By Anusha Sundarrajan, Ph.D.

Imagine feeling anxious and nervous picking a call on your phone and being misgendered. Imagine yourself speaking in a voice that does not align with your gender. This constant feeling of uneasiness is what I saw and sensed in the first transwoman I met in the Fall semester of 2019. As a new faculty in the department of Speech, Language, and Hearing Sciences at San Francisco State University (SFSU), I was entrusted with an opportunity to innovate, build, and establish a university clinic for gender affirming voice care. As someone relatively new to this area of practice, this opportunity was very exciting, and I was looking forward to beginning my learning journey.

I started my position as a tenure track faculty with an interest in voice and its related disorders in Spring 2019. Upon my arrival, I soon realized that gender affirming voice services are an important clinical area, unexplored, intriguing and an important service to my community. I was contacted by Oneida Chi, an alum from our university and a gender queer speech language pathologist with over 20 years of clinical experience in the assessment and treatment of communication disorders across the lifespan. I still recall our first meeting, when Oneida walked into my office and talked about their clinical and life experiences. It was eye opening!!! We instantly connected and shared our common goals and interests. The product of that fruitful conversation is our university clinic for gender affirming voice services serving the transgender and gender diverse, college and the larger community in the San Francisco Bay Area. Our vision is to help participants identify and speak with a voice that they believe matches their gender expression. We used “participant” very specifically to move away from pathology/disorder based terminology to a more inclusive, collaborative term.

I followed Oneida’s lead by attending workshops and gaining guidance and knowledge from speech language pathologists, read textbooks written by experts in the field, and attended training on culturally responsive practices. With their assistance, I started to connect and network with experts in the area and reached out to transgender participants and the members of lesbian, gay, bisexual, transgender, queer, intersex and asexual (LGBTQIA+) communities.

Interorganizational trainings

One of the first initiatives that we took was to connect with the local community members and partner with some of the established organizations in the Bay Area. We partnered with St. James Infirmary, which is a peer based non-profit organization serving the transgender and gender non-conforming community. Our collective goal was to connect with the community members, learn about their problems, and listen to their concerns, and further educate them about voice and voice therapy. In this process, we involved the first-year graduate student clinicians from our department to attend the trainings which would increase their competency for working with the LGBTQIA+ community. We attended these training sessions with the staff at St. James Infirmary to address best clinical practices, for instance, the use of appropriate pronouns, noting relevant questions during the case history process, creating inclusive spaces, and increasing our cultural responsiveness.

Curriculum designing

Our next step was to begin training the first-year graduate student clinicians and to impart knowledge on assessment and treatment of the transgender voice. Students received training on collecting data during the case history specifically asking questions that delivered meaningful responses from the participants, wording the questions effectively and efficiently, collect acoustic and voice data using software such as PRAAT, implement voice therapy techniques such as resonant voice therapy, vocal function exercises, conversation training therapy etc., as well as providing holistic care and thus treating the whole person and not just specific aspects.

Launching the clinic

We worked tirelessly for a full semester to recruit participants in the university campus community. In Fall 2019, three graduate student clinicians started seeing their first transgender participants. Our mantra was simple, we wanted to create a safe and an open environment for all our participants and provide a nonjudgmental and inclusive space to find a voice that defines themselves. Our goal was to not only empower the participants, but also our student clinicians. The clinic procedures comprised of an intake interview where the participants met with their assigned clinicians and completed the preliminary assessments. Following this, participants met weekly to explore and learn safe, healthy, and sustainable techniques for voice modification. We took a personalized and participant centered approach to develop customized therapy plans for each participant. Our approach is holistic and patient centered- it emphasizes collaborative work and addresses how the person is seen and heard by the world.

The intake interview consisted of collecting information regarding the physical and medical history and thoroughly understanding how participants feel about this process. The participants and clinicians engaged in conversations focusing on the anatomy and physiology of voice, what voice means to them, and the different denotations of masculine and feminine voice, who are their voice role models (if they had any), and what does feeling misgendered mean to them.

By the end of Fall semester in 2019, we realized that the clinic was a huge success. Our participants started expressing their wins and how confident they felt about their voices. One of our participants, a recent SFSU graduate who identifies as transmasculine, attested to the clinic’s success. The participant reported that his voice was not representative of his identity before joining the clinic. However, after attending the sessions, he noticed it felt more natural speaking in a voice that felt true to him. “Prior to attending the clinic, I didn’t know how to support my voice in a way that both aligns with my gender identity and is healthy for my voice,” said the participant. “I learned a lot from the clinic in that sense.” He also emphasized that what he learned made him more confident as a journalist and spoken-word poet — two practices that involve a lot of speaking. The participant was interviewed for the campus magazine, and he reported that “In today’s social climate where trans and non-binary people are often underrepresented, he finds this clinic refreshing and sets a great example of what services universities should offer. This type of clinic reassures queer people that we have a place on campus and that we are being seen and heard,” he said. “That’s really special to us.”

In just one semester, we could see that our participants were expressing increased confidence in using their voice and demonstrated successes in the outcome measures such as pitch, resonance, and the whole body. We learnt that the clinic was successful and special to the campus community.

We continued to expand the clinic and successfully recruited 13 participants during Spring 2022. Even with the global pandemic hitting us, our confidence and determination was not deterred. We believe that the program is successful because we walk along the same vocal journey with the participants as they are. We work with campus advocacy groups and local communities in the Bay Area to establish connectedness and the feeling of being “together” and “communal”.

The graduate student clinicians continue to engage in weekly prep meetings with the clinical advisors. We review materials including textbook chapters, journal articles, interviews, podcasts, videos, as well as educational resources from websites such as Med bridge. Our students have not only been able to learn the voice therapy techniques but also think above and beyond in terms of the whole body for their participants. We encourage the students to observe, learn, adapt, and get motivated to embrace this opportunity. We have received positive feedback from the students on how they feel confident in providing service for the transgender and gender diverse people.

Our learnings till now

We started off exploring this exciting area three years ago and now have broadened to develop deep networks and collaborations within this rich community. We have learnt a lot from each other, the students, and most importantly our participants. We are expanding and learning as a community but there is a lot more to be done. We have learnt to be patient and flexible. Having open conversations about gender, sexuality, voice, and body are not driven by any standards or protocols. We need to engage in these topics within the community to learn effectively and efficiently. We need to create a space that is free of any judgment and learn to embrace the knowledge gained as well as the unknown. We also made mistakes but learnt to be patient with us, our students, as well as our participants. We learnt to build connections and collaborations with local and national communities. Finally, we have learnt to celebrate our successes. We cherish and remind ourselves of the beautiful part of our work; fortunate to be part of someone’s vocal journey! It is indeed the most wonderful celebration.

References:

Bravo, K., SF State news (Strategic Marketing and Communications - https://news.sfsu.edu/news-story/sf-state-clinic-helps-transgender-nonbinary-people-find-their-voice (2020)