Proposal of the vocal attendance protocol and vocal redesignation program in the services of the transsexualizing process

nothing to declare. ABSTRACT Purpose: To present the Trans Ambulatory Vocal Protocol (AVP-trans) and the Vocal Redesignation Program (VRP-trans). Methods: The protocol consists of the following steps: 1) user routing; 2) speech therapy evaluation, application of self-perception protocols, referral for otorhinolaryngological evaluation and definition of conduct: individualized therapy (sound source) or VRP-trans for vocal filter; 3) VRP-trans, containing 12 vocal parameters to be worked monthly individually and in a group with the users; 4) After the end of the VRP-trans, the user is referred for vocal re-evaluation and otorhinolaryngological re-evaluation, in which it will be observed if the objective of the vocal redesignation was reached. Results: VRP-trans is a program that aims at developing a vocal filter work for the transgender population, flexible and that contemplates the complaints of this population, in which it presents difficulties to access the health service. Conclusion: AVP-trans and VRP-trans are tools that can subsidize the speech therapy for transgender people in Brazil, outlining mechanisms that allow greater confidence for transgenders in search of social passiveness through voice, minimizing transphobia, establishing comfort


INTRODUCTION
A dissonant experience regarding socio-cultural expectations related to biological gender binarism is an identity issue and not a mental disorder or disease, as areas involving the physical and mental health of trans people regularly define it (1,2) . In this work, transvestites, transsexuals or transgenders, and genderfluid people were considered as trans people.
In this regard and with the resistance exerted by activists of the trans movement from all over the world, discussions about the depathologization of trans identities are growing. Some advances have already been made, such as the removal of gender identity disorders from the chapter on mental illness and its reallocation in the category of conditions related to sexual health, labeled as "gender incongruence" in the International Classification of Diseases (ICD-11) (3) . According to the World Health Organization (WHO), this change was due to the fact that qualifying it as a mental illness can increase the stigma around this population. However, they justify that the maintenance of transsexuality in the ICD-11, used worldwide, could facilitate access to specific health care services.
Therefore, we highlight actions developed in the state of Sergipe, Brazil, which act in line with the depathologization of trans identities. Speech, Language and Hearing Sciences professors in the field of voice and language conceived and inaugurated the interprofessional "Sergipe's Trans Ambulatory -Open doors: welcome and care" 1 , in 2016. This service was honored at the 2nd National Conference on Women's Health, held in August 2017, receiving an honorable mention from the Pan American Health Organization/World Health Organization and the National Health Council (CNS) (4) .
Although the honor received is intended for the action developed by speech therapists, we question if Speech, Language and Hearing Sciences, as a science that studies human communication, present a shortage of scientific literature on programs and strategies for vocal readjustment aimed at the trans population, therefore distancing itself from an audience with frequent complaints of physical and emotional discomfort related to voice and communication.
Thus, discussing strategies and programs for the vocal reassignment of trans people can provide greater access for this population to speech therapy services. To this end, the purpose of this paper is to present the Trans Ambulatory Vocal Attendance Protocol (AVP-trans) and the Vocal Redesignation Program (VRP-trans) for trans people.

METHODS
This study was approved by the Research Ethics Committee under the approval number 48581715.3.0000.5546. All participants signed the Free and Informed Consent Form.
The Trans Ambulatory Vocal Protocol (AVP-trans was designed by three speech therapists working with the trans population to improve the management of the flow of people 1 Original name in Brazilian Portuguese: Ambulatório Trans de Sergipe-Portas abertas: acolher e cuidar and the adherence to treatment in the outpatient clinic of the transsexualizing process, given the high demand for speech therapy. To contextualize the proposal, Table 1 presents the characterization of the population attended at the clinic. The proposed AVP-trans consists of the following steps: 1. The patient can search for these services at will or he is referred by any health professional who observes the vocal complaint. At the clinic, there are ten interprofessional specialties, namely: occupational therapy, psychology, psychiatry, nutrition, speech therapy, gynecology, pharmacy, social work, nursing, and general practitioner.

In the first contact with Speech, Language and Hearing
Sciences, the patient reports his medical history in order to get familiar with his vocal demands and the gender transition process associated with vocal quality. After the anamnesis, in a waiting room, the following vocal self-assessment questionnaires are answered: • Screening Index for Voice Disorder -SIVD (5) . The SIVD was created specifically for the professional use of voice, specifically for teachers, but due to the practicality of the instrument and after discussions and tests, health professionals realized that it could contemplate specific vocal demands of the population attended in the outpatient clinic of the transsexualizing process; Voice-Related Quality of Life (VRQOL) (6) .
• The VRQOL is part of the routine in the voice clinic and is able to measure important data on the impact of vocal quality on the subjects' quality of life; • The Transsexual Voice Quality -male to female -TVQ mtf (7) , is the only instrument specific for the transvestites and transsexuals that is translated into Brazilian Portuguese; • The URICA-VOICE scale (8) allows the understanding of the adherence of transvestites and trans people to the procedures in the voice clinic. The feedback proposed by this instrument contributes to the reformulation of strategies; • The Vocal Fatigue Self-Assessment Scale -VFSAS (9) , for a unique voice treatment regarding each subject' singularities, makes it possible to identify vocal fatigue, a very common complaint among people looking for services in the transsexualizing process; • The Voice Symptom Scale -VoiSS aims at self-evaluating voice and vocal symptoms (10) . The VoiSS is composed of 30 questions covering the physical, emotional, and impairment domains.
After answering the questionnaires, the patient is submitted to a speech-language assessment, while recording his vocal samples for later computerized acoustic analysis of the voice performed by the PRAAT software ® . The suggested evaluated parameters are the temporal aspects of the emission, harmonics, and the distribution of noise in tracing.
During the speech-language evaluation, if the patient did not perform a laryngeal examination, he should be referred to an Ear-nose-and-throat doctor (ENT Doctor). If the ENT Doctor report is positive for an injury/laryngeal disorder, the user is referred to speech therapy to reestablish the function of the sound source and, later, to the Vocal Redesignation Program (VRP-trans). However, if there are no laryngeal lesions, he is directly referred to the VRP-trans.

The Vocal Redesignation Program (VRP-trans) consists of
individual or group activities with the speech therapist and other users participating in the VRP-trans.
Necessarily, the patient will meet with the speech therapist once a month, in which his individual demands will be analyzed using individualized vocal techniques and the prescription of instructions and vocal sensitization. After choosing of the vocal technique procedure domain, the user is referred to group activities.
In order to organize the group, it is suggested that each meeting be conducted by a speech therapist with a maximum of five patients and a duration of 40 minutes or less. During this period, users are encouraged to work on a specific vocal parameter, adapting it to their automatic speech and to their individual needs.
The program is based on Eclectic Vocal Therapy to achieve more effective communication according to the user's demands based on the parameters developed (11) . Direct approaches (12) are used in the performance of vocal exercises according to the Classification of the Categories of usual approaches for speech therapy treatment of dysphonia (11) , and indirect approaches (13) are applied to guidance on vocal well-being.
The proposed duration of the VRP-trans is 12 months with one meeting per month. Each month, both individually and in groups, a specific vocal parameter is worked with a different method, such as body, pitch, loudness, resonance, vocal projection, articulation, speaking speed, prosody, vocal psychodynamics, vocal resistance, vocal expressiveness, and body expressiveness, as in Chart 1.
This chart exemplifies one of the countless work possibilities according to the profile of the users of this service without changes in the vocal fold. Thus, it should not be considered as an option without a complete speech-language assessment.
The stipulated parameters guide the work, but during the meeting, they are associated with the other aspects, respecting the vocal particularities of each patient.
According to the method used, the patients are instructed to perform exercises at home until they return to the outpatient clinic. 4. After the end of the VRP-trans period, the user will be referred for individual vocal speech-language reassessment. If the patient presented laryngeal alterations during the program, he will be referred for otorhinolaryngological evaluation. At this point, it is certified whether the scope of vocal reassignment was reached and it is discussed with the user. It is noteworthy that the patient will be constantly monitored by the speech therapist throughout the VRP-trans, with the possibility of suggesting the speech therapy discharge even before expected, when succeeding on the vocal reassignment.

RESULTS
The care protocol for trans people as well as the vocal rehabilitation program for trans people are presented in Figure 1.  Figure 1 shows the service flow chart for AVP-trans and VRP-trans.

DISCUSSION
In Brazil, there are no epidemiological studies on the exact number of trans people. In the world, there is an estimate that there are 4.6 trans people for every 100 thousand people. In a sample this size, 6.8 are trans women and 2.6 are trans men (14) . In this study, there was a similar proportionality between trans men and women who seek care at the outpatient clinic of the transsexualizing process.
Regarding age, most of them are between 20 and 29 years old, which is a feature presented in other studies that address the profile of users of a service in Rio de Janeiro (15) .
Discussing therapeutic programs developed for the trans population and respecting their uniqueness can reduce the marginalization of these people and improve access to health services. However, besides the specific techniques of each area of health, it is necessary to expand the discussion regarding health specificities and respect for gender identity issues. To welcome the users, it is necessary to recognize the other, legitimizing their health needs, through qualified listening that allows the health professional to adapt the services to the real needs of the assisted person. Only then the effectiveness of health practices can occur (16) .
The speech therapist professional is not included in the Ordinance that regulates the services of the Transsexualizing Process. However, the demand for questions related to the voice of this population is noticeable. Even though it is not covered by the ordinance, most services enabled by the Ministry of Health have the participation of a speech therapist (17) since its proposal demands an interprofessional work environment. The integrated work between the team is fundamental for the success in monitoring the user. Therefore, interprofessionality optimizes comprehensive health care and provides specific monitoring for each user (18) .
AVP-trans and VRP-trans were born due to the need for a vocal program that does not focus on modifying the sound source aspects in isolation, but rather all the other vocal attributes ascribed by the person to the gender to which he or she identifies.
Here the emphasis is on therapeutic listening, which deals with desires and needs, that is, self-designation is the guideline for these services. And this stage can only be reached with a detailed and welcoming rapport. Regarding the instruments, voice selfperception is more and more celebrated in speech therapy, as it allows the therapist to understand the subject's perception of his voice and the aspects that entail vocal production. Studies on the perception of vocal quality are common and important in several investigations (19) .
Certainly, regardless of the vocal adjustments performed empirically to conform to society's desired or expected vocal patterns, these people can change the sound source. Thus, before the program starts, people are referred to the ENT Doctor service and when any change is identified, individual sessions are recommended. In their absence, group care is the preferred alternative. Although studies with voice therapy in therapeutic groups are not abundant, this practice has been considered in services with high demand and has been demonstrated by most studies as efficient or partially efficient for the treatment of dysphonia (20) .
The parameters developed during the VRP-trans were based on the guidelines for initial comprehensive health care for transgender people and non-binary genders (21) .
The established duration of the VRP-trans is twelve months, considering the need for users to follow-up in the outpatient clinics of the transsexualizing process in the two-year preoperative period (22) , concurrent with other specialties. Thus, the speech therapy follow-up would present the flexibility to be carried

CONCLUSION
With the increased demand for Speech, Language and Hearing Sciences services during the transsexualizing process, AVP-trans and VRP-trans are tools that can reinforce speech therapy care to trans people in Brazil. This can outline mechanisms that enable greater confidence for trans people in search of social acceptance regarding their voice, minimizing transphobia, creating a comfort zone, and social satisfaction. The application of AVP-trans and VRP-trans in different services is of paramount importance to enable the development of researches and their improvement.