How the COVID-19 pandemic affects transgender health care - A cross-sectional online survey in 63 upper-middle-income and high-income countries.

Background: Due to the COVID-19 pandemic, access to medical care is restricted for nearly all non-acute conditions. Due to their status as a vulnerable social group and the inherent need for transition-related treatments, transgender people are assumed to be affected particularly severely by the restrictions caused by the COVID-19 pandemic. Methods: As an ad hoc collaboration between researchers, clinicians and 23 community organizations, we developed a web-based survey in German that was translated into 26 languages. Participants were recruited via community sources, social media channels, and snowball sampling since May 2020. The present sample is based on the data collected until August 9, 2020. We assessed demographical data, health problems, risk factors, COVID-19 data (e.g., contact history), and the influence of the COVID-19 pandemic on access to transgender health care services. To identify factors associated with the experience of restrictions, we conducted multiple logistic regression analysis. Results: 5267 transgender people from 63 upper-middle-income and high-income countries participated in the study. Over 50% of the participants had risk factors for a severe course of a COVID-19 infection and were at a high risk of avoiding COVID-19 treatment due to the fear of mistreatment or discrimination. Access to transgender health care services was restricted for 50% of the participants. Male sex assigned at birth and a lower monthly income were significant predictors for the experience of restrictions to health care. 35.0% reported at least one mental health condition and 3.2% have attempted suicide since the beginning of the COVID-19 pandemic. Discussion: Transgender people suffer under the severity of the pandemic due to the intersections between their status as a vulnerable social group, their high number of medical risk factors, and their need for ongoing medical treatment. The COVID-19 pandemic can potentiate these vulnerabilities, add new challenges for transgender people, and, therefore, can lead to devastating consequences, like severe physical or mental health issues, self-harming behavior, and suicidality.

Innovation in speech-language pathology research and writing: Transdisciplinary theoretical and ethical perspectives on cultural responsiveness.

In this paper, we offer three paths for the development of innovation in speech-language pathology (SLP), which enhance the discipline's capacity to address issues of diversity, inclusion and cultural responsiveness: transdisciplinary theoretical research, researcher reflexivity, and changes in ethical standards. First, we engage in a reflective conversation to identify facilitators and barriers to innovation we have encountered as academics who speak and write from personal and professional positionings that move between the privileged and the marginalised. Second, we present the results of a critical discourse analysis of the 2020 revisions to Speech Pathology Australia's Code of Ethics and characterise recent changes in the field's expanding understanding of ethical research and clinical practices. Third, we discuss how speech-language pathologists might reconsider their modes of engagement with clients and research populations in our shared area of specialisation-transgender voice. Together, these insights can support speech-language pathologists in further developing a contemporary, self-reflective, culturally humble and responsive professional culture.

Supporting Well-Being in Gender-Diverse People: A Tutorial for Implementing Conceptual and Practical Shifts Toward Culturally Responsive, Person-Centered Care in Speech-Language Pathology.

PURPOSE: Gender dysphoria is commonly conceptualized as a mental disorder in gender-diverse people who do not identify with the gender assigned to them at birth. Direct support for well-being tends to be delegated to the field of mental health (MH), whereas speech-language pathology (SLP) practice is charged with modifying gender-diverse people's voice and communication in the belief that well-being will improve as a byproduct. However, with the introduction of the minority stress model, gender dysphoria is now understood as the result of sociocultural processes of stigmatization, pathologization, coping, and resilience, and it is to be addressed by all professions providing transgender health services. The purposes of this tutorial are to examine practices in SLP in light of the current conceptualization of gender dysphoria and guide speech-language pathologists in their role in supporting the well-being of gender-diverse people. METHOD: We reviewed the SLP and MH literature in the topic area to compare the two disciplines' conceptualizations and approaches to professional support for gender-diverse people. RESULTS: We propose a transdisciplinary, person-centered, and culturally responsive approach to SLP practice that directly attends to minority stress, microaggressions, coping skills, and resilience factors. CONCLUSIONS: It is not sufficient for speech-language pathologists to delegate support for well-being in gender-diverse people to MH practitioners. Rather, speech-language pathologists need to be proactive in taking responsibility for supporting their clients' well-being based on each individual clinician's knowledge, skills, and capacity to do so. We recommend addressing barriers and facilitators of gender-diverse people's well-being both within SLP as a professional culture and by adapting the clinician's own professional practice.

New perspectives, theory, method, and practice: Qualitative research and innovation in speech-language pathology.

Purpose: Research in speech-language pathology has been dominated by experimental, empirical, and scientific approaches, which build on hypothesis testing and logical, deductive reasoning. Qualitative approaches stem from a different paradigm or world view which imply different questions and methodologies which, for example, emphasise codesign, reciprocity, individual experience and context. This article explores the relationship between qualitative inquiry in the field of speech-language pathology and innovation. It aims to show how the aspirations of the profession can be supported, and how innovation can be achieved, through research which sheds light on the lived experiences and perceptions of clients and families and builds an understanding of how they function in their everyday contexts.Method: We summarise qualitative approaches in speech-language pathology, explain the notion of innovation, and review qualitative research as a source of theoretical, methodological, and practice innovation in speech-language pathology.Result: Not only has qualitative inquiry underpinned examples of theoretical, methodological and practice innovations in speech-language pathology, but it can also play a part in enhancing translation and implementation of research innovations.Conclusion: An explicit consideration of what we mean by innovation is useful for speech-language pathologists. Qualitative research complements other forms of research in the field and has prompted new theoretical understandings, new methodologies and methods of research, and new ways to deliver our services in ways that are responsive to our clients and communities.

Forces Affecting Voice Function in Gender Diverse People Assigned Female at Birth.

OBJECTIVES: The purpose of this study was to explore the factors and practices that have acted as facilitators or barriers to voice function in gender diverse people assigned female at birth (GD peopleAFAB) from a participant-centered perspective and to inform the role of speech-language pathologists in supporting GD peopleAFAB with developing and maintaining functional voice production. METHODS: Transcripts of semistructured interviews with 14 German-speaking GD peopleAFAB were analyzed for the study objectives using a consensual approach to qualitative content analysis. The interviews and their interpretation were conceptualized as co-constructions of participants and researchers who were regarded as experts in their own right. RESULTS: Professional practices (testosterone treatment, professional voice support), speaker practices (self-care and voice use practices, self-evaluation of voice function), conversation partner practices, and supraindividual biocultural forces (vocal demands, normative practices, other biocultural forces) were identified as having influenced the participants' voice function. Professional voice support, a range of phonation practices, and general self- and voice care practices were frequently cited facilitators of functional voice production. The most frequent barriers to voice function included testosterone treatment, slouched posture, excess muscle tension, forceful voice use, and avoidance practices. CONCLUSIONS: Voice function in GD peopleAFAB is influenced by interactions of several forces, most of which may be shared by voice users of all genders. Professional practices should follow a person-centered approach to care in which all parties are well informed of the limitations and possibilities for any intervention, including the often-unquestioned contribution of testosterone treatment.

Oral health interventions for people living with mental disorders: protocol for a realist systematic review.

BACKGROUND: The increasing number of people who experience mental disorders is a global problem. People with mental disorders have high rates of co-morbidity and significantly poorer oral health outcomes than the general public. However, their oral health remains largely a hidden and neglected issue. A complex range of factors impact the oral health of this group. These include anxiety and dental phobia, dietary habits, including the heavy consumption of sugary drinks, substance misuse of tobacco, alcohol, and/or psychostimulants, the adverse orofacial side effects of anti-psychotic and anti-depression medications, and financial, geographic, and social barriers to accessing oral health care. METHODS: The aim of this realist systematic review is to (a) identify and synthesise evidence that explores oral health interventions for people living with mental disorders; (b) explore the context and mechanisms that have contributed to the success of interventions or the barriers and challenges; (c) produce program theories on causal, contextual and mechanistic factors to facilitate outcomes and (d) produce recommendations and guidelines to guide future oral health interventions for people with mental disorders at both the policy and practice level. Using a five-step process, that incorporates primary data collection from key stakeholders, a beginning theoretical framework will be developed to describe contextual and mechanistic factors and how they might impact on the success or failure of oral health interventions for people with mental disorders. Key database searches will be conducted, with data extraction focused on the factors that might have impacted on intervention implementation and outcomes. Quality appraisal of studies will occur, and the theoretical framework will be populated with extracted data. Stakeholder input will support the development and refinement of a theory on oral health interventions for people with mental disorders. DISCUSSION: This will be the first review to take a realist approach to explore the broad scope of causal factors that impact on the success or failure of oral health interventions for people with mental disorders. The approach includes extensive stakeholder engagement and will advance realist systematic review methodology. Review outcomes will be important in guiding policy and practice to ensure oral health interventions better meet the needs of people with mental disorders.Systematic review registration This review protocol is registered with PROSPERO (Number) 155969.

Who or what has the capacity to influence voice production? Development of a transdisciplinary theoretical approach to clinical practice addressing voice and the communication of speaker socio-cultural positioning.

Purpose: The purpose of this conceptual study was to develop a transdisciplinary theoretical approach to clinical practice in the area of voice that is informed by contemporary clinical and social sciences theories of voice production.Method: We used theoretical sampling to survey the clinical voice literature for different conceptualisations of forces that contribute to voice production and analysed these forces' capacity to act ("agency") on voice. We classified the selected conceptualisations according to wider theoretical perspectives that informed them and evaluated their capacity to account for the complexity of voice production.Result: We identified biological determinist, constructionist, and socio-cultural mediation theories as informing the various conceptualisations of voice production and agency. Finding all theories identified in the clinical voice literature inadequate, the conceptualisation of agency as a bioculturally mediated capacity to act was explored and found to be most suitable for a new transdisciplinary theoretical approach to clinical practice in the area of voice.Conclusion: The inextricable interplay between speaker, professional, and listener practices and supra-individual biocultural forces in voice production must be acknowledged. Clients need to be prepared to deal confidently with the multi-faceted, dynamic, and unpredictable nature of how voice function and socio-cultural positioning is produced in social encounters.

Voice Function in Gender-Diverse People Assigned Female at Birth: Results From a Participant-Centered Mixed-Methods Study and Implications for Clinical Practice.

Purpose The purpose of this study was to investigate whether there were indications of restrictions to voice function in our group of gender-diverse people assigned female at birth (GD peopleAFAB) and whether the participants would benefit from professional voice support. Method We conducted a descriptive, cross-sectional, mixed-methods study combining qualitative content analyses of semistructured interviews, phoniatric examinations, and acoustical voice analyses. Fourteen German-speaking GD peopleAFAB participated. The data were examined for indications of restrictions to voice function according to the results of participant self-evaluation, auditory-perceptual analyses, laryngostroboscopic examinations, and acoustical measurements. Results All participants presented with indications of restrictions to voice function, with vocal power, voice quality, singing voice, laryngeal function, pitch range/variability, and vocal control having found to be most frequently affected (in over 60% of participants). Sixty-four percent of participants expressed an interest in professional voice support, with clinicians and researchers recommending professional voice support for 67% and 71%, respectively. Conclusions GD peopleAFAB may experience restrictions to a range of domains of voice function and request or be recommended to participate in professional voice support. Research into this area needs to be intensified so that a more in-depth understanding of the potential voice problems GD peopleAFAB might experience can be produced and members of this group can be provided with more comprehensive, evidence-based, and high-quality professional support if and when they need it.

Do Transmasculine Speakers Present With Gender-Related Voice Problems? Insights From a Participant-Centered Mixed-Methods Study.

Purpose: The purpose of this study was to investigate whether there are indications of gender-related voice problems in our transmasculine participants and to analyze how discrepancies between participant self-evaluations and researcher-led examinations can be best negotiated to ensure a participant-centered interpretation. Method: We conducted a participant-centered mixed-methods study combining qualitative content analyses of semistructured interviews, acoustical voice analyses, and an examination of gender attributions to voice. Fourteen German-speaking transmasculine people, 14 cisfemale control persons, and 7 cismale control persons participated. The data were examined for indications of gender-related voice problems pertaining to vocal gender presentation and gender attribution to voice received from others. Results: Eleven participants (79%) presented with indications of gender-related voice problems. Problems included dissatisfaction with gender-related voice features, difficulties with control of vocal gender presentation, and mismatch between desired gender attribution and gender attributions received from others. Discrepancies between participant self-evaluations and researcher-led examinations were observed in a number of cases. Conclusion: Transmasculine speakers may experience a range of gender-related voice problems. Research and clinical practice with transmasculine people need to be adapted to better match the diversity of the population and the complexity of the processes that shape the production of speaker vocal gender in interaction.

Transmasculine People's Voice Function: A Review of the Currently Available Evidence.

OBJECTIVES: This study aims to evaluate the currently available discursive and empirical data relating to those aspects of transmasculine people's vocal situations that are not primarily gender-related, to identify restrictions to voice function that have been observed in this population, and to make suggestions for future voice research and clinical practice. METHODS: We conducted a comprehensive review of the voice literature. Publications were identified by searching six electronic databases and bibliographies of relevant articles. Twenty-two publications met inclusion criteria. Discourses and empirical data were analyzed for factors and practices that impact on voice function and for indications of voice function-related problems in transmasculine people. The quality of the evidence was appraised. RESULTS: The extent and quality of studies investigating transmasculine people's voice function was found to be limited. There was mixed evidence to suggest that transmasculine people might experience restrictions to a range of domains of voice function, including vocal power, vocal control/stability, glottal function, pitch range/variability, vocal endurance, and voice quality. CONCLUSIONS: More research into the different factors and practices affecting transmasculine people's voice function that takes account of a range of parameters of voice function and considers participants' self-evaluations is needed to establish how functional voice production can be best supported in this population.

Gender-related aspects of transmasculine people's vocal situations: insights from a qualitative content analysis of interview transcripts.

BACKGROUND: Transmasculine people assigned female gender at birth but who do not identify with this classification have traditionally received little consideration in the voice literature. Existing analyses tend to be focused on evaluating speaker voice characteristics, whereas other factors that contribute to the production of vocal gender have remained underexplored. Most studies rely on researcher-centred perspectives, whereas very little is known about how transmasculine people themselves experience and make sense of their vocal situations. AIMS: To explore how participants described their subjective gender positionings; which gender attributions they wished to receive from others; which gender they self-attributed to their voices; which gender attributions they had received from others; and how far participants were satisfied with the gender-related aspects of their vocal situations. METHODS & PROCEDURES: Transcripts of semi-structured interviews with 14 German-speaking transmasculine people served as the original data corpus. Sections in which participants described the gender-related aspects of their vocal situations and that were relevant to the current research objectives were selected and explored using qualitative content analysis. OUTCOMES & RESULTS: The analysis revealed diverse accounts pertaining to the factors that contribute to the production of vocal gender for individual participants and variable levels of satisfaction with vocal gender presentation and attribution. CONCLUSIONS & IMPLICATIONS: Transmasculine people need to be regarded as a heterogeneous population and clinical practice needs to follow a client-centred, individualized approach.

Transmasculine people's vocal situations: a critical review of gender-related discourses and empirical data.

BACKGROUND: Transmasculine people assigned female sex at birth but who do not identify with this classification have traditionally received little consideration in the voice literature. Some voice researchers and clinicians suggest that transmasculine people do not need attention because testosterone treatment leads to a satisfactory masculinization of their voice organs and voices. Others, however, argue that transmasculine people are a heterogeneous group whose members might not share the same body type, gender identity or desire for medical approaches to gender transitioning. Therefore, testosterone-induced voice changes may not necessarily meet the needs and expectations of all transmasculine people. AIMS: To evaluate the gender-related discursive and empirical data about transmasculine people's vocal situations to identify gaps in the current state of knowledge and to make suggestions for future voice research and clinical practice. METHODS & PROCEDURES: A comprehensive review of peer-reviewed academic and clinical literature was conducted. Publications were identified by searching seven electronic databases and bibliographies of relevant articles. Thirty-one publications met inclusion criteria. Discourses and empirical data were analysed thematically. Potential problem areas that transmasculine people may experience were identified and the quality of evidence appraised. MAIN CONTRIBUTION: The extent and quality of voice research conducted with transmasculine people so far was found to be limited. There was mixed evidence to suggest that transmasculine people's vocal situations could be regarded as problematic. The diversity that characterizes the transmasculine population received little attention and the complexity of the factors that contribute to a successful or unsuccessful vocal communication of gender in this group appeared to be under-researched. While most transmasculine people treated with testosterone can expect a lowering of their pitch, it remains unclear whether the extent of the pitch change is enough to result in a voice that is recognized by others as male. CONCLUSIONS & IMPLICATIONS: More research into the different factors affecting transmasculine people's vocal situations that takes account of the diversity within the population is needed.