Health Equity Comes To Medical Illustrations With Launch Of New Image Library

Beauty may be in the eye of the beholder, as the saying goes, but it is not fully represented in medical textbooks. A new initiative, launched last week, aims to change that.

The Reframing Revolution is a royalty-free digital gallery of images that reflect broad diversity of women and women’s bodies. Created by Peanut, an online community for women, the gallery includes hundreds of images of women with a range of skin tones, body shapes, and body hair. The gallery also includes images of elderly bodies and trans and non-binary people. It addresses pregnancy, childbirth, and menopause, among other conditions.

According to research, fewer than 5% of images in medical textbooks show dark skin. Though images generally reflect the distribution of the U.S. population by race, with 20% of images showing Black people and 17% showing other people of color, 75% of those images are of people with lighter skin tones.

A 2022 study of skin tone representation in college-level human sexuality textbooks showed that just 1% of images represented dark skin tones. In a 2021 review of imagery used in the New England Journal of Medicine, 18% of images across specialties and regions were of non-white skin, but in some areas, there were zero images of non-white patients.

Racial and ethnic health disparities have garnered significant attention recently, with large corporations and healthcare institutions taking steps to prioritize health equity.

But that focus hasn’t yet reached medical illustrations and imagery. The clinical consequences of misrepresentation—or limited representation—can be serious.

For example, in dermatology, misdiagnoses and missed diagnoses in people of color can often be attributed to skin color. According to research, people of color may be less likely than others to get skin cancer but more likely to die from it due to later diagnosis and lack of awareness of skin cancer risks.

Lack of diversity in medical imagery can do more than harm people of color. It can also lead to confusion among women and their healthcare providers about what is normal.

In an Australian study focused on female genital cosmetic surgery, 97% of healthcare providers reported that patients expressed concern about whether their genitals were normal or not. Only three-quarters of those providers felt confident assessing or explaining what genital normalcy is.

“The reality is that there is no normal when it comes to body types,” said Michelle Kennedy, founder and CEO of Peanut.

Historically, though, women have been portrayed as nearly universally white, slim, hairless, young, and able-bodied, according to Kennedy. When women don’t fit within this narrow set of images, they risk not getting the healthcare they need.

Kennedy says Peanut decided to take matters into their own hands. Working with Dr. Somi Javaid, an obstetrician/gynecologist and founder of HerMD, and with Biotic Artlab, a visual communications studio, Peanut created imagery that accurately depicts normal anatomy of a wide range of bodies.

The target audience for the new image library includes representatives from the media and the medical community, as well as women themselves.

The images have been thought provoking—even shocking—according to Kennedy. She said some women haven’t been able to immediately articulate or understand why they are shocked by the images. Reflecting on their emotional responses, Kennedy said, women sometimes realize they have literally never seen images like these before and certainly have never been told that such variety in body types and body parts is normal.

Even more than shock at the images themselves, Kennedy said, women find themselves shocked that they have been so accepting of the status quo in how women’s bodies are represented—or not represented.

“I hope every woman discovers these images at some point in her life, that she feels seen and represented, and that eventually these archaic images we are all so accepting of become a thing of the past,” Kennedy said. “We’re hoping to not only educate patients and the medical field but society at large. Women and mothers in all their forms, sizes, and identities need to be represented.”