Abstract
Gendered ageism, the intersection of ageism and gender bias, conceptualizes how social constructions shape attitudes toward older women and restrict their access to societal resources. As oppressive gendered ageist stereotypes can affect how older women perceive their embodied selves, interventions tailored to women’s needs are essential to maintaining a positive identity. This research protocol aims to develop an arts-based intervention specifically adapted to the psychosocial needs of community-dwelling older Italian women. It centers on the embodied self-representations of older women from a life-course perspective that integrates narrative and phototherapy techniques. In the first phase of this research project, a pragmatic approach will be taken to explore professionals’ use of phototherapy techniques with aging women; the data will be analyzed through reflexive thematic analysis. Building on the findings and the literature, an intervention will then be developed for older women. In the second phase, a narrative approach will be taken to probe the embodied self-representations of older Italian women as expressed in their narratives and photographic art products; the data will be analyzed through polytextual analysis of personal narratives. In the third phase, interviews based on the arts-based approach and the Client Change Interview will be conducted with older women to examine the psychosocial contribution of the intervention and their experiences with the artistic process and products; the data will be analyzed through reflexive thematic analysis. To uphold qualitative research rigor, data triangulation, reflexive journaling, auditing, and member checking will be employed. The data collection will be conducted between 2024 and 2025. The findings of this study will shed light on the embodied self-representations of older women in Italy as they emerge in their narratives and phototherapy artworks and will provide an empirically based intervention that integrates narrative and phototherapy techniques tailored to their psychosocial needs.
Keywords
Background
Today, the population distribution is shifting toward older ages, a phenomenon known as population aging (World Health Organization, 2022). In 2024, individuals aged 65 and older accounted for approximately 24.3% of Italy’s total population (Istituto Nazionale di Statistica, 2024). The population of older adults in Italy is expected to be about 34.9% of the population by 2050 (Istituto Nazionale di Statistica, 2022c), as compared to 22% of the population of older adults worldwide (World Health Organization, 2022).
There are also gender differences in life expectancy in Italy, in that women generally live longer than men (Istituto Nazionale di Statistica, 2020). In the Italian population over 65, women constitute 56% of the population (Istituto Nazionale di Statistica, 2021), and this disproportion increases with age to about 83% of the population over 100 (Istituto Nazionale di Statistica, 2022b). The longer life expectancy of women compared to men uniquely influences various aspects of women’s aging processes. For example, women’s higher life expectancy, combined with the tendency for women to marry younger than their male partners, makes widowhood more common among women over 70 (Adena et al., 2023; Carr & Bodnar-Deren, 2009). In Italy, nearly half of women over 75 live alone (Istituto Nazionale di Statistica, 2020). Additionally, older women are disproportionately affected by economic hardships due to lifelong patterns of gender inequality, such as vertical gender segregation, where women are often excluded from top occupational positions (Abatemarco & Russolillo, 2022; Istituto Nazionale di Statistica, 2022a). Given that women generally live longer than men, they may encounter prolonged periods of retirement without sufficient financial resources (Paz et al., 2018). Besides life expectancy, women also experience a specific form of ageism known as gendered ageism as discussed next (World Health Organization, 2022). These challenges emphasize the need for a gender-focused approach in aging research.
Gendered Ageism
Despite the scope of population aging, many older adults do not participate fully in society. This was one of the reasons that the United Nations declared the Decade of Healthy Aging (2021–2030), a global initiative to improve the lives of older people and ensure their dignity and equality (World Health Organization, 2020). One facet of this program is combating ageism, which is defined as stereotypes, prejudice, and discrimination directed toward people based on their age (World Health Organization, 2021).
The concept of gendered ageism relates to the intersection of both ageism and gender bias, which may account for the differences in the ageism experienced by women and men (World Health Organization, 2022). Gendered ageism is responsible for the more restricted access of older women to resources and opportunities, as compared to men (Chrisler et al., 2016; Mahler, 2021; Westwood, 2023). For instance, it produces an important gender pension gap in Italy where men’s annual retirement income was 36% higher than that of women in 2022 (Istituto Nazionale di Statistica, 2023).
The social construction of gender and gendered ageism in Italy has its roots in the country’s socio-political context. For instance, it is worth reflecting on gender relationships in Italy through the distribution of informal care within the family (European Institute of Gender Equality, 2022; Saraceno, 1994). The literature indicates that while women spend on average 5 hours and 14 minutes on daily house and child-related activities, men spend only 1 hour and 40 minutes (Meraviglia & Dudka, 2021). Another example is the 1970 divorce law, which was only introduced about a century after similar laws were passed in most democratic European nations, due to the strong patriarchal architecture within marriage and the family in Italy (Seymour, 2005). The man’s position as the cornerstone of the patriarchal family was considered fundamental to constructing a masculine identity and protecting men’s privileges within marriage.
The Social Constructionist approach to gendered ageism argues that both gender and age are socially constructed. One of the first pivotal conceptualizations of gender as socially constructed was the concept of doing gender as formulated by West and Zimmerman (1987). They viewed gender as something that both women and men do or accomplish in the context of interactions. Thus, gender is not an individual quality, but rather a feature of social situations. Doing gender occurs through communication, behaviors in specific situations, and responses to expectations regarding masculinity and femininity. These expectations are learned and reinforced through social interactions, and influence how people present themselves and interpret others’ behavior based on gender (West & Zimmerman, 1987).
Similarly, the concept of doing age relates to social constructions regarding age, and the ways individuals do or accomplish their age in the context of interactions (Calasanti et al., 2006; Krekula, 2009; Laz, 1998). Accordingly, age is enacted, performed, and accomplished. In accomplishing age, people create and maintain selves, roles, and identities, and attribute meaning to their age and other people’s ages (Laz, 1998). For example, there are expectations related to older women’s clothes choices, such as not wearing bright, attention-grabbing colors (Twigg, 2012). Similarly, certain activities are associated with specific age groups. For example, older adults are frequently perceived as lacking interest in sexual activity, even though research shows that they continue to engage in various sexual behaviors (Gewirtz-Meydan et al., 2018). According to Laz (1998), culture provides people with images and resources for doing age, which shapes features such as age consciousness, expectations about the life course, and feelings, attitudes, and behaviors toward aging. Bodies are also a resource for doing age. In Western society today, women’s physical characteristics, such as gray hair and wrinkles, shape a collective understanding of what it means to be an older woman (Cecil et al., 2022; Clarke & Korotchenko, 2010; Ward & Holland, 2011).
The interaction between age and other social categorizations such as gender and appearance create complex power relations and an unequal distribution of resources (World Health Organization, 2022). In the 1970s, Susan Sontag (1972) claimed that women and men experience different trajectories as they age: whereas men gain prestige and power, women become socially invisible. Women’s experiences of aging and ageism are deeply rooted in their appearance and in the ageist and sexist perceptions of older women’s bodies (Clarke & Griffin, 2008). Gendered ageism manifests in several ways: (a) negative biases in language, such as the term “hag,” which refers to a mean and unattractive older woman (Covey, 1988); (b) less frequent and less favorable media representations of older women; and (c) more negative interpretations of aging signs in women, such as perceptions of reduced competence when women go gray (Barrett & Naiman-Sessions, 2016; Cecil et al., 2022; Edström, 2018). Contemporary social constructions of gender and age challenge older women’s embodied self-representations. This highlights the need for interventions specifically designed to address the psychosocial needs of community-dwelling older women in Italy, helping them maintain a positive sense of identity and body experience as they age.
The Body-Self Relationship
There is no self without a body (Chrisler & Johnston-Robledo, 2018). The self is what perceives, thinks, and acts (Gallagher, 2011). Perception and action inherently rely on embodiment, such that thought is inseparable from both perception and action. As a result, the self is fundamentally an embodied self (Gallagher, 2011; Newen, 2018). The body plays a key role in people’s self-identity and affects the self in many ways, including in terms of self-esteem, self-consciousness, and self-image (Chrisler & Johnston-Robledo, 2018). Given the lifelong pressure on appearance older women are exposed to throughout their lives, the body-self interaction is a key topic in the psychology of women (Bartky, 1988; Bordo, 1989; Calasanti et al., 2012; Clarke & Griffin, 2007).
The recent literature has increasingly delved into the topic of the body and embodiment in older adults, with a particular focus on older women. Despite this progress, the quest for a definitive conceptualization of these terms continues to challenge scholars. The term “embodiment” originates from the scholarly work of Merleau-Ponty (2012). Merleau-Ponty (2012) talked about the lived body, since all perceptions and experiences of the world are embodied in the sense that everything people are, do and know is mediated by the body. One of the main theories in sociology that strives to understand the body and the experience of embodiment is Symbolic Interactionism. According to Waskul and Vannini (2006), there are five different bodies in social interactionism; that is, different ways of thinking about, seeing and understanding the experiences of embodiment. The first is the looking-glass body where bodies are seen and the act of seeing is reflexive. In other words, when people observe others’ bodies, they interpret what they observe; similarly, those who are observed imagine the interpretations of what the observers see and how they feel about it, such that they complete the reflections of the looking-glass (i.e., mirror). The second is the dramaturgical body. This approach highlights human agency, since people do not just have bodies, but rather do their bodies: the body is fashioned, crafted, and manipulated. Embodiment is the active process through which the body is realized and made meaningful. The third body is the phenomenological body. The body is the center and primary source of all knowledge and experience; hence, phenomenological approaches to the body revolve around thick descriptions of lived experience, since meaning is embedded in these embodied experiences. The fourth body is the socio-semiotic body. The meanings of bodies are created in relation to the positioning of the body within a system of signification, with meaning-making the result of human interaction. Finally, the fifth body is the narrative body. The narrative body is embedded in the stories people tell themselves and the stories others tell about both their own bodies and others’ bodies. The current study will use these five ways of considering bodies to explore older women’s embodied self-representations throughout the life course as expressed in narratives and phototherapy techniques.
Embodied Self-Representations of Older Women
Special attention needs to be paid to the embodied self-representation of women, and more particularly, of older women. According to a feminist appropriation of some later Foucauldian concepts, by expecting individuals to conform to commonly accepted societal discourses, society produces compliant, or “docile bodies” (Bartky, 1988; Bordo, 1989). The female body is disciplined through practices such as dieting, exercise, and clothing. The disciplinary techniques through which the “docile bodies” of women are constructed aim at a regulation that is perpetual and exhaustive; namely, “a regulation of the body’s size and contours, its appetite, posture, gestures and general comportment in space, and the appearance of each of its visible parts” (Bartky, 1988, p. 80). Grounded in the concepts of embodiment and the embodied self, and informed by insights from critical and feminist theorists, this study will thus focus on the concept of embodied self-representations as reflected in the personal narratives constructed by older women, along with their gestures, postures, movements, and overall bodily demeanor, as presented in photographic art products.
Body image is a fundamental aspect of people’s sense of self and can have a pronounced influence on women’s well-being (Liechty & Yarnal, 2010; Marshall et al., 2014; Sabik, 2015). Body image is a multidimensional concept, and includes individuals’ perceptions, feelings, thoughts, and evaluations of their bodies (Liechty, 2012). The literature has documented a complex picture of the attitudes and experiences of older women toward their own bodies (Bailey et al., 2016; Cameron et al., 2018; Liechty, 2012; Sabik & Cole, 2017). Recent findings show that body image is an important issue for women throughout their lives and can still be highly relevant for older women (Cameron et al., 2018; Lee & Damhorst, 2022; Liechty & Yarnal, 2010). Women are aware of the societal discourse that situates youth as the defining characteristic of both health and beauty (Calasanti et al., 2012; Clarke, 2018). As women experience bodily changes associated with aging, they may find themselves increasingly distant from societal beauty standards, resulting in feelings of invisibility, incompetence, and diminished social value (Cecil et al., 2022; Clarke, 2018; Westwood, 2023). To retain a positive sense of identity, older women sometimes embrace anti-aging discourses and anti-aging consumerism (Clarke, 2018; Gilleard & Higgs, 2013; Twigg & Martin, 2015).
In this study, the embodied self-representations of older women will be explored through the lens of the life-course perspective, which is a widely accepted framework within the literature on unequal aging. According to the life-course perspective, each individual developmental trajectory is the result of a dynamic interplay between the individual’s embodied personality and the socio-cultural, historical, and political context in which the individual is embedded (Elder et al., 2003). From the life-course perspective, age is a social construction (Elder et al., 2003), so that societal expectations throughout the life course contribute to shaping older women’s experiences of aging (Cameron et al., 2018; Cecil et al., 2022; Lee & Damhorst, 2022).
There is scant literature on the embodied self-representations of older women regarding the psychosocial implications of how older Italian women cope with their changing appearance, bodies, and narratives. To contribute to this area, the present study will explore these themes and develop a therapeutic intervention for older women based on the use of photographs.
Phototherapy Projects and Techniques for the Aging Population
In recent years, there has been a significant increase in the use of photography in therapeutic settings (Loewenthal, 2023). Stewart (1979, p. 42) defined phototherapy as “the use of photography or photographic materials, under the guidance of a trained therapist, to reduce or relieve painful psychological symptoms and to facilitate psychological growth and therapeutic change”.
Photographs can be considered privileged pathways to personal narratives since they are embodied metaphors of clients’ views of the world (Belgiojoso et al., 2016). Photographs do not have a meaning per se, but individuals attribute meaning to them when perceiving or creating them, and this meaning is mediated by people’s beliefs, values, and experiences (Weiser, 2004). The use of photographs in therapy makes it possible to elicit themes that cannot be expressed by words alone, such as implicit, latent, and embodied aspects of personal experience (Keisari, Piol, et al., 2022; Testoni et al., 2019, 2020).
This study will implement phototherapy techniques. Phototherapy techniques are therapy practices that use photographs as catalysts to deepen insights and enhance communication during therapy, in ways not possible in verbal-only therapy (Weiser, 2014). There are five core phototherapy techniques (Weiser, 1999): (1) photos that have been taken or created by the client, (2) photos that have been taken of the client by other people, (3) self-portraits, (4) family albums and other photo-biographical collections, and (5) “photo-projectives” that are based on the idea that the meaning of any photograph is constructed by its viewer during the process of viewing it.
In the current research project, photographs will be used to elicit, support, and create older women’s narratives. We will use the life review approach to guide the creative process. Life review is a narrative therapeutic approach that serves to explore and process one’s life story that leads to a more integrative view by including past, present, and future events, positive memories and achievements alongside the acceptance of failures and harsh life events (Westerhof, 2015; Westerhof & Bohlmeijer, 2014). Processing one’s life story is a fundamental task in old age, which facilitates the reframing of past experiences and their constructed meanings as well as working through unfinished business (Butler, 1963; Erikson, 1982). Life review interventions can prompt improvement in psychological well-being and result in the reduction of depressive symptomatology (Korte et al., 2012; Westerhof & Slatman, 2019). Creative interventions that invite clients to conduct life reviews and reminisce can improve positive mental health indices (e.g., self-acceptance, meaning in life, and satisfaction with life) and reduce depressive symptoms (Keisari, Palgi, et al., 2022). Photographs make it possible to capture the embodied self-representations of older women in the past, present, and future.
Most interventions with older adults have focused on existing photographs, whereas the therapeutic intervention in this project will consist of both autobiographical photographs and photographs created specifically during the therapeutic process. In line with the principles of creative arts therapies, this intervention will be action-oriented, with older women actively and physically involved in the process of directing, enacting, and taking their own photographs, as well as crafting visible and tangible objects in the form of photographs and photocollages (De Witte et al., 2021). This agentic use of photography is designed to offer women the possibility of experiencing a sense of agency in crafting their own narratives as older women.
Few studies have investigated the use of the phototherapy techniques with older women. One exception is a group phototherapy intervention with 12 middle-aged women, who were invited to create their subjective narratives of aging (Martin, 2019). This six-day workshop used different techniques, such as the family album and re-enactment of past photograph. The qualitative findings showed that the women were able to explore their relationship with their visual representations, but also transform and re-define how they were seen as middle-aged women (Martin, 2019).
Diverse interventions based on visual arts have been developed to tackle body image and embodiment in women, including approaches such as clay work (Crocker & Carr, 2021), photomontage (Bat Or & Zemach, 2018) and phototherapy (Martin, 2019). These findings show that these interventions can help women explore, transform, and redefine their relationship with their visual and embodied representations to gain greater confidence and self-acceptance. However, to the best of our knowledge, no interventions have specifically been tailored for older women.
Research Questions
This qualitative research will examine the following research questions, each addressing a specific phase of the research project as described below. In the
Method
This qualitative study will mainly take a narrative approach (Riessman, 2008). First, a narrative approach allows to explore how older women construct their identities through the process of narrative construction (Riessman, 2008); that is, through the act of sorting, filtering, and selecting from their life histories, they choose to claim a particular identity (Spector-Mersel, 2011; Spector-Mersel & Ben-Asher, 2018). Moreover, one’s narrative and ensuing identity are situated within the context of a specific interaction; that is, personal events are selected, organized, and evaluated as meaningful for a particular audience (in this study, the researchers). Second, a narrative approach allows us to consider the complex interplay between the individual, society, and culture; that is, the encounter between personal agency and social structures, like dominant discourses and power relations within a delineated geographic and historical context (Riessman, 2008). Furthermore, as older women are subject to gendered ageism and associated forms of marginalization (Krekula et al., 2018), listening to their personal narratives is a way to understand and validate their subjective experiences and offer them the possibility to reclaim personal agency (Chambers, 2002; Manor, 2023; Riessman, 2008).
Study Design and Intervention
This qualitative study will have three phases. In the
The interviews with the professionals (see Appendix) will take a pragmatic research approach (Kelly & Cordeiro, 2020) to explore their use of phototherapy techniques with aging women. A pragmatic research approach adheres to three methodological principles: (a) an emphasis on actionable knowledge, (b) recognition of the interconnectedness between experience, knowing, and acting, and (c) an understanding of inquiry as an experiential process. It is important to mention that phototherapy is an emerging profession with various pathways for specialization. In some countries, structured training programs are available for therapists, such as the Phototherapy Department at Musrara 1 in Jerusalem and the Italian Network of Phototherapy, Therapeutic Photography, and Social Action Photography 2 . In other countries, individuals may receive training through formal supervision with an experienced professional in the field, such as Judy Weiser, a pioneer in phototherapy. Therefore, this study will involve professionals from different backgrounds.
The findings from the interviews, together with the findings from the literature, will be used to develop a protocol for an intervention for older women that combines phototherapy techniques (Weiser, 1999) with the principles of life-review therapy (Westerhof & Slatman, 2019). The aim of the intervention is to support the psychosocial needs of older women in terms of their embodied self-representations while aging.
In the
In the
Sampling and Recruitment
In the
In the
A combination of convenience and criterion sampling strategies will be employed for these phases (Gill, 2020; Patton, 1990). Senior centers, community centers, or volunteer centers in northeastern Italy will be contacted through web search engines and the intervention will be offered to members who meet the inclusion criteria mentioned above. These organizations and associations will be contacted through emails or telephone.
Data Analysis
In the first phase, after the therapists’ interviews are transcribed verbatim, the verbal data will be analyzed via reflexive thematic analysis (Braun & Clarke, 2020), a method used in qualitative research to identify patterned themes within a given dataset. A reflexive thematic analysis involves the following phases: (1) familiarizing oneself with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes and 6) producing the final report.
In the second phase, after the interviews are transcribed verbatim, polytextual analysis of personal narratives (Gleeson, 2020; Meraz et al., 2019; Riessman, 2012), which serves to analyze a set of visual (visual images and video recordings) and verbal (verbatim transcriptions) data, will be carried out in Italian by two researchers (two research assistants who are clinical psychologists). Given the complex and multifaceted nature of the data in this study, Riessman (2012)’s analysis of personal narratives will be adopted, which is composed of (a) thematic, (b) structural, and (c) performance analyses (Meraz et al., 2019). Thematic analysis focuses on the content (i.e., what was said). Structural analysis focuses on the structure (i.e., how the narrative was shaped). The analysis will center on how participants structure their narratives through phototherapy techniques. Performance analysis focuses on the performative level (i.e., to whom the narrative is directed, how, and why). The analysis will examine how the participants want to be depicted through photographs (Riessman, 2008, 2012). This use of multiple methods of systematic evaluation of narrative data should provide access to a deeper meaning and help establish the validity of the findings (Meraz et al., 2019). It is important to note that while photographs created by participants will be used for analysis, no images that directly depict participants will be published in the final report to ensure their anonymity and protect their privacy.
In the third phase, after the interviews are transcribed verbatim, the verbal data will be analyzed using reflexive thematic analysis as in the first phase (Braun & Clarke, 2020).
Ethics and Dissemination
This study was reviewed and approved by the Ethics Committee of the Faculty of Social Welfare and Health Sciences, University of Haifa (#396–23). All participants will be provided with an informed consent form where it is clarified that participation in the study is on a voluntary basis, and anonymity and confidentiality are guaranteed as well as the right to discontinue participation at any time without penalty or loss of any benefits to which they are otherwise entitled. In the first phase, participants will be asked to provide their informed consent orally at the start of the recorded interview. In the second phase, participants will sign an informed consent form.
The results will be disseminated in articles that will be written in English as part of a doctoral dissertation, submitted for peer-reviewed journal publications and presented at conferences.
Rigor
Several procedures will be employed to uphold the qualitative rigor of the study. Throughout, to maintain reflexivity (i.e., being self-aware and critically reflecting on one’s own biases and assumptions and their influence on the research), the researchers will keep a reflexive journal to document their thoughts, feelings, and actions (Birks et al., 2008; Ortlipp, 2008). In the first and second phases, triangulation (i.e., using multiple methods or data sources in qualitative research to obtain a more exhaustive understanding of a phenomenon; (Flick, 2018; Patton, 1999) will be used. The data will be triangulated from four sources: professionals working with older women with phototherapy techniques, interviews with older women, video recordings, and the art products of the intervention sessions with older women. Moreover, in the second phase, an extended research team will meet regularly to discuss the implementation of the intervention and the research process. The recording of the sessions will be examined against the protocol to ensure treatment fidelity (Hildebrand et al., 2012). In the third phase, an audit procedure will be conducted by a research assistant, an Italian clinical psychologist who is unconnected with the study and can, therefore, offer an outsider’s perspective on the data (Berger, 2015). The research assistant will verify the accuracy of the analysis against the raw data in Italian. Finally, to strengthen the credibility of the researchers’ interpretations, a member-checking procedure will be performed, where the researcher will share the findings with the participants who will be invited to give feedback.
Discussion
The findings of this study will fill a gap in the literature on the embodied self-representation of older women in Italy using both verbal and non-verbal research methods. Furthermore, given the scarcity of studies in the field of phototherapy techniques, and with older women in particular, this study innovates in that it will develop an empirically based intervention adapted to the psychosocial needs of older women in Italy. Finally, it will document the potential transformative contribution of phototherapy techniques to the embodied self-representations of older women.
However, this study is not without limitations. One potential limitation is that phases 2 and 3 focus exclusively on older women with a normal cognitive profile, thus excluding those experiencing cognitive decline and any adjustments tailored for this group. Another potential limitation is that only community-dwelling older women will be included, thus excluding those living in facilities. Another potential limitation is that the first author will conduct both the intervention and the post-intervention interviews. However, the decision not to involve an external researcher was made to preserve the safe environment and trusting rapport established during the intervention. Several strategies will be employed to address potential bias in the qualitative study (Shenton, 2004). Triangulation will be achieved by incorporating multiple data sources, such as video observations of the sessions and participants’ art products, to complement the interviews and provide a broader perspective. Member checking will allow participants to review key findings and confirm their accuracy, promoting a more transparent dialogue. Additionally, potential social desirability bias will be documented in a reflexive journal, and other team members will be involved in the analysis to provide diverse perspectives and reduce the first author’s influence.
Overall, the development of phototherapy interventions based on data collected from professionals and the narratives and artworks of older women in Italy will represent a significant initial step in advancing research in the field of phototherapy, gender, and gerontology. This is particularly crucial for addressing muted and marginalized stories related to the aging female body and for combating social constructions regarding gender and age.
Footnotes
Author Contributions
All authors contributed equally to the conceptualization and design of the study. S.P. (MA, PhD candidate, clinical psychologist trained in the use of the Phototherapy Techniques, female) conducted the literature review that was examined and approved by H.O. (PhD, researcher and Associate Professor, certified psychodrama therapist, male) and S.K. (PhD, researcher and Associate Professor, certified drama therapist, female). All authors read and approved the final manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
