Sex, Gender, and Language in Public Health Communication

It is probably not surprising that Sensible Medicine gets a lot of submissions about transgender issues. It is a part of medicine that is actively evolving, that is mixed up in the culture wars, and that stimulates a lot of “insensible” proclamations from across the spectrum. We have passed on all the submissions. Until today.

I found Elizabeth Barnes’ essay thought provoking. I left it thinking about medicine, the biological differences between men and women, and how we communicate with the remarkably, wonderfully, diverse population we get to care for in the United States.

Adam Cifu

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One of my family members recently got in touch with me after being diagnosed with Parkinson’s disease. As much as I’d love to say he was reaching out for insight from my day job as a philosophy professor (this has literally never happened, but a girl can dream), in this case he got in touch because I also have Parkinson’s disease, and he was wondering if there was anything I could recommend for him to read. I started looking around for some basic, reliable medical information I could send to him, and went to some of the usual suspects for accessible health content. But I was surprised to see several prominent sources of this kind of information using language like ‘sex assigned at birth’ in their discussion of Parkinson’s - a usage that seems to be widespread across their sites.

Here is the Cleveland Clinic’s basic introduction to Parkinson’s:  

If we follow the link, we get an extended discussion of why AMAB and AFAB are the preferred terms, including paragraphs like:

Similarly, on Medical News Today’s introductory Parkinson’s page, we find this disclaimer:

And on Healthline we find ‘assigned male at birth’ discussed as a primary risk factor, as well as an apology for using the term ‘male’ on their introduction to Parkinson's:

I have no doubt that this kind of language is being used with good intentions (and with an aim toward inclusion). But unfortunately, this framing - and its prominence - means that there’s no way I can send this information to my family member. He’s already prone to distrusting ‘mainstream’ medicine, especially since the pandemic. Were he to see this, he would immediately view the content as politicized, and his skepticism would deepen.

I am strongly supportive of the rights of trans people. But in evaluating public health information, we’re evaluating something more than just the words we choose. Public health information is meant to play an important societal role. And to do this effectively, the information these resources contain should be both accurate and helpful. So we can ask, in a case like this, both whether it is accurate and whether it is helpful.

1. Is it accurate?

As it happens, some of the information contained is surprisingly inaccurate. The Cleveland Clinic page on sex difference and sex terminology, for example, identifies the CDC’s alcohol guidelines as an example of a place where “the gender binary often shows up in places where it’s not needed.”

““We have a tendency to separate things more than is necessary,” Kolega says. “In this case, is it really about men versus women? Or is it more about body size?”

Such guidelines are often not even accurate for cisgender people. Think, for example, about a short, small-framed cisgender man versus a tall, muscular cisgender woman. Such binary-focused guidelines likely aren’t the right fit for them, either.”

This is misleading. As the CDC itself points out, males and females metabolize alcohol differently. Even controlling for body size, the same dose of alcohol will usually produce higher blood alcohol levels in a female than in a male.

There is also the repeated claim that biological sex is a spectrum. Most biologists, in contrast, would tell you that sex is a binary - males produce small, mobile gametes, and females produce large, stable gametes. Of course, it’s true that some sex-associated characteristics exist on a spectrum. And likewise, it’s true that a small number of individuals (across many species) can’t be easily classified as either male or female. That doesn’t mean that sex is a spectrum - at least on any standard meaning of ‘spectrum’ - or that sex is determined by the decision of a physician when you’re born. There are, of course, people - including some biologists - who disagree with this consensus. But it’s typically not the role of public health information to ‘teach the controversy’.

Zooming in more specifically to the case of Parkinson’s, this is a case where sex differences really do matter. Males are much more likely than females to develop Parkinson’s. Some of the explanation for this could easily be social differences - things like military service and agricultural labor are considered risk factors for Parkinson’s, and it’s at least partly for social reasons that those risk factors are more common in men. But it’s likely that the striking sex differences (which include both differences in prevalence, symptoms and disease trajectory) are at least partly explained by biological differences between males and females.

The use of language like ‘assigned male at birth’ is, in this context, at best misleading. If you’re male, you’re not more likely to get Parkinson’s because of a decision a doctor made after looking at your genitalia. You’re more likely to get Parkinson’s because of differences between male and female biology - differences we don’t yet fully understand, and which crucially need more (not less) attention.

2. Is it helpful?

Potential inaccuracies aside, incorporating terminology like this almost certainly comes from a place of good intentions. Trans people often report negative experiences with the healthcare system and frustration over the ways they are spoken to and about. This is a serious issue, and one that could easily lead to worse health outcomes for trans people. But I’d speculate that there are relatively few trans and non-binary people with Parkinson’s disease who would be deeply offended by reference to sex categories. There are, however, an increasingly large number of people who are skeptical of public health information, and who view it as politicized in a way they distrust.

If someone like me - a highly educated, affluent, politically progressive, Millennial living in a college town surrounded by other highly educated, affluent, politically progressive Millennials - sees the Cleveland Clinic discussing ‘AMAB’ and ‘AFAB’, I know both what they’re saying and the context for why they’re saying it. And I don’t change my view of the reliability of the information. But this information isn’t - or at least shouldn’t be - written for me. I am atypical for someone with Parkinson’s.

My family member, on the other hand, is among the group most likely to get Parkinson’s - an older white man without a college education from the rural south or Midwest (an area of prevalence sometimes called ‘the Parkinson’s belt’) who has a background working in and around agriculture. This group is also, of course, a group that has seen a sharp increase in distrust of institutions, especially healthcare institutions. And it’s a group especially likely to be unfamiliar with - and very skeptical about - something like describing Parkinson’s disease as more common ‘in people assigned male at birth (AMAB)’.

I don’t agree with my family member’s politics. And I don’t think he should be skeptical of ‘mainstream medicine’ in the way that he is. But nothing about his politics or his skepticism make him any less in need of - or deserving of - accessible, reliable information about his health condition. And this is especially true given that my family member, and people like him, are far more socioeconomically vulnerable (and have far worse health outcomes) than someone like me.

Growing distrust is a major public health issue. And it seems like the kind of public health issue that health communicators should be trying to minimize as much as they can. In that context, it seems like an especially bizarre choice to choose language that (while probably not doing all the much good) threatens to deepen the distrust of a significant portion of the people it’s supposed to be serving.

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Elizabeth Barnes is Professor of Philosophy at the University of Virginia. Her recent book - Health Problems - focuses on difficulties in quantifying and comparing health.