Being accepted by family and friends during the recovery from limb loss is important for a healthy adjustment to life post–limb loss.1,2 Smedema et al. state adjustment is when a person achieves a person-environment congruence and demonstrates reintegration, awareness of remaining assets, positive self-esteem, and active participation in social and recreational activities.3 Individuals who have lost limbs have often reported negative interaction with strangers, family, and friends after their amputation.1 These interactions range from avoiding eye contact with others, being stared at by others, or being asked intimate questions.1 These exchanges sometimes lead to persons with limb loss feeling uncomfortable to the point that they would refuse to take off their prosthetic limb or try to hide the prosthesis altogether.1,2,4 Horgan and MacLachlan2 believe that negative interactions with others may, in part, help explain the increased rates of depression, anxiety, and low self-esteem after amputation. These negative societal interactions may also decrease compliance with prosthetic treatment and their quality of life.1,2
Mass media may be a factor in how society views people with limb loss and could play a role in shaping societal interactions. The impact of mass media on our daily lives has been studied to better understand the role that media plays in public attitudes and perceptions.5,6 Media portrayals of disability have been found to be the most influential factor in promoting and sustaining negative attitudes toward people with disabilities.7–11 Media such as television and news often reinforce these negative attitudes and contain more misinformation and negative stereotypes.8,9,11 The negative portrayal of people with disabilities in mass media may create and reinforce the stigmatized treatment and negative attitudes toward people with disabilities. These attitudes are often expressed by the population without disability through anxiety, pity, segregation, apathy, and embarrassment.5,6,12 Fortunately, these negative attitudes can be changed.5,6,12 According to three studies, positive feelings and perceptions were experienced by subjects without disability when shown positive clips of characters with disabilities.5,6,12,13 In other studies, researchers found that the attitudes of participants without disabilities were statistically more positive after viewing an education film on disability.5,14 Studies on improving attitudes toward people with disabilities have found that the most effective methods are to increase contact with persons with a disability while educating them (especially in an equal status environment) and to provide accurate education to minimize misconceptions.15 Mass media serves as a method to educate society and could potentially be used as a vehicle to improve or worsen attitudes toward people with disabilities.
Stereotyping is common in movie portrayal of people with disabilities. Many are represented as negative stereotypes, such as an evil avenger, a supercrip, and a poster child.12 Evil avengers are often portrayed as angry characters who seek revenge through violent means for their perceived hideous condition. A classic example of the evil avenger is Captain Hook. Hartnett12 describes supercrips as characters who overcome their disability through extraordinary feats. Whereas some may view this representation as positive, others argue that these movies encourage shaming and pitying the person with a disability for not working hard enough to overcome his/her disability to become “normal” again. A classic example of the supercrip stereotype is a “cripple” who learns to walk. The poster child is portrayed as a victim of an awful situation that can be cured by persons in audience with sufficiently high morals to pity and assist those in need of their charity. These stereotypes have negative consequences for the people with disabilities as they ask the viewer to look down on and pity the person with the disability.2
Past studies focused on disabilities in general and little to nothing is known about the current or past portrayal of people with limb loss. There seems to be a generally positive portrayal of military veterans with amputation in mass media.16 This could be representative of a difference in how people with amputation are being viewed by society versus people with other disabilities. In addition, technology today allows greater functional outcomes; as a result, the focus of media seems to have shifted away from limitations.16 With the media exploding with inspirational stories of veterans, paralympians, and dancing stars, it is expected that movies will reflect the positive shift in perception as well. Therefore, previous research on how people with disabilities are portrayed in movies may be a predictor of how portrayal of people with amputation in film may be becoming more positive.
The purpose of this study was to conduct a content analysis on movies from 1966 to 2015 to determine how characters with limb loss/amputations are portrayed. The general hypothesis was that the portrayal of characters with amputation in feature-length movies became more positive over time. This research will be the first step in understanding the current portrayal of characters with amputation in movies. Demonstrating a more realistic and positive image of limb loss through mass media would significantly improve the quality of life of those who have an amputation.
Quantitative content analysis was chosen as it is the most objective, replicable, and reliable media analysis method available.17 This style of content analysis is “the systematic, objective, quantitative analysis of message characteristics,” making it the ideal match for this study.17 This method, called coding, consists of collecting a sample of movies, then analyzing according to preset variables with numerical values. These values were statistically analyzed for correlations and frequencies.
The International Movie Database was used to select feature films released in US theaters between 1966 and 2015. This date range was chosen to include the largest range of time possible within the constraints of the search engine, movie availability, and time. The search strategy included the keywords based on movie descriptors: amputee, prosthetic leg, prosthetic arm, prosthetic limb, artificial limb, artificial arm, artificial leg, mechanical arm, hook for hand, hook for a hand, wooden leg, and peg leg. The movies were then organized by gross box office sales from highest to lowest. The gross box office sales were then adjusted for inflation to a 2015 US dollar, using historical inflation data from the target years (www.treasury.gov/). A threshold was set to 1% of the maximum box office gross (adjusted for inflation). Only movies that grossed more than this threshold were retained for analysis. This was done to ensure that the movies selected were likely to have been seen by a large audience and therefore likely have an impact on societal perception of people with limb loss. There was one researcher who performed the data collection and all of the coding; an additional coder was recruited to perform the intercoder reliability test. For the statistical analyses, another researcher and a statistician were consulted.
The movies were retrieved via Netflix (Netflix Inc., Los Gatos, CA, USA), which were then viewed by the coder from beginning to end to analyze every character with an amputation. For the purpose of this study, only major limb amputations were selected (e.g., above knee, below knee, below elbow, and above elbow). Partial hand and feet amputation and other body parts that are not considered extremities were excluded. In addition, any character who lost a limb and died in less than 5 minutes afterward were also excluded from the study. This is because the portrayal of living with limb loss was the focus rather than the trauma associated with the amputation. Humanoid characters (walking upright and speaking as a human; i.e., Orcs in Lord of the Rings) and animated characters (i.e., Captain Hook in Peter Pan) were included, whereas animals were not.
CONTENT ANALYSIS CODEBOOK DEVELOPMENT
Based on the work of Neuendorf, a content analysis codebook and coding form (see Appendix, http://links.lww.com/JPO/A8) was devised to format and analyze variables for the study.17 Most variables chosen are previously tested by Neuendorf and used frequently throughout her studies. A few variables were added that enabled a more thorough analysis given the purpose of this study. These included amputation level, prosthesis used, prosthesis present or not, and cause of amputation. A pilot study of four movies was conducted to determine that all relevant variables appear and then to iteratively improve the codebook. Findings from this pilot study generated a testing form to next be evaluated for intercoder reliability before the coding of all of the selected movies.
An intercoder reliability test was conducted to ensure the reliability of the coding form. Two coders used the form to code 10% of the total movie sample (randomly selected). Interclass cross-correlation coefficients were generated to compare the coder's decisions. If correlation coefficient was less than 0.70, the codebook would be declared unreliable, the codebook would then be improved, and the test repeated. Official coding began once the interclass cross-correlation coefficients exceeded 0.70. All subsequent movies were then acquired and their content was analyzed.
The primary analysis was carried out to define the frequencies of positive portrayal, heroism, and realistic prostheses of characters with amputation that appeared in movies over time. “Characters with amputation” include people who may or may not have a prosthesis, and “characters who use a prosthesis” describe the times where they were users. Positive portrayal was defined as high rates of heroism and realistic prosthetic use. Heroism was defined as a protagonist who is in the majority of the movie and positively affects other characters (e.g., Luke Skywalker in Star Wars). Realistic prosthesis was defined as a prosthetic limb system that is currently available in clinics today. Negative portrayal was defined as villains, stereotypes, and unrealistic prostheses. Villains are defined as antagonists negatively affecting other characters. Unrealistic prostheses consist of antiquated prostheses such as peg legs (e.g., On Stranger Tides), futuristic such as the robotic limbs (e.g., Star Wars: The Empire Strikes Back), or bizarre prostheses such as a machine gun leg (e.g., Planet Terror). The reasoning behind the historic context of antiquated limbs, such as peg legs, being considered unrealistic is the exposure of prosthetic technology that is not used today. The increased exposure to peg legs causes confusion and gives the impression that people with amputation are more disabled. The term unrealistic is being defined as prosthetic systems that are not used today and are therefore misleading to the general population. These parameters were chosen based off the previous literature that discussed how accurate and positive portrayal of a disability would be the most beneficial to improve the quality of life of those with limb loss.12 The movies analyzed were divided into blocks of time that represented the decade during which the movie was released. The frequency of positive portrayal, heroism, and realistic prostheses within each decade was used to demonstrate the appearance of these variables over time.
The primary analysis required that the character with amputation could be identified as fitting into a hero or villain category as well as the prosthetic type. The primary analysis that defined if characters with amputation were being portrayed in a positive manner (as a hero with realistic prostheses) was filtered to include only characters in which those items could be categorized. The secondary analysis would be performed on the entire data set.
The primary analysis carried out was to determine whether positive portrayal, heroism, and realistic prostheses increased or decreased over time and was performed using Pearson regression. To best demonstrate trends using categorical data while accounting for the likelihood that some years may not have characters with amputation, the data were grouped by decade. The number of appearances of a particular category (e.g., positive portrayal, realistic prostheses, etc.) was normalized to the total number of portrayals within each decade to account for the likelihood that the total number of characters portrayed may not be consistent across decades. Grouping by decade was also necessary to obtain adequate sample sizes within each decade for across-time comparisons. A χ2 analysis was also performed to define if a relationship existed between heroism and type of prosthesis used regardless of time.
A secondary analysis was performed to address general representation of different aspects of the characters with amputation that included level of amputation, cause of amputation, and character stereotype. The secondary analysis involved a right-tailed one-sample Z test to determine if the frequency of a given variable represented a statistically significance majority.
There were a total of 216 movies identified using the search term. The highest grossing movie (adjusted for inflation) was Forrest Gump (Paramount Pictures, 1994) at $620 million. This resulted in a threshold of $6.2 million minimum inflation adjusted gross earnings necessary for retaining that movie for analysis (Figure 1). A total of 162 characters in 118 movies (see Appendix, http://links.lww.com/JPO/A8) were retained and analyzed for content (Table 1). This total was then further reduced to 92 characters in 83 movies in which the character with amputation could be identified as a hero or villain and the prosthetic type could be identified as realistic, antiquated, futuristic, or bizarre prostheses (Table 1). This left a total of 92 characters in 83 movies from 1970 to 2015 used for the primary analysis and 162 characters in 118 movies were used for a more general analysis regarding the prevalence of level or cause of amputation that did not require the character using a prosthesis.
The number of characters with amputation appearing in film significantly increased over time (p = 0.0261, Figure 2).
Heroes did appear more frequently (39%) than villains (31%) over the whole 50 years analyzed but was not statistically significant (p = 0.072) (Figure 3).
When analyzing stereotypes via a frequency analysis, the no stereotypes present (72%) category was the largest, followed by the evil avenger (13%) and supercrip (9%) (Figure 4).
A significant association was found (χ2 analysis) between heroes appearing in film using realistic prostheses while villains appeared with archaic or unrealistic prostheses (p = 0.038) (Figure 5). Characters with amputation appeared as a hero in 28 of the 46 films that grossed below the median ($70 million) for this data set and in 25 of the 46 films that gross above the median with no significant relationship between frequency of heroes and box office gross (p = 0.527).
Amputations due to trauma occurred more frequently (59%, right-tailed p = 0.011) than unknown causes (40%) and amputations due to cancer (1%).
The following results were analyzed from the data set relating to positive and negative portrayal (N = 92 characters). Positive portrayal demonstrated a nonsignificant trend (R = −0.562, p = 0.324) that decreased over time (Figure 6). The frequency of characters with amputation appearing as heroes significantly increased over time (R = 0.966, p = 0.007) (Figure 7). Realistic prostheses decreased over time (p = 0.238) and were less frequent overall (30 characters; Figure 8). Unrealistic prostheses (antiquated and bizarre) were more frequent regardless of time (62 characters) but did somewhat increase (p = 0.238).
The purpose of this study was to conduct a content analysis on movies to determine how characters with limb loss/amputations are portrayed. The data demonstrated that there was no increase in characters with amputation being positively portrayed in movies over time (Figure 2). Positive portrayal was defined as both the character portrayed as a hero while using a realistic prosthesis due to the importance of protagonist and of accurate depictions. In fact, positive portrayal demonstrated a decreasing trend, albeit not significant. The trend for a decrease in overall positive portrayal was likely because of the (nonsignificant) decrease in realistic prosthetic limbs being shown in movies over time. When the frequency of heroism was analyzed without a relationship to the type of prosthesis, it did have a significant increase over time. Heroism started at 30% in the 1970s and reached 70% of the characters with amputation in more recent decades. The frequency of realistic prosthesis being shown in movies was also low throughout the entire period (~30%, Figure 8), meaning that when a prosthesis was shown, it was often unrealistic.
One article titled “Amputee Villains” stated that “Most leading amputee roles in movies are the bad guys!” but only provided three examples as proof.18 The inherent assumption to there being an increase in positive portrayal is that there would be more villains portrayed in movies than were actually present in reality. This may be explained by characters with amputation appearing as villains more often in movies with higher box office sales and would therefore be seen by more people and have a larger influence on perceptions. However, there was no effect of box office gross on whether the character would be portrayed as a hero or a villain. Another potential reason why people may perceive characters with amputation being portrayed as villains, when in fact, they are more often portrayed as heroes, could be related to a “negativity bias.” The negativity bias occurs when negative events, portrayals, or memories make a stronger impact on someone than a positive one does.19 The negativity bias has repeatedly been shown to affect an adult's judgment, decision making, and impression formation.20–24 Adults spend more time looking at negative stimuli and form more complex cognitive representations of negative than positive stimuli.25 In addition, less negative information is required to make trait inferences about other people.26–28 Even infants and children exhibit a strong negativity bias.29–31 The implications of forming stronger impressions on villains and unrealistic representations is that further negative perceptions will continue to be reinforced for every negative portrayal seen. The present analysis cannot determine how negativity bias could be derived from these, but this may explain differences between the reality of how characters with amputation are being portrayed compared with how some may perceive them being portrayed. Knowing that there is a negativity bias inherent with how people perceive the frequency of character portrayal, further underscores the need for more positive and realistic representation of characters with amputation in media.
The significant association between antiquated prostheses and villains demonstrates how people with amputation are more likely to be viewed in a negative context when using an outdated prosthetic system. This has strong implications when it comes to the reimbursement and availability of modern prostheses and the psychosocial effects of not being able to obtain a modern prosthetic system to fit the patient’s needs. Reimbursement from insurance companies is important for patients to be able to afford their necessary prosthetic system. However, sometimes, newer or more advanced prosthetic limbs are not covered by insurance companies. Furthermore, there have been attempts to significantly limit the availability of modern prosthetic systems by denying any reimbursement without first fitting an outdated or inappropriate device.32 As a result, there are functional, psychological, and social negative effects of not getting coverage for the most appropriate prosthetic limbs. Therefore, these data suggest that if public perception follows media portrayal, then people with amputation being fit with outdated prosthetic technology would be perceived in a negative manner. This would compound known problems such as the anxiety and compliance issues after an amputation. It should be noted that antiquated prostheses are technically accurate given the time period in which they are portrayed. Regardless of the time period, showing a character using a peg leg leads to increased exposure to unrealistic technology, which may cause additional confusion and gives the impression that persons with amputation are more disabled.
The general consensus in literature is that stereotypes are harmful because they do not reflect the reality of living with limb loss and encourage the viewers to see the character as a person with disability or a person with amputation.12 The “no stereotypes present” category was found to be the most common, but this does not necessarily imply a positive portrayal. The content analysis included movies where anyone with limb loss, regardless of whether they were a main character or an extra, was analyzed. Therefore, some of the analysis included characters that did not have lines or did not appear long enough in the movie for their stereotype to be identified. The most common of the stereotypes shown was the evil avenger. The evil avenger is considered a negative portrayal in that the character maladapts to his/her situation and lashes out at others.3,12 Two classic examples of this are The Candyman, who haunts and murders others with the rusty hook that is impaling his arm, and Captain Hook in Peter Pan and Hook, who swears revenge on Peter Pan and the lost boys after losing his hand to the crocodile. Maladaptive behavior consists of expressing anxiety, anger, depression, negative self-esteem, social withdrawal, and denial.3 This stereotype is especially harmful when one considers that negative portrayal can have stronger impacts than positive on the general uneducated audience. The supercrip is sometimes seen as positive for highlighting abilities over victimization, but it also implies that people with disabilities should work harder to become “normal” like their “able-bodied” counterparts, when many times that simply is not possible.12 An example of this would be Carl Brashear (Men of Honor), a character who, despite losing his limb, works hard to fulfill his duties as a diver and succeeds against all odds. In addition, this could discourage a person with amputation from accepting a realistic understanding of what he/she (and their prosthesis) will be physically capable of doing.
Inaccurate portrayal of living with limb loss was widespread throughout the movies. In the United States, dysvascular is the most common cause of amputation (54%); however, in the movies analyzed, not one case of dysvascular amputation was represented. The majority cause shown was trauma, despite this being less common compared with dysvascular causes in today's population.33 Other inaccuracies included amputation level shown, in which 40% of movie characters had an upper-limb amputation compared with only 8% in reality.33 Unrealistic prostheses (futuristic/bizarre and antiquated prostheses) were more frequent overall (~70%) and showed a nonsignificant trend that increased throughout time (Figure 8). The representations of nonrealistic prostheses can have a negative effect on the audience when they are unaware of the inaccuracies. When it comes to computer graphics, many people cannot tell if the actor is actually missing a limb or not, and this has created false impressions that people with prosthetic limbs can do more than is possible in real life. An example of these phenomena is the villain Gazelle, in the movie Kingsman, where the character has bilateral transtibial amputations and performs acrobatic feats while slicing up other characters with her prosthetic limbs that include retractable swords. These “prosthetic limbs” closely resemble the running prostheses that athletes wear today. Not all of the audience was aware that these feats, the prosthetic limbs, and even the actress as “an individual with amputations” were all computer generated. This representation brings on another debate of prosthetic limbs being portrayed as weapons. Some of the athletes who were asked to portray the character Gazelle refused because they did not want their athletic limbs to be seen as lethal weapons and incite fear.34 Another negative effect of this is that new prosthetic users could have unrealistic expectations when starting their new life with a prosthetic limb. Many prosthetists then have to manage misunderstandings and expectations with their new patients in addition to their emotional adjustment to the amputation.
Some of the limitations associated with this study include the use of only one database and using only one coder to analyze content. Therefore, some movies that portray characters with amputation may not be present in the database or have not been indexed with a keyword used in this study. However, the large number of movies obtained would lead to an assumption that the movies represent most movies that involve people with amputation. The use of more than one coder may have reduced the chance of inaccurate coding of characters. Although Neuendorf (2002) did comment that more than one coder is preferred, proper training of one coder, with a strong interrater reliability test, is still considered reliable and acceptable, as was the case for this study.17 For the changes over time, the most recent decade is only half present (2010–2015) and therefore may not fully represent all portrayals from 2010 to 2020.
This study represents a first step to define the media's current and historical perception of people with amputation. Positive representations in a widely consumed media form like movies could have a huge impact on the quality of life of those with amputations, and all potential influences should be studied in further detail. The next step could be to explore television portrayals, such as in shows like Dancing with the Stars, and social media portrayals. Studies on how to improve these representations and therefore perceptions would be the most beneficial. Most importantly, education regarding coping and living with an amputation needs to be made more widely available to the public to combat the negative portrayal of persons with amputation in film.
As a popular form of entertainment, movies’ portrayal of characters with amputation may reflect and influence how these individuals are perceived. Our findings showed a nonsignificant decrease in positive portrayal with an increase in heroism and a decrease in realistic prostheses. However, despite persons with amputation being portrayed more often in heroic roles, the portrayals often use unrealistic prosthetic technology and minimize the positive portrayals of these persons. In addition, the audience is more likely to remember negative portrayals, stereotypes, and inaccurate portrayals instead. Given the negativity bias, a stronger push for less negative and inaccurate depictions in media is necessary. In addition, education of the public, interaction with those who have experienced limb loss, and more accurate depictions in media may help dispel myths formed by inaccurate portrayal of people with limb loss by media.
We thank the following for the contributions made to this study: Ashley Rinck for helping with the interrater reliability study and Madeline Bezzant who consulted on statistical analyses. We also thank Dr. Carolyne Ali-Khan, Cheryl Norman, and Les Abernethy for their editorial contributions to the manuscript.
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