Inclusive Language for Medical Education and Qbanks: An Evolving Guide

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March 17, 2021
What is the definition of inclusive language? It’s language that makes people feel included—language that doesn’t discriminate based on a person’s race or ethnicity, sexuality, gender, ability, or socioeconomic status.

In medical education, the way we discuss patients (even hypothetical ones) matters because all learners deserve to feel seen, respected, and included. To address traditionally biased language in medicine, we have created this Inclusive Language Writing Guide for Medical Education and Qbanks to help keep our material consistent and respectful. This ever-evolving guide is available for anyone who finds it useful.

The important work of improving medical education is not going to happen overnight, but with our combined commitment to doing better, we can make a difference. And please reach out with any comments or suggestions—much of what is included here has come from updates released by major style guides and from YOU. Although old questions are continuously updated to address outdated wording, you may find something before we do!

Updated March 2021

Two basic principles have come out of creating the guide, no matter what you’re writing about:

  1. Be as specific as possible (e.g., NOT APPROPRIATE = foreign-born* and APPROPRIATE = from Nepal)
    *Foreign to who? Only you? Anyone in the US? What if your reader isn’t in the US? This is why being specific is important
  2. Only use details relevant to your topic (i.e., no need to bring up a point, like sexual orientation, if it has nothing to do with what you’re writing about)

It is important not to “other” (comparing groups to what you consider “normal”), so don’t use normal when describing the reverse of any of the categories listed below (e.g., normal vs disabled, transgender, gay), and be conscious of othering terms such as differently abled or at-risk.

Here are some of the resources the editing team referred to when creating these guidelines and inclusive language examples. Within the subsections outlined below, you’ll see links to more specific guides, as well:

18F Content Guide
The Diversity Style Guide
The Conscious Style Guide
Sum of Us: A Progressive’s Style Guide


Race and Ethnicity

There aren’t cohesive guidelines about how to use race in medicine (see this article in NEJM for some examples), and it’s a complex topic. On one hand, learners may need to know some common medical guidelines that involve race for the board exams. But on the other hand, these guidelines may be incorrectly equating race with issues that might be due to other factors. (Watch “The problem with race-based medicine,” a TED talk by Dorothy Roberts.)

To help highlight this, and in the hopes of teaching learners to think critically about how race is presented in medicine, we are starting to add this disclaimer in explanations where treatment may be affected by a patient’s race: 

The demographic information in the above explanation follows AMA Manual of Style terminology and may not match the language used in the references. Race is a social construct that is often correlated to certain medical conditions in the literature and evidence-based guidelines. Our hope is to inspire a change in the way race is used in the medical community.

Here are the basic principles we use when the team has decided race or ethnicity should be included in a discussion:

  • When more specific terms can’t be used, we prefer using American Indian, Asian American, Black, and White based on currently accepted wording in major style guides. Rather than the broad and oft-confused terms Latino and Hispanic, use specific descriptors (e.g., Colombian, Mexican American).

  • Any term referring to race or ethnicity should be used as an adjective, not a noun (e.g., White men, patient of Korean descent rather than Whites or a Korean/a Korean American), and they are capitalized and do not use hyphens when more than one word (e.g., not Mexican-American woman, per major style guides).

  • It is important to refer back to the original categories used in studies to determine their relevance (e.g., when estimating glomerular filtration rate, it is suggested to multiply by “1.210 if African American” at sites like this, but the original study uses “Black”). It may be prudent to mention what terms were used in the original data.

  • Do not use the terms nonwhite, Caucasian, Oriental, or Brown. Nonwhite indicates that White is the default and everything else is “other.” Caucasian and Oriental are both outdated terms: Caucasian is commonly used interchangeably with White but specifically refers to the Caucasus region in Eurasia, while Oriental exoticizes and stereotypes the “East” relative to Europe (Asian countries aren’t to the east of every other country). Brown is a nonspecific term that is commonly used in casual language, but it’s best to be specific when describing a person’s heritage.

Socioeconomic Status

Take care to avoid othering language or language that has a negative connotation, especially if it makes a person’s socioeconomic status sound permanent.

Instead of…

Use…

the homeless

people without housing, people experiencing homelessness

third-world, developing countries, poor, or unemployed

low-income, limited-income, resource-limited, resource-poor, or transitional

developed or first-world countries*

high-income, resource-rich, or industrialized

at-risk**

the specific descriptor being discussed

*Othering language works both ways (i.e., we don’t want to use “third-world” OR “first-world” countries, as first-world indicates there are other, lesser, countries). 

**See principle 1 about being specific—this term is vague in the sense of socioeconomic status. For example, if you write “at-risk youth are susceptible to self-harm,” what exactly makes these youth at risk? Be specific. Acceptable usage is “The woman is at risk for diabetes because it specifies what the risk is.

APA Guidelines for Socioeconomic Status


Sex and Gender

Avoid reinforcing gender stereotypes (female nurse vs male doctor, a mother always accompanying a child to doctor visits, assuming that all relationships are heterosexual)

  • fe/male = sex (biological classification), wo/man = gender (a person’s personal & social identity)
    Therefore, correct usage is transgender wo/man (not transgender fe/male)
    Note: a transgender woman was most likely assigned male at birth, and some use MTF (male-to-female), while a transgender man was most likely assigned female at birth, and some use FTM (female-to-male)
  • When applicable to acknowledge nonbinary gender identity or if sex or gender needs to be anonymous, is unknown, or can be used in nonpreferential general terms, use “they” as a singular pronoun

Instead of…

Use…

opposite sex

different sex

hermaphrodite

intersex

gender-neutral

nonbinary, gender nonconforming

born a boy/girl, biologically fe/male

assigned fe/male at birth

sex change, sex reassignment surgery

gender confirmation surgery

normal

cisgender

identifies as a wo/man or nonbinary

is a wo/man or nonbinary


Sexuality

Use the language that a person or group prefers (e.g., some may consider “queer” offensive while others identify as queer).

  • Do not use nonstraight, homosexual, or queer (unless this is how a person or group refers to themselves)
  • Use sexual orientation, not sexual preference, lifestyle choice, or sexual identity
  • Unless knowing a patient’s sexual orientation is necessary to understanding something about them, referring to their spouse or partner is preferred to terms like husband, wife, boyfriend, or girlfriend
  • Wo/men who have sex with wo/men is acceptable terminology when discussing behavior
  • Instead of identifying sexuality (e.g., gay man), it might be better to describe their partner (e.g., has a male sexual partner)—think about principle 2: what is important to the topic?

GLAAD Media Reference Guide


Disability

As with other categories, avoid othering language, and use the language that a person or group prefers.

  • Most of the time, person-first language is preferred, but some people (including many in the Autistic and Deaf communities) prefer identity-first language because they feel the identity is an inherent part of their being
    • person-first: man with diabetes
    • identity-first: autistic man
  • Beware of othering language that implies 100% healthy is normal (e.g., “differently abled”—different from what?)

Instead of…

Use…

differently abled, challenged, handicap(ped)

disabled

normal, able-bodied

without disabilities

suffers from, is a victim of, is afflicted by [disorder, disability, disease]

has [disorder, disability, disease]

wheelchair-bound, confined to a wheelchair

uses a wheelchair

mental retardation

intellectual disability, developmental disability

obese patient

patient with a history of obesity, who is obese, with elevated BMI, with obesity

substance abuse

substance use, substance use disorder

alcoholism

alcohol use disorder, chronic alcohol use, excessive alcohol use

alcoholic

patient with alcohol use disorder, person who excessively uses alcohol

National Center on Disability & Journalism’s Disability Language Style Guide
APA Guidelines for Nonhandicapping Language


Other Terms

Some things don’t fall neatly into categories, and as you may have noticed, language is full of exceptions. Here are some other outdated terms and their suggested replacements.

Instead of…

Use…

provider*

clinician

prostitute

sex worker

elderly, senior, aged, geriatric

older, age range (e.g., patients ≥ 65 years)

admits (e.g., patient admits to drinking two glasses of wine per day)

reports (e.g., patient reports he drinks two glasses of wine per day)

denies

reports no

patient failed [treatment]

patient refractory to, who did not improve from, who didn’t respond to, did not derive benefit from [treatment]

noncompliant [with medication]

discontinued the medication [due to…]

committed/completed suicide

died due to suicide

un/successful suicide

suicide attempt/death

*There are a few reasons this term is problematic. As with most topics, it’s better to be specific.

Please reach out with any questions, comments, or suggestions!

Adam Rosh, Melinda Campbell, & Laura Wilkinson


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