key: cord-0897834-9joqxzyj authors: Roblee, Cole V.; Mendes, Clarion; Horen, Sydney R.; Hamidian Jahromi, Alireza title: Remote Voice Treatment with Transgender Individuals: A Health Care Equity Opportunity date: 2022-02-11 journal: J Voice DOI: 10.1016/j.jvoice.2022.01.012 sha: 39541fb2e51584278bc41c383ab0c533fb5536c8 doc_id: 897834 cord_uid: 9joqxzyj nan 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. 6 (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. 15, 16 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 clientcentered approach to care that is often lacking in many spaces. 17 Many TGNB people experience social anxiety as a result of harassment and mistreatment in public spaces due to their gender identity. 8 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. 18 Gender affirming voice therapy can play an important role in alleviating some of this stress by modifying both gender attribution and self-perceived femininity. 19, 20 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. 21 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. 22 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. 6 They note that a head-mounted microphone positioned at 45-90 degrees away from the mouth is the gold standard for recording voice outcomes. 6 While telehealth has long been considered a promising option to advance access to specialized services in many fields, ie, gender affirmation care, 22,23 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. Telehealth: voice therapy using telecommunications technology Telepractice versus in-person delivery of voice therapy for primary muscle tension dysphonia Delivering group speech maintenance therapy via telerehabilitation to people with Parkinson's disease: A pilot study Use of telehealth during the COVID-19 pandemic: scoping review Implementation of telemedicine in a laryngology practice during the COVID-19 pandemic: lessons learned, experiences shared Observations and considerations for implementing remote acoustic voice recording and analysis in clinical practice Effectiveness of voice therapy in patients with vocal fold nodules: a systematic search and narrative review Gender-affirming telepsychology during and after the COVID-19 pandemic: recommendations for adult transgender and gender diverse populations Telemedicine in transgender care: a twenty-first-century beckoning Standards of care for the health of transsexual, transgender, and gender-nonconforming people version 7 Size and distribution of transgender and gender nonconforming populations: a narrative review Where We Call Home: Transgender People in Rural America The Message Is You Don't Exist": Exploring Lived Experiences of Rural Lesbian, Gay, Bisexual, Transgender, Queer/Questioning (LGBTQ) People Utilizing Health care Services Health inequities in LGBT people and nursing interventions to reduce them: a systematic review Barriers to primary and emergency healthcare for trans adults 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 Perceptual and acoustic outcomes of voice therapy for male-to-female transgender individuals immediately after therapy and 15 months later The effectiveness of oral resonance therapy on the perception of femininity of voice in male-to-female transsexuals Development and preliminary evaluation of the transsexual voice questionnaire for male-to-female transsexuals Video gaming and gaming addiction in transgender people: an exploratory study Telemedicine for gender-affirming medical and surgical care: a systematic review and call-to-action