Interview between Speaker 1 (Meg) and Speaker 2 (Ruchi Kapila)
Episode 71: Gender-Affirming Voice Care for Autistic Clients
[Introductory music]
Welcome to the Two Sides of the Spectrum Podcast. A place where we explore research, amplify Autistic voices, and change the way we think about autism in life, and in our professional therapy practices. I’m Meg Proctor from learnplaythrive.com.
Meg:
Before we get started, a quick note on language. On this podcast, you’ll hear me and many of my guests use identity-affirming language. That means we say ‘Autistic person’ rather than ‘person with autism’. What we’re hearing from the majority of Autistic adults is that autism is a part of their identity that they don’t need to be separated from. Autism is not a disease, it’s a different way of thinking and learning. Join me in embracing the word ‘Autistic’ to help reduce the stigma.
Welcome to Episode 71 with Ruchi Kapila. I really love talking with Ruchi. And this episode is different from any that we’ve had before, in that we talk about the experience of trans and gender non-conforming Autistic people and their voices. Ruchi has a really unique practice where they support their clients to use their voices in ways that feel authentic to them and their gender identity. But this episode isn’t just for SLP’s. The lessons about gender-affirming care are relevant to all of us supporting Autistic people. Because as we know, Autistic people are more likely to be queer, or gender non-conforming, or trans and the details of Ruchi’s work as an SLP and this type of work are so important for us to know, even if we aren’t SLP’s, as we consider what possible referrals we can make to support our Autistic clients.
I’ll tell you about our guest. Ruchi is a neurodivergent speech language pathologist, a trained vocologist, a singing voice specialist and voice teacher in Hayward, California providing speech and singing voice services with a gender inclusive lens. Ruchi teaches and trains other professionals on client-centered gender-affirming voice care, cultural responsiveness, social justice, and intersectional considerations for SLP’s and beyond. They previously co-created and co-hosted a podcast with Asher Marron called The Hyndsyte Project — H-Y-N-D-S-Y-T-E Project — where they interviewed Black and Brown trans, gender non-conforming, and/or queer activists and artists. They’re also a founding member and organizer of the Trans Voice Initiative, which we’ll go into in more detail in the episode. Ruchi is one of the speakers in the Learn Play Thrive 2024 Neurodiversity Continuing Education Summit, teaching on gender inclusive practice for OT’s, SLP’s, and mental health professionals. I’m so excited about this. You can get the details on that at learnplaythrive.com/summit. I have an update for you, we are applying for social work CEU’s for the summit, in addition to OT and SLP CEU’s. We’re really excited about that, because I know so many social workers are supporting gender non-conforming clients and looking for training about how to support their Autistic clients. So, we have that training with the help from Ruchi and others, and we’re excited to provide it. Here is the interview with Ruchi Kapila.
Hi, Ruchi. Welcome to the podcast.
Ruchi:
Meg, thank you so much for having me.
Meg:
I’m really excited to sit down and chat with you. And I want to start with your story. Can you tell us how you became an SLP? And also, how you came to practice in the way that you do?
Ruchi:
Yeah, that’s a long and complicated story. So, you know, I actually grew up in Texas, West Texas, and then moved to East Texas, Fort Worth for a while, but, you know, I grew up in Lubbock, Texas for most of my life. And so, vocal performance ended up being a big part of my life. Like, singing voice, and I probably started taking voice lessons around nine, but didn’t really take them seriously until I was age 12, where I could compete and things. And so, I always wanted to be singing voice, you know, focused or I really enjoyed that part of my life, the visceral kind of feeling of that. But then I also came from a family that really prided themselves on being physicians and being medically focused, and there was a lot of pressure to do that as well. And so, when I found myself at, I think I started at Texas Christian University when I started studying. I was like, pre-med and a vocal performance major at the same time, which is really, really challenging timewise. And as you can imagine, as somebody who found out that they’re neurodivergent much later, it was an executive functioning nightmare, because you’re not going to, you know, three hour lectures a few times a week, it’s like you’re doing music related tasks, and you’re training, you know, music theory, your own vocal training, being part of ensembles and choirs all day, essentially. So, it just didn’t work out. I definitely burned out, you know, and I found myself, like, I felt like I was on a train, like, on an inauthentic path to what it was that I really wanted out of my life. So, I moved to the Bay Area kind of on a whim, dropped out of my classes. Because, you know, my brother was out in San Francisco. So, it was just like, eh, you know, this seems to be more a fit for me socially, you know, and in so many other ways.
And eventually, I was like working, tutoring, doing a lot of stuff. But my family wanted me to — pressure me to do something, you know, while I had been singing, I’ve been struggling with my voice. And that was something that I wanted to explore more, and I did have this strong clinical side. So, it was like, what do I do to put this together? And so, I wanted to be a voice specializing SLP. But, you know, so yeah, I finished my Masters, and my Bachelor’s — my Master’s at Cal State, East Bay, in Hayward, California. And then, was in a lot of acute rehabilitation hospital settings. And that kind of taught me a lot about functional outcomes and thinking about what is motivating to the client, what is right for the client in terms of like, what what they want to work on, or what they’re trying to get back to from a rehabilitation capacity. But then, you know, if I’m looking back at that time, everybody can tell how tangential I am as a communicator now, that I encountered a lot of rigidity in practice from a lot of supervising SLP’s I encountered. Not everyone, but a number of them. And in my graduate program, and I was like, this is not — this doesn’t seem like if I was a patient, or if I was a client, or a student were, you know, in a school that I would ever want to be talked to this way, or that I would want to be worked with in this way, or that I would want people to presume what I should do or what I want to do.
And I wanted to be a big part of changing that in whatever subspecialty I chose. So, you know, I don’t know, I think, you know, after clinical fellowship or around the time of clinical fellowship, I found out I was non-binary after attending a trans-related voice training. Pretty soon all of my SLP friends were neurodivergent people. So, it was like, why am I a magnet to these people? Oh, okay, that makes sense. And I was like, coming into gender-affirming voice care, because it was just like, I had experienced so much, you know, kind of like, I think, trauma and difficulty in navigating my own voice, that it all just kind of came together. And I was like, I want to be able to help people understand their voices and know that they’re with a practitioner who’s gone through things and wasn’t necessarily the person who was easiest to fit in, or to be accepted, or had the best providers given to them or, you know, available to them. So, you know, that’s kind of how it went. That’s kind of how I am doing the thing that I’m doing now. And it is appropriately messy, I would say.
Meg:
That is such an interesting story. We often quote Kristie Patten on the podcast from one of the early episodes when she said, “We build our lives on our strengths,” and that’s really a story of that. You’re like, here’s what I love, here’s what I’m good at, here’s what I’m also good at with the bringing together the voice and the clinical piece. And then, you merged it with your values, which is really interesting, and I think what a lot of us here are trying to figure out how to do. So, your website says you provide, quote, ‘Culturally responsive, humanistic, and holistic voice care for people across the gender spectrum and lifespan’. Can you explain what this is and what this looks like for you?
Ruchi:
Yeah, you can tell from that description, I’m an SLP who took all the psychology courses that they could have. Like, please help me understand my family trauma and myself as much as possible while I’m paying tuition. So, I mean, humanistic from that Carl Rogers perspective of providing unconditional positive regard was something I always wanted to bring. I always, as somebody who took voice lessons or worked with other clinical practitioners, I was always kind of caught up in this: I’m doing something wrong as a client, or as a student, or as a learner. And I wanted to be able to provide a space where I’m like, there isn’t really a wrong here. There is a ‘Is this closer to what you want’, ‘Are you further away from what you want’, what are the barriers that we have some flexibility with or you have some autonomy to shift, and what are the some of the things that maybe you don’t feel like you have autonomy to shift? And can we, you know, can we come to some sort of middle space with each other in that. So, I mean, I think that’s what I think about in terms of humanistic, understanding that voice has — I mean, beyond us just saying there are psychogenic voice considerations — that like the voice is very much tied to our trauma or life experiences, where we feel confident, where we feel safe, and that there’s going to be impact of the space when we’re doing this kind of voice work, which can be really personal and vulnerable.
And from a holistic standpoint, I mean, I want to think about where the voice lives, how are you using it, what’s going to make you feel like you are integrated in these different community spaces and you feel confident or as comfortable as possible using your voice for all of these different needs. I, you know, I consider myself also a singing voice specialist and have a voice studio on the side for specific folks if I feel like I could be of service. So, oftentimes, I’m thinking about singing voice and speech voice considerations for people if I’m working with performers. When I’m thinking about culturally responsive, I mean, voice and what people expect out of you, what you’re coded to sound like comes from a linguistic perspective, comes from a cultural perspective, and that’s not immediately obvious whenever we’re training in voice from maybe a speech language pathology focus, or a classical singing voice pedagogy focus, which I was aware of.
So, you know, my family is Punjabi American, or South Asian American, but Punjabis are like, you know, that’s like the cowboy town of Texas, essentially. So, they’re loud, rambunctious, like, that being — and that’s a stereotype. But it’s very real for a lot of us in terms of like, that’s what voice use was. I mean, and if I tie it back, I’ll say that, you know, my mother had vocal nodules when she was clinically practicing, when I was maybe in my preteens, or teenager, and they wanted her to do confidential voice and [voice softens] sound like this, and really give herself enough vocal rest. And that just wasn’t who she is, or was, and it wasn’t something that she could stick to. And it was a memory that really stuck with me in terms of understanding, like, what do people really want? And what are what are people really wanting to embody whenever they’re communicating with each other? And is what I’m asking them to do or recommending for them, like, even reasonable as an expectation? So, I guess, you know, in a storytelling way, that is kind of what has brought me to consider practicing the way that I do, is just having had some of these experiences and understanding, like, it’s not about what is optimal from a theoretical perspective, but what is functional and supportive from the client’s perspective.
Meg:
I love these curious, open-ended, thoughtful questions you’re putting on the table in places we often just make assumptions. As providers, we so often assume that we know what the client wants, we know what’s best for them. And as part of culturally responsive practice, it sounds like we need to be a lot more curious and make a lot fewer assumptions because we’re going to miss the mark, and people won’t always tell us. We’re just going to be sort of harming that relationship and trust.
Ruchi:
Yeah, and I think I want to add is like, you know, I think an SLP culture, and especially as early clinicians or training clinicians, there’s a lot of pressure on us to know everything, or have developed this idea or this aura of expertise. And I, you know, part of that would be masking for me, honestly, but part of that is also, you know, I’m not really great at misrepresenting myself. And I understood that like, for me, whenever I would try to assert that I was an expert, or I was the clinician, or I am the authority in the space, especially medical places, I’m ashamed to say that came from a place of pride, which didn’t really feel authentic to me. And so, I’d really like to engender and remind SLP’s that really, it’s like the client, or the student, or the patient is the person who’s doing the work, or doing the exploration or approximating whatever it is, the target that’s meaningful for them. And we’re really, we’re prepping this space, obviously cueing, you know, and providing counseling and all of this stuff, but like, I try to remind them, like, these are the people who are actually doing the thing and that is the focus of our practice. And so, as much as I can remind myself, who’s having the experience here that’s tough, who’s trying to move through? I have feelings but I have to take care of my feelings, like, kind of outside of that session space, that that should be the focus.
Meg:
I think that’s probably relatable to folks in any field.
Ruchi:
Yeah.
Meg:
I mean, I remember as a new OT, having the ‘Fake it till you make it’ mindset which really should have been replaced by ‘Be curious, honest, and humble’ as opposed to show you know, something show you know something. I think it’s the sign of a more confident or experienced practitioner, when we can be more open and curious to our clients’ perspectives. I want to zoom in on voice therapy and gender-affirming care, and I’m going to ask folks who aren’t SLP’s to stick with us on this, even though this can feel really specific to your field. It’s something that needs to be on all of our radars, even if we’re just thinking about it in how we refer folks out, but I think it has applicability beyond that. So, I know that voice therapy and gender-affirming care is generally not a big focus in SLP training, if it’s mentioned at all, is that right?
Ruchi:
Yeah. I would say that it’s emerging now. I mean, I definitely know about a number of, you know, I won’t name the whole list, but I know a number of practitioners and clinical instructors as well as professors who are establishing gender-affirming voice clinics, or have established gender-affirming voice clinics as training opportunities. But I wouldn’t say that that is a consistent focus across all institutions, or all universities at this time. And I think it is necessary, given the demand and the need, and sometimes the shortage that you’ll see in certain areas. I didn’t get any real discussion of gender-affirming voice care. And in my university setting, I think there are whispers about people doing that, and it being a subspecialty. But being very, very narrow of a focus. So, I definitely had to do some continuing education to be aware of what it means. But I will also say that, like, even though we have texts that are focused on it in terms of doing gender-affirming voice care and really thinking about community perspectives when doing this work, a lot of that is something that I, you know, had to cobbled together from other trans and gender non-conforming SLP colleagues, from being in community spaces, from being aware of like, there are things that I’m going to miss in community spaces, even if I’m a non-binary practitioner.
Yeah, and that it’s really, you know, in a way that the crop of current trans and gender non-conforming SLP’s who are in the field, as well as our allies who work alongside us but also learn from us, and the community, we’re kind of doing an overhaul of what that means anyway. Because, you know, traditionally, I think in the field, there was a kind of a binary focus of either you want to sound like a cisgender man or a cisgender woman, and you want to be cis-assumed, or, you know, the more common term that you might hear is ‘pass’, and not draw attention to your transness, or your non-binaryness, and identity. But now, you know, we have so many — an understanding that there is a broad spectrum of gender identities, and that may not fit into two boxes. And I know that we’ll talk about it a little bit later. But now that we even have a better understanding that people who are on it, like in trans and gender non-conforming, or trans and gender diverse community, have a big overlap with the neurodivergent — or having neurodivergent traits, I should say — that idea of gender role or gender presentation is further deconstructed. And so, it really has to be, you know, what matters to you when it comes to gender as the individual? And how do you want that to be presented or expressed with your voice and your speech and overall communication? And that’s really what it is.
And so, I mean, yes, we can break it down into individual components of like, we can adjust pitch or intonation, resonance, focus, articulation, prosody. Some people will talk about facial expressions and gestures. I don’t really come into that, because that’s also a hard thing for me to even gender consider. Some people will focus on the physicality of what gender expression is, which is not something I’d rather do. I usually focus more on specifically voice and speech targets. And it’s not for me to decide what’s right or what’s the target, you know. It’s a lot of consensual check ins of how does that sound? How does that feel? Are we warmer? Are we colder? Sometimes it’s on a five-point scale of like, where are you for that? Like, is that a three or a four? What would make it a five? And keeping things very subjective and client-centered whenever we’re working on specific targets. I try to frame this as every client is becoming their own voice mechanic. And that you’ll be able to change the oil, and replace your tires, and do the things, and take care of the instrument or the vehicle as it as it were. And then, if you run into some trouble and you need to see a specialist again, then you know where to find us. But I want you to feel like you can be able to adjust these different voice and speech parameters pretty independently and know where to find those targets from a sensory standpoint.
But all of that It can be very, very tricky when you’re working with people who are neurodivergent. And they map things differently. So, that’s an ongoing conversation, a multimodal conversation that has to happen. And for all of the really patient mental health practitioners and OT’s who’ve been listening, yes, referral is really important. Like, keeping your ears open and understanding that in some of these contexts, which may be outpatient rehab clinics, or medical systems, hospital systems, even the language that we use to describe trans individuals and making sure that piece is consensual as well, making sure that people are not outed or disclosed without consent whenever we’re using their pronouns and names, being really mindful in terms of referral is and how that language is used is something that everybody needs to be aware of and learn. Because you will run into working with a trans and/or gender diverse, gender non-conforming person at some point in your practice, whether they’re seeing anybody for gender-affirming voice care or not, you know. That has definitely happened when I’ve worked in rehab settings as well. And I was grateful to have the knowledge to support these clients in those settings as well. So, that’s kind of my spiel on that.
Meg:
Yeah. You’ve mentioned before, we do know that Autistic people are more likely to be trans or gender non-conforming, and most of the studies show that more Autistic people identify as queer or gender non-conforming in some way than not; there’s over 50% of people. So, if we’re working with Autistic people, this needs to be on our radar. Can you help us tie in gender-affirming care with supporting Autistic folks? And I’m curious if there’s any parallels between neurodiversity-affirming approaches and gender-affirming approaches. Tie it together for us?
Ruchi:
Sure. And just like transparently saying that I’m in a learning experience of my own as well. I think coming into neurodivergent identity is something relatively recent for me probably in the last few years, and people like Rachel Dorsey and Caroline Gaddy and Hillary Crow, and so many other, AC Goldberg, so many other neurodiversity-affirming practitioners and presenters, educators, have been really instrumental in me getting to learn more on this topic and understanding how I interweave these perspectives. I would say, one of the shared tenets that I think is pretty obvious off the bat is with gender-affirming care and neurodiversity-affirming care, it’s like, what is it that the client wants to do? And making sure that what we’re doing in the session is directly related to what does the client want to do and what is going to be most motivating for them in terms of like functional communication outcomes, and the things that they want to be able to engage with. And so, that part is definitely key and something I acknowledge. I openly talk about having a heated blanket, stims that I use with clients so that they feel comfortable, you know, being able to stim in session.
I think, one of the things that was really harmful for me — though, I understood where it came from when I was doing singing, voice training — was the talking about don’t move your hands, don’t try to do, like, mess with your clothing while you’re singing. But it felt like a necessary thing for me to do. And I understand from a performance perspective, it could be confusing or hard for somebody to deal with. But it was also something that I needed. And so, it was good to come back to this and say, hey, these physical things that help us self-regulate and also help us maintain attention are important to keep in the space, especially when you’re learning something as loaded and complicated as voice modification, as it were. I think the other piece is understanding that there are multimodal ways to learn. I often talk about how people learn best, what are the things that have helped them be most successful learning something that is new and challenging in the past. Like, what are the things, like, what should a home program look like for them? Is it like, oh, I want you to really list out steps of how do I do my vocal warmup, and what am I feeling for. And maybe we talked about some sensory considerations that let me know that I’m on target, and I want that in the list so I can provide that. Other folks might say, hey, you know, I want to record a section and be able to listen to myself, and kind of approximate that target every single time. Some people want more flexibility and saying like, hey, you know, I know that I can sign on to a Discord server. There’s a place that I can practice. I would love to have an app where I can just kind of record and listen to myself. And maybe it measures some information about pitch or potentially volume, but I don’t need any like, you know, I want to kind of run with it and in the areas that I feel comfortable with.
So, having flexibility around what does the task look like? What’s going to be most supportive for you in terms of engaging with your voice on your terms, not on what I think would be the most helpful thing for me or what I’ve been taught, but rather, you know, what is what is the thing that will be most accessible for you and will guide you in learning as much as possible, that’s like, I think, one of the biggest things from neurodiversity-affirming approaches I would consider. I think, also just not making assumptions. It’s very easy to make gendered assumptions with clients or like, or try to, you know, you’ve talked about in the past, like a one-size-fits-all approach and deconstructing that. I think it’s really easy for us to cast people in roles and be like, I’ve written this play before, so I know exactly what it is that you want. I really have to remind myself, when I’m working with a client that, hey, I have an idea maybe of where they want to go, but I’ll tell them, hey, this is — we’re throwing darts. I want to see if this is warm or cold for you. And it may not be right. So, we can always shift direction.
I don’t know if this is true for you and your practice, so I wanted to ask you. Like, for me, I often set the expectation that we are colleagues, we are working together. So, this has to work for both of us, but particularly the client. And I’ll say, anytime, you know, no expiration date on giving feedback of something that didn’t work for you in this session. I know it can be trickier with, you know, children, or minors, or adolescents who are less inclined to, because there’s a power differential, give that kind of feedback. But no matter the age of the client, I’ll always say, you know, if there’s anything that you felt like didn’t work for you, or you feel like I have to shift my practice even a little bit, feel free in any sort of way to be able to reach out to me and let me know. Doesn’t matter if it’s a text message, or sending me an e-mail a long time from now, or having an anonymous form, or you want me to take the time to call you, I will do any of all of those things. So, I think that’s an important tenet as well, that’s shared of like, you need to, you know, making the space to be accountable, I think, and providing care.
Meg:
In a previous episode on culturally responsive practice with AC Goldberg, he said that we are going to have breaches and we need to make a plan with the people we’re supporting for how we’re going to address those. So, for anybody who listened to that and was thinking, what does that look like? What does that mean? You just gave us, Ruchi, a great example of what that could look like. And I think we can have these conversations with caregivers. But we don’t want to lose sight of the Autistic child as being our client, not their caregiver or their caregiver’s goal. So, it’s ‘Yes, and’. I love the idea of empowering Autistic kids in this way, too, giving them agency when we can.
Ruchi:
Oh, yeah. Absolutely, absolutely. I, you know, and I mean, there are times where I have had to, like, hold myself accountable. Like, there are times where I was more concerned about something than a client was and I had to explain, hey, you know, sometimes my training in me is very ingrained. And like, I have concerns that probably pop up maybe prematurely. And sometimes I get caught up in like, hey, am I really doing a good job? Or am I really doing enough? And that really wasn’t the focus that I needed to have in the moment. The focus I needed to have was, what was your experience? What are you feeling? How do you feel about your voice? And so, I have, like, you know, out of transparency, I’ve had to have that kind of conversation at times with clients, just to call myself in. And so, it’s more of an encouragement to always track how much of this is really functional for the client and their outcomes versus, you know, something where you want to be able to kind of give yourself this gold star on your chart in the back of your mind. And as much as you can kind of like give yourself positive reinforcement for the work that you do, or the work that you didn’t have to do, instead of holding yourself to that kind of external standard is really, really important.
Meg:
I know one question a lot of people probably have at this point is if you bill insurance for your work, and if people are able to bill insurance for this work.
Ruchi:
They can, and that’s a complicated issue right now, especially with how legislation is working in this country at this time. Because, you know, we’re — is it okay for me to tell when we’re recording?
Meg:
Yeah.
Ruchi:
Yeah, we’re, like, it’s early May of 2023. So, I will say, in my practice, I work almost exclusively now with clients in California, even though I’m licensed in another state as well. I do bill insurance. I’m lucky to be in a contracting situation with a large, you know, medical provider so that I get pre-authorized referrals. But a lot of people have difficulty getting services consistently covered by insurance. That’s the ongoing conversation in most of the forums if you’re looking at gender-affirming voice care or transgender voice and communication work, is people asking, you know, “I got this denied. How do I respond to these denied claims?” I’m pretty much privy to conversations with clients all the time about how other procedures that were supposed to be covered were not covered, or having to negotiate with insurance companies and providers pretty frequently in terms of getting these things that are essentially, you know, lifesaving procedures, procedures that allow people to functionally, you know, participate in the world in so many different contexts and allow them to have, feel of a sense of safety to do so. And so, it is an ongoing process. But yes, I mean, a number of insurance providers, depending on state, depending on a number of different variables, do cover these services. But that’s a really complicated and I think loaded question for like the, for the forum. So, it’s very much like getting in contact with your, you know, licensing board and talking to other providers in a state that you’re working in, is really important to know whether those services are covered and reimbursed.
Meg:
Absolutely. And I just want to clarify for people who might be curious, you said ‘lifesaving’. And the data does support that, that gender-affirming surgeries, and medications, and procedures are specifically linked to lower suicide rates for trans folks. Is that what you’re referring to?
Ruchi:
Yes, absolutely. Yeah. And also, just the general comfort of like, people change in terms of their general livelihood, and what they feel confident enough to do. And when we’re talking about just potential and how people navigate things, I mean, it’s really humbling as a voice provider, who has, I think, limited purview on all of the other things. I definitely don’t ask clients about procedures, or ask clients about their medical history unless it really pertains to voice or respiratory considerations, or articulation, or anything that would be like really central to our process working together. So, it’s just a reminder I want to give practitioners not to be curious or voyeuristic about something that is very sensitive and a vulnerable thing for a lot of clients that we work with. But I will say, like, informally, I get to see people, you know, all of a sudden be able to use their name and pronouns at work and a new workplace, or starting to date again for the first time, or getting to find a group or community where they feel comfortable and supported, or they find another friend who’s also doing gender-affirming voice care, and they get to like, you know, kind of relate to each other, talk about their process or practice with each other in a place that’s not, it doesn’t feel charged or doesn’t feel like there’s something on the line so much. And I can’t really quantify the feeling of getting to see people be themselves unapologetically. And I am very impassioned about anybody who would want to get in the way of somebody getting to experience that in their life. I think everybody, you know, deserves that. I think it’s a human right. So, I’m glad that you brought that up.
Meg:
That’s so lovely. I want to dive into a few examples. Can you give us an example of, or to de-identified or just composite of multiple folks, that exemplifies some of the realities of your clients and how you approach supporting them?
Ruchi:
Sure. So, I mean, I recently presented and so I made some clinical composites, or my kind of a voice session composite, which is not necessarily anybody in particular, just some things that could potentially come up. So, one example I have is, let’s say this person is — this is a fictitious name and profile — so, this person’s name is Jean, and they’re in their early 20’s. I’ll say that they’re non-binary, and they use they/them pronouns. For the sake of this conversation, for clarity, I’ll say they’re assigned female at birth or designated female at birth, so AFAB or DFAB. But usually, I won’t write that in documentation if it’s not needed or required. So, maybe Jean’s chief concern would be that they’ve been taking testosterone for about six months, and they haven’t had satisfactory voice changes. So, a potential quote might be, “My pitch is a little bit lower, but my voice doesn’t sound very different,” or the way that they would want. Their voice goal might be, “I don’t want to automatically out myself as queer and I don’t necessarily want to sound like a cisgender man, but I don’t want my voice to stay so high, especially when I’m stressed or anxious.”
That’s something I hear a lot from either non-binary folks or trans-masculine people who’ve taken for testosterone, is often when they feel like they’re in a point of, you know, high pressure, stress or anxiety, sometimes they feel like their voice sits higher or sounds higher, and they don’t want that to happen. So, there is a place where like a trauma-informed care approach and being able to think about like mindfulness breathing, and being able to, you know, manage as well is like if you have a therapist or mental health practitioner who’s also working with the client, which I frequently do, I’ll often recommend my clients talk about their voice experiences or the specific moments in therapy as much as possible so that we’re navigating these situations concurrently. I mean, ideally, it would be great to have both of us in the space at one time. But, you know, with how billing insurance works, and just how our medical system works right now, it’s often not feasible or attainable. And a secondary concern might be that Jean is also an avocational, contemporary commercial music singer. So, we usually use CCM to talk about music that isn’t like, classically focused. And they’ve been having difficulty navigating their middle register, or the middle of their range, and accessing high notes recently. So, in the last one to two months, they’ve noticed that that’s been more difficult.
So, I’ll just kind of jump in about some of the things that I would be thinking about for this client, you know, do they need another singing voice coach? I will ask them, is this something that is like a priority at this time, or is it the speech the consideration? I’ll try to assess, if I’m seeing them via insurance, I have to make sure that if I’m working on singing voice, that that has either a community participation impact, or maybe it’s an avocational impact, like they work and they get paid to do that, to be able to, I think, you know, make sure that that’s something that insurance should cover, I can make a case for that. Otherwise, I can refer them to, you know, a voice coach who’s, you know, familiar working with trans and gender non-conforming, folks, especially those who’ve taken testosterone. I think the other piece that I keep keeping an eye out for is, you know, what is — what will really get to the point of the sound that this client wants? So, maybe first session, second session, if I need to defer after an evaluation, is thinking about what are voice samples that you like, what are you trying to get at. You’ve given me examples of what you don’t want, what are some things that, you know, sound pleasant to you? And not that we’re trying to imitate anyone else, but rather that you get to discover some different voice qualities that you get to embody, and we can figure out what those are and actually narrow down on that versus, you know, because I have to understand what does sounding like queer mean to this client? What does sounding like a cis-man mean to this client? I have ideas that pop into my head, but I don’t know if those ideas actually coincide with what the client is describing.
And yes, if I hear about stressed or anxious, I’m like, are you working? Is there other considerations? Is this person neurodivergent, sensorily really sensitive, and has specific needs with regard to that? Is there anything in the mental health history that I should be aware of outside of just, you know, all of the stress and potential trauma of being trans and just navigating the world right now? That’s something that would be on my mind. When it comes to, you know, let’s say a general medical history might be intubation for a procedure one year prior with no reported voice, no respiratory changes? There is some research to suggest that there are respiratory considerations and needs for folks who are taking testosterone in the community that you can look at. I think Alicia Heitzman and Jillian River Browy and a bunch of people, I believe, at Portland State University are ones who are kind of like focusing on this. So, it is some interesting emerging research that kind of points to the fact that we do need norms when it comes to respiratory and voice considerations for people who’ve gone through this process, and not comparing to cisgender people who have not gone through this process when it comes to certain markers. But that’s something I would keep in the back of my mind.
They see a gender therapist for care coordination, but they’re not able to afford a therapist at this time, and they’re on a waitlist. So, another thing I might think about as a provider is, do I have resources for low-cost group therapy options, that might be a referral option? Or do I know of anybody who can provide sliding scale? Are there other resources that I can connect the client with that I might be aware of that they may not have access to through their existing network? Those are some things I would think about because in my composite, the client reports a history of depression and otherwise, their medical history is, you know, unremarkable. Some of the other things that I look at with a client might be social history, like is there, in this case, I would say that there’s maybe a strained relationship with father but mother is supportive. They’re disclosed or out amongst friends and roommates, but not at work currently, and maybe they work in food service. So, that gives me an idea of like, you know, financially, economically, how much stability do they have? Are they appropriate for sliding scale? Or do I take their insurance? Is there another provider who’s a better fit who insurance would reimburse? You know, all of those things are considerations that I have to take into account.
That doesn’t necessarily get into the voice intervention. But I will say that, you know, if I see a profile like this, I’m like, there’s a conversation that needs to be had or maybe multiple conversations that need to be had before I can say, what is the goal? I would say the evaluation, like, you know, clinical voice evaluation has to happen. But maybe it’s really like, I know that we’re going to work on diaphragmatic breathing, probably we’re going to work on vocal hygiene considerations. I have some ideas about things that have happened with other people who’ve taken testosterone or challenges that they’ve had. But I don’t know that that’s happening with this client. So, it’s really, it has to be the dynamic assessment piece of like, what’s going on with you? What’s impacting you? What am I hearing? What are you hearing? Is that matching? Is there a mismatch that we have to discuss in terms of what I’m hearing, and what you’re hearing and feeling? And I know the goal writing really happens from that point. And I try to make goals as flexible as possible so that clients can work on whatever it is from week to week, because people’s minds change in this work quite a bit. Sometimes it will be like the pitch is really the problem. And then, they’ll learn about what all of these different parameters mean, how they feel them kinesthetically, or in a sensory sort of way. And then, that changes. And they’ll be like, I thought that’s what I wanted. But then I really wanted to look at resonance, or, you know, I’m fine where the pitch is at, maybe I just want more or less intonation and variation.
So, it’s our job to predict that, you know, we need that much flexibility. Otherwise, we’ll be changing the plan of care almost, you know, maybe week to week for some people. Some people are very certain, they have done a lot of voice modification on their own prior to seeing me though, so sometimes, you know, they’re self-directed enough. And they’re like, I know what it is that I want because I’ve learned from a lot of online resources, I’ve gone through this process before; maybe I’m not the first SLP that they’ve seen. So, you know, it’s a very different kind of framework than a lot of the ones that we inherit in our training, where it’s like, assess, get baseline data during your stimulability testing, during your initial evaluation, and then we’re just trying to keep, you know, in a linear fashion, keep going up, keep going up. And I’m assuming in neurodiversity-affirming care when you’re working with Autistic individuals overall, and the broader neurodivergent community, like, this idea of linear progression isn’t really realistic, either. They’re just going to be sessions that are difficult, or that you’re going to have situations where something is impacting the session, or the trajectory is impacted because there are other life changes that impact a client’s performance or what they’re motivated by, right. So, it’s just, it’s not an easy thing to train also in grad school, I imagine, because, you know, there is limited time. But I hope that that was like, kind of walking through like a profile was helpful.
Meg:
Absolutely. I love that. And I imagine there’s some folks listening who are thinking, “Oh, my gosh, I wish I could find people to refer to in my area,” or even, “I want to be trained to do this.” Can you tell us a little bit about the Trans Voice Initiative, the work they, do the work you do with them?
Ruchi:
Sure. So, Trans Voice Initiative arose in, like, 2020 — I think we formed in 2020 — to address the need that a number of transgender, non-conforming SLP’s and SLP students weren’t necessarily getting the training or focus to do gender-affirming voice work, if they wanted to. That, you know, the voice and upper airway world in SLP is pretty narrow. And so, it’s one of those things of like, you have to know people and you have to have gone through specific trajectories to be considered for a voice and upper airway clinical fellowship, which I certainly didn’t have access to, even though I did a lot of continuing education and preparatory work to be ready for that, because that was my initial goal coming into the field. And so, luckily, you know, now a number of us are voice practitioners who’ve either created our own practices or found our own paths to kind of get into this work. And it’s just really a group of volunteer trans and gender non-conforming SLP’s who are trying to create a training base for and to provide basically free and accessible training opportunities for trans and gender non-conforming SLP’s and SLP students who are interested in getting into this work. One key point I want to say is that every trans or gender non-conforming or gender diverse SLP that you run into doesn’t necessarily want to do gender-affirming voice care. They may want to work in rehab, or they may want to work in early intervention. And a number of us have worked in different capacities outside of gender-affirming voice care. So, it’s an important thing to keep in mind that if you run into somebody who’s in community who is in our field, don’t assume that that’s necessarily what they want to do you for their career goal.
But if it is something that they want to do it, we’re in the process of — Wynde Vastine and Kevin Dorman and I did a training in Colorado where we were hosted by Marie Jetté and Jen Lewon, and it was really, really wonderful. We have a video of the training, which was like a two-day training. So, we’re hoping to splice these and make them available to other trans and gender non-conforming students and SLP’s to support them in kind of self-guided training to do this work. When it comes to cisgender colleagues who want to learn how to do this work, I would highly recommend that you follow TVI, but also follow our individual accounts so that they can know that we’re presenting at different conferences. Like currently, I did a gender-affirming voice care and private practice related talk for the ASHA Private Practice Conference that is ongoing right now. And I also did something with Rachel Dorsey and Bobbi Adams-Brown for being a neurodivergent private practice owner in case anybody’s interested in that. And that’s part of the ASHA Private Practice Conference. So, that’s just one example of talks that I may be giving throughout the year, and I’m not the only person to learn from there. Definitely other trans and gender diverse SLP’s who are part of TVI who are also talking and presenting at different conferences or have online webinars.
The other one I would plug that I know of that could be helpful is AC Goldberg has a Trans Voice Elective that I’m sure he discussed on his podcast episode that is accessible and has different tiers of payment. I also want to say that SLP’s are not the only people that you can learn about gender-affirming voice care from because voice coaches and voice teachers have historically also played a major role. And I think getting to a point where we’re all, you know, talking openly and referring openly and discussing the considerations for supporting the community, especially at a time like this where anti-trans legislation access that minors may have depending on the state that you’re in are fluctuating greatly. And it’s, you know, it’s kind of a terrifying time to be in, in this area of the of subspecialty. I would say there are two recommendations that I have: Liz Jackson Hearns, who has The Voice Lab Inc in Chicago has some self-guided Thinkific courses on gender-affirming voice care. And Liz is, you know, from a singing and theater voice background and voice pedagogy background, is an excellent resource. The other resource that I recommend for either individuals who want to do self-guided modification or clinicians who want to learn about techniques is Renée Yoxon is a Canadian based non-binary vocal coach, voice teacher, who has some online courses that are pretty accessible financially as well. So, those are some resources that I would list that are, you know, community-focused for and by people in the community better, online and accessible, but keep an eye out for TVI members and things that we’re posting for specifically for any of the trans and gender non-conforming students and SLP’s that you know who might be interested, but also cisgender folks can find us at different conferences and talks throughout the year.
Meg:
Thank you so much for sharing all of that. We’ll make sure to link everything in the show notes as well. Ruchi, you’re going to be speaking at the 2024 Neurodiversity Summit for Learn Play Thrive as well, which I’m really excited about. I’m wondering, what’s the thing that you’re looking forward to share or dive into a little bit deeper in your Summit talk that we didn’t touch on today?
Ruchi:
I’m sure it’s gonna be a deeper dive on some of the things that we’ve discussed today. I mean, I definitely would love to talk about trauma-informed care considerations and what it actually looks like in terms of a session, especially since we do have our OT and mental health professional colleagues coming in. I’m sure that there’s a bunch that I can learn from the people who are attending. But I also want to be able to share some of the ways that I, you know, maybe structure a session, or some of the considerations I bring into a session or how I respond in certain situations, which can be, I think, really helpful and approachable for allied health professionals and our interdisciplinary team. I think, being a short form of understanding, you know, when to refer, or how to find us in terms of like vetting out colleagues that are appropriate to refer to for working with trans and gender diverse community members might be a consideration as well. And I think also just learning about more of my client-centered approach, the holistic lens. I usually, in a talk, we’ll talk about kind of what are the bare minimums. But, you know, I know that you’re gonna have such a wonderful conference next year and so I’m really excited to see everybody who’s involved including AC and getting to soundboard with him and make sure that we’re getting to reinforce a lot of these really important tenets for the work that we do.
Meg:
Thank you so much. Tell us if there’s anything else you’re working on, and where we can find you online.
Ruchi:
There are some written work in the works. I am in the process of writing something on neurodivergence and voice, or a neurodiversity voice. We’re working on the title for SIG 3, so I can give you a heads, you know, keep an eye out for that. I’m working with a couple of other neurodivergent colleagues in writing, because I think it’s really important for us to have more and more focus on gender-affirming voice care, and neurodivergent considerations, and neurodiversity-affirming care considerations together. Yeah, I think most of the focus is gonna be writing. And outside of this I’m taking kind of a bit of pause on presentation work. But you can always find me at Kapila Voice on Instagram and Facebook. And if you need to, if you ever wanted to send anybody my way or have a question that you want to ask, kapilavoiceandspeech.clientsecure.me is my practice website. So, again, it’s kapilavoiceandspeech.clientsecure.me. If anybody needs to remember how to spell Kapila, it’s just K-A-P-I-L-A. I’m not used to thinking about it, because it’s always in print. But, you know, just please don’t hesitate to reach out, you know, only good stuff and only questions, obviously. But yeah.
Meg:
We’ll link to everything in the show notes as well. Thank you so much, Ruchi, and I can’t wait to see your talk in the Summit.
Ruchi:
All right. Thanks so much. Bye.
Meg:
Bye.
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Thanks for listening to the Two Sides of the Spectrum podcast. Visit learnplaythrive.com/podcast/ for show notes, a transcript of the episode, and more. And if you learned something today, please share the episode with a friend or post it on your social media pages. Join me next time, where we will keep diving deep into autism.
