Surgical Education Visual Gaps: Anorectal Pathology Image Diversity in Colorectal Surgery Textbooks

We sought to evaluate the representation of different skin tones depicted in images of anorectal pathology found in colorectal surgery textbooks.

Nonillustrated photographic images depicting anorectal pathology were identified and analyzed from colorectal surgery textbooks. Images were classified based on category and pathology. The Fitzpatrick skin phenotype scale and constitutive skin color scale were used to evaluate each image. Fitzpatrick phototypes I-III represented skin of noncolor and phototypes IV-VI represented skin of color. The skin tone distribution was assessed over time and compared to the distribution of the general population.

A total of 744 images from 13 textbooks were included. Textbooks were published from 2003 to 2022. Images were categorized as: diagnostic (78%), surgical (18.7%), postoperative (2.6%), or anatomic (0.7%). There were 466 (62.6%) images depicting benign/noninfectious pathology, 181 (24.4%) of infectious pathology, and 97 (13%) of malignant pathology. Based on the Fitzpatrick scale, most (84.7%) images depicted skin of noncolor. Similarly, using the constitutive scale, 86.9% of images depicted "light or fair" skin tones and only 13.1% depicted "medium or dark" skin tones. Across all pathological categories, noncolor skin was the most prevalent skin tone depicted. Compared to the distribution of skin tones in the general population, the proportion of textbook images depicting skin of color was significantly (P = 0.0001) decreased. Over time, the proportion of images depicting noncolor skin has not significantly changed.

Across all image categories and diagnoses, anorectal pathology is significantly underrepresented on skin of color in colorectal surgery textbook images.