Depictions of Strabismus in Children’s Animated Films

We reviewed animated films from 4 major studios: Pixar, Walt Disney Animation Studios, DreamWorks Animation, and Studio Ghibli. These studios were selected on the basis that they are the 4 studios that have received the most nominations for the Academy Award for Best Animated Feature. We included all full-length feature films released by Pixar, DreamWorks Animation, and Studio Ghibli before 2023. We also included films released by Walt Disney Animation Studios from 1989 to 2022, as 1989's release of the The Little Mermaid was considered the beginning of a period called the “Disney Renaissance,” during which many children’s animated films were released to critical and commercial success.¹⁰ 

At least 1 author reviewed the entirety of each movie and identified potential characters with strabismus. A pediatric ophthalmologist then reviewed all identified characters to confirm the diagnosis of strabismus and classify the strabismus as exotropia (outward drifting of the eyes), esotropia (inward crossing of the eyes), hypertropia (1 eye pointing higher than the other), or disconjugate roving eye movements. Characters were included if the eye misalignment was present the majority of the time the character was on screen. Characters were excluded if their eye misalignment was only present immediately after head trauma.

For each character identified as having strabismus, personality traits and other physical characteristics were independently assessed by 5 raters through a 10-question assessment (Table 1). Primary characters were defined as characters playing a central role in the plot; secondary characters were defined as recurring characters with only a secondary role in the plot; and peripheral characters were defined as characters who appear only briefly with little contribution to the plot. If a rater was not confident how to classify a character for any given question, a score of “neutral” or “unsure” was assigned.

χ² test was used to compare the number of movies with at least 1 character with strabismus among all 4 studios, as well as between American studios (Pixar, Disney, and DreamWorks combined) and the 1 Japanese studio (Studio Ghibli). Fleiss’ κ was used to assess the concordance of scores to the 10 questions in Table 1 between the 5 independent raters, with a κ score of 0.81 to 1.00 indicating “almost perfect” inter-rater agreement, 0.61 to 0.80 indicating “substantial” agreement, 0.41 to 0.60 indicating “moderate” agreement, 0.21 to 0.40 indicating “fair” agreement, 0.00 to 0.20 indicating “slight” agreement, and <0.00 indicating “poor” agreement.¹¹  We used the criteria of at least 60% (3 out of 5) agreement among the 5 independent graders to classify a character as having a trait. A 3 sample proportion test was used to compare proportion of characters with principal, secondary, or peripheral role, and a 2 sample proportion test was then used to compare proportion of characters identified as intelligent versus unintelligent, hero versus villain, and leader versus follower.

The 4 studios released a total of 125 animated movies during the study period. We identified 46 characters with strabismus (Supplemental Table 6), with at least 1 character identified in 33 of the 125 films (Table 2). There was no significant difference in frequency of characters with strabismus among all 4 studios (P = .42), or between the 3 American studios and the 1 studio from Japan (Studio Ghibli) (P = .18).

The number of characters with each characteristic is shown in Table 3. Out of 46 characters, only 2 were primary characters, significantly fewer than secondary characters (N = 11) and peripheral characters (N = 33) (P < .01). Both of the primary characters with strabismus were unanimously judged by the 5 raters to be villains. Nine characters were human or human-like, and 26 did not speak. The most common type of strabismus was exotropia (54%), followed by esotropia (20%), vertical strabismus (13%), and roving disconjugate eye movements (13%).

Inter-rater reliability was assessed for each personality trait among all 5 raters (Table 4). There was substantial agreement (κ 0.61–0.80) among raters for characters perceived to be a villain, leader, follower, or to be frightening. There was moderate agreement (κ 0.41–0.60) for characters perceived to be intelligent, unintelligent, clumsy, or to have other physical deformities. There was fair agreement (κ 0.21–0.40) for characters perceived to be a hero.¹¹ 

The number of characters classified with each personality trait were shown in Table 5. Characters with strabismus were more likely to be portrayed as unintelligent than intelligent (P < .01) and were more likely to depicted as a follower than a leader (P < .01). Seven characters were portrayed to be a villain, and 2 characters were portrayed to be a hero, although the difference in proportions was not statistically significant (P = .16). Over a third of characters with strabismus were depicted as clumsy or accident-prone (35%), 24% were portrayed as frightening, and 35% had other physical deformities.

Characters with strabismus were common in the 125 animated films evaluated in our study, with these characters overwhelmingly more likely to be portrayed negatively than positively. Characters with strabismus were much more commonly relegated to secondary or peripheral roles, as we could only find 2 primary characters with strabismus in any of the films (both of whom were villains). Of the 46 characters with strabismus, these characters were 14 times more likely to be depicted as unintelligent than intelligent, and over 6 times more likely to be followers than leaders.

Research has shown that the content of television shows and movies can significantly affect children’s behavior, beliefs, cognitive development, identity, and moral code from as early as 6 months of age.^12–14  Our study suggests that children watching animated movies may be influenced by these films to associate strabismus with negative character traits.

A major difference between animated characters and live actors is that the physical appearance of animated characters is designed from scratch. Every aspect of an animated character’s physical appearance is the result of a deliberate decision by the animators to visually depict the character that way. In the cases of the 46 characters we identified in this study, the animators made the decision to depict all 46 of those characters as having strabismus.

Although we did not find a single primary protagonist with strabismus, comic-relief characters or villainous characters with strabismus were common. For example, in Disney’s The Lion King, every named character is able to speak, except for 1 – Ed the hyena. Ed is also the only character in the movie with strabismus. He is frequently shown chewing his own limbs and communicates only through manic laughing. Ed was unanimously judged by our 5 raters to be an unintelligent, villainous follower; and the primary antagonist of the film sings about Ed that “it’s clear from your vacant expression, the lights are not all on upstairs.” More recently, Disney’s Moana included a secondary character, Heihei the chicken. Though no other chicken in the film has strabismus, Heihei’s eyes are nearly constantly exotropic or roving disconjugately. A codirector of Moana stated that the animators intended for Heihei to be “the stupidest character in the history of Disney animation.”¹⁵ 

Although negative or neutral depictions of strabismus were plentiful in our study, positive depictions of characters with strabismus were rare. Only 3 characters with strabismus were found to be leaders, but 1 of them was a villain (Cat’s King from Studio Ghibli’s The Cat Returns) and another was unintelligent (Scuttle from Disney’s The Little Mermaid). The only other leader was the peripheral character Forrest Woodbush from Pixar’s The Good Dinosaur, who was also the only character with strabismus from the 125 films who was found to be intelligent. Only 2 characters with strabismus were primary characters who were central to the plot, but both were also villains (Cat’s King from Studio Ghibli’s The Cat Returns and Dave the Octopus from DreamWorks’s Penguins of Madagascar).

Evidence suggests that children’s negative attitudes toward people with strabismus are an acquired stigma that begins around the age of 6, roughly when children start school.¹⁶  Media influences are now so pervasive in children’s lives that the average child spends more time with media than they do in school.¹⁷  We suspect that the negative depictions of strabismus in children’s movies may be a factor in the development of children’s negative attitudes toward strabismus.

The American Academy of Pediatrics policy statement on “Children, Adolescents, and the Media” recognizes the potential harmful effects of negative media portrayals while also recognizing the positive potential of prosocial media content.¹⁸  American Academy of Pediatrics encourages pediatricians to “challenge the entertainment industry to…maximize prosocial content in media and minimize harmful effects,” and our study suggests that pediatricians and ophthalmologists should specifically challenge animation studios to reassess the way they portray strabismus to young audiences.

Our study was limited by the subjective nature of our data; however, we are confident in the validity of our data since our inter-rater reliability was substantial or moderate for all but 1 character trait. The only trait where raters were not in substantial or moderate agreement was heroism, but this may be partly because of the low number of characters perceived to be heroes. Our study also is limited by its lack of a control group, making it difficult to directly compare these 46 characters with the other characters in their respective films. Although we suspect that these negative depictions of strabismus are likely to affect the way that children perceive people with strabismus, further study is needed to determine how much of a psychological impact these negative depictions of strabismus may be having on young audiences.

Characters with strabismus are common in animated films, where they are significantly more likely to be portrayed negatively than positively. These films are marketed to children, and their negative depictions of strabismus are likely to exacerbate the social stigma faced by children with strabismus. Pediatricians and ophthalmologists should advocate that animation studios refrain from using strabismus to visually convey negative character traits.