2022 Student Ethics Essay Award, Second-Place Winner

Transgender Voice Therapy and Parental Consent

by Teauna Brosseau Peters, University of Montana

Marley Baker is a speech-language pathologist (SLP) who has been practicing privately in a clinical setting for several years. Before she started her private practice, Marley was a school-based SLP for 15 years. A prospective 16-year-old client recently contacted Marley and expressed an interest in gender-congruent voice therapy. This adolescent, Avery (they/them/their), informed Marley that their parents do not know about the voice therapy and that they will pay privately for the sessions. Avery further noted that they did not want their participation in therapy known to their parents. During the phone conversation, the SLP learns that Avery is not taking hormonal transition therapy due to their parents' refusal to consent. Marley recently attended her state speech-language-hearing conference where a transgender woman discussed voice transition and the need for more professionals to offer this service. After attending this state conference and investigating preferred practice patterns for gender-affirming voice therapy for transgendered individuals on the ASHA website, Marley determined that voice therapy for transgender people is important and within the SLP’s scope of practice. From the discussion at the conference and from following ASHA Marley learned that voice-gender congruency is vital for the safety and mental health for the members of the transgender community. "If individuals who are transgender do not have a voice that matches their gender identity, there could be a significant negative impact on the self-identity, quality of life, and personal safety," (Byrne, 2007). The situation has created many ethical questions that this SLP must consider. Is the parents’ consent needed to treat an adolescent? Is denying treatment for the adolescent discriminatory or worse, posing a risk to their safety?

First, let's consider Principle I, Article C of ASHA's Code of Ethics (2016) which states,

"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." If Marley denies treatment, would it be considered discriminatory? 

Next, let's think about the consent to treatment. Is Marley able to provide treatment to  16-year-old without parental consent? Principle I, Article H of ASHA's Code of Ethics (2016) states that "Individuals shall obtain informed consent from the persons they serve about the nature and possible risks and effects of services provided, technology employed, and products dispensed. This obligation includes informing persons served about the possible effects of not engaging in treatment or not following clinical recommendations. If diminished decision-making ability of persons served is suspected, individuals should seek appropriate authorization for services, such as authorization from a spouse, other family member, or legally authorized/appointed representative." Marley has investigated state laws regarding consent to treatment but finds them confusing. The law does not explicitly address voice therapy.

The whole situation has left Marley feeling upset and confused about the ethics, laws, and her responsibility as an SLP. She told Avery that she would need to research treatment for voice therapy without parental consent but assured them that she would call with more information. Avery indicated that Marley could contact them on their cell phone; however, even contacting Avery without their parents’ knowledge raises concerns for Marley.

Marley finds the legalities of treating a minor without parental consent a bit nebulous and contacts her state licensing board. Marley discovers that she cannot initiate therapy without parental consent. Principle IV, Article R of ASHA's Code of Ethics (2016) states that "Individuals shall comply with local, state, and federal laws and regulations applicable to professional practice, research ethics, and the responsible conduct of research." Marley understands that this principle signifies that she must know, understand, and practice within the legal limits of her state law.

While Marley understands that treating Avery for voice therapy is not possible without parental consent, she also recognizes that she can do some things to help the teen. Marley refers Avery to a counselor specializing in transgender youth and families to help with the mental and emotional toll this could have on them and their family. Marley provided Avery with educational resources about voice therapy to discuss with their family and counselor. Marley reached out to a therapist that specializes in transgender youth to collect information to pass on to Avery. Marley collected a list of other professionals and SLPs that provide gender-affirming voice therapy for Avery.  Marley plans to work as part of an interdisciplinary team to provide Avery with the therapy they requested once they can proceed. Although Marley was disappointed that she could not initiate therapy immediately, she is ethically bound to adhere to state and federal laws regarding the treatment of minors. By providing Avery and their family with education and resources while respecting their wishes to decline therapy, Marley has made strides in establishing a relationship built on trust and respect. Marley feels that she provided Avery with as many resources and referrals to help them within the legal limitations of her state.  

References

American Speech-Language-Hearing Association. (2016, January 1). Code of ethics. American Speech-Language-Hearing Association. Retrieved November 29, 2021, from https://www.asha.org/policy/et2016-00342/#sec1.5.

Health considerations for gender non-conforming children and transgender adolescents. Health considerations for gender non-conforming children and transgender adolescents | Gender Affirming Health Program. (2016, June 17). Retrieved November 29, 2021, from https://transcare.ucsf.edu/guidelines/youth.

Matthews, J.-J., Olszewski, A., & Petereit, J. (2020). Knowledge, training, and attitudes of students and speech-language pathologists about providing communication services to individuals who are transgender. American Journal of Speech-Language Pathology, 29(2), 597–610. https://doi.org/10.1044/2020_ajslp-19-00148 

Miola, J. (2007). Consent, control and minors – Gillick and beyond. In Medical Ethics and Medical Law: A Symbiotic Relationship, 87–116. https://doi.org/10.5040/9781474200585.ch-005