Abstract
The Acceptance and Action Questionnaire–Stigma is an innovative intervention for promoting occupational justice to support the health and well-being of TGNC people.
Disability studies has placed critical focus on the social conditions that give rise to the notion of “normal” and that stigmatize and pathologize people perceived to deviate from the “norm.” Minich (2016) called for a recognition of disability studies not as a subject, centered on those with conditions traditionally classified as disabilities, but rather as a methodology. This distinction, she urged, would illuminate that the principles that guide disability studies “extend well beyond what is immediately recognized as a disability” (Minich, 2016, para. 6). Moreover, recognizing disability studies as a methodology would “recommit the field to its origins in social justice work” (Minich, 2016, para. 6). Expanding on this claim, Minich further explained,
when I locate the origins of the field in social justice work, I mean not only the widespread US disability rights movement but also other movements for the liberation of people with bodies and minds that are devalued or pathologized but who do not consistently identify (or are not consistently identified) as disabled (para. 6). . . . It must be a methodology that proceeds not from narrowly defined notions of what “counts” as a disability but one that seeks to radically disrupt the multiple sociopolitical ideologies that assign more value to some bodies and minds than to others. (para. 11)
In this vein, this study embraced disability studies as a methodology for conceptualizing and testing an intervention for the health and well-being of transgender and gender-nonconforming (TGNC) people. Through a disability studies lens, we view the health disparities experienced by the TGNC community as resulting from widespread societal stigma and disaffirming political policies that impede occupational justice and therefore restrict meaningful life participation (Hammell & Beagan, 2017; Scout, 2016). Thus, our intervention aims to support the health and well-being of TGNC people by targeting societal stigma beliefs.
Identity Development Evolution and Sharing (IDEAS; Wasmuth et al., 2020) is an interdisciplinary theater intervention. An occupational therapy practitioner conducts narrative interviews with members of a marginalized group, and a professional playwright creates and casts a play to portray those stories. Performances are followed by a conversation among audience members, interviewees, theater professionals involved in the production, and expert panelists. The conversation is moderated by the occupational therapy practitioner, who by training has the skills to craft, in partnership with theater professionals, an occupational justice–centered event that highlights existent occupational injustices as well as affirmative care practices and societal-level solutions.
Theater performance as a medium has been shown to be particularly effective in illuminating and abating implicit (and explicit) biases toward marginalized groups by offering audiences an opportunity to immerse themselves in the stories of others (Meineck, 2017). This approach has been shown to cultivate open-mindedness and change attitudes where more overtly persuasive messaging triggers cognitive resistance (Meineck, 2017; Solomon, 2019). IDEAS is thus able to convey critical information on affirmative practices, whereas other educational approaches have proven to be ineffective (Brottman et al., 2020). The importance and innovation of IDEAS lie in its ability to evoke empathy, understanding, and awareness in audience members by connecting them not to abstract, dehumanized stories but rather to the stories of people in their own communities as well as those who are present, whether in person or virtually, during a postshow conversation. Although notable differences distinguish in-person from virtual performance media, in this study we examined whether the characteristics that these media share (i.e., a focus on personal stories, the reliance on professional playwrights to create engaging scripts, and the real-time collective viewing and discussion of the performance) are adequate to produce favorable outcomes via a virtual performance.
IDEAS moves away from an individualistic, medical model lens that seeks to “fix maladaptations” of people, often within historically marginalized groups. Instead, IDEAS intervenes with stigmatizing and alienating societal systems to promote the well-being of people in marginalized groups. It draws on occupational therapy practitioners’ unique, holistic, and occupational justice–centered knowledge, redirecting focus to systemic injustices rather than immediate physical and social contexts of a client. As Gerlach et al. (2018) pointed out, the medical model–oriented construct of and tendency toward individualism is
underpinned by the assumption that all individuals and population groups have autonomy over their occupations; [it] risks framing social problems as the result of personal deficiencies or lifestyle choices [and] it informs “solutions,” or practice and policy interventions that are primarily focused on changing individuals’ behaviors, skills, or abilities to overcome or adjust to their circumstances. (p. 36)
IDEAS is rooted in the science of occupation: the knowledge that participation in meaningful activity is the cornerstone of well-being (American Occupational Therapy Association, 2020). IDEAS views the health disparities of TGNC people as a product of occupational injustices that limit opportunities to freely engage in health-supporting occupations (rather than as a product of disabling attributes inherent in gender-diverse bodies). Thus, at the core of IDEAS is an appreciation of the principles of disability studies: a commitment to social justice and a dedication to examining how societal stigma places undue harm on the health and well-being of the TGNC population. In effect, this intervention shows promise for improving the lives of TGNC people through its embrace of disability studies; moreover, it also acts on the call to extend the principles of disability studies to the larger body of people harmed by sociopolitical ideologies, which Minich (2016) spoke of as “assign[ing] more value to some bodies and minds than to others” (para. 11). Currently and globally, societal factors rooted in stigma and discrimination restrict occupational justice for TGNC people, illustrating a dire need for innovative, effective solutions to the health of TGNC people that extend beyond the confines of individualism and medical model approaches.
Background
Transgender people are those whose gender identity does not match their sex assigned at birth. Historically, gender has been conceptualized as binary (male–female) despite the prevalence of numerous variations of biological sex and gender (American Psychological Association, 2014). Thus, TGNC people’s identities and variations of biological sex have been pathologized, arguably contributing to implicit (or explicit) biases of society members and health care providers (Scout, 2016). This bias is evidenced by the report of the 2015 U.S. Transgender Survey, which revealed that TGNC people (1) avoid needed medical services because they have been vastly mistreated in health care settings and (2) experience grave occupational injustices in society, such as lacking access to restrooms and experiencing exorbitant rates of physical and sexual violence because of their gender identity or presentation (James et al., 2016).
Challenges to the idea that being TGNC is pathological reflect how the health of TGNC people may have more to do with societal norms than with TGNC people. For example, the American Psychological Association (2014) stated,
A psychological state is considered a mental disorder only if it causes significant distress or disability. Many transgender people do not experience their gender as distressing or disabling, which implies that identifying as transgender does not constitute a mental disorder. . . . Many other obstacles may lead to distress, including a lack of acceptance within society, direct or indirect experiences with discrimination, or assault. (Is Being Transgender a Mental Disorder? section, para. 1)
This passage echoes Hirschmann’s (2012) assertion that disability refers “exclusively to what society, social conditions, prejudices, biases, and the built environment have produced . . . [and is] not applicable to the body per se but to the body in a hostile social environment” (p. 399).
Health care is arguably one of the major agents of stigma. In the United States, health care is grounded in the medical model, in which cure is implemented after the abnormality, injury, illness, or difference is identified. McRuer (2006), in his book Crip Theory, explored the concept of disability, arguing that society, in part because of the medical model, establishes ablebodiedness as compulsory. He aligned this view with compulsory heterosexuality; however, it could also clearly apply to the societal tendency to treat being cisgender (having a gender identity that matches one’s sex assigned at birth) as mandatory. Moreover, TGNC people may also be lesbian, gay, or bisexual and may have to face not only compulsory cisgender norms but also compulsory heterosexuality. According to McRuer, societal institutions and medical communities have a need to establish an agreed-on common ground. Questions such as “Wouldn’t you rather be able to walk?” or “Wouldn’t you rather be heterosexual? [or Wouldn’t you rather be cisgender?]” assume a normality that cannot be disentwined from the other. In other words, there cannot be a normal without socially constructing the abnormal first. According to Hirschmann (2012),
This is the most difficult idea for most nondisabled people to grasp: “Who would want to be [disabled]?” the thinking goes, “of course such people want to be ‘normal.’” But in fact they do not; multiple studies show . . . the major frustration for [people with disabilities] is the prejudicial attitudes and treatment. (p. 399)
Judith Butler (2009) described how “obligatory norms to be one gender or the other (usually within a strictly binary frame)” subvert gender diversity by limiting the possibility space for gender performance, noting how “the reproduction of gender is always a negotiation with power” (p. i). Butler spoke to the precarity that TGNC people face, pointing out that people who live outside of gender norms experience a much greater risk of experiencing violence and harassment, and this risk increases exponentially among TGNC people of color (Griffin, 2016).
Numerous educational methods have been used to reduce provider stigma. However, multiple reviews (Brottman et al., 2020; Chae et al., 2020) have found that existing programs lacked favorable outcomes.
For centuries, theater has been considered to be a powerful art form for eliciting social change (Meineck, 2017). The literature suggests that narrative theater allows audiences to be immersed in entertaining stories and, as such, is “likely to be an exceptionally effective method of countering those attitudes that people are most unwilling to change (such as firmly held ideological or political beliefs)” (Solomon, 2019, p. 40). Meineck (2017) examined ancient Greek theater through a cognitive science lens as acting
upon its audiences to create absorbing narrative action, emotional intensity, intellectual reflection, and strong feelings of empathy, [which] was the key to the transformative artistic and social power that enabled Greek drama to advance alternate viewpoints and display distinctly different perspectives. (p. 1)
The disability community has a rich history of using performance art to address the complex interaction between people with disabilities and people without disabilities, which often results in “othering.” Staring is defined as a more emphatic form of looking; unlike other forms of looking, it signifies the presence of difference and endows it with meaning. According to Thomson (2008), “Staring witnesses an intrusive interest on the part of the starer and thrusts uneasy attention on the object of the stare” (p. 30). People with visible difference experience the stare, not as a stare of beauty or sexuality but as a stare imbued with diagnosis, judgment, and othering. According to Thomson, this otherness draws out stigma that threatens to undo the human bond that is based on corporeal similarity. Performance art combines the visual body with the spoken word and, as such, becomes a liberating act of self-making. Performance art places the object of the stare in control of the dynamic. The starer, or rather the audience, is placed in the uncomfortable position of confronting their bias. By doing so, performance artists with visible differences manage, deflect, resist, and renounce the stare, thereby mounting a critique of the politics of appearance (Thomson, 2008).
Purpose, Need, and Contributions to Occupational Therapy
Assessing the feasibility of IDEAS could advance its future implementation by occupational therapy practitioners. We examined whether IDEAS is feasible as a webinar, which would allow it to have a national or global reach. This outreach is needed because the literature has revealed global biases and insufficient trainings for stigma reduction and affirmative care for TGNC people. Occupational therapy practitioners and other health care providers may therefore benefit from this form of provider education. We anticipated that participation in IDEAS would be experienced as affirming and empowering for TGNC participants and decrease stigma beliefs in audience members.
We also anticipated successful adaptation (i.e., change in the format of a program to meet new circumstances; Bowen et al., 2009) of IDEAS to a webinar platform while taking into account the inherent differences between in-person and virtual performance. With the purpose of assessing IDEAS webinar feasibility, this study addressed the following research questions:
What are the demographic characteristics and size of a convenience sample of community-based audience members and TGNC interviewees?
Does the sample offer the response rates and diversity needed to produce a meaningful range of data?
Do participants’ responses to the intervention warrant future study of efficacy?
Method
Design
This pilot feasibility study was adapted for safety purposes during the coronavirus disease 2019 (COVID-19) pandemic from a live theater performance to a live online webinar play reading and postshow discussion. The university institutional review board (IRB) approved the original study (IRB Protocol No. 1906677292A002) and the post–COVID-19 amendment (March 20, 2020). We report feasibility outcomes of acceptability, demand, and limited efficacy testing.
Participants
We recruited two convenience samples. TGNC interviewees were recruited via flyers provided to TGNC support groups and word of mouth from July 2019 through December 2019. Audience members were recruited for 1 wk leading up to the April 2020 performance; recruitment was accomplished via social media advertisements, targeting health care professionals in addition to the general community.
Instruments
We used the Indiana Psychiatric Illness Interview–Control (IPII–C), a semistructured interview adapted from the IPII (Lysaker et al., 2002), to collect narratives from TGNC participants. The IPII–C asks participants to describe challenges in their lives and how those challenges unfolded, affected their lives, and affected changes in their lives. The IPII–C was readministered within 1 wk after the performance along with an additional question: “Describe your experience of being in this study.”
The Acceptance and Action Questionnaire–Stigma (AAQ–S) survey (Levin et al., 2014) is a reliable and valid measure of stigma and psychological flexibility. The AAQ–S has good interrater reliability (Cronbach’s α = .84) and low to moderate correlations (r = .23–.43) with measures of right-wing authoritarianism, social dominance, ethnocultural empathy, empathic concern, and perspective taking in a sample of 604 graduate students (Levin et al., 2014). Audience participants received a hyperlink to the preshow–postshow survey. We added demographic questions to the pretest such as age, ethnicity, race, education, health care professional background (yes, no), and whether the person identified as a member of the TGNC population (yes, no). This link also provided a brief description of the study and allowed the participant to provide written informed consent.
Intervention
TGNC participants reviewed the study information sheet with the first author (the principal investigator [PI]) and provided verbal consent to participate. They completed the IPII–C (30–60 min) with the first author, a queer, White, cisgender woman without disabilities who was an occupational therapy practitioner directly trained by the IPII–C developer. The interview was audio recorded, transcribed, and deidentified. The IPII–C specifically asks participants to describe a challenging life event; therefore, each interview produced one concrete “challenge” story, contextualized by the unique aspects of the interviewee’s life. The combination of these contextualized stories formed the backbone of the play. The PI reviewed the transcripts, highlighting overlapping thematic content and writing memos to illuminate occupational participation and injustices within stories.
Transcripts and memos were then given to a professional playwright, also a queer, White, cisgender woman without disabilities. The playwright maintained the exact words in the transcripts, with the only exceptions being minor changes to clarify the meaning of words or phrases. The playwright’s role was not to write the story of the play but rather to use her professional theater training to organize the content in a way that created theater that captivated and drew audience members into (rather than alienating them from) the inherent tension and conflict of the stories. After rearranging, aligning, and combining stories, the resulting script consisted of interwoven verbatim stories from each participant, emphasizing common themes.
Stories included TGNC people (1) working at a youth camp and being told they could not be “out” about their gender; (2) being jumped on the train and worrying that their chest and top surgery would be exposed; (3) coming out first as gay and being sent to conversion therapy before coming out as transgender; (4) navigating work, leisure, and role exploration as a gender-nonconforming, female-presenting person; (5) navigating peer relationships in the queer community; and (6) exploring romantic relationships while coming out as transgender.
The PI, TGNC people who were not research participants, and professional actors collaborated to revise and refine the script with the goal of making it affirming, educational, and empathy evoking. The playwright cast all TGNC professional actors and actively sought creative and experiential input from the cast while being transparent about her own positionality (White, queer, cisgender, nondisabled). The group reflexively discussed how to create an affirming rehearsal environment and, ultimately, a play that was authentic to participants’ voices and experiences. TGNC participants reviewed the script, and any requested content edits were made. One participant requested that some family abuse–related content be redacted. To accommodate this request while still giving “voice” to this story, the team hired a TGNC professional dancer and a professional choreographer, who designed a dance piece based on the written story, explaining that
Our bodies are our instruments in dance, carrying color and tone but leaving the exact meaning more fluid and perhaps universal. Experiences that may have been challenging or even painful, things that can shred us to pieces, can also be used to weave something new, beautiful, and poetic from threads.
After learning the choreography, the dancer recorded the piece.
The TGNC actors performed a live reading online, with the recorded dance piece portrayed alongside parts of the reading. The performance was followed by the postshow conversation, guided by the first author, among the audience, a panel of TGNC health experts, the TGNC actors, and the TGNC study participants. The TGNC participants did not perform but were encouraged to participate as panelists.
The IPII–C postshow interviews were conducted by the PI within 1 wk after the intervention. They were recorded, deidentified, and transcribed. Honoraria ($50 gift cards) were provided to the TGNC participants for completing the pre–post interviews and for participating in the postshow conversation.
In summary, IDEAS is composed of the following four essential elements:
Interviews and the postshow panel discussion are moderated by an occupational therapy practitioner who has the expertise to focus on, draw out, and expand on experiences as they relate to occupational participation and occupational justice.
Interviewees’ exact words are maintained (with the exception of minor edits for clarity), and the script is reviewed by interviewees and other members of the focus population.
Theater professionals write and perform the play to ensure quality theater and audience engagement.
The event is free and open to the public.
Data Analyses
Acceptability
Acceptability has been defined as “how the intended individual recipients . . . react to the intervention” and whether the study can successfully recruit eligible participants and generate adequate data (Bowen et al., 2009, p. 454). To assess acceptability, we report recruitment outcomes for the two participant groups, including sample diversity. We also report audience pre- and postshow survey response rates, change scores, and qualitative data on participants’ experiences of the intervention.
To determine how the TGNC participants responded to the process of the intervention, we used the steps of thematic analysis outlined by Clarke and Braun (2014) to examine deidentified transcripts of their qualitative responses; to complete this analysis, we used the question “Please describe your experience of participating in this project” as well as the deidentified transcript from the postshow conversation. The first author, who has expertise in qualitative analysis, and another member of the research team (Annie DeRolf) read each transcript. Both are cisgender, queer, White women without disabilities. Both have clinical experience within a gender health clinic and long-term personal relationships with TGNC people and communities. The researchers considered all data but specifically focused on the data related to identity, social participation, stigma, affirmation, and aspects of the intervention experienced as problematic, harmful, or negative in any way. Initial codes were highlighted, compared, and—through discussion—condensed into overarching themes.
Demand
Analysis of demand examines the likelihood that a program will be used, and it can be assessed by recording the use of the intervention within the defined population or setting (Bowen et al., 2009; Eldridge et al., 2016). We report descriptive statistics on audience registration and actual attendance at the play reading and postshow conversation as measures of demand.
Limited Efficacy
Limited efficacy testing examines whether a new program or process demonstrates promise of success with the intended population (Bowen et al., 2009). We report audience pre–post AAQ–S change scores to indicate potential efficacy of the intervention to reduce stigma beliefs. Audience members who did not submit both pre- and postshow surveys were excluded from analysis. We determined normality of data using the Kolmogorov–Smirnov test, and we used a paired-sample t test to evaluate changes in pre–post audience AAQ–S scores. We analyzed data using SAS statistical software (Version 9.4; SAS Institute, Cary, NC).
Triangulation of data was conducted after all qualitative and quantitative data were collected. We examined AAQ–S change scores alongside qualitative themes from the TGNC participants’ postshow interviews and the postshow discussion.
Results
Acceptability, Demand, and Efficacy
Within 1 wk of sending online invitations, 101 people registered to participate. The 104 people who viewed the performance (registration was not required; 3 additional participants joined who had not registered) were from eight U.S. states and two countries, and 96 (92.3%) participated in the postshow conversation. Eighty-two of 104 (78.8%) audience members consented and completed the baseline survey, and 52 (50%) completed the follow-up survey. Forty-two of 104 (40.4%) audience members completed both baseline and follow-up surveys. Audience members with completed surveys were more likely to be younger than age 35 yr (43.9%), non-Hispanic (95.2%), and White (90.2%); they were also more likely to have a doctorate degree (38.1%) and to be female (90.5%; Table 1).
Audience Demographics (N = 42)
Note. Paired-sample t-test results show the change between baseline and follow-up AAQ–S score was statistically significant, t(41) = 8.18, p < .0001, d = 0.80. AAQ–S = Acceptance and Action Questionnaire—Stigma; TGNC = transgender and gender nonconforming.
Most of the audience members did not self-identify as TGNC (92.5%). Seventeen of the 42 (40.5%) participants who completed both baseline and follow-up surveys self-identified as health care professionals. The 6 TGNC participants (1 trans woman, 1 trans man, and 4 gender-nonconforming people) completed a baseline IPII–C that gave rise to the final script. All were White and between ages 20 and 40 yr. Three lived in large cities, 1 of whom grew up in the rural South. Three grew up in and lived in a rural Midwestern area. Five participated as panelists in the postshow conversation with the audience.
We assessed whether viewing the IDEAS performance resulted in changes in stigma perception among the audience members; we found a significant decrease in AAQ–S scores (indicating reduced stigma beliefs) from baseline (M = 79.93, SD = 12.62) to follow-up (M = 69.74, SD = 12.77), t(41) = 8.18, p <.0001, d = 0.80 (see Table 1). A post hoc power analysis indicated power with 42 participants (.999, or 99.9%), indicating a .001 chance of Type II error. Therefore, recruitment and follow-up were successful because this number was exceeded, despite attrition.
Qualitative Findings
Qualitative analysis of the postshow discussion and follow-up TGNC interviews produced the following three themes: (1) self-identifying and empowerment, (2) rural–urban distinctions and intersectionality, and (3) societal stigma.
Self-Identifying and Empowerment
Self-identifying and empowerment data illuminated the joy that the TGNC participants felt witnessing their stories and educating the audience via their experiences. For example, Participant 1 used the following description to portray their experience of watching the performance:
Hearing my own [story] was like weird, but like good . . . those are things I don’t talk about too much, but they’re big parts of me, so having a hundred people now know that even anonymously was nerve-racking but also important because [those things happen], and I know it doesn’t just happen to me.
Participant 4 expressed a similar sentiment: “By voicing [our experiences] we can make a difference so that those things don’t happen in the future.”
Participants noted joy in seeing and experiencing the creativity that goes into gender expression. Participant 2 stated, “I feel like gender is how you view magic—if you believe it, it is real for you, and no one should question how you perceive it.” Participant 3 noted,
People describe gender as existing on a line with male on one side and female on the other and options in between, but it’s more like a 3D graph with like 12 different planes. I love the creativity that a lot of gender queer people find to express their gender . . . like, “as if Elton John was riding on the back of a luck dragon on the way to a Pizza Hut.”
During the postshow discussion, a TGNC actor explained,
As a gender queer person, my gender changes—the more I try to define it, the more I feel like “no that’s not quite right,” especially as someone who experienced a lot of gender dysphoria prior to affirming top surgery. Before top surgery I was trying so hard to go hard masc . . . I am not a woman . . . After surgery, now I feel free from all of that.
Along similar lines, in response to an audience member who asked how participants “define their narrative and bring their fuller selves to life,” a TGNC actor noted, “I went hard femme, then got hormone replacement therapy, and when I grew breasts I didn’t have to perform being female anymore. Then I realized I was more nonbinary trans feminine.” In response to another question from the audience—“So is it fair to say, then, that gender is an individual experience that is different for everyone?”—a TGNC actor explained,
Yes, it is an individual journey, but an important theme in the script that we haven’t discussed is the importance of community in gender identity, whether it’s that one roommate that loves me, or a group of friends who are gender queer. Those parts of community are so important for working through and helping you understand yourself.
This sense of bonding also came up for other participants. Participant 6 described, “It was soul feeding; you know, it was like these are people that I can relate to even if I don’t share their same stories. That was really neat.” Participant 4 noted, “It is frustrating to hear the negativity, that’s for sure. But it was great to be able to sort of bond through that.”
Participant 1 noted sharing their story to be both positive and uncomfortable: “Talking about stories . . . could like rehash a bunch of stuff and be awful . . . like, Oh God, how did I even survive that? But at the same time, you think, wait, I survived!” By contrast, Participant 2 expressed,
I didn’t really enjoy it. I’m such an anxious and intense person . . . I start to self-edit and you ask me about something specific and then I think about all the things that were also surrounding that memory and event and get really lost in it.
Rural–Urban Distinctions and Intersectionality
Participants’ experiences differed depending on whether they were in rural or urban settings. For example, Participant 4 shared the empowerment that resulted from being able to receive hormone replacement therapy (HRT) during her first appointment in an urban gender health program: “To get hormones without having to talk to a psychiatrist for 2 years is incredibly freeing, it allows people to express their gender in a very personal and specific way.” This experience was in stark contrast to a TGNC actor living in a rural setting who had to undergo 2 yr of psychotherapy before being considered for HRT. This actor stated,
I had to find a psychologist willing to not try to talk me out of being trans. I have to drive an hour [to an urban location] for affirmative care. After gender confirmation surgery I got an infection. I went to a hospital in my rural town and they misdiagnosed what was going on, but even if they had gotten it right, they don’t do gender confirmation surgery here so they couldn’t handle it, so they sent me in an ambulance back to the city.
Participant 2 offered some advice for TGNC people living in rural areas:
In some areas, things have gotten easier. At appointments, you can lead with saying, “Here is how we’re going to talk about my body.” As a trans man, I have an OB-GYN appointment every year, and me and my doctor just went through how we were going to talk about my body and what terms I was and was not comfortable with . . . No one knows more about your body than you do. We often forget that.
Participant 2 also highlighted the need for more exploration of the intersections of gender and race: “I don’t experience the same gender violence that a Black trans woman does or a Latina trans woman, or a brown and Black trans guy. It’s just very, very different.”
Societal Stigma
Although aspects of stigma are implicit in the data noted earlier, participants and actors also explicitly addressed stigma. For example, Participant 5 noted their difficulty in college:
That’s when I got language for who I was, I got pushback—when I finally knew what I needed, nobody else could put in the effort. College years are over thankfully, but until we have a different societal understanding, I don’t see this getting easier.
Participant 2 emphasized,
No one should question how you perceive [your gender]. At the root of this is cis people. Anything relating to trans health issues . . . I don’t think trans people were making things a problem. It is the limited views of cis people that were a problem.
Discussion
A rich body of literature explains how in-person theater captures audiences’ attention and can evoke powerful emotions and perspective shifts. Solomon (2019) suggested that a critical ingredient for capturing attention and eliciting empathy is entertainment; thus, although virtual play readings lack the same embodied experience of attending in-person theater, use of this medium to entertain and engage audiences can likely produce some of the desired effects. Moreover, cowatching an online performance in real time may simulate the sense of a collective in-person experience. IDEAS, translated from an in-person performance to a webinar, maintains a focus on performance, which can be contrasted with a more literary approach to theatrical texts in which the script’s content is the object of focus (Meineck, 2017). Thus, despite not sharing a physical space, some performative elements of live theater are maintained in a live webinar. Audience members and actors participating in IDEAS had the opportunity to engage in real-time conversations about the stories shared; moreover, a great deal of personal disclosure took place among people who joined the webinar, contributing to a sense of shared and personal—albeit virtual—space.
This study demonstrated that the adapted online format of IDEAS allowed for adequate audience member recruitment to establish a meaningful range of data. However, audience demographic characteristics were homogenous with regard to race, age, and TGNC representation. Although it will be important to ascertain strategies to draw a more diverse audience, low TGNC representation in the audience supported our goal of educating members outside this community on affirmative care practices. Considering an expected online survey rate of 50% to 70% (Phillips et al., 2017), the presurvey response rate exceeded expectations (78.8%); moreover, the postsurvey response rate met expectations but was on the low end, with 50.0% completing the follow-up survey. Five of the 6 TGNC participants interviewed for IDEAS were present for the online reading and participated as panelists in the postshow discussion; all 5 completed follow-up interviews. This response rate is an improvement from prior, in-person IDEAS implementation with a different population (Wasmuth et al., 2020), giving us reason to explore online performances in future studies because it may have facilitated TGNC participant attendance. It is also possible that working from home and social distancing because of COVID-19 increased availability.
We anticipated that participation in IDEAS would be affirming and empowering for TGNC participants and that it would decrease stigma beliefs in audience members. Recruitment success allowed us to determine significant pre–post survey differences with >80% power, indicating reduced stigma beliefs with a low risk for a false-negative finding. This quantitative finding mirrored the emphasis and appreciation that TGNC participants expressed regarding the opportunity to educate the audience by sharing their stories and insights. Qualitative data from TGNC participants reflected ways in which the performance became a forum for “assertion and representation of the self,” one in which the performer controls the terms of the encounter (Thomson, 2008, p. 33). Triangulated data suggest that IDEAS has the potential to foster occupational justice, not only as singly experienced during the webinar but, more broadly, in TGNC people’s everyday lives because the intervention appears to reduce societal stigma.
Limitations and Future Research
Although participation by TGNC participants and TGNC audience members was high, recruitment was low for both groups. Convenience chain sampling affected the degree to which the interviewees reflect the full range of TGNC people. Several had a personal or professional connection to arts and theater, which may have drawn them to this project but also potentially limits the diversity of perspectives portrayed in this event. In addition, their ages ranged from 20s to 40s; research would benefit from also including older adults. Considering merged data, all TGNC participants were White, and the majority of audience members were White. Moreover, the interventionists were all White, queer, cisgender women without disabilities. In our future work, it will be critical to intentionally recruit racial and ethnic minority TGNC participants to illustrate the intersectionality of marginalization and issues faced by racial minority trans people, such as the disproportionately high rates of violence that Black trans women experience (Griffin, 2016).
All performers were members of the TGNC community, and some racial diversity was present among performers; however, in future projects, we will need to recruit actors from a larger network of performers, interview a larger sample of participants portraying racial and ethnic diversity, and use qualitative analysis strategies to specifically highlight issues of intersectionality. In addition, we will need to explore marketing methods within and outside the university that intentionally draw a more diverse audience. Finally, we will need to develop partnerships with a more diverse group of researchers and interventionists because the team’s lack of diversity undoubtedly influenced the study’s conceptualization, recruitment, data collection, and analysis.
Implications for Occupational Therapy Practice
The results of this study have the following implications for occupational therapy practice:
Sharing life stories through theater provides a potentially empowering opportunity for TGNC social participation that can reduce stigma beliefs within communities.
Individual well-being for marginalized people may be improved by a population-based approach to health in which theater is used to promote changes in societal attitudes, policies, and health care.
Conclusion
Outcomes of this study were promising. A single 90-min online event drew a large audience, significantly decreased stigma beliefs in audience members, and was experienced positively by the TGNC participants, suggesting that the IDEAS intervention delivered online is feasible in terms of adaptation, demand, acceptability, and limited efficacy testing.
Footnotes
Acknowledgments
This study was funded by the Indiana University School of Health and Human Sciences “Promoting External Applications for Research” program and National Center for Medical Rehabilitation Research Grant K01-HD-101589 (principal investigator: Chih-Ying Li). This work was accomplished in partnership with Summit Performance Indianapolis. We acknowledge and thank those who shared their stories to make this study possible.