Considerations for a Standardized approach to the Use of Nudity in the Clinical Photograph

Michael Peres, MS, RBP
Chair, Biomedical Photographic Communications
Rochester Institute of Technology
Rochester, New York 14623

Dr Stanley Burns, MD, FACS
Director, The Stanley B Burns, M.D. Collection
140 East 38th Street
New York New York, 10016

Dr. David Teplica, MD, MFA
Director Burn Awareness Program
& CEO of D_Teplica Plastic Surgery
Chicago, Illinois

Photography has become an indispensable tool in the delivery of information for the physician and researcher for obvious reasons that need no development. As a tool photography, was quickly adopted a useful way to teach and share from its earliest origins. Because photographic recording has become so common place within medicine for teaching, documentation, research, judicial as well as inspiring contemporary art, many approaches to the making pictures have become rather matter of fact. Consequently, the analysis of approaches used in the production of clinical photography may not be considered to the complexities that reside within.

There are a number of choices every photographer makes prior to making clinical photographs. Many of these approaches are grounded in fact and they may include all the standardized techniques accepted by the practitioners of professional. Proper photographic choice and use of sensitized products and lighting are some examples. Professional competency and experience also influence the approach, however these outcomes reside in ability and skill level. There are however, many subjective choices that also need to be made to produce successful clinical photographs. Composition is one such example as well as the choice to use, and how to include nudity in clinical photography.

Within medicine nudity is extremely common. "OK, Mr. Peres. If you could please take off your clothes and step into this gown, Doctor will be right with you." This request is so common that the physician and the patient proceed almost reflexively. Without reservation nudity and medicine are synonymous. It is the norm. A physician cannot perform a physical exam without the removal of clothing and disrobing is in no way viewed in any other context than as a part of a medical examination. Nudity is not wrong nor dirty and is an absolute necessity. Physicians of genders opposite their patients routinely perform exams with minimal concern for chaperons or claims of impropriety. This is an accepted behavior and part of our society's culture There is absolute belief in the integrity and importance of our society's physicians and trust their requests as relates to treatment.

The use of total nudity is not necessary for all medical exams nor all procedures. In an unscientific random survey of physicians, it was ascertained that for only a few examinations, the absolute minority, is total nudity ever requested. For these, the requirement of nudity is never minimized or made to be in way unusual. In the physical exam between patient and physician, there is a privacy that is unique and focused on the examination, diagnosis and treatment plan. The full acceptance of nudity is real. However when photography requiring nudity is necessary , the why, what and how to considerations are ill defined for many. These subjective decisions provide often challenging problems for some practitioners of clinical photography. This might include the professional medical photographer as well as the physician/photographer. There is an important distinction to make at this juncture differentiating the professional medical photographer from the physician/photographer. Although both make pictures , they probably cannot be considered as the same. As a result of the need for clinical photography, each group has a strong overlap in this arena. Clearly there is more photographic preparation for the professional medical photographer, which in no diminishes the great need of the physician for self generated medical photographs. Often access or expenses preclude physicians for accessing these services routinely. Unfortunately though, the preparation of the medical photographer within the medical environment, specifically as it relates to management of nudity in clinical photography, is an area of minimal preparation.

The standardization and integration of personal approaches used in the examination performed by the physician is first discussed and learned in medical school. There are accepted practices and procedures that are subscribed to and utilized as this standard of conduct. Within the residency experience, necessary personal approaches used in performing exams are honed by each of the future practitioners under the guise of an attending or Chief. This allows for the developing of personal style and comfort level. Within this time, as with all approaches, nudity becomes inconsequential to the treatment and in the opinion of the author, is a problem for the patient, not the practitioner. Obviously this an oversimplification of the educational procedures used, however the point being, attention is paid to the management of nudity in treatment by physicians.For a medical photographer, nudity is routinely encountered. Nudity cannot be avoided for the surgical photographer and it is also very common in many of the other clinical areas including dermatology, orthopedics, pediatrics and plastic surgery as some examples. The main difference for the photographer in these various specialization's, is that patient is fully cognizant of the nudity in the clinical photography as well as their own modesty . Given the frequency for potentials with nudity, limited writings and publication were found by this author evaluating approaches to the management of nudity in clinical photography.

In all the literature searches including the medical photography classics written by Hansell, Williams, Gibson, Smialowski, Longmore and others, this author observed that great detail was spent in each text discussing the standardization of photographic treatments which are vital. In these same texts, minimal attention was devoted to the patient treatment and how to serve the best interest of the patient. Do not misinterpret the author's comments as to diminish the importance of such approaches. The standardization of photographic activities for clinical photography is imperative.

Before further examination of the management of nudity and its requirement in clinical recordings, several points need to be reiterated. The photographic print or transparency is a visual record that can be made at anytime and by anyone. The photographic record is not real and if used in areas outside its intended application, can be misinterpreted. Additionally it must be considered that the taking of clinical photographs is not, nor has it been solely the purview of the clinical photographer. Tools and technology have enabled pictures to be made by everyone with a minimal of skill. The author speculates that if a survey could be undertaken to ascertain who is making the greatest amount of clinical photographs today, it would not be the professional medical photographers , but rather the physician /photographers who produce the majority of clinical photographs. As the further analysis of nudity in clinical recordings is evaluated, these points must be kept in perspective.

The goal of clinical photography is to be an effective visual aid based on, and created for, a specific need displaying the highest degree of photographic excellence. Clinical photography might include but certainly not be limited to applications necessary in grant writing, medical education as well as other publication and media. Patients requiring clinical photography typically have specific reasons to do so and as a result, criteria can be easily be assigned as measuring instruments to assess the success or failure of a photograph. Absolute criteria, found in all the classical literature discussing clinical photography, are the following:
- the correct exposure and the use of the appropriate sensitized product
- adequate DOF for the picture and anomaly shown
- adequate sharpness and use of shutter speeds
- effective use of light necessary to reveal detail and color or texture
- appropriate background and management of light on the background
- appropriate choice and use of lenses
- appropriate choice and use of patient posing
- correct perspective
- the proper use of informed consent and the patient releases form

Something not universally agreed upon by all authors and medical photographer is the appropriateness and extent of the nudity that is either a necessity and/or proper in clinical recordings. Minimal publishing has been completed evaluating the esoteric issues surrounding work in requiring nudity in clinical photography. Consequently approaches relative to the management and psychology of nudity in the clinical photography session can be quite subjective and influenced by many things.

Clearly there are circumstances where total nudity is the requirement. Dermatology and Orthopedics are examples where the removal of clothes provides much higher quality photography. Also surgeries involving the genitals or where sex abuse is suspected are obvious examples where there is little room to deviate from total nudity. However as within all medical procedures, not all situations require total nudity. Consequently, the when to and how to include total nudity is ill defined for practitioners of clinical photographers.

In reviewing current writings, this author found several valid strategies, while in E.F. Linssen text for example, Medical Photography in Practice © 1961 and Longemore's Guide to Medical Photography © 1969, no mention was made to the management and incorporation of nudity in the clinical photographing . In Arthur Smialowski's work, Photography in Medicine © 1960, he gives brief attention to the topic by stating, " Photographs of patients undergoing orthopedic treatments are often taken with various stages of undress. A dressing room should be provided or a corner of the studio may be separated by a curtain for purposes of a dressing area." He goes on to write, "The patient should change into a hospital gown or smock or be covered by a sheet or blanket until the moment the photograph is to be taken. The patient should be not exposed for any longer than is necessary for taking photographs." Additionally he writes, "The pubic area may be covered with a small binder."
In Peter Hansell's well recognized writings in, A Guide to Medical Photography © 1979 found buried on page 149 is a small discussion about the use of chaperones but no reference in the entire text addresses the how and why to use nudity. Trumball as the primary author writes, " It is always advisable to have a chaperone present if a male photographer is photographing a female patient whose clothing is to be removed. In these circumstances embarrassment to the patient is lessened by a female assisting in the dressing and undressing as well as also preventing the possibility of hysterical accusation of assault against the male photographer.

In Gibson's recognized publication, Clinical Photography, N-3 © 1972, E. Kodak publisher, he initiates the discussion about the topic on page 4 stating that "he(the clinical photographer) takes pictures with part or all of their clothing removed to show what is usually an embarrassing condition or deformity. He should not be embarrassed at nudity nor squeamish about the grimness of advanced conditions." On page 51 he states, "No clothes should appear in the area photographed as a general rule. But when working with teenagers for orthopedic problems, some form of brief can be offered them but only if they appear self conscious." (How is that measured or determined?) It would seem that all teenagers would be self conscious but he goes on to write on page 82, "Neither in the atmosphere in the medical studio nor in the photographic results should there be any hint that the patient does something indecorous by disrobing. The area photographed has to be uncovered; the camera field should be less confined to that area plus an anatomical landmark when feasible; and stray clothing should be kept out of the area. Patients are accustomed to being asked to disrobe in clinical settings and photographers should ask for the same procedures." He concludes his suggestions on p 83 by writing, " a cover should not be routinely offered because in many instances can make a patient suddenly conscientious of a nudity not felt before. As a general rule, apart from other considerations, when a female patient is photographed by a member of the opposite sex, a chaperone should be present. Sometimes in ideal situations, a photographer of the same sex provides the best possibility of managing the session."

In the most recent publication on the topic, Robin and Gigi Williams writes in Biomedical Photography © 1992 that, "Assess which clothing, make-up, watches and other jewelry need to be removed and explain your requirements clearly to the patient. Unless there are strong reasons to the contrary such items should never be appear in clinical photographs Many newcomers to medical photography and incidentally many physicians doubt the necessity of removing all clothing from the field of view. " The authors go on to elaborate, "Exceptions are necessary to prevent patient distress or where clothes or other items are relevant to the condition or in the final photograph of a series showing re-constructive surgery." Additionally strategies suggested include, " Always allow the patient privacy in which to dress and undress and never hurry an ill patient. If necessary, preserve modesty by the use of plain surgical drapes. Alternatively, the patient can wear a plain bikini-type garment in full length pictures if recording the genitalia is not necessary. Never leave the patient uncovered longer than is necessary or ask them to remove more articles of clothing than is required. Take the most embarrassing views first gradually allowing the patient to redress in stages."

These writings, while representing useful recommendations and is in some cases dated, doesn't deliver much specificity. Within the great many practical suggestions learned from this august body of authors, there also exists a great deal of ambiguity and interpretation. How to proceed is left up to the photographer on to how to manage nudity in the clinical setting. The clinical photographer hence is often relegated to their own comfort levels in choosing and using the most appropriate strategies for the practice and management of nudity in clinical photography. There appears to be no conformity to approach at any level and the question must be asked, "can there be?".

In analyzing the didactic education of medical photography, much attention is spent on development of the learning of these critical skills during the student's pursuit of their Associates degree at the Rochester Institute of Technology(RIT). The use of effective lighting, posing, the use of the appropriate lens as well as aperture are all stressed. With additional experiences in close-up photography and further refining of camera skills, most students have solid classroom skills in some of the aspects of clinical photography. It is hoped that while on co-op or work study, the student will be further exposed to the required skills and techniques outlined as criteria above. It should be noted however that at RIT which has no clinical affiliation, the experiences provided are only classroom and are quite different than found in the "real" clinical studio with real "sick" patients.

Within the RIT curriculum, which probably exhibits the most idealistic approach, the department subscribes to teaching and the suggestion of total nudity in clinical photography when appropriate. The reasons are simple. The goal of a good clinical photograph is to be the created using the most appropriate technique and producing the "cleanest" photo possible. The inclusion of articles of clothing, undergarments, drapes and/or other objects such as jewelry or make-up only serve to distract the viewer unless their inclusion is part of the story.
To achieve a credible didactic experience for the student that includes nudity, the department requires an assignment investigating the management of nudity in a clinical photography session. This is accomplished by role playing and critiquing the performance of each student. Each student has 15 minutes to run a complete patient photography session requiring total nudity using a model dermatology patient. Following the exercise, the entire class participates in a debrief. At the RIT, we feel this is a start to an educational experience using a classroom and the assignment only begins to address this most complicated problem.

In practice though, things are very different. The variables, the requirements, and the patient, their maturity, the diagnosis, and their treatment all have great influence on the photography. Based on personal experiences as well as a telephone surveys at the following hospitals and medical schools; Duke University, St. Judes Medical Center, Henry Ford Hospital, Johns Hopkins Medical Center, Medical College of Georgia, Children's Hospital, West Virginia University Medical School, and Southern Illinois, it was learned that approaches used varied widely within the continental United States. Below are some of the responses as per the questions posed by this author:

Question #1
Does your hospital or department have a written policy for the management of nudity in clinical photographs:
All respondents - No

Question #2
What is your departments approach to the management and requirement of nudity in the clinical photographs that are made?
All respondents - It depends

Question #3
It depends on what :
- Physician orders
- Lack of no Institutional Policies
- Department philosophy
- Judicial Potential
- Age of patient
- Photographer's beliefs

Other related comments about the topic:
- Specialized Pediatric policies
- Standard approaches are used in our work to produce the optimal clinical photograph. This often requires total nudity.
- Our facility(private practice) requires total nudity in our pictures. No pictures, no treatment, as specified by the physician
- No faces when total nudity is included
- Study dependent

Clearly in analyzing the answers and the variety of approaches , it can be concluded that there is no accepted standard. One other conclusion made, was that each person queried had strong convictions that their approach was clearly correct because that approach was working. They were convinced of this stance because they were having no problems and that there had been no complaints. This might be a valid assumption however still doesn't resolve which methods chosen are best or most appropriate and considered for adoption as a standard, if one can be created.

The lack of conformity as well as diversity in approaches caused further research resulting in the development of this article. The early history of medical photography seemed a logical path to begin analyzing nudity in clinic photographs. The motivation to start here is simple, possibly patterns and or approaches were either era and/or discipline based. It was hypothesized that possibly a parallel might be drawn from early practices to the current lack of standards.

To ascertain the validity of this hypothesis, examination of many historical references was undertaken including the review of, Masterpieces from Medical Photography, as well as Early Medical Photography in America written by Dr. Stanley Burns, MD, FACS, and produced by the Burns Archives. These publications present an extensive collection of photographs as well as in-depth analysis from which a historical perspective on the use of nudity can be speculated. In the review of all the materials that the author had access to, it became apparent from the onset of photography, and its applications in medical, there were few norms applied to the use of nudity in the clinical photograph.

Before evaluating further, it must remembered, any analysis of early medical photography ,that using a 20th century perspective does little to assist with the understanding or contextual reference to the photographs from this period. Photography was very young as a craft/discipline and so the mechanical execution of exposure, focus and development, management of the subject was quite challenging. Exposures were quite long and so subjects needed to be immobilized using furniture or other stabilizing devices, such as braces that were often included in the pictures. Consequently, many of the early medical photographs might have other implications if taken out of the medical arena because of the almost portrait-like quality many of the photographs exhibit. The photographs that were reviewed also exhibit varying degrees of nudity, ranging from none to total. Based on the background of the photographer/physician who produced much of their own work , very loose compositions were often made of very large fields. Almost universally, it was observed both total nudity and not. In some photographs, articles of clothing remained on the patient with men in their neckties and women in full dress for upper torso anomalies. Some unbuttoning of the blouses was observed to reveal what was necessary. In other examples total nudity was adopted

Through Burns' insightful analysis in Early Medical Photography in America, much can be learned relative to the language of the medium and its importance in using history as a frame of reference. Burns writes that(from William Crawford's Keepers of light), " the significance of photography could never be understood until one understood the problems it solved-that is the problem of accurate visual information". Consequently, trying to analyze the how and why nudity was used in clinical photography produced during this time period needs to be contextual and contrasted to the based on the largest sampling of work possible.

The use of total nudity in medical photography seems out of context in the mid-nineteenth century Victorian era. An understanding however of the popular and scientific mindset of the time is necessary to correctly evaluate the concepts at work. What has been overlooked by contemporary general and photographic history audiences is that the nineteenth century ideology that body configurations and especially head shape were important factors in the psychological and physical determinant of mental and physical disease. This obsession with body shape was generally accepted cultural currency.

In the pre-laboratory medical scientific era the most important scientific data obtainable were related to measurement. Much of this acknowledged as pseudo science persisted right up to the start of World War two. The nude photographs of college students are today well known examples of this philosophy. Other examples too numerous to mention abound. Another classic example is that in the mid 1920's where members of Congress had their head measured for brain capacity. (See below photo)

An powerful example of the importance and acceptance of nudity in medical photography is the photograph of a Polish Hassidic Jew with a glandular dysfunction. Orthodox tenets forbid graven images and photographs of Orthodox Jews in the nineteenth century are exceedingly rare and even partially nude photographs are previously unrecorded. In this image, Moishe Friedner of Krakow had his photograph taken so that he did have to personally travel to Vienna to see the leading specialist in glandular diseases. His local physician sent the photograph instead.
As physicians throughout most of the nineteenth century did not know the cause of disease and symptoms could appear anywhere and perhaps were related to body type-either as a cause or result of the disease(i.e. Tuberculosis) whole body photography was common practice. Covering the genitals was not done nor was covering the face. In Burns collections of 1400 Civil War wounded soldiers only a few covered their genitals in a full nude photograph. It should be noted that these images were for clinical consumption so that when the photographs were presented for public view at the 1876 Centennial, fig leafs were added to cover the genitalia. Many of these later altered copyrights survived and confused some later researchers into believing covering of the genitalia was part of civil war medical photography. In reality the practice of total nudity of seemed isolated body wounds served the purpose of identifying changes in posture and body demeanor. This is especially important in orthopedics.

Several examples of the use of nudity are evidenced in Burns' Master Pieces of Medical Photography. The photograph, Muybridge Study of Human Motion by Eadweard Muybridge, produced in 1887, a most ambitious research project which has yet to be reproduced, utilized total nudity. Unfortunately within Muybridge's body of work, his approaches wander from the use of total nudity to no regard for its use.
Other interesting examples of nudity in clinical photographs can be found in other photographs from the same collection of Dr. Burns. The photography of a young scoliosis patient of Dr. Sayre and his suspension device made in 1877 shows very clear awareness of the use of nudity in a photograph by only removing the young patient's blouse and not fully disrobing the patient. Why might Dr. Sayre have chosen to leave the patient's full dress on below the waist? Was the strategy based on patient modesty or simply removing the dress was never considered? Additionally, this photograph has been reproduced several times as examples of early art containing some erotic overtones. Why would a medical photograph be considered art? The answer to this question resides in context. When viewed with other photos from the same body of work and a reference to medicine, it is clearly medical photography yet out of the context of medicine, the photograph becomes something very different.

The last photograph analyzed in an attempt to draw reference from a historical context to nudity, is entitled Young Women with Elephantiasis from Scarlet Fever taken in 1878. In this photo, the subject has been completely disrobed, however her head has been draped with what appears to be her blouse to conceal her identity. This photo most clearly demonstrates the awareness of nudity by the photographer and concern for the patient's animosity. By covering the patient this way, it might be speculated that the photographer hoped to depersonalize the condition/person and provide the patient more comfort.

In this era this patient would not have normally posed covered as this was the conviction of the time. Additionally other nude photographs taken by the photographer O.G.. Mason do not have covered faces. It is my belief that this girl's face was covered because of the horribleness of her condition. She died five days after the photograph was taken. She probably was beautiful as her history suggests and her body was voluptuous from the waist up. She did not want to be remembered as the monstrous beast she was from the waist down.

Total nudity in clinical photography for men and women was common in the nineteenth century. It should be explained that most of these were images of the middle ands lower class as the wealthy have always protected their privacy. This seems to be an important issue for some sociologically bent historians. However to this day the rich pay for isolation and privacy. It is privilege money buys and it is simple as that. Nudity and its inclusion photographically was from the onset handled differently by each photographer and each patient.
Further research was undertaken by examining the publishing's from the Journal of Biological Photography to gain a more contemporary view starting from the mid 1930's. The journal, authored by professional photographers, was reviewed to assess the existence of any writings evaluating the use of nudity in clinical photography. The Biological Photographic Association was founded to share information and techniques necessary for the production of scientific and medical photography. Some interesting snip-its were found, but as with the classical texts, much less was found than expected.

In June of 1948, Albert Sadler authored the first piece to appear in the Journal that addressed the clinical photography , entitled The Preparation of Patients for Photography. In the opening sentence, Sadler shares a strategy which this author considers revealing of the time. "A protest against the unshaven faces that are photographed in the name of medical photography prompted this paper, but it was soon considered advisable to discuss matters pertaining to the preparation of patients for photography." Additionally Sadler develops the premise of the release and consent form in this article in great depth as well providing examples of such forms. He also covers aspects of clinical photography that are consistent with the aforementioned list such as the standardization of backgrounds, lenses, lighting, dressings and use of attendants. With regard to attire he writes, " No clothing of any kind should appear in the picture. Hospital gowns or pajamas should be totally removed: also socks, shoes or slippers. Out patients should undress as required. A good rule to follow is: for face, head or neck, strip the patient to the waist or sometimes in the case of women, drape just above the breast. For thorax and abdomen, all clothing should be removed, but the pubic region may be draped if not essential to the picture. for full length views, no drapes, loin cloths, socks or slippers, but a blind may be used."

From 1931, through July of 1995, a total of only 6 related articles appeared in the Journal. In the November 1950 Issue of the journal written by Edwin Holman and was dedicated solely to Legal Aspects of Patient Photography. In Vol. 35, No 1 February 1967, Robert Gervais evaluated Patient Handling with no mention of the topic. In Vol. 46 No 2, April 1978, Gary Allan, RBP wrote Pediatric photography in comparison to adult photography. "When nude photography is necessary, either with boys or girls, be aware of the embarrassment caused them. With the girls, I ask them to "slip off their clothes and put on their robe. I'll be back in a minute. then I leave. Tap on the door when you are ready. this gives her a chance to compose herself and take a minute to be angry because the probability no one told her that she would have to take her clothes off. It's unfortunate, but there are many times when the photographer is the one to explain the nature of the photographs to be taken."

In only two other issues, were writings found involving discussion of patient photography in the Journal. In Vol. 48 No 4, October 1984, author Michael Tarcniale, Ph.D., RN, revisits the Medical Photographer's role in protecting a patient's right to privacy. While A. Robin Williams, MPhil, FBPA, FBIPP, FRPS, AIMBI writes on the Positioning and Lighting for Patient Photography, his precursor for the piece previously cited.In an attempt to understand more clearly this lack of standards within this profession, the evaluation of nudity in other circles was undertaken to ascertain if there might be parallels. As this research progressed, an interesting paradigm presented itself in the discovery of the work of Joel Peter Witkin. This author came across the work of this artist who incorporates body parts and nudity, cadavers and other of life's unusual creations into his photographic work through very thorough research . Original reactions to the work was quite of horror while being filled with total fascination to the bizarre and unusual. Witkin's photographs, clearly art, are filled with medical subjects. His approaches to their photography violates all the standards that are found in the ethical code of conduct preached as part of the Registered Biological Photographer(RBP) program. It could be speculated that standards of medical photographic approaches are not consistent nor considered within the art world. Breaking rules is probably more true.

In the opinion of the authors, Witkin's subjects treated with minimal respect and dignity and are seemingly portrayed using almost pornographic and/or sadistic treatments. The photographs were clearly not medical photography and were art, however many of Witkin's subjects were traditional subjects of the medical photographer. It might be then be considered for a moment that the subject is not the photograph, but rather the intent of the photograph directs how the picture is categorized. This point is quite important and is supported by the example of Dr. Sayre's early work with scoliosis devices.

Medical Photography or Art. Medical photography or pornography. If this argument is supported, then a medical/clinical photograph of a child out of the context of a medical application could be child pornography if viewed as such, by the viewer. Consequently if the viewer and/or intention is considered to become an integral part of this loop, what criteria can then be chosen for the utilization of nudity in the clinical setting?
In the preface to Forty Photographs, Joel Peter Witkin© 1985, Van Deren Coke, director of photography at the San Francisco Museum of Art, writes, " Medical Photography of Freaks or pornographic work ? The question must be raised but examination of these photographs leads to the answer that there is a mystical and even darkly spiritual quality to his pictures that is at odds with pornography. Pornography is intended to arouse lust immediately, not after contemplating a picture and thinking about its many implications. Pornography is a substitute for actual experiences and tends to trivialize and focus narrowly the sexual urge. Witkin recognizes this strong universal urge and defines its manifestations in broad uninhibited ways. but the results have esthetic as well as emotional power. Pornography lacks the first and deals with the second in a superficial way. By his allusions to art history and his reinterpretations of classical symbols, he signals the seriousness of his work. This being the case, medical photography is intended to serve in teaching and documenting for medicine, medical conditions. Photography is no substitute for reality, however serves an important role.

Witkin produced several photographs that when contrasted to early Medical Photographs, exhibit striking similarities that also exhibit glaring differences . Intent and audience need to be considered for categorizing these photographs. In Burns' Master Pieces of Medical Photography the photograph, Dissected Head in Soup Plate, by Howard Brundage, MD 1905 bears an uncanny similarity to a photograph made by Witkin, Head, of a condemned man's severed head. Intent, not subject matter need to be the criteria as an absolute requirement used in classifying work, if that is possible.

In the January 15, 1995 New York Times Magazine, Ron Rosenblum chronicles a unusual research project referred to as "The Posture Photo Scandal, where the use of nudity, while in every respect a very touchy matter, set off indeed, a kind of touchstone for registering the uneven evolution of attitudes toward body, race and gender in the past century". In the 1940-60's, a researcher from Columbia University, W.H. Sheldon, "held that a person's body, measured and analyzed could tell much about intelligence, temperament, moral worth and probable future achievement". The inspiration for this work came from the founder of Darwinism. Francis Galton, who proposed such a photo archive for the British Population. The research included the production of totally nude photographs of freshmen at Yale, Harvard, Princeton, Vassar, and Smith complete with reference pins sticking out of off the spine. Each of the photographs was analyzed and categorized. Sheldon's theory was based on somatotypes. There existed three classifications: ectomorphs, endomorphs, and mesomorphs. Most of the posture photos', already destroyed because of their sensitive nature, purpose was eugenic. "The data accumulated would have eventually lead on to proposals to control and limit the production of inferior and useless organisms", writes Harvard historian George Hersey. Sheldon produced, An Atlas of Men, that included hundreds of nude photos of men, however An Atlas of Women was never completed which began the downfall of this body of work. These institutions of Higher learning referred to this medical photography as smut, dirt and not welcome in their archives. As it relates to the use of nudity in clinical photography, society and accepted norms of behavior are expected. As time elapsed, these photographs of now-important people fell outside the boundaries of what is accepted behavior. Of the thousands of photographs made, a very few still remain in the National Anthropological Archives in the Smithsonian with very limited access. The biggest question that seems to remain from this science and research is to why it was supported and how its got so far along? Why so many freshmen participated in the nude photography without so much as a whisper and could that happen today?

In a comprehensive analysis of all the evidence presented, a hypothesis might be created stating that many of the current approaches utilized in the inclusion of nudity in clinical photography originate from personal and society values. What might have been accepted practices in the 1880's, may or may not be accepted approaches in the 1980's. As a country, we continue to move towards conservatism and awareness for concerns about the patient. Patient rights, liability and many other important issues govern how health care is currently delivered. With telemedicine on the horizon, multi-media, photo manipulation and ethics , digital cameras, and electronic publishing as the tools in imaging , aspects of clinical imaging can only become more complicated. Consequently, implementation of more standardization in approaches requiring the use of nudity in medical photography, need more than ever, to be adopted.

In conclusion, total nudity should be considered the norm for all situations that require nudity as the norm. These strategies should be considered the absolute objectives whenever total nudity is possible. In that patients are accustomed to being asked to disrobe in clinical settings, photographers should ask for the same procedures. Clearly exceptions will exist where some clothing or such is necessary to tell the story most effectively. If exceptions exist, assess which clothing, make-up, watches and other jewelry need to be kept and explain your requirements clearly to the patient. Unless there are strong reasons to the contrary, such items should never be appear in clinical photographs. All articles of clothing should be removed, and if cover is required a standardized surgical drape should be used as necessary. The inclusion of undergarments often are evidenced first a quick visual scans of the photograph. This outcome results from the brightness, the pattern, the type and or weight of these items as they comprise the photograph. The human perspective of the viewer cannot be diminished in determining the success of a picture. The removal of all extraneous elements provides for a potential of highest degree of visual communication. The inclusion of clothing in pictures does not preclude the communication potential of the photograph, it just diminished it by including extraneous elements.
For photography of the face, head or neck, the patient should strip to the waist or sometimes in the case of women, drape just above the breast. This would include the removal of all jewelry as well. For photography of the thorax and abdomen, all clothing should be removed, but the pubic region may be draped if not essential to the picture. For full length views, no drapes, loin cloths, socks or slippers, should be present if at all possible.

Prior to making the photograph, a consent form should be reviewed and properly filled out by al parties. A complete and honest dialogue needs to be developed to educate the patient the why, what, and how to of what will be happening during the photography session. Once consent has been granted, and to facilitate the dressing and undressing of a patient , a dressing room should be provided for the patient or a corner of the studio and may be separated by a curtain for purposes of becoming a dressing area. There should always be a chaperone present if a male photographer is photographing a female patient whose clothing is to be removed(or vice versa for male patients). In these circumstances embarrassment to the patient is lessened by a female assisting in the dressing and undressing as well as also preventing the possibility of accusation of assault against the male photographer. Neither in the atmosphere in the medical studio nor in the photographic results should there be any hint that the patient does something dirty by disrobing. The area photographed has to be uncovered and consequently the camera field should be less confined to that area plus an anatomical landmark when feasible; and stray clothing should be kept out of the area. A cover should not be routinely offered as mentioned because in many instances can make a patient suddenly conscientious of a nudity not felt before. When working with teenagers for orthopedic problems, some form of brief can be offered them but only if they appear self conscious. Alternatively, the patient can wear a plain bikini-type garment in full length pictures if recording the genitalia is not necessary. Never leave the patient uncovered longer than is necessary or ask them to remove more articles of clothing than is required. Take the most embarrassing views first gradually allowing the patient to redress in stages.

To determine what might be exceptions for standardized approaches including nudity, evaluating a patient's age, maturity and developmental stage might provide a useful analysis. Clearly, infants and adults should be treated as outlined above. In these age groups, there should be no real modesty problems from the patient that can't be overcome with an honest and communicative approach. Of much greater challenge might be the general administering of the photography to the young children and adolescents who don't understand the why and what for.
It must be considered that any patient has the right to refuse photography . The only exception to this being photographs that need to be made for potential judicial reasons of child abuse and/or sexual abuse. In this case, the health care team would make the determination if absolute documentation were necessary and the photography would proceed. Although uncomfortable as this would be, there might be the requirement of the parents to restrain with hands and other devices to assist in controlling the patient which could adversely influence the result. Consequently at the age when a person becomes aware of their body and clothing, tact and strategy become very important as it relates to management photography and nudity. This age for girls and boys is different. For boys this age could be 3 - 3.5 while for girls it typically starts at 2.5 - 3.
Clearly some of the most challenging of patients requiring nudity are the adolescent patients. As puberty sets on, tremendous body changes begin. For these patients, who are extremely self conscientious, very firm yet soft tact should be considered. The goal for total nudity where appropriate should not be compromised to start. If the patient is clearly having problems such as when working with teenagers for orthopedic problems, some form of brief can be offered them but only if they appear self conscious. How this is measured or determined will be challenging. Parents or guardians should always be in the room if comfortable for the patient and seems to have advantage.

Consequently as mentioned, getting permission from the child is first and foremost if they are old enough(mature) to begin to understand. This should be achieved by explaining using age appropriate language. In this approach, the photographer should refer to the "private parts" using the terms that child has given to them. Fully outline the procedure that will be used as well as why. Reinforce that this photography is an exception and no one else should make pictures of their private parts. Teach and emphasize safety through out the session emphasizing again that this is an exception. Secondly get consent from the parent or guardian and utilize a chaperone. Obviously this approach will vary across ages as well as the ability to understand the decision can be adversely influenced by developmental disabilities such as mental retardation. These strategies have evolved into practice as a result of the Clinics dedicated to Sex Abuse of Children which were grew out of the early 1980's. In that most photographs of sex abuse are produced by physicians, their guidelines and recommendations are consistent with contemporary practice. Much work has been accomplished in this area by focusing the procedures on the child and what is best for the child. Concepts of good touch/bad touch as well as teaching of safety have been emphasized.

Beyond the judicial requirement, the ultimate goal of any clinical photograph of a pediatric patient is to consider what is in the best interest of the child. Determining when to and how often falls back into the professional integrity of the photographer. This responsibility should never be underestimated in its importance. For purely educational goals, total nudity probably is not necessary however still remains desirable. Clear communication between the photographer and patient maximizes the potential to succeed. The use of an informed consent allows for all parties to realize the consequences and needs of such photography allows the best environment to work in.

One last concept that might also be considered is one of language and the most appropriate choice. Nudity is not the same as nakedness, nor should it be. There is a distinction. John Berger writes in his book, Looking and Seeing, that' "Nudity is a form of dress." That a person is dressed in light. The concept of nudity is extremely common in the art world. Many great masterpieces from the great sculptures, painters as well as photographers chose to photograph nudity. Within the medical community, we are dealing with a very different concept of nakedness. The removal of clothing is necessary to show the body. The goal of clinical photography is not to dress with light for shape and form as with nudity but rather to reveal information about a medical subject found on or within the body. Nakedness probably reflects the concept most accurately in this application. In closing, much has been laid out for consideration in this very complicated topic. Very challenging concerns remain at the heart of the issue. Intent. It has been seen that if a photograph that has been made for very specific purposes is reviewed by a different audience, it's message is quite different. Consequently, how intent is measured and assessed remains an intangible. Nudity is correct for medical photography, yet when medical photographs are not viewed by medical people, they have meanings beyond medicine. Our society's fascination with imagery might be the primary motivation for this to happen. There are parallel experiences happening within the criminal justice system of our country, where photographs of criminals are be shown in museums and galleries. There is no way to insulate the photograph from other potential uses, however as Burns writes, (from William Crawford's Keepers of light), " the significance of photography could never be understood until one understood the problems it solved-that is the problem of accurate visual information" specific to need of a specific audience..

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