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Response to “Language Matters: Reflecting on Bias in an Anatomy Textbook”

To the Editor:

​​The recent article “Language Matters: Reflecting on Bias in an Anatomy Textbook” looks at the premise that “the sanctity of medical ‘truth’ and ‘evidence’ should preclude any bias.” We agree with this sentiment and acknowledge that historically there has been a lack of diversity and sexual equitability in the presentation of anatomy in textbooks and atlases. In this article, the textbook referenced by the writer was printed in early 2014. While we acknowledge that there have been deficiencies in our textbooks in the past, a lot of content has been updated in newer editions. We continually review the visual and text content to meet the latest medical standards and to depict diverse representations. 

As authors and editors, we take our “responsibility to future physicians and patients” seriously and have consistently made efforts to eradicate bias and ensure equitable representation in our textbooks. For example, during the 1900s, North American and European anatomy atlases and textbooks depicted anatomy using exclusively white and mostly male illustrations, except when required by sexual distinction. We identified this as a problem and, in 2002, undertook an extensive surface anatomy photoshoot, after which Grant’s Atlas of Anatomy 11e, Clinically Oriented Anatomy 5e, and Essential Clinical Anatomy 4e became the first anatomy atlas and textbooks to demonstrate racial and sexual diversity throughout. 

While an important “first step,” literally changing the face of anatomy, the alterations were mostly limited to the surface anatomy photographs. This bias remained evident in illustrations, which are more difficult to re-render, revise, or replace. In subsequent editions, we made a concerted effort to rectify the problem with new or revised figures. We feel we are now close to achieving this important goal. We recognize that students need to study anatomy that reflects the diversity of the patients they are likely to serve. This is an important step towards eradicating medical bias in future physicians.

We have also worked to provide equitable descriptions of gender in our textbooks. In terms of content, anatomy and physiology textbooks largely give attention to male and female sexual anatomy proportionate to their anatomical detail and clinical importance. However, this has not been true for the external genitalia. It’s fair to say that sparse attention has been given to female external genitals and the erectile organ in particular. Within the history of anatomy and physiology textbooks, the clitoris has generally been treated as a miniature penis minus a urethra, and little anatomical information has been provided about it. This is due to a lack of information in the medical literature itself. For example, if you ask most students who have completed their anatomy studies to draw a transverse section of the penis, they will probably be able to produce a reasonable diagram demonstrating the internal anatomy; those same students will be unlikely to have the basis to do something comparable to demonstrate the anatomy of the clitoris. 

This biased representation is a problem, and we have sought to rectify it in our most recent editions. Our own dissections resulted in information that enabled the 9th edition of Moore’s Clinically Oriented Anatomy, released in 2021, and the 7th edition of Moore’s Essential Clinical Anatomy (currently in press) to be the first anatomy textbooks to graphically demonstrate the unique anatomy of the clitoris. We also found that Dr. Grant’s original illustrations, now artistically updated and included in both textbooks, provided an accurate demonstration of the female erectile structures, now referred to as the bulboclitoral organ. In their most recent editions, both textbooks were the first to provide equitable coverage — in both illustration and text — to the female and male external genitalia. We intend to do more in this regard in future editions.

Additionally, the introduction chapter to each Moore’s textbook now includes content that addresses the difference between sex and gender, stating that gender identity is not binary, and that awareness of concepts like gender dysphoria is important for trust and understanding in medical practice. Gender transitioning and gender confirmation surgery are addressed in a clinical correlation, and we have made efforts to avoid the use of binary pronouns. As these efforts demonstrate, achieving equity and diversity are ongoing processes to which we aspire and are aware and dedicated.

While we acknowledge the importance of ongoing editorial vigilance to eradicate bias, we take exception to take terms out of their anatomical context and presenting them as suggesting evidence of bias. For example, it is indicated in the piece that terms such as “thin” and “communicating” are female “tropes.” “Thin” is used in relation to the hairless skin of the labia minora. “Thin skin” is a standard histological description of skin, distinct from “thick skin” such as that of the palms and soles — of either sex. “Communicating” is used in reference to the continuity of the ovarian tubes with the peritoneal cavity, an anatomical fact vital to the process of ovulation. This is a distinctly female anatomical phenomenon — no such communication exists in the male. 

Furthermore, it is incorrect that “Moore’s describes female anatomy as less ‘developed’ than male anatomy.” The term “development” is used specifically in the context of “muscle development” within the pelvic floor. It is common usage and knowledge that exercised muscles become more “developed.” Functional requirements related to urination and ejaculation exercise male perineal muscles routinely, while the same is not true for female pelvic floor muscles. Subsequently, female patients may be encouraged to consciously engage in Kegel exercises with the intention of strengthening (developing) a stronger pelvic floor to help prevent prolapse or reduce problems of urinary incontinence. When placed in their proper anatomical context, we believe the use of the other terms mentioned can be similarly explained. Our books have never described the vagina as vulnerable or delicate, instead emphasizing the practical and clinical importance of its marked distensibility.

In summary, it’s not difficult in our society to find fault with where we’ve been. It is more just, however, to accurately recognize corrections of past omissions and give credit for how far we’ve come. This provides an indication of further progress in the making.

Drs. Anne M. R. Agur and Arthur F. Dalley II
Authors, Moore’s Essential Clinical Anatomy, Moore’s Clinically Oriented Anatomy, and
Grant’s Atlas of Anatomy

Anne Agur Anne Agur (0 Posts)

Physician Guest Author

University of Toronto

Dr. Agur has been a teacher and researcher in the Division of Anatomy, Department of Surgery, Faculty of Medicine University of Toronto, for more than 40 years with a primary research interest in clinically applied normal vs pathological structure and function of the musculoskeletal system including joints, musculotendinous architecture, innervation patterns, spasticity, and pain-generating mechanisms. Dr. Agur has published widely with over 150 peer reviewed publications in basic science, clinical and education journals. Her areas of teaching expertise include clinical anatomy, histology, embryology, and neuroscience. Dr. Agur has received numerous teaching and mentorship awards for her role in the education of Medical, Physical Therapy, Occupational Therapy, Biomedical Communications and Graduate students, as well as for resident teaching and continuing medical education for specialized healthcare practitioners. Dr. Agur has authored/edited numerous books, including Grant’s Atlas of Anatomy (9th-15th ed), Moore’s Essential Clinical Anatomy (1st-7th ed), and Moore’s Clinically Oriented Anatomy (6th-9th editions), mostly with Drs. Moore and Dalley. Anne has received the Henry Gray Distinguished Educator Award, the highest education award for human anatomy education in the anatomical sciences from the American Association of Anatomists (AAA). She is also a Fellow of the AAA. The American Association of Clinical Anatomists awarded Anne the Honored Membership Award “For her distinguished career in and dedicated enthusiasm for, clinically applied anatomy; particularly in recognition of her scholarship, mentoring of research, and education of students around the world.”

Arthur Dalley (1 Posts)

Physician Guest Author

Vanderbilt University School of Medicine

Arthur F. Dalley, II, Ph.D., is Professor Emeritus in the Department of Cell and Developmental Biology at the Vanderbilt University School of Medicine, where served as Director for Medical Gross Anatomy and the Vanderbilt Anatomical Donations Program. He held adjunct appointments in Orthopaedic Surgery and at the Belmont University School of Physical Therapy. His work at Vanderbilt was preceded by 24 years at the Creighton University School of Medicine and 1-year sabbatical at the Mayo Clinic. He received Bachelor of Science (Zoology) and Doctoral Degrees (Anatomy) from the University of Utah. Vanderbilt student and peer teaching awards include Excellence in Teaching and Research for Innovations in Educational Programming Proven to be Effective, election to the AΩA Medical Honor Society and the Vanderbilt Academy for Excellence in Education, recognition as a Master Basic Sciences Teacher, and the graduating class’ annual Shovel Award for Outstanding Faculty Member. National awards include the AAMC/AΩA Robert J. Glazer Distinguished Teacher Award. He received 10 Golden Apple Awards while at Creighton University. In addition to co-authoring multiple editions of textbooks and an atlas with Drs.Keith Moore and Anne Agur (Moore’s Essential Clinical Anatomy, Moore’s Clinically Oriented Anatomy, Clinical Anatomy Cases, and Grant’s Atlas of Anatomy) that have translated into many languages, he served as the Gross Anatomy Consultant for the Stedman's Medical Dictionaries. Dr. Dalley is a founding member of the American Association of Clinical Anatomists, for which he served in all executive offices and editorial board of the journal CLINICAL ANATOMY. He also received the AACA’s highest honors, Honored Membership and the R. Benton Adkins Jr. Distinguished Service Award. He has been a member of the American Association of Anatomists since 1973, serving on the Board of Directors and the Sr. Advisory Board for the journal, Anatomical Educator. He was awarded the AAA’s highest educator honor, the Henry Gray Distinguished Educator Medal, and was named a Fellow of the AAA in 2015.