Occupational Science With a Progress Note Attached
I want to start with a point of clarity: I do not object to anyone studying drag. It can definitely be studied as an occupation. It involves preparation, performance, costume, makeup, role construction, social interaction, community participation, identity expression, skill, and meaning. There is no serious argument that drag is not something people do, or that it cannot be examined through an occupational lens.
But I still scratch my head a little at the topics that seem to get elevated for study. There is no reliable national estimate of drag performers, in part because drag often occurs outside formal occupational categories. But by any reasonable comparison, drag is a niche performance occupation, while ordinary occupations involve hundreds of thousands or millions of people. That raises a question: why does occupational science so often elevate occupations that align with contemporary academic narratives of identity and resistance, while ordinary occupations that structure daily life for far larger populations remain comparatively invisible? It is pretty strange. Maybe this reflects a broader academic attraction to topics that appear edgy or underrepresented, even when their actual relevance to everyday clinical practice is not so clear.
The problem is not the topic. The problem is the overextension - and I want to unpack that a little.
I do not care if people study drag, LGBTQ occupations, sexuality, performance, or any other human activity. Study away. The problem begins when cultural description is presented as occupational therapy application without explaining the therapeutic reasoning.
This was a small qualitative study of five drag performers in California. The authors explored form, function, meaning, identity, belonging, non-belonging, motivation, and resistance. As occupational science, that is fair enough, I guess. Occupational science can study the meanings of occupations. It can describe how people experience their 'doing.' It can examine cultural, political, and social contexts.
But occupational therapy is not simply occupational science with a progress note attached. That distinction matters.
The article eventually moves from describing drag as a meaningful occupation to claiming that drag has “immense relevance to OT” and that occupational therapists can “embrace and integrate such occupations into practice.” That is a very large leap. The study did not examine occupational therapy patients. It did not examine therapeutic outcomes. It did not examine disability, illness, adaptation, safety, intervention planning, clinical reasoning, reimbursement, contraindications, therapist competence, or the ethics of bringing a contested performance occupation into a therapeutic context.
It studied performers talking about their experience of performing. That is not the same thing as occupational therapy evidence. The article invokes the "political practice of occupational therapy," but it does not attempt to explain what that even means in applied clinical terms.
This is where our profession continues to confuse itself. Occupational science may ask, “What is the meaning of this occupation?” Occupational therapy has to ask additional questions. What is the therapeutic purpose? Who is the patient? What is the health-related need? What is being restored, developed, adapted, compensated for, prevented, or supported? What are the risks? What are the boundaries? What are the outcomes? What is the therapist’s role?
Those fundamental clinical questions do not disappear because an occupation is "meaningful" to a small group of people.
This has been a long-standing problem in the relationship between occupational science and occupational therapy. More than a decade ago I wrote about the ongoing basic versus applied science debate in OT and OS. My concern then was that occupational science was increasingly moving toward political and justice-based interpretations of occupation while occupational therapy remained an applied health profession with pragmatic responsibilities to patients, families, payers, institutions, and communities.
That concern has not gone away. Clearly. I suppose I could have written a response like this to any number of previously occurring articles like it - but I think I am also bothered that the article emerges from an occupational therapy educational context, not a freestanding occupational science program. That matters because the professional burden is different. If this were presented solely as occupational science, the study could remain a cultural inquiry into human occupation. But when OT students, OT faculty, and an OT journal move from cultural description into claims about occupational therapy practice, they inherit the obligations of an applied health profession. They must explain therapeutic relevance, not merely occupational meaning.
This was not published in a journal whose primary mission is basic occupational science. It appeared in The Open Journal of Occupational Therapy, a journal that describes its mission as applied research, practice, and education in the OT profession. That means the article’s occupational therapy implications need to be more than a cultural affirmation of a meaningful occupation. They need to satisfy an applied professional burden. I mean, they can publish whatever they want, but it gets a little confusing when articles like this appear and are labeled as 'Applied Research.' What was it applied to, exactly?
In my 'Crisis' article the other day I talked about the need for boundaries - and that boundaries make a profession intelligible. I think that this article illustrates the problem rather neatly. The authors are engaged in a sociological and cultural inquiry. That is fine and I have no objection to that. But then the article imports that inquiry into therapy space without doing the additional work required to justify the therapeutic claim.
So, Meaning is not enough. Belonging is not enough. Identity is not enough. Resistance is not enough.
Those concepts may be important to understanding a person’s occupational life, but they do not automatically establish therapeutic relevance. Many occupations are meaningful and identity-forming without being straightforwardly health-promoting. Gambling can involve routine, skill, hope, community, excitement, and belonging. Overwork can provide identity, purpose, status, financial security, and moral worth. Extreme athletics can provide embodiment, mastery, community, transcendence, and resistance to ordinary risk norms.
The point is not to compare those occupations to drag. The point is to identify the reasoning problem.
A therapy profession cannot responsibly say, “This occupation is meaningful to someone, therefore it should be embraced or integrated into practice.” That is not clinical reasoning. That is affirmation.
Occupational therapists need to understand occupations without automatically endorsing them. We need to respect people without affirming every occupation that people attach to identity. We need to be able to study social and cultural practices without laundering them into therapeutic legitimacy simply because they fit the apparently preferred vocabulary of identity, resistance, and justice.
Like I said, this is not the first article to do this. We have seen other studies of socially contested or identity-laden occupations framed in ways that invite occupational therapy application before the applied reasoning has been established. But I always wonder - do people really encounter these issues on such a scale that they merit discussion in a therapeutic context?
That is why I think articles like this reflect a selection problem in contemporary occupational science. The field often claims to be interested in human occupation broadly, but in practice it tends to elevate occupations that align with a specific moral and academic framework. Occupations that can be described as resistant, transgressive, identity-affirming, justice-oriented, or oppositional to dominant norms are frequently treated as especially worthy of scholarly attention. It is kind of odd, and out of step with what most people encounter regularly in practice.
Meanwhile, ordinary occupations often remain invisible.
Where is the same level of excitement about the occupational life of the lunch line worker who feeds children every day and knows which of the little ones need a smile or an extra scoop? Or the receptionist who holds together the social life of a medical office? Or how about the custodian? The home health aide? The machinist? The church volunteer?
All of these occupations also involve identity, and even belonging and non-belonging. They involve body use, routines, moral meaning, power, invisibility, gender, class, community, and resistance. They involve all the things occupational science says it cares about.
But they do not always carry the same academic currency and don't make their way into the journals. Too banal, maybe?
That is the problem. The inquiry begins to look less like an open investigation of human occupation and more like the selection and affirmation of occupations that already fit a preferred moral ideology.
This is especially concerning when paired with the familiar claim that occupations are not inherently good or bad. In a limited occupational science sense, that claim may have some value. It warns us against simplistic moralizing and reminds us that occupations are situated and contextual, I suppose.
But when that claim is imported into therapy without guardrails, it becomes dangerous. That is what I mean about boundaries.
Occupational therapy is a health profession. It cannot abandon moral, developmental, clinical, and community judgment. Some occupations support health. Some undermine it. Some are adaptive in one context and destructive in another. Some provide belonging while also reinforcing dependency, exploitation, injury, avoidance, or harm. Some are meaningful precisely because they are tied to power, risk, or dysfunction.
A profession that cannot say this clearly has lost its therapeutic center. This is what Gary Kielhofner warned about when he expressed concern that occupational therapy, in its eagerness to develop a science of occupation, might leave behind the therapy in occupational therapy. That warning was not anti-scholarship - it was a warning about professional drift.
We should study and try to understand occupation. We should listen carefully when people describe the meaning of what they do.
But therapy requires more than listening and affirming. It requires discernment - and then real world application.
The better conclusion from this article would have been modest - I wish the students were guided in that direction a little more. Occupational therapists should understand that some people participate in identity-based performance occupations that are deeply meaningful to them. Therapists should avoid dismissing or pathologizing occupations simply because they are unfamiliar, politically contested, or culturally uncomfortable. That would all be fine. They could have even stated that when relevant to a patient’s goals and health needs, therapists may need to understand how such occupations relate to participation, self-expression, social belonging, safety, and access. All of that would be a defensible occupational therapy implication.
But the article goes further. It suggests that drag can be embraced and integrated into occupational therapy practice without doing the hard applied work of explaining when, why, for whom, under what conditions, toward what outcomes, and with what ethical boundaries.
That is not a small omission. It is the central problem.
The line between occupational science and occupational therapy matters. Basic inquiry can describe. Applied practice has to decide. And if it is truly applied, it has to explain how the knowledge should be used, for whom, toward what end, and with what limits.
When that line collapses, occupational therapy becomes vulnerable to every fashionable academic framework or special interest that wants professional legitimacy.
That is not good for the occupational therapy profession. And it is not good for the people we serve.
The article may be acceptable as occupational science. The problem is the leap into occupational therapy application. That leap has to be earned.
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