A Survey of the Awareness of Speech Services Among Transgender and Transsexual Individuals and Speech-Language Pathologists

Awareness Among Transgender and Nonbinary Adults of the Otolaryngologist's Role in Providing Gender-Affirming Care Services

OBJECTIVE

To assess transgender and nonbinary adults' awareness of Otolaryngologists' (ENT) and speech-language pathologists' (SLP) ability to perform various face, neck, and voice procedures for gender-affirming purposes.

STUDY DESIGN

Cross-sectional survey.

SETTING

Online, from February to May 2022.

METHODS

We developed a list of nonsurgical and surgical gender-affirming face, neck, and voice procedures. We asked transgender and nonbinary (TNB) adults which procedures from this list they knew could be performed by specially-trained ENTs or SLPs for gender-affirmation and which listed procedures they knew existed as gender-affirming treatment before the survey. We assessed awareness of ENTs' and SLPs' ability for each procedure across gender identity using Fisher exact tests. We examined if demographic or socioeconomic factors were associated with the total number of gender-affirming procedures participants knew ENTs or SLPs could perform using univariable linear regression.

RESULTS

TNB adults (N = 234) generally knew these procedures existed as gender-affirming treatment (64%-93%). However, TNB adults were largely unaware these gender-affirming procedures could be performed by specially-trained ENTs or SLPs (53% or less), especially procedures unrelated to the voice, neck, and nose (26% or less). Knowledge of ENTs' and SLPs' ability was similar across gender identity for most procedures. Total number of procedures known that ENTs or SLPs could perform did not differ by demographic/socioeconomic factors (p > .05).

CONCLUSION

These findings suggest transgender and nonbinary individuals may not know to seek Otolaryngologists or SLP when desiring gender-affirming face, neck, or voice care. Increased efforts are needed to promote awareness of Otolaryngology's role in providing gender-affirming care.

LEVEL OF EVIDENCE: 4

Clinician and Consumer Perspectives on Gender-Affirming Voice Services

INTRODUCTION

A significant portion of the transgender, nonbinary, and gender-expansive community experiences gender-related voice issues. However, barriers exist to accessing gender-affirming voice care, and most existing voice research does not include the gender-nonbinary population. Our study aimed to examine transgender, nonbinary, and gender-expansive consumer/potential consumer (hereafter referred to as consumer) engagement and compare/contrast consumer and speech-language pathologist perspectives on gender-affirming voice services. A secondary aim was to assess possible voice impairments in transgender, nonbinary, and gender-expansive individuals.

METHODS

Two surveys were distributed via listservs for SLPs and flyers and social media posts for consumers. Surveys included items regarding experience with and accessibility of gender-affirming voice services and clinician competence. Consumers and clinicians answered the same questions from their respective positions. Consumers additionally completed the Voice Handicap Index-10 (VHI-10).

RESULTS

Forty-eight consumer and 54 clinician responses were collected. Twenty (41.7%) consumers were trans women, 15 (31.2%) were trans men, 12 (25%) were gender-nonbinary, and one (2.1%) was gender fluid. VHI-10 responses were in the abnormal range for 61.4% of consumers, and 68.8% indicated desire to receive gender-affirming voice services, including 58.3% of gender-nonbinary respondents. However, only 6.25% of consumers considered themselves as having a voice disorder and 29.2% reported that their voice impairs communication. In contrast, 24.1% of clinicians felt consumers seeking gender-affirming voice services have a voice disorder and 51.2% felt they have an impaired communication ability. Consumers indicated positive perceptions of voice services/providers but reported a variety of barriers to access. SLPs indicated mixed confidence in accessibility of services. Both groups perceived an affordability barrier.

CONCLUSIONS

This study demonstrates the desire and need for gender-affirming voice services and is the first to our knowledge to explicitly include gender-nonbinary individuals' perspectives on them. Understanding how consumer and clinician perspectives differ can help focus provider efforts in improving experiences with, access to, and visibility of gender-affirming voice services.

Readability Analysis and Accessibility of Online Materials About Transgender Voice Care

OBJECTIVE

To determine readability, understandability, and actionability of online health information related to transgender voice care.

STUDY DESIGN

Review of online materials.

SETTING

Academic medical center.

METHODS

A Google search of "transgender voice care" was performed with the first 50 websites meeting inclusion criteria included. Readability was assessed using the Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), and the Simple Measure of Gobbledygook (SMOG). Understandability and actionability were measured by 2 independent reviewers using the Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P). Unpaired t tests were used to compare clinician- and patient-oriented sites, surgical and nonsurgical sites, and sites that discuss nonbinary indications for voice care. Analysis of variance was used to compare sites that discuss voice feminization, masculinization, both, or neither.

RESULTS

Average scores across the cohort for FRES, FKGL, and SMOG were 43.77 ± 13.52, 12.14 ± 2.66, and 11.30 ± 1.93, respectively, indicating materials were above a 12th-grade reading level. PEMAT-P scores for understandability and actionability were 64.95% ± 15.78% and 40.55% ± 23.86%, respectively. Patient-oriented sites were significantly more understandable and actionable than clinician-oriented sites (P < .02). Websites that discussed only voice feminization were significantly more readable according to objective metrics (FKGL, SMOG) than websites that discussed both feminization and masculinization or those that did not differentiate care types (P < .05).

CONCLUSION

Online information written about transgender voice care is written at a level above what is recommended for patient education materials. Providers may improve accessibility of transgender voice care by enhancing readability of online materials.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Listening to Gender-Diverse People of Color: Barriers to Accessing Voice and Communication Care

Purpose The purposes of this study are to gather and analyze perspectives of people from racial and gender minority groups in order to identify barriers to voice and communication services for these populations. Method In focus groups facilitated by community members, 11 people in racial and gender minority groups discussed their gender-related goals and accessibility of voice and communication services. Salient themes were derived using a grounded theory approach and analyzed using an access to care framework. Results During discussion of voice and communication as it relates to gender presentation, most utterances were speculations on the processes and potential outcomes of interventions for voice and communication; the majority of these were characterized as uninformed or misinformed. Conclusions Future studies will need to overcome barriers related to health literacy and beliefs in order to thoroughly assess potential interest or intentions regarding voice and communication services. Additional study is expected to provide valuable information that can be interpreted using the Levesque et al. (2013) framework of access to care and eventually eliminate barriers to voice and communication services for all.

Opportunities to Learn Transgender Voice and Communication Therapy in Graduate Speech-Language Pathology Education: Preliminary E-Survey Findings

Purpose

Clear guidelines are needed for the inclusion of transgender voice and communication services in speech-language pathology graduate curriculum. Standardized training on how to support gender diverse individuals' communication appears to be lacking in graduate curriculum. To better understand current trends in transgender voice and communication training in speech-language pathology graduate programs across the United States, this cross-sequential e-survey study assessed experience with, attitudes toward, and student learning opportunities in transgender voice and communication services among voice instructors and clinic directors.

Method

An open online survey distributed in 2015 was completed by 24 voice instructors and 13 clinic directors. The same survey was completed by 15 voice instructors in 2018.

Results

Based on 2015 findings, a majority of voice instructors and clinic directors in speech-language pathology graduate programs reported that services for transgender voice and communication were not addressed in their graduate education curriculum. Findings from 2018 were similar to results in 2015. Almost all voice instructors included transgender voice and communication therapy in their graduate voice course. There is unanimous agreement that transgender voice and communication services should be part of SLPs' scope of practice.

Conclusions

Findings from 2015 to 2018 suggested an improvement in instruction time spent on transgender voice and communication. Yet, some voice instructors continued to report that the topic was not covered in their coursework. A need exists to adjust guidelines on voice and communication services for gender diverse individuals and offer learning opportunities for this area in graduate speech-language pathology curriculum.

Supplemental Material

https://doi.org/10.23641/asha.12640409

Kumar R, Ravi R, Kunnath LS. Knowledge and attitudes toward transgender community among speech-language pathologists in India: A questionnaire-based exploration

Background: During the transition process, transgender individuals may require voice and communication services. Speech-language pathologists are increasingly involved in rendering clinical services and assisting transgender clients in voice and communication therapy. Previous studies in different countries have highlighted the lack of competence expressed by the speech-language pathologists toward serving the members of the lesbian, gay, bisexual, transgender, and queer communities. Presently, no such findings are available in the Indian context. Thus, a need was felt for identifying the concerns toward treatment for transgender individuals in speech-language pathology settings in India. Aim: The aim of the present study was to assess the knowledge, comfort levels and attitudes of speech-language pathologists practicing in India regarding the transgender community. Method: An online survey method was used to assess the knowledge and attitudes among speech-language pathologists working in India toward the transgender community. Results: The findings of the study revealed higher comfort levels as compared to self-rated knowledge levels in addressing issues related to transgender healthcare. Evidence-based practices toward transgender healthcare emerged as the topic needing more information. The study also helped to identify several moral beliefs and practices for voice therapy for the transgender population. Conclusion: There is a strong need to educate the speech language pathologists toward transgender healthcare in order to promote better cultural competence. The findings of the present study help to identify the lacunae in knowledge as well as to highlight the need to have continuing education programs in this area.

Taiwanese speech-language therapists' awareness and experiences of service provision to transgender clients

Background: One of the most influential factors that affect the quality of life of transgender individuals is whether they can be perceived by others to "pass" in their felt gender. Voice and communication style are two important identifying dimensions of gender and many transgender individuals wish to acquire a voice that matches their gender. Evidence shows that few transgender individuals access voice therapy, and that this is caused by their concerns about stigmatization or negative past experiences within healthcare services. In order to address the negative experiences faced by transgender populations we need a better understanding of healthcare services' current levels of knowledge and LGBT awareness. Some studies of Speech-Language Therapists' (SLTs') experience and confidence working with transgender individuals have recently been undertaken in the United States (US). However, little research has been carried out in Asia. Aims: To investigate Taiwanese SLTs' knowledge, attitudes and experiences of providing transgender individuals with relevant therapy. Method: A cross-sectional self-administered web-based survey hosted on the Qualtrics platform was delivered to 140 Taiwanese SLTs. Results: Taiwanese SLTs were, (i) more familiar with the terminology used to address "lesbian, gay, and bisexual groups" than with "transgender" terminology, (ii) generally positive in their attitudes toward transgender individuals, and (iii) comfortable about providing clinical services to transgender clients. However, the majority of participants did not feel that they were sufficiently skilled in working with transgender individuals, even though most believed that providing them with voice and communication services fell within the SLT scope of practice. Conclusion: It is important for clinicians to both be skilled in transgender voice and communication therapy and to be culturally competent when providing services to transgender individuals. This study recommends that cultural competence relating to gender and sexual minority groups should be addressed in SLTs' university education as well as in their continuing educational programs.