The impact of stuttering on development of self-identity, relationships, and quality of life in women who stutter

Purpose
The experiences of women who stutter have been underresearched. Clinicians have little guidance from the research literature on issues specific to women who stutter and are likely to have less clinical contact with this group than with men who stutter because of the higher prevalence of stuttering in men. This study explored the experiences of a small group of women who stutter with a particular focus on what the main current issues are and how gender may have influenced experiences with stuttering.


Method
This qualitative study involved recruitment of 9 women who stutter (aged 35-80 years) through a support network of people who stutter in Western Australia. All the women had received some form of speech therapy for stuttering, and they came from diverse cultural backgrounds. Individual, semistructured interviews were conducted, recorded, and transcribed verbatim. Data were managed with NVivo 10, and thematic analysis was used to identify recurring themes across the data. Data were coded independently by the researchers and refined through group discussion. Participants also completed the Overall Assessment of the Speaker's Experience of Stuttering.


Results
A core theme of "gendered sense of self in society" emerged from the data. This related to 3 broad themes: perceptions of self that were primarily negative, the impact of stuttering on relationships and social connection with others (relationships with family, peers, colleagues, and intimate partners), and the management of stuttering (internal coping, motivations, and experiences with external support).


Conclusions
Stuttering has a pervasive impact on all aspects of women's lives and affects how they view themselves, their relationships, their career potential, and their perceptions of how others view them in society. The women interviewed in this study often had negative self-perceptions and felt that their quality of life had been impacted by their stuttering. However, the women's stories and experiences of stuttering were shaped by a broader context of perceived sociocultural expectations of females in society. Strong verbal communication was highlighted as a crucial factor in developing identity and forming relationships. This study highlights the need to be aware of the experiences of, and issues facing, women who stutter for clinicians to be more equipped, focused, and successful in their stuttering interventions for women.

S tuttering is increasingly recognized as a complex communication disorder with an interplay of environmental, genetic, and constitutional factors (Guitar, 2014;Yaruss & Quesal, 2006). As speech is the primary form of communication for humans, it is unsurprising that stuttering, a disorder of speech production, has been found to impact on multidimensional aspects of an individual's life (Messenger, Onslow, Packman, & Menzies, 2004). Speech-language pathologists (SLPs) who work in the amelioration of stuttering are not only challenged to treat the presentation of impaired communication but also required to understand the complex interplay of a person's psychosocial, emotional, and cultural influence in relation to stuttering.

The Sex Ratio of Stuttering
Stuttering more commonly affects males than females (Bloodstein & Bernstein Ratner, 2008). Craig, Hancock, Tran, Craig, and Peters (2002) reported an overall ratio of males to females who stutter at approximately 4:1 across all ages, with the ratio varying for different age groups: 3:1 for 2-to 10-year-olds, 4:1 for 11-to 20-year-olds, 2.2:1 for 21-to 49-year-olds, and 1.4:1 for adults over the age of 50 years. It is unclear as to why stuttering is more common in males, but it may be linked with genetic factors; females could be more resistant to inheriting a stutter and/or could have better recovery rates than males (Yairi & Ambrose, 2005). The bottom line is that there are fewer females who stutter. This has implications for understanding stuttering and for clinical practice, because fewer women will be on SLPs' caseloads and are less likely to be included in research studies. Therefore, what is known about stuttering through research is likely to be skewed toward males who stutter.

Health Research, Sex, and Gender
Sex is a biological factor, whereas gender is a concept encompassing behaviors, personality, and beliefs shaped by the culture in which a person lives (Rider, 2000). Within the domains of health research, it has been recognized that sex and/or gender should be considered part of clinical design as a variable and determinant of health (Simon, 2005). Women may differ from men regarding risk for certain medical conditions and how they respond to interventions. Yet, women have been found to be underrepresented in biomedical research and in clinical drug trials (Hoyt & Rubin, 2012). Gender may have implications for how people experience a health condition. For example, the experiences of women with a disability have been noted to differ from men (Chouinard, 2010).

Previous Research Into Experiences of Stuttering and Gender
In the 1970s and 1980s, some studies comparing women and men who stutter yielded results indicating gender differences in the experience of stuttering. Silverman and Zimmer (1979) compared groups of 10 women and 10 men and found that the women who stuttered had higher levels of self-esteem than the men. They proposed that the women may have viewed their stuttering as less disabling than the men. A few years later, Silverman and Zimmer (1982) carried out interviews with both women and men who stuttered and reported that men were more likely to receive counseling or psychotherapy for their stutter, further suggesting that men experienced stuttering as more distressing than women. Silverman and Zimmer (1982) also reported that, in therapy, women who stuttered preferred attitude normalization activities, whereas men preferred speech fluency activities.
These research findings overall could be interpreted in a range of ways and need to be viewed within the context of the time. For example, women may have been less affected by stuttering because of differences in participation in the workforce, and they may have been less likely to access services for other reasons such as lack of finances or increased family responsibilities. The changing role of women in society was thought to be a possible contributing factor to an increase in women who stutter accessing speech therapy services in the 1970s (Feldman, 1977).
Interestingly, a more recent survey about experiences and perceptions relating to employment (Klein & Hood, 2004) of 232 participants recruited through the National Stuttering Association (United States) found that the women (n = 64) were less likely than the men (n = 165) to believe that stuttering would have an adverse effect on employability and job performance. This supports Silverman and Zimmer's (1982) earlier claims that stuttering might still be more of a problem for men than it is for women, at least in the area of employment.
Since the earlier studies published in the 1970s and 1980s, there has been limited research specifically investigating gender differences in experiences of stuttering. Worthy of mention is some research, yielding equivocal results, in the area of listeners' attitudes, judgments, and perceptions of women who stutter compared with men who stutter. Women who stuttered (either hypothetical or actual) were judged by university students more negatively than men who stuttered (Byrd, McGill, Gkalitsiou, & Cappellini, 2017;Silverman, 1982). However, Burley and Rinaldi (1986) and St. Louis, LeMasters, and Poormohammad (2015) found no differences. In Burley and Rinaldi's study, judgments were made by 15-to 35-year-old participants (source not specified), whereas St. Louis et al.'s study had judgments that were made by the general public in the United States and Iran. With such few studies, it is difficult to determine the reason for the difference in findings between them; however, it is likely that a number of factors contribute, depending on the societal and cultural contexts of the people making the judgments at that time. Sheehan (1979) reported a significantly lower selfesteem for women who stuttered compared with their fluent peers as measured by the Rotter Level of Aspiration Board (Rotter, 1942). Sheehan compared this result with a much earlier study conducted, measuring the self-esteem of women who stutter with the same measurement tool (Sheehan & Zelen, 1955), and found that the women in the 1979 study reported higher self-esteem scores than the women in the 1955 study. These studies are interesting as they may reflect societal changes and an improved status of women between 1955 and 1979, with increased equality and vocational opportunities for women over that time (Sheehan, 1979).

Women-Only Studies in Stuttering
There is a need to investigate the experiences and quality of life of the contemporary woman who stutters. In the last few decades, gender roles have continued to shift, at least in developed countries. Women's roles have changed in the household, community, and workplace with increased entry into the workforce and attainment of positions of leadership in traditionally male-dominated fields (Graham-Bethea & Mayo, 2012). Gender equality in the workplace is a contemporary issue in countries such as Australia with a reported gender pay gap at 15.3% (Australian Human Rights Commission, 2018).
There is a dearth of knowledge about how women experience living with stuttering, and it is no wonder that this population has been described as a "minority within a minority" (Graham-Bethea & Mayo, 2012, p. 20). Stuttering is an area of clinical practice where clinicians already lack confidence in their work (Guitar, 2014), and this may be compounded by generally low levels of access by speechlanguage pathology students to women who stutter on clinical placements. A better understanding of women's lived experiences of stuttering may encourage more sensitive and tailored therapy approaches.
Qualitative studies investigating experiences of people who stutter have contributed positively to the field by increasing an understanding of the quality of life of people who stutter (e.g., Plexico, Manning, & Levitt, 2009a, 2009b. However, previous studies have not investigated women who stutter exclusively or discussed findings separately for men and women. For example, research by Plexico et al. (2009aPlexico et al. ( , 2009b on coping in stuttering included nine participants, but only two of them were women. Beilby, Byrnes, Meagher, and Yaruss (2013) interviewed 10 adults who stutter and their respective partners about experiences of living with a stutter and its impact on their relationships, but only one stuttering participant was a woman. Although Klompas and Ross (2004) included seven women and nine men in their study on the impact of stuttering on quality of life in South Africa, findings were not differentiated between men and women who stutter.
The field of women's psychology focuses on the study of women rather than gender differences (Rider, 2000). In the area of stuttering, women's experiences have received little attention aside from Sheehan and Sheehan and Zelen's earlier studies (Sheehan, 1979;Sheehan & Zelen, 1955). A literature search revealed few studies in the gray literature, including conference papers (Blom, Simpson, Herde, & Mertz, 2013;Nang, Dhu, & Geevaratne, 2006) and only one book chapter (Scaler Scott & Boyer, 2015), that were dedicated to the investigation of women who stutter. Although it is positive to see a more focused approach to investigating the experiences and quality of life in women who stutter, these studies were small and findings have not been published in a peer-reviewed journal. Research in this area has not progressed into further or more robust studies with larger numbers.

Research Aims
In light of the paucity of current research on women who stutter and their experiences of stuttering, this study aimed to investigate (a) women's perceptions of living with a stutter, (b) the impact of stuttering on their quality of life, (c) how the women manage their stutter, and (d) their perceptions about how gender might impact on these experiences.
The study differs from previous research by including a larger sample than previous qualitative studies focusing solely on women who stutter. In line with the field of women's psychology (Rider, 2000), the study was not designed to evoke differences between the genders regarding experiences of stuttering. Rather, it was to explore and document the experiences of stuttering and the impact of stuttering on quality of life, as reported specifically by women who stutter, and to interpret the findings to determine if gender had influenced the women's experiences. In contrast to the study by Scaler Scott and Boyer (2015), which used a broad questioning strategy to interview three women, this study was focused on the quality of life and different aspects of the women's experiences, including their management of stuttering within the context of their lives.

Method
The research received ethics approval through the Edith Cowan University Human Research Ethics Committee, and written informed consent was obtained from all participants. All names of participants used in this report are pseudonyms.

Participants
Nine women who stutter were recruited through Speak Easy Association Incorporated, the key local support group for people who stutter in Western Australia. The sample was a convenience sample as the association is the only professional organization in the area representing people who stutter. Women were invited to participate through the association's newsletters and personal contacts of the first author, who has had long-term involvement with the support group. The women's ages ranged from 35 to 80 years, with a mean age of 47 years. Participant eligibility criteria included (a) a clinical diagnosis of stuttering by a qualified speech-language pathologist, (b) identification as a woman, (c) age of 18 years or older, (d) sufficient skills in English to participate in the interview without the need of an interpreter, and (e) no comorbid conditions (i.e., a concurrent diagnosis of psychosis, intellectual disability, neurological condition, and substance abuse) that could potentially impact on the validity of quality-oflife evaluations.
All participants started stuttering in childhood and had received some intervention from a speech-language pathologist. The women represented a diverse range of different cultural backgrounds with eight of nine participants having migrated to Australia from overseas. Four women were born in and migrated from Asia, two were from the United Kingdom, and two were from Europe. Six women had migrated to Australia as adults; two, as children. Five women reported speaking languages other than English. All women resided in Australia as either Australian citizens or held a Permanent Resident status.
To gain a better understanding of the stuttering profile of the women, a stuttering severity measure and measure of the impact of stuttering on quality of life using the Overall Assessment of the Speaker's Experiences of Stuttering (OASES; Yaruss & Quesal, 2008) were collected. Table 1 presents the demographic characteristics for the women.

Stuttering Severity
The entire duration of each interview speech sample was rated using a 9-point perceptual severity rating scale as this did not require any additional testing time or materials. To complete a rating, assessors took into consideration a number of factors and characteristics of the stuttering behaviors exhibited by the women such as stuttering rate, stuttering frequency, and severity of individual stutters (O'Brian, Packman, Onslow, & O'Brian, 2004). The severity rating scale has been shown to be reliable and in correlation with percent syllables stuttered measures (O'Brian et al., 2004). A rating of 1 indicated no stuttering, and 9 indicated extremely severe stuttering. Samples were rated independently by two authors, and reasonable agreement was achieved between them (no more than one scale value). Therefore, an average was taken of the two ratings. Results suggested mild to moderate stuttering severities, as indicated in Table 1.

Quality of Life
The OASES (Yaruss & Quesal, 2008) was used to quantify the impact of stuttering on the lives of the participants as a demographic variable. It assesses an individual's experiences of stuttering in the domains of (a) general information, (b) reactions to stuttering, (c) communication in daily situations, and (d) quality of life. Overall impact scores are presented in Table 1. The overall impact score ranged from 1.33 (mild) to 3.08 (moderate-severe), with a mean rating across all women of 2.44 (a moderate rating according to the OASES).

Interviews
Participants completed case history forms, requesting background information and past treatment history before the interviews. Participants completed an in-depth, semistructured interview in their homes or at a venue chosen as convenient by them. Interviews were conducted by the first and third authors. The first author was the facilitator of Speak Easy Association of Western Australia and therefore had already met the participants. Interviews were audio-recorded using an Olympus VN-5500PC digital voice recorder with a Yoga EM-012 tie clip microphone, and they ranged from 32 to 55 min in duration, with a mean duration of 42 min.
A broad topic guide with interview prompts was prepared based on the research aims of (a) women's perceptions of living with a stutter, (b) the impact of stuttering on their quality of life, (c) how they manage their stutter, and (d) how gender might impact on these experiences. More specific questions around these areas included how stuttering had impacted on their interactions with others, how it impacted on education and work, what coping or management strategies they employed, and what advice they might offer to other women who stuttered. Toward the end of the interview, participants were asked if they had any particular thoughts about women's perspectives on stuttering. Overall, although participants were informed that the research was about women who stuttered, the interviewer phrased questions in such a way that they were not "led" to make links between stuttering and gender. Rather, the researchers wanted to see what emerged in relation to gender before prompting further around this issue. Interviewees were free to focus on issues most prominent to them (Birks & Mills, 2011;Hammersley, 2013). The interview structure is presented in the Appendix.
After each interview, field notes were written regarding the overall impression of the participants, including stutter behavior patterns, displays of emotion, personality traits, and most prominent issues raised. The field notes were later utilized to assist with analysis of the data to establish main themes of the interviews.

Data Analysis
Interviews were transcribed verbatim, and transcripts were uploaded to the NVivo 10 qualitative analysis software program (QSR, 2012) to aid in the thematic analysis. All authors checked the accuracy of the transcripts. Data analysis was iterative. At the initial stage of analysis, the first and third authors collaboratively coded two 10% sections of interview transcripts containing particularly rich data to establish agreement for the thematic analysis. The purpose of this collaborative coding was to ensure that each author's interpretations of the data were consistent with each other at the beginning stages of data analysis.
After transcripts were examined at the initial level, intermediate coding was used to direct data analysis around significant themes (Charmaz, 2006). This is where the researcher revised codes derived from the initial analysis to refine categories and subcategories to conceptualize how the categories related to each other. Increased confirmability was ensured with the use of annotations in the NVivo 10 software program (QSR, 2012) to highlight important quotes and to justify decisions (Charmaz, 2006).
All authors read the transcripts as well as listened to the audio files of the interviews. The relationships between different codes and themes were discussed between researchers, and the theme structure was altered at times during the analysis to produce final results (Braun & Clarke, 2006).
Finally, as part of the member checking process, an interim synopsis of the study findings was sent to the participants to provide a chance to make comments as to whether opinions and points of view had been accurately represented and validated. The women requested no changes. This method of member checking was used to provide research interpretations with credibility (Ryan-Nicholls & Will, 2009).

Major Themes
This study invited women who stutter to share their experiences and stories of living with stuttering. As such, the women spoke openly about how stuttering had impacted on their lives, how they viewed themselves, and how stuttering shaped their identities and self-definition. Therefore, the core theme that emerged was related to identity or sense of self. Through the analysis, it became clear that this was gendered, illustrated in various ways. Insights into the women's perceptions of gender in relation to stuttering were gained, although little was mentioned explicitly in response to the question regarding gender issues. Their sense of self was relational to how they felt they fitted into society, and they were acutely aware of how they thought others perceived them. From this, the core theme emerged as a "gendered sense of self in society." For the purposes of this article, the term society is interpreted broadly to reflect the diverse cultural backgrounds of the participants living in Australia. Three themes emerged from the core theme: (a) primarily negative impacts of stuttering and perceptions of self, (b) connecting with others through the life course, and (c) managing stuttering through strategies, which included formal and informal supports.

Perceptions of Self Were Primarily Negative
Across all the participants, perceptions of self were predominantly negative because of their experiences with stuttering, which developed from an early age. For example, Mabelle said, "I felt like I deserved to be put down… biggest nightmare of my life." Other women spoke about how stuttering influenced their confidence and self-identity. Susan characterized herself as a "dopey person…. I was a bit of a fruit loop that was probably a little bit to cover up for my speech maybe," and Hayley said it "felt as though I wasn't being taken seriously" because of her stutter. Steffi said, "I can't be the person that I want to be." There appeared to be a suggestion that the women deserved to feel negative and to expect negativity from others because the stutter was so unacceptable.
In addition, all the women spoke about encountering negative responses toward their stutter. Patricia's immediate response was "fear, so much fear every time I talked." Steffi was also fearful of speaking up, saying that stuttering "is impacting me, talking to people in certain situations when I go like 'I better not talk now.'" Mabelle said, "as soon as I would start stuttering they would look down on me, 'uh! Not her' and then turn around and talk to someone else." The women spoke of avoidance of certain situations because of stuttering (public speaking, speaking in groups), with eight women saying that their stutters were worse in situations when they had to speak with people with authority, usually managers at work. The women illustrated how they feared negative judgment from others: "Not having children, which is a good thing, I probably would have stuttered dropping them off to school. I would have made a fool of myself," said Mahi. Hayley said, "If I feel there's a mother there or a father there…that they'd be judging me, I would avoid them."

Relationships and Social Connection With Others
The women's negative perceptions of self impacted considerably on their social connectedness. Reflecting back on experiences with growing up with stuttering brought back painful memories. Laya reported, "I was very, very low, especially when you are teen (sic)." Susan said, "I felt insignificant and that carried into me growing up." Similarly, Mahi reflected: Brings up a lot of painful memories…and you want to put that behind you because at that time, at that age, it becomes such a big thing, for your speech because you're growing up, formative years and all these things and socialization.
Experiences during the school years featured strongly in the women's stories. The women considered stuttering to be a hindrance to their ability to fit in and develop friendships. Patricia said she "had very few friends at school because of my stutter." The women reported feeling unsupported and socially isolated, and they were particularly sensitive to situations where the stutter was highlighted in front of their peers. Being labeled as "different" by another girl in front of the class at school was a raw memory for Hayley: What happened was it was a girl at school who said to me you have a stutter…. I was about nine…just the shame of it because she said it in front of a group…. I felt across my forehead was "stutterer"… branded.
Similarly, Mahi said her teacher's reaction to her stutter made her feel embarrassed in front of her peers when she produced a stuttering block: "My teacher was embarrassed for me and she was like 'ok, ok sit down, that's alright'…that was really embarrassing." There were some stories of being taunted and/or bullied because of stuttering. Even those who denied experiencing bullying still reported negative feelings about themselves: They had a fear of negative judgment from others as well as a fear of rejection. Steffi thought that she was spared from overt bullying at school, "I don't know, I'm a girl? Might be because it was not ever severe (the stutter)?" As well as a lack of support at school, six women reported feeling misunderstood and unsupported within their own families. They spoke about the responses of their family, with some being teased or pressured by their siblings. Susan shared feelings from her childhood, "My family was very strict…. I think I probably felt a little bit alone." Four women expressed disappointment at the lack of acceptance and understanding from a parent who stuttered himself or herself.
The women stated that family and friends did not appear to know how to support them. Steffi said about her mother, "She would interrupt me all the time and I found it really embarrassing to the extent where I was like alright I'm not saying anything anymore at all." Similarly, Hayley said: My mother she was very compassionate, but she didn't know what to do, didn't understand…she actually said that, if she'd have realized the impact it would've had on me later in life, she would have done something about it when she was younger…and she thought I'd grow out of it.
Collectively, these early experiences with the women's families emphasize how the stigma of stuttering infiltrated into the closest relationships that the women had growing up with stuttering, reinforcing the negativity of having a stutter for the women in their daily home environment.
Participants also spoke more generally about how stuttering influenced their communicative exchanges beyond school and family and the consequences of this on their selfidentity. Steffi said, "Nobody wants to talk to me because I can't talk properly." Five women who migrated from another country also spoke about how their accents and/or English as an additional language were additional barriers to effective communication. Three women spoke about how their stutters were masked behind their accents and that some Australians perceived their stutter to be a cultural way of speech instead of a speech disorder. The women preferred that others identified their differences in speaking ability to be due to cultural reasons, rather than stuttering. This reinforces yet again the shame that these women experienced with having a stutter. Mabelle (from France) said that, when others thought that her stutter was "something to do with my accent, I thought 'oh thank god.'" Difficulty with being able to speak fluently flowed into the women's relationships when talking in social situations, relating to family members, performing work-related tasks, and establishing romantic relationships, ultimately impacting on the women's confidence and self-belief. Vi-Hung stated that stuttering "made study a lot more difficult, it made work a lot more difficult, it made socializing a lot more difficult, and together with that because your self-esteem goes lower as well, it impacts your assertiveness." Patricia said she had difficulty contributing when other women were present in a social setting, illustrating how she was expected to behave "like a woman" by talking to the girls, but as soon as the men appeared, she was relieved of this expectation. This is a good example of a comment where the issue of gender was raised as important: I'd be left to talk to the girls…and my speech would be so bad and I'd be huffing as I was trying to get my words out…and the men would come in and I'd be happy, because I wouldn't have to talk.
The topic of romantic relationships and dating featured prominently with seven women being in partnered relationships and one woman who talked about a previous relationship. The women described their partners using descriptors that reflected how they strived to be: "confident," "outgoing," "relaxed," and "very well able to speak." Amy considered dating to be the most challenging for her: "The hardest time is probably when you're trying to find a partner." Some women were able to manage by assuming roles that were viewed to be acceptable for how women should behave in society. Patricia said that "I worked out that I didn't have to talk very much when dating, I just had to smile and let them talk." Similarly, Mabelle said, "I would just sit and smile…the first year we started dating, he would do most of the talking and I was just following." The women commonly described ways their partners supported them, in relation to their stutter. Mahi said, "So that was part of his protective nature because he was very fond of me and protective of me in a way." Amy was particularly reliant on her partner expressing that she felt comfortable: "If I can't make that phone call he makes it for me…he does things that I avoid…and I let him." She did go on to acknowledge that this method of support was not ideal, but she was not concerned. Mahi, Patricia, and Susan reflected back on previous relationships with a "talkative" partner and affirmed that it was not an ideal way to cope with the stutter. Patricia said, "My husband did all the talking for me…. I mean it was good in one way but in another (way) you depend too much on another person." Similarly, Mahi said, "I became really reliant on him… became really quiet, in a way he wasn't really doing the right thing by speaking at the time for me. I actually became very dependent on him to do all the talking socially." Several participants reported that their partners were not particularly bothered by the stuttering, which they found to be quite surprising. Most of the women strived to keep their stutters a secret because of the fear of negative judgment: "It's a secret because it's a not perfect thing," said Susan. Some of the women's partners asked about the stutters; for example, Steffi's husband did raise it while they were dating: "He just asked me bluntly 'do you have a stutter?' I thought oh my god, I was so embarrassed, I thought he's going to leave me because of it but he had no issues." However, trivializing stuttering by their partners for some of the women was frustrating as they felt they were misunderstood. For example, when Laya suggested attending a therapy group, her husband said to her, "You don't need to go," and he also failed to notice improvements in her speech as a result of her attendance. She considered herself a "lone fighter" in coping with stuttering.
Career and employment contributed significantly to the identity of the women. Patricia was the only woman not in paid employment. However, she was a volunteer dance teacher. All the women found that stuttering limited their ability to secure work and perform work-related tasks. Mabelle's recent experience at a job interview illustrates this: When you go for interviews, you can't stutter, otherwise you don't get the job, so that was a big sort of stress for me…. People look at you funny like "oh, what's wrong with her?"…and then the interview will end very shortly…they (interviewers) show me the door quite fast.
Six women stated that their career choices were impacted by stuttering. For example, Laya said, "Choosing the career, so I chose to go to the place less demanding in terms of speaking." Similarly, Susan said, "I always wanted to be a teacher but it was too hard with my speech." In contrast, Patricia wanted a job to help with her speech: "I somehow wanted to get jobs on switchboards and on the phone…. I thought it would improve my speech." The women spoke about the communication demands at work and how that was a persistent problem for them: "Going to work was almost a nightmare for me…. I used to think 'oh my god, how is it gonna go today?'" (Mahi). Amy said that "email is a savior!" relieving her of a full reliance on verbal communication.
In some cases, the women attributed the responses of others in the workplace to gender issues. Hayley, who worked in software engineering, said, "There was only really myself and another lady amongst a group of men…in a meeting of ten or fifteen, so I found that intimidating." Mahi reported that "being in a project team it was pretty much male-oriented and I was the only girl there, I think guys are more patient with guys, I suppose a bit of boys club." Mahi also said that "we [women] can be expected to be quieter as well at work but boys they don't have a choice, they have to talk." In summary, this theme of connecting with others demonstrates how early negative experiences of stuttering continue to influence the women's relationships growing up and later in life, when they begin dating and looking for life partners, and developing and building a career for themselves.

Management of Stuttering
Management was a prominent theme throughout the interviews, interwoven with the other themes. In this study, self-management is understood as a mix of internal coping processes and external supports enlisted from professionals or others. The act of going out and seeking professional support was often one that occurred as part of a decision to take control of the stutter. The women spoke of personal changes such as increased confidence and resilience throughout their lives depending on external events. They discussed choices they made to support themselves as women. Most also discussed the importance of clinical treatment for directed management.
Participants discussed the notion of initially feeling helpless about how to manage their stutter; this was particularly apparent for those raised in different cultures and for the older women who grew up in Australia. Some of the women had different expectations of how much they should rely on others for support. Some of the women spoke of inherent personality traits, such as assertiveness and positivity to form a base of internal resilience to assist in managing their stutter. Vi-Hung had the lowest impact score on the OASES (1.33, mild) and stated, "I do have a certain amount of inbuilt assertiveness in me," and she believed her attitude and personality were key to how she managed her stutter overall. She also said that, "with age, as well, you learn that it's fear and ignorance…so you look at it and you say, well it's that person's problem." Similarly, Laya said, "Believing in yourself and your ability… don't think that people will judge you by your stutter, people will judge you by your ability and also what you do and as a person, so what I've found so far is I'm a bit strong (sic) person." Laya added, "It doesn't matter if rich or poor, need to have the drive," referring to the motivation that is needed to make a change with stuttering.
Other women acknowledged that their self-perceptions were important, although they acknowledged that they had not achieved self-acceptance. Susan, who was in her 60s, said, "Getting a bit more confidence even though I'm still not overly confident, I feel more confident about my ability to speak…. I know I can be fluent," and this was helpful in her ability to manage stuttering. Acceptance of stuttering was related to self-disclosure of stuttering. Vi-Hung was very forthright in saying, "I use it (self-disclosure) to teach (others about stuttering)." Laya disclosed her stuttering to managers at work openly. Both Vi-Hung and Laya scored as mild on the OASES. In contrast, the women who were apprehensive and also selective with whom they chose to disclose their stutter were also the women who acknowledged their lack of self-confidence and/or lacked selfacceptance of stuttering. Susan, who previously stated that she was not overly confident, had used self-disclosure a few times, one of them being to a group of people with disabilities, but her comment suggests that she felt she had little to lose by doing this: I only told one group about my stutter by the way… it's people that find it hard to get jobs, and some of them are sort of disabled, some of them have had nervous breakdowns and stuff like that and they're returning to work. I told them, but I haven't told the real people (laughs). In contrast, Steffi reluctantly self-disclosed to a manager at work, and when she did, she did not get a sympathetic response. Steffi demonstrated difficulty accepting her stutter, feeling embarrassed on occasions when her partner and close friend mentioned her stutter to her. She also said, "If I know that somebody knows (I stutter), I don't want to talk to them anymore." All the women sought professional support for their stuttering from SLPs. Some women tried complementary therapies such as hypnotism, and others had traditional therapies from their home countries, not necessarily delivered by health professionals. The main motivations for seeking therapy corresponded to the main themes identified and previously discussed. That is, the women had goals to change how others viewed them, how they felt about themselves, to improve their ability to communicate with others to support their development of relationships as well as to improve their work-related potential. Mahi said, "I just didn't want to be a wallflower socially and things like that." Two external catalysts for seeking external support included the end of long-term romantic relationships for two women. Patricia said, "My husband died and I was in the office…and stuttering terrible (sic), absolutely terrible." For five women, it coincided with moving to Australia from another country and the need to develop new relationships and find work.
All of the six women who migrated to Australia as adults expressed that the need to meet new people and to form new relationships was a motivator to seek speech therapy and/or support for their stutters through a support group. Hayley moved from Ireland and sought support for her stutter: "I guess being new here I kind of wanted to get to know others." Mabelle said, "So when I first moved here (Australia) my stutter was strong and it was my biggest problem, also because of stress 'cause when you go for interviews you can't stutter otherwise you don't get the job." Susan found that therapy was a "turning point in my life." She was one of the seven women who spoke about the benefits that they gained from their speech therapy, strongly recommending it to other women who stutter. Vi-Hung and Steffi were the only two women who reported negative experiences with therapy. Vi-Hung thought that her clinicians lacked knowledge about stuttering and how to treat it.
The women, whether from Australia originally or not, were perplexed at the general lack of understanding of stuttering, how to treat it, and the lack of support services available to them. Five women highlighted that there was a current, and often previous, lack of appropriate support services for people who stutter in their home countries and, as a result, they felt dissatisfied with their therapy experiences. For example, Mahi stated that support in India "was very traditional where you had to put this pebble under your tongue and try to talk," and Hayley said that there was nothing available for her: "I lived in rural Ireland, probably there were very few speech therapists." Seven women had undergone treatment focusing on speech restructuring techniques in a group-intensive and/or individual sessions in Australia. Five of these women spoke about how the speech restructuring techniques resulted in unnatural sounding speech and how they felt that it impacted on their personalities or how others would perceive them. This further illustrates how the women regarded other people's perceptions of them to be of utmost importance. Susan said, "I didn't feel like I was my bubbly self because you couldn't be bubbly when you're really concentrating on slowing down." Amy said, if she used slow smooth speech, her partner "would just look at me as if I was off the planet." Similarly, Mahi said, "I choose not to [use smooth speech] because I don't think you sound intelligent when you talk like that." All the women had been involved with a local support group for people who stutter. Six women had been involved long-term (>10 years), with Patricia having the longest involvement of 36 years. At the time of the interviews for this study, none of the women was actively involved in attending support group sessions, with the most recent involvement being over 1 year ago. The support groups for stuttering played an important role in providing an environment to practice fluency techniques, but the women spoke about how the groups were important for managing the psychosocial impacts of stuttering.
All of the women expressed some benefit in attending support groups as a place where they were not judged: Amy said that it was "a place that you can be yourself," and Mahi reported, "Nobody was there to poke fun at you or judge your intelligence." Steffi said that speaking about stuttering with others "became easier after going." The women also referred to the social and supportive aspects as being particularly useful. Mabelle said, "I met other people who stutter, and I face the same struggles and the same rejection and social isolation…it was healing." Mahi appreciated the "social interaction I gained, coming to a new country as a migrant, not having friends…good lifesaver and I've been so inspired by members." Patricia "made friends," and Susan said, "There were benefits where you could catch up with those people afterwards." There were also aspects of the support group that the women did not find positive. Hayley mentioned that the group demographic was not suitable for her: "It was mostly men…. we (another woman and herself ) actually were a lot younger than most of the men too." Hayley also mentioned that other members had more severe stutters than her and that she was not challenged. She added, "I found that some definitely had a pattern of victimhood…. I kind of got tired of that because it wasn't really a positive experience." Vi-Hung said she became the support person instead, and Steffi found it "frustrating to talk to people who stutter."

Discussion
The purpose of this study was to explore how nine women who stutter described their experiences of living with a stutter, including how it impacted on their quality of life and how they managed their stutter. It also particularly explored their sense of being a woman who stuttered. All their comments contributed to a core theme of "gendered sense of self in society." This concept was related to patterns of beliefs that the women held about themselves as individuals and as members of social groups (e.g., gender/ social roles, value to others, potential capabilities). Loosely based on the psychological notion of self-concept (Bergner & Holmes, 2000), the women's self-identities influenced, and were influenced by, their relationships, the way they viewed responses of others toward their stutter, and how they supported themselves.
Overall, there were experiences of stuttering that were similar to previously published studies such as negative perceptions of self and the negative impact on stuttering in different areas of life. This finding in itself highlights that there are common effects of stuttering across people who stutter regardless of gender. As a speech disorder, stuttering impacts the fundamental functions of communication not only for transaction (transfer of information) but also for interaction (to build and maintain relationships in society). This study shows the importance of communication for these women in their development of self-identity and ability to relate to others. Their stories highlight how every aspect of their lives was influenced in some way by their stuttering, including their sense of self as women and their sense of how others perceived them as women who stuttered.

Gendered Sense of Self in Society
The data from this study indicate that the effect of stuttering on the women's lives was so pervasive that it was impossible to separate their stutter from other elements of their experiences. Stuttering was deeply embedded within every aspect of their lives, from early childhood through school, adolescence, and adulthood, influencing identity formation and maintenance. This affirms other bodies of work (e.g., Boyle, 2013) that stuttering affects one's selfconcept, feelings, and beliefs. For the women in this study, their sense of self as a person who stutters was interpreted to be "gendered" because their integration of experience was a close fusion of being female and being a person who stutters. Our premise is that so much of our expression of femininity is through how we communicate, and how our communication is viewed by others is mediated by their expectations of how women should behave. The quotes from the women in the study suggested that their strategies to cope with stuttering, their portrayal of self, and the partners they chose were all deeply gendered in nature. Identity development is related to self-esteem, and there is growing evidence to support that identity development may be different for males and females (Rose & Rudolph, 2006). Several reviews in the area of psychology suggest that, throughout childhood, girls experience more emotional distress and a low self-esteem in comparison with boys (see Rose & Rudolph, 2006, for a discussion). These findings are relevant to the women in this study; the emotional distress of stuttering, particularly experienced throughout childhood, affected the women's development of self-esteem and self-identity.

Perceptions of Self Were Primarily Negative
The women's negative perceptions of self were related to their self-esteem and self-identity. In line with work by Beilby et al. (2013), the women expressed that reflecting on their experiences of growing up with stuttering was painful. All the women experienced early negative reactions to their stutters either within their own families and/or during school years, a time of life that is particularly important for social and emotional development. It was confronting to learn that the negative attitudes, lack of understanding, lack of acceptance and support, and, at times, bullying came from within the family unit.
It is hypothesized that, over time, negative experiences with stuttering may have led to the development of a fear of others' reactions and attitudes, and this may have contributed to negative self-perceptions. The women in this study shared descriptive emotional reactions related to their stuttering. They were sensitive and apprehensive toward what others thought of their stuttering, especially from people with authority, as well as to the quality of their speech while implementing speech restructuring techniques. They were concerned with negative judgments regarding their intelligence and personality, and some chose not to disclose their stutter to others for such reasons. This anticipation of social harm is in line with findings from the study by colleagues (2009a, 2009b).
A contributing factor to the experiences of the women who stutter is the stigma and negative perceptions associated with stuttering in general. Negative evaluations of people who stutter (Byrd et al., 2017;Silverman, 1982) are linked to negative self-perception and attitudes reported by people who stutter themselves. Some women preferred to be identified as "different" because of their cultural background, rather than for their stutter, emphasizing the stigma of stuttering in society. It is hypothesized that gender played a role in their perception of "fitting in" along with culture, family values, and issues related to immigration.

Societal Influences
Another contributing factor to the women's low selfesteem and negative perceptions of self is the role of power (status) of women in society and how this impacted on the women's beliefs and actions. The women were disempowered as a result of their experiences with stuttering and their negative thoughts and perceptions. In the area of women's psychology (Rider, 2000), power plays a role in influencing what women think and how they behave in certain ways that are expected of women in society. Stuttering was a barrier to effective, confident communicative ability and was therefore a major threat to the ability to assert power (Rider, 2000). This point is supported by a study by Butler (2014) of the experiences of men who stutter specifically in the area of employment and aesthetic labor (i.e., sounding right for the job). Butler concluded that characteristics including "strong," "powerful," and "fluent" are linked with masculinity and with being "respected" at work.
The women's experiences reflected how they were in positions of lesser status and power relative to men and/or others around them, not only because of their stutter but also because they were women, illustrating how the concept of power is related to gender. Most of the women stated that an interaction with a person of high authority to them was particularly difficult. In the workplace, some women mentioned that they felt intimidated by men, were outnumbered, and/or were managed by males. They felt that they were met with less patience or less understanding, attributing some negative responses they received toward their stutter in the workplace to perceived gender roles. This adds depth to Graham-Bethea and Mayo's (2012) suggestion that the growing numbers of women in higherpowered, male-dominated positions in the workplace have not necessarily offset the perception that they remain outsiders in male-oriented workplaces, and the stuttering simply makes the need for a persona of power and confidence more difficult.
More specifically regarding relationships, in the field of psychology, resource theory suggests that the person in a relationship who has more education, income, and occupational status relative to their spouse usually has more power in the relationship (Rider, 2000). Upon interpretation of how the women spoke about their relationships and how they described their partners, there appears to be a power difference between the women and their partners related to speaking ability. The women's difficulties with speaking fluently and their perceptions of self had influenced the dynamics of their intimate relationships. To hide a stutter, the women behaved in ways that were socially acceptable for a woman, for example, with some just sitting and smiling through their dates. Some women were drawn to men who did not care about their stutters and/or protected them from their stutters as well as were talking for them. In addition, although some of the women acknowledged that letting their partners talk for them was a maladaptive coping mechanism that impacted on their level of autonomy, they did not necessarily do anything about it and even felt relief from it, further illustrating this power difference between the women and their partners.
Overall, regarding how the women managed their stutters, there were tendencies for the women to choose paths of least resistance to help compensate for their stuttering. For example, some women chose less verbally demanding jobs, and some women allowed others (partner or males) to take over with the talking in social or work-related interactions. A delicate relationship between internal coping mechanisms and reliance on external sources of support was observed, and this was reflective of the women feeling disempowered. The ways in which the women inwardly dealt with their stutters were often impacted by external life factors, such as by the ending of a relationship or migrating to Australia. Changes in the women's own perceptions of their stutters were achieved with participation in speech therapy and support from others who stutter and with increasing experience and maturity. Such changes in self-perceptions were often attributed to internal traits such as assertiveness, positivity, and confidence. These traits were observed to contribute to the women feeling more empowered and enabled.

Communication for Social Purposes
The women in this study emphasized the social aspects of their lives. They provided rich accounts of how stuttering impacted on their relationships as well as their feelings of connectedness with family, friends, significant others, colleagues, and/or broader cultural communities. A comprehensive review of sex differences in peer relationship processes of boys and girls from early childhood through adolescence by Rose and Rudolph (2006) concluded that girls are more prosocial. More specifically, girls in comparison with boys engage more in social conversations (in particular with other girls), they are "nicer" to others, and they typically place more importance on connection-oriented goals (e.g., being inclusive).
The women in this study illustrated how stuttering impacted their ability to demonstrate and develop prosocial behaviors and/or qualities and how their perceived lack of acceptance and support from others was poignant. Stuttering eroded the women's sense of confidence and increased their anxiety during interactions, particularly when talking within a group (either in the social and/or work setting) and/or dating.
It has been found that girls are more sensitive to the status of their peer relationships and friendships (Rose & Rudolph, 2006), a point reflected by the women in this study. Although bullying was not explicitly shared by all the women, the key issue was to do with rejection and isolation (not having friends). This supports the finding that children who stutter are vulnerable to peer rejection (Davis, Howell, & Cooke, 2002).
There is evidence to suggest that girls are more likely to seek support, express emotions, and dwell on situations that cause stress than boys (Rose & Rudolph, 2006). The women in this study emphasized the importance of the social benefits achieved through their participation in attending support groups for people who stutter, over the practice of fluency techniques. This somewhat supports Silverman and Zimmer's (1982) finding that women may prefer therapy activities targeting the normalization of stuttering. Support groups are important as a source of exchange for people who stutter and play a role in helping people who stutter achieve acceptance and better psychological well-being (Boyle, 2013;Yaruss, Quesal, & Murphy, 2002). What is noteworthy was the mention of gender minority in support groups, although this comment was made by one woman only.

The Contemporary Woman
The women's decisions to seek external support for their stutters through speech pathology and/or another health professional, and/or participation in support groups for people who stutter were motivated by their desire to change their own identity and how others perceived them and to improve their social relations and their careers. In contrast to previous experiences with therapy as children and/or as young adults, the benefits of more recent therapy and participation in support groups were generally well received by the women. This reflects a general improvement in the availability and quality of the services for people who stutter.
Most of the women shared stories of how stuttering negatively affected the area of employment (Butler, 2014;Klein & Hood, 2004). There were experiences that further illustrate gendered issues around the development of identity and communication for social purposes. For example, the women emphasized issues to do with how others perceived their capability, what colleagues thought of them, and the quality of their interactions with others at work. Butler (2014) described how men who stutter felt discriminated against because of their speech; however, the women in this study reported that the discrimination they experienced was not only because of their speech but also because of their gender.
Stuttering was a major hindrance in the area of employment for the women who stutter, and this may be a reflection of more participation in the workforce for women in general. Most of the women spoke about hindrances to their careers related to real, or perceived, limitations due to their speech abilities, gravitating toward jobs that required fewer talking demands. They sought support for their stutters to work on fluency techniques and practice to help with social relations and with their job performance. Therefore, the impact of stuttering is likely to be similar as it is for men who stutter (Butler, 2014).
Interestingly, in response to the question "What are your thoughts" [about gender and stuttering], most of the women interpreted this question to be about the consequences to do with career and employment as a point of differentiation. Some women felt that stuttering may be more of a hindrance for men than women because of men traditionally being the breadwinners, but other women expressed that, in the modern age in a country like Australia, gender should be an irrelevant factor.

Limitations and Future Directions
Although emergent themes were generated that provide an exploratory base for future research, a small sample size was used in this study and there were, as expected, differences in the women's stories. Of all the women, Vi-Hung's story was noticeably different as she was reluctant to share negative experiences with stuttering like the other women did and spoke very little about her social support. Rather, she focused a lot more on her therapy experiences and how her work life was impacted by stuttering.
Although the sample of participants was broad and diverse in terms of culture, age, and therapy background, all of the women were recruited through a support group for people who stutter (Speak Easy Association), and they had accessed speech pathology. Australia is a multicultural society, and therefore the diversity of the caseload is not necessarily unusual in an urban setting in a capital city in Australia. Because the sample represents women who attended the support group, it represents a natural grouping rather than an engineered group for the purposes of research. The women were also highly educated, with six of nine in possession of tertiary degrees, and all but one were participating in the workforce. Therefore, the women in this study are likely to be of similar profile to the women clinicians will have on their caseloads. That is, stuttering impacts them negatively enough to warrant some external support.
Nonetheless, analyzing the experiences of women who are not involved with self-help and/or women with more of a diverse range of educational and occupational history may also unearth further important issues. Other identified limitations of this study are that there were no younger women (i.e., under 30 years old) and no women having a "severe" impact of quality-of-life scores on the OASES. Therefore, these results may not express the insight of the younger woman or a severely impacted woman.
Further research into the benefits of support groups may be worthwhile, including whether groups for women might allow them to more freely share their specific experiences with one another. This study did not involve direct comparisons with men who stutter, so it may be useful to compare the stuttering experiences between genders regarding relationships, culture, and workplace challenges. In addition, this study highlighted interesting issues as to how stuttering is perceived cross-culturally.

Clinical Implications
In seeking a broader conceptualization of stuttering, it is imperative that SLPs consider the importance of gender to treat stuttering more holistically and effectively. This study highlights a range of issues facing the contemporary woman who stutters and affirms the importance of addressing self-beliefs as indicated by Plexico et al. (2009aPlexico et al. ( , 2009b and Leahy, O'Dwyer, and Ryan (2012). The findings suggest that stuttering impacts not only experiences of being a woman but also experiences of life roles. There is evidence to indicate that women have greater emotional reactivity than men to emotional images (Lungu, Potvin, Tikàsz, & Mendrek, 2015), and that they are twice as likely to have depression and anxiety disorders compared with men (Steel et al., 2014). Therefore, for clinicians, it is critical that stuttering management incorporates the psychosocial impacts of stuttering, including attitudes and positive self-acceptance (e.g., Leahy et al., 2012;Yaruss et al., 2002), in addition to targeting fluency skills in therapy. Clinicians need to be aware of women's motivations for therapy as well as have knowledge of what appropriate supports are available to help women connect with others. Fluency therapy that evolves to consider an individual's circumstances and lifestyle demands is therefore pivotal.
Education and advocacy is an important facet of stuttering management. It is important to work with people who stutter throughout their early and school years and to involve families and teachers in the therapeutic process to facilitate positive self-esteem and identity development. Treatment programs focusing on stuttering education and bullying prevention pave the way in supporting school-aged children who stutter more appropriately (e.g., Langevin & Prasad, 2012), but early intervention programs to educate parents, and to explore and desensitize negative attitudes about stuttering, are also warranted. Raising awareness in workplaces may also help reduce the negative attitudes that so impact women who stutter.

Conclusions
In summary, the stories of the nine women who stutter revealed themes that are consistent with other published research about the quality of life of people who stutter but add to this work by drawing out how stuttering and gender interrelate. We suggest that experiences with stuttering are intricately related to the women's identities, what is important to them, how they cope and manage their stutter, and how they connect with others. Our findings may provide clinicians with a more nuanced understanding of stuttering as experienced by women in a context where there is limited direction currently in the research literature. This work may offer a base for the development of more informed and sensitive approaches to support and assist women who stutter.