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Clinical
Volume 55, Issue 3, March 2026

Embedding cultural safety to combat racism against Aboriginal and Torres Strait Islander peoples: Advice for healthcare settings

Bronwyn Wilkes (Gundungurra)    Lisa J Whop (Wagadagam, Gumulgal)    Katherine A Thurber (non-Indigenous)    Emily Colonna (non-Indigenous)    Raymond Lovett (Ngiyampaa/Wongaibon)   
doi: 10.31128/AJGP-09-25-7844   |    Download article
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Background

Structural racism is ubiquitous, causes substantial harms and often reveals itself in interpersonal discrimination against Aboriginal and Torres Strait Islander peoples. The Australian health system is not immune from the perpetuation of racism, which has become increasingly prevalent in recent years.

Objective

This article offers guidance for health practitioners on meeting their responsibilities to provide culturally safe care for Aboriginal and Torres Strait Islander peoples.

Discussion

Addressing racism requires acknowledgement of its existence and impacts, structural change across societal systems, and ongoing resistance to the evolving ways in which it manifests. An important part of these efforts is for health practitioners and institutions to fulfil their responsibilities to provide culturally safe care and culturally safe working environments for Aboriginal and Torres Strait Islander peoples. Central to cultural safety is ongoing reflective practice and action to address power differentials and the way that practitioner attitudes, knowledge and practising behaviours affect care delivery and practice environments.

ArticleImage

UTKU AN ALARRAKUDHI by Teho Ropeyarn and Saltwater People

Racism is unlawful, unethical and lethal.1–3 It has extensive negative impacts for Aboriginal and Torres Strait Islander peoples, preventing the attainment of human rights, social justice and healthy lives. Racism operates through ‘systems within societies that cause avoidable and unfair inequalities in power, resources, capacities and opportunities across racial or ethnic groups’.4 Racism is inherent to the structures of settler-colonial societies such as Australia; it is not only enacted through attitudes and interpersonal interactions, but also embedded within societal structures, institutions and social norms that reinforce each other.2,5

Eradicating all forms of racism requires dismantling settler-colonial systems that are founded on racist ideologies and that perpetuate racism, trauma and inequities. The Australian health system is one such system in which racism is structurally inherent,3 that continues to produce inequitable outcomes,6 and in which Aboriginal and Torres Strait Islander peoples are increasingly experiencing discrimination.7 Ensuring cultural safety across the health system is an important part of broader efforts to address racism at its foundations. As the National Indigenous Health Leadership Alliance explains,8 cultural safety involves a commitment to equity grounded in self-reflection and cultural self-awareness:

Cultural safety represents a key philosophical shift from providing a service regardless of difference to care that takes account of peoples’ unique needs. Cultural safety is central to Aboriginal and Torres Strait Islander people and their relationships with the health system. Cultural safety describes a state, where people are enabled and feel they can access health care that suits their needs, are able to challenge personal or institutional racism (when they experience it), establish trust in services and expect effective, quality care.

It requires all people to undertake an ongoing process of self-reflection and cultural self-awareness and an acknowledgement of how these impact on interactions and service delivery. Critically, cultural safety does not necessarily require the study of any culture other than one’s own: it is essentially about being open-minded and flexible in attitudes towards others. Identifying what makes others different is simple – however, understanding our own culture and its influence on how we think, feel and behave is much more complex, and often goes unquestioned.8

Racism is an enactment of power to preserve privilege. Meaningfully addressing racism against Aboriginal and Torres Strait Islander peoples requires the ceding of power by non-Indigenous peoples. Ongoing critical reflection on the personal power and privilege held by health practitioners must underpin action to hand back power to Aboriginal and Torres Strait Islander peoples. This is central to enacting cultural safety.

This article provides guidance for health practitioners on meeting their responsibilities to provide culturally safe care for Aboriginal and Torres Strait Islander peoples.

Race is a sociopolitical construct with biological impacts

Racialisation is a social and political phenomenon whereby groups of people are categorised into ‘races’ on the basis of characteristics such as physical appearance, ancestry and/or culture, under the assertion that these characteristics reflect innate differences between ‘races’.5,9 While racial science has long been discredited,9 notions of race and racism continue to be used by those with power to control the lives and lands of racialised peoples around the world.10 In Australia, racism underpins the ongoing processes of settler colonisation that deprive Aboriginal and Torres Strait Islander peoples of connection with their lands, waters, languages, cultures, identities and other positive determinants of health and wellbeing.

How does racism affect health and wellbeing?

Racism affects health and wellbeing through multiple pathways.4,5,11 These can include exposure to physical, psychosocial, socioeconomic and legal stressors, which can interact and compound over life courses and generations. Racism creates negative determinants of health including stress, trauma and risk of physical injury and death through exposure to racially motivated violence and substandard care.3–5,9,11–13 Racism also impedes access to protective social, cultural, environmental and economic determinants of health, and it can give rise to coping mechanisms that are not supportive of health.5,14 Racism contributes to inequitable access to healthcare and legal services, which exacerbates poor health outcomes and creates vicious cycles that entrench poor health and wellbeing.1

A direct path between racism and health is via chronic stress. Experiencing or anticipating racism triggers the fight-or-flight response,11 activating the sympathetic nervous system and hypothalamic–pituitary–adrenal axis, producing elevated heart rate, blood pressure, blood glucose and inflammation.11 The cumulative physiological burden of repeated or chronic activation of stress pathways (allostatic load) can lead to changes in cardiovascular, gastrointestinal, endocrine, metabolic, neurological and immune systems, with long-term immunosuppressive effects.15 Higher allostatic load is associated with all-cause mortality, cardiovascular disease, diabetes, cancer, psychological distress and periodontal disease.15,16

There is international and population-specific evidence of racism’s negative and far-reaching impacts on health and wellbeing.4,14,17,18 A national study involving over 8000 Aboriginal and Torres Strait Islander adults identified dose–response relationships between discrimination and psychological distress, low happiness, low life satisfaction, pain, doctor-diagnosed depression and anxiety, low life control, choosing not to self-identify as Aboriginal and/or Torres Strait Islander, feeling torn between cultures, feeling disconnected from Aboriginal and/or Torres Strait Islander culture, alcohol dependence, current smoking, gambling, poor/fair general health, diabetes, heart disease, high blood pressure and high cholesterol.14 A study of Aboriginal and Torres Strait Islander men found that discrimination was associated with higher prevalence of suicidal thoughts,19 consistent with international evidence on associations between racial discrimination exposure and both suicide ideation and attempt.20

Racism in the Australian health system

Racism exists across Australia – the health system is no exception. This takes many forms, including occupation of sovereign Indigenous lands and displacement of Aboriginal and Torres Strait Islander peoples, structural and epistemic forms of racism in the design and delivery of health services and medical education, interpersonal racial discrimination, and more.21

The structural racism inherent in the Australian health system is evidenced in the inequitable outcomes and preventable deaths it produces.3,21 Aboriginal and Torres Strait Islander peoples experience more than double the total burden of disease of non-Indigenous Australians.22 As an example, Aboriginal and Torres Strait Islander peoples are 2.1 times as likely to be diagnosed with lung cancer and 1.8 times as likely to die from lung cancer than non-Indigenous Australians.23 These inequities have their roots in predatory targeting of Aboriginal and Torres Strait Islander peoples by the tobacco industry and payment in tobacco rations rather than wages until as recently as the 1960s.24

Eurocentric biomedical models of health dominate much of the Australian health system, emphasising reductionist and individualist approaches.21 These are contrary to holistic conceptions of health and wellbeing held by many Aboriginal and Torres Strait Islander peoples, wherein ‘health is viewed in a holistic context that recognises not only physical health and wellbeing but also the social, emotional and cultural wellbeing of individuals, families and communities’.25 These differing conceptions underpin a foundational disconnect between the needs of Aboriginal and Torres Strait Islander peoples and the ability of Eurocentric services to meet those needs.

Healthcare settings are sites of interpersonal racial discrimination against Aboriginal and Torres Strait Islander people who are receiving and providing care. Data from Mayi Kuwayu: The national study of Aboriginal and Torres Strait Islander wellbeing show that in the 18 months since the Voice to Parliament referendum (15 October 2023 – 14 April 2025), over half (51.8%) of Aboriginal and Torres Strait Islander adults experienced discrimination when seeking healthcare.7 The prevalence of healthcare discrimination faced by Aboriginal and Torres Strait Islander adults has increased substantially in recent years, as have experiences of vicarious racism – such as hearing jokes or insulting comments about, or witnessing unfair treatment of, Aboriginal and Torres Strait Islander peoples – which is pervasive at 78.8%.7 These figures likely underestimate true exposure, given underreporting biases and the inability to capture the totality of ways in which racism manifests. Aboriginal and Torres Strait Islander health professionals experience racism frequently at work and often encounter resistance or retribution when identifying injustices.13

Health practitioners’ responsibilities to provide culturally safe care

The importance of healthcare that is culturally safe and free of racism is acknowledged within many guiding documents8,25–28 and embedded in the Health Practitioner Regulation National Law – the nationally consistent legislation passed by each state and territory parliament that governs the regulation of health practitioners.29 The codes of conduct that cover all 16 registered health professions require practitioners to ensure culturally safe practice.30–34 Good medical practice: A code of conduct for doctors in Australia31 acknowledges that ‘cultural safety is a critical component of patient safety’35 and must be specifically considered as part of good practice. Adopting the National Scheme’s definition,35 the code of conduct states:

Cultural safety is determined by Aboriginal and Torres Strait Islander individuals, families and communities.

Culturally safe practise is the ongoing critical reflection of health practitioner knowledge, skills, attitudes, practising behaviours and power differentials in delivering safe, accessible and responsive healthcare free of racism.31

©  Aboriginal and Torres Strait Islander Health Strategy Group 2026

©  Medical Board of Australia 2026

©  Australian Health Practitioner Regulation Agency 2026

To ensure culturally safe and respectful practice, the code of conduct states that ‘medical practitioners must:

  1. acknowledge colonisation and systemic racism, social, cultural, behavioural and economic factors which impact individual and community health;
  2. acknowledge and address individual racism, their own biases, assumptions, stereotypes and prejudices, and provide care that is holistic, free of bias and racism;
  3. recognise the importance of self-determined decision-making, partnership and collaboration in healthcare which is driven by the individual, family and community;
  4. foster a safe working environment through leadership to support the rights and dignity of Aboriginal and Torres Strait Islander people and colleagues’.31

©  Aboriginal and Torres Strait Islander Health Strategy Group 2026

©  Medical Board of Australia 2026

©  Australian Health Practitioner Regulation Agency 2026

Engaging in culturally unsafe practice can result in deregistration as a health practitioner.36

Acknowledge that racism exists, is pervasive and causes harm

It is important to acknowledge that ‘racism is prevalent in the Australian health system and kills Aboriginal and Torres Strait Islander Peoples through direct and indirect means’.13 A summit of approximately 300 Aboriginal and Torres Strait Islander health workforce stakeholders identified several key actions to address racism, including that health practitioners, administrators and others working in the health system need to understand ‘the systemic presence of racism as a first step to addressing it’.13 Denying the existence of racism or the seriousness of the harms it causes, or viewing incidents as isolated ‘one-off’ events, causes additional harm and contributes to Aboriginal and Torres Strait Islander health practitioners leaving the health workforce, which further undermines cultural safety.13 The Australian Health Practitioner Regulation Agency (Ahpra) Aboriginal and Torres Strait Islander Anti-Racism Policy (available at www.ahpra.gov.au; refer to direct link in reference) provides detailed guidance on understanding and responding to racism against Aboriginal and Torres Strait Islander peoples.37

It is also important to understand that racism is perpetuated in different forms and can be difficult to recognise if you are not part of the racialised group. Negative attitudes and prejudice are not the only ways that racism manifests; racism is routinely perpetrated ‘irrespective of the good or ill will of individuals’2 through ‘practices, procedures, patterns, and policies that operate to privilege members of particular racial groups’2 and that are ‘rarely visible to those that are privileged by [them]’.2 As Elias and Paradies articulate, ‘for institutional racism to thrive, people need only be “colour blind,” “meritocratic,” ignore the reality of existing privilege and injustices, and simply let the systems and structures reproduce the status quo.’2 Meaningfully addressing racism in the health system requires the structures that reproduce the status quo to be disrupted and, as Watego et al articulate, ‘non-Indigenous health workers to consistently interrogate the complex entanglement between the seeming benevolence of health care and the violence inherent to the settler colony.’3

Deliver high-quality, culturally safe, trauma-informed care

The National Guide to preventive healthcare for Aboriginal and Torres Strait Islander people (National Guide) sets out recommendations, across a range of organ- and disease-specific conditions, designed to support health practitioners to deliver culturally safe care.38 Practitioners should consult the National Guide and apply the recommendations, as appropriate. It is important that care be based on the specific needs and presentations of the individual receiving care rather than generalisations that belie the diversity within Aboriginal and Torres Strait Islander peoples.

The National Guide contains a chapter on the health impacts of racism,39 with recommendations drawn from a review of clinical guidelines, other literature and input from an expert Advisory Group comprised of Aboriginal and Torres Strait Islander health practitioners and managers. The chapter includes implementation tips and resources for practitioners to provide trauma-informed (refer to Box 1), culturally safe care.39 Reflective practice and well-credentialled cultural safety training are important parts of this, but to be effective, these must be ongoing efforts rather than once-off tick-box exercises.3,40,41 Supporting self-determined decision making by Aboriginal and Torres Strait Islander peoples and families is also an important part of cultural safety. This can be facilitated by tools such as the Finding Your Way shared decision-making model,42 the Heart Health Yarning Tool43 and Making Decisions Together model for lung cancer screening.44

Box 1. Trauma-informed practice
Traumatic experiences can cause changes in nervous system functioning and the ability to feel safe and in control and form connections with others – unhealed trauma leaves a person continually on the lookout for danger.47 Accounting for trauma and its effects is important to avoid causing further harm.

Frameworks for trauma-informed practice have been adapted by Aboriginal practitioners and organisations from the ‘4 Rs model’ developed by the US Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration (SAMHSA).47–49 The SAMHSA 4 Rs model includes the following principles for trauma- informed practice:
  • Realise the widespread impact of trauma and understand potential paths for recovery
  • Recognise the signs and symptoms of trauma in clients, families, staff and others involved with the system
  • Respond by fully integrating knowledge about trauma into policies, procedures and practices
  • Actively Resist re-traumatisation49
The SAMHSA model was adapted to add a fifth ‘R’ – replenish – by Jiman and Bundjalung woman Professor Judy Atkinson, in collaboration with the Healing Foundation and multiple Aboriginal communities:
  • Replenish, refill or rebalance the ability to care for each other, self and Country, and bring about calmness, connection and healing.47
The Damulgurra program (formerly the Culturally Responsive Trauma Informed Care [CRTIC] program) developed by Aboriginal Medical Services in the Northern Territory (AMSANT) adds Revive and Regenerate to the 4 Rs. This reflects the aim of reviving connection to community, land, culture and ourselves, and the ‘ultimate goal of empowering Aboriginal communities to regenerate and revive their own local healing frameworks’.48

Various resources exist to help practices and practitioners better understand trauma and its effects, and how to become trauma informed. Some examples include:
Address all forms of racism in your organisations and communities

Just as there are many ways in which racism manifests, there are many opportunities for addressing it. Tools exist to support the identification and monitoring of institutional racism, such as Marrie and Marrie’s matrix template,45 and to improve health service delivery for Aboriginal and Torres Strait Islander peoples, such as the One21seventy Systems Assessment Tool.46 Practitioners in leadership positions should address structural racism by influencing policies and procedures within their organisations, for example: implementing anti-racism policies with accountability mechanisms; ensuring that culturally safe complaints mechanisms exist for reporting racism; regularly monitoring the cultural safety and equity implications of organisational processes; and investing in actions to attract, retain and grow the Aboriginal and Torres Strait Islander health workforce.13,39

Advocating for people receiving healthcare and providing practical assistance to overcome barriers to accessing health services, where appropriate, can be an important contribution to cultural safety. As Wyber et al articulate, ‘primary care staff who – patiently and respectfully – wrangle patient travel arrangements are role modelling advocacy and the pursuit of equity to their colleagues’.40

Aboriginal and Torres Strait Islander health practitioners can form anti-racist communities of practice to build solidarity, support and strategic tools to challenge racism and deal with backlash that follows.3 Non-Indigenous practitioners must support Aboriginal and Torres Strait Islander colleagues, including by sharing power in clinical and other settings, creating environments that support cultural needs to be met, reporting racism, and supporting the reporting of racism without resistance or retribution.13

Conclusion

Racism is embedded within the foundational structure of the Australian health system. Disrupting racism requires persistent vigilance and resistance to the evolving ways that racism manifests and causes harm. Critical praxis – both reflection and action – is central to the ongoing efforts required by health practitioners to meet their responsibilities to do no harm and to provide culturally safe care for Aboriginal and Torres Strait Islander peoples. Critical reflection and action must be directed towards the power held by practitioners and healthcare institutions and how this power influences Aboriginal and Torres Strait Islander peoples providing and receiving care. Non-Indigenous practitioners must cede power and be accountable to Aboriginal and Torres Strait Islander peoples for providing culturally safe care so that healing from the collective harms of racism is driven by Aboriginal and Torres Strait Islander self-determined priorities.

Key points

  • Racism is embedded in structures across Australian society and often reveals itself in interpersonal discrimination against Aboriginal and Torres Strait Islander peoples.
  • Discrimination and racism against Aboriginal and Torres Strait Islander peoples have been increasing in recent years, including in healthcare settings.
  • Addressing racism and the harms it causes requires acknowledgement of its existence and impacts, structural change and ongoing resistance to the evolving ways in which it manifests.
  • Health practitioners and healthcare institutions have responsibilities to provide culturally safe care and culturally safe work environments for Aboriginal and Torres Strait Islander peoples.
  • Ongoing reflective practice and action to address power differentials are central to cultural safety.
Competing interests: LJW is a member of the Australian Health Practitioner Regulation Agency (Ahpra) Aboriginal and Torres Strait Islander Health Strategy Group. BW is a member of the Australian Health Practitioner Regulation Agency (Ahpra) Research Evaluation Committee. The other authors declare no interests.
AI declaration: The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript.
Provenance and peer review: Commissioned, externally peer reviewed.
Funding: Funding was provided to the authors’ institution by NAACHO towards the costs of preparing this manuscript. LJW and RL are supported by the National Health and Medical Research Council of Australia (NHMRC) Investigator Grants (#2009380 and # 2033534 respectively). The funding sources had no role in the writing of the manuscript.
Correspondence to:
bronwyn.wilkes@anu.edu.au
Acknowledgements
The authors acknowledge all Aboriginal and Torres Strait Islander peoples on whose lands we conduct our work, including Ngunawal, Ngunnawal and Ngambri peoples, where this article was written. We offer our respects and gratitude to Elders, Ancestors, all who have cared for Country and kept culture strong and continue to do so. We acknowledge the advice and input of the Aboriginal and Torres Strait Islander Expert Advisory Group to the ‘Health impacts of racism’ chapter in the National Guide to preventive healthcare for Aboriginal and Torres Strait Islander people (4th edn); that chapter informed this article. This article covers content, including racism and suicide, that can be distressing to read – support is available through 13YARN (13 92 76), Lifeline (13 11 14), and other services and resources (refer to Yardhura Walani information).
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