Remote Voice Treatment with Transgender Individuals: A Health Care Equity Opportunity

Abstract

Telehealth has long been considered a promising option to advance access to specialized services such as voice therapy,1Mashima PA Birkmire-Peters DP Syms MJ et al.Telehealth: voice therapy using telecommunications technology.Am J Speech Lang Pathol. 2003; 12: 432-439Crossref PubMed Scopus (93) Google Scholar,2Rangarathnam B McCullough GH Pickett H et al.Telepractice versus in-person delivery of voice therapy for primary muscle tension dysphonia.Am J Speech Lang Pathol. 2015; 24 (PMID:25836732): 386-399https://doi.org/10.1044/2015_AJSLP-14-0017Crossref PubMed Scopus (39) Google Scholar,3Quinn R Park S Theodoros D et al.Delivering group speech maintenance therapy via telerehabilitation to people with Parkinson's disease: A pilot study.Int J Speech Lang Pathol. 2019; 21 (Epub 2018 Jun 7. PMID:29879854): 385-394https://doi.org/10.1080/17549507.2018.1476918Crossref PubMed Scopus (16) Google Scholar and the coronavirus disease (COVID-19) pandemic has expanded the use of this technology substantially throughout the health care system.4Doraiswamy S Abraham A Mamtani R et al.Use of telehealth during the COVID-19 pandemic: scoping review.J Med Internet Res. 2020; 22 (Published 2020 Dec 1): e24087https://doi.org/10.2196/24087Crossref PubMed Scopus (113) Google Scholar,5Strohl MP Dwyer CD Ma Y et al.Implementation of telemedicine in a laryngology practice during the COVID-19 pandemic: lessons learned, experiences shared [published online ahead of print, 2020 Jun 23].J Voice. 2020; 20 (S0892-199730234-4)Google Scholar Growing experience with remote voice assessment6Schneider SL Habich L Weston ZM et al.Observations and considerations for implementing remote acoustic voice recording and analysis in clinical practice [published online ahead of print, 2021 Aug 5].J Voice. 2021; 21 (S0892-199700196-X)Google Scholar and treatment7Alegria R Vaz Freitas S Manso MC Effectiveness of voice therapy in patients with vocal fold nodules: a systematic search and narrative review.Eur Arch Otorhinolaryngol. 2020; 277 (Epub 2020 May 22. PMID:32444967): 2951-2966https://doi.org/10.1007/s00405-020-06059-8Crossref PubMed Scopus (6) Google Scholar suggest that telehealth will remain an important tool, even as in-person interventions resume. Moving forward, the health equity implications of telehealth practice require consideration. The authors aim to describe how the remote delivery of voice therapy is uniquely situated to promote healthcare equity for Transgender and Nonbinary (TGNB) individuals. TGNB people have historically been marginalized in society,8James S.E. Herman J.L. Rankin S. et al.The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality, Washington, DC2016Google Scholar a problem which has been exacerbated by the social and economic upheaval of the COVID-19 pandemic. A 2020 survey identified that more than 50% of self-identified TNBG respondents were at a high-risk of developing COVID-19 and had restricted access to gender-affirming healthcare services.9Koehler A, Motmans J, Leo Mulio A, et al. [published online ahead of print, 2021 Oct 18]. Int J Transgend Health. 2021Google Scholar Telehealth is poised to address limitations in health care access for TGNB individuals as it has already been implemented in other fields, including surgery and behavioral health.10Pankey TL Heredia Jr, D Vencill JA et al.Gender-affirming telepsychology during and after the COVID-19 pandemic: recommendations for adult transgender and gender diverse populations.J Health Serv Psychol. 2021; ([published online ahead of print, 2021 Oct 16]): 1-9https://doi.org/10.1007/s42843-021-00048-z]Crossref Google Scholar,11Asaad M Rajesh A Vyas K et al.Telemedicine in transgender care: a twenty-first-century beckoning.Plast Reconstr Surg. 2020; 146: 108e-109eCrossref PubMed Scopus (9) Google Scholar Prior to the pandemic, access to voice therapy for TGNB people represented an important gap in care. The World Professional Association for Transgender Health (WPATH) has identified gender-affirming voice training as a necessity for many TGNB individuals.12Coleman E Bockting W Botzer M et al.Standards of care for the health of transsexual, transgender, and gender-nonconforming people version 7.Int J Transgenderism. 2012; 13: 165-232Crossref Scopus (1756) Google Scholar However, in the largest survey of transgender people to date, 46% of transfeminine respondents indicated that they have not yet received behavioral voice therapy but wanted to pursue that option.8James S.E. Herman J.L. Rankin S. et al.The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality, Washington, DC2016Google Scholar Given that TGNB people may make up as much as 2% of the population,13Goodman M Adams N Corneil T et al.Size and distribution of transgender and gender nonconforming populations: a narrative review.Endocrinol Metab Clin North Am. 2019; 48: 303-321Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar this represents a significant unmet need. TGNB people living in rural environments are particularly vulnerable to healthcare access limitations. Currently, one in four (27%) TGNB people living in rural locations travel more than 75 miles to access gender affirming medical care.14Movement Advancement Project. 2019. Where We Call Home: Transgender People in Rural America. Available at: www.lgbtmap.org/rural-trans.Google Scholar While this travel distance may be feasible for other gender-affirming healthcare needs that require intermittent medical visits (ie, hormone replacement therapy), long travel times are likely to prevent access to voice therapy altogether. In order to be maximally effective, voice therapy requires frequent sessions, creating a barrier to care access for individuals who live a long distance from a qualified practitioner. The costs incurred for traveling long distances include lost wages, lodging and fuel, and diminished safety being in an unfamiliar community. The use of telehealth technologies such as those presented by Schneider et al.6Schneider SL Habich L Weston ZM et al.Observations and considerations for implementing remote acoustic voice recording and analysis in clinical practice [published online ahead of print, 2021 Aug 5].J Voice. 2021; 21 (S0892-199700196-X)Google Scholar (ie, remote voice recording) hold important promise for addressing these barriers to voice therapy access. While geographic barriers are considered frequently for use of telehealth, TGNB people also face unique social barriers to healthcare access. Due to a long history of marginalization by healthcare systems, as well as the rigid gender categorization which frequently accompany them, many TGNB distrust healthcare spaces.15Henriquez NR, Ahmad N. The Message Is You Don't Exist": Exploring Lived Experiences of Rural Lesbian, Gay, Bisexual, Transgender, Queer/Questioning (LGBTQ) People Utilizing Health care Services. SAGE Open Nurs. 2021;7:23779608211051174. doi: 10.1177/23779608211051174. PMID: 34869861; PMCID: PMC8642108.Google Scholar,16Medina-Martínez J Saus-Ortega C Sánchez-Lorente MM et al.Health inequities in LGBT people and nursing interventions to reduce them: a systematic review.Int J Environ Res Public Health. 2021; 18 (PMID:34831556; PMCID: PMC8624572): 11801https://doi.org/10.3390/ijerph182211801Crossref PubMed Scopus (5) Google Scholar Telehealth provides an important opportunity for individuals to engage with voice therapy in a more comfortable environment. It also may empower TGNB individuals to participate in a client-centered approach to care that is often lacking in many spaces.17Vermeir E Jackson LA Marshall EG. Barriers to primary and emergency healthcare for trans adults.Culture Health Sexuality. 2018; 20: 232-246Crossref PubMed Scopus (25) Google Scholar Many TGNB people experience social anxiety as a result of harassment and mistreatment in public spaces due to their gender identity.8James S.E. Herman J.L. Rankin S. et al.The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality, Washington, DC2016Google Scholar This means that actions that many cisgender people might find routine, such as checking in to an appointment, can be sources of substantial stress for TGNB people.18Azul D Hancock AB. Who or what has the capacity to influence voice production? Development of a transdisciplinary theoretical approach to clinical practice addressing voice and the communication of speaker socio-cultural positioning.Int J Speech Lang Pathol. 2020; 22 (Epub 2020 Feb 16. PMID:32063069): 559-570https://doi.org/10.1080/17549507.2019.1709544Crossref PubMed Scopus (14) Google Scholar Gender affirming voice therapy can play an important role in alleviating some of this stress by modifying both gender attribution and self-perceived femininity.19Gelfer MP Tice RM. Perceptual and acoustic outcomes of voice therapy for male-to-female transgender individuals immediately after therapy and 15 months later.J Voice. 2013; 27: 335-347Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar,20Carew L Dacakis G Oates J. The effectiveness of oral resonance therapy on the perception of femininity of voice in male-to-female transsexuals.J Voice. 2007; 21: 591-603Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar However, this benefit cannot be realized if patients do not have access to care. Telehealth presents an important opportunity for TGNB people to engage more comfortably with this care. Telehealth voice therapy for TGNB individuals may help to reduce gender misattribution in public, and therefore increase trust in accessing future healthcare which requires in-person intervention. Telehealth also may be a uniquely successful intervention for many transfeminine patients. For instance, one common metric used to identify the success of both voice therapy and voice surgery for transfeminine patients is whether patients are perceived correctly as women while speaking on the telephone.21Dacakis G Davies S Oates JM et al.Development and preliminary evaluation of the transsexual voice questionnaire for male-to-female transsexuals.J Voice. 2013; 27: 312-320Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar The telehealth format provides an opportunity to simulate that scenario. That has the potential to give the therapist and patient a more realistic view of how the TGNB individual may be perceived in daily life when communicating in a virtual format or over the phone. TGNB patients also are likely to have the technology necessary to obtain good recordings as there are high rates of internet and video game use in this population.22Arcelus J Bouman WP Jones BA et al.Video gaming and gaming addiction in transgender people: an exploratory study.J Behav Addict. 2017; 6: 21-29Crossref PubMed Scopus (18) Google Scholar Many TGNB individuals have access to head-mounted microphones and internet at home that would further support the use of a virtual platform. In Schneider et al., the authors sought to validate the use of less accurate recording technology, such as cell phone microphones, in the capture of voice samples for analysis.6Schneider SL Habich L Weston ZM et al.Observations and considerations for implementing remote acoustic voice recording and analysis in clinical practice [published online ahead of print, 2021 Aug 5].J Voice. 2021; 21 (S0892-199700196-X)Google Scholar They note that a head-mounted microphone positioned at 45-90 degrees away from the mouth is the gold standard for recording voice outcomes.6Schneider SL Habich L Weston ZM et al.Observations and considerations for implementing remote acoustic voice recording and analysis in clinical practice [published online ahead of print, 2021 Aug 5].J Voice. 2021; 21 (S0892-199700196-X)Google Scholar While telehealth has long been considered a promising option to advance access to specialized services in many fields, ie, gender affirmation care,22Arcelus J Bouman WP Jones BA et al.Video gaming and gaming addiction in transgender people: an exploratory study.J Behav Addict. 2017; 6: 21-29Crossref PubMed Scopus (18) Google Scholar,23Stoehr SR Hamidian Jahromi A Hunter EL et al.Telemedicine for gender-affirming medical and surgical care: a systematic review and call-to-action.Transgender Health. 2021; ([published online ahead of print:5 Jul 2021])https://doi.org/10.1089/trgh.2020.0136Crossref Scopus (3) Google Scholar voice therapy, etc., in our opinion, the remote delivery of voice therapy is uniquely situated to promote healthcare equity for TGNB patients. Further study and implementation of virtual recording technology for voice therapy in the TGNB populations may address not only existing health disparities, but also may offer important additional information on the overall implications of telehealth in the field of voice.