care because it was unaffordable (Bradford and Ryan, 1988). In the MLHS, 12.3% of the lesbian sample reported that they did not have health insurance, compared to a state rate of 9.7% of Michigan women in general (Bybee and Roeder, 1990).

Although most middle-aged lesbians surveyed in the NLHCS reported good to excellent health, 27% reported that they lacked health insurance. Analysis indicated that lack of insurance may be more prevalent among lesbians with particularly serious health conditions. Lesbians without insurance were significantly more likely to report heart disease, to have Pap tests less often or never, to smoke, to have eating disorders (either overeating or undereating), and to be victims of physical and sexual abuse and antigay violence (Bradford et al., 1994a).

Personal and Cultural Barriers to Health Care Access for Lesbians

Personal and cultural barriers that affect access to care for lesbians include the lack of cultural competency among health care providers, the fear of coming out to providers, and the lack of lesbian focus in preventive and other health care.

Cultural Competency of Health Care Providers. Cultural competency refers to a set of skills that allows providers to give culturally appropriate high-quality services to individuals from cultures different from the providers'. These skills include understanding the culture and values of the group, the ability to communicate in the same language, and understanding the impact of group membership on health status, behavior, and attitudes. Cultural competency typically refers to providing services to people of different racial or ethnic groups. However, it also appropriately captures the skills needed to provide services effectively to lesbians. Providers who are culturally competent with respect to lesbians would be expected to understand the reasons lesbians might be reluctant to seek medical care and the impact of homophobia on the provision of services to lesbians; to be aware of the range of health problems experienced by lesbians as well as their health care risks; to avoid making heterosexual assumptions in the gathering of medical and social health information



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