# The skin color and gender of high-fidelity simulation manikins in US simulation centers and their use in cultural humility training

## TL;DR

This study finds that while most US simulation centers use high-fidelity manikins to teach cultural humility, the manikins' skin color and gender distribution do not match the US population's diversity.

## Contribution

The study provides the first empirical analysis of manikin diversity in simulation centers and its alignment with cultural humility training goals.

## Key findings

- Most simulation centers use manikins for cultural humility training, but skin color and gender proportions differ from US Census data.
- Manikin skin color proportions were 51.5% light, 30.9% medium, and 17.6% dark, deviating from the hypothesized 60/20/20 split.
- Manikin gender proportions were 64% male and 36% female, rejecting the 50/50 null hypothesis.

## Abstract

Our objectives were to evaluate what proportion of simulation centers use high-fidelity simulation manikins to teach cultural humility, and to evaluate if manikin skin color and sex breakdown are representative of the USA population.

Surveys were sent to simulation centers from our simple random sample. Key outcomes included skin color and gender of manikins and if cultural humility was taught via simulation. Point and interval estimates were calculated for the proportion of light-, medium-, and dark-colored manikins, the proportion of female and male manikins, and the proportion of centers using simulation to teach cultural humility. Confidence intervals were employed to test the null hypothesis that light/medium/dark skin color was 60/20/20 and female/male was 50/50 which is extrapolated from the US Census data.

Our response rate was 75% (41/55). All of the 41 responding simulation centers had manikins (1.0000, 95% CI: 0.9180, 1.0000). Twenty seven of the 41 simulation centers with manikins reported simulation scenarios with cultural humility (0.6585, 95% CI: 0.5127, 0.8044). Proportions of light-, medium-, and dark-colored manikins were 0.5150 (0.4669, 0.5625), 0.3086 (0.2651, 0.3547), and 0.1764 (0.1563, 0.1964), respectively. Proportions of male and female manikins were 0.6402 (0.6163, 0.6640) and 0.3598 (0.3360, 0.3837). The null hypotheses that skin color follows a 60/20/20 split and gender follows a 50/50 split were rejected.

Most simulation centers surveyed teach cultural humility via simulation, however their manikins do not reflect the sex and skin tone of the USA population.

The online version contains supplementary material available at 10.1186/s41077-026-00408-z.