Inclusive Language for Medical & Health Education: An Evolving Guide

What is 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, age, ability, or socioeconomic status.

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

After reading, if you’re ready to test what you’ve learned, check out the free Quiz for a Cause: Inclusive Language in Medical Education in your Rosh Review Boost Exams box.

Take the free Inclusive Language Quiz:

1. Create a free account (existing users can skip this step).
2. Add the exam in the Boost Exams box (or here).
3. In your dashboard, click My Exams > Boost Exams.
4. Start the 26-question quiz!

The important work of improving health care education and patient interactions 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 current best practices from expert clinicians and advocacy groups, updates released by major style guides, and YOU. Although old questions are continuously updated to address outdated wording, you may find something before we do!

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Updated September 2023

This guide was originally created to address language used in Qbanks (i.e., regarding hypothetical patients), but conscientious wording is also essential in patient interactions and medical records. But keep this in mind: these guidelines will not pertain to every patient and every medical scenario, as individuals may have their own preferences about the language they use to refer to themselves or their loved ones. Often, the best solution is to directly ask the patient for their preferred terms.

Three basic principles have come out of creating the guide, no matter what you’re discussing:

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? This is why being specific is important
   
   
2. Only use relevant details (i.e., no need to bring up a point, like sexual orientation, if it has nothing to do with what you’re discussing, like Lyme disease)
   
   
3. When interacting with patients, never make assumptions; always elicit the pertinent information, whether it is a patient’s desired gender-affirming interventions or their decision to fast for Ramadan

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. 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

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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, some common medical guidelines involve race, which may be important to know 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, like social determinants of health (SDOH). (Watch “The problem with race-based medicine,” a TED talk by Dorothy Roberts.)

SDOH include conditions of birth and living that influence health, such as politics, socioeconomic status, and access to health care, education, safe environments, and nutritious food.

To help highlight this, and in the hopes of teaching learners to think critically about how race is presented in medicine, we 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 the Qbank:

• 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, we aim to 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). The hyphen can denote otherness by showing equal weight between the two terms (i.e., Mexican-American indicates the person is Mexican and is also American). Leaving the term open (no hyphen) shows that Mexican is an adjective describing American, so the person is an American who has Mexican ancestry.
• 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.
  • 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.

But remember, individual patients may have their own preferences about the language they identify with. For example, while the editing team chooses to use specific language such as Mexican American to refer to a hypothetical patient in the Qbank, an actual patient may identify as Hispanic, Latina/e/o/x, Chicana/e/o/x, etc.

JAMA Inclusive Language for Reporting Demographic and Clinical Characteristics

NEJM Catalyst Social Determinants of Health

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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
the poor, the unemployed	person with low income, with no income, who is not currently employed
third-world, developing countries	low-income, limited-income, resource-limited, resource-poor, transitional
first-world*, developed, Western** countries/world	high-income, resource-rich, 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).

**Western is traditionally code for predominantly White countries that were originally colonized by European countries. Try to be more specific about what you’re truly trying to say.

***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—economics, exposure to violence, poor nutrition, another factor? Be specific, such as “Youth residing in foster care are at higher risk of [or have higher rates of] self-harm compared to youth in the general population.” This specifies the factor that puts these individuals at risk.

APA Guidelines for Socioeconomic Status

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Sex and Gender

In Qbanks and other hypothetical content, 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 and social identity)

• Therefore, correct usage is transgender wo/man (not transgender fe/male)
  • Note: transgender is an umbrella term that is not limited to binary sex and gender. Some terms you may encounter in materials about transgender individuals and when interacting with patients include MTF (male-to-female), indicating a transgender woman who was assigned male at birth, and FTM (female-to-male), indicating a transgender man who was assigned female at birth. However, these terms still focus on the binary of male and female, so some consider them outdated.
• When applicable to acknowledge nonbinary gender identity or if sex or gender needs to be anonymous, is unknown, or can be used in general terms, use “they” as a singular pronoun
• Whether through hormone therapy, surgery, or another means, people of all genders (e.g., man, woman, nonbinary, cisgender, transgender) seek gender-affirming care to align their personal or perceived societal expectations of their gender.

Instead of…	Use…
opposite sex	different sex
hermaphrodite	intersex
gender-neutral (to refer to person or population)	nonbinary, gender diverse
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, nonbinary	is a wo/man, nonbinary

Clinicians should be familiar with community resources where they can refer transgender patients for any care that can’t be obtained in the office and should also familiarize themselves with the unique physical and mental health care needs of transgender patients. 

UCSF Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People

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Sexuality

A person’s sexual orientation describes who they are romantically, physically, or emotionally attracted to. It is separate from one’s gender identity, which is how a person sees themself (e.g., transgender, nonbinary, cisgender). Defer to the language that a person or group prefers. For example, 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 themself)
• Use sexual orientation not sexual preference, lifestyle choice, or sexual identity
• In hypothetical situations, unless knowing a patient’s sexual orientation is necessary to understanding something about them, referring to their spouse or partner is preferred to husband, wife, boyfriend, or girlfriend
  • In clinical situations, nonbinary language (spouse, partner) is appropriate when the sex or gender of a patient’s partner is unknown
• 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? Does it matter whether the patient is gay, straight, or bisexual or what behaviors they engage in (e.g., sex with partners of the same or a different sex)? For example, if you’re working in STI prevention, a patient’s sexual behavior is likely the most important information; if you’re working with an adolescent, their sexual attraction may be pertinent; and if you’re doing public health work, patients’ sexual identity may be most relevant

GLAAD Media Reference Guide

Collecting Sexual Orientation and Gender Identity Data in Electronic Health Records

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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.
  Tip: look for words that end in -ism, -ic, -ict, -ee, and -ed (e.g., alcoholism, quadriplegic, addict, amputee, disfigured) and switch to person-first language
  • person-first: man with diabetes; person with an amputation
  • identity-first: autistic man
    
• Beware of othering language that implies 100% healthy is normal (e.g., “differently abled”—different from what?)
  
• Avoid stigmatizing and labeling language

Instead of…	Use…
differently abled, challenged, handicap(ped), special needs	disabled, functional needs (depending on context)
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	developmental disability, intellectual developmental disorder
obese/overweight patient	patient with a history of obesity, with obesity/overweight, with elevated BMI, with a BMI of [X] (for adults)
addict	patient who is addicted to [X]
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
clean/dirty drug test results	positive/negative
clean [meaning abstinent from drugs]	never used, no longer using [X]
rehab	treatment, treatment center
insane asylum	psychiatric hospital
[patient] is [bipolar, schizophrenic,…]	[patient] has, with [bipolar disorder, schizophrenia,…]
amputee	patient with an amputation
invalid	patient with a chronic medical condition
vegetable	in a nonresponsive state, comatose

National Center on Disability & Journalism’s Disability Language Style Guide
APA Guidelines for Nonhandicapping Language
NIDA Preferred Language for Talking About Addiction

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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, be specific (e.g., physician, PA, NP)
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
complains/complaining of	has, notes, reports
chief complaint	chief concern
patient failed [treatment]	patient refractory to, who did not improve from, who didn’t respond to, did not derive benefit from [treatment]
patient management	management of [condition]**
noncompliant [with medication]	discontinued the medication [due to…]
committed/completed suicide	died by/due to suicide
un/successful suicide	suicide attempt/suicide
doesn’t speak English***	has limited English proficiency, requires/prefers assistance in [language], requires an interpreter
smoker (e.g., patient is a smoker)	smokes (e.g., patient smokes cigarettes)
drug user (e.g., patient is an IV drug user)	uses drugs (e.g., patient uses IV drugs)

*There are a few reasons this term is problematic. As with most topics, it’s better to be specific.
**The disease or condition is managed. Patients are cared for/treated.
***It is important to remember that proficiency may decrease when sick or scared. Also, be sure not to assume or generalize their proficiency. Confirm with the patient.

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Remember to test your inclusive language knowledge with the Inclusive Language Qbank—free in your Boost Box.

This guide was developed by Melinda Campbell and Laura Wilkinson with the editing team: Lisa Alchier, Grace Satterfield, Kristina Lazdauskas, Joshua Bligh, Sherri Reed, Kristin Marino, and Gina Jansheski, MD, with the help of Morgan Leafe, MD, MHA; Melinda Chen, MD; Charmian Lewis, MD; and Adam Rosh, MD.