Visual Misrepresentations: The Lack of Skin Tone and Sex Equity in General Surgical Textbooks.

Objective: Lack of racial and ethnic diversity in educational material contributes to health disparities. This study sought to determine if images of skin color and sex in general surgery textbooks were reflective of the U.S.

Design: All human figures with discernable sex characteristics and/or skin tone were evaluated independently by 4 coders. Each image was categorized as male or female. Skin tone in each image was categorized using the Massey- Martin skin color scale. This data was compared to 2020 U.S. Census Data.

Setting: U.S. Medical School.

Participants: Not applicable.

Results: A total of 1179 images were evaluated for skin tone alone; 293 images for sex alone. 650 images depicted characteristics of both sex and skin tone. Interrater reliability was 0.78 for skin tone and 0.91 for sex. While the U.S. population is 59.3% white, 29.5% non-black persons of color and 13.6% black, in surgical textbooks, 90.7% of images were white, 6.5% were non-black persons of color, and 2.8% were black. Distribution of skin tone for all textbooks were significantly different. (p < 0.001) compared to the U.S.

Population: The U.S. population is 49.5% male and 50.5% female. When images of sex specific genitalia and breasts are excluded, surgical textbook images are 62.9% male and 37.1% female. Only 1 textbook had a distribution of sex that was similar to the U.S.

Conclusions: Despite increasing diversity in the U.S. population there is a lack of skin tone and sex diversity in traditional surgical textbooks.