Supporting and Working With Transgender and Gender-Diverse People

Communication sciences and disorders (CSD) professionals might have questions when working with transgender and gender-diverse people. The term gender-diverse is used throughout this page as an umbrella term that encompasses those who identify as transgender, nonbinary, or not cisgender.

The following provides guidance for appropriate practice in the professions and should not be considered an exhaustive source or a replacement for continuing education. The content in this webpage reflects a common understanding of language use in 2021. Language and culture are dynamic, and they shift over time. It is our responsibility to stay up to date on terminology and find out which terms our clients, patients, and students use.

Pronoun Use 

ASHA’s Code of Ethics does not specifically mention pronoun use. However, using affirming personal pronouns shows respect and creates an inclusive environment. When working with gender-diverse populations, be sure to first read the considerations about your professional responsibilities for best practice by consulting ASHA’s 2017 Issues in Ethics Statement on Cultural and Linguistic Competence and the ASHA Practice Portal page on Gender Affirming Voice and Communication.

It is appropriate to ask someone their name and pronouns, but it is important to approach the question respectfully. One way to do this is to include your pronouns when first introducing yourself. For example, “My name is Terry, and my pronouns are she/her/hers.” Introducing yourself this way invites others to reciprocate your gesture by providing their name and the pronouns that they use. Once you have learned their correct pronouns, you should use those pronouns with 100% accuracy when talking about them, whether they are present or not.

When their family does not support the pronouns they are using, ask the client what they want you to do regarding pronoun use. If they are concerned about the reaction of their family members, then consider using gender-neutral pronouns or just using their name instead of pronouns. As the service provider, our first responsibility is to the people we serve. Using correct pronouns is a way of respecting their dignity and falls in line with ASHA’s Principle of Ethics I. In addition, not using a client’s correct name or pronouns—or misgendering a client in other ways—can contribute to their stress.

Impact and Benefits of Correct Pronoun Use

Not acknowledging pronouns and name is a form of misgendering. Stigma, prejudice, and discrimination can cause stress (e.g., negative affect, lower self-esteem) and lead to concerns about personal security for LGBTQIA+ people, triggering psychological harm, according to McLemore (2015). In addition, research suggests that not acknowledging gender identity may negatively impact a person’s perception of the quality of care that they are receiving, which may in turn reduce patient/client satisfaction in gender-diverse populations. Failure to acknowledge gender identity may also lead to self-imposed behavioral modification, which could negatively impact service delivery (Merritt, 2020).

Research indicates that respecting gender identity results in better health outcomes. It indicates an acceptance of their identity that leads to feelings of inclusion. The service provider’s goal is to foster a sense of safety by using the client’s pronouns and name—which can help build rapport, thereby facilitating positive treatment outcomes.

Making Mistakes 

If you unintentionally misgender an individual when speaking to them or about them, apologize, correct the error, and move on. Seek to empathize with the other person’s lived experience, and express accountability for your mistake. Drawing excess attention to the error can put them in the uncomfortable position of feeling as though they must comfort you. Remember that the best apology is one that does not make excuses or invalidate the other person’s feelings.

Nonbinary Pronouns

Nonbinary or gender-neutral pronouns such as they may be used as a singular pronoun and substitute to he or she according to APA Style and Merriam-Webster. Because the pronoun they is syntactically plural (similar to the pronoun you), verbs attached to they will be those associated with plurals as well, even when the pronoun is semantically singular: “They like to cycle on weekends” (c.f., “You like to cycle on weekends”). It may sound strange to you at first but consider this: You probably already use singular they when a person’s gender is unknown. For example: “Someone left their cell phone in the room. I hope they come back for it!”

Gender-neutral pronoun use is as varied and unique as gender-diverse people, even in languages where gender is marked. If you are unsure of how to use gender-neutral pronouns in a person’s language, then ask them how they use it. The United Nations offers guidance for gender-inclusive language.

If the family and/or individual requests, a service provider should work on nonbinary pronouns (e.g., they/them, ze/hir) with individuals who have language disorders, as part of their therapy language targets. The use of nonbinary pronouns is becoming more commonplace as our language evolves to include all genders. Teaching the use of nonbinary pronouns is a way to foster a more gender-inclusive environment.

Pronoun Use in Treatment Plans and Reports

Service providers should first ask the individual to identify what name, affixes, and pronouns to use—and to specify the contexts in which to use them in future verbal communication and in all official written documentation that might include records and documentation to third party payers. As an alternate, the service provider could use the individual’s name in lieu of pronouns in written documentation or refer to them as “the client/patient/student.” Consider implementing any of the following suggestions to modify forms and individual records after establishing how the individual wants to be identified:

• Use codes or nondescript, colored stickers so that only you or other key staff can interpret this information (suggested by Brotman and Ryan (2001) [PDF], p. 35).
• If you maintain paper charts, make a simple notation inside the individual’s folder indicating the name and pronoun.
• If you maintain electronic medical records, explore the capability to customize fields in electronic medical software systems to securely store information (i.e., names and pronouns) accessible only to clinical staff.
• Edit your intake form to include name as well as your name as it appears on your identification card. Provide a blank to allow the option of writing in the sex/gender (suggested by the Transgender Law Center [PDF]).
• Use the individual’s name instead of pronouns throughout written communication shared with third parties.

The term biological male or biological female is information that needs to be referenced only if it is directly pertinent to the provision of care. You can use the terms assigned male at birth (AMAB) or assigned female at birth (AFAB) to acknowledge the sex that was assigned at birth, which may or may not align with the person’s gender. The terms biological male and biological female oversimplify a complex subject and overlook people who are intersex. Complex anatomical, hormonal, and chromosomal variations exist, making the meaning of any “biological” label indefinite or inaccurate.

Pronoun Use in Test Norms

There is very little current research on how transgender and gender-diverse people perform in relation to those included in the normative data associated with cisgender males and females. Webb and colleagues (2016) suggest (a) using clinical judgment to determine which scores best reflect clinical observations, (b) using the scores that align with the person’s gender identity (if applicable), or (c) for gender-diverse individuals, asking them which scores they would like you to use. It is important to note that scores may be considered invalid if the norming population does not reflect the individual.

Privacy Concerns

It is never acceptable to disclose an individual’s LGBTQIA+ status, medical and surgical history, or sex assigned at birth to colleagues or those not directly involved in that individual’s care. According to the ASHA Code of Ethics, Principle of Ethics I, Rule P, we are to protect the confidentiality of our clients’/students unless “doing so is necessary to protect the welfare of the person or of the community, is legally authorized, or is otherwise required by law.” Confidentiality is guarded by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), FERPA, and individual state laws.

It is not generally appropriate to ask someone about their medical history related to gender-affirming surgeries or hormone status. Genital status of any person is not relevant to the practice of audiology and speech-language pathology. Asking about gender-affirming surgeries out of curiosity or interest is inappropriate. It might be relevant to ask, “Have you had surgery that required intubation?” However, asking the question, “What kind of surgery did you have?” is not appropriate. A notable exception is if the gender-affirming surgery directly impacts voice and speech production. It would be appropriate to ask for a list of all current drugs (whether prescribed or not), with duration and dosing information because drugs or their side effects may impact communication. Those taking endocrine-related medications, such as testosterone, may describe impacts on their voice—and it would be helpful to understand the timeline of those medications and the experienced consequences (see Metastasio, Negri, Martinotti, & Corazza, 2018).

If the individual is under 18 years of age, parents may request educational records through the Family Educational Rights and Privacy Act of 1974 (FERPA); this information should be included in any discussion with a student who is a minor. Individual institutions (e.g., school districts) may offer more guidance regarding gender-diverse issues, and your state policy may offer a person more privacy rights than that person has under federal law.

Family Considerations to Keep in Mind

CSD professionals must be prepared to work with gender-diverse clients and members of their support system. It is growing increasingly common to encounter people who are members of diverse family structures that include biological families and/or chosen families. Chosen family is a term that originated within the LGBTQIA+ community and is used to describe “non-biological kinship bonds, whether legally recognized or not, deliberately chosen for the purpose of mutual support and love.” When in doubt about the relationships between individuals who attend a meeting or the social support that a client has, ask for clarification and guidance: Working closely with the family will ensure that pronouns—and the contexts in which to use them—are correct. Strive to affirm their gender identity, and respect their gender expression, recognizing health disparities that may impact their ability to pursue services. Hays, Steckley, and Walden shared some specific ways in which you can express acceptance and create a safe space at their 2014 ASHA Convention presentation.

• Consider using gender‐neutral terms in forms and notices—such as the term caregiver or guardian—to avoid traditional, gendered terms like mother.
• Ask the caregivers—or the individual directly—about the terminology that they use when referring to each other (e.g., daddy, papa).
• Respect the caregivers’ or family members’ gender expression and gender identity, and consistently use the pronouns that they have indicated they use.
• Find ways to address each family’s diversity in clinical services—including the use of materials that reflect gender-inclusivity and diverse family structures.
• For gender-fluid populations, pronoun use may vary between appointments. Normalize the process of asking for their name and gender pronouns at each appointment check-in.
• Aim to include family members in clinical activities.
• Educate yourself about microaggressions so that you can better recognize when they occur.
• Practice how to respond when you witness microaggressions to ensure that LGBTQIA+ families feel valued and respected.

Creating a Supporting Workplace Environment

First, adopt a posture of cultural humility and responsiveness, and encourage and foster the same for everyone in the environment. Some environmental modifications that are welcoming to gender-diverse populations and that also model inclusivity include (a) updating forms to reflect gender-diverse populations, (b) using culturally sensitive materials in service delivery, (c) respecting and using correct pronouns, and (d) providing access to gender-neutral bathrooms (based on information from the National Center for Transgender Equality). Best practice would also include consultation with a university or workplace diversity and inclusion office for additional resources and information. Additional information can be found through the National Center for Transgender Equality and the Welcoming Schools resource A Checklist for a Welcoming LGBTQ and Gender Inclusive School Environment (published by the Human Rights Campaign Foundation).

Advocating and Facilitating Workplace Change

There are several things that we can do to advocate for and facilitate change within our work settings to benefit our clients:

• In academic settings, advocate for LGBTQIA+ issues to be infused throughout the curriculum.
• Be a vocal advocate for LGBTQIA+ issues to be included in local policies to address discriminatory behavior and inappropriate conduct (e.g., association or employer guidelines, state licensure board and federal guidelines). If discriminatory behavior arises, follow existing policies, and involve an administrator for facilitation, if needed.
• Identify people with expertise in LGBTQIA+ issues to provide training and in-services for faculty and staff.
• If you work at a school, give a gender- and sexual orientation–affirming booklist to the library, and support student-led LGBTQIA+ groups.

ASHA thanks the ASHA Multicultural Issues Board, L’GASP: LGBTQIA+ Caucus of ASHA, and other CSD professionals, including gender-diverse people, cisgender professionals, and CSD graduate students for their contributions in creating this page.

Additional Resources

Organizations and Projects

• Family Acceptance Project
• GLAAD
• GLSEN
• Human Rights Campaign
• PFLAG
• The National Center for Transgender Equality
• The Trevor Project
• The World Professional Association for Transgender Health (WPATH)
• Trans Student Educational Resources (TSER)

Articles

American Bar Association (2020). Respecting gender identity in healthcare: Regulatory requirements and recommendations for treating transgender patients.

Azul, D. (2015). On the varied and complex factors affecting gender diverse people’s vocal situations: Implications for clinical practice. Perspectives on Voice and Voice Disorders, 25(2), 75–86.

Fassinger, R. E. (2008). Workplace diversity and public policy: Challenges and opportunities for psychology. American Psychologist, 63(4), 252–268.

Goldberg, AC. (2019). Our transgender language choices make all the difference. The ASHA Leader, 24(4), 6–7.

Herek, G. M., & Garnets, L. D. (2007). Sexual orientation and mental health. Annual Review of Clinical Psychology, 3, 353–375.

Knutson, D., Koch, J. M., & Goldbach, C. (2019). Recommended terminology, pronouns, and documentation for work with transgender and non-binary  populations. Practice Innovations, 4(4), 214–224.

Lomotey, B. A. (2011). On sexism in language and language change: The case of peninsular Spanish. Linguistik Online, 70(1).

Lomotey, B. A. (2018). Making Spanish gender fair: A review of anti-sexist language reform attempts from a language planning perspective. Current Issues in Language Planning, 19(4), 383–400.

Oates, J., & Dacakis, G. (2017). Inclusion of transgender voice and communication training in a university clinic. Perspectives of the ASHA Special Interest Groups, 2(10), 109–115.

Taylor, S., Barr, B.-D., O’Neal-Khaw, J., Schlichtig, B., & Hawley, J. L. (2018). Refining your queer ear: Empowering LGBTQIA+ clients in speech-language pathology Practice. Perspectives of the ASHA Special Interest Groups, 3(14), 72–86.

Voyzey, G. A. (2015). Meeting the cultural, therapeutic, and individual needs of the lesbian, gay, bisexual or transgendered patient. Perspectives on Gerontology, 20(3), 85–103.

Books

Croteau, J. M., Bieschke, K. J., Fassinger, R. E., & Manning, J. L. (2008). Counseling psychology and sexual orientation: History, selective trends, and future directions. In S. D. Brown & R. W. Lent (Eds.), Handbook of counseling psychology (4th ed., pp. 194–211). John Wiley & Sons.

Holden, G. W. (2015). Parenting in nontraditional families. In Parenting: A dynamic perspective (2nd ed., pp. 294–315).

Other 

• American Psychological Association’s Practice Guidelines for LGB Clients
• National Center for Gender Equality Fact Sheet on U.S. Department of Education Policy Letter on Transgender Students [PDF].
• National Council of Teachers of English Statement on Gender and Language.
• Services and Advocacy for GLBT Elders (SAGE) and National Center for Transgender Equality (NCTE). (2012). Improving the lives of transgender older adults: Recommendations for policy and practice.
• U.S. Department of Health and Human Services’s Your health information, your rights infographic [PDF]
• U.S. Department of Justice Responding to transgender victims of sexual assault