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. Author manuscript; available in PMC: 2024 Feb 1.
Published in final edited form as: Stigma Health. 2022 Jan 20;8(1):85–92. doi: 10.1037/sah0000356

Discrimination of Sexual and Gender Minority Patients in Prostate Cancer Treatment: Results from the Restore-1 Study

Michael W Ross 1, B R Simon Rosser 1, Elizabeth J Polter 1, Alex J Bates 1, Christopher W Wheldon 2, Ryan Haggart 3, William West 4, Nidhi Kohli 5, Badrinath R Konety 6, Darryl Mitteldorf 7, G Kristine MC Talley 8, Morgan Wright 1
PMCID: PMC9917961  NIHMSID: NIHMS1763994  PMID: 36779009

Abstract

This study is the first to quantify experiences of discrimination in treatment undertaken by sexual and gender minority prostate cancer patients. Participants were 192 gay and bisexual and one transgender prostate cancer patients living in the US recruited from North America’s largest online cancer support group. In this online survey, discrimination in treatment was measured using the Everyday Discrimination Scale (EDS), adapted for medical settings. Almost half (46%) endorsed at least one item, including 43% that the provider did not listen, 25% that they were talked down to, 20% that they received poorer care than other patients, 19% that the provider acted as superior, and 10% that the provider appeared afraid of them. While most (26.3%) rated the discrimination as “rare” or “sometimes” (EDS=1–3), 20% reported it as more common (EDS≥4). Most attributed the discrimination to their sexual orientation, or to providers being arrogant or too pushed for time. Discrimination was significantly associated with poorer urinary, bowel, and hormonal (but not sexual) EPIC function and bother scores, and with poorer mental health (SF-12). Those who had systemic/combined treatment (versus either radiation only or surgery only) were more likely to report discrimination. This study provides the first evidence that discrimination in prostate cancer treatment, including micro-aggressions, appear a common experience for gay and bisexual patients, and may result in poorer health outcomes.

Introduction

While there is a large literature on everyday discrimination, and a smaller literature on discrimination based on sexual orientation and gender identity, less is known about discrimination experiences of sexual and gender minorities (SGM) when they are patients. Balik et al 2020 completed a systematic review of discrimination against sexual and gender minority in health care settings. They found that the rate of discrimination experienced by SGM populations varied from as low as 2% to as high as 42%. Ruben et al. (2019) report that discrimination is also common among SGM veterans seeking healthcare at veterans’ affairs facilities. Additionally, Casey et al. found in a nationally representative sample of SGM adults that discrimination during health care encounters regularly occurred, with 16% of participants indicating they had faced discrimination. These findings have been replicated in multiple studies in sub-Saharan Africa which have also found that discrimination against SGM populations is common in health care settings (Fay et al., 2011; Risher et al., 2013).

Specific patient populations, such as men who have been diagnosed with prostate cancer, have not been surveyed about their experiences of discrimination while undergoing treatment and their attributions of such discrimination. To inform this study, in 2016, we conducted clinical interviews with 19 sexual minority prostate cancer patients. While several spoke of positive experiences in treatment, at least three described negative experiences (West et al., 2021).

The first reported, “The reason I left my urologist was because he, even though I’d told him innumerable times that I was gay, he [kept saying], ‘Bring the wife in.’ I thought, ‘Why am I with this person?’” The second described his experience this way. “The urologist, who I went to for the biopsy, when I identified myself as a gay man, he immediately walked behind the desk and sat down and never came close to me again. … He really wanted nothing more to do with me or I with him, so I left that practice immediately.” A third described his experience. “I think it was during the first encounter with the urologist. He said, ‘So, you’re married and you have children.’ I said, “Well, I’m married but I don’t have children. Because we’re working in a part of the body where I think it might matter, [I said] ‘I’m gay.’ He did the most funny thing. He kind of put his hands up in front of his chest, sort of like hands up, don’t shoot. [He responded], ‘It’s okay. Don’t worry. I’m not going to hurt you. Biopsy won’t be worse because you’re gay.’ [I] wondered, ‘Oh, do you punish people? Do you give them a really rough biopsy?” We appreciate the physicians in these accounts likely did not intend to offend their patients, however their actions and words were perceived negatively and as evidence of a negative healthcare encounter.

We concluded from these interviews, first, that not all patient experiences were positive, and second, that these negative experiences were sufficient in some cases for patients to change their treatment. So, we decided to include measurement of perceived experiences of discrimination in treatment for this quantitative study.

SGM populations face significant cancer health disparities, however they remain a severely under-researched population with the absence of SGM cancer studies being well documented (Alexander, Parker, & Schwetz, 2016; Kent et al., 2019; Graham et al., 2011). According to a recent review by Kent et al., (2019), SGMs face a disproportionate burden of cancer, with little known about their unique experiences and needs. Indeed, prior to this study, only 1–2 papers on prostate cancer in SGM were published per year and most of these were anecdotal accounts. To address this gap in research, the Restore-1 study was conducted to study the sexual sequelae of prostate cancer in SGM patients with the long-term objective to improve clinical treatment (Rosser et al., 2020). In addition, based on our qualitative interviews with patients, we decided to investigate how SGM patients experience treatment, including experiences of discrimination. Consistent with Minority Stress Theory, we hypothesized that experiences of discrimination in treatment would be associated with poorer treatment outcomes.

Methods

Participants

The Restore-1 study protocol was approved by the University of Minnesota Institutional Review Board (1408S52902). Recruitment for the survey was conducted online at Malecare.org, a large North American cancer support group and advocacy organization. Annually, 800–1000 newly diagnosed Gay and Bisexual Men) GBM with prostate cancer seek support from Malecare. Participants were recruited through the organization’s email listserv and banner advertisements: “Sexual Effects of Prostate Cancer in Gay and Bisexual Men.” By clicking on the advertisement, potential enrollees were transported to the study Web site where they completed an eligibility screener. To be eligible, a participant had to check that they: (1) were a gay, bisexual, or other man who has sex with men, or transwoman assigned male at birth (2) had been treated for prostate cancer, and (3) resided in a US zip code or Canadian postal code. For consent, we adapted our published chunked online consent protocol (Rosser, et al., 2009a). Enrollees reviewed and affirmed seven screens detailing study purpose, risks, benefits, and payment preference. A cross-validation and deduplication protocol (Grey et al., 2015) was used to flag and manually investigate suspect surveys. Data collection began October 21, 2015, and ended January 1, 2016 (72 days). Each participant received a $25 gift card as compensation.

Our primary recruitment strategy was a series of four emails sent to Malecare.org members at approximately 7–10-day intervals, supplemented by advertisements on Malecare.org. In total, we received 502 click-throughs onto our welcome page. A total of 434 (86.5%) passed eligibility, and 417 (96.1%) consented to participate. Prior to analysis, our cross-validation and deduplication protocol identified 233 surveys as likely invalid or duplicative (DeWitt et al., 2018). One incomplete survey was also removed, leaving 193 (99.5%) surveys deemed to be from unique, valid participants. All study procedures were approved by the University of Minnesota’s human participants’ protection program.

Measures

The survey questionnaire was in English and consisted of 15 sections, with a total of about 150 questions. To minimize participant burden, skip and branch patterns were used to administer only those questions that were relevant to each participant. We used the Experiences of Discrimination Scale (Williams, 2012), with seven items for provider interaction, and 10 items of respondent characteristics, including sexual orientation. In addition, an “other” category was included, as well as a “refuse to answer” option. The original scale (Williams, 2012) as modified by Peek et al. (2011) for medical settings was used, with the question “During your interactions with health care providers for prostate cancer treatment, how often did the following happen? Peek et al.’s response options (Never, Rarely, Sometimes, Most of the time, Always, and Refuse to answer) were used. “What do you think were the main reason(s) for these experiences?” was used to expand the original scale’s 10 categories.

The Everyday Discrimination Scale (EDS) is particularly useful for looking at intersectional discrimination. In a study of obese treatment-seekers by Pearl et al. (2018), 29% reported discrimination based on weight, and over half also reported discrimination based on African American race. Diabetes-related stress and depressive symptoms were studied in African American and LatinX patients by LeBron et al. (2014). They report that diabetes-related disease was significantly associated with discrimination in the LatinX but not the African American population, and recommend the need to address stressors unique to specific minorities in everyday life.

One of the advantages of the EDS is that attribution of the reason for discrimination that occurs can be measured. The attributions include the respondent’s ancestry or national origins, gender, race, age, religion, height, weight, sexual orientation, or education or income level, with other relevant categories added as appropriate. Thus, multiple attributions are possible, which is important if there are several perceived characteristics on which discrimination can be based. These intersectional factors are largely visible or salient features of the person filling out the test. We were particularly interested in sexual minority men with prostate cancer’s experiences with health care providers, since being a sexual or gender minority is a largely hidden stigma.

Prostate cancer specific quality of life was assessed using the Expanded Prostate Cancer Index Composite (EPIC) scale. The 50-item scale measures frequency and perceived bother in four different domains (urinary, bowel, sexual, and hormonal). Each domain and subscale are scored from 0 to 100, with higher scores indicating better function and less bother. The EPIC-50 scale has acceptable scale and subscale reliability (r≥0.80) and internal consistency (α≥0.82) (Hart et al., 2014; Wei et al., 2000). The 12-item Short Form Survey (SF-12) was used to estimate overall health-related quality of life, with the generic measure yielding two subscales (mental and physical functioning). Each subscale is scored from 0 to 100, with higher scores indicating better health. Two-week test-retest reliability for the physical subscale was r=0.80 and r=0.76 for the mental subscale (Ware, Kosinski, & Keller, 1996). To measure internalized homonegativity, we used the short form of the Reactions to Homosexuality scale (Smolenski et al., 2010).

Demographics, Sexual Characteristics, and Medical Information

Demographic questions (age, gender, sex at birth, race, ethnicity, and education) were adapted from the US Census. Sexual characteristic questions (identity, degree of outness, relationship status, and HIV status) were based on prior research (Rosser, et al., 2009b; Rosser, et al., 2009c). Medical characteristic questions included prostate-specific antigen (PSA) level at diagnosis (a biomarker used in prostate cancer screening) and Gleason score (a measure of tumor aggressiveness) and current prostate cancer status), the wording of which was taken from prior studies (Brimo et al., 2013; Latini et al., 2009; Wassersug et al., 2016). Prostate cancer treatment was investigated by asking participants to check which of nine treatments they have undergone.

Analysis

Univariate analyses were conducted to estimate the crude associations between discrimination as a binary variable and key sociodemographic, sexual, and medical participant characteristics. Continuous variables were assessed using t-tests and chi-square tests were used to analyze categorical variables. T-tests were used to compare scores in each EPIC-50 subdomain and each SF-12 subscale across discrimination as a binary variable. Binary logistic regression was used to evaluate the relationship between discrimination and treatment type. All reported p-values were two-sided. Data were analyzed using Stata version 12 (StataCorp, College Station, TX).

Results

Of the 193 men enrolled, 94.3% were from the U.S. and 5.7% Canada. The great majority (90.7%) identified as gay/homosexual, one as transsexual assigned male at birth, and 9.3% identified as bisexual, gay and bisexual, bisexual and heterosexual, or “a man who has sex with men”. The modal age category was 60–69 (42.5%) followed by 50–59 (28.5%). Race categorization was White (89.1%), Black/African American (4.7%), Asian American (2.1%), Native American (1%), and the remainder identifying as other races or multiracial. Ethnicity was 96.4% non-Hispanic, 3.1% Hispanic, and modal education was graduate degree (41.5%) followed by bachelor’s degree (35.8%) and high school/GED or associates degree (22.8%). Current relationship status was married or long-term relationship (to a man) 53.4%, dating 6.7%, widower, divorced or no longer in relationship, 7.3%, and single 30.1%. “Outness” about sexual orientation was out to all/almost all 60.6%, out to most people 17.1%, to about half 4.7%, to a few 15.5%, and not out 2.1%. Most (79.3%) participants reported being fully out to their primary care provider, followed by their nurse educator (64.2%), urologist (61.5%), surgeon (61.1%), and oncologist (58.4%). Due to an error in the survey program, forty-four participants who saw a urologist were not given the follow-up question regarding outness to their urologist.

Data on EDS responses appear in Table 1. The attributions of discrimination and “other” responses are reported in Table 2. Overall, 53.7% reported no experience of discrimination, while 46.3% endorsed at least one item as having occurred to them during treatment. The most common reported forms of discrimination (or micro-aggression) were “You felt like a doctor or nurse was not listening to what you were saying” (endorsed by 42% of patients); “A doctor or nurse acted as if he or she thinks you are not smart” (24%); “You were treated with less courtesy than other people” (18%); “A doctor or nurse acted as if he or she was better than you” (18%); “You were treated with less respect than other people” (18%); “You received poorer service than others” (13%); and “A doctor or nurse acted as if he or she was afraid of you” (8%). Participants selected the frequency of each discriminatory experience, from “never’ to “always”, but no participant answered more than “most of the time” on any item. In terms of EDS score, where 0 was no discrimination, through to 4 (always), where total possible score was 28, 10.5% scored 1, 10% scored 2, 5.8% scored 3, with the remaining 20% ranged between 4 and 22 (Figure 1).

Table 1.

Everyday Discrimination Scale Responses

During your interactions with healthcare providers for prostate cancer treatment, how often did the following happen?

Never Rarely Sometimes Most of the Time Always Refuse to Answer
N % N % N % N % N % N %
You were treated with less courtesy than other people 155 80.3 18 9.3 16 8.3 1 0.5 0 0 3 1.6
You were treated with less respect than other people 158 81.9 17 8.8 14 7.3 1 0.5 0 0 3 1.6
You received poorer service than others 167 86.5 13 6.7 10 5.2 1 0.5 0 0 2 1.0
A doctor or nurse acted as if he or she thinks you are not smart 145 75.1 22 11.4 19 9.8 4 1.0 0 0 3 1.6
A doctor or nurse acted as if he or she was afraid of you 176 91.2 10 5.18 6 3.11 0 0 0 0 1 0.52
A doctor or nurse acted as if he or she was better than you 156 80.8 15 7.8 14 7.3 5 2.6 1 0.5 2 1.0
You felt like a doctor or nurse was not listening to what you were saying 110 57.0 37 19.2 37 19.2 6 3.1 0 0 3 1.6
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Table 2.

What do you think were the main reason(s) for these experiences?

N %
Your ancestry or national origins 1 1%
Your gender 4 2%
Your race 2 1%
Your age 7 4%
Your religion 1 1%
Your height 0 0%
Your weight 1 1%
Some other Aspect of your physical appearance 3 2%
Your sexual orientation 18 9%
Your education or income level 4 2%
Other 24 12%
Refuse to answer 5 3%
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“Other” category responses for Discrimination Arrogance

Attitude /motivation of urologist

Doctor’s attitude - condescending

Doctors can be arrogant assholes

Medical elitism

Medical personnel tend to discount feelings of non-pros

They know it all

One doctor was curt

One ignorant, insensitive nurse

Poor customer service skills

My emotional state -- I was quite upset and my first doctor clearly didn’t like that doctor’s assumptions about dealing with Lupron

The health care professionals sometimes seemed more concerned about their personal success rate at the expense of my desires

Too much in a rush

Time constraints of doctor

Figure 1. Distribution of EDS Scores.

Figure 1

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EDS score on X axis, frequency on Y axis

Experiences of discrimination were not significantly different for those who were more out about their sexual orientation in general, and were not different for those who were out about their sexual orientation to their specialist (see Table 3), nor for demographics including age, race, education or partnership status.

Table 3.

Demographic, Sexual, and Medical Characteristics of Study Participants by EDS Score

(N=193 GBM Treated for Prostate Cancer)
EDS Score=0 EDS Score>0 p-value
N 102 88
Demographics
Age 63.9 (8.4) 62.9 (8.0) 0.36
Race/Ethnicity 0.41
White/Non-Hispanic 91 (89) 75 (85)
Non-White and/or Hispanic 11 (11) 14 (15)
Education Level 0.15
Less than high school, high school, GED, some college, or associate’s degree 26 (25) 18 (18)
Bachelor’s 40 (39) 29 (32)
Graduate Degree 36 (35) 43 (48)
Sexual Orientation Identity 0.95
Gay/Homosexual 93 (91) 80 (90)
Bisexual or Other 9 (9) 8 (9)
Current Relationship Status (to a man) 0.68
Single, dating, divorced, or no longer in a relationship 43 (43) 40 (47)
Married or in a long-term relationship 56 (57) 46 (53)
Outness 0.74
Out to most, all, or almost all the people I know 77 (75) 71 (81)
Out to about half or fewer people I know 25 (25) 17 (19)
Medical Characteristics
HIV Status 0.85
HIV negative 89 (87) 78 (89)
HIV Positive 13 (13) 10 (11)
Treatment 1 0.04
Surgery (Only) 61 (60) 37 (44)
Radiation (only) 19 (19) 16 (19)
Combined/Systemic 21 (21) 31 (3y)
Geographic Region 0.904
Canada 5 (5) 6 (7)
Midwest US 17 (17) 11 (13)
Northeast US 23 (23) 22 (25)
Southern US 21 (21) 18 (20)
West Coast 36 (35) 31 (35)
Time since diagnosis (Mean, SD) 5.61 (4.36) 5.85 (4.66) 0.73
PSA at diagnosis (Mean, SD) 6.94 (5.23) 8.29 (7.70) 0.21
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Next, we compared those who reported experiences of discrimination in treatment against those who reported no discrimination on key outcomes. Demographically, those who reported experiences of discrimination were more likely to have had combined or systemic treatment (that is, any combination of radiation and surgery, hormones, or chemotherapy). When treatment is regressed on experiences of discrimination using binary logistic regression, those who had undergone surgery had a 37.8% probability of experiencing discrimination (SE = 0.05, 95% CI = 0.28 – 0.47, p < .001), while radiation treatment had a 45.7% probability (SE = 0.05, 95% CI = 0.29 – 0.62, p < .001) and systemic/combined treatment had a 59.6% probability of experiencing discrimination respectively (SE = 0.07, 95% CI = 0.46 – 0.73, p < .001).

On internalized homonegativity, we observed a significant relationship between those who reported discrimination and those who did not. Spearman correlation between the total EDS scale response and the total IH scale response was rs = 0.181, p = 0.012. Using the most common treatment outcomes (EPIC and SF-12), discrimination as a binary variable was associated with significantly poorer outcomes on all the EPIC measures except sexual ones, and on the SF-12, significantly poorer outcome for mental health (Table 4).

Table 4.

Relationship between Experienced Discrimination and Key Outcome Measures

EDS=0 EDS>0 p-value
N 102 88
EPIC (ranging from 0–100, higher scores indicate better function/less bother) Urinary Function 85.1 (17.7) 77.7 (20.3) <0.01
Urinary Bother 79.9 (18.7) 68.7 (21.5) <0.01
Sexual Function 41.5 (23.5) 40.0 (21.9) 0.63
Sexual Bother 57.5 (24.0) 51.6 (25.9) 0.10
Bowel Function 91.4 (9.4) 86.5 (13.4) <0.01
Bowel Bother 89.0 (12.1) 79.8 (18.0) <0.01
Hormonal Function 84.2 (15.9) 73.5 (19.6) <0.01
Hormonal Bother 87.5 (14.0) 75.4 (20.3) <0.01
SF-12 (ranging from 0–100, higher scores = better QOL) Physical 53.0 (8.2) 52.0 (9.5) 0.44
Mental 49.8 (9.3) 41.7 (12.2) <0.01
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Discussion

This is the first study of prostate cancer in sexual minority men, sufficiently large to investigate the effects of discrimination on treatment outcomes. This study stands out because the experiences of SGM cancer patients have not been fully explored, which is important given the intensity and consequence of their healthcare interactions. Previous research demonstrates that experiences of discrimination can result in delayed care and lower utilization of health services (Balik et al, 2020). This could be extremely consequential for an SGM individual with cancer.

We highlight four main findings. First, almost half of participants (46.3%) reported experience of discrimination in treatment. Second, of those who reported experiencing discrimination, 20.0% scored 4+ (consistent with multiple aggressions or more serious problems) while 26.3% scored 1–3 on the EDS (more consistent with microaggressions, defined as indirect, subtle, or unintentional discrimination against members of a marginalized group.). Third, the most common problems experienced were: “You felt like a doctor or nurse was not listening to what you were saying”, where about half said something other than “never”, and “A doctor or nurse acted as if he or she thinks you are not smart,” where a quarter said something other than “never”. Fourth, experience of discrimination in treatment strongly predicted poorer outcomes on seven of ten key outcomes.

Participants identified three common reasons why they experienced discrimination. Of the 88 participants reporting discrimination, 22 (24.7%) attributed it to a characteristic of the provider, 19 (21.3%) attributed receiving poorer treatment to their sexual or gender minority status, and 7 (7.9%) to their age. This suggests that provider non-humility, provider homonegativity, and, to a lesser extent, provider ageism appear the three biggest attitudinal barriers that providers need to address. Previous research has identified widespread implicit bias for heterosexual vs. lesbian and gay people among heterosexual healthcare providers (Sabin, Riskind & Nosek, 2015).

These findings are consistent with theories of stigma such as Minority Stress (Meyer, 1995). The relatively small but positive correlation between internalized homonegativity and total discrimination score is consistent with enacted stigma and felt stigma being interrelated in sexual minority men. According to Minority Stress Theory, discrimination in treatment may lead to poorer treatment outcomes both directly by minorities receiving poorer care, and indirectly through internalized homonegativity, leading to a poorer valuation of one’s own sexual orientation and expectation of poorer outcomes (Meyer, 1995).

The sizable number of participants who, instead of attributing the discrimination to any aspect of themselves, wrote in responses attributing the discrimination to their provider, was unexpected. Consistent with microaggressions being indirect and subtle, it could be that the participants were signaling that they were uncertain as to the underlying reasons why the provider acted in this manner and were unsure whether it was in reaction to their sexual orientation or some other aspect of themselves or not. Attributing the discrimination to the provider is also consistent with a movement within gay (and bisexual) men’s health to advocate, not only for HIV prevention and treatment, but for gay men’s health more holistically (Halkitis, 2010). It builds on other studies of sexual minority discrimination which concluded, “Initiatives to promote and protect the health of gay men must be rooted in the recognition of the systemic role of discrimination, while supporting men’s resilience in actively resisting discrimination.” (Handlovsky et al., 2018).

These results must be interpreted within the demographics of this sample as male, predominantly white, well-educated and out (regarding their sexual orientation). Given several of these characteristics impart “privilege,” these men simply may not be used to receiving inferior treatment. The finding that the most common complaint was feeling talked down to or the provider acting as though the patient was not educated is consistent with the participants feeling their educational level was not sufficiently taken into account. Recently, a study of over 100 urologists found most prefer to avoid questions about sexual orientation, have greater comfort discussing sex with heterosexual patients than sexual minority patients, lack knowledge about sexual minority patients, and desire more education (Amarasekera et al., 2019). The most common complaint of all patients is not being heard or simply being ignored.

The only clinical variable that significantly discriminated between those with high versus low EDS score was type of treatment. Those with combined or systemic treatment had higher EDS scores than those who had just surgery (which did not differ from those who had radiation). It might be hypothesized that those with more treatment modalities, or more extended treatment, had more time in treatment, and thus more opportunities to experience discrimination. More time with healthcare practitioners could result in worse care.

The key conclusion of this study is that about half of the participants perceived they received inferior care or experienced discrimination, which in turn, was associated with worse treatment outcomes. We highlight three implications. First, this validates the importance of studying the effects of discrimination on treatment. Second, it points to an urgent need to address cultural non-humility, homonegativity, and ageism both in training and as part of continuing education of providers. Third, the findings present an opportunity to acknowledge that perceptions of discrimination alter outcomes and our training in culturally competent care must extend to include sexual minority cultures.

This study has several limitations. First, as the first study of sexual and gender minority prostate cancer patients to quantify experiences of discrimination in treatment, we cannot know the reliability of these findings. Second, this was a cross-sectional study so temporality and causality cannot be assumed. While it is consistent with theory and intuitive to posit that discrimination in treatment leads to poorer outcomes, it may be that those who have poorer outcomes in treatment are more likely to negatively evaluate their providers, or that some third variable (e.g., depression) may impact both treatment and outcome. Third, this sample was recruited from an online website providing clinical and support services to patients. The sampling frame from which this sample was recruited may be biased towards those who experienced more problems, post-treatment. Fourth, this sample was predominantly white, well educated, gay, out and living in the US or Canada. We caution the results may not generalize to sexual minorities of color, those less educated, those more closeted or quiet about their sexuality, and residents of other countries. It is possible, even likely, that experiences of discrimination are more common (and intersectional) in these populations. Fifth, we note that there was only one transgender identified person in the study, and that the published EDS scale did not include “gender minority” or “transgender” as a category. Future research should include this as an explicit option to be more inclusive. Finally, while this is the largest study of sexual and gender minority prostate cancer patients to date, it was still fairly small and may be under-powered to detect smaller differences.

This study should be replicated in other settings and with other populations. Future research should recruit a larger sample of sexual and gender minority patients (and indeed such as study is in progress in Restore-2: Rosser et al., submitted for publication). To examine the experience of other minorities in prostate cancer treatment, we hope researchers will replicate these findings in studies of racial and ethnic minority prostate cancer patients as well. In addition, it would be illuminative to use the Experiences of Discrimination in Treatment scale also in white, cisgender heterosexual patients, as this would help identify to what extent treatment is experienced as poor across all patient groups. And it may clarify if what sexual and gender minorities internalize as poor treatment attributed to their sexual orientation, is in fact poor treatment that other groups attribute to some other characteristic.

Finally, these findings may be used to improve prostate cancer treatment systemically. Beyond the individual provider, these results appear to indicate that clinic systems and the professions providing treatment have an equity problem in prostate cancer healthcare. Improving the training of providers, the system of clinical care, and the treatment of minorities, should improve the treatment experience for sexual and gender minorities, which may ultimately improve patient outcomes.

Funding:

The Restore study was funded by the National Cancer Institute (NCI): “Understanding the Effects of Prostate Cancer on Gay and Bisexual Men,” (Grant number: 1 R21 CA182041; PI: B.R.S. Rosser) The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health

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