The Right Choice When Treating Transgender Voice

Transgender Voice Changes. Those words may be intimidating or “something I read a sentence about in graduate school,” but they represent a much needed area of education and support. This is not a matter of agreeing or disagreeing with the transition to the opposite sex, but of helping patients in need. We, as speech-language pathologists, are bound by our code of ethics to maintain a cutting-edge perspective in our area of specialty. Any SLP with a license should be aware of this type of service and what is happening in current events.

Just as we are capable of effectively modifying phonemes in children, we have the skills to modify pitch and resonance in transgender voice intervention. We cannot, however, refuse to treat these patients because of our own beliefs. I may believe feeding tubes are unethical, but I cannot refuse to complete a swallow evaluation and treatment based on how I feel. I have a responsibility to evaluate and treat a person coming to me for help if I possess the skills to improve that person’s quality of life.

Voice sessions are usually one of the first things a client begins after hormone replacement therapy has started. Modifications to frequency, resonance, inflection, gestures and word choice are targeted with great care to avoid tension that would cause vocal damage. Sessions require anywhere from 4-9 months and are much more labor intensive than a surgical procedure. The journey to the opposite sex is different for each client, and sometimes gender fluid clients may have goals for a voice quality that is “in between.” Clients are often emotional and full of uncertainty and apprehension about what to do next, so determining which personal pronoun your client prefers is important. Maintaining cultural competence and compassion for this population is vital because like the iceberg of fluency/stuttering, we only see 10% of what exists.

A question is raised, though, about the ethics of providing services to modify or enhance communication performance. Is gender dysphoria a disorder? The DSM-5 recognizes it as a disorder with a specific diagnosis code, and it is not our place to determine the validity of medical diagnoses. Our scope of practice includes typical and atypical communication in the following areas: resonance, language and voice. It also specifically states that we provide clinical services to modify or enhance communication performance for things like accent modification or transgender voice. Speech treatment helps a person overcome an obstacle, and in our code of ethics, it specifically states we cannot discriminate in the delivery of professional services on the basis of gender, gender identity/gender expression or sexual orientation. We help children use fluency tools to overcome the obstacle of stuttering, we strengthen and re-educate swallow muscles to overcome the obstacle of aspiration, and we help those uncomfortable expressing themselves overcome that obstacle so they can fully express who they are.

So what about billing? What we can bill for is diagnosis driven, and reimbursement is determined by the patient’s individual insurance plan. As long as treatment is appropriate for diagnosis, you can bill for your services. As with any other service denial, appeals can be made, but sometimes the patient is left responsible for the balance. Yahoo news published an article about insurance coverage for transgender sex-reassignment health care. It stated that some Fortune 500 companies were adding coverage for this type of health care for their employees. This includes sex-reassignment surgery (SRS) and hormone therapy as well as some counseling. The coverage, however, is not extended to cosmetic surgery. Voices are used to communicate and they are the first thing others hear when we make a phone call, but at this point in time insurance companies do not consider transgender voice changes medically necessary.

Voice intervention allows these patients to finalize a missing puzzle piece, check off a box and become more comfortable in their own skin. Transgender clients are just like other speech clients and only wish for the best quality of life. For them, that means voices to reflect who they are on the inside. A speech-language pathologist can make every difference by utilizing his or her unique skill set and experience to help.

Education is the most effective tool we have for helping clients generalize treatment goals, so why aren’t we educating ourselves at every opportunity?  If you don’t feel competent treating individuals who wish for transgender voice change, you are obligated to seek out and refer the patients to clinicians who do. There is a Facebook group which can help with finding a qualified clinician called “Transgender Voice & Communication.” Also, WPATH SOC 7 has included voice and communication in their standards of care. We may encounter transgender patients, students, colleagues or clients, so whether or not we agree or feel comfortable with their lifestyles, we must strive to be culturally sensitive to all populations.

Portions of this blog were originally published in November 2014 on, but have been updated and modified for this post.

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.


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