SLPs play a central role in clinical services for voice and communication in gender-diverse communities. The professional roles and activities in speech-language pathology include clinical/educational services (differential diagnosis, assessment, planning, and treatment), prevention and advocacy, counseling, administration, and research. See ASHA's
Scope of Practice in Speech-Language Pathology.
Appropriate roles for SLPs include, but are not limited to, the following:
- Educating other professionals on voice and communication needs of individuals who are transgender or gender diverse—and the role of SLPs
- Conducting a comprehensive, culturally and linguistically appropriate assessment
- Referring to other professionals to rule out other conditions, determine etiology, provide support, and facilitate access to comprehensive services
- Developing treatment plans, providing treatment, documenting progress, and determining appropriate dismissal criteria
- Counseling individuals and their families regarding voice- and communication-related issues
- Providing education aimed at preventing further complications that may lead to vocal misuse and/or overuse
- Remaining informed of research in voice and communication services
- Remaining current with changes in terminology and other cultural considerations
- Advocating for individuals at the local, state, and national levels
- Serving as an integral member of an interdisciplinary team working with individuals who are transgender or gender diverse and their families/caregivers
As indicated in the
Code of Ethics (ASHA, 2016), SLPs who serve this population should be specifically educated and appropriately trained to do so. The World Professional Association for Transgender Health (WPATH) has developed standards of care for health care professionals working with individuals who are transgender and gender diverse, including assistance on providing voice and communication services. This guidance may help determine prerequisite skills and clinical considerations. In addition, WPATH outlines additional services and treatments by health care professionals, which may provide a baseline of information for practitioners (WPATH, 2011).
The male/female binary construct is not adequate to represent the gender-diverse community. It may be useful for clinicians to consider gender across three parts (WPATH, 2011):
- Sex—an individual's biological and physical attributes, such as chromosomes, sex hormone levels, and genitals. Sex is assigned either in terms of “male” or “female.” Intersex is a term used for individuals born with a reproductive or sexual anatomy that does not seem to fit the typical definitions of female or male. Sex that is assigned at birth does not always align with gender identity. For example, a transmasculine individual is someone who was assigned female at birth and who identifies more with masculinity than femininity. A transfeminine individual is someone who was assigned male at birth and who identifies more with femininity than masculinity.
- Gender identity—an individual's sense of being male, female, both male and female, or an alternative gender. An individual who is cisgender is an individual whose gender identity is congruent with their sex assigned at birth. An individual who is transgender has a gender identity that differs from their sex assigned at birth. In English, transgender is an adjective (e.g., the correct usage would be “a transgender person”) and should not be used as a noun (Bouman et al., 2017).
- Gender expression—characteristics in personality, appearance, and behavior that may be perceived as masculine, feminine, both, or neither. Gender expression may vary along the gender continuum. Gender expression may change over time and may differ depending on the environment.
A growing number of individuals identify as gender nonconforming. Gender nonconforming describes individuals whose gender identity, gender self-attribution, and/or gender expression differs from their sex assigned at birth in a given culture and/or differs from cultural stereotypes/societal rules about how one's gender identity should be based on sex assigned at birth.
Individuals who do not identify with their sex assigned at birth and who wish to express a more masculine or feminine presentation may enter a period of transition. Transition is an individualized and personal process during which time an individual changes from identifying and presenting in a manner culturally accepted for their gender assigned at birth to the preferred gender expression. The duration and nature of the transition varies and is unique to each individual. Transitioning may range from undergoing nonmedical procedures (e.g., cutting hair, wearing more masculine or feminine clothes and makeup) to undergoing medical procedures (e.g., hormone treatment, voice and communication services, and a variety of surgical options).
Of note, sexual orientation and sexual preferences are separate and distinct from one's gender.
It is incumbent upon the clinician to use appropriate terminology demonstrating awareness and sensitivity to the client. Clinicians proactively remain educated and up to date with terms that are still evolving and thus tend to become outdated and/or offensive. Clinicians ask the client's names and pronouns for presentation at work, at home, and in social situations. At present, many insurance forms and data collection forms still have underlying gender-binary bias. Familiarity with terminology is an important way of allowing the client to self-identify. Terminology changes, and it varies from person to person; thus, it should be used in a manner that is appropriate, respectful, and sensitive.
Some individuals who seek and receive medical services have a diagnosis of Gender Dysphoria (Diagnostic and Statistical Manual of Mental Disorders, 5th ed. [DSM-V]; American Psychiatric Association, 2013). It is not in the scope of practice for an SLP to diagnose a client with gender dysphoria. In order to receive the diagnosis of Gender Dysphoria, one must meet
a list of criteria indicated in the DSM-5 (American Psychiatric Association, 2013).
Sensitivity to clients starts at the initial point of contact, including everyone from the building staff who work the front desk to the administrators responding to appointment requests. Office support staff and clinicians participate in sensitivity training to increase awareness for working with gender-diverse populations. Notice the imagery and artwork displayed around the office as well as photos and families represented in treatment materials and information.
Physical adjustments may need to be made to facilities. These modifications may include
- gender-neutral restrooms;
- visible pronoun identification for all staff, on badges or name plates; and
- publicly visible, prominently displayed nondiscrimination policy and Safe Zone sticker.
Intake and case history forms modifications are necessary to reflect the client. Clients may use more than one name and/or pronoun across a variety of settings, socially, or at work. It is important to ask for the client's current legal name to be used if submitting for reimbursement to a third-party payer. Forms regarding pronoun usage and gender identity should be provided to all clients, regardless of the service that they seek, in order to ensure inclusiveness.
See ASHA's Practice Portal page on
Cultural Competence for more information.
Prior to submitting for coverage to insurance, clinicians ask about the required identifying information, including the client's name and sex, to use for prompt and successful reimbursement.
Coverage varies for services related to gender transition. Such services may be covered with the medical diagnosis of Gender Dysphoria. At this time, diagnosis criteria for Gender Dysphoria is indicated by “significant distress or social/occupational impairment” (American Psychiatric Association, 2013; Hann, Ivester, & Dodd Denton, 2017).
Many states plus DC have affirmative coverage for transition-related care for Medicaid and private payers. Although some coverage may be provided for voice and communication services for a diagnosis of Gender Dysphoria, there can be barriers to accessing it. Due to changing legislation, coverage options change quickly. According to the 2015 U.S. Transgender Survey (James et al., 2016), nearly 25% of respondents reported having experienced challenges with insurance regarding services related to gender. Nearly one third of respondents indicated that none of their health care providers knew that they were transgender.
For additional information about health insurance coverage and payment for transition-related care, see
Reimbursement of Voice Therapy Services for Transgender People.
Comprehensive evaluation considers current voice and communication skills to determine a treatment plan in collaboration with the client. Intake forms and client interviews indicate how the client wishes to present at home, at work, and in social situations. A client needing to modify their voice and communication consistently and permanently will require different voice and communication approaches than a client who needs access to a variety of voices and communication identities. It is also important to consider that not every transgender or gender-diverse person wants to sound like or communicate like a cisgender person. Goals related to voice and communication are specific to each individual and may change over time.
Transgender and gender-diverse clients may undergo a variety of medical, surgical, physical, social, and personal procedures—as well as legal procedures—to increase the congruence between their gender identity and gender presentation. Not all of these procedures will directly impact communication. SLPs should obtain information pertaining to any hormone therapies to determine the possible influence on the voice and voice mechanism (Hancock, Childs, & Irwig, 2017). For instance, testosterone treatment generally adds mass to the vocal folds. This may lower the pitch to varying degrees. In addition, there are a number of surgical options (Davies, Papp, & Antoni, 2015) that may alter the structure of the vocal folds and/or the larynx and that could possibly impact vocal pitch, loudness, quality, and resonance and/or swallowing. Surgery can influence oral, laryngeal, and pharyngeal structure and mechanisms as well as the ability to consistently maintain practice during the rehabilitation process. These surgeries can include facial feminization/masculinization, chest or breast reconstruction, laryngeal surgery and surgical modifications of the face and neck, electrolysis/laser hair removal, and so forth. Some—but not all—individuals may elect to have gender affirmation surgery. The SLP is aware of medical factors that influence the continuum of care and coordinates service delivery with any other provider or case manager. Clinicians consult with other medical professionals to ensure smooth, effective, and safe coordination of services.
In 2011, WPATH developed and published the 7th version of Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. These standards recommend the following areas of focus on which an SLP can work:
- Vocal health
- Voice: Pitch, intonation, and volume
- Language (including pragmatics, syntax, and semantics)
- Nonverbal communication, which may include vocalizations such as coughing and laughing
- Real-life experiences/authenticity/safety
(Adler, Hirsch, & Pickering, 2018)
It is essential to have thorough knowledge of any existing disorder or prior intervention to ensure the best course of treatment. In 2013, Hancock and Garabedian conducted a retrospective file review of clients receiving voice feminization treatment between 2006 and 2011. Of these clients, 28% had a voice disorder not related to their gender presentation (Hancock & Garabedian, 2013).
Client perspective is critical in the assessment process. A subjective analysis from the client's perspective, including video and audio recordings, are components of assessment that allow for documentation and analysis of progress over time. This may also serve as motivation for the client as measures of success. Self-rating scales are an effective way to gather perspective, set goals, and understand how the client wishes to use their voice (Dacakis, Oates, & Douglas, 2017a, 2017b; Dacakis, Davies, Oates, Douglas, & Johnston, 2013). There is often a discrepancy between a client's and a clinician's perception of vocal parameters. Frustrations may often be expressed by the client, whose self-perception can be hypercritical (Azul, Arnold, & Neuschaefer-Rube, 2018).
Collaborating with the client's lead is critical for determining needs and goals. As stated earlier, gender identity and communication needs are unique to the individual. The clinician acts as a guide on the basis of stated concerns and priorities. Incongruence between verbal and visual presentation to communication partners may have significant implications, including implications for safety. However, goals focus on creating a voice that is authentic, comfortable, and safe (Hancock, 2015). The ultimate goal is to assist the client in achieving an authentic voice and communication style based on their needs. Some individuals prefer a gender-neutral presentation, whereas others require flexibility for a more masculine or feminine presentation, depending on social or work environments. For these individuals, vocal flexibility may rise to the top of the list of treatment goals.
Targeting a combination of voice parameters to address vocal modification is more effective than just modifying fundamental frequency (F0) or pitch (Davies, 2017). Emerging literature shows that modifications in resonance alter perception of gender (Hirsch, 2017). Underlying fundamentals of voice services for transgender individuals may overlap with fundamentals of therapeutic intervention with a client who has a functional voice disorder. Therefore, intervention strategies and techniques from functional voice disorders and resonance disorders may be incorporated into transgender voice services. However, applications and techniques may vary. For example, whereas clients with voice disorders may use vocal function exercises to facilitate a return to healthy voice function, transgender clients may use these exercises to facilitate a safe increase or shift in their pitch range. In addition, clinicians may incorporate strategies specific to working with voice modification for transgender and gender-diverse clients—strategies such as direct pitch modification, resonant voice therapy, semi-occluded vocal tract exercises, vocal function exercises, and accent method. Nonverbal and pragmatic goals are established to reflect the client's gender presentation.
See ASHA's Practice Portal pages on
Voice Disorders and
Resonance Disorders or ASHA's On Demand Webinar
Transgender Voice and Beyond: Voice and Communication Training for Gender Expression for more information.
A common misperception is that androgen cross-sex hormones often result in the lowering of pitch, which eliminates the utility of voice treatment (Azul et al., 2018; Nygren, Nordenskjöld, Arver, & Södersten, 2016). However, the extent, rate, and experience of lowering is quite variable and not always satisfactory (Irwig, Childs, & Hancock, 2016; Ziegler, Henke, Wiedrick, Helou, 2017). Hormone therapy for voice masculinization increases testosterone levels, thus adding mass to the vocal folds and, typically, lowering the pitch in varying degrees. Hormone treatment does not result in changes to other aspects of voice (e.g., intonation, volume, and nonverbal communication) that may influence how gender is attributed to them by others. Furthermore, studies indicate that some men use a higher speaking pitch than their new lower pitch range allows (Papp, 2011). Voice masculinization may focus on lowering pitch, adopting chest resonance, and reducing pitch variation (Schneider & Courey, 2016).
Studies indicate that trans women who participate in voice treatment, particularly when it involves increasing F0 and/or moving resonance forward, can achieve a more feminine voice and overall satisfaction (Davies, 2017; Oates & Dacakis, 2015). Listener perception studies indicate that ean F0 (perceived as pitch) and semitone range is a strong predictor of listener's perception of the speaker's gender, and of the speaker's own perception of the femininity of their voice (Owen & Hancock, 2010). For trans women, general professional consensus indicates that raising speaking F0 is critical to adopting a gender-congruent voice; however, the target speaking fundamental frequency (SFF) in several studies ranges from 155 Hz to 220 Hz (Davies, 2017). Additional studies indicate that any F0 higher than 180 Hz is more likely to be perceived as female, whereas anything lower than 130 Hz is more likely to be perceived as male (Leung, Oates, & Chan, 2018). SFF has been the most widely studied voice feature, and there is strong evidence for its influence on gender perceptions. However, in 2018, Leung and colleagues (2018) indicated that only 41.6% of variances in perceptions of speaker gender can be explained by SFF. Therefore, modification of other voice features—such as intonation, resonance, and loudness—may be important in helping a client reach their voice goals. For example, many researchers have found modification to both increasing F0 and moving resonance forward to be important in feminization (Carew, Dacakis, & Oates, 2007; Gelfer & Mikos, 2005; Hillenbrand & Clark, 2009; Hirsch, 2017). Femininity associated with voice is somewhat greater with softer volume, more precise articulation, and more variable intonation. Rate of speech and stress do not appear to be associated with gender perception (Leung et al., 2018).
Speech, Language, and Nonverbal Communication
Articulation, loudness, speech rate, word choice, sentence structure, discourse pragmatics, facial experience, eye contact, gesture, posture, gait, and body movement all influence gender perception. However, clinicians note that variability in how these are perceived exists within cultures and across cultures. For example, appropriate distance when speaking varies across gender and across cultures. There is no one universal model for a masculine or feminine presentation. Working together to establish goals for how the client wishes to express their gender is essential to establishing a set of goals.
Timelines for reaching goals may be influenced by the client's age, frequency of treatment, other gender-related interventions, and overall percentage of time living in their gender identity. A number of factors influence the ability to present as the client's self-identified gender in all settings. It can be challenging to allow for time or context within which to practice. Opportunities for practice should be incorporated into sessions, both individual and group. Home assignments may include audio and video recording to allow for monitoring of changes by both the client and clinician. To enhance carryover in connected speech and generalization to voice use in everyday activities, clinicians may use a variety of options, including video chatting, talking on the phone, and meeting at another location such as at a restaurant or coffeehouse. These activities allow for opportunities to work in realistic scenarios. Use of the new voice and ways of communicating may be challenging to introduce, incorporate, and maintain in daily life. Consideration of these factors is necessary when developing the treatment plan with the client.
Group intervention provides an opportunity for clients to practice carryover in a safe social situation. Clinicians facilitate the group norms and overall goals, whereas individual participants can work toward their individual goals. Groups provide a safe opportunity to receive feedback and celebrate success toward goals (Adler et al., 2018). This may be particularly important for individuals who do not have the opportunity to practice their skills in different environments. In a presentation to WPATH regarding a 5-year retrospective study of a voice and communication program, of note were the gains in self-esteem (and, in addition, voice and communication) as judged by clients and listeners (Pickering & Kayajian, 2014).
Many clients may seek the assistance of mental health providers for support during transition. Discrimination, stigma, and/or violence toward the transgender community can negatively impact psychosocial well-being (White Hughto, Reisner, & Pachankis, 2015). Mental health providers become a collaborative partner to the SLP. Some issues may arise during treatment that pertain to adjusting to the mind–body–spirit connection. Some clients may experience distress; some will not. SLPs help the client transition to a new voice and to a new way of communicating and hearing themselves differently. SLPs are not trained mental health service providers; however, they may find themselves in positions where it may be beneficial to have familiarity with skills and strategies used by trained mental health service providers. It is within the SLP's roles and responsibilities to provide counseling that facilitates change in how clients feel and think about themselves. All communities are diverse, including gender-diverse communities; therefore, techniques and approaches are vast and need to be individualized (Adler et al., 2018). Clinicians may find themselves assisting clients in various emotional states connected to their voice—these emotional states range from frustration, grief, and anger to acceptance and enthusiasm. Individual clients may require different approaches because their journeys are all unique and individual (Adler, 2017). Transgender and gender-diverse clients come to clinicians with a number of experiences and needs. Treatment goals and plans focus on understanding and using a new voice and/or method of communication as well as maintaining a safe voice and preventing phonotrauma. Additional knowledge and skills in counseling that are specific to transgender populations assist clinicians in providing support to clients.
Use of Technology
A number of mobile and web-based apps—in conjunction with voice treatment—may assist to facilitate with generalization and carry over. It is important to become familiar with the technology available to clients and to determine whether they are, in fact, using these apps. Cell phones and tablets have audio and video capabilities that make technology a natural resource for home practice. Some web-based tools have been developed specifically for trans speakers, but some others are more generic (e.g., apps for piano playing, guitar tuning, etc.). Inappropriate practice can contradict treatment efforts and lead to development of hyperfunctional voicing patterns.
Ethical considerations for SLPs include provision of services under the scope of the expertise.
Issues in Ethics Statement on Cultural and Linguistic Competence (ASHA, 2017) further clarifies principles pertaining to gender identification.
Principle of Ethics I: Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities, and they shall treat animals involved in research in a humane manner.
Rule B. Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided.
The implication of Rule B is that if a professional feels unprepared to serve an individual on the basis of cultural and linguistic differences, then they should use the option of an appropriate referral. Voice modification borrows a number of strategies and techniques from voice disorder intervention. A number of clients may also begin with a request for voice modification services without realizing that they also have a voice disorder that should be treated first.
The clinical protocol for voice and communication modification services for trans people are built from skill sets developed from working in the area of voice—including pitch, resonance, intonation articulation, language, and nonverbal communication. Additional knowledge and training for sensitivity to working with trans people is essential and will build on existing skills.
Rule C. Individuals shall not discriminate in the delivery of professional services or in the conduct of research and scholarly activities on the basis of race, ethnicity, sex, gender identity/gender expression, sexual orientation, age, religion, national origin, disability, culture, language, or dialect.
The implication is that the clinician may not refuse services based on an individual's gender identity/expression that are not related directly to gender transition (e.g., voice disorder, cognitive-communication disorder post-stroke, etc.).
Legislation related to gender identity is constantly evolving.
Title VII of the 1964 Civil Rights Act, a federal regulation, prohibits discrimination in any federally funded program on the basis of race, color, sex, or national origin. This includes any public or private facility—such as a hospital, clinic, nursing home, public school, university, or Head Start program—that receives federal financial assistance, such as grants, training, use of equipment, and other assistance.
As of 2019, more than one third of states plus DC have affirmative coverage for transition-related care for Medicaid and private payers. Although some coverage may be provided for voice and communication services related to gender transition, there can be barriers to accessing it. For a current list of states and additional information on health insurance coverage, see
Reimbursement of Voice Therapy Services for Transgender People.
Seek legal counsel if you have questions or concerns regarding the impact of federal or state law on transition-related care.