Updates in Surgery (2022) 74:1915–1923 https://doi.org/10.1007/s13304-022-01355-w ORIGINAL ARTICLE Diversity bias in colorectal surgery: a global perspective Franco Marinello1 · Christina A. Fleming2,3 · Gabriela Möeslein4 · Jim Khan5,6 · Eloy Espín‑Basany1 · Gianluca Pellino1,7 · Diversity Bias Study Collaborators Received: 20 July 2022 / Accepted: 8 August 2022 / Published online: 9 September 2022 © The Author(s) 2022 Abstract There is a specific lack of data on equity and injustices among colorectal surgeons regarding diversity. This study aimed to explore colorectal surgeon’s lived experience of diversity bias with a specific focus on gender, sexual orientation or gender identity and race or religion. A bespoke questionnaire was designed and disseminated to colorectal surgeons and trainees through specialty association mailing lists and social media channels. Quantitative and qualitative data points were analysed. 306 colorectal surgeons responded globally. 58.8% (n = 180) identified as male and 40.5% (n = 124) as female. 19% were residents/registrars. 39.2% stated that they had personally experienced or witnessed gender inequality in their current work- place, 4.9% because of sexual orientation, and 7.5% due to their race or religion. Sexist jokes, pregnancy-related comments, homophobic comments, liberal use of offensive terms and disparaging comments and stereotypical jokes were commonly experienced. 44.4% (n = 135) did not believe their institution of employer guaranteed an environment of respect for diversity and only 20% were aware of society guidelines on equality and diversity. Diversity bias is prevalent in colorectal surgery. It is necessary to work towards real equality and inclusivity and embrace diversity, both to promote equity among colleagues and provide better surgical care to patients. Keywords Diversity · Gender · Race · LGBTQ + · Colorectal surgery Introduction inclusivity (EDI) in work practice. This has been a result of considerable reports of inequality, prejudice and dis- In current practice, the medical and surgical community has crimination that has been prevalent in the workforce. The become far more cognisant of the importance of diversity experience of diversity bias is common in surgery with dis- and the importance of promoting equality, diversity and crimination broadly reported against women, the “lesbian, gay, bisexual, transgender, and questioning” (LGBTQ +) Members of The Diversity Bias Study Collaborators are listed in the community and discrimination based on race and religion acknowledgements section. 2 * Franco Marinello Department of Colorectal Surgery, CHU Bordeaux, franco.marinello@vallhebron.cat Bordeaux, France 3 * Gianluca Pellino Royal College of Surgeons in Ireland, Dublin, Ireland gipe1984@gmail.com; gianluca.pellino@unicampania.it 4 Center for Hereditary Tumors, Ev. Krankenhaus Christina A. Fleming BETHESDA, University of Düsseldorf, Duisburg, Germany christinafleming49@gmail.com 5 Colorectal Department, Portsmouth Hospitals University Gabriela Möeslein NHS Trust, Portsmouth, UK g.moeslein@bethesda.de 6 School of Health and Social Care, University of Portsmouth, Jim Khan Portsmouth, UK mkhan702@aol.com 7 Department of Advanced Medical and Surgical Sciences, Eloy Espín‑Basany Università degli Studi della Campania “Luigi Vanvitelli”, eloy.espin@vallhebron.cat Naples, Italy 1 Colorectal Surgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona UAB, Barcelona, Spain 13 Vol.:(0123456789) 1916 Updates in Surgery (2022) 74:1915–1923 as frequently described reasons [1]. While great progress orientation. Section four investigated possible prejudices has been made in reducing the prevalence of overt or explicit related to race or religion of the respondents. For these sec- bias, the experience of unconscious or implicit bias is still tions, if the answer was positive, they were asked to further prevalent [2]. Unconscious bias is commonly experienced as describe specific situations or experiences through multiple micro-aggressions. Micro-aggressions may be described as response options and/or through a brief free-text explana- subtle snubs, ‘slights’ and insults directed towards an indi- tion. Section five investigated participant awareness of work- vidual’s identity based on a stereotype or historic bias about ing place or scientific association policies or recommenda- the social or cultural group that they identify with [3]. tions relating to diversity bias. Following initial design, the As a traditionally male dominated profession, femini- questionnaire was distributed and piloted among the steer- sation of the surgical workforce is increasing. However, ing group to ensure content and face validity. The feedback women can experience a high rate of gender-based dis- received from this was used to further refine the question crimination in medical school, residency and practice [4, items both in terms of content and wording to minimise 5]. Moreover, the synthesised literature of the lived experi- ambiguity and improve question neutrality. The question- ence of women in surgery suggests that gender bias both naire is detailed in Appendix A. The design of the survey discourages female medical students from pursuing a career and the reporting of the results adhered to the CHERRIES in surgery and contributes significantly to higher attrition Guidelines [8]. [6]. There is also little data on diversity bias experienced by colleagues who identify as LGBTQ + , or those who belong Population identification and dissemination to a minority ethnic race or religion. A recent report, showed these surgeons had endured one or more type of experience Colorectal surgeons (consultants/attendings) and colorec- short of harassment, bullying or abuse in their workplace [7]. tal surgeons in training (resident/trainee/fellow) worldwide To date there is a lack of reported data on the experience were invited to participate in this study. The questionnaire of diversity bias specifically among colorectal surgeons. The was opened for a six-week study period: July 1st to August aim of this work was to explore the colorectal surgeon’s 15th 2021. The questionnaire was disseminated through (residents/registrars and attendings/consultants) lived expe- mailing lists of several European surgical scientific soci- rience of diversity bias with a specific focus on gender, race eties including: the Spanish Association of Coloproctol- or religion and sexual orientation or gender identity. ogy (AECP), the Italian Association of Colorectal Sur- gery (SICCR), the European Society of Coloproctology (ESCP), and the Association of Surgeons of Great Britain Materials and methods and Ireland (ASGBI). The questionnaire was further dis- seminated through social media platforms including Twit- Questionnaire creation and validation ter and WhatsApp groups using the following link: “https://​ forms.​gle/​D85er​YLQo9​HRbHM​DA “. The responses were The aim of this questionnaire was to explore bias in colo- anonymised and confidential in line with Google’s privacy rectal surgery relating to three specific factors i.e., gender, policy (https://​polic​ies.​google.​com/​priva​cy?​hl=​it, accessed sexual orientation, or gender identity (LGBTQ +), and race on 2 January 2021). Participants were required to provide or religion. A semi-structured online questionnaire was used informed consent by clicking a specific checkbox at the end to collect data from the study respondents with the principle of the questionnaire, after being informed that all data would of snowball sampling method (non-probabilistic sampling) be used only for research purposes and that name and institu- via “Google Form”, an online self-administered data collec- tion of practice could not be identified. Participation in the tion and hosting tool (‘Google LLC’ Mountain View, CA, questionnaire was voluntary and no incentive was offered. USA). Formal review board approval was not required due to the For developing the online questionnaire, two patterns nature of the study. were selected including: single answer questions through multiple choice options, and open questions through short Analysis answers. No sample size calculation was performed since this was a cross-sectional study. The questionnaire contained Data collected and gathered in the google forms was down- three sections. Section one included demographic character- loaded in Microsoft excel sheet (Microsoft, Richmond, istics of the respondents (age, gender, and country of pro- Virginia) for analysis. Quantitative variables were reported fessional practice and stage). Section two explored poten- using frequency (percentage) whereas mean [standard devi- tial gender related inequalities experienced or witnessed at ation (SD)] was used to report quantitative variables. No the respondent’s workplace. Section three explored poten- further statistical analysis was performed given the sample tial bias related to the respondents or co-workers’ sexual characteristics. The qualitative comments were summarized 13 Updates in Surgery (2022) 74:1915–1923 1917 for inductive thematic analysis. A list of areas for action was as: not achieving a promotion or appropriate professional developed, based on the results of the survey. advancement (47.5%), lack of opportunity to develop a particular surgical technique (24.2%), and impact on income due to gender differences (18.3%). Some respond- Results ents also described that they felt they were not invited to present at conferences or attend congresses due to their General characteristics gender (3.3%) (Fig. 2). Furthermore, 72 respondents (23.5%) reported that they had suffered attacks, humiliat- A total of 306 participants responded to the questionnaire ing comments, or a negative work environment due to their during the study period from 37 different countries. Coun- gender. The majority of these experiences were described tries that are represented are summarised in Fig. 1. This as sexist jokes, or pregnancy-related comments (Table 3). included 58.8% (n = 180) who identified as male and 40.5% (n = 124) who identified as female. The majority of responses were from consultant surgeons (n = 248–81%), and the Sexuality‑related bias rest from residents/trainees. The most common age group responding was the 36–45 years group (n = 111–36.3%). A Only 15 respondents (4.9%) stated that they had been per- complete summary of demographic characteristics and pri- sonally affected by their sexual orientation at their work- mary country of practice for all respondents are summarised place (Table 2). The main experience categories described in Table 1. were not achieving a promotion or advancing profession- ally when expected (52.6%), lack of opportunity to develop Gender‑related bias a particular surgical technique (21.1%) and direct impact on income (15.8%) (Fig. 2). A total of 54 surgeons (17.6%) One-hundred and twenty respondents (39.2%) stated that indicated that they experienced or witnessed attacks, they had personally experienced or witnessed first-hand humiliating comments, or a negative work environment situations of gender inequality in their current work- because of their or other colleagues’ sexual orientation, place (Table 2). The main categories are summarised in mainly due to homophobic comments and jokes, or the Table 3. Of them, the main inequalities were described liberal use of offensive terms (Table 3). Fig. 1  Heatmap of countries represented by respondents 13 1918 Updates in Surgery (2022) 74:1915–1923 Table 1  Demographic information of participants Institutions, specialty associations and call Total no. participants % (n) for change Gender Almost half of the respondents (n = 135–44.4%) thought Male 58.8 (180) their work institution or employer did not guarantee respect Female 40.5 (124) in gender equality, sexual orientation, or race diversity. Fur- Not specified 0.7 (2) thermore, the majority of them (n = 252–82.9%) indicated Age categories (years) their work institution or employer did not develop programs 25–35 25.5 (78) regarding respect in these topics. Only 20% of the colorectal 36–45 36.3 (111) surgeons who are affiliated with Scientific Societies, stated 46–55 26.5 (81) that the scientific association they hold membership with 56–65 9.5 (29) had a program regarding respect in gender equality, sexual > 65 2.2 (7) orientation, or race diversity. In Appendix B, the authors Career stage outline a summary of all free-text comments describing the Resident 19 (58) experience of diversity bias from respondents. From this Consultant 81 (248) data the experience of bias described in each situation could Primary Country of Practice have been improved by surgeons in 88.6% (n = 70) of cases, Spain 43.8 (134) medical schools, hospitals or institutions in 46.8% (n = 37) Italy 20.9(64) and speciality societies in 35.4% (n = 28). Based on the find- United Kingdom 3.3 (10) ings of this study, the authors recommend specific action Ireland 2.3 (7) plans to reduce diversity bias in colorectal surgery (Fig. 3). Australia 1.6 (5) Other European Union Countries 10.1 (31) Other Non-European Union Countries 8.2 (25) Discussion Not specified 9.8 (30) Specialty Association Memberships This study identified that diversity bias is experienced in ACPGBI 11.4 (35) global colorectal surgery practice. Almost half of respond- AECP 35 (107) ents had experienced or witnessed gender bias in their cur- ASGBI 5.2 (16) rent workplace with, 4.9% experiencing bias due to sexual ESCP 57.2 (175) orientation or gender identity and 7.5% due to race or reli- SICCR​ 18.6 (57) gion. The study further identified how such bias can impact Other National Colorectal or General Surgery society 32 (98) on income, opportunity to develop skills and academic No Scientific Society related to Coloproctology 7.2 (22) profile and overall career progression. Particular verbal and open bias were also reported including sexist jokes, pregnancy-related comments, homophobic comments, lib- eral use of offensive terms and disparaging comments and stereotypical jokes were commonly experienced. Equality, diversity and inclusivity (EDI) is important in healthcare. It is established not only in healthcare but also in corporate organisations that diverse teams work better [9]. Race and religion‑related bias Highly functioning and effective teams have the potential and ability to deliver improved patient care. Each individual Twenty-three (7.5%) responding colorectal surgeons stated that can bring a unique point of view and personal, social and they had been personally affected by their race or religion in culture experience to the table to enhance patient care. Bias, their workplace (Table 2). Of these experiences, the main cate- as defined in the oxford dictionary, is a ‘strong feeling in gories again were not achieving a promotion or advancing pro- favour of or against one group of people often not based fessionally (38.5%), not achieving the opportunity to develop on fair judgement’. Bias may further be categorised as con- a particular type of surgical technique (26.9%), and impact scious (also described as explicit, describing ones’ aware- on income (11.5%) (Fig. 2). Also, 38 respondents (12.4%) ness of their prejudices) and unconscious (also described described that they experienced or witnessed attacks, humili- as implicit, describing ones’ lack of insight into their own ating comments, or a negative work environment because of personal attitudes towards certain groups). Diversity bias their race or religion, especially due to disparaging comments is a more recently utilised term used to describe individual or stereotypical jokes (Table 3). or systemic bias to those considered in different or more 13 Updates in Surgery (2022) 74:1915–1923 1919 Table 2  Personal experiences of diversity bias in current practice and personal impact of diversity bias as reported by participants Personal reported experiences of diversity bias in current practice Overall group Yes No % (n) % (n) Gender Personally affected/witness situations of gender inequality 39.2 (120) 60.8 (186) Felt attacked/subjected to humiliating comments 23.5 (72) 76.5 (234) Sexual orientation/gender identity Personally affected due to your sexual orientation 4.9 (15) 95.1 (291) Felt attacked/subjected to humiliating comments 17.6 (54) 82.4 (252) Race/religion Personally affected due to your race/religion 7.5 (23) 92.5 (283) Felt attacked/subjected to humiliating comments 12.4 (38) 87.6 (268) Personal reported impact of diversity bias % (n =) Gender bias Sexual orientation/gender Race/religion (n = 120) identity (n = 23) (n = 15) My income has been affected 5.8 (7) 6.7 (1) 13 (3) Impact on promotion or professional advancement 47.5 (57) 60 (9) 43.5 (10) Not invited to present/attend at congresses 3.3 (4) 6.7 (1) 4.3 (1) Publishing in scientific journals 0.9 (1) – 4.3 (1) Development of surgical technique 24.2 (29) 20 (3) 30.6 (7) Other 18.3 (22) 6.7 (1) 4.3 (1) Table 3  Qualitative thematic summary of experience of harassment practice including robotics, artificial intelligence (AI), big and experience of humiliating comments data and enhanced imaging, it is also increasingly obvious Qualitative themes (from free text responses) that the delivery of innovative surgical care is pioneered by an increasingly diverse group of surgeons from non- Gender bias General sexist behaviour and comments traditional social backgrounds also with increasing female Inappropriate sexual comments “risk of pregnancy”…”rota gaps” representation. As a result, it is fair to say that overt bias is Menstrual references to explain behaviour beginning to decline. However, the emergence and preva- “this procedure needs a strong man” lence of subconscious or implicit bias commonly in the form “the girl”, “good girl”, “not bad for a girl” of micro-aggressions persists [3]. For example, this study “too….” – “ambitious, blond, emotional, difficult” identified that while one quarter of respondents felt openly Sexual orienta- Homophobic comments tion/gender Use of derogatory terms targeted due to their gender, closer to 40% felt they experi- identity Insinuation of HIV + status enced some form of discrimination due to gender bias, so “not a real man”, “not manly enough” while not all bias is open and obvious it can still occur in a Race/religion General racist comments more subtle way. Racist “jokes” It is notable that over 60% of the respondents were under “dirty”, “poor”, “all the same” Anti-Islamic/terrorist characterisations 45 years of age. This could be explained by two possible Expected to perform lower resulting in less opera- reasons. The first is that this age group is more active in tive opportunity social networks and is more willing to answer this type of surveys. The second could be that young people are more sensitive to equality issues, more aware of potential bias at minority groups for example of gender, social or societal their workplace, and more willing to report injustices. groups to those within which we personally identify [7]. Surgery has been traditionally a male dominated specialty It is important to recognise that the practice of surgery and while feminisation of the surgical workforce is increas- is in an exciting period of transition [10]. As many new ing, up to 2/3 women still report being deterred from pursu- technologies and techniques are integrating into surgical ing a career in surgery, experiencing discrimination in the 13 1920 Updates in Surgery (2022) 74:1915–1923 Fig. 2  Summary of experience of diversity bias in current colorectal surgery practice (A) and professional areas that have been impacted by bias (B) surgical workplace and feeling under-represented in leader- These issues tend to commence in medical school. It has ship positions [11, 12]. A large systematic review published been reported that sexual minority students are more likely in early 2021 exploring the unspoken reality of gender bias to report stress, isolation, verbal insults and harassment or in surgery identified four broad themes in qualitative analy- threats, and they are approximately twice as likely to experi- sis, as experiences of women in surgery from 300 female ence depression and related mental health comorbidities [15, respondents. These included: a general unfavourable work 16]. It has previously been reported that surgeons were par- environment with harassment and inability to establish legit- ticularly likely to discourage sexual minorities from entering imacy; challenges in motherhood, in particular insufficient their specialty [17]. A more recent study provided further support from other women, work life balance challenges and evidence that specialties such as surgery are perceived as negative perceptions of working mothers; a male-dominant less inclusive of sexual minorities [18]. This leads to under- culture encouraging female exclusion, requirement to con- representation of LGTBQ + physicians in surgery and a lack form to male standards and inequalities in career progression of role models. Thus, the global colorectal community needs and finally social pressure encompassing generally higher to consider how this impacts both colleagues and patients. expectation and acceptance of gender stereotypes [11]. For example, some gay patients may be more open to discuss While efforts have been made to support the progress of anal disorders with an LGTBI + colorectal surgeon which women in surgery, there is still remains a lack of progres- could enhance patient care. sion to leadership positions and creating a balanced work In this study a low number of respondents felt they were environment supportive of parenthood [7, 13]. affected by their sexual orientation at work, which may There has been an improvement in the social acceptance be impacted by a high number of heterosexual respond- of homosexuality and the LGBTQ + community during the ents, which was not recorded. However, a higher num- last decades. Despite this positive change, many gay, lesbian ber of respondents experienced or witnessed attacks, and bisexual doctors still face many dilemmas, including humiliating comments, or a negative work environment societal expectations that heterosexuality is the norm [14]. because of their or other colleagues’ sexual orientation. 13 Updates in Surgery (2022) 74:1915–1923 1921 This finding contrasts with the results of an independent review on diversity and inclusion for the Royal College of Surgeons of England (RCSEng), which revealed that over 70% of LGBTQ + medics had endured one or more type of harassment or abuse in the previous two years related to their sexual orientation ranging from feeling unable to talk about their private life at one end of the spectrum to homo- phobic name-calling at the other end [7]. It is important to ensure that the root of this stigma in bias is targeted. There is a significant lack of data describing surgeons experience of diversity bias due to race or religion from a European perspective. This study identified that 7.5% of Black and minority ethnic (BME) colleagues felt dis- criminated against due to their race or religion and 12.4% felt they had been openly discriminated against includ- ing receiving comments from generalising negative ste- reotypes and to overt racism. Data from the UK suggest significant bias is experienced by BME colleagues and this can impact on academic and clinical performance and experience. Disparity is observed in professional inter- collegiate examinations with BME candidates objectively achieving lower scores [19]. BME colleagues are also less likely to be appointed to specialist surgical training schemes, more likely to experience bullying and harass- ing behaviour in the workplace and are more likely to be reported to regulatory authorities compared to white/Cau- casian colleagues [7]. This is not just in healthcare provid- ers but disparities in provision of healthcare services and clinical outcomes are also observed [20, 21]. While challenges in diversity bias exist both in health- care and specifically in colorectal surgery, it is important to consider how some of them may be overcome. The increasing current interest by surgical colleges and spe- cialty organisation to focus action on and prioritise EDI is greatly welcomed. The Kennedy Report (2021), published by the RCSEng, called for large scale re-evaluation of how equality and diversity and inclusivity is approach by the surgical community. It highlighted that while a diverse community of surgeons is needed, inclusivity (seeking input and insight from a diverse group) and belonging (making space for everyone and valuing the richness that comes from different perspectives and experiences) are also essential. It is also important to consider the impor- tance of ‘role-modelling’ and ‘visibility initiatives’ so that future leaders in surgery can see themselves and identify with current leaders in their field. Policies with clear pro- cedural application and pathways for raising concerns aligned with actionable outcomes should be an absolute requirement by all medical and surgical colleges and spe- Fig. 3  Infographic recommendations for surgeon, institution and spe- cialty and trainee organisation. It is important that these cialty society level change based on results to overcome diversity bias actions commence as early as medical school (or prefer- in colorectal surgery ably sooner in life) to ensure that the cultural acceptance of bias is wiped out. 13 1922 Updates in Surgery (2022) 74:1915–1923 This study has limitations. The response rate is not clearly Funding Open access funding provided by Università degli Studi della quantifiable due to the broad dissemination of the question- Campania Luigi Vanvitelli within the CRUI-CARE Agreement. All authors have no source of funding. naire link through social media platforms. Since no regis- tration was required to respond the survey, double filling Declarations could not been prevented. Only three factors (gender, sex- ual orientation/identity and race or religion) were assessed. Conflict of interest The authors have no conflict of interest. These overarching categories of bias were selected as they encompass a significant majority of factors under which bias Ethical standards This study was conducted in adherence with ethical is experienced, however, the authors recognise that this is standards. not an exhaustive list and that the experience of bias can Human and animals rights This articles does not contain any studies be multifaceted and relate to an extensive list of personal, with human participants or animal performed by any of the authors. professional, and societal factors. Also, some participants who had a more negative experience might have been more Informed consent Informed consent was obtained from all individual participants who answered the questionnaire. willing to respond the survey. While gender variables were recorded, respondents were not asked to describe their sex- ual orientation or race or religion. Another limitation of this Open Access This article is licensed under a Creative Commons Attri- bution 4.0 International License, which permits use, sharing, adapta- study is that a specific subgroup analysis among different tion, distribution and reproduction in any medium or format, as long demographic variables of respondents was not performed. as you give appropriate credit to the original author(s) and the source, Despite its limitations, this study is the first cross-sec- provide a link to the Creative Commons licence, and indicate if changes tional study aiming to expose biases among surgeons from were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated 37 countries providing a broad, global insight into the diver- otherwise in a credit line to the material. If material is not included in sity bias in colorectal surgery, even though there were lim- the article's Creative Commons licence and your intended use is not ited responses for some countries. In the context of increased permitted by statutory regulation or exceeds the permitted use, you will reporting about inequalities in career progression, oppor- need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. tunities, and access to surgical training and practice [22, 23], this study provided additional information on EDI in surgery, and identified issues that need urgent action. References Conclusion 1. Salles A, Awad M, Goldin L et al (2019) Estimating implicit and explicit gender bias among health care professionals and surgeons. JAMA Netw Open 2:1–12. https://​doi.​org/​10.​1001/​jaman​etwor​ Diversity bias exists in colorectal surgery. 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