This case study centers around gender-affirming voice therapy. What does a communication professional need to know in order to best serve Joe?

Barriers to Quality Care –

Gatekeeping - Healthcare professionals block access to care due to stigma and/or unfair judgments made

Finances - Lack of income, insurance does not cover voice therapy, lack of insurance

Access to Care - Lack of access to the service, limited access to quality care

Approach to Therapy

• clients often have goal of "passing" which is problematic due to reinforcing the belief that people perceived to be the gender they were assigned at birth are better than those who are transgender.

• Metatherapy - clients can create their own goals as they think about therapy and their communication goals. They have the opportunity to define their identity "and their communication and gender expression in relationship to that identity."

• Modeling - client-led therapy, chosen from diverse options presented. Clients practice a continuum of expressive techniques to determine their preferences.

Clinical program at NCCU followed Two Clients

Both clients struggled with some level of both:

• dysphoria due to their assigned gender and how they have been perceived and

• distrust of the medical community

• So, trust was built through empathy and allowing the clients to lead or slow down the therapy as needed.

• In addition, clients had plenty of time to process their identities and determine how they wanted to express their gender going forward.

• Both clients decided on the pronouns they wanted to use during the therapy process, as inititially one was very unsure and accepted all pronouns while the other initially wanted he/him and switched to they/them.

• Mental health, including anxiety, depression and social anxiety are important to address, especially in group therapy settings before the client can gain comfortability.

• The client's support network should also be considered, in imagining how the client will present themself going forward. One client ultimately needed to cut ties with multiple people in order to confidently move forward in their chosen identity.

• Singing was the key for both clients to finally reach their goals. JR reached an average of 130 Hz with chest resonance and masculine intonation, without testosterone therapy. Their goal was to get consistently gendered male over the phone and this was achieved successfully through the program.

FtM Voice Training. (2023). YouTube - Jordan Ross Communication . Retrieved 2024, from https://youtu.be/z8GD2twTgys?si=xPfbN1yel9uyp2Qq.

Matthews, J. J., Olszewski, A.,  Petereit, J. (2020). Knowledge, Training, and Attitudes of Students and Speech-Language Pathologists About Providing Communication Services to Individuals Who Are Transgender. American Journal of Speech-Language Pathology, 29(2), 597-610. https://doi.org/10.1044/2020_AJSLP-19-00148

Myers, B.,  Bell, T. (2020). Adapting Vocal Function Exercises for Voice Masculinization. Perspectives of the ASHA Special Interest Groups, 5(4), 861-866. https://doi.org/10.1044/2020_PERSP-20-00076

Smith, C. J. (2020). Culturally Competent Care for Transgender Voice and Communication Intervention. Perspectives of the ASHA Special Interest Groups, 5(2), 457-462. https://doi.org/10.1044/2020_PERSP-19-00117

o   From binary transwomen and transmen (who identify as the gender opposite to the gender assigned to them at birth

o   To nonbinary genders, who identify in between male and female, agender or beyond the gender binary

o   anatomical sex is no longer a meaningful aspect of identity

o   correct terminology in place of “sex” = “assigned male at birth” or “assigned female at birth” (identifies physical characteristics of sex)

§  binary classification system, does not account for intersex

§  cisgender vs transgender

o   Gender identity reflects an inner sense of gender – outwardly expressed in various ways

o   Thus, gender expression is unique to the individual and clinicians helping a client express this (potentially new) identity must consider the “goals and features of the client’s voice, sense of self, and desire to be understood as an individual.”

·        Clinicians must be aware of any biases, judgments, or preconceived ideas they may hold regarding transgender individuals. In addition, recognize their power as a healthcare professional to avoid discriminatory practices.

·        Clinicians must ensure they allow clients to make their own decisions, and not decide for them if they are “ready” to transition or not.

·        Training and education are recommended to support SLP’s in becoming comfortable and confident with effectively treating this population.

o   Only 30 voice and speech clinicians in the U.S. are listed on the World Professional Association for Transgender Health – not enough for the population.

o   Office of Multicultural Affairs (OMA) “provides resources to help SLP’s provide transgender voice services.”

·        Avoid prescriptive models in modification therapy

·        Use descriptive approaches only – providing many examples to clients and allowing them to choose based on how they feel about them “and what they would like to emulate.”

·        Provide opportunities for clients to practice both “extreme and subtle aspects of targeted-gender communication.”

·        Allow client to practice “until a natural expression emerges.”

o   Clients will often feel as though they are “faking” at first.

o   Practice along a continuum allows the client to determine which communication pattern matches their gender expression.

·        In general:

o   Trust and empathy are keys to success.

o   Listen to what the client wants.

o   Allow targets to emerge and change throughout therapy as client’s “self-understanding and ability changes.”

Cultural Competence in Transgender Care

• SLP Practitioners should be able to respond to the needs of diverse clients.

•  Knowledge Skills and Attitude (Van De Bergh & Crisp, 2004)

  • When working with LGBTQ clients, acquiring knowledge includes learning the history of the community, knowing relevant terms and kinesics, understanding the discrimination the community has faced, and the policies that may work for or against the community.

  • ‘Skills’ means having the ability to create a safe environment for any given client and providing affirming services.

  • ‘Attitude’ involves self-reflection and understanding implicit biases one may have towards a certain group of people. 

  • By building knowledge, skills, and attitude, a practitioner can work towards building cultural competence.

• Perception of LGBT+ youth can be affected by factors such as geographic location and socio-economic status

  • According to the survey, the amount of SLP’s and students who believe gender affirming voice therapy to be a medical necessity is larger in number in the west (75%) than in the south (61%)

Based on the survey, while many SLP students and practitioners believe that transgender care is an important part of the job, there has been lack of training towards this topic and a majority of SLP's do not possess the knowledge necessary to properly care for transgender individuals.

Matthews et al. have proposed training methods including

• Graduate courses that cover the extent of the issue such as multicultural issues

• Including sessions about the topic at conventions or conferences

• Seminars for both graduate students and practicing professionals.

Above all, cultural competency should be prioritized when serving transgender clients.