Gender-Affirming Voice Therapy Advocacy

Language is dynamic, and terminology evolves. The terminology on this page reflects terms currently used in health care and education policy. When treating members of the transgender and gender nonconforming community, clinicians are encouraged to ask their client what terminology they (the client) use. Similarly, the policy landscape is rapidly evolving. This information is current as of June 30, 2023, and will be updated as needed.

Background

According to the World Health Organization (WHO), gender-affirming health care can include any single intervention or combination of interventions—including social, psychological, behavioral, or medical (including hormonal treatment or surgery)—designed to support and affirm an individual’s gender identity when it conflicts with the gender they were assigned at birth.

A voice that is incongruent with gender identity can negatively impact quality of life, attract unwanted attention, and greatly impact personal safety. Therefore, many individuals in this population wish to change their voice and/or communication style.

Role of Speech-Language Pathologists

Speech-language pathologists (SLPs) provide gender-affirming voice therapy within their scope of practice and may be part of an interprofessional team focused on providing services related to vocal health. Modifying usual pitch, adopting new mouth shapes, or producing the voice in a different way than usual can be fatiguing and potentially damaging, leading to problems like vocal fatigue and dysphonia. Without treatment, this can lead to vocal cord nodules, polyps, or scarring.

SLPs can help patients safely modify their voice and communication behaviors—including verbal and nonverbal communication, such as vocal pitch, intonation, voice quality, resonance, fluency, articulation, pragmatics, and vocalization (e.g., laughing)—through evidence-based interventions and patient-focused functional goals.

Stay Informed, and Get Involved

State and Federal Advocacy

ASHA is troubled by ongoing state legislative and regulatory efforts to restrict clinicians’ ability to provide gender-affirming care and its potential effect on the health of transgender people across the country. In addition to actively tracking legislation affecting transgender health care nationwide, ASHA opposes policies that directly inhibit access to gender-affirming voice therapy for transgender and gender nonconforming populations. ASHA’s Government Affairs and Public Policy team is also committed to guiding and supporting our members who are interested in joining state-level advocacy efforts on this issue. ASHA also developed the following issue brief and talking points to assist individuals seeking to advocate on this issue:

Issue Brief [PDF]
Talking Points [PDF]

Members seeking to consult with their state association and licensing board for questions specific to the state(s) where they practice can find local contacts at ASHA State-by-State.

Several law groups are offering pro-bono consultations for providers who need to clarify their ability to continue providing services. Consider reaching out to your state bar association or groups such as Lawyers for Good Government for legal advice.

In addition, we encourage members who want to be more involved in legislative campaigns at the federal and state level to learn more about a few of the many organizations spearheading these efforts via the links below.

Federal Protections

The following federal laws, regulations, and guidance address this issue:

Title VII of the 1964 Civil Rights Act prohibits discrimination on the basis of sex.
Title IX of the Education Amendments of 1972 bans discrimination based on sex by public schools. The U.S. Department of Education has issued a notice of interpretation [PDF] that, in light of the U.S. Supreme Court’s 2020 decision in Bostock v. Clayton County, discrimination on the basis of gender identity is sex discrimination under Title IX. However, in keeping with a federal court order [PDF], the department has been preliminarily restrained from implementing this document in Alabama, Alaska, Arizona, Arkansas, Georgia, Idaho, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, Ohio, Oklahoma, Tennessee, South Carolina, South Dakota, and West Virginia.
The U.S. Department of Health and Human Services (HHS) [PDF] has issued a Notification of Interpretation and Enforcement of Section 1557 of the Affordable Care Act stating that discrimination based on gender identity is sex discrimination under Title IX.
HHS also states [PDF] that gender dysphoria may be considered a disability in some cases, but clear guidelines have yet to be established.
Section 504 of the Rehabilitation Act prohibits discrimination based on disability in programs or activities that receive federal financial assistance, and Title II protects qualified individuals with disabilities from discrimination in state and local government programs.

Potential Court Protection

The U.S. Court of Appeals for the Fourth Circuit recently ruled in Williams v. Kincaid [PDF] that gender dysphoria was not excluded under the Americans with Disabilities Act (ADA) and may be considered a disability in some cases. The Fourth Circuit case has limited reach, and this issue has yet to be addressed by the U.S. Supreme Court or amended in the ADA. HHS also states that gender dysphoria may be considered a disability in some cases [PDF], but clear guidelines have yet to be established. Gender dysphoria’s classification as a disability is something to monitor.

Comments and Testimonies

See ASHA's full list of comments, letters, and testimonies:

Related Resources

Questions?

For questions about legislation in the states, please contact ASHA’s State Affairs team at states@asha.org. For questions about federal laws, regulations, and guidance, please contact ASHA’s Health Care and Education Policy team at reimbursement@asha.org.