Keywords
queer theory - culturally responsive pedagogy - LGBTQ + - transgender - speech-language
pathology
Learning Outcomes: As a result of this activity, the reader will be able to:
-
Discuss theories related to teaching graduate students to best serve LGBTQ+ clients.
-
Critically analyze their own teaching in order to become more inclusive and culturally
responsive.
-
Define terms that are commonly used to describe gender and sexual diversity in a culturally
responsive manner.
Historical Context and Current Status
Historical Context and Current Status
Diversity related to biology and culture continues to thrive. Nevertheless, historical
and ongoing efforts across the world to erase, criminalize, and otherwise invalidate
people from marginalized groups continue to manifest health disparities for those
who are most vulnerable. Since 1969, with the creation of the Black Caucus, which
would later be known as the National Black Association for Speech, Language, and Hearing
(NBASLH), the narrative of teaching diversity within Communication Sciences and Disorders
(CSD) programs has continued to grow and evolve. Eventually, the American Speech-Language
Hearing Association (ASHA) and the Council for Academic Accreditation (CAA) strengthened
the requirement that CAA-accredited programs infuse information on diversity, equity,
and inclusion (DEI) across the curricula for audiology and speech-language pathology
(SLP).[1] These policies requiring CSD faculty to include multicultural content throughout
their curricula formally began in 1994, when CSD instructors, who are predominantly
White, would never have received such an education when they were students.[2] In fact, around the time of the implementation of these pedagogical requirements,
Wallace (1997) reported that 67% of certified SLPs practicing in the field of adult
neurogenics did not feel competent serving diverse populations.
A study by Stockman et al investigated how CSD faculty in the United States were navigating
these new requirements; however, they did not investigate how instructors included
topics related to sexual orientation and mentioned only the broad category of “gender.”[2] Interestingly, in the original survey, Questions 30 and 43 asked “Which of the group
differences do you emphasize within your course content?” Question 30 pertained to
courses not devoted specifically to multicultural/multilingual issues and Question
40 pertained to those courses that were devoted to the topic. The options included
“race, ethnicity, geographical region, socioeconomic class, and gender.” The LGBTQ+
Caucus of ASHA (L'GASP) recorded an oral history project, and one of the authors of
the survey revealed that in the original version of the questionnaire, sexual orientation
was included as one of the options. However, officials at ASHA requested that the
investigators remove sexual orientation from the list of topics, because they thought
it would be too controversial to include it.[3]
Since that survey was created, ASHA has come to embrace the need for professionals
to become more educated about serving the LGBTQ+ population. Discrimination on the
basis of gender, gender identity, gender expression, and sexual orientation are all
included within guiding policy documents, such as the ASHA Code of Ethics and CAA
standards for accreditation,[1]
[4] as well as resources on their Web site for supporting gender diverse clients.[5] In fact, the revised CAA standards (effective January 2023) strengthened the requirement
that programs give students the “opportunity to identify and acknowledge” numerous
concepts related to decreasing bias and increasing DEI as they relate to multiple
identities, including gender identity, gender expression, sex, and sexual orientation.[4]
The resources are meeting a need in the profession, because according to some recent
surveys, many SLPs and graduate students do not feel comfortable serving the members
of the LGBTQ+ community.[6]
[7] While 77.8% of SLP students agreed that treating clients who were transgender was
within the SLP scope of practice, and 82.2% believed that it was their ethical responsibility,
only 20% stated that they had received training to work with transgender people.[7] Even though it appears that a high number of SLP students agree that treating transgender
clients is part of their job as an SLP, it is notable that almost one in four of them
did not feel that it was. It is unclear if these respondents feel they should actively
deny speech-language services to transgender people because it is not within the scope
of practice, or if they believe that gender-affirming voice and communication services
are outside the scope of practice. While both possibilities represent misconceptions
about our field, they are also evidence of beliefs that could cause harm to any transgender
clients that seek services from them, even if it is for issues unrelated to their
gender. Hancock and Haskin reported that although SLPs expressed generally positive
feelings toward the LGBTQ+ community, many were still uncomfortable working with the
population primarily due to a lack of knowledge.[6] While literature regarding multicultural instruction in SLP continues to grow, very
little of this literature mentions diversity related to gender and sexual orientation.
Mahendra presented a sample course description of a graduate-level class dedicated
to the instruction of LGBTQ+ issues.[8] The sample course included (1) self-assessment of knowledge, experiences, and implicit
biases; (2) group demographics and LGBTQ+ history; (3) and health disparities and
research devoted to understanding the healthcare needs of the LGBTQ+ community. They
identified several areas that students felt would improve understanding related to
LGBTQ+ people. Some of these suggestions included (1) how to be an ally, (2) guest
lectures from marriage and family therapists, and (3) working with transgender children,
and techniques for gender-affirming voice and communication therapy.
The results of Mahendra's study are similar to findings with nursing education conducted
by Higgins and colleagues. Higgins and colleagues conducted a review of research investigating
best practices when educating nursing students about working with the older adult
LGBTQ+ community.[9] There were several themes that were pertinent to teaching graduate students in SLP:
(1) including information about LGBTQ+ history, particularly for working with older
LGBTQ+ people; (2) acknowledging that the LGBTQ+ community is not homogenous, but
a group with diverse perspectives and experiences; (3) including interactive educational
methods for students; and (4) involving LGBTQ+ people in the curriculum development.
Little discussion has been devoted to helping SLP instructors teach their students
about issues related to LGBTQ+ people. This article seeks to fill that gap and pull
the pedagogy of culturally responsive education into the discussion of educating CSD
graduate students to deliver compassionate care to LGBTQ+ clients, students, patients,
and families.
Theoretical Foundations
As our profession moves firmly into the 21st century, some foundational paradigms
that have largely gone unquestioned and unexamined are beginning to be examined with
a critical eye by an increasing number of people. One of the main tasks of preparing
future professionals to interact with a diverse population is to increase awareness
of those unexamined paradigms so that they may begin to increase their clinical knowledge
and skills.[10]
This discussion will be framed using a critical epistemology,[11] meaning that current accepted practices and procedures will be discussed in a way
that will shine light on how they support oppressive processes, such as heteronormativity,
cisnormativity, misogyny, racism, and ableism. We will frame the discussion using
several theoretical models, namely, Queer theory/Quare theory,[12]
[13] DisCrit,[14] the Minority Stress Model,[15] the Ethics of Care,[16]
[17]
[18] and Culturally Responsive Pedagogy.[19]
In every scholarly discussion, analyses and interpretations are biased according to
the lived experiences of the authors. Therefore, we offer these positionality statements
as a reference for the reader to understand the perspectives of the authors. Gregory
Robinson is an associate professor living in Central Arkansas. They are a nonbinary,
White speech-language pathologist. Andi Toliver-Smith is an assistant professor, who
divides her time between Central Arkansas and the District of Columbia area. She is
a cis female Black speech-language pathologist. Lorraine Stigar is a DrPH student
in public health. They are a nonbinary, White doctoral candidate living in Central
Arkansas.
Queer/Quare Theory
This article invokes premises of Queer theory[12] through an understanding that categories of gender and sexuality are social constructed.
Humans create terms that attempt to categorize a gradient reality. Just as colors
exist on a spectrum of light that are perceived by most humans as gradual change from
red to violet, that spectrum of colors is divided into categories that humans will
call red, orange, yellow, etc. These categories are partly supported by the measurable
effects of light influencing sensory nerves in the eyes and brain but also created
through cultural understanding and meaning made by humans based on their experiences
with other humans. The reality of sexuality and gender is no different. Gender is
somewhat biological and somewhat cultural.[20] In reality, it exists on a spectrum that is divided into categories by humans based
on their experiences with other humans. Because cultures change over time, so do the
categories.
Due to the fact that concepts of gender are significantly shaped by sociocultural
influences, the story of gender is different for different sociocultural groups. Johnson
proposed Quare theory as a way to fill the void of Black perspectives represented
in many discussions of Queer theory.[13] It is an acknowledgment of the historical factors that have coalesced to create
a different understanding of gender, gender expression, and sexuality in people from
the Black diaspora compared with other sociocultural groups.[38]
DisCrit Theory
DisCrit theory[14] combines critical race theory and disability studies. It posits that racism and
other forms of discrimination and oppression are built upon ableism. The historical
tradition of pathologizing marginalized identities is an effort to dehumanize or degrade
people using the very forces of oppression extended to disabled people. DisCrit is
particularly relevant in this discussion, because the field of SLP is built upon a
foundation of pathologization of speech and language differences.[21]
Minority Stress Model and the Ethics of Care
Minority Stress Model and the Ethics of Care
The minority stress model and the ethics of care work in concert with each other.
The minority stress model[15] provides a framework of understanding the psychological impact of discrimination,
rejection, and micro- and macro-aggressions on people that may be occurring regularly
for marginalized people. These effects may be mitigated by developing resilience that
comes in the forms of a personal sense of acceptance and pride and connection with
others.
The ethics of care[16]
[17]
[18] is an ethical philosophy that frames ethical practice as a set of behaviors that
seeks to care for others. Caring involves paying attention to the suffering of others,
recognizing the responsibility to use power and privilege to help relieve that suffering,
developing the competence to provide care that is desired by the person and beneficial,
and to respond to care received with gratitude.
Culturally Responsive Pedagogy
Culturally Responsive Pedagogy
While the population at large includes clients and patients from diverse perspectives
and experiences, so does the population of graduate students. One of the big challenges
with graduate school preparation is that when students enter a program, it is impossible
to know their values, beliefs, biases, and perspectives. In fact, the students themselves
may not have a conscious awareness of these aspects of culture, particularly regarding
how they can influence their own interactions with others. Therefore, a critical part
of DEI education involves helping students develop awareness of these aspects in themselves.
This point is where culturally responsive pedagogy comes in.
Culturally responsive pedagogy, as described by Gay, stipulates that instructors should
meet the students where they are.[19] Teaching is viewed as a relationship that responds to each student with the understanding
that all learning is filtered through the lens of our past experiences with the various
cultural groups that have shaped them. Students are encouraged to apply new knowledge
to old concepts. In turn, the style of teaching is validating and understanding of
diverse values and beliefs. It seeks to liberate and empower students to apply their
knowledge to their own lives. It also seeks to be transformative for students, as
they acquire new information that might challenge old beliefs.
Hammond specifically addresses three parts to create a culturally responsive environment:
building awareness and knowledge, building learning partnerships, and building intellective
capacity.[22] She further defines culturally responsive teaching as an educator's ability to recognize
students' cultural displays of learning and meaning-making and respond positively
and constructively with teaching moves that use cultural knowledge as a scaffold to
connect what the student knows to new concepts and content to promote effective information
processing. All the while, the educator understands the importance of being in a relationship
and having a social-emotional connection to the student to create a safe space for
learning. Evidence indicates that providing a culturally responsive education can
strengthen student connectedness with school and enhance learning.[23]
Students from various cultural backgrounds, including those who are LGBTQ + , must
feel safe when engaging in classroom activities in order for learning to take place.
If students do not feel safe and accepted, they will ultimately “shut down” and become
unresponsive to our efforts. The students must have an active voice in creating their
learning environment. By supporting the students' culture and their identity, educators
show their willingness to learn. One of the key components of culturally responsive
teaching is that both the student and the educator have something to teach and learn.
In traditional educational environments, the classroom is often a space where the
educator dominates the classroom; however, in this case the student also makes contributions
to the learning environment. By empowering the students to become active agents in
their own learning, the material is infused with greater personal meaning for the
students.
Culturally responsive pedagogy for the purpose of preparing future SLPs, however,
is not just concerned with the instructional techniques of the instructor. In the
field of speech-language pathology, the task of being a culturally responsive teacher
for the CSD instructor is to create culturally responsive teaching skills within their
students. For this reason, it is important to note that culturally responsive teaching
does not simply allow past cultural knowledge to exist without challenges. Instead,
it fosters the increasing self-awareness of what students believe and helps them identify,
challenge, and disrupt those biases that might impede clinical practice among diverse
groups of people. This task requires both the instructor and the student to acknowledge
that they have things to learn and things to teach each other. This understanding,
in turn, allows that dialectical relationship to continue as the student becomes a
clinical practitioner and begins the same practice with their clients.
Hyter and Salas-Provance provide us with two ways of using culturally responsive teaching.[24] They describe both the human rights approach and viewing cultural responsiveness
through the social justice lens. Human right refers to the privileges that all human
beings have regardless of their social station, identity, or racialized background.
Communication is considered to be essential to our humanity and is a human right.
They further ascertain that everyone has the right to freedom of opinion and expression.
These rights are for all people and extend to those with communication disabilities.
The human rights approach can be achieved by incorporating core values into clinical
practice, educational endeavors, and scholarship using five values as a guide to teaching.
Those values include fairness, respect, equality, dignity, and autonomy or FREDA.
Hyter and Salas-Provance point out how communication professionals often work outside
of these parameters by using culturally and linguistically biased assessments, which
often result in the disproportionate representation of Black and Indigenous children
of color in special education and by having limited presence of people from culturally,
racially, and linguistically diverse backgrounds in the profession.[24] It is important that the LGBTQ+ people within these cultures be recognized and represented,
especially while engaging in clinical practice, policy development, teaching, and
scholarship.
When implementing culturally responsive teaching through a social justice lens, it
is important to recognize the inherent dignity of all people and to value every life
equally. This view calls for both personal reflection and social change to ensure
that each of us has the right and the opportunity to thrive in our communities.[24] As a field, we must acknowledge that oppression does indeed exist and work toward
ending systemic discrimination and structural inequities. This model describes the
differences between affirmative and transformative actions and how both should be
used to mitigate injustice. A social justice approach requires immediate, pragmatic
action paired with a larger critical analysis, and to fight against structural violence.
Structural violence was initially described by Galtung in 1969. It occurs when the
social structures, such as the economy, politics, and cultural institutions, cause
avoidable inequities. Clinicians do not usually receive education about structural
violence and its social forces; however, our interventions will fail if we are unable
to understand the social determinants of disorders and disease.[25] The LGBTQ+ culture has been subject to structural violence in that they often have
unequal access to healthcare and are systematically denied medical treatment that
preserves their mental health. This culture is often exposed to physical violence
as well. These acts of violence are sanctioned and performed by law enforcement and
supported by government agencies. This is commonplace for this population, even in
the workplace and professional settings (see [Table 1]).
Table 1
Social and health disparities among the LGBTQ+ population
|
Condition
|
Rate
|
Affected group
|
|
Poverty
|
Two times greater (cf., gen. pop.)[a]
|
TGNB
|
|
Three times greater (cf., gen. pop.)[a]
|
TGNB people of color
|
|
Unemployment
|
Two times greater (cf., gen. pop.)[a]
|
TGNB
|
|
Four times greater (cf., gen. pop.)[b]
|
TGNB people of color
|
|
Homelessness
|
30%[a]
|
TGNB
|
|
50%[a]
|
TGNB who are undocumented
|
|
41%[b]
|
TGNB who are Black
|
|
Attempted Suicide
|
41%[a]
|
TGNB
|
|
49%[b]
|
TGNB who are Black
|
|
Eight times greater (cf., gen. pop.)[c]
|
LGB+
|
|
Two times greater (cf., gay/lesbian)[c]
|
Bisexuals
|
|
Harassment at school
|
50%[b]
|
TGNB who are Black
|
|
Harassed in a medical setting
|
28%[a]
|
TGNB
|
|
Refused care in medical setting
|
19%[a]
|
TGNB
|
|
Required to educate medical providers
|
50%[a]
|
TGNB
|
|
Postponed necessary healthcare due to fears of discrimination
|
76%[a]
|
TGNB
|
|
Rejected by family/friends
|
50%[a]
|
TGNB
|
|
39%[c]
|
LGB+
|
|
Physically attacked
|
38%[a]
|
Trans women
|
|
20%[a]
|
Trans men
|
|
16%[a]
|
Nonbinary
|
|
30%[c]
|
LGB+
|
|
Rejected from a place of worship
|
19%[a]
|
TGNB
|
|
29%[c]
|
LGB+
|
|
Target of jokes or slurs
|
58%[c]
|
LGB+
|
|
Depression
|
Six times (cf., gen. pop.)[c]
|
LGB+
|
|
Rape/Sexual Assault
|
46%[c]
|
Bisexual women
|
|
47%[c]
|
Bisexual men
|
|
47%[a]
|
TGNB
|
Abbreviations: TGNB, transgender and nonbinary; LGB + , lesbian, gay, bisexual, and
other sexual minorities.
a James et al.[32]
b The Task Force, National Black Justice Coalition, and National Center for Transgender
Equality.[33]
c Movement Advancement Project.[31]
Both a human rights approach and social justice lens approach require an understanding
of equity and intersectionality. Educators must pursue deeper understanding to adequately
support students of this culture.
Curricular Content
Horton-Ikard and colleagues outlined some considerations in creating a multicultural
course in communication sciences and disorders. While, their article did not mention
the topics related to LGBTQ+ people, specifically, many of the principles to be considered
are the same.[10] Namely, when educating students about diverse groups of people, such an education
includes the broad educational categories of awareness, knowledge, and skills. These
categories are reflected in the standards for certification commonly known as the
KASA objectives.
Awareness
Awareness involves providing students with opportunities to become mindful of their
own biases, covert and overt systems of discrimination and oppression, and the harms
that result from systemic oppression to marginalized groups of people, including those
who are LGBTQ + . Increasing awareness requires that students understand how people
at the intersection of multiple marginalized groups (e.g., Black trans women) often
experience discrimination across all of their communities, which can increase health
disparities such as mental health support and lack of access to appropriate healthcare.
Among all of these considerations in regard to increasing awareness, perhaps the most
challenging is when students are tasked with confronting their own biases. Confronting
their own biases and/or those biases that are present in people that they care about
may create cognitive dissonance, denial, resistance, and anger/shame. These uncomfortable
feelings are often avoided by seeking justification for the biases. Some may justify
their biases by claiming that their religion prohibits them from caring for certain
groups.[26] Others may claim that these groups “chose” that “lifestyle,” and therefore they
should expect the discrimination that comes with it. Still others may claim that such
discussions about DEI are “political” and should be avoided.
At the core of all of these, rationalization attempts are normativity, supremacy,
and erasure. Normativity is the characterization of some traits to be “normal” and
others to be “deviant.”[27] For example, heteronormativity centers heterosexual relationships as the default,
and any other relationship to be abnormal.[28] Cisnormativity is the belief that identifying as one of the two sex categories assigned
at birth is the only “normal” gender. Processes of normativity are ways of denying
inclusion and equity for groups because these are the processes commonly used to deny
individuals who are considered “different” such as disabled people from the supports
they need. In general, supports and validation is provided as a default to those without
disabilities. Any supports that are outside that “norm” are considered “special” and
require verification and justification. The fact that ableism, or discrimination against
people with disabilities, is used as a guiding force for discrimination against other
marginalized groups is addressed by the DisCrit theory.[14]
Supremacy is related to normativity.[29] Normativity assumes some traits present across a diverse population to be normal
and classify others as abnormal. This assumption of normality provides those with
“normal” traits a whole host of privileges. Embedded within these privileges is an
assumption of supremacy, or the belief that some groups of people are inferior to
other groups of people. For example, at some university programs, same-sex relationships
are punishable offenses that may lead to expulsion or other disciplinary actions for
students. In essence, those who have a heterosexual orientation may be considered
superior, sanctioned by God, and may discuss their relationship without concern for
safety. Conversely, those with other sexual orientations may be considered to be an
“abomination.” Therefore, the mere association with such individuals may be forbidden
by some universities controlled by religious groups or students who come from similar
religious backgrounds.
Erasure is the process of denying the existence of groups of people as valid members
of society. Erasure can be either passive or active.[30] Active erasure is achieved through intentional subjugation of queer identities.
Passive erasure manifests from a lack of knowledge, and is the type of erasure that
arguably would be most common among graduate students. This is often performed as
a lack of “understanding.” Students may say, “I just don't understand how anyone can
be trans; it just doesn't make sense to me.” Passive erasure may come from an assumption
that the feelings within oneself may simply be projected onto another person in an
attempt to understand. Sometimes this attempt at empathy is marginally successful.
For example, even though a person may not have ever experienced the death of a loved
one, many of us can imagine how we might feel if that did happen. While such an imagining
may be imperfect, it does get the person close to an understanding of someone else
who did just lose a loved one. However, understanding the feelings associated with
sexual orientation, gender identity, and other personal traits are not as accessible
using this attempt at empathy. A person with heterosexual orientation may find it
completely impossible to imagine same-sex attraction. A cisgender person may find
a transgender identity incomprehensible. When lack of understanding is used as an
attempt at erasure, students should be reminded that the very fact that they cannot
understand it is justification for the unique experience. Helping students release
the need to “understand” without releasing the need to be “understanding” is part
of the journey to increasing awareness.
Knowledge Development
Increasing knowledge may depend on increasing awareness. Some students may be so resistant
to the concepts concerning LGBTQ+ people, and they will not be able to acquire new
knowledge. However, sometimes exposure to facts and evidence allows for an increase
in awareness of biases. Knowledge relevant to LGBTQ+ people include terminology, rates
of social and health disparities, and processes for disclosing sexual orientation
and gender.
Terminology. The language associated with LGBTQ+ people is rapidly changing to keep up with advancing
knowledge related to gender and sexual orientation. A list of terms with commentaries
is provided in the Appendix.
Social and health disparities. Selected social and health disparities experienced by LGBTQ+ people are presented
in [Table 1]. This list of disparities was collated from the results of two national surveys.
One survey was devoted to sexual orientations,[31] and the other included only transgender and nonbinary (TGNB) people.[32] These disparities are largely amplified for Black, Indigenous, and other LGBTQ+
people of color.[33] For example, while overall TGNB people are twice as likely to be in poverty and
twice as likely to be unemployed, TGNB people of color are three times more likely
to be living in poverty and four times more likely to be unemployed. Half of TGNB
people who are undocumented have experienced homelessness, compared with 30% of TGNB
as a whole. It is also noteworthy to understand that a greater number of LGBTQ+ people
have a diagnosis of autism.[34]
[35] Hall and colleagues compared health disparities among LGBTQ+ autistic people to
autistic people who were not LGBTQ + .[36] They reported significantly higher rates of mental illness, poor physical health,
and inability to access needed medical care among the autistic LGBTQ+ group.
Disparities across sexual orientations tend to be greater for bisexual and other multiple
gender attractions compared with lesbian and gay people. Namely, bisexual women are
far more likely to have been raped or otherwise sexually assaulted, compared with
lesbian and heterosexual women, and bisexual people are far more likely to attempt
suicide compared with lesbian and gay people. These disparities are often associated
with double discrimination experienced by many bisexual people, meaning that they
may experience rejection and other forms of oppression from both the gay/lesbian and
heterosexual communities. In addition to these social and health disparities, transgender
people are three to six times more likely to have a diagnosis of autism,[34] and people with autism are almost eight times more likely to be TGNB.[35]
The psychological effects of discrimination and oppression for marginalized groups
have been identified in several minority stress models, pertaining to race, sexual
orientation, and disability. The models have a lot of similarities. Namely, they generally
classify stresses as either external (those coming from outside the person) or internal
(those generated by the thoughts of the person). Those stresses are mitigated by the
existence of supports and/or internal resilience (e.g., a sense of pride in their
identity, connection to a group of similar people). The culmination of external and
internal stresses in the context of supports or a lack of supports manifests outcomes
for the person that may be beneficial or detrimental. These minority stress models
are important sources of knowledge for students, because they can help them see their
role preventing external stresses, namely understanding the accumulation of internal
stresses and encouraging factors that increase resilience against those stresses.
Processes for disclosing sexual orientation and gender. Processes for disclosing sexual orientation and gender are important knowledge for
students in working with LGBTQ+ clients, because it helps them understand how to respond
when a client makes such a disclosure. When someone discloses their sexual orientation
or gender, it is often referred to as “coming out”; however, it may be helpful for
students to understand it more as “inviting in.” Since there are numerous societal
risks that come from being LGBTQ + , many people attempt to protect themselves by
disclosing only those aspects of themselves to people they deem to be safe.[37] Robinson and Crisp conducted a survey across the United States of LGBTQ+ people.
Respondents were asked how a teacher should and should not respond when a student
discloses their sexual orientation or gender identity.[38] Themes of positive responses were celebration, validation, gratitude, noticing the
courage, identifying as a safe space, giving advice, and no response. Themes of negative
responses included the following: taking away agency of coming out (e.g., suggesting
to remain closeted, pressuring them to come out to others, telling them that you already
knew or could tell from their behaviors), questioning their certainty or suggesting
it is just a phase, prying about personal issues, apathy/dismissing/alienation (e.g.,
“that's no big deal,” “don't talk to me about that”), pressuring them to educate you
or others, or bringing up religion. Many clients never disclose their sexual orientation
or gender identity to their SLPs and audiologists[38]; however, when they do, they trust the professional with information that is highly
personal, vulnerable, and may put them at significant risk.
Skill development. Although SLPs have been serving LGBTQ+ clients and families across the scope of practice,
the expansion and embracing of gender-affirming communication services has provided
students with opportunities to increase their skills about unique and non-unique issues
affecting the TGNB population and, by association, the broader LGBTQ+ population.
ASHA has published resources to help professionals provide LGBTQ+ affirming care,
including a published online resource devoted to clarifying how clinical practitioners
can better support gender diverse populations.[5] However, clinical skill development comes from experience working and interacting
with the LGBTQ+ population. Such experience is often provided to students in university
clinics that provide gender-affirming communication services for the local TGNB community.
However, universities should explore other opportunities for students serving the
LGBTQ+ community, such as providing voice and hearing screenings at LGBTQ+ pride events
and community organizations that serve the LGBTQ+ community.
One skill that is important for SLP students is counseling the LGBTQ+ population.
In general, counseling skills for this population are similar for the wider population,
and should include guided experiences for students to practice counseling skills associated
with listening, empathy, paraphrasing, and challenging. However, some adaptations
need to be understood by students engaging in counseling LGBTQ+ clients. As explained,
LGBTQ+ people are likely to be experiencing discrimination daily that may span from
microaggressions to physical assault. As the minority stress model[15] illustrates, the external stresses build up to create internal stresses. Factors
that may mitigate these stresses include developing a sense of pride in their identity
and a feeling of connectedness with others. Therefore, the clinicians need to develop
skills in helping to develop empowerment and affirmation. Due to societal forces of
heteronormativity and cisnormativity, many LGBTQ+ people are faced daily with subtle
and overt messages that deny or vilify their existence. These messages created a conflict
between what they are being told they are or should be and what they know they are
as the experts on their own identity. To alleviate this conflict, the SLP practices
affirmative care.
Affirmative care involves the following agreements: (1) the client is the foremost
authority on their own gender and sexual orientation; (2) they are in control of disclosing
these aspects of themselves to others; and (3) meaning is expressed through symbols
that communicate understanding and acceptance of identity. The SLP student should
be allowed safe space to practice these affirmative care skills, which may involve
role play, written or verbal responses to case presentations, simulated clients, or
actual clients from their practicum experiences.
Many of the primary symbols that carry power to affirm or disaffirm gender are contained
in language. In English, such symbols are direct references to gender (e.g., man,
woman, guy, girl, boy), third-person singular pronouns in English (e.g., he, she,
they), honorifics and titles (e.g., Mr., Ms., Mx., Dr., Professor), and descriptors
(e.g., pretty, handsome). Referring to people's gender in an accurate way is a basic
level of respect for anyone, but for TGNB people, this basic act of respect does not
always happen, which makes it even more important for SLPs to be accurate. Due to
the unequal power and the vulnerable nature of the relationship between an SLP and
their client, progress in therapy depends on the client feeling safe. Therefore, SLPs
should share their own pronouns and ask for the pronouns of their clients. When the
pronouns are learned, the SLP need to practice to assure 100% accuracy. Little research
has been done on how to improve accuracy with new pronouns, but the nonbinary author,
Jeffrey Marsh, suggested that the change may be more at the semantic level of language
than the morpho-syntactic level. In other words, if an SLP is struggling to use the
correct pronouns with a TGNB client, the issue may be about the fact that the SLP
does not “see” that client as the gender they are.
Conclusions
Instructors in speech-language pathology are tasked with preparing professionals to
work across an expansive scope of practice. This task is expected to be achieved within
5 to 6 semesters for most graduate programs. This task, in itself, may seem daunting.
Therefore, instructors will commonly state that they “do not have time” to add information
about diverse groups into the curriculum.[39] This resistance represents an understanding of multicultural education that Stockman
et al referred to as annexation, or the belief that DEI are topics to be added to
content that is already present.[2] A more efficient and effective model is that of integral infusion.[38] Integral infusion calls upon instructors to realize that their educational content
already includes information about race, ethnicity, gender, and sexual orientation,
whether it is obvious or not. If these topics are not mentioned or critically examined,
it does not mean that they are not being addressed; it means that the content is relying
on assumptions of normativity that privilege those groups in power. Therefore, strategies
for educating SLP students on issues concerning LGBTQ+ people and other marginalized
groups are often less about adding additional content and more about recognizing when
gender, sexual orientation, race, and ethnicity are being assumed or amplified in
educational content and then looking for small ways to disrupt those assumptions.
Consider this example of the opening of a case study on a graduate school test: “This
case is a 5-year-old male diagnosed with a fetal alcohol spectrum disorder. He presents
with…” The processes of infusing diverse perspectives and dismantling oppressive,
unexamined systems require even this small item to be critically questioned. Consider
the following. Why is the fact that the case is a “male” highlighted as one of the
most important pieces of information in this case description? Notice that the gender
of the child is presented even before the diagnosis itself, and it is also redundant
information because the pronoun he is used in the following sentence. The age, of course, would be necessary to interpret
any results from the assessment that follows, but gender is of marginal importance.
What relevant information is not remarked on that could influence the interpretation
more than gender? Arguably, the language(s) spoken by the child is of utmost relevance
to the interpretation of the results, but in this case it is not mentioned. What is
assumed by not mentioning the language(s) spoken by the child? Many might assume that
this child speaks only English. Why is this assumption, given that the majority of
the world is not composed of monolingual English speakers? This elevation of gender
as relevant information, failure to mention language(s) spoken, and the default assumption
of English as the only language, are small considerations in a case representation
that actively, albeit unwittingly, reinforce oppressive systems of normativity.
The work of dismantling the systems of the past that are obsolete, harmful to marginalized
groups, and impair the clinical education of our future professionals is accomplished
through the tiny choices instructors make every day. This work involves meeting the
students where they are (i.e., culturally responsive teaching), creating safe spaces
of affirmation and validation, and helping students, not just understand others' perspectives
but to be more understanding of different ways of constructing meaning and purpose
out of life.
Appendix Glossary of terms related to sexual orientation and gender diversity
|
Term
|
Definition
|
Further comments
|
|
Gender
|
The characteristics and roles of women and men according to social norms
|
While sex may be described as female, male, and intersex, gender may be described
as feminine, masculine, androgynous, and much more
|
|
Gender identity
|
The innate, personal sense a person has regarding who they are along the spectrum
of male to female
|
|
|
Gender expression
|
How a person chooses to convey their gender in terms of clothing, mannerisms, communication,
etc.
|
|
|
Transgender
|
A term for people whose gender identity, expression, or behavior is different from
those typically associated with their assigned sex at birth
|
Transgender is a broad term and is good for everyone to use.
“Trans” is shorthand for “transgender.”
Transgender should be used as an adjective not a noun, thus “transgender people” or
“trans people” are appropriate but “transgender” is disrespectful.
Do not put an –ed on the end (“transgendered”)
|
|
Transgender man
|
A person who is a man, but was assumed to be female at birth
|
Previously referred to as “female-to-male” (FTM) and “male-to-female” (MTF).
Avoid writing these as one word (e.g., trans woman/trans man)
|
|
Transgender woman
|
A person who is a woman, but was assumed to be male at birth
|
|
AMAB/AFAB
|
Assigned (or assumed) male/female at birth
|
Preferred term over “biologically male/female”
|
|
Intersex
|
A person who has biological features commonly associated with both male and female
people
|
Intersex conditions occur in 1.7% of the population.[40]
[41]
Many people don't know they are intersex until puberty.
Ambiguous genitalia (one sign of intersex) occurs in 6/1,000 births (∼65 babies with
ambiguous genitalia born every day in the United States.[42]
Surgeries are often performed without the knowledge or consent of the parents.[43]
[44]
The occurrence of ambiguous genitalia is increasing.[45]
Intersex conditions do not constitute a “disease” but a failure of the binary classification
of sex to capture all possible variables.[43]
|
|
Cisgender (cis man, cis woman)
|
A person who is the gender they were assumed to be at birth
|
|
|
Queer
|
An umbrella term to describe any combination of numerous genders and sexual/romantic
orientations
|
Queer was used as a slur, but many in the LGBTQ+ community have reclaimed it. However,
not everyone may be comfortable with this term due to its history
|
|
Nonbinary
|
A person who is neither entirely male nor female
|
There are multiple nonbinary gender identities.
Some nonbinary people consider themselves transgender, and some do not
|
|
Gender nonconforming
|
A person who does not express themself in a way that is expected according to cultural
expectations aligned with their gender assumed at birth
|
|
|
Two-spirit
|
A Native American term for a person who is TGNB
|
Refers to indigenous third, fourth, and fifth genders that were erased due to colonization
|
|
Dead name
|
A person's name associated with the gender they were assumed to be at birth
|
Calling a trans person by their dead name (dead naming) is often psychologically harmful
|
|
Gender dysphoria
|
A feeling of (often extreme) discomfort associated with the misalignment of the true
gender and the one assumed from birth
|
May be triggered by body, face, voice, micro- or macro-aggressions, or internalized
oppressive thoughts
|
|
Gender Euphoria
|
A feeling of joy associated with one's gender
|
May be triggered by people using the correct name, pronouns, achieving a desirable
voice, and communication style, clothing, etc.
|
|
Sexual orientation
|
Innate attraction, sexual or romantic
|
Sexual orientation should not be assumed based on behaviors, interests, gender expression,
or relationships (e.g., bisexual people are still bisexual, even when they are in
heterosexual passing relationships; gay people are still gay even though they have
never had a same-gender relationship
|
|
Gay
|
A man or nonbinary person, who is romantically and/or sexually attracted to other
men (exclusively/predominantly)
|
“Gay” is also used as an umbrella term, similar to queer; however, some may consider
this usage an erasure of bisexuality
|
|
Lesbian
|
A woman or nonbinary person, who is romantically and/or sexually attracted to other
women (exclusively/predominantly)
|
|
|
Bisexual
|
A person attracted to people who are the same and different genders
|
Some use bisexual and pansexual interchangeably; some do not. When a difference is
made, bisexuals experience different types and/or levels of attraction for different
genders and pansexuals experience attraction that is unaffected by gender.
Misconception: Bisexual people do not only experience attraction in accordance with
the gender binary. Bisexual people are often attracted to nonbinary people and may
even be nonbinary, themselves
|
|
Pansexual
|
A person attracted to people regardless of gender
|
|
Heteronormativity
|
The overriding, sociological assumption that heterosexuality is the “normal” sexuality
that should be assumed for everyone and other orientations are deviant
|
|
|
Homophobia/biphobia/transphobia
|
The irrational fear of lesbian, gay, bisexual, and TGNB people
|
These fears are unfounded and often associated with LGBTQ+ people being:
a. Contagious: associating with LGBTQ+ people will change the gender or sexual orientation
of others
b. Dishonest: associating the time it takes to understand themselves and tell others
with lying or hiding
c. Sexually predatory: association with pedophilia and sexual assault
|
Abbreviation: TGNB, transgender and nonbinary.
