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determining whether there are systematic differences in use and outcome among groups in society and whether these differences are the result of barriers to care. The committee finds that there is evidence that lesbians may face particular challenges in all three areas.
Structural Barriers to Health Care Access for Lesbians
Structural barriers that affect health care for lesbians include potential barriers presented by managed care systems and the fact that lesbian relationships are often not afforded the same legal standing as heterosexual marriages.
Managed Care. Most Americans indicate that their first choice is to see a physician in the physician's private office. Although some lesbians report that they prefer other types of providers (e.g., naturopaths, chiropractors, nurse practitioners) and to receive care in clinics, the majority report that they receive primary care from a medical doctor (Bradford et al., 1994b; Bybee and Roeder, 1990; Moran, 1996; White and Dull, 1997). Although data are not yet available to determine the impact of managed care on the quality of health care for lesbians, the committee believes that negative consequences are possible for the following reasons:
Limits placed on the behavior of providers by managed care organizations may introduce barriers to the effective care of lesbians. For example, pressure to keep visits short may compromise building of trust between a provider and a lesbian patient, making it less likely that the patient will disclose her sexual orientation.
It is more difficult for patients to choose a lesbian-friendly medical or mental health care provider. With unrestricted access to providers, as in fee-for-service plans, lesbians have the option of seeking out lesbian or lesbian-friendly providers. Under managed care plans, however, higher levels of coverage of health care services are generally limited to providers who are part of that particular plan. This may make it very difficult for some lesbians to identify any provider who is lesbian or lesbian-friendly, given the limited number of these providers in general. Managed care plans can reduce these barriers by identifying lesbian- or