ECMI Minorities Blog. Towards Equitable Treatment of Speech-Language Impairments in Minority-Language Speakers
*** The blog posts are prepared by the authors in their personal capacity. The views expressed in the blog posts are the sole responsibility of the authors concerned and do not necessarily reflect the view of the European Centre for Minority Issues. ***
Authors: Pavlina Heinzova & Maddi Dorronsoro Olamusu | https://doi.org/10.53779/AQMM2333
Speakers of regional and minority languages are often multilingual because they also need to acquire the majority language to interact with the larger community, navigate different societal spheres, and access public services, among other things. Despite different legal frameworks protecting minority language speakers, the majority language is oftentimes the only entry point for obtaining essential public services, such as healthcare. Limited access to healthcare services provided in a minority language may place speakers at a personal disadvantage or even compromise their health. Indeed, being able to use a minority language when attending a medical centre or an appointment with a psychologist constitutes an important facet of linguistic human rights, recognized by the European Charter for Regional and Minority Languages under Article 13 (2)(c). In this article, we focus on the case of Basque in the Basque Autonomous Community. Although the Basque public healthcare system falls under the competence of the region, the implementation of language rights in this public service remains a challenge, particularly in specialized healthcare services. Here we focus on speech-language therapy, where language plays a fundamental role in both assessment and treatment. By examining the legislative framework and Basque media, we provide an overview of the situation, and through interviews, we illustrate the experience of Basque speakers with language impairments and the career-related obstacles of Basque speech-language therapists. Our goal is to bring attention to the challenges and rights of minority language speakers in the critical sector of healthcare.
Legal frameworks and the situation in the Basque Autonomous Community
In the Basque Autonomous Community, both Spanish and Basque are recognised as co-official languages at the regional level. Citizens’ language rights are codified in Law 10/1982 – the legal framework regulating the official use of Basque. This law recognises fundamental rights to use Basque in public administration, education, media, and at work. To guarantee the exercise of such rights, a system of language profiles is applied to each job listing in the public service, meaning different levels of Basque proficiency are a prerequisite for working across diverse spheres of the public sector such as education or administration. However, the public healthcare system, known as Osakidetza, was left outside of the language profile application system when it was established in 1984. Osakidetza did not prioritize language rights as one of its foundational principles, which has resulted in subsequent challenges when integrating Basque into the organization and its services. Nowadays, public healthcare services cannot always guarantee citizens their right to be treated in Basque.
More recent regulations and measures (e.g., the Decree 19/2024 to Normalise the Use of Basque in the Public Sector or the Third Scheme to Normalise the Use of Basque in the Public Healthcare System) have aimed to fill the gap regarding patients’ language rights. For example, citizens can now register their preferred language, report language-related issues, or request a Basque-speaking healthcare practitioner (e.g., a doctor, a nurse, or a midwife). Nonetheless, the Hizkuntza Eskubideen Behatokia [Observatory for Language Rights] pointed out that Osakidetza is not ready to offer all its services in Basque: “It makes no sense to ask users in which language they want healthcare if the organization is not prepared to provide the service in Basque”1. As a result, access to Basque-speaking healthcare professionals, particularly in more specialised fields (e.g., neurology or speech therapy), is often not possible, partially due to the lack of Basque proficiency requirements for these positions.
The lack of practitioners who speak a relevant minority language in the public healthcare system has direct consequences. Studies have shown that failure to find a therapist who speaks a patient’s minority language can result in late diagnosis of neurodevelopmental disorders or in less effective psychotherapeutic interventions. This issue is even more pressing when it comes to the diagnosis and treatment of speech-language impairments, which often result from underlying neurological issues. When an individual’s language capacity is impaired, a speech-language therapist is the health professional responsible for evaluating, diagnosing, and treating these pathologies. Crucially, in speech-language therapy, language is not only a communication tool but lies at the heart of examination, diagnosis, and clinical intervention. Adequate mastery of the treated person’s preferred language should, therefore, be mandatory for all speech-language pathologists. Indeed, clinical interventions that do not include the speaker's preferred language can severely limit the rehabilitation outcomes, as also discussed in a recent article published by the Basque magazine Argia.
When aphasia affects a minority-language speaker
The problem at hand can be illustrated on the treatment of aphasia, an acquired loss of language skills resulting from damage to brain tissue that occurs after an acute stroke, a traumatic brain injury, or due to an underlying neurodegenerative disorder (e.g., Alzheimer’s disease). The incidence of aphasia, which typically affects an individual’s ability to speak and understand language, is on the rise with 300,000 new cases diagnosed across Europe each year. Treatment of aphasia is centred around therapy that consists of practising the impaired language skills and learning alternative communication strategies while capitalizing on the remaining language abilities. In acute stroke patients, prompt therapy is crucial, as early interventions yield better results and are most effective within the first six months after brain injury. Although the urgency to find a qualified speech-language therapist is key to optimal recovery, minority language speakers often struggle to get the treatment they need within this narrow time window.
To showcase the issue, we interviewed Lurdes2 (aged 68) from the Basque province of Gipuzkoa, who speaks Basque as her first language. Lurdes suffered from an acute stroke a few years ago and, like many others, she started experiencing language-related difficulties soon after being hospitalized. Once diagnosed with aphasia, Lurdes was immediately referred to a speech-language therapist within Osakidetza. Crucially, she was never offered the option of a Basque-speaking therapist. Without giving the language-related issue much thought (understandably so, considering her health condition), Lurdes started attending sessions with a Spanish-speaking professional. As she reports: “It never even crossed my mind. I was told: ‘you have to go to such a place’, and that was it”.
This scenario shows the vulnerable situation of a stroke survivor, who is not in the position to explore diverse therapy options and who, at the same time, may be unaware of their language rights. In such a situation, the patient uncritically follows the medical advice received. Considering the language rights listed above, offering a Basque-speaking person who has suffered an acute stroke the option of a therapist in their first language should be a well-established practice in the public healthcare system. However, an interim evaluation survey conducted by Osakidetza itself pointed out that medical services in Basque are not being proactively offered, but only provided upon the patient’s request. Lurdes herself attested that if a Basque-speaking professional had been offered to her, she would have certainly opted for one: “I would do it [the therapy] in Basque, that's my language, my first word is always Basque, wherever I go I always start speaking in Basque.”
Are new training opportunities enough to reduce the critical shortage of therapists?
One of the reasons why Lurdes was not advised to seek a language therapist in her preferred language is the critical lack of trained Basque-speaking speech-language pathologists working for Osakidetza. Indeed, the general lack of professionals in this area is a broader issue. As an article in the newspaper Berria from December 2023 pointed out, the Basque Association of Speech-Language Therapists had around 400 members at the time; only 12 speech-language therapists were working in the public healthcare system of the Basque Autonomous Community with over 2 million inhabitants. The number of speech therapists is already unable to cover the population’s needs. After adding the minority-language element into the equation, the situation becomes clear: in the public healthcare system, it is virtually impossible to receive speech-language therapy in Basque. Even if a person is aware of their rights and requests treatment in Basque, the processing of such a claim will at best result in a significant delay in treatment. This puts minority-language speakers with speech impairments in a difficult situation.
In a related piece of news from January 2022, the Hizkuntza Eskubideen Behatokia criticised a public job listing for a speech-language therapist vacancy where proficiency in Basque was not a compulsory requirement, but only an asset in obtaining the position. The organization underlined the importance of speech-language therapists’ proficiency in the local languages and emphasised that only treating the population in Spanish can lead to “misdiagnosis and/or under-diagnosis and limit the possibilities for greater functional rehabilitation”, reminding Osakidetza that its healthcare professionals should be able to treat patients in both Spanish and Basque.
The shortage of language therapists in the Basque Autonomous Community is a structural issue that can be partially attributed to the lack of training opportunities offered in the region. In fact, it was not until the current academic year (2024-25) that the University of the Basque Country started offering an undergraduate degree in Speech-Language Therapy. This means that all current speech-language pathologists have been trained in universities outside of the Basque Country.
This is also the case of Ane2 (aged 28), a speech therapist from the province of Gipuzkoa. Like all her colleagues, Ane had to pursue her degree outside of the Basque Country because it was the only option to study speech-language therapy. Although there are professional development and training opportunities targeting speech-language therapists in the Basque Country, only one course on Atypical Language Development in Bilingual Children that Ane could recall was offered in Basque. Most local professional development courses in her field were taught in Spanish. Having completed her degree, Ane now works in a private clinic in Tolosa, a municipality with a relatively high number of Basque speakers. Around 70 % of Ane’s clients wish to be treated in Basque:
There is a big demand for treatment in Basque […]. There are quite a few speech therapists in the area that work in Basque, but there are not enough of us to respond to the demand. I hope that now, with the possibility of studying for the undergraduate degree here, the number of speech-language therapists will go up […]. Let’s hope there will be more professionals, because anywhere you go the clinics are full.
Ane’s words are encouraging for minority-language speakers interested in pursuing a career in speech-language therapy. The newly offered Speech-Language Therapy degree with 40 available places is now taught in a multilingual mode, where certain obligatory courses are delivered in Basque, others in Spanish, and some in English. New opportunities for aspiring Basque-speaking therapists offer hope for Basque speakers in need of speech-language interventions. If all goes well, in less than four years from now, new speech-language therapists will be ready to deliver therapy in Basque, some of them hopefully providing their services within the public healthcare system.
Most of Ane’s clients are children with developmental speech and language disorders who are referred to her clinic through their schools or by a paediatrician, but sometimes it is the parents who take a proactive role. Just like persons with aphasia, children with speech, language, or reading disorders such as dyslexia also greatly benefit from early intervention. As Ane emphasizes: “An early diagnosis and treatment are very important: the child suffers less, and it is better for their self-esteem and their relationships.”
Nonetheless, childhood multilingualism, which is common for many minority-language speakers, can often complicate the diagnosis of language impairments. For example, language delays resulting from language disorders can resemble normal delays, which parents often mistakenly attribute to their child learning multiple languages simultaneously. This can lead to late diagnoses of language impairments. Moreover, multilingual children cannot be properly diagnosed with the same tools as their monolingual peers, as these tools were developed and normed on monolingual children. Thus, alternative measures are necessary for proper diagnosis in multilingual populations. As Ane also contests in this regard: “Bilingualism here is a big deal […]. Children with language difficulties need to handle two languages from the start and there is a lack of information in that regard […].”
Yet, the newly offered Speech-Language Therapy degree provided by the University of the Basque Country only offers a one-semester obligatory course on ‘Speech-Language Therapy in Multilingual Environments’ and a one-semester optional course on ‘Challenges in Multilingual and Multicultural Environments’. Considering the omnipresence of multilingualism in the Basque Autonomous Community, this leaves one wondering why the courses dedicated to the issues of multilingualism form such a marginal part of this eight-semester degree.
Conclusion
Despite Basque speakers’ right to medical interventions in their minority language, a general lack of access to speech-language therapy provided in Basque is a daily reality in the Basque Autonomous Community. Those who need such interventions will likely not receive them within the public healthcare system, where trained Basque-speaking speech-language pathologists are hard to find. This reality sharply contrasts with the fact that Basque-speaking therapists are deemed more suitable and appropriate for those who predominantly use Basque in their everyday communication.
Although the availability of healthcare services in an individual’s preferred regional or minority language is a key prerequisite to equitable clinical practices, it is certainly not the norm either for Basque speakers or for many other minority-language speaking groups, including Irish speakers in Ireland or Welsh speakers in Wales, regions facing a similar shortage of trained speech-language pathologists.
More initiatives across healthcare education programs targeting students pertaining to language minorities as well as course instructions offered in minority languages would certainly improve the situation. When developing the early-career options for minority language speakers and those interested in healthcare services in minority-language communities, courses on topics concerning multilingualism should be integrated as core parts of the curricula. Indeed, multilingual language acquisition and use, typical of many language minorities, have direct implications for language assessment and diagnosis. Improving resources and training in this area would enhance the quality of clinical interventions. The need for quality services for this vulnerable group is urgent, as minority language speakers have the same rights to quality healthcare services as everyone else.
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(1) The English translations of the Basque originals throughout this blog post were provided by the authors.
(2) Names of people interviewed for this post were pseudonymized.
