Getting our act together: a qualitative evaluation of the impact of a play on issues relating to women, sex work and substance use [version 1; peer review: awaiting peer review]

Background: The arts have always sought to explore significant social issues through literature, performing arts and visual art. However, more recently there has been an increase in the use of theatre as a means of gauging audiences’ perception and understanding of key social issues. The primary aim of the current evaluation was to seek the views of audience members, service users of addiction services and expert commentators as regards their perception of a number of key issues related to the content of a play entitled Madame Geneva. Methods: The evaluation used an exploratory qualitative design incorporating a dualistic approach to the research process: including post show discussion with panellists and members of the audience and a focus group comprising service users who had also viewed a live performance of the play. Results: The topics elucidated by the performance of the play included women and sex work, women and substance use, and impact on policy and practice. The discussion of the issues raised reiterated that women still experience high levels of oppression and discrimination in areas of substance use, sex work and welfare ‘reform’ which are often couched within male dominated political discourses and structures in contemporary society. Conclusions: The arts and specifically dramaturgical representations of substance use and related issues is an effective method of initiating important pragmatic and policy discussion of issues, which affect women


Introduction
In Northern Ireland (NI) alcohol-specific death rates have increased among females by approximately 84% from 6.4 to 11.8 deaths per 100,000 females between 2013 and 2016 (Office for National Statistics [ONS], 2013). On 1 March 2017, a total of 5,969 persons were reported to be in treatment for misuse of alcohol and/or drugs in NI, 1850 of these individuals were women (Department of Health [DoH], 2017). Yet, in light of the mortality rates, the number of women in treatment does not reflect accurate figures of women in NI who need treatment. The resistance to seeking treatment is likely to be related to the considerable stigma that women from NI feel concerning seeking help; many have stated that they perceive others might judge them as a poor parent or carer as a result of their substance use (Plant, 2008). Furthermore, individuals from NI are particularly vulnerable to developing an alcohol and drug issues as those who have been exposed to environments of conflict are, particularly at risk (Duffy et al., 2020). The medium of theatre, which has emerged in recent decades as a contributor to positive social action, can assist in the liberation of the disempowered (Boal, 1979).
Theatre and raising awareness Although the social impact of the arts has become an increasingly familiar phrase in policy debates, few studies have attempted to define it. Landry et al. (1993) posit a notable exception, as the social impact of the arts is related to effects outside the products or practices of the performance and can have an ongoing impact upon people's lived experience. In reference to this definition, the social impact of the arts are those effects which are extended beyond actual arts experiences and have resonance with the lived experiences. For Lingayah et al. (1996), one way of looking at the social impact is by considering the effects on individuals and how this impacts interpersonal relations.
While the arts have always sought to explore significant social concerns, recently there has been a growing use of theatre as a method to gauge audiences' perception and understanding of fundamental social issues (Knowles & Cole, 2008). This method has been to enhance dialogue, and improve quality of life especially for disenfranchised, excluded, and constrained groups (Knowles & Cole, 2008). Taylor (2003, p.12) explains: "The theatre becomes a medium for action, for reflection but, most important, for transformation a theatre in which new modes of being can be encountered and new possibilities for humankind can be imagined." The medium of theatre delivers an innovative and evocative method to compel shifts in understandings and perceptions of audience members in relation to specific issues. The impact of applied theatre should influence and cause a measurable change beyond the immediate beneficiaries of a project, supporting audience members and those participating to feel less oppressed and more empowered. However, there is much debate as to whether changed feelings last beyond the theatre environment and whether this medium of raising awareness leads to changed lives and fairer social systems (Knowles & Cole, 2008). A body of literature is emerging to address practical questions as to what applied theatre is and to respond with appropriate methodologies to address the questions posed (Nicholson, 2014;Prentki, 2013;Vettraino et al., 2017).
Although societal attitudes towards women have changed since the 1800s, it is nevertheless clear that we still cling to some of the archaic ideas about how society views women who have alcohol and drug-related issues and problems. For example, women who have caring roles often feel that they are demonised for their drug and alcohol issues, particularly when they interact with social services in relation to their child's welfare (Dewey et al., 2021). Moreover, for some sections of the female population, the discriminatory attitudes are further exacerbated by women's lifestyle choices. For example, women who are involved in the sex work industry experience multilevel and complex oppressions on individual, community and societal levels (Hester et al., 2019). The transgenerational impact of trauma for those living in a post-conflict society adds another dimension to the difficulties and has a significant effect on alcohol and drug use in older and younger generations. As first use of alcohol at ages 11-14 years dramatically increases the risk of SUDs in later life, early intervention is necessity (DeWit et al., 2000). The theatre has the potential to be an efficient method for social liberation, yet it is evident that robust research methodologies are necessary for ascertaining and presenting the holistic importance of the arts.

Stigma, labelling and discrimination
Societal perceptions of women who use alcohol and drugs are best understood in the context of relationships. Society expects a woman to be a loving wife, a nurturing mother and a monogamous sexual partner and when she deviates from these prescribed roles, she will most likely encounter stigma and discrimination (Erol & Karpyak, 2015). Day et al. (2004, p.166) explain: "These and other discourses around gender and alcohol clearly work to consolidate drinking aa male endeavour, as women who attempt to enter this domain are cast as likely victims either of their own alcohol abuse or of drunken men intent on damage." Women and excessive alcohol use are linked to early initiation into sex and coercive sex (Stueve & O'Donnell, 2005). However, although women who are alcoholics are vulnerable, they are also often criticised as being partially responsible for any harm that they suffer. In addition, women who drink excess amounts of alcohol are often deemed sexually promiscuous (George et al., 1988). Supposed promiscuity in women drinking alcohol is also often associated with the neglect of children and family in general which causes further discrimination on individual, community and structural levels (Carter, 1997). These parallels between alcohol consumption and female sexuality have been compounded for centuries. In particular, public houses have been identified as the most common territory for women working in the sex industry (Purcell, 1994). As payment for sex is often linked to alcohol and drug use, this adds the further dimension of possible conflict with the legal system (Li et al., 2010). As the gender gap narrows and stigma remains, there are issues to consider in the form of the impact of shaming behaviour on women who drink alcohol and the effect this has on their drinking behaviours.
Substance Use Disorders (SUDS) in a post-conflict situation The prevalence of poor mental health and impaired physical health as linked to exposure to post-conflict environments has repeatedly been demonstrated in epidemiological studies (Karam et al., 2014). In efforts to cope with psychopathological symptoms and the related adverse affective and physiological states, drugs and alcohol are often used to alleviate or suppress the suffering (De Jong et al., 2003;De Jong et al., 2001). This strategy has been labelled self-medication (Khantzian, 1985). Furthermore, a positive association between trauma-exposure and psychopathology has been referred to as dose-effect (Ertl et al., 2016). The self-medication hypothesis predicts that psychotropic substances, in particular, are most often consumed to alter mood, which helps cope with the psychological strains related to trauma (Ertl et al., 2016). Such efforts to self-manage difficult emotions often prevent or delay help-seeking as the substance use disorder (SUD) becomes a method of coping (Ezard et al., 2011). Post-traumatic stress disorder (PTSD) is the most frequently reported psychiatric consequence of traumatic events such as living in a site of conflict. By not recognising the connection between exposure and symptoms, providers frequently misdiagnose or do not adequately attend to SUD-PTSD comorbidity (Ouimette & Brown, 2003). In an NI context, there have been notable transgenerational effects of trauma deriving from 'The Troubles' (Downes et al., 2013), including increased levels of transgenerational PTSD. Research in post-conflict settings indicates that high unemployment, homelessness, SUDs and domestic violence are dominant features, often these difficulties lead to further distress which can perpetuate the continuance of a cycle of trauma (Pedersen, 2002). The moral implications and moral legitimacy of commercialised sex provoke strongly held and highly polarised reactions. Despite the differing viewpoints and arguments stemming from contrasting moral values, making a rational evaluation of the advantages and disadvantages of both perspectives is difficult. The difficulty is complicated by the lack of robust data, which emerges in part from the covertness of sex work and the understandable unwillingness of those involved to align themselves as sellers or buyers of .In addition,, "stigma, the private and hidden nature of the sex industry, and the transience of activities mean that estimating prevalence is challenging" (Hester et al., 2019 p35). The current figures are therefore likely to be higher in reality than the recognised figures. The House of Commons Home Affairs Committee Prostitution report (2016, p.3) estimates that there are approximately 72,800 sex workers in the UK and approximately 11% of British men aged 16-74 years have paid for sex on at least one occasion. The continued shame and stigma, which is attached to those who are involved in sex work, is evidenced by their reluctance to talk about their experiences and the subsequent paucity of research available in this area. The silence through stigma experienced by women in sex work is associated with a host of psychosocial vulnerabilities. Women typically report experiences of compounded trauma, including exposure to childhood physical abuse and childhood sexual abuse, interpersonal violence in adulthood and substance use (Medrano et al., 2003).

Sex work and stigma
The most recent debate concerning stigma centres on the terminology used to describe those involved in the commercialisation of sex. The term sex worker has been employed to avoid invoking the stigma associated with the derogatory connotations of the label "prostitute" (Sanders et al., 2017). By a change in terminology, this is an effort to promote ownership over the individual's career choice and separate occupation from identity as the economic implications are made more prominent (Sanders et al., 2017). Weitzer (2009, p.1) explains sex work is recognised as: "the exchange of sexual services, performances, or products for material compensation. It includes activities of direct physical contact between buyers and sellers as well as indirect sexual stimulation." Although the terminology has the intention of empowerment and granting more agency to those offering sex-based services, sex workers still experience high levels of stigma. Prostitutes have been discriminated against and stigmatised by the government, church communities, neighbours, and family, for centuries (Sanders et al., 2017). While sex work itself is not a criminal offence in England, Scotland and Wales, the government has been notorious for incarcerating sex workers under the guise of disturbing public order. However, there is a case to suggest that sex work is intrinsically linked to criminality in the forms of trafficking, coercion, and illegal drugs. Therefore, it is not surprising that there are increased levels of stigma, above and beyond, that which is experienced by those abusing substances such as alcohol or drugs (House of Commons, 2016). The stigma was, of course, more overt in the eighteenth century as suspected prostitutes were arrested, publicly dragged to prison, reminding all bystanders of their shameful behaviour (Luddy, 2007). The reality and the ever-present possibility of discrimination by police, church, neighbours, and family confirm the incomplete social acceptance of prostitutes in both the eighteenth-century and sex workers in contemporary society today.

Objectives
The primary aim of the current evaluation was to seek the views of audience members, service users of addiction services and expert commentators as regards their perception of key issues related to the content of the play Madame Geneva, staged by Macha productions in June 2017. The play, set in 18 th century London, examined a number of socio-political issues concerning women, addiction and sex work where gin played a significant part in women's 'downfall' through sex work and/or addiction problems. The situation is controlled and benefitted by the dominant patriarchy of the era. The topics elucidated by the performance of the play included: 1. Women and sex work 2. Women and substance use (primarily alcohol)

Ethical approval
Ethical approval was granted by the Queens University Belfast, School of Social Sciences, Education and Social Work Ethical Approval committee in May 2017.

Research design
The primary aim of the current evaluation was to seek the views of audience members, service users of addiction services and expert commentators as regards their perception of a number of key issues related to the content of the play "Madame Geneva: A Tale of Gin and Prostitution", staged by Macha productions in June 2017. The evaluation used an exploratory qualitative design (Sarantakos, 2010), incorporating a dualistic approach to the research process: including post-show discussion with panellists and members of the audience and a focus group comprising service users who had also viewed a live performance of the play. A purposive sampling technique (Sarantakos, 2010) was used to select the focus group participants and the post show discussion attendees. Both groups were invited to join the separate discussion as they had attended a performance of the play.
Focus group with service users A Queen's University Belfast (QUB) researcher (CB) from the project team convened a focus group with women who have alcohol-related problems and who are participants in a local service user group. The focus group was convened in the theatre where the play was performed, and it was held immediately after a matinee performance of the play. The aims of the focus group were to establish the respondents' perceptions of two primary issues: their experiences of substance use and how the play facilitated the discussion of their experiences of addiction and subsequent service provision. The focus group guide included questions on how the play influenced their views of women and alcohol addiction in the 18 th century, which was linked to perceptions of women with alcohol issues in today's society. Experiences of stigma and oppression as result of drinking alcohol were also explored. Focus group participants were also asked how services could respond specifically to working with women who have alcohol related problems. They were also asked if the production and staging of a play a good way of raising awareness of the stigma and oppression faced by woman who have alcohol issues. All materials including consent form, information sheet and topic guides are provided as extended data (Campbell, 2021).
Six women participated in the focus group discussion after the play which was staged in the Lyric Theatre Belfast on May 22 nd , 2017. The women were identified from a regional drug and alcohol Service User Network (SUN) in Northern Ireland. SUN is comprised of individuals who have experienced SUDs over the last number of years. The women were all active lobbyists for service user participation in the planning of local drug and alcohol services and sit on various committees through which they represent the service user's voice in practice and policy related issues They were contacted by female Regional Service User Network (RSUN) workers who described the project to them, provided them with project documentation and advised them that the lead researcher would follow up contact within one week to ask if they would participate in the focus group. They were asked to consider the participant information sheet and consent form and that a copy would be provided to them prior to the performance. The female researcher who convened the focus group (CB) did not have any prior relationship with the service user group (SUN) or with any of the focus group members.
Prospective focus group participants were informed that attendance at the performance was not reliant upon participation in the focus group and they could withdraw from the research process at any stage. It was also recognised that the content of the play might precipitate upsetting thoughts/ images/thoughts of past experiences for the participants and therefore the women were provided with a named person who was available to talk with them after the show on an individual basis (a British Association for Counselling and Psychotherapy registered counsellor was available at the theatre if immediate assistance was requested by any of the participants). Furthermore, participants were provided with a list of organisations and telephone numbers and were advised to seek help from their general practitioner (GP) if necessary, after the focus group discussion.

Post-show discussion with panel guests and audience members
A series of post-show discussions was convened on four occasions immediately after the performance of the play. These were moderated by (JE & CB) JE was known to some of the panel members and by a number of the audience members as she is widely recognised in the Dramatic Arts sector in Northern Ireland. It was difficult to ascertain the nature of the relationship between the two post show convenors and each audience member due to the post show time frame and the varied nature of the audience.
Post show discussion questions focused on how women with alcohol issues are viewed by society. There was also a consideration of stigma towards women with hazardous or dependent drinking problems and how this compared with views on male drinking behaviours.
In total, 71 audience members and nine panel members took part in the after-show discussions. Those audience respondents and panel members who participated in the discussion were offered advice that if an individual felt distressed and would like support with any emerging concerns as a result of issues raised by the performance they should contact helplines relevant to the discussion themes and topics as discussed (contact details were also provided via the participant information sheet [PIS] before and after the performance). Alternatively, we also recommended that any individual could contact their GP for support and or advice on any of the issues raised by the performances.
Prior to the performance, members of the audience were provided with PIS and consent forms and the research process was also described verbally at this stage by (JE & CB). At the post-performance juncture, audience members were once again invited to remain, and signed consent forms were collected before the discussion commenced.
All transcripts from the focus group and after-show discussions were anonymised and participants were assured that they would not be personally identified through written tracts or within any verbal context preceding or following the performance or through publications. The information from the discussion forums and focus group were collected using QUB audio recorders and data was immediately transferred to a secure, password protected file. Participants were assured that their views on the discussion topics would remain entirely confidential and any potentially identifying factors would be removed from transcripts to ensure participant safety on disclosure of information. All information was anonymous and stored confidentially. In addition, all data was encrypted and stored securely on QUB premises and will be destroyed after five years in accord with QUB guidelines.

Data analysis
Data from the qualitative post-show discussions and focus group were digitally recorded and transcribed verbatim. Qualitative data analysis was conducted with use of the NVivo software tool (V.11), using both thematic and narrative approaches (see, for example, Bryman, 2008;Lewis-Beck et al., 2004). Through this process, a number of categories were developed, coded and reduced to identify emergent themes and issues and to explore the relationships between issues. Two data coders (CB & AC) noted emergent themes and subthemes from the data and these were checked by a third member of the research team (PM) for inter coder reliability (Sanders & Cuneo, 2010).

Results
The findings are presented according to the post-show topics as discussed by the panel members (PM) and audience participants (AM) on four occasions after the performance of the play 'Madame Geneva' (Campbell, 2021). The narrative is also supplemented with material generated through the service user focus group participants (FG). The three topics included: women and sex work, women and substance use (with a focus on alcohol), and impact on policy and practice.

Women and sex work
Initially, the post-show discussion focused on how women were denigrated historically due to their involvement in sex work or if they had specific complex issues of mental health and addictions problems.
"I think a lot of what the play demonstrates is how women are still vilified, even historically, if they have taken part in sex work or have had mental health issues and addiction." (DP) The theme of 'rescue' was also outlined by another post-show discussion participant who highlighted that the protection of women is often hidden within a reforming agenda where some support organisations may have differing motivations for providing support for sex workers.
"…if you scratch the surface of a lot of these ideas around protecting women, it's actually about reforming them and making women behave as they should. Some of the organisations that are involved in sex worker rescue services, particularly in the South of Ireland… it throws into question what people's real motivation is." (DP) Choice A member of the audience discussion group underlined that choices for women should be provided outside of sex work. The participant posed the question as regards what support could be made available to women from low social and economic resource areas who wanted alternative job opportunities.
"I was wondering what help there might be for women who may not think of sex work as a choice. It was expressed in the play about, "Okay, it's either sex work or starvation". When you have children to look after, whatever decade you're living in, it's something they need to do." (AM) One panel member stressed that there were two reasons why women chose sex work as a job; financial and because it was their job of choice.
"…it's both. It's financial reasons. You have the people who drink, [and take] drugs. They'll go out to fund their habits. Then, you have the people who like what they do. They go out because they want to do it and they like their job…" (DP)

Feminism and sex work
There was a very insightful and informative debate in relation to feminism and sex work with the view that there were many and varied schools of thought in relation to the discussion which has evolved over the last few decades. Firstly, there was the view that some areas of feminist thinking did not fully appreciate the multi-faceted and highly nuanced world of sex work. Indeed, some perspectives simply served to engender more stigma, whilst other feminist ideologies focused on the empowerment of women and the recognition of women's autonomy and self-determination as a sex worker.
"If you follow any feminist discussions or input into social issues, you'll know that feminism has a bit of a problem when it comes to sex work. There are tensions, in that some of the work that feminists have tried to do in shaping policy has been incredibly harmful and further stigmatised sex workers. The other side of that coin is that a lot of young feminists are in the groups that are coming through now that are based on intersectionality." (DP) There was also a comparison made between the feminist debates expounded in the play that represented views in the 1800s with those which are embodied in current debates.
"There are still some groups in London, for example -and in Dublin as well -who are lobbying very heavily for public policy that is about further criminalising sex work. The whole narrative around that -it's interesting to watch the [feminist] debates that played out in the play, because they're exactly the same as the ones that go on now." (DP) One service user from the focus groups commented on how we place importance on trying to 'fix' women and focus on preventing them from being engaged in sex work.
"...how it was about how we fix women and stop women doing this, it was a man-made problem that caused women to be that way and then they're having to face the downfall. There was no talk about how do we re-educate men not to go to prostitutes or to stay away from this, it was all solely the woman's fault." (FG) The feminist discussion also considered the Nordic model which examines the 'demand' for sex work. It was surmised that some proponents of specific feminist ideologies were opposed to the idea of male sexual entitlement as the primary reason for supporting the non-legitimisation of sex work.
"…like you were saying, the Nordic model and the whole idea that you tackle demand. For a lot of feminists, their support for that comes out from a place of not being able to handle the thought of male sexual entitlement, that men can just go and have sex with any woman they want. There is a desire to challenge that. I have come to a place where I can see that there is nothing inherently wrong with someone -male or otherwise -purchasing sex from a sex worker. What's wrong is a man who goes into that situation and cannot respect someone's boundaries, cannot act in a way that is non-violent, cannot properly respect the nature of that relationship and the consent and everything else." (DP)

Sex work -the moral debate
The spotlight on policy continued as part of the discussion on the morality aspect of sex working. One participant commented that the play highlighted the issue of how society and (male) legislators can become entrenched in a judgmental morass about how we address women's issues in general.
"I think the play highlighted that women are the fabric of society and if women become addicted or their morals are seen as loose, then the patriarchal society falls apart and we're living in a world of madness and anarchy, which clearly isn't the case. This view was corroborated by another discussion panel member who stressed that male-dominated government committees were essentially making major policy decisions about critical issues concerning the welfare of women, again a situation which is reminiscent of male-centric 18 th -century political structures and discourses.
"We just had a quick chat about this in the interval, about when Lord Morrow's bill to criminalise the purchase of sex was going through… By the end of the bill going through, that was an all-male Stormont [NI government] committee. It was the only one that was all-male... So, the focus on the men in the play talking about the women, that has not changed." (DP)

Women and substance use
The post-show discussion group also focused on the comparison between substance use issues in the 18 th century and the 21 st century, the reasons for substance use problems, service provision for women with alcohol and drug-related problems and 'next steps'.

Comparison between substance use issues in the 18 th Century and today.
The debate centred on the issue of alcohol misuse as a public health problem in the 18 th century. The author of the play highlighted that it was most likely the first time that a psychoactive substance was viewed as causing a public health problem in the UK and that comparisons could be made with the current scale of the problems related to drugs and alcohol use in the 21 st century.
"There was a narrative, there was a feminising of the alcohol. It was called 'Madame Geneva'. All the ills of the darkness and evils that were seen as being in gin then became placed on prostitution. For me, as far as I was aware and maybe there will be another historian in the room that can challenge me on it, it was the first time that there was a mass addiction that [UK] society had to cope with and you can maybe see within the play that at times." (DP) This point was further reinforced by another discussion panel member who indicated that women today are also addressing issues around dependence on prescription medication alongside alcohol and that the problems may be underestimated due to the 'hidden' nature of addiction issues for women.
"…all of those things are in the mix with addictions because prescriptions are free in Northern Ireland, so, therefore, women tend to go more for tablets, medication, but drinking as well. It is a hidden sort of a thing…" (DP) Respondents from the service user focus group highlighted how women are castigated for their substance use problems more so than their male counterparts, particularly if there is social services involvement with the family.
"Women are more demonised than men, you know, especially when it comes to addiction and especially in place where there's families and if the father's drinking. Social Services very rarely would get involved but if it's the mother that's drinking and it's brought to their attention, Social Services would be in straight away and the risk of losing your kids becomes very, very high." (FG)

Reasons for substance use problems.
Post show discussion participants indicated three main reasons for what they perceived as the root-causes of substance use problems in the region; trauma, socio-economic deprivation and the conflict/post-conflict situation in NI. The conflict and postconflict situations in NI were also perceived as having a significant impact on women developing substance use related issues over the last three decades. One participant highlighted the presence of a motivation 'to stay alive' that was precipitated by living in a conflict situation and how that may have dissipated in a post-conflict era. This was further compounded by the high rate of unemployment and inequalities within in the fabric of life in NI.
"It is totally relevant because, in a war-like situation, there has been research done, that people when they are involved in a conflict, there is a motivation, there is a motivation to stay alive, so therefore when the motivation is absent, and they have nothing to do. Unemployment in Northern Ireland is very high; social equality is a very big issue here." (DP) One panel member highlighted that trauma was evident in the majority of service users that she has worked with in addictions services over the last number of years.
"The root of addiction, from my experience, is based on trauma, whether it is trauma in childhood or trauma in adulthood, it is there." (DP).
Social and financial factors were also propounded as underlying reasons for inequalities in accessing services, particularly for individuals and families from lower socio-economic groupings.
"I think also that if you are suffering from addiction but you happen to be poor as well, your chances of recovery, your chances of access to the support that you need and the treatment that you need is much more difficult as well?" (AM) However, one participant stated concern that the discussion around addiction often neglected to include those people from more economically advantaged areas and that indeed substance use issues were experienced by members from all sections of the population.
"I have a concern that when we talk about addiction and look at addiction, we perceive it as a working-class problem, when indeed, obviously, we know that addiction knows no boundaries but that there is an extra added element to addiction when there is poverty involved as well.." (AM)

Service provision for women
In general, service provision for substance use problems was perceived by the post-show discussion members as insufficient and notably lacking in the area of specialised provision for women.
"The women's hostel… I'm not saying it's a panacea for all ills but it definitely would make a big difference. ***** has been looking for funding for ten years and it's not happening at the moment" (DP).
"There is no women's hostel facility for women in Northern Ireland that has a long-term programme anything more than six months. There are a lot of women that come to our hostel, looking to know when is there a place going to be open [for women] because they know there is talk about it." (DP) There was also agreement in the discussion that rehab services for men were more likely to be funded and established more quickly than for women.
"What you also said earlier about when somebody had asked about the women's refuge, the women's hostel, that that is a constant issue, I find, and not just here as well, globally." (AM) Service users also outlined the lack of aftercare provision for women who have substance use issues and how they felt abandoned by the system, which had helped them up to a certain point in their recovery journey.
"I think aftercare needs to be improved, you know, it's all well and good coming out of somewhere like *****, maybe spending a year and a half, two years in ***** but once you leave there and you're out on your own, properly on your own after you've been in a cocoon for like two and a bit years, there's not always that brilliant follow on." (FG) The impact of the play and next steps The play was praised by panel members and audience participants as a highly articulate vehicle for raising many important issues around sex work and addiction issues.
"I think the play is really cleverly written and it does raise issues that women will deal with throughout different centuries and decades. We just need to have that awareness at all times, because we might not have a lot of women as political leaders, but hopefully, in the future, the majority could be women and we could at least have equal numbers." (AM) Another audience member suggested social media as a conduit for more discussion or indeed as a means for lobbying members of parliament (MPs) to keep the conversation alive.
"Just before you finish, could I just say thank you for doing that [the play], so much. Even if it is just our group here, even if we could perhaps Facebook or Tweet or whatever or even just have that conversation because I do believe that personal is political." (AM) A panel member talked about a similar group of workers from statutory and voluntary sectors addictions and service users who tried to address similar issues and the question posed then was posed again to the audience and the panel after the performance of Madame Geneva.
"What are we going to do with the energy in this room?'" (DP).
In response a panel member stated "Community can change everything. If the community gets behind the project, or starts a project, that is where it starts. A wise woman said, 'it takes a village to raise a child' but it also takes a community to raise awareness and it is getting it out there" (DP).

Discussion
The findings generated various important points, which highlighted the impact the performance of Madame Geneva had on the audience. The following summarises the main points raised by the data generated from the discussion. It is hoped that it will be used as a foundation for further analysis of the core issues, which have been emphasised as the result of the performance of this seminal work. The discussion of the issues raised has reiterated that women still experience high levels of oppression and discrimination in areas of substance use and sex work, which are often couched within male-dominated political discourses and structures in contemporary society.
It was also clear that there was a difference of opinion as regards the many and varied feminist schools of thought concerning an understanding of the nature of sex work and particularly a woman's right to choose this work pathway. Some referred to a hard-line feminist view that was firmly opposed to what they saw as the oppression of women who were involved in sex work. It was felt that this view might further reinforce stigma and discrimination experienced by sex workers while others underlined that the primary concern should be focused on the safety of woman involved in the sex work industry and that women should be empowered to make their own choices (Day et al., 2004). There was also a strong view that male-dominated political structures were making critical decisions on behalf of women concerning their needs, rights, wishes and welfare in the area of sex work.
The post-show discussion also highlighted that the problems associated with gin in mid-18 th century England was most likely the first time that a psychoactive substance was viewed as causing a public health problem in the UK. Focus group respondents also emphasised that direct comparisons could be made with the current scale of the problems related to drugs and alcohol use in the 21 st century, specifically the use of alcohol sales to boost "government moneys". Focus group and audience member participants indicated three main reasons for what they perceived as the root-causes of substance use problems in the region: trauma, socio-economic deprivation and the conflict/post-conflict situation in NI.
Service provision for substance use problems was discussed by focus group respondents who were particularly scathing of social services as regards their judgemental attitudes and often heavy-handed approach to dealing with mothers which had substance use issues (Plant, 2008). It was also agreed that there was insufficient specialised service provision for women who have substance use problems and this was notably lacking in the aftercare component of the care continuum, a situation currently reflected in the lack of available female-only facilities for women who have substance use problems in NI. In addition, Meyer et al. (2019) highlight that there is a need for more data collection in the area of public health and women and substance use, an area which has a paucity of research in Northern Ireland and the UK in general.
Furthermore, it was evident that male political leaders who are involved in writing policies which have relevance to women precipitated strong negative emotions in both panellists and audience members. There was a critical consensus that men should consider the importance of their decision making when shaping policies and subsequently the lives of vulnerable women. At a policy level, it is crucial to examine the vehicles for connecting people's stories with decision makers, i.e. politician and civil servants those who hold power via the funding to maintain active collaborations and to achieve positive results within communities.
The performance of Madame Geneva was also lauded as an excellent "standalone piece of art" as well as a means for discussing the issues highlighted above. The impact of the arts as a medium for raising awareness was also viewed positively and one panelist suggested that it "amplifies voice" and helps to frame the oppression of women not only in the 18th Century but also in contemporary society. It was also highlighted that the arts should be made more available to groups of people who suffer multiple oppressions and disadvantages. Moreover, as well as helping individuals and communities in need, it may also serve to assist professionals to connect with their own experiences and feelings in dealing with difficult cultural legacies which have been generated by the NI conflict, including addictions, dual diagnoses and grief.
In future drama productions and/or theatre-based interventions which are aimed at addressing issues related to health and social change, writers, directors and producers should improve on how they provide nuanced messages related to communities to mobilise change. The lack of long-term funding was seen as ultimately preventing longitudinal research and data capture. A renewable funding stream would permit this and subsequently support the leverage of further funding. Realistically however, this requires better funding from the government on a long-term basis and rather than the current trend of short-term funded projects which could be viewed as a tokenistic nod to the arts as a possible vehicle for change.