Research on Ageing and Social Policy

Volume 12, Issue 2, 30^th July, 2024, Pages 146 – 165

 The Author(s) 2024

http://dx.doi.org/10.17583/rasp.15017

The Impact of Gendered Ageism and Related Intersectional Inequalities on the Health and Well-being of Older Women

Guiomar Merodio, Ana Martínez Ortiz de Zárate, Fanghanyu Zhu & Javier Morentin-Encina

Abstract

Gendered ageism contributes to invisibility and homogenization of older women, harming their health, quality of life and limiting their social participation. Health issues related to aging have received increasing attention in the scientific literature. However, studies on aging that include a gender dimension or ethnic aspects remain scarce. This article presents the results of a systematic review on older women’s health and wellbeing, gender inequalities, age discrimination experienced by older women and their intersections with other forms of discrimination. Between January and February 2023, we conducted a literature review using PRISMA in the Web of Science Core Collection, MEDLINE and SciELO Citation Index. We selected 43 empirical studies from different countries focusing on women over 65 years. The findings show the incidence of discrimination and inequality in health care experienced by older women, ageist attitudes among health care providers and other professionals, experiences of abuse and gender-based violence among older women. Additionally, the study examines the impact of ageism and other forms of discrimination on the health of LGBTQ+ older people, ethnic minorities, older women with disabilities, and other non-traditional groups.

Keywords

Gendered ageism, older women, health, intersectionality, inequalities

Ageism is the third leading cause of discrimination worldwide after racism and sexism (WHO, 2022). A study in 57 countries found that one in two people harbors ageist attitudes, highlighting ageism as a pervasive global issue (WHO, 2022). Ageism permeates many institutions and sectors of society. It is widespread and normalized, leading to poorer healthcare and negative health outcomes (Ben-Harush et al., 2017). The WHO (2022) highlights consequences such as lower life expectancy, poorer physical and mental health, slower recovery from disability, and cognitive impairment. Ageism also reduces the quality of life for older people, increasing their social isolation and loneliness (WHO, 2022). These effects increased and became more visible during the COVID-19 pandemic (Merodio et al., 2020). Despite its negative health consequences, ageism remains a neglected global health problem (Officer et al., 2020). In addition, older people often experience ageism but may be less aware of its impact on them (Ziganshina et al., 2020).

Attention to age-related issues has increased in the scientific literature, with publications doubling from 11% to 24% in the first decade of the 21st century. However, studies that include ethnic or cultural dimensions remain rare. Recognizing age as an inequality is crucial for understanding its impact on health experiences and shaping healthcare policies of institutions and organizations (Barrett & Michael, 2022).

In scientific research on ageing, gender is beginning to be considered as a cross-cutting determinant with a relevant impact. However, research on aging from a gender perspective is still scarce (Perrig-Chiello, 2007; Fernández-Mayoralas et al., 2018). Women tend to live longer, suffer more from chronic diseases, and are more likely to be caregivers (Rochon et al., 2020). Understanding aging from a feminist perspective means considering the relationship between aging and gender. Ageism often intersects and interacts with other forms of stereotyping, prejudice and discrimination, including ableism, sexism and racism (WHO, 2022). Ageism significantly impacts women, who face age-related stereotypes that are perceived more negatively due to the influence of sexism. Traditionally, older women have been depicted as submissive, less competent, and less independent than men, with diminished attractiveness and perceived intellectual capacity, thus often undervalued in comparison to other age groups (HelpAge Spain, 2021).

Older women experience multiple discrimination resulting from the intersection of sexism, ageism, and other categories that may be grounds for discrimination (Krekula et al., 2018). For example, the health of older African American women is impacted by a lifetime of discrimination and inequalities that combine ageism, racism, sexism, and classism, resulting in higher mortality rates (Boseman, 2009). According to 2019 European Union data, above the age of 75, the risk of poverty is higher for women, at 23.3%, compared with men (Office of the High Commissioner for Human Rights, 2021).

This article presents the results of a systematic search of the international scientific literature focusing on the incidence of gendered ageism and related intersectional inequalities on the well-being and health of women over 65 years of age.

The study is part of the EDA-MUJER research project (Merodio, 2023-2024) funded by the Instituto de las Mujeres of the Spanish Ministry of Equality. The aim of this research project is to overcome ageism and sexism by identifying the social contributions of older women that reduce gender inequalities and ageism in three areas: social participation, formal and non-formal education and health.

The review highlights the barriers faced by older women in achieving health equity and wellbeing. It contributes to understanding the impact of gendered ageism in health and advancing efforts to overcome it.

Methods

Between January and February 2023, two researchers from the EDA-MUJER project conducted a search of the scientific literature on gender inequalities and age discrimination suffered by older women and its intersection with other forms of discrimination, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology (Moher et al., 2009).

The scientific literature search was conducted in the Web of Science Core Collection, MEDLINE and SciELO Citation Index databases without temporal, territorial, or linguistic restrictions.

The descriptors used in the search were: ageism + elderly women; gendered ageism + inequalities; ageism + gender + intersectionality; ageism + women + education; ageism + gender + disability; ageism + gender + minority groups; ageism + gender + rural areas; ageism + elderly women + social participation; ageism + overcoming; elderly women + adult education + empowerment; ageism + elderly women + empowerment; social activism + old women; ageism + elderly women + health.

A total of 565 articles were identified. The identified articles were exported to Excel to identify duplicates, resulting in a total of 223 scientific articles for review. Two researchers analyzed the topics and abstracts of the articles and identified 169 articles after applying the following eligibility criteria for article selection:

· Available evidence on gender inequalities and age discrimination experienced by women and their intersection with other forms of health discrimination.

· Type of study: peer-reviewed articles.

· Type of design: any type of empirical study.

· Type of population: studies that focus on women over the age of 65. If the article included other age groups, the specific findings for women over 65 were analyzed. We also pay particular attention to articles that, in addition to including women over 65 years of age, provided information on different profiles and characteristics of the participants, such as women with disabilities or from minority groups.

We established the following main exclusion criteria: articles on ageism that did not provide segregated and specific results on older women, studies of systematic reviews of the scientific literature, theoretical articles, articles on legislative issues, as well as descriptive studies on the social representation of older people in the media, films, literature, etc., were excluded if they did not show the consequences of this representation on the health and well-being of older women.

The full text of each article was then reviewed, resulting in a total of 43 final articles. Eligible articles were organized in an Excel spreadsheet. For the qualitative analysis of the content of the selected final articles, an analysis matrix was created in Excel with the following categories: country; study methodology; sample/participants; incidence of ageism; incidence of sexism-gender inequality; intersection with other forms of inequality; positive experiences in overcoming age discrimination. Twelve researchers associated with the research project participated in the final analysis of the results of the scientific literature according to this matrix.

Figure 1

Shows the Process of Searching and Selecting Articles Using the PRISMA Guidelines (Moher et al., 2009)

Results

The literature review reveals widespread gender-based ageism among women aged 65 years and older, which often intersects with other forms of discrimination, exacerbating inequities and impacting their health and well-being. The COVID-19 pandemic has further marginalized this demographic, especially affecting LGBTQ+ people, racial minorities, women with disabilities, and other marginalized groups. The review's findings are structured around several central themes: the significant barriers to health care access faced by older women, including underrepresentation in clinical trials essential to understanding effective treatments for conditions such as cardiovascular disease and breast cancer. The review also identifies biases and discriminatory practices among healthcare professionals, which influence treatment outcomes and psychological well-being. Abuse and gender-based violence remain prevalent problems, compounded by disparities in care experienced by LGBTQ+ older people, ethnic minority women, and people with disabilities. Positive experiences in combating ageism highlight the need for tailored social and medical interventions to improve healthcare equity for older women. The review found that the intersection of ageism with other forms of discrimination disproportionately affects non-traditional groups, highlighting the complexity of the challenges and reinforcing the need for inclusive health policies and practices.

Discrimination and Inequality in Health Care for Older Women

Research across various domains highlights the pervasive discrimination and ageism faced by older women in healthcare settings, leading to adverse impacts on their health, well-being, and life expectancy.

Older women are notably underrepresented in clinical trials, especially in cardiovascular disease (CVD) research, leading to gaps in understanding medication efficacy and safety for this demographic (Vitale et al., 2016). Similarly, a literature review focused on ageist attitudes in breast cancer treatment for women over 70 revealed a widespread exclusion of this demographic, due to medical personnel underestimating their life expectancy and overemphasizing caregiving responsibilities, which hinders access to necessary treatments like radiotherapy. Furthermore, older women are less likely to seek information or assert themselves with healthcare providers. The review suggests that treatment decisions for women over 70 should prioritize general health over age, resembling those for women aged 50-60, unless serious comorbidities exist (Pritchard, 2007). In Italy, a retrospective study of 49,058 patient records manifested ageism within the health system. In breast cancer treatment, younger women were more likely to undergo breast-conserving surgery than older women. Older female patients with lower clinical severity were also more likely to undergo radical surgery than younger women (Di Rosa et al., 2018).

Moreover, a study comparing treatment approaches for older Black and White women with breast cancer in the U.S. highlighted increased likelihoods of axillary lymph node dissection omission and post-breast-conserving surgery radiation omission in older women, especially Black women. These disparities suggest a compound effect of ageism and racism within the healthcare system, impacting treatment outcomes based on race and age (Mandelblatt et al., 2002).

In England, Wales, and Northern Ireland, research into the treatment of older women with urinary incontinence indicated a preference for less active therapies, like sanitary pads and containment-oriented therapies, over surgical interventions. Older women were much less likely to be offered surgical intervention to treat incontinence compared to younger women, despite evidence supporting surgical options for older patients (Griebling, 2011).

In the context of healthcare discrimination, various studies have focused on the interactions and relationships between health care professionals and older patients.

A study in Columbia, Canada, on chronically ill older patients uncovered inadequate care, revealing that these patients employ various strategies to gain medical staff's attention. They prioritize their health concerns due to limited consultation time, with some bringing companions, seeking alternative information sources, or being compliant patients by "doing what they are told." Remarkably, 26% view themselves as a burden on the healthcare system, and a third report ageism affecting their interactions with healthcare providers, attributed to internalized negative stereotypes or experiencing discriminatory practices. This ageism makes them uncomfortable discussing mental health or sexuality issues (Clarke et al., 2014).

A recent study from Nova Scotia, Canada, found that patient age significantly influences their relationship with healthcare providers and treatment received. Nearly half of participants reported medical personnel taking older patients' symptoms less seriously, leading to perceptions of lower care quality and increased medication prescriptions. Ageism was evident in condescending treatment from healthcare workers, who often disregarded opinions and treated patients as children. However, most participants attributed ageist attitudes to stories from others rather than personal experiences. Women cited factors such as acting younger, being assertive yet respectful, selecting older or female doctors, and maintaining positive long-term relationships with physicians to avoid ageism. The study involved white, European descent women, with one-third holding academic degrees and over half having high school education, predominantly living in urban areas (Macrae, 2018).

A literature review on social and cultural influences on urinary incontinence help-seeking behaviors among older Korean-American women revealed a perception of incontinence as a normal aging aspect managed by family rather than healthcare providers. Despite being a treatable condition, Korean-American women endure significant psychological, social, and physical challenges related to urinary incontinence due to low help-seeking rates and a need for culturally tailored education and interventions (Kang & Crogan, 2008). Urinary incontinence detrimentally affects the quality of life for many older women in long-term care facilities like nursing homes, with research indicating a lack of focus on understanding this condition from the affected women's perspectives. Older women express concerns about the physical implications of urinary incontinence and the institutional culture of urinary incontinence in long-term care. To improve their health, it is crucial to provide individualized care, empower the women themselves, and address ageism in long-term care settings (MacDonald & Butler, 2007).

Furthermore, studies on older women in correctional facilities highlight unique health risks, including medical staff's indifferent attitudes, mistrust in prison healthcare, and vulnerability to violence from younger inmates (Gueta, 2020).

Ageist Attitudes Among Health Professionals and Other Groups

Numerous studies have examined ageist attitudes among healthcare professionals and university students, especially those pursuing careers involving older adults. A study in Turkey with 488 medical students discovered that female students, those in their final year, students willing to care for older adults and those who lived with them showed less ageism (Oral et al., 2021). Similarly, a survey in Poland with 813 medical and health sciences students found more positive attitudes among female students (Podhorecka et al., 2022b). Both studies emphasize the importance of integrating health and aging topics into educational curricula and promoting interactions with older adults to foster positive attitudes

A further descriptive study in Turkey evaluated nursing and medical students' attitudes towards age discrimination in Intensive Care Units (ICU), revealing positive attitudes among ICU staff toward elderly individuals, despite associating senility with negative attributes (eg.weakness, disease, and mental deterioration). Notably, those not living with older adults showed more negative attitudes (Naldan et al., 2018).

In Poland, a study with 252 physiotherapy students found that contact with older adults before training positively influenced attitudes toward older people. Educational strategies, continuous learning, and supervision sessions aimed at developing empathic skills can reduce ageist attitudes among physiotherapy students (Podhorecka, 2022a).

A study in Valencia, Spain, involving 377 nursing students found that female students and those with extensive experience with older adults held more positive attitudes. However, not all experiences with older people were positively scored. Previous experiences with older individuals had a dual effect: experience with people in residences was associated with a more negative attitude than experiences with older adults outside of residences (López-Hernández et al., 2021).

Additionally, a study in Florida, USA, with 5.112 social work students and 5,116 criminal justice students found their negative attitudes about older people’s sexual behaviors. Stereotypes included perceptions of older adults as genderless, disinterested in sexual activity and sexually inactive, and even greater prejudice against older women (Kane, 2008).

Lastly, an analysis of advertisements in nursing magazines identified a distorted representation of older patients, with men more often depicted as critically ill or suffering from heart diseases compared to women. This underrepresentation fails to accurately portray patient diversity, potentially impacting reader perceptions and nursing practices (Lusk, 1999).

Consequences of Ageism on the Health and Well-Being of Older Women

Discrimination in healthcare settings is associated with disability in older people. A U.S. study involving 6,017 individuals over 50 (average age 67, with 56.3% women) was associated with the development or worsening of disabilities over four years in one-third of participants. Furthermore, one in five adults over 50 experiences discrimination in healthcare facilities, with one in seventeen experiencing frequent discrimination associated with new or worsening disabilities over four years (Rogers et al., 2015). Similarly, a French study of 298 seniors aged 60 to 92 found 40% perceived age-related negative stereotypes, directly correlating with poorer health outcomes and lower self-esteem (Macia et al., 2007).

The Health and Retirement Study in the U.S. suggests that depressive symptoms among individuals over 50 and their spouses can increase perceptions of age discrimination, indicating a cyclical relationship between mental health and discrimination perception (Ayalon, 2018). This relationship is mirrored in South Korea, where a study of 207 elderly individual showed discrimination, particularly against older women, increases stress and depression, with urban residents and those in poorer health or economic conditions facing higher discrimination. However, social support can mitigate stress and depression (Lee & Kim, 2016).

Furthermore, the National Longitudinal Survey of Older Women in the U.S. (1967-2003) revealed that concern about their financial situation can aggravate chronic stress and negative self-perceptions, intensifying ageism, thereby deepening depression, and reducing life satisfaction among older women (Shippee et al., 2019).

However, positive interventions can combat the discrimination they face. A Swedish study shows that older women can improve their health and well-being and combat healthcare inequalities by taking part in outdoor recreational activities. The study, involving 266 participants, (62.4% were women, average age of 74.7 years) demonstrated the importance for an adapted nature and sustained participation in outdoor activities to promote active and healthy ageing. Since not participating in some activities often leads to a sense of loss, while engaging in activities, whether alone or in groups, provides significant benefits. Exercising alone allows individuals to choose their pace and terrain according to their needs, while the chosen solitude provides an opportunity for solitary reflection. On the other hand, outdoor activities with others can foster mutual support and social interaction (Zingmark et al., 2021).

Gendered Ageism During the COVID-19 Pandemic

During the COVID-19 pandemic, older people suffered multiple discriminations based on age, as reflected in medical care and their rights to social participation. In the Community of Madrid, a study conducted among 447 study participants (average age 83.8, 63.1% women), revealed that 38% contracted COVID-19, 20% suffered adverse hospitalization effects, and 70% were room-confined. Furthermore, 41% perceived older people as a burden on health and social services. A notable 80% felt their age group faced more severe pandemic impacts compared to younger people, and 50% considered hanging out with older people to be more dangerous in terms of contagion. Self-assessment results were negative, as half felt less valuable than younger counterparts, and 38% saw their situation deteriorate with age (Rodriguez-Rodriguez, 2022).

Moreover, transgender elders faced increased emotional and social challenges, according to a qualitative study in India involving ten individuals over 60 who reported increased feelings of "age discrimination" during the pandemic. Their experienced feelings of marginalization (perceived stigma, discrimination, social exclusion, loss of dignity, and reduced medical access), vulnerability from the dual burden of age and gender (ageism, sexual well-being deterioration, feelings of otherness), and multiple physiological, psychosocial, and economic survival threats. Despite 8 out of 10 participants reported loneliness, social disconnection and depression, the strength and resilience found in relationships and intimacy provided essential support (Banerjee & Rao, 2021).

Furthermore, across 27 European countries and Israel, a study on individuals over 50 showed significant gaps in healthcare access during the COVID-19 pandemic: 12.14% gave up treatment, 26.18% postponed it, and 5.05% were denied treatment. Women were more likely to report foregoing healthcare assistance (Settels & Leist, 2022). Additionally, in Poland, a survey on preventive and protective measures for the elderly during the COVID-19 pandemic revealed that 50% of people opposed exclusive shopping hours for seniors, while nearly half were indifferent to elderly activation programs, 35% in favor showed more awareness of aging issues. The study suggests that developing targeted policies and educational campaigns to reduce age discrimination in Poland and other countries is crucial, as a high level of knowledge about aging leads to greater awareness of activities that improve the quality of life for the elderly, especially under pandemic conditions (Podhorecka et al., 2021).

Older Women Victims of Gender Violence or Abuse and Experiences of Ageism

Professionals' attitudes towards older women experiencing gender-based violence impact both case detection and intervention methods. A Portuguese study on professionals handling such cases revealed two distinct approaches: a feminist perspective favoring a more individualized approach for each victim and a generalized view that groups older victims together, neglecting their specific needs. The latter approach often trivializes and normalizes gender-based violence, framing it as family conflicts due to the longer relationship durations and showing less concern for older than younger victims. This behavior suggests a possible underestimation of the risks faced by older women, despite incidents of threats or attempted assaults. Highlighting the importance of developing targeted intervention methods, this emphasizes the necessity to address the particular needs of older women to effectively support them against gender-based violence (Magalhães, 2016).

Similar findings were observed in Israel, where social workers tended to differentiate cases based on the victim's age. For younger victims, cases were more likely to be defined as abusive, unlike those involving older women. These results reveal a combination of sexism and age discrimination that increases older women's vulnerability (Yechezkel & Ayalon, 2013).

A study among older Yoruba people in Nigeria revealed that individual, relational, and cultural dynamics influence elder abuse susceptibility, including physical abuse and neglect. Engaging older Yoruba men and women (average ages 74.5 and 65.6 years) and religious leaders identified two main forms of physical abuse: bodily harm and movement restriction, which question the elder's capacity and judgment, thus being dehumanizing. Neglect appeared as care denial and emotional withdrawal. Adherence to societal norms reduced mistreatment, emphasizing conformity's role in elder abuse prevalence (Agunbiade, 2019). Participants noted older women might be more susceptible to maltreatment due to complex social relationships, poverty, and continued partner violence. Emotional expressiveness or non-conforming traits increased their risk, as did mental illness, epilepsy, and HIV/AIDS. Lack of resources forced some to beg publicly, while certain personality traits or past good behavior offered protection, even with chronic diseases. This highlights how older people negotiate the factors leading to abuse. The study also noted a significant lack of policies and legal frameworks to protect them (Agunbiade, 2019).

A study conducted in Ontario and Alberta, Canada, with 77 older individuals and 3 caregivers, on experiences of mistreatment, found that cultural factors, ageism, and gender are pervasive in elder abuse. The study identified four key patterns of abuse: intergenerational abuse cycles, lifelong violence, exposure to multiple subtypes of elder abuse, and continuous spousal abuse, with many victims suffering in silence. This issue is exacerbated by societal ageism, which also affects police investigation efforts into elder abuse cases. For older individuals identifying as gay, lesbian, or transgender, abuse can result from isolation, lack of support and social violence, underscoring the lack of support networks and community, which increases vulnerability to mistreatment and abuse (Walsh et al., 2007).

Impact of Ageism and other Forms of Discrimination on the Health of Older LGTBQ+ People, Ethnic Minorities, Women with Disabilities and Other Non-Traditional Groups

Older LGBTQ+ individuals are disproportionately more likely to live alone than their heterosexual counterparts. They also face a higher risk of disability, poverty, homelessness, social isolation, depression, alcohol dependence, financial disparity, housing inadequacies, and premature institutionalization. Concerns about discrimination in care facilities, senior centers, transportation, and home care services are prevalent among older gays, lesbians, and bisexuals. A study in Denver (USA) involving focus groups and interviews with LGBTQ+ elders aimed to understand their concerns about the challenges of aging in place, particularly the fear of increased isolation (notably for those without a partner), and social and health needs, support and care needs, poverty, and depression. A significant obstacle was the lack of traditional family support, compounded by the absence of religious and spiritual support, and inadequate healthcare that fails to address the unique needs of older LGBTQ+ individuals by overlooking their sexual orientation, gender identity, and family contexts (Boggs et al., 2016).

In the United Kingdom, a study of 266 non-heterosexual people over the age of 50 (102 women and 164 men) explored the impact of not being heterosexual on aging experiences. It underscored how social and cultural factors like social class, ethnicity, sex, and disability shape life circumstances and support networks in old age, highlighting the field's need for more research. The findings suggest aging for non-heterosexual elders can lead to both positive environments that are connected, supported, and empowering, and negative scenarios that are less creative, unsupported, and disempowering (Heaphy et al., 2004).

A survey in the U.S. involving 189 sexual minority adults over 50 (117 women and 72 men) assessed the impact of ageism and heterosexism on their psychological well-being, including life satisfaction, quality of life, psychological distress, and loneliness. It found a significant link between experiencing ageism and increased psychological distress and loneliness, with age-based discrimination being a predictor of anxiety and depression in this group. Nonetheless, a robust finding was the positive correlation between greater social support and improved psychological well-being (Bethany et al., 2022).

Another U.S. study with 6,286 older adults explored how intersectional discrimination affects health, revealing that such discrimination leads to poorer self-rated health and more depressive symptoms compared to experiencing minimal or no discrimination. Specifically, discrimination based on economic status significantly worsened self-rated health more than age discrimination alone (Lu et al., 2022).

In India, a study involving 629,888 individuals examined the role of socioeconomic status and financial empowerment on gender differences in health and healthcare utilization among the elderly. Results indicate that older women in India report worse health, higher disability prevalence, and slightly fewer chronic conditions than men of the same age, alongside reduced healthcare access. These disparities are largely attributed to gender differences in socioeconomic status and subsequent financial empowerment, suggesting that financial empowerment for women in developing countries like India could enhance their health outcomes by enhancing their ability to engage in primary and secondary prevention throughout their lives (Roy & Chaudhuri, 2008).

Perceptions of aging, what it means and implies, were also studied among women with intellectual disabilities in a study conducted in Israel with 19 women. They face challenges associated with aging, including health problems, lack of autonomy, and loss of loved ones, alongside the unique social issues posed by the combination of gender, age, and intellectual disability. This group identified that prevailing social stereotypes of aging, such as being sick and dependent, feed into their negative perception of aging. However, their optimism, positive attitude towards life, positive self-perception, and support networks help them overcome difficulties encountered (David et al., 2015).

A study in India explored autonomy and functional diversity among older adults in both rural and urban settings, revealing significant gender disparities. Women exhibited higher levels of frailty and functional limitations than men, along with higher disability rates. These gender-related differences in health were attributed to factors such as education, employment status, physical activity, and migration status. Urban-rural disparities were influenced by education, wealth, employment, and community engagement. Notably, women with higher education levels living in the wealthiest quintile had a lower risk of functional limitation and disability. Furthermore, a healthy weight and active lifestyle in older age correlated with positive health outcomes (Anand et al., 2020).

A qualitative study conducted in Canada through focus groups with 76 seniors aged 60-69, including women and non-traditional groups, as well as 43 caregivers, overwhelmingly identified the existence of ageism at all levels, from their personal relationships to their relationship with institutions and service delivery. Seniors reported inadequate services tailored to their needs, poor treatment by service providers, and frequently feeling belittled or ignored by medical staff. This experience of stereotypes and judgments had become internalized and led to a diminished self-esteem among the elderly. The study found that women, along with older individuals with cognitive or physical disabilities, were perceived as more susceptible to abuse due to their inability to defend themselves. This vulnerability extends to increased risks of sexual abuse, re-victimization, and challenges in reporting abuse. At the societal level, for older people with disabilities, ageism and ableism combine to further disempower and dehumanize. Participants also shared experiences of racism, prejudice, discrimination related to language barriers and physical differences, homophobia affecting older lesbian women through isolation and discrimination, and how poverty further contributes to the vulnerability and risk of elder abuse (Walsh et al., 2010).

Qualitative research in Canada involving 32 women over 65, from diverse cultural, ethnic, and socioeconomic backgrounds (including immigrants, First Nations, Japanese-Canadian, and women from community and social clubs), explored their healthcare negotiation experiences. These experiences were shaped by challenges related to service access, power dynamics, and poverty, with many women feeling unheard, patronized, and ignored until their conditions worsened. Meeting their health needs was a difficult process that required support from other individuals and groups. They relied on support from family, friends, and various organizations (religious, cultural, or online) to meet their healthcare needs (Kinch & Jakubec, 2004).

An exploratory study in the U.S. involved 20 lesbian women over 65 using home care services due to serious illness or chronic disability examined the formal and informal experiences, focusing on their encounters with ageism, sexism, and heterosexism. While most reported having good support systems in the first phase of the survey, seven (over one-third) felt isolated, attributing this to their age and disability, with limited friendships. Although a minority of participants faced homophobia from caregivers, the majority established positive, trusting relationships with them, regardless of the caregivers' sexual orientation or their own. Pets played a crucial role in their support networks, underscoring their importance to these older lesbian women's well-being (Butler, 2017).

In Australia, a recent survey on ageism with 613 people over 60 years of age (181 lesbian women and 432 gay men) found that experiences of ageism and concerns about others' acceptance of one's sexual orientation (as a broad indicator of sexuality-related stigma) predicted poorer mental health and well-being (Lyons et al., 2022).Older gay or bisexual men reported compounded stigma related to HIV and aging (Johnson Shen et al., 2018).

The literature review investigated the health impacts on older individuals from ethnic minority or LGBTQ backgrounds, highlighting how intersections of ageism, ethnic and sexual orientation discrimination, affects their well-being.  The discrimination leads to mistreatment, deteriorating health, reduced activity, and increased health issues, including self-harm and higher usage of antidepressants, potentially resulting in elevated mortality, suicide attempts, seizures, and strokes among other serious health problems. Victims of homophobia also experience more infrequent and substandard medical care. However, social and community support, safe spaces and a sense of belonging are positive factors that support individual well-being. Additionally, religiosity/spirituality, strong social networks, and resilience are crucial in alleviating the impacts of stigma and its challenges (Laganá et al., 2021).

Conclusions

This paper explores gender-age discrimination and its intersection with sexism, ageism, and ableism faced by older adults, especially older women, and those who identify as LGBTQ+, minority, or disabled. These forms of discrimination, including gender-based violence are prevalent yet often overlooked in healthcare and society, leading some patients to adopt strategies to gain medical staff's attention (Clarke et al., 2014). This paper examines how intersectional discrimination affects health and well-being, especially during the COVID-19 pandemic, which makes this group more vulnerable to inadequate treatments (Settels & Leist,2022; Podhorecka et al., 2021). In addition, our study demonstrates positive experiences of overcoming age discrimination and provides insights for effective strategies and interventions to promote equality and improve their self-esteem, quality of life and the well-being of older women in diverse communities (Zingmark et al., 2021; Bethany et al., 2022).

Our analysis identified that older women face healthcare treatment disparities based on age, gender, and stereotypes. Discrimination exists among healthcare workers and the elderly, who often feel they burden the system (Clarke et al., 2014). This self-devaluation deters them from seeking necessary care, affecting access to proper treatment. Furthermore, by integrating the intersections of race, sexual orientation, and ability, we clarify how these identity dimensions further complicate experiences of ageism and sexis. Older women often struggle to receive tailored treatment and their abuse and gender-based violence are often neglected, particularly for those lacking relationships and resources (Banerjee & Rao, 2021; Agunbiade, 2019).

The COVID-19 pandemic has exacerbated healthcare disparities for older women, increasing their marginalization and psychological vulnerability (Banerjee & Rao, 2021). Additionally, the increasing isolation and vulnerability of LGBTQ+ older people, as well as the specific challenges faced by ethnic minority groups and women with disabilities, highlight the urgent need for healthcare systems to be more inclusive and personalized (David et al., 2015). This calls for the implementation of preventive interventions before the next health or pandemic crisis

From a theoretical perspective, our research emphasizes the need for healthcare policy and practice to be aware of the complexity of gender-age discrimination and intersectional discrimination. It advocates for the inclusion of older women in decision-making and the tailoring of policies to meet their needs (UNECE, 2023; UN DESA & UN Women, 2022). There is also an urgent need to train healthcare providers to recognize and mitigate their biases to ensure more equitable, patient-friendly care for all patients. This outbreak highlights the increased risks to vulnerable populations in times of health crisis, requiring updated healthcare systems with effective interventions and preventions. These interventions can improve the health and social care services they receive, thereby benefiting their physical and mental health and improving their quality of life (Tellado et al., 2024).

Although our study provides important insights into older women's experiences of discrimination, it has several limitations. Some data may underrepresent minorities and older individuals, failing to accurately reflect the diversity of patients. Future studies should aim for larger and more diverse samples to address this issue. Additionally, research should further investigate ageism and gender discrimination using mixed methods and incorporating qualitative research to capture the lived experiences of older women from diverse backgrounds. Most studies included in the review were cross-sectional, limiting the identification of causal relationships between experienced discrimination and health outcomes. As numerous agencies highlight, there are few studies with representative and comparable data disaggregated by gender and age (HelpAge International, 2023; UNECE, 2023; WHO, 2022). More longitudinal research is needed to understand the long-term impact of gender-age discrimination and intersectional discrimination on elders' health.

In conclusion, this study highlights the disparities that exist due to gender and age discrimination, as well as intersectionality, and how they affect the health and well-being of older women. Targeted interventions and the creation of inclusive environments are essential in addressing these challenges. More research is needed to develop effective strategies that can be implemented by policy makers, healthcare providers and communities to overcome gendered ageism.

Funding

The study has been funded in the framework of the project “EDA-MUJER. Participación Democrática de Mujeres Mayores para Superar el Edadismo” under the grant number Ref. 38-3-ID22 by the Instituto de las Mujeres, Spanish Ministry of Equality, Spain.

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