Forty years ago, recommendations for gender-affirming voice interventions were based on stereotypes and differences between cisgender men and women, the occasional conference presentation (e.g., Kalra 1977), and just two peer-reviewed case studies of women assigned male at birth: one changing their fundamental frequency (Bralley et al 1978) and another their non-verbal behaviors (Yardley 1976). It was also around this time that Kitajima Tanabe & Isshiki (1979) were refining parameters of cricothyroid approximation surgery on excised human larynges to have a surgical option for trans women seeking to elevate their vocal pitch.

Today voice and communication interventions are guided by higher-quality empirical research on effectiveness, professional standards informed by multi-disciplinary and international collaborations of researchers and practitioners, and people who are in the gender-expansive community (e.g., transgender, non-binary, genderqueer). Voice specialists supporting well-being directly (i.e., balancing communication-based stressors and resources) is an approach informed by clients and colleagues with lived experience in the gender expanse and the minority stress model from the mental health field. This is more affirming than an indirect approach focused on achieving congruence (i.e., changing behaviors to align with sociocultural normative practices) that potentially builds a stressor of ongoing concealment (Azul et al 2022). Remarkable exponential progress continues as we navigate new – and some longstanding – sociopolitical challenges. The purpose of this issue of Seminars in Speech and Language is to feature the understandings and practices of today as a clear benchmark in the story of progress.

The issue begins with a paper by linguists Hope and Lilley investigating how speech is used in social indexing (i.e., signaling belonging in social groups) for gender. This study fills scientifically and socially important gaps in the speech perception literature by including synthetic stimuli that are outside of binary gender norms and a group of gender-expansive listeners. The findings have implications for clinical use of auditory perception in gender-affirming care, as well as for a multiply marginalized group: non-binary people who use speech generating devices. Overall, the direction of this work promises to improve and expand how speech-language pathologists serve non-binary people.

The next two articles improve our ability to inform and empower clients to make their own decisions in a biopsychosocial approach, a central tenant of the person-centered care model that much of healthcare is striving toward today (Grover et al 2022). People need providers who explain information and support their chosen path to well-being. Voice surgery may be a part of that path, so Dwyer et al have written about the current surgical options for voice in the format of responses to questions commonly asked by treatment-seeking people. Next, Schatzki et al provide an innovative interdisciplinary example for providing professional support to teens and their parents via a 3-hour workshop about mental health challenges and resources, as well as voice care and safe voice exploration. Adolescents are a growing segment of the gender expansive population (Herman et al 2022), yet we are only beginning to understand their needs and the potential contribution of voice and communication services. To quickly gain an understanding of the many intervention options and diverse needs of clients, it is critical to integrate information from multiple disciplines and perspectives.

The final two articles were invited with the hope of impacting the future of this topic in education and research, two of our most powerful tools for systemic change. Robinson et al offer a compelling paper, rich in theoretical foundation and practical action steps for individual professors and supervisors as well as programs. To conclude this issue, Quinn and Hancock guide researchers toward ethical practices of reflexivity and collegiate relationship with the community, which are becoming standard across health disciplines (Aronowitz et al 2015).

Papers in this issue are each written by authors with varied professional degrees, lengths of career, and lived experiences belonging to or serving the populations involved. The quality and impact of our work improve with diverse collaboration; this is especially evident and powerful when collaborating with representatives from the communities served (Cole 2017). This issue of Seminars in Speech and Language demonstrates a positive trajectory toward a future in which all papers about this area of clinical practice include community representation in authorship. This would not have been possible even a few years ago. However, there is still a critical need to make the visibility of trans and non-binary professionals in clinical practice and research safe and valued.

In addition to the opportunities described in the last two papers of this issue, progress toward systemic change can happen through our collective efforts in professional organizations. Advocacy within and for our professions is an important element in our practices (e.g., ASHA 2016a). On the international level, World Professional Association for Transgender Health (WPATH) is the largest organization committed to making healthcare safe and accessible for people of all genders. WPATH has regional organizations (e.g., Asia, Australia & New Zealand, Europe, United States) to offer regional conferences during the years there is not a WPATH conference and to address issues that may be specific to local healthcare or political systems. Transgender Professional Association for Transgender Health (TPATH) is “open only to those who identify within the trans and gender diverse spectrum” and was formed to ensure representation in the leadership and programming of WPATH and support trans identified members of the various PATH chapters, researchers, clinicians, and healthcare recipients.

A Voice and Communication chapter was only added to WPATH's published Standards of Care in 2012 (7th edition) after much advocacy from SLP pioneers led by Dr. Richard Adler. The voice and communication chapter greatly expanded with a systematic review and Delphi process for consensus in the 8th edition (2022) with the primary purpose of educating other healthcare professionals and policymakers about the relevant professionals and evidenced-based practices available to support voice and communication needs. Current members are advocating for reducing barriers of cost so that more clinical providers, who generally do not have access to the financial support or motivation that most researchers do, will participate in the education and advocacy work of WPATH. Growing recognition and membership of voice specialists (e.g., speech-language pathologists, laryngologists, voice teachers) in WPATH has led to advanced voice courses within WPATH Global Education Initiative programming, and a certification pathway is in development.

National professional associations and their subgroups are following global movements - codifying rights to communication for all genders and organizing educational standards and opportunities. The Code of Ethics for SLPs and otolaryngologists prohibit discrimination on the basis of gender identity (ASHA 2016b, AAO-HNS 2019), and the SLP Scope of Practice explicitly includes “transgender and transsexual voice and communication” (ASHA 2016a). The Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC) updated the 2020 Standards for Certificate of Clinical Competence for SLPs to include demonstrating knowledge of professional issues of diversity, equity, and inclusion (Standard IV-G). These changes are in response to the growing evidence of the positive impact of gender affirming care over the past 40 years, as well as members learning and advocating for change. Our professional organizations need members committed to pressing toward healthcare that respects and centers the person rather than centering stereotypes and harmful normative practices. To that end, the information within this issue of Seminars in Speech and Language will be useful as we work together and advocate for further progress.

Article published online:
07 March 2023

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