Breaking down binaries: The imperative of change

Abstract

For International Women's Day (IWD) 2025, Wiley created a multi-journal special issue titled Gender Equity in Health Care. Medical Education was invited to participate resulting in a collection of papers, in this issue, that deal with gender equity in health professions education.^1-5 Unsurprisingly, these papers show persistent, and in some cases increasing, unequal power distributions and gender-based discrimination within medicine. My aim in this editorial is not to repeat all the ways in which we are failing—you can read the papers. Instead, building on this year's IWD 2025 theme of Accelerate Action, I wish to call for action in the form of more critical and participatory research that seeks change and upends binaries and binary thinking.

In 2010, Regehr⁶ published an influential paper called ‘It's not rocket science’, arguing that health professions education research is more complex than rocket science that relies on structured, linear systems and identifiable factors. He suggested that the metaphor of the natural sciences—and associated ideas such as objectivity and simplicity—was no longer serving the field, as it legitimised what constituted good research in health professions education in unhelpful ways. He urged researchers to shift from an imperative of proof (a narrowly defined search for ‘evidence’) to an imperative of understanding where researchers explore education-related phenomena in their natural setting.⁶ He also argued that we needed to become more comfortable with complexity.

Regehr's paper was influential. It is still a key paper for graduate students who come to our field particularly from the health professions and the natural sciences where evidence, proof and objectivity are the common research frames. Given the persistence of hierarchical gendered systems demonstrated in the collection of papers in this issue, I have increasingly been contemplating the need for another shift in how we conceptualise research—towards an imperative of change. This demands that the goal of our research is not only to understand and reframe phenomena but to change practice and avoid binary oppositions. Binary thinking can reinforce inequities in its oversimplification of identities, marginalising those who do not fit into those categories and upholding power structures that benefit dominant groups.

Rather than viewing knowledge as representative of a natural world out there, we might instead see it as a set of relations. It is not only that we as researchers are always in relation (to the topic, the methods, the participants, etc.), but also knowledge itself is relational. It does not exist solely in the minds of individuals to be filled, acquired and critiqued, but knowledge emerges through interconnections and is shaped by relationships. Respect, reciprocity and responsibility are crucial to relationships (research and otherwise) and underpin action.

When framing research as imperative of change, then relationality is key because ‘relational thinking conceives of agency as being a distributed effect of different actors, instead of being situated in one human actor solely’ (p. 31).⁷ A relational view lends us a different perspective on what it means to be critical. Rather than assuming the dispassionate and critical outside observer role, striving to debunk and unveil, a relational critique is situated in the ability to intervene and to do so from the perspective of being engaged and with care.⁸ In other words, rather than adopting a disinterested and external gaze to objectify the natural world, in a relational vein, the researcher is equally part of the world and takes up an active role.⁷ Therefore, we relate to the research in an engaged and caring way moving towards new practices and improvement.⁹

Relationality also challenges typical binary thinking about the researcher's role, particularly the ‘insider’/‘outsider’ artificial divide that we ascribe to when we consider our role in research. Wilson¹⁰ in his book titled Research is Ceremony speaks to relational accountability—being accountable to your relations—as the foundation of Indigenous methodologies. Indigenous scholars propose that we are always both by virtue of the complex, multilayered relationships we hold with participants¹¹; participants relate to us by virtue of any number of identities, which cannot be separated and left at the door. Rix,¹¹ reflecting on her role as a researcher, nurse, wife and white woman and in relation with her Indigenous participants, notes: ‘Separating my roles and positioning myself was less important than what resulted from my involvement and interaction with the research and how effective I was as a research “instrument”’ (p. 6). I am reminded of Haraway¹² noting that ‘all drawings of inside-outside boundaries in knowledge are theorized as power moves, not moves toward truth’ (p. 576). By avoiding binaries such as insider and outsider, we might be able to be more reflexive of how our multiple identities are always in relation with the research and the participants. It allows us to relate to participants differently, to be more generous and reciprocal in sharing. This is necessary for imperative of change research.

Imperative of change research is action oriented and critical. It locates within the critical paradigm, which seeks to change systems of socio-political power through collaboration with community. One research practice that offers considerable promise is participatory approaches that seek to include and benefit people who inhabit particular contexts.¹³ Participatory action research has a long and proud history in education and is a good example of the sort of critical paradigm research I am calling for here. It aims at changing ‘practitioners' practices, their understandings of their practices, and the conditions in which they practise’¹⁴ (p. 463; original emphasis). A key underpinning of participatory action research is that it is done collectively. ‘Decisions about what to explore and what to change are taken collectively’ leading to individual and collective transformation.¹⁴ Some decolonising and Indigenous methodologies also belong within the participatory research umbrella. Alternately, researchers might wish to lean into feminist and new materialist thinking, fundamentally relational and often driven by social justice imperatives, it allows us to move beyond binaries and consider how knowing, being and choosing cannot be disentangled.¹⁵

With this editorial, I hope to prompt health professions education researchers towards critical research that opposes binaries and changes practices for the benefit of those involved. Naidu² notes that health professions education research must look beyond dominant epistemic frameworks to use decolonial, indigenous epistemologies to research gender and gender inequity. These approaches she argues ‘invite understanding of gender not as static and categorical but as a dynamic multiplicity, where gender fluidity is the norm rather than an alternative’ (p. 1036). Common to the papers in this issue is the need to problematise and challenge gender binaries that entrench inequity—thus, to be committed to partiality and fluidity.¹² Whereas our current dominant research frameworks in health professions education have served us well, it might be time for change.