AJSLP

Research Article

Speech-Language Pathologists’ Knowledge and Attitudes Regarding Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Populations Adrienne Hancocka and Gregory Haskina

Purpose: The cultures and service needs of lesbian, gay, bisexual, transgender, and queer (LGBTQ) minority groups are relevant to speech-language pathologists (SLPs). In particular, transgender individuals seeking communication services from SLPs in order to improve quality of life require culturally and clinically competent clinicians. Knowledge and attitudes regarding a population are foundational stages toward cultural competency (Turner, Wilson, & Shirah, 2006). The purpose of this research is to assess LGBTQ knowledge and attitudes among aspiring and practicing SLPs. Method: An online survey was completed by 279 SLPs from 4 countries. Results: Mean accuracy scores on LGBTQ culture questions were near 50%. Self-ratings indicated more

comfort than knowledge, with generally positive feelings toward LGBTQ subgroups. Transgender communication is within SLPs’ scope of practice, yet 47% indicated such services were not addressed in their master’s curriculum, and 51% did not know how to describe transgender communication therapy. When respondents were asked to indicate priority of 10 LGBTQ topics for a continuing education seminar, communication masculinization/ feminization best practice and case examples had the highest mean priority scores. Conclusion: There is a need to promote LGBTQ cultural competence within speech-language pathology. This study provides direction for improving LGBTQ cultural competence among SLPs.

C

is demonstrated by respecting and being trusted by individuals of a particular culture. Speech-language pathologists (SLPs) master cultural competency for people with communication disabilities because this culture is directly addressed in professional education curriculum and encountered routinely. Cases (educational or in live practicum) all require an understanding, sensitivity, and delivery of services with considerations of the disability and associated beliefs about the disability in mind. Cultural competency related to a client’s cultures of race, ethnicity, religion, gender, and sexual orientation is also important but relatively less intrinsic to the profession than the culture of disability. Furthermore, every client served has a culture to be considered, not just those in a minority group. The American Speech-Language-Hearing Association (ASHA, 2004) urges clinicians to consider the client’s cultural and linguistic communities when providing services. One frequently encountered context is when cultural and linguistic influences on communication are considered in order to distinguish difference from disorder and provide clinically appropriate services. In addition, clinicians must understand how their own

ultural competency involves the ability to deliver services with appropriate consideration to the cultural beliefs, behaviors, and needs of the patient (Centers for Disease Control and Prevention, National Prevention Information Network, 2008). Possessing knowledge of a culture does not constitute competency, although it is a good start. Development of cultural competency has been conceptualized as a series of stages: awareness (i.e., knowledge), sensitivity (i.e., attitudes), competency (i.e., skills), and mastery (i.e., ability to train others; Turner, Wilson, & Shirah, 2006). Cultural awareness, such as understanding terminology associated with a group, can progress to sensitivity when a deeper understanding shapes appropriate attitudes and a commitment to eliminating inequities. Knowledge and attitudes are both precursors to cultural competence, which

a

The George Washington University, Washington, DC Correspondence to Adrienne Hancock: [email protected] Editor: Krista Wilkinson Associate Editor: Julie Barkmeier-Kraemer Received July 7, 2014 Revision received November 11, 2014 Accepted January 7, 2015 DOI: 10.1044/2015_AJSLP-14-0095

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Disclosure: The authors have declared that no competing interests existed at the time of publication.

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cultural beliefs and biases influence their ability to provide effective services. ASHA’s Multicultural Issues Board published a Knowledge and Skills document outlining policy requiring culturally and linguistically appropriate services and listing knowledge and skills related to sensitivity, advocacy, and service provision for a number of communication disorder and difference areas (ASHA, 2004). Although SLPs cannot ethically provide services without appropriate knowledge and skills (ASHA, 2010), they also cannot discriminate in the delivery of professional services (ASHA, 2010). Therefore, SLPs must develop cultural competency for any areas in which they are lacking. Opportunities to gain cultural competency in several cultural contexts should be intentionally included in SLPs’ professional education.1 In 2009, ASHA’s Special Interest Group on Culturally and Linguistically Diverse Populations’ Perspectives newsletter focused on lesbian, gay, bisexual, transgender, and queer (LGBTQ) culture; this is an example of promoting awareness and knowledge as a foundational step toward cultural competency in a particular area (Masiongale, 2009). The Office of Multicultural Affairs (OMA) of ASHA is in place to address cultural and linguistic diversity of professionals and persons with communication disorders and differences. The OMA website (http://www.asha.org/practice/ multicultural/) offers resources for assessing and developing cultural competence, including sample syllabi for multicultural/ multilingual issues. The OMA’s definition of multiculturalism includes race, ethnicity, national origin, culture, language, dialect, gender, gender identity, age, sexual orientation, socioeconomic status, religion, and ability. Yet, the vast majority of resources and funded projects on this website are related to bilingualism and racial and ethnic minorities. A similar proportion of attention to this topic was found in a survey study of multicultural course syllabi in communication science and disorders departments. The bicultural/bilingual topic was addressed in most of the 13 courses, but LGBTQ and religions were included in only one (Stockman, Boult, & Robinson, 2003). This suggests that the LGBTQ culture is underaddressed despite it being included in several of ASHA’s policies. Therefore, the LGBTQ cultural competency of aspiring and practicing SLPs may be lacking. Survey results presented in this article investigate this possibility and potentially provide direction for improving LGBTQ cultural competency.

LGBTQ As with other minority groups, the LGBTQ group has within-group diversity. Several studies indicate that one’s socioeconomic status and racial and ethnic culture can influence the experience of being lesbian, gay, bisexual, or transgender (Chae & Ayala, 2010; Nuttbrock et al., 2009; Ross, Essien, Williams, & Fernandez-Esquer, 2003). The hundreds of terms 1

Several resources are provided by ASHA at http://www.asha.org/ Practice/multicultural/International-Resources-to-Develop-CulturalCompetence/.

used by and to describe people in this group of sexual and gender minorities are beyond the scope of this article, but a few common terms are broadly defined and differentiated. For example, lesbian, gay, and bisexual terms refer to sexual orientation, and transgender and queer terms refer to gender identity. Gay can be an umbrella term for homosexuality, but commonly homosexual men are described as gay, and homosexual women are described as or called lesbian. Bisexual indicates sexual attraction to both males and females. People of asexual or nonbinary sexual orientations (e.g., asexual, pansexual) are included in the LGBTQ community as well. Transgender is also an umbrella term but relates to gender identity or intrinsic sense of being male, female, or alternative gender. The terms genderqueer or gender nonconforming describe individuals who do not conform to a binary system of gender. Most people who are transgender desire to live—to various extents—as a gender other than what they were assigned at birth and may or may not desire surgical modification of their primary and/or secondary sex characteristics to establish greater congruence with their gender identity. For example, people who occasionally cross-dress, are intersex (i.e., indistinct chromosomal or genital sex characteristics), or are transsexual (i.e., seek medical interventions to change primary or secondary sex characteristics) can all be considered transgender. Sometimes a Q is included with the more common LGBT acronym. This usually stands for queer, which can be used to describe a dynamic conception of sex, gender, and sexuality. As there are numerous terms used to specify identities and attractions, queer is sometimes used as the ultimate umbrella term. It is worth noting that the use of this term is a change from recent history when queer was used as a derogatory term. Less often, the Q indicates that those who are questioning are welcome. Last, allies are not included in the acronyms but are a large part of the LGBTQ community. These are people who support and actively participate in LGBTQ culture but do not fall into any of the categories described above. They are often, but not necessarily, family members of people who identify as LGBTQ. Although quite diverse, LGBT or LGBTQ is frequently discussed as one community and is considered a minority group. One uniting factor is that they live in a heteronormative culture in which heterosexuality is considered the normal sexual orientation and sexual and gender minorities are considered abhorrent and stigmatized (Yep, 2003). LGBT populations historically “have been marginalized through the law and through psychiatric diagnoses” (Institute of Medicine, 2011, p. 32). Homosexuality was not completely removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM) until 1986, after three decades of evidence demonstrating that it was not a psychological pathology. The U.S. Supreme court struck down all sodomy laws in 2003 (Lawrence v. Texas, 539 U.S. 558, 2003). Still, some government policies (e.g., military personnel, U.S. Food and Drug Administration blood donation) restrict LGBT populations (Institute of Medicine, 2011). Gender dysphoria is included in the Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM–5;

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American Psychiatric Association, 2013) as a mental disorder. The DSM–5 changed gender identity disorder to gender dysphoria partially to emphasize that incongruence between birth gender and gender identity is a disorder only if it causes distress. Much controversy surrounds this issue, as transgender advocates assert the distress is a result of the surrounding culture rather than the transgender identity itself. Another consideration is that one accepted treatment for gender dysphoria is to live as the desired gender (e.g., prescribed hormones, surgeries, counseling); removal of this diagnosis from the DSM potentially would limit access to the medically necessary interventions. Advocacy for LGBTQ recognition and rights has increased, as has opposition. Violence motivated by a victim’s sexual orientation or gender identity is now considered criminal and carries a sentencing enhancement (Institute of Medicine, 2011, p. 42). In 2013, the U.S. Supreme Court declared Section 3, but not Section 2, of the Defense of Marriage Act unconstitutional (United States v. Windsor, 570 U.S., 2013), thus the federal government now recognizes legal marriages of same-sex couples for the purpose of federal laws or programs (e.g., Social Security), but no state is required to legalize or recognize same-sex marriages performed in other states (see http://www.glaad.org/ marriage/doma for more information).

Health Disparities Despite recent events increasing the recognition, protection, and legal rights of the various LGBTQ populations, discrimination and disparities still exist. One consequence of the social stigma and discrimination is health disparities for the LGBTQ population. Issues with mental health (e.g., depression and anxiety, suicide attempts), substance abuse, obesity, and tobacco use are disproportionately high in sexual and gender minorities (Dean et al., 2000; Makadon, Mayer, Potter, & Goldhammer, 2007). Individuals may be reluctant to seek care or disclose sexual or gender identity to their care providers—or to those who serve their spouses and children—for fear of “homophobic reactions, confidentiality concerns, past negative experiences with providers and fear of being stigmatized” (Mayer et al., 2008, p. 993). The health care profession must earn the trust of the LGBTQ populations it has often stigmatized (and sometimes still stigmatizes). These concerns are prevalent among members of the LGBTQ community who have communication impairments and seek services from SLPs. In a survey of LGBT people with speech and language impairments, only 35% and 43%, respectively, reported disclosing their orientations, and the majority reported perceiving a heteronormative bias (Kelly & Robinson, 2011). Yet, the vast majority of respondents considered disclosure important, citing the opportunity to include partners in the consultation and/or treatment process. The exceptions in this survey were the three respondents who were transgender and seeking voice feminization services. They obviously did disclose their status but noted utilizing social networks to find a clinician with content and cultural

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competence in this area before seeking services. Approximately 46% of transgender women seek voice feminization services (Hancock, 2015). Turner et al. (2006) explained that two of the largest barriers to LGBTQ culturally competent health care are providers’ lack of awareness related to LGBTQ patients’ specific health care needs and their inability to provide competent care even if they are aware of those health care needs. In a survey of Swedish nursing and medical students, Rondahl (2009) found that only 34% attained a passing score (i.e., 70% accurate) on a test of LGBT medical practices and laws. Rondahl posits that without knowledge about LGBTQ families and relationships, nursing and medical professionals cannot have a full understanding of an LGBTQ person’s life, thereby limiting their cultural competence. The same consequence is likely for SLPs working in any setting (e.g., health care, schools, private practice) without knowledge and sensitivity toward LGBTQ people.

Transgender Communication Services In particular, transgender individuals seeking voice and communication services from SLPs in order to improve their quality of life require culturally and clinically competent clinicians. Alignment of visual gender presentation and voice can be vital to a successful transition for some individuals. A significant factor in successfully and happily living as transgender is the ability to be perceived by other people as the preferred gender, especially in social and occupational circles (Davies & Goldberg, 2006). Referred to as passing or blending, this is helpful for acquiring and maintaining a job as well as a sense of security. However, not all transgender people are focused on achieving this status. Recent standards of care published by the World Professional Association for Transgender Health (WPATH, 2011 pp. 52–54) indicate the goal of treatment should be to find a comfortable gender expression rather than conforming to binary gender expressions currently expected by a social majority (pp. 52–54). Whether focused on other people’s perceptions or simply a communication style that feels genuine, people who are transgender seek speech-language pathology services because their voice and communication are obstacles to living a healthy, satisfying life. Yet, it can be difficult to find providers who are supportive of transgender people and who are skilled in the communication masculinization/feminization process (Davies & Goldberg, 2006). This barrier to essential health care for transgender people is one example of the health disparities seen within the LGBTQ population. Speech treatment for transgender individuals typically involves teaching them how to adopt speech patterns and conversation styles characteristic of males or females, including safely adjusting pitch and learning nonverbal communication styles (Davies & Goldberg, 2006; Gelfer, 1999). Changing the acoustic correlates to both pitch and resonance features of a voice toward female normative values (i.e., higher pitch and more forward resonance than males) dramatically increases the likelihood that a voice is perceived as a female’s, more so than changing pitch or resonance features alone (Hillenbrand

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& Clark, 2009). Several studies have reported positive treatment outcomes for adult male-to-female transgender speakers after targeting pitch and resonance in conjunction with intonation, rate, nonverbal communication, or overall vocal health (Carew, Dacakis, & Oates, 2007; Dacakis, 2000; Gelfer & Tice, 2013; Hancock & Garabedian, 2013; Soderpalm, Larsson, & Almquist, 2004). There is evidence that similar approaches can be used with adolescent clients (Hancock & Helenius, 2012).

Rationale and Purpose In order for any stigma, discrimination, and health disparities for the LGBTQ population in the domain of speech-language pathology to be eliminated, clinicians must have the knowledge and attitudes foundational to culturally competent skills. The purpose of the present research is to assess LGBTQ knowledge and attitudes among aspiring and practicing SLPs. Further, the correlation of these with respondent characteristics (i.e., age, gender, sexual orientation, relationship with LGBTQ community, and professional education and experiences) is explored. Although transgender individuals represent the population most affected by a lack of LGBTQ knowledge among practicing SLPs, it is also important to evaluate the foundational stages of cultural competence regarding all subgroups of this minority group because any client or family could identify with these cultures. Information indicating current status of SLPs’ knowledge and attitudes will be useful in developing educational opportunities to improve LGBTQ cultural competency.

Method An institutional-review-board-approved survey was distributed via two listserves for voice: Special Interest Group 3 of the ASHA and Voiceserve, a discussion forum sponsored by the University of Iowa Department of Otolaryngology— Head and Neck Surgery. Respondents were welcome to forward the survey link to other people; thus, the survey was distributed via other special interest groups as well (e.g., global issues, fluency, and neurogenic disorders). Data were collected between January 21 and February 3, 2014. Due to the snowball methods of recruitment and the use of the Internet, it is difficult to estimate a response rate. It was predetermined that respondents identifying themselves as younger than 18 years of age or in a profession outside of speech-language pathology would not be included. The survey included questions regarding respondent characteristics; self-ratings of knowledge, comfort, and feelings about LGBTQ people; and LGBTQ terminology and culture. All self-ratings were on a scale of 1–5; culture and terminology questions required multiple-choice answers (one correct, three foils, and “I’m not familiar with this term”). Ten terminology questions were adapted from the Miami University Office of Resident Life (n.d.) lesson plan—which is based upon Adams, Bell, and Griffin’s (2007) Teaching for Diversity and Social Justice (2nd ed.)—and five true/false (T/F) questions posed common stereotypes or facts about

LGBTQ people. In addition, open-ended questions addressed knowledge of voice feminization treatment practices, feelings about serving the LGBTQ community, and potential topics for inclusion in educational programs. The survey is presented in the Appendix. These topics were selected for the survey based upon the two foundational stages of cultural competence as described in the aforementioned model of Turner et al. (2006). Awareness (i.e., knowledge) of LGBTQ culture is assessed directly using multiple-choice questions about LGBTQ terminology and an open-ended question about voice treatment for a specific subpopulation. Sensitivity (i.e., attitudes) is assessed using T/F questions about LGBTQ culture and stereotypes. Self-ratings of knowledge and comfort are indirect measures of awareness and sensitivity, respectively. Medians, interquartile range, and nonparametric statistics (i.e., Kruskal–Wallis one-way analyses of variance [ANOVAs], post hoc Mann–Whitney tests, and Spearman correlations) were used for the age and self-rated knowledge and comfort variables because the sample distributions were negatively skewed and therefore did not meet criteria for using parametric analyses. In contrast, the terminology knowledge and stereotype adherence scores were normally distributed, so mean, standard deviation, and parametric statistics (i.e., one-way ANOVAs, post hoc Tukey’s honestly significant difference [HSD] tests, and Pearson productmoment correlations) were used. Nonparametric statistics were used for all comparisons between geographic regions because the sample sizes were quite unequal.

Results Descriptive Statistics Respondent characteristics. Three hundred and two people initiated the survey. Twenty-six people who did not complete any questions beyond personal demographics were removed from the analysis. Further, one person identifying as a psychotherapist, one person from Singapore, and three undergraduate students were removed because these characteristics differentiated them from the majority of the sample in ways that could potentially affect the conclusions. Therefore, survey responses from 279 people are included in this article (see Table 1). Eight of those 279 people completed the demographic and terminology questions only, exiting the survey before the self-rating questions. The 279 people included in the data analyzed resided in the United States (n = 217), Australia (n = 53), Canada (n = 7), and New Zealand (n = 2). Forty of the 50 U.S. states were represented in the sample, plus the District of Columbia. Eight out of 10 of the states in Australia and five of the 10 provinces in Canada were represented in the sample. Ages of respondents answering the age question ranged from 22 to 75 years of age (M = 41 years, SD = 13.3). Two hundred and fifty-four (91%) of the respondents identified as female, 24 as male, and one as gender nonconforming. Characteristics of the sample’s self-reported sexual orientation, affiliation with the LGBTQ community, and

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Table 1. Respondent characteristics (n = 279). Characteristics Location Australia Canada New Zealand United States Gender Male Female Gender nonconforming Sexual orientation Heterosexual Homosexual Bisexual Other Friends or colleagues in LGBTQ community None Few (50%) Professional experience SLP graduate student SLP clinical fellow SLP for 1–10 years SLP for 11–20 years SLP for over 20 years Extent that transgender voice and communication was covered in master’s curriculum None Some in class Some in practicum Some in class and practicum Extensively in class or practicum Did not get a master’s degree in speech-language pathology

%

19.0 2.5 0.7 77.8 8.6 91 0.4 86 8 6 8 65 24 3 14 8 33 19 26 47 31 4 11 2 5

Note. LGBTQ = lesbian, gay, bisexual, transgender, queer; SLP = speech-language pathologist.

professional education and experience were hypothesized to potentially influence knowledge and attitudes; therefore, self-reported demographic information was collected and analyses were completed according to some of these categories. The majority of the sample was heterosexual (86%) and reported having few LGBTQ friends or colleagues (65%). Level of experience in the speech-language pathology profession was diverse, but more than half had 10 years of experience or less (including 14% graduate students). Almost half of the respondents did not learn about transgender voice and communication in their master’s education. Both age and level of experience data were collected to avoid an assumption that they were redundant. Given the history of the LGBTQ population’s civil rights, it was hypothesized that older age may be associated with less knowledge and more negative attitudes. Although it is perhaps likely that an older person attended a master’s program and began professional experience longer ago, the actual years-ofexperience measurement is a more direct reflection of when the respondent attended a master’s educational program and how many years were spent in practice. It is possible that respondents entered the SLP profession later in life and/or took a hiatus from the profession for any variety of reasons.

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Therefore, both of these questions were included in the survey. The Pearson product-moment correlation between age and level of experience was significant but moderate (r = .66, p < .001); therefore, the age and years of experience variables were both kept in subsequent analyses. Self-rated knowledge, comfort, and feelings. Respondents were asked to rate their knowledge and comfort, separately, for each of the following: the process of coming out for people who are LGBTQ, LGBTQ culture, LGBTQ health issues, role of SLP in LGBTQ health care, and voice feminization/masculinization services. The ratings were on a 1–5 scale, with a higher rating indicating more knowledge/ comfort. Overall, respondents were more comfortable than knowledgeable with the issues presented (see Table 2). They were least knowledgeable about LGBTQ health issues. They were least comfortable with voice feminization/masculinization services and LGBTQ health issues. Respondents were also asked to rate their feelings toward particular subgroups of the LGBTQ population, including lesbian women, gay men, bisexual people, queer/gender nonconforming people, maleto-female transgender, and female-to-male transgender. Generally, respondents were very positive about each population, but it was a skewed distribution with some negative scores. They were relatively more negative toward transgender people and less negative toward homosexual subgroups (see Table 3). Influence of personal moral beliefs. Respondents were provided a blank text box and asked, “Considering your personal moral beliefs, what scenarios would be most difficult for you to provide quality services to an LGBTQ patient? (if none, please write ‘none’).” Out of 267 responses, 236 (88%) respondents wrote “none.” The answers from the remainder of responses that indicated reservations about providing services fell into two categories: LGBTQ morality concerns and a reported lack of competency in providing Table 2. Descriptive statistics for comfort and knowledge of lesbian, gay, bisexual, transgender, queer (LGBTQ) topics (n = 279). Topics Knowledge Process of coming out for LGBTQ people LGBTQ culture LGBTQ health issues Role of SLP in LGBTQ health care Voice feminization/ masculinization services Comfort Process of coming out for LGBTQ people LGBTQ culture LGBTQ health issues Role of SLP in LGBTQ health care Voice feminization/ masculinization services

M

SD

Mdn IQR Skewness

2.66 1.147

3

1

0.345

2.59 1.019 2.26 1.065 2.59 1.030

2.5 2 2

1 1 1

0.362 0.333 0.305

2.66 1.126

3

2

0.251

3.94 1.043

4

2

−0.721

3.88 1.049 3.75 1.064 3.86 1.052

4 4 4

2 2 2

−0.628 −0.444 −0.679

3.73 1.166

4

2

−0.689

Note. Scale is 1–5; higher numbers indicates more knowledge/ comfort. IQR = interquartile range; SLP = speech-language pathologist.

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Table 3. Descriptive statistics for feelings toward lesbian, gay, bisexual, transgender, queer (LGBTQ) individuals (n = 279). Individuals Lesbian women Gay men Bisexual people Queer/gender nonconforming people Male-to-female transgender Female-to-male transgender

M

SD

Mdn

IQR

Skewness

4.35 4.38 4.29 4.22 4.23 4.22

0.910 0.890 0.933 0.982 0.953 0.957

5 5 5 5 5 5

2 1 2 2 2 2

−0.981 −1.047 −0.831 −0.827 −0.800 −0.797

Note. Scale is 1–5; higher numbers indicates more knowledge/comfort. IQR = interquartile range.

adequate care. Twenty out of 267 (8%) respondents reported a lack of competency in providing adequate care. Some examples of this category of response include “Situations requiring clinical skills that are beyond my proficiency”; “I don’t have enough knowledge or skill to work individuals who have had a sex change”; and “I consider myself to be an open person, and feel the biggest challenge would be practical techniques necessary for voice therapy.” Eleven out of 267 (4%) respondents reported issues related to perceptions of LGBTQ morality. Some examples of this category of response include “Uncomfortable with someone who has changed their sex surgically (transgender?)”; “In the instance where a person intends to entrap or mislead others for their own personal satisfaction”; and “Anyone, regardless of orientation, who prefers activity with minors.” LGBTQ culture knowledge and stereotypes. Ten multiplechoice questions on LGBTQ terminology were included in order to assess knowledge. However, two questions were disregarded after the survey began; one question was missing the correct answer (Survey Question 9), and one question had a foil that was too close to the correct answer (Survey Question 11). Performance on the eight remaining terminology questions ranged from zero to eight correct (M = 4.240, SD = 2.261; see Table 4). The frequencies of the scores obtained on the terminology questions are depicted in Figure 1, which resembles Gaussian distribution suggesting a strong test. There were three questions in particular for which the majority of participants chose the answer choice “I am not familiar with this term.” Those questions include (a) a heterosexual person who confronts heterosexism/homophobia (answer: heterosexual ally), (b) a person born with both male and female physiological or anatomical sex characteristics (answer: intersex), and (c) the assumption that heterosexuality is the only normal sexual identity (answer: heteronormativity). Five T/F questions were used to assess stereotype adherence. Each T/F question also had the option to respond

“I don’t know” (see Table 5). Two out of five T/F questions were basic questions related to LGBTQ individuals and health care, including (a) many LGBTQ patients report negative interactions with health care providers (answer: true), and (b) most LGBTQ people feel their identities should not affect the care they receive from health care providers (answer: true). Overall, respondents performed well on the health-related questions, with 80% and above choosing the correct answer. Three out of five T/F questions were stereotypically charged questions about homosexuals, including (a) gay men often report going through a “bisexual phase” during their adulthood (answer: false); (b) most gay men have been sexually abused at some point during their childhood (answer: false); and (c) studies have shown that gay men have more feminized patterns for certain cognitive tasks, such as spatial perception and remembering where objects are placed; studies have also shown masculinized results for lesbians in innerear functions and eye-blinking reactions to loud noises (answer: true). For all three of the stereotypically charged questions, the majority of respondents chose the answer choice “I don’t know.” Figure 1. Distribution of scores on terminology knowledge questions (total possible score = 0–8).

Table 4. Descriptive statistics for terminology knowledge and stereotype adherence (n = 279). Concepts Terminology knowledge Stereotype adherence

Range

M

SD

Mdn

IQR

0–8 0–5

4.24 2.42

2.261 1.169

4 3

4 1

Note. Higher scores indicates more knowledge/stereotype adherence. IQR = interquartile range.

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Table 5. Frequency of responses on stereotype adherence (n = 279). Stereotype adherence questions True/false questions, n (%) Many LGBTQ patients report negative interactions with health care providers (answer: true) Most LGBTQ people feel their identities should not affect the care they receive from health care providers (answer: true) Gay men often report going through a bisexual phase during their adulthood (answer: false) Most gay men have been sexually abused at some point during their childhood (answer: false) Studies have shown that gay men have more feminized patterns for certain cognitive tasks, such as spatial perception and remembering where objects are placed. Studies have also shown masculinized results for lesbians in inner-ear functions and eye-blinking reactions to loud noises (answer: true)

Correct

Incorrect

I don’t know

181 (65%) 242 (87%)

3 (1%) 1 (0.01%)

95 (34%) 36 (13%)

51 (18%) 170 (61%) 26 (9%)

44 (16%) 10 (4%) 21 (9%)

184 (66%) 99 (35%) 232 (83%)

Note. LGBTQ = lesbian, gay, bisexual, transgender, queer.

Knowledge of communication feminization treatment for male to female. Respondents were provided a blank text box and asked, “What is typically included in communication feminization therapy for male-to-female transgender people? (If you don’t know, leave this blank).” Approximately 51% (137 of 271) respondents left the text box blank. The answers provided from the other half of the respondents varied greatly. The lists of communication behaviors provided were very likely not intended to be exhaustive but perhaps an indication of priority or relevance. Generally, all behaviors listed were consistent with those recommended in the WPATH (2011, pp. 52–54) standards of care and research literature (Gelfer, 1999; Hancock & Garabedian, 2013; Oates & Dacakis, 1983). Three behaviors were mentioned by the majority of those who answered this question (n = 134): 81% included pitch, 54% included prosody (e.g., intonation, rate, or volume), and 50% included nonverbal communication (e.g., gestures, posture, eye contact). Somewhat less common answers were as follows: 33% of respondents included language (e.g., vocabulary, syntax), 29% included pragmatics (e.g., feminine patterns and style of language), and 19% included resonance/tone. Less than 15 people mentioned voice quality, articulation, breath support, education, or addressing vocal hygiene. Several included phrases such as “and many more” or “etc.” or vague terms such as “voice therapy.” Continuing education priorities. Respondents were asked to “provide a priority score for topics to be addressed in a seminar for SLPs about LGBTQ patient care” using 5-point scales (1 = do not address to 5 = must address). Ten topics were provided, which varied from knowledge of various cultures to case examples and best practices. The 10 topics are listed in Table 6 with descriptive statistics. Distribution of sample responses were negatively skewed toward high priority for all topics. These data were also analyzed for frequency of ratings of 4 = high priority and 5 = must address. Topic rankings by mean and frequency of high ratings were similar.

Inferential Statistics Effects of experience. Kruskal–Wallis one-way ANOVAs compared distributions of self-rated knowledge and comfort

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variables between four levels of experience (i.e., graduate student or clinical fellow [CF], 1–10 years, 11–20 years, over 20 years of experience). Knowledge of role of SLP in LGBTQ health care (p = .044) and knowledge of voice feminization/ masculinization services (p = .005) were the only variables with data sufficient to reject the null hypothesis of equality across groups (i.e., p < .05). Therefore, post hoc Mann– Whitney tests were used for these two variables to determine which categories of experience were different. The median of self-rated knowledge of the role of SLP in LGBTQ health care was highest in the over 20 years of experience group; differences between groups only reached significance for the graduate/CF versus over 20 years of experience comparison (U = 79, p < .001). Median self-ratings of the knowledge of voice feminization/masculinization services were also highest in the over 20 years experience group; differences between groups reached significance for the graduate/CF versus over 20 years experience comparison (U = 1,160, p < .001) and the 1–10 years versus over 20 years comparison (U = 2,769, p = .025; see Table 7). One-way ANOVAs were used to compare the four experience level subgroups for stereotype adherence and terminology knowledge. The groups were not different for stereotype adherence, F(3, 278) = 0.708, p = .548. However, terminology knowledge was significantly different, F(3, 278) = 4.276, p = .006, and Tukey’s HSD post hoc comparisons revealed significant differences between the graduate/CF group and all other groups: 1–10 years experience (p = .027), 11– 20 years experience (p = .017), and over 20 years (p = .006). In each comparison, the graduate/CF group had higher scores. No other post hoc comparisons were significant. Effects of age. Kruskal–Wallis one-way ANOVAs compared distributions of the age and self-rated knowledge and comfort variables between five age groups (i.e., ages 22–29 years, 30–39 years, 40–49 years, 50–59 years, 60– 75 years). Knowledge of LGBTQ health issues (p = .014), knowledge of role of SLP in LGBTQ health care (p = .003), and knowledge of voice feminization/masculinization services (p = .005) were the only variables with data sufficient to reject the null hypothesis of equality across groups (i.e., p < .05). Therefore, post hoc Mann–Whitney tests were used for these two variables to determine which categories of experience were different.

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Table 6. Descriptive statistics for priority scores for each potential topic in a seminar (n = 279).

Potential topic Communication masculinization/feminization best practice (EBP) Case examples Ethical and legal implications for LGBTQ services Perspectives from LGBTQ speakers LGBTQ terminology Harassment/bullying Transgender culture Gay/lesbian culture LGBTQ demographics Outreach plans for LGBTQ community

M

SD

Mdn

IQR

Skewness

% of sample rating topic 4 or 5

4.57

0.640

5

1

−1.655

95

4.52 4.43 4.41 4.13 4.09 3.91 3.81 3.75 3.47

0.655 0.711 0.725 0.816 0.914 0.827 0.859 0.824 0.886

5 5 5 4 4 4 4 4 4

1 1 1 1 1 1 1 1 1

−1.428 −1.205 −1.333 −0.705 −0.832 −0.745 −0.540 −0.284 −0.572

94 90 90 80 77 74 67 65 64

Note. IQR = interquartile range; EBP = evidence-based practice; LGBTQ = lesbian, gay, bisexual, transgender, queer.

Self-ratings of the 22–29 and 30–39 years of age groups were generally lower than self-ratings of the 50–59 and 60– 75 years of age groups (see Table 8). Self-rated knowledge of LGBTQ health issues was significantly different in comparisons between the 60–75 years of age group and the 22–29 (p = .024) and 30–39 years of age groups (p = .001). Self-rated knowledge of role of SLP in LGBTQ health care was significantly different in comparisons between the 60– 75 years of age group and all other groups: 22–29 (p = .001), 30–39 (p < .001), 40–49 (p = .031), and 50–59 (p = .040) years of age groups. Self-rated knowledge of voice feminization/masculinization services was significantly different in comparisons between the 50–59 and 22–29 years of age groups (p = .015) and comparisons between the 60–75 years of age group and all other groups: 22–29 (p < .001), 30–39

(p = .003), 40–49 (p = .004), and 50–59 (p = .040) years of age groups. One-way ANOVAs were used to compare the five age groups for stereotype adherence and terminology knowledge. The groups were not different for stereotype adherence, F(4, 276) = 1.993, p = .096, or terminology knowledge, F(4, 276) = 1.922, p = .107. Effects of location. Kruskal–Wallis one-way ANOVAs compared distributions of the age and self-rated knowledge and comfort variables between two geographic regions: the United States/Canada and Australia/New Zealand. Self-ratings of knowledge by the United States/Canada group were generally higher than self-ratings of the Australia/New Zealand group (see Table 9). Statistically significant differences between the groups were found for age (p < .001), knowledge

Table 7. Descriptive statistics and p values comparing levels of experience.

Topics Knowledge Process of coming out for LGBTQ people LGBTQ culture LGBTQ health issues Role of SLP in LGBTQ health care Voice feminization/masculinization services Comfort Process of coming out for LGBTQ people LGBTQ culture LGBTQ health issues Role of SLP in LGBTQ health care Voice feminization/masculinization services

Test questions Terminology knowledge Stereotype adherence

Graduate student or clinical fellow (n = 50)

1–10 years (n = 97)

11–20 years (n = 57)

Over 20 years (n = 75)

p

Mdn (IQR)

Mdn (IQR)

Mdn (IQR)

Mdn (IQR)

.112 .069 .323 .044* .005*

3 (1) 3 (1) 2 (2) 2 (1) 2 (2)

3 (1) 2 (1) 2 (2.5) 2 (1) 2 (2)

2 (2) 2 (1) 2 (1) 2 (2) 2 (2)

3 (1) 3 (1) 2 (1) 3 (2) 3 (2)

.583 .210 .186 .280 .131

4 (2) 4 (2) 4 (2) 4 (2) 4 (2)

4 (2) 4 (2) 4 (2) 4 (2) 4 (2)

4 (2) 3 (2) 3 (2) 4 (2) 4 (1)

4 (2) 4 (2) 4 (2) 4 (2) 4 (2)

p

M (SD)

M (SD)

M (SD)

M (SD)

.006* .548

5 (3) 3 (1)

4 (4) 2 (1)

4 (2) 3 (1.5)

4 (4) 3 (1)

Note. IQR = interquartile range; LGBTQ = lesbian, gay, bisexual, transgender, queer; SLP = speech-language pathologist. *Significant at the p < .05 level.

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Table 8. Descriptive statistics and p values comparing age groups. 22–29 years of 30–39 years of 40–49 years of 50–59 years of 60–75 years of age (n = 78) age (n = 69) age (n = 51) age (n = 50) age (n = 31) Topics

p

Knowledge Process of coming out for LGBTQ people LGBTQ culture LGBTQ health issues Role of SLP in LGBTQ health care Voice feminization/masculinization services Comfort Process of coming out for LGBTQ people LGBTQ culture LGBTQ health issues Role of SLP in LGBTQ health care Voice feminization/masculinization services

Test questions Terminology knowledge Stereotype adherence

Mdn (IQR)

Mdn (IQR)

.185 .107 .014* .003* .000*

3 (1) 3 (1) 2 (1.25) 2 (1) 2 (1)

3 (1) 2 (1) 2 (2) 2 (1) 3 (1)

.422 .072 .105 .208 .008*

4 (2) 4 (2) 4 (2) 4 (2) 4 (2)

4 (2) 4 (2) 4 (2) 4 (2) 4 (2)

p

M (SD)

M (SD)

.107 .096

4.82 (2.261) 2.51 (1.090)

3.93 (2.534) 2.25 (1.288)

Mdn (IQR)

Mdn (IQR)

2 (1) 2 (1) 2 (1) 3 (1.25) 2 (2)

Mdn (IQR)

3 (1) 3 (1) 2 (2) 2 (2) 3 (2)

3 (2) 3 (1) 3 (1) 3 (1.25) 3 (2)

4 (2) 4 (2) 4 (2) 4 (2) 4 (2)

4 (2) 5 (1) 4 (2) 4 (2) 5 (1)

M (SD)

M (SD)

M (SD)

4.08 (1.915) 2.24 (1.222)

3.94 (2.106) 2.37 (1.112)

4.19 (2.242) 2.87 (1.024)

4 (2) 3.5 (2) 3 (2) 4 (2) 3 (1)

Note. IQR = interquartile range; LGBTQ = lesbian, gay, bisexual, transgender, queer; SLP = speech-language pathologist. *Significant at the p < .05 level.

of the process of coming out (p = .010), knowledge of LGBTQ culture (p = .004), knowledge of LGBTQ health issues (p = .006), and knowledge of role of SLPs in LGBTQ health care (p = .011). Relationships between LGBTQ cultural knowledge and beliefs and participant characteristics. Correlations of the extent of relationship with the LGBTQ community to terminology knowledge (r = .267, p < .05, r2 = .07) and to

stereotype adherence (r = .347, p < .05, r2 = .12) had relatively large correlations, and these were statistically significant. Thus, the extent of relationship with the LGBTQ community could predict approximately 7% of the variance in terminology knowledge scores and 12% in stereotype adherence scores. Extent of relationship with the LGBTQ community was also correlated with age (r = −.128, p < .05, r2 = .02) and experience level (r = −.180, p < .05, r2 = .03). These weak

Table 9. Descriptive statistics and p values comparing regions.

Topics Age Knowledge Process of coming out for LGBTQ people LGBTQ culture LGBTQ health issues Role of SLP in LGBTQ health care Voice feminization/masculinization services Comfort Process of coming out for LGBTQ people LGBTQ culture LGBTQ health issues Role of SLP in LGBTQ health care Voice feminization/masculinization services

Test questions Terminology knowledge Stereotype adherence

Canada and United States (n = 224)

Australia and New Zealand (n = 55)

p

Mdn (IQR)

Mdn (IQR)

.000*

40 (25)

31 (14)

.010* .004* .006* .011* .068

3 (1) 3 (1) 2 (1) 3 (1) 3 (2)

2 (2) 2 (1) 2 (2) 2 (1) 2 (1)

.575 .462 .334 .202 .558

4 (2) 4 (2) 4 (2) 4 (2) 4 (2)

4 (2) 4 (2) 4 (1) 4 (1) 4 (2)

p

M (SD)

M (SD)

.053 .841

4.38 (2.246) 2.41 (1.141)

3.71 (2.266) 2.44 (1.288)

Note. IQR = interquartile range; LGBTQ = lesbian, gay, bisexual, transgender, queer; SLP = speech-language pathologist. *Significant at the p < .05 level.

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significant correlations indicated that older, more experienced respondents were associated with lower scores on the terminology questions (see Table 10). Correlations between all self-ratings and terminology scores were all statistically significant at the p < .05 level (see Table 11). The variables with the relatively strongest correlations to terminology score were self-ratings of knowledge of the process of coming out (r = .513, r2 = .26), LGBTQ culture (r = .466, r2 = .22), and LGBTQ health issues (r = .476, r2 = .23). The variables with the strongest correlations to stereotype adherence score were self-ratings of knowledge of the process of coming out (r = .432, r2 = .19), LGBTQ culture (r = .503, r2 = .25), and LGBTQ health issues (r = .409, r2 = .17).

Discussion The purpose of the present research was to assess LGBTQ knowledge and attitudes among aspiring and practicing SLPs as indicators of LGBTQ cultural competence. Overall, SLPs’ self-ratings indicated more comfort than knowledge, with generally positive feelings toward LGBTQ subgroups. Many respondents indicated they were open to learning more (i.e., appropriate attitudes) but did not feel they had the clinical skills to provide transgender voice therapy, for example. Respondents held slightly more negative feelings toward transgender individuals compared to individuals who are gay, lesbian, or bisexual. These differences in feelings may stem from societal gender norms and lack of knowledge related to the transgender population. In the context of previous literature suggesting that LGBTQ individuals often modify their daily activities because of fear of prejudice, this slight tendency toward more negative feelings related to transgender people increases the burden placed on this subgroup (Masiongale, 2009). Clinicians may benefit from education about what qualifies as a person who is transgender, how gender identity is different from sexual orientation, and how the challenges involved with transitioning can be navigated. The increased performance among the graduate/CF group on the terminology questions suggests that those individuals currently learning SLP practices are more likely to have encountered LGBTQ terminology. Other than the Table 10. Rho values (Spearman).

Characteristic Age Gender Sexual orientation Relationship with LGBTQ community Experience level Curriculum

Terminology knowledge

Stereotype adherence

−.128* −.006 .005 .267*

.045 −.07 .005 .347*

−.180* .083

.022 .044

Note. LGBTQ = lesbian, gay, bisexual, transgender, queer. *Significant at the p < .05 level.

Table 11. Rho values (Spearman).

Topic Self-rated knowledge Process of coming out for LGBTQ people LGBTQ culture LGBTQ health issues Role of SLP in LGBTQ health care Voice feminization/masculinization services Self-rated comfort Process of coming out for LGBTQ people LGBTQ culture LGBTQ health issues Role of SLP in LGBTQ health care Voice feminization/masculinization services

Terminology knowledge

Stereotype adherence

.513*

.432*

.466* .476* .353* .263*

.503* .409* .341* .236*

.263*

.356*

.290* .287* .208* .191*

.353* .352* .247* .220*

Note. LGBTQ = lesbian, gay, bisexual, transgender, queer; SLP = speech-language pathologist. *Significant at the p < .05 level.

increased performance on LGBTQ terminology among the graduate/CF group, the performance among the other experience levels did not vary significantly. Although they scored higher on LGBTQ terminology knowledge, the graduate/CF group self-reported lower comfort and knowledge regarding the role of the SLP in LGBTQ health care. This could be explained by the lack of experience with patient care among the graduate/CF group when compared to other experience levels. In this case, concerted effort to include LGBTQ culture in clinical practicum would be recommended. Adding an element of LGBTQ culture to a case study (e.g., the child with language delay has lesbian parents; the voice client with nodules completed vocal feminization therapy 4 years ago) or inviting a transgender person who participated in voice feminization therapy to share her experience with a class would be good starting points. Educators may host a panel of relevant professionals (SLPs, psychologists, social workers, policy experts) and members of the LGBTQ community for students in an interprofessional education setting. In fact, the authors of this study met through such a panel, and this article is a product of the second author’s cornerstone project for The George Washington University’s LGBT Health & Public Policy Graduate Program. Presenting aspiring and practicing SLPs with the opportunity to advance LGBTQ cultural competency—both their own as well as their colleagues’—could help to reshape the manner in which these providers interact with their patients for the better. SLPs’ ability to serve LGBTQ individuals is related to health care access and, consequently, improvements in quality of life for these individuals (Hancock, Krissinger, & Owen, 2011). It is fortunate that issues of morality do not appear to present a significant barrier to caring for LGBTQ individuals. Although a small portion of the sample did report issues related to morality, the scarcity of these personal/ moral conflicts is promising for the future of LGBTQ

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cultural competency among SLPs. Furthermore, the tendency to avoid adhering to stereotypical responses could indicate that the sample was socially cognizant and avoided accepting stereotypes as facts. Of the 31 respondents who noted a reservation about serving LGBTQ individuals, 20 of them specifically cited concerns that they would not be competent in the area rather than personal issues with the population. It is encouraging that reservations about serving this population are primarily due to lacking skill-based knowledge and not indications that moral issues with LGBTQ interfere with treatment of an individual. For the remaining 11 people (4% of the sample) who expressed discomfort with providing services to LGBTQ individuals, increasing knowledge of this population’s health care needs could help them to develop sensitivity and understanding when dealing with these patients. Sensitivity toward the diversity found among the LGBTQ population is an important component of building cultural competency (Turner et al., 2006).

Transgender Services Clinical and cultural skills are difficult to assess using an online survey; however, this was explored using an openended question about clinical practice standards for transgender communication feminization services. Fundamental frequency (pitch) and resonance are, by far, the most frequently recommended target areas in the literature (Gelfer, 1999; Hancock & Garabedian, 2013; Oates & Dacakis, 1983; WPATH, 2011 pp. 52–54). Yet, only half of the SLPs gave any response, and of them, pitch was mentioned in only 81% of the responses and resonance/tone only in 19%. The other answers included behaviors that are intuitive and supported by expert opinion but still lack strong empirical support. The low number of clinicians knowledgeable in this area is likely related to the finding that nearly half of the sample reported that transgender voice and communication was not addressed at all in their SLP training. This is consistent with other reports that LGBT is not often covered in academic course curriculum (Stockman, Boult, & Robinson, 2003) and that there is a paucity of SLPs who are knowledgeable on transgender voice feminization/masculinization services (Davies & Goldberg, 2006). This is alarming because of the implications it has for the ability of licensed SLPs to serve the widest range of individuals possible. For male-tofemale transgender individuals in particular, passing as female can be difficult, which can be a major source of stress. Beyond the aesthetic cues that indicate the gender of a person, voice and communication style is important for successful transition and well-being. The stress and stigma that can occur as result of failing to pass can be detrimental to safety and health outcomes (Xavier & Simmons, 2000).

Limitations Some of the limitations of the present research include the sample size and its lack of male respondents (8% male). However, ASHA recently reported that only 2.9% of SLPs

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who hold the Certificate of Clinical Competency are male (ASHA, 2013). Also, the LGBTQ terminology questions may not have been easily understood by respondents living outside the United States due to cultural differences in terminology. Furthermore, as with any voluntary self-report method of data collection, there is potential for biases in sampling and participants’ responses.

Future Directions All 10 of the provided topics related to LGBTQ culture and related clinical practice were ranked by the majority of these SLPs as high priority or must address in an educational seminar. Including LGBTQ cultural issues in academic courses and developing continuing education seminars to expand SLPs’ knowledge of the health care needs of LGBTQ individuals would be effective starting points in building cultural competency. Readers are directed to Steckly’s (2009) article in ASHA’s Perspectives newsletter for an overview of LGBTQ terms and demographics. The results of the present research suggest that the majority of SLPs fall somewhere within Turner et al.’s (2006) awareness stage of LGBTQ cultural competency. Therefore, many SLPs may be ready for coursework to develop specific techniques for creating LGBTQ-friendly environments; incorporating culturally sensitive and relevant assessment and treatment materials; and delivering specialized services, such as voice feminization. Examples of specific outcomes may include the following: 1.

Understand the cultural background that has led to marginalization of LBGTQ people in health care settings and the resulting psychological and emotional distress.

2.

Explain basic LGBTQ culture, including terminology, common health issues, and discrimination experiences.

3.

Express sensitivity to LGBTQ individuals by understanding apprehensions to pursue health services due to negative health care experiences.

4.

Increase comfort level of interacting with LGBTQ people.

5.

Describe the role of voice and communication in a transgender person’s identity.

6.

Construct a treatment plan for transgender voice and communication services, including the behaviors most effective for achieving passing status.

In addition to the cultural competence of individual clinicians, the SLP profession can encourage and facilitate the creation of culturally competent workplaces so that clients feel more comfortable disclosing LGBTQ membership status. Kelly and Robinson (2011) summarized several recommendations from the Human Rights Campaign and the Gay and Lesbian Medical Association for fostering a safe environment—for example, use open-ended intake forms so that clients can use their own terms for gender and relationship status, include sexual orientation and gender as protected

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information in the office’s patient bill of rights, and establish relationships with LGBT community centers and members. Furthermore, close collaboration with partners in similar professions (e.g., counseling, education, physical therapy, medicine, nursing) could provide insights and opportunities to learn and master cultural competencies. It is likely that culturally sensitive practices would be adopted quickly if there were consistency across the professions. Such collaborations and cross-trainings could expedite speechlanguage pathology toward a profession recognized for sensitivity, knowledge, and skills regarding the LBGTQ population.

Conclusion Most SLPs are comfortable with the LGBTQ minority populations but do not feel knowledgeable about LGBTQ culture. Many do not know, but are willing to learn, how to provide communication feminization services to people who are transgender. Results from this survey indicate that LGBTQ cultural competence in speech-language pathology is ripe for improvement.

References Adams, M., Bell, L., & Griffin, P. (2007). Teaching for diversity and social justice (2nd ed.). New York, NY: Routledge. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists and audiologists to provide culturally and linguistically appropriate services [Knowledge and skills]. Available from http://www. asha.org/policy American Speech-Language-Hearing Association. (2010). Code of ethics [Ethics]. Available from http://www.asha.org/policy American Speech-Language-Hearing Association. (2013). 2013 Membership survey. CCC-SLP survey summary report: Number and type of responses. Available from http://www.asha.org Carew, L., Dacakis, G., & Oates, J. (2007). The effectiveness of oral resonance therapy on the perception of femininity of voice in male-to-female transsexuals. Journal of Voice, 21, 591–603. Centers for Disease Control and Prevention, National Prevention Information Network. (2008). Cultural competence. Available from http://www.cdcnpin.org/scripts/population/culture.asp Chae, D. H., & Ayala, G. (2010). Sexual orientation and sexual behavior among Latino and Asian Americans: Implications for unfair treatment and psychological distress. Journal of Sex Research, 47, 451–459. Dacakis, G. (2000). Long-term maintenance of fundamental frequency increases in male-to-female transsexuals. Journal of Voice, 14, 549–556. Davies, S., & Goldberg, J. (2006). Clinical aspects of transgender speech feminization and masculinization. International Journal of Transgenderism, 9, 167–196. Dean, L., Meyer, I. H., Robinson, K., Sell, R., Sember, R., Silenzio, V. M. B., . . . Tierney, R. (2000). Lesbian, gay, bisexual, and transgender health: Findings and concerns. Journal of the Gay and Lesbian Medical Association, 4, 102–151. Gelfer, M. P. (1999). Voice treatment for the male-to-female transgendered client. American Journal of Speech-Language Pathology, 8, 201–208.

Gelfer, M. P., & Tice, R. M. (2013). Perceptual and acoustic outcomes of voice therapy for male-to-female transgender individuals immediately after therapy and 15 months later. Journal of Voice, 27, 335–347. doi:10.1016/j.jvoice.2012.07.009 Hancock, A. B. (2015). Voice-related quality of life for transgender Americans. Manuscript submitted for publication. Hancock, A. B., & Garabedian, L. (2013). Transgender voice and communication treatment: A retrospective chart review of 25 cases. International Journal of Language & Communication Disorders, 48, 54–65. Hancock, A. B., & Helenius, L. (2012). Adolescent male-to-female transgender voice and communication therapy. Journal of Communication Disorders, 45, 313–324. Hancock, A. B., Krissinger, J., & Owen, K. (2011). Voice perceptions and quality of life for transgender people. Journal of Voice, 25, 553–558. Hillenbrand, J. M., & Clark, M. J. (2009). The role of fundamental frequency and formant frequencies in distinguishing the voices of men and women. Attention, Perception, & Psychophysics, 71, 1150–1166. Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: The National Academies Press. Available from http://www.ncbi.nlm.nih.gov/books/NBK64806 Kelly, R. J., & Robinson, G. C. (2011). Disclosure of membership in the lesbian, gay, bisexual, and transgender community by individuals with communication impairments: A preliminary web-based survey. American Journal of Speech-Language Pathology, 20, 86–94. Lawrence v. Texas, 539 U.S. 558, (2003) Makadon, H., Mayer, K., Potter, J., & Goldhammer, H. (Eds.). (2007). The Fenway guide to lesbian, gay, bisexual, and transgender health. Philadelphia, PA: American College of Physicians. Masiongale, T. (2009). Ethical service delivery to culturally and linguistically diverse populations: A specific focus on gay, lesbian, bisexual, and transgender populations. Perspectives on Communication Disorders & Sciences in Culturally and Linguistically Diverse Populations, 16(1), 20–30. Mayer, K. H., Bradford, J. B., Makadon, H. J., Stall, R., Goldhammer, H., & Landers, S. (2008). Sexual and gender minority health: What we know and what needs to be done. American Journal of Public Health, 98, 989–995. Miami University, Office of Resident Life. (n.d.) Cultural competency resources: Gender and sexuality quiz. Retrieved from http://www.units.miamioh.edu/saf/reslife/reslife/manuals/ manual/CPR_committee/Programming/Gender%20and% 20Sexuality%20Quiz%20Lesson%20Plan.docx Nuttbrock, L., Bockting, W., Hwahng, S., Rosenblum, A., Mason, M., Marci, M., & Becker, J. (2009). Gender identity affirmation among male-to-female transgender persons: A life course analysis across types of relationships and cultural/lifestyle factors. Sexual and Relationship Therapy, 24, 108–125. Oates, J. M., & Dacakis, G. (1983). Speech pathology considerations in the management of transsexualism: A review. British Journal of Disorders of Communication, 18, 139–151. Rondahl, G. (2009). Students’ inadequate knowledge about lesbian, gay, bisexual and transgender persons. International Journal of Nursing Education Scholarship, 6, 1–15. doi:10.2202/1548-923X. 1718 Ross, M. W., Essien, E. J., Williams, M. L., & Fernandez-Esquer, M. E. (2003). Concordance between sexual behavior and sexual identity in street outreach samples of four racial/ethnic groups. Sexually Transmitted Diseases, 30, 110–113.

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Soderpalm, E., Larsson, A., & Almquist, S. A. (2004). Evaluation of a consecutive group of transsexual individuals referred for vocal intervention in the west of Sweden. Logopedics, Phoniatrics, Vocology, 29, 18–30. Steckly, R. G. (2009). Gay, lesbian, bisexual, and transgendered people: An introductory discussion of terminology and demographics. Perspectives on Communication Disorders & Sciences in Culturally and Linguistically Diverse Populations, 16(1), 4–10. Stockman, I., Boult, J., & Robinson, G. (2003, November). Multicultural content in speech-language pathology and audiology curricula: A survey of ASHA-accredited programs. Paper presented at the American Speech-Language-Hearing Association Annual Convention, Chicago, IL.

Turner, K., Wilson, W. L., & Shirah, M. K. (2006). Lesbian, gay, bisexual and transgender cultural competency for public health practitioners. In M. D. Shankle (Ed.), The handbook of lesbian, gay, bisexual, and transgender public health: A practitioner’s guide to service (pp. 59–83). New York, NY: Harrington Park Press. World Professional Association for Transgender Health. (2011). Standards of care for the health of transsexual, transgender, and gender non-conforming people (Version 7). Minneapolis, MN: Author. Retrieved from http://www.wpath.org. Xavier, J., & Simmons, R. (2000). The Washington transgender needs assessment survey. Washington, DC: The Administration for HIV and AIDS of the District of Columbia Government. Yep, G. A. (2003). The violence of heteronormativity in communication studies. Journal of Homosexuality, 45, 11–59.

Appendix (p. 1 of 4) Survey of Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Knowledge and Attitudes

1. If you are in the United States, enter your state. If you are outside the United States, enter your country and state/ province/etc. 2.

What is your age in years?

3.

Which best describes you? a. Speech-language pathologist (SLP) student—undergraduate

b. SLP student—graduate c. SLP clinical fellow d. SLP with 1–10 years experience e. SLP with 11–20 years experience f. SLP with over 20 years experience 4.

Was transgender voice and communication addressed in your SLP master’s degree curriculum? a. I didn’t get my master’s degree in SLP

b. Not at all c. Some in class d. Some in practicum e. Extensively in class or practicum 5.

How many of your friends or close colleagues identify with the LGBTQ community? a. None

b. Few (less than 20%) c. Many (20%–50%) d. Most (majority) 6.

What is your sexual orientation? a. Homosexual

b. Hetereosexual c. Bisexual 7.

What is your gender? a. Male

b. Female c. Male-to-female transgender d. Female-to-male transgender e. Queer f. Gender non-conforming

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Appendix ( p. 2 of 4) Survey of LGBTQ Knowledge and Attitudes

8.

A heterosexual person who confronts heterosexism/homophobia: a. Heterosexist

b. Queer c. Heterosexual ally (CORRECT ANSWER) d. Transphobic e. I’m not familiar with this term 9. A system of cultural beliefs and practices that assume a fixed, binary system of gender into which everyone must fit: [This question was removed from analyses.] a. Heterosexual privilege b. Transgender expression c. Gender identity d. Transsexual privilege e. I’m not familiar with this term 10.

A person born with both male and female physiological or anatomical sex characteristics: a. Transsexual

b. Polyploidy c. Intersex (CORRECT ANSWER) d. Bisex e. I’m not familiar with this term 11. Fear of or discomfort with people who do not meet our cultural expectations for gender expression: [This question was removed from analyses.] a. Heteronormativity b. Gender phobic c. Sexist d. Transphobic (CORRECT ANSWER) e. I’m not familiar with this term 12. A person whose self-definition challenges and disrupts traditional binary conceptions and boundaries of gender and sexuality: a. Intersex b. Gender confused c. Cross dresser d. Transgender (CORRECT ANSWER) e. I’m not familiar with this term 13.

A system of institutional and cultural beliefs, norms, and practices that advantages heterosexuals: a. Sexism

b. Homophobic c. Heterosexism (CORRECT ANSWER) d. Gender roles e. I’m not familiar with this term

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Appendix ( p. 3 of 4) Survey of LGBTQ Knowledge and Attitudes

14.

A person’s sense of being a woman, a man, or other gender identification: a. Sex

b. Gender expression c. Queer d. Gender identity (CORRECT ANSWER) e. I’m not familiar with this term 15.

The assumption that heterosexuality is the only normal identity: a. Gender normativity

b. Heteronormativity (CORRECT ANSWER) c. Gender roles d. Gender ideals e. I’m not familiar with this term 16. An umbrella term used by some lesbian, gay, or bisexual people to refer to themselves, often to avoid binary static conceptions of sex, gender, and sexuality: a. Bisexual b. Queer (CORRECT ANSWER) c. Orientation d. Transgender e. I’m not familiar with this term 17.

The system of advantages received by heterosexuals in a heterosexist society: a. Heterosexism

b. Gender advantage c. Gender Privilege d. Heterosexual privilege (CORRECT ANSWER) e. I’m not familiar with this term 18.

Gay men often report going through a “bisexual phase” during adulthood. a. True

b. False (CORRECT ANSWER) c. I don’t know 19.

Many LGBTQ patients report negative interactions with health care providers. a. True (CORRECT ANSWER)

b. False c. I don’t know 20.

Most gay men have been sexually abused at some point during their childhood. a. True

b. False (CORRECT ANSWER) c. I don’t know 21.

Most LGBTQ people feel their identities should not affect the care they receive from health care providers. a. True (CORRECT ANSWER)

b. False c. I don’t know

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Appendix ( p. 4 of 4) Survey of LGBTQ Knowledge and Attitudes

22. Studies have shown that gay men have more feminized patterns for certain cognitive tasks, such as spatial perception and remembering where objects are placed. Studies have also shown masculinized results for lesbians in inner-ear functions and eye-blinking reactions to loud noises. a. True (CORRECT ANSWER) b. False c. I don’t know 23.

Please rate your knowledge of the following: (1 = no knowledge to 5 = expert knowledge) a. Process of coming out for people who are LGBTQ

b. LGBTQ culture c. LGBTQ health care issues d. Role of SLP in LGBTQ health care e. Voice feminization/masculinization services 24.

Please rate your comfort of the following: (1 = uncomfortable to 5 = very comfortable) a. Process of coming out for people who are LGBTQ

b. LGBTQ culture c. LGBTQ health care issues d. Role of SLP in LGBTQ health care e. Voice feminization/masculinization services 25.

Rate your feelings toward the following groups: (1 = mostly negative to 5 = mostly positive) a. Lesbian women

b. Gay men c. Bisexual people d. Queer/gender non-conforming people e. Male-to-female transgender f. Female-to-male transgender 26. Considering your personal moral beliefs, what scenarios would be most difficult for you to provide quality services to an LGBTQ patient? (if none, please write “none”) 27.

Provide a priority score for topics to be addressed in a seminar for SLPs about LGBTQ patient care. (1 = should not address, 2 = low priority, 3 = neutral, 4 = high priority, 5 = must address) a. LGBTQ terminology

b. LGBTQ demographics c. Gay/lesbian culture d. Transgender culture e. Ethical and legal implications for LGBTQ services f. Harassment/bullying g. Outreach plans for LGBTQ community h. Communication masculinization/feminization best practice (EBP [evidence-based practice]) i. Case examples j. Perspectives from LGBTQ speakers 28. What is typically included in communication feminization therapy for male-to-female transgender people? (If you don’t know, leave this blank)

Hancock & Haskin: Attitudes Toward LGBTQ Groups

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