Inclusive Language in Sexual and Reproductive Health

The terminological preferences of many people living with HIV were articulated by Dilmitis and colleagues in the Journal of the International AIDS Society. The authors called for a vocabulary where “terms are clear, not clouded by ambiguity, … do not perpetuate or play into stereotypes, and do not hurt or marginalize the very people they seek to support.” These two principles – straightforward writing and supportive language – offer a blueprint for any attempt at respectful scientific discourse, but the way we pursue them also determines our success in fostering healthy discussion and debate. As the new Social Media Editor for BMJ SRH I would like to take this opportunity to reflect on how we discuss language.

As experts by experience, Dilmitis et al called for language that puts people first, meaning “patients with HIV” rather than “HIV patients”. The phrase “ending mother to child transmission” was criticised for treating women as blameworthy and missing the opportunity to involve men in what they called the prevention of vertical transmission. These suggestions are helpful because they highlight specific problems and offer reasonable alternatives.

More controversially, Dilmitis et al also suggested that acronyms should be avoided when describing people, prompting my forthcoming letter in JAIDS exemplifying the problems that can arise.

A novel paper examined how first sexual experience related to later HIV status among Kenyan women. Later HIV positive status was associated with an older partner, an experience arranged by an older relative, an exchange of sex for money or gifts, or a first sexual experience prior to or within one year of menarche. Throughout the paper the authors used the acronym “AGYW”, as an abbreviation for Adolescent Girls and Young Women. However the authors’ conclusions that AGYW should be encouraged to use condoms missed the point: men should be encouraged to use condoms because they are the powerful party in these high-risk encounters. We suggested that the words “girls” and “young” had been obscured by the acronym. The people they denoted, evidently vulnerable to acquiring HIV, had been dehumanised and lost in the alphabet soup. We suggested that spelling the acronym out, and not conjoining two concepts with “and” might avoid these issues.

You can read our letter and decide whether the criticisms were reasonable. After all, it’s not always clear cut. Here are some tricky problems:

• Pejorative terms should be avoided, but should replacements be neutral or affirmative?
• It is a good principle to describe people using their preferred terms. But what if there are diverse preferences within the group?
• At what point does a commonplace term like “infection” become too stigmatized to use?

Sometimes regarded as an impediment to critique and debate, sensitive word choice is in fact essential to getting the point across, and not just because it demonstrates respect and improves understanding. Within the contemporary intellectual milieu, a poor choice of terminology can attract criticism which might miss the point or even lead to accusations of malice. Ungenerous criticisms can slow down the serious business of preserving health and upholding rights; it’s better not leave oneself exposed. But, within good faith debate, isolated errors need to be distinguished from cases where loose language leads to sloppy thinking and generates bad policy.

So, although bad language can be hurtful or open the writer up to criticism, finger-wagging about it risks creating a culture that is elitist and exclusionary. It risks silencing valuable voices or missing out on good ideas. And even weak points made by the wrong people can helpfully articulate the vox populi.

We should communicate with accurate and gracious terminology but we do the discourse a disservice when we fail to show generosity towards people who chose other words (particularly when communicating cross-culturally). An understated “can I pick up on the implications of that word” can promote dialogue. A self-righteous “gotcha” is less likely to be constructive. I’m sure I’m as guilty as anybody else of getting that distinction wrong at times.

The BMJ SRH blog is a safe space. We avoid exclusionary language and we avoid exclusive linguistic rules. But although we eschew shibboleths we pursue clarity and courtesy. This is a place to wrestle with the words we choose, honing and co-producing a lean vocabulary. But it is a training ring not a street fight, so let’s be clear and courteous in our pursuit of politeness and precision.

I hope we can choose the right words, disagree well with people who use different words, and continue to develop an improved language for the promotion of sexual and reproductive human rights and health.


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