Our Practice
We have tried to be honest about the evidence throughout. Two of the four topics below are well studied. Two of them are not studied at all, and where that is the case we say so rather than dressing up an educated guess as established practice. You are entitled to know which is which.
At a glance
- Chosen name and pronouns go in your record and are what we use; a legal name lives in the billing field only.
- Speech-in-noise tests use different talkers — QuickSIN female, HINT and BKB-SIN male — and the choice changes the score. We record which test and recording were used and keep it constant across visits.
- Hearing loss is associated with HIV in large cohort studies, but that study did not find it explained by time on antiretroviral therapy or adherence. A repeated baseline audiogram is the useful response.
- After a substantial voice change, re-check own-voice comfort and occlusion. Real-ear verification will not detect an own-voice problem, because it deliberately does not use your voice.
- There is no published audiology guidance on speech testing for trans patients and none on hearing aids after voice change. Where we are reasoning rather than citing, we say so.
The chart, and why it is not a small thing
Your chosen name and pronouns go in your record and are what our front desk and clinicians use, including on reminders and follow-up calls. Where a legal name is required for insurance billing, it lives in the billing field and nowhere else. This sounds administrative because it is, but the consequence is not administrative: being misnamed in a waiting room is one of the most commonly cited reasons LGBTQ+ patients delay or avoid healthcare, and delayed hearing care has a particular cost. Untreated hearing loss compounds. The average person waits years to act on it already, and adding a reason to put it off is not neutral. If your insurance card and your name do not match, tell us when you book and we will have it set up before you arrive rather than at the desk in front of a room.
Speech testing, talkers, and what we write down
Here is a piece of clinical detail almost nobody explains. A speech-in-noise test is not one test. QuickSIN uses a female talker against four-talker babble; HINT and BKB-SIN use a male talker. Those are properties of the recordings, and the choice measurably changes the score — the signal-to-noise ratio you need for fifty percent correct is not the same across them. So a result only means something next to another result from the same test and the same recording. We record which test and which recording were used, and we keep it constant across your visits, so that a change in your score is a change in your hearing rather than a change in the disc. That is good practice for every patient. We raise it here because when a patient's voice or presentation is not what a clinician unthinkingly expects, an unexamined talker choice is exactly the sort of thing that quietly creeps in. There is no published guidance on speech audiometry for transgender and gender-diverse patients — we looked, and the audiology literature on trans care is about clinical culture rather than test procedure. Consistency is what protects you in the absence of guidance. One clarification while we are here: standard speech testing uses recorded talkers or the clinician's voice, never yours. Your own voice comes into it only when we are checking occlusion, which is the next section but one.
Hearing and long-term HIV treatment
This one is genuinely established, and it is more interesting than the version usually repeated. A large cohort study published in JAMA Otolaryngology–Head & Neck Surgery, drawing on the Multicenter AIDS Cohort Study and the Women's Interagency HIV Study, found that adults living with HIV had measurably poorer hearing thresholds than HIV-negative comparators — on the order of ten decibels on average, at both low and high frequencies. The American Academy of Audiology's position is that several large studies now point consistently toward an association. What makes it worth understanding rather than just knowing is the part usually left out: in that study the difference was not explained by white blood cell count, viral load, duration of antiretroviral therapy, or adherence. So the common assumption that it is the medication is not what the data showed. The older nucleoside analogues — zidovudine, stavudine, didanosine — carry historical ototoxicity signals, and anyone treated with those decades ago has a specific reason for a baseline. But for someone on a modern regimen, the honest position is that an association exists and the mechanism is not settled. What we do about it is unglamorous and useful: if you are living with HIV, get a baseline audiogram and repeat it, so that change is measured against your own history rather than against a population average. That is the same advice we would give anyone with a known risk factor, and it is worth more than a theory about why.
Hearing aids after voice training or voice surgery
If your voice has changed substantially — through training, through surgery, or through testosterone — and you wear hearing aids, three things are worth checking, and we should be upfront that none of them rests on published evidence. There is no literature on this and no manufacturer guidance. What follows is reasoning from mechanisms that are documented, clearly labelled as such. First, own-voice processing. Some hearing aids are trained during fitting to recognise your voice; Signia's implementation builds a spatial model of the path from your mouth to the microphones and states plainly that detection is based on spatial cues rather than the sound quality of your voice, remaining reliable when the voice is raised, hoarse or speaking another language. That mechanism argues a change in pitch or resonance should not defeat it. Signia does not address voice change anywhere in its documentation, so treat that as a documented silence, not a reassurance. Second, occlusion — the boom or blocked feeling of your own voice. The occlusion effect is concentrated below one kilohertz and varies strongly with the vowel being spoken. A lower fundamental frequency puts proportionally more of your own voice into exactly that region, so it is reasonable to predict occlusion may feel worse after masculinisation and better after feminisation. No study has tested that. It is a reason to re-check, not a finding. Third, and this is the one that matters most: real-ear verification will not catch any of it. Verification uses a standardised international speech signal, built from six talkers, which is deliberately independent of your voice. That is exactly why your fitting stays valid through a voice change — and exactly why an own-voice complaint will not show up on the measurement. So the check has to be a conversation and a re-fit, not a printout. If your voice has changed since your aids were fitted, book a check and say so when you book.
What we do not claim
We are a general audiology practice, not a specialist gender clinic, and we do not have specific training in gender-affirming care beyond keeping current with the audiology literature — which, on the topics above, is thin. We do not provide voice therapy; that is a speech-language pathology specialty and if you need it we will say so and point you elsewhere rather than improvise. What we can offer is competent hearing care from clinicians who will use your name, choose and record your tests carefully, know why a baseline matters after decades on HIV treatment, and take an own-voice complaint seriously instead of pointing at a verification screen. If that is what you were looking for, request an appointment or call 650-342-9449, and tell us anything you would like us to know before you arrive.
Frequently asked questions
A few questions worth asking
Will you use my chosen name?
Yes, in your record, at the desk, and on reminders and follow-up calls. A legal name is stored only where insurance billing requires it. If your insurance card does not match the name you use, tell us when you book and it will be set up before you arrive rather than sorted out at the front desk.
Does HIV or antiretroviral therapy cause hearing loss?
Large cohort studies consistently find poorer hearing thresholds in adults living with HIV — around ten decibels on average in the JAMA Otolaryngology study. But that study did not find the difference explained by viral load, duration of treatment or adherence, so the simple version where the medication is the cause is not what the evidence showed. Older nucleoside analogues such as zidovudine and stavudine do carry historical ototoxicity signals. The practical answer is to get a baseline audiogram and repeat it, so change is measured against your own history.
My voice has changed. Do my hearing aids need refitting?
Possibly, and it is worth a check. Own-voice detection in the aids that use it appears to rely on the spatial path from your mouth to the microphones rather than the sound of your voice, so it should survive a change — though no manufacturer addresses voice change directly. Occlusion is the more likely complaint, since it is concentrated in the low frequencies where a lowered voice puts more energy. Real-ear verification will not show any of this, because it uses a standard signal rather than your voice, so the check is a conversation and a re-fit.
Do you offer voice therapy?
No. Voice training and voice feminisation or masculinisation are speech-language pathology, not audiology. We will not improvise it. If you need that we will tell you so and help you find the right professional.
Is there research on audiology care for transgender patients?
Very little. Two tutorials appeared in the American Journal of Audiology in 2023, both on clinical culture and terminology rather than test procedure. There is no published guidance on speech audiometry for trans and gender-diverse patients, and nothing at all on hearing aid fitting after voice change. We would rather tell you the gap exists than write around it.