which affects the voice and pitch. Because of these physical changes and hormonal changes, it is difficult to focus on pitch. Previous studies have shown that therapy shaped from adult therapy can be effective. Transition in aging populations Few studies have looked into the transition in the elderly. A survey has shown that many elderly members of the LGBT community do not disclose their LGBT status to their clinicians, including members that receive speech therapy; they choose not to disclose this information because they are afraid it would negatively affect their access to services. Controversy There are two major areas of controversy for professionals working on the voices of transgender people. The first is regarding vocal surgery, and the second is regarding bigender voice therapy. Professional opinion is mixed regarding the use of vocal surgery. There is currently a lack of outcome data, particularly longitudinal data, for pitch-elevating surgery, and outcomes have not been well-monitored over time. Because of this, some SLPs do not think that phonosurgery is a viable treatment option. Others believe it is, and still others believe it should be considered only as a "last resort" after the desired pitch change has not been seen in therapy. Critics cite variability in outcome, lack of outcome data, and reported negative effects like compromised voice quality, decreased vocal loudness, adverse impact on swallowing/breathing, sore throat, wound infection, and scarring as reasons to avoid vocal surgery. Proponents argue that surgery may protect a person's voice from damage caused by repetitive strain to elevate pitch in therapy. Ultimately, the decision to undergo surgery is up to the patient, with input from a knowledgeable physician and SLP. There is also some controversy regarding the use of a bigender voice. A person may want to have both a masculine and a feminine voice in their vocal repertoire, possibly to fit with their own bigender identity, or to read as a different gender in different contexts. Many clinicians will not train bigender voice, arguing that it decreases the opportunity for practice, and it may be difficult or even damaging to the vocal folds for the person to switch from one voice to another. However, Davies, Papp and Antoni (2015) reference the ability of actors to use different accents and dialects, and people to learn different languages as a sign that training a bigender voice may be a viable treatment goal. See also Chest voice