Column Editor: Holly Harris, MA
By Holly Harris, MA, Jacob Wolframe, PhD and Branka Agic, MD, PhD
The authors have engaged in generative conversations about the limits and politics of language typically used in health systems and associated education. We recognize that we live in and through words, and thus language constructs our realities (LeFrançois, Menzies, & Reaume, 2013). Language is rooted in complex histories, power hierarchies, and social structures, such as those present in health systems and education. Though language is often regarded as objective, and the political nature of language is often overlooked, “words can create barriers, misconceptions, stereotypes and labels that are difficult to overcome” (Vojak, 2008 as cited in Richards, 2018, p. 460). Critically analyzing the language we use can reveal and even challenge power structures (Ng and Deng, 2017). Although our practices will continue to evolve, here we share some approaches we have found helpful in informing language choices that challenge existing oppressive structures and are better aligned with the goal of actualizing more equitable and inclusive futures.
We use language as a tool to organize, categorize, simplify, and label the world around us. While the approach of simplification may seem appealing, it can inadvertently promote separateness, othering, and isolation, obscuring the rich diversity and nuances that exist within our social world. In pursuit of equity, diversity, and inclusion (EDI), we must recognize and consider the intersecting identities and factors that influence the ways in which people navigate the world.
Coined by Kimberlé Crenshaw in 1989 to describe how systems of oppression intersect and overlap to create distinct experiences of discrimination for people with multiple marginalized identities, intersectionality conceptualizes knowledge as situated, contextual, relational, and reflective of political and economic power (2018). Intersectionality “references the critical insight that race, class, gender, sexuality, ethnicity, nation, ability, and age operate not as unitary, mutually exclusive entities, but rather as reciprocally constructing phenomena” (Collins & Bilge, 2020, p. 1). While it may seem like intersectionality and the categorical nature of language are mutually exclusive, through discursive resistance and critical reflexivity, we can intentionally choose language that aligns with principles of EDI.
What is Discursive Resistance and Critical Reflexivity?
Through critical reflexivity, we can catalyze the evolution of language to reflect the intersectional and complex nature of the human experience. Critical reflexivity is the iterative process of examining, questioning, and challenging the underlying assumptions that shape our perceptions, interpretations, and actions (Norton & Sliep, 2018). By understanding the assumptions that underpin the language we use, we can choose language that better aligns with the values of equity and inclusion (Vojak, 2008).
Discourses are historically situated systems of knowledge and ideas that are mediated by and shaped through social structures and institutions, such as hospitals/health systems, education systems, or governments (Foucault, 1972; Young, 1981). Discursive resistance involves efforts to unpack and critically examine the discursive foundations behind a particular narrative, idea, phrase, or word. Unpacking the language we use and choosing to use language that comes from a place of resistance to harmful discourses is a subtle but powerful political act. In the following section, we provide practical questions that can be used as a guide to applying critical reflexivity to engage in discursive resistance by choosing language that aligns with EDI principles.
Questions to Consider
The origin of a particular term and its context are important to consider as language choice can signal affinity with a discourse: an institution or community, a philosophy, or a political stance (Foucault, 1972; Vojak, 2008). We may use different language than we would have chosen to use in the past to correspond with evolving understandings, norms, and values. We may also use language aspirationally, to reflect a direction we hope a discourse will shift towards, even if it is not there yet. We encourage readers to consider these questions as a framework when reflecting on your language choices in your work, and more broadly, your life. These are questions we, the authors, use in our own lives and work in health systems and health professions education and were developed based on our learned and lived expertise. As an example, as we move through these questions, we would like to use the term “equity deserving.”
1. Where does this term come from? What is the historical context?
Examining the origins of a particular term can provide insights into the historical and political ideologies that underpin it, thus allowing us to reflect on if the term is aligned with our current understandings of EDI. For example, the term “equity-deserving” has recently become popular in the EDI sphere in Canada. The term “equity deserving” is a revision to an earlier term “equity-seeking” proposed by Wisdom Tettey in his installation address as Vice President and Principal of University of Toronto Scarborough (Tettey 2019). The earlier term “equity-seeking” was introduced by Canadian governmental bodies and was defined in the context of public service staffing in the Public Service Employment Act (Government of Canada , 2022). The term “equity-seeking” was intended to emphasize the actions of groups fighting for equal access, social justice, and reparations (Government of Canada, 2022). Tettey critiqued equity-seeking for “perpetuat[ing] a perception of these groups as interlopers” and proposed equity-deserving as an alternative (Tettey, 2019). Equity-deserving has in turn been critiqued because everyone deserves equity, not just particular groups of people (Government of Canada, 2022). The most recent iteration of the term is “equity-denied” which is an improvement in that it puts the onus onto structures that work to disadvantage particular groups, rather than a deficit that inherently exists for these groups. We can see through the evolution of this term the way that the discourse around equity has gradually shifted over the past 20 years, and been reflected back into official government language.
2. Is there a term that better aligns with our vision of EDI?
We can apply critical reflexivity to offer intentionality the terms we choose to use to describe groups. Consistent with bias free language guidelines (American Psychological Association, 2020), we recommend being “appropriately specific”. Specific terms challenge the simplification and homogenization of diverse groups. For example, we should choose racialized people rather than equity-denied groups when our focus is on experiences and impact of racism as a social determinant of health.[1] We should choose Indigenous Peoples rather than racialized people when we are talking about the effects of racism, intergenerational trauma, ongoing colonialism, and land dispossession on Indigenous Peoples. Where relevant, it is best to name the particular Indigenous Peoples instead of using pan-Indigenous terminology to acknowledge the diverse and distinct Nations of Indigenous Peoples (Younging, 2018). While blanket terms can allow us to talk about commonalities across groups, such as experiencing similar negative effects on health, income, social connections, life expectancy, access to services, etc., as previously mentioned, they can also obscure important differences within and between groups.
3. Who does this word give power to? How does it reinforce or deconstruct harmful power imbalances? What does it problematize?
Carol Bacchi’s approach to policy analysis entitled “What is the Problem Represented to Be” can be useful in critically analyzing the language we use (Bacchi, 2009). This approach “starts from the premise that what one proposes to do about something reveals what one thinks is problematic (needs to change)” (Bacchi, 2012, p. 21). In individualistic societies (e.g. Canada, United States, United Kingdom, etc.), there is a tendency to problematize the individual rather than complex structural inequities (LeBlanc and Kinsella, 2016; Black, Pondugula and Spearman-McCarthy, 2022). Specifically, there is a tendency to assume that people are the source of the challenges and adversity they face, rather than these challenges being the product of interrelated social causes, structures, and/or relations (LeBlanc and Kinsella, 2016). By offering intentionality to our language choices, and being mindful of the intersections of different identities and experiences, we can choose terms that redirect responsibility from oppressed groups to oppressive structures. This is often met with resistance.
The attempt to use words with precision may involve using more words, or involve jargon, compromising readability. When pushing the boundaries of language, we may be told we need to be more concise. Feedback may also include that our language is too political or academic. This often occurs when the language being used falls outside of the accepted discourse. The lexicon we tend to use in the EDI sphere is that which has already made it into the dominant discourse: that used in legislation, government funding opportunities and initiatives, and disciplines like medicine or law. As an example, in EDI work, many use the term equity-denied rather than oppressed or structurally marginalized. Marginalization has trickled up into government language to some degree (Government of Canada, 2022), but in our experience, the language of oppression is often shied away from as too radical, too harsh, admitting too much, similar to the resistance to using the word genocide to describe what the Canadian state, in concert with other institutions, did to Indigenous Peoples (Talaga, 2019). By using the term “oppressed,” for example, we can elucidate the structural nature of the challenges that influence the experiences of the groups of people we are talking about. Oppression is prolonged unjust treatment; an exercise of control, power, or exploitation (Oxford University Press, 1989). It is a word that puts the onus on governments and institutions that create and/or perpetuate inequities. As such, it is political, and, in our experience, is often critiqued as such: “too political.” We suggest that there is value in being political: by naming oppression and/or marginalization, to putting the focus on structural forces, we are in a small way shifting the onus back onto the structures of power.
4. Can we demonstrate our commitment to ongoing learning and accountability?
As social and cultural values evolve, so must our understandings, and as such our language. Offering intentionality to our language choice based on the larger social vision of equity and inclusion is the first step. That must be followed up by a commitment to ongoing learning and accountability. By creating space to acknowledge that the language choices we have made in the past may no longer be reflective of our social vision, we can commit to a growth mindset. Accountability means in part being open to language that is new to us and exploring the roots and reasons for new terms when we learn of them. If they better fit the values we want to bring to the systems we work in, we can change our language. We do not have to cling to what is familiar as long as we use those new words in a way that gives other people an entry point into learning that language too.
Conclusion
Although discursive resistance is not without its challenges, it is essential in challenging social structures and systems that oppress people. Through critical reflexivity and discursive resistance, we can destabilize dominant oppressive structures, shape policies and practices, shift the balance of power in institutions, and in time, realize more equitable and inclusive futures.
Authors
Holly Harris, MA, is Research Coordinator, Education, Centre for Addiction and Mental Health (CAMH), Toronto, Canada
Branka Agic, MD, PhD, is Assistant Professor, Dalla Lana School of Public Health, University of Toronto and Department of Psychiatry, University of Toronto and Independent Scientist, Education,Centre for Addiction and Mental Health (CAMH), Toronto, Canada
Jacob Wolframe, PhD, is Health Equity Specialist, Provincial System Support Program, Centre for Addiction and Mental Health (CAMH), Toronto, Canada
References
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Bacchi, C. (2009). Analysing policy. Pearson Higher Education AU.
Bacchi, C. (2012) Introducing ‘What’s the Problem Represented to be?’ In Bletas, S., Beasley, C. (Eds) Engaging with Carol Bacchi: Strategic Interventions and Exchanges Adelaide: University of Adelaide Press, p.21-24.
Black, C., Pondugula, N. and Spearman-McCarthy, E.V. (2022) ‘Words Matter: Stylistic Writing Strategies for Racial Health Equity in Academic Medicine’, Journal of Racial and Ethnic Health Disparities, 9(6), 2071–2076. https://pubmed.ncbi.nlm.nih.gov/36251121/
Collins, P.H. and Bilge, S. (2020) Intersectionality. John Wiley & Sons.
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Murji, K., & Solomos, J. (2005). Racialization: Studies in Theory and Practice. Oxford University Press. https://play.google.com/store/books/details?id=INmP6-mdEccC
Foucault, M. (1972) The Archaeology of Knowledge and the Discourse on Language. Translated from the French by A. M. Sheridan Smith. Pantheon Books, New York.
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Appendix A
Positionality Table
| Holly Harris. I am a white, middle-class, cisgender woman, with graduate-level education born and raised on stolen land. I identify as someone who is neurodivergent and as a consumer/survivor of the psychiatric system. I am employed by a tertiary mental health care facility as a research coordinator and have been involved in peer support and patient-oriented research for six years. I leverage my lived experiences as a source of expertise to highlight the voices of those who have been historically silenced. I acknowledge that my lived and learned experiences influence the value I place on specific ideas. |
| Jacob Wolframe. I am a white, middle-class Settler living in Anemki Wiikwedong (Thunder Bay, ON) on the territory of the Anishinaabe people of Fort William First Nation. I am a queer non-binary trans person and an invisibly disabled psychiatric survivor. I hold a MA and PhD in English and Cultural Studies and a HBA in English and Women’s Studies. Over the past decade, I have worked in fundraising, research administration, and equity, diversity, and inclusion roles in non-profit, post-secondary education, and healthcare settings. The language and methodologies of my humanities background are often at odds with the institutional structures in which I work. I strive to bring them into conversation. |
| Branka Agic. I am a white, first-generation immigrant cisgender woman who came to Canada fleeing a war in my home country. I hold a MD and PhD in Health and Behavioral Sciences, and work as a scientist at a Canadian mental health research and teaching hospital. I recognize the significance of my personal experiences, social identities, and professional background in shaping my perspectives, biases, and privileges. I leverage my positionality to challenge systemic barriers, center marginalized voices, and work towards building a more equitable and inclusive society. I am committed to ongoing self-reflection and education to enhance my understanding of diverse experiences and perspectives. |
[1]The term racialized people refers to a group of people categorized according to physical features or ethnic characteristics, and who are discriminated against on that basis (Government of Canada, 2022). The terms racialized and racialization have been circulating in this sense since the 1970s (Murji and Solomos, 2005) and are useful because they highlight race as not a biological reality, but a historically contingent process, wherein a group of people are constructed as a social category (a race) or an individual is understood to be a member of that category (race) (Dalal, 2002; Crenshaw, 2018; Hochman, 2018). The term has been critiqued for various reasons, however, including that it is not well understood, that it conflates race and racism, and that it is too broad (Hochman, 2018).
