Voice Training for Trans Women

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by Chris Reeder Young | photo by Feliza Vasquez

( Above photo: Marisa Actis made her gender transformation about three years ago. Her voice, however, didn’t naturally sound feminine. Here she works with University of Memphis speech pathologist John Sandidge to train her voice to match her new identity.)

When my editor pitched for a contributor to write about the Transgender Voice Development Program at the University of Memphis (UM), I realized how little I knew and how much there is to know about one of Memphis’ most affirming and compassionate community clinics. Trans and gender non-conforming individuals come here to work with a speech pathologist to develop their voices in ways that are most matched with who they are.

With any healthcare or allied health affirming therapy, the issue of cost barriers and affordability will arise for advocates who seek to inform equitable policy.

We know that LGBTQ+ healthcare policy is paramount to saving lives. The most powerful and effective policies are bolstered by the voices of the people who will be most impacted by that legislation, and oftentimes their stories are disproportionately
sorted to the margins. As we know, bigoted, top-down legislation is the most harmful for LGBTQ+ individuals and Tennessee is no stranger to witnessing problematic and voiceless legislation slink across desks.

Human-centric policy and programming will always save lives and the best practices will always begin with the human voice.

Marisa’s Voice

When Marisa Actis and her spouse Krystal moved to Memphis 13 years ago, Marisa found a career at St. Jude in chemistry. Although she is originally from Argentina, and she had been in the U.S. for a while “Memphis felt like home, and my spouse and I both blossomed together here.”

For the last 10 years, Marisa has been exploring what gender meant to her. Three years ago, she realized that transitioning was where her path was headed. She and her spouse reached out and got involved with Memphis LGBTQ+ networks for gender- affirming support and began her journey. Marisa saw an article one day and learned about the Trans Voice Development Program.

John Sandidge (MA CCC SLP) and his team at the Memphis Speech and Hearing Center (MSHC) started working with Marisa. The program focused on vocal warm-ups, cool-downs, and developing habits that matched feminization for Marisa while also protecting her vocal cords.

“I had friends who had transitioned and done some voice development programs, whether it was self-taught through YouTube or with a specialist. I’m someone who does better when I have an instructor or someone to guide me on a personal level…this program helped me feel supported, and it was all so intriguing and validating.

“One of the things I learned from John and his students during the program is to be patient and take care of my voice so I can develop it into something that is right for me.”

The MSHC program not only focused on skilled, client- centered care but on honoring who a person is, the time that that person may need in the program, and that one’s experience not be bound by the limitations of cost.

John’s Voice

With a life influenced by David Bowie, watching drag shows, and living queer dynamics in Memphis as well as Los Angeles, John is a witness to the evolutions of trans communities and what being trans means to so many. He shared that “this isn’t dress up. It’s someone who believes they aren’t who their assigned body has been, and through speech and voice therapy, we can help people be who they want to be.”

As a professor and clinical practitioner, John emphasizes that providing this allied health support to trans people can improve safety and wellbeing in many ways. “Once their voice is intact, they can fully live as their true ‘vocal selves.’ It’s incredibly important to provide this support; it’s extremely rewarding, and we are saving lives. We are welcoming. We are a safe space.”

Accessing voice development therapy can be hit or miss for individuals who are starting their journey. “There’s a lot of snake oil on Youtube; I’ve watched it,” John says. “It’s always pitch- based and that can really damage your voice and body. There’s so much erroneous information, and if you don’t know what you’re looking for, you can’t tell what true vocal training is and what could damage you. A speech pathologist who is able to personally and patiently work with you on your vocal goals is something that everyone deserves and should be able to access and afford.”

Voice-Informed Policy and Affordability

Health insurances, whether it be Medicare, Medicaid or single-payer, are all different when it comes down to coverage for gender-affirming care. The goal one day is for federal policy to be as inclusive as possible so that people can get the care they need no matter where they are in the U.S. or what coverage they have.

From a national perspective, Title VII prohibits denying the right to federally funded services, including Medicare or Medicaid, based on a person’s “sex.” Of course it doesn’t mean a person’s gender-affirming healthcare will be covered or even acknowledged, so federal efforts to mandate inclusion have carried to some state and single-payer policies but are not as substantial as trans healthcare advocates would like for those policies to be.

The Patient Protection and Affordable Care Act (ACA) requires that “a health plan or health insurer that receives federal financial assistance from the Department of Health and Human Services (HHS) cannot categorically exclude all services related to gender transition and/or make coverage decisions in a manner that results in discrimination against a transgender individual.” This of course is a step in the right direction but there needs to be more equitable trans coverage. Although some states are evolving, an average of 18 states have affirmative coverage for transition-related care for Medicaid and/or coverage requirements for private payers (Tennessee is not one of the states btw). Where there is momentum around the specific inclusion of gender-affirming voice therapies, there can still be barriers to accessing it such as transportation to appointments.

Thinking from a state perspective, advocates see a lot of variations in true access and affordability, especially for single-payer policies. To explore this variation and future impacts, researchers conducted a cross-sectional study of 150 insurance companies and healthcare payers to analyze the equality of state-by-state coverage for gender-affirming surgery and voice therapy. Only four (2.7%) had affirming policies; 113 (75%) had no policies, and lagging coverage for voice- modifying surgeries and therapies were inconclusive. Until policy is further developed, and for those with private/single-payer insurance, advocates suggest exploring the following questions for navigating the system:

  • What services may or may not be covered for transition-related care?
  • If voice therapy is denied, how can it be appealed?
  • What provider types are eligible to deliver services for transition-related care?

To fill some of the gaps in access, the Transgender and Legal Defense and Education Fund has identified some details about voice therapy and surgery coverage. Thinking locally, if a person doesn’t have insurance or if insurance doesn’t cover services that the MSHC offers, their Board of Directors offers a Client Assistance Program (CAP) that can clients cover costs if they qualify.

“Most of the time (voice therapy) is not covered,” John said, “but we have a wonderful cost services program so anyone who comes into the clinic can at least apply. There’s no guarantee they will qualify, but it’s a start, and the MSHC can work with you. Health insurance should cover these things, and there will be evolution in insurance hopefully one day.

If you are a full-time student at (UofM), it’s free to participate in the voice program, and we do take insurance if you have a policy that covers the voice therapy.”

Getting services covered by insurance is a challenge, Marisa added. “I’m thankful that my insurance covered this program…it’s a wonderful program and the staff are supporting and affirming to who I am.”

The Impacts of Voice in Memphis

With UM being a long- standing epicenter of graduated education in communication sciences and disorders, the program is growing. “The more graduate students we have,” John says, “the more we can serve the community.”

Clients at the MSHC also include persons with language disorders, swallowing disorders, developmental disorders affecting language and cognition, and persons learning to speak with their cochlear implants or hearing aids.

“This program impacted me in so many ways,” Marisa shared. “I have received a lot of help from LGBTQ+ networks on how to file name changes and make affirming changes, but the voice training is so important because when I’m talking on the phone and making appointments for a name change or other affirming process, part of what others pick up on when they meet me is to try to figure out my identity. The conclusion people make about one’s identity is not just what they see but also what they hear. Being able to use your most authentic and affirming voice to communicate what you’re trying to do is such an important part of life. Being able to present my true self is very important as I face society and as I advocate for myself.”

Future Voices

Addressing economic and legislative barriers to gender- affirming resources like surgeries and voice therapy is an important part of improving healthcare inequities in LGBTQ+ communities. Leveling disparities through inclusive and affirming policy isn’t just for folx accessing these valuable and life-saving health resources now but for future generations as well.

Marisa shared that these affirming therapies allow people to “be themselves and express themselves, especially in public. Having the platform to speak while using the voice that fits you gives you a safety blanket.”

To learn more, call the MSHC at 901 678-2009 or visit: www.memphis.edu/mshc/

To donate to the CAP program, visit: https://securelb.imodules.com/s/1728/interior.