When we assess speech and language therapy (SLT) services, we will look at care for people who are on the trans care pathway.
Speech and language therapy services play a vital role in the trans care pathway. Although the testosterone hormone causes the voice to drop to a deeper pitch, oestrogen does not affect the voice. So, people with variations of sex characteristics (VSC), trans and non-binary people of any birth assignment may benefit from vocal exercises to gradually make changes to their voice (for example, the pitch, intonation, resonance, speech rate, phrasing patterns). These services can also help with non-verbal communication patterns (for example, gestures, posture/movement, facial expressions) that help to people to feel more comfortable with their gender identity.
How we assess care for trans and non-binary people in speech and language therapy services
To inform our assessments, we engaged with the LGBT Foundation. We asked trans people what makes a good service. We will use this feedback when looking at the key questions and our local teams will talk with staff and ask questions about specific areas, or observe the environment if we visit a service.
Effective
Therapists are competent in the specific speech and language needs of trans people who need voice and communication therapy.
There are no formal minimal standards for assessing voice and communication in trans and non-binary people. The length of treatment for trans and non-binary people should compare with that for other people with similar treatment needs.
We will check whether treatment is equal for all. For example, the length of treatment for trans women generally ranges from a minimum of 15 hours to a maximum of a year of weekly sessions. Optimal treatment time for each person will vary, depending on the degree of change needed, the person’s natural abilities, the amount of time and energy the person devotes to practice, and whether they have other psychosocial difficulties.
Some trans women may undergo voice feminisation surgery. It is recommended that they consult speech and language therapy service to maximise the surgical outcome, help protect vocal health, and learn non-pitch related aspects of communication.
Individuals may choose which communication behaviours they would like to acquire according to their gender identity, in line with their own individual communication preferences. Services can use their assessment about a person to inform and support these decisions.
To help gather evidence, we will check monitoring data or speak with staff and ask questions relating to:
- training to ensure staff are competent in assessing and developing communication skills for people with VSC, trans and non-binary people
- training to ensure staff have a basic understanding of trans health, including hormonal and surgical treatments and psychosocial issues.
Caring
Staff respond positively to enable trans and non-binary people to feel confident when using services and address people by their preferred name, title and pronoun.
When interacting with each trans or non-binary person, it is best to ask them how they want to be addressed and how they understand themselves. Ultimately, the ‘correct’ terminology is whatever the trans or non-binary person uses to describe themselves.
Staff are aware that a person’s voice on the phone may not match their preconceptions about their gender.
Staff should be aware that there is no reliable way to know whether a patient is trans or non-binary unless the patient tells them. It is important to be mindful of the language to use and avoid assuming gender. Misgendering someone can exacerbate their gender dysphoria and highlights the importance of using gender-neutral language.
Responsive
People have the option of one-to-one sessions or group sessions.
People get a realistic waiting time for SLT services.
SLT providers promote their services to GPs and trans and non-binary people, so people are more aware of what is available locally.
Services invite people to give feedback on their treatment.
Access to SLT services for trans and non-binary people varies widely geographically. Currently, there are not enough competent or confident SLT services nationally with access to supervision and a gender dysphoria clinic multidisciplinary team. Ideally, the local SLT provider can treat initial stages of voice therapy in one-to-one sessions, followed by group therapy work, social communication and psychosocial integration of voice and communication.
It is best to use a one-to-one setting to:
- determine the appropriate average speaking pitch
- work with aspects that a person finds especially challenging
- deal with dysphonia (difficulty in speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords).
A facilitated group format will help to:
- enable participants to share observations, insights and practical advice
- encourage peer support and reduce self-consciousness that a client may experience when working alone with a therapist
- maintain and embed changes made in therapy.
To help gather evidence, we will speak with staff and ask questions relating to:
- peer review and outcome monitoring of the service
- how people access the service, waiting times and how these are communicated
- how the service is promoted to GPs or trans and non-binary people
- the approach to one-to-one and group therapy with trans and non-binary people
- asking for feedback, and the responses to positive feedback, complaints or suggestions for change from people who have used the service.
Services should also consider:
Effective key question: Ensuring there are policies that communicate a zero-tolerance approach to discrimination, bullying and harassment based on gender identity, gender expression and sexual orientation. Staff should receive training and understand when a trans or non-binary person’s identity is relevant to their healthcare and their role in the trans care pathway.
Responsive key question: Making staff aware that it may be unlawful to disclose a patient’s trans identity without their consent under the Gender Recognition Act 2004. It is both good practice and compliant with law to respect a trans or non-binary person’s identity and amend all medical records accordingly in line with the person’s affirmed gender.
Further information
- Trans healthcare (General Medical Council)
- Supporting transgender and gender diverse people (Royal College of Psychiatrists)
- Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People Version 7 (World Professional Association for Transgender Health (WPATH))
- Beaumont Society - a self-help body run by the transgender community, providing support, advice and training.
- Galop is a community led group for lesbian, gay, bi, trans and queer people. It offers confidential trans advocacy support to help with tackling discrimination, hate crime, sexual violence or domestic abuse. G
- GIRES (Gender Identity Research and Education Society) empowers and gives a voice to trans, gender non-conforming, non-binary and non-gender individuals, as well as their families. They produce publications on health, legal and other issues.
- The LGBT Foundation supports trans people through a helpline, providing advice, support and information, befriending and counselling. Its website also has resources for health care professionals caring for lesbian, gay, bisexual or trans clients or patients.
- Mermaids is a support group for families, children and young adults who are affected by gender identity issues.