Recommended Framework for Training in Speech Feminization/Masculinization

Recommended Framework for Training in Speech Feminization/Masculinization Prepared by Joshua Goldberg Education Consultant, Transgender Health Program January 2006 a collaboration between Transcend Transgender Support & Education Society and Vancouver Coastal Health s Transgender Health Program, with funding from the Canadian Rainbow Health Coalition s Rainbow Health Improving Access to Care initiative

Page 1 Recommended Framework for Training Speech Feminization/Masculinization Clinicians in BC Context In 2003, following the closure of the Gender Dysphoria Program at Vancouver Hospital, Vancouver Coastal Health (VCH) adopted a decentralized community-based approach to transgender care. As there is wide variability in expertise and familiarity with transgender care among community-based practitioners, there is a need for practice guidelines and clinical training to encourage consistency and quality of care. While promotion of general sensitivity/awareness is a first step in improving the quality of care to transgender people, clinical guidance and training are needed in the delivery of specialty services relating to crossdressing and gender transition. The following recommendations are part of a comprehensive package submitted to VCH as part of the Moving Beyond Trans-Sensitivity: Developing Clinical Competence in Transgender Care project. The project, a partnership between Transcend Transgender Support & Education Society and the Transgender Health Program (with funding from Health Canada through the Canadian Rainbow Health Coalition), aims to create best practice guidelines and a plan for systematic training of students and professionals already in practice in adolescent care, endocrinology, mental health, primary medical care, speech, and surgery. Speech Feminization/Masculinization Speech feminization/masculinization services are delivered primarily by speech-language pathologists (speech therapy) and otolaryngologists (vocal surgery). In BC, there is one communitybased speech-language pathologist (SLP), one hospital-based SLP, and one hospital-based laryngologist listed in the Transgender Health Program (THP) s resource guide as providing voice feminization services. All three clinicians (Shelagh Davies, Cindy Reynolds, and Murray Morrison) are in Vancouver/North Vancouver. While the number of male-to-females (MTFs) in BC who need pitch-elevating surgery is not known, this is a highly specialized treatment that would likely be recommended for only a small number of MTFs (and affordable by an even smaller number, as the surgery is not covered by MSP). The need for this service in BC can thus likely be met through the existing clinical service i.e., there is not a current need to train new surgeons. It is recommended that the THP maintain a close working relationship with Dr. Morrison at the Pacific Voice Clinic of VGH and that VCH commit to create a long-term training plan for a successor (e.g., through a surgical fellowship) to ensure continuity of care. Speech therapy is needed by a larger number of transgender people (both MTF and FTM, including crossdressers and other non-transsexuals as well as transsexuals) and requires multiple sessions, often over an extended period of time. The current service map, which is concentrated in Vancouver, is therefore not feasible as a delivery plan for transgender people in BC. Optimally, the network of care envisioned by Dr. Kopala will include at least one trans-competent SLP in each health region, with a highly trans-experienced SLP in the Lower Mainland providing ongoing clinical supervision and mentorship to those in more rural/remote areas. The following recommendations relate to the creation of a training plan for SLPs.

Training Framework: Speech Feminization/Masculinization Page 2 Expert Input An internet search was used to identify post-secondary SLP programs that include training in transgender speech/voice. Interviews were conducted with the following clinicians to explore the structure of training in their programs and discuss the development of trans-specific clinical training for SLPs already in practice: Katharine Blaker, M.S., CCC-SLP Clinical Instructor and Clinic Coordinator, Department of Speech and Hearing Sciences, University of New Mexico, Albuquerque, NM, USA Georgia Dacakis, Grad.Dip.Comm.Dis., M.Ed. Lecturer, School of Human Communication Sciences, La Trobe University, Australia Reinhardt Heuer, Ph.D., CCC-SLP Professor, College of Health Professions, Temple University; Supervisor, Voice Clinic, Temple University Speech-Language-Hearing Center, Philadelphia, PA, USA Brian Petty, M.A., CCC-SLP Clinical Speech Pathologist, Division of Otolaryngology, University of Wisconsin Hospital and Clinics, Madison, WI, USA Additionally, two local clinicians were interviewed and invited to provide feedback on drafts of this framework: Shelagh Davies, M.Sc., S-L.P.(C) Clinical Instructor, School of Audiology and Speech Sciences, UBC Linda Rammage, Ph.D., S-L.P.(C) Director, Provincial Voice Care Resource Program; Sessional Instructor, School of Audiology and Speech Sciences, UBC Core Competencies SLPs providing speech change services to transgender people should have expertise in three areas: a) Speech/voice science: knowledge of theory relating to adult speech/voice production, speech/voice disorders, and speech/voice therapy, as well as clinical experience assessing and treating typical speech/voice disorders in adults b) Transgender basics: terminology, diversity of gender identity and gender expression, the processes involved in gender transition, general trans-specific psychosocial issues that shape clients goals and treatment options, and clinical trans-sensitivity protocols (e.g., use of preferred gender pronoun and name); real-life exposure to the transgender community c) Speech feminization/masculinization: gender differences in speech/voice, the effects of hormones on speech/voice, assessment of transgender speech parameters, treatment options (surgical/non-surgical), therapeutic techniques (surgical/non-surgical), evaluation, followup It is also recommended that SLPs have at least two years clinical experience prior to undertaking transgender voice work, as transgender speech change is highly specialized work involving a high degree of clinical sophistication (including excellent interpersonal skills).

Training Framework: Speech Feminization/Masculinization Page 3 Current Training Speech/voice training The UBC School of Audiology and Speech Sciences (in the Faculty of Medicine) offers a Master of Science with a major in Speech-Language Pathology, involving alternating periods of universitybased didactic study with periods of supervised clinical practice. Graduates meet the academic and practical requirements for professional certification with the Canadian Association of Speech- Language Pathologists (CASLPA). SLP programs are also offered in English at the University of Alberta, University of Western Ontario, University of Toronto, McGill University, and Dalhousie University, and in French at Université d'ottawa, Université de Montréal, and Université de Laval. At UBC, there is only one course on voice in the masters level curriculum (and it was the opinion of the instructor of this course that other Canadian SLP programs had similar extent of content). To supplement masters level voice training, the Provincial Voice Care Resource Program (PVCRP) at Vancouver Hospital offers a three-week voice disorders intensive training program once or twice per year. The training intensive is intended for SLPs in community-based practice, and is comprised of one week didactic instruction (anatomy/physiology of speech and the nature and management of voice disorders), followed by two weeks clinical observation (voice assessment, treatment, and outcome measurement) and professional practice training at the Pacific Voice Clinic. Upon completion of the intensive training, the PVCRP provides clinical supervision/mentorship for graduates first two clients with voice disorders. An intensive training format (three 3-week blocks) is also used by the University of Iowa to augment the voice training available at the masters level (van Mersbergen, Ostrem, & Titze, 2001). Students and post-graduates receive university credit for completion of the intensive training. This is the only training program specifically focused on voice science in the USA. Trans-specific speech/voice training According to the voice instructor in the UBC SLP masters program, there is currently no transgender content in the curriculum (although students may choose to do a project on transgender voice). While it would arguably be useful for SLP students to be exposed to very basic transgender information as in SLP programs in the USA and Australia, the UBC School of Audiology and Speech Sciences recently completed an extensive curriculum redesign and it is therefore highly unlikely that further changes are possible at this time. To the best of the instructor s knowledge, there is no postsecondary or post-graduate training in transgender speech/voice in Canada. Although the Transgender Health Program has delivered sensitivity/awareness training to clinicians in the past and has a curriculum that could be used with speech professionals, there is no systematic plan relating to basic transgender education, and nobody currently available to deliver training. Training Recommendations 1. One-week transgender speech intensive A combined didactic and experiential training intensive is recommended as the primary means of training SLPs. Drawing from the structure of the Provincial Voice Care Resource Program s voice disorders intensive, a transgender speech intensive could include:

Training Framework: Speech Feminization/Masculinization Page 4 pre-reading: Trans Care Project literature review and speech guidelines didactic training (mornings): transgender basics, gendered aspects of speech/voice, trans-specific treatment options, trans-specific assessment and therapy techniques, trans-specific outcome evaluation observation (afternoons): assessment, group and 1:1 therapy, outcome evaluation supervision for first two transgender clients after completion of training The table below provides a more detailed outline for the proposed curriculum. Table 1: Suggested Curriculum for Transgender Speech Intensive Day Time Topic Details Mon Tue Wed Thu Fri PM Transgender basics Introduction to the transgender community Gendered aspects of speech/voice terminology diversity of gender identity and gender expression processes involved in gender transition transgender psychosocial issues sensitivity protocols (intake form, charting, preferred pronoun/name) video: Gender Line panel of speech clients talking about their experiences with speech work vocal parameters: pitch, voice quality, inflection, formant frequency/resonance, loudness/intensity motor speech parameters: perceived onsets of consonants, durational characteristics discourse parameters: language, non-verbal aspects of communication the effects of cross-sex hormones on speech/voice Treatment options speech therapy: individual and group formats, importance of home practice overview of pitch-elevating surgical techniques self-directed speech modification (video, internet reading, etc.) PM Group therapy observation of Changing Keys group Trans-specific assessment and treatment planning review of elements of speech/voice assessment: history, perceptual assessment, use of acoustic software, evaluation of discourse pragmatics and non-verbal communication parameters trans-specific issues in therapeutic rapport trans-specific client history trans-specific treatment goals: passability, comfort evaluation of potential psychosocial difficulties and supports treatment planning for special populations (e.g., transgender individuals with learning/speech/hearing disabilities) PM Assessment observation of assessment of transgender clients (1 FTM, 2 MTF) Trans-specific developing client observational skills therapy techniques to feminize/masculinize specific parameters of speech/voice modification of standard treatment protocols (LMRVT, Stemple s vocal function exercises, etc.) for the transgender population evaluation of progress and modification of treatment during therapy PM Individual therapy observation of 1:1 therapy with transgender clients (1 FTM, 2 MTF) Outcome evaluation and followup reassessment at the conclusion of therapy clinical followup after termination of therapy (e.g., refresher courses) longitudinal outcome evaluation ethical issues in reporting outcome data PM Followup observation of refresher session with Changing Keys participants, OR panel of former clients discussing long-term issues, OR detailed case review relating to longitudinal maintenance of change

Training Framework: Speech Feminization/Masculinization Page 5 To ensure a basic level of competency in speech/voice, it is strongly recommended that as part of the application process SLPs be asked to provide information about previous formal training in voice therapy, the types of voice techniques already learned (through certificate programs, independent research, etc.), and clinical experience working with non-transgender people (to determine general clinical skills). General voice therapy training (such as the voice intensive programs offered through PVCRP or the University of Iowa) may be required as a prerequisite. As the number of SLPs in BC interested in this training would likely be quite low (1-2 per year) it may be appropriate to open it to others across Canada (and perhaps the USA) with an interest in transgender speech. This would help offset training costs. To remove financial barriers to participation, clinicians in BC should be financially compensated for their time during training (it is unlikely that SLPs in private practice or the public health sector could afford to take a full week away from practice). A trainee stipend should be incorporated into the training budget. Table 2: Suggested Budget for Transgender Speech Intensive Training fee Item Cost facilitator (including followup supervision) $8,000 1-week salary for 1 BC clinician $3,000 Logistics facility rental VCH facility advertising $100 materials (handouts, binders, certificates) $150 panel honoraria $500 misc supplies (nametags, etc.) $50 refreshments $400 administration (registration, certificate) $200 Subotal: $12,400 Anticipated registration fees (5 x $500): $2,500 Estimated total: $9,900 Note: An additional $5,000 would be needed in the first year for development of curriculum and handouts 2. Supplemental education in transgender basics In many general health and psychosocial disciplines, basic transgender sensitivity/awareness is all that is required in most cases. Speech feminization/masculinization is a specialty service and general sensitivity/awareness is insufficient for competent practice. It is therefore recommended that basic transgender training be delivered primarily as part of a clinical intensive rather than as a separate endeavour. However, there is benefit to making SLP students, recent graduates, and SLPs without vocology expertise aware of transgender issues, so those approached by transgender clients have a basic understanding of service options (and to pique interest in taking more advanced clinical training). To accomplish this it may be appropriate to open the transgender basics lecture provided as part of a transgender speech intensive to SLP students, recent graduates, and others who do not fulfill the requirements for the entire training but are interested in transgender speech. Alternatively, transgender awareness/sensitivity content could be offered as a seminar or practicum placement

Training Framework: Speech Feminization/Masculinization Page 6 specifically for SLP students in conjunction with the UBC School of Audiology and Speech Sciences (preferably to count towards course credit). 3. Continuing education Trans-competent SLPs should meet on a regular basis to share case studies, discuss new research findings, etc. This could be accomplished by a special meeting at the annual BCASLPA conference and/or virtual conferences (online or video link). Local SLPs should also be supported to share information nationally at the annual CASLPA conference and other relevant professional gatherings. Health regions can support local clinicians to stay informed of developments in the transgender speech field by helping fund collaborative research with international colleagues and travel to the biennial conference of the Harry Benjamin International Gender Dysphoria Association. New research findings should be incorporated into the Trans Care Project guidelines, and a re-review of the speech/voice literature performed every 5 years (with new findings incorporated into the training). References (1) van Mersbergen, M., Ostrem, J., & Titze, I. R. (2001). Preparation of the speech-language pathologist specializing in voice: an educational survey. Journal of Voice, 15, 237-250.