Efficacy of intensive voice feminisation therapy in a transgender young offender

Gender-Affirming Voice Training for Trans Women: Acoustic Outcomes and Their Associations With Listener Perceptions Related to Gender

OBJECTIVES

To investigate acoustic outcomes of gender-affirming voice training for trans women wanting to develop a female sounding voice and to describe what happens acoustically when male sounding voices become more female sounding.

STUDY DESIGN

Prospective treatment study with repeated measures.

METHODS

N = 74 trans women completed a voice training program of 8-12 sessions and had their voices audio recorded twice before and twice after training. Reference data were obtained from N = 40 cisgender speakers. Fundamental frequency (fo), formant frequencies (F1-F4), sound pressure level (Leq), and level difference between first and second harmonic (L1-L2) were extracted from a reading passage and spontaneous speech. N = 79 naive listeners provided gender-related ratings of participants' audio recordings. A linear mixed-effects model was used to estimate average training effects. Individual level analyses determined how changes in acoustic data were related to listeners' ratings.

RESULTS

Group data showed substantial training effects on fo (average, minimum, and maximum) and formant frequencies. Individual data demonstrated that many participants also increased Leq and some increased L1-L2. Measures that most strongly predicted listener ratings of a female sounding voice were: fo, average formant frequency, and Leq.

CONCLUSIONS

This is the largest prospective study reporting on acoustic outcomes of gender-affirming voice training for trans women. We confirm findings from previous smaller scale studies by demonstrating that listener perceptions of male and female sounding voices are related to acoustic voice features, and that voice training for trans women wanting to sound female is associated with desirable acoustic changes, indicating training effectiveness. Although acoustic measures can be a valuable indicator of training effectiveness, particularly from the perspective of clinicians and researchers, we contend that a combination of outcome measures, including client perspectives, are needed to provide comprehensive evaluation of gender-affirming voice training that is relevant for all stakeholders.

Acoustic and Perceptual Effects of Articulation Exercises in Transgender Women

PURPOSE

This study measured the impact of articulation exercises using a cork and articulation exercises for lip spreading on the formant frequencies of vowels and listener perceptions of femininity in transgender women.

METHODS

Thirteen transgender women were recorded before and after the cork exercise and before and after the lip spreading exercise. Speech samples included continuous speech during reading and were analyzed using Praat software. Vowel formant frequencies (F1, F2, F3, F4, F5) and vowel space were determined. A listening experiment was organized using naïve cisgender women and cisgender men rating audio samples of continuous speech. Masculinity/femininity, vocal quality and age were rated, using a visual analogue scale (VAS).

RESULTS

Concerning vowel formant frequencies, F2 /a/ and F5 /u/ significantly increased after the lip spreading exercise, as well as F3 /a/, F3 /u/ and F4 /a/ after the cork exercise. The lip spreading exercise had more impact on the F2 /a/ than the cork exercise. Vowel space did not change after the exercises. The fundamental frequency (fo) increased simultaneously during both exercises. Both articulation exercises were associated with significantly increased listener perceptions of femininity of the voice.

CONCLUSION

Subtle changes in formant frequencies can be observed after performing articulation exercises, but not in every formant frequency or vowel. Cisgender listeners rated the speech of the transgender women more feminine after the exercises. Further research with a more extensive therapy program and listening experiment is needed to examine these preliminary findings.

Gender-Affirming Voice Training for Trans Women: Effectiveness of Training on Patient-Reported Outcomes and Listener Perceptions of Voice

PURPOSE

Although speech-language pathologists have provided gender-affirming voice training for trans women since the 1970s, evidence for this training's effectiveness remains weak. Our study aimed to redress limitations of earlier studies and evaluate voice training effects on outcomes important to trans women.

METHOD

Seventy-four trans women (19-54 years old) who wanted a more female-sounding voice were recruited through two health facilities and provided with an eight- to 12-session voice training program based on contemporary literature, usual clinical practice, and client-centered care principles. Self-reported outcomes and an audio-recorded reading sample were collected 3 months before, immediately before and after, and 3 months after training. Forty cisgender speakers were audio-recorded reading the same sample material as comparison voices. Seventy-nine naive listeners made gender-related voice ratings of an extract from these audio recordings. Training effectiveness was evaluated using group-level analyses (linear mixed-effects models) and individual-level analyses to establish what proportion of participants improved to a predetermined relevant degree.

RESULTS

Group-level analyses demonstrated positive training effects, maintained 3 months posttraining, for trans women's vocal satisfaction, perceptions of voice-related social participation, and self- and listener perceptions of their voices. Individual-level analyses also demonstrated positive effects. Two thirds of trans women increased vocal satisfaction to a relevant degree, one third who reported restricted social participation before training reduced this restriction to a relevant degree, and all were rated more female-sounding after training (although not all to a relevant degree).

CONCLUSIONS

All trans women participants made progress toward their voice goals and maintained those gains at follow-up. These findings provide evidence that gender-affirming speech-language pathology services warrant prioritization. Further research is warranted to investigate factors predicting outcomes of voice training for trans women.

A speech therapy for transgender women: an updated systematic review and meta-analysis

BACKGROUND

We systematically reviewed the literature and performed a meta-analysis on the effects of speech therapy and phonosurgery, for transgender women, in relation to the fundamental frequency gain of the voice, regarding the type of vocal sample collected, and we compared the effectiveness of the treatments. In addition, the study design, year, country, types of techniques used, total therapy time, and vocal assessment protocols were analyzed.

METHODS

We searched the PubMed, Lilacs, and SciELO databases for observational studies and clinical trials, published in English, Portuguese, or Spanish, between January 2010 and January 2023. The selection of studies was carried out according to Prisma 2020. The quality of selected studies was assessed using the Newcastle-Ottawa scale.

RESULTS

Of 493 studies, 31 were deemed potentially eligible and retrieved for full-text review and 16 were included in the systematic review and meta-analysis. Six studies performed speech therapy and ten studies phonosurgery. The speech therapy time did not influence the post-treatment gain in voice fundamental frequency (p = 0.6254). The type of sample collected significantly influenced the post-treatment voice frequency gain (p < 0.01). When the vocal sample was collected through vowel (p < 0.01) and reading (p < 0.01), the gain was significantly more heterogeneous between the different types of treatment. Phonosurgery is significantly more effective in terms of fundamental frequency gain compared to speech therapy alone, regardless of the type of sample collected (p < 0.01). The average gain of fundamental frequency after speech therapy, in the /a/ vowel sample, was 27 Hz, 39.05 Hz in reading, and 25.42 Hz in spontaneous speech. In phonosurgery, there was a gain of 71.68 Hz for the vowel /a/, 41.07 Hz in reading, and 39.09 Hz in spontaneous speech. The study with the highest gain (110 Hz) collected vowels, and the study with the lowest gain (15 Hz), spontaneous speech. The major of the included studies received a score between 4 and 8 on the Newcastle-Ottawa Scale.

CONCLUSION

The type of vocal sample collected influences the gain result of the fundamental frequency after treatment. Speech therapy and phonosurgery increased the fundamental frequency and improved female voice perception and vocal satisfaction. However, phonosurgery yielded a greater fundamental frequency gain in the different samples collected. The study protocol was registered at Prospero (CRD42017078446).

The Experiences of Trans and Gender Diverse Clients in an Intensive Voice Training Program: A Mixed-Methodological Study

Intensive schedules in behavioral voice therapy and training have been proposed to have a range of positive benefits including enhanced outcomes, high client and clinician satisfaction, and reduced client attrition. In the sub-field of behavioral voice training for trans and gender diverse clients, intensive schedules may also present a means of increasing service access opportunities for a vulnerable population. Despite the proposed benefits there has been limited research investigating client experiences in intensive voice training programs. The current study utilized a mixed-methodological approach to compare participant experiences in an intensively scheduled (three 45-minute sessions per week, over 4 weeks) versus a traditionally scheduled (one 45-minute session per week, over 12 weeks) voice training program for trans and gender diverse participants aiming to develop a perceptually feminine-sounding voice. Participant experiences were compared using a satisfaction questionnaire delivered to both training groups as well as thematic analysis of semi-structured interviews conducted with participants in the intensive group. Results suggested that individuals in the intensive training program had both positive and negative experiences related to the intensive schedule, but all viewed the program favorably and expressed a preference for intensive training based on their experiences. However, it was also found that overall satisfaction and attrition did not differ significantly between the intensive and traditional training groups and that many factors contributing to participant satisfaction in the intensive program were unrelated to the intensive schedule. Results from the current study also suggest that experiences in intensive programs may be highly variable and mediated by factors such as clients' individual personalities and preferences. The current study concludes that intensive schedules present a viable alternative to traditional schedules in practice, with additional considerations and directions for future research also discussed.

Short-Term Acoustic Effects of Speech Therapy in Transgender Women: A Randomized Controlled Trial

PURPOSE

This study measured and compared the acoustic short-term effects of pitch elevation training (PET) and articulation-resonance training (ART) and the combination of both programs, in transgender women.

METHOD

A randomized controlled study with cross-over design was used. Thirty transgender women were included and received 14 weeks of speech training. All participants started with 4 weeks of sham training; after which they were randomly assigned to one of two groups: One group continued with PET (5 weeks), followed by ART (5 weeks); the second group received both trainings in opposite order. Participants were recorded 4 times, in between the training blocks: pre, post 1 (after sham), post 2 (after training 1), and post 3 (after training 2). Speech samples included a sustained vowel, continuous speech during reading, and spontaneous speech and were analyzed using Praat software. Fundamental frequency (f _o), intensity, voice range profile, vowel formant frequencies (F _1-2-3-4-5 of /a/-/i/-/u/), formant contrasts, vowel space, and vocal quality (Acoustic Voice Quality Index) were determined.

RESULTS AND CONCLUSIONS

Fundamental frequencies increased after both the PET and ART program, with a higher increase after PET. The combination of both interventions showed a mean increase of the f _o of 49 Hz during a sustained vowel, 49 Hz during reading, and 29 Hz during spontaneous speech. However, the lower limit (percentile 5) of the f _o during spontaneous speech did not change. Higher values were detected for F _1-2 of /a/, F ₃ of /u/, and vowel space after PET and ART separately. F _1-2-3 of /a/, F _1-3-4 of /u/, vowel space, and formant contrasts increased after the combination of PET and ART; hence, the combination induced more increases in formant frequencies. Intensity and voice quality measurements did not change. No order effect was detected; that is, starting with PET or ART did not change the outcome.

[Interface of speech-language pathology in the process of gender reassignment from male to female]

BACKGROUND

Voice is crucial for gender identification during the transition process, as voice feminization plays a significant role in the success of passing. In order to be able to classify the role of voice treatment during the interdisciplinary gender reassignment process of MzF-trans*, possible recommendations for action for the cooperation with the medical doctors are needed.

MATERIAL AND METHODS

Four expert interviews from the disciplines of otolaryngology, endocrinology, and plastic surgery were conducted to establish a potential guideline consensus for the role of speech-language pathology as an interface to the male-to-female gender reassignment process.

RESULTS

Based on the expert interviews, it is uniformly recommended that voice treatment should be considered early in the transition. Primarily, conservative therapy should be considered to avoid e.g. irreversible surgery of the larynx. The focus of voice treatment in voice feminization is centrally on the adaption of the speaking fundamental frequency. In postoperative cases, speech-language pathology is intended to adapt the speech pattern to the new anatomy and prevent complications, such as uneconomic voice and speech.

CONCLUSION

The current interviews represent a first insight into the cooperation between speech-language pathology and the medical specialties for the treatment of MzF-Trans*. In order to implement the recommendations from the preliminary expert interviews for a potential guideline consensus, consultation with involved professional societies and more randomized trials of specific voice treatments in MzF-trans* are needed.

Experiences of Transgender Women with Speech Feminization Training: A Qualitative Study

This study investigated the experiences of transgender women after following sessions for speech feminization using semi-structured face-to-face interviews. Transgender women who completed a clinical trial were invited for an interview and 12 accepted the invitation. Interviews were conducted using an interview guide and were recorded and transcribed verbatim. NVivo 12 was used for qualitative data analysis, applying an inductive thematic approach. Four main themes were identified: communication, therapy experiences, impact on mental health, and external factors associated with the outcomes. For most participants, fear of speaking in public decreased after the training and all participants mentioned improved vocal characteristics. Though, reactions ranged from needing more speech therapy to being satisfied with the results. Coping strategies during misgendering occasions differed a lot between participants. More emotive counseling during speech feminization sessions is necessary to help clients in managing possible negative emotions.

The Effectiveness of Gender Affirming Voice Training for Transfeminine Clients: A Comparison of Traditional Versus Intensive Delivery Schedules

INTRODUCTION

Gender affirming voice training is a service provided by speech language pathologists to members of the trans and gender diverse community. While there is some evidence to support the effectiveness of this training, the evidence base is limited by a lack of prospective studies with large sample sizes. Finally, there has been only limited research investigating the effectiveness of this training when delivered on intensive (compressed) schedules, even though such schedules are used in clinical practice and may have practical benefits such as increasing service access for this vulnerable population.

METHODOLOGY

This study aimed to investigate and compare the effectiveness gender affirming voice training among 34 trans individuals presumed male at birth who shared a goal of developing a 'female-sounding voice'. Among these 34 participants, 17 received their training on a traditional schedule (one 45-minute session per week over 12 weeks) and 17 on an intensive scheduled (three 45-minute sessions per week over 4 weeks). Building on a previous mixed methodological study which indicated that these two training groups were equally satisfied with training outcomes, the current study utilised a wide range of self-report, acoustic, and auditory-perceptual outcome measures (including self-ratings and listener-ratings of voice) to investigate training effectiveness.

DISCUSSION

Results from this study indicated that both training programs were similarly effective, producing positive statistically significant change among participants on a range of outcome measures. Participants in both groups demonstrated significant auditory-perceptual and acoustic voice change and reported increased satisfaction with voice, increased congruence between gender identity and expression, and a reduction in the negative impact of voice concerns on everyday life. However, as has been the case in past studies, training was not sufficient for all participants to achieve their specific goal of developing a consistently 'female-sounding voice'.

CONCLUSION

This study provides evidence to suggest that gender affirming voice training for transfeminine clients may be similalrly effective whether delivered intensively or traditionally. This study provides evidence to support the practice of using a wide range of outcome measures to gain holistic insight into client progress in gender affirming voice training programs.

Perceived gender and client satisfaction in transgender voice work: comparing self and listener rating scales across a training program

BACKGROUND/AIM

Scales used to collect perceptual ratings related to a speaker's gender are widely used in gender affirming voice training for trans individuals. Such scales may be used as outcome measures to gain insight into whether training has helped clients meet personal goals related to gender expression. These scales are also widely used in general research investigating the relationship between vocal characteristics and perceptions of speaker gender. However, past studies in these areas have varied in the terminology used to label rating scales and the impact of this variation is currently unknown. Additionally, research has not yet fully explored the relationship between self- and listener-ratings of trans participant voices and trans participant satisfaction with voice, and whether or not these relationships change after trans participants undertake gender affirming voice training. This research paper aimed to explore these relationships and address these research gaps.

METHODS

A group of 34 trans participants were asked to rate their voices before and after participating in gender affirming voice training. Trans participant voice samples from before and after training were also presented to a group of 25 listeners for rating. Perceptual ratings were made on two Visual Analogue Scales (VAS) with anchors 'very feminine/very masculine' and 'very female/very male'. Trans participants also rated their satisfaction with their current voice on a VAS with anchors 'very satisfied/very unsatisfied'. Correlation coefficients were calculated to investigate the relationship between collected ratings.

RESULTS

Differences in scale labels were found to have minimal impact on ratings made by both trans participants and listeners. Trans participant self-ratings were found to correlate with listener ratings, but this correlation was not strong Trans participant self-ratings had a consistently stronger relationship with their self-rated vocal satisfaction. The study contributed new findings that these differences may be more pronounced after trans participants have completed voice training.

DISCUSSION/CONCLUSION

This study suggests that results from past studies that have used differently labelled scales to collect ratings related to gender perception based on voice are suitable to compare. This study also discusses the implications reported differences between trans participant self-ratings and listener ratings may have for research and clinical practice.

Effects of speech therapy for transgender women: A systematic review

Background: For transgender women, communication and speech characteristics might not be congruent with their gender expressions. This can have a major influence on their psychosocial functioning. Higher quality of life scores were observed the more their voice was perceived as feminine. Speech language pathologists may play an important role in this, as the gender affirming hormone treatment for transgender women does not affect the voice. Aim: This systematic review aimed to provide speech and language pathologists with the current literature concerning the effects of speech therapy in transgender women in terms of acoustic and perceptual outcomes. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used for reporting this systematic review. The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (using the PubMed interface) and Embase (using the embase.com interface) were used as electronic databases. All individual studies which measured the effects of speech therapy in transgender women were evaluated with a risk of bias assessment tool and levels of evidence. Relevant data were extracted from these studies and a narrative synthesis was performed. Results: 14 studies were identified through the databases and other sources. These studies show positive outcome results concerning pitch elevation, oral resonance, self-perception and listener perception. However, methodological issues contribute to problems with generalization and reproducibility of the studies. Conclusion: There is an urgent need for effectiveness studies using RCT designs, larger sample sizes, multidimensional voice assessments, well-described therapy programs, investigators blinded to study process, and longer-term follow-up data. Speech and language pathologists who work with transgender women may find these results essential for defining therapy goals.

Speech and language therapy for adolescents in youth justice: A series of empirical single-case studies

BACKGROUND

Adolescents in contact with youth justice are a vulnerable and marginalized group at high risk of developmental language disorder (DLD) and other communication difficulties. Though preliminary studies have demonstrated the benefits of speech and language therapy (SLT) services in youth justice, limited research has empirically tested the efficacy of intervention in these settings.

AIMS

To evaluate the extent to which intensive, one-to-one language intervention improved the communication skills of incarcerated adolescents with below-average (> 1 SD below the mean) language and/or literacy skills.

METHODS & PROCEDURES

A series of four empirical single case studies was conducted, using multiple baseline intervention design. Individualized intervention programmes were administered, and progress on outcome measures (probes) was evaluated throughout the baseline, intervention and maintenance phases using Tau-U, a non-parametric distribution-free statistic. Additional measures were used as secondary outcomes of the intervention, including standardized language subtests, subjective rating tools by participants and their teachers collected pre- and post-intervention, and a brief structured participant interview, independently administered by youth justice staff.

OUTCOMES & RESULTS

Medium-to-large effect sizes, the majority of which were statistically significant, were detected on the primary outcome measure across the four cases, indicating improvements in the targeted communication skills. Positive results were also evident in comparisons of pre- and post-measures on standardized language subtests, subjective self- and teacher ratings of communication, and the participants' impressions of the interventions. For those participants who could be followed up, gains in language skills were generally maintained at 1 month post-intervention.

CONCLUSIONS & IMPLICATIONS

This study provides further evidence of the efficacy of one-to-one SLT intervention for adolescents in youth justice in order to address language and literacy difficulties. These findings inform future SLT service provision for adolescents in these settings, with clear policy and practice implications. Future research should investigate the wider benefits to individuals' engagement in youth justice intervention and recidivism, as well as assessing maintenance of gains over a longer period. What this paper adds What is already known on this subject The high rates of DLD in youth justice is well known, with difficulties spanning multiple areas of language and literacy. SLTs are increasingly working in community and custodial youth justice settings, and a few preliminary studies have demonstrated the effectiveness of such work. What this paper adds to existing knowledge This study extends the evidence base of the efficacy of SLT for language and literacy difficulties in youth justice, using a series of four empirical single case studies. It is also argued that SLT should be more actively considered in planning multidisciplinary interventions for young people in custody. What are the potential or actual clinical implications of this work? The results of this research support current moves to include SLT services in youth justice systems, and illustrate for clinicians currently working in this sector a way of structuring and measuring the impact of intervention services.