The Structural Roots of Ageism and Ableism: What It Means for LGBTQ+ Older Adults

Abstract:

Ageism and ableism are structural phenomena that negatively shape the lived experiences of LGBTQ+ older adults and older people from all communities. Addressing the needs and aspirations of LGBTQ+ elders requires dismantling structural ageism and ableism. This article explores the roots and impact of ageism and ableism on elders and suggests pathways for mitigating their impact, including building upon decades of experience and learning, and adopting the successful strategies deployed by the disability rights movement.

Key Words:

ableism, advocacy, ageism, disability rights, discrimination, LGBTQ+

LGBTQ+ elders—the population SAGE represents and serves—experience severe challenges as members of overlapping disadvantaged and marginalized social groups. Through SAGE’s work and a growing body of research, we know that LGBTQ+ elders face social isolation; discrimination in healthcare, housing, and employment; disproportionate rates of poverty; health disparities; and lack of access to caregivers and other elder supports. All these challenges are exacerbated for LGBTQ+ elders of color and transgender elders.

SAGE was founded to address the needs of LGBTQ+ elders, who were effectively excluded from mainstream service systems and often lacked the care and support system traditionally provided by biological families. Over time, SAGE has expanded to provide a wide variety of programs and services, meals, social interaction, and housing supports. In addition, over the last decade, SAGE has increasingly turned to policy advocacy, training for aging-services providers, and other strategies to combat the systemic barriers facing LGBTQ+ elders.

The systemic barriers confronted by LGBTQ+ elders grow out of a pernicious combination of biases, including homophobia, transphobia, ageism, and ableism.

Most discussions of ageism focus on social attitudes and individual experiences of discrimination. But ageism is not just a reflection of attitudes. Like racism and gender bias, ageism is a system of awarding social, economic, and other forms of privilege. Ageism is part of the institutions and the legal frameworks that organize our society. Currently, this structural aspect of ageism is under-emphasized in discussions of and advocacy on elder issues. This prevents many advocacy efforts from recognizing and challenging the root causes of age-based inequity.

Ableism—the bias against people who have, have had in the past, or are viewed as having, a disability—is an essential element of ageism. Most people as they age experience one or more disabilities, encountering similar challenges to those faced by younger people with disabilities. Also, many of the assumptions, stereotypes, and negative attitudes about disability mirror those about aging. Simply put, one cannot advocate for elders, and against ageism, without considering ableism.

Just as we must take a structural and systemic approach to challenging anti-LGBTQ+ bias, we need to embrace a structural understanding and approach to ageism that includes ableism. This article will explore these ideas and begin a conversation about how to put them into practice.

What Is Structural Bias?

Structural treatments of bias first gained attention in the 1960s. Kwame Ture and Charles Hamilton highlighted the concepts of systemic and structural racism with Black Power: The Politics of Liberation (1967). They argued that racism is based on both individual attitudes and structures within society and that while individual racism can often be easily identified, the structural barriers are so entrenched that they may be invisible and widely accepted. The concept of structural racism has evolved since the 1960s and today is understood as social, economic, and legal policies, practices, and institutions that disadvantage people because of their race or ethnicity (Bouie, 2021). For example, the fact that many neighborhoods have few residents of color is not just a reflection of local attitudes but also the result of historic practices of lending, subsidizing, marketing, and selling property that systematically excluded people of color. These structures did not arise by accident. They were designed to protect and enshrine racial segregation and White supremacy.

In the 1970s and 1980s, feminist thinkers applied structural bias to understand the roots of gender inequality and legal, economic, political, and domestic institutions that empower men, and their historical control over inheritance and family, while disempowering women, eventually recognizing that the terms “men” and “women” are themselves socially constructed (Millett, 1970). Radical feminist theory led to the growth of queer studies, which advanced an understanding of gender oppression as institutional and structural.

Structural bias continues to be studied in many different contexts, including structural racism in healthcare (Brown et al., 2016), housing (Rothstein, 2017), and criminal justice (Bishop, 2020); and structural sexism in healthcare (Dusenbery, 2017), employment (Tankersley, 2018), and education (Davis & Reynolds, 2018).

Structural Ageism Is Everywhere

While age-based discrimination is prohibited in equal-employment opportunity laws (U.S. Equal Employment Opportunity Commission, 2023), ageism often is seen as an issue of ageist attitudes, held by specific individuals, that can be addressed with training, lists of “dos and don’ts,” and elders’ self-empowerment.

But ageism goes beyond negative attitudes about aging and elders; it is embedded in our laws and social structures, which essentialize youth while marginalizing and disempowering elders. Ageism is how society operationalizes the view of elders as less valuable, less deserving of resources, and as excluded from our general society and communities, just as ableism does to people with disabilities, and homophobia and transphobia to LGBTQ+ people.

We see examples of ageist structures everywhere. According to AARP, 64% of elders have experienced or witnessed age discrimination at work and 56% are fired or coerced to resign at some point once they pass the age of 50 (Choi-Allum, 2022). Professional-services firms (among others) and even some government agencies still have mandatory retirement ages. Much like LGBTQ+ workers and people with disabilities, older employees are often excluded from training opportunities, communication, and choice assignments. And only 8% of U.S. companies include ageism in their DEI initiatives (Gerhardt et al., 2022).

Structural ageism manifests in municipalities’ spending decisions, which frequently invest little in amenities like paratransit, benches, and public bathrooms that make it possible for older adults to move freely in their communities while addressing their physical needs. Barriers in the built environment serve to exclude older adults from comfortably inhabiting public spaces.

Commerce also communicates and reinforces ageism. Marketing and product development is overwhelmingly geared toward younger people even though 56 cents of every dollar spent in the U.S. comes from a consumer age 50 or older (Choi-Allum, 2022). Despite their extraordinary spending power, in the rare cases when older people do appear in advertisements, they often are portrayed in denigrating ways, as incapable, out of touch, or unpleasant. This kind of messaging reinforces ageist attitudes at scale, which become embedded in a self-reinforcing cycle.

Structural ageism is particularly evident in healthcare. Elders have a hard time accessing medical care. Often they have trouble obtaining care for medical problems because their symptoms are dismissed as natural aspects of aging and, like people with disabilities, often they are denied services routinely provided to others. A study of 9,000 hospitalized patients revealed that healthcare professionals were significantly more likely to withhold life-sustaining treatments from older patients, even after controlling for prognosis and patient preferences (Inouye, 2021).

Many hospitals have policies to avoid using feeding tubes for older patients, instead referring them to terminal care (Inouye, 2021). Similarly, there are formal and informal age limits on HIV testing (Fitzpatrick, 2011), vaccines (Lloyd-Sherlock et al., 2022), and some medical procedures (Pelham, 2023). And many insurance companies refuse to authorize surgery or exploratory procedures, such as sleep apnea tests, for older patients that are routinely approved for younger people (Wyman et al., 2018).

Structural ageism impacts every aspect of life, from the built environment of our communities to business practices and what products are available to the mental and physical well-being (and life expectancy!) of older people.

Ageist Systems and Policies Can Be Used to Take Away Elders’ Autonomy

Ageism includes assumptions that older people are less capable of living independent lives. Increased dependency is sometimes a reality in the aging process, and dependency unfortunately invites abuse. As a result, systems have been created to protect older adults from abuse. But according to the American Bar Association, abuse of the guardianship and elder-protection system is common enough that it has its own nickname, “silver collar crimes,” and the Florida Attorney General’s office has a department dedicated to investigating them (Palmieri, 2021). In 2017, a real estate agent was convicted of perjury and theft for using her relationship with local courts, social workers, and medical providers to have herself appointed the legal guardian for scores of elders, who were generally fully competent and independent. She would then move them to care facilities and sell their homes and possessions for her own profit (Aviv, 2017).

While it is essential to have systems in place to address the reality and risk of elder abuse, ageism manifests in systems that can unnecessarily withdraw autonomy from elders.

Ageist assumptions can overwhelm actual data about older people’s capabilities. In New York State, anyone can lodge an anonymous complaint with the Department of Motor Vehicles alleging that an older driver is not competent (New York State Office for the Aging, 2019). Regardless of the merit of the complaint, the driver is required to take a new road test to keep their license; even when studies show older drivers are safer than young drivers (Steed, 2021). Protection is important, but systems that are open to manipulation and infected by ageism often become structures that reinforce and multiply ageist practices.

Ageism Also Shows Up in the Aging Sector

The insidious and systematic nature of ageism is evidenced by the fact that we see it even in the aging sector, which can treat elders as dependent and passive, needing to be managed, and forced to comply with the choices providers think are best. Examples include paternalistic provider policies prohibiting older adults from making basic human choices about what they eat and drink and where, when, and with whom they seek out sexual intimacy. Like people with disabilities, older people are frequently relegated to restrictive care facilities and protocols. Too often, elders are not viewed as active members of society, but as people who need support, a message that can paint them as resource drains or burdens rather than contributors to their communities.

Historically, we sometimes have seen examples of this in the promotional efforts of nonprofits in the aging sector, which are cash-strapped. The image of the helpless elder can be exploited to good effect in fundraising and publicity. To attract donations and other forms of support, victim-oriented messages emphasize illness, dependency, and plight. While sometimes effective in attracting resources and attention to organizations that desperately need both, these messages reinforce ageist stereotypes and are dehumanizing.

We also see the structures of ageism in aging-advocacy organizations, which like most nonprofits often are overwhelmingly staffed and led by younger people. It is all too easy to make decisions without consulting with and being guided by elders. The importance of combating these trends is why SAGE adopted the principle that “elder voices come first” as a core organizational value.

At the Intersections

Most of us wish to live a long life. Living longer usually means experiencing disability in some form, whether it be reduced vision or hearing, mobility issues, or chronic health conditions. More than half of older Americans will experience a disability that requires up to 2 years of long-term services and supports; about 1 in 7 older Americans will experience a disability for more than 5 years (Office of Behavior Health, Disability and Aging Policy, 2021). So, when we think about dignified, inclusive aging, we must include disability.

Incorporating anti-ageist and disability-rights perspectives into SAGE’s work with and on behalf of LGBTQ+ elders is an effort to work at the intersections of these overlapping lived experiences and advocacy areas. It means challenging long-standing and overlapping biases about aging, disability, and LGBTQ+ identity.

One area in which this shows up is in stereotypes about sexual intimacy. A narrow view of sexual orientation is that it is based solely on sexual desire and activity, rather than reflecting a full range of relational preferences and an essential part of one’s identity that inspires personal pride. In an ableist and ageist world, sexual intimacy is presumed to be confined to young, able-bodied people. Because LGBTQ+ people are stereotypically defined by their sexual orientation, the ageist and ableist framework makes it oxymoronic and unimaginable that someone could be older, disabled, queer, and a sexual being who needs culturally competent care.

The misconception that elders and people with disabilities exist outside the spectrum of human sexuality can erase the existence of LGBTQ+ people in both communities. And it has real consequences for how they receive care. In some cases, it can manifest in cognitive dissonance for elder and disability-related service providers when they’re asked to be LGBTQ+-welcoming. Within the framework of ableism and ageism, the frequent response that “we don’t have people like that here” is better understood (while woefully misguided).

At the same time, elements of LGBTQ+ communities that have historically prized youth and normative physical beauty also participate in biased behavior and erect structural barriers to access. Until recently, the social locus for many gay men was the bar scene, which historically was unwelcoming of older people and rarely accessible to people with disabilities. This also has been true for other kinds of LGBTQ+ social spaces, including community centers and service providers, where older adults often lament that they have “aged out” of social relevance and become invisible, even as their need for support and community grows. SAGE constituents often recount that once they reach a certain age, they no longer feel welcome in a wide range of community spaces. Not surprisingly, it is deeply painful for LGBTQ+ older adults to find themselves rejected by the community—and its welcoming, shared spaces—they helped make possible.

Similarly, people with visible disabilities often feel they are not valued and are rejected by a “hook-up” culture. As a result, LGBTQ+ people with disabilities have sometimes formed their own communities.

LGBTQ+ elders experience the overlapping biases of anti-LGBTQ+ bias, bias within their own community, ageism, and ableism. Recognizing the interplay of these biases and how they are structurally embedded is essential to advocating effectively with and on behalf of LGBTQ+ older people.

Learning From the Disability-Rights Movement

When we think about how to unravel structural bias, it’s helpful to turn to the disability-rights movement, which shares many themes and issues relevant to anti-ageism work and efforts for greater dignity for LGBTQ+ elders. The disability-rights movement was largely defined by challenging structural barriers, both physical and institutional. The physical barriers—including an environment not accessible to wheelchair users, and a lack of braille signage and sign-language interpreters, and public accommodations that aren’t set up for Little People—were largely accepted until the 1970s and 1980s. Although physical and institutional barriers still exist, the disability-rights movement has made significant progress in the intervening decades.

Behind the physical barriers were institutional barriers. Historically, the approach to disabled people mirrored the approach to elders and other marginalized groups like the LGBTQ+ community: “out of sight, out of mind.” People with disabilities were systematically excluded from education, employment, and the community and often secluded in care institutions with problematic conditions and practices.

The disability-rights movement’s focus on discriminatory and exclusionary institutions and structures led to the identification of “ableism” in society. Ableism assumes that “typical abilities” are superior; it defines people by their disability and assumes that they need “fixing,” or to be put away from society and denied control over their own life decisions (Davis, 2006).

Until the passage of the Rehabilitation Act of 1973, there were basically no civil rights protections for people with disabilities in the United States. Section 504 of the Rehabilitation Act prohibited discrimination against people with disabilities and mandated that recipients of federal funding make accommodations (Office for Civil Rights, 2006). This meant, for example, that universities and hospitals had to treat people with disabilities like other students, patients, and employees and provide adaptations that allowed them to be fully integrated.

This paved the way for the first comprehensive civil rights law for people with disabilities in the United States, the Americans with Disabilities Act (ADA). Organizing for the ADA began in the 1980s and gained momentum until its passage in 1990. It was passed thanks to the active and visible organizing and grassroots protest of large numbers of people with disabilities across the country. During the struggle for the ADA, important links were formed between the disability-rights movement and the LGBTQ+ community over ensuring that the law would cover people living with HIV/AIDS.

Like ageism and anti-LGBTQ+ bias, one effect of ableism is that people with disabilities are denied autonomy and independence. The disability-rights movement asks that, rather than thinking of disability as defined by what someone can or cannot do, instead we think of it as defined by what a person can or cannot access in a world designed to exclude them. This same thinking can be used to inspire inclusive systems and structures that acknowledge and respect people of all ages, abilities, sexual orientations, and gender identities.

Conclusion

Ageism and ableism are structural phenomena that negatively shape the lived experiences of LGBTQ+ older adult and older people from all communities. Addressing the needs and aspirations of LGBTQ+ elders requires dismantling structural ageism and ableism. This is easier said than done, among other reasons because structures of marginalization are invisible to many and often are assumed to be givens and necessities.

Fortunately, in seeking to confront and defeat structural ageism and ableism, LGBTQ+ older adults and their allies are not breaking entirely new ground. Instead, we can build upon decades of experience and learning, including from movements to dismantle structural racism and the successful strategies deployed by the disability rights movement. A key starting point is naming and lifting up the ideas that ageism-induced and ableism-induced challenges confronting LGBTQ+ older people are not just the result of biased attitudes but also perpetuated and reinforced by structures and systems. Naming this reality is the foundational first step to crafting effective strategies to dismantle those structures so that all LGBTQ+ older people—and all older adults—can thrive in a world of boundless opportunities for each of us as we age.

Michael Adams is the CEO of SAGE. He is based in New York, NY.

Photo credit: Shutterstock/lewan

References

Americans with Disabilities Act of 1990, 42 U.S.C. § 12101 et seq. (1990).

Aviv, R. (2017, October 2). How the elderly lose their rights. The New Yorker. https://www.newyorker.com/magazine/2017/10/09/how-the-elderly-lose-their-rights.

Bishop, E. T., Hopkins, B., Obiofuma, C., & Owusu, F. (2020). Racial disparities in the Massachusetts criminal system. The Criminal Justice Policy Program, Harvard Law School. https://blackcommunityhamburg.blackblogs.org/wp-content/uploads/sites/920/2020/09/2020-09_Massachusetts-Racial-Disparity-Report-FINAL.pdf

Bouie, J. (2021, November 9). What ‘structural racism’ really means. The New York Times. www.nytimes.com/2021/11/09/opinion/structural-racism.html?searchResultPosition=12

Brown, T. H., Richardson, L. J., Hargrove, T. W., Thomas, C. S. (2016). Using multiple-hierarchy stratification and life course approaches to understand health inequalities: The intersecting consequences of race, gender, sex, and age. Journal of Health and Social Behavior 57(2), 200–22. https://doi.org/10.1177/0022146516645165https://doi.org/10.1177/0022146516645165

Choi-Allum, L. (2022). Age discrimination among workers age 50-plus. AARP Research. https://doi.org/10.26419/res.00545.001

Davis, L .J. (2006). Constructing normalcy. In Disability Studies Reader (2nd ed., pp. 3–16). Routledge.

Davis, L., & Reynolds, M., (2018). Gendered language and the educational gender gap. Economic Letters 168(C), 46-48.

Dusenbery, M. (2018). Doing harm: The Truth about how bad medicine and lazy science leave women dismissed, misdiagnosed, and sick. HarperOne.

Fitzpatrick, L. (2011). Routine HIV testing in older adults. AMA Journal of Ethics 13(2), 109–11.

Gerhardt, M. W., Nachemson-Ekwall, J., & Fogel, B. (2022, March 8). Harnessing the power of age diversity: Generational diversity should be a source of diversity, not division. Harvard Business Review. https://hbr.org/2022/03/harnessing-the-power-of-age-diversityhttps://hbr.org/2022/03/harnessing-the-power-of-age-diversity

Inouye, S. K. (2021). Creating an anti-ageist healthcare system to improve care for our current and future selves. Nature Aging, 1, 150–2. https://doi.org/10.1038/s43587-020-00004-4

Lloyd-Sherlock, P., Guntupalli, A., & Sempé, L. (2022, Sept. 30). Age discrimination, the right to life, and Covid-19 vaccination in countries with limited resources. Journal of Social Issues, 10.1111/josi.12561.

Millett, K. (1970). Sexual politics: A manifesto for revolution. Doubleday.

New York State Office for the Aging. (2019). Are you concerned about an older driver? https://aging.ny.gov/system/files/documents/2019/09/Are%20you%20concerned.pdf

Office of Behavioral Health, Disability, and Aging Policy. (2021, January). Long-term services and supports for older Americans: Risks and financing. U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation. https://aspe.hhs.gov/sites/default/files/private/pdf/265126/LTSSOlAmRB.pdf

Office for Civil Rights. (2006, June). Your rights under Section 504 of the Rehabilitation Act. U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/ocr/civilrights/resources/factsheets/504.pdf

Pelham, V. (2023, Oct. 16). Confronting ageism in healthcare. Cedars-Sinai Blog. https://www.cedars-sinai.org/blog/confronting-ageism-in-healthcare.html#:~:text=About%2020%25%20of%20people%20over,quality%20of%20life%2C%20and%20depression 

Rothstein, R. (2017). The color of law: A forgotten history of how our government segregated America. Liveright.

Steed, T. (2021, October 21). Older drivers can be safer drivers—with support. AARP. https://www.aarp.org/auto/driver-safety/older-drivers-fewer-accidents/

Tankersley, J. (2018, August 19). How sexism follows women from the cradle to the workplace. The New York Times. https://www.nytimes.com/2018/08/19/business/sexism-women-birthplace-workplace.html.

Ture, K. & Hamilton, C. (1967). Black power: The politics of liberation. Vintage.

U.S. Equal Employment Opportunity Commission (EEOC). (2023). Age Discrimination. https://www.eeoc.gov/age-discrimination.

Wyman, M., Shiovitz-Ezra, F., & Bengal, J. (2018, May 23). Ageism in the health care system: Providers, patients, and systems. Contemporary Perspectives on Ageism, 193–212.