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An Interdisciplinary Approach to Working with Trans Clients

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Join Sand Chang, PhD, and Ruchi Kapila, CCC-SLP as they discuss the best practices for offering care to transgender clients in a collaborative and holistic way. 

Hosted by Dr. Natalia Zhikhareva, this group of experts offer their insight on what to expect when working with transgender clients, why working with an interdiplinary group is important, and how you can start getting involved with the trans community. They also address different biases clinicians who are not part of the LGBTQIA+ community might have. 

Most importantly, they offer encouragement and advice when working with transgender clients, and the best training resources that are helpful for this line of work.

  1. Introductions
  2. What would you say the biggest obstacle is that the trans community encounters in each of your fields?
  3. Are there obvious blind spots when it comes to biases and clinicians who are straight or not part of the LGBTQIA+ community?
  4. What are the trainings and certifications that both of you have found helped in working with the trans community?
  5. How does an SLP fit into the care team for working with transgender clients?
  6. For those of us just getting started working with the trans community, how do we best prepare intake documents or first sessions for our clients?
  7. How important is it to work with an interdisciplinary team when working with the trans community?
  8. When is the right time for a therapist or counselor to refer out to an SLP in the transition process?
  9. Do you have any advice regarding letters to give clients well in the midst of transitioning?
  10. What are the cultural or racial effects on a trans person either a pre or post transition that can affect their care?
  11. Would you like to share anything that we haven’t touched on yet today?

1. Introductions

Dr. Jamison Merrell: Hello everyone and welcome to our Ask The Experts Webinar. Our topic for discussion today will be An Interdisciplinary Approach To Working With Trans Clients, and my name is Dr. Jamison Merrell, I will be your facilitator today. Really excited to be here discussing this important topic with all of you. Here’s a look at our agenda for the next hour or so, as we’ll start with introductions from our two speakers, and then we’ll go through your questions and wrap up together with some final thoughts. And our first speaker is Dr Z. Dr Z, would you like to introduce yourself and tell us a little about your practice?

Dr. Natalia Zhikhareva: Sure absolutely, thank you for having me here. I’m really excited to be here, always enjoy participating in any kind of discussions with other clinicians and other providers in the field. My name is Natalia Zhikhareva, Dr. Z PhD for short. And I solely specialize in transgender care. I’m a clinical psychologist based in Los Angeles, California and I’ve been in trans field for about 15 years now and pretty much all I do solely is focus on trans field.

Dr. Jamison Merrell: And our next speaker is Ruchi. Ruchi would you like to introduce yourself and tell us a little about your practice?

Ruchi Kapila: Yes, thank you Jamison for having me and Dr. Z, it’s so wonderful to co-present with you. I’m Ruchi Kapila, I’m a Punjabi- American non-binary speech language pathologist based in Hayward, California. I’m ASHA Certified as well as California and Texas licensed. I’m also a vocologist or somebody who works on vocal habilitation and a voice teacher with a background as a trained soprano. I provide private singing and speech voice services with a gender inclusive lens through my sole proprietorship and business Kapila Voice and Speech Services. My background was also in acute care and acute rehabilitation services so I was working with a lot of people post stroke, post brain injury, and other acute trauma with regard to cognitive communication rehabilitation as well as swallowing rehabilitation.

I have a podcast called The Hindsight Project where I interview Black and BIPOC trans and gender non-conforming activists and artists, that’s something that I started last year. I’m also a part of Trans Voice Initiative where I’m a volunteer member amongst other trans and gender non-conforming SLPs looking to provide equitable and inclusive services to the trans community as well as uplifting TGNC SLPs to be able to provide gender affirming voice work. I’m currently just became an admin for SLPs of Color in addition I’m Director of Social Media, Equity, Diversity, Inclusion Member, or Committee Member I should say, and Board Member for Festival Opera in Walnut Creek, so I try to spread myself across many different areas related to voice in terms of advocating for TGNC community.

Dr. Jamison Merrell: Fantastic. Thank you both so much for being here today. We’ll start jumping into our questions now. All right, so our first question today was submitted by Angelica who asked, “What would you say the biggest obstacle is that the trans community encounters in each of your fields?” So since we’re taking a interdisciplinary look today, therapy and speech language pathology specifically. Ruchi, I’ll start with you and then Dr Z.

2. What would you say the biggest obstacle is that the trans community encounters in each of your fields?

Ruchi Kapila: That’s a complicated question Jamison. I think identifying one obstacle that TGNC community faces unilaterally is really difficult. I think the things that pop up for me are cost of services and barriers to receiving services, gatekeeping that can occur. I would say anecdotally when I’ve worked with clients and if they’ve fallen off of engaging in services, a lot of that’s related to insurance no longer reimbursing for other services that are necessary for what feels gender affirming for that particular client, whether it’s electrolysis or hormone replacement therapy, changes in terms of modality or therapy services like psychotherapy services become more expensive and so the client is left juggling what they have to prioritize instead of having access to everything that’s important for them in terms of gender affirming services.

The other piece that I’ve noticed is that TGNC folks experience disproportionate levels of harassment as well as microaggression and macroaggression triggers when navigating medical settings. The National Center for Trans Equality has many resources talking about percentages of how people report on surveys, the things that they experience trying to navigate our systems of care, whether it’s through insurance or physicians, and being able to obtain the services that they need to feel affirmed and to feel supported. And so there are so many barriers that go along with that and if you start being in intersections related to race, socioeconomic status, education, et cetera, then it can be even more and more difficult for TGNC folks to obtain these services that they want.

Dr. Jamison Merrell: Yeah, so definitely a lot of barriers to face, but thanks for pointing out some of the the biggest ones that you’ve seen. Dr. Z, what would you add?

Dr. Natalia Zhikhareva: Yeah, I definitely agree with Ruchi, it’s not an easy question to answer. In my field, it will depend on the population you’re working with. Are you working with children? Are you working with adults? The demographics where the person is located their context their environment as well as their socioeconomic status. In my experience, and I work solely with adults, my experience there is I would probably point out three biggest barriers that I see consistently. One is not enough therapists specializing or at least focusing on transgender care field. And what I mean by that is I see a lot of people who will go and see somebody who lists their gender inclusive or gender affirming on their website and then it comes to some essentials such as writing evaluation letter for gender services, they’re not able to provide that. So I see that consistently, so I think that lack of training, lack of people really going out there and learning how to work in this field if that’s something you want to do is really missing.

Another barrier that I see is gatekeeping, especially gatekeeping when it comes to gender affirming evaluation letters for surgeries. A lot of people in my field, again I’m talking solely about adults, a lot of people that I work with are very ready, have really made informed consent decisions about any kind of surgeries that they plan on having and when they reach out in order to get the evaluation letter sometimes they are quoted as they need to see somebody six months to a year in order to get a letter and as somebody who’s specialist in this field, I think that’s incredibly unnecessary to delay somebody from getting surgery for such long period of time.

So I say that’s the biggest barrier, I see that as a gatekeeping, and I see that as being really unnecessary and lastly the final one is a really big one is financial accessibility to care. The more specialized somebody is going to be the higher end financial tiers are going to be at in terms of charging for their services. I’m one of those people and I’m very transparent about that and as a result I’m not accessible to everybody so that’s another challenge is that while certain populations are able to get access to me, a lot of other populations are not. So having a much more distributed accessibility to care is really essential.

Ruchi Kapila: Yeah, I do want to pick you back off of that too, Dr Z reminded me of another thing that I wanted to include is that whenever speech language pathologists think about trans voice care they’re like, “Oh, it’s going to be so cool I can expand into gender affirming voice care and then I can feel really good about what I’m providing to the community,” without recognizing that we run into trans and gender non-conforming folks everywhere. So we all need to be well trained to be more gender inclusive and gender expansive in our practices working across the board, birth to geriatrics because we never know when we’re going to encounter somebody who needs that kind of support and needs that kind of inclusivity when it comes to intake forms when it comes to gendered language that’s unnecessarily so in our evaluation and therapeutic practices. But I think I’ll get into that a little bit later in our in our talk.

Dr. Jamison Merrell: Absolutely, thank you both so much for your perspective. So moving into our next question here, which I think lends nicely to what we were just talking about here a little. Are there obvious blind spots when it comes to biases and clinicians who are straight or not part of the LGBTQIA+ community? So as clinicians are there certain blind spots you’ve seen that are common and we could all be more mindful of looking out for?

3. Are there obvious blind spots when it comes to biases and clinicians who are straight or not part of the LGBTQIA+ community?

Dr. Natalia Zhikhareva: Okay, I’ll start answering that question if I may. We just kind of touched based on some of those blind spots. In my field, the less you spend time immersing yourself in the community you want to work with, the bigger your blind spots are going to be. That’s just the reality of things. Also, in addition to having a better understanding of how our identity stands to formulate in terms of just psychologically and internally as well as how that relates to our sense of self in relationship to gender is big because a person can present this particular gender expression only to realize that that doesn’t really necessarily fit comfortably with them and switch or modified as they go along so having an understander that gender identity and of itself is for a lot of people can be fluid and or could be an ongoing process throughout their lifespan is important so again I think the blind spots are just if you’re really going to work with this population which I think is great and very much needed just train yourself and there’s a lot of training opportunities there I know we’re going to touch base on those as well and the easiest training you can do is just start connecting to people who already specializing in the field and start looking at their resources for that information.

Ruchi Kapila: I think you give a lot of coverage to the things I’m going to discuss to you Dr. Z. I think one of the major barriers is that there are so many pieces that we don’t see that can be triggering for TGNC folks whether it comes to saying something like preferred or personal pronouns instead of just saying pronouns differentiating an intake versus having you know a name that is chosen versus a name that’s going to be on their insurance or a name that’s on their financial documents and not necessarily for example dead naming or using the name assigned at birth for a client that’s something that’s really common in terms of blind spots we run into I think making assumptions about what the client wants like Dr. Z also talked about.

The commonality and frequency in which we meet people who are gender fluid or gender non-conforming and what feels affirming for them in terms of gender may not be obvious to somebody who is cisgender folks might assume oh you just want to fit in you just want to belong but the more and more you spend time in TGNC community or LGBTQIA+ spaces or at Pflag you’ll start to see that people are also very passionate about radicalizing what gender looks like or deconstructing what gender looks like, and so you have to go and meet a client with a fresh lens every time and also be aware of any projections that you come in with.

And even as a non-binary person myself who might be coded as Fem or cis-assumed, I have to also be aware whenever I’m meeting a new client that I might I’m going to be inclined to fill in the blanks about what this client might want, what they’re looking for, what they need and I have to kind of pause myself and allow the client to speak for themselves and drive what the service provision model looks like and allow them to show me, “This is what I’m looking for, this is how you can be helpful for me.” And there’s no service provision without them for saying that and giving me that direction that map. I completely agree with Dr. Z that if you’re not using the resources of TGNC-led spaces or LGBTQIA+-led spaces, you’re going to fall into pitfalls with regard to stereotyping and making assumptions.

The other piece to be aware of too is that in larger LGBTQIA+ umbrella spaces there can be a lot of transphobia and there can be a lot of microaggressions and assaults to be aware of. So just because something might be LGBTQ friendly, it might not be entirely friendly to members of the trans or gender non-conforming community and that’s something to be aware of and to listen to members of that community about too.

Dr. Jamison Merrell: Great. Yeah, so important to not make those assumptions and then also flowing right into our next question, building on the topic of educating yourself, what are the trainings and certifications that both of you have found helped in working with the trans community? So obviously a lot of training’s out there, but which ones have you personally uh both found to be helpful and worthwhile? Dr. Z, I’ll start with you and then Ruchi.

4. What are the trainings and certifications that both of you have found helped in working with the trans community?

Dr. Natalia Zhikhareva: Sure. So sadly, our educational system is very much like in terms of having a very good inclusive gender diversity course or courses and as there’s not a lot of people who graduate, myself included when I finished grad school, I was in education. So I think there are right now a lot of areas where you can get training wpass.org has a lot of training they do. Personally what I found to be the most helpful is to work with community as much as possible to… Well for me at least because I’m solely specializing in this, it was pretty easy because that was the only community that I needed to focus on. On top of that, there’s a lot of conferences, a lot of meeting internationally and locally that take place, a lot of seminars. Never underestimate the seminars thinking that you know everything you do. To this day, I attend all of them because the research is ongoing the trans field is growing and as a result you’re always going to learn something new.

In addition to that, there’s a lot of books that you can read offhand that are going to give you a first-hand trans experience. Now there is going to be a very specific trans experience because those books are specific to those individual experiences but nonetheless, they will help you widen the scope of your lens and widen the scope of your understanding. So I think, it’s pretty easy these days, for example my website has a lot of blogs on medical interventions and gender formic surgeries and a lot of research behind them. I also have Youtube channel where I speak a lot about gender issues, all those things are out there it’s free content so anybody who wants to specialize all they have to do is just start digging in and pretty much start vetting some time to study and to look into it. But I think all of those things are out there and if you’re really passionate and interested, I don’t really see anything stopping you.

Ruchi Kapila: I agree that there are a number of resources available to clinicians and to voice specialists who want to learn more about serving trans and gender non-conforming community. Like I said before, I think it’s going to be a necessity across our field, across the board because we’re going to see pediatric or students coming out, we’re going to see people come into rehab facilities, at school nursing facilities, hospitals, and we want to be able to serve this community minimizing any likelihood of microaggression, right?

So I would say that in speech language pathology as a whole, trans and gender non-conforming issues became a hot ticket related to gender affirming voice and related to broadening aspect of the field as opposed to the fact that these folks exist in our communities and need to be served for an array of medical health related issues that might not be actually related to being trans or being gender non-conforming, right?

But we don’t necessarily have an established standard of how we work with trans and gender non-conforming people and what cultural responsiveness looks like when we’re meeting these people’s needs. So what I would say is that you, like Dr. Z said, you have to kind of put together a program for yourself transplaning that’s headed by AC Goldberg and Chris Rehs-Dupin has a lot of resources and are a subscription-based website where they talk a lot about how to adapt forms, how to adapt practices in your clinical setting, thinking about the overlap between TGNC folks who are also neurodivergent, whether they’re autistic or have ADHD and how to adapt resources for the community in that way. So that’s a great resource to use.

I mentioned the National Center For Transgender Equality getting involved with like Pflag as well as local LGBTQIA+ centers. I think Dr Z you’re completely right that you have to go from a community-based perspective and and talk directly to members of the community and see what’s missing there as well as reading any survey results and that sort of thing. In terms of actual trainings and certifications, I wouldn’t say that there’s anything specifically formal that’s TGNC focused. I know that Leah Helou, Christie Block and Sandy Hirsch have a biennial voice training which I’m even more likely to recommend now that they are including non-binary and trans SLPs in the formulation of this workshop. I will also add that there are a couple of courses that I’ll be doing and presenting at that I’ll mention at the end of this webinar.

There are a number of books that Adrian Hancock has published, Richard Adler and Sandy Hirsch have published with that are related to voice. But my advice is to go beyond and look at TGNC-led publications like Gender Outlaw by Kate Borenstein and Beyond The Gender Binary by Alok Vaid-Menon. Another excellent example that I’ve used in some of my publication work is Black On Both Sides, A History Of Trans Identity by C. Riley Snorton. So don’t feel as a speech language pathologist that you’re trying to just get continuing education units and just get whatever ASHA is covering for you in terms of getting continuing education, you have to go way beyond what you consider our scope or our community so to speak to really learn about what’s needed in TGNC community and meeting their needs.

Dr. Natalia Zhikhareva: Yeah, I just want to add to that. On my website I also have a list of suggested books, both for mental health professionals as well as they’re broken on by subject matter so that’s going to be really helpful. Another thing is that if people watching this and are thinking about going into this field or primarily specializing in it or devoting part of their practice to this field, don’t be afraid to roll up your sleeves and do the work. Meaning you’re gonna have to devote your time and sometimes the time is going to have to be free time but you’re going to get a lot out of it. If you can open up a support group and do it for free you’re going to attract a lot of people, you’re going to immerse yourself in that experience. Immersion is, in my opinion, it goes miles miles away. You can go and volunteer at a local LGBTQ center or at a local trans clinic, all of that is going to really help you to get hands-on direct experience and also an understanding, not only what changes people struggle with, but it’s going also give you a wider lens of what kind of service people need and it’ll help you pretty much focus on what your practice needs to focus on.

Dr. Jamison Merrell: Really great recommendations, thank you both. Okay, and this next question I will direct specifically to you Ruchi which is, How does an SLP fit into the care team for working with transgender clients?

5. How does an SLP fit into the care team for working with transgender clients?

Ruchi Kapila: That’s complicated. So it depends on what the trans client needs, right? It could be that for example Dr Z. has a client who wants to work on voice or has identified voice is something that they want to navigate to find a more gender affirmation configuration around and so I get a referral that way. So gender affirming voice is the thing that everyone thinks about that. Or I have this preschooler, elementary school age, or high school age student at school or a pediatric client who is coming out and I need resources navigating that. Or how do I teach pronouns? Those are the things that, like I talked about earlier, speech language pathologists are like, “Oh this is where trans stuff lives,” and it doesn’t, it lives across the board.

I’ll give an example, I was covering at an acute rehab facility and I’ve told this story a few times, but I had a patient that was admitted that I had to do an evaluation for who’s a black trans woman who was a drag performer as well in San Francisco. And I had to go in to assess for cognitive communication deficits. I had to go in to look at motor speech deficits after a neurological impact. I don’t remember if it was a stroke or a brain injury or what happened in that particular case, but I went in and I discussed how I’m non-binary, I offered my pronouns, she offered her pronouns, she said, “Oh, are you trying to tell me that you’re family?” And we had a much easier time going through this evaluation together because I’d earned her trust and I understood kind of norms of communicating within community.

So an SLP can fit into the care team for working with a transgender client across the board. Traditionally, we’re looking at gender affirming voice services but I want to reinforce that you’re not going to know if somebody’s trans or gender non-conforming by looking at them. It’s not necessarily going to be in the chart so what the whole piece that a speech language pathologist can bridge the gap on is an intake and having these conversations being able to navigate this interaction from a gender inclusive lens and being able to be gender inclusive and expansive in practices. And then that allows the client to come out to you or disclose to you or not, depending on what is warranted in the service provision model. Does that make sense or is there any sort of follow-up question you want to ask Jamison?

Dr. Jamison Merrell: Yeah, thank you so much. So it sounds like there are a lot of… To summarize, a lot of different ways that a speech language pathologist could be involved in that process and so many different angles and ways of being part of a care team regardless of how a particular client what their gender is.

Ruchi Kapila: And the only thing that I wanted to add on this note is that whenever we’re working with gender affirming voice modification, it’s really important to note that a lot of times, in these cases, the voice is not pathological. We have to remember that the pathology, if anything exists around voice, if there’s nothing wrong with the vocal folds or nothing there’s no medical compromise that that pathology actually exists in like a societal focus on binauristic thinking, needing to assign people. If we didn’t have that, I don’t know how many clients I would see necessarily for gender affirming voice services. So when we think about it in that way, there are SLPs can provide gender affirming voice services, there are also voice, teachers voice practitioners, diction coaches who can provide these kinds of services too if we understand that there is no underlying medical or vocal fold pathology.

So that’s an important thing, that the SLP often is part of a much greater voice team that involves their community members, maybe acquire bands that they sing with. The therapist is involved as well as maybe this isn’t identified as a modality for them to find, use their voice in ways that are more affirming and therefore have holistically a more affirming experience. But that’s complicated, everybody has a different system or team that’s related to their particular gender identity and their journey I should say.

Dr. Jamison Merrell: Great. All right, and our next question is, for those of us just getting started working with the trans community, how do we best prepare intake documents or first sessions for our clients? So we know how important that first meeting is and that first impression, so what things can we be doing as clinicians to make sure that we’re giving our client a positive experience or a more inclusive experience on that first meeting?

6. For those of us just getting started working with the trans community, how do we best prepare intake documents or first sessions for our clients?

Dr. Natalia Zhikhareva: Okay, I’ll start tackling this one. So prior to talking about intake documents, I think transparency is going to be key if you’re starting working in this field and you’re about to see your first or second or third or fourth trans client. In other words you still have not had a wide range of transgender or gender diverse individuals you worked with, I think it’s best just to be very honest and upfront about it. Chances are, given your lack of experience, you are going to mess up on pronouns, chances are you are going to make mistakes and I’m telling you from experience that people coming into our offices care less about us making mistakes and care more about what for the ones who do make a mistake. And the best thing we can do is we can apologize and try the best. Especially if you are transparent from the get-go and were pretty clear about your lack of experience people are going to be very understandable about that.

In terms of intake documents, the best you can do just to be very gender inclusive. Make sure that you have variations on there other than male and female, make sure that you include not only clients name but also preferred name for individuals because a lot of people will have preferred name. So just be very inclusive, broaden your scope of intake forms. I think there’s a lot of resources online that can include all those. My intake forms are relatively simple, it just asks people what their preferred name or their preferred pronouns and if they have any kind of gender education at a moment and if not, I also leave a spot for that because sometimes, a lot of times actually people coming to me are not sure which gender identity they carry. So just be very open and have a pretty much broad range of intake forms.

Ruchi Kapila: I agree with a lot of that. I do think if you’re starting to work with the trans community, you should do a lot of leg work before you start taking that first client. I think you should have a list of referral opportunities for trans and gender non-conforming clinicians because I know anecdotally that a number of us don’t get those referrals and those referrals disproportionately go to cisgender clinicians within our field at least and there are a number of us who are trying to build practices who have the training from both being part of community as well as engaging in these resources. It took me a very long time to start as a voice practitioner serving the trans and gender non-conforming community because I understood how nuanced it is, how sensitive it can be, and I spent a lot of time at my local like Oakland LGBTQIA+ center as well as talking to other trans and gender non-conforming speech language pathologists before I kind of made the jump and I was actually pushed to because of the voice experience that I have.

I want to add that you can definitely, like Dr Z said, expand what your forms look like, don’t make assumptions and don’t ask about marital status unnecessarily, don’t make assumptions when it comes to family since chosen family is a big thing in community and everybody’s support networks look very different. Making, like you said, what is the name that you choose versus what is the name of your documents is huge for intake forms. I would also add that investing in consulting with a trans clinician for this type of need is huge and will give you more nuanced information based on the region that you’re in or based on maybe the overlapping communities that you’re serving because they may be more black and brown trans community members that have different needs or maybe it’s going to be different being in California versus Texas versus on the East Coast so you have to be sensitive to all of these different considerations.

My recommendation is transplaining with AC Goldberg. AC Goldberg does provide one-to-one consultation on your forms and giving you information on that. You can also read, there is a textbook that was released recently that was Dr. RaMonda Horton’s Critical Perspectives on Social Justice and Speech Language Pathology. So there is a chapter related to LGBTQIA+ issues that Greg Robinson and Andy Toliver-Smith published, they talk about this at length as well as The Singing Teacher’s Guide To Transgender Voices, Liz Jackson-Hearns and Brian Kramer published this textbook, they also talk about intake forms and how to avoid microaggressions. So as much as you can find these text-based resources in terms of adapting intake documents and possible pitfalls or barriers that might come up in your first session that’s huge as well as investing in PGNC clinicians and asking them, “How do you adapt this? I’m starting to see these clients but I want to make sure that this is inclusive.”

And then if you’re addressing both the needs of TGNC community as well as like cisgender folks in your clinical context, expand the gender inclusive and gender expansive language across the board. Like I said, you never know when somebody is a part of community or where somebody will be at in transition and so you don’t want to single out trans clients as being like I have these forms for you because I have misattributed you as being part of community or made an assumption, have those form changes for everybody across the board within your clinical context.

Dr. Jamison Merrell: Great, thank you both so much. And our next question submitted by Megan who asks, “How important is it to work with an interdisciplinary team when working with the trans community?” Some examples, therapist, SLP, OT. So Dr Z, I’ll let you take this one first and then Ruchi.

7. How important is it to work with an interdisciplinary team when working with the trans community?

Dr. Natalia Zhikhareva: In my experience, it’s very crucial. I personally have a network of people locally because I’m licensed in California and Florida. Also, I have a networking team in West Florida and locally of voice therapists, electrologists, surgeons, you name it. And I think it’s really important because we’re all going to be referring to one another and especially for individuals that are going to need a little bit higher level of care, being able to be in that interdisciplinary team is crucial, especially when it comes to surgeries, being able to communicate across the board and have open channel communication is going to be a key.

So in my experience, it’s definitely not the work anybody does alone. I don’t think there is such a thing so I think that connection and networking across the board is very, very important, including as well as within my field as well. So for example, while I do specialize in gender issues, I don’t specialize in everything else so if I do have somebody who is coming in for example who is perhaps is on autism spectrum or somebody who has dyslexia identity disorder, I certainly do refer them out because that’s just not my scope of expertise. So having again that the toolset of network providers that you work with and collaborate with and work across the boards is incredibly crucial.

Ruchi Kapila: I agree. I think from my scope it’s a little bit different in terms of who I end up interacting with. I would be very much open to interacting with a psychologist or a therapist if a client wanted to. I try to let them lead as much as possible whether that communication happens or not sometimes clients want to keep those fears separate and that’s understandable. What’s more likely in terms of my interaction, in terms of my current practice is consulting with an ENT or a speech language pathologist that’s part of a voice and swallowing center that might be performing gender affirming voice surgeries. And while we don’t often recommend them because there can be many outcomes and they may not necessarily lend themselves to a client having the broadest voice like volume range or pitch range, we don’t necessarily recommend them especially for voice performers.

But I may have questions about, what are the possibilities for a particular client if a client doesn’t feel affirmed just doing the behavioral voice modifications? Is this a good candidate to talk to you about X procedure or if they have a vocal fold pathology and I don’t feel like working via telly I can necessarily address this to the extent that I need to, I can refer them to a voice and swallowing center where there’s a speech language pathologist who has direct access to instrumentation to look at the vocal folds and to assess if there’s anything additional going on so that we can expand our care team and make sure that this client’s voice needs are being met appropriately.

I haven’t had the experience of working in a school-based setting so to talk about necessarily PTOT and SLP for a trans student or a gender non-conforming student. I’m sure it comes up, but I also think it’s one of those situations where you have to be gender inclusive and also there are other comorbidities or other complications that are going on that also require the attention like you would for any cisgender client as well. So I think an interdisciplinary team is always important but it’s always a matter of is there a pathology, what’s the nature of the pathology, who’s on that team? And that’s going to be different for each client.

Dr. Jamison Merrell: Definitely. Great. All right, and then moving into our next question, when is the right time for a therapist or counselor to refer out to an SLP in the transition process? So kind of building off of, when do you need to maybe start establishing or building out or helping your client to build out that interdisciplinary team for themselves? Dr. Z, if you’d like to start and then Ruchi?

8. When is the right time for a therapist or counselor to refer out to an SLP in the transition process?

Dr. Natalia Zhikhareva: So in my experience, ideally for voice therapy, gender affirming voice therapy, you want it for people as soon as possible to start working with you. Now having answered that, that is also going to highly depend on various factors. One, whether voice something is a dust cause them quite a bit of gender dysphoria and two, whether they actually are interested and want to modify their voice. Not everybody who is transitioning are interested in modifying their voice, a lot of people are comfortable with their voice. So for some people voice is going to matter for a lot of others it does not.

So if you have a client out there for whom voice gives quite a bit of dysphoria or even if it doesn’t cause any dysphoria but it is something that they want to modify, I would say, in my opinion, you have to refer as soon as possible because voice therapy, as Ruchi can attest to, can take some time, it is something that people need to dedicate time and practice to in terms of mastering it and I always tell people that psychologically, from a psychological point of view, it is not so much about time in terms of mastering the voice, but it is the time that you need to invest in order to make that leap from being very hyper vigilant when you actually are talking in your voice versus to talking on auto pilots the way I do for example right now and that psychological leap sometimes takes a while. So for that reason I recommend starting, if voice is something you want to do, you need to start immediately.

Ruchi Kapila: I agree with Dr. Z that there shouldn’t be any sort of gatekeeping process whether a therapist makes a recommendation or bridges that gap with me or if it’s somebody who gets my name off of the website or through an LGBTQIA center, what have you, somebody should have the right to have voice services at any time and it can be at multiple times in the process. I would say that, like Dr. Z said, transition looks different for everybody, sometimes transition is never ending and really gender is just this kind of like long journey for people and so you want them to know that they have access to these services at any time.

I think the other thing that comes up for me is that sometimes when somebody comes to me, they aren’t ready in terms of, like you talked about, the hyper vigilance or not feeling like they have the physical space for vocal play or not feeling necessarily ready and sometimes it means that a client needs to spend more time with the therapist or I need to give them a bit of a break or a buffer so that they have time to kind of work through any surrounding issues trauma or considerations around the voice because the voice is so personal and integrated into so many aspects of life. But yeah, Dr Z is absolutely right that it can take a lot of time for some clients because they’ve had some voice performing history or feel more comfortable with voice play or a modification in the session will not take as much time it really just depends on the client. But I don’t necessarily think that there is like a ding ding ding check mark or green light for when somebody is appropriate for voice services, they just have to self-select and say that that’s what they want.

Dr. Jamison Merrell: Great. So yeah, really hearing from both of you that, as with most things, it’s really going to depend on the situation, depend on the client but great, thank you both. So moving into our last couple of questions here, do you have any advice regarding letters to give clients well in the midst of transitioning? Dr Z?

9. Do you have any advice regarding letters to give clients well in the midst of transitioning?

Dr. Natalia Zhikhareva: Okay, so this is a little bit of a bad question to me because I’m assuming we’re talking about gender evaluation letters that are needed for gender forming procedures whether it is for in some states hormones whether it is for starting electrolysis or having any kind of gender forming surgeries giving in the midst of transitioning. So the evaluation letters are a very significant part of a individual’s transition journey and the reason why they’re significant is because that is a document that people need in order to get insurance coverage, and it’s also documented they need in order for a lot of providers to grant services to gender diverse communities. So they become essential doorways into really moving on forward with your goals and moving on forwards with your gender transition.

In my practice, and again I’m talking about adults, I don’t work with children so in speaking about working with adults, I’m very comfortable in writing and providing letters from the get-go, and that’s because I feel comfortable and competent in being able to assess the presence of gender dysphoria and being able to assess whether a person does not have any kind of secondary things going on that may interfere with their ability to make judgment for themselves. When we are writing for gender affirming letters, we are, at least I’m going to speak for myself, I am evaluating for two very key primary things. One, do they have gender dysphoria? And two, are they able to consent for the services they’re seeking? That’s it. I’m not evaluating for them proving to me anything, I’m not evaluating for whether to have been living in preferred gender for a year or two even though that’s what your past say so.

We have to remember the past guidelines are not mandated, they’re not set in stone, so given that I work with adults, I usually get people who’ve been struggling with gender dysphoria for a number of years and as a result, they’re really suffering pretty much in terms of their symptomology. So letters become very imperative. I’m very comfortable writing the letter, I actually offer letters completely at no cost to gender diverse community. People have to be either California or Florida residents, that’s just licensure rules. But I write about eight to ten letters a week so I’m very comfortable assessing adults for any kind of needed letters. If anybody out there is interested in providing letters, feel free to contact me, I’d be happy to share you my template, I’d be happy to kind of consult with you and walk you through thinking what to assess for and how to assess for.

Again, in my opinion, given my specialty, it does not take me long to evaluate somebody just because this is my field and I feel very competant in it, I also don’t think it’s necessary for anybody to be evaluated longer than I would say two to maybe five max sessions if you’re going to evaluate somebody and if you’re experienced in this field. I hold a very strong opinion, you don’t need to drag somebody for six months to a year in order to provide a letter. I’m sorry, if you’re taking six months to derive a diagnosis, to me that’s that’s quite a red flag. 

Ruchi Kapila: I am not in that, I never have to write letters myself so I appreciate Dr Z shedding light on what are the expectations and that was a great learning opportunity for me as well.

Dr. Jamison Merrell: Great. And then this is actually our final question for today, so what are the cultural or racial effects on a trans person either a pre or post transition that can affect their care? So another broad one for you both, but I’ll start with you Ruchi and then Dr Z.

10. What are the cultural or racial effects on a trans person either a pre or post transition that can affect their care?

Ruchi Kapila: So complicated, so dependent on intersectional considerations for each person whether they have family support or what their support network looks like. Are they bilingual, an english language learner? What does their community look like, what are their resources at work, how are their experiences at work? Level of education to the extent that it impacts their ability to to find work or to be gainfully employed. If I think about what it is to be Punjabi-American and how that impacts what it is to be non-binary that goes in many, many spectrum and I can’t really quantify or consolidate what it would mean to be black and trans. We know that black trans people are disproportionately impacted in terms of violence, fatality, murder. But how does one quantify why that is and what that means?

I mean, I imagine I’m going to be navigating this throughout my career in terms of thinking about intersectionality and how people are disproportionately affected by um several facets or aspects of their identity and their lived experience it can mean you know not being able to have access to insurance not having any access to um transportation not being able to have access to basic things like internet or a phone being able to engage with services and not having that direct connection right um which means we may disproportionately see transgender non-conforming folks with relative privilege I wouldn’t know how to expand upon that further I think if anything we have to engage with reading as well as viewing documentaries or anything that talks about intersectionality, anything that talks about the black trans experience and continue to engage with black trans leaders, especially in terms of what actually impacts communities. I don’t think I would be the person to to consolidate all of that in one answer.

Dr. Natalia Zhikhareva: I agree, I think it is a very, it’s an incredibly complicated question. It’s a very difficult one to answer because, listen in my opinion, the pre and post transition tends to, how should I say, the outcome or how well your pre and post transition is going to go for you that’s, in my experience, fall into three factors. If you have those three factors your chances are going to be a little bit better off. And they are how psychologically resilient you are in order to dealing with a number of stressors in your life, what your support system is like, and what’s your access to resources. And all of those factors are also going to be affected by your race, your background, your livelihood by all of the things and I think that culture and racial effects definitely fall into those aspects of that.

So that’s a very difficult question to answer but one thing that I can say is, it is important when working with individuals to consider their culture and racial background, to consider all of the things in terms of how it’s going to affect their pre and post transition and hopefully finding any kind of resources or support that they need to have a successful transition whatever that may be for them.

Ruchi Kapila: I’ll also add that if you’re trying to serve all community members to the best of your ability, recognize you’re going to have a blind spot where you’re going to have to refer to someone and have lists of black and brown practitioners, queer practitioners, trans and gender non-conforming practitioners to refer to because they may just be a better fit for this client than you are. I mean it happens with me even though I am a person of color, even though I am non-binary, I can’t necessarily serve every person’s particular needs or be the right person for their particular triggers or trauma or anything that they’re bringing into the session. And I think if you start working from, “How can I make this as inclusive for somebody who is a person of color, who is trans, who has a disability, who may be neurodivergent, am I covering as many of my bases for people who are minoritized or historically underrepresented and historically underserved in my clinical sphere?” And if you can work from that space, then you’re probably providing a more equitable space for everyone who’s coming in with the understanding that they’re going to be blind spots.

Dr. Natalia Zhikhareva: Yeah, just to add a little bit of what Ruchi just said, sometimes sadly depending where you’re at, you won’t have access of networking people to refer to, right? So I think at that point the transparency becomes important if you’re transparent and open about your lack of experience, that’s going to be really helpful in working with people where you’re really not immersed in their experience one way or another.

Ruchi Kapila: Yeah, the humility piece and being able to level out what the power differential is with the client is so huge and saying, “You have the right to correct me because you’re the one who actually directs what the care is supposed to look like,” I think that’s one of the hardest things that we’re not actually taught in a lot of our programs, maybe in mental health professions more than speech language pathology, because we have that concept of client centered care patient-centered care but we don’t necessarily have a lot of great living models of what that looks like.

Dr. Jamison Merrell: Yeah absolutely. So important and thank you both so much. So wrapping it up here, we’re now going to move into final thoughts so I want to give you each a chance to share anything you’d like to that we haven’t touched on yet today. So I’ll start with you Dr Z and then you Ruchi, anything you’d like to share.

11. Would you like to share anything that we haven’t touched on yet today?

Dr. Natalia Zhikhareva: Trying to think what my final thoughts would be. Perhaps it would be best to share from things I wish I had access to going into this field. And one of the things I can’t stress enough is not to be afraid to reach out, not to be afraid to reach out to people out there who are in the field who are focusing on the field. I can speak for myself, as somebody who specializing in this field, I’m always eager to discuss issues, I’m always eager to help out, to share resources, because again, the field is very much needs people that can focus on this community. So not being afraid to reach out is going to be instrumental and just be mindful, be ethical, just do the right thing.

If you are going to work with this population and you’re lacking experience, get some experience. Don’t just put that your LGBTQ friendly therapist or LGBTQ friendly voice pathologist or electrologist if you have not had any experience at all because yes that will attract your clients, but chances are you’re probably not going to do any good because you’re lacking that experience. If you’re attracting those clients, just be transparent and just say that I’m starting in the field, I don’t have any experience at all, you’re my first client and allow the client to decide whether they still want to work with you or not. And if they do, that’s great, and if they don’t, that’s just the way it is. So I guess that would be my final thoughts and I’m accessible to everybody, anybody watching this are welcome to email me or contact me for any information. If you need a template for evaluation letters, you’re welcome to have it. I’m always for sharing resources across the board.

Ruchi Kapila: I try to be an open book and provide resources as well as much as I can or point people to the folks who are doing it better than I am, which happens. I wanted to bring up Trans Voice Initiative again. We are a group of trans and gender non-conforming speech language pathologists and either current or aspiring voice practitioners who are trying to fundraise for peer training of other TGNC SLPs and students so that we can ensure that we can establish a standard of what gender affirming voice modification looks like, when it comes to intake, when it comes to how we navigate doing this voice work. I want to impress upon that the majority of the research that we have is led by cisgender clinicians which means there are blind spots in terms of what we’re measuring and whether those pieces are clinically relevant or holistically relevant in terms of voice for the TGNC community and the only way to really navigate that is to have a better and more robust presence of TGNC SLPss and TGNC SLP students coming into the field.

So definitely check us out at transvoiceinitiative.com, you can follow us @transvoiceinitiative on Twitter and Instagram and @voice_trans on Twitter. Did I say Twitter and Instagram? I meant @transvoiceinitiative on Facebook and Instagram, @voice_ trans for Twitter. We’re over halfway to our fundraising point to be able to do these peer trainings throughout the year for other TGNC SLPs so whatever you can do to support us and if you can’t support us financially right now please share our account on your social media platforms and get other interdisciplinary care providers to support this initiative individually as a speech language pathologist, whatever you can do to start mentoring TGNC SLPs or other black or BIPOC SLPs to come into the field to create equity from the inside is everything.

But you have to do that with the acknowledgement that you’re learning from these people as well so acknowledging the power differential of mentoring someone but also knowing that they’re bringing in valuable insight from their respective communities that ideally will change the way that we provide culturally responsive care. I’ve mentioned some of these other resources already. Another place you can check out is genderminorities.com that has a pretty excellent glossary with regard to TGNC terminology that that’ll be helpful for you for forms and having conversations. As well as Pflag, which is at pflag.org. There are a couple of forums on Facebook that you can follow as a speech language pathologist or a voice practitioner gender spectrum voice and communication is one of them an LGBTQIA+ speech language pathologist on Facebook.

If I were to share anything else, I have a couple of publications that are coming out that are in chapters that I’ll share once published and I’ll make sure that they’re on simple practice so they can disseminate that information. I will be presenting along with some folks from Trans Voice Initiative for Trans Pride I believe it’s the Trans Pride Pittsburgh Health and Wellness Conference that’s October 14-16. Also Voice Lab Incorporated, which is headed by Liz Jackson-Hearns and Alexandra Plattos Sulack, they’re having a conference that same weekend in October so just check out Voice Labs website I think it’s voicelab.com. And I’ll also be at Laryngology in March to talk about gender affirming voice as well as how I create gender affirming voice maps for individual clients.

Transplaining, I can never plug enough in terms of being able to have all these individual courses that are intersectionally motivated talking about issues for people of color, talking about issues for those who are bilingual, anything that’s related to disability or neurodivergence is covered on that platform. I have a lecture related to prepping for intersectional thinking and AC Goldberg is a wonderful resource if you’re looking for somebody to explain and talk about how to adapt your forms just like Dr Z had also talked about.

There is a course on the ASHA, it’s an on-demand webinar I think it’s a ASHA learning portal and it’s called Building a Culturally Inclusive and Gender Affirming Space. Oneida Chi is a non-binary colleague of mine and co-presents with Xavier Lord Williams and Rafa Brown Sampayo, so definitely check that out as another intro course in terms of making your clinical context a little bit more TGNC friendly.

Dr. Jamison Merrell: Fantastic. Thank you both so much for being here, it was truly a pleasure to sit down with you both today. Thank you for being here. I did also want to mention that a recording of this webinar will be going out to anyone who attended today so you can expect to see that in the next couple of days and I did also just want to briefly mention two of our CE courses for folks looking to dig into this topic a little more. One is Writing Clinical Letters of Referral for Gender Affirming Medical Care by Moe Brown, fantastic course. And the other is Gender Minority Stress in Trans and Nonbinary Clients with Cadyn Cathers, another fantastic course. In closing, I want to thank you all for being here today, I really appreciate it, and I hope everyone has a fantastic rest of your day, thanks so much, bye.

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