Teaching Queer Concepts to Graduate Students in Communication Sciences and Disorders: Culturally Responsive Pedagogy to Foster Affirmative Clinical Practice

Abstract

There is a growing body of literature informing pedagogical content and strategies of diversity, equity, and inclusion in the education of speech-language pathologists. However, little discussion has included content related to LGBTQ+ people, even though LGBTQ+ people exist across all racial/ethnic groups. This article seeks to fill that void and provide instructors of speech-language pathology with practical information to educate their graduate students. The discussion uses a critical epistemology and invokes theoretical models, such as Queer/Quare theory, DisCrit, the Minority Stress Model, the Ethics of Care, and Culturally Responsive Pedagogy. Information is organized according to developing graduate students' awareness, knowledge, and skills and challenges instructors to modify current course content to disrupt systemic oppression.

Keywords

queer theory - culturally responsive pedagogy - LGBTQ +  - transgender - speech-language pathology

Learning Outcomes: As a result of this activity, the reader will be able to:

• Discuss theories related to teaching graduate students to best serve LGBTQ+ clients.

• Critically analyze their own teaching in order to become more inclusive and culturally responsive.

• Define terms that are commonly used to describe gender and sexual diversity in a culturally responsive manner.

Historical Context and Current Status

Diversity related to biology and culture continues to thrive. Nevertheless, historical and ongoing efforts across the world to erase, criminalize, and otherwise invalidate people from marginalized groups continue to manifest health disparities for those who are most vulnerable. Since 1969, with the creation of the Black Caucus, which would later be known as the National Black Association for Speech, Language, and Hearing (NBASLH), the narrative of teaching diversity within Communication Sciences and Disorders (CSD) programs has continued to grow and evolve. Eventually, the American Speech-Language Hearing Association (ASHA) and the Council for Academic Accreditation (CAA) strengthened the requirement that CAA-accredited programs infuse information on diversity, equity, and inclusion (DEI) across the curricula for audiology and speech-language pathology (SLP).[1] These policies requiring CSD faculty to include multicultural content throughout their curricula formally began in 1994, when CSD instructors, who are predominantly White, would never have received such an education when they were students.[2] In fact, around the time of the implementation of these pedagogical requirements, Wallace (1997) reported that 67% of certified SLPs practicing in the field of adult neurogenics did not feel competent serving diverse populations.

A study by Stockman et al investigated how CSD faculty in the United States were navigating these new requirements; however, they did not investigate how instructors included topics related to sexual orientation and mentioned only the broad category of “gender.”[2] Interestingly, in the original survey, Questions 30 and 43 asked “Which of the group differences do you emphasize within your course content?” Question 30 pertained to courses not devoted specifically to multicultural/multilingual issues and Question 40 pertained to those courses that were devoted to the topic. The options included “race, ethnicity, geographical region, socioeconomic class, and gender.” The LGBTQ+ Caucus of ASHA (L'GASP) recorded an oral history project, and one of the authors of the survey revealed that in the original version of the questionnaire, sexual orientation was included as one of the options. However, officials at ASHA requested that the investigators remove sexual orientation from the list of topics, because they thought it would be too controversial to include it.[3]

Since that survey was created, ASHA has come to embrace the need for professionals to become more educated about serving the LGBTQ+ population. Discrimination on the basis of gender, gender identity, gender expression, and sexual orientation are all included within guiding policy documents, such as the ASHA Code of Ethics and CAA standards for accreditation,[1] [4] as well as resources on their Web site for supporting gender diverse clients.[5] In fact, the revised CAA standards (effective January 2023) strengthened the requirement that programs give students the “opportunity to identify and acknowledge” numerous concepts related to decreasing bias and increasing DEI as they relate to multiple identities, including gender identity, gender expression, sex, and sexual orientation.[4]

The resources are meeting a need in the profession, because according to some recent surveys, many SLPs and graduate students do not feel comfortable serving the members of the LGBTQ+ community.[6] [7] While 77.8% of SLP students agreed that treating clients who were transgender was within the SLP scope of practice, and 82.2% believed that it was their ethical responsibility, only 20% stated that they had received training to work with transgender people.[7] Even though it appears that a high number of SLP students agree that treating transgender clients is part of their job as an SLP, it is notable that almost one in four of them did not feel that it was. It is unclear if these respondents feel they should actively deny speech-language services to transgender people because it is not within the scope of practice, or if they believe that gender-affirming voice and communication services are outside the scope of practice. While both possibilities represent misconceptions about our field, they are also evidence of beliefs that could cause harm to any transgender clients that seek services from them, even if it is for issues unrelated to their gender. Hancock and Haskin reported that although SLPs expressed generally positive feelings toward the LGBTQ+ community, many were still uncomfortable working with the population primarily due to a lack of knowledge.[6] While literature regarding multicultural instruction in SLP continues to grow, very little of this literature mentions diversity related to gender and sexual orientation. Mahendra presented a sample course description of a graduate-level class dedicated to the instruction of LGBTQ+ issues.[8] The sample course included (1) self-assessment of knowledge, experiences, and implicit biases; (2) group demographics and LGBTQ+ history; (3) and health disparities and research devoted to understanding the healthcare needs of the LGBTQ+ community. They identified several areas that students felt would improve understanding related to LGBTQ+ people. Some of these suggestions included (1) how to be an ally, (2) guest lectures from marriage and family therapists, and (3) working with transgender children, and techniques for gender-affirming voice and communication therapy.

The results of Mahendra's study are similar to findings with nursing education conducted by Higgins and colleagues. Higgins and colleagues conducted a review of research investigating best practices when educating nursing students about working with the older adult LGBTQ+ community.[9] There were several themes that were pertinent to teaching graduate students in SLP: (1) including information about LGBTQ+ history, particularly for working with older LGBTQ+ people; (2) acknowledging that the LGBTQ+ community is not homogenous, but a group with diverse perspectives and experiences; (3) including interactive educational methods for students; and (4) involving LGBTQ+ people in the curriculum development.

Little discussion has been devoted to helping SLP instructors teach their students about issues related to LGBTQ+ people. This article seeks to fill that gap and pull the pedagogy of culturally responsive education into the discussion of educating CSD graduate students to deliver compassionate care to LGBTQ+ clients, students, patients, and families.

Theoretical Foundations

As our profession moves firmly into the 21st century, some foundational paradigms that have largely gone unquestioned and unexamined are beginning to be examined with a critical eye by an increasing number of people. One of the main tasks of preparing future professionals to interact with a diverse population is to increase awareness of those unexamined paradigms so that they may begin to increase their clinical knowledge and skills.[10]

This discussion will be framed using a critical epistemology,[11] meaning that current accepted practices and procedures will be discussed in a way that will shine light on how they support oppressive processes, such as heteronormativity, cisnormativity, misogyny, racism, and ableism. We will frame the discussion using several theoretical models, namely, Queer theory/Quare theory,[12] [13] DisCrit,[14] the Minority Stress Model,[15] the Ethics of Care,[16] [17] [18] and Culturally Responsive Pedagogy.[19]

In every scholarly discussion, analyses and interpretations are biased according to the lived experiences of the authors. Therefore, we offer these positionality statements as a reference for the reader to understand the perspectives of the authors. Gregory Robinson is an associate professor living in Central Arkansas. They are a nonbinary, White speech-language pathologist. Andi Toliver-Smith is an assistant professor, who divides her time between Central Arkansas and the District of Columbia area. She is a cis female Black speech-language pathologist. Lorraine Stigar is a DrPH student in public health. They are a nonbinary, White doctoral candidate living in Central Arkansas.

Queer/Quare Theory

This article invokes premises of Queer theory[12] through an understanding that categories of gender and sexuality are social constructed. Humans create terms that attempt to categorize a gradient reality. Just as colors exist on a spectrum of light that are perceived by most humans as gradual change from red to violet, that spectrum of colors is divided into categories that humans will call red, orange, yellow, etc. These categories are partly supported by the measurable effects of light influencing sensory nerves in the eyes and brain but also created through cultural understanding and meaning made by humans based on their experiences with other humans. The reality of sexuality and gender is no different. Gender is somewhat biological and somewhat cultural.[20] In reality, it exists on a spectrum that is divided into categories by humans based on their experiences with other humans. Because cultures change over time, so do the categories.

Due to the fact that concepts of gender are significantly shaped by sociocultural influences, the story of gender is different for different sociocultural groups. Johnson proposed Quare theory as a way to fill the void of Black perspectives represented in many discussions of Queer theory.[13] It is an acknowledgment of the historical factors that have coalesced to create a different understanding of gender, gender expression, and sexuality in people from the Black diaspora compared with other sociocultural groups.[38]

DisCrit Theory

DisCrit theory[14] combines critical race theory and disability studies. It posits that racism and other forms of discrimination and oppression are built upon ableism. The historical tradition of pathologizing marginalized identities is an effort to dehumanize or degrade people using the very forces of oppression extended to disabled people. DisCrit is particularly relevant in this discussion, because the field of SLP is built upon a foundation of pathologization of speech and language differences.[21]

Minority Stress Model and the Ethics of Care

The minority stress model and the ethics of care work in concert with each other. The minority stress model[15] provides a framework of understanding the psychological impact of discrimination, rejection, and micro- and macro-aggressions on people that may be occurring regularly for marginalized people. These effects may be mitigated by developing resilience that comes in the forms of a personal sense of acceptance and pride and connection with others.

The ethics of care[16] [17] [18] is an ethical philosophy that frames ethical practice as a set of behaviors that seeks to care for others. Caring involves paying attention to the suffering of others, recognizing the responsibility to use power and privilege to help relieve that suffering, developing the competence to provide care that is desired by the person and beneficial, and to respond to care received with gratitude.

Culturally Responsive Pedagogy

While the population at large includes clients and patients from diverse perspectives and experiences, so does the population of graduate students. One of the big challenges with graduate school preparation is that when students enter a program, it is impossible to know their values, beliefs, biases, and perspectives. In fact, the students themselves may not have a conscious awareness of these aspects of culture, particularly regarding how they can influence their own interactions with others. Therefore, a critical part of DEI education involves helping students develop awareness of these aspects in themselves. This point is where culturally responsive pedagogy comes in.

Culturally responsive pedagogy, as described by Gay, stipulates that instructors should meet the students where they are.[19] Teaching is viewed as a relationship that responds to each student with the understanding that all learning is filtered through the lens of our past experiences with the various cultural groups that have shaped them. Students are encouraged to apply new knowledge to old concepts. In turn, the style of teaching is validating and understanding of diverse values and beliefs. It seeks to liberate and empower students to apply their knowledge to their own lives. It also seeks to be transformative for students, as they acquire new information that might challenge old beliefs.

Hammond specifically addresses three parts to create a culturally responsive environment: building awareness and knowledge, building learning partnerships, and building intellective capacity.[22] She further defines culturally responsive teaching as an educator's ability to recognize students' cultural displays of learning and meaning-making and respond positively and constructively with teaching moves that use cultural knowledge as a scaffold to connect what the student knows to new concepts and content to promote effective information processing. All the while, the educator understands the importance of being in a relationship and having a social-emotional connection to the student to create a safe space for learning. Evidence indicates that providing a culturally responsive education can strengthen student connectedness with school and enhance learning.[23]

Students from various cultural backgrounds, including those who are LGBTQ + , must feel safe when engaging in classroom activities in order for learning to take place. If students do not feel safe and accepted, they will ultimately “shut down” and become unresponsive to our efforts. The students must have an active voice in creating their learning environment. By supporting the students' culture and their identity, educators show their willingness to learn. One of the key components of culturally responsive teaching is that both the student and the educator have something to teach and learn. In traditional educational environments, the classroom is often a space where the educator dominates the classroom; however, in this case the student also makes contributions to the learning environment. By empowering the students to become active agents in their own learning, the material is infused with greater personal meaning for the students.

Culturally responsive pedagogy for the purpose of preparing future SLPs, however, is not just concerned with the instructional techniques of the instructor. In the field of speech-language pathology, the task of being a culturally responsive teacher for the CSD instructor is to create culturally responsive teaching skills within their students. For this reason, it is important to note that culturally responsive teaching does not simply allow past cultural knowledge to exist without challenges. Instead, it fosters the increasing self-awareness of what students believe and helps them identify, challenge, and disrupt those biases that might impede clinical practice among diverse groups of people. This task requires both the instructor and the student to acknowledge that they have things to learn and things to teach each other. This understanding, in turn, allows that dialectical relationship to continue as the student becomes a clinical practitioner and begins the same practice with their clients.

Hyter and Salas-Provance provide us with two ways of using culturally responsive teaching.[24] They describe both the human rights approach and viewing cultural responsiveness through the social justice lens. Human right refers to the privileges that all human beings have regardless of their social station, identity, or racialized background. Communication is considered to be essential to our humanity and is a human right. They further ascertain that everyone has the right to freedom of opinion and expression. These rights are for all people and extend to those with communication disabilities.

The human rights approach can be achieved by incorporating core values into clinical practice, educational endeavors, and scholarship using five values as a guide to teaching. Those values include fairness, respect, equality, dignity, and autonomy or FREDA. Hyter and Salas-Provance point out how communication professionals often work outside of these parameters by using culturally and linguistically biased assessments, which often result in the disproportionate representation of Black and Indigenous children of color in special education and by having limited presence of people from culturally, racially, and linguistically diverse backgrounds in the profession.[24] It is important that the LGBTQ+ people within these cultures be recognized and represented, especially while engaging in clinical practice, policy development, teaching, and scholarship.

When implementing culturally responsive teaching through a social justice lens, it is important to recognize the inherent dignity of all people and to value every life equally. This view calls for both personal reflection and social change to ensure that each of us has the right and the opportunity to thrive in our communities.[24] As a field, we must acknowledge that oppression does indeed exist and work toward ending systemic discrimination and structural inequities. This model describes the differences between affirmative and transformative actions and how both should be used to mitigate injustice. A social justice approach requires immediate, pragmatic action paired with a larger critical analysis, and to fight against structural violence. Structural violence was initially described by Galtung in 1969. It occurs when the social structures, such as the economy, politics, and cultural institutions, cause avoidable inequities. Clinicians do not usually receive education about structural violence and its social forces; however, our interventions will fail if we are unable to understand the social determinants of disorders and disease.[25] The LGBTQ+ culture has been subject to structural violence in that they often have unequal access to healthcare and are systematically denied medical treatment that preserves their mental health. This culture is often exposed to physical violence as well. These acts of violence are sanctioned and performed by law enforcement and supported by government agencies. This is commonplace for this population, even in the workplace and professional settings (see [Table 1]).

Table 1 Social and health disparities among the LGBTQ+ population

Condition	Rate	Affected group
Poverty	Two times greater (cf., gen. pop.)[a]	TGNB
	Three times greater (cf., gen. pop.)[a]	TGNB people of color
Unemployment	Two times greater (cf., gen. pop.)[a]	TGNB
	Four times greater (cf., gen. pop.)[b]	TGNB people of color
Homelessness	30%[a]	TGNB
	50%[a]	TGNB who are undocumented
	41%[b]	TGNB who are Black
Attempted Suicide	41%[a]	TGNB
	49%[b]	TGNB who are Black
	Eight times greater (cf., gen. pop.)[c]	LGB+
	Two times greater (cf., gay/lesbian)[c]	Bisexuals
Harassment at school	50%[b]	TGNB who are Black
Harassed in a medical setting	28%[a]	TGNB
Refused care in medical setting	19%[a]	TGNB
Required to educate medical providers	50%[a]	TGNB
Postponed necessary healthcare due to fears of discrimination	76%[a]	TGNB
Rejected by family/friends	50%[a]	TGNB
	39%[c]	LGB+
Physically attacked	38%[a]	Trans women
	20%[a]	Trans men
	16%[a]	Nonbinary
	30%[c]	LGB+
Rejected from a place of worship	19%[a]	TGNB
	29%[c]	LGB+
Target of jokes or slurs	58%[c]	LGB+
Depression	Six times (cf., gen. pop.)[c]	LGB+
Rape/Sexual Assault	46%[c]	Bisexual women
	47%[c]	Bisexual men
	47%[a]	TGNB

Abbreviations: TGNB, transgender and nonbinary; LGB + , lesbian, gay, bisexual, and other sexual minorities.

^a James et al.[32]

^b The Task Force, National Black Justice Coalition, and National Center for Transgender Equality.[33]

^c Movement Advancement Project.[31]

Both a human rights approach and social justice lens approach require an understanding of equity and intersectionality. Educators must pursue deeper understanding to adequately support students of this culture.

Curricular Content

Horton-Ikard and colleagues outlined some considerations in creating a multicultural course in communication sciences and disorders. While, their article did not mention the topics related to LGBTQ+ people, specifically, many of the principles to be considered are the same.[10] Namely, when educating students about diverse groups of people, such an education includes the broad educational categories of awareness, knowledge, and skills. These categories are reflected in the standards for certification commonly known as the KASA objectives.

Awareness

Awareness involves providing students with opportunities to become mindful of their own biases, covert and overt systems of discrimination and oppression, and the harms that result from systemic oppression to marginalized groups of people, including those who are LGBTQ + . Increasing awareness requires that students understand how people at the intersection of multiple marginalized groups (e.g., Black trans women) often experience discrimination across all of their communities, which can increase health disparities such as mental health support and lack of access to appropriate healthcare.

Among all of these considerations in regard to increasing awareness, perhaps the most challenging is when students are tasked with confronting their own biases. Confronting their own biases and/or those biases that are present in people that they care about may create cognitive dissonance, denial, resistance, and anger/shame. These uncomfortable feelings are often avoided by seeking justification for the biases. Some may justify their biases by claiming that their religion prohibits them from caring for certain groups.[26] Others may claim that these groups “chose” that “lifestyle,” and therefore they should expect the discrimination that comes with it. Still others may claim that such discussions about DEI are “political” and should be avoided.

At the core of all of these, rationalization attempts are normativity, supremacy, and erasure. Normativity is the characterization of some traits to be “normal” and others to be “deviant.”[27] For example, heteronormativity centers heterosexual relationships as the default, and any other relationship to be abnormal.[28] Cisnormativity is the belief that identifying as one of the two sex categories assigned at birth is the only “normal” gender. Processes of normativity are ways of denying inclusion and equity for groups because these are the processes commonly used to deny individuals who are considered “different” such as disabled people from the supports they need. In general, supports and validation is provided as a default to those without disabilities. Any supports that are outside that “norm” are considered “special” and require verification and justification. The fact that ableism, or discrimination against people with disabilities, is used as a guiding force for discrimination against other marginalized groups is addressed by the DisCrit theory.[14]

Supremacy is related to normativity.[29] Normativity assumes some traits present across a diverse population to be normal and classify others as abnormal. This assumption of normality provides those with “normal” traits a whole host of privileges. Embedded within these privileges is an assumption of supremacy, or the belief that some groups of people are inferior to other groups of people. For example, at some university programs, same-sex relationships are punishable offenses that may lead to expulsion or other disciplinary actions for students. In essence, those who have a heterosexual orientation may be considered superior, sanctioned by God, and may discuss their relationship without concern for safety. Conversely, those with other sexual orientations may be considered to be an “abomination.” Therefore, the mere association with such individuals may be forbidden by some universities controlled by religious groups or students who come from similar religious backgrounds.

Erasure is the process of denying the existence of groups of people as valid members of society. Erasure can be either passive or active.[30] Active erasure is achieved through intentional subjugation of queer identities. Passive erasure manifests from a lack of knowledge, and is the type of erasure that arguably would be most common among graduate students. This is often performed as a lack of “understanding.” Students may say, “I just don't understand how anyone can be trans; it just doesn't make sense to me.” Passive erasure may come from an assumption that the feelings within oneself may simply be projected onto another person in an attempt to understand. Sometimes this attempt at empathy is marginally successful. For example, even though a person may not have ever experienced the death of a loved one, many of us can imagine how we might feel if that did happen. While such an imagining may be imperfect, it does get the person close to an understanding of someone else who did just lose a loved one. However, understanding the feelings associated with sexual orientation, gender identity, and other personal traits are not as accessible using this attempt at empathy. A person with heterosexual orientation may find it completely impossible to imagine same-sex attraction. A cisgender person may find a transgender identity incomprehensible. When lack of understanding is used as an attempt at erasure, students should be reminded that the very fact that they cannot understand it is justification for the unique experience. Helping students release the need to “understand” without releasing the need to be “understanding” is part of the journey to increasing awareness.

Knowledge Development

Increasing knowledge may depend on increasing awareness. Some students may be so resistant to the concepts concerning LGBTQ+ people, and they will not be able to acquire new knowledge. However, sometimes exposure to facts and evidence allows for an increase in awareness of biases. Knowledge relevant to LGBTQ+ people include terminology, rates of social and health disparities, and processes for disclosing sexual orientation and gender.

Terminology. The language associated with LGBTQ+ people is rapidly changing to keep up with advancing knowledge related to gender and sexual orientation. A list of terms with commentaries is provided in the Appendix.

Social and health disparities. Selected social and health disparities experienced by LGBTQ+ people are presented in [Table 1]. This list of disparities was collated from the results of two national surveys. One survey was devoted to sexual orientations,[31] and the other included only transgender and nonbinary (TGNB) people.[32] These disparities are largely amplified for Black, Indigenous, and other LGBTQ+ people of color.[33] For example, while overall TGNB people are twice as likely to be in poverty and twice as likely to be unemployed, TGNB people of color are three times more likely to be living in poverty and four times more likely to be unemployed. Half of TGNB people who are undocumented have experienced homelessness, compared with 30% of TGNB as a whole. It is also noteworthy to understand that a greater number of LGBTQ+ people have a diagnosis of autism.[34] [35] Hall and colleagues compared health disparities among LGBTQ+ autistic people to autistic people who were not LGBTQ + .[36] They reported significantly higher rates of mental illness, poor physical health, and inability to access needed medical care among the autistic LGBTQ+ group.

Disparities across sexual orientations tend to be greater for bisexual and other multiple gender attractions compared with lesbian and gay people. Namely, bisexual women are far more likely to have been raped or otherwise sexually assaulted, compared with lesbian and heterosexual women, and bisexual people are far more likely to attempt suicide compared with lesbian and gay people. These disparities are often associated with double discrimination experienced by many bisexual people, meaning that they may experience rejection and other forms of oppression from both the gay/lesbian and heterosexual communities. In addition to these social and health disparities, transgender people are three to six times more likely to have a diagnosis of autism,[34] and people with autism are almost eight times more likely to be TGNB.[35]

The psychological effects of discrimination and oppression for marginalized groups have been identified in several minority stress models, pertaining to race, sexual orientation, and disability. The models have a lot of similarities. Namely, they generally classify stresses as either external (those coming from outside the person) or internal (those generated by the thoughts of the person). Those stresses are mitigated by the existence of supports and/or internal resilience (e.g., a sense of pride in their identity, connection to a group of similar people). The culmination of external and internal stresses in the context of supports or a lack of supports manifests outcomes for the person that may be beneficial or detrimental. These minority stress models are important sources of knowledge for students, because they can help them see their role preventing external stresses, namely understanding the accumulation of internal stresses and encouraging factors that increase resilience against those stresses.

Processes for disclosing sexual orientation and gender. Processes for disclosing sexual orientation and gender are important knowledge for students in working with LGBTQ+ clients, because it helps them understand how to respond when a client makes such a disclosure. When someone discloses their sexual orientation or gender, it is often referred to as “coming out”; however, it may be helpful for students to understand it more as “inviting in.” Since there are numerous societal risks that come from being LGBTQ + , many people attempt to protect themselves by disclosing only those aspects of themselves to people they deem to be safe.[37] Robinson and Crisp conducted a survey across the United States of LGBTQ+ people. Respondents were asked how a teacher should and should not respond when a student discloses their sexual orientation or gender identity.[38] Themes of positive responses were celebration, validation, gratitude, noticing the courage, identifying as a safe space, giving advice, and no response. Themes of negative responses included the following: taking away agency of coming out (e.g., suggesting to remain closeted, pressuring them to come out to others, telling them that you already knew or could tell from their behaviors), questioning their certainty or suggesting it is just a phase, prying about personal issues, apathy/dismissing/alienation (e.g., “that's no big deal,” “don't talk to me about that”), pressuring them to educate you or others, or bringing up religion. Many clients never disclose their sexual orientation or gender identity to their SLPs and audiologists[38]; however, when they do, they trust the professional with information that is highly personal, vulnerable, and may put them at significant risk.

Skill development. Although SLPs have been serving LGBTQ+ clients and families across the scope of practice, the expansion and embracing of gender-affirming communication services has provided students with opportunities to increase their skills about unique and non-unique issues affecting the TGNB population and, by association, the broader LGBTQ+ population. ASHA has published resources to help professionals provide LGBTQ+ affirming care, including a published online resource devoted to clarifying how clinical practitioners can better support gender diverse populations.[5] However, clinical skill development comes from experience working and interacting with the LGBTQ+ population. Such experience is often provided to students in university clinics that provide gender-affirming communication services for the local TGNB community. However, universities should explore other opportunities for students serving the LGBTQ+ community, such as providing voice and hearing screenings at LGBTQ+ pride events and community organizations that serve the LGBTQ+ community.

One skill that is important for SLP students is counseling the LGBTQ+ population. In general, counseling skills for this population are similar for the wider population, and should include guided experiences for students to practice counseling skills associated with listening, empathy, paraphrasing, and challenging. However, some adaptations need to be understood by students engaging in counseling LGBTQ+ clients. As explained, LGBTQ+ people are likely to be experiencing discrimination daily that may span from microaggressions to physical assault. As the minority stress model[15] illustrates, the external stresses build up to create internal stresses. Factors that may mitigate these stresses include developing a sense of pride in their identity and a feeling of connectedness with others. Therefore, the clinicians need to develop skills in helping to develop empowerment and affirmation. Due to societal forces of heteronormativity and cisnormativity, many LGBTQ+ people are faced daily with subtle and overt messages that deny or vilify their existence. These messages created a conflict between what they are being told they are or should be and what they know they are as the experts on their own identity. To alleviate this conflict, the SLP practices affirmative care.

Affirmative care involves the following agreements: (1) the client is the foremost authority on their own gender and sexual orientation; (2) they are in control of disclosing these aspects of themselves to others; and (3) meaning is expressed through symbols that communicate understanding and acceptance of identity. The SLP student should be allowed safe space to practice these affirmative care skills, which may involve role play, written or verbal responses to case presentations, simulated clients, or actual clients from their practicum experiences.

Many of the primary symbols that carry power to affirm or disaffirm gender are contained in language. In English, such symbols are direct references to gender (e.g., man, woman, guy, girl, boy), third-person singular pronouns in English (e.g., he, she, they), honorifics and titles (e.g., Mr., Ms., Mx., Dr., Professor), and descriptors (e.g., pretty, handsome). Referring to people's gender in an accurate way is a basic level of respect for anyone, but for TGNB people, this basic act of respect does not always happen, which makes it even more important for SLPs to be accurate. Due to the unequal power and the vulnerable nature of the relationship between an SLP and their client, progress in therapy depends on the client feeling safe. Therefore, SLPs should share their own pronouns and ask for the pronouns of their clients. When the pronouns are learned, the SLP need to practice to assure 100% accuracy. Little research has been done on how to improve accuracy with new pronouns, but the nonbinary author, Jeffrey Marsh, suggested that the change may be more at the semantic level of language than the morpho-syntactic level. In other words, if an SLP is struggling to use the correct pronouns with a TGNB client, the issue may be about the fact that the SLP does not “see” that client as the gender they are.

Conclusions

Instructors in speech-language pathology are tasked with preparing professionals to work across an expansive scope of practice. This task is expected to be achieved within 5 to 6 semesters for most graduate programs. This task, in itself, may seem daunting. Therefore, instructors will commonly state that they “do not have time” to add information about diverse groups into the curriculum.[39] This resistance represents an understanding of multicultural education that Stockman et al referred to as annexation, or the belief that DEI are topics to be added to content that is already present.[2] A more efficient and effective model is that of integral infusion.[38] Integral infusion calls upon instructors to realize that their educational content already includes information about race, ethnicity, gender, and sexual orientation, whether it is obvious or not. If these topics are not mentioned or critically examined, it does not mean that they are not being addressed; it means that the content is relying on assumptions of normativity that privilege those groups in power. Therefore, strategies for educating SLP students on issues concerning LGBTQ+ people and other marginalized groups are often less about adding additional content and more about recognizing when gender, sexual orientation, race, and ethnicity are being assumed or amplified in educational content and then looking for small ways to disrupt those assumptions.

Consider this example of the opening of a case study on a graduate school test: “This case is a 5-year-old male diagnosed with a fetal alcohol spectrum disorder. He presents with…” The processes of infusing diverse perspectives and dismantling oppressive, unexamined systems require even this small item to be critically questioned. Consider the following. Why is the fact that the case is a “male” highlighted as one of the most important pieces of information in this case description? Notice that the gender of the child is presented even before the diagnosis itself, and it is also redundant information because the pronoun he is used in the following sentence. The age, of course, would be necessary to interpret any results from the assessment that follows, but gender is of marginal importance. What relevant information is not remarked on that could influence the interpretation more than gender? Arguably, the language(s) spoken by the child is of utmost relevance to the interpretation of the results, but in this case it is not mentioned. What is assumed by not mentioning the language(s) spoken by the child? Many might assume that this child speaks only English. Why is this assumption, given that the majority of the world is not composed of monolingual English speakers? This elevation of gender as relevant information, failure to mention language(s) spoken, and the default assumption of English as the only language, are small considerations in a case representation that actively, albeit unwittingly, reinforce oppressive systems of normativity.

The work of dismantling the systems of the past that are obsolete, harmful to marginalized groups, and impair the clinical education of our future professionals is accomplished through the tiny choices instructors make every day. This work involves meeting the students where they are (i.e., culturally responsive teaching), creating safe spaces of affirmation and validation, and helping students, not just understand others' perspectives but to be more understanding of different ways of constructing meaning and purpose out of life.

Appendix Glossary of terms related to sexual orientation and gender diversity

Term	Definition	Further comments
Gender	The characteristics and roles of women and men according to social norms	While sex may be described as female, male, and intersex, gender may be described as feminine, masculine, androgynous, and much more
Gender identity	The innate, personal sense a person has regarding who they are along the spectrum of male to female
Gender expression	How a person chooses to convey their gender in terms of clothing, mannerisms, communication, etc.
Transgender	A term for people whose gender identity, expression, or behavior is different from those typically associated with their assigned sex at birth	Transgender is a broad term and is good for everyone to use. “Trans” is shorthand for “transgender.” Transgender should be used as an adjective not a noun, thus “transgender people” or “trans people” are appropriate but “transgender” is disrespectful. Do not put an –ed on the end (“transgendered”)
Transgender man	A person who is a man, but was assumed to be female at birth	Previously referred to as “female-to-male” (FTM) and “male-to-female” (MTF). Avoid writing these as one word (e.g., trans woman/trans man)
Transgender woman	A person who is a woman, but was assumed to be male at birth
AMAB/AFAB	Assigned (or assumed) male/female at birth	Preferred term over “biologically male/female”
Intersex	A person who has biological features commonly associated with both male and female people	Intersex conditions occur in 1.7% of the population.[40] [41] Many people don't know they are intersex until puberty. Ambiguous genitalia (one sign of intersex) occurs in 6/1,000 births (∼65 babies with ambiguous genitalia born every day in the United States.[42] Surgeries are often performed without the knowledge or consent of the parents.[43] [44] The occurrence of ambiguous genitalia is increasing.[45] Intersex conditions do not constitute a “disease” but a failure of the binary classification of sex to capture all possible variables.[43]
Cisgender (cis man, cis woman)	A person who is the gender they were assumed to be at birth
Queer	An umbrella term to describe any combination of numerous genders and sexual/romantic orientations	Queer was used as a slur, but many in the LGBTQ+ community have reclaimed it. However, not everyone may be comfortable with this term due to its history
Nonbinary	A person who is neither entirely male nor female	There are multiple nonbinary gender identities. Some nonbinary people consider themselves transgender, and some do not
Gender nonconforming	A person who does not express themself in a way that is expected according to cultural expectations aligned with their gender assumed at birth
Two-spirit	A Native American term for a person who is TGNB	Refers to indigenous third, fourth, and fifth genders that were erased due to colonization
Dead name	A person's name associated with the gender they were assumed to be at birth	Calling a trans person by their dead name (dead naming) is often psychologically harmful
Gender dysphoria	A feeling of (often extreme) discomfort associated with the misalignment of the true gender and the one assumed from birth	May be triggered by body, face, voice, micro- or macro-aggressions, or internalized oppressive thoughts
Gender Euphoria	A feeling of joy associated with one's gender	May be triggered by people using the correct name, pronouns, achieving a desirable voice, and communication style, clothing, etc.
Sexual orientation	Innate attraction, sexual or romantic	Sexual orientation should not be assumed based on behaviors, interests, gender expression, or relationships (e.g., bisexual people are still bisexual, even when they are in heterosexual passing relationships; gay people are still gay even though they have never had a same-gender relationship
Gay	A man or nonbinary person, who is romantically and/or sexually attracted to other men (exclusively/predominantly)	“Gay” is also used as an umbrella term, similar to queer; however, some may consider this usage an erasure of bisexuality
Lesbian	A woman or nonbinary person, who is romantically and/or sexually attracted to other women (exclusively/predominantly)
Bisexual	A person attracted to people who are the same and different genders	Some use bisexual and pansexual interchangeably; some do not. When a difference is made, bisexuals experience different types and/or levels of attraction for different genders and pansexuals experience attraction that is unaffected by gender. Misconception: Bisexual people do not only experience attraction in accordance with the gender binary. Bisexual people are often attracted to nonbinary people and may even be nonbinary, themselves
Pansexual	A person attracted to people regardless of gender
Heteronormativity	The overriding, sociological assumption that heterosexuality is the “normal” sexuality that should be assumed for everyone and other orientations are deviant
Homophobia/biphobia/transphobia	The irrational fear of lesbian, gay, bisexual, and TGNB people	These fears are unfounded and often associated with LGBTQ+ people being:  a. Contagious: associating with LGBTQ+ people will change the gender or sexual orientation of others  b. Dishonest: associating the time it takes to understand themselves and tell others with lying or hiding  c. Sexually predatory: association with pedophilia and sexual assault

Abbreviation: TGNB, transgender and nonbinary.

Conflict of Interest

None declared.

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Publication History

Article published online:
07 March 2023