Refining Your Queer Ear: Empowering LGBTQ+ Clients in Speech-Language Pathology Practice PDF

Perspectives of the ASHA Special Interest Groups SIG 14, Vol. 3(Part 3), 2018, Copyright © 2018 American Speech-Language-Hearing Association Refining Your Queer Ear: Empowering LGBTQ+ Clients in Speech-Language Pathology Practice Sarah Taylor Departm...

Perspectives of the ASHA Special Interest Groups SIG 14, Vol. 3(Part 3), 2018, Copyright © 2018 American Speech-Language-Hearing Association Refining Your Queer Ear: Empowering LGBTQ+ Clients in Speech-Language Pathology Practice Sarah Taylor Department of Social Work, California State University, East Bay Hayward, CA Ben-David Barr Department of Social Work, California State University, East Bay Hayward, CA Jennifer O’Neal-Khaw Smith College School for Social Work Northampton, MA Becca Schlichtig Independent Research Collaborator Hayward, CA Janet L. Hawley Department of Speech, Language, and Hearing Sciences, University of Arizona Tucson, AZ Disclosures Financial: Sarah Taylor has no relevant financial interests to disclose. Ben-David Barr has no relevant financial interests to disclose. Jennifer O’Neal-Khaw has no relevant financial interests to disclose. Becca Schlichtig has no relevant financial interests to disclose. Janet L. Hawley has no relevant financial interests to disclose. Nonfinancial: Sarah Taylor has no relevant nonfinancial interests to disclose. Ben-David Barr has no relevant nonfinancial interests to disclose. Jennifer O’Neal-Khaw has no relevant nonfinancial interests to disclose. Becca Schlichtig has no relevant nonfinancial interests to disclose. Janet L. Hawley has no relevant nonfinancial interests to disclose. Purpose: Speech-language pathologists (SLPs) have a unique opportunity to engage diverse youth and adults in developing their authentic voices and sharing experiences. Although they may not necessarily be employed in programs with a specific LGBTQ+ focus, they are likely to work with LGBTQ+ youth and adults. The article begins with a discussion of how many people identify as LGBTQ+ and why a focus on LGBTQ+ affirmative human services practice is needed. The 2nd section of the article provides an overview of key concepts in working with LGBTQ+ individuals. Case studies of 2 LGBTQ+ youth who experienced academic and personal challenges conclude the article. The article includes an appendix listing several simple ways for SLPs to engage in LGBTQ+ affirmative human services practice. Conclusions: LGBTQ+ affirmative practice is within the scope of an SLP’s role and is consistent with the American Speech-Language-Hearing Association Code of Ethics. SLPs can use the unique relationship they have with individuals, as well as their roles within schools and human services organizations, to support and empower LGBTQ+ individuals and contribute to building inclusive communities. 72 Downloaded from: https://pubs.asha.org Akiko Fuse on 09/18/2022, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions  Recent research on competence in working with LGBTQ+1 communities among speech- language pathologists (SLPs) suggests that, although most SLPs express a willingness and acceptance toward serving LGBTQ+ individuals, they feel underprepared to do so (Hancock & Haskin, 2015; Kelly & Robinson, 2011; Sawyer, Perry, & Dobbins-Scaramelli, 2014). This is particularly true for competence in serving trans* individuals (Hancock & Haskin, 2015; Matthews, Sullivan, Freeman, & Myers, 2017). SLPs are in a unique position to support clients in expressing their authentic voices. Given that SLPs work in a variety of home- and community-based settings, it is essential that SLPs be ready to empower LGBTQ+ individuals as they develop or regain communication skills within their natural environments. The authors of this article (“we”) are LGBTQ+-identified individuals and allies with extensive experience in serving our community in clinical, community-based, and school settings from K–12 through higher education. Although most of the authors of this article have a social work background, three of us also have connections to speech-language pathology practice. The first author (Taylor) has given guest lectures on working with LGBTQ+ individuals to speech- language pathology students for several years and has also engaged with SLPs as a parent of a child with a disability. The last author (Hawley) is an SLP with a background in working with trans* individuals. The second author (Barr) served as the executive director of an LGBTQ+ center for 10 years in California and has lived experience as a gay man who was referred to speech-language pathology services as a child for a “lisp.” Although Barr’s experiences were decades ago, LGBTQ+ people may still be treated inappropriately by SLPs operating from outdated models. An example of this was in the 2014 film Do I Sound Gay?, in which David Thorpe, the filmmaker, sees an SLP who criticizes what may be seen as aspects of his speech that “sound gay” (Gertler & Thorpe, 2014). Our goal in writing this article is to provide some background information and tools to support SLPs in better serving LGBTQ+ individuals. The first part of the article discusses the importance of providing culturally sensitive human services practice with LGBTQ+ individuals. We then explain key concepts and terms used by the LGBTQ+ community. The article includes two case studies highlighting opportunities for SLPs to engage with an LGBTQ+ youth. In addition, a list of LGBTQ+ affirmative practices that SLPs and other human services professionals can integrate into their daily practice are provided in the Appendix. Need for LGBTQ+ Affirming Human Services Practice When we speak with social work and speech-language pathology students about working with LGBTQ+ individuals, there is often at least one person in the class who mentions that they do not plan to work with LGBTQ+ individuals, and so information about our community is not relevant to their future practice. Other students suggest that the LGBTQ+ community has made so much progress in acceptance over the past several years that a specific focus on LGBTQ+ individuals is no longer needed. This second type of comment seems to arise frequently in the San Francisco Bay Area where the first four authors live and work. The relative acceptance of LGBTQ+ individuals in this region as compared to other areas of the United States often leads people to believe that bias and discrimination are rare; however, our clinical and lived experiences and a wide field of academic research suggest otherwise. In this section, we describe the prevalence of LGBTQ+-identified individuals in our society and provide examples of barriers, insults, microaggressions, and biases that still impact the social, political, and civil rights of LGBTQ+ community members. 1 Throughout this article, we use the acronym LGBTQ+ to include individuals who are queer, questioning, and those who identify with the community but with a wide variety of labels that cannot fully be captured in any acronym we use, as indicated by the + sign. We prefer LGBTQ+ to sexual and gender minorities as a broader and more affirmative term than any that refers to us as minorities, thus reinforcing cisnormativity and heteronormativity. We use the term trans* to denote the varied identities and labels preferred by transgender and gender-nonconforming individuals. The * is used to indicate gender identities ad infinitum. Please see the section of this article entitled Key Concepts and Terms Used in the LGBTQ+ Community for further description of concepts. 73 Downloaded from: https://pubs.asha.org Akiko Fuse on 09/18/2022, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions How Many People Identify as LGBTQ+? Accurate data on the LGBTQ+ community are difficult to obtain due to a variety of factors, such as definitional ambiguity; failure to ask about sexual orientation and gender in many community-based surveys and clinical intake forms; and discrimination, stigma, and shame that inhibit LGBTQ+ individuals from disclosing their identities (Baker & Durso, 2015; Deutsch, 2016; Gates, 2011; Meerwijk & Sevelius, 2017). The lack of data on the size, scope, and needs of the LGBTQ+ community makes it difficult to allocate resources appropriately, deemphasizes the need for training in LGBTQ+ competency for professionals across human services and medical fields, and contributes to a sense of invisibility of LGBTQ+ individuals. Although progress has been made in including more and better questions about LGBTQ+ identities on community surveys, this progress is often threatened by political or other discriminatory agendas that prevent these questions from being asked. Two recent examples of this were the proposal by the Administration for Community Living, a component of the U.S. Department of Health and Human Services, to remove a question about sexual orientation from the National Survey of Older Americans (Durso, 2017). Another example was the U.S. Census Department’s assertion that there is “no federal data need” to add questions about sexual orientation and gender identity in the 2020 Census (Thompson, 2017). Despite these limitations, the available data, which are likely to be underestimates, suggest that the LGBTQ+ community is large and growing. It is quite likely that SLPs working in almost any setting serve individuals who identify as LGBTQ+. A recent Gallup survey indicates that 4.5% of respondents (n = 340,000) identified as LGBT when asked the question, “Do you, personally, identify as lesbian, gay, bisexual or transgender?” (Newport, 2018). This estimate is a 1% increase since 2012. Notably, it is unclear whether individuals who identify as queer, questioning, or gender nonconforming would respond affirmatively to this question. The same Gallup survey found important differences in LGBT identification by age, gender, and income (Newport, 2018). The number of individuals who self-identified as LGBT varied greatly by age, with 8.2% of those born between 1980 and 1999 doing so as compared to 1.4% of those born between 1913 and 1945 (Newport, 2018). One recent statewide study of California adolescents found that 27% of youth ages 12–17 years reported that they are viewed as gender nonconforming by classmates at school (Wilson, Choi, Herman, Becker, & Conron, 2017). The national Gallup survey found that more women (5.1%) than men (3.9%) self-identified as LGBT (Newport, 2018). Individuals with lower incomes self-identified as LGBT at a higher rate than those with higher incomes, with 6.2% of those earning less than $36,000 per year self-identifying as LGBT as compared to 3.9% of those with incomes of $90,000 or more (Newport, 2018). A review of multiple national surveys suggests that LGBTQ+ self-identification does not vary significantly by race or ethnicity (Gates, 2014). In addition to age variation in LGBTQ+ identification, there are state and regional differences in these estimates. Over 5% of adults in Vermont identify as LGBT as compared to just 2% in South Dakota (Gates, 2017). The San Francisco Bay Area is the metro region with the highest percentage of adults who identify as LGBT (6.2%), as compared to 2.6% in Birmingham, Alabama (Newport & Gates, 2015). Differences by location may be related to migration patterns but also are more likely related to impact of social stigma on comfort with self-identification. Prevalence of specific subpopulations within the LGBTQ+ community also varies considerably. Bisexuals may be the largest subgroup within the LGBTQ+ community, with 1.8% of adults nationally identifying as such, yet they are the least likely within the LGBTQ+ community to be “out” to family members and friends (Brown, 2017). This may be due to presumed heterosexuality when bisexual people are with partners of a different sex than themselves, perceptions of bisexuals as promiscuous or confused, and a tendency for others to view sexual orientation as binary (Scherrer, Kazyak, & Schmitz, 2015). A meta-analysis of studies of the number of trans* individuals found that approximately one in 250 individuals identifies as trans* (Meerwijk & Sevelius, 2017); 74 Downloaded from: https://pubs.asha.org Akiko Fuse on 09/18/2022, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions however, other studies report a much higher rate of 0.6% (Flores, Herman, Gates, & Brown, 2016). As noted above, the number of youth who identify as gender nonconforming is much higher than these estimates (Wilson et al., 2017). Data about the size and variations within the LGBTQ+ community are an important part of the lens SLPs and other human services professionals should bring to their practice. In an area in which few people identify as LGBTQ+, individuals may be at a higher risk for discrimination, stigma, and shame, thus making LGBTQ+ affirmative practice even more critical (Hatzenbuehler, 2011). Given that relatively few identify as trans* as compared to lesbian, gay, bisexual, or queer, practitioners need to ensure that trans* voices are not lost within the larger LGBTQ+ community. The large differences between age cohorts in LGBTQ+ identity suggests that those working in schools or other youth-serving settings should be very well prepared to serve LGBTQ+ youth. Those working with older adults should be sensitive to the issues facing a demographically small group of people who came of age in a much less accepting world (Fredriksen-Goldsen et al., 2011). Social, Political, and Civil Rights Barriers for LGBTQ+ Individuals Although a lot of progress has been made in the civil rights and social acceptance of LGBTQ+ people, there is more work to be done. LGBTQ+ people have been able to marry in states such as Vermont since 2004; however, same-sex marriage was not legally recognized at the federal level until the Supreme Court’s 2015 decision in Obergefell v. Hodges. In many U.S. states, there is no law preventing workplace, housing, or public accommodation discrimination based on sexual orientation or trans* gender identity (Movement Advancement Project, 2018a). An example of the level of contentiousness involved in guaranteeing the rights of LGBTQ+ individuals is in the Masterpiece Cakeshop v. Colorado Civil Rights Commission (2017), which involved a bakery that refused to provide a wedding cake for a gay couple in 2012. The case took over 5 years to move its way through the courts, and ultimately, in June 2018, the Supreme Court issued a very narrow ruling that supported the baker’s refusal to bake a cake for a same- gender wedding. Although the issue may seem insignificant, that of a wedding cake, the prolonged court battle suggests that much more is at stake and highlights the ongoing culture conflicts between those seeking LGBTQ+ equality and those who oppose LGBTQ+ equality on grounds of free speech and/or religious rights. The court ruling in the Cakeshop case was so narrowly defined that it is a ruling unlikely to apply to any future cases. This is because the Cakeshop incident occurred before the supreme court’s marriage ruling (Obergefell v. Hodges, 2015) was in effect and before same-gender marriages were legal in Colorado. What has been left for future court (and cultural) battles is the determination as to whether religious beliefs can be used as a basis for limiting LGBTQ+ people’s full and equal participation in American society. New cases that will have implications far beyond a wedding cake, such as right to adoption for LGBTQ+ parents, are now beginning to make their way through federal and local courts. LGBTQ+ youth are particularly vulnerable to the effects of discrimination, harassment, and microaggressions given their developmental stage and limited ability to choose and control their environments. Experiences of family rejection of LGBTQ+ youth have been associated with higher rates of suicidality, substance use, and depression as compared to LGBTQ+ peers experiencing family acceptance (Ryan, Huebner, Diaz, & Sanchez, 2009). A national study by the Human Rights Campaign (2018a) found that 67% of LGBTQ+ youth hear their families make negative statements about LGBTQ+ people, 70% have been bullied at school, only 26% feel safe at school, and just 13% have heard positive messages about LGBTQ+ people at school. As a result of these daily experiences of microaggressions, bullying, and harassment, 77% of LGBTQ+ youth report feeling depressed, and 95% have difficulty in sleeping (Human Rights Campaign, 2018a). Within the LGBTQ+ community, those who identify as trans* are frequently targets of discrimination and violence. Gordon et al. (2018) found a significant correlation between gender nonconformity and bullying victimization in a study conducted in four urban schools in the United States. This is true even in the San Francisco Bay Area, a region perceived as more 75 Downloaded from: https://pubs.asha.org Akiko Fuse on 09/18/2022, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions accepting of LGBTQ+ individuals. In 2013, an agender teen named Sasha was set on fire by a peer while riding the public bus in Oakland, California (Slater, 2015). The controversy around equal access to restroom facilities for trans* individuals is another example of discrimination. Fifty-one percent of trans* youth have no access to a bathroom or locker room that matches their gender identity. Fifty-eight percent of these youth said they do not feel safe using the bathroom that matches their gender identity, and 65% reported that they try not to use the bathroom at school (Human Rights Campaign, 2018a). Recent studies also highlight that trans-identified youth report significantly higher rates of suicide attempts with 50.8% of female- to male-identified trans youth reporting a suicide attempt during their adolescence (Toomey, Syvertsen, & Shramko, 2018). These are just some examples of how trans* and gender-nonconforming people experience discrimination, bullying, and harassment within systems and society at large. The prevalence of these types of incidents, along with daily microaggressions, contribute to health disparities and a sense of internalized stigma and shame for many LGBTQ+ individuals. Microaggressions are defined as “subtle forms of discrimination, often unconscious or unintentional, that communicate hostile or derogatory messages, particularly to and about members of historically marginalized social groups” (Nadal, Whitman, Davis, Erazo, & Davidoff, 2016, p. 488). Bias refers to a preference toward or against a person or particular group. Implicit bias refers to our assumptions and viewpoints that are often framed in ways that we may not be actively aware of. These biases are tied to the development of stereotypes and prejudice (Greenwald & Krieger, 2006). Research on the impact of microaggression and bias has shown that these stressors contribute to significant health and mental health disparities among socially disadvantaged groups (Warnecke et al., 2008). Health disparities research began by examining discrimination’s impact on disadvantaged groups such as African Americans where social stress has been shown to contribute to higher rates of low–birth weight babies, diabetes, chronic heart disease, and other health disparities when compared to dominant population groups (American Psychological Association, n.d.). These health disparities have also been shown to exist among LGBTQ+ people (Mays & Cochran, 2001). Meyer (1995, 2003) has defined this impact among LGBTQ+ individuals as “the minority stress model.” Bias and discrimination impact LGBTQ+ people across their life span and impact all aspects of their lives such as at school, work, public accommodations, and health care. The recent report from the Movement Advancement Project found that 34% of LGBTQ+ individuals who experienced discrimination avoid public places such as stores and restaurants, 18% avoid doctor visits, and 10% avoid public transportation (Miller, 2018; Movement Advancement Project, 2018b). Statistics such as these reveal the ways in which “lesbian, gay, bisexual, and transgender (LGBT) individuals live within a heteronormative and gender-normative context of persistent invalidation” (Puckett & Levitt, 2015, p. 329). SLPs and other human services professionals can help to address these experiences of invalidation through LGBTQ+ affirmative practices. One way to begin to do this is through learning about the key concepts and terms used in the LGBTQ+ community. Key Concepts and Terms Used in the LGBTQ+ Community Learning terminology can be a confusing and anxiety-provoking experience for many professionals when providing services to members of the LGBTQ+ community. The goal for many when attending our cultural competency trainings is to receive a list of proscribed words and terms that can be used when working with LGBTQ+ clients. Although we provide links to a few glossaries of terms in this article’s reference list (Human Rights Campaign, 2018b; Trevor Project, 2017; University of California, Davis Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual Resource Center, 2018), it must be stressed that we are in a time of dynamic growth in how members of the LGBTQ+, same-gender loving, all-gender loving, gender fluid, polyamorous, and ad infinitum describe ourselves. Our community is engaged in an ongoing process of redefining current terminology. 76 Downloaded from: https://pubs.asha.org Akiko Fuse on 09/18/2022, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions  It is understandable that many people feel confused by the shifting nature of LGBTQ+ terminology. We believe that the growth in terminology reflects the process of self-identity that comes from an interplay of internal feelings (often referred to as orientation), behaviors or actions, and the terms and labels used to describe and help us understand these feelings and actions. Thus, identity (the names people use to describe themselves) is a complex process of making meaning out of actions, feelings, and ways to describe that to oneself and others. The growth in newer terms and expanding identities, although confusing, can also be viewed as a positive blooming of individual expression, one that we hope will continue to develop for quite some time. To navigate this evolving landscape, we believe that distinguishing between the domains of sexual orientation, gender identity, and gender expression is essential. The sexual orientation, gender identity, and gender expression domains are characteristics shared by all people and exist on a continuum. We each have a sexual orientation, which describes our romantic and sexual attractions (or lack thereof). We also each have a gender identity, which can describe identification with traditional gender identities of male, female, and/or include more expansive identities that may include agender, gender fluid, gender creative, and trans* identities (and likely many other expanding terms that support individuals in the acceptance and expression of their gender identities). An additional component of gender identity is understanding the difference between sex assigned at birth and gender identity. Individuals with traditional gender identities that align with their biological sex organs and their gender assigned at birth are referred to as “cisgender.” Cis is a Latin word referring to “on this side of,” as opposed to trans, defined as “on the other side of” (Steinmetz, 2014). For some, there may be confusion about how individuals have gender identities that do not align with their natal sex organs. Gender identity is less related to natal sex organs and more connected with internal gender identification. In this more expansive view, gender identity can be in alignment with natal sex organs and/or include identities that are not consistent with a gender assigned to individuals at birth. In other words, some people who identify as men may have vaginas, and some who identify as women may have penises. In addition, there are individuals born with ambiguous genitalia that may be referred to as “intersex.” For some intersex and trans* people, there is a desire to seek surgical or hormonal interventions to support an alignment of their natal sex organs and gender identity. However, many intersex and trans* people do not utilize medical interventions; this may be related to personal choice, lack of access to culturally competent health care, and/or lack of access to adequate medical insurance. In addition to our sexual orientation and gender identity, individuals also have a style of gender expression. This refers not to biological sex or gender identity but to what noted gender theorist Judith Butler (1990) refers to as “gender performance” or how people communicate their gender identity in daily life through signifiers such as hairstyles, clothing, and mannerisms. Gender expression is important because it can serve to connect individuals, as when people find another’s gender expression attractive, but also put individuals at risk when their gender expression differs from societal expectations, and others have a negative or even threatening reaction to that difference. A helpful illustration of these concepts is shown in Figure 1. The gender unicorn (Trans Student Educational Resources, 2014) distinguishes gender identity (rainbow brain), gender expression (green dots shown to the left of the image), chromosomal sex (double helix), physical attractions (orange heart), and emotional attractions (red heart). These aspects of identity are illustrated as independent continuums to reflect the wide variation in individual aspects of gender identity, gender expression, sex assigned at birth, physical attractions, and emotional attractions or attachments. 77 Downloaded from: https://pubs.asha.org Akiko Fuse on 09/18/2022, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions Figure 1. The gender unicorn (Trans Student Educational Resources, 2014). Reprinted with permission. Given the complexity of gender identity, gender expression, and sex assigned at birth, SLPs and other human services professionals should avoid ascribing pronouns based on physical appearance. Trans* and gender-nonconforming individuals experience misgendering through incorrect use of pronouns as a microaggression. A best practice is to ask about the pronouns people use, share your own pronoun when introducing yourself as a means for inviting others to do the same, and use a person’s name rather than a pronoun when in doubt. Some trans* and gender-nonconforming individuals use they as a singular, gender-neutral pronoun, and this should be respected as an appropriate and grammatically correct use of they (Guo, 2016). Other gender-neutral pronouns include zie, ey, and more (University of Wisconsin, Milwaukee, Lesbian, Gay, Bisexual, Transgender Resource Center, 2018). Case Example 1 This case is a composite based on our experiences in working with LGBTQ+ youth in school-based settings. GS is a 15-year-old individual who describes his sexual orientation as “gay” and his gender identity as male/questioning. GS uses he/him gender pronouns. He has used public school speech pathology services since he was in elementary school due to a speech sound disorder and stuttering, but he has made a lot of progress and now receives just 30 min per month of consult services, in which the SLP collaborates with his teachers to ensure that GS continues to receive accommodations such as alternatives to making oral presentations in class. The school SLP also recommended that he attend the teen program of the local National Stuttering Association chapter. After attending once, he did not go back stating, “the kids weren’t like him.” He was referred for services at our Pride Center due to low grades (failing most of his classes), presenting as distracted (e.g., staring out the window, not completing work). With his clinician, a Pride Center mental health provider working at a local high school campus, GS reports feeling invisible and unable to communicate effectively. He often shuts down rather than engage in interpersonal communication and will ignore people (teachers, peers) when they speak to him. GS reports that he has one teacher who tries to help him; however, he generally feels invisible at school and in his family. 78 Downloaded from: https://pubs.asha.org Akiko Fuse on 09/18/2022, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions  GS reports feeling nervous and anxious all the time. He describes experiencing depressive symptoms and often presents with a low affect. He engages in self-injurious behaviors, including cutting. GS reports drinking alcohol on multiple occasions and says that the drinking and self- injury are attempts to let pain out or not feel anything. In meetings with his providers, GS presents as irritable and moody, often expressing frustration and anger. Other times, he is less irritated and can engage and participate in art therapy activities. GS struggles with very low self-esteem, stating, “I am ugly and I hate myself.” He feels stuck in school and that he is not equipped to be successful in that system. The Pride Center clinician and GS’s English teacher were particularly supportive, providing positive interactions and openness for the student to talk about his identity. GS responded well to others, showing interest in his identity because he was trying to figure out how he views himself and struggling to make sense of his sexuality and gender. Although GS was referred for testing to identify different learning needs, his struggles with sexual and gender identity were not directly addressed in any assessment report provided by the school. Students such as GS can benefit from teachers and other school staff developing posters, school education programs, and other environmental efforts to create a welcoming school climate. It is worth noting that GS regularly arrived for sessions and did appear to make connections with providers, expressing that he feels misunderstood and lacked language to articulate his needs. GS frequently expressed disconnection from others and the community, feelings of hopelessness, and loneliness. The team, including the SLP, consistently used person-centered and strengths- based interactions with this student and emphasized the importance of valuing himself as a member of the LGBTQ+ community. As a result, he consistently engaged with his clinician and case manager and, with support, was able to begin to share his feelings. Beyond GS’s clinician, there were other adults who interacted with GS throughout his school day. These include (a) his regular classroom teachers (including the one who regularly tried to help him), (b) the staff who referred him to clinical counseling, and (c) staff who have tested him for learning needs. Other staff who interacted with GS included school principals, guidance counselors, sports coaches, and school secretaries. In a school setting, all of these staff members have an opportunity to contribute to creating an inclusive and welcoming school culture for LGBTQ+ youth. Case Example 2 Marley is a 16-year-old Latinx2 individual, self-referred to a local university clinic seeking assistance with voice feminization and gender transition. They currently prefer the pronouns they/them but stated that they may use feminine pronouns after they achieve their desired voice. Marley reported a history of self-practice to feminize voice with resultant fatigue and soreness and thus sought professional assistance. They self-described a “typical transnarrative” of preferring clothing and activities typical of females since they was a toddler. They reported anxiety and depression at the onset of puberty given changes in their body and masculinization of voice. Given bullying at the current public school, Marley’s parents recently arranged for Marley to attend a smaller, more inclusive school. Per report of their mother, Marley was apparently thriving in the new setting and had acquired a variety of new friends in the school’s LGBTQ+ community. Best practices for a trans voice/communication evaluation include conducting a complete case history focused on medical history, transition process, and potential voice abuse–misuse factors as well as investigating current concerns and possible goals. This is followed by assessment of voice and other communication behaviors. Review of medical history showed onset of 2 Latinx is a gender-neutral term for Latino/Latina. 79 Downloaded from: https://pubs.asha.org Akiko Fuse on 09/18/2022, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions testosterone-suppressing medication at age 14 years, well after the onset of puberty, and the recent addition of estradiol. Marley also takes Prozac for depression. Marley reported being “most of the way” through the transition process (i.e., out to family, friends, and in the community) but noted that the lack of a feminine voice was holding them back, saying, “my voice interferes with my ability to live as a woman and does not reflect the true me.” Daily voice use included conversation with friends, talking in class, talking in noisy hallways at school, and singing in a punk band. They described their singing style as “yelling” and stated, “Every time we have band practice, [my voice] always hurts afterwards because it’s a lot.” Current voice was described as “very masculine,” and they ultimately hope to achieve a “relatively female voice.” In terms of nonverbal presentation, Marley has not figured out their style yet and currently wears gender-neutral “punk” attire. Although designed for adults (Dacakis, Davies, Oates, Douglas, & Johnston, 2013; Davies & Johnston, 2015), the Transsexual Voice Questionnaire for Male-to-Female Transsexuals (Dacakis et al., 2013) was administered. The results suggested that Marley’s voice (i.e., the lack of congruency with their gender) is having an impact on their emotional, physical, and functional life. For example, on a scale of 1 (rarely or never) to 4 (usually or always), they reported a 4 in the emotional arena (i.e., usually or always feel self-conscious about how strangers perceive my voice (4)). In terms of physical consequences of her current voice, they noted that my voice “gives out” in the middle of speaking (3), and functionally, they indicated that they usually or frequently (4) avoid using the phone because of my voice. Based on an acoustic evaluation of voice, Marley presented with a speaking fundamental frequency of 126 Hz. Although typical children have a fundamental frequency of approximately 256 Hz, cisgender men (aged 20–69 years) demonstrate an average speaking fundamental frequency range from 107 to 132 Hz, and cisgender women of the same ages range from 189 to 224 Hz (Colton, Casper, & Leonard, 2011). These findings suggest that their larynx had already responded to testosterone (i.e., matured) prior to starting spironolactone. Trial therapy during the evaluation showed that Marley was able to imitate models for a voice closer to the gender-neutral range (145–165 Hz) at the word and simple phrase levels. Following the evaluation, the clinician and Marley agreed upon a plan of care, which included goals focused on feminizing their voice and enhancing the gender congruency of their verbal and nonverbal behaviors. The clinician educated Marley regarding vocal hygiene (i.e., developing more optimal ways to sing and reducing yelling and straining to talk in noisy environments). Recommendations also included referrals to a local LGBTQ+ supportive youth “lounge” and a local transgender community support and advocacy program, which provides youth and family services. Finally, the SLP requested a release of information to contact and coordinate services with their psychologist, as needed. LGBTQ+ Affirmative Practices for SLPs and Other Human Services Professionals As described in this article, LGBTQ+ individuals experience bias, microaggression, and discrimination across their life span, and these chronic microassaults can have a negative impact on individuals’ health and well-being. These impacts are particularly acute for youth, who are at a vulnerable stage of development. For this reason, the case studies focus on youth; however, the messages of acceptance and inclusivity conveyed by LGBTQ+ affirmative human services practice are essential for people of all ages. LGBTQ+ affirmative practice is consistent with the American Speech-Language-Hearing Association (2016) Code of Ethics. Principles of Ethics I.C. requires that SLPs do not discriminate in the delivery of professional services or in the conduct of research and scholarly activities on the basis of a client’s identity, including gender identity/gender expression and sexual orientation. Principles of Ethics I.B. is also particularly relevant. It is within the scope of an SLP’s role to make referrals and develop interprofessional collaborations that support those we serve; thus, SLPs should 80 Downloaded from: https://pubs.asha.org Akiko Fuse on 09/18/2022, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions be prepared to refer clients to mental health, recreational, social, and other professionals who can meet the needs of LGBTQ+ individuals. Principles of Ethics III calls upon SLPs to support individuals with “unmet communication and swallowing needs.” LGBTQ+ and, particularly, trans* individuals represent a group that are underserved and have unmet needs. Finally, Principles of Ethics III.E. obliges SLPs to educate the public regarding the professional services we provide. SLPs provide services that include voice and other aspects of communication in support of an individual’s overall presentation, including areas in which speech-language enhancement may be desired, such as in individuals who wish to make their voice consistent with their gender expression. Although larger societal and organizational change takes time, there are many simple and low-cost practices SLPs and other human services professionals can engage in to support and empower LGBTQ+ individuals. It is our belief that if enough professionals implement these practices, we can build schools, organizations, agencies, and communities that are truly inclusive. We share some ideas in the Appendix but encourage practitioners to collaborate with LGBTQ+ individuals to build on this list in their organizations and workplaces. The ideas listed in the Appendix are a few ways that SLPs and other service providers can make as conscious efforts to be more inclusive of LGBTQ+ clients and model acceptance in the workplace. In our case examples, we highlighted ways that use of inclusive language and practice supported young people in gaining confidence to articulate their thoughts and feelings. We also provided examples of how providers, teachers, and systems at large can be more mindful about finding ways to use inclusive language, symbols of acceptance, and modeling of use of gender pronouns as ways to reduce barriers to culturally humble care for LGBTQ+ people. It is evident that, in many ways, LGBTQ+ people are more visible today than they have been in the past, but there is still a long way to go to reach true inclusivity and equality. Human services providers can make choices every day in their work to shift away from heteronormative and cisnormative assumptions and utilize inclusive language with clients. Acknowledgments The authors would like to thank Nidhi Mahendra, Associate Professor, Communicative Disorders and Sciences, San Jose State University, for her suggestion that we write this article. We would also like to extend our appreciation to Trans Student Educational Resources for granting permission to use the “gender unicorn” in this article. Finally, the first author would like to thank California State University, East Bay. Her partnership with the first four coauthors of this article, who were employed at an LGBTQ+ community center during her sabbatical in 2016–2017, was strengthened during the sabbatical, and this article is one product of that time. References American Psychological Association. (n.d.). Health disparities and stress [Fact sheet]. 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Approaching health disparities from a population perspective: The National Institutes of Health Centers for Population Health and Health Disparities. American Journal of Public Health, 98(9), 1608–1615. 83 Downloaded from: https://pubs.asha.org Akiko Fuse on 09/18/2022, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions Wilson, B. D. M., Choi, S. K., Herman, J., Becker, T., & Conron, K. (2017). Characteristics and mental health of gender nonconforming adolescents in California. Retrieved from https://williamsinstitute.law.ucla.edu/ demographics/gender-expression-ca-youth/ History: Received June 2, 2018 Revised September 26, 2018 Accepted October 10, 2018 https://doi.org/10.1044/persp3.SIG14.72 84 Downloaded from: https://pubs.asha.org Akiko Fuse on 09/18/2022, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions Appendix. Suggestions for LGBTQ+ Affirming Human Services Practice Engage in lifelong learning about issues, concepts, and terms in the LGBTQ+ community. Understand and teach that we all have a gender identity, sexual orientation, and variety of gender expressions—and work to increase the boundaries of gender expression that are acceptable in our society (e.g., help make it okay for boys to cry, to be nurturing). Avoid making assumptions about anyone’s gender identity or sexual orientation based on their appearance. GS, for example, identifies as gay, and it can be stressful to constantly work with adults who assume he is heterosexual. The same goes for his gender identity. Remember that coming out is not a one-time event and respect people’s individual ways of coming out (or choosing not to) in different settings, with different people. In the case of GS, his coming out process around his sexual orientation or gender identity may look different as he discloses his identities to different people in his life. Consider sharing your own pronouns as a way to invite others to do the same. For instance, an SLP named Angela could introduce herself to new clients by saying, “Hello my name is Angela, and I use she/her gender pronouns.” Other ways to proactively share pronouns include adding them to an e-mail signature or to a name tag. These efforts normalize the practice of discussing gender pronouns with clients and convey to people who do not identify with their natal sex that it is safe to disclose their pronouns and gender identity. It also creates an opportunity for you to become an ally and educate others about gender identity and gender pronouns. Use gender-neutral terms in your intake procedures and on your intake forms (partner vs. wife/husband and parent/guardian vs. mother/father). Display rainbow stickers, the gender unicorn, or other welcoming images in your clinic and offices where all your clients can see them. Post statements calling for the respect and inclusion of LGBTQ+ people. Conduct an LGBTQ+ environmental scan of your clinic or office and ask yourself: Does this look like an inclusive and welcoming space for LGBTQ+ people? Create space for preferred name on your client files and make sure you and clinic staff do not “out” transgender clients in your waiting rooms and public settings by using names they no longer use. Refer clients to LGBTQ+ centers and youth organizations that will help promote socialization and that may be able to support clients in completing legal name changes. CenterLink is an international community of LGBTQ+ centers. They have an online directory (CenterLink., 2018). Apologize and correct yourself if you mistakenly use incorrect gender pronouns or names for a trans* person (saying “oops, excuse me,” and then correcting yourself is a simple way to correct misgendering mistakes). Post signage that supports all gender bathrooms or notes the locations of the nearest private bathrooms available for clients so that people do not have to ask for this information. 85 Downloaded from: https://pubs.asha.org Akiko Fuse on 09/18/2022, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions  Work to avoid binary discussions with your clients of gender and sexuality (e.g., male/female or straight/gay). Instead, frame discussions about gender and identity across the spectrums presented in the gender unicorn. Use intake questions that ask people about feelings and behaviors rather than seeking labels. For GS, that might mean asking him if he dates boys, girls, both, or no one rather than asking if he is gay or straight. Also asking him what pronouns he uses will create opportunities to discuss gender identity in a less threatening way than asking if he is trans* identified. If you have a teaching role, incorporate LGBTQ+ examples, stories, films, materials, and so forth into your work with clients in the same way you would integrate content on people of varying races/ethnicities, cultures, ages, socioeconomic statuses, religions, and so forth. 86 Downloaded from: https://pubs.asha.org Akiko Fuse on 09/18/2022, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions