Exoskeletons for all: The interplay between exoskeletons, inclusion, gender, and intersectionality

Abstract

In this article, we investigate the relation between gender and exoskeleton development through the lens of intersectionality theory. Exoskeleton users come in a wide variety of shapes, sizes, and genders. However, it is often the case that wearable robot engineers do not develop such devices primarily on the premise that the product should fit as many end users as possible. Instead, designers tend to use the one-size-fits-all approach-a design choice that seems legitimate from the return of an investment viewpoint but that may not do as much justice to end users. Intended users of exoskeletons have a series of user criteria, including height, weight, and health condition, in the case of rehabilitation. By having rigid inclusion criteria for whom the intended user of the technology can be, the exclusion criteria will grow in parallel. The implications and deep-rootedness of gender and diversity considerations in practices and structural systems have been largely disregarded. Mechanical and robot technology were historically seen as part of a distinct male sphere, and the criteria used today to develop new technology may reflect the biases that existed in another time that should no longer be valid. To make this technology available for all, we suggest some tools to designers and manufacturers to help them think beyond their target market and be more inclusive.

Full text

Research Article
Roger Andre Søraa* and Eduard Fosch-Villaronga
Exoskeletons for all: The interplay between
exoskeletons, inclusion, gender, and
intersectionality
https://doi.org/10.1515/pjbr-2020-0036
received November 28, 2019; accepted April 6, 2020
Abstract: In this article, we investigate the relation between
gender and exoskeleton development through the lens of
intersectionality theory. Exoskeleton users come in a wide
variety of shapes, sizes, and genders. However, it is often the
case that wearable robot engineers do not develop such
devices primarily on the premise that the product should fit
as many end users as possible. Instead, designers tend to use
the one-size-fits-all approach –a design choice that seems
legitimate from the return of an investment viewpoint but
that may not do as much justice to end users. Intended users
of exoskeletons have a series ofusercriteria,including
height, weight, and health condition, in the case of
rehabilitation. By having rigid inclusion criteria for whom
the intended user of the technology can be, the exclusion
criteria will grow in parallel. The implications and deep-
rootedness of gender and diversity considerations in practices
and structural systems have been largely disregarded.
Mechanical and robot technology were historically seen as
part of a distinct male sphere, and the criteria used today to
develop new technology may reflect the biases that existed in
another time that should no longer be valid. To make this
technology available for all, we suggest some tools to
designers and manufacturers to help them think beyond
their target market and be more inclusive.
Keywords: exoskeletons, gender and technology, inter-
sectionality, inclusive design, exclusion, data bias, access,
discrimination
1 Introduction
Robotic technology is increasingly present in the health-
care sector. Robots perform useful tasks for humans and
assist humans in performing tasks by processing and
acting upon the information collected by several sensors.
They can be a powerful tool for assisting people with
illnesses or disabilities because they can supplement the
work provided by the health-care professionals –both in
medical treatment and in rehabilitation –and support
people in prevention programs [1]. Robots may be helpful
in lessening the burden of care assistants by performing
automated tasks. In this respect, the European Parliament
[2]discuss how care robots might “free caregivers from
tedious work and allow them to devote more time for
diagnosis and better-planned treatment options”and thus
make doctors’work more efficient [3]. Recent findings also
suggest that artificial intelligence (AI)-powered diagnostic
tools in some cases can outperform physicians in the
diagnosis of probabilities for disease and conditional
interdependencies [4].
The use of technology in medical care is becoming
more prevalent. This includes devices, integrated platforms,
and services aimed at promoting the well-being of users,
patients, and formal and informal caregivers; and the use of
technology that allows people with health impairments to
be more independent, thus improving their quality of life
[5]. Robot-mediated gait training is one example of a
technology that helps patients with reduced gait function
[6]. In the 1990s, body weight-supported treadmill training
with manual assistance was developed to improve walking
function for patients with neurological impairments [7,8].
However, walk rehabilitation process was (and it is still)
very costly and labor intense –it usually requires a team of
two to five people. Robot technology has been proven to be
an effective method for rehabilitation, requiring only one
therapist to supervise a training session [9].
Despite the apparent benefits of such technology,
research on care robot technologies suggests that their

* Corresponding author: Roger Andre Søraa, Department of
Interdisciplinary Studies of Culture & Department of Neuromedicine
and Movement Science, NTNU Norwegian University of Science and
Technology, Trondheim, Norway, e-mail: roger.soraa@ntnu.no
Eduard Fosch-Villaronga: eLaw Center for Law and Digital
Technologies, Leiden University, Leiden, The Netherlands,
e-mail: e.fosch.villaronga@law.leidenuniv.nl
ORCID: Roger Andre Søraa 0000-0001-6800-0558;
Eduard Fosch-Villaronga 0000-0002-8325-5871
Paladyn, Journal of Behavioral Robotics 2020; 11: 217–227
Open Access. © 2020 Roger Andre Søraa and Eduard Fosch-Villaronga, published by De Gruyter. This work is licensed under the Creative
Commons Attribution 4.0 Public License.

implementation is not straightforward, and new ethical,
legal, and social concerns arise from the human–robot inter-
actions [10–12]. Some authors argue that robot technology,
especially when coupled with AI, “can be used to foster
human nature and its potentialities, thus creating opportu-
nities; underused, thus creating opportunity costs, or over-
used and misused, thus creating risks”[13],suggestingthat
adoption is inevitable and that the current debate no longer
focuses on the question of whether robot technology has an
impact on society but on whether and to what extent this
impact is going to be positive or negative.
Seeing technology as a social construct and not a
natural force that arrives in society can help us under-
stand how technology is being produced, implemented,
and used in the “social construction of technology”[14].
It can also help illuminate the intricate relationship
between the user and producer and the potential
coproduction that happens in that relation [15,16]. For
instance, one essential concern is how different indivi-
dual users’attributes might lead to their exclusion from
technology. This critique has been around for decades,
thanks in particular to the feminist understanding of
technology, and remains quite unexplored in the context
of robot technology. In this sense, technology –including
robots –is not created in a vacuum. They arise as a result
of –and reflect –human needs and ingenuity; they create
new relationships between humans and also transform
the way we see the world [17].
Disability studies seek to challenge the view that
disability is synonymous with human failing [18]by
creating space to explore the multitude of complexities of
people who are disabled [19]. Within disability studies,
exoskeletons are quite a new topic of inquiry, but they
have received some attention notably by Lajeunesse et al.
[20], who give an account of exoskeletons used for spinal
cord injury patients, and Goggin [21], who argues that
exoskeletons can lead to novel forms of mobility
opportunities for their users.
In this article, we investigate the interplay of inclusion
and gender perspectives and exoskeleton development
from the lens of intersectionality. Exoskeleton users come
with a wide variety of individual attributes, shapes, and
sizes. However, wearable robot engineers do not usually
develop such devices primarily on the premise that the
product should fitasmanyendusersaspossible.Instead,
designers tend to rely on the one-size-fits-all approach –
with some adjustment possible. Such a design choice
seems legitimate from a return of an investment view-
point, but it may not do as much justice to end users.
Intended users of exoskeletons have a series of user
criteria, including height, weight, and, in the case of
rehabilitation, health condition. When the inclusion
criteria for whom the intended user of the technology are
rigid, the exclusion criteria are necessarily just as rigid.
We draw on feminist scholarly understandings of gender
and technology to better understand how people adapt to
technologies such as exoskeletons. We use the concept of
intersectionality to see how people with disabilities are not
just “disabled”but hold, as every human does, a wide
variety of other identities. Furthermore, we explore whether
being disabled can lead to double or multiple levels of
exclusion, disregard, or discrimination. The implications and
deep-rootedness of gender considerations in technology
practices have been disregarded in the development of
exoskeleton technology. Mechanical and robot technology
were historically seen as part of a distinct male sphere and
the criteria used today to develop new technology may
reflect the biases that existed in another time that should
no longer be valid. To make exoskeletons available –and
enabling –for all, we suggest some tools to help designers
and manufacturers think beyond their target market, be
more inclusive, and avoid discrimination.
2 Gender, technology, and
intersectionality theory
“Gender refers to psychological, social and cultural factors
that shape attitudes, behaviours, stereotypes, technolo-
gies and knowledge”[22]. As a social construct, gender
relates to, but is not identical to, sex, which is biologically
and physiologically determined. Just as gender is in a
context flux and negotiation –e.g., gendered understand-
ings of the body or who can drive a car –so is technology.
To better understand how a technology such as exoske-
leton can be understood on the social, nontechnical
level –for example, by zooming in on the inclusion and
exclusion of users –gender perspectives can inform the
understanding of what exoskeletons can and cannot do for
different groups of people.
Feminist scholars stress that technology has for too
long been part of the male sphere and thus inevitably
reflects inevitably certain biases, as discussed by
Wajcman [23], who argues that gendered power relations
mediate the development of technology because “tech-
nology is always a form of social knowledge, practices,
and products. It is the result of conflicts and compro-
mises, the outcome of which depends primarily on the
distribution of power and resources between different
groups in society”. She argues that this could be achieved by
looking at how technology is being made and used by male
218 Roger Andre Søraa and Eduard Fosch-Villaronga

power and interests. Technology is not created in a vacuum,
as can be seen through the concept of “situated knowledge”
[24], which focuses on the interrelation of “thinking with”
both epistemologically, ontologically, ethically, and politi-
cally. In a semiotic materialist notion, situated knowledge
helpstogobeyondthe“god trick god trick of seeing every-
thing from nowhere”[24], showing how knowledge is not
neutral, but socially constructed. In her “Cyborg Manifesto,”
Haraway [25]takes the interweaving of technology and
gender on a slightly different perspective, by introducing the
cyborg concept into technofeminism:
A cyborg is a cybernetic organism, a hybrid of machine and
organism, a creature of social reality as well as a creature of
fiction. Social reality is lived social relations, our most important
political construction, a world-changing fiction […]The cyborg
is a matter of fiction and lived experience that changes what
counts as women’s experience in the late twentieth century.
This is a struggle over life and death, but the boundary between
science fiction and social reality is an optical illusion.
In contemporary society, the cyborg concept is so
commonly used that the theoretical conceptualization must
be explicitly mentioned when writing about cyborgs. People
using exoskeletons integrate their bodies with a robotic
device in a seamless manner, becoming in a way an actual
cyborg. Scholars like Berg and Lie [26]continued the
feminist technoinquiry by discussing the question, “do
artifacts have a gender,”continuously unwrapping the
black boxes of technology in a gendered framework, using
gender theories to understand technology.
One theory within gender studies that addresses how
people are made of a wide variety of personal attributes is
intersectionality theory, which can be used to give a
more comprehensive understanding of bias and direct
and indirect discrimination based on individual (and
sometimes clashing)identities. Intersectionality theory
illustrates how gender discrimination and other forms of
discriminating (e.g., racism, homophobia, xenophobia)
may interact and strengthen each other, as defined by
Crenshaw [27], who first used it to describe the double-
discrimination Black women face:
Black women are regarded either as too much like women or
Blacks and the compounded nature of their experience is
absorbed into the collective experiences of either group or as
too different, in which case Black women’s Blackness or
femaleness sometimes has placed their needs and perspectives
at the margin of the feminist and Black liberationist agenda.
Intersectionality can be defined as “the interaction
between gender, race and other categories of difference
in individual lives, social practices, institutional arrange-
ments, and cultural ideologies and the outcomes of these
interactions in terms of power”[28].Intersectionality
perspectives have been included in a variety of topics on a
structural level, such as psychology [29]and mainstreaming
studies [30]. On a more individual level, McCall [31]discusses
how different personal attributes make us up as people and
individuals and makes each individual belong to multiple
societal subgroups. All of these together contribute to the
creation of identity politics [32].
This theory has also received criticism. Nash [33],for
example, problematizes: “thelackofadefined intersectional
methodology; the use of black women as quintessential
intersectional subjects; the vague definition of intersection-
ality; and the empirical validity of intersectionality.”In our
contribution, we do not seek to remedy these four valid
criticisms regarding the theory, as we have found it to be a
useful theoretical perspective to show how several identities
overlap and create complex understandings of people
having more than just one identity, leading them to being
subject to systems of oppression and even discrimination.
There has, however, been scholarly attempts to justify/refine
intersectionality into a more operable theoretical tool [31,34].
We draw on the abovementioned feminist scholarly under-
standings of gender and technology to better understand
how we as humans adapt to and are made to better or worse
use technologies such as exoskeletons.
3 Methods and typology of
exoskeletons
The use of exoskeletons in rehabilitation is a relatively
new research field, with the most important technological
developments happening within this past decade. How-
ever, several research groups and clinics across the world
have made notable advances inunderstanding the benefits
that patients have when using this novel technology.
Exoskeletons have the potential to revolutionize the
rehabilitation context completely. Exoskeletons provide
health benefits, including improvements in gait function,
body composition, aerobic capacity, bone density, spasti-
city, bowel function, and quality of life [6,35]. Moreover,
exoskeletons allow a freer and more natural movement
while walking than that provided by body weight-
supported treadmill training. Exoskeletons offer much
independence in a variety of everyday settings such as
shopping malls, local parks, and movie theaters [6].
Exoskeletons also provide excellent help in repetitive–
intensive gait training interventions [36]and help patients
combat several chronic health-related consequences that
are likely to affect persons with a spinal cord injury [37].
Exoskeletons for all 219

Over the years, these devices are becoming less and less
bulky. See an example in Figure 1.
Evidence concerning the rehabilitation of stroke
patients is somewhat weaker, with fewer extensive studies
to provide evidence. A recent scoping review found only
seven pre-post clinical studies and four controlled trials,
although it concluded that exoskeleton-based gait training
in patients with subacute stroke had meaningful improve-
ment when compared to traditional therapy [36].These
studies show that exoskeletons can be used safely in gait
training in a clinical environment [38]. However, there is
still a lack of research in certain key areas, including their
use outside of a clinical setting [39]and especially relating
to social science and humanities perspectives, on their
impact on the daily life of the user from a nonmedical point of
view. Although tests on exoskeletons show the potential for
significant medical, technological, and social improvements
for patients, there is still little understanding of how this
technology will be implemented efficiently.
Several types of exoskeletons exist in the market and in
research settings to date, with a varying degree of com-
plexity, weight, and applications. The Lokomat (Hocoma,
Switzerland)involves patients using body weight support on a
treadmill. Motorized braces move the patients’legs through
trajectories that imitate standard gait patterns. Other robot
devices include stepping machines like the Gait Trainer
(RehaStim, Germany)and the G-EO, which uses movements
similar to those of elliptical machines (Reha Technology AG,
Switzerland). Another example is KineAssist (HDT Global,
USA), which uses body weight support around the pelvis and a
treadmill reacting to the patient’s movements [40].
Forthisstudy,weinvestigatethosewearablerobots
connected with the H2020 Cost Action 16116 on Wearable
Robots,¹ that is, on physical assistant robots that “physically
assist a user to perform required tasks by providing supple-
mentation or augmentation of personal capabilities”[41].
Although there is confusion whether or not these devices can
be considered medical devices [12],a“prescription device
that is composed of an external, powered, motorized orthosis
Figure 1: Indego therapy; photo courtesy of Parker Hannifin Corporation, USA.

1https://wearablerobots.eu/
220 Roger Andre Søraa and Eduard Fosch-Villaronga

that is placed over a person’s paralyzed or weakened lower
extremity limb(s)for medical purposes”is recognized as a
medical device by the FDA. Moreover, what matters is the
intended purpose of the device, something reinforced by art.
Section 1.3 of the European Union Regulation of Medical
Devicesthatstressesthat“deviceswithbothamedicalanda
non-medicalintendedpurposeshallfulfil cumulatively
the requirements applicable to devices with an intended
medical purpose and those applicable to devices without an
intended medical purpose”[42].
In the following section, we compile several examples of
exoskeletons available in the market and analyze their
different results. For our selection, we combined a nonsyste-
matic online search with the Google search engine, using the
key words: “‘marketed’AND ‘exoskeleton’”;“‘exoskeletons’
AND ‘for’AND ‘sale’”;“‘buy’AND ‘an’AND ‘exoskeleton’” to
seek companies currently selling exoskeletons. This showed
that lower limb (as opposed to upper limb)products from
large, respected companies dominated the online presence.
The results were varied and lacked consistency in the amount
of information freely available online, making the compilation
and visualization of these products in a single chart difficult.
The majority of companies did not have technical information
online, forcing potential clients to contact them for further
inquiries. Although this is a good strategy for marketing
purposes, it presented a significant obstacle in our research
and data collection.
As a second step, therefore, we sought further details by
directly contacting the companies using their online contact
forms. Unfortunately, the majority of the companies did not
reply. After careful thought, we present the information we
found online from mid-/large-sized companies (Table 1).
Although our sample is limited, it is rich in results; it
identifies and illustrates a trend that seems to replicate in
different domains. In this regard, we included “EksoWorks”
in the chart to complement our understanding of the impact
that the physical embodiment of current exoskeletons has on
constraining the access to technology by design.
4 Results
The section below includes three available commercial
products: the US-based Ekso Bionics,² Indego,³ and
Cyberdyne from Japan.⁴Considering the available informa-
tion online, we focused on EksoHealth for gait training,
Indego for therapy, and HAL for well-being. Rewalk⁵is a
major player in the market; however, they do not have any
technical information online and did not respond to our
requests for information, so they are excluded. Other
excluded robots include Twiice from Switzerland⁶and
MarsiBionics from Spain,⁷both of which have yet to begin
mass production of exoskeletons. In Table 1, we look at some
specific technical information concerning the device and the
users.
We can deduce some results from Table 1. The
majority of the companies have both physically impaired
patients and people without a medical condition as
intended users (e.g., workers who perform physically
demanding labor). Concerning the weight parameter, we
see that the upper weight limit from HAL and Ekso is
100 kg. The average body weight for an American male is
91 kg.⁸While fully clothed, which adds another kilo or
two, many users on the heavier side would be excluded
from the possibility of using the exoskeletons. Indego
allows for slightly more, with 113 kg as the maximum
weight. Similarly, the minimum limit for weight can also
cause a problem, as HAL requires users to weigh at least
40 kg. This could be problematic in countries like
Madagascar or Bangladesh, where the average weight of
women is about 49 kg [43].
Concerning the height parameter, we observe that
Japanese Cyberdyne starts at 150 cm, followed by Ekso
Bionics at 152 cm and Indego at 155 cm. The World
Population Review [44]reports that the country with the
shortest average human height (Indonesia)has an average
height of 62.2 inches (157 cm). This implies that many
Indonesians would be too short to use these devices. There
are many other populations –such as Filipino women
[45]–who could likely be prevented from using the
devices. There are also categories other than nationality –
e.g., individuals with dwarfism –that would similarly
exclude potential users. Although some companies are
investigating pediatric orthoses (Hocoma,⁹for instance,

2https://eksobionics.com/. Although its website is not forth-
coming about its headquarters, it is a US-based company that
additionally has a significant presence in the EU and Asia. https://
www.bloomberg.com/profile/company/EKSO:US
3http://www.indego.com/indego/en/home

4https://www.cyberdyne.jp/english/
5https://rewalk.com/rewalk-personal-3/
6http://twiice.ch/
7https://www.marsibionics.com/?lang=en
8See Froehlich-Grobe et al. [46]for data on self-reported height and
weight of the average wheelchair user. The reason why American
males were chosen in the example here is because they represent one
of the most overweight and richest countries in the world.
9https://www.hocoma.com/solutions/lokomat/modules/#
Pediatric-Orthoses
Exoskeletons for all 221

offers pediatric orthoses for persons with femurs between 21
and 35 cm), there are not currently any mainstream items,
further excluding children and youth. Even in such situa-
tions, age is not a common or a specific parameter that
companies take into account. They focus more on femur
length or hip width. Populations can also be excluded for
being too tall –menintheNetherlandshaveanaverage
height of 183 cm, suggesting that Cyberdyne’s device, which
can accommodate a maximum height of 200 cm, would be
the only device that is broadly available to many Dutch users.
Concerning the weight of the device, Ekso Bionics proves
to be the most massive (25 kg); but on their website, the
company stresses that patients bear only their weight. Indego
is 12 kg for personal use and a bit heavier for medical
purposes (18 kg). HAL reports being in between, with a
device weight of 14 kg. (We are not considering the 9 kg
single-legged device because the others are double legged.)
Other results suggest that HAL from Cyberdyne is the only
company offering the possibility to adjust the shoe size. The
same company also has a gender specification, that of the
hip width. For men, the size is 28–36 cm, whereas for women
it is 32–40 cm. Pricewise, the majority of the companies do
not have their prices online and force potential buyers to
contact them directly for more information.
Table 1: User and device characteristics for some commercially available exoskeletons from Ekso Bionics, Indego, and Cyberdyne
Parameter Exoskeletons
Ekso Bionics Indego HAL, Cyberdyne
Intended user/
health condition
EksoHealth is for patients, and
EksoWorks is for workers
Indego personal offers users with
spinal cord injury a new level of
independence at home and in the
community. Indego therapy is a
lower limb powered exoskeleton
which enables therapists to offer
task-specific and intensive gait
training
HAL for Well-Being Lower Limb type
Pro is a wearable robot designed
for inducing the improvement in
physical function in the lower limb,
for the wearer with chronic
conditions
User height range 5′–6′4″(152–193 cm)Height range: 5′1″–6′3″
(155–191 cm)Maximum hip width:
16.6″(42.2 cm)Femur length:
14″–18.5″(35–47 cm)
S size: 150–165 cm, upper leg
length 36–38 cm, lower leg length
35–38 cm M size: 160–175 cm,
upper leg length 38–41 cm, lower
leg length 37–41 cm L size:
170–190 cm, upper leg length
40–45 cm, lower leg length
39–45 cm XL size: 180–200 cm,
upper leg length 43–48 cm, lower
leg length 42–48 cm
Supported weight Maximum weight: 220 pounds
(100 kg)
Maximum weight: 250 lb (113 kg)Minimum weight: 40 kg Maximum
weight: 100 kg
User age N/A N/A N/A
Intended use EksoHealth is to gait train.
EksoWorks is for workers for fatigue
reduction for overhead
manufacturing, assembly, and
construction
Personal or medical Personal
Device size Adjustable hip width and abduction Hip width range: 13.3″–16.6″
(34–42 cm)Upper leg length range:
14.6″–19.3″(37–49 cm)Lower leg
length range: 16.5″–21.7″
(42–55 cm)
S/M/L/X
Device weight 55 lbs. (25 kg), but patients bear
only their own weight
Personal: 26 lbs. (12 kg)Medical: 39
lbs. (18 kg)
Double-leg model: 14 kg Single-leg
model: 9 kg
Shoe size N/A N/A 23.0, 24.0, 25.0, 26.0, 27.0, 28.0,
29.0, 30.0 cm
Gender
considerations
N/A N/A Hip width: male size: 28–36 cm
and female size: 32–40 cm
Price Not available for personal use To be consulted To be consulted
222 Roger Andre Søraa and Eduard Fosch-Villaronga

5 Discussion
In this section, we apply a feminist critique through an
intersectional lens in order to better understand the social
context of the individual relating to exoskeleton tech-
nology. Based on the results, we have selected three
individual attributes –height, weight, and age –that
affect how a user may be included or excluded from using
exoskeleton technologies. We also include discussion of
matters of socioeconomic status (relating to the price of
the exoskeletons)as critical inclusion/exclusion criteria.
5.1 Exoskeletons for all?
Height and weight are the two most important para-
meters for exoskeleton use, but the technological fit for
the standard user might also lead to exclusion. As
Wajcman [23]writes on the topic of hay bales which
require workers to be able to lift precisely 50 kg in the
particular weight of the standard hay bale: “male
workers use their bodily and technical effectivity to
design machinery and machine tasks to constitute
themselves as the capable workers and women as
inadequate.”Similarly, exoskeletons have been given a
certain standard measure at one point in their design
and development history. As we can see, devices may
support from 100 to 113 kg of maximum weight. This
excludes users who have a weight under or over the
weight limits. Intended users of exoskeletons have a
series of user attributes that developers need to bear in
mind for effective development and implementation.
Most important of those is the health condition of the
user, which excludes a large number of users who do not
have the body strength required to use the exoskeleton.
In an industry, this would exclude those workers
required to use these devices for work; in a rehabilita-
tion context, this could impede patients from accessing a
technology that may benefit them. Although health
condition-oriented exoskeletons seem to help realize
the goals of personalized medicine, they also seem to
highlight the need to develop exoskeletons for the other
conditions, whichever those may be, pressuring devel-
opers and health-care systems to provide an equal and
fair access to health-care technological solutions.
It is not only the weight of the technology but also the
embodied technological adoption through the users’body
weight that matters for successful domestication of
exoskeleton technology. As seen in the comparison, users
of these exoskeletons can never weigh less than 40 kg, nor
more than 113 kg. If they do so, they are excluded from
use. This is problematic, as there are several issues with
weight in contemporary societies. Malnourishment and
starvation are causing massive health pandemics in the
global south, and the global north faces the opposite
problem of obesity and overeating. Both of these global
demographic weight trends are increasing at both ends of
the spectrum and causing multiple health issues. In turn,
this can make gait treatment and rehabilitation difficult as
the users might not be within the weight limits of the
technology. The weight limit is both a social construct and
a result of technological constraints. To build an
exoskeleton that supports heavier patients would lead to
having heavier, clunkier, and more cumbersome devices
which could then be in conflict with users of decreased
arm strength (some of whom might be barely able to use
the current system now).
Another aspect that seems to be highly problematic
on a structural level is the price of exoskeletons. We did
not find the exact price of the exoskeletons of the
companies we analyzed due to the lack of the companies’
transparency. However, some articles suggest that the
price range of exoskeletons varies between US$30,000
and US$200,000, which suggests that patients in emer-
ging and developed countries cannot afford to obtain such
a solution for their condition [47]. Although there may be
many exoskeleton solutions out in the market, their use
largely remains limited to the rehabilitation center or
wealthy patients. It is an undeniable fact that disadvan-
taged people are recurrently excluded from the benefits of
technological development. At an extreme, in some
capitalist economies only the rich can afford to live
when contracting a severe disease, whereas the poor who,
due to their socioeconomic situation, cannot afford
medicines would die in a worst-case scenario. In more
egalitarian societies like the Nordic European countries, it
is the state’s responsibility to provide good minimal equal
health care for all citizens. However, exoskeletons
currently are not seen as “necessary enough”for patients
to have their own, due primarily to the high cost of the
technology. Also, there is little evidence on the social
impact of using the technology.
One essential unaddressed issue is whether there is
enough competition to cover all market needs at
affordable prices. At the moment, providers try to suit
as many users as possible from a cost perspective, not
specializing in specific minority targeted audiences. If
some companies created exoskeletons just for children,
while in healthy competition with other providers,
would that create more affordable solutions? For some
other considerations, private actors might not be in a
position to afford developing technologies that cover the
Exoskeletons for all 223

whole market, thus prompting the question of public
support or mandatory requirements for certain features –
e.g., language support for indigenous people who might
not speak the official/majority state language but whose
developers might not have the resources (or profitability)
to include in their original design.
5.2 Technological bias as user exclusion
Technological biases reflect how technology embodies
social knowledge, practices, and products. Although we
cannot claim to know if the exoskeletons in question are
“being made and used by male power and interests”[23],
there are certain gender biases that can be seen through
target users. Going back to Berg and Lie’s[26]feminist
techno-inquiry of artifacts’genders, we can likewise
prompt the question: “do exoskeletons have a gender?”
By this, we do not mean the physical exoskeleton itself,
as it is not gendered in the same way as a social robot or a
chat program that may be given male/female design
choices [48]. Instead, we wonder what the design script
of the exoskeleton implies symbolically for the intended
user. Here gender theories can help better understand
user exclusion, and especially intersectionality can be
fruitful.
To give an intersectional account of the user of
exoskeletons, we need to look at who the intended user
is, but, more importantly, who she is not. By looking at
the technology user criteria, there are specific attributes a
user must fit within. She cannot be too tall or too short,
and she cannot be too overweight or underweight. She
must be healthy enough to be able to strap on the
technology if she is to use it by herself. These choices will
necessarily exclude many users who could, for example,
find themselves being too young and healthy normally be
required to use a wheelchair for life but too tall to be able
to walk with an exoskeleton. Disabled people –already a
minority in society –are not just “disabled”but hold, as
every human does, a wide variety of other identities. How
can this, especially in regard to disabled people, lead to
double or multiple levels of exclusion, discrimination, or
disregard? Are exoskeleton users more in control of their
life when using exoskeletons? And, revisiting the concept
of coproduction [16], are the users involved in coproduc-
tion processes of the technology?
As Haraway [25]prompts with her Cyborg concept,
one novel way of thinking about the exoskeleton user is
precisely as a cyborg where humans and machines merge
as cybernetic organisms; and although this sounds quite
futuristic, we already see the start of this through
exoskeleton use. Through active inclusion, by under-
standing and eliminating exclusion criteria, more people
could and should have the opportunity to walk again if
that is their wish and the technology allows it. By looking
at the rigid inclusion criteria for whom the intended user
of the technology can be, we can thus also see whom the
intended user is not meant to be.
5.3 Intersectional users of exoskeletons
For a better understanding of the exoskeleton users, we
argue that it is imperative to see the users as unique and
actively engage with their multiple identities. People
come from all walks of life, have diverse genders, ages,
socioeconomic backgrounds, upper arm strength, weight,
and height. For a good development and implementation
usage of exoskeleton technology, it is important that
producers, health-care technology providers, health-care
staff, and formal and informal caregivers be aware of
patients’unique individuality. As of now, technology
seems to treat users as black boxes: the input and the
output are known, but not what happens in the black box.
We propose that, instead, technology should understand
the user attributes and the effects it has on them.
Unboxing the “user-as-a-black-box”can serve as an
argument for a better sociotechnical understanding of
the user as a technology–human hybrid –as people using
exoskeletons integrate their bodies with a robotic device
become a sort of cyborg. Making developers and designers
aware of the effect technology has on users may confront
them with the responsibility they have. The following
chart provides a list of inclusive design choices that
designers and manufacturers could consider when de-
signing exoskeletons, which we term “inclusive design
choices for exoskeleton design”(Table 2).
By considering these and other related issues when
building, testing, and receiving feedback on the tech-
nology, creators, designers, and technology developers
can increase the usability of their technology by better
including a myriad of users –not only those who fit
within the relatively high threshold standards. This may
also help realize the dignity of the users, which should
be central to how manufacturers design and build these
robotic devices [50]. Going back to Haraway’s[24]
situated knowledge, she describes how “bodies as
objects of knowledge are material-semiotic nodes. Their
boundaries materialize in social interaction.”In this
case, this relates to how the producers’way of selecting
and excluding which “bodies that matter.”The ones
that need the technology the most could risk being the
224 Roger Andre Søraa and Eduard Fosch-Villaronga

ones that are not able to use it due to, for example,
being a couple of kilos or centimeters over or under the
limits. Since the technology –and the knowledge put
into development and redevelopment –is situational,
and sociomaterially constructed, inclusive criteria can
better inform the production and also the use of exo-
skeletons.
5.4 Limitations and further studies
The limited public availability of information concerning
exoskeletons limited this study. The majority of large,
international companies do not have specificinformation
online. Additionally, given that there are currently only a
few companies developing exoskeletons, the data were
dependent on a few selected available companies that could
provide the data. Following Nash’s(2008)critique of
intersectionality, the lack of a specific, defined intersectional
methodology is also a potential issue, but here we have
used it more as a conceptual tool. Additionally, we do not
seek to give an empirical validity of intersectionality, as our
data material does not include user studies. However, this
could be a focus on further studies. Future studies may also
cover a growing area of application, i.e., exoskeletons for
work purposes. Exoskeletons may improve and support the
working conditions of staffperforming demanding physical
tasks, such as lifting patients. Overall, exoskeletons may
help reduce fatigue in difficult jobs, such as manufacturing,
assembly, and construction. More in-depth studies are also
needed to investigate the coproduction that producers have
with end users regarding exoskeletons.
6 Conclusion and further
recommendations
By having rigid inclusion criteria for whom the intended
user of the technology can be, exclusion criteria will grow
in parallel. This holds for exoskeletons and may lead to
discriminatory scenarios. By integrating a deeper under-
standing of how users of exoskeleton come in a wide
variety of attributes, shapes, sizes, gender, and wealth,
and that there is no general “one-size fits all,”exoskeleton
technology holds the potential for being more inclusive.
To make this technology available for all who need it,
designers and producers must also think beyond their
target market. However, how this extra mile of inclusive
Table 2: Inclusive design choices for exoskeleton design
Human feature Technology solution
Height considerations Make exoskeletons that can accommodate very tall people as well as short people, e.g., children,
or persons with dwarfism
Weight considerations Make sure exoskeletons can support overweight and underweight people. This is especially
important since a disproportionate amount of people in wheelchairs are overweight because of
their more sedentary life
Correlated condition
considerations
Make buttons in different patterns, so that green-red color-blind people can easily operate them
without the fear of pushing the wrong-colored button. Create buttons with different textures for
blind people and add auditory response sensors
Capability considerations Make the exoskeleton as easy as possible to put on and operate with minimal upper body
strength required, so that the users who are also minorly impaired in their upper body but
severely impaired in their lower body can benefit from the technology
Gender and sex considerations Be aware of bodily differences between men and women and ensure that the exoskeleton design
is not a result of a man-only team, designing for men. A diverse group of employees or users
should be involved at all levels and also be included in the target user group
Cultural considerations People from different sociocultural backgrounds might relate to robotic technology in widely
different manners. Acceptance rate and levels of trust differ, and what might work well in one
region might not be ideal in others. Therefore, be sure to include a robust sociotechnical
perspective in the development and testing of the technology to better understand how to adhere
to different cultural values
Inclusivity considerations Think about the importance of including typically marginalized communities such as the LGBTQ+
in the development of technology to avoid discrimination and reinforcing the existing biases [49].
Be inclusive-by-design and remember that any inclusion criteria may represent exclusion criteria
for other communities. Careful reflection on these aspects when developing
technology –including exoskeletons –can benefit both society and the individual
Exoskeletons for all 225

design should be implemented is not within the scope of
this article. Some potential solutions could be to give
incentives for technology producers to also include users
who do not fit the standard frames of the technology, thus
realizing and providing “exoskeletons for all.”
Acknowledgments: This article has been partially funded
by the LIFEBOTS Exchange project funded by the
European Union’s Horizon 2020 research and innovation
program under the Grant Agreement No. 824047 and by
the LEaDing Fellows Marie Curie COFUND fellowship, a
project that received funding from the European Union’s
Horizon 2020 research and innovation program under the
Marie Skłodowska-Curie Grant Agreement No. 707404.
References
[1]E. Broadbent, N. Kerse, K. Peri, H. Robinson, C. Jayawardena,
T. Kuo, et al., “Benefits and problems of healthcare robots in
aged care settings: a comparison trial,”Australas. J. Ageing,
vol. 35, no. 1, pp. 23–29, 2016, DOI: 10.1111/ajag.1219.
[2]European Parliament, Civil Law Rules on Robotics European
Parliament resolution of 16 February 2017 with recommenda-
tions to the Commission on Civil Law Rules on Robotics (2015/
2103(INL)), 2017. Available: http://www.europarl.europa.eu/
sides/getDoc.do?pubRef=-//EP//NONSGML+TA+P8-TA-2017-
0051+0+DOC+PDF+V0//EN.
[3]M. Butter, A. Rensma, J. V. Boxsel, S. Kalisingh, M. Schoone,
M. Leis, et al., Robotics for healthcare: final report, 2008.
Available: https://repository.tudelft.nl/view/tno/uuid%
3Abeddf38c-e88c-4d2a-8394-e7234d9b3e8a.
[4]S. Razzaki, A. Baker, Y. Perov, K. Middleton, J. Baxter,
D. Mullarkey, et al., “A comparative study of artificial
intelligence and human doctors for the purpose of triage
and diagnosis,”arXiv preprint arXiv:1806.10698, 2018.
[5]P. Sale, M. Franceschini, A. Waldner, and S. Hesse, “Use of
the robot assisted gait therapy in rehabilitation of patients
with stroke and spinal cord injury,”Eur. J. Phys. Rehabil.
Med., vol. 48, pp. 111–121, 2012.
[6]A. S. Gorgey, L. L. Goetz, and R. Sumrell, “Exoskeletal
assisted rehabilitation after spinal cord injury,”Atlas of
Orthoses and Assistive Devices, 5th ed., Elsevier, 2019,
pp. 440–447, DOI: 10.1016/B978-0-323-48323-0.00044-5.
[7]A. Wernig and S. Muller, “Laufband locomotion with body
weight support improved walking in persons with severe
spinal cord injuries,”Paraplegia, vol. 30, pp. 229–238, 1992,
DOI: 10.1038/sc.1992.61.
[8]E. Høyer, B. Normann, R. Sørsdal, and L. Strand, “Rehabilitation
including treadmill therapy for patients with incomplete locked-
in syndrome after stroke; a case series study of motor recovery,”
Brain Injury,vol.1,pp.34–45, 2010, DOI: 10.3109/
02699050903471805.
[9]G. Colombo, M. Joerg, R. Schreier, and V. Dietz, “Treadmill
training of paraplegic patients using a robotic orthosis,”
J. Rehabil. Res. Dev., vol. 37, pp. 693–700, 2010.
[10]C. Holder, V. Khurana, F. Harrison, and L. Jacobs, “Robotics
and law: key legal and regulatory implications of the robotics
age (Part I of II),”Comput. Law Secur. Rev., vol. 32,
pp. 383–402, 2016, DOI: 10.1016/j.clsr.2016.03.001.
[11]R. Leenes, E. Palmerini, B. J. Koops, A. Bertolini, P. Salvini,
and F. Lucivero, “Regulatory challenges of robotics: some
guidelines for addressing legal and ethical issues,”Law
Innov. Technol., vol. 9, pp. 1–44, 2017, DOI: 10.1080/
17579961.2017.1304921.
[12]E. Fosch-Villaronga, Robots, Healthcare and the Law:
Regulating Automation in Personal Care, Routledge, 2019.
[13]L. Floridi, J. Cowls, M. Beltrametti, R. Chatila, P. Chazerand,
V. Dignum, et al., “AI4People –An ethical framework for a
good AI society: opportunities, risks, principles, and recom-
mendations,”Minds Mach., vol. 28, pp. 289–707, 2018,
DOI: 10.1007/s11023-018-9482-5.
[14]W. E. Bijker, T. P Hughes, and T. J. Pinch, Eds., The Social
Construction of Technological Systems: New Directions in
the Sociology and History of Technology, MIT Press, 1989.
[15]M. Etgar, “A descriptive model of the consumer co-production
process,”J. Acad. Mark. Sci., vol. 36, pp. 97–108, 2008,
DOI: 10.1007/s11747-007-0061-1.
[16]S. Jasanoff, Ed., States of Knowledge: The Co-production of
Science and the Social Order, Routledge, 2004.
[17]E. Fosch-Villaronga and B. Özcan, “The progressive inter-
twinement between design, human needs and the regulation
of care technology: the case of lower-limb exoskeletons,”
Int. J. Soc. Robot., 2019, DOI: 10.1007/s12369-019-00537-8.
[18]D. Goodley, Disability studies: an interdisciplinary
introduction, Sage, 2016.
[19]S. L. Snyder, B. J. Brueggemann, and R.G. Thomson, Eds.,
Disability Studies: Enabling the Humanities, Modern
Language Association of America, 2002.
[20]V. Lajeunesse, C. Vincent, F. Routhier, E. Careau, and F.
Michaud, “Exoskeletons’design and usefulness evidence
according to a systematic review of lower limb exoskeletons
used for functional mobility by people with spinal cord
injury,”Disabil. Rehabil. Assist. Technol., vol. 11, pp. 535–547,
2016, DOI: 10.3109/17483107.2015.1080766.
[21]G. Goggin, “Disability and mobilities: evening up social
futures,”Mobilities, vol. 1, pp. 533–541, 2016, DOI: 10.1080/
17450101.2016.1211821.
[22]C. Tannenbaum, R. P. Ellis, F. Eyssel, J. Zou, and
L. Schiebinger, “Sex and gender analysis improves science
and engineering,”Nature, vol. 575, pp. 137–146, 2019,
DOI: 10.1038/s41586-019-1657-6.
[23]J. Wajcman, Feminism confronts technology, Penn State Press,
1991.
[24]D. Haraway, “Situated knowledges: the science question in
feminism and the privilege of partial perspective,”Feminist
Studies, vol. 14, pp. 575–599, 1988.
[25]D. Haraway, “A manifesto for cyborgs: science, technology,
and socialist feminism in the 1980s,”in Feminism/
Postmodernism, L. J. Nicholson, Ed., Routledge, 1990.
[26]A. J Berg and M. Lie, “Feminism and constructivism: do
artifacts have gender?,”Sci. Technol. Hum. Values, vol. 20,
pp. 332–351, 1995.
[27]K. Crenshaw, “Mapping the margins: intersectionality,
identity politics, and violence against women of color,”
Stanf. Law Rev., vol. 43, pp. 1241–1299, 1990.
226 Roger Andre Søraa and Eduard Fosch-Villaronga

[28]K. Davis, “Intersectionality as buzzword: a sociology of
science perspective on what makes a feminist theory
successful,”Feminist Theory, vol. 9, pp. 67–85, 2008,
DOI: 10.1177/1464700108086364.
[29]E. R. Cole “Intersectionality and research in psychology,”
Am Psychologist, vol. 64, pp. 170–180, 2009, DOI: 10.1037/
a0014564.
[30]R. K. Dhamoon, “Considerations on mainstreaming
intersectionality,”Polit. Res. Q, vol. 64, pp. 230–243, 2011,
DOI: 10.1177/1065912910379227.
[31]L. McCall, “The complexity of intersectionality,”in Intersectionality
and beyond: Law, Power and the Politics of Location,E.Grabham,
D. Cooper, J. Krishnadas, and D. Herman, Eds., Routledge-
Cavendish, 2008.
[32]N. Yuval-Davis, “Intersectionality and feminist politics,”Eur. J.
Women’s Stud., vol. 13, pp. 193–209, 2006, DOI: 10.1177/
1350506806065752.
[33]J. C. Nash, “Re-thinking intersectionality,”Feminist Rev.,
vol. 89, pp. 1–15, 2008, DOI: 10.1057/fr.2008.4.
[34]F. Ferrando, “Is the post-human a post-woman? Cyborgs,
robots, artificial intelligence and the futures of gender: a case
study,”Eur. J. Futur. Res., vol. 2, p. 43, 2014, DOI: 10.1007/
s40309-014-0043-8.
[35]C. B. Baunsgaard, U. V. Nissen, A. K. Brust, A. Frotzler,
C. Ribeill, Y. B. Kalke, et al., “Exoskeleton gait training after
spinal cord injury: an exploratory study on secondary health
conditions,”J. Rehabil. Med., vol. 50, pp. 806–813, 2018,
DOI: 10.2340/16501977-2372.
[36]J. Mehrholz, S. Thomas, C. Werner, J. Kugler, M. Pohl, and B.
Elsner, “Electromechanical‐assisted training for walking after
stroke,”Cochrane Database Syst. Rev., vol. 5, p. CD006185,
2017, DOI: 10.1002/14651858.CD006185.pub4.
[37]J. J. Eng, T. Lam, and D. R. Louie, “Research team gait speed
using powered robotic exoskeletons after spinal cord injury,”
J. Neuroeng. Rehabil., vol. 12, p. 82, 2015, DOI: 10.1186/
s12984-015-0074-9.
[38]J. Eng and D. Louie, “Powered robotic exoskeletons in post-
stroke rehabilitation of gait: a scoping review,”J. Neuroeng.
Rehabil., vol. 13, p. 53, 2016, DOI: 10.1186/s12984-016-
0162-5.
[39]P. H. Chen, R. H. Wang, R. L. Wang, D. J. Liou, and J. S. Shaw,
“Gait disorders in Parkinson’s disease: assessment and
management,”Int. J. Gerontol., vol. 7, pp. 189–193, 2013,
DOI: 10.1016/j.ijge.2013.03.005.
[40]A. Esquenazi, and M. Talaty, “Robotics for lower limb
rehabilitation,”Phys. Med. Rehabil. Clin. N. Am., vol. 30,
pp. 385–397, 2019, DOI: 10.1016/j.pmr.2018.12.012.
[41]International Organization for Standardization, “ISO 13482:
2014 Robots and Robotic Devices −Safety requirements for
personal care robots,”Available: https://www.iso.org/obp/
ui/fr/#iso:std:iso:13482:ed-1:v1:en:term:3.15.
[42]European Union Medical Device Regulation, https://www.
medical-device-regulation.eu/2019/07/04/mdr-article-1/.
[43]World Data, “Average Sizes of men and women,”Available:
https://www.worlddata.info/average-bodyheight.php.
[44]World Population Review, Average Height by Country 2020,
2020. Available: http://worldpopulationreview.com/
countries/average-height-by-country/.
[45]B. Lozada, “Filipinos second-shortest in Southeast Asia,”
Inquirer.net, April 25, 2014. Available: https://globalnation.
inquirer.net/102688/filipinos-second-shortest-in-
southeast-asia.
[46]K. Froehlich-Grobe, D. E. Nary, A. VanSciver, R. A. Washburn,
and L. Aaronson, “Truth be told: evidence of wheelchair users’
accuracy in reporting their height and weight,”Arch. Phys.
Med. Rehabil., vol. 93, pp. 2055–2061, 2012, DOI: 10.1016/
j.apmr.2012.05.005.
[47]E. Abdelkarim and S. M. Brahim, “Development and control
of a low cost Exoskeleton system with an interactive HMI
designed for paraplegic children,”Int. J. Sci. Eng. Res., vol. 10,
pp. 1326–1331, 2019.
[48]R. A. Søraa, “Mechanical genders: how do humans gender
robots?”Gend. Technol. Dev., vol. 21, pp. 99–115, 2017,
DOI: 10.1080/09718524.2017.1385320.
[49]A. Poulsen, E. Fosch-Villaronga, and R. A. Søraa, “Queering
Machines,”Nat. Mach. Intell., vol. 2, p. 152, 2020, DOI:
10.1038/s42256-020-0157-6.
[50]L. Zardiashvili and E. Fosch-Villaronga, “‘Oh, dignity too?’
Said the robot: human dignity as the basis for the governance of
robotics,”Minds Mach., 2020, DOI: 10.1007/s11023-019-09514-6.
Exoskeletons for all 227