Introduction
Butler (Reference Butler1969) first introduced the term ageism, describing it as another form of bigotry similar to racism and sexism. Defined as ‘prejudice or discrimination against or in favour of an age group’ (Palmore Reference Palmore1990: 4), ageism directed towards older adults is typically negative. Older persons are stereotyped as lonely, depressed, incompetent, asexual, intellectually rigid, sickly and senile (Bennet and Gaines Reference Bennet and Gaines2010; Kite and Wagner Reference Kite, Wagner and Nelson2002). Ageism may also take the form of negative attitudes and feelings about the ageing process, old age and older people, and discrimination against older adults (Kite and Wagner Reference Kite, Wagner and Nelson2002; Palmore Reference Palmore, Palmore, Branch and Harris2005). Occurring at both the individual and institutional level (Angus and Reeve Reference Angus and Reeve2006), ageism is pervasive (Cuddy, Norton and Fiske Reference Cuddy, Norton and Fiske2005), and so much a taken-for-granted part of culture that it often goes unnoticed and unchallenged (Wilkinson and Ferraro Reference Wilkinson, Ferraro and Nelson2002). Frequently seeing frail older patients with multiple, complex health problems, health-care professionals may be even more susceptible than the general public to ageism (Pasupathi and Lockenhoff Reference Pasupathi, Lockenhoff and Nelson2005). In their review of 30 years of ageism research, Wilkinson and Ferraro (Reference Wilkinson, Ferraro and Nelson2002: 350) report: ‘Research has consistently shown that the attitudes of health care professionals regarding older adults tend to be the same as or even worse than society in general.’ Indeed, ageism may be learned in medical school (Remmes and Levy Reference Remmes, Levy, Palmore, Branch and Harris2005). This is where Butler (Reference Butler, Palmore, Branch and Harris2005: xv) says he ‘first confronted ageism’, and was ‘shocked by the medical lexicon concerning older persons, abounding as it did with cruel and pejorative terms, such as crock, which was also used to denigrate any older woman who was no longer young’.
Entering their later years with significantly fewer resources than men (McDaniel Reference McDaniel, Garner and Mercer2001), and within a society where women are valued more for their physical appearance than men (Sontag Reference Sontag1972), older women are especially likely to be targets of ageism. Indeed, they are likely to experience a ‘double jeopardy’ because of the combined effects of ageism and sexism (Palmore Reference Palmore1990). In a culture obsessed with youthfulness and physical attractiveness, older women face a ‘double standard’, perceived as reaching old age sooner than men (Zeplin, Sills and Heath Reference Zeplin, Sills and Heath1987), and more likely to be negatively stereotyped and devalued than older men (Hummert, Garstka and Shaner Reference Hummert, Garstka and Shaner1997). Losing social value because of their ageing bodies, they are stigmatised and rendered invisible (Hurd Clarke and Griffin Reference Hurd Clarke and Griffin2008). Ageism within the health-care setting is likely to be of special concern to older women who are frequent users of the health-care system; ‘Ageist stereotypes add another dimension to sexism, increasing the potential for devaluation of women's health concerns’ (Nussbaum et al. Reference Nussbaum, Pitts, Huber, Raup Krieger and Ohs2005: 295–6).
Despite a vast body of literature documenting its prevalence within the health-care setting, in particular in older adults’ encounters with physicians, few studies have investigated older patients’ subjective experience of ageism and whether ageism during medical encounters is of concern to them. To date, researchers have tended to focus on documenting stereotyping and discriminatory practices, little attention being given to how older persons experience, interpret and respond to ageism in the medical setting. Especially surprising, since they constitute the majority of the older population, and interact more frequently with physicians and the health-care system than older men and younger persons, research investigating older women's subjective experience of ageism and/or sexism during medical encounters is sparse (Tannenbaum and Mayo Reference Tannenbaum and Mayo2003). With the potential to affect patient–physician interaction and the quality of care older women receive negatively, ageism and sexism within the health-care setting are important issues. This study examines older women's views about and subjective experience of ageism during interactions with physicians, addressing the sparsity of research on older adults’ perspective on ageism, and experience as targets. It investigates: (a) whether older women believe ageism is likely to occur during medical encounters; (b) whether they believe they have experienced ageism during interactions with physicians; and (c) whether ageism in this context is of concern to older women. Experience with sexism is also examined, investigating whether older women believe sexism is likely to occur during a medical encounter, whether they believe they have experienced it and whether they think sexism in the health-care setting is a concern for older women.
Literature review: ageism, sexism, older women and physicians
There is ample research evidence indicating that ageism is pervasive within the health-care system and older patients are likely to experience it during interactions with physicians (Greene et al. Reference Greene, Adelman, Charon and Hoffman1986; Kane and Kane Reference Kane and Kane2005; Meisner Reference Meisner2012; Pritchard Reference Pritchard2007; Silliman Reference Silliman2009). Ageism is manifested during medical encounters in numerous ways. Physicians can be condescending, older patients’ complaints may be taken less seriously than those of younger patients and symptoms may be inappropriately attributed to the normal process of ageing (Adelman, Greene and Charon Reference Adelman, Greene and Charon1991; Greene and Adelman Reference Greene and Adelman2003). Physicians may spend less time with older patients (Radecki et al. Reference Radecki, Kane, Soloman, Mendenhall and Beck1998), trivialise or discount their medical problems (Black Reference Black2000; Greene et al. Reference Greene, Adelman, Charon and Hoffman1986), and provide them with fewer proven medical therapies or different treatment options (Maly, Leake and Stillman Reference Maly, Leake and Sillman2004) than provided to younger patients (Cherubini, Corsonello and Lattanzio Reference Cherubini, Corsonello and Lattanzio2012; Sifer-Riviere et al. Reference Sifer-Riviere, Girre, Gisselbrecht and Saint-Jean2010). Physicians, for example, are less likely to promote preventive care to older patients (Walter et al. Reference Walter, Flick, Neuber, Fischer, Hussein and Schwartz2010), and less likely to recognise and treat depression in older adults (Koenig Reference Koenig2007), some holding the belief ‘that nothing [can] be done for this group of patients’ (Burroughs et al. Reference Burroughs, Lovell, Morley, Baldwin, Burns and Chew-Graham2006: 369). Physicians are less likely to raise psycho-social issues with older patients, and are more responsive to patient-initiated psycho-social concerns when patients who raise them are young (Greene et al. Reference Greene, Hoffman, Charon and Adelman1987). Although older adults are ‘the largest users of approved drugs’, they have been ‘consistently excluded from clinical trials’ (Palmore Reference Palmore, Palmore, Branch and Harris2005: 167).
More likely to seek medical attention than men (Armstrong Reference Armstrong, Raphael, Bryant and Rioux2006), women are more critical of physicians and more likely to express dissatisfaction with their care (Todd Reference Todd1989). Theorising and research concerning women and health care highlight stereotyping, sexism and gender bias (Armstrong Reference Armstrong, Raphael, Bryant and Rioux2006). Compounding sexism, there is ample evidence of ageism in older women's medical care. Male physicians can be condescending and paternalistic (Henderson Reference Henderson1997; Todd Reference Todd1989). Older women's health problems are often trivialised and dismissed (McCandless and Conner Reference McCandless, Conner and Garner1999; Sharpe Reference Sharpe1995). Their symptoms are likely to be ‘psychologised’ or labelled psychosomatic (Rodeheaver and Datan Reference Rodeheaver and Datan1988). They are more likely than older men to be diagnosed with anxiety and depression (Malatesta Reference Malatesta2007) and prescribed sleeping pills and tranquillisers (Currie Reference Currie2003). Women with symptoms of coronary heart disease are not treated as aggressively as males (Feldman et al. Reference Feldman, Huynh, Des Lauriers, Giannetti, Frenette, Grondin, Michel, Sheppard, Montigny, Lepage, Nguyen, Behlouli and Pilote2013). Although prevalence of arthritis is greater in women than men, and women are affected with greater severity, women are not offered the same treatment options as men (Godfrey and Nelson Reference Godfrey and Nelson2008). More likely to be diagnosed with breast cancer than younger women, older women are less likely to be included in studies of breast cancer (Greene and Adelman Reference Greene and Adelman2003), screened for breast cancer and to receive the same level of care as younger women (Silliman Reference Silliman2009). Physicians are less likely to discuss sexual health with older women as compared with younger women (Nusbaum, Singh and Pyles Reference Nusbaum, Singh and Pyles2004). For a long time, women were ignored in health and medical research even though conditions studied affected both women and men (Gochfeld Reference Gochfeld2010; Greaves Reference Greaves, Armstrong and Deadman2009).
The few studies that have investigated older women's perspectives on their health-care experiences indicate that older women experience and are concerned about ageism (Evans and Robertson Reference Evans and Robertson2009; Henderson Reference Henderson1997). They believe their symptoms and concerns may not be taken as seriously as those of younger patients, and that they may receive inferior treatment because of their age (Tannenbaum, Nasmith and Mayo Reference Tannenbaum, Nasmith and Mayo2003). They complain that doctors do not always treat them with respect, and that they are not given enough information, especially about prevention (Evans and Robertson Reference Evans and Robertson2009; Tannenbaum and Mayo Reference Tannenbaum and Mayo2003). They report that their emotional and psychological health-care needs are not adequately addressed (Tannenbaum, Nasmith and Mayo Reference Tannenbaum, Nasmith and Mayo2003). Older women are often dissatisfied with the quality of physician communication (Evans and Robertson Reference Evans and Robertson2009; Maly, Leake and Sillman Reference Maly, Leake and Sillman2004). Liang et al. (Reference Liang, Kasman, Wang, Yuan and Mandelblatt2006) found, for example, that physicians failed to inform older women patients adequately about the use of mammography. Importantly, older women who were satisfied with physicians’ communication were more likely to intend to get a mammogram. Sidell (Reference Sidell, George and Ebrahim1992) found older women were highly critical of physicians. They felt doctors were not willing to listen to the information they had to give about their bodies and health problems. Ageism, over-prescribing and sexism were also areas of dissatisfaction.
Theoretical framework and methodology
Focusing on women's subjective experience, the study was guided by a symbolic interactionist perspective and insights derived from feminist theory. Symbolic interaction emphasises significance of meaning and social interactions in the study of human behaviour (Mead Reference Mead1934). The subjective standpoint of individual actors is of central concern, based on the premise that ‘human beings act toward things on the basis of the meanings that the things have for them’ (Blumer Reference Blumer1969: 2). Agency is emphasised; humans are conceptualised as having the capacity to construct and modify meaning and make choices among alternative lines of action (Hewitt Reference Hewitt1991). Subjective experience is also central to feminist theory, a key premise being that women's situations and experience must be the focus of attention if their interests and concerns are to be investigated and understood adequately (Calasanti Reference Calasanti, Bengston, Gans and Putney2008). Viewing gender as a fundamental element of social organisation, feminist theorists focus on the effects of gender stereotyping, and gender as a basis of inequality (Calasanti Reference Calasanti, Bengston, Gans and Putney2008; Gustafson Reference Gustafson and Mandell2005). Feminist analyses of health have drawn attention to gender disparity, gender-based inequalities and issues such as the exclusion of women from health research (Greaves Reference Greaves, Armstrong and Deadman2009). Feminist research illuminates how health-care institutions, particularly medicine, have neglected many of women's health-care needs (Armstrong Reference Armstrong, Raphael, Bryant and Rioux2006). Unfortunately, despite feminist theory's central focus on gender inequality, feminist scholars have failed ‘to theorize age relations – the system of inequality, based on age’ (Calasanti, Slevin and King Reference Calasanti, Slevin and King2006: 13). Apart from interest in the medicalisation of menopause, they have given little attention to either older women or ageing, choosing to focus on issues pertinent to younger women (Calasanti and Slevin Reference Calasanti and Slevin2006).
Sociologically, the patient–physician relationship is conceptualised as inherently asymmetrical; possessing special technical knowledge, the physician has power and occupies a position of dominance (Freidson Reference Freidson1989). Lacking this special knowledge, the patient occupies a position of relative dependency and subordination. Patients are not, however, wholly without influence in the medical encounter. Well-informed, highly educated patients are apt to challenge physicians and insist on adopting an active role in their care (Freidson Reference Freidson1989). Individuals living with chronic illness for years, knowing a great deal about the treatment and management of their conditions, may also be less willing to accept the physician's absolute authority (Freidson Reference Freidson1989). Social changes and movements, such as the patients’ rights movement, medical consumerism and women's health movement, have altered the patient–physician relationship, with the result that patients are less likely to unquestioningly accept physicians’ right to dominance (Rodwin Reference Rodwin1994). Younger women, particularly well-educated, middle-class women, are less likely to accept patriarchal elements of domination in the relationship (Freidson Reference Freidson1989). There has been a shift away from ‘a paternalistic doctor-centered model of the clinical encounter’ to a more democratic, patient-centred encounter where patients are less likely to be passive recipients of care and more likely to expect to be ‘negotiators’ of their own health care (May et al. Reference May, Rapley, Moreira, Finch and Heaven2006: 1024). Evidence suggests older patients are less likely to prefer a shared decision-making practice style and more likely to prefer a more traditional model than younger patients (Adams et al. Reference Adams, Price, Tucker, Nguyen and Wilson2012). Tending to be more passive than younger patients (Beisecker Reference Beisecker1996), they are less likely to ask doctors questions (Weitzman and Weitzman Reference Weitzman and Weitzman2003), and not as inclined to challenge physician authority (Bastiaens et al. Reference Bastiaens, Van Royen, Pavlic, Raposo and Baker2007). However, this does not mean all older persons will define the situation in the same way. From a Blumerian interactionist perspective, power is conceptualised ‘not as an objective condition or subjective experience, but as a matter of intersubjective accomplishment’ (Prus Reference Prus1999: 5), thus older patients may find ways to actively resist physician influence despite their vulnerability.
Adopting a theoretical framework emphasising subjective meaning, this is a study of older women's perceptions and beliefs about their interactions with physicians and the meanings they give to their experiences. Since the primary aim of the study was to develop an in-depth understanding of older women's subjective experience of ageism and/or sexism, the in-depth, face-to-face interview was the research instrument of choice. Audio-recorded interviews were conducted with 36 older women, ranging in age from 55 to 97 years. All participants were white and of European descent. Twelve (33.3%) had a university degree; seven of these with a Master's degree. More than half (55%) had either completed high school or been close to completing high school education. All lived in the province of Nova Scotia, Canada, all but seven residing in an urban location. Twenty-two participants (61%) had women physicians, 14 (38.9%) had male doctors. Generally speaking, the sample had women of both middle- and working-class socio-economic status. Assuming younger women might be more assertive in articulating health-care needs and concerns, expect more from physicians and be more willing to challenge them, one objective of the study was to compare experiences and views of younger, older women (55–74) and older, older women (75+). Recruiting older, older women proved to be more difficult than anticipated; only 12 participants are 75 years or older; 24 fall within the 55–74 year range.
An interview guide was used to focus the conversation (Rubin and Rubin Reference Rubin and Rubin1995) and ensure certain topics were covered; however, most questions were open-ended so participants could describe their experience in their own words. Moreover, the women were given ample opportunity to talk about aspects of their experience and issues deemed significant to them. All interviews were conducted by the author; all but two took place in participants’ homes, the two exceptions conducted in the researcher's home. The sample was recruited primarily through a notice placed in a local newspaper, and a snowball technique, some women suggesting others who might be willing to participate. Two participants were recruited through local senior organisations. After a brief discussion of its content to ensure the women knew what was expected of them, and their rights as participants, each was asked to sign two consent forms, one for the interview, the other granting formal permission to record it. Ethics approval was obtained from the Mount Saint Vincent University Research Ethics Board.
Following principles of qualitative data analysis outlined in Coffey and Atkinson (Reference Coffey and Atkinson1996), Lofland and Lofland (Reference Lofland and Lofland1995) and Charmaz (Reference Charmaz2006), the data were analysed inductively. The analysis was guided by the initial research questions, concepts and insights derived from the theoretical framework guiding the study, and relevant body of literature (Marshall and Rossman Reference Marshall and Rossman2011). Some codes and themes are based on interactionist concepts (e.g. agency) which served as ‘sensitizing concepts’ (Van den Hoonard Reference Van den Hoonard1997). Adopting the general principles of grounded theory (e.g. generating concepts and properties through the constant comparative method), the primary focus was placed on categories emerging directly from the data, identifying their properties and the relationships among them (Charmaz Reference Charmaz2006; Glaser and Strauss Reference Glaser and Strauss1967). Interview transcripts were read and re-read, as initial understandings of the data were tested and contradictions and inconsistencies carefully examined. Many analytical memos were written as conceptual categories were developed and connections among them identified (Charmaz Reference Charmaz2006).
Findings
Data analysis revealed three interwoven themes pertinent to ageism: perceptions and beliefs about physicians and ageism; personal experience of ageism and concern about it; and beliefs about when older patients are likely to be targets of ageism and ways to avoid it. Older women's perceptions of and experience with sexism was a fourth, much less prominent, theme.
Older women's perceptions and beliefs about physicians and ageism
To investigate whether participants believed ageism might occur during older patients’ interactions with physicians, they were asked two questions: ‘Do you think it makes any difference to the doctor whether his or her patient is an older or younger person?’ and ‘Do you think the age of the patient in any way influences how the doctor treats the patient?’ They were also asked if they could explain, or elaborate. Twenty-six women (72%) believed patient age makes a difference to a physician, four (11%) did not think age mattered, while six (17%) said they did not know or ‘hoped it didn't’. A larger majority (29 women, 80%) believed patient age was likely to influence how a physician treats a patient, only four believing it would not. Although neither of these questions asks explicitly about ageism, comments participants made in response to both indicated that they believe ageism is very likely to occur during a medical encounter. To investigate perceptions about ageism further, participants were later asked a third, more explicit, question: ‘Do you believe that doctors take older patients’ symptoms and health concerns as seriously or less seriously as they take the symptoms and concerns of younger patients?’ Seventeen (47%) believed physicians take older patients’ symptoms and concerns ‘less seriously’; only five (14%) thought physicians take older patients’ symptoms and concerns as seriously as those of younger patients. Unsure, the remaining 14 made comments such as: ‘I would hope they'd take it seriously’ and ‘well, I've heard that [doctors take older patients concerns less seriously], but I don't know what to think’. Replies to these specific questions, along with comments participants made elsewhere during the interview, reveal how, in their view, patient age matters and ways in which ageism might be manifest during medical encounters.
Doctors prefer younger patients
One of the most common themes in explanations of why patient age would make a difference to a physician and/or how patient age might influence how a physician treats a patient was the belief that doctors prefer and have more interest in younger patients:
My opinion is that doctors prefer younger people. (Maureen, 79 years)Footnote 1
I suspect they take a more active interest in younger patients. They may kind of write you off as, it's all in your head. (Heather, 69 years)
Some believed doctors ‘don't want to waste their time on older people’ because older patients are ‘more labour intensive’. Others believed, ‘There are doctors who don't want elderly patients because they take more time.’ Vivian maintained, ‘Doctors don't want to take older people [because] … some doctors are worried about older people, frightened about the litany of what they're going to have to handle.’ As Vivian's comment indicates, and an issue to be discussed later, it was not uncommon for participants to stereotype older adults negatively.
Physicians are likely to patronise, discount and be dismissive
A second prominent theme concerning how and why patient age might matter to a physician and influence how the patient is treated was the belief that patient–physician interaction will be different when the patient is an older person, ageism likely to be manifest in the form of physicians patronising older patients, discounting what they have to say, or being dismissive and disrespectful. Many participants believed physicians ‘can be patronising towards older people’. Talking down to the patient or treating the older patient ‘like a little child’ was a frequently cited example of this type of behaviour:
They talk down to you, ‘yes dear, don't you worry dear, I'll look after you’. Just the way they talk to you. (Vivian, 79 years)
Oh definitely, the way they interact with them. If the patient is 75, maybe infirm, I think the doctor will talk down to them … How insulting is that? (Mary, 59 years)
Others believed physicians were less likely to pay attention to what older patients have to say, apt to be disrespectful and less likely to ‘listen to what [older patients’] issues were’, physicians not listening being a common complaint:
I kind of think they listen more to younger people. (Edna, 85 years)
They'll talk to their son or daughter rather than to them … but I mean … the patient has the right to be treated [with dignity and respect], you know, he's present in the room, he's not a fly on the wall. (Shirley, 63 years)
Ageism as inadequate medical treatment or ‘It's just old age’
A third prominent theme in explanations of why and how patient age matters and was likely to influence how a physician treats a patient was the belief that older patients would not likely receive the level or quality of care given to younger patients. Sixty-five-year old Liz, for example, did not think physicians would show the same level of interest in older patients: ‘We're on our way out, therefore, you know, the young sort of get paid attention to first.’ Similarly, 89-year-old Maude stated: ‘I think it [age] makes a difference, yes. I think they're more inclined to look into what's wrong with the younger person, you've heard them say, “she's older; we won't bother.”’ Explaining why she thought patient age would influence how a doctor treats a patient, she stated: ‘Yeah, he wouldn't be as avid looking after an older person. He wouldn't be as intense … I would think they would think, “oh well, we won't do that because they're older.”’ Many participants indicated that they did not like to take medications, often voicing disapproval of physicians who were, in their view, ‘too quick to prescribe them’. Some believed physicians were especially likely to prescribe medications in their treatment of older rather than younger patients instead of exploring other options or further investigation:
The general attitude is they're old, give them a pill. (Judy, 64 years)
I don't really think that they're that concerned with the elderly, I think they just want to prescribe drugs. (Maude, 89 years)
The belief that ageism was likely to be manifest in the form of older patients receiving lower-quality care than younger patients was particularly evident in replies to the question, ‘Do you believe that doctors take older patients’ symptoms and health concerns as seriously or less seriously as they take the symptoms and concerns of younger patients?’ The following statements exemplify this commonly held view:
Less seriously, I think they tend to feel that if you're this age, you have to expect aches and pains … [if the patient was younger], they would deal with it. (Lorraine, 68 years)
No … they put an elderly person in a maintenance mode, just keep them breathing … [rather than making an effort to work towards] resolving the issue. (Judy, 64 years)
By far the most frequently cited example of why and how patient age might negatively impact the quality of treatment received was the belief that physicians would be more likely to attribute patient symptoms and complaints to ‘old age’:
I feel sometimes they think ‘well, she's old, so you know, we'll just put that down to old age and not pay much attention to it’. (Hannah, 89 years)
Yes well, when you're 60 plus, you go to the doctor with a complaint, they'll say ‘it's your age, we all have to get old, do you really want to go through that [surgery] now at your age?’ (Lorraine, 68 years)
Patient may be to blame, not the doctor
A striking sub-theme occurring frequently throughout the data was the idea that the patient rather than the physician might be to blame if an older patient encountered ageism. Typically, negative stereotypes of older adults were employed to rationalise or justify physician behaviour. The following responses to the question ‘Do you think the age of the patient in any way influences how the doctor treats the patient?’ typify this view:
There's an awful lot of cranky old people. If I was the doctor, I wouldn't want to spend time with them. (Edna, 85 years)
No, except I've heard others ‘well the doctor doesn't want to bother with me anymore’. Maybe there isn't anything the doctor can do about it, maybe they're just complainers. (Nora, 83 years)
Common among those suggesting the patient might be responsible for physician ageist behaviour was an emphasis on personality and attitude of the patient, personality and attitude seen as more relevant than age:
I think the personality affects it more than age. I think the personality of the patient. If you're not a hypochondriac or sour on the medical system or whatever, if you're appreciative … [a doctor will treat you well]. (Doris, 70 years)
I think it has a lot to do with the attitude of the patient themselves. I think it has a lot to do with the patient herself. (Ruby, 89 years)
Personal experience of ageism and concern about it
Although, a majority believed older patients were likely to encounter ageism during interactions with physicians, and many examples of possible manifestations were offered, few claimed to have personally experienced it. To investigate personal experience of ageism during a medical encounter, participants were asked two questions: ‘Do you think your age in any way influences how your doctor treats you?’ and ‘Have you personally experienced ageism in your interaction with a physician?’ Twenty-eight (78%) said they did not think their age in any way influenced their physicians’ treatment of them. Interestingly, three women who thought their age might be influencing how their physicians were treating them cited examples of ‘positive ageism’ (Palmore Reference Palmore1990), or possibly age-differentiated behaviour rather than ageism (Pasupathi and Lockenhoff 2002). One, for example, replied: ‘Yes, I definitely do. She has more patience with me.’ In response to the second question, a large majority (31 women, 86%) said they had not personally experienced ageism. Many younger, older women thought they were too young to experience it. For example, 55-year-old Rhonda stated: ‘I think it's way too early.’ Asked if she thought patient age mattered to a physician, 66-year-old Sharon replied: ‘I have no idea, I'm not of that age.’ Noteworthy, although the number of older, older women in the sample is small, nine of the 12 who were 75 years or older were among those reporting they had not personally experienced ageism. Participants were also asked ‘Is ageism something you are concerned about in your interaction with a physician?’ Sixteen (44.4%) indicated ageism was of concern, however, half (50%) said they were not concerned about it, a somewhat higher proportion of the older (58%, seven participants) than younger, older women (46%, 11 participants) indicating they were not concerned about ageism.Footnote 2 Noteworthy, of the 13 younger, older women indicating concern about ageism, several said they were not as much concerned about experiencing it now, as they were about experiencing it later:
Not at the present time, but I'm aware of it and it does scare me for the future. (Judy, 64 years)
Although most said they had not personally experienced it, frequently distinguishing between their own and ‘other doctors’, belief that ageism exists and concern about it appeared to be based on ‘stories’ they heard from friends and others about their experiences with physicians. Asked, for example, if she thought patient age influenced how a physician treats a patient, 68-year-old Mary stated: ‘It certainly could, one hears stories about some older people feeling they don't matter and they don't get the care they would like to receive.’ Similarly, 64-year-old Judy believed ageism exists because: ‘I just hear things. There are doctors who don't want elderly patients because they take time. I just hear stories.’
Belief that ageism exists and concern about it among many of the younger, older women was founded on observations of their parents’ experience. Although she had not personally experienced it, 55-year-old Nancy, for example, explained why she was concerned about ageism: ‘Oh of course, I feel that, I've seen that with my mother and the interactions with her physicians. I most certainly think it exists.’ Concerned about ageism, 55-year-old Vicky stated: ‘I guess based on my experience this last eight years with my parents when I had been going to medical appointments and … you know, I have seen incidences where I was glad I was with them, because I think they would have been pushed aside.’ Similarly, 62-year-old Paula's concern was based on her mother's ‘unsatisfactory experiences’: ‘Yes, this is not based on my experience or my doctor, but [mother's doctor]. I don't think he always takes her concerns seriously.’
When are older patients likely to become targets and can ageism be avoided?
Despite extensive documentation of its prevalence within the medical setting, how does one explain the finding that a majority of the participants (86%) claimed not to have personally experienced ageism? It may be that few experienced ageism because, as many of the younger women suggested, many were not yet old enough to be targeted. The average age of the participants was 72 years, with only 12 being 75 or older. As previously reported, most of the younger women believed ageism during a medical encounter exists, but did not think they would have to deal with it until they were older:
Well, I'm not concerned right now at 56, but I think I will be when I get up there in age. (Bonnie, 56 years)
It's not something I've given thought to, in another 20 years, if I were 80 or 85, that would be a different discussion. (Connie, 60 years)
It may be few personally experienced ageism because most had relatively good health. A majority (83%) rated their health as ‘excellent’, ‘very good’ or ‘good’, and some believed healthier older adults were less likely to be targets of ageism. Asked if she was concerned about ageism, for example, 68-year-old Irene replied: ‘I don't think that will happen to me. No, I haven't given that any thought because I'm in good health.’ Responding to the same question, 79-year-old Vivian stated: ‘I think it's getting better, because we're healthier and not sitting in the rocking chair anymore.’ Linking ageism with chronic illness, some implied older patients were more apt to be targets if they had chronic conditions and multiple complex health problems. Associating older age with decline and deterioration in health, many younger, older women, who thought they were too young to experience ageism, expressed this view. For example, 56-year-old Bonnie stated: ‘Well, I mean, I guess, I'm not there yet. Maybe if I would have this conversation fast forward another ten years, and, if I had other health issues or whatever, I might have more experience that way.’ Mary, 59 years old, thought a physician would be more likely to ‘talk down to’ the patient if the patient was ‘75, maybe infirm’. Explaining why she believed physicians would not take older patients’ symptoms and concerns as seriously as those of younger patients, 74-year-old Dorothy stated: ‘I would say if the complaint is very repetitive, I can see where the doctor might get frustrated, or if the patient doesn't follow the regime.’ Stereotyped as having ‘multiple complaints’, ‘more of a challenge [since] so many things can go wrong with them’ and less likely to comply with physician recommendations, older, older patients were seen to be at greater risk of experiencing ageism. Worthy of note, two of the five who said they had personally experienced ageism were living with chronic, complex medical conditions. Both believed their physicians were too quick to suggest their problems were the inevitable result of ‘old age’. Stella, for example, living with a painful chronic condition from which she could not get relief, complained about what she viewed as her physician's lack of empathy, with ageism a theme permeating her interview. Very dissatisfied with her physician, she complained repeatedly that he ‘makes fun of [her] and says “what do you expect, you're 89 years old?”’
Some participants suggested that they had not personally experienced ageism because they looked or acted ‘young for their age’. Believing her age did not influence the way her doctor treated her, 77-year-old Janet, for example, stated: ‘He does say I'm young for my age.’ Believing appearance relevant, 66-year-old Sharon had not personally experienced ageism, but ‘wondered if that might change because of my grey hair’. Among those who thought patient attitude and personality mattered more than age, 86-year-old Irene implied that one could avoid ageism if one remained ‘young’:
I think it depends on the patient. There are some older patients that are really old, some older patients that are young for their years. It depends on the patient and the attitude of the patient. I think that is most important.
It is also possible few personally experienced ageism because many adopted the role of the ‘good patient’, adopting this role being seen as a strategic means by which one could positively influence the patient–physician relationship, and possibly avoid ageism. Frequently, especially in replies to the question, ‘How would you describe yourself as a patient?’, participants maintained they had a good relationship with their physician because, unlike ‘other older people’, they were ‘good patients’. The two most common descriptors of the ‘good patient’ were one who ‘doesn't call the doctor about every little thing’ and one who ‘is not a complainer’. Commonly, participants contrasted themselves as patients with the stereotypical older patient who went to the doctor too often and unnecessarily. Noting she went to her doctor only when necessary, 70-year-old Doris, for example, believed other older people relied too heavily on the health-care system: ‘Yeah … I'm sure a lot of seniors go to the emergency like they hang around a shopping centre, you know, “oh, somebody's going to touch me and tell me I'm okay”’. Stating, ‘I don't run to the doctor at the drop of the hat’, 84-year-old Norma said she would go to her doctor only ‘if the condition persists’. Edna, 85 years old, who was annoyed her physician wanted to see her every three months, compared herself with ‘lots of people [who] run to the doctor if they've got a headache … [making] a nuisance of themselves’, indicating she would go to a doctor only if the problem was ‘something serious’. Believing the ‘good patient’ is one who does not complain, 68-year-old Lorraine stated: ‘I'm a good patient. I'm not a complainer.’ Similarly describing herself as ‘a good patient, like I don't complain about anything’, 85-year-old Edna believed her doctor was not taking her symptoms and concerns less seriously because she too was ‘not a complainer’. Appropriate attitude also characterised the ‘good patient’. Gertie, 97 years old, believed physicians would take older patients’ symptoms just as seriously as those of younger ones if they, like her, presented with the proper attitude: ‘You know, I have people all around me saying “they think we're so old”, and I say, “well you know, I find them alright”. I sometimes wonder if it's the personality of the person too, you know, that kind of negative, and I'm more positive’.
Some, especially older, older women, believed they were ‘good patients’ because they acknowledged the physician as ‘the expert’ and tried their best to follow physician recommendations, unlike the stereotypical older person seen as less likely to be ‘compliant’ (‘I don't think older people always follow the doctor's recommendations’). Describing herself as a ‘good patient’, 86-year-old Irene, for example, said she was both compliant and not one to ‘waste the doctor's time’: ‘Good, I listen to the doctor and … do what they tell me to … I'll add to that, when I see a doctor, I really need one, and, if I need one, I have to pay attention to what they have to say.’ Being compliant, or in other ways a ‘good patient’, did not necessarily mean being passive. Most participants were assertive patients, some very assertive, as illustrated frequently throughout the data (e.g. ‘I'm not afraid to speak my mind’; ‘I just didn't take the prescription and I told him so’). Describing herself as a patient, 61-year-old Laura, for example, said: ‘I wouldn't say I'm demanding, I'm assertive … [but] I'm compliant.’ Indeed, some believed they had avoided ageism because they were assertive patients. Asked if she was concerned about ageism, 61-year-old Roberta replied: ‘No, because I'm assertive.’ Asked if she had personally experienced ageism, 69-year-old Heather stated: ‘No, I'm kind of in their face.’ Replying to the same question, 73-year-old Emily said: ‘This talking down crap, calling you dear … If a doctor said that to me, he would probably regret it.’ Being ‘easy to get along with’, ‘assertive but polite’ and ‘respectful of the doctor's time’ were all means by which participants presented to physicians as ‘good’, ‘not old’ patients.
Believing physician age a relevant factor, some thought younger physicians were less likely to engage in age discrimination.Footnote 3 Although 60-year-old Connie, for example, believed ‘ageism exists’, she thought ‘it probably depend[s] on the age of the physician, a young physician of 30 … [less likely to be ageist]’. Also suggesting that physician age is relevant, another thought younger physicians were less apt to be ageist, because ‘there would be more sensitivity training than in the past’. A participant who said she had not personally experienced ageism thought women physicians would not be as likely to be ageist as male physicians: ‘I have female doctors … if I was with a male doctor … [the situation might be different].’ With the majority (61.1%) of participants having women physicians, if her assumption is correct, this may be another reason so few reported that they had personally experienced ageism. Some suggested length of the patient–physician relationship might be relevant. Asked if she thought patient age mattered to a physician, 61-year-old Laura replied: ‘I don't think it does to my doctor because she has known me right through … 20 plus years.’ Asked if she was concerned about ageism, with her about to become the patient of a new physician, her reply reflects the belief that older adults are less likely to experience ageism in a long-term relationship where the physician is more likely to see the patient as a person rather than an ‘old person’: ‘I am with this new person [physician], how long will it take to get that relationship with this new person? It's Laura and Bob coming in … [rather than two older patients].’ Explaining why she thought her doctors were not treating her any differently because she was older, 70-year-old Doris referred to the long-standing relationship she had with her gynaecologist: ‘My gynaecologist went through the divorces with me, his and mine; together we marched through life … so we're totally in sync.’ Although 13 (36%) had a patient–physician relationship of short duration (less than three years), at least one-third (30.5%) had been patients of their physicians for 20 years or more.
Older women, physicians and sexism
Participants had much less to say about the possibility of sexism occurring during a medical encounter, and, in general, were less responsive to questions about sexism than questions about ageism. There were many more ‘don't know’ replies, responses that could not be easily coded and missing data (often because participants veered off the topic, or did not seem to have anything more to say about it). Asked whether patient gender made a difference to a physician, only nine (25%) believed it did, compared to 26 (72%) who believed patient age made a difference. Reflecting what appeared to be lower levels of awareness about sexism, 16 (44%) said they did not know whether patient gender made any difference to a physician; comments such as ‘I honestly never thought about it’ and ‘I would not have a clue’ were common. One of the seven who thought patient gender mattered thought it would matter more to a male than female physician, her comment reflecting a stereotypical view of the female patient as more time consuming: ‘Yeah, I do. I think they take a sigh, “oh God, I'm going to be here for a month” … [especially if the physician is male].’ Overall, however, there were few elaborations in participants’ replies to this question, in stark contrast to the many comments made about physicians and ageism.
Asked if they thought patient gender influences how a doctor treats a patient, only six (16.6%) thought it did, compared to 29 (80%) who thought patient age would influence how a physician treats a patient. Again, many replies took the form of ‘It shouldn't’ or ‘I don't know’. The comments of those who believed patient gender would influence physician treatment of a patient included typical sexist stereotypes of the older female patient (e.g. ‘a bit ditsy [or] not very smart’):
Well, I think maybe, in general, women can get put in a category of being whiners and complainers. (Liz, 65 years)
Asked ‘Do you think your gender in any way influences how your doctor treats you?’, a vast majority (83%) were quick to reply ‘no’. Later asked if they had experienced sexism in their encounters with physicians, 27 (75%) said they had not. A few, earlier during the interview, described instances of sexism experienced when they were young women, however, none of these women reported experiencing it later in life. Although relatively few reported personally experiencing it, 14 (54%) of 26 women, asked if they thought sexism during a medical encounter was a concern for older women, said sexism was of concern to them. Some, for example, thought a physician ‘might downplay an older woman's concerns’ or have ‘this attitude that if you're an older woman, you're a little silly’ and ‘you don't really understand all that's going on within your own body’. Asked if she thought sexism was a concern for older women, one woman replied: ‘Oh yeah, the bit about it's all in your head.’ Another believed sexism was more likely to occur ‘with older male physicians who have been practising for a long time’.
Discussion and conclusion
Consistent with results of previous studies (Evans and Robertson Reference Evans and Robertson2009; Henderson Reference Henderson1997; Sidell Reference Sidell, George and Ebrahim1992; Tannenbaum, Nasmith and Mayo Reference Tannenbaum, Nasmith and Mayo2003), the findings of this research indicate older women believe ageism likely to occur during medical encounters and are concerned about it. Inconsistent with previous research, few claimed to have personally experienced it. Some indicated they did not believe all physicians were ageist, however, distinguishing between their own and ‘other doctors’, many believed physicians generally were likely to engage in ageism. That a majority said they had not personally experienced ageism is a provocative finding, given extensive documentation of its existence within the health-care setting (Feldman et al. Reference Feldman, Huynh, Des Lauriers, Giannetti, Frenette, Grondin, Michel, Sheppard, Montigny, Lepage, Nguyen, Behlouli and Pilote2013; Koenig Reference Koenig2007; Pritchard Reference Pritchard2007), and previous studies of older women patients reporting ageism a common complaint (Evans and Robertson Reference Evans and Robertson2009; Tannenbaum, Nasmith and Mayo Reference Tannenbaum, Nasmith and Mayo2003). Possibly most had physicians who did not hold prejudiced attitudes towards older patients or engage in age discrimination. Indeed, this may be one reason why a majority were highly satisfied with their physicians (MacRae Reference MacRae2015). This would, however, be inconsistent with findings indicating prevalence of ageism within the health-care system. Participants may have been targets of ageism but were unaware they had experienced it. Both physicians and patients may have difficulty recognising ageism, especially its more subtle forms. As Sharpe (Reference Sharpe1995: 11) has suggested, ‘the propensity of physicians to dismiss or diminish the importance of certain women's complaints (e.g., arthritis, incontinence) as normal ageing, and therefore, not warranting further attention’ may not be perceived as ageist, by either physician or patient, since the tendency to associate the ageing process with disease ‘permeates both the popular and medical culture’.
One of the costs of ageism is victims of prejudice and discrimination often adopt the dominant groups’ negative image of the subordinate group (Palmore Reference Palmore1990). Older persons, Palmore notes, ‘tend to accept many of the negative stereotypes about old age that younger people accept’ (Reference Palmore1990: 80). Paralleling other findings (Hurd Clarke, Bennett and Korotchenko Reference Hurd Clarke, Bennett and Korotchenko2014), many participants adopted negative stereotypes typically associated with their own age group. This was especially evident in the comments of those suggesting older patients might be to blame for physician ageist behaviour; patient blame supported by employing negative stereotypes of older patients. Throughout the data were numerous examples of ageist beliefs and internalisation of negative stereotypes. The belief that a particular health problem was something one had to accept because of one's age was, for example, not uncommon, expressed by one participant as: ‘Doctors can't cure old age.’ Knee pain was interpreted as ‘just part of the ageing process’; it was pointless to inform physicians about a condition because ‘there's nothing they can do about it’. A troubling finding was that some older, older women had chosen to live with an intimate health problem rather than endure the embarrassment of pursuing it with their male physicians. Although modesty was a concern, some also implied there was shame in revealing ‘an old female body’ (Calasanti, Slevin and King Reference Calasanti, Slevin and King2006). For example, 89-year-old Hannah, explaining why, although she would like to have a breast exam, she had ‘so far, let it go’, said she was not comfortable asking her male physician for it, ‘especially when you're old like I am you know’.
Contradicting the stereotype of the passive, older female patient, participants were employing strategies to avoid becoming targets of ageism. Reflecting an interactionist conceptualisation of human beings as actively engaged in negotiating reality (Mead Reference Mead1934) and impression management (Goffman Reference Goffman1959), attempting to influence physicians’ definition of the situation, they employed strategies such as being the ‘good patient’ or being assertive to negotiate favourable patient–physician interaction, avoid ageism and optimise their care. Avoiding identification with their own group, similar to the participants of Hurd Clarke, Bennett and Korotchenko (Reference Hurd Clarke, Bennett and Korotchenko2014), they distanced themselves from the stereotypical older patient who was too quick to run to the doctor, unreasonable, full of frivolous complaints and not likely to follow physician recommendations. Distancing, or attempting to ‘pass’ (Palmore Reference Palmore1990) as members of the ‘not old’ dominant group, may have also been a strategy employed to avoid scapegoating (Binstock Reference Binstock2005): older people commonly seen as a societal burden, blamed for numerous problems most especially the ever-escalating cost of the health-care system. Not surprising, many noted they did not ‘spend all [of their] time in the doctor's office’ and ‘[prided themselves] on not going to the doctor [too often] and taxing the system’.
Some distanced themselves from the stereotypical ‘old person’ by identifying with the new stereotype of the healthy, active, ‘young old’ adult (Rozanova, Northcott and McDaniel Reference Rozanova, Northcott and McDaniel2006), implying that acting and looking young was a means by which to avoid ageism. This may be a successful strategy as research indicates attitudes towards older people vary according to the sub-type target persons represent, the ‘young-old’ ‘golden ager’ being less likely to be negatively stereotyped than the ‘oldest-old’ ‘curmudgeon’ (Hummert, Garstka and Shaner Reference Hummert, Garstka and Shaner1997). As Kite and Wagner suggest, if individuals know they are becoming part of a group about which society holds many negative stereotypes, they can maintain positive self-identity (and possibly avoid ageism), if they are able to ‘avoid becoming a member of this group by maintaining a youthful demeanor and appearance and by avoiding any behaviors associated with the elderly’ (Reference Kite, Wagner and Nelson2002: 150). This strategy is not, of course, an option for those living with chronic illness or disability. Noting ‘[c]ontextual information has long been shown to be more influential than age information in judgments of older adults’, Kite and Wagner (Reference Kite, Wagner and Nelson2002: 139) report that ‘[f]actors such as health status, for example, are better predictors of attitudes toward older adults than is target age’. Some participants thought they were unlikely to experience ageism because they had good health. Many younger women who thought they were too young to experience ageism believed they would experience it in the future when, associating ‘old’ with inevitable illness and disability, among the ‘oldest old’, they would become targets. Research indicates that chronic illness and complex health problems can negatively affect the patient–physician relationship and patient satisfaction (Campbell and McGauley Reference Campbell and McGauley2005; Poot et al. Reference Poot, den Elzen, Blom and Gussekloo2014). With physicians finding chronically ill patients whose medical problems are difficult to manage challenging, older adults with multiple morbidities are at risk of being perceived ‘difficult patients’ (Hahn Reference Hahn2001) and possibly targets of ageism. Indeed it has been suggested that the challenges chronically ill older patients present is one of the reasons why some physicians prefer not to treat older patients (Adams et al. Reference Adams, McIlvain, Lacy, Magsi, Crabtree, Yenny and Sitorius2002).
The study findings point to important directions for future research. There is need for further study of ageism in the health-care context, investigating ageism from the perspective of both older patients and physicians. A limitation of this study that is participants were not asked to define ageism; research examining older adults’ definition of ageism could yield important information about their consciousness of it and ability to detect its more subtle forms, contributing to current understanding of ageism. The findings raise the important question: when and on what basis do physicians deem a patient ‘old’ and engage in ageism? Apart from studies of medical students, research investigating physicians’ perspective on ageism is lacking. Research examining patient characteristics and conditions mediating its occurrence would yield knowledge that could be practically applied to enable physicians to become more conscious of, and hopefully counter, ageist beliefs and practices. Are patients not likely to be seen to be ‘old’, as some participants suggested, until their eighties or nineties? Are the ‘oldest old’ the most likely targets of ageism? Research indicating the ‘oldest old’ are the most likely to be negatively stereotyped is based on samples of the general public, not physicians. Does youthful appearance or acting young protect older persons from ageism, as some participants suggested? One of the few studies to examine perceptions of the ‘beginning of old age’, Hori (Reference Hori1994) found change in appearance and loss of physical vigour were perceived to be the most common markers of ‘old age’. This was a Japanese study of rural residents, however, not a study of the views of health professionals. Are chronic illness, disability and ageism related, as some participants believed? More than 25 years ago, Palmore (Reference Palmore1990: 86) suggested ‘[t]he problem of ageism is partly a result of cultural lag’, arguing: ‘[t]wo or three generations ago the majority of people over 65 probably did fit one or more of the stereotypes about elders’. Today, older adults, in general, are healthier, rates of disability among older people have declined and life expectancy has increased substantially; ageism should thus be less prevalent. This study's findings could indicate the gap between stereotypic beliefs about the health of older people and reality is decreasing. Further research is needed to investigate this hypothesis.
How patient assertiveness influences patient–physician interaction, including the occurrence of ageism, needs further investigation. When assertive older patients negate the stereotype of the passive older patient, are physicians less likely to identify them as ‘old’ and subsequently less likely to stereotype them? Many participants in this study were assertive patients, examples of the assertive older patient permeating the data. Statements such as ‘It's my body’ and ‘I have the right’ occurred frequently as they presented their perspective on the patient–physician relationship, some indicating they would not tolerate ageism (‘No, and I'd tell them off if they did’) or sexism (‘…and if I have anything to do with it, it won't’). Some studies indicate physicians are inclined to view assertive patients more favourably, and respond to their treatment requests (Adler, McGraw and McKinlay Reference Adler, McGraw and McKinlay1998), so patient assertiveness may have, as some believed, protected them from ageism.
Future studies investigating whether physician characteristics such as age and gender are associated with ageism would be useful. A majority (61%) of the participants in this study had women physicians, and almost all who did were very satisfied with them. This may be a factor contributing to the low number of women reporting a personal experience of ageism. Research has shown women physicians are perceived as more warm and friendly, caring and empathic, and better listeners than male physicians (Bylund and Makoul Reference Bylund and Makoul2002; Nicolai and Demmel Reference Nicolai and Demmel2007). Being more comfortable with women doctors (Shaw and Ogden Reference Shaw and Ogden2006; Van Til, MacQuarrie and Herbert Reference Van Til, MacQuarrie and Herbert2003), and because of their personal manner, patient-centred style of care and willingness to discuss psycho-social needs, women tend to prefer women physicians (Bertakis and Azari Reference Bertakis and Azari2012; Noori and Weseley Reference Noori and Weseley2011; Roter and Hall Reference Roter and Hall2004). Perhaps physicians who make an effort to become better acquainted with and more sensitive to patient needs are less apt to engage in ageism. Some participants thought younger physicians were less likely to be ageist than older physicians. However, research indicates ageist assumptions and negative perceptions of caring for older patients continue to persist among medical students (Higashi et al. Reference Higashi, Tillack, Steinman, Harper and Johnston2012). Efforts are under way to revise medical school curricula to improve students’ perceptions of older patients and their care, however, the effect of the ‘hidden’ curricula (Higashi et al. Reference Higashi, Tillack, Steinman, Harper and Johnston2012) and whether change in behaviour and attitude achieved can be sustained among practising physicians needs to be investigated. Significance of length of the patient–physician relationship is a fruitful direction for future research. Is ageism less likely to occur in long-standing relationships where physicians are more likely to know the patient well? The findings of Adams et al. (Reference Adams, McIlvain, Lacy, Magsi, Crabtree, Yenny and Sitorius2002) offer some support for this view. They found some older physicians felt closer to their older patients and ‘a complex medical situation that occurred within the context of a long-term doctor–patient relationship was perceived differently from a complex medical situation in the context of a new relationship’ (Adams et al. Reference Adams, McIlvain, Lacy, Magsi, Crabtree, Yenny and Sitorius2002: 840). Perhaps physicians who know their older patients well are less likely to view them as ‘old’ patients, rendering them less likely targets of ageism.
Although a substantial number of participants indicated they were concerned about sexism during interactions with physicians, in general, the women appeared less conscious of sexism than ageism. Discussing older women's dissatisfaction with physicians, including concerns about ageism and sexism, Sidell (Reference Sidell, George and Ebrahim1992: 186) reports: ‘The women were clearly aware of ageism, but they were not so aware of sexism.’ She suggested the older women may have been less aware of sexist behaviour because they had not been exposed to or involved in the women's movement. Although there did appear to be more awareness of sexism among the younger and usually more educated participants in this study, there was not the level of awareness and concern about sexism anticipated. Additional research is needed to investigate further the double jeopardy hypothesis suggesting older women are likely to experience a double disadvantage of sexism and ageism during medical encounters.
This study contributes valuable insight into ageism as subjectively experienced and the ways older persons may attempt to resist it. The findings illustrate that ageism, sexism and the double jeopardy hypothesis are complex issues, and underscore the importance of attending to individual perception and contextual information. A significant limitation is that the findings are based on an ethnically homogeneous sample of women who volunteered to participate; many were well educated, most were urban and none identified as other than heterosexual. Although many had health problems, most rated their health as excellent or good. Only 12 were 75 years or older, making investigation of cohort differences difficult. Further research with more diverse samples would more fully delineate and illuminate conditions under which older women are likely to become targets of ageism, sexism or both during medical encounters, and ways they might be empowered to avoid it.
Acknowledgements
This research was funded by an internal grant from Mount Saint Vincent University. The author would like to thank the women who participated in the study, the anonymous reviewers for their helpful suggestions and comments, as well as Marisa Grant for her assistance with the preparation of the manuscript.
