Operationalizing the Journal of Human Lactation’s Gendered Language Policy

Sex and Gender Should be Considered Two Separate Variables and Should Use Appropriate Terminology

Across the globe, cultures have identified non-binary gender identities for millennia. Although it is mainly cultural anthropologists who have identified this cross-cultural phenomenon, it is by no means a new or a Western phenomenon (Vincent & Manzano, 2017). The lack of familiarity with the body of work about gender diversity by anthropologists has been the source of much of the confusion about non-binary language. However, describing this bio-cultural phenomenon as gender identity is a newer conceptualization (Stoller, 1964). Today, gender identity is a term that has become mainstream (Richards et al. 2016).

Ideally, the demographic variables that researchers collect would include both sex and gender identity, when it is relevant to the topic studied. Both sex and gender identity could well be relevant to much of the research we do that focuses on the sociocultural context within which infant feeding occurs; it would likely be less relevant in studies focusing on the biochemistry of human milk.

Of course, we acknowledge that collecting and distinguishing these two variables separately may not be feasible within some cultural contexts where acknowledgement of transgender and non-binary gender identities may cause substantial harm. In this case, we suggest the authors include a brief statement acknowledging that they did not find it to be culturally appropriate to ask about sex or gender when defining their sample selection criteria; hence, when they use the words “mother” and “women” the reader recognizes their cultural context and assumptions, as well as how these relate to their study findings.

If Sex and Gender Identity Have Not Been Separated During the Conceptualization or Conduct of The Study, a Rationale Should Be Provided

We recognize that most established measurement instruments and most population-based surveys do not make distinctions between sex as a biological identity, and gender as social identity, or role. Therefore, it is most appropriate for authors who use these terms to acknowledge this situation within the limitation section of their manuscript (i.e., our survey did not include questions about sex or gender identity; therefore, the influence of these variables on the study outcomes could not be evaluated). Acknowledging the limitation of not having clearly defined the variables of sex and gender is essential, just as it is essential to acknowledge how the measurement of other study variables and design elements may have influenced the results.

Inclusion and Exclusion Criteria Should Address Both Sex and Gender in Adequate Detail or Provide Rationale for its Omission

When considering sex and gender identity as separate variables, we are required to ask for a clearer definition than previously accepted (Tannenbaum et al., 2016). Often, in the research manuscripts we receive, the sample definition (i.e., inclusion criteria) includes either the words “mother” or “women.” The word “mother” has been the object of many discussions within the lactation community and has a long history with a huge body of research within the social sciences. Of course, it is customary within most cultures and situations to use the term mother to identify the biological parent birthing an infant. However, the term mother as used in common language can also refer to a personal identity and/or to their social caregiving role, which may or may not be the same person as the biological parent. When the biological parent and the caregiving parent are the same person, the alignment between biological sex and the gendered caregiving role is so complete that the need for any distinction loses force. However, when these are not the same people or when the gender identity of the biological parent has changed with time, the alignment lessens between sex and gender and the need for distinction becomes more apparent. For example, the biological mother may be a surrogate or have placed her baby for adoption, while a different person may have assumed the role of primary caregiver and may self-identify as a mother or father; the birth mother may or may not be providing human milk to help supplement feeding; the adoptive parents could be feeding with donor human milk. In lesbian couples, one may be the birth parent while both may identify as mother; the birth mother may be breastfeeding and pumping, while the non-birth mother may be using a Supplemental Nursing System (SNS) to feed their baby. Likewise, the birth parent could have transitioned from identifying as a woman to identifying as masculine or nonbinary and now use the term father; this person could be lactating and breastfeeding as well (McDonald, 2016).

The distinction between the variety of sociocultural and biological meanings of the term mother is where the issue of gendered language appears. The language used in research must be precise, without any ambiguity, which is why we are asking our authors to be clear about who they mean when they use the term mother. For example, the inclusion criteria might be phrased “birth parent or mother,” “self-identified mothers,” “persons self-identifying as women,” or “persons identifying as the primary caregiver.” One researcher solved this issue by asking her participants “what is your role in the family?” and then chose only those participants self-identifying as mothers. In describing her sample, the inclusion criteria included “self-identified mothers,” which was a clear and definitive definition of what the term mother meant within the context of this study. As with any research variable, once the author has defined it they are free to use the term throughout their paper and do not need to repeat the definition. The problem is that we, as researchers and authors, have made assumptions and previously have not clearly defined these variables.

If Sex or Gender Data Could Have Been Relevant But Was Not Collected, This is a Limitation to be Discussed

Although this situation has been addressed within some of the points above, a discussion of relevance bears a bit more explanation. Relevance is the key word in the JHL policy statement. Tannenbaum et al. (2016, p. 5) ask the following questions, which we feel should guide our authors to determine relevance in establishing sex and gender identity as separate variables: “Do a range of gender identities need to be considered when asking the [research] question?” and “for whom does this implementation strategy [intervention or study results] work and under which circumstances?” Collecting information on both sex and gender diversity may not be relevant to a particular study. As usual, the study questions will dictate variable definitions, measurement, conceptualization, data collection, and data analysis (Heidari et al., 2016). For example, for many (but not all) manuscripts JHL receives about donor milk, the sex or gender identity of the donors may not be relevant; therefore, it could be omitted.

Separating sex and gender identity into two variables is a relatively new development in designing, conducting, and writing about research. Therefore, it has not yet been universally incorporated into author directions or publication standards (Gogovor et al., 2021); however, a very definite move toward this change has been occurring over the past 10 years in the publishing world (Tannenbaum et al., 2016). It is a newer, more inclusive way of thinking about breastfeeding and lactation that takes some readjusting of how most of us think. Therefore, it is very possible that making the differentiation between these two variables may not occur to researchers until they are writing up their study and realize that in the particular context of their study, gender identity might have influenced the results but was not collected. In these cases, acknowledging that this oversight could have affected study results in the limitations section is essential.

The external validity of all studies is a major concern relating to how useful a particular study may be for others who want to use the findings. “External validity captures the extent to which inferences drawn from a given study’s sample apply to a broader population or other target populations” (Findley et al., 2021). If vague, non-precise, definitions are used to define a study’s sample, there is a threat to external validity. This is what has been occurring within lactation research with the lack of clear and precise definitions of some of the key terms commonly used. In this case, the quality of the data has been compromised, possibly leading to misunderstandings that can be harmful in clinical situations.

Data Should be Disaggregated by Sex and Gender Identity Where Appropriate. If This Was Not Considered Relevant or No Significant Differences Were Found, This Should Be Stated

In cases where researchers have collected differentiated sex and gender identity data, results need to include these variables. It is possible that disaggregation of gender categories might produce very small numbers of participants within specific gender identity groups or categories compromising the types of statistical analysis that can be done. We ask that authors clearly state the rationales for data analysis decision-making in these cases, just as they do for all analyses decisions.

Only Data Relevant to the Manuscript Should be Presented to Avoid Unnecessary Medicalization or Stigmatization of Gender Nonconformity

There is a long history of research and healthcare that has harmed sex and gender minorities though the pathologizing of gender and sex variance (Schwend, 2020). Johnson (2016, 2018) has explored how the medicalization of trans identities has affected trans people, the community, and, further, how it dictates who gets medical care, legal recognition, and social support and validation. As a journal in the healthcare field, we feel morally compelled to attend to this issue in JHL. The editorial staff will work with authors should there be a case where information in a manuscript could lead to unnecessary medicalization or stigmatization of any person or group.

Avoid Implying or Ascribing Binary Gender When Gender is Unknown

Gender is inherent in many of the words we use and is often implied intentionally or not, through our language. Being inclusive means using gendered language when we know the gender of the people we are talking or writing about while also not assuming that we know if we are not certain.

Avoid Terms That Imply or That Rely on Assumptions That Sex and Gender are Exclusively Binary Structures

In reality, sex and gender are not exclusively binary structures (Tannebaum et al., 2016; Richards et al., 2016). Phrases or terms that rely on a binary assumption should be avoided as they are both imprecise and possibly unfounded. For example, using the combined term “he/she” as an inclusive option is not appropriate, as it is only including two genders not all genders (APA, 2020, p. 140). Using gender neutral pronouns like “they” or “their” would be more appropriate in this case. Another instance of binary language is the term “opposite sex” (APA, 2020, p. 140). This term relies on the assumption that there are only two sexes or genders. When we consider a scenario in which there are more than two categories, the term “opposite” no longer clearly identifies anyone.

In the case that a study explicitly outlines that the data were collected within a binary construct some of these concerns may be alleviated as the binary is no longer assumed. Although authors in this case may still wish to consider other concerns like reinforcing biases.

Terms/Variables Used in the Manuscript Require Operationalized Definitions (e g., “Mother, Woman, Breastfeeding)

The frequently not well-defined terms “mother” and “women” have been discussed above. However, the term “breastfeeding” remains too often poorly defined. Although the difference between lactation (the physiological process of making milk) and the behavioral process of feeding that milk is clear, these are often conflated in the research literature (Yourkavitch & Chetwynd, 2019). There are a number of established definitions for the term breastfeeding (Labbok & Starling, 2012; Noel-Weiss et al., 2012; World Health Organization, 2008), which are often used to operationalize this variable in research studies. These taxonomies are aimed at how to quantify the amount of human milk feeding. The act of feeding human milk from the breast or from a device along with the behavior of the infant suckling are all different aspects of behavior often inaccurately lumped into the term breastfeeding (Yourkavitch & Chetwynd, 2019).

When Using Pronouns to Refer to Specific Persons, Use The Pronouns They Use to Refer to Themselves. If Pronouns are Unknown or a Hypothetical Person is Being Discussed, Non-Gendered Pronouns Should Be Used or Pronouns Should Be Avoided All Together

Another area where people ascribe gender in language is through the use of pronouns. When using pronouns, ensure that you are using the pronouns that people use to refer to themselves. If you do not know the pronouns used by that person, then either use a gender-neutral pronoun or restructure the sentence so that no pronoun is used. For example, “on the fourth day of treatment, she reported. . .” versus “on the fourth day of treatment, they reported. . .” versus “on the fourth day of treatment, the participant reported. . ..” While some may be unfamiliar with using “they/them” in the singular, the Publication Manual of the American Psychological Association (7^th Edition), the style manual used by JHL, endorses the use of “they” as a singular third-person pronoun in scholarly writing and can be used as a resource on how to use it properly (APA, 2020, p. 120–121).

When referring to groups or hypothetical people for whom the gender is not relevant, avoid using gendered terms as this can reinforce harmful stereotypes. For example, “If I went to a doctor, I bet he would say I was fine, but if I went to a lactation specialist, I think she would be more willing to listen.” In this sentence, the gender of the doctor and lactation specialist are not relevant to the point being made. Using gender in this case only serves to reinforce gender stereotypes that doctors are assumed to be men and lactation specialist are assumed to be women. In the same way, applying gender to hypothetical persons based on roles further reinforces the gendering of those words and roles. It would be more appropriate to use gender neutral pronouns “If I went to a doctor, I bet they would say I was fine, but if I went to a lactation specialist, I think they would be more willing to listen.” Or to restructure the sentence to avoid pronoun usage all together “I bet a doctor would say I was fine, but I think a lactation specialist would be more willing to listen.”

Be Respectful

The intent of the gender language policy is to promote equity and accuracy in the articles we publish by respecting and honoring other peoples, cultures, experiences, and identities. In the writing of a manuscript use the terms that people use for themselves as much as possible. Gender identity and social roles are an important part of many people’s lives. This includes transgender and gender non-conforming (TGNC) people, as well as cisgender people. For this reason, removing gendered language entirely is not an inclusive option. We have tried to provide guidance in as many aspects of this as we can. However, there will always be situations that we cannot anticipate or cover in written materials. In these cases, the prime consideration is respect for other people’s experiences, identities, and cultures.

JHL Does Not Have an Official Preference for Gender-Related Acronyms

It has become common practice to refer to certain communities with a combined acronym (i.e., LGBTQ+, which stands for Lesbian, Gay, Bisexual, Transgender, and Queer plus other identities that are not represented by the acronym). No consensus exists on an official or correct acronym. Rather, the acronym should change depending on who the authors want to indicate or include. Note that every letter stands for a unique group of people and that often the subject matter may not apply to all groups (APA, 2020, p. 146). For example, a statement may only apply to LGB (gay, lesbian, and bisexual) groups; thus, the “full” acronym may not be accurate or appropriate. When using the + sign, it is meant to be inclusive of all sex and gender minorities, which is a large and diverse group of communities and cultures. Additionally, there are culturally tied gender roles that are sometimes added to the acronym that may not be appropriate. For example, Two-Spirit, is an umbrella term used to indicate several traditional identities from different Native American tribes. Therefore, in a study done in India, it would most likely be inappropriate, if this group is not represented in India, to use the acronym 2SLGBTQ as the “2S” represents Two Spirit. When using an acronym consider which groups you wish to talk about and ensure that you are including those groups, but not overextending.