Like hearing people, deaf people have problems rooted in both biology and environment [1]. One can recognize, in some deaf people, the presence of disabilities while still appreciating Deaf ways of being in the world as different, not deficient, and sometimes as advantageous. The beauty of sign language, the benefits of communication in this visual means, and the strong sense of community and culture entice many hearing people into contact with deaf people and the Deaf world. Many hearing people decide to work with deaf people not because we want to fix or help people we see as less than us, but because we are drawn to a language, culture, and world we see as very appealing. We seek contact with deaf people because of what this adds to our lives. It is striking just how many hearing people see involvement with deaf people as enriching our lives, and how many of us become crusaders for deaf people, whether or not this is welcomed by deaf people themselves. Indeed, many hearing people in this field, far from wanting deaf people to become more hearing, seem to want themselves to become more Deaf.

The disadvantages that some deaf people face include the high prevalence of neurologically based learning disabilities, the systemic obstacles to learning sign language, the resulting fact that many deaf children begin school without native language skills in any language, the fund of information gaps that make it hard to associate new learning with old learning and relatively low levels of literacy overall. It also appears to be the case that deaf people experience higher levels of traumatic and abusive experiences. The advantages that many signing deaf people have over hearing people include superior performance in visual spatial organization and memory, the ability to read facial expressions for emotion, visual attention, and certain kinds of mental manipulation. Belonging to a close cultural community can give one a strong sense of identity and a network of friends, family and associates such that one never feels alone.

Hearing Loss

Hearing impairment is a generic term referring to all types, causes, and degrees of hearing loss [2]. To delineate the impact of a hearing loss on the development of English speech, language, and literacy, a number of descriptive variables have been identified, including degree of hearing impairment; age at onset; age at identification; etiology; presence of additional disabilities; and hearing status, level of involvement, communication mode, socioeconomic status of the parents or caregivers.

An individual’s hearing threshold level is indicated on the audiogram across a range of octave frequencies between 250–8000 Hz. The individual’s audiogram results are often reflected in one number, known as a pure tone average (PTA). It is the average unaided threshold across three frequencies (500, 1000, and 2000 Hz) and is thought to reflect an individual’s abilities to detect speech information. The PTA is designed to chart hearing sensitivity    from    0 to 110   dB. Much of   the emphasis in describing hearing loss has been placed on the degree of hearing loss. Although all of the factors mentioned previously should be considered concomitantly, degree of impairment has assumed the most weight in determining the educational placement of children who are d/Deaf or hard of hearing, rehabilitation procedures, and even the selection of amplification systems.

To simplify matters, here we group hearing loss into five categories: slight, mild, moderate, severe, and profound. Traditionally, students in the first three categories have been referred to as hard of hearing, whereas those in the last one are labeled as deaf. Students in the category of severe hearing loss can constitute a mixed bag, so to speak. Historically, these students have been labeled as either hard of hearing or deaf, depending on their use of residual hearing (i.e., remaining or usable hearing).

As indicated by the opening passages, speech remains the most basic and prevalent form of communication for most humans, despite the proliferation of technological devices [2]. In fact, spoken language is the real engine of verbal communication. Reading and written language are built upon or, to put it bluntly, parasitic upon the spoken-language capacities of individuals. Strong development in the spoken-language form—via phonology, morphology, syntax, semantics, and pragmatics— influences the acquisition of literacy skills, such as reading and writing in English.

In human evolution, speech emerged as the most basic and efficient form of communication, probably as a result of the evolution of the physiological properties of the central nervous system. Earlier forms of communication may have been nonverbal, involving the use of the hands and body movements. However, it was evidently more efficient to free up the hands for manual activities and to communicate via voice.

Community

When people refer to the deaf community, what often comes to mind is the picture of a community of people signing [3]. One way to define the deaf community is to see it as comprising “those deaf and hard-of-hearing individuals who share a common language, common experiences and values and a common way of interacting with each other and with hearing people” (NL Association of the Deaf, n.d.). It is easy to think of this community as a monolithic entity. But in actuality this term represents a very diverse entity with demographic, audiological, linguistic, political, and social dimensions. There are international, national, regional, and local deaf communities that share and work together to achieve common goals. The deaf community includes deaf children (both spoken and sign language users) of hearing parents, deaf children of Deaf parents, hearing members who participate as parents of deaf children, hearing children of Deaf adults (popularly known as CODAs, which stands for children of deaf adults), marriage or life partners, siblings, and so on. The term deaf is used to denote individuals with hearing differences that preclude the understanding of speech through hearing alone, with or without the use of auditory amplification. In contrast, the term Deaf culture refers to individuals within the deaf community who use American Sign Language (ASL) and share beliefs, values, customs, and experiences. These Deaf individuals are not only deaf offspring of Deaf parents; they are also deaf individuals with hearing family backgrounds who learn about Deaf culture in adolescence or adulthood, if not earlier.

However, unlike earlier deaf generations, recent generations get together less often in person at clubs to exchange news, ideas, signs, and stories. With the proliferation of captioned television and movies, the Internet, electronic mail, smartphones, relay services, and mainstreaming, which facilitates virtual interactions, small regional and local Deaf clubs and settings have diminished in numbers across the country. Yet the preservation and promotion of the psychosocial aspects of the deaf community still exists through alternative means: home entertainment, conferences sponsored by organizations such as Deaf Senior Citizens and the National Association of the Deaf, sports competitions, Deaf festivals, alumni events, and, of course, the Internet. Speaking of the Internet, as one Deaf American stated, “My smartphone is my DeafSpace. . . . I go there . . . for Deaf people”.

Communication

There are still many complaints in the Deaf community about inadequate interpreter services, telephone services, and captioning. In part, this is due to inherent limitations in the services and technologies themselves [4]. Communication through an interpreter is often flawed, depending as it does on a third party who enables the communication to occur, but also prevents direct one-on-one communication. Interpreted communications can suffer from inaccurate transmission of both language and tone. TTY (telecommunication devices) and relay conversations are much slower than comparable voice communications would be, and both also lose affect and nuance, even when both parties to the conversation are skilled writers and readers. Errors in captioning and real-time transcriptions are legendary and would be comical if people were not depending on the captions for access to television, videos, and movies.

Many complaints come from people who have received some accommodations, but who felt that the communication was inadequate. In common health care scenarios, a doctor will ask a deaf patient to bring a hearing relative to interpret. If no one is available, the doctor will resort to writing back and forth, even though the patient requests an interpreter. If the patient continues to insist, the doctor may use a staff member who can fingerspell or knows some simple signs. Even if a skilled interpreter is brought in, he or she may not be competent to interpret for this particular patient or in a health care setting. A patient may be uncomfortable and may request a known interpreter who can interpret most effectively for her. Some deaf patients insist on an interpreter certified by the Registry of Interpreters for the Deaf (RID) or the NAD (National Association of the Deaf).

Communication is a subjective interactive process that is difficult to quantify. Any communication exchange is fraught with potential misunderstanding. The likelihood of misunderstanding is multiplied enormously when the partners to an exchange have different native languages. The likelihood of misunderstanding is greater again when the modalities of communication are different, as between a sign/verbal pair of communicators. Such pairs may have great difficulty achieving understanding, not only of vocabulary and grammar, but also of tone and nuance. Satisfaction with a communication exchange must also be measured from the context of each member of a communication pair. One person may experience an exchange as highly satisfactory and effective, while the other partner to the same exchange may experience frustration and a sense of incomplete understanding.

Right to Health

The typical approach to public health consists of four steps: (1) identify the problem through the systematic collection of data; (2) identify the causes of the problem using research on causes, risk factors, and potential interventions; (3) design, implement, and evaluate interventions; and (4) test, monitor, and evaluate effectiveness of promising interventions in diverse settings, and monitor and adapt them to enhance their impact and cost-effectiveness [5]. This approach, familiar to public health professionals, differs from the typical process through which human rights objectives are met. When a right to health framework is introduced, it can complement the public health approach, but the means and methods are of a different nature.

The effective realization of the right to health, like any human right, depends on a process of norm elaboration and enforcement. In the domestic system, law is binding, and the courts and the police are available to use force to compel compliance. In the international human rights regime, the term ‘enforcement’ refers to coerced compliance, while the more common term ‘implementation’ refers to supervision, monitoring, and general effort to hold duty-holders accountable. Implementation is further subdivided into promotion—preventive measures to ensure respect for human rights in the future—and protection—responses to violations that have occurred. The means and methods of implementation may be summarized in three forms of promotion and five forms of protection, all of which are relevant to the realization of the right to health.

The role of medicine in identifying, preventing, or curing medical conditions; treating symptoms; and improving or maintaining physical functioning has become the backdrop for treating hearing differences as something to be ameliorated, remedied, or cured through medical treatment, including surgery, particularly for middle ear issues or cochlear implants [3]. Without surgery, the focus becomes that of enabling access to sound through auditory technology (hearing aids and other assistive listening devices), accompanied by intensive auditory and speech training to facilitate the use of spoken language as a means of approximating the hearing ideal such that the deaf person can function like a hearing person. This intensive auditory and speech training is also indicated for children and adults going through cochlear implantation. Overall, this process gives rise to the implied message that to hear differently is to be disabled and therefore this condition is unacceptable.

Overtly or covertly, society often equates disability with powerlessness, incompetence, burdensomeness, abnormality, forced dependency, or a condition to be overcome by sheer motivation. Therefore, the deaf person may strive to be as “hearing” as possible, thereby denigrating the condition of being deaf and increasing the comfort of hearing individuals around them. Some professionals encourage parents to place their deaf children in public schools with hearing children in the interest of “helping” deaf children “overcome their disability” and fit into mainstream society. Users of ASL use a sign of a box, made outside the ear, to illustrate what they see as a focus on the ear. This sign, with its English translation of “pathological model,” encompasses their feeling that the medical/disability view imposes restrictions on them by overly focusing on their access to communication through sound via the ear instead of through vision.

Deaf mental health is the name for this clinical specialty requiring mastery of this complex interplay of cultural and disability considerations [6]. Without special training in Deaf mental health, clinicians make predictable mistakes. Some will be cultural faux pas such as asking culturally Deaf people to use their voice and to speech-read. Others may be serious clinical mistakes, like misdiagnosing Deaf culturally normative behaviors (i.e., highly expressive non-verbal communication) as indicators of psychopathology.

In Deaf mental health, the cultural model of Deaf people is necessary as part of a framework for service delivery. The cultural model emerged in reaction to the long-standing medical-pathological model of deaf people, the conceptualization of deaf people as those with a problem of sensory deprivation. The cultural model, in contrast, focuses upon the Deaf community as a linguistic and cultural minority group. With growing recognition of sign languages as legitimate natural languages, and a parallel respect for Deaf culture, it was a natural step to argue that mental health services for deaf people should work from a cultural, as opposed to a disability, perspective.

Health care facilities should take special steps to make sure that deaf people know about services the hospital normally offers and about any special services to which they may be entitled because of their disabilities [7]. For example, many hospitals provide new patients with an orientation to the hospital, its personnel, and its services. All such information should be available in writing at a level of English that most people can understand. It should include an easy-to-read notice about the availability of sign language interpreters, portable TTYs, and other special services. If a facility gives information by telephone, it should ensure that deaf people can get the same information using a TTYequipped telephone.

Some deaf people do not know about hospitals' legal obligations. They may not know how to request an interpreter. It is the hospital's responsibility to provide this information. Hospitals also should have easy-to-read notices posted in the emergency room, outpatient clinic, and all admitting areas to inform deaf people of how they can obtain interpreter services or other assistance.

Institutions

Nowhere is this negative construction of deaf people more solidified than in the marriage of medical and educational institutions; this represents one of the most (if not the most) important sites of acculturation and enculturation for deaf people [8]. For both parents of deaf children and deaf children themselves, the formation of “deaf” as a social identity often becomes more clearly defined and understood in educational programs. Educational professionals come into families’ lives as soon as their deaf baby qualifies for early intervention services. Parents are then provided with streamlined support, advice, and information that appear to be unbiased about how they could help their deaf child access language and education. Early intervention experts (predominantly hearing) inform the parents that they are to make an “informed choice” for the sake of their deaf child and society at large and help them make decisions with educational placements. Educational placements often determine whether deaf children will be seen as individuals with broken ears (based on the medical model) who need to be remediated in order to gain status and respect within the larger society or as individuals with a unique characteristic (based on the cultural/social model) that leads to identification with human diversity, bilingualism/multilingualism, and Deaf culture and communities. The former is the default approach in the current medical and educational system. This can be attributed to the fact that for the last 250 years, deaf education has been dominated by a hegemony whose social structure has framed deafness as a deficit. In other words, approaches, methods, and practices in deaf education have been developed based on hearing people’s terms and on their capital, language, worldview, and epistemology. Even though research has demonstrated variable and often less-thandesired outcomes in hearing-centric approaches focusing on speech and listening, these approaches continue. If deaf children do not master speech and listening, they may often wrestle with not only language deprivation, but also with developing a healthy self in the midst of a society that is more tolerant towards those who approach hearing expectations and norms. The relations between the society at large, medical and educational professionals, the parents and their deaf child as described earlier contribute to the challenges of developing a healthy deaf identity. The development of a healthy deaf identity is defined as a positive attitude toward oneself, one’s culture, and the related community. Medical and educational institutions over time have effectively disciplined the deaf body using medical and educational terminology, stigmatized symptoms, created audiological solutions and encouraged the belief that somehow the hearing loss will be fixed with interventions.

Professions

The world rarely accords with the neat distinctions our language presupposes in dealing with it [9]. This is somewhat less true in the case of the social world, for we fashion it to reflect our ideas and purposes. However, our purposes, goals, and conceptions are often complex and intertwined. They develop over time, weaving a complexity that even patient analysis can only in part resolve into distinct elements. This is especially the case with regard to the professions. Nursing, medicine, and the law, for example, do not reflect a conceptually unified set of goals and purposes. Rather, they have developed, as do all professions, in response to a series of shifting perceptions of important human tasks. Thus one is likely to have serious difficulty discovering the way in which nurses, physicians, or lawyers aid us in coping with the world, caring for other individuals, or curing or resolving problems. This is in part the case because the service goals that determine professions are a heterogeneous accretion of purposes, as much determined by historical accident as clear conceptual necessity. In addition, learned professions possess not only goals directed to societal or client service, but to the development and maintenance of knowledge and skills. This distance between the altruistic and intellectual goals of learned professions introduced a major complicating factor in the description of professions and their relations with their clients. In addition, professions are modes of gaining a livelihood. As a result, they become natural vehicles for developing and protecting special financial and social perquisites. Much of what one associates with being a nurse, physician, or lawyer is a reflection of often longestablished social divisions of power, prestige, and financial advantage. This is probably nowhere more true than in the contrast between the positions of nurses and physicians.

Medical Law

Medical law is unusual amongst legal subjects as there is considerable academic debate over whether it is a distinct subject at all [10]. The growth in healthcare during the 20th century, both in terms of technological advances and social expectations, means that we are all likely to encounter doctors, nurses and other healthcare workers on a professional basis at some point in our lives. As with any human relationship, the law seeks to regulate it but the discipline of medicine brings with it specific emotive and moral complications. Our encounter with healthcare may involve one of our most intimate interests: mortality; reproduction; a life free of pain and suffering. In a democratic society governed by the rule of law, the law must step in to regulate these issues but it does not, and should not, do so in a moral vacuum. Abortion, euthanasia, transplants, assisted conception, and so on, are ethical, as well as legal, issues and an entire philosophical subject of medical ethics has developed to study them. The question remains, however, whether there is a distinct legal subject which focuses on the law regulating healthcare.

Doubt has arisen because medical law is an academic version of the cuckoo. When a medico-legal problem arises, medical law utilises the principles and remedies of other branches of law. So, traditionally, if you wanted to know about the legal duties imposed upon your doctor – his legal standard of care in providing treatment – you would need to refer to the law of torts; if you wanted to know whether you would face legal liability for helping a terminally ill loved one to die, you would need to consult the criminal law; if you wanted to know whether an underage child could obtain contraceptives or an abortion without parental consent or knowledge, you would need to refer to the principles of family law. A medical lawyer needed to be a jack of all trades but, as the issues specific to healthcare increased (for example because the terminally ill could be kept alive for longer or because new technology enabled new uses of the human body), the traditional rules of these other branches of law had to be adapted.

Deafness that occurs in early childhood significantly affects the ability to learn speech, because about 90% of deaf children have parents who can hear and do not know sign language. Their upbringing and school education are usually monolingual, focused on the language of that country as well as orally, and very often sign language is bypassed or suppressed. The specific language of deaf people is traditionally considered to be the sign language of the area in which they live, which develops where two or more deaf people meet. People whose mother tongue is sign language always think in that language. Sign language is also used by people with normal hearing not only in communication with the deaf but also among themselves. These are relatives and friends of deaf people, sign language translators, pedagogues and people interested in sign language. Sign languages are complete languages, which have all the characteristics of spoken language. They possess their own grammar, with the space in front of the body of the person speaking it playing an extremely large role. Each sign of this language can be phonologically decomposed into phonemes, which include four parameters: the   configuration of the hand, its orientation, movement and position. In addition, body posture, movement dynamics, facial expressions, and sometimes lip movements play an additional role in communication.

1. Glickman, N.S. “What is deaf mental health care?” Deaf mental health care, edited by N.S. Glickman, Routledge, Taylor & Francis Group, New York, 2013, pp. 13.

2. Paul, P.V. and G.M. Whitelaw. “Hearing and deafness: An introduction for health and education professionals.” Jones and Bartlett Publishers, Sudbury, 2011, pp. 4, 140.

3. Leigh, I.W. and J.F. Andrews. “Deaf people and society: Psychological, sociological and educational perspectives.” 2nd ed., Routledge, Taylor & Francis Group, New York, 2017, pp. 17, 21.

4. Geer, S.S. “When ‘equal’ means ‘unequal’—and other legal conundrums for the deaf community.” Language and the law in deaf communities, edited by C.L. Lucas, Gallaudet University Press, Washington, 2003, pp. 134–136.

5. Marks, S.P. “The emergence and scope of the human right to health.” Advancing the human right to health, edited by J.M. Zuniga, S.P. Marks and L.O. Gostin, Oxford University Press, Oxford, 2013, pp. 17.

6. Glickman, N.S. and W.C. Hall. “Culture and disability.” Language deprivation and deaf mental health, edited by N.S. Glickman and W.C. Hall, Routledge, Taylor & Francis Group, New York, 2019, pp. 1.

7. Legal rights: The guide for deaf and hard of hearing people. 5th ed., Gallaudet University Press, Washington, 2000, pp. 105.

8. Holcomb, L. et al. “Sociological perspectives on deaf identities.” Deaf identities: Exploring new frontiers, edited by I.W. Leigh and C.A. O'Brien, Oxford University Press, Oxford, 2020, pp. 38–39.

9. Engelhardt, H.T. Jr. “Physicians, patients, health care institutions and the people in between: Nurses.” Caring, curing, coping: Nurse, doctor, and patient relationships, edited by A.H. Bishop and J.R. Scudder Jr., The University of Alabama Press, Tuscaloosa, 1985, pp. 62–63.

10. Wicks, E. “Human rights and healthcare.” Hart Publishing, Portland, 2007, pp. 1.