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Commentary: Knowing It When We See It: Reflections on Pornography

Hull, Sharon K. MD, MPH

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doi: 10.1097/ACM.0b013e3181939222
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In this issue, Dr. Edward Halperin1 presents the tale of an ill-fated anatomy textbook that created a firestorm of criticism from the emerging feminist movement in the early 1970s when it was published. Explaining the relevance of this article to medical education today, he indicates that this story “can teach us that medicine is fundamentally a social activity which occurs in the context of social mores and customs … [and] … that mutual respect between student and teacher or author and reader is an essential element of education.”1 In these statements, he is correct. But why, exactly, do we need to read this article at this time in the history of medical education?

I must reflect upon my personal response to Halperin’s article and my own career experiences in order to answer this query. Upon being asked to offer commentary on this article, I seriously questioned the decision to publish it, particularly if the photograph of a nude woman in a “pinup” pose was to be included. There seems no academic necessity for the inclusion of the photograph, and I was not convinced that there was a need for the paper to be published at all. However, my reaction has evolved over time, and over the writing of this commentary. It is this evolution that perhaps offers a rationale for the importance of reading Halperin’s article.

At first encounter, the title and abstract catch my attention, compelling a full reading of the narrative on the strength of tabloid interest alone—I am captivated. As I reach the heart of the tale, I ask several questions. Is this just a lively historical footnote, or should I be outraged that this text was ever used to teach medical students? What can we learn from this anecdote? I am fascinated by the intrigues of the medical publishing industry and horrified at the degree of ingrained sexual exploitation so recently tolerated. And then I come to the photographs … and ask, “Why on earth should we reproduce these photographs in a journal of the stature of Academic Medicine? Or, do we learn something valuable by seeing the vivid proof of acculturated sexism as it existed just a few years ago?”

The generational context of feminist response to intimidating and otherwise inappropriate behavior is important in framing the reasons for reading this article today. Historically, the “first wave” of feminism resulted in the women’s suffrage movement in the late 19th and early 20th centuries; the “second wave” describes the women’s liberation movement of the 1960s and 1970s. The “third wave” of the feminist movement arose at the end of the 20th century and redefined the tenets of feminism; women from this era view gender issues, and the raising of the alarm over harassment and sexism, very differently from their predecessors.2

Wear and colleagues3 describe the ways in which women medical students from this third-wave group tend to choose nonconfrontational approaches to sexual harassment and discrimination such as avoiding those whose behavior is offensive, and choosing not to report offensive behavior in order to be seen as “team players,” or out of a conviction that reporting the behavior will not change it. This has been evident to me over the course of many years in medical education, both as a faculty member and as an administrator. I have personally counseled medical students, in the not-too-distant past, to come forward in an “official” capacity regarding their very personal experiences of unprofessional behavior on the part of medical school faculty, both clinical and nonclinical. Learners of both genders, responding to myriad forms of inappropriate behavior, still hesitate or decline to report such behavior, despite efforts to normalize appropriate faculty–learner interactions and efforts to provide a “safe haven” for reports from those affected by abuses of power or authority.

Why are women of my generation hesitant to address unprofessional behavior amongst our colleagues, given today’s less tolerant environment for such behavior compared to that encountered by Dr. Estelle Raimey and those who helped her counter the publication of this textbook? In discussing this with colleagues from the era of second-wave feminism, some of them report that they did not speak up because they could not do so and “get in the door.” It is possible that my generation of women, as well as other historically underrepresented minorities, having “gotten in the door” of medicine in increased numbers, feel they cannot speak up and remain in the profession. Perhaps we have become complacent in the face of the many advances that have been made, both in support of women in medicine and in the diminished tolerance for outright sexist behavior. It is important to remember, though, that the threat of retaliation is not gone and that the price of speaking up remains high.

This, to me, is the heart of the issue, the key to the relevance of Halperin’s paper. I believe I shall always find the photograph objectionable, but I have come to believe that we must read this story because the violation of professional mores between teacher and learner still occurs. We must not see the publication of this textbook as a mere historical footnote, nor should we take solace in the retelling of the story and the inclusion of the pinup photograph in this journal in 2009 as simply a description of a problem from bygone days. For all the openness we profess in the academy, our learners still find it difficult to speak up about such behavior.

For those who still do not speak up, for those who have the courage to speak and who find that retaliation remains a reality, for Dr. Raimey and others like her, on whose shoulders we all stand, please read Halperin’s article. Reflect on your own responses to it, whatever they may be. And please forward it to a colleague.


1 Halperin EC. The pornographic anatomy book? The curious tale of The Anatomical Basis of Medical Practice. Acad Med. 2009;84:278–283.
2 Orr CM. Charting the currents of the third wave. Hypatia. 1997;12:29–45.
3 Wear D, Aultman JM, Borges NJ. Retheorizing sexual harassment in medical education: Women students’ perceptions at five U.S. medical schools. Teach Learn Med. 2007;19:20–29.
© 2009 Association of American Medical Colleges