The anatomy of diversity: Applying critical disability theory to anatomy education

We like to think that we are more progressive than the Romans. And, in many ways, we are. Advances in medicine have eradicated many deadly diseases, and our understanding of public health is such that we no longer use lead as a sweetener.¹ However, when it comes to the attitudes and systemic inequalities surrounding disability, our progress is, surprisingly, less impressive. While we may no longer marginalize disabled people in exactly the same way the Romans did (which, horrifyingly, often involved abandoning newborn disabled children to the elements²), ableism continues within our society in both overt and hidden ways.³ And make no doubt about it, ableism is violence.⁴

Ableism is evident within all branches of health professions education,⁵ including anatomy education.⁶ Traditional anatomy curricula, models, and textbooks feature the “ideal” body, excluding or marginalizing representations of disability and so equating normality with bodies that are enabled.⁷ * Dissection and prosection usually occur on donors without visible disabilities, adding to a lack of disabled representation within anatomy education.^{8, 9} This, coupled with a frequent focus on teaching what is considered to be “normal” anatomy,⁹ implies that any deviation is abnormal or of lesser importance. This tendency to depict and prioritize the “ideal” body within anatomy education is not only a reflection of historical biases; it actively shapes the perception and attitudes of future anatomists and healthcare professionals and could negatively influence their ability to provide inclusive, empathetic care to diverse patient and learner populations. This is detrimental, given that anatomists play key roles in giving language to the human body and in shaping learners' perspectives on the body, its function, and variation at a formative stage in health professions education.¹⁰

Critical disability theory (hereafter, CDT) can provide us with a framework for understanding and addressing the ableism perpetuated within anatomy education materials, attitudes, and behaviors. We operate in line with Hall's¹¹ understanding that CDT is an interdisciplinary methodology that includes critical disability studies but expands to encompass a broad range of theories from across multiple disciplines.¹¹† As a methodology, CDT challenges individualistic explanations of, and perspectives on, disability. Simply, it puts forth that disability is not an inherent personal deficit, or a personal responsibility, but results from complex interactions between social, cultural, political, and economic factors. Though language is debated and there are differences in preferences between countries and between communities, many CDT scholars use identity-first language (i.e., disabled person, rather than person-first language person with a disability), in recognition of the importance of disability as an inherent and valued aspect of identity and diversity.¹³ It is important to respect the preferences of those within various communities regarding language—for example, people with cognitive disabilities tend to use person-first language, whilst Autistic people tend to use identity-first language.¹⁴ Given that we are engaging with CDT, and based on our own preferences as UK scholars, one of whom is disabled and uses identity-first language, we use identity-first language throughout. Overall, our purpose in employing CDT is to question established approaches to, and perspectives on, disability within a field and take action to advocate for changes in practice. This is a key tenant of CDT, and scholars must make themselves activists through their work.¹⁵

Despite its uptake within academia more broadly, and increasing references to critical approaches to studying disability within health professions education, we have identified an absence in exploring the intersection of CDT and anatomy education. Whilst it is not our intention for this to become a formal or comprehensive literature review, a series of searches using the keywords (“anatomy” AND “education”) AND (“critical disability studies”) across key medical and health databases (including MEDLINE, PubMed, ERIC, and Web of Knowledge) in January 2023 returned no relevant papers. Considering ongoing ableism within the field's practices (as with other branches of health professions education), and our own experience of this gap in the field, this absence is concerning.

This Viewpoint article aims to bridge this gap by applying critical disability theory to anatomy education. We explore, integrating our personal experiences as learners and teachers of anatomy with CDT literature, how CDT can inform and transform contemporary anatomy education, supporting inclusivity of practice. We offer practical tips and approaches to education in service of this objective.

Our joint perspective is informed by lived experience of disability, of work as a healthcare professional, and by experiences from the perspective of teacher and learner. The varied experiences of our team add depth to our exploration, including deep understanding of the challenges and oppression disabled people face, and practical understanding of the realities of educational practice. Our experiences of anatomy and anatomy education, in particular, have provided us with a sensitivity to the language used when discussing the human body. We hope to leverage these diverse perspectives to offer a path forward for a more holistic approach to anatomy education that challenges ableist norms and promotes inclusivity.

Ableism involves discrimination or social prejudice based on an individual's physical, emotional, mental, or cognitive status.³ In its most basic, and shocking form, it is the belief that people fitting a specific standard of what is deemed “normal” physical, mental, or emotional ability, are superior to those not meeting these socially constructed standards. Ableism can be internalized, in that it can be unconsciously adopted by individuals (who may or may not be disabled), leading them to undervalue their own, or others' own, abilities, and worth. This internalization is a result of pervasive societal attitudes and can have a profound impact on a person's well-being, as well as mental health.¹⁶

Ableism also manifests externally in various ways, particularly in institutions and societal structures¹⁷. Most people will be familiar with the ways that it appears in the form of physical barriers, such as inaccessible buildings and transportation, but perhaps less familiar with its manifestation as attitudinal barriers, such as prejudice and the stigmatization of disability.¹⁸

Research specifically focusing on ableism within anatomy education is limited. Within broader educational literature, we know that the presence of ableist ideas and assumptions within the curricula acts to reinforce stereotypes. This contributes to the isolation and marginalization of disabled students and learners.¹⁹ In the health professions, curricula contain limited content on disabled people's experiences, which negatively influences student awareness (e.g., within Kinesiology: Narasaki-Jara et al.²⁰). Whilst some professions are making progress at inclusion of content to enhance learner understandings of disability (e.g., within Occupational Therapy and Physiotherapy²¹), the overall representation of disability in curricula remains inadequate both in terms of strength and nature of representation²²—for example, in a recent analysis of cases within a case-based learning medical school curricula at one institution, only 4/53 cases mentioned disability, and none defined disability according to CDT.²³

In anatomy education specifically, there has been a sustained framing of disability as a problem for academic performance for the past five decades (see, e.g., Rochford²⁴ which discusses “spatial learning disabilities” and exam underachievement in anatomy), which has only begun to shift meaningfully in the last few years. There have, across the past few years, been early calls for diverse representation within teaching materials and practices that are inclusive of disability.¹⁰ An intersectional approach to representation is key, though most literature focused on diverse representation within anatomy education does not consider disability as an intersection of minoritized identity. Whilst there is space for in-depth exploration of individual minoritized identities within the context of anatomy education, we see a gap for intersectional approaches inclusive of disability.

We have compiled a list of possible ways ableism might manifest, drawing from wider educational literature on ableism, and our own personal experiences in anatomy education. This list is given, for context, in Table 1.

Whilst a comprehensive review of CDT is beyond the scope of this relatively focused Viewpoint article, here we offer some additional detail on this methodology to contextualize our discussion of its application to anatomy education and also to act as a repository for relevant and pertinent references to those interested in taking this methodology forwards in their own work may wish to explore.

CDT, as previously, is a methodology that challenges ableist and individualistic views of disability. Many working in health professions education will have been taught the “medical model” of disability, where disability is framed and discussed as a pathology or problem that needs addressing.²⁵ CDT counters this perspective, and a key tenant of the methodology is emphasis on disability as a social construct, influenced by social, cultural, economic, and political contexts and norms.¹⁵ CDT is necessarily interdisciplinary and benefits from working across disciplines as the methodology can draw on theories from psychology, sociology, education, law, etc., to explore and analyze how society constructs and perceives disability at various levels (e.g., individual, group, the level of organizations, the level of societal structures such as schools, and healthcare).¹¹ Importantly, CDT is an intersectional methodology and promotes exploring disability and challenging oppression across minoritized identities, given the intersecting nature of discrimination.²⁶

Building on its foundational argument that disability is a social construct, scholars exploring society using CDT often argue, in various contexts, that society is ableist and exclusionary by design (e.g., Hamraie²⁷). In other words, people within society build societal structures so that they have barriers that prevent disabled people from full participation and thriving in all contexts. The concept of Universal Design is an idea beginning to take root within medical education, where Jain and Scott²⁸ have discussed the importance of this approach in building truly accessible environments for all, rather than taking a more individualistic approach to helping singular people, or small groups, vault over barriers.

Translational work is also key to CDT, that is, the idea that academics, educators, and scholars should not only engage in theoretical work but also use theoretical work to drive real change in the world. Academics and educators occupy positions of professional power and often experience privilege across many intersections in their own identities. It stands, then, that they have the potential to enact significant positive change if they take action and responsibility to do so. Translating academic and educational research into practice, including but not limited to changes to teaching and learning, activism, and advocacy, is key. This helps us move beyond a purely theoretical approach to exploring disability within anatomy education to the design and implementation of pedagogical strategies that support inclusivity across diverse contexts internationally.

Given the emphasis within CDT on practice, here we consider the practical implications of this discussion of CDT and manifestations of ableism within anatomy education for anatomy educators, and educational researchers.

When considering the practical implications of CDT for anatomy education, we see the radical potential this methodology offers for the field. Underscoring all of the implications we suggest herein is the need for additional research. We lead with this need as this discussion has largely been informed by wider theory and our own practice, rather than empirical work scrutinizing the application of this methodology to the varied educational contexts and issues within anatomy education. Empirical research on disability and ableism within anatomy education, and work drawing on or applying CDT is key if we are to move forwards toward practice inclusive of, and for, disabled people.

The first implication we wish to highlight involves a close examination of current curricula for ways in which a focus on the “ideal” body is upheld, and perpetuated. The concept of the “hidden curriculum” is well-established within anatomy education, the idea that curricula send messages outside what is formally said or taught.^29-31 Anatomy education's current lack of representation of disability and focus on “normal” anatomy sends a strong message through the hidden curriculum about what “normality” is (i.e., that it excludes disability). A broader spectrum of human diversity, for example, within anatomical models, is important, including the representation of disabled people with varied types of disability, to begin to shift hidden curricula messaging. This should begin to help broaden understanding in a way that reflects the diversity that is present within the population; graduating students will go on to serve as healthcare professionals and/or as educators.⁷ Addressing the hidden curriculum is notoriously challenging—it can be difficult to “see” what is “hidden,” and to bring about change requires consistent and concentrated effort.³² Learners, as new entrants into educational spaces, offer fresh sets of eyes on hidden curricula and are well-placed to identify the implied ways that “things are done.” Working with learners, collaboratively, to audit and address³³ the ways in which the “ideal body” is held up as the gold standard by anatomy curricula represents a promising direction for addressing current ableism within curricula content,³⁴ and filling gaps that can equally communicate messages through the absence of content.³⁰ Considering opportunities within anatomy education to reflect on how anatomy changes over the course of one's life, and how donors may become disabled at different times, may help counter this narrative. Educators also have important roles to play as role models—one way in which the hidden curriculum is communicated is through role modeling³²—when faced, for example, with a more challenging dissection with a visibly disabled donor, communicating frustration sends a message to learners that this donors' body does not conform to the expected norm, and thus is less valuable for educational purposes.

The second implication we feel it is important to communicate to educators and researchers is the importance of learning about, considering, and adopting pedagogical strategies that forefront accessibility. This means doing more than only adjusting your individual teaching materials (e.g., adding closed captions to videos) or approaches (e.g., not penalizing absences) to enhance accessibility, though these changes form a necessary and important part of overall work to facilitate the creation of accessible environments. Jain and Scott,²⁸ writing within the context of medical education, insightfully observe: “When barriers are left in place but addressed through individualised means, we believe too often this practice reflects inertia rather than thoughtful deliberation at the nexus of norms and values” (p. 1) and, as previously in this article, introduce Universal Design to the field as a way of building from inception accessible environments. The path to anatomy education environments that adhere to the principles of universal design involves questioning the approach we currently take to addressing challenges or barriers within our educational environments. A critical perspective on how our current actions to remove barriers, though well-intentioned, could be misguided in that they sustain an individualistic approach to accessibility is key.³⁵ Whilst we are not suggesting educators disengage with supporting individuals to address barriers to accessibility, we are suggesting, aligned with Jain and Scott,²⁸ that this needs to be coupled with deep and reflexive thought regarding the implications of their practice and the way in which barrier removal is framed and treated by their organization. Engaging in advocacy to build environments that are accessible from the ground up, and adhere to Universal Design principles, challenges the ableism within anatomy education resulting from inaccessible environments by design. We have provided some examples on how anatomy education may engage with universal design, to anchor this suggestion, in Table 2.

Our final recommendation for educators and researchers is that we all must consider how we can take more active roles in advocating for disabled people's rights and equity within educational environments. Just as we, in this section of our article, are attempting to translate theoretical insights to practice, so too must we all continuously look for opportunities to influence how things are done at a ground level.³⁶ Whilst we have attempted to offer practical recommendations, without implementation and action on these in practice, efforts are wasted.³⁷ Anatomists are particularly well-placed to become disability advocates, as practitioners with deep knowledge of the human body, variations in bodily type and function, and as educators who work closely with students in formative stages of their education (e.g., in medical education anatomy instruction occurs from an early stage in most programs).¹⁰

Activism will depend on the context of each educators' organization and setting but may involve advocating for more inclusive curricula content, or teaching strategies (as above), widening access and participation to education and/or employment, and promoting policies nationally and organisationally that provide disabled people with opportunities to thrive, as well as survive. Activism can present significant challenges,³⁸ for example, criticism from those who seek to uphold the status quo, challenges balancing teaching commitments and activism, etc., and so taking steps to find a community of support through like-minded peers and mentors is key. Building this network of support benefits not only activism efforts, where collaborative action is beneficial but also each individual in access to advice and guidance.³⁹ Just as what activism looks like in practice differs, so too will this community—educators might seek local colleagues (we would suggest engaging in equity committees, for example, as a way of identifying people with shared interests), or national and international colleagues (e.g., through conference networks, or social media).

In this Viewpoint article, we have utilized critical disability theory (CDT) to explore how ableism within anatomy education can be actively addressed by educators and researchers working in the field. We have drawn on our own lived experiences to consider key manifestations of ableism within anatomy education—namely, gaps in knowledge and content, biased content and teaching strategies, poor accessibility, and poor representation—and offered three headline recommendations for educators interested in addressing these manifestations of ableism: (1) Critically examine the hidden curricula, (2) embrace universal design, and (3) engage proactively in activism. This article represents an early springboard for these conversations, and there are significant gaps regarding what we know in relation to disability and ableism within anatomy education. We hope researchers will take up the mantle regarding the need for further work exploring the hidden curriculum in this space, and application of CDT as a methodology. Collectively, as educators, researchers, and scholars, it is critical that we not only understand the “anatomy” of diversity but also actively engage in practices that challenge ableist norms and promote inclusivity. We might do well to remember that to move past the antiquated views of our forebears, anatomy education should not just be for the “ideal” body, but for every body.

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