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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A list of public bathroom signs that are more useful than gender designations

Anyone who follows the news in America knows about the public bathroom debates that have been springing up all around the country over the past year.  North Carolina is the famous one, but Mississippi, Virginia, South Dakota, and Washington state have asked (or are asking) similar questions.  Should transgender people be allowed to use the bathrooms that are consistent with their gender identities? Or – the age-old question – do groups of primarily white men know marginalized people they’ve never met  better than these people know themselves?

As a cisgender person (meaning my gender identity matches the gender I was assigned at birth), I am not remotely qualified to describe the experience of feeling uncomfortable in the bathroom I’m told I must use.  I do not know what it’s like to identify as genderqueer, genderfluid, gender non-conforming, agender, or any other identity which can complicate the experience of using bathrooms designated specifically for men or women.  Still, this series of debates has left me wondering what we gain by assigning gender to bathrooms at all. Why should I care about the gender of the person washing their hands next to me?  What does it matter if the person using the toilet before or after me stands up when they pee? I will put the seat down if I have to. If necessary, the person after me can put it back up.  It’s not difficult.

There are, however, plenty of other things that I would like to know about a public bathroom before I use it.  How many of you have stood outside a bathroom door, knocked, and waited five minutes only to realize that the room had three stalls and you could have waited inside the whole time?

Just me?  Okay.

Anyway, I’ve compiled a list of things that people might want to know about a public bathroom before they knock on the door or set foot inside, things that are far more useful than knowing which gender is allowed entry.  I admit that some of these may be difficult to depict in easily-recognizable symbols, but we can work out the kinks later.

  1. This bathroom is accessible.
  2. This is the only accessible bathroom within a 5-mile radius. Please be considerate and pee somewhere else.
  3. There’s a changing table in here.
  4. This bathroom has stalls.
  5. No stalls here.
  6. Knock first. Seriously. You’ll thank us later.
  7. There are urinals in here.
  8. There are only urinals in here.
  9. The motion-sensor light will switch off after three minutes.  Flail, jump around, or dance to switch it on again.
  10. Please show respect for the family of roaches that lives in the wall.
  11. Toilet is broken. Flush at your own risk.
  12. This bathroom is being cleaned right now.
  13. Nothing in here has been cleaned since the building was first constructed.
  14. The attendant standing in front of the sinks will expect a tip after you’ve washed your hands.
  15. You will be expected to wash your hands before exiting the bathroom.
  16. Step carefully; we set mouse traps.
  17. This bathroom needs a code to get in. Buy something, and we’ll tell you what it is.
  18. We couldn’t be bothered to include a bin for used pads and tampons.
  19. We did include a pad/tampon dispenser, which was last stocked circa 1982.
  20. Our toilets have motion sensors. Please do not be alarmed when they flush under you.
  21. The plunger is under the sink.
  22. Our toilet is literally a hole in the ground. Good luck!
  23. People of all genders use bathrooms. It is absolutely none of your business what they look like under their clothes.

What do you think?  Did I miss anything?

On “Geek Spaces” and the Social Politics of Pokemon Go

Kenney Park, next to Davis Square in Somerville, Massachusetts, is a small but popular space containing a basketball court, a playground, an open plaza, a fountain that people can walk through on hot days, and – recently – four Pokéstops. This plus its proximity to other Pokéstops and gyms has made Kenney Park a popular location among players of the new augmented reality game Pokémon Go.  To the outside observer, this looks like oddly-clumped groups of people staring at their phones and occasionally spouting phrases like “one more Gastly and I can evolve a Gengar” while oblivious toddlers chase their grandparents through the water jets at the center of the plaza.

I want to stress that we – and I do mean we, as I myself have caught more Charmanders in Kenney Park than I have everywhere else combined – have never disrupted the activities of the people who visit these spaces for reasons other than Pokémon Go.  We are not loud, we are not unruly, and we aren’t in anyone’s way.  In every setting I’ve encountered while playing this  game, Pokémon Go players quietly coexist with non-players in these public spaces.

Yet our presence seems to have an effect on some people, and not in a good way.

One night as I was leaving Kenney Park (my battery was low and I needed to recharge), I passed a trio of white 20-somethings on the street corner across from the plaza.  One of them, the only woman, said: “I just feel really uncomfortable right now.” One of the others replied, “I just wanna go in there and knock everyone’s phones out of their hands.”

Had I been a braver person, I would have politely requested that this guy stop being a douche (or worse).  That, however, is not who I am.

One evening in Boston Public Garden,  a young woman and two people who were presumably her parents passed through another popular Pokémon Go spot.  I overheard her say, “Literally everyone here is playing Pokémon right now,” with the same tone and facial expression one would use to complain that no one in the house ever showers. She even held up her hands as if to ensure we kept our distance.

The man who could have been her father made eye-contact with me, so I smiled at him and nodded.  He looked away, uncomfortable, and I returned to my game.

It’s not just people loudly and pointedly voicing their discomfort with our presence.  I have, both individually and as part of a group, received taunts, jokes, and downright harassment by people who for some reason object to us playing Pokémon Go in public spaces.  Comments have ranged from passive aggressive and immature (“Did I run over a Pokémon?  GOOD!”- from a cyclist who looked old enough to be my father) to direct and downright abusive (“Hey ****s! Stop playing ****ing Pokémon Go!” – from a young man in the backseat of a passing car).

These incidents did not surprise me.  I have had geek interests since childhood and am well aware by now of the stigma around geek culture.  It has, however, surprised me to see that Pokémon Go players as a whole appear to be immune to these harassments when they occur. We exchange eye-rolls, laugh to each other, or often don’t react at all.

I once overheard a player describe an incident where a man attempted to throw water balloons at the players gathered in Kenney Park.  According to the story, he made multiple attempts, but the balloons kept hitting the curb instead of the crowd.  Eventually, one player shouted, “Try spinning them!” and every player in the plaza burst out laughing.

I wish I had been there.  Not only because then I could confirm that this incident actually happened, but because it would have been a joy to witness after years of being internally and externally shamed for having geek interests.

(Spinning the Pokéballs, for those who don’t know, is a technique that is used to try to capture Pokémon who are particularly powerful and/or difficult to catch.)

Plenty of people who enjoy Sci Fi, fantasy, or other so-called “geek genres” understand the experience of othering by people who do not share these interests.  We’ve been laughed at, ostracized, and/or openly shamed for years.  For me, high school and college was a slow discovery that other people shared my level of engagement in series such as Harry Potter, Star Wars, even cartoons and comic books.  It was a revelation; I didn’t need to hide who I was anymore because there were people just like me.  I could join geek communities and be proud of myself as a part of them.  This discovery literally changed my life.

Even so, geek culture has typically been relegated to niche spaces such as comic book stores, conventions, and of course the internet.  Geek spaces run wild on the web as fans from all over the world intensively discuss fictional characters and worlds, sharing their own artwork and writing with one another.  Still, these spaces have typically existed separately from the mainstream, and geek culture  has not been integrated into our society as a whole.  For example, it is common to see people in public spaces playing basketball, frisbee, or even baseball.  Less common: public Dungeons and Dragons tournaments.  Tabletop role-playing games are conducted in the back rooms at comic book stores or in players’ apartments.  We revel in who we are, possibly more than we ever have, but we continue to do so quietly, privately.

And then Pokémon Go happened.

Pokemon Go, by nature, directly contradicts the isolationism that has been intrinsic to geek culture for so long.  It forces players to walk around our neighborhoods, encourages us to gather in public places such as Kenney Park or Boston Public Garden. The aim is to get people active and exploring their spaces.  It has succeeded in this, of course, but it has also pushed parts of geek culture into spaces where we have not previously existed so openly. And that is making a lot of people uncomfortable.  We are not disruptive, but we are visible, and that appears to be too much for some people.

Many “non-geek” communities seem to view people with geek interests as being socially-awkward white men who live in our parents’ basements and have never had a girlfriend.  (For the record, as a white woman who does not live with her parents and DOES have a girlfriend, I see this reputation for what it is.) Pokémon Go is directly contradicting that stereotype.  We are all genders.  We are all ages.  We have a range of abilities, and we would have an even wider range if this game were created to be more accessible. We are straight, we are cis, and we are LGBTQIAP+.  We are black, white, Asian, Latinx, indigenous, and multi-racial.  We are single people, couples, families, and friends.  We are nearly everyone.  This diversity is obvious the first time you encounter a gathering of people playing Pokémon Go, and it’s beautiful.

The concept of a diverse group of people publicly enjoying a geek interest is apparently so threatening to the social order that some people – all of whom, as far as I’ve witnessed, have been white men – need to taunt and harass us as if we were all back in middle school.  The brilliant thing is, this time it’s not working.  We see these taunts for what they are and are unfazed.  Empowered by each other, we proudly exist in public spaces that belong to us as much as they belong to the people who neither know or care what a Voltorb is.  Because there are six billion people in this world and if coexistence wasn’t possible, humanity wouldn’t have lasted this long.

I recognize that I am drawing parallels with other marginalized groups, specifically pertaining to race, gender, gender identify, sexual orientation, disability, ethnicity, religion, and any number of other factors I may have missed. While I would never say that the experience of geek culture is proportional to what these groups have faced – in many cases these situations are literal matters of life and death – but the idea is similar. We have long accepted our marginalization and are now pushing for visibility and acceptance in public spaces, literally and metaphorically. This can feel threatening and upsetting to the people who have occupied those spaces for decades (centuries, even) and are suddenly feeling as though we are somehow infringing on their “rights.”  Hopefully this backlash will fade as these majority groups learn that we are not pushing them off the bench, merely compelling them to make room for us to sit there too.

So yes, I will continue to play my game based on an anime based on a manga based on a game.  I will pause in my attempts to catch that Fearow in order to smile at the small child chasing a butterfly in front of me.  I will carefully step around the water jets in order to access the Pokéstop at the back of the park. I will coexist with people outside of geek culture, proud to be who I am and like what I like. And that guy who believes I simply need to “get a boyfriend,” will someday, I hope, get over it.