In October, President Biden formally apologized for the U.S. Indian boarding school system—a brutal legacy of forced assimilation that inflicted profound harm on Indigenous communities and continues to reverberate today. For those who are unfamiliar, Native children at these boarding schools suffered horrific physical, mental, emotional, and sexual abuse, all while being isolated from their families and communities. By 1926, nearly 83 percent of Native children were attending these schools. The purpose of the Indian Boarding School Policy was explicitly to “Kill the Indian in him, and save the man.” To this end, Native children were often starved or brutally punished for speaking their Native languages. The abduction and forced assimilation of children also impacted families by erasing culture and connection, depriving families of healthy and happy relationships within the community. The trauma inflicted has affected Native communities for generations and continues to be passed on to this day.

As a Native American medical student, I come from a long line of Indigenous women shaped—and often scarred—by the systems and policies forced upon us. When I heard this apology, I thought first of them. I thought of my great-great-grandmother, Cordelia, who spoke fluent Konkow, carried stories and songs of our people, and knew our ancestral lands intimately. I thought of her daughter, my great-grandmother Mary, who wore the stark white dress and stockings of the boarding schools, speaking less of our language and learning to tread cautiously around her culture. I thought of my grandmother, Judy, who entered public school in San Francisco, where Konkow was completely replaced by English and a sense of alienation. I thought of all of my relatives who never made it out of the boarding school era alive and those still living today with the mental and biological impacts of this intergenerational trauma.

– Madison Esposito reflects on the multigenerational impacts of these policies.

Intergenerational trauma refers to the transmission of the physical, mental, and emotional effects of trauma across generations, whereby descendants of individuals who experienced historical and current traumas have significant health impacts and worse health outcomes. For Indigenous communities, the impacts of forced assimilation, land loss and displacement, cultural erasure, and systemic discrimination have created and perpetuated transmission of intergenerational trauma, resulting in the disproportionate burden of chronic diseases such as diabetes, heart disease, infectious diseases, substance use, mental health disorders, and suicide. Native communities have longstanding and well-established Indigenous knowledge on the individual and community impacts of trauma, including the biological manifestation of intergenerational trauma and its transmission to future generations. Western research is catching up in studying and understanding the mechanisms behind the generational transmission of trauma, including the epigenome and how epigenetic changes are transmitted during the prenatal period. Research has linked epigenetic processes with mental and behavioral conditions, cancer, immune system deficiencies, and chronic diseases.

To be clear, these molecular findings are not meant to be understood as implicit, inalienable, or personal defects of the individual. A recent study showed an association between historical trauma in Alaska Native peoples with different patterns of gene methylation, while also demonstrating a protective effect related to cultural identification and general well-being. It is crucial to recognize the importance of cultural connection and identity in the overall health and well-being of AI/AN people, especially within the context of historical injustices that continue to profoundly impact communities. Despite changes in the expression of our genes due to trauma, Indigenous well-being can still flourish with connection to Indigenous ways of knowing and culture. It is in this type of connection that we need to focus our interventions and care practices as future and current physicians working with Native patients.

We can accomplish this change through medical education, where providers can learn to respond not only to acute illnesses but also to the deep-seated, trauma-based health disparities Native communities face. The current default in the medical curriculum of reducing Native identity to a “risk factor” without any recognition of the root causes of these health disparities is not acceptable. This lack of understanding in medicine makes it harder for Native patients to find compassionate, informed care and contributes to the staggering levels of distrust Native people feel toward health care. To meet the needs of Native patients effectively, medical professionals must understand intergenerational trauma’s unique and pervasive impact on Native health.

Integrate intergenerational trauma into medical education

As intergenerational trauma manifestation is multifactorial and spans different aspects of a patient’s health, it is crucial for providers to understand the biological basis of trauma transmission and disease manifestation, such that treatment regimens can be directed toward addressing it. Providing education in the context of Indigenous history—such as the boarding school era and Indian Relocation Act—provides critical context that connects history to current health outcomes. This could include case studies, workshops, and discussions that focus on a holistic approach to health and disease, looking beyond immediate presentation and focusing on long-term prevention and healing.

Expand the concept of trauma-informed care

Trauma-informed care is becoming a standard approach in health care but is limited by superficial ideas of trauma and the lack of experience and representation from members of marginalized communities. This means not only recognizing the patient’s trauma but also understanding the cultural and historical factors that shape it. For Indigenous patients, trauma-informed care should include knowledge of Tribal history (political disempowerment, identity loss, and genocide), cultural practices, and the systemic factors that contribute to health disparities. This can be accomplished through community-based participatory research, upholding Tribal sovereignty in research initiatives, and consulting with Tribal public health authorities. Providers who understand these factors are better equipped to build trust, communicate effectively, and avoid unintentionally retraumatizing patients.

Promote cultural sensitivity and collaboration

Respecting a patient’s cultural background isn’t just polite—it’s crucial for effective treatment and developing a therapeutic alliance. Medical professionals should engage with Indigenous communities, listening to their perspectives on health, healing, and wellness. Working in collaboration with Tribal health organizations or cultural liaisons can provide insight that enriches the patient-provider relationship. By integrating cultural knowledge into treatment plans, providers can create a safe and supportive environment for Indigenous patients.

Encourage lifelong learning and humility

Providers should approach Indigenous patients with an open mind and a willingness to learn. Intergenerational trauma is complex and doesn’t look the same in every patient. Some may display resilience, while others may struggle with mental health or physical illnesses linked to trauma. Medical education should ideally instill the value of humility in health care, teaching providers that they may not have all the answers and that the best care comes from working collaboratively with patients and communities. It may seem daunting to ask for this information, and many providers may be overwhelmed with how to even start learning about the Native communities they serve, but there is a wealth of Indigenous organizations ready to help and collaborate with anyone interested in learning more about the Native experience within the U.S. Most, if not all, have websites that can be quickly found with a simple web search.

An apology from President Biden is the first step in recognizing the traumas inflicted on Native people. However, it is equally important to move beyond apologies and take action. Despite investigations through the Federal Indian Boarding School Initiative, little has been done in the health care sphere to address the long-term implications on AI/AN health outcomes. As Native people experience high burdens of chronic disease and significantly decreased life spans compared to the national average, it is essential for health care to recognize the burden of intergenerational trauma on their patients and work toward treatment options and risk reduction, including efforts to reduce the emotional suffering experienced by Indigenous people. This is the first step in ensuring that Indigenous patients receive equitable, compassionate, and informed care that acknowledges the deep historical and current sociopolitical factors fostering mistrust in medical systems. Words cannot undo the lasting impacts of boarding schools on generations of Native peoples and cannot mend what has been stolen from us. Healing requires action. Our health care system can provide that action, not only as a system of power that has its own history with Native peoples but as a system that can address how intergenerational trauma shapes the health and well-being of Native communities. It is long overdue for both undergraduate and continuing medical education to take responsibility and work toward building trust and providing equitable care to the original peoples of the lands they live on.

Madison L. Esposito and Katlin T. Wilson are medical students.