Greta McLachlan: A textbook example of sexism in medical education

Sexualised images of women in surgical textbooks send a dangerous message, says Greta McLachlan

A few weeks ago, there was a Twitter storm about the images used in a surgical textbook. It created such a frenzy that numerous newspapers covered the story. There are two editions 2002 and 2014. I will only be discussing the 2014 edition here, leaving the 2002 edition to the madness of history.

The 2014 edition has several examination images where a fully dressed male doctor is examining an undressed (wearing bra and pants) female patient, even for a shoulder or elbow examination. To make this more worrying, the female patient for a pectoral examination has changed into a push up bra reminiscent of the “hello boys” wonder bra advert of the 90s. She is looking somewhat seductively at the camera, with a full face of make up on. The examiner is barely in the shot. For all the images accessible on preview, the patient is always a woman, looking directly at the camera, and the doctor always a man.

I am told that this textbook is clinically very good, meaning it has likely been seen by many trainees and students. Cambridge University Press, the publisher of the 2014 edition of textbook, even said “this book is widely used and has been well reviewed in academic journals.”

But the message that this sends is a dangerous one. It objectifies women into sexual beings. Even worse it objectifies patients into sexual beings. By placing the patient in a wonder bra with eyes looking directly at the camera, it teaches our trainees that patients can be sexualized and it’s okay to view them this way. It tells female trainees that they are sexual beings, only there for male gratification. It teaches female doctors that they do not belong within the world of medicine except as patient. It teaches these things so subliminally that for five years we barely even noticed them.

For five years this book has been used by students, trainees, and consultants. It has been “well reviewed by academic journals,” none of whom found cause for concern in these images.

And in all honesty, five years ago, had I seen this book and images, I am not sure I would have noticed them either. Perhaps I would have sighed or laughed, text a few people to share how ridiculous they were. But I wouldn’t have got it. I wouldn’t have understood the nuances of these images. With this in mind, I do not blame the contributors of this book, although of the 23 who contributed only one was a woman. This is bigger than individuals. It illustrates an epidemic of poor culture.

Fortunately, these images were called out by Kate Ahmed on Twitter. Perhaps in this post #metoo world and the influence of #timesuphealthcare campaign, we have learnt that not calling out these insidious behaviors can have consequences. Look at the recent statistics that 3% of doctors have witnessed or experienced sexual harassment from a colleague.

If we don’t evolve and learn we are left tolerating the bad behaviors of the past. We will all at some point get things wrong during this process, but it’s how we address these wrongdoings that matters.

Cambridge University Press put out two statements during this Twitter storm. The first was, in my view, fairly weak, but the second stated: “we are removing the current edition from sale. It will remain out of print until a thoroughly revised third edition is produced. We are sorry for the offense and upset this has caused”. They replied to concerns from The American Association of Orthopaedic Surgeons, via a letter AAOS posted online, inviting AAOS to review the book prior to its 3rd edition publication. They also sent a letter to Kate Ahmad, which she has posted on her Twitter feed.

Within the week, there was more.

This time at a European conference. A speaker had put the image of a women’s bottom in a thong on their last slide. It was met on Twitter with much the same reaction. Within a day a statement was put out by the European Association of Cardio thoracic surgery, who apologized for the sexist slide, thanked Rebecca Dobson for bringing it to their attention, thanked another speaker at the course who had raised it there. The speaker who shared the slide apologised. The European Association of Cardiothoracic surgery said: “It’s disappointing that we need to state explicitly in writing that slides of this nature will not be tolerated, but we have updated our guidance in case, to make it abundantly clear.

As apologies goes, this statement deserves a round of applause.

But it is concerning that both of these cases are from educational content. What learning points can we salvage?

Well, people are starting to feel comfortable calling out these types of sexist microaggressions, because we know that if we don’t call it out then they can percolate through a culture and make it toxic.

Those with the power are starting to act and stamp out these behaviours.

Our culture is changing. This takes time and it needs all of us to take part. The majority of people, male and female, that I have spoken with agreed that these images were not appropriate, and understood how misplaced they are in 2019.

Some did not. We still have work to do.

Greta McLachlan is a general surgical trainee. Twitter @geemclachlan

Competing interests: None declared.