Roles and Responsibilities

SLPs play a central role in clinical services for gender affirming services. 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 gender affirmation services—and the role of SLPs
• Conducting a comprehensive, culturally and linguistically relevant assessment
• Referring to other professionals as needed
• Developing treatment plans, providing treatment, documenting progress, and determining appropriate dismissal criteria
• Providing education to promote vocal health and avoid vocal damage in pursuit of desired vocal changes as part of gender affirmation services,
• Remaining informed of research in gender affirmation 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).

Cultural Sensitivity

Terminology

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 Clinicians proactively remain educated and up to date with terms that are still evolving and thus tend to become outdated and/or offensive.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, clinicians use it in a manner that is appropriate, respectful, and sensitive. Please see HRC-Glossary of Terms, PFLAG Glossary of Terms and ASHA’s resource on Supporting and Working with Transgender and Gender-Diverse Individuals

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).

Clinic Modifications

Sensitivity to clients starts at the initial point of contact and continues throughout all interactions. Office support staff and clinicians participate in sensitivity training to increase awareness for working with gender-diverse populations. Sensitivity is critical to building relationships, maintaining privacy and creating safe spaces for clients/patients/students.

Notice the imagery and artwork displayed around the office as well as photos and families represented in treatment materials and information. Ensure that you are being inclusive of diverse populations.

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.

Inclusive intake and case history forms are necessary. 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 name to be used if submitting for reimbursement to a third-party payer. It can be triggering for clients to say this name aloud. Using this name may be triggering. Clinicians may ask client/patient/student to verify the name by writing it down and asking for a yes/no verification as opposed to saying it aloud. Provide forms regarding pronoun use and gender identity to all clients, regardless of the service that they seek, in order to ensure inclusiveness.

See Supporting and Working with Transgender and Gender-Diverse Individuals, Self-Relfection: Gender Inclusivity [PDF], and ASHA's Practice Portal page on Cultural Responsiveness for more information.

Insurance

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. If a client is not out to their insurance company clinicians may use initials and eliminate use of pronouns when writing reports for submission.

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 for Gender Affirmation Services.

Assessment

Comprehensive evaluation considers current voice and communication skills to develop a treatment plan in collaboration with the client. Intake forms and client interviews indicate how the client presents at home, at work, and in social situations. Client goals reflect the fluidity needed for their gender expression in all settings. It is also important to refrain from imposing the clinician's constructs of gender. Focus on the client's and their goals, what they feel fits them and what best represents their authentic voice. 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 only obtain information 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. However, gender affirmation surgery does not influence the voice. Therefore, asking questions on a standard intake form and/or during initial intake is not relevant for service delivery. 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 and effective 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 may work:

• Vocal health
• Resonance
• Voice: Pitch, intonation, and volume
• Articulation
• 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. A subjective analysis from the client's perspective, including video and audio recordings, are components of ongoing 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). Questionnaires can also be helpful tools during assessment to understand voice-related experiences. 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).

Providing Voice and Communication Services

Collaborating with the client's lead is critical for setting needs and goals. As stated earlier, gender identity and communication needs are unique to each individual. The ultimate goal is to assist the client in achieving an authentic voice and communication style based on their needs. Affirmative goals focus on creating a voice that is authentic, comfortable, and safe (Hancock, 2015). Some individuals prefer a gender-neutral vocal 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 gender affirmation voice services 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 gender affirmation 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, gender affirmation services may use these exercises to facilitate a safe shift in 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 may be established if that is consistent with the client's goals.

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.

Lowering Pitch

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 increases testosterone levels, 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 transmen 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).

Raising Pitch

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 an 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. Do not assume the areas of communication a client will want to work on. Working together to establish goals for how the client wishes to express their gender is essential to establishing a set of goals.

Considerations in Service Delivery

Timelines for reaching goals may be influenced by the client's age, frequency of treatment, other gender-related interventions, and overall time available to use their authentic voice. A number of factors influence the ability to present as the client's gender in all settings. It can be challenging to allow for time or context within which to practice. Incorporate opportunities for practice into individual and group sessions. 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.

The Department of Health and Human Services released guidance in March 2022 about provision of services under Section 504 of the Rehabilitation Act of 1973. Section 504 protects qualified individuals with disabilities from discrimination in programs and activities receiving federal funding. Gender dysphoria may, in some cases, qualify as a disability under these laws. Not all individuals seeking gender affirming voice services have gender dysphoria. It is inappropriate to restrict care based on gender, on gender dysphoria, or on one’s own perception of gender or gender dypshoria. See HHS Notice and Guidance on Gender Affirming Care, Civil Rights, and Patient Privacy

Group Intervention

Group intervention provides an opportunity for clients to practice carryover in a supportive 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).

Counseling

Clients may seek the assistance of mental health providers for support during transition. Discrimination, stigma, and/or violence toward the gender diverse community can negatively impact psychosocial well-being (White Hughto, Reisner, & Pachankis, 2015). Mental health providers are collaborative partners 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.

See ASHA’s Practice Portal pages on Counseling For Professional Service Delivery and Cultural Responsiveness.

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 pitch-tuning apps (e.g., apps for piano playing, guitar tuning, etc.). Inappropriate practice can contradict treatment efforts and lead to development of hyperfunctional voicing patterns.

Ethics

Ethical considerations for SLPs include provision of services under the scope of the expertise.

The 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.

Rule B. Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided.

If a professional feels unqualified to serve a person they should make the appropriate referral.The clinical protocol for gender affirmation services is built from skill sets developed from working in the area of voice—including pitch, resonance, intonation articulation, language, and nonverbal communication; however additional knowledge and training for sensitivity to working with gender diverse populations is essential.

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 age; citizenship; disability; ethnicity; gender; gender expression; gender identity; genetic information; national origin, including culture, language, dialect, and accent; race; religion; sex; sexual orientation; or veteran status.

SLPs are uniquely qualified to provide gender affirming voice therapy. Not all clinicians will provide gender affirming voice therapy nor are they required to do so. However, clinicians may not refuse service based on a person's gender, gender identity or gender expression.

See ASHA’s Code of Ethics, Prohibitions Against Discrimination Under ASHA Code of Ethics, Issues in Ethics: Cultural and Linguistic Competence and Supporting and Working with Transgender and Gender-Diverse Individuals

State and Federal Regulations

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.

According to Section 1557 of the Patient Protection and Affordable Care Act (ACA) [PDF], which is the primary anti-discrimination provision of the ACA, a health plan or health insurer that receives federal financial assistance from the Department of Health and Human Services (HHS) cannot categorically exclude all services related to gender transition and/or make coverage decisions in a manner that results in discrimination against gender diverse individuals (i.e., deny a claim or impose limitations or restrictions on any health service). Recent guidance further emphasizes that restricting a health care provider from providing or prescribing gender affirming services may be considered a violation of Section 1557. If staff at a facility reports individuals (e.g., a parent or child) for seeking gender affirming care, they may be in violation of Section 1557 if that health care provider or facility receives federal financial assistance. See HHS Notice and Guidance on Gender Affirming Care, Civil Rights, and Patient Privacy [PDF]. 

The Health Insurance Portability and Accountability Act of 1996 (PL 104-191), also known as HIPAA, includes provisions for the privacy and security of health information. Clinicians may not disclose patient gender without either written or explicit verbal permission. Intake form and initial sessions discuss name and pronoun to use in the waiting room, on phone calls, leaving voice mail messages, and in sessions. Clinicians do not disclose information prior to checking in with their client. Recent guidance reinforced that patient privacy and information may not be disclosed unless required by law. See HHS Notice and Guidance on Gender Affirming Care, Civil Rights, and Patient Privacy [PDF] for additional clarification about the circumstances that constitute “required by law.”

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 for Gender Affirmation Services.

Seek legal counsel if you have questions or concerns regarding the impact of federal or state law on transition-related care.

Language is dynamic and terminology has evolved over the years as our understanding of gender grows. International use of terminology may not be consistent with use in the U.S. Prior research and journal articles may use titles and language that is no longer used.  Eliminating this research would erase years of content intended to provide best practices and tips in provision of gender alignment services. This information can help guide best practices, while the clinician stays current with the most appropriate terminology and uses the terms provided to them by the client/patient/student.

ASHA Resources

• ASHA Statement On Brigham Young University Administration Decision To Deny Speech Services for Transgender Clients
• Gender-Affirming Voice and Communication Change for Transgender and Gender-Diverse People
• Prohibitions Against Discrimination Under ASHA Code of Ethics
• Reimbursement of Voice Therapy for Gender Affirmation Services
• Resonance Disorders Practice Portal page
• Self-Reflection: Gender Inclusivity [PDF]
• Supporting and Working with Transgender and Gender-Diverse Individuals
• Voice Disorders Practice Portal page

Non-ASHA Resources

This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.

• GLAAD Tips for Allies of Transgender People
• GLAAD Transgender Resources
• GLSEN
• National Center for Transgender Equality
• Royal College of Speech & Language Therapists - Trans and Gender-Diverse Voice & Communication Therapy
• The Williams Institute
• Title VII of the 1964 Civil Rights Act
• Transgender Patient Services & Support: Resources for Providers and Hospital Administrators
• Voice-related Experiences of Nonbinary Individuals (VENI) Development and Content Validity - ScienceDirect
• Welcoming Schools
• What is Gender Dysphoria
• What to Expect at the Doctor: Navigating Conversations Around Social and Medical Transition
• World Professional Association for Transgender Health (WPATH)
• Voice and Speech Trainers of America (VASTA)

Adler, R. (2017). The SLP as counselor for the transgender client. Perspectives of the ASHA Special Interest Groups, 2(10), 92–101. https://doi.org/10.1044/persp2.SIG10.92

Adler, R., Hirsch, S., & Pickering, J. (Eds.). (2018). Voice and communication therapy for the transgender/gender diverse client: A comprehensive clinical guide (3rd ed.). San Diego, CA: Plural.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

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Azul, D., Arnold, A., & Neuschaefer-Rube, C. (2018). Do transmasculine speakers present with gender-related voice problems? Insights from a participant-centered mixed-methods study. Journal of Speech, Language, and Hearing Research, 61, 25–39. https://doi.org/10.1044/2017_JSLHR-S-16-0410

Bouman, W. P., Schwend, A. S., Motmans, J., Smiley, A., Safer, J. D., Deutsch, M. B., . . . Winter, S. (2017). Language and trans health. International Journal of Transgenderism, 18, 1–6. https://doi.org/10.1080/15532739.2016.1262127

Carew, L., Dacakis, G., & Oates, J. (2007). The effectiveness of oral resonance therapy on the perception of femininity of voice in male-to-female transsexuals. Journal of Voice, 21,591–603. https://doi.org/10.1016/j.jvoice.2006.05.005

Civil Rights Act of 1964, P.L. 88-352, 20 U.S.C. §§ 241 et seq.

Dacakis, G., Davies, S., Oates, J. M., Douglas, J. M., & Johnston, J. R. (2013). Development and preliminary evaluation of the Transsexual Voice Questionnaire for male-to-female transsexuals. Journal of Voice, 27, 312–320. https://doi.org/10.1016/j.jvoice.2012.11.005

Dacakis, G., Oates, J., & Douglas, J. (2017a). Associations between the Transsexual Voice Questionnaire (TVQ^MtF) and self-report of voice femininity and acoustic voice measures. International Journal of Language and Communication Disorders, 52, 831–838. https://doi.org/10.1111/1460-6984.12319

Dacakis, G., Oates, J. M., & Douglas, J. M. (2017b). Further evidence of the construct validity of the Transsexual Voice Questionnaire (TVQ^MtF) using principal components analysis.Journal of Voice, 31, 142–148. https://doi.org/10.1016/j.jvoice.2016.07.001

Davies, S. (2017). The evidence behind the practice: A review of WPATH suggested guidelines in transgender voice and communication. Perspectives of the ASHA Special Interest Groups, 2(10), 64–73. https://doi.org/10.1044/persp2.SIG10.64

Davies, S., Papp, V., & Antoni, C. (2015). Voice and communication for gender nonconforming individuals: Giving voice to the person inside. International Journal of Transgenderism, 1, 117–159. https://doi.org/10.1080/15532739.2015.1075931

Gelfer, M. P., & Mikos, V. A. (2005). The relative contributions of speaking fundamental frequency and formant frequencies to gender identification based on isolated vowels. Journal of Voice, 19, 544–554. https://doi.org/10.1016/j.jvoice.2004.10.006

Hancock, A. B. (2015). The role of cultural competence in serving transgender populations. Perspectives on Voice and Voice Disorders, 25(1), 37–42. https://doi.org/10.1044/vvd25.1.37

Hancock, A. B., Childs, K. D., & Irwig, M. S. (2017). Trans male voice in the first year of testosterone therapy: Make no assumptions. Journal of Speech, Language, and Hearing Research, 60, 2472–2482. https://doi.org/10.1044/2017_JSLHR-S-16-0320

Hancock, A. B., & Garabedian, L. M. (2013). Transgender voice and communication treatment: A retrospective chart review of 25 cases. International Journal of Language and Communication Disorders, 45, 313–324. https://doi.org/10.1111/j.1460-6984.2012.00185.x

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Hillenbrand, J., & Clark, M. (2009). The role of F0 and formant frequencies in distinguishing the voices of men and women. Attention, Perception & Psychophysics, 71, 1150–1166. https://doi.org/10.3758/APP.71.5.1150

Hirsch, S. (2017). Combining voice, speech science and art approaches to resonant challenges in transgender voice and communication training. Perspectives of the ASHA Special Interest Groups, 2(10), 74–82. https://doi.org/10.1044/persp2.SIG10.74

Irwig, M. S., Childs, K., & Hancock, A. B. (2016). Effects of testosterone on the transgender male voice. Andrology, 107–112. https://doi.org/10.1111/andr.12278

James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality. Retrieved from http://www.ustranssurvey.org/report

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Nygren, U., Nordenskjöld, A., Arver, S., & Södersten, M. (2016). Effects on voice fundamental frequency and satisfaction with voice in trans men during testosterone treatment—A longitudinal study. Journal of Voice, 30, 766.e23–766.e34. https://doi.org/10.1016/j.jvoice.2015.10.016

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Papp, V. G. (2011). The female-to-male transsexual voice: Physiology vs. performance in production (Unpublished doctoral dissertation). Rice University, Houston, TX.

Pickering, J. E., & Kayajian, D. (February 2014). Group voice and communication intervention: The first five years. Paper presented at the 2014 World Professional Association for Transgender Health Biennial Symposium, Bangkok, Thailand.

Schneider, S., & Courey, M. (2016). Transgender voice and communication-vocal health and considerations. In M. Deutsch (Ed.), Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people(pp. 161–171). Retrieved from http://transhealth.ucsf.edu/pdf/Transgender-PGACG-6-17-16.pdf

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Acknowledgements 

Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Voice and Communication Services for Transgender and Gender Diverse Populations page:

• Richard Adler, PhD, CCC-SLP
• Kimberly Dahl
• Kevin Dorman, MS, CCC-SLP
• Eryn Gitelis, MA, CCC-SLP
• Adrienne Hancock, PhD, CCC-SLP
• Sandy Hirsch, MS, CCC-SLP
• Jairus-Joaquin Matthews, PhD, CCC-SLP
• Jennifer Oates, PhD
• Sarah Penzell, MA, CCC-SLP
• John Pickering, PhD, CCC-SLP

Citing Practice Portal Pages 

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association (n.d.) Voice and Communication Services for Transgender and Gender Diverse Populations. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Transgender-Gender-Diverse-Voice-and-Communication/.