It really IS about ethics this time: cultural competence, evidence-based practice, and LGBTQ+ issues in allied health

Two years ago, I was doing a home visit as part of my job as an Early Intervention speech-language pathologist (SLP), when a parent suddenly and unexpectedly launched into an angry, homophobic rant.  We had been discussing age-appropriate activities to encourage language development, and I had suggested several pretend-play ideas, a few of which clashed with this parent’s perception of the child’s gender.

In the resulting diatribe, during which the phrase “no [offspring] of mine” as well as several gendered and homophobic slurs were used liberally (so to speak), the parent argued that people could choose to be “homosexual,” that homosexuality could be triggered by gender-nonconforming behavior, and – of course – queerness of any variety  was  “unnatural.”  The other parent’s response made it clear that the two were in full agreement on this topic.

At this point, I became acutely aware of the fact that both parents were positioned between me and the door.

My mounting anxiety dissipated when, in a moment of dramatic irony, the tirading parent made this statement: “I’m [xx] years old and I’ve never met a gay person in my life.” I resisted the urge to giggle hysterically and/or pointedly re-introduce myself.  Instead, I directed the conversation to the previous topic and continued the appointment with every ounce of professionalism I could muster.

I should note that neither parent ever said anything even hinting at violence.  Between that and a fortunate lack of gaydar in the family, it was clear that my – and the child’s – safety  was not in question.  So, despite vehemently disagreeing with their beliefs, in spite of the many terrible situations that may arise as this child grows older, even though it gave me a bad taste in my mouth to even return to that house, I continued to work with the child until months later, when for unrelated reasons I left Early Intervention altogether.

In short: I did my job.

When I became an SLP in the United States, I signed a Code of Ethics by the American Speech-Language Hearing Association (ASHA).  Among other things, this code clearly states:

Individuals shall not discriminate in the delivery of professional services or in the conduct of research and scholarly activities on the basis of race, ethnicity, sex, gender identity/gender expression, sexual orientation, age, religion, national origin, disability, culture, language, or dialect.

“Culture” being the keyword here.  In signing the ASHA code of ethics, I agreed to abide by the principle of “cultural competence,” as defined here:

Cultural competence involves understanding and appropriately responding to the unique combination of cultural variables—including ability, age, beliefs, ethnicity, experience, gender, gender identity, linguistic background, national origin, race, religion, sexual orientation, and socioeconomic status—that the professional and client/patient bring to interactions.

Since neither my nor the child’s safety was in question, I had no ethical reason to refuse to work with this family. Had I chosen not to return, I could have delayed services for several weeks while the family waited for another provider to be assigned, simply because their belief system clashed with my identity. This was not what I had agreed to do as an SLP. This was not culturally competent.

I tell this story to make it clear that cultural competence and anti-discrimination work in both directions.

From time to time, I encounter articles or discussions related to queer issues in SLP spaces on social media.  For example, ASHA has posted a few articles about voice specialists who work with transgender people.  Typically, the response to these articles is overwhelmingly positive, which gives me a warm fuzzy feeling and makes me feel proud to have chosen this career.

Yet, there’s always that one person.

In response to articles about voice work with transgender people, the dissenter typically expresses the hope that insurance companies are not expected to pay for these services.  Other comments invoke the “love the sinner, hate the sin” cliche. On rare occasions, I have even seen comments similar to those made by the homophobic parent.

Every time this happens, there’s a sizable backlash to which the the dissenter  responds defensively.  You bigot, they say to people who find their homophobia and/or transphobia offensive, how dare you discriminate against my right to have personal beliefs?!

Moving past the issues with that statement – not because they’re irrelevant but because they’re outside the focus of this entry – I feel the need to point out that ASHA-certified SLPs are ethically required to put our personal beliefs aside in professional contexts. We can have our opinions, but we check them at the door when we’re working.  Neither is there room for personal beliefs, especially ones that have no basis in scientific evidence, when we discuss issues related to professional practice.

Which brings me to another Ethic in ASHA’s Code:

Individuals who hold the Certificate of Clinical Competence shall use independent and evidence-based clinical judgment, keeping paramount the best interests of those being served.

Evidence-based practice means that we make clinical decisions, such as who to treat, how to treat them, and when to stop, based on up-to-date and well-conducted empirical studies. If you want to believe that queer people are “unnatural,” you do so in your own time until you have scientific evidence to support your claim.

To that end, there is evidence to support the legitimacy of gender dysphoria, as well as mixed but largely supportive evidence that transitioning significantly benefits transgender people.  Further research is needed, of course, but we have passed the point of being able to claim scientifically or professionally that transgender people are “unnatural” or “wrong.”

Instead, we as SLPs should be questioning the role of voice in the transition process.  Is voice change a medically necessary component of transitioning?  Can hormone therapy sufficiently alter voice, or do transgender people require additional  services?  How do we differentiate between transgender people who medically require SLP services, and people for whom it is elective?

I am not a voice specialist.  I don’t have the answers to these questions.  If the research exists, I haven’t found it.  If it doesn’t, I hope someone is conducting it.  I’d love to read the results.  Until then, we need to approach this issue with cultural competence, relying on the research we do have and leaving our personal biases out of the discussion.

Cultural competence in LGBTQ+ issues is not limited to voice therapy. Queer people exist everywhere: in hospitals, rehab centers, nursing homes, schools. An Early Intervention SLP may very well be asked to work with a toddler who has two moms or two dads.  In any case, the ASHA Code of Ethics requires SLPs to treat queer clients/patients/students, families, and caregivers  with the same respect, dignity, and clinical expertise that we treat cisgender-heterosexual people, regardless of personal beliefs.  As a queer SLP, I am required to treat openly bigoted clients, caregivers, and families in the same way.

So yes, when a patient says “I disagree with gays getting married” during a language assessment, I put aside my emotional reaction in order to plan treatment.  Their belief that I shouldn’t be allowed to get married does not negate their right to regain their communication skills, just as choosing to treat this person does not invalidate my commitment to marriage equality.

If you want to attend a church that believes queer people are “unnatural,” if you choose to reject friends and relatives who come out, those are your decisions.  As soon as you project your beliefs onto the people you work with, you violate the code of ethics you signed when you became certified.  I agreed to abide by that code and I renew my commitment to it every year. I do so with the understanding the SLPs across the country are doing the same.

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