Have You Talked to Your Tables About the Dangers of Sex Bias?

The problem of bias is well documented in the biosciences. Even since the Health Revitalization Act of 1993, which laid out guidelines intended to ensure more equitable representation of women and minorities in federally funded scientific research, the problem persists. A 2010 study published in The Journal of Women’s Health found that, among 46 clinical studies enrolling both sexes, women comprised on average 37% of the participants, and among 69 studies, 87% did not conduct analyses by race or ethnicity, and 18% did not report differences in the racial makeup of the study sample at all. Examples of this sort abound and, setting aside the pernicious sociohistorical and nuanced biologic reasons for this phenomenon, the resulting reality is that medicine, as applied to women and minorities, is less evidence based because most research is extrapolated from a homogeneous population—white men.

But even as we attempt to resolve these problems—ensuring that guidelines are in place and that they are followed when conducting new research—there is another, more subtle way that these biases creep into the biomedical literature. Even if the study itself was conducted using a diverse population of participants, sometimes the reporting elides this fact.  As a manuscript editor I have encountered this problem more often than one would expect, and the culprit is usually the table.

In this table, as in many tables that I have encountered, “white” and “male” are the default. Women’s bodies and the bodies of racial and ethnic minorities are implied by the number of white male bodies present.

A good rule when presenting data in tables is to make sure that when you are reporting the sex of participants, if you choose to report only 1 sex, choose the sex that constitutes the majority of the sample. When reporting on racial and ethnic differences, be as specific as possible (even if these comprise a small percentage of participants). Who are the “others?”

The current edition of the AMA Manual of Style does not explicitly lay out these precautions, but in chapter 4, section 1, you will notice that every example shown for presenting data in tables follows these guidelines.

This is not merely a problem of “political correctness” or social equity—it is a question of accurate reporting and just plain good science.—Gabriel Dietz





Go, Embargo, Go

So what’s an embargo, anyway? There’s the economic trade kind, but let’s stick to the news kind (much more relevant for AMA Style Insider readers). I spoke with Jann Ingmire, the JAMA and Archives Journals media relations guru, and she explained that embargoes exist primarily to give reporters the opportunity to cover a story in a more thorough way.

Here’s how they work: Embargoed material is released to members of the press prior to being released to the public, usually a few days early. This gives reporters time to do research, conduct interviews, and write a really great piece. When the embargo lifts, journalists are already prepared to report on newly published scientific studies.

Most of the time, the system works, but occasionally, an embargo is broken. Ms. Ingmire said she tries to give reporters the benefit of the doubt because, usually, it’s simple human error. Sometimes, though, the embargo break is flagrant. When this happens, reporters are sanctioned and stop receiving embargoed material.

Embargoes make it possible for everyone—from the independent blogger to the major media outlet—to have the same opportunity to gather a story. If you want to learn more, read embargowatch.wordpress.com, a blog that chronicles how embargoes affect news coverage.—Lauren Fischer

Minority Report

Risk factors included racial/ethnic minority status, male sex, higher hemoglobin A1c level, use of insulin, longer duration of diabetes, and higher systolic blood pressure.—From This Week in JAMA, August 11, 2010.

The meaning of the adjective minority in this statement may appear to be clear to the reader. However, what constitutes minority status for race/ethnicity? In which country, population, or time? And in this context—risk factors for diabetic retinopathy—why would minority status per se (as opposed to a specific genetic background, or perhaps lower socioeconomic status and resulting lack of access to health care) be a risk factor? This usage points to a common but probably outdated use of the term minority to refer to a population of people. Why is this term to be avoided in this context?

Merriam-Webster’s Collegiate Dictionary1 defines minority as “a part of a population differing from others in some characteristics and often subjected to differential treatment; … a member of a minority group (an effort to hire more minorities)” and The American Heritage Dictionary of the English Language2 states, “A racial, religious, political, national, or other group regarded as different from the larger group.” These definitions evolved from the more basic meaning of minority. Insofar as usage and equity are concerned, however, historian Amoja Three Rivers stated emphatically 20 years ago that “at least four-fifths of the world’s population consists of people of color. Therefore, it is statistically incorrect as well as ethnocentric to refer to [them] as minorities. The term ‘minority’ is used to reinforce the idea of people of color as ‘other.’”3 The white race is becoming a “minority” in many countries where that had previously not been the case, including the United States. Nor are women to be considered minorities simply by their numbers (as an example of this, in the United States in the academic year 2008–2009, among first-year enrollees in medical school, there were 9619 men and 8889 women, compared with 10 576 men and 6205 women in 1988–19894).

When used as a noun to describe and thus label and marginalize a racial/ethnic, gender-specific, physically disabled, or other group of persons with a common trait, minority (and minorities) is an exclusive term that should be avoided.

Note: Minority (and majority) is appropriate to use when describing, for example, the count (number) in an election, an opinion of a nation’s high court, or in common usage to mean less than half (or more than half) of a given sample.—Roxanne K. Young, ELS, with thanks to Margaret A. Winker, MD

1. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003.

2. The American Heritage Dictionary of the English Language. 3rd ed. Boston, MA: Houghton-Mifflin Co; 1992.

3. Maggio R. Talking About People: A Guide to Fair and Accurate Language. Phoenix, AZ: Oryx Press; 1997:273.

4. Barzansky B, Etzel SI. Medical schools in the United States, 2008–2009. JAMA. 2009;302(12):1353(appendix I, table 2).

Mistakes Were Made

The January-March 2011 issue of Science Editor is devoted to the theme of correcting the scientific literature, something that happens to our journals on a regular basis. In 2011 alone, we’ve already logged more than 70 corrections. With the advent of rushing to get everything online as soon as possible, sometimes it seems like we are doing more corrections than ever. Or maybe it just feels that way because with online articles, we can go in and fix that darn typo rather than just let it be. Hard to say.

You can check out the post about it at the Science Editor Editor’s Blog, and (if you are a Council of Science Editors member) read the whole thing at the CSE site. Also, feel free to leave a comment and let us know how your publication handles corrections in print and online.—Lauren Fischer

Who Was That Masked Manual?

No one wants to be a don’t, a fashion faux pas splashed in full color across the page of a widely circulated fashion magazine. In an attempt to protect the identity of the don’t, one such periodical places black bars over the eyes of each fashion offender. Is this technique sufficient to spare the person the potential humiliation and ridicule that may follow? The AMA Manual of Style offers a resounding no.

Reports of medical cases and research can be greatly enhanced by a photographic or illustrative example of the condition under discussion. Imagine reading a case report of a unique rash with no accompanying photograph, or an article about a newly developed surgical technique without before-and-after images or an illustration of the surgeon’s approach. A picture, it is often said, is worth a thousand words (see 7.5.4, Clichés).

Medical journals have a responsibility to protect patients’ rights to privacy and anonymity, including the deletion of patients’ names, initials, and assigned numbers from case reports; the removal of identifying information from radiographs, digital images, and laboratory slides; and the deletion of identifying details from descriptions of patients or study participants in published articles (see 5.8.2, Patients’ Rights to Privacy and Anonymity).

Until the late 1980s, placing black bars over the eyes of patients in photographs was accepted as a way to protect their identities. However, some journals began to discontinue this practice when it became apparent that bars across the eyes do not preserve confidentiality (see 5.8.2, Patients’ Rights to Privacy and Anonymity). The Uniform Requirements for Manuscripts Submitted to Biomedical Journals concurs, noting that “masking the eye region in photographs of patients is inadequate protection of anonymity.”1

When detailed descriptions, photographs, or videos of faces or identifiable body parts are included with a manuscript that might permit any patient to be identified (even if only by the patient himself or herself), authors should obtain written permission from the identifiable patients (or legally authorized representatives) to publish the information. An example of the patient permission form used by JAMA and the Archives Journals is available at http://pubs.ama-assn.org/misc/patientconsent.pdf. The journal may wish to state (eg, in the Acknowledgment) that the patient shown and/or described has provided written permission.

If such permission cannot be obtained, another approach the journal might take is to remove nonessential potentially identifying details. For example, a patient described as a “20-year-old woman from suburban St Louis with end-stage renal disease undergoing dialysis” could be rewritten as a “young adult woman with end-stage renal disease undergoing dialysis.”

However, altering descriptive characteristics (eg, sex) is not appropriate because it is a form of falsification and may be misunderstood by readers and others conducting secondary analyses of published reports. The best way to provide complete information while protecting patient rights is to obtain informed consent for publication. Informed consent for this purpose requires that an identifiable patient be shown the manuscript to be published or waive his/her right to review the paper.1

To protect patients and to spare potential legal woes, medical journals should not use black bars on photographs in the attempt to preserve confidentiality. The image should be replaced with one that has permission for publication or one in which identifiability is not an issue, or the article should run sans photograph.—Stacy L. Christiansen, MA

1. Uniform Requirements for Manuscripts Submitted to Biomedical Journals: ethical considerations in the conduct and reporting of research: privacy and confidentiality—patients and study participants. http://www.icmje.org/ethical_5privacy.html. Accessed May 9, 2011.