What’s in a pronoun? Why gender-fair language matters

Introduction

“The influence of language on thought is obligatory or at least habitual: thought is always, or under most circumstances, guided by language”

(Malt et al, 2003)

As the surgical workforce diversifies, the hierarchies and gender norms that have long characterized the profession are being challenged. This culture change has created a climate where overt discrimination is no longer tolerated and overall rates are declining^1,2. However, while these gains are commendable, discrimination hasn’t disappeared—it has become subtler. Implicit biases, which are the automatic and often unconscious beliefs each of us hold, are a key example and may contribute to the well-recognized gender achievement gap in surgery.^3,4

Implicit biases can manifest in many ways, from decisions regarding who should be on an expert panel to the posture we assume when speaking with a colleague, but one of the most powerful ways implicit bias can act is through language. Currently, many in surgery lack a robust understanding of how their language can perpetuate gender or other stereotypes. Often, when it comes to terminology reform, male and female skeptics alike shrug off a need for change, dismissing any linguistic modernization as mere political-correctness. This approach is neither helpful nor appropriate. Here we review the science detailing the ways language reinforces gender inequality and offer strategies to decrease linguistic bias.

Why You Should Care: The Impact of Gender Bias in Language

Linguistic relativity, or the idea that language directs thought, has been shown to operate in multiple contexts.^5,6 In a 2014 study, investigators demonstrated that objects’ grammatical gender strongly predicted whether Spanish/Russian (gendered language) speakers classified objects as feminine or masculine.⁷ In other words, their language guided their decisions. In this case the result seems inconsequential—few would be deeply invested in whether a table is referred to in masculine or feminine terms; however, linguistic relativity becomes problematic when language reinforces inequality.

There is growing evidence that societies with gendered language consistently display deeper gender inequality than societies with neutral language.^8,9 For instance, in the aforementioned study, Russian/Spanish-speaking participants displayed more sexism on the study’s social attitude scale than their English-speaking counterparts. Similarly, using the Global Gender Gap Index which “benchmarks national gender gaps on economic, political, education- and health-based criteria”, Prewitt-Freilino et. al demonstrated that countries where >70% of the population spoke a gendered language scored lower on both the overall index and on economic subscales.¹⁰ In this context, it appears that language not only reflects and defines culture, but actually shapes cultural norms.

Language appears to play a particularly important role in molding individuals’ attitudes toward gender and occupation. Bem and Bem’s landmark study reported that women were significantly less likely to apply for jobs with masculine suffixes (-man versus –person).¹¹ In a simulated hiring experiment, German-speaking business students rated standardized female applicants as less suitable for high-power positions when the job description used male rather than paired forms (e.g. Geschäftsführer versus Geschäftsführerin/Geschäftsführer).¹² Moreover, research suggests that language-induced stereotyping can be difficult to overcome. Even when explicitly told that masculine generics (“he/him”) are meant to include all genders, using male pronouns causes readers to imagine men. For instance, college students who were told to complete sentences about professionals using the gender-neutral they reported picturing fewer men than those who completed sentences using he/him, even though both groups were clearly informed that pronouns referred to men and women.¹³

Perhaps most critically, elements of linguistic bias appear to start early. According to Gottfredson’s theory on career development, by age six, children begin eliminating occupations that contrast with their gender self-concept.¹⁴ Therefore, language surrounding gender and professional potential may be highly influential during this time. In experimental settings, female schoolchildren deemed women to less successful in stereotypically male professions (e.g. engineer, astronaut) when teachers described the occupation using masculine rather than gender-neutral terminology.¹⁵ More broadly, numerous studies demonstrate that children’s general linguistic environment also skews male. Analyses of children’s literature indicate that not only do male storybook characters vastly outnumber females, but male characters enjoy heroic roles whereas female characters are relegated to dependency themes. Furthermore, reading stereotypically masculine stores has been shown to immediately narrow the scope of play that girls accept as appropriate for their gender.

Taken together these results lend credence to the conclusion that gendered language is not benign. Language bias has real and measurable consequences for individuals and society.

Gendered Language in Medicine and Surgery

Medicine is not immune to language bias. While studies are limited, their conclusions mirror findings from other disciplines Gender bias has been repeatedly documented in the language used for federal funding award reviews, letters of recommendation, and tenure promotion evaluations.^16–20 Formal recommendations frequently praise female physicians for “being part of a team”, highlight women’s teaching abilities, and refer to ‘her training’. In contrast, male physicians’ evaluations commend their “decisiveness”, often reference their research, and refer to ‘his career.’ Differences extend to verbal language as well. As reported by Files et al., women introduced by men in professional settings were significantly less likely to be referred to by their title than men introduced by men.²¹

This linguistic bias, although often implicit and unintentional, reinforces gender norms and perpetuates stereotyping. By using a different set of descriptors to depict valued male (assertive, ambitious) and female (warm, communal) behaviors, we predispose female surgeons to face conflicts between their gender roles and professional advancement. Language patterns that diminish women’s standings by omitting their titles and downplaying their individual contributions make it more difficult for women to be seen as leaders. The accumulation of these and other microinvalidations, potentiate constructs where women don’t have an equal presence at the table—operating or boardroom. As a result, female physicians continue to grapple with slower advancement, lower pay, and higher attrition. Moreover, because many of these biases operate at the subconscious level, they are difficult to identify and address. Thus, mindful strategies to combat biases are needed.

What can you do: Strategies to Avoid Gender Bias in Language

Gender-fair language has been proposed to reduce both discrimination and gender stereotyping. This can be accomplished through a variety of approaches, a few of which are highlighted here:

1. Language Neutralization

Here, gender-neutral forms replace masculine forms or are removed all together. For example, in lieu of gender-specific words such as “chairman” or “policeman”, the corresponding “chairperson” or “police officer” is used. In cases where the gender is unknown or indeterminate, or in languages where the traditional norm is to use a male pronoun to refer to all genders, a neutral pronoun should be used instead.²² ‘They” is now widely accepted to have both singular and plural usages. The use of ‘(s)he’ or ‘him/her’ is better than exclusively defaulting to a male generic, although this terminology reinforces gender binaries and may still be problematic for transgender individuals. Completely new pronouns such as ‘ze’ also exist, but have not been widely adopted.²³

2) Language Feminization

Feminization is another approach; it relies on the proper use of feminine forms to increase the visibility of women in traditionally male fields. For example, masculine generic terms are replaced with feminine-masculine word pairs. So instead of ‘professor’, one would specify ‘woman professor’.²² This strategy is somewhat more controversial. Although some data suggest that feminine-masculine word pairs increase female mental imagery (meaning more individuals who read the term picture women), others suggest that this approach also reinforces gender binaries.^24,25 Additionally, some argue that this feminization undervalues female versions by tacitly confirming that terms such as ‘professor’ are implicitly male. Attempts to feminize words using gender-specific stems (e.g. stewardess, comedienne) face similar problems, as their longer more complex forms ensure female versions are never the default.

3) Self-awareness and objectivity

Finally, and perhaps most importantly, authors must be self-reflective and objective about their own biases. Although this discussion focuses on gender bias, similar issues exist in the language used to describe many populations. When writing publicly about any group, authors should refer to members by their preferred terms, whether based on race/ethnicity, gender, sexuality, or any other identity parameter. Authors should seek out diverse feedback to mitigate the chance that their language will reinforce disparity, and strive for a people-first approach.

How we can all evolve

Ultimately, in language, as in medicine, taking the position that our current approach is justified because ‘it has always been our approach’ is not tenable. Much like the adoption of any new technology or technique, evolving our terminology will almost certainly cause growing pains. However, surgical workforce demographics have changed and are going to keep changing. Thus, we must be rigorous in establishing a nomenclature that promotes not only gender-inclusive language, but processes that represent the broad racial, social, and sexual identities of our colleagues. In the end, achieving linguistic perfection may not be possible, but we should strive for the same standards applied to all surgical trainees: make a good faith effort, seek consultation when you are unsure, and admit humbly and openly when you have erred. The onus is on all of us to challenge our biases and do better.