About half the states in this country have laws banning health insurers from having transgender exclusions and half do not, according to Colorado-based think tank Movement Advancement Project. Several states are finding themselves at the center of fierce debate over access to gender-affirming care for youth, with ongoing legal proceedings challenging bans on such care.

Gender-affirming care can come in many forms and differ from person to person. One aspect of care you may not have thought about much is the voice. For some transgender and gender non-confirming people, modifying the voice to more closely match their identity can be critical. It can also be expensive and time-consuming.

For more on the cost, care and hurdles of accessing this form of gender-affirming care, “Marketplace Morning Report” host Nova Safo spoke with Ruchi Kapila, a speech-language pathologist specializing in gender-affirming vocal training.

The following is an edited transcript of their conversation.

Nova Safo: Can you explain the coaching you are providing? How does that work?

Ruchi Kapila: I mostly tend to serve trans and gender non-conforming or trans and gender diverse individuals. People will find me often through word of mouth or direct referrals, and they come in and usually I get some version of a, “You know, I’m not really happy with my voice, it doesn’t align with my gender identity.” Or somebody says that they want to be cis assumed or “pass,” they want to be assumed the way that they see themselves.

Safo: And so, how do you go about helping your clients?

Kapila: Usually, it’s about kind of seeing where they are at with their voice and being able to see how they respond to some stimulability work. Which means, are they able to do different voice exercises or feel different parts of their vocal range when it comes to pitch? How does it feel when they shift resonance? So a demonstration I might do is going more towards, like, the back of my mouth, where I’d be like, how does it feel when your voice does [in a deep tone] 1, 2,3,4,5, versus more in the middle of my mouth [in a more standard tone] 1,2,3,4,5, and I can even break things really forward [in a high tone voice] 1,2,3,4,5, just as an example of shifting resonance and seeing where somebody’s comfort level is with that. And then we also do the same with pitch, as well as intonation and getting a sense of if somebody wants to trend more monotone, versus having very high, exaggerated versions of intonation and being able to vary that on a daily basis for their communication needs.

Safo: And are there clients you get who are not transgender, who are cisgender?

Kapila: I’ve had a few where people have had concerns about… they were forced to code switch a lot, and they’re like, “I want to find a voice representation,” which is probably more related to, you know, intonation, prosody, some, some stuff about, like, actual articulation of sounds that feels more authentic to them as a person from their particular cultural background. So they might have felt like they had to change their voice too much to adjust. So it’s not unheard of for people to seek gender-affirming voice care as a cisgender person as well.

Safo: And does insurance cover the work you do?

Kapila: For my clients, I would say it can. Especially in the state of California, it’s not as much of an issue, but there can be a limitation in terms of sessions. Like, for example, I was a contracted provider for a larger health organization in the state, and the cap might be 12 sessions. And it’s possible, you know, it’s possible a client reaches those goals within 12 sessions, and it’s possible that they need a lot more than that. I would say a lot of us as private practitioners often do this work, private pay and can offer a super bill for people to submit to insurance as well.

Safo: Does this mean there’s a cost barrier to people accessing this care?

Kapila: Absolutely. I mean, that’s one of the reasons that at the Oakland LGBTQ Center, I do a free gender-affirming voice class that’s around exploration once a month, because I know that there are people who may not be able to access this information readily, and it is oftentimes like life saving as a gender-affirming voice, you know, access point. So I want to be able to provide that, I would say a number of people also provide group classes or asynchronous options for voice. And there are a lot of like resources online that people will usually do self guided training with as well. And some of it’s really high quality with really great, you know, voice science behind it, and a lot of good experience, and some of it, you know, may not be as helpful across the board, but I try to withhold judgment in terms of, you know, certain techniques, because every person’s different.

Safo: But certainly it sounds like, with all the scientific, medical complexities of this, that clients would benefit from very highly trained people like you helping them?

Kapila: Absolutely and I think the other piece that’s really important, while having the expertise is really valuable, is that being a member of community, being non-binary myself, having an understanding of nuances and I’m not necessarily going to be the perfect provider for every single person, right? But being able to navigate, like, really, you know, sensitive and vulnerable conversations about the voice that’s like, I would say 90% of what I do. The technical part is, is wonderful, but being able to get there in a way that makes a client feel safe and supported is everything. And I would say that there are voice teachers and voice coaches who do excellent work as well.

Safo: Why do you think this is so important, specifically for transgender people?

Kapila: Because the voice and communication is a major, I think, barrier in terms of work, life, everything that we do, socially, dating. It’s something that is so Integral and connected, you know, in our bodies, if that’s not lining up in a way that people feel comfortable with, how do they self advocate? How do they get to connect with others? Not to say that there aren’t people who use, you know, augmentative and alternative communication or sign language who don’t feel like, you know, integrated, that’s also their voice, but having access to that is their right, and I like to be able to support them in that.

Safo: You know, we have seen a lot of legislation to limit, ban gender-affirming care, especially in terms of the access to it for young people. How are you navigating all of this with your clients?

Kapila: I am licensed in Texas and California, but in California I haven’t had any specific issues. I will say that my colleague from L’GASP, which is the LGBTQ caucus of the American Speech Language Hearing Association, recommended and has done the research that like gender-affirming voice care is not something that should also be under the ban, based on their research across the states. And it’s something that speech language pathologists should still be advocating for providing. I have often advised people to find their loopholes. If there is something that’s happening when it comes to providing gender-affirming voice care, if there’s another thing that could be considered a voice disorder, whether it’s, you know, there are some hoarseness, muscle tension dysphonia, provide the treatment that you can and also loop in, you know, opportunities to refer to voice coaches, voice teachers, who may not be as impacted in their workplace. There isn’t any reason for behavioral voice intervention to be impacted by the ban, and it’s something that we as professionals push against. The other piece that’s really harrowing is the lack of access to hormone replacement therapy for these like youth who are trans and at risk, they really need that support. And basically, what happens if you take away HRT or access to hormones at an early age is that we’re going to see a lot more people potentially getting gender-affirming voice care as adults that might have not needed it if they had gotten this intervention in time. And so that’s something that impacts their whole life, in a way. Outside of you know, the harassment, the bullying, the feeling ostracized and othered because of this legislation, there’s a real impact for us as providers, having to think about these long term ramifications of we’re going to be, you know, providing services to a lot more people because they didn’t, you know, get interventions in time potentially.