Ageism as an Invisible and Pervasive Form of Bigotry

AGEISM Ageism as an Invisible and Pervasive Form of Bigotry Ageism is one of the most invisible and yet pervasive forms of bigotry. We define ageism as the systematic stereotyping, prejudice, and discrimination against individuals based on their age.2 Bigotry, in the context of ageism, is the manifestation of a collective ill-will directed at less-privileged groups which systemically manipulates, degrades, and denies the dignity and autonomy of individuals within those groups in order to maintain perpetual dominance over them. There are three key manifestations of ageism as a persistent form of bigotry: cognitive (stereotypes), affective (prejudice), and behavioral (discrimination). The pervasiveness of ageism has been well documented across multiple national and global studies. The most recent U.S. representative survey indicated that 82 percent of older persons experience ageism on a daily basis.3 More than two in three older persons are exposed to ageist messages in their day-to-day lives. Ageism can take place across multiple levels.4 From a societal level, ageism functions as a social determinant of health that systematically denies the dignity and autonomy of individuals. On an individual level, ageism can manifest in negative beliefs about aging, such that the expectation that older persons are a homogenous group, all asexual, impoverished, unhealthy and incapable of caring for themselves – or conversely that they are a part of the wealthy elite. This connotation erroneously provides a binary view of older persons’ abilities: either they are disabled or they are “still young,” with no possibility for middle ground. Additionally, although individuals can become targets of ageism from societal sources due to their age, negative attitudes in aging could also be self-directed as a result of internalized ageism from structural ageist bigotry. Such manifestations include denigrating selfevaluations, including sentiments like “I am so old, and I am useless.” All forms and levels of ageism have been shown to significantly and inversely impact individuals’ health, quality of life, and fundamental human rights.5 According to a recent global systematic review of ageism of 422 studies and seven million participants in five continents, it was found that the injurious reach of ageism spans across 11 health and well-being domains.6 In addition to the profound human and health costs, the financial cost of ageism is extremely hefty: In 2013 in the U.S. alone, ageism in the form of negative age stereotypes and self-perceptions was associated with excess annual costs of $63 billion for the eight most expensive health conditions.7 This amounts to $1 in every $7 spent on these health conditions. This excess health care spending was derived from incorporating estimates of annual prevalence of ageism, healthcare cost data, and the effect sizes for the impact of ageism on health; the year 2013 was chosen as it was the most recent year for which health care cost data were available. Similar to other forms of bigotry, ageism has been built into the fabric of contemporary U.S. society. However, ageism is also intricately unique from other forms of bigotry with respect to its wide reach. In contrast to a subset of the population suffering from bigotry based on various forms and anchors of oppression, we are all targets of ageism. The injustice of using age to divide and categorize people must be recognized and acknowledged as a key form of systematic oppression that is evident across national borders and diverse social-cultural contexts. Wide Reach of Ageism Across All Age Groups The impact and wide reach of ageism is clear across all age groups.8 In one way or another, we are all experiencing ageism and perpetuating it simultaneously. While recognizing the “ageless” nature of this bigotry phenomenon, in this current report, we chose to focus ageism against older persons for the following reasons. First, ageism against older persons is extremely pervasive, and therefore teasing out this unique form of bigotry against older persons can maximize population impact. Second, the consequences of ageism with respect to health and human rights violations are more severe in older persons, relative to younger persons. Third, research on ageism toward younger persons is still in its relatively nascent stage. Therefore, our focus on ageism toward older people can be advantageous to build an evidence base approach toward bigotry. Last, ageism toward older persons is inextricably linked to its downstream, rippling effects that ultimately harm persons across all age groups. For example, initiators of ageism (i.e., bigots of ageism) also suffer from the consequence of ageism, as it limits the opportunities and resources in fostering positive and meaningful intergenerational exchanges. In short, we recognize ageism toward younger people is an extremely important and relevant issue and therefore deserves more attention as we move the field forward. Ageism Increasingly Negative and Injurious Over Time Compelling evidence has shown that ageism has become worse and damaging over time. Although the term “ageism” was officially coined in 1969 by the geriatrician Dr. Robert Butler,9 throughout human history there has been categorization of groups based on age. However, in those early primitive societies, including colonial America, older age was often valued favorably.10 Older persons were seen as providers of wisdom, knowledge, and guidance. As the number of older persons increased, especially the proportion of those who experienced frailty and cognitive impairment, the negative perception regarding older adults as a burden to society also increased. A recent computational linguistic study examined synonyms of elderly over the last 200 years by compiling a database of American English including over 400 million words. In this study, researchers found that age stereotypes have become increasingly negative over two centuries. As early as the 1880s, age stereotypes switched from being positive to being negative.11 This phenomenon was in part due to the historic and economic contexts. Modernization of medicine further exacerbated the negativity of images and stereotypes related to aging. This increasing negativity was further perpetuated and exacerbated by media portrayals, popular culture representations, and marketing industries.12 For instance, researchers in visual representation of aging have found that the representations of older adults have gotten progressively worse since the 1950s. This trend was drastically reduced in the early 2000s only because some older adults were being represented as models of successful aging by appearing ‘younger’ and wrinkle-free in their looks and actions.13 Ageism Operates Across Multiple Reinforcing Points Ageism operates across multiple levels of impact: the structural level (i.e., in which societal institutions reinforce systematic bias against older persons), dyadic level (i.e., seeping through day-to-day social interactions), and the individual level (i.e., the effect of older persons’ views of aging on their health). The multiple socio-ecological levels in which ageism operates are inextricably linked, because disparaging views of aging that are shown by word and deed at the structural level are further assimilated in interpersonal interactions, and subsequently internalized at the individual level.14 All of these levels of ageism interact and reinforce each other. To illustrate, in the context of employment, older workers are more likely to be discriminated against and excluded from corporate promotions and training opportunities. On an interpersonal level, older workers may experience toxic, ageist commentaries on a day-to-day basis. On an individual level, workers who assimilate negative age stereotypes from society are likely to erroneously perceive their abilities as inferior to that of younger co-workers. This internalized misconception can lead to potential withdrawal or lack of initiative for work engagements. This, in turn, can compound encounters with workforce structural ageism. Individuals ultimately are left with no resources to cope with the ill-effects of structural ageism. Structural Ageism: Explicit and Implicit Policies and Practices that Perpetuate Ageism At the structural level, ageism operates in the form of discriminatory social policies and prejudicial norms against older persons propagated by societal institutions. Structural ageism can also include age-based biases of individuals who are part of these larger societal institutions, such as policy makers or health care providers.15 The injurious health effects of structural ageism have been shown to exist across country borders and time.16 Structural ageism in the form of discriminatory social policies can refer to the macro-level policies and practices that discriminate against or restrict resources and opportunities for older persons. For example, a commonly used matrix to evaluate population age ratio across countries (i.e., the proportion of older people relative to that of younger-age population), is the “dependency ratio.” This derogatory term assumes individuals sixty-five and over can no longer contribute to the economy, suggesting they are as dependent as young children. This baseless assumption causes an expectation for older adults to retire around this age, even if they are completely capable of continuing their job. This expectation may lead to individuals retiring before they are actually ready to do so, perpetuating the idea that individuals over a certain age do not contribute to the economy. There are multiple pathways in which structural ageism can have a profound impact on our lives. A direct pathway may be that policy and practice directly impacts older persons’ lives and quality-of-life issues by unjustifiable exclusion, and by creating a hostile and invalidating social environment where older persons are deprived of their core humanness. Another potential psychological pathway may be that ageism operating at the structural level could trickle down to shape individuals’ negative age beliefs, which in turn affect health, behavioral, and quality of life outcomes.17 Additionally, it is also plausible that in social contexts that denigrate a specific outgroup, individuals would be more acceptive of the behaviors toward that group. Last, considering structural ageism embodies a sociopolitical climate that disempowers older persons, the embedded hierarchical power relations would render powerless older persons with maladaptive coping mechanisms and fewer resources to protect themselves from unfair treatment. Interpersonal ageism Interpersonal ageism refers to the ways in which ageism seeps through social interactions to impact relationships and day-to-day interactions. To illustrate, interpersonal ageism can include the use of age to devalue someone, to denigrate their dignity or capacity, or to patronize them. Interpersonal ageism occurs commonly in our communication and interactions with one another. Interpersonal ageism is shown to be common; almost half of older persons (45%) experience ageism in interpersonal interactions.18 Focusing on the interpersonal form of ageism is important as it can offer promising opportunities for prevention strategies. However, currently we still lack standardized and systematic measures to evaluate the pervasiveness and impact of this form of dyadic ageism. This should be an important next step for research and practice. Individual ageism At the individual level, ageism can manifest in culture-based negative age stereotypes (i.e., beliefs about older people in general) or negative self-perceptions of aging (i.e., beliefs held by older persons about their own aging). The clear link between individual ageism and health has been documented in at least six meta-analyses and systematic reviews.19 It is critically important to note that ageism operating at the individual level appeared to be a direct product of the structural form of ageism operating at the societal level.20 Therefore, ways to combat cultural- and social-based ageism would require structural responses and strategies. Another mechanism in which ageism can operate is through implicit channels.21 That is, individuals who hold ageist thoughts may do so without being aware of these thoughts.22 The mechanism between implicit ageism and individuals’ health and quality of life issues can be seen as a parallel manifestation of implicit racism. Ageism that operates on an unconscious level has been shown to affect older persons’ health, functioning levels, and quality of life. Conversely, this mechanism can also represent opportunities for change. Indeed, endorsing implicit beliefs about positive aging can help promote equal treatment. A series of experimental studies have shown that older persons’ health and behaviors can be improved through the priming of implicit age stereotypes.23 Harmful Impacts of Ageism on Older Persons’ Health, Well-being, and Human Rights Ageism interacts with almost every domain of life. For purposes of this report, we list ten major ways in which ageism significantly impedes the human rights and quality of life of older persons. Based on the conversation group transcripts, we also weave in narratives from older persons themselves where appropriate, in order to demonstrate the lived experiences of those who are impacted the most. 1. Poor health and well-being outcomes The wide reach of ageism is seen across multiple health and wellbeing domains. These well-researched areas of impact include mental health, physical health, cognitive health, and social relationships. For example, a seminal study on the robust linkage between ageism and health showed that ageism is associated with earlier death by 7.5 years.24 Ageism is also linked with risky health behaviors, such as unhealthy diet, medication noncompliance, excessive drinking, and smoking. Researchers postulate that ageism deleteriously affects the health of older persons through psychological, behavioral, and physical pathways.25 For example, ageism can be linked to adverse health outcomes through decreased purpose of life (psychological pathway), decreased engagement in health-promoting activities (behavioral pathway), or increased stress biomarker of inflammation (physiological pathway). 2. Denial of access to healthcare “He (participant’s aging father) had pain for a long time in his legs. The doctor said, ‘Well, what do you expect (…)!’” – Participant 28 from conversation group. “I'm 73 years old. Don't call me ‘young lady,’ that is so patronizing. Or ‘honey’ or ‘sweetie.’ How dare you, you don't know me like that.” – Participant 35 from conversation group. Denial of access to healthcare and treatment is among the most researched aspects of ageism. It has been found that age can dictate who receives certain procedures or treatment in oncology, cardiology, psychiatry, critical care, internal medicine, rheumatology, radiology, neurology, sexual and reproductive health, and internal medicine.26 Older persons in health care are often perceived as powerless and voiceless. Elderspeak, the infantilization of older persons through speech, or healthcare professionals ignoring older persons and only speaking to those accompanying them, are two examples of everyday ageism that are prevalent in these fields. This further points to the need to understand structural sources of ageism, including attitudes of health care professionals as they resemble part of the existing hierarchical power structure. 3. Denial of participation in research The systematic denial of participation in research of older persons creates an intrinsic paradox, considering that older persons are the largest group of healthcare consumers, and yet they are excluded from most health research. Older persons are shown to be excluded from trials of treatments, including in oncology, cardiology, neurology, rheumatology, psychiatry, nephrology, urology, health-risk behavior, and internal medicine.27 4. Lack of work opportunities Older persons faced ageism throughout all the employment-cycle stages. Overall, the AARP notes about two-thirds of today’s workers aged 45 to 74 have experienced age discrimination in the workplace.28 In previous systematic reviews on ageism in the workforce, it was found that 90.9 % of the 22 associations surveyed revealed that employers were significantly less likely to hire older job applicants than younger job applicants. Once employed, older workers had less access to training (78.6%) and those who faced ageism in the workplace were more likely to retire early (61.5%).29 5. Exclusion from technology “I think people will assume because you're not a digital native that you're not able to write it or you don't know it, or you can't understand it, or have good ideas about it.” - Participant 33 from conversation group. Ageism in technology has been considered one of the most rampant forms of bias in industry.30 Technology has been perceived as youth-driven in terms of its ideas, developments, and creation. The updates of technological tools are also said to have a generational divide, creating the false image that older persons are less likely, or less willing, to adapt to new advantageous technological tools. Yet, this falsified image conflicts with research findings. In fact, older persons are just as likely to use digital technology and social media as their younger peers.31 The exclusion of older persons in the research and design of technology at the structural level is fundamentally the culprit of this assumed digital divide.32 6. Targets of interpersonal violence An emerging line of research has begun to address the downstream effects of ageism: interpersonal violence. In a cross-national study, ageism that operates at the structural level was found to be associated with higher prevalence of violence toward older persons.33 Another study based on family caregivers of older persons found that explicit and implicit individual ageism was associated with higher proclivity to perpetrate elder abuse.34 Specifically, supported by theoretical frameworks of ageism,35 researchers have found that the mechanism behind structural ageism fueling higher proclivity to perpetrate violence toward older persons was via stronger endorsement of individual ageism.36 7. Prejudicial treatment in housing opportunities “In my opinion . . . nursing home care is based on a very ageist assumption that we should just put people away and not have to see them.” - Participant 33 from conversation group. Equal rights in finding affordable and accessible housing are protected under the Fair Housing Act, 42 U.S.C. §§ 3601–3619, which forbids discrimination based on race and ethnicity, religion, familial status, or age. However, older adults continue to face barriers in securing their rights, considering the rampant age and ability segregation when it comes to housing and community services.37 They may be forced to leave their homes in the context of rapid urbanization or social disruptions due to the lack of access to care in their homes. The age-segregated arrangement based on older persons’ needs and levels of care, including long term care settings, is further removed from the idea that promotes “aging in place.” 8. Financial Exploitation (Describing a financial scam) “She got a call from somebody claiming to be her grandson and he used the name in the family he had looked up on Facebook and so he knew the names (…).” - Participant 28 from conversation group. Older workers are more frequently targeted as potential victims of financial scams, relative to their younger counterparts.38 This is because fraudsters are targeting the negative stereotypical image of older persons, as lonely, likely more trusting, and with more money sitting in their accounts than younger individuals. This negative stereotype also includes the projection that many older persons may suffer from cognitive impairment, and this medical condition may cloud their judgment and decision-making capacity. Instead of treating this condition, initiators of ageism decide to exploit it. It is estimated that older persons lose more than $3 billion per year to scammers and fraudsters.39 9. Unfair media portrayals “Well, you know what happens, sometimes, is that some old people are the super seniors or they're the unicorns. And then, sometimes the older people are fetishized: “oh isn't she cute?” – Participant 35 from conversation group. In the entertainment industry, films and TV programming frequently exclude older persons or present them in demeaning roles. There is a sharp contrast between the representation of older persons on prime-time TV relative to the aging population in the community. This represents another key structural problem: most of the screenwriters of movies or TV are white men under the age of 40.40 This phenomenon further applies to the entire team of modern culture makers: directors, producers, agents, and actors all embody and perpetuate a youth-oriented stereotype.41 While we continue to appreciate the significance of the “#OscarsSoWhite” hashtag that began to transform the entire industry, we know of no social movements in similar scale that combats the insidious ageism in popular culture. 10. Baseless youth-oriented marketing schemes “One of the marketing brochures is of different ages they treat. Children…adolescents, adults and older adults. And older adults…starts at age 55 and they actually showed them hunched over with a cane, like a caricature.” – Participant 28 from conversation group. As a youth-oriented industry, the anti-aging and beauty industry is arguably one of the most persistent disseminators of ageism. In order to encourage potential consumers, marketers promote the fear of aging through negative age beliefs. These businesses that promote anti-aging continue to reinforce and perpetuate the idea that beauty is not in the eye of the beholder. Rather, beauty is synonymous with youth. The marketplace behind this myth is vast and extremely profitable. Market surveys have shown that the anti-aging industry profited by more than $400 billion in 2021.42 This is an increase of over 900% in profits in comparison to $40 billion gross in products and services roughly two decades ago. Anti-wrinkle products have continued to enjoy high sales over the last decades, in part because many celebrities or influencers, representing at the core a hierarchical power imbalance between the “old” and the “young,” openly advocate for the use of botox or other anti-aging aesthetics, which in turn promote the use of these products. Rampant Ageism During and Beyond COVID-19 Pandemic This report is particularly timely during the ongoing COVID-19 pandemic. Extensive research has shown that older persons’ well-being has been gravely compromised during the pandemic, as they experience increased exposures to wide-spread ageism, social isolation with potential abuse perpetrators, and reduced options and opportunities for support.43 Considering that the health and social consequences of COVID-19 will continue to undergird the ways we live, age, and interact with others, augmenting interventions to promote positive and diverse images of aging to circumvent ageism may be particularly critical both during and beyond the evolving COVID-19 crisis. Addressing Ageism through a Much-Needed Intersectional Lens In line with intersectional research,44 there is an urgent need to better understand how intersecting systems of power may reinforce ageism directed at marginalized groups within older populations. Ageism intersects with and diverges from other categories of bigotry in innumerable ways. Aging, and the nature of time, interacts with every identity in unique and often confusing ways. Ableism and ageism often work side by side, making it difficult to distinguish between the two. For instance, one common ageist stereotype is that older people are slow, and the act of brushing past a slow-moving older person in a huff and calling them an “old fart” is indeed ageist. Yet what caused the irritation in the first place had to do with the slow person’s ability, not their age, so the irritated person is also being ableist. At the structural level, it is important to note that multiple forms of bigotry and discrimination likely coincide and aggravate its impact. For example, a recent cross-national study on structural ageism found that countries reporting high levels of structural ageism also coincided with those that reported greater structural inequality in other realms of bigotry.45 This emerging line of research provides compelling evidence to suggest that analyses that only focus on one single form of bigotry are likely insufficient to understand population-level impact of systematic oppression. Structural systems of oppression are mutually manifested to reinforce health inequalities. This phenomenon necessitates the integration of an intersectional investigation in order to devise and implement much needed multi-systemic and multifaceted prevention and intervention strategies. As structural systems of oppression converge to reinforce health inequalities, integrating an intersectional and multi-level stigma framework into future research will also help align collective societal resources to those with the greatest needs.46 To maximize impact, there is a dire need to examine ageism through an intersectional lens. For example, gendered ageism, or the specific way ageism interacts with sexism, creates a double jeopardy for older women while uplifting the ideal older man. The unrealistic and sexist beauty standards expected of young women are also expected of older women, even though they are impossible at any age. Denying the wrinkles many aging bodies experience in order to maintain a certain appearance is as ageist as it is sexist. It is known that structural-level as well as individual-level gender-based stigma places women at higher risks for disparities.47 However, whether and to what extent ageism and gender-based stigma may interact to disproportionately place older women at greater risk for health disparities is not clear, and we need more research and advocacy around these issues. Another example for intersectional illustration is the potential cross-fertilization of ageism and classism. In our colleagues’ contribution on classism, they call for an expansion on Social Security and Medicaid, and add as a caveat “we should address the fact that many Black people never live to 65 so never benefit from these programs.”48 Indeed, aging itself is a privilege denied to many due to lack of resources. This truth is too often ignored in discussions around ageism. In fact, there is a habit of calling ageism “the last acceptable prejudice.” Those who use this framing are desperately trying to bring attention to ageism to make meaningful change. But in attempting to acknowledge the wide-spread harms of ageism in its many forms, this singles it out, rather than recognizes, the ways age intersects with other forms of oppression to produce great personal and social harm. The argument against ageism is strong enough—it doesn’t need to be compared to other forms of bigotry. And yet it cannot be dismantled without dismantling all forms of bigotry. Centering the issue of ageism and ageism alone will run the risk of perpetuating white supremacy, heteronormativity, capitalism, and colonialism. Without an intersectional approach, the fight against ageism could easily become a lopsided cause for privileged and fortunate individuals who live long. Demanding age justice while denying or ignoring justice for all will run the risk of appropriating other social justice movements. Structural Bigotry Requires Structural Responses: Solutions to Dismantle Ageism Despite the grave impact of ageism as a deep-rooted form of bigotry, recent emerging research has shown that ageism can likely be modified. A systematic review of ageism interventions suggested that education, as well as efforts to enhance greater, higher-quality intergenerational contact, may serve as a promising basis for ageism intervention.49 To dismantle ageism, we offer some potential structural responses below that can work in concert with other parallel strategies to combat bigotry. First, the most effective way to diminish the negativity and impact of ageism will be through structural channels.50 At the structural level, law and policy present unique opportunities to catalyze a paradigm shift, as prior existing approaches for combating ageism are mostly tailored toward individual ecology. Such a structural approach may focus on reducing ageism through improving political-legal, economic, as well as intergenerational support for older persons. Policies and laws which use age restrictions in place of more accurate limitations must be heavily scrutinized to uncover who the restrictions actually serve. Second, in educational sectors, efforts may include revealing the contributions of all individuals across age groups, by providing accurate representations of older individuals, and encouraging empathy building for all age groups. Critical participatory action research is a helpful tool for accurate and relevant research. Third, other top-down approaches by public health practitioners, advocates, and policy makers should include broad societal-based campaigns. These may include increasing diverse representation of aging through media portrayals and campaigns that promote visibility of heterogeneity.51 These campaigns may also include consensus conferences or working group campaigns, such as our current antibigotry convening efforts. Last, another possible mechanism may be through the increase of greater and higher-quality intergroup contact between older and younger persons. Interventions must start young, and awareness must increase for everyone. Research has shown that positive contacts between members of different age groups can lead to more favorable intergroup attitudes and relations.52 These positive interactions may be fostered in social settings, including age-diverse workplaces, religious congregations, or social media communities. In conclusion, to promote equity among all individuals, this report highlights the importance of extending the work on dismantling ageism to understanding and combating other avenues of structural bigotry. Older persons have a voice, and we must honor it.