ethics

How Many Is They?

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Since I’ve been a manuscript editor, JAMA Network journals have published a few articles about health care for transgender patients. I’ve had the good luck to edit a few—they are always interesting—but this week, I realized that there is a grammatical issue in editing these articles that I have never heard fully addressed.

The issue is not what pronouns to use for transgender individuals—that question is well-known. Because the English language uses gendered pronouns, people who change their gender expression or whose gender isn’t accurately defined by labels are faced with several choices: should they go by she, he, a singular they, or a neologism, such as xe?

The news media has addressed this, including The New York Times articles in 2016 and 2017, with another written by transgender English professor Jennifer Finney Boylan in 2018. These articles often make the same points: that people can get confused by this transformation of language, but that people who want to use pronouns that reflect a gender different from their assigned sex should have their wishes respected. This squares with the approach used in JAMA Network journals.

But it also raises a question rarely addressed: what about verb conjugation? In the present tense, English applies a letter s to the third-person singular (he, she, or it runs) but not to the first-person singular, first-person plural, second-person singular, and third-person plural (I, we, you, and they run). So, if an article uses a singular they, should it be conjugated like the third-person plural (run) or like the third-person singular (runs)?

While editing, I have realized that the default method of using the singular they along with someone’s name (or a descriptor, such as the patient) involves flip-flopping between singular and plural verb conjugations (eg, “The patient is receiving gender-affirming treatment, and they are pleased with the outcome thus far”). A consistent use of the singular they would seem to require using third-person singular conjugations throughout (“The patient is receiving treatment…. They is pleased…”) or plural conjugations throughout (“The patient are receiving treatment…. They are pleased….”). Is either approach correct?

The public discourse on pronouns has not provided much insight. It has prompted the argument that we all use forms of singular they-series pronouns in casual language, in sentences such as “If someone wants gender-affirming treatment, that is their choice” or “Give them an injection.”

But that is distinct from the current issue. In these usages, the pronoun is usually objective (them) or possessive (their or theirs), and the verb is conjugated in the third-person singular alongside another subject. (In the example sentences, these are “someone” and “that,” and in the command, an unspoken “you.”) When the singular they is placed immediately before the verb, the question of conjugation instantly reappears.

Weighing “they run” vs “they runs,” I looked for guidance in the AMA Manual of Style. It offered a few relevant thoughts: “In an effort to avoid both sex-specific pronouns and awkward sentence structure, some writers use plural pronouns with singular indefinite antecedents… Editors of JAMA and the Archives Journals prefer that agreement in number be maintained in formal scientific writing.”

But that seemed short of clear instructions. Still uncertain if constructions like “they is pleased” would please anyone, I reached out to Jennifer Finney Boylan, the New York Times contributor whose article on pronouns was published in 2018.

A quick email to her university address got an equally quick response. “I’m not certain about this,” she wrote. “I want to endorse ‘they is’ because the non-specific pronoun is still referring to a singular individual. On the other hand, ‘they are’ sounds better to my old, English professor ears.”

That seemed similar to how our society is handling the matter. On her authority, I decided to stick with conjugations that shift from singular to plural and let the matter rest until a thoughtful body of grammarians, popular opinion, and perhaps the next edition of the New York Times’ article series on pronouns weigh in with a definitive answer to conjugating verbs after a singular they.—M. Sophia Newman

Patient Privacy

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Sometimes before I go to bed, I like to check in on one of my favorite YouTubers, Dr Pimple Popper (the nom de internet of dermatologist Sandra Lee), who posts videos of dermatologic procedures and skin care treatments. I particularly enjoy watching videos of dilated pore extractions, and I don’t mind watching lipoma extractions either (although I do sometimes fast-forward through the excisions). I know these types of videos can get viewers’ stomachs churning a bit, but I think it’s no worse than various photographs in medical journals I have worked at over the years. And because of my occupation, I do wonder about patient privacy and anonymity.

Patients featured on this YouTube channel may have a cyst near their eye or ask for blackheads to be removed from their cheek, and their faces are clearly visible. In many videos, Dr Lee chats with her patients, and although she sometimes edits out personal details, some of it stays. Dr Lee says that patients do sign consent forms before videos are published.

Similarly, when manuscript editors of medical journals encounter photographs of patients, we must review whether the photograph might intrude on patient privacy. Authors must obtain written permission from patients (or their legally authorized representatives) for any descriptions, photographs, or videos of patients or identifiable body parts and indicate that such consent was obtained in the Methods or Acknowledgment section. When I started in this field as an editorial assistant, I processed a manuscript that described a skin lesion on a patient’s back. In an accompanying photograph, the patient’s distinctive tattoo was visible, and I needed to ask the author to either obtain patient consent or have the photograph cropped because the patient (as well as anyone who knew he had that tattoo) would be able to identify himself. Results of imaging studies and photos of laboratory slides may also have identifying information that should be removed.

Protecting patient privacy also extends to what is in the text of an article. When editing case descriptions, case reports, and personal essays, nonessential identifying data (eg, sex, specific ages, race/ethnicity, occupation) should generally be removed unless the author has permission or the information is clinically or scientifically relevant and important. Authors and editors should not falsify or fictionalize details; doing so may introduce false or inaccurate data.

Read more about patient’s rights to privacy and anonymity in section 5.8.2 of the AMA Manual of Style.—Iris Y. Lo

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

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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

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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

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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

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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?

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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.