Intentional Inconsistency as Gender‐Neutral Language Evolves

As the editors of the Journal of Midwifery & Women's Health (JMWH), we are increasingly being asked about the use of gender-neutral language. Authors are unsure about wording in their manuscripts, and midwifery faculty have practical and philosophical questions about making courses and curricula gender neutral. Some gender-neutral language has become common in midwifery, such as asking a woman about her partner rather than using a gender-specific term such as husband or boyfriend, which assumes heterosexuality. However, language that rejects a gender binary entirely, by using wording that doesn't limit gender to only 2 options of woman or man, can be controversial. This editorial discusses gender-neutral language and related updates to JMWH style guidance. The gender of pronouns is a longstanding challenge for authors and editors. For many years, masculine pronouns, such as he and his, were used as the default when referring to someone whose gender was unknown and purported to be inclusive of both genders.1 Over time, there have been efforts to be gender neutral by using constructions such as (s)he and her or his that are explicitly inclusive of men and women. However, the combination of masculine and feminine pronouns can be awkward in writing and reinforces a gender binary.2 To avoid these constructions, people began using they and their as singular. This was considered poor grammar for many years but is increasingly accepted as standard English today.3, 4 The next edition of the AMA Manual of Style, which is the style used for articles published in JMWH, will allow “the use of plural pronouns with singular indefinite antecedents (eg, Everyone allocates their time) in an effort to avoid sex-specific pronouns and awkward sentence structure.”5 Many editors and writers still believe it is best to avoid singular uses of they and their in formal writing when possible. For example, the sentence “Each midwife allocates their time” could be changed to “Midwives allocate their time.” A more recent development in gender-neutral language in midwifery is replacing woman with other terms, such as person or patient, which are inclusive of individuals across the gender spectrum. Some midwives want midwifery articles, textbooks, curricula, organizational documents, and other publications to move fully to such gender-neutral language. Midwives’ opinions about this major shift in language vary and can simplistically be divided into 2 positions. Those who support universal gender-neutral language believe that exclusive use of women when referring to the persons cared for by midwives is no longer appropriate as a broader understanding of gender identity is becoming apparent. They note that midwives are currently providing a variety of types of care for individuals who do not identify as women, including perinatal care and gender-affirming hormone therapy. Those who disagree with universal gender-neutral language note that the vast majority of individuals midwives care for consider themselves to be women. They may also recall years of advocating for women to stop being referred to as patients because many women seeking health care are not ill but rather experiencing normal physiologic and developmental processes, such as pregnancy or menopause.6 Some midwives are distraught at the idea that the word woman is disappearing in writing after all of their efforts to make women, rather than their body parts or clinical conditions, the subject of sentences. Changing “The preeclamptic placenta develops abnormally” to “The placenta in a woman who has preeclampsia develops abnormally” is a recent, hard fought success. We have heard these and other valid arguments that span both perspectives as well as the range of opinions between them. As editors, we must consider not only the rationales for language changes, but also the ramifications of such changes. While moving to gender-neutral language will seem more inclusive to some individuals, it may make other individuals uncomfortable. Some women and midwives find gender-neutral pregnancy and birth language, such as pregnant people and birthing individual, awkward and even alienating. Midwives care for a large, broad population of individuals who have diverse gender identities and language norms. In addition, the rules of gender-neutral language are still in flux.3 After careful consideration of the rationales for and ramifications of universal gender-neutral language, we believe a stepwise progression is most appropriate in JMWH at this time. Women who are cared for by midwives may be referred to as patients or clients. The use of patient or client is the author's choice, so long as usage is consistent. However, the words woman and women are preferred wherever possible. Authors who choose to use gender-neutral language may use person(s), people, or individual(s) in lieu of woman and women. Gender-neutral language should not be used for gender-specific study populations. For example, a study that only included women as participants should be described as such, rather than described as a study of people. Some readers and authors will undoubtedly be disappointed we are not moving to universal gender-neutral language in JMWH now. We want to be clear that this decision does not reflect any desire on our part to be exclusionary of individuals who are transgender or gender non-conforming. We recognize gender is not binary. We believe everyone deserves evidence-based, culturally-sensitive care, which includes asking individuals what words they use to describe themselves and honoring their preferences. There have been several articles in JMWH related to transgender care during our tenure,7-12 and we hope to receive new manuscripts that address gender-diverse populations. We want to reiterate our longstanding commitment to people-first language that avoids dehumanizing words and phrases. The Journal's style is to refer to people before referring to their conditions, such as using women with diabetes instead of diabetic women, and to not use dehumanizing terms for people, such as subjects, controls, or cases. We have recently noted that some authors are avoiding gender language in writing by removing people entirely. For example, it is easy to change “the woman has contractions” to “the uterus contracts” or “low-risk women” to “low-risk labors.” However, making uterus or labor the subject of a sentence instead of the person who has the uterus or is in labor negates the centrality of the individual who is the true subject of the sentence. The reductionism of people to their biologic parts and physiologic processes is an inappropriate step backwards, and we urge authors to avoid such language. Midwives can acknowledge their long history of inclusive and culturally sensitive care at the same time they acknowledge their decades serving as women's health care providers caring for a population so often underserved. We want to honor our history, all aspects of it, as we move forward. Midwives’ longstanding support for women, so often relegated to a secondary place in society, can and should include support for those who for so long have been given no place in society. The challenge will be blending language to be inclusive and supportive of all people, without inadvertently being exclusionary of anyone. Gender-neutral language is an evolution that is in progress, and it is an evolution we are watching very carefully. For now, our goal as the editors of JMWH is to offer style flexibility that honors a wide range of opinions regarding gender-neutral language. We will continue to engage in thoughtful observation and conversation as dialogue continues about optimal gender language in midwifery. We have had numerous conversations with colleagues who have contributed to our thoughts on gender-neutral language in midwifery and would especially like to thank Melissa Avery, Ali Cocco, Simon Adriane Ellis, Rebekah Kaplan, Julia Phillippi, Kerri Schuiling, Tanya Tanner, and Stephanie Tillman for their comments and insight.