Vocal Approach to Transgender Individuals: The Journey Taken in Chile and Argentina

Introduction

Until the beginning of the 21^st century, transsexuals, transvestites, and homosexuals were diagnosed with a disorder, classified by medical manuals such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). A group of eleven experts representing the member countries of the World Health Organization (WHO) worked on the revision of the ICD-10 [1], and the ICD-11 adopted their suggestions, proposing the change of the term "transsexual" to "gender incongruence"; diagnosing this group requires recognizing a noticeable and enduring mismatch between an individual's experienced gender and their assigned sex, as defined by the ICD-11. Merely observing variations in gender behavior and preferences is not sufficient for diagnosis [2].

Individuals with gender incongruence (GI or transgender) may express a desire to make body modifications that bring them closer to their desired gender; therefore, accessing a multiprofesional healthcare team can be an option if they require surgery and medical, psychological, speech therapy, and other treatments.

The speech therapy approach to transgender voice is justified if it is understood that the voice is an extension of personality [3] and fundamental for interpersonal relationships. According to Chaloner [4], to approach transgender individuals, speech therapists must be sensitive to multidisciplinary work, have a deep knowledge of laryngeal physiology, and possess communication skills as well as being psychologically balanced. Until 2006, few studies were carried out on changes in the voice and communication of trans people, but, since this date, a significant increase has occurred in investigations, coinciding with social, political, and cultural changes. Only at 2009, the World Professional Association for Transgender (WPATG) included Speech and Voice to the Standards of Care, as treatments transgender may access [5]. Malebran [6] refers to the aesthetic and non-rehabilitative nature of vocal approach and comments that in Chile, trans women are more frequently referred to this approach.

As Södersten et al. refer (2019), transgender health care has different realities around the world until these days. Aware of this variety in the approach to transgender individuals, the WPATH periodically releases a series of multiprofessional recommendations, known as the Standards of Care (SOC). These guidelines provide a framework for the care and support of transgender people, considering the diverse needs and experiences within this community. By recognizing and addressing this variety in the approach to transgender individuals, WPATH aims to promote more inclusive and effective healthcare and support for this population. It is important to stay updated on these recommendations to ensure that transgender individuals receive the best possible care and support [7]. Currently, it is suggested that a holistic approach not focused only on frequency be offered, but including attention to vocal health, intensity, prosody, pitch, resonance, articulation, verbal and non-verbal communication, and authenticity [5].

An integrative review notes that speech therapy and hormonal treatment can be the first option for voice adjustment of the assumed gender, as it does not imply significant risks and is relatively inexpensive. If there is no improvement, vocal surgery would be another option [8].

In recent years, the demand for vocal approach by transgender individuals has increased. Therefore, this article aims to reflect on the journey taken by two experts, identifying current norms, statistics, and vocal approach in Chile and Argentina.

Reflections on the Chilean Reality

Regulations History

In Chile, the road to a law protecting transgender individuals was long. The Penal Code of 1874 classified "sodomy" as a crime. 125 years later, Article 373 of the Penal Code criminalizes homosexual acts offending "modesty or good manners"; the interpretation of this article could lead to criminalize lesbian, gay, bisexual, and transgender, queer, intersex, and asexual (LGBTQIA+) individuals. In 2014, consensual sexual acts between adults of the same sex were decriminalized. In 2017, Article 2 of the Labor Code included sexual orientation as one of the prohibited reasons for workplace discrimination. In the same year, the mental health protection bill was approved by the Chamber of Deputies, where Article 6 states that "mental health diagnoses cannot be made based solely on a person's identity or sexual orientation". This bill is being examined by the Senate since September 2020 [9].

In November 2018, Law 21120 was enacted, recognizing and guaranteeing the "Right to Gender Identity", which gave transgender individuals the possibility to request rectification of their gender, sex, and registered name [10]. Effective since December 2019, Law 21120 aims to regulate the procedures for accessing rectification of a person's birth certificate regarding their sex and name, before the respective administrative or judicial body [11]. This right can also be exercised by minors under eighteen and over fourteen years old through their legal representatives [10]. The principles and rights of Law 21120 include guaranteeing dignity in the treatment of trans individuals, prohibiting discrimination and pathologization against trans individuals, ensuring confidentiality of data of trans individuals, recognizing the progressive autonomy of trans children and adolescents, and respecting the best interests of the child to recognize and respect their gender identity [11]. In this regard, in May 2019, the bill 12660-18 (known as "Nothing to Correct") was presented in the Chamber of Deputies, which establishes "conversion therapy" as a form of domestic violence and arbitrary discrimination against LGBTI youth [9].

Healthcare System

The response of the Chilean healthcare system to the specific needs of the trans population remains a challenge [12]. The tendency towards pathologization and mistreatment in healthcare is still a reality [13]. In a recent survey, 95% of trans people reported experiencing discrimination in healthcare centers, characterized by questioning of their trans identity, teasing, verbal discrimination, and even denial of specialized care [14]. This situation may be related to the lack of specific training for healthcare professionals [15]. Mistreatment and the smaller number of specialized professionals may lead to lower adherence to required healthcare treatments [16]. Discrimination in healthcare towards trans individuals can be of two types: active and passive; the former is exemplified by violent care from professionals who prioritize their personal beliefs over the dignified care of trans individuals, while the latter can be understood as invisibility [17].

However, there are also positive experiences: Dr. MacMillan, a urologist, was a pioneer in gender reassignment surgery in our country, performing surgery on 448 people at the Carlos Van Buren Hospital in Valparaíso between 1976 and 2009, when he retired. His work was outstanding both in terms of his professionalism and his humanity.

Recently, Chile has 18 hospitals and/or family health centers (Cesfam) that reported receiving trans users, but not all of them have a trained multidisciplinary team. National reference centers for trans care include the Dr. Leonardo Guzmán Hospital (Antofagasta), Sótero del Río (Santiago), and Van Buren (Valparaíso) [18]. In 2012, the Hospital Las Higueras developed a specific protocol for the care of trans people. Additionally, this hospital works to engage with the community through the formation of the Participation Table in Health for Trans Users (or Trans Table), which has provided sensitivity training to professionals in the national health network, increasing the number of professionals knowledgeable in this area [19].

In 2010, a Clinical Pathway was developed to identify and adapt the availability of resources in the public health system, offering a national proposal on body realignment surgeries. The Clinical Pathway was the result of work between the Division of Disease Prevention and Control (DIPRECE) and the Undersecretariat of Public Health to facilitate access to care for people with incongruences between their physical sex and gender identity [20].

Demographic Statistics

The demographic statistics are still unreliable. Methodologically, the 2015 Casen survey had formulation errors in its questions, so the data collection was not clearly considering transgender people. Likewise, the results indicated that the population that recognizes themselves as heterosexual is 98.51%, those who identify as gay or lesbian are 1.04%, bisexual 0.37%, and "other" 0.02%. Within the "other" category, transgender people may be included [21].

Supported by the Chile Organizing Trans Diversities (OTD) group in 2020, a survey was conducted during the COVID pandemic, asking 409 trans people from Chile about their economic and health realities during quarantine. It was found that 61.08% were trans men, 22.17% were trans women, 9.61% were gender-fluid, 3.2% were non-binary, 2.96% were other, and 0.99% were transvestites [22].

But this number is far from reality. Between 2012 and 2015, 200 trans people requested to change their names in Chile; another source states that between 1990 and 2019, 750 people had managed to change their names [23]. This number increased by 197% since the approval of the Gender Identity Law (2021 people). In 2020 alone, the number of name rectifications increased by 2064% compared to 2019, with 58% corresponding to trans men. 39% of trans people with name changes are from Santiago, followed by trans people from the Valparaíso and Bío-Bío regions [24]. It is estimated that there are 80,000 trans people throughout Chile, making up 0.5% of the population [16].

The lack of knowledge of the real number of trans people contributes to delaying a public health policy plan. However, during 2022, a working group was created in the Ministry of Health (Minsal) between professionals from the 18 referred health services to advance with an attention flowchart and protocols to be applied throughout the national territory.

Voice therapy approach

In 2005, I decided to introduce the topic of transgender individuals in relation to voice therapy into my undergraduate classes, inspired by research conducted in Australia and England. It generated so much surprise and interest that in 2006, I began a study on the voice characteristics of transvestites and transsexuals with my students at the University of Valparaiso. At that time, both groups were categorized under "identity and gender disorders" in the ICD, classified as pathologies and therefore subject to treatment and rehabilitation in healthcare. The aim of the study was to characterize voice parameters, investigate possible signs and symptoms, and refer individuals with voice impairments to speech therapy. The group was heterogeneous and faced discrimination; I was unable to refer study participants to consultations or Ear, Nose & Throath (ENT) evaluations, as there was a certain bias that they would be "poor patients", prone to not taking care of their own health and potentially giving a "misleading image" to other patients who needed voice therapy. However, the group was highly interested in caring for their voices, with the expressed desire linked to the need for nondiscrimination and better job opportunities, once they obtained a voice that completed the image they had of themselves and helped them avoid marginalization.

This first investigation led to a more structured one conducted during the period of 2011-2012 in Viña del Mar. The study observed anatomical and physiological characteristics of trans women and offered voice therapy or laryngeal surgery to raise the fundamental frequency. After a complete vocal evaluation (including both Speech and Language Pathology/SLP and ENT diagnosis), vocal pathologies were ruled out and a feminization vocal program for people with gender identity disorder was offered, created by the researcher, and called FEMI-TIG. The most common alterations found were, in the otolaryngology field, posterior laryngitis and pharyngolaryngeal reflux, and in the speech therapy field, interdentalization, intense laryngeal tension due to the maintenance of a high larynx in the neck, vocal fatigue, breathy voice, nasal/hypernasal resonance, and horizontalized articulation. None of the trans women had received speech therapy before, all were undergoing hormone therapy without medical accompaniment, and all reported negative psychodynamics related to their voice.

Transgender women who chose to participate had to sign a commitment letter to the FEMI-TIG program and receive a vocal hygiene orientation. Sessions were weekly and lasted 30 minutes, always exploring auditory, proprioceptive, and visual feedback in phonation, perceiving communication skills, optimizing breathing and cervical/ scapular relaxation, balancing resonance, establishing a new f0, reinforcing pragmatic speech skills, and working on prosody. The structure of the approach relied on the selection of vocal techniques and their execution with different musical intervals until completing an octave. After 10 sessions, a reevaluation of the SLP and ENT was performed, examining laryngeal structures and phonatory tasks with nasolaryngofibroscopy and verifying the stabilization of the f0 in spoken voice. The FEMI-TIG program was successful in allowing flexibility in vocal range for transgender women, achieving an average f0 of 235Hz. The younger the transgender woman, the greater adherence to the program was perceived. The benefits of the program were also noted in better vocal hygiene and control of vocal abuse in all transgender women, as well as improvements in resonance parameters, prosody, respiratory, and postural aspects of speech. Laryngeal surgery was not necessary after the ten sessions [6].

The results of the FEMI-TIG program were presented at the First Ibero-American Congress of Professional Voice and Vocal Clinic, at the University of Chile, Santiago, in October 2012. On this occasion, it was received as a pioneering and controversial work. There were no other colleagues working with transgender individuals in Chile at that time, and the topic sparked curiosity about how to approach the vocal needs of this group. However, criticisms were also heard about how ethical it would be to develop a voice to "deceive" heterosexual people. I highlight the positive aspect: the Latin American audience present allowed the possibility of discussing the subject. The exchange with the Argentine colleague, Virginia Zangroniz, began there.

Over the years, I have seen how laws protecting the LGBTQIA+ community in Chile have progressed, and at the same time, how different organizations have organized to fight for their rights (OTD, Movilh, among others). These organizations have become stronger and gained representation, putting pressure on the political environment to advance laws protecting against discrimination; among their demands was the depathologization of gender identity and the right to change one's identity document in the civil registry.

Currently, vocal care for transgender Chileans is no longer so rare, with options throughout the national territory in hospitals, private clinics, and associations. However, the approach to vocal care takes different paths today. While some care focuses solely on pitch modification of the voice, others have opted to incorporate elements of language, speech, and gestural expression into their approach. The trans voice is no longer seen as a vocal "pathology" that requires a rehabilitation plan, but rather as a vocal approach that provokes an aesthetic adjustment of the voice to the desired gender. Some colleagues even do not defend voice adjustment to a certain gender and pursue gender neutrality, as a reflection of reality in countries like Australia and some states in the United States. Personally, I believe this is not yet the reality in Latin America.

My work is characterized by providing voice care to transgender men and women who want to explore their vocal possibilities to feel comfortable with their voices. Personally, I do not use terms such as "therapy", "rehabilitation", or "diagnosis" with this group. Instead, the question I ask during voice evaluations is "what do you expect from my approach?" and I remain open to the other person's expectations, which are usually straightforward: "to not be discriminated against because of my voice." To date, having worked with over 400 transgender individuals, I have only had one user who asked for a neutral voice, as everyone else sought to feminize or masculinize their voice. I apply self-awareness protocols and generally offer a vocal self-awareness workshop to those interested, and then work on a plan from there.

Although they are more numerous, transgender men are not regularly referred to speech therapy services due to the masculinization of their voice experienced with hormone treatment. In 2006, I agreed with this practice, but today I question it: I have observed that many present inappropriate speech and articulatory adjustments, which contribute to the development of symptoms frequently observed in clinics, such as fatigue, hoarseness, voice strain, breaks, and instability. Research with trans men are limited but enough to set these issues. Additionally, speech requires small adjustments that allow for greater comfort when speaking, providing security and confidence.

My experience with transgender adolescents has shown that a prior speech therapy approach before hormonal treatment improves auditory and proprioceptive monitoring, avoiding the development of inadequate vocal hygiene and facilitating supraglottic adjustments that allow for a healthy voice during the gender transition.

It is important to note that in speech therapy, it is common for trans women to not recognize their voice after feminization. The fear that the voice will not represent their new identity is constant, and this insecurity is reinforced by the violence and social discrimination that still exists in Chile. It is usual for trans individuals to have a history of social rejection or experience at least one episode of social and/or intrafamily violence. Discrimination in the workplace is still a reality, despite current laws. Therefore, I believe that in the near future, it would be interesting to bring speech therapy closer to the "active voice", accompanying trans individuals in daily and/or social activities, building vocal empowerment together.

The trajectory of speech therapy in Chile regarding the care of trans people has advanced significantly. Today, there is a concern among professionals to improve their knowledge on the topic, organize discussions relevant to the approach, research new proposals to contribute to a better quality of life related to phonation in this group, and create training programs that allow for a more prepared multidisciplinary team. I provide training, participate in conferences, and give lectures in Chile and Latin America, which allows me to see how society has changed its position on the topic, although there is still a long way to go. We are few SLP throughout the country who are dedicated to the trans issue, but this number grows every day, and the desire to provide better care is the driving force behind our continued training.

Reflections on the Argentine Reality

Regulations History

Since 2010, in the expansion of rights for people, the Equal Marriage Law No. 26,618 was already in force. This law made Argentina the first country in Latin America to recognize the right to marriage between people of the same sex throughout the national territory. With the Gender Identity Law 26743 [25], sanctioned on May 9, 2012, a new era begins in terms of rights for transgender individuals in particular and for the general population. This law recognizes the right of individuals to be registered in their National Identity Document (DNI) according to their gender identity. Additionally, this law acknowledges the right to comprehensive healthcare, but it does NOT require any type diagnosis or surgeries to prove one's identity.

The 26.743 law allowed for the change of name, image, and gender in personal documentation, considering the self-perceived identity as fundamental. It also stopped pathologizing trans identities and mandated the compulsory medical plan of the public and private health systems to cover hormonal therapies and total or partial surgical interventions to adapt the bodies of those who required it. I want to emphasize that neither of these two laws would have been possible without the tireless organized struggle of the LGBT movement. Lohana Berkins, a transgender activist and human rights fighter, formed the National Front for the Gender Identity Law, which was an alliance between many organizations that pushed for the enactment of what would become the Gender Identity Law two years later, in 2010. Their goal was the depathologization, dejudicialization, destigmatization, and decriminalization of trans identities.

After much effort and with the support of many legislators who pushed for the project, finally (and also initially), on May 9, 2012, the 26743 Identity Gender Law was enacted, establishing the right to gender identity of people. In article 2, the definition of gender is given as the internal and individual experience of gender as each person feels it, which may or may not correspond to the sex assigned at birth, including personal experience of the body. This may involve modifying the appearance or function of the body through pharmacological, surgical, or other means, as long as it is freely chosen. It also includes other expressions of gender, such as clothing, speech, and manners.

In 2021, with the sanction of decree 476/2021 [26], the option to choose the "X" nomenclature on the DNI and passport was introduced to recognize and legitimize gender identities beyond the female/male binary. This decree expanded the rights recognized by the previous law.

Another fundamental law is the Trans Quota Law, sanctioned on June 24, 2021, as Law 27636 [27], promoting access to formal employment for transgender and gender-diverse people, named after "Diana Sacayan-Lohana Berkins". This law aims to address the historical injustices that this population has suffered.

While these laws are in effect throughout the national territory, their implementation and enforcement vary, and we do not currently have statistics on this matter.

Healthcare System

Argentina has a solvent public healthcare system that caters to the population's needs [28]. Therefore, transgender individuals who require medical attention should be able to receive it in hospitals and primary care centers available throughout the national territory. Additionally, there is a mixed healthcare modality accessible only to those who have registered employment, which provides them with Social Security (healthcare providers) coverage [29,30]. Under this system, they have access to healthcare services under the Mandatory Medical Program [30], which are provided in various hospitals and healthcare centers, both public and private, due to the mixed nature of this system. Furthermore, there is also healthcare coverage in the Private Health Insurance sector [31].

Regarding the healthcare of transgender individuals, Argentina has a few specialized centers where various gender-affirming surgeries, psychological support, and speech therapy are provided under a single service. The Dr. Ricardo Gutiérrez Hospital in La Plata, in the province of Buenos Aires, is one such center. In the Autonomous City of Buenos Aires (CABA), similar services have been available in various hospitals for several years. However, at the time of writing, we do not have comprehensive data and specific names to avoid omissions or inaccuracies. The purpose of this publication is to reflect on the beginnings of speech therapy services for transgender individuals, and at the time when I started, none of these laws had been implemented. All of them were enacted after I began this work. It is worth noting that, since the Gender Identity Law, providing healthcare to transgender individuals is an obligation for the entire healthcare system. However, this "obligation" is not always fulfilled, and there are numerous unmet demands, including various breaches or refusals to provide care reported by transgender individuals in different media and groups.

Despite the existence of these laws, the efforts of the government and private healthcare providers, there are still a limited number of specialized reference centers, not only in terms of the excellence of the services, treatments, support, or training they offer. Word of mouth recommendations continue to be a common way of self-care and collective care for most of the transgender people surveyed. Based on an informal oral survey, transgender individuals recommend healthcare professionals with whom they have had positive experiences, not only in terms of healthcare but also in terms of their human quality and empathetic listening during their interactions.

As for speech therapy services, there has not been a precise survey of how many places offer such services across the country or how many centers have specialized speech therapists for transgender individuals. In the city of La Plata, the Dr. Ricardo Gutiérrez Hospital remains a reference in this field, as it has been working on this topic since 2013 and has experienced significant demand, not only from healthcare system users, consultees, or patients but also from professionals in other healthcare teams, from other hospitals, and from students in Speech Therapy programs interested in training, not only from La Plata but from various locations in the province and the country. After more than ten years, the demand for care has increased, but the number of professionals with the training and willingness to work in this area of practice has not grown accordingly. Of course, there are various professionals working in both CABA and the provinces of Córdoba, Santa Fe, and San Luis, among others, with whom we have knowledge and have exchanged ideas. However, there is still a need to establish a common space for exchange and training for young professionals who require it. It is a concern that there are relatively few professionals interested in this field.

Currently, in voice support consultations, there is a noticeable prevalence of transmasculine individuals, unlike the early years when the demand was primarily from transfeminine individuals. In terms of the age of the individuals seeking services, it has decreased, and the majority are now adolescents. Most of these adolescents attend with the support of their close family or adult mentors.

Demographic Statistics

About statistics, exceed the possibilities of conducting such research with the time and dedication they deserve, and we lack both the financial resources and the personnel to carry out the task of research, data collection, and analysis. The existing statistics to which we have had access do not accurately reflect the reality in which transgender individuals live or the state of healthcare in various areas and healthcare providers, both public and private, at this moment.

Returning to the Gutiérrez Hospital in La Plata, a recent survey conducted at the institution reveals that in the hormone therapy consultation room under the care of Dr. Claudia Capandegui since its establishment, there are 853 patient medical records, and the surgical team, led by Dr. Cesar Fidalgo and Dr. Daniel Bustos, has performed over 1000 surgeries from its inception to the present. Many of the referrals from these healthcare spaces are directed to both the psychological support department, led by Licenciada Andrea Pineda Aristegui, and the speech therapy department, overseen by Licenciada María Virginia Zangroniz.

Voice therapy approach

In 2012, a person came to my private practice, who, with their demand, introduced me to the topic that now occupies today almost all my work. This "surnamed and not named" [32] person presented themselves saying "I am a trans boy" and what I saw in them coincided with the idea of a boy that I had up to that moment, from their voice to certain characteristics attributed to masculinity such as facial and body hair. And here I stop because it seems appropriate to quote Preciado [33] when he states that, in our society, facial hair and voice, not the penis or vagina, not the X or Y chromosomes, are the cultural signifiers of gender [34].

Paradoxically, what I was looking for was to recover some of the high notes that he had lost due to the hormone treatment he had been undergoing with testosterone. I searched for specialized literature and then remembered that in 2012 I had heard colleague Celina Malebran talk about her experience with vocal work with trans women. It caught my attention that in Chile they spoke of Gender Identity Disorders (TIG) while in Argentina they spoke of Gender Dysphoria. I contacted her and told her that I was starting this experience in La Plata, and we began a series of exchanges. Together we lamented the absence of bibliographic material and from that moment on I shared with her my doubts and concerns.

In 2012, the Gender Identity Law (Law 26.743) came to repair some of the injustices that trans people must fight daily, including terminological and semantic ones. By 2013, my search for bibliographic material and information led me to the Urology Service of the Dr. Ricardo Gutiérrez Acute Zone Hospital in La Plata, where in 1997 the surgeon César Fidalgo and his team had successfully carried out the first "sex change surgery" in the country. I requested an interview with Dr. Fidalgo to discuss my incipient experience and ask him to put me in contact with the speech therapy team. I was greatly surprised when he told me that there was no one there who dealt with the voice, but he was interested in my story and offered me the opportunity to join the team he coordinated to carry out the same experience that I had come looking for. I presented my resume with a work proposal, and my incorporation was almost immediate.

Article 11 of the law 26.743 discusses the right to personal development, whereby all persons over the age of 18 may access total and partial surgical interventions and/or comprehensive hormonal treatments to adapt their body, including their genitalia, to their self-perceived gender identity, without requiring judicial or administrative authorization. With the enactment of this law and being part of the Genital Reassignment Team at the Gutiérrez Hospital, I understood that this work had to be constructed from an interdisciplinary approach, where the result is a clear modification of the perspectives of the disciplines and a new product arising from that exchange, with reflections on these new realities. Therefore, my first challenge was with a trans woman who wanted to feminize her voice. In those early days, most of the clients stated that they needed or wanted a voice that referred to their current gender identity, seeking vocal adequacy, while a minority did not approach vocal work in binary terms.

Meanwhile, I continued to see my first patient once a week, developing a work plan. To achieve our initial goal of acute recovery, I relied on elements related to voice professionals and worked extensively on expanding their vocal possibilities. I acknowledge that I had a privileged situation because this person had musical knowledge and previous experience working with their voice. Based on this background, I developed a work plan that I initially called "Healthy Vocal Adaptation", which consisted of supporting people who wanted to work on their voice. The main goal was to achieve vocal comfort and communicative well-being. Although the objectives remain valid and have expanded, the current name is now "Vocal Transition Support". Since then, many people with different demands have been treated by me in the context of this space in public health, where I have been working on a pro-bono basis since then and continue to work in private practice.

Currently, while attending to trans people in my private practice whose medical coverage is derived from registered work that allows them this possibility, I noticed that the diagnoses with which they arrived at my consultation did not match reality. As what is not named does not exist, I decided not to ignore the matter but rather highlight it. Through my work with the College of Speech Therapists of the Province of Buenos Aires, Regional La Plata, in conjunction with the various colleges that make up the province, I brought to the Assembly where new speech therapy diagnoses were being discussed, the need to include vocal adaptation according to law 26.743 as a mode of political intervention that left behind those diagnoses that invisibilized trans people, and instead talk in terms of what was really happening in the consultation room. In fact, by Resolution No. 171/2019 of the Superior Council of the College of Speech Therapists of the Province of Buenos Aires, as of 2019, vocal adaptation treatments in trans people are included in the nomenclature of the province.

At my clinic work, there is a dimension that was not as clear to me until that first consultant, which is the dimension of desire. From that first experience, there was a modification in my professional identity and a paradigm shift that I am grateful for: listening before speaking became a rule, as did the avoidance of anticipation, like questions emerged that I had previously taken for granted, such as "How do you feel about your voice?" "What is your desire in relation to your voice?" In my experience up to that point, the people who came seeking vocal treatment wanted to regain their voice, heal, and cure. From my professional knowledge, it was clear what I had to do in a vocal evaluation or rehabilitation, even how to provide guidance to prevent a vocal pathology. And, of course, the dimension of desire came into play, but not in this way. During this time, I learned a great deal about listening, and I also learned that not all the people who came were patients; we can talk about "users of the health system" far from the idea that there must be a pathology to be treated in order to be heard and supported.

If during the ENT evaluation that I suggest at the beginning of the work plan, a vocal pathology appears, then it would need to be treated first with medical or speech therapist approach. Only then, and for the duration of the treatment, will they be a "patient" and only after that can they begin with the specific transgender vocal work, with the freedom and availability that is needed. I understood that the path that I have developed, I learned in non-academic contexts, far from undergraduate and graduate training spaces, and that it was and continues to be necessary to have a lot of patience and not be frustrated by what one does not know, and that from that lack of knowledge new knowledge, possibilities, and networks are structured.

In these years I have found myself very alone and at the same time very accompanied and secure. Alone in terms of discipline. In La Plata, there was no other speech therapist to exchange experiences with, and, in the rest of the country, I did not know of similar experiences, until in 2015, when I presented my work with trans people, "Experience in health and vocal aesthetics with trans people", during the 3^rd Provincial Congress of Speech Therapy - New strategies and fields of speech therapy intervention. I was able to approach the work of two colleagues who were developing an experience with trans women in a Health Center in the Autonomous City of Buenos Aires. Simultaneously, in March 2016, I published my first article outside of the hospital setting.

In the previous paragraph, I mentioned feeling supported and secure, and I owe that to the team of which I am a part, along with other dedicated and outstanding professionals in the Comprehensive Health Care Team for Sexual Diversity. The team's name change reflects the progress we have made, the paradigm shift, and the recognition that the response to these issues is not solely medical but involves other disciplines and is part of a constantly evolving and dynamic system. With successes and failures, we serve over 800 individuals each year, always understanding that gender is a social, cultural, and political construct that is constantly evolving.

Since 2012, when I began working in this new field of speech therapy intervention, I finally felt invited to participate after a deeper reading of the Gender Identity Law, which in Article 2 mentions speech patterns and mannerisms, as well as the enjoyment of comprehensive health. At that point, I no longer felt like I needed permission to participate and act. Legitimacy comes from work, study, research, and exchange, as well as the understanding that what is mentioned in Article 2 applies to speech therapists, since achieving communicative well-being is a fundamental part of our support.

Currently, I am working in teams, writing, and participating in talks and training sessions to share this search and encounter with others. This journey, which began years ago, has been and continues to be a great learning experience that I am grateful for.

Since 2016, I have been giving an annual lecture in the Functional Anatomy of Voice course, under the direction of Dr. Begonya Torres Gallardo, in the Faculty of Medicine and Health Sciences at the University of Barcelona. In this lecture, I bring in my colleagues from my team to talk about the comprehensive approach to the health of trans individuals, from the perspective of hormonal, psychological, and vocal support. Similarly, I have given talks at the University of La Plata in the Faculty of Social Work in the curriculum complementation cycle of the Bachelor of Speech Therapy, at the National University of San Martin for the Diploma in Sexual and Reproductive Health, and, since 2019, I have been an external advisor for the extension project of the University of San Luis called "More and More Trans Voices."

Even though I have only been working in this new area of intervention for a few years, it has been intense and a great learning experience. There is still a need for a cultural, scientific, and educational shift, but many of us are working from different areas and places to make this happen. We still have a lot of work ahead of us. While we have the law, it is not fully enforced, and we must continue to demand compliance in every area. We need to ensure that trans people have equal employment opportunities and that reparations are made for the historical injustices they have faced. Only then can we begin to talk about equality.

Discussion and Conclusion

The proposal aimed to present the narrative of two speech therapists and their experiences with trans voices in Argentina and Chile, combining a reflective and critical analysis. The current process of depathologizing trans individuals has been a great achievement for this community, celebrated in both countries, but it also highlights areas that need to be addressed. Understanding the path taken is important, as information about the journey helps to reduce violence and discrimination, creating opportunities for dialogue and inclusion.

In the last decade the visibility of transgender has increased. The WPATH (World Professional Association for Transgender Health) has established care standards for health professionals since 1979 [7]. Currently, we have SOC 8, launched on September 2022, which provides guidance and serves as a reference for healthcare professionals to support transgender and gender diverse individuals in the pursue of personal comfort with their gender identity, considering care with their overall health, psychological well-being, and self-fulfillment [34]. But in our reality, in Chile and Argentina, due to economic, political, and social (even religious) backgrounds not all healthcare centers implement what is suggested by SOC 8; and that constitutes a challenge for healthcare professionals in both countries.

In this journey, what is most comforting and encouraging for us to continue is the validation from the trans individuals and the invitations to speak on the topic, train colleagues and other health professionals, actions that give us the feedback that the path we have traced has been recognized.

After presenting the current regulations, statistics, health panorama, and vocal approach towards transgender individuals in Chile and Argentina, critical points that require further attention are reflected upon: documenting the reality of speech therapy care for this population in the aforementioned countries, limitations in the implementation of depathologization are observed; seeking reliable statistics; managing actions in the public system that favor a more active participation of both the trans individual and the multidisciplinary team and health personnel (eliminating violence in personal treatment); training the multidisciplinary team and health personnel, and minimizing the lack of knowledge about the benefits of voice work in transgender men and women.

These detected aspects could benefit from multicenter investigations that strengthen speech therapy actions for this group.

References

1. Robles García R, Ayuso-Mateos JL. CIE-11 y la despatologización de la condición transgénero. Rev Psiquiatr Salud Ment [Internet]. 2019;12(2):65-7. doi: https://doi.org/10.1016/j.rpsm.2019.01.002

2. Amigo-Ventureira AM. Un recorrido por la historia trans*: desde el ámbito biomédico al movimiento activista-social. Cad Pagu [Internet]. 2019;(57):e195701. doi: https://doi.org/10.1590/18094449201900570001

3. Behlau M, Pontes P. Avaliacao e tratamento das disfonías. 1º ed. São Paulo: Editora Lovise; 1995. 312 p.

4. Chaloner J. A voz do Transexual. In: Freeman M., Fawcus M, editores. Distúrbios da voz e seu tratamento. 3a ed. São Paulo: Editora Santos; 2004. p. 245-67.

5. Pickering J, Greene M. Voice and communication modification: historical perspective. In: Adler R, Hirsch S, Pickering J, editors. Voice and communication therapy for the transgender/gender diverse client, a comprehensive clinical guide. 3rd edition. San Diego: Plural Publishing; 2019. p 67-85.

6. Malebran MC. La terapia vocal en el transexual, experiencia de tratamiento vocal. En: Pérez R, editor. I Congreso Iberoamericano de Voz profesional y clínica vocal. Libro de Resúmenes; 2012 Oct 4-6; Santiago, Chile: Ediciones Escuela de Fonoaudiología, Facultad de Medicina, Universidad de Chile; 2012. p. 20.

7. Södersten Mª, Nygren U, Hertegärd S, Dhejne C. A. Multidisciplinary approach to transgender health. In Adler R, Hirsch S, Pickering J, editors. Voice and communication therapy for the transgender/gender diverse client: a comprehensive clinical guide. 3rd edition. San Diego: Plural Publishing; 2019. p. 1-19.

8. Malebrán Bezerra de Mello MC, del Campo Rivas MN. Efectividad de la terapia vocal versus tiroplastía en la voz de mujeres transgénero: una revisión integrativa. Rev Investig Innov Cienc Salud [Internet]. 2021;3(1):48-60. doi: https://doi.org/10.46634/riics.53

9. Mendos LR, Carrano Lelis R, López de la Peña E, Savelev I, Tan D. Homofobia de Estado 2020: Actualización del Panorama Global de la Legislación. Ginebra: ILGA World; 2020. 346 p.

10. Ley 21.120. Reconoce y da protección al derecho a la Identidad de Género. Diario Oficial No. 42.225 (Dic 10, 2018) [Internet]. Disponible en: https://www.bcn.cl/leychile/navegar?idNorma=1126480

11. ChileTrans. Ley de identidad de género [Internet]. [citado 2021/11/05]. Disponible en: https://www.movilh.cl/trans/ley-de-identidad-de-genero/

12. Donoso C, Núñez S, Parra-Villarroel J. Significado que otorgan las personas trans a sus experiencias en la atención en el sistema de salud chileno. Revista Chilena de Salud Pública [Internet]. 2018;22(2):126-34. doi: https://doi.org/10.5354/0719-5281.2018.53235

13. Day M. La discriminación que enfrentan personas trans y no binarix en servicios de salud en Santiago, Chile [proyecto de investigación independiente] [Internet]. [Santiago de Chile]: Instituto de Salud Pública de Chile; 2017. 35 p. Disponible en: https://otdchile.org/wp-content/uploads/2018/06/MORGAN-DAY-Informe-final-redaccio%CC%81n-ok.-.pdf

14. Linker D, Marambio C, Rosales F. Informe sobre Encuesta T: 1ra Encuesta para personas trans y de género no-conforme en Chile. Resumen ejecutivo [Internet]. 2017 Oct. Patrocinado por el programa Global Equality Fund de la Embajada de Estados Unidos. Disponible en: https://otdchile.org/biblioteca/encuesta-t-2/

15. Chárriez M, Seda J. Los servicios de apoyo a las personas transgénero: una realidad imperceptible. Revista Griot [Internet]. 2015;8(1):73-84. Disponible en: https://revistas.upr.edu/index.php/griot/article/view/1500

16. Zapata A, Díaz K, Barra L, Maureira L, Linares J, Zapata F. Atención de salud de personas transgénero para médicos no especialistas en Chile. Rev Med Chile [Internet]. 2019;147(1):65-72. doi: https://doi.org/10.4067/S0034-98872019000100065

17. Valenzuela-Valenzuela A, Cartes-Velásquez R. Salud comunitaria, la experiencia de salud trans en el Servicio de Salud Talcahuano, Chile. Psicoperspectivas [Internet]. 2020;19(2):142-53. doi: https://doi.org/10.5027/psicoperspectivas-Vol19-Issue2-fulltext-1789

18. Malebrán MC, Meneses ME. Acompañamiento fonoaudiológico en la transición vocal. Experiencia en Chile y Argentina. Conferencia presentada para la Sociedad Argentina de la Voz; 2022 May 28.

19. Ministerio de Salud de Chile. Vía Clínica para la adecuación corporal en personas con incongruencia entre sexo físico e identidad de género [Internet]. La entidad. 2010. 19 p. Disponible en: https://www.minsal.cl/portal/url/item/d126e58ba4cb53f5e040010165017912.pdf

20. Sepúlveda P. La desconocida cifra de la población trans en Chile [Internet]. La Tercera. 2018 Mar 11. Disponible en: https://www.latercera.com/tendencias/noticia/la-desconocida-cifra-poblacion-trans-chile/95089/

21. OTD. Encuesta 2020 Población Trans de Chile ante la crisis provocada por el COVID-19 [Internet]. La entidad; 2021. 104 p. Disponible en: https://otdchile.org/biblioteca/poblacion-trans-de-chile-ante-la-crisis-generada-por-el-covid-19-encuesta-2020/

22. Muñoz León F. Estándares conceptuales y cargas procesales en el litigio antidiscriminación. Análisis crítico de la jurisprudencia sobre Ley Zamudio entre 2012 y 2015. Rev derecho (Valdivia) [Internet]. 2015;28(2):145-67. doi: https://doi.org/10.4067/S0718-09502015000200008

23. Mostrador Braga E. A un año de la Ley de Identidad de Género, más de 2.200 personas trans han cambiado su nombre y sexo registral [Internet]. Elmostrador. 2020 Dec 21. Disponible en: https://www.elmostrador.cl/braga/2020/12/21/a-un-ano-de-la-ley-de-identidad-de-genero-mas-de-2-200-personas-trans-han-cambiado-su-nombre-y-sexo-registral/

24. Ley 26.743. Establécese el derecho a la identidad de género de las personas. Boletín Oficial No. 32.404 (May 24, 2012). Disponible en: http://servicios.infoleg.gob.ar/infolegInternet/verNorma.do?id=197860

25. Decreto 476/2021. Boletín Oficial No. 34.706 (Jul 21, 2021). Disponible en: http://servicios.infoleg.gob.ar/infolegInternet/verNorma.do?id=352187

26. Ley 27.636. Ley de promoción del acceso al empleo formal para personas travestis, transexuales y transgénero “Diana Sacayán - Lohana Berkins”. Boletín Oficial No. 34.697 (Jul 8, 2021). Disponible en: http://servicios.infoleg.gob.ar/infolegInternet/verNorma.do?id=351815

27. Argentina.gob.ar. Superintendencia de servicios de salud [Internet]. Buenos Aires, Argentina [citado 2021/12/03]. Disponible en: https://www.argentina.gob.ar/sssalud

28. Ley 23.660. Régimen de aplicación. Boletín Oficial No. 26.665 (Dic 29, 1988). Disponible en: http://servicios.infoleg.gob.ar/infolegInternet/verNorma.do?id=62

29. Ley 23.661. Sistema Nacional de Seguro de salud (ANSSAL). Boletín Oficial No. 26.555 (Dic 29, 1988). Disponible en: http://servicios.infoleg.gob.ar/infolegInternet/verNorma.do?id=63

30. Decreto 492/1995. Programa Médico Obligatorio. Boletín Oficial No. 28.236 (Sep 26, 1995). Disponible en: http://servicios.infoleg.gob.ar/infolegInternet/verNorma.do?id=27540

31. Zangroniz V. Voces y vocalidades trans. En: Alessandroni N, Torres Gallardo B, Beltramone C, editores. Vocalidades: la voz humana desde la interdisciplina [Internet]. La Plata: GITeV; 2019. p. 197-217. Disponible en: http://hdl.handle.net/2445/151599

32. Preciado PB. Testo Yonqui. Madrid: Espasa Calpe; 2008. 324 p.

33. Aguirre A, Otero L. Características de la voz en personas transexuales: el género expresado y el género percibido. Revista Fonoaudiológica ASALFA [Internet]. 2016;63(1):8-28. Disponible en: https://www.fonoaudiologica.asalfa.org.ar/index.php/revista/article/view/79

34. Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health [Internet]. 2022;23(suppl 1):S1-S259. doi: https://doi.org/10.1080/26895269.2022.2100644