Roles and Responsibilities

Speech-language pathologists (SLPs) play a central role in clinical services for gender affirmation. The professional roles and activities in speech-language pathology include clinical and 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:

• Educate other professionals on gender affirming voice—and the role of SLPs.
• Conduct a comprehensive, culturally and linguistically relevant voice and communication assessment.
• Refer to other professionals as needed.
• Develop treatment plans, provide treatment, document progress, and determine appropriate dismissal criteria.
• Provide education to promote vocal health and avoid vocal damage in pursuit of desired vocal changes as part of gender affirmation services.
• Remain informed of research in gender affirming voice and communication services.
• Remain current with changes in terminology and other cultural considerations.
• Serve as an advocate for clients.
• Serve as an integral member of an interdisciplinary team (e.g., endocrinology, otolaryngology, social work, psychiatry, psychology, gynecology, plastic surgery) working with people who are transgender or gender-nonconforming and their families/caregivers.

As indicated in Principle II, Rule A of the ASHA Code of Ethics (ASHA, 2023), 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 people who are transgender and gender-nonconforming, including resources 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 (Coleman et al., 2022).

Please see the Ethics and State and Federal Regulations sections below for more ethical and regulatory considerations.

Cultural Responsiveness

Terminology

Gender, as a social construct, is often represented—and oversimplified—by the binary system of male and female. Over time, many have recognized that their gender may not align with the sex assigned at birth. Gender does not fit into a binary construct. Expanding response options to questions about gender and examining how we ask questions are important to ensure that goals and outcomes are patient centered. Clinicians proactively remain educated and up to date with terms that are still evolving and may become outdated and/or offensive. It is essential for the clinician to use appropriate terminology demonstrating awareness and sensitivity to the client. Clinicians ask the client’s names and pronouns for work, at home, and in social situations, to ensure a client’s privacy and safety is protected and the client is not disclosed or “outed.” 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 the HRC Glossary of Terms, the PFLAG Glossary of Terms, and ASHA’s resource on supporting and working with transgender and gender-diverse people.

Clinic Modifications

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

Nearly one third of respondents of the 2015 U.S. Transgender Survey reported that none of their health care providers knew that they were transgender (James et al., 2016). People may not be comfortable with asking clinicians detailed questions about gender affirming voice. Having openly available and accessible materials about gender affirming voice in the clinical space and on the website may provide the opportunity for individuals to review materials to determine if they wish to pursue services.

Additional adjustments are made to facilities and materials. These modifications include the following:

• Gender-neutral restrooms.
• Visible pronoun identification for all staff, on badges or name plates.
• Diverse representation among the imagery, artwork, and treatment materials.
• Publicly visible, prominently displayed nondiscrimination policy and Safe Zone sticker. Safe Zone stickers show that all staff received sensitivity training to support LGBTQIA+ (lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, and more) people. Safe Zone or Safe Space stickers are available from various organizations, including the Safe Zone Project and GLSEN, Inc. Before using a Safe Zone sticker in a facility, ensure that all staff are adequately trained in cultural responsiveness and support of the LGBTQIA+ community with accountability systems, so the space is truly safe.

Inclusive intake and case history forms are necessary for these services. 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 and pronouns to be used in treatment, with family, during communications and the name to be used if submitting for reimbursement to a third-party payer. If the person does not use the name they were given at birth, clinicians always refer to the client by their chosen name and provide rationale for confirmation of their “dead name” or the name listed on official documentation. The clinician may ask the client/patient/student to verify the name by writing it down and asking for a yes/no verification—saying this “dead name” aloud can be triggering. Provide expansive options in forms regarding pronoun use, honorifics, relationships, and gender to all clients, regardless of the service that they seek, to ensure inclusiveness.

See ASHA’s resource on supporting and working with transgender and gender-diverse people, Self-Reflection: Gender Inclusivity [PDF], Building a Culturally Inclusive & Gender Affirming Space (ASHA On Demand Webinar), and ASHA’s Practice Portal page on Cultural Responsiveness for more information. See also the U.S. Department of Education Toolkit [PDF].

Documentation and Reimbursement

Before verifying benefits or submitting claims to insurance, clinicians ask the client for the identifying information that should be used in communications with their insurance. If a client uses the name assigned at birth with their insurance company, then clinicians may avoid confusion by using initials and eliminating the use of pronouns when writing reports for submission. In documentation and billing, clinicians verify the inclusion or omission of gender, names and pronouns, and which institutions will have access to these documents.

Some people who seek and receive medical services have a diagnosis of gender dysphoria under the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (American Psychiatric Association [APA], 2022) or the International Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification. 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 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (APA, 2022). Coverage varies by payer and plan for services related to gender affirmation. A medical diagnosis of gender dysphoria is often necessary to receive insurance coverage for gender affirming care services but does not guarantee it. However, not all transgender and gender-nonconforming people experience dysphoria or distress from incongruence (APA, 2022).

For additional information about health insurance coverage and payment for gender affirming care, see Payment of Gender-Affirming Voice Therapy. See also ASHA’s resource on advocacy for gender affirming voice therapy.

Assessment

According to the eighth version of the Standards of Care for the Health of Transgender and Gender Diverse People (Coleman et al., 2022), an SLP with expertise to provide services to transgender and gender-nonconforming people may work on the following areas:

• articulation
• language (including pragmatics, syntax, and semantics)
• nonverbal communication, which may include vocalizations such as coughing and laughing
• real-life experiences/authenticity/safety
• resonance
• vocal health
• voice: pitch, intonation, and volume

Collaboration With the Client

Comprehensive evaluation considers current voice and communication skills to develop a treatment plan in collaboration with the client. 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. Some clients may not have goals that reflect the binary constructs of masculine and feminine voice. Focus on the client’s self-determined goals, what they feel fits them, and what best represents their authentic voice. Goals related to voice and communication are specific to each person and may change over time.

Client perspective is critical. A subjective analysis from the client’s perspective, including video and audio recordings, is a component of ongoing assessment that allows 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 et al., 2013, 2017a, 2017b). 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. The client may have a hypercritical self-perception and may express frustrations about their progress (Azul et al., 2018).

Social and Case History

Intake forms and client interviews gather the following information to develop a person-centered plan of care:

• Names and pronouns used
• at home,
• at school,
• at work, or
• socially.
• Can a voicemail be left? If so, please indicate which name(s) to use.
• Previous and/or current procedures, such as hormone replacement therapy, specifically impacting speech and voice production and/or respiration.
• History of intubation and previous surgeries, including but not limited to laryngoplasty, vocal fold injection, or top surgery, that may affect voice quality and/or the laryngeal, pharyngeal, and respiratory functions.
• Existing disorder(s) or condition(s).
• Prior speech, language, or communication interventions.
• Client’s current voice and communication goals.
• Current presentation in the following settings:
• home
• school
• work
• social
• Desired presentation in the following settings:
• home
• school
• work
• social

Transgender and gender-nonconforming 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 and their presentation. Not all of these procedures will directly impact communication. SLPs obtain information only to determine the possible influence on the voice and voice mechanism (Hancock et al., 2017). For instance, the use of chest binders, to form a more masculine chest, may impact respiration and phonation (Block et al., 2019). In addition, there are surgical options (Davies et al., 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 structures 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—people might receive genital gender affirmation surgery. However, this gender affirmation procedure does not influence the voice. Therefore, asking such questions on a standard intake form and/or during initial intake is not relevant and is often considered an invasion of privacy for service delivery. The SLP is aware of medical and nonmedical factors that influence the continuum of care (see Social Determinants of Health) and coordinates service delivery with an interprofessional team to ensure smooth and effective delivery of coordinated services. It is also essential to have thorough knowledge of any existing disorder, condition, or prior intervention to ensure the best course of treatment.

Assessment Tools

Assessment tools developed specifically for gender affirming voice training are typically client self-report measures that examine the wide range of potential needs among transgender and gender diverse people seeking gender affirming voice and communication training. While these questionnaires can provide valuable information for gender affirming voice and communication training, medically oriented voice questionnaires, such as the Voice Handicap Index, may be needed to assess experiences when there are vocal pathology symptoms (Shefcik & Tsai, 2021). However, self-rating scales of vocal health tailored to the transgender and gender diverse populations may be more accurate, as they separate out whether vocal concerns are indicative of the speakers’ vocal health or self-perceptions of voice congruence (Hancock et al., 2017).

Person-Centered Care

Following the client’s lead is critical for setting needs and goals because gender and communication needs are unique to each person. The ultimate goal is to assist the client in achieving an authentic voice and communication style based on their needs while protecting their voice mechanism. Modifying voice without proper guidance can encourage maladaptive patterns of voice misuse, leading to phonatory trauma and voice disorders such as muscle tension dysphonia and vocal nodules (Hillman et al., 1989; Karkos & McCormick, 2009).

Gender affirming voice therapy may not be available to all ages depending on state law and may require additional and unique considerations (Hirsch et al., 2019). See WPATH’s Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 for additional information on working with transgender and gender-nonconforming people of different ages. See ASHA’s resource on gender affirming voice therapy advocacy for specific state information.

Voice

Gender affirming voice and communication therapy focuses on a combination of characteristics, including pitch, resonance, speech, and nonverbal communication, to better align gender and gender expression (Hancock & Garabedian, 2013). Clinicians might incorporate aspects of intervention strategies traditionally used with functional voice and resonance disorders but modify the strategies to meet the client’s goals. For example, the clinician may have their client use vocal function exercises to safely shift the vocal pitch range. Strategies specific to working with voice modification for transgender and gender diverse clients include the following:

• accent method
• diaphragmatic breathing
• direct pitch modification
• expiratory muscle strength training
• flow phonation
• resonant voice therapy
• semi-occluded vocal tract exercises
• vocal function exercises
• vowel modification and formant shifting

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.

Affirming goals focus on creating a voice that is authentic, comfortable, and safe (Hancock, 2015). Some people prefer a “gender-neutral” vocal presentation, whereas some people require flexibility for a more masculine or feminine presentation, depending on social or work environments. For these clients, vocal flexibility may rise to the top of the list of treatment goals. A speaking fundamental frequency (SFF) higher than 180 Hz is more likely to be perceived as feminine, whereas any fundamental frequency (F0) lower than 130 Hz is more likely to be perceived as masculine (Leung et al., 2018), and an androgynous, or gender neutral, SFF ranges from 145 Hz to 175 Hz (Davies et al., 2015). Practitioners are encouraged to avoid an overemphasis on SFF and to focus on client-specific concerns when approximating a more gender affirming voice configuration.

Voice Modification Goals

The client’s self-determined voice modification goals are set in the beginning based on how they would like to express their voice sex (i.e., male, female, androgynous) or voice gender (i.e., masculine, feminine, gender neutral). Some people may aim to increase SFF and/or moving resonance forward (Carew et al., 2007; Gelfer & Mikos, 2005; Hirsch, 2017; Leyns et al., 2023). SFF, average formant frequency, and sound pressure level can be predictors of the listener’s perception of the speaker’s gender (e.g., Hardy et al., 2020). Additional voice features, such as intonation, resonance, and loudness, may help the client reach their voice goals. Historically in the literature, 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). However, these standards for “voice feminization” rely on gender binary norms and may not represent the goals of transgender women, nonbinary clients, or transfeminine clients (Goldberg & Kapila, 2023). Cisgender women’s voices feature a diverse range of pitch, resonance, and vocal tract configurations; therefore, there is no single definition for voice feminization (Goldberg & Kapila, 2023). While research may reference these terms, consider moving away from binary labels in consultation with clients, such as asking for examples of voices they would like their voice to sound like, to set appropriate goals and to determine which acoustic and auditory perceptual markers are tracked for progress (Goldberg & Kapila, 2023).

Not all people seeking “voice masculinization” require hormone therapy to do so. Clinicians might use behavioral voice approaches, such as modified vocal function exercises (e.g., Myers & Bell, 2020) and circumlaryngeal massage and laryngeal reposturing (e.g., Dahl et al., 2022), to help their clients achieve a perceived lower pitch. Voice masculinization may also focus on adopting chest resonance and reducing pitch variation (Schneider & Courey, 2016).

A common misperception is that androgen cross-sex hormones often result in the lowering of pitch, which eliminates the need for voice treatment (Azul et al., 2018; Nygren et al., 2016). However, the extent, rate, and experience of using hormone therapy alone are quite variable and not always satisfactory (Irwig et al., 2017; Ziegler et al., 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 perceived by others. For example, some transmasculine speakers receiving hormone therapy might feel uncomfortable with using a lower pitch, so they use a higher habitual speaking pitch than their new lower pitch range physiologically allows (Papp, 2011).

Speech, Language, and Nonverbal Communication

The following areas can influence gender perception:

• articulation
• body movement
• discourse pragmatics
• eye contact
• facial expression
• gait
• gesture
• loudness
• posture
• sentence structure
• speech rate
• word choice

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. Clinicians also consider that clients may have additional underrepresented and marginalized identities that shape their unique experiences. These intersecting identities influence the clients’ goals, understanding of available services, access to services, self-acceptance, and acceptance by the people around them (Hancock & Downs, 2021). 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 patient-centered plan of care. See ASHA’s Practice Portal page on Cultural Responsiveness.

Considerations in Service Delivery

Timelines for reaching goals and outcomes may be influenced by the client’s age, frequency of treatment, other gender-related interventions, and overall time available to practice using their authentic voice. Clients may be able to choose the frequency of treatment that works best for their lifestyle (Quinn et al., 2022).

Various factors influence the ability to present as the client’s authentic gender in all settings. Goals and needs may also change as the client’s self-expression and gender identity evolve (Smith, 2020). It can be challenging to allow for a time or place to practice. The clinician can incorporate opportunities for practice into individual and group sessions and monitor changes with audio and video recordings. 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. When developing a treatment plan with a person seeking gender affirming voice services, the clinician considers the potential challenges of introducing, incorporating, and maintaining the new voice and communication style in daily life.

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 each participant can work toward their own personal goals. Groups provide a safe opportunity to receive feedback and celebrate success toward goals (Kayajian et al., 2019). This may be particularly important for people who do not have the opportunity to practice their skills outside of the clinic environment. People may enjoy reaching their specific voice and communication goals with peer support, which encourages consistency, confidence, and self-esteem (Merrick et al., 2022; Pickering & Kayajian, 2014).

Counseling

SLPs help the client transition to a new voice and to a new way of communicating and hearing themselves differently. Clinicians may find themselves working with clients in various emotional states connected to their voice—ranging from frustration, grief, and anger to acceptance and enthusiasm. Discrimination, stigma, and/or violence toward the transgender and gender-nonconforming community can also negatively impact psychosocial well-being (White Hughto et al., 2015). 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 (Adler & Pickering, 2019). It is within the SLP’s roles and responsibilities to provide counseling that facilitates change in how clients feel and think about and their communication. In addition to the SLP supporting clients’ well-being, clients may seek the assistance of mental health providers for support during transition. 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.

All communities are diverse, including gender diverse communities. Each client may require different individualized approaches because their journeys are all unique (Adler, 2017). Transgender and gender diverse clients come to clinicians with different needs, expectations, and experiences, including the experiences of intersecting identities (Hancock & Downs, 2021). Clinicians may benefit from gaining additional knowledge and skills in counseling that are specific to transgender populations.

See ASHA’s Practice Portal pages on Counseling in Audiology and Speech-Language Pathology and Cultural Responsiveness. See ASHA’s resource on trauma-informed care.

Use of Technology

Telepractice can be a viable way to provide services if it fits with the client’s lifestyle and if they have access to the appropriate equipment (Myers et al., 2022). Virtual visits, as an alternative to or in conjunction with in-person visits, may encourage clients to continue voice therapy (McKenna et al., 2023).

Various mobile and web-based apps—in conjunction with voice treatment—may assist with generalization and carryover. 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.). Clinicians who are familiar with the technology can educate their clients on using it as part of their home program to avoid inappropriate practice, which can contradict treatment efforts and lead to the development of hyperfunctional voicing patterns.

Ethics

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

The Code of Ethics (ASHA, 2023) and the Issues in Ethics Statement on Cultural and Linguistic Competence (ASHA, 2017) further clarify 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 A. Individuals shall provide all clinical services and scientific activities competently.

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 are essential to working with transgender and gender-nonconforming populations.

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. However, not all clinicians are qualified to provide gender affirming voice therapy nor are they required to do so. However, clinicians may not refuse services for which they are qualified based on a person’s gender, gender identity, or gender expression.

Principle of Ethics II: Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence and performance.

Rule A. Individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience.

SLPs who serve this population should be specifically educated and appropriately trained to do so.

See ASHA’s Code of Ethics, Prohibitions Against Discrimination Under ASHA’s Code of Ethics and Enforcement by the Board of Ethics, Issues in Ethics: Cultural and Linguistic Competence, and Supporting and Working With Transgender and Gender-Diverse People.

State and Federal Regulations

Legislation and regulations related to gender identity and treatment are constantly evolving. Although there are federal protections for transgender and gender-nonconforming people, these are dependent on the interpretation of a given presidential Administration. Once an Administration changes, these guardrails can be easily reinterpreted or eliminated. State laws and regulations will vary. See ASHA’s resource on gender affirming voice therapy advocacy for additional information about specific regulations. For information on health insurance coverage, see Payment of Gender-Affirming Voice Therapy.

Seek legal counsel if you have questions or concerns regarding the impact of federal or state law.

ASHA Resources

• ASHA Voices: Gender-Affirming Voice Services
• ASHA On Demand Webinars:
  • Building a Culturally Inclusive & Gender Affirming Space
  • Supporting Transgender and Nonbinary Students: A Guide for School-Based Audiologists and SLPs
  • Transgender Voice and Beyond: Voice and Communication Training for Gender Expression
• Consumer resource: Gender Affirming Voice and Communication Change
• Gender Affirming Voice Therapy Advocacy
• Prohibitions Against Discrimination Under ASHA’s Code of Ethics and Enforcement by the Board of Ethics
• Payment of Gender-Affirming Voice Therapy
• Self-Reflection: Gender Inclusivity [PDF]
• Social Determinants of Health
• Supporting and Working With Transgender and Gender-Diverse People
• Trauma-Informed Care

Non-ASHA Resources

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

• AAO-HNS/F Statement on Transgender Voice
• GLAAD: Tips for Allies of Transgender People
• GLAAD: Transgender Resources
• GLSEN
• Human Rights Campaign Foundation: Creating Safe and Welcoming Schools
• Human Rights Campaign Foundation: Glossary of Terms
• Human Rights Campaign Foundation: Transgender Patient Services & Support: Resources for Providers and Hospital Administrators
• National Center for Transgender Equality
• PFLAG: LGBTQ+ Glossary
• RCSLT: New Long COVID Guidance and Patient Handbook
• Royal College of Speech & Language Therapists: Trans and Gender-Diverse Voice & Communication Therapy
• Safe Zone Project
• The Williams Institute
• U.S. Department of Education Toolkit: Creating Inclusive and Nondiscriminatory School Environments for LGBTQI+ Students [PDF]
• Voice-related Experiences of Nonbinary Individuals (VENI) Development and Content Validity – ScienceDirect
• 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 Association (VASTA)

Language is dynamic and terminology evolves. Use of terminology on this page reflects best practices and global research that spans several decades. International use of terminology may not be consistent with use in the United States. Prior research and journal articles may use titles and language that are no longer used. Eliminating this formative research would erase years of content intended to guide best practices. However, clinicians ask their client what terminology they use.

Adler, R. K. (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. K., & Pickering, J. (2019). The role of the SLP in counseling. In R. K. Adler, S. Hirsch, & J. Pickering (Eds.), Voice and communication therapy for the transgender/gender diverse client: A comprehensive clinical guide (3rd ed., pp. 41–55). Plural.

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

American Speech-Language-Hearing Association. (2017). Issues in ethics: Cultural and linguistic competence [Ethics]. https://www.asha.org/Practice/ethics/Cultural-and-Linguistic-Competence/

American Speech-Language-Hearing Association. (2023). Code of ethics [Ethics]. https://www.asha.org/policy/

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(1), 25–39. https://doi.org/10.1044/2017_JSLHR-S-16-0410

Block, C., Papp, V. G., & Adler, R. K. (2019). Transmasculine voice and communication. In R. K. Adler, S. Hirsch, & J. Pickering (Eds.), Voice and communication therapy for the transgender/gender diverse client: A comprehensive clinical guide (3rd ed., pp. 141–189). Plural.

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Dahl, K. L., François, F. A., Buckley, D. P., & Stepp, C. E. (2022). Voice and speech changes in transmasculine individuals following circumlaryngeal massage and laryngeal reposturing. American Journal of Speech-Language Pathology, 31(3), 1368–1382. https://doi.org/10.1044/2022_AJSLP-21-00245

Davies, S., Papp, V. G., & Antoni, C. (2015). Voice and communication change for gender nonconforming individuals: Giving voice to the person inside. International Journal of Transgenderism, 16(3), 117–159. https://doi.org/10.1080/15532739.2015.1075931

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Goldberg, A. C., & Kapila, R. (2023). Barriers to care and cultural responsiveness in transgender and gender nonconforming voice modification. In M. S. Courey, S. K. Rapoport, L. Goldberg, & S. K. Brown (Eds.), Voice and communication in transgender and gender diverse individuals: Evaluation and techniques for clinical intervention (pp. 27–42). Springer International. https://doi.org/10.1007/978-3-031-24632-6

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

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Acknowledgments

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 Gender Affirming Voice and Communication page (formerly known as Voice and Communication Services for Transgender and Gender Diverse Populations):

• Richard Adler, PhD, CCC-SLP
• Tallulah Breslin, MS, CCC-SLP
• Kimberly Dahl, MS, CCC-SLP
• Kevin Dorman, MS, CCC-SLP
• Eryn Gitelis, MA, CCC-SLP
• Adrienne Hancock, PhD, CCC-SLP
• Sandy Hirsch, MS, CCC-SLP
• Ruchi Kapila, 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.). Gender affirming voice and communication [Practice portal]. https://www.asha.org/practice-portal/professional-issues/gender-affirming-voice-and-communication/