Even though a hearing loss is one of the most common of physical and sensory impairments, it is also perhaps the most misunderstood and underestimated. It has been called the "invisible" condition since it is not possible to "see" a hearing loss directly, only its effects upon behavior and communication. The fact that these effects can be so variable, depending upon the individual and the situation, is what makes hearing loss such a confusing condition.

Sometimes a person with a hearing loss can fully comprehend utterances, sometimes not at all, and sometimes only partially. This confusion and uncertainty, often not even fully apprehended by the person with the hearing loss, is what is responsible for the tension, conflicts and anxieties that are often the daily fare of someone with a hearing loss. Indeed, by diminishing a person's ability to effectively engage in interpersonal communication, the condition has the potential to impact every aspect of one's life, ranging from the psychosocial to the cultural and vocational domains.

In short, it is not a condition that should be treated casually, with haphazard, ill-advised and superficial measures taken to ameliorate its effects. Such an approach trivializes the impact that impaired communication can have upon the life and well being of the affected person. Given the significance of the sense of hearing, SHHH believes that people with hearing loss require the care of qualified professionals who follow best professional practices.

Once the medical implications of a hearing loss have been considered and managed, the most effective therapeutic measure is usually appropriately selected hearing aids. At the present time, hearing aids can be purchased by consumers from many sources, ranging from Hearing & Speech Centers, Otologists, Audiologists, and Hearing Instrument Specialists to mail order catalogues and Internet sites. These latter alternative sites for obtaining hearing aids are likely to increase in the future, particularly since many catalogues and Internet sites offer apparently substantial discounts compared to the more traditional sources. It is not the province or intent of the Hearing Loss Association of America to dictate to consumers from where they should purchase hearing aids.

Rather, HLAA takes a position that no matter how or from whom a hearing aid is obtained certain requisite conditions need to be considered to ensure that the interests of people with hearing loss are fully protected.

These follow:

1. It is recommended that people obtaining a hearing aid, particularly new hearing aid users, first receive a medical evaluation (by a primary care physician, otolaryngologist or otologist). This provision, in accordance with current FDA regulations, can be waived by informed adults (over the age of 18) if they so desire.

2. Every potential hearing aid candidate should receive a comprehensive audiological evaluation, conducted by an audiologist with the appropriate state license to practice audiology or, in states that do not have licensing provisions, by someone who holds the requisite professional audiological credentials.

3. A component of this audiological evaluation must be the determination of "red-flag" observations, those that would mandate a medical referral. These include:

a) a recent history of progressive or sudden hearing loss, tinnitus, vertigo, otorrhea (ear drainage), otalgia (ear pain), fluctuating hearing, aural pressure or fullness;
b) an abnormal external ear canal or tympanic membrane on otoscopy;
c) conductive hearing loss as manifested by an air-bone gap;
d) abnormal immitance measures;
e) 10 db or more asymmetry in thresholds between the two ears at two or more frequencies; and,
f) speech perception scores much poorer or asymmetric than expected on the basis of the pure-tone thresholds.

4. HLAA believes that the selection of a hearing aid for a specific person is a highly individualized process, one that requires a personal relationship between the dispenser and the consumer. It is necessary to consider the life style and communication demands upon a consumer, in addition to the nature of the hearing impairment, before it is possible to make an informed decision regarding an instrument that incorporates the necessary features and electroacoustic characteristics.

5. HLAA believes that the hearing aid selection process should incorporate those tests and measurements that reflect current "best professional practices." These may include various types of objective aided and unaided speech tests, individualized electroacoustic programming via a computer interface real-ear measures as well as subjective self-assessment performance and handicap scales.

6. HLAA reaffirms our previous position papers that directly impact upon the hearing aid selection process. These are:

a) Hearing Aids (including a 60-day trial period, and the desirability of binaural aids and telecoils);b) Hearing Assistive Technologies (their evaluation and selection); and,
c) the inclusion of a Group Hearing Aid Orientation Program into the routine hearing aid dispensing process.

In summary, the fact that a hearing loss can have profound effects upon people necessitates that remediation measures be conducted personally by qualified professionals. The hearing instrument itself is only a tool, but a sophisticated and complex one that requires individualized fitting by trained personnel. Furthermore, because a hearing loss can affect the psychosocial, vocational, and social-cultural domains, rehabilitative measures are often required that transcend the simple provision of hearing aids and/or other assistive technologies. The selection of a hearing aid, in other words, needs to be conceptualized as a package, one that incorporates the evaluation and provision of other remedial measures related to the impact of a hearing loss upon a person's life.