Discussing women’s sexuality is uncomfortable. Societal culture refers to women of childbearing age as girls. Worse yet, women who are comfortable with and in control of their sexuality are generally the target of more stigmatizing labels such as “bitch,” “slut” or “whore.” Sociocultural messages that portray the ideal woman as passive, soft and naïve belie our often-espoused values and institutional policies that support women’s rights, health and equality. While the sanctity of medical “truth” and “evidence” should preclude any bias, I was surprised that my first-year anatomy textbook blatantly upheld gender stereotypes and failed to explain male and female anatomy equitably.
My frustration with this seemingly small injustice prompted me to consider how biased language might impact patients: if required reading mis- and under-represents female anatomy, does such biased language fester outside the textbook mille-feuille, too? Even if you, the reader, believe I am too politically correct, I encourage you to stay with me and consider how language reflects and shapes our world. We need a better medical lexicon that accurately communicates meaning without introducing bias.
Consider some terms used to describe male anatomy in Moore’s Essential Clinical Anatomy: “heavy,” “force,” “expulsive,” “penetrate[s],” “pushing” and “richly.” Then consider terms used to describe female anatomy: “thin,” “light,” “serves,” “receives” and “communicates.” “Male” and “female” tropes clearly persist in the text. Does the uterus not provide “force” (even “expulsive” force) when “pushing” out a baby? Does the penis not have parts that “serve” a purpose and “communicate” with other structures? No structure in the human body is as durable, tough and flexible as the vagina, yet most medical texts depict it as a vulnerable, delicate vessel.
Moore’s even states that the vagina “receives the penis and ejaculate during intercourse,” as if the vagina plays no active role in sexual intercourse despite the consensus that the vagina expands when aroused. Depicting heterosexual sex as either active or passive denies future physicians access to an understanding of consensual sex. Instead, not unlike pornography, the male gaze informs our understanding of female anatomy. Without proper terminology and explanations, how are medical students supposed to understand female anatomy, let alone discuss it with and treat future patients?
Moore’s also describes female anatomy as less “developed” than male anatomy. Although “development” can indicate size, the terminology inappropriately characterizes the differential development of reproductive structures, which are ill-suited to such comparison. For example, Moore’s describes the deep transverse perineal muscle as developed “typically only in males” and the perineal muscles as “generally more developed in males than in females.” Certainly, structures could be different in females because they have different purposes but not because they failed to develop fully. I would not call the clitoris an underdeveloped penis nor testicles underdeveloped ovaries; each differentiated into uniquely male or female structures according to a particular biological pathway.
Unsurprisingly, Moore’s only mentions “orgasm” in a half-page section titled “Erection, Emission, Ejaculation, and Remission” and marginalizes female reproductive anatomy to lists of parts and locations without describing functions. Essentially, Moore’s acknowledges that the clitoris exists. True, the clitoris doesn’t obviously become erect like a penis, but why is “anatomical position” erection, anyway? How much of a man’s life is actually spent with an erect penis? Moreover, why is the female sexual cycle barely described if arousal is an anatomical “norm?” Where is the “Expansion, Secretion, Orgasm (dare I say?) and Return” section for the female?
The female sexual response cycle lacks true consensus, but anatomic and physiologic explanations for arousal, orgasm and remission do exist yet are not described in as much detail as the male cycle. There is no reason to omit well-established information or fail to acknowledge that the female sexual response cycle requires more research. As a result, Moore’s not only leaves nascent physicians ill-prepared to understand basic female anatomy and a large part of their patient population but also perpetuates harmful stereotypes that may influence patient care.
Women are less likely to receive timely treatment for acute abdominal pain in the ED, more likely to be misdiagnosed with a mental health condition when presenting with cardiac disease, and, in the United States, more likely to die in childbirth than in any other high-income country. Even outside the hospital, women are less likely to receive bystander CPR due to their perceived fragility and fears over sexual assault accusations. It worries me that women — not to mention people of color, LGBTQIA+ patients or other marginalized communities and identities — often have poorer care outcomes because of society’s baseline befuddlement and discomfort with their bodies.
Equitable descriptions of male and female anatomy should be presented in all anatomy textbooks to better prepare medical students for the variety of patients they will care for. Sections should also be devoted to anatomy outside the male-female binary. This could include descriptions of gender-affirming surgery, intersex patients and more. Although including all anatomical variations in a textbook would be challenging and unrealistic, the societal implications of reproductive structures deserve further consideration. While coronary artery anatomy, for example, can vary significantly, the position of arteries does not contribute to sexism and bias in medical care. Moore’s has a responsibility to future physicians and patients to be inclusive, equitable and scientific in its teachings.
Beyond teaching anatomy, healthcare professionals can and should do better with how we talk to and about patients in general. In addition to gender-biased language, physicians regularly use terms such as “noncompliant,” “chief complaint” and “denies” to describe patients. These terms not only suggest that patients are untrustworthy but also are inconsistent with physicians’ roles as nonjudgmental care providers.
Stigmatizing language is also inconsistent with physicians’ commitment to evidence-based medicine. Research has shown that language impacts not only perceptions of and attitudes toward patients but also provider decision-making and treatment plans. A 2018 study demonstrated that biased language in the medical record led to increased negative attitudes toward and less aggressive pain management of a hypothetical patient with sickle cell disease presenting with a vaso-occlusive crisis. Neutral language fostered more positive provider attitudes toward the hypothetical patient as well as better pain control. Similarly, the stigmatizing term, “substance abuser,” as opposed to the neutral, “substance use disorder,” has been found to perpetuate biased attitudes toward patients and justify punitive measures against them.
Additionally, when researchers examined descriptions of unexplained chronic pain, they found that providers frequently described men as stoic and strong and women as sensitive and emotional. As a result, men’s chronic pain was managed more effectively, while women received more antidepressants and mental health care referrals. Anti-biased language functions not only to improve subjective feelings toward patients but also to ensure they receive equitable treatment.
Because I think we can do better with addressing bias in medical school, beginning with biased language, I have organized an anti-biased language session for my medical school peers based on a pilot workshop for health care professionals on reducing stigmatizing language in medicine. Reflecting on and updating the words we choose with colleagues and patients should be a requisite part of practicing ethical and evidence-based medicine.
Image credit: Diana, anatomy (CC BY-NC 2.0) by ClassicalRenewal
Editor’s note: The views expressed in this article are the author’s and do not reflect those of in-Training or Pager Publications, Inc.