Silenced by design: epistemic injustice and older women's experiences in total hip replacement.

Despite the increasing prevalence of total hip replacement (THR), older women’s post-operative experiences—particularly those related to pain, sexual wellbeing, and quality of life—remain insufficiently recognized within orthopaedic research and clinical practice. Drawing on bioethics and theories of epistemic injustice, this article offers a philosophical analysis of how gendered ageism shapes what counts as relevant knowledge in post-THR care. Building on Katrina Hutchison’s account of moral aggregation in medical device design, I argue that harms to older women arise not primarily through overt discrimination but through the cumulative effects of research design choices, outcome measures, and clinical norms that systematically marginalize experiential and age-specific concerns. To explain how these structural conditions translate into lived silencing within clinical encounters, I apply Kristie Dotson’s concept of testimonial smothering, showing how older women may reasonably withhold testimony about pain or sexual wellbeing in anticipation of misunderstanding, dismissal, or trivialization. Rather than presenting new empirical data, the article synthesizes existing research on orthopaedic outcomes, clinician–patient communication, and sexuality in later life to demonstrate why testimonial smothering in THR contexts is both plausible and ethically significant. Finally, drawing on José Medina’s notion of micro-resistance, the paper outlines modest, practice-level interventions that can mitigate epistemic exclusion within existing clinical and research environments. Attending to older women’s experiences in THR thus reveals broader structural challenges in how medical knowledge is produced, authorized, and acted upon in contexts of health equity.