We are writing to respond to the article by Ritchie Johnson originally published online in July 2022.¹ We acknowledge their interest in and efforts to discuss an important issue, namely the description of sex and gender in medical journal articles. The current guidance in the AMA Manual of Style recommends the following:

Sex refers to the biological characteristics of males and females. Gender includes more than sex and serves as a cultural indicator of a person’s personal and social identity. An important consideration when referring to sex is the level of specificity required: specify sex when it is relevant. In research articles, sex/gender should be reported and defined, and how sex/gender was assessed should be described. In nonresearch reports, choose sex-neutral terms that avoid bias, suit the material under discussion, and do not intrude on the reader’s attention.²

We wish to address a few of Ritchie Johnson’s specific references to the AMA Manual of Style.² First, while there is a brief mention of our ongoing efforts to revise the section on inclusive language regarding sex, gender, and sexual orientation, Ritchie Johnson points out several places where the current guidance is unclear or not comprehensive. We are aware of the need for more robust guidance, examples, and discussion regarding sex, gender, and sexual orientation as well as the need to address nonbinary and gender diverse identities. A revision of this nature takes a good deal of time and research, as we learned in completing the major update regarding the reporting of race and ethnicity.³ Our revision is in process and many of the points raised by Ritchie Johnson will be addressed in the forthcoming update. For example, the following interim guidance appears in the Instructions for Authors of JAMA and the JAMA Network journals⁴: 

The term sex should be used when reporting biological factors and gender should be used when reporting gender identity or psychosocial/cultural factors. The methods used to obtain information on sex, gender, or both (eg, self-reported, investigator observed or classified, or laboratory test) should be explained in the Methods section. The distribution of study participants or samples should be reported in the Results section, including for studies of humans, tissues, cells, or animals. All participants should be represented, not just the category that represents the majority of the sample (unless the study concerns a disease or condition relevant to a single sex, such as prostate cancer). Studies that address pregnancy should follow these recommendations, and if the gender identity of participants was not assessed, use the terms “pregnant participants,” “pregnant individuals,” “pregnant patients,” etc, as appropriate.

Ritchie Johnson notes that when “the biological sex of a patient is known…it should be reported accordingly” and that more precise, self-reported data are needed. We agree, as noted in our interim guidance cited above, and it is certainly within the purview of style manuals and journal editors, as well as research funders, to encourage researchers and authors to collect and report such data. 

The language used to describe study participants in the medical literature is of paramount importance, which is why the AMA Manual of Style committee is working to develop comprehensive, consistent, and sensitive guidance in the ongoing revision. We will have our draft updated guidance reviewed by experts on diversity, equity, and inclusion to ensure we recommend using clear, consistent, appropriate, and inclusive language and we invite readers of this letter to provide feedback. 

Stacy L Christiansen, MA
Managing Editor, JAMA
Chair, AMA Manual of Style

Tracy Frey, BA
Deputy Managing Editor, JAMA Network
Committee member, AMA Manual of Style

Acknowledgment 

We thank Annette Flanagin, RN, MA, Executive Managing Editor, JAMA and JAMA Network, and committee member, AMA Manual of Style, for her thoughtful comments on this letter.

References and Links

1. Ritchie Johnson A. Thoughts on sex and gender inclusive language in medical publishing. Sci Ed. [accessed August 31, 2022]. https://www.csescienceeditor.org/article/thoughts-on-sex-and-gender-inclusive-language-in-medical-publishing/
2. Frey T, Young RK. Correct and preferred usage. In: Christiansen S, Iverson C, Flanagin A, et al. AMA manual of style: a guide for authors and editors. 11th ed. Oxford University Press; 2020. [accessed August 31, 2022]. https://academic.oup.com/amamanualofstyle/book/27941/chapter/207567296?searchresult=1#369661816
3. Flanagin A, Frey T, Christiansen SL, AMA Manual of Style Committee. Updated guidance on the reporting of race and ethnicity in medical and science journals. JAMA. 2021;326:621–627. https://doi.org/10.1001/jama.2021.13304
4. Reporting demographic information for study participants. JAMA instructions for authors. Updated August 12, 2022. [accessed August 31, 2022]. https://jamanetwork.com/journals/jama/pages/instructions-for-authors#SecReportingRace/Ethnicity