Cyclic patterns of high-risk behaviours within ballet culture

Abstract

Background

To determine whether a sample of pre-professionally trained, professional, and retired ballet dancers experienced body dysmorphia, eating disorders (EDs), perfectionism, Obsessive–Compulsive Disorder (OCD), anxiety, depression, substance use, sexual abuse, and injuries within ballet culture.

Methods

A total of 10 female ballet dancers aged 18–25 years of age participated in a structured interview either in-person or online via Zoom. Interview questions were open-ended to capture the richness of participant responses. The Exercise Science Thematic Analysis Model was utilized to analyze the participant responses. This study used a semantic focus and what has been described as a ‘top-up’ or deductive approach. The purpose of the study was to determine whether body dysmorphia, EDs, perfectionism, OCD, anxiety, depression, substance use, sexual abuse, and injuries were described in the participant narrative.

Results

Participant responses were organized into the following categories: the overarching theme, themes, sub-themes, level one emerging themes (emergent in > or = 5 participant responses), and level two emerging themes (emergent in < 5 participant responses). The overarching theme was cyclic trauma with two themes: lack of control/inconsistency/instability and perfectionism. Subthemes included body dysmorphia and EDs, mental health, injuries, sexual violence and substance use. The majority of the participants (60%) expressed feeling a of lack of control, instability, and/or inconsistency in the ballet world. Eight out of ten (80%) participants provided responses consistent with perfectionism. All participants stated that the subthemes body dysmorphia/EDs, mental health, and sexual violence were problematic in ballet culture. Injuries emerged as a subtheme in 70% of interviews and substance use was mentioned by 30% of participants although no participants had first-hand experience with substance use in the context of ballet. Complex-Post Traumatic Stress Disorder (C-PTSD) emerged as a theme which was unexpected and thus, requires further exploration in future research with ballet dancers.

Conclusion

The findings of this study indicate that ballet environments expose dancers to several health risk factors. Steps should be taken to reduce the risk of harm associated with these health risk factors.

Background

Ballet is an art form that requires physical and mental strength to succeed at an elite level. While ballet teaches the importance of hard work, discipline, and resilience, its culture and norms can also reinforce potentially negative practices amongst dancers. In ballet, there is a considerable emphasis on aesthetics, and as a result, dancers may engage in unhealthy behaviours to meet some of the demands of the ballet industry or develop disorders in the process of training/working in the field. Additionally, because of the cultural norms within ballet, it is also possible for dancers to fall victim to abuse in school and company settings. Body dysmorphia, eating disorders (EDs) [1, 2], perfectionism, obsessive–compulsive disorder (OCD) [3], anxiety, depression [4], substance use, and sexual abuse are all speculated to be prevalent in ballet culture.

There are high rates of prevalence for body dysmorphia [5, 6] and EDs [7,8,9,10] in ballet. While body dysmorphia and EDs are multifactorial and impact psychological and emotional well-being, they also impact physical health. A majority of pre-professional and professional ballet dancers are constantly striving for perfection. While this is not inherently negative, Goodwin et al. [11] determined that relentless self-criticism and perfectionism are linked to body dysmorphia and ED [12]. Zoletić and Duraković-Belko [6] further studied perfectionism and determined that there was a greater prevalence of ED symptomology in dancers with neurotic perfectionism. Because there is a high prevalence of EDs in ballet, an important comorbidity to highlight is OCD due to the many parallels in neurophysiology [13,14,15]. OCD is correlated with perfectionism [16], a common trait in ballet dancers. OCD is likely caused by both genetic and environmental factors [17]. Further, anxiety and depression are disorders that often co-occur with EDs [18] and in individuals that train and/or compete at elite levels [19,20,21].

Substance use is a topic that has not been thoroughly studied in ballet dancers. While there have been some studies suggesting that ballet dancers use nicotine [22, 23], it is unclear whether cultural and/or environmental factors contribute to dancers’ participation in smoking [24]. Further, some studies have suggested that nicotine is used to suppress dancers’ appetites [23, 25, 26] and thus, could be associated with the prevalence of EDs in ballet dancers. According to Zenic et al. [23], alcohol consumption is less likely in female ballet dancers due to the higher calorie count and the aesthetic demands of ballet. Additionally, the use of other substances (e.g. depressants, stimulants, hallucinogens) in ballet dancers has not been studied. However anecdotally, the use of substances such as cocaine has may have occurred in some companies.

Authoritarian practices and teaching styles are common in ballet schools and companies. This style of teaching is associated with an increased prevalence of sexual violence [27]. Although there are no peer reviewed sources to document the prevalence and impact of childhood sexual abuse and sexual assault on ballet dancers, recent allegations of abuse and assault have come to light. For example, there have been recent sexual assault and abuse legal cases involving members of the Royal Winnipeg Ballet, Boston Ballet, and the English National Ballet. As ballet culture is resistant to change [28], maintaining silence on substance use and sexual violence is to be expected.

Ballet is also physically demanding; therefore, injuries are prevalent and could contribute to the development of psychiatric disorders (EDs, depression, anxiety) [29, 30]. Additionally, disorders such as EDs could contribute to the development of an injury due to loss of bone mineral density in combination with overuse injury [31] or overtraining due to perfectionism [32]. Smoking could increase the risk of injury as nicotine has anti-estrogenic effects, causes vascular damage, and causes inflammation [33].

Overall, there are several potential components of ballet culture that are harmful and could have long lasting impacts on dancers both physiologically and psychologically. There are numerous physiological abnormalities that overlap among the stated risk factors. As mentioned by Blinder et al. [18], in individuals with EDs, there was a high prevalence of depression, anxiety, and OCD. Substance use was found to be more prevalent in individuals with Bulimia Nervosa (BN) [18], however, Holderness et al. [34] discovered that amphetamine use is more common in individuals with AN. Childhood sexual abuse is associated with an increased risk of developing an ED, depression, anxiety [35], and/or PTSD [36].

To date, there are no studies on the prevalence of the combination of the previously mentioned negative aspects of ballet culture: body dysmorphia, EDs, perfectionism, OCD, anxiety, depression, substance use/misuse, sexual abuse, and injuries. The aim of this study is to determine if there are patterns of behavioural risk within ballet culture in pre-professionally trained, professional, and retired ballet dancers. The positive aspects of ballet participation were not studied. This study involved semi-structured interviews of female professional dancers, retired dancers, and dancers who trained at the pre-professional level to collect detailed information regarding their experiences in ballet. The purpose of this study is to determine whether body dysmorphia, eating disorders (EDs), perfectionism, obsessive–compulsive disorder (OCD), anxiety, depression, substance use, sexual abuse, and significant injury histories are present in the participant responses.

Materials and methods

Methodology

This qualitative study utilized the exercise science thematic analysis model created by Braun, Clarke and Weate [37] to identify themes prevalent in ballet culture. The study employed a semantic focus meaning explicit experiences, ideas, and words of interviewees were coded and reported rather than the underlying messages in the data [37]. As the structured interview (Table 1) was designed to create dialogue around the negative aspects of ballet culture, this study used what Braun, Clarke, and Weate [37] call a ‘top-up’ or deductive approach.

Table 1 Structured interview questions and prompts

Participants

This study included 10 female ballet dancers aged 18–25 years of age. This age range was selected to ensure the data are representative of the current ballet culture in North America. Participants were identified from professional ballet companies in Canada and the United States as well as through social media platforms. To meet the inclusion criteria, participants received at least two years of pre-professional ballet training, currently dance professionally in a ballet company, or are retired from a professional ballet company. Individuals who trained at recreational/competition studios were excluded. All participants completed a written consent form. The form explained that the interview content will remain confidential. The number of participants in the present study exceeds the minimum number of six recommended by Braun et al. [37]. The ethics of the study were reviewed and approved by the University of the Fraser Valley Human Research Ethics Board (approval number 101082).

Procedure

Data collection occurred from January to April 2023. Interviews were conducted in-person and over Zoom. In-person interviews were audio recorded using a smartphone and online interviews were recorded using Zoom. The recordings were utilized to create the interview transcripts. All participants received the same introduction prior to the start of the interview. The introduction explained the background of the interviewer (MP) and how the interviewer is connected to ballet. The goal of sharing the background of the interviewer was to build rapport and understanding with each participant. This component of the interview was also intended to establish common ground regarding ballet terminology and an understanding that the interviewer may have had shared experiences. The introduction reiterated the conditions of the consent form and participants were reminded that they could skip any questions that they did not feel comfortable answering or stop the interview at any time without penalty. Participants were reminded that confidentially would be maintained and any names, schools, or companies disclosed during the interview would be given a generic label in the transcript. The importance of answering each question honestly was stressed to the participant.

Data analysis

After transcribing the interviews, the six-phase model by Braun et al. [37] was utilized. This six-phase model consists of familiarization, coding, theme development, refinement, naming, and writing up. Phase one of the model was familiarizing; reading and re-reading the data and taking notes. After phase one was complete, the coding phase commenced. Coding the data involved systematically tagging the data. Phase three was thematic development which consisted of grouping codes together to generate a broader theme. Phase four was refinement which involved ensuring each theme has a central concept and the sub-themes were coherent with one another. This study followed the recommended three theme levels [37]; overarching themes, themes, and sub-themes. Phase five consisted of naming the themes and phase six consisted of writing up the final thematic analysis product.

Results

The results of this study are ordered into the following categories: the overarching theme, themes, sub-themes, level one emerging themes, and level two emerging themes. Level one emerging themes (L1 ET) were themes that emerged in five or more participant interviews and level two emerging themes (L2 ET) are themes that emerged in less than five participant interviews.

Overarching theme: cyclic trauma in ballet

As shown in Fig. 1, the overarching theme in this study was cyclic trauma in the ballet world. Numerous participants stated that normalized practices and behaviours within the ballet world were modelled or suggested by those in a position of power from previous generations. This was a frequent pattern that emerged amongst participant interviews; modelled behaviours/suggestions from superiors manifesting into actions exhibited by students. In turn, it was stated that peers often influenced one another which further contributed to cyclic trauma.

Fig. 1

Overview of overarching theme, themes, sub-themes, and emerging themes. Brackets contain number of participants out of 10 with responses within each theme

For example, P10 stated that on occasion, teachers encouraged disordered eating with young students which resulted in peers influencing one another due to competitiveness and/or jealousy:

“…teachers would say, like, ‘You should eat, you should take an apple and slice it and make the apple last all day. Like eat a slice throughout the day and that's like all you should eat and maybe a bowl of broth.’… or if someone was anorexic or was starving themselves or like, everybody would be jealous of them… the more people that had it, like, the more you felt like you had to have it, like eat like that too, you know?” (P10)

As students, many of the participants stated that they looked to teachers, ballet masters, and directors for guidance. As stated by P1, students adopted harmful practices/behaviours and applied suggestions from “superiors”:

“…I think that students’ behaviour was a consequence, or like an artifact of the teachers’ behaviours. Um and that it was like, they saw that being modeled and so then we thought, ‘Oh, that's what we should care about. That's what we should value, I'm gonna start doing this’… I think teachers like light the eating disorder fire, and like your peers like tend to kind of just like, you know, pour gasoline on it. Um, unintentionally often, I think.” (P1)

Ballet teachers, masters, and directors were not the sole contributors to cyclic trauma in the ballet world. Parents, and specifically those who were retired classical ballet dancers, also contributed to the continuation of the cycle as stated by P4:

“I'd been told to lose weight, unfortunately, by my mother, who was a dancer because people at [ballet school] had talked to her about my body and she thought it would be better coming from her.” (P4)

As stated by P2, it is possible that superiors with a fixed mentality in schools and companies believe it is a necessary rite of passage to endure trauma in the ballet world:

“I think in the past, it's very unfortunate that like, my ballet masters had to go through that, but I think that they think, ‘Oh, I had to go through this... quote, unquote, abuse. So, you have to do it too."Umm... yeah, so I think it's just kind of like, ‘This is how the ballet world has always been’ where it's like, no, the world outside is changing and I think that we also have to change as well.” (P2)

Ultimately, multiple participants revealed that superiors are products of the environments that they have trained in and/or worked in. For example, P4 explicitly drew the following conclusion:

“…there's a lot of, there's a lot of trauma that a lot of people experience in the ballet world. And I think that, you know, we can point the blame to people who are in charge, but they also have experienced a great deal of trauma. It's like, it's essentially like the family idea of generational trauma occurs in the ballet world.” (P4)

In short, cyclic trauma imposes the harmful components of ballet culture on all individuals involved in the ballet world—dancers, teachers, directors, and parents. The progression towards the promotion of healthier behaviours in ballet culture remains stagnant and thus, maintains the cycle of trauma. Within this overarching theme, two secondary themes emerged: ‘lack of control, instability, and inconsistency’, and ‘perfectionism’.

Themes

Lack of control, instability, and inconsistency

A majority participants (60%) expressed feeling a of lack of control, instability, and/or inconsistency in the ballet world. This theme emerged while discussing injuries, body dysmorphia, EDs, mental health, and sexual violence. Participants revealed that while experiencing a lack of control due to ballet culture, it was not abnormal to cope through controlling a variety of variables such as eating habits and exercise. Patterns of this theme emerged in participant responses while reflecting on their time as students:

“…you felt like you couldn't control whether um it was casting and like, eating disorder and what your body looked like, or um if your parents gave money to the school or things like that. So I feel like that was... um you just never knew what to expect or what that day would bring like, like comments from the teachers or stuff like that.” (P3)

In addition, issues with control exist in the lives of professional classical ballet dancers. P5 mentioned that the theme persisted while working in a company:

“…it's so not within our hands, really, it's within the hands of whoever's in charge of kind of kind of making these arbitrary casting and contract decisions and all that stuff.” (P5)

The matter in which participants lacked control or experienced instability and/or inconsistency remained the same as both students and professionals and included casting, school acceptances, job contracts, feedback from teachers and/or directors. When control was lost, such as enduring an injury, a frequent pattern of unhealthy coping mechanisms in attempt to regain control was present in participant responses. For example, both P1 and P4 stated that their attempt to regain control during an injury was through controlling their eating:

“…I felt very out of control. And like, you know disordered eating and stuff was already- already a factor. And then it only got worse, a little bit through my injury. Because I like it wasn't able to control with exercise and XYZ…” (P4)

“…once that control was taken away from me, once my- I felt like my physical body had failed me in some way, I resorted to other measures to try and kind of maintain as much control over the situation as I could. And that often ended up being in um how (I) was eating, how I was exercising in ways that were permitted for the injury I had or sometimes not permitted, but I did it anyways.” (P1)

Perfectionism

Perfectionism was an anticipated theme. Eight out of ten (80%) participants suggested that ballet culture was one of the largest contributing factors to perfectionism in ballet dancers. For instance, P9 stated that the construct of a perfect ballet dancer and the expectations that come with attempting to achieve perfection exist in ballet culture:

“I definitely um have struggled with it um and I know countless others who have. Um, I think it just, it really comes down to like, I feel like just like the ballet world, like, it's just like, the mirrors and like, the whole, like, just outlook on like this, like, perfect, like image or whatever that we call, you know, a ballet dancer.” (P9)

Additionally, training that occurred during childhood shaped the mindset of ballet dancers. For example, P3 mentioned that the constant correcting during training contributes to a perfectionist mindset:

“I feel like the ballet culture kind of plants those seeds in your head from a very early age, especially since you're like taught to nit-pick at everything and always correcting yourself or the teachers correcting you.” (P3)

Consistent with P3’s statement, P10 suggested that ballet (particularly pre-professional and professional levels of ballet) attracts individuals who are habitual perfectionists. However, in an environment where dancers are consistently striving for unattainable perfection, the deterioration of mental health may occur:

“…I think that's part of what attracts, like the type of people that ballet attracts. Um, are these like, extreme perfectionist or um really competitive people that... Yeah, it definitely, like feeds into anxiety, and depression.” (P10)

Moreover, striving towards the “perfect standard” is often intrinsically motivated because of particular personality types as stated by P9:

“I honestly think it's just that like, impossible, like, perfect standard um, that we all, you know, kind of are striving for and hold ourselves to. Um, so I think, at least for me, like this is a huge factor um that contributed to like some downfalls and mental health.” (P9)

As stated by P4 and P7, external pressures from teachers and/or directors to reach “unrealistic ideals” (P4) also contributed to toxic perfectionism:

“I think there's a lot of perfectionism is like, the root in my opinion, perfectionism and low self-esteem, because they go hand in hand are like the root of most mental health issues. And also, the unrealistic ideals that are placed upon dancers, in order to be like, perfect, and like, it's never enough.” (P4)

“…it's more just like, like, trying to see the unattainable, like being perfect. Um, and just like, yeah, so that, and like, having standards that are too high, like, not even for ourselves, but just like, the artistic staff like, you know? We need more than two weeks to learn a whole ballet and then do it perfectly.” (P7)

Overall, perfectionism was associated with multiple sub-themes that were explored during the interviews: body dysmorphia and EDs, mental health, injury, sexual violence, and substance use.

Sub-theme: body dysmorphia and eating disorders

All ten participants stated that both body dysmorphia and eating disorders were a rampant problem in the ballet world. Several emerging themes surfaced throughout the interviews while exploring body dysmorphia and EDs: school and company standards, direct and indirect language, validation/praise/reward, competition and comparison, and shaming/guilting/public humiliation.

Level one emerging theme: school and company standards

While discussing body dysmorphia and EDs, the standards set by schools and companies emerged as a pattern during nine interviews (90%). To fit the mold that schools and companies required, participants described that one of the only ways to do so was through heavily controlling their physical appearance:

“… but then I feel like in the ballet world, it's a difference [compared to non-ballet environments] of being unhealthy equals being fat and then being anorexic equals being healthy… there's one company in Europe that said you had to be eighty-five pounds or less, no matter what height you were, which was at that point, I just laughed…” (P6).

Many of the participants expressed that during training and auditions, at both the student and professional level, that there was a greater focus on aesthetics rather than their abilities. P1 provided insight on this subject:

“…when auditioning for I’d say, like very high-level um programs, either at the student level or at the professional level, it felt to me much more like I was auditioning my body, than I was auditioning my dancing…unfortunately, given the nature of a lot of the places that I was at, my recovered body would not have been welcomed in the same spaces that I was welcomed in before.” (P1)

Level one emerging theme: direct and indirect language

All (100%) of the participants stated that direct and/or indirect commentary by superiors regarding their bodies or their peers’/colleagues’ bodies was a frequent occurrence. Superiors told dancers to lose weight or commented on specific parts of dancers’ bodies that they deemed unaesthetically pleasing. Direct comments were made privately, publicly to an individual or to a whole class, and often during times of peak stress. For example, as stated by P2, comments have been made prior to performances:

“… I know people who have been told that they were fat right before they had to go on stage and do a performance and that or like, ‘Do you even work out? Do you even go to the gym?’” (P2)

Excerpts from interviews with P1 and P10 provide further insight as to what superiors have said during interactions:

“… teachers um, would explicitly tell friends of mine to, like lose 20 pounds, and they would get moved up a level or to get a breast reduction and they’d get moved up, or they would be moved down if they didn’t lose weight, um or given explicit guidelines on what to eat, and at what times of day.” (P1)

“… covers her eyes and goes, ‘Oh, you all have thunder thighs, it just looks like you sit on the couch and eat Doritos all day’ and, and then she pointed to one girl in the class and she was like, ‘The only person that looks okay, is this girl. And everyone else, oh, you're gonna break the boy’s back during partnering. You guys aren't going to be able to do partnering.’ And ‘Oh, you're not going- I know you guys look okay for normal people, but most normal people are obese’ [participant laughing].” (P10)

Additionally, participants also mentioned that different descriptors were used by superiors. As mentioned by P3, the language used by superiors was sometimes passive and indicative that participants needed to lose weight or change their appearance in some capacity:

“… they never used the word ‘fat’, they just said that you looked ‘soft’.” (P3)

In addition, rather than using language as a means of communicating, superiors also resorted to touch. Hands-on correcting is common in ballet training, however, P8 revealed it was also used to convey to participants that they needed to lose weight or change their bodies:

“… if it’s identified by your- your teacher or your director, or your- you know, by like the little like slap or the little pincher, that definitely is something that is also a way of it being, being made known. And yeah, there’s been direct conversations like, ‘Hey, if you lose, you know, 5–10 pounds, probably better’.” (P8)

Participants experienced and knew of other dancers that had to meet certain physique requirements to receive or renew their contract. This point links to the theme of loss of control, instability, and inconsistency. Dancers were often given “the talk” by directors as described by P7:

“…they were kind of given not an ultimatum, but they were like, told that they're given like a contingency like, ‘Okay, we'll give you a contract provided that you lose,’ like not- I don't know if it was like a set amount of pounds, but like, provided that you slimmed down to look more similar like the other dancers in the company.” (P7)

Some participants also described experiencing the opposite type of conversations with teachers and/or directors. A few participants had been told on occasion that they were too thin and needed to gain weight to look more aesthetically pleasing before entering a school or joining a company. For example, P1 and P2 had been told that they were too thin or that they looked the greatest they had ever looked by different superiors during the same time frame. Additionally, P7 described herself as “naturally thin” and stated that she had experienced this type of interaction on multiple occasions at different schools:

“The director asked me if I was eating. And I was like, ‘Yeah, I'm eating.’ And they were like, ‘Well, you look weak.’ And I was like, ‘Okay’, like, then I tried to make a joke out of it, it was like, ‘I'll eat some more ice cream.’ And then they're like, ‘No, don't do that.’” (P7)

Level one emerging theme: validation/praise/reward

Across participant interviews, the L1 ET of validation/praise/reward emerged in seven interviews (70%) when questions regarding body dysmorphia and EDs were discussed. Participants disclosed that they were directly praised for their appearance after weight loss and that they were occasionally rewarded with opportunities such as acceptances, better casting, and jobs. Validation, and in particular, external validation, is sought after in ballet culture as mentioned in the interview with P4:

“… it’s such an external validation thing. Like you always need external validation. So, you know, it’s never going to be enough for your director, they’re always going to have something to say, which is not a bad thing, but it's also like, it's the way that that is portrayed is- it’s like, if you mess up, you're a failure.” (P4)

Numerous participants commented on how they received praise and reward for their transformations because of their EDs which in turn, translated to increased chances of success. This assumption was not uncommon amongst participants. In fact, across numerous interviews, a pattern of receiving better treatment from superiors and receiving greater opportunities regarding casting, job offers, and/or school acceptances emerged. At a peak training period and unfortunately, at one of the lowest points in P1’s ED, P1 shared her experiences after experiencing drastic weight loss:

“I started to be treated a lot differently in the environments that I was in. Um, teachers started to really notice me, I was being corrected a lot more… more corrections, you get them more, they tend to care about your success and think you have potential… I was moved up a level within the first two weeks because of my body and because I was told that my body, you know, didn’t belong in what they designate as the ‘bad bodies level’… I was like 50 pounds lighter than I had been the year before. And to me at the time, that felt very validating and I was like, ‘Oh, I did it right. I- this is what I had to do and now look at all these opportunities that are opening up’… I was like, ‘Oh, this is it. I have like figured it out um, like I finally have all these things coming to me. Teachers are more receptive to me. I’m getting to do all these roles that I never thought I’d get to do and go to programs that I didn’t think I’d ever get into.’” (P1)

Throughout multiple interviews, participants mentioned that as students, they and/or their peers would receive better treatment from teachers when their bodies fit into the desired ballet aesthetic. Most of the time, validation and praise ultimately resulted in a reward as stated by P6:

“… unfortunately, teachers will treat you better if you’re the skinny one, and you’ll get better roles.” (P6)

Further, depending on the professional school’s program, summer intensives ranged from four to eight weeks and varied in intensity (e.g. five to six days per week and six to twelve hours per day). The training at summer intensives is often more intense than that of a regular, year-long program and thus, a slight change in body composition because of the increase in activity is to be expected. However, as mentioned by P8, because of the focus on aesthetics, participants revealed that they would be praised and rewarded for their weight loss after summer intensives:

“As soon as you lost that weight after the summer, just because you were walking a little extra or you were training in the summer intensive all day long. Or, you know, you you lost it inherently because all you do is dance all day long. Then you come back and, you know, come back to the company or the school and they're like, ‘Wow, you look so good! Here is X, Y and Z role.’ Your dancing profoundly didn't change in the timespan that you were away, but what changed is evident why you- it's evident as to why you actually got that role.” (P8)

Additionally, the pattern of validation and praise leading to reward also persists into dancer’s professional careers. P2 stated that the simultaneous occurrence of her weight loss and increase in opportunities at work resulted in the assumption that her success was a product of weight loss:

“… I had started losing weight, I was getting more opportunities at work… in my head, it was like, ‘Oh, I’m getting these things because I’m losing weight.” (P2)

Level one emerging theme: competition and comparison

A theme that emerged among eight participants (80%) was competition and comparison. This theme was speculated to arise due to personality characteristics and was fostered by external sources such as superiors and peers. Competition and comparison were combined to create a L1 ET as they often coincided throughout the participants’ statements. This theme emerged while participants talked about their experiences as both a student and as a professional (if applicable). While discussing EDs with P2 (who is a current professional), she explained that the competition and comparison between herself and a colleague was the “driving point” for her ED:

“I think it was just kind of the competitiveness and the comparing kind of wore me down over time…we came back from summer and um, a fellow dancer came back and she was probably 20–30 pounds lighter within, well not 30 pounds, but maybe like 15–20 pounds lighter in the span of four or five weeks, So that- that happened so that was kind of a-a very big driving point for me.” (P2)

Based on the data from the interviews, it was clear that competition and comparison occur in ballet at a very young age. As young students, participants stated that they would often compare themselves to their peers including technique, body parts, and eating habits. The comparison led to competition, and this was often perpetuated by superiors within the schools. For instance, P6 described her experience with a professional school at the age of 11:

“… at age 11, they told me I was too fat to join the school, um which was kind of shocking because that was pre-pubescent age, all the girls are tiny. Um, so from that age, you kind of focus on how much you weigh and what you look like and compare yourself.” (P6)

During their teen years training at professional schools, two participants shared that they used to compare their eating patterns to other dancers:

“I think I almost just like, would like see what other people were eating and just like subconsciously would kind of like adapt my own eating patterns to that.” (P9)

P10 shared what it was like boarding at professional schools and having to eat in the same place as her peers for all meals of the day, every day. Additionally, P10 described conversations that would occur in the dining hall which would influence her actions:

“…eating in the dining hall, and you're comparing yourself, comparing, like eating meals with your like, with dancers all the time, and then comparing, like, what they're eating to what you’re eating, um and stuff like that. And then, you know, hearing that, ‘Oh, like so and so made herself throw up or took laxatives or hasn’t eaten in three days.’ Like, that all is like, ‘Okay, I should be doing that too.’” (P10)

As previously mentioned, superiors would often encourage competition amongst peers through direct comparison either publicly or privately. This resulted in some of the participants being alienated by peers. For example, during P1’s ED, she was praised by superiors who used her as a prime example to shame her peers. P1 shared her experience regarding the repercussions of the comparison and competition initiated by superiors:

“… I became very isolated. A lot of my friends stopped talking to me um because teachers would directly like compare my body to theirs in class and tell them that, you know, they should lose weight and give it to me or that I should throw out my scale and give it to someone else…” (P1)

Level two emerging theme: shaming/guilt-tripping/public humiliation

Four participants (40%) mentioned that shaming, “guilt-tripping”, and public humiliation occurred while discussing body dysmorphia and/or EDs. Participants stated that this emerging theme occurred both privately and publicly in front of their peers or colleagues. For instance, P1 described her experiences of being shamed and publicly humiliated as a student:

“…the teacher would pull me to the middle of the room and tell me that I looked like there was something that was wrong with me and that I should be taken to the hospital or would pull me and someone else into the room and say, ‘You should give ten pounds to [P1] and like, then you both would look great.” (P1)

During the interviews, participants revealed that costume fittings were a frequent place of shaming and public humiliation. Costume fittings often occurred in front of teachers and/or directors, peers, and the wardrobe department staff. As a teenager, P10 was cast as a “little boy” in one of the ballets that the school was performing. P10 mentioned that there were younger boys and girls that could have been cast as this role, however, P10 was cast instead. She mentioned that the costume did not fit properly as she was 17 years old and no longer had a pre-pubescent body. P10 described her experience being shamed and humiliated in front of her peers:

“…I remember in the costume fitting, my teacher just starts, like, laughing and is like, ‘You look like you have huge pecs.’ And then everybody in the class start- or like in the fitting started laughing. And I just cried the whole rest of the day because first of all, I was so embarrassed that I even had to do this part…” (P10)

It was found that shaming and humiliation not only occurred with students, but with professionals as well. P6 mentioned that costume fittings were a time when she had been shamed as a professional dancer. Additionally, she mentioned shaming would sometimes occur in the form of casting being stripped from dancers as the director did not want dancers wearing certain costumes due to their bodies:

“… during costume fittings, poke us and say, ‘Will it fit you?’ And I was like, ‘Yes, it is on my body, thank you.’…she [director] would also pull people out of ballets… she pulled a girl out because she didn’t want her wearing white.” (P6)

Sub-theme: mental health

All participants (100%) stated that they believe mental health is a problem in ballet culture. Several participants commented on how you need to have “thick skin” in the ballet world. Throughout the participant interviews, superiors seemed to exhibit a lack of empathy and a “hardcore” mentality. P1 mentioned that she was often told, “we’re gonna throw you into this, and if you sink or swim, this could change your whole career.” Additionally, P2 and P6 mentioned that dancers are often reluctant to tell artistic staff about any problems related to their mental health. For example, P2 explains what her and her colleagues have been told by the artistic staff of their company and why they do not disclose their mental health struggles:

“I think that we definitely turn a blind eye to mental health in general because we’re just told to suck it up…we’ve been told, ‘Oh, you can come talk to me whenever you want,’ but no one’s gonna go to the artistic director’s office and tell them how much of a hard time they are having because they’re afraid that it’s going to affect casting, and that’s going to affect other things… you don’t want to seem weak.” (P2)

Similarly, P6 also mentioned that being seen as “weak” by artistic staff is not an option:

“…we tend to hide it, because we don't want to be seen as weak… My ballet company here says that they want it to be a healthy environment and us to be open, but when we're too open, that's when we get taken off the list.” (P6)

P1 and P4 also mentioned that ballet dancers are dehumanized as they are taught and are treated like “objects” or “machines”. While discussing mental health with P4, she explained the impact of objectification:

“I think that we are not taught that we are humans, we are taught that we are like objects that people's desires almost in a way that they like, you look at somebody dancing, and like, that is the most important thing. Like your feelings are not important.” (P4)

Level one emerging theme: anxiety

Nine out of ten participants (90%) either experienced anxiety or believe that anxiety is a problem in the ballet world. For example, P3 shared about her experience with anxiety:

“I knew like I was really struggling with anxiety back then. But like, looking back at it now, um, it was really um extreme uh and severe uh… just like it definitely stemmed from ballet. Just from uh, the atmosphere that I had lived in for the three years that I was at [ballet school], um it definitely just promoted a lifestyle of like, anxiety.” (P3)

Level two emerging theme: OCD

OCD was a less common emerging theme found in four out of the ten participants (40%). Some of the participants were diagnosed with OCD and others commented stating that they knew of other dancers with an OCD diagnosis. P1 shared how OCD and ballet affect her day-to-day life as a retired professional:

“… a lot of things feel like life or death situations. Um, when I like, turn in a paper for example… it’s given me a lot of residual problems just with like fear of making mistakes… just like a mix of perfectionism, anxiety, and OCD… I you know, read things way too much and spend, you know, hours more on assignments than I need to, and that definitely feels like it um came from ballet just because I’m worried that um like any small mistake is going to have extremely dramatic consequences.” (P1)

Level two emerging theme: C-PTSD

During participant interviews, two participants (20%) disclosed their C-PTSD diagnosis; a disorder that was unexpected and not explored. One of the two participants elaborated on their C-PTSD diagnosis, however, there was no further questioning regarding C-PTSD as it was not a focal point in this study. P1 shared how ballet contributed to her C-PTSD and how her C-PTSD affects her in the “real world”:

“… the flashback and like the PTSD, I’ve noticed more now that I’ve stopped [dancing]. Um, just like being out in the real world, and then having moments where something um in the space like, gives me the littlest inkling of a thing that happened with a ballet instructor, and I just, like, snap right back there.” (P1)

Level two emerging theme: depression

Depression was mentioned by two out of ten participants (20%) classifying it as a level two emerging theme. One of the participants shared her experience with depression while training at a professional school:

“… I definitely experienced depression, my last year, especially at [ballet school], my senior year of high school. Yeah, really bad. I was just like, very- it was like a lot of things where… I was really injured. I was really lonely. And I didn’t know what I was doing.” (P10)

Additionally, P6 shared about a colleague who was asked to leave the company due to her struggles with mental health:

“Um, in this company, there was a girl who, during her company meeting, was told that she doesn’t have the mental health to stay here, because she had depression…” (P6)

Sub-theme: injuries

In seven out of ten (70%) interviews, injuries surfaced as a theme. Injury severity and duration varied between participants. Most of the time, injuries overlapped during discussions regarding body dysmorphia, EDs, and mental health. Further, a lack of control was associated with injuries and the previously mentioned themes.

Level two emerging theme: temporary period of positivity

A temporary period of positivity because of injuries emerged as a theme in two participants (20%). For example, P4 shared how her injury helped solidify her identity outside of the ballet world:

“I actually was really grateful for my injury because it made me certain of what I wanted to do and who I was outside of like, being a dancer… I needed to find that identity because, you know, dance is only like a finite amount of time in your life… that was really transformative for me.” (P4)

Further, P1 shared how her injuries provided her with a “reality check” and pushed her to practice healthier behaviours that would promote a more sustainable lifestyle as a ballet dancer:

“… broadly speaking, yes, I do think that a lot of these injuries did um, temporarily help me take care of myself. I think that there were moments after each injury that I had, where I was able to kind of reality check and realize that I was not invincible, and that, you know, I couldn’t run on fumes all the time without consequences um, and so in those ways, I think it actually did inspire some like positive behaviour.” (P1)

Sub-theme: sexual violence

Level one emerging theme: unbalanced power dynamic

All participants (100%) mentioned that sexual violence was a problem in ballet culture. The most substantial emerging theme for all participant interviews was the unbalanced power dynamic between superiors and dancers. Participants stated that teachers, directors, and male dancers often have greater power over female dancers in schools and in companies. For example, P1 shared her experiences with sexual violence while she attended a professional school and while she auditioned for companies:

“I have received like, threats from other male dancers before about like, sexual, like violence and assault… and um, I was auditioning for a ballet company… and um I took company class, and went up to his office afterwards, and he was like, ‘Well, I don't- I don't think that your, your dancing is what I'm looking for, but you have a really pretty body, you know, and you could do something with that.’ And the way that he like, looked me up and down…” (P1)

Numerous participants described the sexual violence that they or their peers endured occurred in a school setting. P6 shared her experience at a professional school and the ramifications that occurred after she spoke out:

“…he said he was just tickling me, which is also weird for a seventy-year-old, to tickle a 16-year-old. That's not right. So, then he was fired from [ballet school] and I, in a way was blacklisted from [ballet school]… other teachers who were best friends with [teacher] did not like me and they would be very blunt about that. Um, so I dealt with that, which I was the only dancer who spoke out about it. My best friend also was touched, and she wouldn’t speak out because she didn't want to be blacklisted…I also knew that he had done stuff that was worse to 14-year-old girls. So, I didn't want that to continue happening.” (P6)

P9 argued that sexual abuse is a large problem in ballet culture as it emerged as a “trend” following her from one school to another. Further, she mentioned that there appears to be a lack of consent in the classroom. P9 shared how teachers have used hands-on corrections to take advantage of their position in power:

“…there have been instances of like, you know, like, improper, like sexual misconduct, like things like this. And the fact that those followed me to, like, not just one school, but to a second school like, that's… you know, a trend… there’s definitely a lack of consent in the ballet classroom… Like there has been moments where, you know, like I’ve definitely like been touched inappropriately. Um, and the teachers just kind of get away with it because they’re you know, like, correcting us and they’re using like hands on correction.” (P9)

Securing job contracts can be very difficult in the ballet world. As the excerpt from P1’s interview mentioned, directors and other artistic staff have abused their power through attempting to make sexual advances on dancers. P1 and P2 mentioned that they know of individuals who have overlooked sexual harassment. Additionally, it was mentioned that they know of dancers that have fallen victim to bribery from a director and thus, consent was not valid:

“…as ballet dancers, we want jobs so badly and we- there's so like there's so few jobs and so many people who want them um we're willing to overlook some, a lot of things like sexual abuse or sexual harassment, because we want the job and we'll do anything to get there.” (P2)

“I would have done anything, you know? I almost killed myself, you know, from an eating disorder and try and get a job [participant laughing]. You know, you are so desperate that it is you know, you're not really consenting, you're- you're doing it because you're- you're so close. And you're like, ‘Oh, if I have to do this, like if I have to do this one last thing to get this job.’ And so, I know a few dancers who have been in that situation where they did it… and for some of them it worked.” (P1)

Participants revealed that partnering with male dancers was another way that power would often be abused. The topic of objectification emerged again when P6 disclosed how it felt to be partnered (due to school casting) with a fellow male dancer after they abused their power:

“…having to be touched by someone who saw me as a thing rather than a person, was a very hard experience.” (P6)

Further, P2 revealed that professional male dancers have also taken advantage of their power:

“he’s in a place of power…other girls like have partnered with him and he said, some very gross comments to them or like, would add in like in a [ballet] pas de deux, would just like add in kisses (in) places where they're not supposed to be on stage so there's nothing to do about them. It's just very weird when you see them taking advantage…” (P2)

Sub-theme: substance use

The participant comments regarding substance use were minimal. Participants stated that substance use was more common amongst professional dancers from previous generations (30%). Additionally, it was stated by three participants (30%) that cigarettes were commonly used by ballet dancers of previous generations. Further, some participants (40%) revealed that a few current professional ballet dancers are known to use cocaine, or they have heard of dancers that use cocaine due to its stimulatory effects and weight control.

Discussion

The purpose of this study was to explore the potentially harmful components of ballet culture through interviews with pre-professionally trained, professional, and/or retired classical ballet dancers. Several substantial emerging themes were discovered. For example, validation/praise/reward, competition and comparison, and shaming/guilt-tripping/public humiliation all stemmed from discussions regarding body dysmorphia and EDs.

Overarching theme

The overarching theme in this study was cyclic trauma in the ballet world. Through participants’ experiences and statements, it was evident that trauma from previous generations has been passed on to the current generation of dancers. As previously mentioned by Piran [28], the ballet world is resistant to change; participant interviews stating that superiors demonstrate a fixed mentality supports this notion. Many of the participants speculated that it could be unintentional or a result of previous generations believing it is a necessary rite of passage to train and/or work in environments that maintain toxic practices and behaviours to become better dancers. Trusting that superiors would act as role-models and deliver the highest quality of training, participants attended professional schools with the hope that it would lead to success in the industry. Many of these professional schools likely delivered high quality training, however, because of cyclic trauma, some superiors projected their trauma onto students. Further, consistent with the statement that the ballet world being resistant to change, Piran [28] notes that some superiors were calloused and insisted that the present, uncompromising state of ballet culture should be accepted as “the way it is” (P2). Overall, cyclic trauma appears to be the common link between the themes, sub-themes, and emerging themes as superiors who were also once students, perpetuated the effects of trauma.

Themes

The two most substantial themes were lack of control/inconsistency/instability and perfectionism. Lack of control/inconsistency/instability was an overarching theme for the sub-themes of body dysmorphia, EDs, injuries, mental health, and sexual violence. Perfectionism was an anticipated theme which encompassed the sub-themes of body dysmorphia, EDs, and mental health.

Lack of control

During the interviews, there was a pattern of a lack of control that occurred while students and during professional careers. This was often in the form of lack of control over school acceptances, job contracts, casting, and injuries. Some participants stated that they would attempt to regain control through exercise such as exercise in excess or going against physician or physiotherapist orders to refrain from exercise. Consistent with the findings of Sundgot-Borgen [29], multiple participants disclosed that they had either developed EDs because of losing control due to an injury [38] or their pre-existing ED worsened in attempt to regain control in some capacity. Further, participants stated that a lack of control was also a factor in the development or worsening of their EDs. While auditioning for schools and/or companies, numerous participants stated that they felt that their bodies were being auditioned more than their abilities. Thus, participants stated that if control over their physique could be gained, then they would have greater control over their environment. This is because the chances of being accepted into a school/offered a job contract increased with weight loss. Similarly, participants stated that regaining control through EDs and weight loss could potentially improve casting. Additionally, a lack of control contributed to mental health struggles. Participants stated that a lack of control contributed to substantial anxiety, OCD, and sometimes depression; all of which are also associated with EDs [15, 18].

Instability

On a broad scale, instability is present in the ballet world. Job opportunities are scarce, causing professional dancers to often rely on annual contract renewals, and students to rely on acceptances to schools and/or summer intensives to train at annually. On a smaller scale, even if dancers have been accepted into a school or have a contract, variability in casting, treatment from superiors, and politics introduce instability and possibly inconsistency. The ballet industry is highly competitive with limited spots in schools and limited job contracts for the number of dancers. Therefore, there is an element of unpredictability and thus, a lack of control, inconsistency, and instability. As mentioned by P7, some dancers did not meet the physique requirements of the director and therefore, not offered a job the following year. This instability is also common in the school setting; failure to meet physique requirements or speaking out about sexual violence could result in casting being stripped away from dancers or being blacklisted.

Inconsistency

Inconsistency also emerged in the participant interviews while discussing body dysmorphia and EDs. Numerous participants stated that there were periods of time that their bodies were celebrated by some superiors and shamed by others. With participants admitting to relying on external validation from superiors, this often led to confusion and body dysmorphia. This pattern was particularly troublesome for participants while they were students, however, this theme also surfaced while discussing participants’ professional careers. The pattern of inconsistency was linked to mental health struggles as it was said to create anxiety and further perpetuate body dysmorphia and EDs.

Perfectionism

Perfectionism was an anticipated theme, and it surfaced during discussions of body dysmorphia, EDs, and mental health. This theme was anticipated because it is often linked to body dysmorphia and EDs [6]. According to Fostervold Mathisen et al. [32], it was found that perfectionism could contribute to an increased risk of injury through overtraining, however this was not mentioned by participants in this study. Instead, perfectionism only emerged during discussions regarding body dysmorphia and EDs, further supporting what was suggested by Zoletić and Duraković-Belko [6]. Additionally, several participants stated that ballet dancers are “natural perfectionists”; a suggestion by Goodwin et al. [11] stating that perfectionism is a trait supports this notion. It was suggested that ballet, particularly at high levels, attracts perfectionists due to the nature of the artform. Ballet has a hypercritical culture, and dancers are always striving for perfection and attending to small details. In addition to the relentless self-criticism described by participants, it was suggested that the expectation to be “perfect” was also placed upon them by superiors. During discussions regarding mental health, perfectionism emerged as a theme in 80% of participant interviews. It was stated that superiors and the ballet world in general “promoted a lifestyle of anxiety” (P3). It was expected that dancers should meet perfection in all aspects of ballet; physique, technique, optimal timing of progression back from an injury, learning repertoire and performing ballets perfectly after learning/rehearsing for short time periods. With reliance on external validation and meeting personal expectations, the constant stress and pressure to excel or meet perfection can create mental health struggles amongst dancers.

Sub-themes and emerging themes

In this study, the sub-themes were anticipated in participant responses. Every participant in this study believed that both body dysmorphia, EDs, mental health, and sexual violence were a problem in ballet culture. The interviews revealed that injuries (70%) and substance use (60%) varied in severity and prevalence.

Body dysmorphia and EDs

All participants reported having body dysmorphia and most of the participants stated that they are not aware of any ballet dancer that does not have body dysmorphia. The results of this study represent a significant increase in body dysmorphia prevalence in ballet dancers in comparison to findings by André et al. [5]. Anorexia Nervosa (AN) and BN were the most frequently reported EDs mentioned by participants. In this study, 80% of participants disclosed that they have/had EDs and 40% of participants disclosed that they were admitted into an in-patient treatment centre. This finding was anticipated given the prevalence of body dysmorphia in this sample and that body dysmorphia is often a predisposition to EDs [6].

L1 ET: professional school/Company standards

The standards placed on ballet dancers by schools and companies are high. This was a frequent theme that emerged while discussing body dysmorphia and EDs in addition to its contribution to the theme of perfectionism. Given that 90% of participants stated that school and/or company standards were related to body dysmorphia and/or EDs, it can be said that this emerging theme contributes to the prolonged stress state associated with body dysmorphia and EDs.

L1 ET: direct and indirect communication

Interviews revealed the harsh language, passive negative language, and non-verbal forms of communication used by superiors in the ballet world. Based on the findings of this study, it can be assumed that superiors in professional schools and companies utilize these forms of communication to convey to dancers that they need to lose weight or change a component of their physique. The negative communication that occurs in the ballet world is akin to bullying. In a study by Östberg et al. [39], it was found that repeated exposure to bullying was related to stress markers in mid-adolescents. Adolescents that had endured bullying exhibited reduced cortisol levels, blunted cortisol responses, and hypothalamo-pituitary-adrenal axis (HPA) axis dysregulation [39]. Additionally, the findings by Östberg et al. [39] support the findings by Crosby et al. [40] who stated that bullying increases an individual’s risk for developing Post Traumatic Stress Disorder (PTSD) due to HPA axis dysregulation. Moreover, participants in the present study reported that superiors referred to them “fat” as well as other inappropriate comments regarding their bodies. Based on the findings by Östberg et al. [39], it is possible that this emerging theme alone could contribute to a chronic stress state.

L1 ET: competition and comparison

Multiple participants stated that this emerging theme was a driving factor for body dysmorphia and EDs. Competition was often initiated by oneself, peers, and/or superiors through comparison. This theme could act as a stressor for ballet dancers and thus, contribute to their overall stress state. Furthermore, competition and comparison are related to the subsequent emerging themes of validation/praise/reward and shaming/guilt-tripping/public humiliation.

L1 ET: Validation/Praise/Reward

As previously mentioned, participants stated that ballet dancers seek and/or rely on external validation. Numerous participants stated that these factors were provided by superiors in response to weight loss because of an ED. Cleary, this pattern reinforces harmful ED behaviours as dancers are provided with validation, praise, and/or reward and often in front of peers. This theme is related to the emerging theme of comparison; peers will compare themselves to those who are being praised in class or rewarded for weight loss. For example, a dancer that receives better casting as a reward for weight loss is used as an exemplar for other dancers.

L2 ET: Shaming/Guilt-tripping/public humiliation

40% of participants revealed that they endured shaming, guilt, and/or public humiliation during their time as a student and/or as a professional ballet dancer. Participants reported that shaming occurred by comparison to others, such as being compared to another student in terms of physique. According to Rohleder et al. [41], shame and guilt are distinct emotions; shame is associated with self or low self-esteem and guilt is a feeling about a particular event. There is also a link between shame, perfectionism, and EDs. In a study by Howard et al. [42], the viscous, cyclical relationship of shame and perfectionism was explored; failing to meet standards leads to shame and the need to strive to alleviate shame leads to perfectionism. This cycle is related to EDs (particularly AN) as they became a source of pride or an antidote to shame, eventually leading to feelings of failure when pride was not achieved [42]. Further, Howard states that EDs can be a vice to numb shame [42]. Alternatively, these authors also found that participants felt shame for having an ED or breaking dietary rules [42]. This further feeds into the cycle of perfectionism as participants felt they were not living the perfect life [42].

Mental health

L1 ET: anxiety

In this study, 90% of participants stated that they had struggled with mental health or knew of ballet dancers suffering from anxiety related to ballet culture. According to Blinder et al. [18], there is a relationship between anxiety disorders and EDs. It is unclear whether anxiety was present before participant’s EDs or vice versa, however, anxiety is associated with HPA axis dysregulation [43]. The results of this study suggest that anxiety is present in many ballet dancers and thus, serves as another factor that could contribute to a chronic stress state.

L2 ET: OCD

Often associated with EDs and perfectionism [6], OCD was classified as a level two emerging theme prevalent in 40% of participant interviews. The results of this study indicate that EDs and perfectionism are prevalent in ballet and thus, the prevalence of OCD reported by participants was expected. As suggested by Pauls et al. [44], stress, trauma, and neuroinflammation contribute to an individual’s risk of developing OCD. There is an overlap between ED and OCD regarding neurobiological abnormalities [6]. Thus, given the high prevalence of EDs in ballet dancers, the presence of OCD was anticipated.

L2 ET: depression

Depression was less common in the participant responses. Consistent with findings by Fostervold Mathisen et al. [32], 20% of participants disclosed that they had feelings of depression or were diagnosed with depression in this study. Additionally, depression was primarily related to injuries; a finding consistent with Moola and Krahn [45]. Multiple acute stressors, such as injuries, are linked to an increased risk of the development of depression [46] and chronic depression is associated with HPA axis dysregulation [47]. In this study, the contributing factors to the development of depression seen in participants were unknown. However, acute stressors such as injury and other emerging themes such as direct and indirect communication or shaming/guilt-tripping/public humiliation are likely contributors to the development of depression in ballet dancers.

L2 ET: C-PTSD

Two participants mentioned that they were diagnosed with C-PTSD. As noted, Crosby et al. [40] found that bullying was associated with the development of PTSD. This finding was unexpected, and C-PTSD was not queried in this study. It is unclear what factors contributed to the development of C-PTSD in the participants, although, it was mentioned in the context of ballet culture. This emerging theme is important to note as it may be beneficial to explore C-PTSD prevalence and risk factors in pre-professionally trained, professional, and/or retired classical ballet dancers.

Sexual violence

Sexual violence emerged as a theme in all participant interviews. Sexual violence occurred in both the school and company ballet environments. The emerging theme that remained consistent between these environments was the unbalanced power dynamic between the dancer and the superior.

L1 ET: unbalanced power dynamic

In early years of ballet training, obedience is reinforced in young dancers [48]. This reinforcement carries forward to the professional ballet realm and thus, creates a perpetual unbalanced power dynamic between dancers and superiors. As described by Gaedicke et al. [49] and Tjønndal [27], obedience increases the risk of grooming and sexual abuse; a pattern that emerged throughout participant interviews. Additionally, participants stated that superiors objectified them through chosen language and the way in which they were treated, further reinforcing the power differential between dancers and superiors. Participants were told they should be “desired” by spectators and by their partners. In addition to obedience being reinforced at a young age, participants were also exposed to objectification as students.

Participants stated that power was often abused in the classroom, during class time and in front of other dancers. Specifically, participants disclosed that superiors would often use hands-on correction as a means of sexually assaulting dancers during class. Additionally, participants revealed that fellow male dancers also took advantage of their power in various situations. For example, pas de deux was often a time when male dancers would exploit their power. Many participants described partnering as being a “grey area” as it was difficult to determine whether some grips or touches were an accident or executed purposely. It was stated that because there are fewer male dancers, they are often protected by schools and companies because they are in high demand and more difficult to replace. Aside from the lived experiences of the participants in this study, participants also stated that they knew of superiors sexually abusing other dancers within the schools and some of the same superiors had sexually assaulted them.

While discussing participants’ professional careers, findings remained consistent regarding who abused power: superiors and male colleagues. Numerous participants mentioned that other dancers obtained job contracts or advancement within the company in exchange for sexual favours with superiors. Additionally, participants mentioned that fellow male colleagues would abuse their power while performing onstage and thus, the victim felt unable to defend themselves. This unbalanced power dynamic is reinforced through a continuous cycle in both school and company environments that has persisted over generations in the ballet world. Additionally, single incidents of sexual violence could act as stressors layered upon other themes (body dysmorphia, EDs, perfectionism) in this study. These stressors could contribute to the development of other comorbidities such as anxiety, PTSD, and depression.

Injuries

Injuries were noted in 70% of participant interviews; a theme that greatly overlaps with EDs and mental health. Injuries were associated with a lack of control/instability/inconsistency and were therefore related to EDs. Participant responses revealed that injuries were often a gateway for the onset of an ED or that they contributed to the escalation of a pre-existing ED. EDs were used as a coping mechanism in attempt to regain control. Additionally, injuries often resulted in mental health struggles. Participants disclosed that they felt depressed and/or anxious while being injured as for some, it meant a pause or loss of their livelihood or their purpose.

L2 ET: Temporary Period of Positivity

20% of participants disclosed that their injury/injuries resulted in a temporarily positive state. Post-injury, the participants stated that they realized they had to care for their bodies to heal. Participants stated they started fueling their bodies with food and being more aware of their bodies’ limits during rehabilitation. One participant mentioned that she realized her body was not “invincible” and thus, she temporarily changed her habits which elevated the perception of control before relapsing back into her ED. Additionally, another participant mentioned that her injury allowed her to solidify her identity outside of ballet. There were no other net positives that emerged from the interviews. Further research is required to determine whether there are potential correlations between ballet and other positives such as high levels of success in other fields because of discipline and rigorous training.

Substance use

The results of this study suggest that substance use was more prevalent in professional dancers of previous generations. None of the participants disclosed that they currently use any substances. In previous generations, it was mentioned by 40% of participants that smoking cigarettes was a means of appetite control and thus, weight-loss in ballet dancers. However, only one participant stated that she had used nicotine products previously with this intention. Cocaine was the only other substance mentioned in 30% of the participant interviews. None of the participants in this study have ever used cocaine, however, participants reported knowing colleagues that do/have or have heard rumours of dancers in certain companies using cocaine for alertness and/or weight loss. Overall, findings of this study indicate that while substance use may occur, it is not as prevalent as in previous generations.

Limitations

There are several limitations to this study. Bias could be present in the sample given that it was initially obtained through convenience and expanded via snowball sampling. In addition, the questions were intended to elicit conversation on the negative aspects of ballet culture therefore biasing the responses toward the negative. Additionally, the results of this study relied on retrospective participant responses. As such, it is possible that the experiences disclosed were unintentionally inaccurate. Further, it is possible that participants limited the details disclosed in their responses out of fear that their identity would be revealed to schools and/or companies or that they were not yet ready to discuss the content of this study in greater detail than was disclosed. Lastly, the study had 10 participants. When considering whether a sample size is adequate, the sample must be considered relative to the population. The total number of people in the population (pre-professional and professional ballet dancers) is likely in the 1000 s. Therefore, the percentage representation of this sample is relatively high compared to most other studies that include 10 s or 100 s of participants and generalize to populations of hundreds of thousands or even millions of people. Further, large numbers of participants are typically not required for quantitative research. The number of participants exceeded the suggested minimum sample size of six for qualitative studies as recommended by Braun et al. [37].

Conclusion

The aim of this study was to determine if there are patterns of behavioural risk within ballet culture in pre-professionally trained, professional, and retired ballet dancers. An overarching theme of cyclic trauma was identified that encompassed body dysmorphia, EDs, mental health, injuries, sexual violence, substance use as well as the emerging themes of this study. With the large number of themes, subthemes, and emergent themes, it is possible that bi-directional relationships exist among them. It is likely that exposure to stressors common in ballet environments and the components of ballet culture predispose ballet dancers to cognitive, emotional, or physiologic health risks. Steps should be taken to reduce these health risk to ensure a culture of safety for all participants.