Finding the Right Words: Cohesion and Divergence in Inclusive Language Guidelines

Treating patients and colleagues with respect is a foundational value in the healthcare professions.Treating patients and colleagues with respect is a foundational value in the healthcare professions. In relating respectful behavior to inclusive communication, in 2021 the Centers for Disease Control and Prevention of (CDC) published its Health Equity Guiding Principles for Inclusive Communication (CDC, 2021). Within these principles for inclusive communication, the CDC publication highlights the importance of using preferred terminology for population groups as a way of communicating inclusiveness and respect. The American Psychological Association (APA) and the American Medical Association (AMA) have also published timely guidance for inclusive language that identifies preferred terms. Given multiple sources of guidance, those who work and teach in healthcare arenas may navigate several sets of recommendations at one time. A comparative textual analysis highlights the common recommendations, as well as areas of difference.

Background

Language changes with time and region. As the CDC guidelines highlight, language is a social tool; it changes as cultural norms change, reflecting both time and place (CDC, 2021). Harmon (2021) explored the changing status of terminology that is preferred or not preferred. Such evolving terms include “BIPOC” (an acronym for Black Indigenous People of Color) and “queer” (a term that was historically pejorative, but has been reclaimed as a self-affirmation). Historically, there has been no sanctioned procedure for identifying an entire population group’s preference in self-referents. Evidence suggests, for example, that “BIPOC” is a term that is not preferred by those to whom it refers (Harmon, 2021).

...language is a social tool; it changes as cultural norms change, reflecting both time and placeDespite challenges to identify preferred terms, the endeavor to recognize such terms is a longstanding one in the literature. References to inclusive language and preferred terminology as a way to communicate respect begin to appear in the literature in the 1980s, primarily in the context of gender inclusion within religious faith (Russell, 1985), Similarly, guides to “bias-free language” also appear in the literature at this time, with cautions that failure to use the correct terminology may result in being labeled a “racist” or “sexist” (Pickens, 1985).

Richer and Weir (1995) connect the era’s discussions about “politically correct” language to inclusive language and trace popular discourse about preferred terminology initiatives to the 1960s. As a testimony to the changing nature of language, the meaning of the term “politically correct” itself has changed since its original use, which dates back before the language initiatives discussed by Richer and Weir. The term can be found in a United States Supreme Court Decision in 1793, in a comment regarding appropriate ways to identify the people-centered identity of the United States (Chisolm v. Georgia, 1793). The term “politically correct” is now more often used to suggest a mode of communication that is excessively regulated (Chow, 2016).

Healthcare providers may consult several resources to learn more about inclusive language and preferred terminologyHealthcare providers may consult several resources to learn more about inclusive language and preferred terminology (see Table 1). The CDC created its guidance online through its website as the Health Equity Guiding Principles for Inclusive Communication (CDC, 2021). Within the website are distinctions between preferred terminology and terms that may be viewed as less appropriate. The latest AMA manuscript guidelines for inclusive language appear in the AMA Manual of Style (2020), in a section entitled “Inclusive Language.” AMA distinguishes terminology to “avoid” from terminology that is “preferred.” In 2021, the AMA partnered with the Association of American Medical Colleges (AAMC) to create and release a language guide, the goal of which is to advance health equity (AMA-AAMC, 2021). In this guide, the AMA and AAMC embrace and adopt material from the CDC website. The APA (2020) publication manual contains a section called “Bias-Free Language Guidelines” which also addresses inclusive language. As a companion to this section, the APA website contains information that includes lists that distinguish terminology it identifies as “problematic” from terminology it views as “preferred.” In 2021, the APA published an additional online resource for inclusive language guidelines, which draws directly from the publication manual (APA, 2021a).

Table 1. Publication Information, Audience as Identified by Organization, and Availability

These organizations embrace the notion that language will change, and hence qualify suggestions for preferred terminology with caveats that allow for this evolution. In this respect, the CDC makes the most strident statement,

This is a living document which will be adapted as both language and cultural norms change. This is not a style guide and is not meant to be prescriptive or exhaustive, but rather to provide principles, resources, and specific suggestions (CDC, 2021, para. 4). Readers may question the difference between “being prescriptive” and “suggesting.” In general, “prescribing” may be interpreted as giving direction; “suggesting” may be interpreted as identifying how things may be done.

Methods

The aim of this project was to compare guideline documents from national organizations that addressed inclusive language and preferred terminology. A comparative content analysis considered published documents from three national organizations (n = 6) that provide guidelines for communication: The Centers for Disease Control and Prevention; The American Psychological Association; and the American Medical Association. The scope of analysis was limited to terminology identified as “preferred “and “not preferred.” Preferred terminology was designated as such by the organizations, sometimes as an explicit label, sometimes in passages explaining the justification behind endorsement of particular terminology. Terminology identified as not preferred was designated by the organizations under categories such as avoid, problematic or instead of. All terms identified as preferred or not preferred were collected from the documents. Using the electronic search function, an application of the Boyer-Moore algorithm programmed in Adobe^TM, Google Chrome^TM, and Apple Books^TM, the presence or absence of collected terms across documents was assessed with differences in designations and context flagged.

The scope of analysis was limited to terminology identified as “preferred “and “not preferred.” Readability, using the Flesch Reading Ease Formula (1948) and the Gunning Fog Index (1952) was assessed through free online software. To conduct the assessments, sample passages comprised of approximately 300 words excerpted from the introductory text of the documents were collected for submission.

Results

Person-First Language
Person-first language seeks to identify the person before characteristics that may define them.References to person-first language appear throughout the organizational documents. Person-first language seeks to identify the person before characteristics that may define them. For example, rather than identifying someone as a “diabetic” or “diabetic patient,” person-first language endorses identification as a “person with diabetes.” The AMA manual recommends person-first language regarding diseases, disorders, and disabilities. The CDC guidelines indicate that person-first language is a key principle in its approach regarding both disability and socioeconomic status. While the APA manual also discusses person-first language use, it explicitly recognizes identity-first language as a potentially respectful approach, as may be determined by some individuals and groups (e.g., blind person, deaf person). 

Use of Singular “They”
All of these three organizations describe use of the singular “they” in varying degrees. For the APA manual, the phrase “he or she” is no longer preferred and should be replaced by the singular “they,” unless the writer knows that the referents all prefer “he” and “she” pronouns. This is a change from the position held in the sixth edition of the APA manual (2009). The CDC guidelines similarly discourage the use of gendered pronouns. In its publication manual, the AMA suggests rewriting text to align use of “they” pronouns to plural reference points. If the resulting revision would be unwieldy, then a singular “they” may be viewed as appropriate.

Demographics
Guidance is consistent across the three organizations related to preferred terminology to describe demographics...Guidance is consistent across the three organizations related to preferred terminology to describe demographics such as age, income, socioeconomic status, sexual orientation, race, ethnicity, disabilities, disease, and disorders. Areas in which the electronic search identified differences were limited to the following specific topics: visual impairments; use of the term “homosexual” as an adjective; use of the terms “disabled”, “Latinx”, “underrepresented;” and appropriate designation for indigenous populations in the United States (see Table 2).

Table 2 Topics discussed across organizations

Readability
With respect to readability scores, all advisory materials from the three organizations were assessed as “Difficult” or “Very Difficult” by the Gunning Fog Index (1952) and the Flesh Reading Ease Formula (1948). Both assessments are based in part on the average length of sentences and the average number of syllables in the words. Such assessments indicate that the texts are written for readers at a college level.

Discussion

The identified common ground among the guidance...provides a hopeful foundation for the success of an inclusive communication effort.The identified common ground among the guidance emanating from these three organizations provides a hopeful foundation for the success of an inclusive communication effort. Employing person-first language and the singular “they” are roundly endorsed as paths to respectful identification. Further consideration of limited areas of difference, however, may suggest a few cautions.

Visual Impairment
Regarding visual impairment, the three organizations differ in terms of appropriate language use. Each organization acknowledges that those who are visually impaired may prefer to adopt identity-first language; there are prominent movements that argue that person-first language can be disempowering. Therefore, the APA guidelines (2020; 2021a; 2021b) identifies “blind person” and “visually impaired person” as preferred terminology. The CDC guidelines (2021), while acknowledging a potential disconnect for those who prefer identity-first language, largely maintains an emphasis on person-first language with respect to blindness. The AMA guidelines (2020) aligns with that of the APA in identifying “blind people” for inclusion in preferred terminology. The AMA manual also extends its guidelines to discouraging use of visual metaphors. It further cautions that study descriptors such as “double blind” may be viewed as inappropriate to some audiences.

Disability

These differences are consistent with distinctions made with respect to person-first language. Matters regarding sexual orientation also offered evidence of differences in approach. In matters of disability, generally, there are additional differences between the APA guidelines (2020; 2021a; 2021b) and the CDC guidelines (2021). These differences are consistent with distinctions made with respect to person-first language. The APA guidelines lists “disabled person” as a preferred term, while the CDC guidelines identify the term “disabled” as one to be generally avoided. The AMA manual (2020) aligns with the CDC guidelines in this respect, listing “disabled child” as terminology to avoid. A preferred approach for both organizations would identify a person “with a disability.”

Sexual Orientation
Matters regarding sexual orientation also offered evidence of differences in approach. The APA guidelines (2020, 2021a; 2021b) and the CDC guidelines (2021) both recommend avoiding the term “homosexual” in any circumstance. The AMA manual (2020) however indicates that the term may be permissible when used as an adjective (e.g., homosexual or heterosexual male). 

Race and Ethnicity
Discussions regarding race and ethnicity contained differences for inclusive communication. In general terms, the APA guidelines (2020; 2021a; 2021b) identifies the term “underrepresented” as a preferred way of describing a historically marginalized group. Conversely, an update on guidelines from the AMA (2021) discourages the term, used in conjunction with the term “minority.” The more recent AMA guideline (2021) asserts that the term “underrepresented” suggests a failure; a state of being insufficient.

Communities
In terms of particular communities, the APA manual (2020; 2021a; 2021b) addresses the term “‘Native American,” indicating that this term, “may be preferred to ‘American Indian’.” Conversely, the CDC guidelines (2021) discourage use of the term “Native American” and instead endorses “American Indian person” as a reference point. Both organizations indicate that specific tribal names should be used when known. The AMA manual aligns with the CDC guidelines in its preference for “American Indian,” but indicates that “Native American” may be acceptable as well.

Both organizations indicate that specific tribal names should be used when known. Emerging around 2015, “Latinx” is a relatively new term in the English language. It has been suggested as a gender-neutral replacement for “Latino,” a traditionally used term that designates Spanish-speaking persons and their descendants (Salinas, & Lozano, 2021). Guidance documents from the three organizations analyzed in this project support continued use of the terms “Latino” and “Hispanic” in adjective form (AMA, 2020; APA, 2020, 2021a, 2021b; CDC, 2021). Similarly, the organizations all recognize some nuance and need for rigor in application as the two terms are not synonymous. For example, the CDC guidelines (2021) and APA manual (2020) both mention “Latinx” as an alternative adjective that may have potential application. The term Latinx is not mentioned in the AMA manual (2020), but it is a suggested option in its 2021 guidelines.

Further areas of difference may be implied but are not explicit. Further areas of difference may be implied but are not explicit. For example, the AMA (2020) and APA (2020) manuals use the term “African American” as a noun in some contexts. The CDC guidelines (2021) provide examples of the term only as an adjective. Further, while the racial descriptors “White” and “Black” begin with capital letters in the APA manual (2020) and CDC (2021) guidelines, they appear in all lower case in the AMA (2020) manual manuscript guidelines. In the AMA’s 2021 language guidelines, it indicates that “Black” and “white” are more appropriate, citing the standards of the Associated Press (2022).

Recommendations

Health professionals who wish to embrace inclusive language as a means to demonstrate respectful writing in any of these contexts may find daunting the prospect of dissonances in identified terminology preferences, combined with the potential for future changes. It need not be. First, the foundational interest in person-first language across the guidelines informs many language choices across diseases, disorders, disability, and socioeconomic status. There were zero instances of “person with/who . . .” on a list of terms to avoid in any of the organizational guidelines (AMA, 2020; 2021; APA, 2020; CDC, 2021).

...the foundational interest in person-first language across the guidelines informs many language choices... Additionally, instances of disagreement may be addressed with an alternative word choice. If there is potential for disagreement on the suitability of a term such as “underrepresented,” an alternative such as “historically marginalized” may be considered. Uncertainty regarding use of “Native American” may be resolved through identification of a particular tribe (e.g., Sioux). If there is uncertainty about the appropriate use of “Latinx,” the terms Latino or Hispanic (as appropriate) retain status as preferred in adjective form.

It has become more common to ask open questions about pronoun preferences. In this same tradition, preferences related to disability (e.g., visual impairment), which may vary on an individual basis, may also be ascertained. Healthcare professionals routinely ask probing questions. In this context, questions about a patient’s preferred terminology for discussion are as reasonable as classic questions about how a patient might like to be addressed. For example, the American Heart Association (AHA) has worked to develop an approach to help healthcare providers gain a better understanding of the communities they serve. This approach has four parts: Question, Listen, Reflect and Learn (Manos, 2019). In the context of this analysis, the question instead queries how healthcare providers can navigate language uncertainties. Listening, reflecting and learning will require research in the community itself, as described by an AHA research partner, “The best way to learn about others is to listen to them” (Manos, 2019, p. 31).

The changing nature of language demands that speakers and writers continue to learn and adapt over their lifetime. Inevitably, there will be mistakes in choices of terms along the way. Even those with the best intention may unknowingly use a term that is inappropriate. In these cases, the best suggestion is an attitude that is open to learning, and a quick apology (Udelf, 2020). The changing nature of language demands that speakers and writers continue to learn and adapt over their lifetime. If there is uncertainty in the best path to create an inclusive message, it is reflective of the importance of the task and struggle to find enduring expressions of respect in contexts of constant change.

Author

Miriam R. B. Abbott, MA
Email: mabbott@mccn.edu
ORCID ID: 0000-0002-4715-6112

Associate Professor Miriam R. B. Abbott has served Mount Carmel College of Nursing in Columbus, Ohio for more than a decade as a Composition and Cultural Competence instructor. She has worked with nursing colleagues to publish across several mediums, navigating the recommendations of multiple style manuals and changing standards.