For writers and editors of scientific publishing, usage and word choice are critically important. This is especially true when describing patients or other individuals and when discussing race and ethnicity. The language used must be clear and precise and must reflect fairness, equity, and consistency in the reporting of race and ethnicity.
The AMA Manual of Style provides extensive guidance to those who write, edit, and publish in the biomedical literature, including a dedicated section on inclusive language. Even though the latest edition of the manual was just published in 2020, ongoing and recent events spurred us to revisit the guidance on reporting race and ethnicity (and we will be examining other content in the inclusive language section as well, including sex and gender, age, socioeconomic status, and persons with diseases, disorders, or disabilities).
The committee responsible for writing and producing the manual began reassessment of the guidance on reporting race and ethnicity in the spring of 2020. The first decision we made was to recommend capitalization of all racial and ethnic categories (e.g., Black and White are now uppercase). This was presented a year ago in Science Editor,1 along with a preview of some of the topics we were beginning to discuss.
The stylebook committee embarked on an 8-month process of research, writing, editing, external review, and revision. The initial revision was published as an editorial in JAMA in February 2021 with an invitation for wider public review and feedback. Numerous reviewers and scholars with expertise in diversity, equity, and inclusion provided extensive feedback; some of them disagreed with each other. We then conducted another round of research, revision, and review.
The new updated guidance was published in JAMA and incorporated in the online manual in August.2,3 This section is unique in that it completely replaces the original content online. It is freely available to anyone not only as a chapter outside the paywall, but as a PDF as well.
What follows is a very brief summary of some of the new guidance in this chapter. We welcome writers and editors to use the guidance, to share it, and to cite it. Most importantly, we welcome further feedback on the content. This guidance is not intended to be final but is presented with the understanding that further updates will be necessary as the dialogue surrounding race and ethnicity evolves. There were some issues on which we received conflicting advice; those terms in particular will require careful monitoring.
Changes to Presentation of Terms
Race and Ethnicity
The original section was titled “Race/Ethnicity.” However, there are numerous subcategories within race and ethnicity. Given that a virgule (slash) often means “and/or,” which can be confusing, we no longer recommend using this construction; as a term it’s “race and ethnicity.”
As mentioned earlier, we recommend consistency in the capitalization of all racial and ethnic categories. The original style capitalized only terms derived from geographic entities (e.g., African American, Asian); we now recommend consistency in capitalization for all terms. However, we recognize that there are situations in which a writer or editor may deem the capitalization of a particular term as inappropriate (e.g., “white supremacy”) and use discretion to vary from this style guidance.
Modifiers not Nouns
Do not present race and ethnicity as nouns; i.e., do not label people as their race and ethnicity, just as we recommend not labeling them with a condition (e.g., asthmatics). If race and ethnicity are discussed, they should be modifiers (e.g., Asian patient, Black individual) or predicate adjectives (e.g., patients who are Asian or Black).
List race and ethnicity categories in alphabetical order, not in order of proportion.
Most combinations of proper adjectives derived from geographic entities are not hyphenated (e.g., African American patient).
Abbreviations of categories for race and ethnicity should be avoided. In rare instances they may be needed due to unavoidable space constraints in a table or figure, in which case they should be defined in a footnote.
Use of Specific and Collective Terms
Do not use these terms as nouns because they may be inaccurate or stigmatizing. If appropriate, include a modifier when using the word minority, for example, “racial and ethnic minority groups.” The term minoritized may be acceptable as an adjective (e.g., “racial and ethnic minoritized group”). “Groups that have been historically marginalized” could be suitable in certain contexts if clearly explained.
This term may carry negative connotations and should be avoided, unless it was specifically used in data collection (and in such a situation it should be clearly defined). The terms multiracial and multiethnic may be acceptable if the specific categories these terms comprise are defined. Another option may be a category such as “more than 1 race and ethnicity,” if study participants were able to self-identify with more than 1 entry on a form, for example. These terms require a clear understanding of how the data on race and ethnicity were collected.
If a comparison among racial and ethnic groups is valid and useful to report, indicate the specific groups. In most cases, study designs and statistical comparisons of White vs “non-White” individuals should be avoided in favor of more precise reporting. If such a comparison is justified, authors should explain the rationale and specify what categories are included in the “non-White” group.
The term “other” is a catchall category and should be avoided. Authors should be as specific as possible when reporting racial and ethnic categories. If the numbers in some categories are so small as to potentially identify study participants, the specific numbers and percentages do not need to be reported, provided this is noted. For cases in which the term other is used but not defined, further explanation should be requested.
People of Color
This term was introduced to mean all racial and ethnic groups not considered White and also as an indication of antiracist, multiracial solidarity. However, there is concern that the term may be “too inclusive,” thereby minimizing differences among groups. The preference always is to describe or define the specific racial or ethnic categories included or intended to be addressed.
Underserved and Underrepresented
Terms such as underserved (e.g., when referring to disparities among groups) or underrepresented (e.g., when referring to a disproportionately low number of individuals in a particular program) may be used provided the categories of individuals included are defined at first mention.
Many related topics are discussed in the updated manual. A greatly expanded reference list provides support for our findings, and many of the references are excellent resources for further reading. We are implementing this new guidance at the JAMA Network and collecting responses and suggestions for future updates.
Our intention was to provide up-to-date, equitable, and consistent guidance on a critically important issue in scientific publication. We welcome feedback on ways we can continue to improve this guidance for researchers, authors, editors, and readers of the scientific literature.
References and Links
- Christiansen SL. Inclusive language: race and ethnicity. Sci Ed. 2020;43:95–96. https://doi.org/10.36591/SE-D-4303-95
- Frey T, Young RK. Race and ethnicity. In: Christiansen S, Iverson C, Flanagin A, et al., editors. AMA Manual of Style: A Guide for Authors and Editors. 11th ed. Oxford, UK: Oxford University Press; 2020. [accessed August 27, 2021]. https://www.amamanualofstyle.com/view/10.1093/jama/9780190246556.001.0001/med-9780190246556-chapter-11-div2-23
- Flanagin A, Frey T, Christiansen SL, for the AMA Manual of Style Committee. Updated guidance on the reporting of race and ethnicity in medical and science journals. JAMA. 2021;326(7):621–627. https://doi.org/10.1001/jama.2021.13304
Stacy L Christiansen, MA, Managing Editor, JAMA, and Chair, AMA Manual of Style committee.
Opinions expressed are those of the authors and do not necessarily reflect the opinions or policies of their employers, the Council of Science Editors or the Editorial Board of Science Editor.