By Aishling Heffernan

An image can be synonymous with representation, and representation often leads to inclusion. It might be inclusion in dialogue, or simply resting in the thoughts of another. It may be representation via film or print. It may be representation experienced in real life, a poster made by a protestor that catches your eye. Representation is the art of inclusion. It can signal the moment you feel seen because someone who looks like you appears on stage speaking about things you have felt, seen, heard or experienced. Representation is the power and art of inclusion, but it is also the sign-post and the catalyst for attention. When we see an image, we don’t just take it in. We attend to that image. So we have to ask what it means when there are blank spaces in our depictions of people – in our news, our films, our felt-sense of our world. What does exclusion mean when we know that representational inclusion can be so powerful? That it grabs attention? And, in the world of women’s health, what are the repercussions for little, no, or inaccurate depictions of women?

Since 1979, the UN Convention for the Elimination of all Forms of Discrimination Against Women has been signed and ratified by different countries. It’s CEDAW for short. In it’s first article, CEDAW defines discrimination as: “any distinction, exclusion or restriction made on the basis of sex which has the effect or purpose of impairing or nullifying the recognition, enjoyment or exercise by women…”; in private, political and social spheres. CEDAW requires that states must take action on the elimination of discrimination, as defined by the convention (Article 12). When we focus on women’s health, we see patterns of discrimination that are represented within subtle, visual levels, that are pervasive across the dominant medical model in every nation, and which negate gender awareness where it is vital to women’s welfare: in the educational material of our healthcare systems and providers.

In 2008, Science Daily released the findings of a visual gender parity study, focusing on medical textbooks, conducted by Professor María José Barral from the University of Zaragoza. Her study found that white, heterosexual male images were used as the body-template across 16,329 images in 12 medical textbooks. These textbooks were chosen for analysis by the Professor and her researchers because they are also the 12 most recommended medical texts by the top-20 medical universities across the US, Canada and Europe. For neutral body-parts (think limbs) European text-books used male bodies 12% of the time, with female bodies represented by just 2%.

If we get a little analytical ourselves about Barral’s data, we find that a 12%/2% difference represents a 83.3% reduction in depictions of female bodies compared to male. Her study goes further: in 9 out of those 12 textbooks, only Caucasians are depicted. This represents a unique challenge for anyone of an ethnicity that is not ‘white’. Transgender depictions were not covered in the scope of this research, but we can easily assume a similar drought of visual education would appear if it had been.

We have to ask, would you trust a Doctor to diagnose you correctly, if they had only been exposed to your gender (image) roughly 18% of the time throughout their entire education? Would you expect them to take your concerns seriously, and to work with you over an extended time period with the recognition that there might be gaps in their knowledge? If something is unseen, and excluded, if there is no representation then we have to acknowledge that within the sphere of medical education, that (lack of) impact is felt in the bodies of the patients of doctors who are implicitly educated that persons not ‘white-male’, are a blank space. A blank space that when experienced in real life medical situations, must then fit the male-template, or be relegated to the unknown.

In a 2009 article titled “From gender bias to gender awareness in medical education”, the researchers note that gender is a determinant of health and healthcare, and that medicine has been seen as a ‘gender-blind’ field. They see this gap of gender specific medical, educational, data as a unique opportunity to balance the scale of inequity between genders, while recognising that the re-education of medical students or experts is multi-disciplinary, complex, and requires an integrative approach. But to do that, medical leaders need to prioritise this task.

In 2011, this exact question around the prioritisation of gender in medicine was examined and published in an article titled, “’Important… but of low status’: male education leaders’ views on gender in medicine”. The title actually does say it all in this case. Researchers found that out of the male medical leaders interviewed,: “‘All informants were able to articulate why gender matters. As doctors, they saw gender as a determinant of health and, as bystanders, they had witnessed inequalities and the wasting of women’s competence. However, they had doubts about gender-related issues and found them to be overemphasised. Gender education was seen as a threat to medical school curricula as a consequence of the time and space it requires.’”

There’s a famous story about renowned anthropologist Dr. Margaret Mead that goes like this: a student of hers asked Dr. Mead what the first sign of civilisation in a culture was. The student expected the typical answer: clay pots, tools, or other culturally significant artifacts. Instead, Mead replied that the first signs of civilisation were marked on the remains of a 15,000 year old healed, but once broken, femur. Healing a broken bone without modern medicine takes six weeks. In the animal kingdom, Mead stated, if you break something, you die. You can’t forage, you can’t escape a predator, you are grounded, and therefore helpless. A healed bone means that someone stayed with this ancient ancestor. Someone bound their leg, fetched water, and food. Someone helped keep predators at bay.

The first sign of civilisation was the human capacity for care.

We have to ask ourselves, in this frame of what it means to care, and what it means when we leave out the depiction of the female body in medical education. If civilisation is the ability to care and to assist healing, what message does it send to exclude the female body from the education of our health-caregivers?

In 2018, AERA (American Educational Research Association) published a research article from a group of researchers situated in universities in Australia. Titled “Gender Bias in Medical Images Affects Students’ Implicit but not Explicit Gender Attitudes”, the study investigated whether images in anatomical textbooks had the knock-on effect of causing mis-diagnoses for women (hint, the study finds that they, in fact, do.). Referencing no less than 14 articles in the introduction alone on the ways in which gender bias can impact women’s diagnosis, with direct links to studies examining the dangers of implicit biases for women’s health, the study concluded that, “…viewing gender-biased images can have a significant impact on the implicit gender attitudes of students studying anatomy”.

From pain being perceived as more emotional rather, than physical when a woman reports it to her doctor than when a man does, to doctors missing male fertility issues (as fertility has been socio-culturally linked to women), to doctors being less-likely to send women for cardiovascular testing for the same reported symptoms as men – the research on the misdiagnosis of women is not just a matter of fixing an educational semantic of political correctness, but an immediate need to heal the fractured education of healthcare-workers worldwide. While images alone cannot fix the plethora of educational mishaps that medicine has evidently made in relation to gender, they are imperative in reducing implicit bias in our healthcare providers during the seminal time of their education. Correct, inclusive anatomical images are vital to the education of our doctors, and to the life and health of the women whose health they are purported experts in.

The unique opportunity presented by having a focal point, a clear issue to be addressed, (gender-blind anatomical images), isn’t always so neatly packaged when we discuss issues of gender disparity. When we focus on the seemingly innocuous details that create implicit biases we have a chance to action change in a way that is focused. Powerful. Cohesive. And, potentially, faster-acting than other interventions that aim to reduce bias. Our doctors, nurses and healthcare workers have a right to an adequate, gender-woke education. Men have a right to have fertility concerns noticed, but, frankly, most of all, women have the right to be represented in medical textbooks. We have the right to have our concerns taken seriously. We have the right to lives that are not peppered with casual disrespect, or gaslighting in our doctor’s office. The repercussion of gender-blind, non-inclusive images in medical textbooks are the lives of women. So maybe this blog-post can be wrapped up in one simple sentence:

We have the right to be seen.