EPISODE 37

[INTRODUCTION]

[00:00:00] ANNOUNCER: Do you enjoy listening to On the Ear, but wish you could earn ASHA CEUs for it? Start today! SpeechTherapyPD.com has over 175 hours of audio courses on-demand, with an average of 19 new audio courses released each month. Here's the best part, each episode earns you ASHA Continuing Ed Credits. Oh, no wait. This is the best part. As a listener of On the Ear, you can receive $20 off in annual subscription when you use code EAR21. Just head to SpeechTherapyPD.com to sign up and use code EAR21, E-A-R-2-1 for $20 off your annual subscription.

[00:00:48] DS: You're listening to On the Ear, an audiology podcast sponsored by SpeechTherapyPD.com. I'm your host, Dr. Dakota Sharp, Au.D, CCC-A, audiologist, clinical professor and lifelong learner.

While I primarily work with pediatric cochlear implants and hearing aids, I am absolutely intrigued by the many areas of audiology and communication in general. This podcast aims to explore the science of hearing, balance and communication with a variety of experts in hopes of equipping you to better serve your patients, colleagues and students. Let's go! We are live and On the Ear, brought to you by SpeechTherapyPD.com.

[INTERVIEW]

[00:01:35] DS: In our role as clinicians, especially in the world of communication, trust between ourselves and our patients is critical for success. A key component for cultivating trust with our patientÕs starts from a place of inclusivity, do our patients feel welcome? How can we make sure that transgender and gender nonconforming patients feel seen and included? Today's guest is going to help guide us through these conversations and ensure our clinical care is affirming for every patient we meet? 

Dr. Madison Howe Au.D, CCC-A, pronouns she, her, hers is a Pediatric Audiologist at Arkansas Children's Hospital and an adjunct instructor at the University of Arkansas for Medical Sciences. She received her doctorate of audiology degree from Auburn University. Dr. Howe is very involved with the Society for Ear, Nose, and Throat Advancement and children or SENTAC. She's given multiple presentations as an ally to the gender-diverse community. She is a firm believer in patient-centered care for all patients, including diverse cultural groups. 

[DISCLOSURE]

[00:02:25] DS: Just a couple of quick financial disclosures. I'm the host of On The Ear, and receive compensation from SpeechTherapyPD.com. Dr. Howe received compensation for her contributions to this presentation. Dr. Howe, Madison, whatever is the best way to refer to you, let me know. I'm so glad you're here.

[00:02:42] MH: Thanks, Dakota. Definitely Madison is just fine.

[00:02:46] DS: Perfect, perfect. I know, both working in pediatrics, it's hard to walk around with the doctor moniker. You shed that pretty quickly when you walk in the door with some kids, you don't want to freak them out.

[00:02:56] MH: Definitely. I feel like, I have to remind myself sometimes to use it in certain situations.

[00:03:02] DS: Agreed. Agreed. Yes, I've read an article that you wrote for Ð I think, it was the ASHAWire. 

[00:03:08] MH: Actually, there. Yeah. 

[00:03:10] DS: It was so interesting to me. There was something in all the difference, your presentations have been to and conferences and things like that, I've just never heard someone speak to Gender-Affirming Care and audiology and how this is important. Of course, the light bulb went off, I was like, ÒOf course this is important.Ó Of course, in the last few years as we become a lot more aware of our own implicit biases and how those impacts our clinical care, I hadn't really thought about how my implicit biases when it comes to gender identity could be impacting the way I approach patients, especially in pediatrics. I'm so grateful that you wrote that. It came across my eye because I think this is such an important conversation.

[00:03:46] MH: Yeah. I mean, it's definitely something that I never meant to become the expert on. I'm definitely still growing and learning myself. It just came to me, my first transgender patient that I saw, I thought, ÒOkay, this is a new thing. I'm going to learn this.Ó Then by my fourth or fifth one, I thought to myself, I really need to do some research and some training and then quickly realize that there's not much out there in Gender-Affirming Care for our field. I really wanted to try to share the things I did learn, and hopefully spark a conversation, which I think the article is definitely done because here we are today.

[00:04:25] DS: Yes, that's amazing. Actually, I think that's a perfect place to start our conversation. Would you mind sharing one of those early stories that made you curious about exploring this topic further as a clinician?

[00:04:36] MH: Yeah, absolutely. I mean to give you some background like you said. I'm at Arkansas Children's Hospital. I don't think our state is necessarily one that comes to mind when you think of being progressive and having a lot of attention about things like gender diversity. I remember the first time going out into the waiting room to call back a patient and my chart said it was a nine-year-old male. Clearly, the person walking towards the clinic door after I called the name appeared female. My first thought was, oh, registration must have gotten something mixed up in the system. Clearly, this is a girl, and didn't really think much on moved on. 

Then when I got the family back in the room, Mom said to me, ÒWe're new here, so we wanted to tell you, your chart probably says male, but she is transgender. We are in the process of transitioning.Ó She uses she her pronouns. Thankfully, that was just the absolutely most perfect first experience that can happen.

[00:05:40] DS: Sounds pretty smooth.

[00:05:42] MH:  The family was great. They advocated for this patient. They really were very open and upfront about it. I quickly realized from that first encounter, that my implicit bias was so obvious that my first thought was, oh, registration, put this in wrong. This is a girl, not a boy. I never even crossed my mind. It could be a transgender patient. That was really my first encounter with realizing that implicit bias in myself. 

[00:06:10] DS: Yeah. I mean, how great that it was such a family who was prepared for that conversation, and that you went into it with that mindset as well. I'm glad to hear it went so positively. I'm sure there's people listening out there have had more challenging first time experiences with this where their biases or challenged for the first time. 

[00:06:28] MH: Yes. 

[00:06:29] DS: I think, yeah. So from that point, then, it sounds like you experienced several more patients, I guess, with a similar situation. Eventually, that made you want to explore this a little bit further. I'm curious before we dig deeper into gender diversity as a topic in clinical care. If we think about it more in the zoomed-out lens of like, our ethical obligations from a competence standpoint. Like I said before, I mean, I've listened to many talks that talk about cultural competence, and a lot of ways for audiological care, but never in a way that was regarded, never regarded gender identity. How do you see gender identity, cultural competence like ethical obligations as clinicians? How do those three mesh with each other?

[00:07:14] MH: Yeah. I mean, I think especially being in pediatrics, the word that comes to me versus patient-centered care. We are always striving to provide patient-centered care. That means that every person is different. Everyone and every individual is different, they come with a different set of values and beliefs. It's our goal as clinicians and ethical providers to provide them care in the way that fits their beliefs and values. So I think a word that goes along with cultural competency is just ever-evolving and ongoing. I think as the world continues to change, we have to continue to adapt and continue to learn how to provide our patients best care. 

I mean, I think of even now, as a millennial, I'm now starting to realize my patients are not in the same generation as me, and they have different needs. I'm having, to learn and adapt and learn about TikTok and all these cool things just to try to connect with them. It's the same thing for gender diversity, learning the patient's preferences, and their beliefs, and their background. I do think it's really cool several organizations AAA and ASHA, SENTAC. They've all come out with statements in their code of ethics now that support, providing, Gender-Affirming Care. It really just comes back to that patient-centered care and ethical charge that we have to really provide holistic, patient-centered care for each individual.

[00:08:47] DS: Wow. That was a beautiful breakdown of that. I think, I completely agree with you with how things are changing Ð how the world continues to change. It's up to us to stay educated and to keep up. So I'm grateful that we're able to talk about this, because this certainly falls into that category. Speaking of the whole big picture topic of Gender-Affirming Care, how would you define that term for people who might not be familiar with it?

[00:09:10] MH: Yeah. Like I said, I think it's something that's growing and evolving. So by the time this podcast gets posted, there might be a new term for it, but for me, right now, Gender-Affirming Care is providing specifically audiology services to a patient in a way that supports the gender that they align with. It means, not saying you are born with female parts, so I'm going to address you as she, saying, how do you want to be addressed? What pronouns do you use? 

Thinking through family dynamics and different things that are associated with gender, you notice that, does that person have a good relationship with their family? Are they out to them? Are they struggling? Is that going to be a part of the picture as we're caring for this for person with hearing loss? Really, it comes down to how does the individual identify themselves and how they align? Then actively choosing and participating with them to make sure that they are being cared for in the way they want to be cared for.

[00:10:15] DS: That's great. That's great. I think it's so critical that this aspect of we use the term gender identity and identity is such a powerful term, right? How we view ourselves? What our identity is this so important? So it's such a critical component. I think of all the other ways that make up one of our patientsÕ identities, those are all things we'd want to support, and be knowledgeable about and so this is just another aspect of that, that's really critical for our care. I think that that was a perfect definition for that. Thank you for sharing that. 

[00:10:43] MH: Okay.

[00:10:44] DS: Okay, in a previous episode, we've talked a bit about implicit bias more specifically, when it comes to racial biases. I'm curious how Ð it sounds like you had one example, I guess, if some implicit bias showing. I'm curious if there's other example that maybe people have shared with you and their experiences, as they've learned more about gender diversity, as it relates to them as clinicians, and how we see implicit bias bubble up in this realm.

[00:11:11] MH: Yeah. I mean, implicit bias is just something that'll sneak up on you. So many people have opened up to me and that's one thing I've loved through getting so personal on this topic is the amount of people who've come forward and shared an embarrassing experience that they realized they had this bias, but how they're not actively trying to overcome it. Some, I've definitely heard of for sure, the initial thought of, oh, the paperwork was wrong. I think a lot of times some verbiage I've heard is someone saying, ÒOh, I thought she was just a tomboy.Ó Or, ÒOh, I thought he was just a little feminine.Ó 

I hear a lot of, especially audiologist talking about when theyÕre, they realize their biases, when they're having a child pick out a hearing aid color, that maybe if itÕs a little girl, they're showing them pink and purple first. In your mind, there's nothing wrong with that, but it's a bias. It's something society has trained us to associate certain colors with certain genders, things like that or talking more from the speech side, when we might have a speech pathologist working with one of our kids with hearing loss, and maybe they think, ÒOh, she's a girl, she want her voice to sound more feminine and we need to work on that.Ó It's just the societal norms that we've been raised in and we've just been trained to think the certain things associated with certain genders. 

That's a lot of what people tell me when they think about their biases is just, ÒOh, they had on a pink shirt, I thought it was a girl.Ó It's interesting to think about how society has formed those biases in us, and how we, we actually do use them a lot more than we realize. I mean, just today, I think I had a little girl picking out pink and purple ear molds and my first thought was, ÒOh, so cute. ItÕs so girly.Ó It's like, okay, timeout. They're just colors, what makes that girly? It's also a process of just learning to accept that biases happen. Don't punish yourself for having them. Instead, work on trying to overcome them, because everyone has them. Instead of getting down on yourself or thinking that way, just think about how you can improve for the next time.

[00:13:31] DS: That's great. I love that you gave us some perfect examples of ways that these things flare up. Then also what we can do about it, acknowledging it, not getting down on yourself, and learning from it. Yeah, I'm hoping later on, as we speak a little bit more to maybe some specific cases, we can talk about some of those very audiology-specific ways that these things bubble up. The friend of mine, who was in that previous episode, Dr. Logan Hamlin, she spoke to some of the ways those implicit biases show up racially in audiology. They were so interesting. Some were related to device color, but also the way that some technology works with different hairstyles and things like that. It was so interesting and so important to learn these kinds of things. 

If we don't know, to even think about how we're accidentally causing these micro aggressions, sometimes it's hard to learn from them, right? I think it's important that we share even any other specific ideas that we have. But before we get to that, actually, I was wondering if you could share, and I know, this is another thing too, that probably, no, definitely changes over time. It's continuing to change and maybe outdated and no time for now, but if there's any appropriate terminology that maybe we could use, because I've seen gender diverse, I've seen, gender non-conforming or transgender, what are the best Ð I know, a lot of this is going to be patient-centered, right? If we're going to use their pronouns, things like that, but are there any, acceptable terminology that we should be trying to use that itÕll be most appropriate?

[00:14:55] MH: Yeah. I agree, and a lot of it is patient-centered. I really like the term gender diversity, because it encompasses so much. Using a term transgender can be specific to someone who has transitioned to one specific gender, but here are gender identities out there like non-binary, where they actually don't identify with one of our stereotypical genders of male or female. There's gender fluid patients that feel their gender changes, and they identify with different genders or things at different times. I love the term gender diversity because I feel that encompasses all those different terms. 

Gender-affirming practice doesn't necessarily mean we're affirming a certain gender. It just means we're affirming the gender diversity that is out there. There's a few more terms that you might hear, like cisgender. I'm cisgender, I identify as female, and I was born female. Then the term transgender female would be someone that was assigned male at birth but identifies as female. I think transgender historically has had a very different connotation, but now it's really primarily used just in the context of someone who has transitioned. There's also a term Gender Dysphoria that you might hear a lot and that's referring to the distress, the anxiety, the depression, that an individual feels when they're not feeling they align with the gender they were assigned at birth. 

That's something whenever we're talking about a patient that's experiencing these thoughts and feelings. It's often labeled as gender dysphoria. Those are just some of the terms I felt like that float around. I definitely think that they're constantly changing. I feel like I'm always looking on the Internet or trying to figure out if there's new terms out there, but definitely gender diversity, I think is one of my favorite ones. If I'm referring to a patient that I'm working with, and maybe they're still figuring out their gender, or maybe they're still exploring that. Then I would say, theyÕre a gender diverse patient, that's the category I would put that in.

[00:17:18] DS: That's great. That's great. Thank you for sharing all of those. I'm curious to another one that I see a lot would be like AMAB or AFAB which I think is assigned male at birth.

[00:17:29] MH: Yes, those are abbreviations. I feel like are mostly used in text. I see those a lot on hashtags on social media, sometimes I'll see them in a medical record. Again, I think it really comes down to what the individual feels that they identify as. I definitely think, there's some people out there that the term transgender has historically had a negative association. So maybe saying, ÒThey're transgender.Ó That brings up harmful emotions to them. They might prefer to have a different term, but really, I think the best thing is just to ask them, and the first few times that can feel a little bit awkward, but truly, once you can ask them, it opens up a door of trust and comfort. It's amazing to see the relationship change once you get over that initial hump of I feel weird asking this question.

[00:18:25] DS: Because they have the benefit that comes from asking that question can be so huge in establishing rapport. Yeah, that's so true. Cool. Okay. So for maybe clinicians who have been in the field for a very long time, who like you have only in the last few years started to see, I mean, maybe they previously had seen gender diverse patients and didn't realize it or didn't know what to say or ask. Does it seem like there is a rise in gender-diverse patients, especially in the world of hearing loss?

[00:19:01] MH: I definitely think so. Like I said, when I saw my fourth or fifth transgender patient here in Arkansas, I quickly realized what the demographic of our state here if this is what I'm seeing, I know, this is something that's everywhere. We've definitely seen huge jumps and numbers, the prevalence of transgender youth has doubled in the last five years, doubled. I mean, that's a lot. Then specifically with hearing loss, there's over 300 million people that identify LGBTQ plus that are deaf or have hearing loss. This is not a small group by any means. 

Another interesting thing people who are deaf and hard of hearing, historically have actually either come out as gay, lesbian, transgender later in life, because they didn't have access to information on this this community, simply because there wasn't a lot of ASL out there that was communicating this thing. We see a lot of these patients that come out a little later in life. It's just as interesting to connect hearing loss and gender diversity. I really do think we're seeing a big boom right now, partly because of social media, people have access to talking to each other and sharing their feelings, and finding someone that will support them and encourage them.

[00:20:30] DS: Yeah, absolutely. Yeah, maybe on the rise, maybe this is just a population we haven't been as aware of, but I am curious, in relation to that the cultural competence then of clinicians when it comes to working with gender-diverse patients. I mean, I don't know if there's been research done on this, right? But I know more recently, there's been more and more research looking into are clinicians aware of their own implicit biases, especially when it comes to things like socio-economic factors and race. We're starting to understand more about our profession as a whole as it relates to these things and our own cultural competence. Has there been any research out there about audiologists, cultural competence when it comes to working with gender-diverse people?

[00:21:13] MH: There really hasn't. If you look in ASHA leader articles, there's been a couple articles, but primarily, the education has focused on using pronouns, which is definitely a huge and very important part of providing Gender-Affirming Care, but have really, all I've seen in my own journey trying to educate myself and develop cultural competency in this area, I really only found information about pronoun use. I do think our organizations and our places that we work are starting down this road, but I do think it's a very new thing that we're just starting to see formal training on this. I was even talking to a group of AUD students the other day and just said, ÒHave you all learned anything about this?Ó Their response was, ÒWell, only what I see on Instagram.Ó 

[00:22:06] DS: Which is maybe good, maybe that's a good, yeah, hard to say.

[00:22:09] MH: I do hope that at the core of our education, is starting with those ad program. I do hope this is something that we're educating students on. Hopefully, it will just continue to grow. It'll continue to be a part of continuing education for every audiologists out there.

[00:22:29] DS: Yeah, absolutely. I think, I smell a research project for you there to understand current political attitudes and awareness of our own cultural competence when it comes to this, because I mean, I don't know if the research supports this, but I do feel like a lot of times when it comes to topics like this, that we're not familiar with, sometimes people overestimate their competence. I know, the more I learned the less I know, almost the less I realized I knew in the first place, maybe it's a better way to put it. 

You brought up that some of the research has looked at awareness of pronouns and utilizing pronouns, whether that's in documentation or in intake paperwork. I'm curious, I feel like when it comes to people who aren't as familiar with the gender-diverse community, sometimes it's just boiled down to pronouns that just tends to be the major talking point and sometimes debating point for people when it comes to this. I'm curious how pronouns play into clinical care, I guess, in that way and how we can approach them and how they can be incorporated, I guess, into our clinical care.

[00:23:33] MH: Yeah. I think it's something that we don't really think about as cisgender individuals. It's like, ÒWell, I've always been a she. Why do I need to tell someone, that's what I am.Ó It's definitely a very important part of providing Gender-Affirming Care, addressing people how they want to be addressed. Then recognizing that using the wrong pronoun could definitely cause someone gender dysphoria, where they have all of this traumatic feelings and emotions come up about their whole transitioning process and maybe past trauma that they had before they transitioned. So the importance of that, just in life is so important, but especially as an audiologist when you're trying to build trust and rapport with your patients. 

I mean, the simplest thing is just making sure you call them by the right name. I mean, it's like, one time I went to a wedding and the minister said the wrong names at the altar. Clearly, that ruined the whole wedding, so it's very similar to that like, what if youÕve been calling this person by the wrong pronoun or addressing him in the wrong way this whole time and that's all they can focus on, because it's an upsetting thing. So you really boils down to just respect for the person, too. So I think we see a lot more on our email signatures nowadays, people are putting their pronouns on there. I think that's a great place to start. 

I'd love long-term for hospitals in places to be putting pronouns on name badges. I think that's a great way to spark the conversation, but really the simplest way is to introduce yourself, so for instance, if IÕm unsure of a patient's pronouns, and I don't want to directly ask them, I could say, ÒHi. I'm Dr. Madison Howe, your audiologist today.Ó I use she her pronouns, and it just opens up the door, gives an opportunity for the patient to respond back with their pronouns as well. To me, that's really the most natural way to make it flow to ask for a pronoun.

[00:25:37] DS: Yeah. I love that example. I think you're exactly right. Sometimes one of the biggest barriers might be just that discomfort of wondering how to bring this up because it's not coming from a place of disrespect. You're just trying to ultimately to be as respectful as possible, but how do you even ask this question? So just declaring it as yourself, can be a great way to invite that conversation. I think that's an awesome example for that. That's great. 

[00:25:59] MH: I think, case intake forms are the easiest way to do it, because then you don't even have to ask, it's just written on the paper when you get it. With bigger organizations, for instance, working at a hospital, it can be harder to get the intake, paperwork changed, and I just, I like to ask and spark that conversation. I think it also shows them, this is a safe space to talk about these things, because not every patient that is experiencing these feelings is fully out or fully discovered other identifying, and maybe they don't have anybody to talk to you about it, and just you asking a question that shows that you are a safe place for diversity and opening that door, might allow them to really feel comfortable opening up to you. 

[00:26:51] DS: Yeah, that's awesome. That's a great reminder, too. I feel like sometimes in healthcare, we can seem very intimidating to patients, especially working with pediatrics, depending on how you approach them at all. They might already be reserved being in the doctor's office or being at the hospital. So this is just another way to really invite them in and support them and affirm them early on in the conversation. 

Okay, so speaking of that self-expression and those kinds of things. I'm curious, I think you brought up a great example earlier of hearing aid colors, and how those can be a form of self-expression, in a way. How we can sometimes accidentally support our gender biases and how we talk about hearing aid colors. But I'm curious in what other aspects of audiology care do we see either these biases arise or maybe even opportunities to check those biases in ways we might not expect?

[00:27:48] MH: Yeah. Definitely, the hearing aid color was the most obvious to me. It's so true. We do it every day, where you see a pink outfit, and you think, ÒOh, that's for a girl.Ó So it's a big one. I think, thinking through different toys. So I might pull out the princess toys when I think it's a girl and she's going to want to play with princesses in pediatrics, especially, we have lots of toys, or, ÒOh, this boy might want to play with the cars.Ó I catch myself saying, ÒWhy don't I let them choose? Why don't I let them pick out the toy they want to play with, instead of me just pushing my bias of thinking, this is a girl and she wants to play with princesses.Ó That's one way specifically with pediatrics that I've caught myself a few times.

[00:28:39] DS: Yeah. I completely agree. I have done the same thing. I reached a point where I was like Ð I think the only way that I'm going to stop doing this is if I just offer two options of very, very different previous gender conforming ideals like, ÒDo you want to do princesses or do you want to do cars? You can pick one of those two.Ó Then oftentimes, honestly, a lot of our toys now are less than less within those categories. We've got the monkey and the bananas. We've got the ring stack. You know what I mean? Neither of those fit into either category. We don't have to worry about potentially offending anyone with that a thing, which is great. 

[00:29:18] MH: Yeah. It's crazy to think too, about how young that process starts. When I was educating and trying to learn more about gender development and gender diversity, finding that children actually are starting to understand their own personal gender by around 16 months. They can recognize that stereotypical things associated with their gender. Really, almost have a fully developed stereotype of gender by three to five years old and that seems so young to me. You would think, ÒOh, they're only three they don't understand this is a princess and it's historically been a toy for GirlsÓ but they can and that they can express that. That was really shocking to me to realize how young that starts forming.

[00:30:09] DS: Wow. Yeah. That's another great example. Yeah, I hadn't thought about that at all. I think that's a really interesting fact about how early we program our society into conforming to the standards that we've made up. Yeah, thank you for sharing that. I'm curious if there's been any other audiology-specific scenarios that have bubbled up or just things we can be more mindful of in maybe the way that we provide clinical care? 

[00:30:37] MH: Yeah.

[00:30:37] DS: To avoid those kinds of things.

[00:30:40] MH: Yeah. One specific thing comes to mind, because in my mind this is just, it broke me for days. I didn't sleep. I was losing sleep over this situation where I had a teenage patient come in, who transitioned. I had previously seen them as a different gender but at this visit came in and expressed that they have a new name and new pronouns and that all went very smoothly. I was using those pronouns. I was doing everything I could to be an ally for this person. Then we did our appointment. Hearing aids are working great. She's got great aided benefit, and I send them out the door.

A couple of weeks later, I get a phone message from a parent saying they wanted to come in, there were some issues with the hearing aid and she comes in and she says, ÒWell, it's not a sound issue. The issue is, every time I connect my hearing aids to my phone, my dead name pops up.Ó Dead name. 

[00:31:42] DS: Oh, wow. I didn't even think about that. 

[00:31:45] MH: No, so you know, dead name is the name they used before transitioning. So for instance, I think a popular when people think of is Caitlyn Jenner. If you were to refer to Caitlyn as Bruce Jenner, that would be dead naming, that's a very hurtful and harmful thing to transgender people. It just brings up a lot of emotions. So this girl, every time she would connect her phones to her hearing aids, it was popping up with her dead name. Of course, she was so sweet and said, ÒI tried to ignore it and I try to think a bit.Ó It was emotional for her. It was all because I didn't think to change her name to Noah when I was programming her hearing aids.

[00:32:26] DS: Wow, yeah, yeah. 

[00:32:27] MH: I mean, I had changed it in the medical record. I had used gender-affirming language in my report, but just that day, in the moment, I forgot to change her name to Noah. So it was as simple as changing her name and Noah, reconnecting her hearing aids and saving it, and that fix the problem. I mean, that just broke me to think this 15-year-old who probably loves streaming on her phone was actually gotten to the point where she was not connecting her hearing aids to her phone anymore because it was so emotional for her. 

[00:33:02] DS: Wow. 

[00:33:03] MH: Something is as simple as my mistake had this impact on her. So that stuck with me. I definitely remember to change even a preferred name of a cisgender patient. I try really hard to remember to update Noah now. That was a learning experience that you don't hear about in a webinar or in a textbook. That was one thing I just learned through experience.

[00:33:25] DS: Yeah. That is a perfect example. I'm really glad you share that. I know that's a really Ð I'm sure, that's a really hard memory to get back to. I mean, I had never even thought of that. I probably would have done the exact same thing. I think that's a really helpful reminder of a really easy way to do something that can really hurt someone in a way we wouldn't even have considered before or thought to change. Thank you for sharing that. 

[00:33:49] MH: Yeah.

[00:33:50] DS: I'm wondering what other ways I guess, I mean Ð I guess, this is even really that specific to audiology, but just ways we can be more gender-affirming and the ways we talk to our patients and their families. I think of like, I follow a lot, I use a lot of Ð it's not slang anymore, because I'm old, but I'm way like, ÒWay to go, dude.Ó language like that, that can very easily fall into specific gender categories and could very easily be incorrect.

[00:34:21] MH: Yeah.

[00:34:22] DS: I'm curious just more general, gender-affirming language we should be, maybe mindful of?

[00:34:27] MH: Well, definitely in English we have an easy, because really, for us, the only gendered parts of our languages are pronouns. Then words that we have societally associated with gender and other languages like Spanish, every ending of a word has an O or an A, pretty much, and that's associated with a gender. Truly, we have one of the easiest languages to be gender-affirming with. It's just an interesting thing when I was studying gender-affirming practice, realizing, ÒOh, we should do this. This is easy for English speakers.Ó 

Definitely, I think in pediatrics especially, we kept ourselves using terms like dude and girlfriend. I had one supervisor and I thought it was so cute. She call the kids, ÒLadybugÓ and stopping and realizing that that could have a negative connotation for someone. 

[00:35:23] DS: Sure. 

[00:35:23] MH: That's really important. I try really hard to be mindful of my compliments, so saying something like, ÒYou look pretty today.Ó Or, ÒYou look handsome.Ó 

[00:35:35] DS: Oh, wow. Yeah.

[00:35:36] MH: Could for some people be associated with a gender. I try really hard to be careful with words I'm using when I compliment people. I also think it's just a really good practice to compliment people on their personal characteristics, not necessarily how they look that day. That's something I've tried. Just you know, I love that you walked up here with confidence. You don't have to say, ÒOh, I like your outfit.Ó Or, ÒI think you look pretty today.Ó That's one way I really try to apply gender-affirming language more using honorifics, especially here in the south, we say things like, ÒYes, ma'am.Ó And ÒYes, sir.Ó All the time. 

I catch myself doing it with patients all the time like, ÒYou got it, ma'am.Ó Remembering that. Actually, I had a conversation with someone in the gender-diverse community who's from the south. I said, ÒOkay, I am guilty at Chick-fil-A.Ó I say, ÒThank you, ma'am.Ó I don't know that the lady at the drive-thru is identifying as female. So am I impolite if I just say thank you? Because as a Southerner, that feels impolite to not say, ÒThank you, ma'am.Ó Catching yourself with some of this, those little things that you never have had to think about before, but just thinking about the impact your words can have on someone is really important. 

[00:37:07] DS: Now being in the south, though, we do have the privilege of y'all. 

[00:37:09] MH: We do.

[00:37:10] DS: Y'all is a great one, right?

[00:37:11] MH: It is.

[00:37:12] DS: YÕall is the answer.

[00:37:14] MH: Yes.

[00:37:15] DS: To addressing a crowd. I love a good, y'all. 

[00:37:18] MH: Yeah. 

[00:37:18] DS: Cool, cool. Awesome. Yeah, those are all really good reminders of the ways that those things can pop up. Okay, but when we inevitably mess up, and use the wrong honorific or drop a dead name? What do we do? How should we be approaching these conversations?

[00:37:40] MH: I can speak to this one from my experience, for sure. I remember the first time I messed up, I was so apologetic. I drew so much attention to it. Honestly, I think that made the whole situation worse. Everything I've read and working with people who are gender diverse, it is a resounding quickly make an apology, but move on, do not draw more attention to it, than needs to be. I think you personally are probably going to beat yourself up more than the situation will, so just quickly move on, apologize, I'm sorry, correct yourself and move on. Don't draw unnecessary attention to it. It doesn't feel natural, because you're going to want to as a caring provider, apologize and try to make it better, but truly, I think, less is more when you just move on, correct yourself and try for better next time.

[00:38:35] DS: That's great. That's a really helpful, and what's the word? Forgiving way to approach these things, because, I guess inevitably, yeah, we are going to make mistakes in this realm. We're learning all the time, right? We can't instantly be the experts on all aspects of cultural competence, but it comes with having grace for the patients and for yourselves, being willing to acknowledge the mistake and move on. I think that's really, really good advice. 

[00:39:02] MH: Yeah. 

[00:39:03] DS: Try not to make it all about yourself.

[00:39:05] MH: Well, and I think, too, we often think of ourselves as being the expert in the room, but when you're working with someone in the gender diverse community, you've got an expert right in front of you. I think it's really important to build a partnership with your patient not just a one-way relationship. Often, I'll even say, ÒHey, I'm trying to grow in this area. I'm learning and I want to be better. Can you hold me accountable? Can you help me be better when you call me out on something if I say something wrong?Ó It feels weird and a little awkward at first, but I really feel that's how I've learned so much of this is just from being open and honest with my patients and saying, ÒHey, I want to be a better ally for you. Will you help me?Ó 

[00:39:49] DS: Yeah. 

[00:39:50] MH: I think it empowers them, too.

[00:39:52] DS: Yeah, that's awesome. That's awesome. Because we're all in it together and at the end of the day like the goal is better care for them, right?

[00:39:59] MH: Yeah.

[00:39:59] DS: I'm sure most of our patients would be really happy that we're taking the time in the first place, because we learned that with all of the conversations I've had about improving cultural competence, it's the effort that so many of our patients are so grateful for. I'm going to provider who's really taking the time to try to learn and understand.
[00:40:18] MH: Definitely.

[00:40:18] DS: Switching gears a little bit to Ð Well, I mean, I guess it's not really that much of it, a gear switch because it's more about this language aspect of it. I do feel sometimes in a previous episode, we've talked more specifically about working with interpreters and the interesting and maybe awkward social encounters that can come from a third party, being a part of the conversation, but also not being a part of the conversation. 

[00:40:41] MH: Yes. 

[00:40:42] DS: Have you ever had Ð have you had any experiences with that or anything to share when it comes to working with gender-diverse patients and also having an interpreter?

[00:40:50] MH: Yeah.

[00:40:50] DS: Involved? 

[00:40:51] MH: It's funny, Dakota. I actually listened to Ð re-listened to that episode with Kelly Murphy, the other day, because it's one of my favorites. I think working with interpreters is something that doesn't feel natural to anyone. It's something you have to work to get better at. In that episode, Dr. Murphy mentioned sometimes she likes to have an interpreter meet with her before going in to talk with the family. I've found that really effective for this population, too. If I have to have an interpreter, just pulling them aside at the start of the visit, and saying like, ÒHey, I don't know if you know that Johnny's transgender and they use they-them pronouns. Are you are you comfortable with that?Ó and just establishing pronouns, their name, giving some background information, especially if it's a patient who's still exploring, and discovering, and just checking in with the interpreter, and seeing their comfort level with the vocabulary, that could be associated with that. 

Especially, it can get challenging when maybe you have a patient and parents who aren't aligning, maybe the family has not accepted this part of the child. So the interpreter might need to be aware of things can get a little bit complicated and a little heated. So I really think just giving the interpreter that professional courtesy of a little heads up before going in, is important. That I found can be really, really impactful.

[00:42:21] DS: Awesome. Awesome. Yeah. That's a great reminder for how to navigate those conversations sometimes. Yeah, I think I also love that episode. I also love Kelly. I'm glad to hear that you're going back and listening to it. That makes me feel so awesome. I'm like, that's such a good episode. I'm glad people are listening to it. Yes, but definitely I love incorporating, working with the interpreter ahead of time to make sure that conversation goes as smoothly as possible, is great. I'm hoping we're going to have some time to talk about some more specific cases. 

[00:42:50] MH: Yeah. 

[00:42:51] DS: Maybe still on this realm of the more professional issues aspect of it, when it comes to charting and using the right terminology and documentation and how and where and when to talk about those things in a visit note. How do you approach those things? How do you recommend listeners approach that? 

[00:43:13] MH: Yeah. I think, thankfully, without of us that are working with a large electronic medical record system, it makes it a little bit easier. So for instance, we use epic and epic has really simple way to put into the chart, their gender identity. Then what epic defines is legal sex or sex was assigned at birth. So that's really nice because you can quickly view it all in there. 

I still like to incorporate some of it in my documentation as well. Specifically, if a patient were to express to me their gender transition or gender identity, for the first time at a visit, I like to just put in my introductory statement, a brief introduction of who the patient is, just like I would for anyone else. I might say, ÒSusie is a 12-year-old female.Ó Then for this patient who discloses something to me, I might say, ÒSusie is a 12-year-old, assigned male at birth, who identifies as female.Ó Then from that point on, I simply use the gender-affirming pronoun, because you can reference back to that introductory statement to understand more if there's questions.


I really like to use gender-affirming language throughout my report, because then any other doctor, physician, or maybe someone at school that's reading that report, it sets them up for success too, because then they get to say the patient seeing me first, then going to ENT and ENT reads my note. Well, they don't have to ask the patient what their pronoun is, because they've got it right there. I think remembering to set other people up for success through that is important. I've asked to read up on some things that say really you only need to address the gender assigned at birth, one time in documentation. For instance, at that initial visit, when you see them, you would write that introductory statement. Then from then on out at any subsequent visit, you would just use gender-affirming language.

[00:45:19] DS: Got it. That's awesome. That's a great idea. Then, more out of curiosity than anything else, I mean, depending, I guess, on how a patient decides to present or if they've never had an opportunity to share their pronouns, is it safer to just utilize the assigned at birth pronouns within the documentation? Is it a better bet to use gender-neutral language like they said, ÒTheir hearing aid is broken.Ó How do you tend to approach that in documentation when you're not exactly sure what their answer is to that?

[00:45:53] MH: That is a tough one. I think my preference would be to just use their name, a lot, but there are some situations where you can't get away from a pronoun. I do think using they-them might be a more appropriate one, especially if you know they're actively in the process of exploring their pronouns. I think that's a good option to try. It's definitely hard. This is something that you have to practice and it takes time. I still remember going back to a report a few days later, reading the report, and realizing one time I use the wrong pronoun in a sentence. It takes practice so that you know, just the fact that you're thinking through those things and actively keeping it on the front of your mind, I think helps.

[00:46:40] DS: Yeah. I think it's hard too, because I know there are some dot phrases in epic that will automatically pull. So if you haven't updated it, I guess in their sheet, it will automatically use whatever app pronoun for them and that can later, you're like, ÒOh, my gosh. It just auto-populated that and I had no idea.Ó 

[00:46:58] MH: Yeah. 

[00:46:59] DS: All a good reminder to make sure we're keeping up with this in our documentation, too, because that's where it can I guess, sneak up on you Ð and really expected.

[00:47:07] MH: Really, honestly, the easiest ones for me are, we have a gender spectrum clinic at our hospital. If the patient's already attended that clinic, that report can provide so much good information about how the patient is identifying. If you're able to do a chart review and see documentation from a gender clinic, or a social worker, I think that can really also help you get some insight, and I often look at how they write their reports, because I consider them the experts in that area.

[00:47:35] DS: Absolutely. That's a great place to start, right, as someone who is the expert there. Cool. Okay, before we get to specific cases. I wanted to ask you a little bit different from providing clinical care. I guess maybe the approach for this is probably going to be pretty similar, but co-workers who are gender diverse is one question I had for you. If there's a different way we would approach that or anything you want to speak to on having co-workers who are gender diverse, but also maybe seeing a co-worker who doesn't approach these conversations well. Speaking up when it comes to being an ally, and speaking up to people who might be cisgender and not being respectful or not being gender-affirming in their care. What advice you have for audiologist who might find themselves in that situation and maybe how to approach those conversations?

[00:48:25] MH: Yeah. That's a tough one. Well, first, as far as having co-workers who are transgender or gender diverse. In many corporations and companies, it's actually a form of sexual harassment if you do not address that person in the way they are identifying. I think that's pretty cut and dry for me. You're going to get a ride up to HR if you're not doing that. 

[00:48:48] DS: Yeah.

[00:48:49] MH: You should definitely be doing that. As far as seeing someone not do it. It's been a journey for me since I actually, presented a presentation on this just to a small group of people in an ASHA SIG 9, and it blew up. So I've gotten a lot of emails, some messages from people that aren't necessarily positive. I understand they're some political and sometimes religious or cultural upbringings that have people form beliefs. So I would say if you're seeing a co-worker that is not practicing Gender-Affirming Care, I think the best thing to do is just to remind them of what we are called to do as audiologists. 

I've caught myself reminding people that this is actually in the ASHA Code of Ethics. You have your Cs and we're called to provide this. Oftentimes, I just say, ÒHey, I noticed this. Did you know that about the patient?Ó Hopefully, a lot of times they're going to say, ÒOh, no. I didn't know that. Thank you for letting me know, I'll be better next time.Ó But thankfully, I haven't encountered anyone actively and purposefully not using this when they know better. I think really just reminding your co-workers that this isn't just a preference thing. This is an ethical thing that we are charged with as audiologists. 

[00:50:13] DS:  Absolutely. 

[00:50:15] MH: I think, it's hard for us to hold each other accountable, but that's the only way our field is going to continue to grow and learn.

[00:50:22] DS: Absolutely, yeah. That's a really helpful reminder that it is our ethical obligation to say something, right? Then we're all only going to get better if we can recognize these situations and do something about it. Yeah, I think that's a really helpful reminder.

[00:50:35] MH:  I've had parents say to me, because there's definitely times where parents are not on the same page as that patient, and they'll say something to me about, ÒHow could you? As a Christian, or as a Southerner, support this.Ó I just have said I leave my religious, political, whatever beliefs at the door when I put on my audiology hat. I think just remembering to walk in there with patient-centered mindset.

[00:51:01] DS: That's a great reminder. That's awesome. Thank you for sharing that. Okay, so I think we've got some time to talk case studies. 

[00:51:08] MH: Yeah.

[00:51:08] DS: I'm very excited about this. I will say, I have had at least that we had open discussions about only two patients, so far. We had a really big discussion, but one of them was in my fourth year. He was, I want to say 12, 13, we were like almost high school age. We had a whole conversation because grandma was primary caregiver. Grandma had no idea how we were going to navigate this conversation. Grandma warned me he is using he. I don't know, if she back then, I mean, I guess disclosing pronouns wasn't probably as prevalent back then, but she did make it clear that this person was thinking through some of these differences and how they viewed themselves and what their identity was when it came to gender and preferred a different name than their typical name, but was still figuring that out. 

When I asked him his name, he actually said a different name than grandma had just told me. I was like, ÒYup, I see. We're working through it. We're trying to figure out our name first.Ó I didnÕt do these things. It was such an interesting experience. I was fortunate, too. I do feel like it was a really positive format to explore this conversation, as it related to his hearing loss, as related to, yeah, he was in the process of getting worked up for a cochlear implant, and working through that process together was really, really special. That was a case that I appreciated, but I'm curious if there's others that either you have experienced or that people have shared with you, that you feel like maybe glean some helpful reminders when it comes to this topic.

[00:52:40] DS: Yeah. One that immediately pops into mind, I had a patient who transitioned who had a pretty precipitously sloping high frequency hearing loss and was assigned male at birth, but transitioning to be female, the family had opted to not seek cochlear implantation. The patient asked me they said, ÒI'm transitioning, I want to identify as female. I'm transitioning to female and I'm taking these medications to alter my body. I know, one of the effects is my voice is going to sound higher pitched. I want to sound more feminine.Ó I quickly realized that we were going to have to have a really talk about realistic expectations, because based on their hearing loss and not pursuing cochlear implantation, it was going to be really hard for this patient to hear some of those high-frequency cues that they would need to start down the road of modulating their voice.

We actually discussed that and revisited cochlear implantation as an option, or could that maybe help, but in the end, we talked about working with a speech therapist in the voice clinic, that really having a realistic expectation of, it might be really hard for you to hear some of these high-frequency sounds and modulate your own voice. We just max the hearing aids out, the best we could, but I never thought I would be sitting there trying to give a hearing aid as much high-frequency gain as I could so that the patient could modulate their own voice to sound differently. So that was interesting Ð

[00:54:24] DS: That is super interesting. Yeah, in a way I never expect our audiological care to factor in someone's gender identity, but wow, what a helpful reminder. I mean, that's tough. That's definitely, definitely tough to try to make your case. I mean, we tried to make the case all the time that someone would qualify and would just do so well with a cochlear implant, but to think that it could have an impact in that aspect of their life is just really interesting.

[00:54:49] MH: Yeah. Another one that comes to mind for me, too, is it was like an 11 or 12-year-old and came in with foster parents. The foster parents stepped out of the booth to take a phone call. I was just making small talk with a patient as we're getting inserts and getting set for testing and they disclosed to me that they were identifying as a different gender and starting to have these feelings. So I asked if they had talked to anyone and they said, no. I asked if they wanted to talk to anybody and they said, no and that was hard for me as an audiologist, especially working with kids. I'm a fixer. So that was really hard, I don't want to betray this child's trust, but am I concerned, gender diverse population has high rates of self-harm and suicide. Am I worried about this patientÕs safety? Do I need to say something? Do I need to call social work? 

Thankfully, we had the opportunity to talk a little later in the visit. I got to explain to the patient a little more what that looks like talking to somebody and what that can do. They came around to talking with the social worker, but it was definitely a little, just a moment of like, oh, my gosh, I have this secret, and I want to help, but I canÕt. That's an interesting area of, especially working with pediatrics is figuring out, are you are you out to your parents? Do you have someone to talk to? Do you want resources? Not all of them do.

[00:56:23] DS: Yeah. Wow. Yeah, those can be really tough conversations. I guess if your goal is to help and it sounds that patient really just wanted to share that information with somebody, anybody to listen, if they hadn't had an opportunity to really explore that conversation with someone before. Hey, so it sounds you did a great job of being inclusive and getting their trust, that's pretty awesome. 

[00:56:46] MH: Yeah. 

[00:56:47] DS: Yeah, definitely. It can be a really difficult conversation. Cool. Well, we're getting close to the end of our time. I did want to wrap up with maybe a couple different things. I don't know, in what order whatever order you want to address them, but one thing would be, what's the best way to stay up-to-date? Whether it's with gender-affirming terminology or just cultural competence when it comes to this topic, what's the best way to stay up-to-date on these things? 

Then also what do you feel are the biggest lessons, especially for people who may be, this is a world that's completely new to them, they've never even considered how to be gender-affirming, as an audiologist or as a clinician, what you feel like the best, first steps are? Maybe we can start with that one. What would be the best first steps for someone who is just getting at this? They're like, ÒYou know what, I want to be gender-affirming? What can I start doing this week?

[00:57:43] MH: Yeah. I think, step one, is to let your guard down in the sense of you're going to mess up, you're going to feel awkward at first, just set that expectation, and it's okay. I think, if you are working with a patient that's gender diverse, one of the very first things you can do is just tell them that you want to learn to be an ally, you want to be better, and ask for their help. I think it's just great to build that partnership. Then I think another really simple thing is just start practicing with your own pronouns when you introduce yourself to people, start saying, ÒHey, I'm Dr. Dakota Sharp, and I use blah, blah, blah, pronouns.Ó 

I think that's something that takes practice. It gets to the point where you realize it's doing spondee words for SRT you forget that you're doing them, because they just feel so second nature. I think that's a really easy step. Then maybe find a co-worker that can you, ÒHey, will you hold me accountable? Will you help me with this?Ó Having someone else hold you accountable can really be a positive thing, too.

[00:58:50] DS: That is awesome. That's really good advice that I hadn't even considered is someone you trust, who you feel like would be able to check you on these things, and getting them in the loop and you guys working together to both improve this care that you're providing. I think that's a really, really good idea. I think that's a great idea for all, a lot of the aspects of what we do, right? As having someone we can be accountable to who will call us out in these moments when we don't even recognize what we're doing when we recommend the princess toy or the truck toy and didn't even acknowledge it. I think that's a really great idea. I'm appreciative of that idea.

 [00:59:22] MH: Yeah. It's like, I even realized the other day, we have a box of stickers labeled the boy stickers and the girl stickers.

[00:59:28] DS: Oh, no. 

[00:59:29] MH: ItÕs a simple as that. Oh, I need to Ð

[00:59:31] DS: Really, yeah. Yeah. 

[00:59:32] MH: I need to talk to her, we need to quit. Then we have gender-neutral stickers. It's like, well, maybe we need to just make them all gender neutral. Little things like that. I think you can just look around and start making small changes and small steps. That really, I love the idea of just partnering with your patient and let learning from them.

[00:59:51] DS: Yeah. Let them lead you and teach you. That's really where you're going to learn the best. Awesome.

[00:59:55] MH: Then I think, your other point was about, how do you continue learning? How do you find resources? I really do think that there's two great things happening in our field right now, one being that. A lot of organizations requiring CEUs like ASHA or requiring now a certain number of hours in cultural competency and diversity. So with that, I think will come a lot more opportunities for webinars and talks and continuing Ed on these sorts of topics. I know, for instance, it's intact this year, we have a whole panel on gender diversity, that I think using your resources that you have there, but also, just communicating with other people. 

It's as simple as, you have an audiologist friend that works at a different hospital somewhere else and calling them up and say, ÒHey, are you encountering these gender-diverse patients? What are you doing? How are you working with them? What challenges have you faced?Ó I think just opening up a conversation, and I see a lot of that happening in some of the audiology Facebook groups. I think the more and more we just keep it as a hot topic in the front of our minds, that we will continue the conversation and continue to grow and learn.

[01:01:10] DS: Awesome, awesome. That is the perfect encapsulation of where we go next. I love that. Thank you so much. I'll be looking forward to any presentations youÕll be providing on that topic because this has been such a fruitful, such an amazing conversation. I have learned so much talking to you. Thank you so much for taking the time.

[01:01:26] MH: Yeah. Thanks for having me, Dakota. It's an area we can all grow and learn in. So I hope to hear a lot more things like this in the future.

[01:01:35] DS: Awesome. If any listeners out there had questions for you or wanted to reach out if they had anything they wanted to ask you about, what would be the best way to get in touch?

[01:01:42] MH: Yeah. Email me for sure. My email is howe H-O-W-E-M-L @archildrens.org, so itÕs howeml@archildrens.org. I'd love to field any questions or if you have a case you want to talk about or if you just need a long-distance accountability partner. I'm here.

[01:02:06] DS: Awesome. Awesome. Thank you so much again, Madison. It's been so great talking with you. I hope you have a great rest of your day. 

[01:02:13] MH: Thanks, Dakota.

[OUTRO]

[01:02:16] DS: That's all for today. Thank you so much for listening, subscribing, and rating. This podcast is part of an audio course offered for continuing education through SpeechTherapyPD. Check out the website if you'd like to learn more about the CEU opportunities available for this episode, as well as archived episodes, just head to SpeechTherapyPD.com/ear. ThatÕs SpeechTherapyPD.com/ear.

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