A Brief Guide to AMA Inclusive Language Guidelines

Language is powerful and can be used to illuminate, explain, heal, hurt, include, or exclude. 

The English language is evolving constantly, and medical communicators need to stay abreast of best practices. Inclusive language is one way that medical communicators can avoid bias and create a respectful climate for all people. 

The AMA Manual of Style is a trusted resource for applying terminology that is fair, equitable, and consistent. Many medical and scientific journals adhere to AMA style, and medical writers and editors are expected to be familiar with the evolving guidelines. 

What do medical communicators need to know about AMA’s inclusive style guidelines? How do these evolving guidelines affect the word choices of medical communicators? What are the best practices for applying AMA inclusive language guidelines to medical writing?

Inclusive Language

In a 2023 article in the AMWA Journal, Tracy Frey of the JAMA Network describes the purpose and process of updating the guidelines for reporting race and ethnicity. “Terminology, usage, and word choice are critically important, especially when describing people and when discussing race and ethnicity,” Frey writes. “Inclusive language supports diversity and conveys respect. Language that imparts bias toward or against persons or groups based on characteristics or demographics must be avoided.”

The Inclusive Language section of the AMA Manual of Style (11.12) steers writers and editors to language that promotes equity and fairness while honoring people’s identities. Because disagreement on terms exists within various communities, people creating style guides like the AMA’s face challenges in capturing the most appropriate language. 

Here is what the authors have to say in the Introduction to the Inclusive Language section: 

“Avoid the use of language that imparts bias against persons or groups on the basis of gender or sex, race or ethnicity, age, sexual orientation, socioeconomic status, or disability or disorder. Avoid generalizations without context (such as minorities) and stereotypes and be specific when choosing words to describe people.”

How does this principle apply to the language used to describe people’s race and ethnicity?

Race and Ethnicity

Race and ethnicity are not scientific or biological categories, making it challenging for medical communicators to apply consistent, accurate terminology to describe people’s racial and ethnic backgrounds. However, race and ethnicity carry significant social meaning, and they do not exist in a vacuum. 

The authors of the AMA Manual of Style note that one of the goals of content published in medical and scientific publications is to reduce bias. “The reporting of race and ethnicity should not be considered in isolation but should be accompanied by reporting of other sociodemographic factors and social determinants, including concerns about racism, disparities, and inequities, and the intersectionality of race and ethnicity with these other factors,” the authors write.

Before examining the most significant updates to the AMA Manual of Style, it is useful to internalize definitions of the terms race and ethnicity.

According to  the AMA Manual of Style,

• Race: “The Oxford English Dictionary currently defines race as ‘a group of people connected by common descent or origin’ or ‘any of the (putative) major groupings of mankind, usually defined in terms of distinct physical features or shared ethnicity.’”

• Ethnicity: “Membership of a group regarded as ultimately of common descent, or having a common national or cultural tradition.’”

Language Issues in Health Care and Research

It is not simple to separate out the many factors that affect health outcomes: race and ethnicity, social determinants of health, socioeconomic factors, and structural inequities. It is generally useful to identify the race or ethnicity of research participants, but there are a number of caveats for reporting, including avoiding oversimplifying racial dichotomies. 

JAMA Network journals provide the following guidance for reporting race and ethnicity:

“The Methods section should include an explanation of who identified participant race and ethnicity and the source of the classifications used (eg, self-report or selection, investigator observed, database, electronic health record, survey instrument).

If race and ethnicity categories were collected for a study, the reasons that these were assessed should also be described in the Methods section. If the collection of data on race and ethnicity was required by the funding agency, that should be noted.

Specific racial and ethnic categories are preferred over collective terms, when possible.”

In addition, the Results section should include the race and ethnicity of the study population.

Terms to Avoid

The AMA Manual of Style explores the use of terms to describe race and ethnicity, and suggests avoiding the following:

• Race/ethnicity. Using the forward-slash (virgule) merges the terms and is often used to mean and/or. Use race and ethnicity instead.

• Minorities. The term minorities as a stand-alone noun is vague and can be perceived as creating a hierarchy. Instead use the adjective form: racial and ethnic minority groups or racial and ethnic minority individuals. The terms underserved populations or underrepresented populations are acceptable if the categories have already been identified.

• Other. For obvious reasons, other is a term to be avoided. Even if a small number of people fit into a racial or ethnic category, it is preferable to specify rather than use other as a label.

• People of Color. Although this term is used colloquially, it has been criticized for erasing differences. Similarly, the terms BIPOC (Black, Indigenous, and people of color) and BAME (Black, Asian, and minority ethnic) are acceptable in colloquial use, but not in scientific writing. 

• Non-White. This term is an oversimplification at best, and potentially misleading.

• Spanish-speaking. The terms Hispanic, Latino or Latina, Latinx, and Latine are preferred. 

• Mixed race. Unless this term is used in data collection, it should be avoided.

The terms multiracial and multiethnic exist in a gray area. If people self-identify as more than one race and the terms are defined, they may be acceptable. The AMA Manual of Style provides the following example:

 “In this study, 140 participants (25%) self-reported as multiracial, which included 100 (18%) identifying as Asian and White and 40 (7%) as Black and White.”

Capitalizing Black and White

One of the most debated changes to AMA style refers to the capitalization of Black and White to be consistent with capitalization of other racial and ethnic terms such as Asian, Alaska Native, and Latino. Take note of author choice in terms and the terms participants use to self-report.

Until the most recent 11th edition, black and white were not capitalized in the AMA Manual of Style. However, the manual’s committee listened to concerns about the differing treatment of racial categories. “The committee has concluded that we will now capitalize both Black and White, which aligns with the capitalization preference applied to other racial/ethnic categories,” the authors write.  

Exceptions to this would be cases where capitalization could be considered inappropriate, such as “white supremacy.”

Terms to Describe Indigenous People

The following terms are acceptable to use when referring to Indigenous peoples. When possible, specify the nation or peoples.

• American Indian, Alaska Native, or Indigenous peoples, rather than Native American
• Native Hawaiian
• Pacific Islander
• Indigenous people
• Indigenous peoples of Canada
• Aboriginal people

Nouns vs Adjectives

AMA style promotes person-first language, and this applies to racial and ethnic terms. For example, it is not acceptable to use the terms Asians, Blacks, Hispanics, or Whites. Instead, use the adjectival form: Asian participants, Black patients, Hispanic children. 

Hyphenation

Proper adjectives related to geography are not hyphenated: African American, Asian American, and Indian American.

A Changing World

Race and ethnicity are critical components to understanding science and health care. However, they represent just one piece of our dynamic, evolving language. The AMA Manual of Style: A Guide for Authors and Editors Chapter 11: Correct and Preferred Usage also includes updated guidance for language pertaining to sex and gender, sexual orientation, socioeconomic status, ability, and more. The AMA will continue to update sections of the style guide as new guidance emerges. Stay tuned!

For medical communicators seeking best practices on inclusive language, the AMWA course, Updated Guidance on Inclusive Language for Science Writers and Editors, is an overview of the updates to the AMA Manual of Style and shares tips on where to find guidance and resources.

AMWA acknowledges the contributions of Laura Shum, PhD, for peer review in the development of this AMWA resource.