September 30, 2024
Dear Members of the AMA Manual of Style Committee:
We write as members of the Harvard GenderSci Lab, an interdisciplinary research group that innovates concepts, methods, and theories for scientific research on sex and gender in biomedicine. We celebrate the Committee’s attention to respect, inclusion, and accuracy in the use of these terms.
Specifically, the draft Guidance’s recommendations in the following areas represent a significant advance over current practice and an important new baseline for medical reporting of sex and gender variation that we hope will be replicated across scientific publishing:
We offer the following recommendations to strengthen these features of the guidance, drawing on our interdisciplinary expertise and empirical research.
Summary of recommendations:
Discussion
The AMA defines sex as “[a] biological construct that designates a combination of gonads, chromosomes, external genitalia, secondary sex characteristics, and hormonal balances, although there is variation in the biological attributes that constitute sex and how these attributes are expressed” (p. 8). We applaud this emphasis on variation in sex-related variables. However, the draft Guidance also acknowledges that “Sex is assigned at birth based on external genitalia and indicated in birth certificates” (p. 8).
We call attention to the difference between these definitions of “sex”: one refers to specific biological attributes, and the other acknowledges that sex is a system of classification. In biomedical research, these two meanings are often conflated, with assigned categories relied upon as proxies for more specific and precise variables. These variables may include karyotypes, organ inventories, hormone levels, or a wide range of environmental covariates, all of which may vary in ways that are not well captured by the categorical variable “sex” (Richardson 2022; DiMarco et al. 2022; Albert and Delano 2022; Bauer 2023). For example, estradiol levels in cisgender men will overlap with those of cisgender women early in the menstrual cycle and in post-menopause (Frederiksen et al. 2020).
A helpful clarification would be for the Guidance to instruct researchers to be more explicit in defining sex-related factors (e.g., chromosomes, hormones) as distinct from sex as a set of assigned categories, and to exercise caution in interpreting the meaning of those categories. The Guidance should remind researchers to critically interrogate whether sex categories themselves are appropriately interpreted as explanatory, or rather should be understood as serving as proxies for other, perhaps unidentified, causal variables (Pape et al. 2024).
The draft Guidance offers researchers direction on how to use sex and gender categories when presenting results. Some of this guidance focuses on the importance of recognizing categories beyond women and men: for example, “If a study includes gender and only reports on men and women and not additional categories, acknowledge that gender is not binary in the discussion of gender differences” (p. 13). Similarly: “When reporting on gender and sex differences, be as specific as possible, even if people in these categories comprise a small percentage of participants, unless there are concerns about identifiability” (p. 13).
Calling the attention of researchers to a wider range of categories beyond female/male and woman/man is laudable. A further step would be to provide more concrete guidance to researchers for accurately describing variation within and across these sex- and/or gender-classified groups. The draft Guidance notes that the SAGER guidelines recommend “analyses of sex or gender differences and similarities, when appropriate” (p. 13). In current biomedical practice, however, claims of sex or gender difference typically rely upon an average difference between groups, with limited attention to distributions. Reporting data by categorical “sex” or “gender” may perpetuate this practice, which obfuscates distributions and within-group variation. This runs the risk of biasing epidemiological estimates of disease prevalence (e.g. Hammer et al. 2015) and proliferating spurious sex difference comparisons (Garcia-Sifuentes and Maney 2023). To address this, the Guidance could specifically encourage researchers to report, describe, and, where possible, visually depict distributions of sex-related values, including discussing the significance of overlap between groups and intra-category variation.
The AMA’s Guidance on the Reporting of Race and Ethnicity in Medical and Science Journals acknowledges the risk of relying on oversimplified racial categories which may contain significant heterogeneity, and recommends caution and careful analysis of structural or institutional factors in the use of these categories (Flanagin et al. 2021; see also Chew et al. 2024). We recommend analogously expanding the recommended language in the Guidance to include the concepts of structural sexism and gender/sex, which would greatly enhance the ability of researchers to interpret the meaning of any findings associated with sex- and gender-related variables.
The draft Guidance currently states that gender can incorporate “norms, behaviors, and roles” (p. 5). Importantly, it also states that “gender is hierarchical,” pointing to structural elements that entail relations of inequality and oppression (p. 6). But too often gender is solely understood by medical researchers to represent individual-level traits. Structural sexism (e.g., Homan 2019) draws attention to legal, policy, and infrastructural barriers to gender equity. Including the term “structure” in the definition of gender, and including the term structural sexism in the Guidance’s glossary, better reflects current practice in studies of gender in relation to health and medicine, and expands researchers’ ability to describe the potential causal factors that result in sex and gender disparities.
Finally, just as the AMA warns researchers that institutional and structural racism may be mistakenly attributed to biological differences (Flanagin et al. 2021), the current Guidance could urge caution in assuming a biological basis to any differences observed between sex-classified groups––an assumption that the term “sex differences” tends to convey. We and others (van Anders 2015, Danielsen et al. 2022, Lee et al. 2023) have increasingly found the term “gender/sex” productive and useful in publications to describe the broad swath of instances in which gender, sex, and the entanglement between the two is unknown. Including this term in the glossary may be helpful given its increasing prevalence.
The Guidance uses the APA’s definition of intersectionality as “the way in which individuals are shaped by and identify with a vast array of cultural, structural, sociobiological, economic, and social context” (p. 7). It suggests further that the concept captures “the vast within-group differences in identities found among members of marginalized and dominant groups” and “the multiple social and cultural identities that intersect within an individual’s life” (p. 7) This definition, which largely limits intersectionality to the complexity of individual identity, is discordant with the use of this term in women’s, gender, and sexuality studies and in public health sciences (McCall 2005, Bowleg 2012, Else-Quest and Hyde 2016, Boulicault et al. 2023). It is also in tension with a reference to intersectionality elsewhere in the Guidance, which describes intersectionality as “overlapping systems of oppression and disadvantage” (p. 4).
We encourage the Guidance to center this second approach to intersectionality in their glossary of terms. Consistent with social science and theoretical expertise on intersectionality (Hill Collins 2000, Crenshaw 1991; see also Haslanger 2015; 2020) individual identities would be understood as situated within interlocking, macro social-structural systems, such as racism and sexism, which are rooted in hierarchy and power. Like the concept of structural sexism, this approach would support researchers in recognizing the vast systems of inequality that structure individual experiences of health and illness as well as the important point that these intersecting systems may not manifest in all individual-level identities or experiences of discrimination. That is, intersectionality highlights the limits of categories (see point 2, above). Researchers may also benefit from field-specific guidance for taking up the concept of intersectionality in their analyses of sex and gender in the biomedical sciences and in the field of public health (e.g., Bowleg 2012, Krieger et al. 2018, Homan et al. 2021, Rushovich et al. 2021, Bauer et al. 2021, Hull et al. 2023).
In sum, the draft guidance represents a valuable and timely resource for researchers, reviewers, and journal editors as they develop more inclusive and precise language for sex- and gender-related variation in the biomedical sciences. We offer these suggestions with the goal of maximizing the benefits of these efforts, and thank the Committee for the opportunity to submit this comment.
Sincerely,
Marina DiMarco, Assistant Professor of Philosophy, Washington University in St. Louis
Madeleine Pape, Institute of Social Sciences, University of Lausanne
Sarah S. Richardson, Aramont Professor of the History of Science and Professor of Studies of Women, Gender, and Sexuality, Harvard University; Director, GenderSci Lab
Cosignatories:
Alexander Borsa, PhD Candidate, Department of Sociomedical Sciences, Columbia University Mailman School of Public Health
Marion Boulicault, Lecturer in Feminist Philosophy, University of Edinburgh
Ann Caroline Danielsen, PhD Student, Department of Social & Behavioral Sciences, T.H. Chan School of Public Health, Harvard University
Emily Dore, Postdoctoral Research Fellow, Department of Social & Behavioral Sciences, T.H. Chan School of Public Health, Harvard University
Annika Gompers, PhD Student, Department of Epidemiology, Rollins School of Public Health, Emory University
Patricia Homan, Associate Professor of Sociology, Director of Research and Strategic Initiatives for the Public Health Program, Florida State University
Katharine Lee, Assistant Professor of Anthropology, Tulane University
Ben Maldonado, PhD Candidate, Department of the History of Science, Harvard University
Hannah Niederriter, Undergraduate Student, Department of Molecular and Cellular Biology & Women, Gender, and Sexuality Studies, Harvard University
Meredith Reiches, Associate Professor of Anthropology, University of Massachusetts Boston
Atlas Sanogo, Lab Manager, GenderSci Lab, Harvard University
Maayan Sudai, Associate Professor of Law, University of Haifa
Alex Thinius, Lecturer, Department of Literary and Cultural Analysis, Universiteit van Amsterdam & Department of Metaphysics & Philosophical Anthropology, Radboud Universiteit Nijmegen
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