Published January 9, 2023 in Neurology Blogs,

By Z Paige L’Erario, MD

I am very proud of mine and my colleagues’ work published in September in Scientific American: Mind Matters.1 This represents a career accomplishment for any medical professional, transgender or otherwise.

Bridges to other disciplines –such as speech-language pathology– are imperative for neurologists to build in order to ensure our future success in an increasingly diverse world and workforce. Since the number who hold multiple, intersecting, oppressed identities2 is small within neurology, those from historically oppressed communities may need to reach outside the profession to establish connections to mentorship, collaborators, and career opportunities. Further, multidisciplinary,3 coordinated care is good practice ,4 regardless of our identities.

I hope this work provides helpful reasoning to create affirming clinical and research systems of care for transgender and gender diverse people.

Click here to read the full Scientific American article.


  1. ZP Lerario. Voice Training Is a Medical Necessity for Many Transgender People. Scientific American: Mind Matters. Published September 19, 2022.
  2. S Saleem, S Naveed, AMD Chaudhary, et al. Racial and gender disparities in neurology. Postgrad Med J 2021;97(1153):716–722. DOI: 10.1136/postgradmedj-2020-138584
  3. SW Pedersen, M Suedmeyer, LWC Liu, et al. The role and structure of the multidisciplinary team in the management of advanced Parkinson’s disease with a focus on the use of levodopa–carbidopa intestinal gel. J Multidiscip Healthc 2017;10:13–27. DOI: 10.2147/JMDH.S111369
  4. JC Foo, V Jawin, TY Yap, et al. Conduct of neuro-oncology multidisciplinary team meetings and closing the “gaps” in the clinical management of childhood central nervous system tumors in a middle-income country. Childs Nerv Syst 2021;37(5):1573-1580. DOI: 10.1007/s00381-021-05080-4

Voice Training Is a Medical Necessity for Many Transgender People

By Z Paige Lerario on 

Calling customer service is a situation we all know and dread. We navigate a maze of automated voice commands, hoping to speak with a real live person. For some that live connection is a relief—but not for everyone.

Within seconds the customer service agent uses cues from someone’s voice—pitch, for instance—to decide to describe the caller as “sir” or “ma’am.” For many who are transgender, that language is distressing when they are identified by the wrong gender pronoun or title. When we do not affirm a transgender person’s identity, that person’s risk for anxiety, depression and suicide can increase.

I am an openly transgender neurologist and activist. My research and that of others in this field point to two key ways we can support transgender people whose voice and gender identity do not align. First, small changes in language can help cisgender people (those whose gender aligns to traditional male and female categories assigned at birth) be more sensitive and accurate in the words they use. Second, gender-affirming voice treatments can be effective medical care, giving transgender people a valuable tool to express their identity to the outside world.

Many people perceive specific vocal traits as either masculine or feminine. For example, high pitch and vocal resonance from the face and mouth are often linked to a feminine identity. Low pitch and resonance from the throat and chest seem masculine. And different brain areas appear to process the voices of masculine versus feminine speakers. When people are unsure about a speaker’s gender—as when experimenters manipulate audio to produce ambiguous voices—listeners show distinct brain activity as well.

Often a person’s perceptions of voice and gender reflect long-standing beliefs learned over many years through social and cultural upbringing. For example, because many have been taught that gender is only male or female, their ability to describe voices that are more gender-ambiguous is limited. Nonbinary individuals are more likely to correctly identify speakers with such voices.

But this history, and the associations in the brain, does not mean these judgments are unchangeable. Learned behaviors can be unlearned or relearned. For example, my colleagues and I published a study looking at how language influences gender perception when hearing someone’s voice for the first time. We recorded 24 transgender and cisgender people repeating a range of short words. Then 105 people of diverse genders from across the U.S. listened to these recordings and rated the gender of the speaker along one of several different scales. We found that the terms used in each scale could influence how listeners rated the gender of a speaker’s voice. A scale that included binary “male” and “female” options led to more extreme results, rating speakers at one end or the other. But more graded “masculine” versus “feminine” scales led to rankings closer to the center, which allowed for individuals with an ambiguous or intermediate gender to be better represented. So a relatively small change in language could help reduce the odds of misgendering others.

More directly, voice therapies, both nonsurgical and surgical, can help a transgender person change their vocal characteristics, aligning them with their gender identity. Voice training is less costly and invasive than a throat operation, making it a more common starting point. Through sessions with a licensed speech-language pathologist, transgender people learn to control pitch, resonance, word choice and other vocal behaviors. Studies have found that most transgender people who undergo this training are satisfied with their results. Such training can improve quality of lifereduce voice-related disability and boost self-confidence.

Despite its benefits, many public and private health-care insurers in the U.S. do not cover voice training for transgender people. With several U.S. states now trying to ban gender-affirming health care for transgender adolescents, the situation will likely get worse. Many in the transgender community pursue self-training, without professional supervision. This increases their risk of learning unhealthy speech patterns that can damage vocal tissue.

We should recognize voice training and gender-affirming surgeries as medical necessities, which should be covered by insurance. Like puberty blockers and gender-affirming hormones, these interventions save lives.






Affirming Evidence-Based Care for Young Patients Who Are Transgender or Gender Diverse



The data is clear: We should expect an increasing number of transgender and gender diverse (TGD) youth presenting to our practices over the coming years.1 We must ask ourselves: Are we prepared to treat these patients and their families with the most affirming, evidence-based treatment available?2


Case Example

For discussion purposes, consider a prototypical case of “Bar,” an 11-year-old child who presents to your office accompanied by his parents. Bar was assigned female at birth but recently began identifying with “he/him” pronouns; he is scared to face impending puberty. Bar’s father informs you that he is afraid Bar will be “bullied for being gay.”


Supporting the Patient and Their Family

Recent qualitative studies suggest that the caregivers’ response and adjustment to their TGD child’s identity development is critical to the child’s mental health.3 An integrative family therapy approach should affirm and support the TGD child in an equal partnership between the caregivers and the child.4 Addressing attunement and attachment is important for the family system, as there is likely longstanding intergenerational trauma from adoption of rigid, binary gender norms.5 Families should prioritize building psychosocial support for, and affirming the gender identity of, the TGD child, rather than focus on worries like “Is this my fault?” “What went wrong?” or “Is this just a phase?” The family may express grief due to the loss of an expected future they associated with the assigned sex of a transitioning child.6

Distress tolerance and interpersonal relationship dynamics can be tested during a gender transition7; as a result, many with gender dysphoria may be misdiagnosed with personality disorders.8 Dialectical behavioral therapy is a good therapeutic option for these patients.9 It is important that group therapy options provide affirming environments for transgender group members. This includes the facilitator’s role modeling of appropriate usage of pronouns and chosen names during therapy sessions.

Disclosing a shared identity with a patient can aid the therapeutic alliance by displaying understanding and empathy for the patient’s experience, which can facilitate trust and reciprocity.10,11 It is vital that providers reflect on whether self-disclosure is being done with the intent of improving patient care, and peer supervision around this can be of value.

Psychiatrists should model inclusive environments to their TGD patients within their offices and clinical spaces.12 Patients and their families should feel safe to give feedback to the psychiatrist when they fail to produce an affirming patient experience.2 In these situations, the administrative response should be transparent and timely, and it should address the root cause of the issue. Psychiatrists should collaborate and advocate with the family and other community and mental health professionals, such as school psychologists and counselors, to create affirming environments within the child’s home and school life.13 It is imperative that work with TGD patients involves ongoing feedback and participation from affected community members throughout the learning and healing process.14

To create a more affirming environment for a TGD child, psychiatrists should collaborate with the family, school, and community. For example, using noninvasive and empowering language can be a great first step in establishing not only a good environment, but also a therapeutic alliance. See Table 1 for more information, and the Sidebar.


Psychiatric Terminology: Is the Field Doing Enough?

Gender Dysphoria and Its Significance in the TGD Community

Gender dysphoria is a term that originated within psychiatry. The DSM-5-TR defines gender dysphoria as “the psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.” Gender euphoria is an accepted term used in the TGD community that recently entered the peer-reviewed literature.15 It is defined as a “joyful feeling of rightness” and the “powerfully positive emotions” that comes from one’s gender. See Figure 1 for more details on gender dysphoria and euphoria.

Gender dysphoria is caused by repeated exposure to gender-nonaffirming environments, which can result in higher rates of depression, anxiety, trauma and stress disorders, rumination, somatization, and suicidality in TGD individuals.16-21 The mismatch between a person’s self-identified gender and invalidating environments can occur within multiple domains, including online, home, school, athletic, employment, carceral, and health care settings.22-28 Access to affirming environments and health care improves mental health outcomes28-30; on the other hand, nonaffirming environments and barriers to health care increase disparities for TGD individuals.31,32 Due to recent attempts to criminalize evidence-based affirming health care for TGD individuals, psychiatrists should expect to see an increase in patients presenting with gender dysphoria in the near future.33


The Gender Minority Stress and Resilience Theory

The Gender Minority Stress and Resilience Theory describes the disparate impact of risk and protective factors on the experience of internalized (proximal) and external (distal) oppression in TGD communities.34 These stress and resilience factors combine with other forms of social identity–based discrimination, such as racism and socioeconomic disadvantage. Taken together, this intersectionality is responsible for the structural pathways leading to systemic health care inequities experienced by TGD community members (ie, social determinants of health).35 Figure 2 provides more details on minority stress and resilience.

Minority stress models have been used to explain the increased risk for biological, psychological, and social health disparities observed in TGD communities. These biological factors include increased rates of cardiovascular disease and cancer-related outcomes, whereas psychological outcomes of minority stress include depression and suicidality.36-38 Among the TGD community, social disparities and structural disadvantages have been noted in increased rates of incarceration, housing instability, underinsurance, and risk behaviors, such as substance misuse as a negative coping mechanism.27,39-41

Figure 2  expands on this topic and gives examples of resilience, or protective factors, that moderate the effect of minority stress.42 Resilience factors include methods to create systemic and structural changes that increase the psychosocial support and affirming environments available to TGD individuals.43 Additionally, TGD individuals can learn skills such as community building, advocacy, role modeling, and other expressions of pride, self-worth, and self-acceptance.


Conclusion of Case Example

You diagnose Barr with gender dysphoria and provide supportive psychotherapy throughout the social transition process. You present Barr with information regarding his local community center, where Barr becomes active in peer support and social activities. You provide educational resources to Barr’s parents, who join their local PFLAG (Parents, Families, and Friends of Lesbians and Gays) chapter to speak with other parents of TGD children. You discuss the changes in pronouns with Barr’s school psychologist and work with school administration to help develop strategies for Barr to express his gender authentically within the school’s policies.

After a year of treatment, although Barr feels more confident in his masculine gender expression, he reports ongoing depression due to expected changes with puberty. As a result, you refer Barr and his parents to a gender-affirming endocrinologist to discuss options regarding potential puberty suppression and timing.


Concluding Thoughts

Psychiatrists are in a unique position to empower their patients by recognizing and addressing key issues surrounding gender and sexuality. This includes the use of sensitive and inclusive language and assisting the field in adapting to ongoing evolution of community standards of care. Similarly, it is important to integrate transition and resocialization efforts with the patient’s family, community centers, and school professionals. Table 2 provides a list of potential resources to help in this endeavor. Together, we can work to provide affirmative and evidence-based care for all youth, whether or not they identify within the gender binary.


Originally Published November 29, 2022 in:

Psychiatrists are in a unique position to empower their patients by recognizing and addressing key issues surrounding gender and sexuality.”

Beyond Sex An introduction to terminology on gender, sex and sexual orientation.This is the Sidebar of the article

TABLE 1. Recommended Psychoeducational Approach for Families of a Transgender or Gender-Diverse Child

Table 1. Recommended Psychoeducational Approach for Families of a Transgender or Gender-Diverse Child


Figure 1. Experience of Gender AffirmationFigure 1. Experience of Gender Affirmation


Figure 2. Minority Stress & Resilience Model

Figure 2. Minority Stress & Resilience Model


Table 2. Recommended Provider, Educator, Family, and Patient Resources

Table 2. Recommended Provider, Educator, Family, and Patient Resources


1. Jones JM. LGBT identification in U.S. ticks up to 7.1%. Gallup. February 17, 2022. Accessed October 3, 2022.

2. Turban J, Ferraiolo T, Martin A, Olezeski C. Ten things transgender and gender nonconforming youth want their doctors to know. J Am Acad Child Adolesc Psychiatry. 2017;56(4):275-277.

3. Bhattacharya N, Budge SL, Pantalone DW, Katz-Wise SL. Conceptualizing relationships among transgender and gender diverse youth and their caregivers. J Fam Psychol. 2021;35(5):595-605.

4. Keeley S. Integrative family therapy with transgender, gender diverse, and non-binary (TGDNB) young people. Aust N Z J Fam Ther. 2022;43(1):151-162.

5. Coolhart D, Shipman DL. Working toward family attunement: family therapy with transgender and gender-nonconforming children and adolescents. Psychiatr Clin North Am. 2017;40(1):113-125.

6. Fey B, Ahola J, Casoy F. Treating family members of transgender and gender-nonconforming people: an interview with Eric Yarbrough, M.D. Focus (Am Psychiatr Publ). 2020;18(3):296-299.

7. Austin A, Craig SL, D’Souza S, McInroy LB. Suicidality among transgender youth: elucidating the role of interpersonal risk factors. J Interpers Violence. 2022;27(5-6):NP2696-NP2718.

8. Goldhammer H, Crall C, Keuroghlian AS. Distinguishing and addressing gender minority stress and borderline personality symptoms. Harv Rev Psychiatry. 2019;27(5):317-325.

9. Sloan CA, Berke DS. Dialectical behavior therapy as a treatment option for complex cases of gender dysphoria. In: Kauth MR, Shipherd JC, eds. Adult Transgender Care: An Interdisciplinary Approach for Training Mental Health Professionals. Routledge/Taylor & Francis Group; 2018:123-139.

10. Johnsen C, Ding HT. Therapist self-disclosure of sexual orientation revisited: considerations with a case example. Journal of Gay & Lesbian Mental Health. 2022.

11. Banerjee SC, Staley JM, Alexander K, et al. Encouraging patients to disclose their lesbian, gay, bisexual, or transgender (LGBT) status: oncology health care providers’ perspectives. Transl Behav Med. 2020;10(4):918-927.

12. Acosta W, Qayyum Z, Turban JL, van Schalkwyk GI. Identify, engage, understand: supporting transgender youth in an inpatient psychiatric hospital. Psychiatr Q. 2019;90(3):601-612.

13. Brown JM, Naser SC, Brown Griffin C, et al. A multicultural, gender, and sexually diverse affirming school-based consultation framework. Psychol Sch. 2022;59(1):14-33.

14. Katz-Wise SL, Sansfaçon AP, Bogart LM, et al. Lessons from a community-based participatory research study with transgender and gender nonconforming youth and their families. Action Research. 2019;17(2):186-207.

15. Beischel WJ, Gauvin SEM, van Anders SM. “A little shiny gender breakthrough”: community understandings of gender euphoria. Int J Transgend Health. 2021;23(3):274-294.

16. Dhejne C, Van Vlerken R, Heylens G, Arcelus J. Mental health and gender dysphoria: a review of the literature. Int Rev Psychiatry. 2016;28(1):44-57.

17. Chumakov EM, Ashenbrenner YV, Petrova NN, et al. Anxiety and depression among transgender people: findings from a cross-sectional online survey in Russia. LGBT Health. 2021;8(6):412-419.

18. Wanta JW, Niforatos JD, Durbak E, et al. Mental health diagnoses among transgender patients in the clinical setting: an all-payer electronic health record study. Transgender Health. 2019;4(1):313-315.

19. Cardoso Silva D, Salati LR, Villas-Bôas AP, et al. Factors associated with ruminative thinking in individuals with gender dysphoria. Front Psychiatry. 2021;12:602293.

20. Konrad M, Kostev K. Increased prevalence of depression, anxiety, and adjustment and somatoform disorders in transsexual individuals. J Affect Disord. 2020;274:482-485.

21. Toomey RB, Syvertsen AK, Shramko M. Transgender adolescent suicide behavior. Pediatrics. 2018;142(4):e20174218.

22. Abreu RL, Kenny MC. Cyberbullying and LGBTQ youth: a systematic literature review and recommendations for prevention and intervention. J Child Adolesc Trauma. 2018;11(1):81-97.

23. Brown C, Porta CM, Eisenberg ME, et al. Family relationships and the health and well-being of transgender and gender-diverse youth: a critical review. LGBT Health. 2020;7(8):407-419.

24. Kosciw JG, Clark CM, Truong NL, Zongrone AD. The 2019 National School Climate Survey: the experiences of lesbian, gay, bisexual, transgender, and queer youth in our nation’s schools. GLSEN. 2020. Accessed October 3, 2022.

25. Kulick A, Wernick LJ, Espinoza MAV, et al. Three strikes and you’re out: culture, facilities, and participation among LGBTQ youth in sports. Sport, Education and Society. 2018;24(9):939-953.

26. Waite S. Should I stay or should I go? Employment discrimination and workplace harassment against transgender and other minority employees in Canada’s Federal Public Service. J Homosex. 2021;68(11):1833-1859.

27. Reisner SL, Bailey Z, Sevelius J.Racial/ethnic disparities in history of incarceration, experiences of victimization, and associated health indicators among transgender women in the U.S. Women Health. 2014;54(8):750-767.

28. Kattari SK, Bakko M, Hecht HK, Kattari L. Correlations between healthcare provider interactions and mental health among transgender and nonbinary adults. SSM Popul Health. 2019;10:100525.

29. Russell ST, Pollitt AM, Li G, Grossman AH. Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. J Adolesc Health. 2018;63(4):503-505.

30. Turban JL, King D, Kobe J, et al. Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS One. 2022;17(1):e0261039.

31. James SE, Herman JL, Rankin S, et al. The report of the 2015 U.S. transgender survey. National Center for Transgender Equality. 2016. Accessed October 3, 2022.

32. Puckett JA, Cleary P, Rossman K, et al. Barriers to gender-affirming care for transgender and gender nonconforming individuals. Sex Res Social Policy. 2018;15(1):48-59.

33. Turban JL, Kraschel KL, Cohen IG. Legislation to criminalize gender-affirming medical care for transgender youth. JAMA. 2021;325(22):2251-2252.

34. Meyer IH. Resilience in the study of minority stress and health of sexual and gender minorities. Psychol Sex Orientat Gend Divers. 2015;2(3):209-213.

35. Heise L, Greene MH, Opper N, et al; Gender Equality, Norms, and Health Steering Committee. Gender inequality and restrictive gender norms: framing the challenges to health. Lancet. 2019;393(10189):2440-2454.

36. Streed CG Jr, Beach LB, Caceres BA, et al; American Heart Association Council on Peripheral Vascular Disease; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; Council on Hypertension; and Stroke Council.Assessing and addressing cardiovascular health in people who are transgender and gender diverse: a scientific statement from the American Heart Association. Circulation. 2021;144(6):e136-e148.

37. Flentje A, Heck NC, Brennan JM, Meyer IH. The relationship between minority stress and biological outcomes: a systematic review. J Behav Med. 2020;43(5):673-694.

38. Pellicane MJ, Ciesla JA. Associations between minority stress, depression, and suicidal ideation and attempts in transgender and gender diverse (TGD) individuals: systematic review and meta-analysis. Clin Psychol Rev. 2022;91:102113.

39. Glick JL, Lopez A, Pollock M, Theall KP. Housing insecurity and intersecting social determinants of health among transgender people in the USA: a targeted ethnography. Int J Transgend Health. 2020;21(3):337-349.

40. Bakko M, Kattari SK. Differential access to transgender inclusive insurance and healthcare in the United States: challenges to health across the life course. J Aging Soc Policy. 2021;33(1):67-81.

41. Connolly D, Gilchrist G. Prevalence and correlates of substance use among transgender adults: a systematic review. Addict Behav. 2020;111:106544.

42. Matsuno E, Israel T. Psychological interventions promoting resilience among transgender individuals: Transgender Resilience Intervention Model (TRIM). The Counseling Psychologist. 2018;46(5):632-655.

43. Reisner SL, Bradford J, Hopwood R, et al. Comprehensive transgender healthcare: the gender affirming clinical and public health model of Fenway Health. J Urban Health. 2015;92(3):584-592.


Ethical Questions in the Field- Is Refusal of Service to a LGBTQIA2S+ Client Acceptable in Social Work Practice?

November 12, 2022

By Z Paige L’Erario, MD, NYS CRPA/CPS-provisional and Holly Fancher, LMSW, MSEd

Originally Posted in Social Work Today; Vol. 22, No.4, P.22 


This case study examines a field intern’s right to refuse clinical services to a sexual or gender minority client.

Discriminatory behavior against sexual and gender minority clients is often more a systemic issue than an individual one. Social workers have professional and ethical duties and obligations to provide culturally competent clinical services to every client, regardless of their sexual orientation and gender identity. However, there are several states currently introducing anti-LGBTQ legislation, which raises a question about the ways in which a supervisor may handle a social work student who refuses to provide clinical services to a sexual or gender minority client.

Refusal by a field intern to provide services to a sexual or gender minority client should be viewed through the lens of a person-in-environment, which requires a biopsychosocial approach to fully address the issue. Techniques for approaching a social worker who refuses to work with a client based on their sexual orientation or gender identity include the following:

• engaging, assessing readiness for change, and motivating social work students to learn more about culturally competent care for sexual and gender minorities;

  • pairing the student with a more experienced social worker to observe culturally competent practice;
  • providing the student access to sensitivity and diversity training;
  • increasing supervision sessions to include discussions of values, stereotypes, and oppression that currently impact social work practice and skills to learn to address gaps in culturally competent practice; and
  • reassigning the student to an agency where their personal beliefs and institutional values will not be in conflict.



Case Study
The following case study has been presented within the Fordham Graduate School of Social Service’s online Master of Social Work curriculum:

At Field Agency X, a social work intern refuses to provide clinical services to their assigned client due to the client’s perceived or confirmed gender identity or sexual orientation. For example, the intern is assigned the case of a same-sex couple who wish to begin a family. They seek support and advisement on options for fertility treatments. However, the intern demands the case be reassigned, citing religious and moral objections. In essence, the intern has requested not to engage diversity and difference in practice, one of the core competencies of social work education.

How should a field supervisor, who oversees social work students, address this situation? To get a handle on the matter, the following questions should be considered:

  • Can a social worker refuse service to someone solely because of their identity or the way they look or act? What if the client had been refused care because they were a racial minority?
  • Can a social work student be allowed to graduate if they refuse to learn about or cannot adopt the core competencies of social work practice, such as the biological diversity of gender, sexuality, and identity formation? Should personal beliefs or lack of cultural competency be allowed as a reason to refuse service to a client?
  • Should we allow a social work student to practice in ways contrary to professional and ethical standards?



Case Study Discussion
In answering these questions, it’s imperative to consider the ethical, professional, and legal obligations that govern a social worker’s practice. Professional social workers have a foremost “duty of care” in which they are “legally obligated to provide a reasonable standard of care in delivering social work services.”1 Furthermore, “clients have a right to expect that [social workers] will discharge professional responsibilities in a competent manner.”1

Excluding clients on the explicit basis of their sexual orientation or gender identity disregards this duty of care and is in opposition to the United Nation’s Universal Declaration of Human Rights and the NASW’s Code of Ethics.2,3 Furthermore, discrimination involving medically necessary health care needs based on sexual orientation or gender identity is federally illegal, with additional protections against discrimination in public accommodations in many states and localities.4-6

Therefore, this social work intern’s refusal to treat a client due to their sexual orientation or gender identity raises multiple ethical concerns and violations of social work practice policy.


Social Work Code of Ethics
NASW identifies social work’s core values in the preamble to its Code of Ethics. Two core values (social justice and dignity) are violated when a social worker refuses to treat a client on the sole basis of their sexual orientation or gender identity. The preamble suggests that “the primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty.” Therefore, social workers have an intrinsic professional responsibility to care for those of sexual or gender minority status.

In the Ethical Standards Section 1.05 of the Code of Ethics, social workers are described to have specific ethical responsibilities to clients: “Social workers should demonstrate understanding of culture and its function in human behavior and society, recognizing the strengths that exist in all cultures.”

Professional ethics dictate that students develop and demonstrate cultural awareness and humility by engaging in serious and critical self-reflection, defined as understanding their own biases and engaging in self-correction. It is essential that those working with sexual and gender minorities be able to fulfill their professional responsibilities outlined in the Code of Ethics by demonstrating a working knowledge of social diversity and the nature of oppression, which applies to sexual orientation and gender identity. At the very least, social work students should remain open to learning more about queer culture.


Universal Declaration of Human Rights
The Universal Declaration of Human Rights applies to all people, including sexual and gender minorities. Article 1 specifically states that “all human beings are born free and equal in dignity and rights.” Social workers should not be allowed to purposefully exclude clients based on their minority status; that kind of personal decision does not fulfill either their professional responsibilities or the basic human rights defined in the Universal Declaration.

Article 16 of the Universal Declaration of Human Rights reads, “Men and women of full age … have the right to marry and to found a family.” Social workers must not discriminate against those who choose to do so based on personal beliefs. Instead, they should fulfill their professional responsibilities as outlined in the Code of Ethics.


Legal Protections Against Clinical and Public Service Discrimination
In the case study, the intern’s choice to exclude clients from clinical services based on their sexual orientation or gender identity may be illegal, depending on the intern’s practice location and the reimbursement and funding sources. Health care can be considered a segment of social work services, a part of the clinical support services that clients may receive at their social work agencies. There are federal protections against health care discrimination for sexual and gender minority clients in Section 1557 of the Affordable Care Act, which established broad civil rights protections in health care, barring discrimination based on sex (including sexual orientation and gender identity) in “any health program or activity” that receives federal financial assistance.6

This policy was upheld recently by the Department of Health and Human Services in the Biden Administration.6 There are additional health care and public accommodations nondiscrimination laws that would apply at the state and local level.4,5 However, recent legislation introduced in several states has attempted to criminally ban transgender adolescents from receiving medically necessary gender-affirming care, which may embolden agencies and their representatives from refusing clinical services related to their sexual and gender minority clients.7


Professional Development Plan
In the best-case scenario, this intern is responding to their client without the ability to separate their professional responsibilities from their personal beliefs. In other words, the intern is unable to practice cultural awareness or incorporate sensitivity and diversity into their practice. In the worst-case scenario, the intern is acting unethically, unprofessionally, and possibly illegally.

Ethics flow from values and can be thought of as values in action. In the case study, by refusing to work with a same-sex couple, the intern is choosing their personal beliefs over their professional obligations, which means their actions amount to unethical practice. As the field instructor and intern work collaboratively to search for ways to resolve the conflict between their personal beliefs and professional obligations, it is hoped the intern learns to be comfortable with discomfort.

The supervisor should recognize that the agency’s staff are entitled to their personal beliefs, but these beliefs cannot be incorporated into their practice at the expense of their clients. Still, changing attitudes and behaviors takes time, effort, a flexible perspective, patience, persistence, and coordinated planning. A supervisor should be ready to support an intern going through such changes.

In the short term, the best way to serve these clients is to reassign them to a more experienced social worker. Outside of a research study with informed consent, it is not acceptable to use this client as part of the intern’s professional development.

After reassigning this client to another social worker, assessing the intern’s readiness for change is important. Using a 1 to 10 scale outlining “readiness for change” may be helpful to better comprehend this individual’s starting point—their motivations, perspectives, and understanding of the situation.8

Dealing with values is central to social work practice. As an inexperienced professional, the intern needs to learn they belong to both their individual value system and the value system governing the profession of social work practice. As a person also belonging to their environment, the student is defined by both. The intern’s attitudes and behavior are shaped by the complex interactions of their environment in the same way as are their clients.

By understanding that everyone involved in the situation belongs to systems composed of interrelated and interdependent parts, the supervisor—using ethics as their practice framework—must find ways to support the intern while they grow into a social worker. A good starting point would be to ask the intern: “How open are you to learning more about sexual and gender minorities?”

A biopsychosocial assessment means a nonjudgmental exploration of the intern’s capacity to nonjudgmentally respond to the concerns, needs, and problems of sexual and gender minority clients. Depending on the student’s answer, the supervisor can ascertain where the intern is in the process of addressing their implicit biases and their desire to learn more about queer culture.

The supervisor is ultimately responsible for providing ethical clinical services for all clients seeking services at that agency. While the profession undoubtedly wants interns to succeed, there needs to be a timeframe established for professional improvement. The agency’s mission cannot be indefinitely sacrificed for one staff member, but nonjudgmental practice dictates that goals be created and a contract established with the intern in the same manner they would be with any client. Ethical social work practice is not just about clients; supervisors must also adhere to the same values and standards.

The supervisor should earnestly attempt to develop awareness and empathy by setting up additional clinical sessions with the intern to discuss the following:

  • how the intern’s attitudes and beliefs about sexual and gender minorities influence their capacity to practice social work;
  • the historical and current stereotypes, prejudice, discrimination, and oppression impacting sexual and gender minorities; and
  • the skills that the intern could use when providing services in an ethical manner, including engagement, empathy, cultural competency, active listening, and reflection.

Supervisors may want to consider having the intern shadow more experienced social workers to see ethical practice firsthand. Keep in mind that such a strategy requires the client’s consent. Additionally, the supervisor could help the intern enroll in culturally competent practice trainings to develop diversity practice skills.

If, however, the intern found the discontinuity and conflict between their personal and professional selves too much to handle, it may be time to acknowledge that they are not a good fit for a secular agency. One option for the intern would be to consider working for a faith-based agency that is more consistent with their religious or moral perspective.

Once it becomes clear that an individual needs a different kind of working environment, it is important that supervisors do not fall into unprofessional practice, displaying negative behavior themselves by thinking about or treating the intern in disparaging or derogatory ways. All relevant parties practicing social work should use the theories and skills taught in everyday environments.

Often, personal vs professional difficulties reflect a systemic issue more than an individual one. What is considered right and wrong in terms of behavior is always rooted in the social environment, and it is still likely that this social worker will be able to provide meaningful services for other clients whose social and religious upbringing is more aligned with their own, thus integrating micro and macro practice lenses. A nonjudgmental approach requires that supervisors also apply a strength-based model toward interns, clients, and the larger agency. Hopefully, this social work intern will be able to reconsider their perspective and practice. Sometimes it is hard to know exactly where people exist along the change continuum, and it often takes several cycles for the planted seeds to produce new awareness and understanding.




Revisiting the Discussion Questions
Embedded in social service education, competencies, values, ethics, and practice is the tenet that no one should be refused service based on a historically oppressed identity. If such discriminatory behaviors arise, steadfast interventions should encompass the person-in-environment and systems perspectives. Agencies should also engage individuals displaying cultural insensitivity with a motivational interviewing approach, as well as provide dedicated inclusivity training and positive role modeling.

For social workers, it would be contrary to professional duties and responsibilities to remain intentionally ignorant of diverse cultures and refuse services on this basis. Social work students continually need to reach outside their comfort zones to learn culturally inclusive practices for all clients.

Supervisors must lead by example and commit to a high standard of ethical and inclusive conduct for both themselves and students.


— Z Paige Lerario, MD, NYS CRPA/CPS-provisional, is a neurologist and transgender activist. They are a graduate student of social service at Fordham University.

— Holly Fancher, LMSW, MSEd, holds two master’s degrees, one in social work and one in higher education. She teaches at Fordham University in the online MSW program and is working on her PhD in social welfare at the CUNY Graduate Center.


1. Cournoyer BR. The Social Work Skills Workbook. 8th ed. Cengage Learning; 2017.

2. Universal declaration of human rights. United Nations website. Accessed August 17, 2021.

3. Code of ethics. National Association of Social Workers website. Accessed April 13, 2022.

4. New York State Division of Human Rights. New Yorkers Are Protected From Gender Identity Discrimination by Hospitals.

5. Nondiscrimination laws. Movement Advancement Project website. Accessed April 13, 2022.

6. Shear MD, Sanger-Katz M. Biden administration restores rights for transgender patients. The New York Times. May 10, 2021. Accessed October 1, 2021.

7. Turban JL, Kraschel KL, Cohen IG. Legislation to criminalize gender-affirming medical care for transgender youth. JAMA. 2021;325(22):2251-2252.

8. Rollnick S, Heather N, Gold R, Hall W. Development of a short “readiness to change” questionnaire for use in brief, opportunistic interventions among excessive drinkers. Addiction. 1992;87(5):743-754.


Disclosures: Lerario serves on the editorial board of Neurology: Clinical Practice, has been hired as an expert witness for plaintiff by Weiss Law, and is the vice-chair of the LGBTQI section of the American Academy of Neurology. Fancher reports no financial disclosures relevant to the manuscript.

My Experience as a Transgender Physician with Mental Illness


  By Z Paige Lerario, MD, NYS CRPA/CPS-p

  Originally posted July 20th, 2022 in NAMI Blogs


AlabamaArizona and Texas have recently passed legislative efforts to ban gender-affirming health care to transgender adolescents. This is highly concerning and relevant, as 2% of younger Americans identify as transgender, a term that refers to people whose gender identity (an internal sense of self) does not align with the sex they were assigned at birth.

A gender transition, or the process a transgender person undergoes to express their gender more in line with their internal identity, is a critical component of maintaining their mental health. Research shows that transitioning in affirming environments is life-saving for many transgender people; supportive communities, culturally competent health care and choosing a new name and gender pronouns improves mental health outcomes, including suicidality (which transgender people are significantly more at risk for).

Conversely, non-affirming environments and systemic barriers to health care result in higher rates of depression, suicidality and substance misuse in the transgender community, as compared to their cisgender peers. Therefore, we have reason to believe that this anti-LGBTQ+ legislation will worsen the mental health of our transgender youth and adolescents, in addition to increasing the stigma experienced by an already vulnerable population.

This challenge is compounded by a shortage of affirming health care providers for the transgender community. As a transgender physician living with mental illness, I understand the fear and pain that the stigma of transgender identity and mental illness can bear when receiving health care services. I am often left feeling unseen or ignored by the health care system at times of my greatest need. 

Unpacking The Reality In Numbers

In 2015, the National Center for Transgender Equality performed the largest survey of adult transgender community members living within the U.S. The results are eye-opening and point to largescale systemic barriers preventing transgender people from receiving medically-necessary health care services of adequate quality and cultural competence. 

  • At least one in four (25%) of the survey respondents reported issues with health insurance coverage, including the denial of medically necessary gender-affirming services, such as hormone therapy or transition-related surgeries.
  • One-third (33%) had at least one negative experience with a health care provider related to being transgender, such as verbal harassment, refusal of treatment or having to educate the provider to receive the standard care for transgender patients.
  • Approximately one in five (23%) respondents did not see a doctor when they needed to because of fear of being mistreated as a transgender person.

These findings demonstrate an unaddressed public health issue, but also, they are impacting real people in their everyday lives.

While my experience does not represent the full diversity of the gender expansive community, my hope is that sharing my experience will help other transgender people with mental illness feel less alone and have hope for recovery in their journeys.

My Experience In The Health Care Field

Since coming out and transitioning, I have faced unexpected discrimination within the health care system, even as a physician myself. On multiple occasions, I have been refused medically necessary health care specifically due to my gender identity. This discrimination worsened when I began openly identifying to my providers as a patient experiencing a serious mental illness. Even living in New York City, there are few mental health providers who understand and are affirming of transgender patients. There are even fewer who are transgender themselves or willing to disclose they have lived experience with a serious mental illness.

I would have more trust in a mental health provider who is my peer: that is, someone who has lived experience with mental illness and the resulting stigma. As a result, I often need to teach my mental health providers about what it is like to live as a transgender person in recovery from serious mental illness. And professionally, I am left with a small number of colleagues who openly share my identities.

When I do find affirming providers, my commercial health care insurance has not covered their services on multiple occasions. I am privileged to be a physician, and therefore, can pay for many of these transition-related expenses out of pocket. This in turn buys me further “passing” privilege, meaning I have undergone a medical and surgical transition, which allows me to appear cisgender. However, there are many others who cannot afford to undergo a medical or surgical transition, or do not wish to do so.

Navigating Patient-Doctor Relationships

I often ask my treating physicians if they have experienced serious mental illness. This is most often met with, “that is none of your business,” when, in fact, I believe it is highly relevant. In these moments, my provider made me feel like they believed mental illness was something shameful. In many stigmatized and shame-based mental illnesses, disclosing a shared identity with a patient can be healing and increase trust in the relationship between patient and physician. Conversely, acknowledging potential awareness gaps and implicit bias is also an important practice for all health care providers. 

For me, once experiencing the societal sting of transphobia, any other stigmas I hold are no longer worth hiding. I proudly share my identities as a transgender physician living with mental illness, and I believe these experiences have increased my value to society as I can better understand my patients’ perspective and their place within the full range of humanity. This understanding is the basis for a cultural awareness which can improve the healing environment of our offices and the social well-being of our patients.

In recent years, I have met many adolescents who boldly identify as neurodivergent, transgender community members. I have faith this generation can help teach physicians to holistically treat their patients and the environmental factors impacting the health of their brains and bodies. I hope some of these adolescents will say, “I can become a doctor, too.”  Because they can, and we can do better to make room for them.


If you are transgender and have symptoms of mental illness, please contact a provider experienced in gender-affirming therapy at the World Professional Association of Transgender Health:

The Trevor Project has free, confidential, 24/7 support services for LGBTQ+ youth:

The following are resources from the Human Rights Campaign on LGBTQ+ youth:

The following are educator resources from the Gay and Lesbian & Straight Education Network:

Pledge to take the 2022 US Trans Survey and increase transgender representation in health care policies, research, education and practice:



“Now is the time we need pride the most. We cannot succumb to fear or shame, and we cannot stand down to threats of violent oppression. We are under attack by a conservative legislative agenda that ignores our medical evidence and peer-reviewed literature. We must fight for our patients to receive the medically necessary health care they deserve. We should call in allies to actively engage and support those of historically oppressed genders the other 11 months of the year.” 

By Z Paige Lerario, MD, NYS CRPA/CPS-p

Originally published in Psychiatric Timeson June 13, 2022

Pride: An Opposite Action Against Unnecessary Shame


Let’s face it: Being part of a historically oppressed community can be stressful. We know that individuals who identify as transgender or nonbinaryface higher rates of discrimination at all levels of American society.1 This discrimination ranges from microaggressions to lack of accessibility to frank violence, including verbal harassment and physical assault. The peer-reviewed literature describes the impact of oppression in minority stress models.2 Cumulative exposure to discriminatory environments create systemic health care disparities and worsened outcomes for historically oppressed communities.3

More recent data evaluate the transgender and nonbinary community’s resiliency through the building of positive coping skills and psychosocial support.4,5 These resiliency factors protect transgender and nonbinary individuals from the deleterious health consequences of systemic oppression. The list of resiliency factors is long and includes community building, activism, and role modeling. But, when discussing what best fights the harmful effects of systemic oppression, the common denominator remains: “pride.”

Attribution theory—developed by Fritz Heider and later modified by Bernard Weiner—examines the thought processes behind behaviors, their causes, and their effects.6 People make sense of the world around them by grouping behaviors into those that are internally or externally controlled. Society tends to view more favorably and support those who are deemed not to have control over their problems. Conversely, society often punishes those whose problems are believed to be caused by internal or individual-level factors and decisions. Attribution theory has been tested in multiple policy areas, including issues surrounding historically oppressed genders.6 Such theories are important to explain the impact of medically incorrect ideology that being transgender or nonbinary is a personal “choice” that can be prevented.

Many in the United States misunderstand, hate, fear, shame, or frankly deny the existence of historically oppressed genders. The majority of Americans have never personally met someone who is transgender or nonbinary.7 Those who know a transgender or nonbinary person are more likely to believe that a person’s gender can differ from their sex at birth. Gender minorities have existed in various cultures for centuries, including in people indigenous to North America.8 Although often stigmatized, in some cultures gender diversity has been legally recognized, celebrated, or even revered. In the 1950s, a psychologist named John Money proposed a theory of “gender neutrality” at birth.8 He described gender as developing from a socialization process occurring after birth. Although initially criticized, such theories are becoming more accepted in Western society as rights for nonbinary-identifying individuals are gained. Therefore, it is important to note that gender is a sociocultural construct, and the acceptance of gender diversity is impacted by exposure to transgender and nonbinary individuals.

Shame can be internalized when it is placed on individuals of historically oppressed genders in a broad range of formats and contexts. Persistently invalidating environments can lead to emotional dysregulation and associated areas of interpersonal dysfunction.9 This is unfortunate, since gender identity (referring to an individual’s innate internal sense of self) is not a choice and is found to be largely stable even amid exposure to nonaffirming environments and external pressures to “detransition,” or to go back to living as the sex assigned at birth.10

As a transgender physician, in moments when I begin to internalize oppression, I remind myself of Marsha Linehan’s groundbreaking work creating treatment for borderline personality disorder. Linehan developed dialectical behavioral therapy, which has now been proven to be effective in multiple clinical trials to reduce suicidality and inpatient hospitalization in various high-risk conditions.11 Dialectical behavioral therapy skills have been applied to the treatment of clinical distress caused by gender dysphoria.9

In dialectical behavioral therapy, Linehan teaches the use of “opposite action” when emotions do not fit the facts of reality.12 Experiencing shame, for example, produces the action urge to hide or avoid the shaming stimulus. The opposite action of an urge to hide is sharing the secret with others who will accept it. Over time, an individual practicing opposite action will develop feelings of pride. They will realize there is no fact-based reason to continue to feel shame.

Obviously, facts are important. So, what are they?

Gender diversity is real and exists. Gender-affirming environments, policies, and medical care are lifesaving and should be normalized.13 Being transgender or nonbinary is nothing to be ashamed of. Instead, many from these communities provide the world a sense of creativity and inspiration.

And then some of the facts are more saddening, particularly in the fields of medicine and psychiatry. Throughout the last century, patients of historically oppressed genders and sexual orientations have faced forcible silencing, violence, and medical atrocities. These horrors occurred at the hands of our predecessors and continue in many ways today. Our treatment of and experimentation with these communities include castration, lobotomies, electroconvulsive therapy, and aversive conversion therapy, all based on pseudoscience.14 The lack of our profession’s support for these communities persists in ongoing legislation and policies that ban transgender and nonbinary children from receiving medically necessary and lifesaving health care.15-17

We have pathologized normal diversity, identities, behaviors, and practices in our diagnostic and statistical manuals for far too long. For example, homosexuality was removed as a listed disorder in 1974, but persisted in various forms as an ego-dystonic condition until 2013.18 Transgender identity existed in various forms of the manual and persists today as an ego-dystonic condition known as gender dysphoria, a condition expressed by some transgender and nonbinary individuals.8 A gender dysphoria diagnosis is often necessary to justify coverage of lifesaving interventions to public and private health care insurers. This implies that a transgender or nonbinary patient is required to concede a mental health diagnosis before attaining medically necessary health care. In many ways, those in the psychiatric profession remain the gatekeepers of gender expression in patients from historically oppressed genders who wish to undergo a transition.

Yet, through it all, the transgender community has championed pride alongside their cisgender allies. The numbers within the community grow, particularly in younger generations, where 2% identify as transgender.19 And the pride celebrations every June have become bigger, bolder, and more accepted by mainstream society.

Now is the time we need pride the most. We cannot succumb to fear or shame, and we cannot stand down to threats of violent oppression. We are under attack by a conservative legislative agenda that ignores our medical evidence and peer-reviewed literature. We must fight for our patients to receive the medically necessary health care they deserve. We should call in allies to actively engage and support those of historically oppressed genders the other 11 months of the year. We need to mentor, develop, and promote trainees and colleagues from historically oppressed communities, and include them in the research and peer-review process. We should value their professional contributions and provide them with authorship and payment for their lived expertise (which is what I prefer to call lived experience).

Most of all, we need to remain composed, as we are the eye of the hurricane. And this month, our pride will sweep across the country.


Dr Lerario (@MPLerario) is a board-certified neurologist and graduate student of social service at Fordham University, where they perform activism and research for the transgender community. Their work has been published in Neurology: Clinical Practice, the Journal of Speech Language and Hearing Research, and the Harvard Public Health Review Journal, among others.



1. James S, Herman J, Rankin S, et al. The Report of the 2015 U.S. Transgender Survey. 2016. Accessed June 10, 2022.

2. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol Bull. 2003;129(5):674-697.

3. Streed CG, Beach LB, Caceres BA, et al, on behalf of the American Heart Association Council on Peripheral Vascular Disease; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; Council on Hypertension; and Stroke Council. Assessing and addressing cardiovascular health in people who are transgender and gender diverse: a scientific statement from the American Heart Association. Circulation. 2021;144(6):e136-e148.

4. Matsuno E, Israel T. Psychological interventions promoting resilience among transgender individuals: Transgender Resilience Intervention Model (TRIM). The Counseling Psychologist. 2018;46(5):632-655.

5. Testa RJ, Habarth J, Peta J, et al. Development of the gender minority stress and resilience measure. Psychology of Sexual Orientation and Gender Diversity. 2015;2(1):65-77.

6. Haeder SF, Sylvester S, Callaghan T. Shared stigma: the effect of LGBT status on attitudes about the opioid epidemic. World Medical & Health Policy. 2021;13(3):414-435.

7. Minkin R, Brown A. Rising shares of U.S. adults know someone who is transgender or goes by gender-neutral pronouns. Pew Research Center. July 27, 2021. Accessed June 10, 2022.

8. Turban JL, de Vries ALC, Zucker KJ, Shadianloo S. IACAPAP Textbook of Child and Adolescent Mental Health: Vol. Transgender and Gender Non-Conforming Youth (2018th ed). International Association for Child and Adolescent Psychiatry and Allied Professions; 2018.

9. Sloan CA, Berke DS, Shipherd JC. Utilizing a dialectical framework to inform conceptualization and treatment of clinical distress in transgender individuals. Professional Psychology: Research and Practice. 2017;48(5):301-309.

10. Turban JL, Loo SS, Almazan AN, Keuroghlian AS. Factors leading to “detransition” among transgender and gender diverse people in the United States: a mixed-methods analysis. LGBT Health. 2021;8(4):273-280.

11. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757.

12. Linehan MM. DBT Skills Training Manual. Guilford Press Publications; 2015.

13. Dolotina B, Turban JL. A multipronged, evidence-based approach to improving mental health among transgender and gender-diverse youth. JAMA Network Open. 2022;5(2):e220926.

14. Blakemore E. Gay conversion therapy’s disturbing 19th-century origins. June 28, 2019. Accessed June 10, 2022. History.

15. Cole D. Arizona governor signs bill outlawing gender-affirming care for transgender youth and approves anti-trans sports ban. CNN Politics. March 30, 2022. Accessed June 10, 2022.

16. Goodman JD. How medical care for transgender youth became ‘child abuse’ in Texas. The New York Times. March 11, 2022. Accessed June 10, 2022.

17. Miles K. Families of transgender youth in Alabama face some difficult choices. National Public Radio, National (Morning Edition). May 3, 2022. Accessed June 10, 2022.

18. Drescher J. Out of DSM: depathologizing homosexualityBehav Sci (Basel). 2015;5(4):565-575.

19. Jones JM. LGBT identification in U.S. ticks up to 7.1%. Gallup. February 17, 2022. Accessed June 10, 2022.


My Authentic Voice: Expanding the Sound Between Man and Woman

By: Z Paige Lerario, MD, NYS CRPA/CPS-p

May 2, 2022

Blog originally posted in:

Neurology Blogs, Voices: Lived Experience

Based on the original research article published in:

The Journal of Speech, Language, and Hearing Research

In collaboration with the team at New York University’s:

Acoustic Phonetics and Perception Lab


Nearly a decade ago, when I started to come out as transgender, I knew I had two major counts against me if my goal was to “pass” as a cisgender woman in society. One was my large skeletal size, and the other was my deep, natural voice.  At the time, I was too afraid to irreversibly change my biology with vocal feminization surgery. So, I was excited to find affordable vocal feminization services at NYU’s Speech-Language-Hearing Clinic in 2014. 


“We need more nonbinary voices speaking out publicly.”

Words Matter:  The words we use to describe gender influence how listeners perceive gender. 

Learn more about pronouns and and gender wording issues at:

GLSEN Pronouns Guide

As a clinical resident in neurology, my paycheck barely covered the rent and utilities of my fourth-floor walkup apartment on the Upper East Side, which had twice more animals living in it than rooms.  Health care insurance coverage of medically necessary, transition-related expenses was not a privilege I had at the time. I paid low-fee, out-of-pocket expenses to meet confidentially with students supervised by expert speech pathologists for vocal feminization services. I remember begging them not to tell anyone that I went there, since I worked frequently with speech pathologists in New York City as part of my job as a neurologist. The care and compassion I received in this clinic remains some of the best treatment I have received by any healthcare provider during my transition. They say you “get what you pay for,” but I think health care too often overlooks the healing value of providing an affirming environment to patients from historically oppressed communities. 

At the time, I was in intense denial of my transgender identity, and I dared not use the word “transgender” out loud in my sessions. Nevertheless, I was encouraged gently to explore my physical and vocal femininity, and I was thanked for my presence and authenticity. There were support groups with others at similar points in their transitions who were also struggling with their vocal identity.  I even wore some makeup and women’s jeans during one of my sessions.

The most intense gender euphoria I experienced during my transition came in a letter from this clinic describing my semester performance achievements. The first sentence described me as a “transgender woman.” I felt these words made my existence real for the first time ever. Although I had never used these words myself, this report from my assigned speech pathologist had provided me with the permission to be myself. Still to this day, I never allowed another person to read this letter. At the time, I was too afraid that if someone invalidated this experience, I wouldn’t have the confidence to come out and transition. Today, I know no one can take my identity away from me, but I keep that letter to myself, proof that I owe no one of my existence.

Another important lesson that I learned at NYU is how disabling and life-limiting a masculine voice can be for some transfeminine speakers. My masculine voice seemingly gives permission to others to question my existence. Male puberty poisoned my larynx, and feminizing hormones could not restructure my misshapen vocal organ. As my body changed with hundreds of thousands of dollars of doctor’s visits, medications, and surgeries, my natural speaking voice remained the same as before my transition, without dedicated intervention. I felt like my voice was no longer mine, and the dissonance between my speech and physical appearance became apparent. 

If I chose to use the phone, I either allowed myself to be misgendered and unseen, or I risked outing myself and the resultant discrimination that follows. Therefore, I stopped using the phone whenever I could.

When I publicly spoke or met a new person, I needed to make a quick judgement as to the safety of using my natural voice or manipulating my vocal gender expression to match my physical appearance. This is an exhausting exercise, and I often made mistakes on who was safe to trust when revealing my gender identity. The process of coming out never ends.

I dare not use my natural voice at airport security or in geographic regions that delegitimize the existence of transgender identities. These situations could pose threats to my human rights or physical safety.  Although my identity is nonbinary, and therefore “passing” is not a goal of mine, I acknowledge that in many spaces being visibly or audibly gender nonconforming can be dangerous emotionally and physically. I hope safety for the transgender community improves, but on the Transgender Day of Remembrance, we count the number of brutally murdered transgender people.

As a result, my life feels painstakingly performative, and the stigma of transgender identity can be silencing. I frequently code-switch between either speaking in my natural voice and a learned feminine vocal expression, or even between speaking and remaining silent. When my performance fails, I constantly fight to not internalize the stigma of gender nonconformity and the resultant public humiliation, defeat in self-confidence, and societal devaluation which may come with it, especially if I’m having an already bad day.

These concerns were specifically measured by the Steinhardt clinic throughout my gender transition. Two scales were used, the Voice Handicap Index (VHI-10), a scale commonly used to measure impairment for people with voice disorders, and the Trans Woman Voice Questionnaire (TWQV), a scale developed to specifically look at the voice concerns of transfeminine speakers. I scored a 68 on the VHI-10 in June 2020, which ranges from 0-120.  Scores over 60 on the VHI-10 indicate severe impairment, as seen with patients with vocal cord paralysis or severe vocal fold scarring.1 My areas of highest disability were noted in the questions: “I find other people don’t understand my voice problem” and “my voice problem upsets me.” Through gender-affirming medical services, including feminizing speech therapy, my scores on the TWVQ, a self-evaluation survey consisting of 23 questions, I found my scores and self-confidence gradually improve by almost 75%.2 For me, such gender-affirming services are lifesaving. They should be considered medically necessary and covered by health care insurance on a national basis.

I do not aim to project my experience onto others: many transgender people are not disabled, by their voices or otherwise. Most transgender people lead functional, inspiring, productive lives doing everything and anything.  Many had the confidence to be themselves for decades before me. And every transgender person — past, present, and future — is my role model, as every transition is unique, inspiring, and educational in its own light.

I am privileged to benefit from the system those before me have begun to change, and for so many reasons, still requires much substantial change. We are everywhere and have been everywhere throughout our shared human histories. Now, I hope more of us make the difficult decision to be ourselves visibly and to stop conforming to a gender binary that is holding us back from recognizing the true beauty and diversity of gender and sexuality. We need more nonbinary voices speaking out publicly.



1. Jacobson BH, Johnson A, Grywalski C, Silbergleit A, Jaconsen G, Benninger MS.  The Voice Handicap Index (VHI): Development and Validation. American Journal of Speech-Language Pathology 1997;6(3):66-70.

2. Dacakis G, Davies S, Oates J, Douglas J, Johnston J. Development and preliminary evaluation of the Transsexual Voice Questionnaire for male-to-female transsexuals. J Voice 2013; 27(3):312-320. doi:10.1016/j.jvoice.2012.11.005


“Children remember what they are taught; What they should do, And what they should not. Whom they should love, And whom they should hate. What is one’s choice, And what is one’s fate.”

Wei Dewdney (they/it)

Greenburgh Pride 2021 | Edgemont GSA


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What We Are Taught

Children remember what they are taught;

What they should do,

And what they should not.

Whom they should love,

And whom they should hate.

What is one’s choice,

And what is one’s fate.


Children are computers

Storing codes and data.

And the teachers and the tutors,

They reach into the corners of their minds

And shove fistful after fistful 

Of corrupted files.

Ignorant and blissful.


Children learn and grow,

Some may even mature.

All those years ago

And all those things they learned

Will stick with them


The seeds will sprout a stem.


Children are watered and fertilized 

With opinions from those who 

Anticipate our demise.

But it’s all just a joke.

Acquire an extended vocabulary,

Of slurs and insults,

As our corpses collect in the cemetery.


Children keep secrets

In well-hidden files,

It’s where they hide their weakness.

Their identity.

Their so-called “unholy” desires

So they hate themselves and others

Like them, to please those whom they admire.


Children programmed to hate themselves often meet their end too soon.

I hope you enjoyed the funeral service

This afternoon. 

You got what you wanted.

Blood on your hands.

I hope you are proud

Of where you stand.


Children die, wanting to be free.

Those seeds that were first planted

Have now become a tree.

With the swing of an axe,

Its wood is collected

And turned to a casket.

Buried by those to whom the children were subjected.


Children remember what they are taught.

Their shoulders weighed down

By the hate you’ve brought.

How to close our minds,

How to traditionalize our thoughts,

The reality is that this is

What we are taught.


I creep out of the solitude

Of sleep

And meet my reflection with

A sigh


Of confusion,

As I still cannot recognize

That person in the mirror.

My body’s 


Surface area is

Disproportional to the amount

Of utter hatred that protrudes

From my own 



My ears are pierced

With rusted metals,

Engraved the words



My voice lingers in the

Air as I laugh

And smile.

Who is that?


Who is that?

Who is that?

I can’t recognize this name

You have assigned me.

Who is that?

Who is that?

You tack paper onto

My forehead that writes;



My head starts to bleed

What did you expect?

You stuck a damn tack into



Who are you

To stick tacks into my



Who are you

To tell me who I can

Or can’t be?

Who are you?


Strange figure in the mirror.

Strange voice that fills the air.




Who am I?


The Nonbinary Physician Activist: “Do No Harm” Implies Equity as the Outcome.


Gender nonconformity and outspoken nonbinary voices are stigmatized in medical professionalism.  Anti-LGBTQ climates in healthcare and research settings are psychological iatrogenesis which require structural changes to avoid further malpractice.  Academic medicine should take largescale and immediate action based on lessons learned from the lived expertise and the paid work being performed by activist and social justice thought leaders.  Intersectional, community-based participation, autonomy, and ethical representation should be standard in all components of clinical care and research.  This is especially true in post-pandemic practice, in which historically-oppressed communities’ trust in our healthcare system continues to decline.  We must move focus of translational care “from bench to bedside to embrace,” and we should target equity as our main quality assurance outcome.


 Originally Posted in: Harvard Public Health Review: Edition 42 



What Does Visibility Mean to Me?

I view my gender expression as free expression of identity, of thought, of self, and of art. Some forward-thinkers may perceive my gender expression favorably, some may feel ambivalent, and some may laugh or scowl at it or have violent or shocked reactions to it. Nevertheless, it commands attention.”



Original Post Found at:

Fordham GSS News

(Read It Here)



Fordham GSS

The Daily Visibility of Nonbinary Identity in Social Innovation

Z Paige Lerario, MD, NYS CRPA/CPS-provisional                                                                                                 

MSW Candidate, Fordham Graduate School of Social Service
Vice-Chair, LGBTQI Section of the American Academy of Neurology 

March 31, 2022

Dr. Z Paigle Lerario


As a graduate student of social service at Fordham University, I take my positionality seriously. I am white, I am a physician, I am able-bodied, and I have had every educational opportunity available to a person born in the United States. I am also transgender and nonbinary, which too often takes a front seat in how people perceive me. I am visibly out and trans most days of the year. And because of this, most people are surprised to learn I am a neurologist.

That’s probably because I do not “pass” in society as a cisgender person and because I exist in this world as neither a man nor a woman. I am in the mindset that I do not owe it to society, to my colleagues, to my clients, or to anyone else to look or act in a specific way before I am respected as myself and the identities I claim. I am exactly what a neurologist looks like, nothing more and nothing less.

I have learned the importance of this self-affirmation as a social work student. Loving oneself is a part of self-care, self-improvement, and self-empowerment. And I believe as a future social worker, I should first make progress toward loving myself before I can be fully available to the clients I serve.

Often the societal expectation is transgender people should “pass” visibly and behaviorally as cisgender; that is, we should not appear as transgender openly. In many of the helping professions, this forced cisgender normalization erases culturally appropriate standards of transgender and nonbinary expression and identities. Although transgender people have existed everywhere through all of time, many of us are silenced by violent oppression: such as banning healthcare, banning sports participation, banning representation in education, and banning facilities access, among various others.

The majority of Americans have not knowingly had a conversation with a transgender person (Minkin & Brown, 2021). This includes some of our country’s decision makers and thought leaders (Crary D & Whitehurst L, 2021). So how can they make informed decisions on laws and policies which affect transgender people? And do those of us with a transgender family member, coworker, fellow student, teammate, or friend wish for these policies to be made without adequate representation from the communities affected? This is a time when one in fifty members of generation Z identify as transgender, and one in five identify within the LGBTQ+ community (Jones JM, 2022). We need social innovation and structural adaptations to accommodate a quickly changing demographic of the incoming American workforce.

On this day, now nationally recognized by President Biden, we acknowledge what barriers and biases many transgender people encounter daily in achieving the many successes of our community. For me, the Transgender Day of Visibility shows respect for the authentic self which I (and so many others before me) display to the world, and the consequences we have faced in doing so.


Dr. Z Paige Lerario


I admit I am privileged. I am privileged to afford health insurance and surgeries and new wardrobes and legal name changes. Too many transgender people do not have these privileges. Some may need to hide, out of safety—emotional or physical— or for fear of losing employment, housing, healthcare, family, friends, mentorship or education.

Nevertheless, gender diversity in any form or voice is a gift to be celebrated. Nonconformity to outdated binary standards of gender expression need not only be championed by those who are transgender or nonbinary. I view my gender expression as free expression of identity, of thought, of self, and of art. Some forward-thinkers may perceive my gender expression favorably, some may feel ambivalent, and some may laugh or scowl at it or have violent or shocked reactions to it. Nevertheless, it commands attention.

Therefore, I urge readers to stand out in their gender expression, today, and every day. And above all, recognize the gift of authenticity and empowerment transgender people provide to the world every day of the year.



Crary D & Whitehurst L (2021). Lawmakers can’t cite local examples of trans girls in sports. Associated Press News. Accessed online on March 15, 2022 at:

Jones JM (2022). LGBT Identification in U.S. Ticks Up to 7.1%. Gallup: Politics. Accessed online on March 15, 2022 at:

Minkin R & Brown A (2021). Rising shares of U.S. adults know someone who is transgender or goes by gender-neutral pronouns. Pew Research Center. Accessed online on March 15, 2022 at:


Because in authenticity, I have found inspiration, strength and passion in leadership. And when you have these qualities, there is no longer reason for dominance and no longer room for complicity or silence.

Mackenzie P Lerario, MD, NYS-CRPA/CPS-p

                                                                                                  The Necktie in Professional Dress Codes: An Outdated Symbol of Masculine Oppression

My dad taught me many things. One lesson that remains with me to this day is the importance of a good necktie. “Power ties” he called them in my childhood, often citing the symbolic authority of the red necktie on Donald Trump, then a real estate mogul. In these moments, my dad reinforced a learned cultural value that masculinity represents strength, and that this messaging should be front and center in our leaders. At the time, I did not understand how personally significant this social cue was for me. Nor did I know the same man would later write historic executive actions as President which rolled back eras of progress for gender-expansive citizens of our country.


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