AMA Manual of Style - Stacy L. Christiansen, Cheryl Iverson 2020

Inclusive Language
Correct and Preferred Usage

Any classification according to a singular identity polarizes people in a particular way, but if we take note of the fact that we have many different identities . . . we can see that the polarization of one can be resisted by a fuller picture. So knowledge and understanding are extremely important to fight against singular polarization.

Amartya Sen²³

Avoid the use of language that imparts bias against persons or groups on the basis of gender or sex, race or ethnicity, age, physical or mental disability, or sexual orientation. Avoid generalizations (such as minorities) and stereotypes and be specific when choosing words to describe people.

Note: Avoid using “non-” (eg, “white and nonwhite participants”), which is a nonspecific “convenience” grouping and label. Such a category may be oversimplified and misleading, even incorrect. Occasionally, however, these are categorizations used for comparison in data analysis. In such cases, the author should be queried. Multiracial and people of color are sometimes used in part to address the heterogeneous ethnic background of many people.

11.12.1 Sex/Gender.

Sex refers to the biological characteristics of males and females. Gender includes more than sex and serves as a cultural indicator of a person’s personal and social identity. An important consideration when referring to sex is the level of specificity required: specify sex when it is relevant. In research articles, sex/gender should be reported and defined, and how sex/gender was assessed should be described.¹⁵ In nonresearch reports, choose sex-neutral terms that avoid bias, suit the material under discussion, and do not intrude on the reader’s attention (see 11.7, Age and Sex Referents).

Note: Use man or men when referring to a specific man or group of men and woman or women when referring to a specific woman or a group of women. Similarly, chairman or spokesman might be used if the person under discussion is a man and chairwoman or spokeswoman if the person is a woman. Any of these might be used in an official title, for example, Michele Smith, alderman of the 43rd Ward, City of Chicago.

Do not attempt to change all words with man to person (eg, manhole). If possible, choose a sex-neutral equivalent such as sewer hole or utility access hole.

Terms such as physician, nurse, and scientist are sex-neutral and do not require modification (eg, female physician, male nurse) unless the sex of the person or persons described is relevant to the discussion (eg, a study of only female physicians or male nurses).

After completing internship, the physician specialized in emergency medicine and worked at several hospitals in California. She was selected as an astronaut candidate by NASA in 2007.

11.12.1.1 Presenting Data in Tables.

When reporting the sex of participants in a table, include both sexes, as defined in the study, regardless of ratio. Do not use “white” and “male” as the default. When reporting on racial and ethnic differences, be as specific as possible (even if these comprise a small percentage of participants). Define the participants who are in the “other” category (see 4.1.2, Organizing Information in Tables).

11.12.2 Personal Pronouns.

Avoid sex-specific pronouns in cases in which sex specificity is irrelevant. Do not use common-gender “pronouns” (eg, “s/he,” “shem,” “shim”). Reword the sentence to use a singular or plural non—sex-specific pronoun, neutral noun equivalent, or change of voice; or use “he or she” (“him or her,” “his or her[s],” “they or their[s]”). The use of the “singular they” construction is permitted when rewriting would be awkward or unclear (see 7.2.3.2, Pronoun-Pronoun Agreement).

11.12.3 Race/Ethnicity.

Race is defined as “a category of humankind that shares certain distinctive physical traits.”²⁴ Ethnicity relates to “groups of people classed according to common racial, national, tribal, religious, linguistic, or cultural origin or background.”²⁴

Similar to gender, race and ethnicity are cultural constructs, but they can have biological implications. Caution must be used when the race concept is described in health-related research. Some have argued that the race concept should be abandoned, based on the scientific evidence that human races do not exist per se. Others argue for retaining the term race but limiting its application to the social, as opposed to the biological, realm.

A person’s genetic heritage can convey certain biological and therefore medically related predispositions (eg, cystic fibrosis in persons of Northern European descent, lactose intolerance in persons with Chinese or Japanese ancestry, Tay-Sachs disease in persons with Jewish Eastern European ancestry, sickle cell disease seen primarily in persons of West African descent).

Specifying the race or ethnicity of a person can provide information about the generalizability of the results of a specific study. However, because many people in ethnically diverse countries, such as the United States, Canada, and some European, South American, and Asian nations, have mixed heritage, a racial or ethnic distinction should not be considered absolute, and it is often based on a person’s self-designation.

The JAMA Network journals include the following direction in their Instructions for Authors:

Aggregate, deidentified demographic information (eg, age, sex, race/ethnicity, and socioeconomic indicators) should be reported for all research reports and systematic reviews along with all prespecified outcomes. All demographic variables assessed should be reported in the Methods section. All demographic information collected should be reported in the Results section, either in the main article and/or in an online supplement. If any demographic characteristics that were collected are not reported, this should be explained. Summary demographic information (eg, baseline characteristics of study participants) should be reported in the first line of the Results section of Abstracts.

An explanation of who classified individuals as to race, ethnicity, or both, the classifications used, and whether the options were defined by the investigator or the participant should be included in the Methods section. The reasons that race/ethnicity was assessed in the study also should be described in the Methods section. Race/ethnicity of the study population should be reported in the Results section.

Methods

Study Population, Baseline Survey, and Resurvey

The design and methods of the China Kadoorie Biobank (CKB) study have been reported in detail elsewhere.^26,27 Overall, 512 891 adults aged 30 to 79 years were enrolled from June 25, 2004, through July 15, 2008, from 5 rural and 5 urban areas in China. The CKB participants were confirmed to be of Chinese ancestry based on findings of principal component analysis of genotyping data, where available. The baseline survey included a detailed questionnaire and physical measurements (including anthropometry and blood pressure).

Methods

Self-reported Race

Individuals were categorized as African American or non—African American. Children’s race was based on the parent’s report.

Methods

Study Populations

Three National Health and Nutrition Examination Survey (NHANES)¹⁷ cross-sectional samples (2007-2008, 2009-2010, and 2011-2012) were used to characterize the ages (range, 8-80 years) at which self-reported African American (n = 4973), white American (n = 8886), and Mexican American (n = 3888) populations transitioned between ideal blood pressure, prehypertension, and hypertension across the life course. This analysis began in September 2014 and was completed in November 2015. Participants who had a physical limitation on both arms (eg, rashes, casts, or edema) that prevented measurement of blood pressure were excluded. We also excluded non-Hispanic Asian, other Hispanic, and other race/ethnicity (including multiracial/multiethnic) because of small sample sizes. Demographic and health information collected in the study¹⁷ followed appropriate procedures for written informed consent, and the study was approved by local institutional review boards.

When mention of race or ethnicity is relevant to an understanding of scientific information, be sensitive to the designations that individuals or groups prefer. Be aware also that preferences may change and that individuals within a group may disagree about the most appropriate designation. For terms such as white, black, and African American, manuscript editors should follow usage (although Caucasian is sometimes used to indicate white but is technically specific to people from the Caucasus region in Eurasia and thus should be avoided).

In the United States, the term African American may be preferred to black (note, however, that this term should be allowed only for US citizens of African descent). A hyphen is not used in either the noun or adjectival form (see, 8.3.1.6, When Not to Use Hyphens).

In reference to persons indigenous to North America (and their descendants), American Indian is generally preferred to the broader term Native American, which is also acceptable but includes (by US government designation) Hawaiian, Samoan, Guamanian, and Alaskan natives. Whenever possible, specify the nation or peoples (eg, Navajo, Nez Perce, Iroquois, Inuit).

Hispanic and Latino are broad terms that may be used to designate Spanish-speaking persons as well as those descended from the Spanish-speaking people of Mexico, South and Central America, and the Caribbean. However, the terms are not interchangeable because Latino is understood by some to exclude those of Mexican or Caribbean ancestry. In either case, these terms should not be used in noun form, and when possible, a more specific term (eg, Mexican, Mexican American, Latin American, Cuban, Cuban American, Puerto Rican) should be used.

Similarly, Asian persons may wish to be described according to their country or geographic area of origin (eg, Chinese, Indian, Japanese, Sri Lankan). Note that Asian and Asian American (Chinese, Chinese American, and so on) are not equivalent or interchangeable.

11.12.4 Age.

Discrimination based on age (young or old) is ageism. Because terms like seniors, elderly, the aged, aging dependents, old-old, young-old, and similar "other-ing" terms connote a stereotype, avoid using them. Terms such as older persons, older people, older adults, older patients, older individuals, persons 65 years and older, or the older population are preferred. Use older adults, a term less likely to connote discrimination and negative stereotypes, when describing individuals 65 years old and older.

Note: In studies that involve human beings, age should always be given specifically (eg, “older people aged 75 to 84 years” or “children younger than 12 years”) (see 11.7, Age and Sex Referents).

Adultism is a form of ageism in which children and adolescents are discounted.^25,26

11.12.5 Socioeconomic Status.

Avoid labeling people with their socioeconomic status, such as the poor or the unemployed. Instead, terms such as low income and no income are preferred. See also limited-income, low-income, resource-limited, resource poor, transitional.

11.12.6 Terms for Persons With Diseases, Disorders, or Disabilities.

Avoid labeling (and thus equating) people with their disabilities or diseases (eg, the blind, schizophrenics, epileptics). Instead, put the person first. Avoid describing persons as victims or with other emotional terms that suggest helplessness (afflicted with, suffering from, stricken with, maimed). Avoid euphemistic descriptors, such as physically challenged, special, or special needs.

Avoid metaphors that may be inappropriate or insensitive and do not translate well (blind to the truth, deaf to the request). For similar reasons, some publications avoid the term double-blind when referring to a study’s methods.

Note: Some manuscripts use certain phrases many times, and changing, for example, “AIDS patients” to “persons with AIDS” at every occurrence may result in awkward and stilted text. In such cases, the adjectival form may be used, although this is not preferred.

11.12.7 Sexual Orientation.

Sexual orientation should be indicated in a manuscript only when scientifically relevant. The term sexual preference should be avoided because it implies a voluntary choice of sexual orientation not supported by the scientific literature. In some contexts, reference to specific sexual behaviors (eg, men who have sex with men) may be more relevant than sexual orientation.

The nouns lesbians and gay men are preferred to the broader term homosexuals when referring to specific groups. Avoid using gay or gays as a noun. Heterosexual, homosexual, bisexual, asexual, and intersex may be used as adjectives (eg, heterosexual men).

A member of a heterosexual or homosexual couple may be referred to as spouse, companion, partner, or life partner. Same-sex couple and same-sex marriage are appropriate terms.

See also LGBTQAI in 13.0 Abbreviations, the GLAAD Reference Guide-Transgender Issues website,¹⁶ and the Gender Equity Resource Center website.¹⁷

Principal Authors: Tracy Frey, BA, and Roxanne K. Young, ELS

Acknowledgment

Thanks to the following for reviewing and providing comments to improve the manuscript: Helene M. Cole, MD, formerly of JAMA; Gabriel Dietz, MA, JAMA Network; Barbara Gastel, MD, MPH, Texas A&M University, College Station; Julie Gerke, ELS, IQVIA, Parsippany, New Jersey; Carissa Gilman, MA, American Cancer Society, Atlanta, Georgia; Emily A. Greenhow, JAMA; Trevor Lane, MA, DPhil, Edanz Group, Fukuoka, Japan; and Peter J. Olson, ELS, Sheridan Journal Services, Waterbury, Vermont.

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