• sexual and gender disorders
• medical education & training
• gynaecology
• medical ethics

Should clinicians be using the word ‘woman’ in medical language? Are phrases like ‘human milk’, ‘parental’ and ‘hand-held notes’ preferable to ‘breastmilk’, ‘maternal’ and ‘maternity notes’1? Whether to adopt a new terminology is a complex question, worthy of reflection and analysis, and open dialogue between patients, clinicians and academics. While new phrases might be argued as socially progressive, their ability to translate into medical practice or general health messaging seems currently uncertain. Clinicians might be put into a difficult position of balancing various concerns around language choice in healthcare communication, and it is, therefore, important they are aware of multiple viewpoints.

The omission of words such as ‘woman’ or ‘mother’ in favour of ‘gender inclusive’ or ‘gender neutral’ terminology tends to signal the clinician’s acknowledgement of a minority group. It is a form of communication aiming to be sensitive to the needs of transgender people, who have an identity or sense of self that is incongruent with their reproductive biology. Transgender patients require medical care appropriate to their bodies, but may not wish to be described by common words that reference their natal sex. Thus, an argument made for gender inclusive terminology might be that because some individuals with the capacity to gestate a child do not identify as women, pregnancy ought not be described solely as a ‘women’s issue’.1–3 Academic publications may adopt gender neutral language for topics in female reproductive health. Examples include: a study protocol on menstruation using ‘people who menstruate’,4 an update of cervical cancer screening guidelines writing ‘individuals with a cervix’5 or an ethics paper exploring elective caesareans during the COVID-19 pandemic writing ‘pregnant person’.3 Yet, gender neutral language may be met with resistance when applied to other contexts.

When Brighton and Sussex University Hospitals (BSUH) NHS Trust launched their guide to ‘Gender Inclusive Language In Perinatal Services’,1 the document came under significant public scrutiny in the UK.6 This guide included a table of suggestions to expand on existing clinical terminology, such as using ‘breast/chestfeeding’ instead of ‘breastfeeding’ and favouring ‘maternity or perinatal’ over ‘maternity’. Unlike some approaches to adopting gender inclusive language (where words like ‘woman’ might not appear at all), BSUH guideline authors aimed for an ‘additive’ approach, writing: ‘if we only use gender neutral language, we risk marginalising or erasing the experience of some of the women and people who use our services’”1 Despite this strategy, the debate around gender neutral phrases and when it is appropriate to associate the word ‘woman’ with female reproductive biology reached the UK House of Lords, as Lord Hunt asked: ‘do we really want to see demeaning terms such as ‘menstruators’, ‘individuals with a cervix’, ‘birthing bodies’ or even ‘chest feeders’?’.7 It is not unreasonable to expect that some women may feel debased by a term like ‘menstruators’, and clinicians have the same obligations to them not to use language that deeply offends.

When introducing their rationale for gender neutral language, Ross and Solinger noted: ‘the danger that excising the word ‘woman’ in order to include transgender persons in our reproductive justice analysis can have the effect of effacing the particular lived experiences of women’.2 Indeed, it seems difficult to justify routine omission of the word woman, if some women object to being described by various alternative phrases. Logically, the same arguments that support gender inclusive language for transgender people apply equally to women who may feel erased or dehumanised by terminology labelled ‘neutral’. If the aim is to maximise respect for every person’s sense of self, it must follow that female patients who simply understand themselves as women cannot either be expected to ‘go along silently with language in which they do not exist’.2

A further consideration for this language is the intended audience. Perry asked: ‘This kind of language is feted as ‘more inclusive’, but the question we should be asking is, inclusive of whom?’.8 Indeed, if writing for the general public, the use of some gender inclusive formulations may go against principles of jargon-free communication. Using simple words instead of convoluted phrases or anatomical terms is clearer, especially as survey data suggest widespread lack of knowledge regarding the female reproductive system.9 There may also exist other barriers to understanding a phrase like ‘people with a cervix’, for example: disability, differing socioeconomic, cultural or educational backgrounds, or limited knowledge of English.

In developing gender neutral terminology, care ought to be taken when choosing the alternative vocabulary. For example, perinatal may be understood as a period of time between 22 weeks gestation and 7 completed days after birth. Maternity typically more specifically denotes the female person undergoing the process of pregnancy and childbirth, whose medical needs may span pre-pregnancy, antenatal, intrapartum and postpartum care. The BSUH suggestion of using perinatal instead of maternity may, therefore, risk confusion around medical context and accuracy.

A deeper concern is whether gender inclusive linguistic changes could have the unintended consequence of making biological sex conceptually less visible and much more difficult to clearly explain in healthcare and medical education. Two distinct gametes and biological roles are identifiable in human sexual reproduction. The word female traditionally signified a type of reproductive system with a unique structure and function compared with the male. ‘Woman’ in the context of ‘women’s health’ thus suggested that this field of medicine is interested in issues affecting the female biological sex (in a similar way as the root of the word ‘gynaecology’ comes from the Greek word for woman). Both reproductive biology and personal identity, as separate phenomena, are important to medicine and research.10 Do we need an unambiguous medical word to indicate that uterus-havers, individuals with a cervix and pregnant persons have in common a specific type of reproductive system? In plain language, how should we indicate such persons as biologically distinct from the epididymis-owners, prostate-possessors and seminal fluid producers? How should health educators explain the basic general differences between the bodies of menstruators and ejaculators? Should we have simple terms indicating which persons are more likely to require a pill for erectile dysfunction instead of one for abortion?

Arguably, discussions around gender neutral terminology appear to focus mainly on alteration of female-specific language, rather than amending male-associated words. An Irish newspaper covered the public controversy following a decision by the Health Services Executive (HSE) to remove the word woman from their cervical cancer screening information, remarking that meanwhile HSE’s ‘information page on prostate cancer refers frequently to ‘men’ but has not been updated since 2011’.11 In a similar example, Prostate Cancer UK refers to men on their information page, while acknowledging that some people with a prostate may not identify as men.12 If gender neutral phrases might risk confusing the broader population13 but are intended to be inclusive of all transgender people, then clinicians ought to reflect on any asymmetry in what language is being adopted to describe members of each biological sex. Should there exist an imbalance, for example, if simpler words are routinely being used in men’s health rather than women’s health, then the reasons for this and potential implications might be useful to examine.

The final point to highlight is that gender inclusive phrases ought not be viewed as one-size-fits-all for transgender people, either. For example, this piece uses the term transgender as an umbrella descriptor for simplicity, but that decision comes at the expense of nuancing equally valid ways for how a person might describe their gender incongruence, using words like trans, gender minority, non-binary, agender, transmasculine, gender variant and gender non-conforming. There are over 60 terms to describe aspects of gender, some of which themselves may have different meanings depending on the individual using these words, thus the landscape is complex.14 Transgender people are highly diverse in identities, expressions and opinions as to which terms of address they prefer; some may not wish to be referred to by either traditional medical words or any new suggestions for gender neutral terminology (especially if the inclusive phrases use names for sexual anatomy or functions of reproductive physiology with which that person wants no association).

Navigating this contested issue in medical communication seems challenging, but also presents opportunities for clinicians to be actively involved in listening and contributing to these conversations. Retaining scientific terminology specific to biological sex and human reproduction is vital: how else are we to speak of differences between females and males? Respecting and centring individual needs is important: how else are patients going to feel welcome to attend a clinic? Clinical terminology needs to be cognisant of diverse audiences, flexible to different purposes and allow dialogue on local and global levels. Language in healthcare should aim for clear and respectful communication. When it comes to choosing the right words for communication on biology and identity, clinicians need more discussion.