framework where healthcare workers acknowledge individual’s dignity and address their own biases, and healthcare organizations support and hold themselves accountable for providing cultural safety as defined by individuals and their communities (Curtis et al., 2019).

This study is also informed through the lens of intersectionality theory. The theory posits that systems of power such as gender, ethnicity, race, sexuality and others overlap and intersect and manifest large-scale structures of oppression and privilege such as sexism, racism, and heteronormativity (Crenshaw, 1991). These interactions take place in an environment of connected systems and structures of power (e.g., laws, policies, state governments and other political and economic unions, religious institutions, media). Among these proceedings, are interrelated arrangements of privilege and oppression framed by colonialism, imperialism, racism, homophobia, ableism and patriarchy (Hankivsky, 2014). Use of an intersectional lens acclimates researchers to the multifaceted systems of power that define participants’ experiences in different socio-cultural settings, and how relationships between social position and power reproduce health inequities (Cayir et al., 2021).

This study was guided by intersectionality theory, which informed the research design, data collection, and analysis by focusing on how overlapping systems of power shape the healthcare experiences of BWNN. In the research design, an intersectional lens shaped the focus on structural inequalities and the selection of participants whose experiences reflect multiple, interacting forms of marginalization. During data collection, this perspective informed the development of open-ended questions that explored how social class, ethnicity, gender, and other social positions jointly influence interactions with the healthcare system, while allowing participants to define which factors were most outstanding in their experiences. In the analysis phase, intersectionality guided an iterative interpretation of the data, examining how these interconnected power structures operate together within institutional and social systems rather than in isolation. This approach enabled a deeper understanding of how overlapping systems of power produce specific forms of disadvantage (Hankivsky et al., 2014), contributing to a deeper exploration of marginalization in the Basque healthcare system and supporting the amplification of BWNN voices in relation to more equitable policies and practices. Intersectionality embraces the complex interactions necessary to understand social disparities (Bowleg, 2012), particularly among historically oppressed groups such as BWNN.

Setting

The setting of this study is the Basque province of Nafarroa, one of the seven provinces of the territory known as Euskal Herria (Basque Country), where Osasunbidea is the public provincial organization that manages its healthcare system.

Sampling and Recruitment

Starting in November 2022, we used purposive and snowball sampling methods for recruitment, using a flyer in Basque. Eligibility criteria were: self-identified Basque women or gender non-normative individuals aged 18 and older, who speak and understand Basque, and have utilized the healthcare system at least three times in the past year, either as patients or caregivers. We chose the term “gender non-normative individual” in consultation with members of the Basque LGBTQ+ community, as it is used by Basque institutions to describe those whose identity differs from the gender assigned to them at birth, including transgender and non-binary individuals. Flyers were shared in public health clinics, and via WhatsApp among local feminist, LGBTQ+, and women’s groups, and Basque cultural associations.

Sample

We collected information about participants’ age, ethnicity, employment, and educational status (Table 1).

Table 1.

Participants’ Characteristics

Characteristic	Detail
Total Participants	37
Gender Identity	35 women, 1 non-binary, 1 chose not to disclose
Age Range	22 to 84 years
Median Age	49.6 years
Sexual Orientation	28 heterosexual, 7 bisexual, 1 non-heterosexual, 1 no response
Racial/Ethnic Identity	Euskaldun: 29
	Euskaldun and Nafar (native or person with roots in Nafarroa): 4
	Nafar: 1
	Nafar, Euskaldun, and Spanish: 1
	Multiracial: 1
	No response: 1
Educational Background	8th-12th grade: 5
	Technical school: 8
	3-year degree: 3
	4- or 5-year degrees: 13
	Post-graduate degrees: 2
	Other: 5
	No response: 15
Employment Status	Employed: 19
	Retired: 7
	Self-employed: 3
	Unemployed: 3
	Disability: 2
	No Response: 2

Data Collection

The interview guide was created through an iterative process. It was refined after conducting the initial interviews and through discussion among team members, resulting in addition and rephrasing of some questions. The semi-structured interview guide explored participants’ socio-cultural backgrounds, caring experiences, healthcare experiences, cultural and gender identities, and preferred treatment options.

After analyzing the content of the interviews, we created the focus group guide to facilitate member checking and to investigate whether participants experienced fear during their healthcare encounters. Following completion of individual interviews, we invited all participants to join one of four focus groups, with 24 participants agreeing to participate. Interviews and focus groups were conducted in Basque by [G.E.N.]. We conducted 37 in-depth interviews between November 2022 and April 2024. Participants signed written informed consent before the interviews, which lasted between 23 and 80 minutes. To ensure confidentiality, we deidentified the collected data.

The interviews were then transcribed verbatim with the help of a Basque language transcription and translation software, and a transcriptionist. The translation process was guided by the framework proposed by Abfalter et al. (2020), which conceptualizes translation through seven key dimensions: why, when, what, who, how, where, and by what means. This framework supports methodological rigor and transparency in multilingual research.

Data were collected in participants’ preferred languages to enhance the authenticity and depth of responses, and subsequently translated into English to facilitate team-based analysis. Translation was conducted in two phases: prior to data collection and during data preparation. In the first phase, study materials (e.g., consent forms, interview guides, and focus group guides) were translated from English into Basque. In the second phase, qualitative data from open-ended responses were translated from Basque into English prior to analysis. Translating at this stage helps preserve linguistic and contextual meaning and improves the quality of findings (Abfalter et al., 2020).

Translation activities involved multiple contributors to ensure accuracy and cultural appropriateness. Translation was conducted collaboratively by the primary researcher [G.E.N] and a Basque language translator completing the final stage of his interpreter degree, and was subsequently reviewed by an additional researcher, with consensus reached on the final version. All contributors demonstrated sociolinguistic competence in both languages and familiarity with relevant cultural and discourse conventions. In the first phase, translations were performed by the principal researcher with support from Basque translation software. In the second phase, qualitative data were translated by a Basque language translator in collaboration with the primary researcher, following a hermeneutic approach. This approach emphasizes cultural and contextual interpretation to preserve the intended meaning of participants’ expressions (de Jesús-Espinosa et al., 2024).

We conducted 36 hours of ethnographic observations in six healthcare settings, with the agreement of team managers within each facility and in collaboration with the department of health. Observations were conducted randomly during regular clinic hours on weekdays, between 8am and 3pm. We observed cultural, language, and gender-related expressions and interactions in each facility, focusing on open public areas such as admission and waiting rooms. We noted interactions between healthcare workers and patients, cultural expressions within the healthcare center (music, decorations, healthcare promotion flyers, reading material), and language use within the facility. Each observation lasted approximately 120 minutes and was conducted three times between December 2023 and March 2024. We included field notes from the observations and throughout the study in the data analyses.

Data Analysis

Since data collection and analysis occurred concurrently, actively constructed categories and themes guided subsequent recruitment and data collection strategies. Participant recruitment concluded once the sample and ethnographic observations had produced a sufficiently broad range of experiences to address the study aims. Actively constructed codes and categories became repetitive and could be included in previously identified themes. The discussions lasted between 58 and 85 minutes and were transcribed and translated according to the previously established procedures.

A multi-level process was conducted to gain familiarity with the data, which was classified and indexed in categories, creating more manageable units for revision by co-authors. We classified field notes in a similar manner. To assist in detecting patterns and analyzing relationships within the data, we utilized ATLAS.ti software. We defined and labeled sections of the text to establish codes (Charmaz, 2014). These codes were examined for repetition, analogies, and differences to identify constructing themes. Throughout the coding process, we engaged in peer debriefing and consultation to identify main themes and subthemes while considering alternative interpretations of the data. Memos written during data collection and analysis contributed to the final main themes. Reflexive memos were written throughout data collection and coding to support ongoing reflection and analytic development. These memos were discussed within the research team and used to inform the development of actively constructed themes. By comparing and integrating insights from memos with interview and observational data, we worked iteratively across data sources, which supported the refinement of the final themes and a more comprehensive understanding of participants’ experiences. Data triangulation was used by converging evidence from interviews, focus groups, field notes, and observations to develop thematic statements (Grove & Gray, 2019).

Ethical Considerations

We used pseudonyms to protect participant identities and obtained formal written consent from each participant. The study was approved by the Health Department of Nafarroa and its corresponding ethics committee (Record # PI_2022/104), and University of California, San Francisco Institutional Review Board (IRB #22-36656).

Researcher Positionality

As the primary researcher I considered my insider status as a Basque working-class feminist activist and nurse working with patients from the researched community by practicing continuous reflexivity. I critically observed how this position may have shaped the decisions I made throughout the research process (Cayir et al., 2021). During fieldwork my position facilitated collaboration with local and national feminist, cultural and language associations and eased the establishment of meaningful and trustworthy relationships. As a nurse and employee in the public healthcare system my position allowed a collaborative environment during the research process. This position could potentially create mistrust with participants, as I was seen as part of the system they were criticizing, and with fellow healthcare workers, who viewed me as someone scrutinizing their work.

During the interviews my positionality as a researcher and healthcare worker entailed conducting this research from a position of power and privilege. During the interviews I was concerned that participants might perceive I was conducting this research for personal interests. I acknowledged the benefits of conducting this research for my academic goals and I discussed with the participants how this research could improve healthcare experiences for BWNN. Several participants mentioned being grateful that I was conducting this study and addressing healthcare system-related topics. My position of privilege provided the opportunity to use resources, skills and privileges available to me to access the experiences of those whose stories are invisible to the social majority (Madison, 2020), in this case the stories of BWNN.

Findings

Many participants expressed experiencing gender bias and discrimination during the healthcare encounter. This discrimination often intertwined with oppression related to cultural identity and language, enhancing the experience of marginalization of BWNN in the healthcare setting. Through participants’ shared experiences, we identified three themes: knowledge transmission gap regarding women’s health issues, discrimination based on sexual or gender identity, and obstetric and gynecological violence, as barriers to the implementation of cultural safety. Acknowledging participants’ autonomy during the healthcare encounter was identified as a facilitator to cultural safety.

Gender is central to the main findings, thus it’s important to note that the Basque language, in its most used form, does not mark gender. Therefore, unless specifically highlighted by participants, the gender of healthcare workers remains unidentified. However, within Osasunbidea, the public healthcare system in Nafarroa, over 65% of doctors and 92% of nurses are women (Nafarroako Gobernua, 2022). This indicates that gender bias and discrimination in healthcare may not be linked to the gender identities of individual healthcare workers, rather they are likely embedded within broader systemic structures of power.

Knowledge Transmission Gap Regarding Women´s Health Issues

Overall, participants felt there was a significant gap in knowledge transmission about their health, particularly concerning women’s health. This gap manifested in several ways. On one hand, participants perceived healthcare workers as reluctant to share knowledge about their medical conditions or those of their dependents. On the other hand, many felt that the healthcare system does not prioritize women’s health, leading to insufficient research and knowledge in this area. Participants expressed frustration and insecurity about this knowledge gap, which they perceive as a form of gender bias and discrimination.

Ainara, a 49-year-old Basque woman, has had several temporary jobs throughout her life, and is currently working as a server in the hospitality industry. She was born and raised in a large Basque city but moved to a rural valley in the northern part of Nafarroa in her early twenties, partly so she could raise her children in an Euskaldun (Basque-speaking) environment. She has a son in his early twenties who has a disability due to complications suffered after brain surgery, and a teenage daughter. She has had multiple experiences in the healthcare system during her pregnancies, childbirth, and most recently while caring for her son. She has most of the responsibility for her son’s care and has experienced great frustration due to a gap in knowledge transmission regarding her son’s treatment and recovery. Ainara feels that the gap in knowledge transmission from the healthcare system to patients and family members obstructs her ability to make informed decisions.

[after surgery] I didn't expect to see my son like that, and I wasn't ready. And they don't give you any information about what his process should be … at least, what we are going to see, because the fact that my son's reasoning or understanding was that of a 3-year-old, I didn't know how long that was going to go on.

Ainara also perceives a gap of knowledge transmission, especially when it comes to women’s health issues. She finds this knowledge gap incomprehensible—especially in areas like maternity and childbirth, since they are experiences women have had throughout history—and has led to a deep mistrust of the healthcare system. During her pregnancy, Ainara realized how little she and the previous generations around her knew about pregnancy and childbirth.

[Pregnancy] It's what we’ve most known about women. … I would ask my mother, did you know this? Was your pregnancy like this? Did you have this information? And no, we didn't know … somehow you obtain certain information, and you’re like, I am learning this now and I haven’t heard about this anywhere? … I see that women are in the background and it's true …

As a working-class woman, she faces unfavorable working conditions in a highly feminized profession, putting her at a social and economic disadvantage in caring for her son. Additionally, as a Basque woman, she bears increased responsibility and social scrutiny as a mother and caregiver. Ainara connects her lack of access to knowledge to a broader reluctance among healthcare workers to share knowledge, limiting her ability to make informed decisions about her own health and her son’s. She attributes this to a gap in knowledge transmission about women’s health, that has persisted across generations and is related to an interruption of cultural knowledge transmission. This aligns with research indicating that this gap arises from a historically androcentric perspective in health sciences that has frequently overlooked women’s health (Valls-Llobet, 2020), as well as a disruption in the transmission of knowledge about women’s bodies dating back to the European witch hunts (Federici, 2004; Nausia Pimoulier, 2012). She perceives that the healthcare system, instead of supporting her healing process, reinforces the patriarchal norms she encounters daily. As a result, she distrusts the healthcare system. Through an intersectional lens, Ainara’s experience illustrates how multiple forms of oppression—classism, sexism, and cultural supremacy—intersect with larger power structures such as capitalism, colonialism, and patriarchy, increasing her vulnerability as both a patient and a caregiver.

Several participants criticize the gap of knowledge transmission from the healthcare system regarding symptoms of menopause, expressing a sentiment that this gap is related to how the healthcare system does not emphasize women’s health issues as much as men’s. Eihara is a 48-year-old Basque language teacher on medical leave at the time of the interview. Although she spent part of her childhood in an Euskaldun area in the northern part of the province, at the age of 10 she moved with her family to a city in the southern part of the province, where Basque speakers are a minority. Recent gynecological surgery has led to an increase in her interactions with the healthcare system. She perceives a significant gap in women’s knowledge about their bodies, using menopause as an example. Eihara argues that information about menopause is insufficiently communicated to women, both within the healthcare system and in broader societal contexts. She links this lack of knowledge transmission to the social devaluation of women, which she believes contributes to decreased interest and research within healthcare.

I think there's not much information … we have some changes in our body with menopause and some special needs that until that moment (menopause) weren’t there. And women still don't know, even if they're menopausal, what the different things they can do or whatever… I think some basic things are considered, but some everyday life things are still not taken into account. And then I'm sure that if men were going through menopause, everything would have been investigated … I’m sure about it.

As an ethnic minority woman, Eihara navigates the healthcare system with increasing frustration about multiple communication barriers. On one hand, she struggles because she is prevented from communicating with healthcare workers in her language; on the other hand, she is not receiving the information necessary to make informed decisions about her health. Eihara’s efforts to change practitioners did not lead to different outcomes, indicating that the problem extends beyond individual attitudes or practices. Instead, it points to a structural problem rooted in societal devaluation of women. A dynamic that is reproduced within the healthcare system and conditions the quality-of-care women receive. She connects this gap in knowledge transmission specifically to women’s health issues, highlighting that it is a common experience among women, reinforcing her belief that the healthcare system fails to meet her needs and enhances her experience of discrimination. The knowledge gap was mentioned as a source of anxiety and concern.

Eihartze is a 52-year-old Basque woman living an hour's drive from the city in the eastern part of the province. She is a teacher currently on disability while recovering from lymphoma. Eihartze resides with her husband and their youngest child, who is 14 years old. She has two older children who live in the city. Additionally, she alternates caregiving duties for her elderly parents with her sisters. Eihartze’s experiences with the healthcare system have intensified over the past few years as both she and her oldest son have received cancer treatment. She has struggled with the gap in knowledge transmission regarding both her own illness and her son’s. For Eihartze, who previously worked as a journalist and educator, it is crucial to be informed. She links the gap in knowledge transmission to the power dynamics that shape healthcare encounters. She states, “It's key to me to be informed. Information is power, and they know it …” After completing her chemotherapy, she experienced symptoms of menopause. Eihartze felt that not knowing chemotherapy could lead to premature menopause increased her anxiety and confusion:

I mean the side effects caused by the chemotherapy … You don´t know how you are going to be mentally or the physical consequences or that your period disappears from one day to the next … All of a sudden, I started with hot flashes and sweating, starting with chemo, right? And I was thinking shit, shit! What is this? And when I found out that clearly that … it was a consequence of menopause. Sure, I was grateful because it's not lymphoma anymore … my two options were, my lymphoma is back on or it's menopause. So, between those two options, the fact that it was menopause, was like, that´s good, right? But nobody explained anything to me.

Eihartze has an increased emotional and physical caregiving load. Living in a rural area makes it more difficult for her and her family to access the specialized health services she needs. However, the main cause of her frustration and anxiety during this experience is the gap in knowledge transmission. For Eihartze, the withholding of knowledge is a conscious act that reinforces the power difference between her and healthcare workers, perpetuating the hierarchical structure of the healthcare system.

A gap in knowledge transmission regarding women’s health issues was recurrent in participant’s experiences. This gap was seen as being tied to the historical and systemic oppression of women also reflected in the healthcare system. The failure to transmit knowledge is viewed as reinforcing power imbalances within healthcare encounters, leading to unsafe experiences for participants. Consequently, the gap of knowledge transmission in women’s health is a significant barrier to cultural safety for BWNN.

Discrimination Based on Sexual or Gender Identity

Participants reported bias and discrimination based on sexual and gender identity throughout their healthcare experiences. The following stories illustrate how gender bias influences treatment and diagnosis, while gender discrimination reinforces power imbalances and fosters distrust in the healthcare system.

Iholdi, a 52-year-old Basque woman, works as a teacher at a local high school in a predominantly Euskaldun area of Nafarroa. Though generally in good health, she has had several encounters with the healthcare system, both as a patient and a caregiver. Iholdi strongly identifies with her Basque heritage and describes herself as having a strong personality, and she believes that male healthcare workers often feel challenged when women, like herself, question their authority. Iholdi sees this defensiveness, rooted in her gender identity, as similar to the rejection she experiences for being Euskaldun:

They imagine that I’m going to complain, or that I won’t shut up, or … that I’m going to say what I think, right? And that, they don’t like it. I think that a lot of men … with women they have, docile women, obedient … with them, it’s easier, right? Because in those situations they have the power … And with some specific doctors, I notice that they want to use and mark their power. “You, be quiet, you’re the sick one, and I give the orders.” … it seems to me that since they are with a woman they are in a defense-attack situation and that your word is not worth the same.

Iholdi’s experience is significantly conditioned by the interconnectedness of systems of power and the use of the hierarchal structure of the healthcare system to enhance power relations. As a confident Basque woman, she feels that male practitioners are defensive when women question their authority, particularly because she does not meet the patriarchal expectation of the “docile” or obedient woman. Iholdi compares this experience to cultural discrimination, noting a distinct difference in interactions with healthcare workers depending on whether they share her ethnic background. Iholdi’s gender and ethnicity concurrently influences how she is treated, leading to gender and ethnic bias and discrimination.

And that's what happens to me, the same thing, and then when you talk and the one in front of you is Euskaldun, there is a connection, and then there is something, right? There's a connection or a distance. For being woman or being Euskaldun … But because of being woman and Basque it’s clear, clear. For better or worse, but yes, yes, there's a big change.

Iholdi’s narrative illustrates how gender and ethnic identity jointly shape her interactions with healthcare practitioners. She reports feeling either a sense of affinity or distance depending on whether the practitioner shares her gender or ethnolinguistic background. These shifting dynamics emphasize her understanding that gender roles and ethnolinguistic positioning fundamentally condition the quality of her healthcare encounters and contribute to the reproduction of both gender and cultural bias during the healthcare encounter.

Participants also noted that physical ailments or expressions of stress were often misdiagnosed as anxiety or depression, echoing literature suggesting that Western medicine tends to over diagnose women with these conditions (Bacigalupe & Martín, 2021), a bias rooted in the historical dismissal of women’s health concerns (Valls-Llobet, 2020). Amalur is a 57-year-old Basque woman who works part-time as a porter and part-time in a school dining room. She lives in a large town in the center of Nafarroa where the Euskaldun population is a minority. Amalur lives in a house that has belonged to her family for several generations with her husband and two sons. She has deep roots in the area and has previously expressed her preference to use cultural or other alternative healing practices. She also uses the public healthcare system, as needed. She recalls when she was having stomach aches mostly in the afternoon. She went to her GP to see if they could help her with the pain. The GP was dismissive regarding her symptoms and directly diagnosed her with anxiety.

Look, okay, it’s true that I’m a bit nervous, I know it … I mean, I think I can still handle my mind, so it’s not that. And, yes, they gave me pills for anxiety. Of course, I didn’t take them. In the end I went to the osteopath, …And well, that’s it, I took fennel, and so on and it went away.

Amalur believes that being a woman involves an increased caregiving role, which adds a certain level of anxiety to her life. However, she feels that her healthcare provider is dismissing her physical symptoms, despite Amalur’s insistence otherwise. She states “So, regarding women, well, if you are a woman, you have a responsibility, sons, grandad or dad… You already have that anxiety. And I said, ‘damn, it’s not that.’”

Amalur’s experience reflects common biases women face within the healthcare system, where emotional stress from overburdened caregiving roles is often linked to psychological illness, leading to physical ailments also being dismissed or portrayed as exaggerations (Valls-Llobet, 2020). Amalur identifies this bias and opts to search for alternate healing practices within her community which she considers a safe and effective alternative to a healthcare system where she feels prejudged and is unable to meet her healthcare needs.

Several participants reported feeling judged for their sexual practices. During healthcare encounters, providers often assume that participants are engaged in monogamous, heterosexual relationships, with a focus on intercourse. Sexual education is based on this presumption, leading to discrimination and judgment against those with diverse sexual practices. Participants are aware that, despite belonging to an ancient culture where women historically held more social power than in neighboring communities (Bullen, 2003), their society is currently strongly influenced by dominant heteropatriarchal norms.

Laiene, a 43-year-old Basque woman working as a teacher, lives in a predominantly Euskaldun area in western Nafarroa. She has used healthcare services both as a caregiver for her parents and as a patient, primarily for gynecological issues and follow-up appointments. Laiene emphasizes the importance of having healthcare practitioners who share her culture and language. She also values healthcare workers with a feminist perspective on health. However, her experiences reveal that she has often felt judged for her sexual practices:

There I've felt judged, in relation to my sexual relationships, right? Well, if you don't have a steady partner, and I've felt judged because then many practices are directed to heterosexuals, right? No one asks you or not, right? Some assumptions for me are very disturbing, and then I've felt judged.

Regarding her encounters with the gynecologist she describes how she anticipates potential discriminatory attitudes based on negative perceptions healthcare workers may hold regarding her gender, or ethnic identity.

And I always ask, and do you know Basque? “No, eh” shoot, always that, -- fuck, right? That has always been the first question. Do you know Basque? No? And the second concern was well, they don't know, they´re not Euskaldun, let´s see how they treat me as a woman, right? It's been those two landmarks for me. And often, both have not been good. Because they are not Euskaldun. And other times, being Erdaldun (non-Basque speaking), the interaction has been good, but other times the interaction has not been good either, and I've felt judged.

Laiene’s experience illustrates how various forms of oppression overlap to shape her encounters with the healthcare system. She anticipates that heterosexism and cultural/language supremacy will influence her healthcare experience. Additionally, she recognizes the interconnectedness of her identities, believing that a positive healthcare experience depends on a feminist perspective that acknowledges her position as an ethnic minority woman. Her anticipation of judgment based on sexual practices, gender, and ethnic identity illustrates that these social categories do not operate in isolation; rather, they interact dynamically to influence how she is perceived and treated. This aligns with a broader intersectional feminist approach to healthcare. Through intersectionality we can understand how social categories like gender, ethnicity, race, and socio-economic status are interconnected and complex rather than independent and unidimensional (Bowleg, 2012). It also recognizes that various systems of power intertwine to shape individual experiences and power dynamics, which cannot be understood simply by adding up each category (Bowleg, 2012).

Laiene’s exemplar highlights various forms of gender bias and discrimination that intertwine with participants’ experiences of ethnic marginalization. Healthcare workers often act as conscious or unconscious perpetuators of overlapping oppressive structures, replicating heterosexist and cultural values that exacerbate discrimination experienced by BWNN. Thus, gender bias and discrimination are barriers to achieving cultural safety.

Obstetric and Gynecological Violence

Participants reported numerous experiences of obstetric and gynecological violence. Obstetric violence is the control exerted by healthcare providers over women’s bodies and reproductive processes reflected in dehumanizing treatment and the excessive medicalization of natural functions resulting in a loss of autonomy and the freedom to make choices about their own bodies and sexuality, thus adversely affecting women’s overall quality of life (Annborn & Finnbogadóttir, 2022). Gynecological and obstetric violence include inappropriate or non-consensual acts, feelings of guilt for questioning certain procedures, sexist behavior during gynecological consultations, and the performance of painful procedures without offering anesthesia during or after childbirth (Committee on Equality and Non-Discrimination, 2019). A recurrent issue was the focus of maternity in women’s health. Participants have been judged either for not wanting to give birth, or for the age they decided to give birth. This continuous judgement reflects a disregard for BWNN’s right to make decisions about their bodies and constitutes an attempt to control their reproductive freedom.

Auza is a 40-year-old non-binary individual. They are self-employed and reside in a small town in the northern part of the province, where most of the population speaks Euskara. Although they are currently seeking gender affirming care, Auza perceives that their encounters with the gynecological services both prior and during their gender transition have insisted on focusing on fertility although they insisted that they did not wish to give birth.

… you could see it over and over again in the way I was being treated. Somehow, I was losing fertility, because I was getting older and as I was being treated as a woman, … this was above everything else. And I could say that I’m not going to have children, I will never have them, I’m not going to give birth, but even though, … they will continue with that logic all the time … And when I started transitioning, the same thing. At the time they explained the hormone issue, I clearly stated that fertility was not important to me, and even though they continued insisting.

On the one hand, while being treated as a woman, Auza faces a common social pressure experienced by women related to the belief that every woman is socially expected to accept maternity as their destiny and main life goal (Annborn & Finnbogadóttir, 2022). This belief is reinforced by the historical idealization of motherhood in Basque culture, which persists to some extent today (Bullen, 2003), a notion that persists in social and cultural contexts outside the clinical setting. On the other hand, as a non-binary individual, Auza experiences ongoing marginalization due to healthcare workers making constant assumptions and misconceptions about their body and reproductive desires. These assumptions exemplify how gender non-normative individuals encounter microaggressions in gynecological settings that undermine their lived experiences (Pulice-Farrow et al., 2022). Auza’s experiences as a Basque gender non-normative individual are shaped by heterosexist and transphobic norms structurally embedded in both the healthcare system and their culture.

Several participants described feeling judged and mistreated for requesting or refusing certain practices, including experiencing retaliation for giving birth in a certain way. Obstetric and gynecological violence is more common during childbirth, when women and birthing individuals are in a particularly vulnerable position (Annborn & Finnbogadóttir, 2022).

Graxi, a 39-year-old Basque woman, is currently on maternity leave after the birth of her first child. She lives with her partner and child in an apartment on the outskirts of the provincial capital. Her interactions with the healthcare system have involved fertility treatments before her pregnancy, prenatal care, and her birthing experience. Graxi chose to have a home birth, assisted by midwives. While the birth itself went smoothly, the delivery of her placenta was delayed, prompting her to visit the emergency room with her partner and baby. Upon arrival, Graxi encountered retaliation and contempt towards her beliefs, which she attributes to her decision to deliver at home, despite her gynecologist’s advice against it due to her high-risk pregnancy. Graxi clearly identifies her experience as “obstetric violence”.

… I had no anesthesia, no epidural, I mean, everything was natural, and when they were giving me the stitches it was really painful, and I was like please “give me something” and “Well, since you don’t want anything” and I was like “… it’s not that I want nothing”, I mean, I don’t want to have pain, I mean, one thing does not take away the other. And I told them “No, no, give me as much as you can of the local one” … And the pain was horrible, I was screaming and screaming …

Graxi later had a rectal palpation where she felt she was treated roughly.

And he said, we needed to check if the anus is alright, so he put his finger into my anus. And well, there are things, that need to be done with more or less gentleness, and well for me this man, did not have a lot of gentleness, …

After these events Graxi decided she was ready to return home with her child. Hospital staff considered that her child was at risk and insisted on keeping the child overnight. Graxi refused. Upon discharge healthcare workers refused to provide the documentation for Graxi to be able to register her child at the registrar’s office stating they had not witnessed the birth which led to unnecessary distress and multiple bureaucratic issues for her family.

Well, for me the thing that happened to us is obstetric violence, and then I read the violent acts that happen and yes, without any doubt women, …that they don’t let woman decide how they want to give birth…, if I decided that I wanted to give birth at home, it is because I felt a free person and more empowered at home than in some hospital.

Graxi’s experience reflects multiple forms of obstetric violence, where she is consistently judged and punished for asserting her right to make decisions about her own health and that of her child. The healthcare practitioner inflicts unnecessary physical harm by performing aggressive procedures, compounded by the psychological and emotional distress caused by the failure to register her child’s birth. Graxi attributes this treatment to retaliation linked to her beliefs, exemplifying the dismissal of cultural birthing practices—a common experience among Indigenous women facing medical colonization (Pilarinos et al., 2023). By advocating for a home birth, Graxi asserts her right to autonomy in healthcare, which provides her with a sense of empowerment and safety. While obstetric violence poses a significant barrier to cultural safety, promoting patients’ autonomy in healthcare can act as a facilitator.

Another form of gynecological violence is evident in the social and institutional pressure placed on women to breastfeed. Alaia, a 44-year-old Basque woman, lives with her partner and two children in a small, predominantly Euskaldun village in the northern part of the province. Her experiences with healthcare services have been both as a patient and as a caregiver for her children and parents. Alaia has expressed a preference for female and Euskaldun providers, as they make her feel calmer and safer. She recalls an incident where she felt pressured to continue breastfeeding, even though it was painful for her, and she had already decided to stop. Alaia went to her follow-up appointment with the midwife alone. The midwife, who was male and Erdaldun, asked her why she hadn’t brought her baby. After she explained that she had decided to no longer breastfeed. The midwife responded, “…you need to suffer a little so that things turn out better after, you know?” Alaia perceived this response as unnecessarily judgmental and felt pressured by the practitioner.

And I said, but I can’t, …psychologically I’m not doing well at all, and I decided, …and I always thought that if I couldn't, I wouldn’t breastfeed, but at the moment, when it was my turn, it was really complicated. Because in the end, it looks like you are a bad mom, because you don’t breastfeed, you know? Well, but, always, you don’t know how much he insisted. You don’t know how much he insisted!

Alaia arrives at the healthcare encounter in a vulnerable position due to psychological distress which was exacerbated by not being able to breastfeed her child. Upon arrival she encounters an Erdaldun practitioner which forces her to express herself in a language that she does not feel comfortable with. The practitioner instead of reassuring Alaia, puts pressure on her to breastfeed, increasing the discomfort and stress she is experiencing. This pressure results in shaming and instilling feelings of guilt which is a form of symbolic gynecological violence. Alaia’s experience reinforces research findings that pressure to breastfeed leads to increased stress and anxiety as well as feelings of guilt and shame for the mother (Grattan et al., 2024).

These testimonies reveal the pervasive nature of obstetric and gynecological violence experienced by BWNM. These accounts highlight the judgment, mistreatment, and lack of autonomy imposed by healthcare providers. Participants consistently faced social and institutional pressures, such as being judged for their reproductive choices, enduring painful medical procedures without adequate anesthesia, and experiencing retaliation for asserting their rights. Additionally, non-binary individuals like Auza face further marginalization due to assumptions about their reproductive desires. Cultural expectations surrounding maternity and breastfeeding also contribute to this violence, as seen in the cases of Graxi and Alaia.

These experiences emphasize the importance of promoting patient autonomy in healthcare. Autonomy in healthcare decision-making refers to an individual’s ability to make unrestricted choices for themselves and their dependents, with full access to relevant information and services (Idris et al., 2023). The principle of respect for autonomy requires healthcare providers to acknowledge individuals’ rights to hold personal views and make choices based on their values (Lindberg et al., 2014). This aligns with the need for healthcare workers to be trained in reflexivity and assessing their biases to ensure cultural safety.

Discussion

Findings from this study highlight various forms of gender bias and discrimination experienced by BWNN during healthcare encounters. A gap in knowledge transmission regarding women’s health issues is a major impediment for BWNN to receive optimal health services and leads to sentiments of mistrust towards the healthcare system. These findings are consistent with research suggesting that knowledge of women’s health has been limited due to the historically dominant androcentric perspective in the health sciences (Valls-Llobet, 2020). Additionally, findings indicate an intergenerational gap of knowledge transmission related to historical colonial and patriarchal oppression (Federici, 2004; Mujika Garate, 2023). Thus, the implementation of cultural safety requires culturally specific procedures, research, and methods to increase information and knowledge focused on the needs of BWNN.

Bias based on sexual and gender identity is another finding of this study. Numerous studies show how gender bias in healthcare is an important social determinant of health and has detrimental health effects (Shannon et al., 2019), including mental health, revealing that women are adversely affected by gender bias (Bacigalupe & Martín, 2021). Study results also highlight discrimination with patients seeking gender affirming care or those who reveal sexual practices that fall outside of the heterosexual norm. Motherhood is insisted upon by healthcare workers and judgement regarding when and how women should become mothers is evident. This encouragement arises from the prevailing belief that society inherently expects women to regard motherhood as their primary life goal (Annborn & Finnbogadóttir, 2022). This belief is further reinforced by the idealization of motherhood in Basque culture (Bullen, 2003), this societal expectation is carried to the clinical setting.

Collectively, these findings highlight how healthcare practices rooted in restrictive gender norms reinforce gender inequality, ultimately translating into increased health risks (Shannon et al., 2019). Consequently, discrimination based on gender and sexual identity is a significant barrier to cultural safety for BWNN. Steps to overcome this barrier include promoting patients’ autonomy in healthcare, gender-sensitivity educational interventions and health policies aimed at the reduction of gender inequities (Chilet-Rosell & Hernández-Aguado, 2022). Introducing updated conceptualizations of gender affirmation care and sexual identity are also ways to identify and address gender discrimination within the healthcare system.

Gynecological and obstetric violence is a worldwide phenomenon that has been disregarded (Perrotte et al., 2020). Our findings suggest that it is also occurring in the Basque Country and needs to be addressed from the unique perspective of BWNN. Study results show that BWNN are subject to sexist behavior, non-consensual acts and judgement regarding their choices of treatment. Although most of these experiences occur during childbirth, other medical interventions during gynecological examinations are also perceived as forms of invisible violence and gender discrimination (Annborn & Finnbogadóttir, 2022). Findings indicate that these experiences frequently coincide with ethnic and linguistic discrimination, highlighting the need to expand our understanding of marginalization through intersectional frameworks (Scott et al., 2023). Diminishing these marginalizing experiences will be necessary to overcome obstacles to cultural safety for BWNN.

Participants highlight the importance of being able to make informed decisions regarding their health and their bodies. Empowering women in healthcare decision making and appropriate use of healthcare services can decrease morbidity and mortality rates in women and their children (Idris et al., 2023). The exemplars of Graxi, Alaia, and Iholdi demonstrate that BWNN advocate for the respect of their autonomy, and that satisfaction and confidence increase when they are able to make informed decisions regarding their own and their family’s care. The principle of respecting autonomy requires healthcare workers to recognize patients’ rights to make decisions based on their own values (Lindberg et al., 2014). To achieve this, healthcare workers must be trained in self-reflection and bias awareness, which is essential for delivering culturally safe care.

Limitations

One limitation is that data was collected in Euskara and analysis was performed in English. The unique perspective and understanding provided by each language may have led to the loss of data through translation. We attempted to alleviate this by reading the transcripts in Euskara and the English translation. This study was conducted in Nafarroa therefore results may not be transferable to other Basque regions. The study sample mostly included heterosexual cis-gender women, underrepresenting gender and sexual minorities.

Conclusions

This qualitative study explores the experiences of BWNN with healthcare in the Basque Country, contributing to fill a significant gap in research within the European setting. Findings from this study highlight discrimination experienced by BWNN due to their marginalized position related to gender and ethnicity in the healthcare setting. This is concerning given that these experiences lead to sub-optimal healthcare. However, findings also provide guidance to better practices, promoting women’s autonomy in healthcare services and promoting non-biased gender equity in healthcare which may act as facilitators to cultural safety for BWNN.

These findings highlight important gaps in nursing and clinical practice and emphasize the need to integrate cultural safety within healthcare in the Basque context. Addressing these gaps requires healthcare organizations and educational institutions to prioritize cultural safety training that critically engages with the historical roots of cultural supremacy and sexism, and their ongoing impact on BWNN patients. Embedding cultural safety within university-level healthcare curricula, particularly in nursing and medical education, is essential to prepare future healthcare workers to respond effectively to the diverse and intersecting needs of this population. Strengthening these approaches may contribute to more equitable, responsive, and inclusive healthcare practices. Finally, the findings generated in this study may extend beyond the Basque setting and be relevant to other Indigenous women and gender non-normative individuals globally. As such, the findings contribute not only to understanding experiences within the specific study context but also to the broader body of knowledge on women and gender non-normative individuals’ experiences of healthcare.

ORCID iDs

Garbiñe Elizegi Narbarte https://orcid.org/0000-0001-5360-1289

Leslie Dubbin https://orcid.org/0000-0002-7044-5799

Ethical Considerations

This study was undertaken in partnership with the Department of Health of the Government of Nafarroa, and its corresponding ethics committee (Record # PI_2022/104), and was approved by the University of California San Francisco Institutional Review Board (IRB #22-36656). All participants gave written informed consent to participate in this study.