Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This scoping review addresses a timely and under-synthesized topic — the intersection of ageism and LGBTIQA+phobia in healthcare, viewed through a nursing lens. The manuscript is methodologically transparent (PRISMA-ScR compliant, prospectively registered on OSF), and the three-tier barrier taxonomy (structural, relational, social) provides a clear and useful organizing framework that is applied consistently from Results through Discussion. The PRISMA flow diagram numbers are internally consistent and check out arithmetically, which is a good sign of careful reporting. I recommend major revision, primarily to address the methodological inconsistency and quality-appraisal justification noted below, alongside a set of smaller but necessary corrections.

Major points

1. Age-inclusion criterion vs. actual study populations. The stated PCC population is “LGBTIQA+ people aged 65 years and over,” and the PubMed search was explicitly filtered to “Adults ≥ 65 years old.” However, several included studies have substantially broader age ranges — Kittle et al. (50–95), Prasad et al. (50+), Buczak-Stec et al. (40–70), Nguyen et al. (18–64), Adams et al. (≥15, general population). Please clarify explicitly in Section 2.3 how these studies met the stated inclusion criterion — for example, was inclusion based on age-disaggregated subgroup analyses for older participants, or was the ≥65 threshold relaxed in practice to ≥50 to capture a broader “older adult” literature? As currently written, the discrepancy between the stated criterion and the actual sample looks like an inconsistency that will draw scrutiny from readers and indexers alike.
2. Justification of the SIGN quality-appraisal tool. The manuscript states that SIGN levels of evidence were “adapted for observational studies, qualitative studies, and integrative reviews” but does not explain how this adaptation was performed. SIGN was designed around an intervention/therapy evidence hierarchy and does not map cleanly onto qualitative research, opinion papers, or historical case studies — several of which appear in your included sources (e.g., Matthews 2022, Sperling 2024, Perone 2024, Gillani 2026). Since you already ground your methodology in JBI guidance elsewhere in the manuscript, please justify why SIGN was chosen over a JBI-specific critical appraisal instrument (JBI has dedicated checklists for qualitative research, cross-sectional studies, etc.), or provide a supplementary table describing exactly how each design type was mapped onto the SIGN levels.

Minor points

3. Table 2 (Franco-Rocha O / 2025 row) contains a stray, orphaned “I” character in the Main Barriers column that appears to be a formatting artifact from table editing — please remove.
4. Several reference entries have corrupted or garbled formatting, most visibly #11 (“Rev Med [Internet]. 32d. C.;1:33-50”) and #21 (“Ann Intern Med [Internet]. 169d. C.;7:467-73”), which look like broken volume/issue exports from reference management software. Please review the full reference list carefully for similar artifacts before resubmission.
5. Language: overall fluent and readable, but a light copyediting pass is needed. Examples: an untranslated Spanish term appears in Section 3.2.2 (“invisibilización” — should be “invisibilization” or rephrased); a duplicated phrase appears in Section 4 (“real life real-world social networks”); a few other sentences would benefit from tightening for clarity.
6. Given how quickly this literature is growing, please strengthen the positioning of this review relative to the two other very recent, closely related reviews already cited within your own manuscript — Constantinou et al. 2025 (scoping review on older transgender people’s discrimination in healthcare) and Johansen et al. 2026 (integrative review on healthcare experiences of older LGBT+ adults). A sentence or two in the Introduction or Discussion explicitly stating what this review adds beyond those two (e.g., the explicit ageism × LGBTIQA+phobia intersectional framing, and the nursing-practice implications) would strengthen the novelty claim.
7. Consider noting in the Limitations that the heterogeneity in age range across included studies (point 1 above) may itself be a source of the “considerable variability” already acknowledged regarding definitions of “older adult” — tying these two limitations together would make the limitations section more coherent.

None of these issues undermine the overall value of the synthesis, which is well-organized and clearly written; they are addressable with revision rather than requiring new data collection.

Comments on the Quality of English Language

The manuscript is generally fluent and comprehensible, and the overall academic register is appropriate for the journal. However, a light copyediting pass is recommended before publication. Specific issues noted:

• An untranslated Spanish term appears in Section 3.2.2 ("invisibilización") — this should be rendered in English ("invisibilization") or rephrased.
• A duplicated/redundant phrase appears in Section 4 ("real life real-world social networks") — likely an editing artifact that should be resolved to one term.
• A few sentences throughout, particularly in the Discussion, are long and heavily subordinated, which occasionally obscures the main claim (e.g., the sentence in Section 4 beginning "The evidence map further demonstrates that inequalities in health insurance coverage..." strings together multiple citations and clauses in a way that would benefit from being split into two sentences).
• Reference list formatting inconsistencies (e.g., entries #11 and #21, where volume/issue data appears corrupted as "32d. C.;1:33-50" and "169d. C.;7:467-73") suggest a reference-manager export error rather than a language issue per se, but should be corrected alongside the language edit.

None of these issues impede comprehension of the science, but a professional language edit would improve readability and polish before typesetting.

Author Response

This scoping review addresses a timely and under-synthesized topic — the intersection of ageism and LGBTIQA+ phobia in healthcare, viewed through a nursing lens. The manuscript is methodologically transparent (PRISMA-ScR compliant, prospectively registered on OSF), and the three-tier barrier taxonomy (structural, relational, social) provides a clear and useful organizing framework that is applied consistently from Results through Discussion. The PRISMA flow diagram numbers are internally consistent and check out arithmetically, which is a good sign of careful reporting. I recommend major revision, primarily to address the methodological inconsistency and quality-appraisal justification noted below, alongside a set of smaller but necessary corrections.

Major points

1.- Age-inclusion criterion vs. actual study populations. The stated PCC population is “LGBTIQA+ people aged 65 years and over,” and the PubMed search was explicitly filtered to “Adults ≥ 65 years old.” However, several included studies have substantially broader age ranges — Kittle et al. (50–95), Prasad et al. (50+), Buczak-Stec et al. (40–70), Nguyen et al. (18–64), Adams et al. (≥15, general population). Please clarify explicitly in Section 2.3 how these studies met the stated inclusion criterion — for example, was inclusion based on age-disaggregated subgroup analyses for older participants, or was the ≥65 threshold relaxed in practice to ≥50 to capture a broader “older adult” literature? As currently written, the discrepancy between the stated criterion and the actual sample looks like an inconsistency that will draw scrutiny from readers and indexers alike.

We appreciate this important observation. As originally specified in the protocol, the PCC framework defined the Population as “LGBTIQA+ people aged 65 years and over”, and the PubMed search was restricted to adults ≥ 65 years to identify studies explicitly focused on older adults. In CINAHL, Scopus and the Cochrane Library, however, no age filters were applied, and during screening we adopted a pragmatic life‑course approach consistent with the heterogeneity of age definitions in the existing literature. Specifically, we included studies that either (a) reported age‑disaggregated findings for older participants or (b) focused on adults in mid‑ to later life (typically ≥50 years), where barriers and health outcomes were directly relevant to the accumulation of disadvantage into older age.

To enhance transparency, we have now clarified this approach in Section 2.3 (“Selection of Sources of Evidence, Data Extraction, and Data Synthesis”) by adding the following paragraph immediately after the list of inclusion criteria (lines 174-183).

In addition, we have revised Section 4.4 (“Limitations of the Evidence Base and the Present Scoping Review”) to make this limitation explicit and link it to the variability in definitions of “older adult”. The previous sentence on heterogeneity has been replaced (lines 523-527).

We hope these clarifications resolve the apparent inconsistency between the PCC definition and the actual study populations and make our life‑course approach explicit to readers and indexers.

2.- Justification of the SIGN quality-appraisal tool. The manuscript states that SIGN levels of evidence were “adapted for observational studies, qualitative studies, and integrative reviews” but does not explain how this adaptation was performed. SIGN was designed around an intervention/therapy evidence hierarchy and does not map cleanly onto qualitative research, opinion papers, or historical case studies — several of which appear in your included sources (e.g., Matthews 2022, Sperling 2024, Perone 2024, Gillani 2026). Since you already ground your methodology in JBI guidance elsewhere in the manuscript, please justify why SIGN was chosen over a JBI-specific critical appraisal instrument (JBI has dedicated checklists for qualitative research, cross-sectional studies, etc.), or provide a supplementary table describing exactly how each design type was mapped onto the SIGN levels.

We agree that further justification and explanation were needed. We followed JBI methodological guidance for scoping reviews, which generally discourages excluding studies based on formal critical appraisal and emphasizes mapping the evidence base regardless of quality. In this context, our aim was to provide a simple, cross‑design indication of the relative strength and consistency of the findings, rather than to determine eligibility.

We selected the Scottish Intercollegiate Guidelines Network (SIGN) levels of evidence because they offer a concise hierarchical framework that can be applied across heterogeneous study designs (analytical observational, qualitative, mixed‑methods and reviews) using a single taxonomy, instead of multiple design‑specific JBI checklists. We then adapted the SIGN levels to the types of designs included in our review as follows: analytical observational studies (e.g., cross‑sectional and cohort designs) were classified as level 2+ or 2‑ depending on risk of bias and analytical rigor; qualitative and other non‑analytical designs (e.g., grounded theory, phenomenological studies, historical case studies) were assigned level 3; opinion papers were classified as level 4; and integrative or scoping reviews synthesizing observational and qualitative evidence were generally mapped to level 2‑.

To make this rationale explicit and avoid any ambiguity, we have revised Section 2.4 (“Quality Assessment”) (lines 254-272).

We trust that this expanded explanation clarifies both our choice of SIGN and the way in which the tool was adapted for the heterogeneous designs included in the review, while remaining consistent with JBI guidance for scoping reviews.

Minor points

3.- Table 2 (Franco-Rocha O / 2025 row) contains a stray, orphaned “I” character in the Main Barriers column that appears to be a formatting artifact from table editing — please remove.

We appreciate the reviewer’s attention to detail. The orphaned “I” character in the Main Barriers column of the Franco‑Rocha et al. (2025) row was indeed a formatting artifact from table editing. We have removed this character in the revised version.

4.- Several reference entries have corrupted or garbled formatting, most visibly #11 (“Rev Med [Internet]. 32d. C.;1:33-50”) and #21 (“Ann Intern Med [Internet]. 169d. C.;7:467-73”), which look like broken volume/issue exports from reference management software. Please review the full reference list carefully for similar artifacts before resubmission.

We agree that the corrupted formatting in reference entries #11 and #21 (now#23). We have reviewed the full reference list and corrected these and other minor inconsistencies in volume, issue and pagination formatting prior to resubmission.

5.- Language: overall fluent and readable, but a light copyediting pass is needed. Examples: an untranslated Spanish term appears in Section 3.2.2 (“invisibilización” — should be “invisibilization” or rephrased); a duplicated phrase appears in Section 4 (“real life real-world social networks”); a few other sentences would benefit from tightening for clarity.

We thank the reviewer for the helpful suggestions regarding language. In Section 3.2.2, we have replaced the untranslated Spanish term “invisibilización” with an English expression (“invisibility of identities and relationships”) to ensure consistency of language. We have also corrected the redundant phrase “real life real‑world social networks” so that it reads simply “real‑world social networks”, and we have split one of the longer, heavily subordinated sentences in the Discussion into two shorter sentences to improve clarity. We have undertaken a light copyediting pass throughout the manuscript to address similar issues of style and readability (lines 357-359).

We thank the reviewer for pointing out that some sentences in the Discussion were long and heavily subordinated. In particular, the sentence beginning “The evidence map further demonstrates that inequalities in health insurance coverage…” has been revised to improve readability while preserving its original meaning.

In the revised manuscript, this sentence has been split into two shorter sentences (lines 436-442).

This change is intended to make the main claim more transparent to readers, while maintaining the original set of supporting references for each component of the argument.

6.- Given how quickly this literature is growing, please strengthen the positioning of this review relative to the two other very recent, closely related reviews already cited within your own manuscript — Constantinou et al. 2025 (scoping review on older transgender people’s discrimination in healthcare) and Johansen et al. 2026 (integrative review on healthcare experiences of older LGBT+ adults). A sentence or two in the Introduction or Discussion explicitly stating what this review adds beyond those two (e.g., the explicit ageism × LGBTIQA+ phobia intersectional framing, and the nursing-practice implications) would strengthen the novelty claim.

We appreciate the reviewer’s suggestion to more clearly situate our scoping review in relation to Constantinou et al. (2025) and Johansen et al. (2026), both of which are cited in our manuscript. We have now added explicit statements in the Introduction and Discussion outlining how the present review complements and extends these works: by focusing specifically on the intersection of ageism and LGBTIQA+ phobia, by synthesizing barriers across structural, relational and social levels, and by foregrounding nursing practice and education implications. We believe these additions strengthen the novelty claim and clarify the added value of our synthesis (lines 114-119).

7.- Consider noting in the Limitations that the heterogeneity in age range across included studies (point 1 above) may itself be a source of the “considerable variability” already acknowledged regarding definitions of “older adult” — tying these two limitations together would make the limitations section more coherent.

We agree that the heterogeneity in age ranges across the included studies should be explicitly tied to the “considerable variability” already acknowledged regarding definitions of “older adult”. As noted in our response to Major Comment 1, we have revised Section 4.4 to state that the included sources span mid‑life to later life (e.g., ≥50 years and ≥65 years) and that this heterogeneity in age range and operationalization of “older adult”, together with variability in LGBTQIA+ identity categories, limits direct comparison of findings and should be considered when interpreting the evidence (lines 539-545).

None of these issues undermine the overall value of the synthesis, which is well-organized and clearly written; they are addressable with revision rather than requiring new data collection.

Comments on the Quality of English Language

The manuscript is generally fluent and comprehensible, and the overall academic register is appropriate for the journal. However, a light copyediting pass is recommended before publication. Specific issues noted:

An untranslated Spanish term appears in Section 3.2.2 ("invisibilización") — this should be rendered in English ("invisibilization") or rephrased.

In Section 3.2.2, the untranslated Spanish term “invisibilización” has been replaced with the English expression “invisibility of identities and relationships”, ensuring consistent use of English throughout the text.

A duplicated/redundant phrase appears in Section 4 ("real life real-world social networks") — likely an editing artifact that should be resolved to one term.

The duplicated and redundant phrase “real life real‑world social networks” has been corrected so that it now reads simply “real‑world social networks” in the relevant section.

A few sentences throughout, particularly in the Discussion, are long and heavily subordinated, which occasionally obscures the main claim (e.g., the sentence in Section 4 beginning "The evidence map further demonstrates that inequalities in health insurance coverage..." strings together multiple citations and clauses in a way that would benefit from being split into two sentences).

Several long and heavily subordinated sentences in the Discussion have been revised for clarity. In particular, the sentence beginning “The evidence map further demonstrates that inequalities in health insurance coverage…” has been split into two shorter sentences that separately describe (a) the linkage between structural inequalities and experiences of discrimination and (b) the resulting pattern of cumulative vulnerability across the life course, with the original supporting citations retained for each part.

Reference list formatting inconsistencies (e.g., entries #11 and #21, where volume/issue data appears corrupted as "32d. C.;1:33-50" and "169d. C.;7:467-73") suggest a reference-manager export error rather than a language issue per se but should be corrected alongside the language edit.

We have reviewed the full reference list and corrected formatting inconsistencies arising from reference‑manager export errors, including the corrupted volume/issue data in entries #11 and #21 (now #23).

None of these issues impede comprehension of the science, but a professional language edit would improve readability and polish before typesetting.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This scoping review addresses a relevant and timely topic, and the manuscript presents several strengths, including a clearly formulated research question, the use of the PCC framework, the consideration of structural, interpersonal, and social barriers, and the attempt to connect the findings with nursing practice, minority stress, and intersectionality. Overall, the manuscript is well structured, and the topic is clearly relevant to healthcare practice and policy.

However, I believe that important methodological issues need to be addressed before the manuscript can be considered for publication.

1. The eligibility criteria and the populations actually included require substantial reconsideration. The Methods section explicitly defines the population as LGBTIQA+ people aged 65 years and older. However, several of the sources included in Table 2 do not appear to meet this criterion. Examples include studies involving participants with lower age ranges. This has a substantial impact on the other sections of the review and represents a highly relevant methodological flaw.

2. There is also an inconsistency regarding eligible publication types. The manuscript states that commentaries, editorials, and purely theoretical articles without sufficiently developed empirical data were excluded. However, Table 2 includes Matthews et al. as an “opinion paper” based on previous evidence and clinical recommendations rather than as a direct empirical study. Therefore, the rationale for its inclusion should be clarified or the source should be reconsidered. More generally, the authors should verify that all included sources comply with the stated criteria.

3. The search strategy requires substantial clarification and greater reproducibility. The searches presented in Table 1 use different limits depending on the database, including a five-year restriction in some searches but only a one-year restriction in part of the Scopus search.

4. The manuscript states that the SIGN levels of evidence and grades of recommendation were “adapted” to observational studies, qualitative studies, and integrative reviews, but the adaptation procedure is not described.

5. The manuscript should distinguish more clearly between direct evidence on ageism and broader evidence concerning health inequalities among LGBTIQA+ people. The stated objective includes mapping how both ageism and LGBTIQA+phobia have been conceptualized. However, several of the included studies appear to focus primarily on social support, mental health, health behaviours, access to services, socioeconomic disadvantage, or LGBTQIA+ experiences more broadly, without directly assessing ageism.

6. In relation to the previous point, the title, objectives, synthesis, and conclusions should remain closely aligned with the evidence ultimately retained. If the revised corpus primarily maps barriers experienced by older LGBTIQA+ people rather than studies specifically examining the intersection between ageism and LGBTIQA+phobia, the title and objectives may need to be reformulated accordingly.

7. The reporting of the study selection process should be reviewed to ensure full consistency with PRISMA-ScR. The manuscript states that 124 records were screened and that 76 were excluded because the full text was unavailable or because they were outside the scope of the review. Unavailable full texts should normally be distinguished from records excluded during title and abstract screening and reported at the appropriate retrieval stage.

Finally, the manuscript would benefit from careful language editing and greater consistency in terminology. Different acronyms such as LGBTIQA+, LGBTQIA+, LGBT+, and related variants are used throughout the text.

Author Response

This scoping review addresses a relevant and timely topic, and the manuscript presents several strengths, including a clearly formulated research question, the use of the PCC framework, the consideration of structural, interpersonal, and social barriers, and the attempt to connect the findings with nursing practice, minority stress, and intersectionality. Overall, the manuscript is well structured, and the topic is clearly relevant to healthcare practice and policy.

However, I believe that important methodological issues need to be addressed before the manuscript can be considered for publication.

1.- The eligibility criteria and the populations actually included require substantial reconsideration. The Methods section explicitly defines the population as LGBTIQA+ people aged 65 years and older. However, several of the sources included in Table 2 do not appear to meet this criterion. Examples include studies involving participants with lower age ranges. This has a substantial impact on the other sections of the review and represents a highly relevant methodological flaw.

We thank Reviewer 2 for highlighting the methodological implications of the age‑inclusion criterion. As noted in our response to Reviewer 1, the PCC framework initially defined the Population as “LGBTIQA+ people aged 65 years and over”, and the PubMed search was restricted to adults ≥ 65 years. In CINAHL, Scopus and the Cochrane Library, no age filters were applied, and during screening we adopted a pragmatic life‑course approach: we included studies that either reported age‑disaggregated findings for older participants or focused on adults in mid‑ to later life (typically ≥50 years) where barriers and health outcomes are directly relevant to the accumulation of disadvantage into older age.

We have now made this approach explicit in Section 2.3 (lines 170-179) and have revised Section 4.4 to acknowledge that the heterogeneity in age ranges and operational definitions of “older adult” is a limitation that affects comparability across studies. In the revised manuscript, the text clarifies that some sources focus on adults ≥65 years, while others examine broader age bands (e.g., ≥50 years or adult samples with age‑stratified analyses), and that this heterogeneity should be borne in mind when interpreting the strength and scope of the evidence (lines 539-545).

2.- There is also an inconsistency regarding eligible publication types. The manuscript states that commentaries, editorials, and purely theoretical articles without sufficiently developed empirical data were excluded. However, Table 2 includes Matthews et al. as an “opinion paper” based on previous evidence and clinical recommendations rather than as a direct empirical study. Therefore, the rationale for its inclusion should be clarified or the source should be reconsidered. More generally, the authors should verify that all included sources comply with the stated criteria.

We appreciate the reviewer’s observation regarding the consistency between our stated exclusion criteria and the inclusion of Matthews et al. in Table 2. In the original version, we excluded “commentaries, editorials, and purely theoretical articles” lacking sufficiently developed empirical data. Matthews et al. (2022), although presented as an opinion paper, synthesizes previous empirical evidence and clinical recommendations to discuss ways of improving care for older LGBT+ people, and was included for its direct relevance to nursing practice and service organization.

To avoid ambiguity, we have refined the wording of our exclusion criteria in Section 2.3 to specify that we excluded commentaries and editorials that do not draw on empirical evidence or clinical recommendations relevant to older LGBTIQA+ people. We also clarify in Table 2 and Section 2.4 that Matthews et al. is classified as an opinion‑based synthesis (SIGN level 3), used to contextualize practice implications rather than as primary empirical evidence. We have verified that all other included sources comply with the revised criteria (line 191).

3.- The search strategy requires substantial clarification and greater reproducibility. The searches presented in Table 1 use different limits depending on the database, including a five-year restriction in some searches but only a one-year restriction in part of the Scopus search.

We thank Reviewer 2 for drawing attention to the apparent inconsistency in the time limits reported in Table 1. The intention of our search strategy was to apply a five‑year restriction across all databases in order to focus on the most recent evidence. The “1 year” limit that appears in part of the Scopus search in the original table was an error arising from the reference‑manager/export process rather than a deliberate methodological choice.

In the revised manuscript, we have corrected Table 1 so that all database searches are consistently reported as restricted to the last five years, in line with the Methods description. This correction is intended to eliminate the apparent discrepancy and improve the reproducibility of the search strategy.

4.- The manuscript states that the SIGN levels of evidence and grades of recommendation were “adapted” to observational studies, qualitative studies, and integrative reviews, but the adaptation procedure is not described.

We appreciate that the adaptation of the SIGN levels of evidence required clearer description. As detailed in the revised Section 2.4, we selected SIGN because it provides a concise, cross‑design hierarchy that can be applied across analytical observational studies, qualitative research, mixed‑methods designs and reviews. We then mapped each study design to the SIGN levels as follows: analytical observational studies were classified as level 2+ or 2‑ depending on risk of bias and analytical rigor; qualitative and other non‑analytical designs (e.g., grounded theory, phenomenological studies, historical case studies) were assigned level 3; opinion papers were classified as level 4; and integrative or scoping reviews synthesizing observational and qualitative evidence were generally mapped to level 2‑. Table 3 presents the resulting level of evidence and grade of recommendation for each source, which were used solely to describe the strength and consistency of the evidence, in line with JBI guidance for scoping reviews (lines 254-272).

5.- The manuscript should distinguish more clearly between direct evidence on ageism and broader evidence concerning health inequalities among LGBTIQA+ people. The stated objective includes mapping how both ageism and LGBTIQA+ phobia have been conceptualized. However, several of the included studies appear to focus primarily on social support, mental health, health behaviours, access to services, socioeconomic disadvantage, or LGBTQIA+ experiences more broadly, without directly assessing ageism.

6.- In relation to the previous point, the title, objectives, synthesis, and conclusions should remain closely aligned with the evidence ultimately retained. If the revised corpus primarily maps barriers experienced by older LGBTIQA+ people rather than studies specifically examining the intersection between ageism and LGBTIQA+ phobia, the title and objectives may need to be reformulated accordingly.

We thank the reviewer for this nuanced methodological point. We agree that relatively few of the included studies explicitly operationalize “ageism” as a measured construct. Many sources instead document barriers, discriminatory experiences and health inequalities affecting older LGBTIQA+ people, which we interpret through an ageism and LGBTIQA+ phobia lens.

To address this, we have revised the Introduction and Discussion to make this distinction explicit. The revised text clarifies that the evidence map brings together studies that either directly examine age‑related discrimination in healthcare or report barriers and inequalities affecting older LGBTIQA+ people in ways that are consistent with ageist and cisheteronormative dynamics, even when the term “ageism” is not used in the original articles. We have also added a sentence in the Limitations noting that explicit ageism measures are scarce and that our intersectional interpretation of ageism and LGBTIQA+ phobia is based on conceptual alignment rather than on uniform operationalization of ageism across studies.

In light of this clarification, we have maintained the current title, which reflects the conceptual framing of the review, but we have slightly refined the objectives paragraph in the Introduction (lines 110-113) to emphasize that our aim is to map barriers and inequalities within healthcare affecting older LGBTIQA+ people and to examine how ageism and LGBTIQA+ phobia are addressed or implied in the existing literature, rather than to restrict inclusion to studies that explicitly label ageism as such.

In the section on limitations, it was noted that relatively few of the included studies explicitly operationalize “age discrimination” as a measurable construct (lines 523-527). It also clarifies the intersectional approach to age discrimination and discrimination against LGBTIQA+ individuals based on the conceptual correspondence between the barriers described and age-related and cisheteronormative dynamics (lines 545-549).

7.- The reporting of the study selection process should be reviewed to ensure full consistency with PRISMA-ScR. The manuscript states that 124 records were screened and that 76 were excluded because the full text was unavailable or because they were outside the scope of the review. Unavailable full texts should normally be distinguished from records excluded during title and abstract screening and reported at the appropriate retrieval stage.

We thank Reviewer 2 for highlighting the need to distinguish more clearly between records excluded at title–abstract screening and full‑text articles excluded because they were outside the scope of the review or unavailable. In the revised manuscript, we have updated both the PRISMA‑ScR flow diagram and the corresponding text to reflect these stages separately.

Specifically, we now report that, after title–abstract screening, full‑text articles were assessed for eligibility and that 76 full‑text articles were excluded at this stage: 22 because they were outside the scope of the review and 54 because the full text could not be obtained despite reasonable efforts. These changes bring the reporting of the study selection process into closer alignment with PRISMA‑ScR guidance and clarify the reasons for exclusion at the full‑text stage.

Finally, the manuscript would benefit from careful language editing and greater consistency in terminology. Different acronyms such as LGBTIQA+, LGBTQIA+, LGBT+, and related variants are used throughout the text.

We appreciate the reviewer’s observation regarding the use of different acronyms (LGBTIQA+, LGBTQIA+, LGBT+, and related variants) throughout the manuscript. In the revised version, we have harmonized terminology by adopting “LGBTIQA+” as the primary umbrella term for sexual and gender minority populations, ensuring greater consistency in the narrative sections.

The only remaining variations in acronyms appear when we describe individual studies that use specific terminology (e.g., LGBT+, LGBTQIA+) in their original publications (table 2 and Spanish law). In those cases, we have deliberately retained the authors’ own acronyms to accurately reflect the populations and labels used in each study, while clarifying in the Methods that “LGBTIQA+” is used as the overarching term in this review. We hope this approach balances consistency of terminology with fidelity to the primary sources.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The changes made by the authors address the issues raised by this reviewer.