Transmasculine people's vocal situations: a critical review of gender-related discourses and empirical data

Clinical Focus: The Development and Description of a Palette of Transmasculine Voices

PURPOSE

The study of gender and speech has historically excluded studies of transmasculine individuals. Consequently, generalizations about speech and gender are based on cisgender individuals. This lack of representation hinders clinical training and clinical service delivery, particularly by speech-language pathologists providing gender-affirming communication services. This letter describes a new corpus of the speech of American English-speaking transmasculine men, transmasculine nonbinary people, and cisgender men that is open and available to clinicians and researchers.

METHOD

Twenty masculine-presenting native English speakers from the Upper Midwestern United States (including cisgender men, transmasculine men, and transmasculine nonbinary people) were recorded, producing three sets of speech materials: Consensus Auditory-Perceptual Evaluation of Voice sentences, the Rainbow Passage, and a novel set of sentences developed for this project. Acoustic measures vowels (overall formant frequency scaling, vowel-space dispersion, fundamental frequency, breathiness), consonants (voice onset time of word-initial voiceless stops, spectral moments of word-initial /s/), and the entire sentence (rate of speech) that were made.

RESULTS

The acoustic measures reveal a wide range for all dependent measures and low correlations among the measures. Results show that many of the voices depart considerably from the norms for men's speech in published studies.

CONCLUSION

This new corpus can be used to illustrate different ways of sounding masculine by speech-language pathologists performing gender-affirming communication services and by higher education teachers as examples of diverse ways of sounding masculine.

Gender-Diverse Patients' Awareness and Utilization of Gender-Affirming Laryngological Services

OBJECTIVE

Despite gender-affirming laryngological services (GALS; eg, voice therapy or surgery) being available nationwide, there is a discrepancy between the number of transgender and gender diverse (TGD) people with vocal incongruence and those who pursue services. Primary care is an important setting for accessing gender-affirming care, including learning about GALS. The purpose of this study was to understand the relationship between access to primary care and utilization of GALS.

METHODS

An anonymous cross-sectional online survey was developed in REDCap. Between June-November 2022, 187 TGD respondents answered all questions related to this analysis. We assessed the relationship between having a primary care provider (PCP) and use of GALS via logistic regression.

RESULTS

Of the 167 individuals who reported having a PCP, 54% reported familiarity with GALS, compared to 45% of individuals without a PCP. Compared to the group without a PCP, a greater proportion of individuals with a PCP had received professional voice therapy (21% vs 5%) and voice surgery (3% vs 0%). Logistic regression models did not demonstrate a significant effect of primary care access on either familiarity with, or use of, GALS.

CONCLUSION

Most respondents (89%) were linked to the medical community through a PCP. A greater proportion of respondents with a PCP had accessed professional voice therapy and voice surgery compared with respondents without a PCP, though this difference was not statistically significant. Increased communication between GALS providers and PCPs would raise awareness of available services and may strengthen the referral pipeline to increase access to vocal care.

LEVEL OF EVIDENCE

Level III.

First-Person Perspectives of Gender-Affirming Voice Feminization Training: A Mixed Methods Approach

OBJECTIVES

Despite evidence for the validity of using client-led outcome measures in gender-affirming voice training (GAVT), the existing body of research on voice feminization relies heavily on acoustic-perceptual measures without additional qualitative exploration of client experience. Additionally, the authors are not aware of any existing studies prompting client input on the voice feminization methods they find most helpful in achieving their voice goals. The current study focuses on crucial client perceptions of GAVT for voice feminization and identifies the methods clients find most helpful.

METHODS

Using a mixed-methods approach, we gathered numeric and qualitative survey data from 21 individuals who engaged in GAVT supporting voice feminization. We conducted follow-up interviews with five survey participants to gather additional qualitative data on client experiences and perceptions of GAVT.

RESULTS

Quantitative and qualitative data reveal that clients are satisfied with GAVT supporting voice feminization, perceive their clinicians as being culturally inclusive, and identify oral/forward resonance work as one of the most helpful voice training methods. Interestingly, however, frequency of work on oral/forward resonance during training did not predict voice satisfaction post-training.

CONCLUSIONS

Clients identified oral/forward resonance as one of the most helpful methods of voice feminization and found their GAVT experiences to be supportive of their voice goals. These findings emphasize the importance and value of client-led outcome measures when investigating effective approaches to GAVT.

Voice and Communication in Transmasculine Individuals One Year Under Testosterone Therapy: A Qualitative Study

OBJECTIVES/HYPOTHESES

The purpose of this study was to investigate voice and communication difficulties in transmasculine individuals to develop evidence-based voice and communication training programs.

STUDY DESIGN

Qualitative study.

METHODS

Eight transmasculine individuals, who had received testosterone therapy (TT) for at least 1year, were included in this study. Semistructured interviews were conducted by two experienced voice clinicians. The software program NVivo was used for transcribing and coding the interviews. Data were processed using a thematic analysis.

RESULTS

The thematic analysis resulted in the identification of five major themes. Most transmasculine individuals experienced a pitch decrease during the first year of TT and encountered voice-related problems, with a higher incidence during the initial period. Additionally, some participants experienced increased satisfaction with how others attributed their gender after 1year of TT. However, others still experienced a discrepancy between external gender attribution, self-attribution, and their desired attribution by others. Many participants did not receive voice and communication training. In many cases, voice had a significant impact on their well-being and daily life.

CONCLUSIONS

It's difficult to generalize the results of the current study, since the population of transmasculine individuals is heterogeneous in terms of their subjective gender positioning, desired gender attribution, gender attribution received from others, and gender-related aspects of their vocal situation. Some clients may express dissatisfaction with specific aspects of their voice and communication and may require professional support. Therefore, clinical practice for transmasculine individuals should adopt an individualized approach based on a comprehensive examination of the client's perspective.

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.

The Communicative Participation Item Bank-Gender-Diverse Version: Item Bank Calibration and Short Form

PURPOSE

The purpose of this study was to calibrate an item set for a new version of the Communicative Participation Item Bank (CPIB) specifically for use with gender-diverse clients. This new version contains a new item stem as well as other minor wording changes from the original CPIB in order to be acceptable to gender-diverse respondents.

METHOD

Survey data on 47 candidate items were collected from 434 transgender individuals: 219 assigned female at birth (AFAB) and 215 assigned male at birth (AMAB). Item response theory analyses included evaluation of unidimensionality, local dependence, fit to a graded response model, and differential item functioning (DIF) between AFAB and AMAB respondents.

RESULTS

The original set of 47 items was unidimensional, but 16 items were removed due to local dependence, resulting in a final item bank of 31 items. There was no evidence of DIF between AFAB and AMAB participants. Reliability of the full item bank is good (i.e., > 0.8) between T scores of 20 and 76 and high (i.e., > 0.9) between T scores of 20 and 68. The short form had good reliability (i.e., > 0.8) between T scores of 24 and 64.

CONCLUSIONS

The Communicative Participation Item Bank-Gender-Diverse (CPIB-GD) version provides a new option for person-reported outcome measurement with gender-diverse clients. Clinicians are cautioned to use only the new CPIB-GD with gender-diverse clients, and not the original CPIB due to unacceptable wording in the original version for this population. The original CPIB remains valid and appropriate for the populations for which it was developed.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24993309.

Polycystic Ovary Syndrome and Alteration of Vocal Function: A Systematic Review and Meta-Analysis

INTRODUCTION

Polycystic ovary syndrome (PCOS) is a common hormonal disorder among young women, correlated with hyperandrogenism. Among the symptoms of PCOS, vocal alterations are quite unknown. Dysphonia may be related to hyperandrogenism, and there is no consensus about its prevalence and the severity of vocal disorders, which can cause noticeable discomfort.

METHODS

A systematic review of the literature was conducted. Four studies on PCOS that evaluated the phonatory system were included for a total of 174 patients (96 PCOS, 78 controls), and a meta-analysis on comparable data was performed.

RESULTS

Four studies evaluated parameters related to vocal symptomatology, altered audiometric examination, and findings at the laryngoscopy in patients affected by PCOS versus controls. Although the individual studies showed increased incidence of alterations and a tendency to develop speech fatigue in women with PCOS, when the results of studies were pulled in meta-analysis, the overall difference was not statistically significant. The studies themselves were very different from each other; therefore, it is hard to draw any firm conclusions.

DISCUSSION

The aim of this study was to assess the prevalence of vocal alterations, the correlation with hyperandrogenism, the quality of life, and the voice changes after starting a therapy for PCOS. The present meta-analysis failed to find any difference in terms of PCOS and control cohort. However, the lack of high-quality studies makes it difficult to draw firm conclusions. New and larger studies or big population program data are therefore warranted.

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.

Vocal Fold Thinning in Transgender Patients

PURPOSE

Transgender individuals strive to match their voice and gender identity. An increased glottal gap is often noted on stroboscopy without a clear etiology. We hypothesize this gap can be quantified and results from hormone replacement therapy impacting laryngeal tissues.

METHODS

Videostroboscopy exams were retrospectively collected for transgender patients from a tertiary care laryngology practice over two years. Data included hormone duration/type and voice therapy duration. Modal pitch videostroboscopy frame counts determined the open quotient in consecutive vocal fold cycles. Glottal opening was measured using the widest still frame gap during stroboscopy with fully adducted arytenoids.

RESULTS

Sixteen transgender patients, along with male and female controls, were included, with 15 patients on hormone therapy (mean = 18 months). Voice therapy, employed in 9/16 patients, ranged from 0 to 23 months (mean = 10.67). One-way ANOVA testing revealed a difference between the open quotient in transgender individuals, males, and females.Tukey's post hoc test identified transgender patients as different from both male (P <0.001) and female (P = 0.037) controls. Length of hormone therapy did not correlate to glottal area measurement or open quotient. Conversely, voice therapy length correlated to increased glottal area (Kendall's Tau = 0.03). Mean phonation time, VHI-10, and mean pitch did not correlate to measured glottal area on stroboscopy.

CONCLUSIONS

The increased glottal gap noted in many transgender patients, quantified via the open quotient, differs from male and female controls. Results suggest these findings may correlate to duration of voice therapy.

Exploring Motives and Perceived Barriers for Voice Modification: The Views of Transgender and Gender-Diverse Voice Clients

PURPOSE

To date, transgender and gender-diverse voice clients' perceptions and individual goals have been missing in discussions and research on gender-affirming voice therapy. Little is, therefore, known about the client's expectations of therapy outcomes and how these are met by treatments developed from views of vocal gender as perceived by cisgender persons. This study aimed to explore clients' individual motives and perceived barriers to undertaking gender-affirming voice therapy.

METHOD

Individual, semistructured interviews with 15 transgender and gender-diverse voice clients considering voice therapy were conducted and explored using qualitative content analysis.

RESULTS

Three themes were identified during the analysis of the participants' narratives. In the first theme, "the incongruent voice setting the rules," the contribution of the voice on the experienced gender dysphoria is put in focus. The second theme, "to reach a voice of my own choice," centers around anticipated personal gains using a modified voice. The third theme, "a voice out of reach," relates to worries and restricting factors for not being able to reach one's set goals for voice modification.

CONCLUSIONS

The interviews clearly indicate a need for a person-centered voice therapy that starts from the individuals' expressed motives for modifying the voice yet also are affirmative of anticipated difficulties related to voice modification. We recommend that these themes should form the basis of the pretherapy joint discussion between the voice client and the speech-language pathologist to ensure therapy goals that are realistic and relevant to the client.

Gender-Affirming Voice Surgery: Considerations for Surgical Intervention

The purpose of this article is to provide an overview of the current state and available evidence surrounding surgical voice care for the transgender and/or gender expansive population. The term "gender expansive" has been proposed as an inclusive term to classify those who do not identify with traditional gender roles but are otherwise not confined to one gender narrative or experience. We aim to review indications and candidacy for surgery, surgical procedure options for altering vocal pitch, and typical postoperative expectations. The role of voice therapy and considerations for perioperative care will also be discussed.

Modifying the Communicative Participation Item Bank (CPIB) for individuals receiving gender-affirming communication care: Stakeholder feedback from cognitive interviews

INTRODUCTION

The Communicative Participation Item Bank (CPIB) is a person-reported outcome measure designed for adults with communication disorders. The CPIB has not been validated for use with clients seeking gender-affirming communication care. The purpose of this study was to determine modifications needed to the CPIB for it to be appropriate for transgender respondents.

METHODS

Individual qualitative cognitive interviews were conducted with 14 transgender adults (seven assigned male at birth, six assigned female at birth, one intersex / assigned female at birth). As participants completed the CPIB, they were asked to 'think out loud' to share their reactions to the items, reasons for their item responses, and any recommendations for changing the CPIB. Interviews were recorded, transcribed, and analyzed to identify common and salient trends in participants' feedback.

RESULTS

The most salient change participants required was in the CPIB item stem. The original stem ("Does your condition interfere with….") is inappropriate for transgender clients because referring to being transgender as a 'condition' is unacceptable. A new stem ("How difficult is it for you to ….") was acceptable to participants. The original CPIB uses the phrase 'family and friends' to refer to safe and comfortable communication partners. Participants in this study reported that this does not reflect the experiences of many transgender people who are not accepted by their biological families. The recommended alternate wording is "people who know you well." The items reflected situations that were relevant to participants, and wording was acceptable with few exceptions. Participants suggested they would have responded to the CPIB items differently earlier in their transition, with their scores improving over time.

CONCLUSIONS

The original CPIB questionnaire should not be used with transgender clients due to unacceptable wording. The modified items generated from this study require psychometric calibration for a new CPIB version for clients seeking gender-affirming communication care.

Intonation Parameters in Gender Diverse People

OBJECTIVES/HYPOTHESIS

Although intonation is often addressed in speech training for gender diverse individuals, the relationship between intonation and femininity/masculinity ratings remains unclear. The aim of this study was to examine differences in intonation parameters in gender diverse individuals. Moreover, the relationship between acoustic intonation parameters and femininity/masculinity ratings was investigated.

METHODS

Speech samples of semistructured speech were elicited from cisgender (cis) (107 ciswomen, 104 cis men), transgender (trans) (19 trans women, 10 trans men), and non-binary (n = 11) individuals using a prosody protocol. An objective acoustic analysis was performed to compare intonation parameters (upward/downward/flat intonation shift, general and final intonation shift, general fundamental frequency range, fundamental frequency variation index) between groups. In addition, a listening experiment was conducted, consisting of a cis and gender diverse listening panel (n = 41). The listeners were asked to rate the femininity/masculinity of speech samples (n = 57) using a visual analogue scale. Correlational analyses were used to examine the relationship between intonation parameters and femininity/masculinity ratings.

RESULTS

Similarity was found in the intonation parameters of participants with a similar gender identity. In non-binary speakers, no significant differences in acoustic intonation parameters were found between these speakers and the cisgender speakers. In addition, no significant correlations were found between the acoustic intonation parameters and the femininity/masculinity ratings in the groups with cis men, cis women, and non-binary participants. However, moderate to strong significant correlations were found between acoustic intonation parameters and femininity/masculinity ratings in the trans participants.

CONCLUSIONS

Intonation is a "speech marker" that distinguishes between groups with a different gender identity. No relationship was observed between intonation and femininity/masculinity ratings for cisgender and non-binary speakers. However, the significant relationship between these parameters for transgender participants (trans men and trans women) provides evidence for intonation exercises in gender affirming voice, speech, and communication training, and therefore contribute to evidence-based intonation training in transgender persons.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Resynthesis of Transmasculine Voices to Assess Gender Perception as a Function of Testosterone Therapy

PURPOSE

The goal of this study was to use speech resynthesis to investigate the effects of changes to individual acoustic features on speech-based gender perception of transmasculine voice samples following the onset of hormone replacement therapy (HRT) with exogenous testosterone. We hypothesized that mean fundamental frequency (f o) would have the largest effect on gender perception of any single acoustic feature.

METHOD

Mean f o, f o contour, and formant frequencies were calculated for three pairs of transmasculine speech samples before and after HRT onset. Sixteen speech samples with unique combinations of these acoustic features from each pair of speech samples were resynthesized. Twenty young adult listeners evaluated each synthesized speech sample for gender perception and synthetic quality. Two analyses of variance were used to investigate the effects of acoustic features on gender perception and synthetic quality.

RESULTS

Of the three acoustic features, mean f o was the only single feature that had a statistically significant effect on gender perception. Differences between the speech samples before and after HRT onset that were not captured by changes in f o and formant frequencies also had a statistically significant effect on gender perception.

CONCLUSION

In these transmasculine voice samples, mean f o was the most important acoustic feature for voice masculinization as a result of HRT; future investigations in a larger number of transmasculine speakers and on the effects of behavioral therapy-based changes in concert with HRT is warranted.

Supporting Well-Being in Gender-Diverse People: A Tutorial for Implementing Conceptual and Practical Shifts Toward Culturally Responsive, Person-Centered Care in Speech-Language Pathology

PURPOSE

Gender dysphoria is commonly conceptualized as a mental disorder in gender-diverse people who do not identify with the gender assigned to them at birth. Direct support for well-being tends to be delegated to the field of mental health (MH), whereas speech-language pathology (SLP) practice is charged with modifying gender-diverse people's voice and communication in the belief that well-being will improve as a byproduct. However, with the introduction of the minority stress model, gender dysphoria is now understood as the result of sociocultural processes of stigmatization, pathologization, coping, and resilience, and it is to be addressed by all professions providing transgender health services. The purposes of this tutorial are to examine practices in SLP in light of the current conceptualization of gender dysphoria and guide speech-language pathologists in their role in supporting the well-being of gender-diverse people.

METHOD

We reviewed the SLP and MH literature in the topic area to compare the two disciplines' conceptualizations and approaches to professional support for gender-diverse people.

RESULTS

We propose a transdisciplinary, person-centered, and culturally responsive approach to SLP practice that directly attends to minority stress, microaggressions, coping skills, and resilience factors.

CONCLUSIONS

It is not sufficient for speech-language pathologists to delegate support for well-being in gender-diverse people to MH practitioners. Rather, speech-language pathologists need to be proactive in taking responsibility for supporting their clients' well-being based on each individual clinician's knowledge, skills, and capacity to do so. We recommend addressing barriers and facilitators of gender-diverse people's well-being both within SLP as a professional culture and by adapting the clinician's own professional practice.

Masculinization Laryngoplasty

A description of pitch reduction thyroplasty has been around for decades, primarily used for high-pitched voice disorders in cisgendered men. Currently, the application of an Isshiki type III thyroplasty and its modifications is mainly used in transgendered men who fail to achieve sufficient pitch reduction from speech therapy and masculinizing gender-affirming hormone therapy. The current state of the procedure with a description of commonly used modifications is reviewed.

Voice-Gender Incongruence and Voice Health Information-Seeking Behaviors in the Transgender Community

Purpose Voice-gender incongruence has predominantly been investigated in the past through the perspective of feminine-identifying individuals seeking feminine-sounding voices. The purpose of this study was to determine the prevalence of self-reported voice-gender incongruence in the transgender, nonbinary, and gender-nonconforming (TNG) community and to describe health information-seeking behaviors exhibited when individuals attempt to address their voice and communication challenges. Method An online survey was designed with questions targeting the self-reported prevalence of voice-gender incongruence, characteristics of this complaint, and health information-seeking behaviors. Valid standardized measures, including the Voice Handicap Index and the Barriers to Help-Seeking Scale, were also included. Results Four hundred five participants were sorted into three groups based on gender identity (feminine, masculine, gender-neutral) to facilitate comparative analysis. Ninety-six percent of participants reported the experience of voice-gender incongruence in the past, and 88% reported that they currently experience voice-gender incongruence. There were no significant differences in reported voice-gender incongruence between groups. Voice Handicap Index scores were significantly higher for those who currently experience voice-gender incongruence (p < .0001) and reflected differences in how much this concern bothers participants, as rated on a Likert scale, ranging from no problem to a very big problem (p < .0001). Barriers to Help-Seeking Scale scores indicated that the masculine group perceived greater barriers to seeking help as compared to the feminine group. Discussion We present foundational evidence for the prevalence of voice-gender incongruence within the TNG community and barriers encountered when individuals attempt to access care. Future work should investigate the specific needs of subgroups within the TNG community and whether those who desire feminine-, masculine-, and/or androgynous-sounding voices experience voice-gender incongruence and access to services differently. Supplemental Material https://doi.org/10.23641/asha.12462422.

Culturally Competent Care for Transgender Voice and Communication Intervention

Purpose

Despite constituting 4.5% of the population, the lesbian, gay, bisexual, transgender, queer+ community is poorly understood by the health care community. Seventy percent of transgender individuals report discrimination in health care, and 51% of speech-language pathologists do not know clinical techniques for transgender clients. This community is particularly obscured by its high degree of diversity, which can be confusing for clinicians who are unfamiliar with the nuances of the culture or unprepared to adapt to a gender-affirming therapy model.

Method

Methods focus on gender affirmation and community trust building. Specific targets included exploring self-expression through reflection, metatherapy, and observation of self and others in regard to various communication strategies. Clients were provided opportunities to practice and experience a gradient of degrees of gendered communication to make the experience affirming to their gender identity.

Results

Results were reflected in two case studies, Kasi, a transfeminine client, and RJ, a transmasculine client. Kasi began therapy as directionless, abrasive, and conflicted about their voice and transition goals. They concluded therapy focused, motivated to communicate more clearly, and achieving technical targets that were unexpected given starting points. Kasi made this progress in collaboration with the resilient focus of the clinical team on their validity and affirmation. RJ began therapy highly distrustful of therapy but unable to pursue hormone replacement therapy for pitch lowering. Their goal was to achieve voice modification through therapy. RJ finished their treatment consistently gendered as male on the phone and in public, with 130 Hz without testosterone.

Conclusions

Voice therapy is a vital health safety service for transgender clients, and increasing access to culturally competent care should be a concern for all speech pathologists. Building trust and empathy with this community will be a significant step in breaking down gatekeeping practices in the field and in the larger medical practice.

Forces Affecting Voice Function in Gender Diverse People Assigned Female at Birth

OBJECTIVES

The purpose of this study was to explore the factors and practices that have acted as facilitators or barriers to voice function in gender diverse people assigned female at birth (GD people^AFAB) from a participant-centered perspective and to inform the role of speech-language pathologists in supporting GD people^AFAB with developing and maintaining functional voice production.

METHODS

Transcripts of semistructured interviews with 14 German-speaking GD people^AFAB were analyzed for the study objectives using a consensual approach to qualitative content analysis. The interviews and their interpretation were conceptualized as co-constructions of participants and researchers who were regarded as experts in their own right.

RESULTS

Professional practices (testosterone treatment, professional voice support), speaker practices (self-care and voice use practices, self-evaluation of voice function), conversation partner practices, and supraindividual biocultural forces (vocal demands, normative practices, other biocultural forces) were identified as having influenced the participants' voice function. Professional voice support, a range of phonation practices, and general self- and voice care practices were frequently cited facilitators of functional voice production. The most frequent barriers to voice function included testosterone treatment, slouched posture, excess muscle tension, forceful voice use, and avoidance practices.

CONCLUSIONS

Voice function in GD people^AFAB is influenced by interactions of several forces, most of which may be shared by voice users of all genders. Professional practices should follow a person-centered approach to care in which all parties are well informed of the limitations and possibilities for any intervention, including the often-unquestioned contribution of testosterone treatment.

Voice Function in Gender-Diverse People Assigned Female at Birth: Results From a Participant-Centered Mixed-Methods Study and Implications for Clinical Practice

Purpose The purpose of this study was to investigate whether there were indications of restrictions to voice function in our group of gender-diverse people assigned female at birth (GD people^AFAB) and whether the participants would benefit from professional voice support. Method We conducted a descriptive, cross-sectional, mixed-methods study combining qualitative content analyses of semistructured interviews, phoniatric examinations, and acoustical voice analyses. Fourteen German-speaking GD people^AFAB participated. The data were examined for indications of restrictions to voice function according to the results of participant self-evaluation, auditory-perceptual analyses, laryngostroboscopic examinations, and acoustical measurements. Results All participants presented with indications of restrictions to voice function, with vocal power, voice quality, singing voice, laryngeal function, pitch range/variability, and vocal control having found to be most frequently affected (in over 60% of participants). Sixty-four percent of participants expressed an interest in professional voice support, with clinicians and researchers recommending professional voice support for 67% and 71%, respectively. Conclusions GD people^AFAB may experience restrictions to a range of domains of voice function and request or be recommended to participate in professional voice support. Research into this area needs to be intensified so that a more in-depth understanding of the potential voice problems GD people^AFAB might experience can be produced and members of this group can be provided with more comprehensive, evidence-based, and high-quality professional support if and when they need it.

Toward a Protocol for Transmasculine Voice: A Service Evaluation of the Voice and Communication Therapy Group Program, Including Long-Term Follow-Up for Trans Men at the London Gender Identity Clinic

Purpose: A service evaluation was undertaken with 10 participants identifying as trans men who received voice and communication group therapy and 12-month follow-up at the London Gender Identity Clinic between February 2017 and March 2018, to investigate levels of satisfaction, how helpful they found the program in facilitating vocal change and skill development, and whether they would recommend it to others. Methods: Participant evaluations of overall and ideal rating of masculinity of voice, and level of feeling comfortable with voice, evaluations of voice skills and changes in speaking and reading fundamental frequency were retrospectively reviewed and analyzed. Results: Six participants reported being very satisfied with the service; four were satisfied. Eight participants found the program very helpful in achieving voice and communication change; two found it helpful. Eight strongly agreed and two agreed with recommending the service. Participants' overall and comfort ratings of voice significantly increased (p<0.01), while there was no significant change in ideal ratings (p=0.063), and a significant decrease in the difference between overall and ideal ratings (p<0.01). Participants achieved a significant decrease in fundamental frequency for reading and speaking (p<0.01), a significant decrease in voice fatigue (p=0.039) and restriction in voice adaptability (p<0.01), a significant increase in confidence in public speaking (p<0.01), but no significant change in vocal projection (p=0.07). Conclusion: Ten trans men reported high levels of satisfaction with the voice group program and long-term follow-up, making significant positive shifts in voice skills and vocal self-perception. These findings apply locally but suggest appropriate interventions toward a transmasculine voice modification protocol.

Organizing the voice questionnaire for transgender persons

Background: The validated Transsexual Voice Questionnaire Male to Female (TVQ^MtF) and the adapted TVQ Female to Male (FtM) (TVQ^FtM) are both 30-item-long questionnaires used to evaluate self-perception of voice in transgender persons. They are part of a series of questionnaires completed by transgender persons during follow-up of cross-sex hormone therapy (CSHT). Aim: The aim of this study was to examine if these questionnaires can be organized. Methods: The TVQ^MtF or the TVQ^FtM was filled out at the start of CSHT, by 145 trans women and 83 trans men. Data were analyzed by factor analyses on both the questionnaires. Results: The factor analyses resulted in a three-factor solution for both the TVQ^MtF and the TVQ^FtM. The three factors were labeled as anxiety and avoidance, vocal identity, and vocal function. Conclusion: Both the questionnaires can be organized into three factors. This could contribute to making shorter versions of the questionnaires. Shorter versions would be useful to hormone prescribing physicians to track down more quickly voice problems in trans people undergoing virilizing or feminizing hormone treatment.

Longitudinal Case Study of Transgender Voice Changes Under Testosterone Hormone Therapy

The purpose of this study was to comprehensively evaluate voice and speech changes in one healthy 30-year-old transgender male undergoing testosterone therapy for transition. Testing occurred at three timepoints before cross-sex hormone therapy and every 2 weeks thereafter for 1 year. Data collected included measures of acoustics, aerodynamics, and laryngeal structure and function via flexible laryngoscopy. Analysis included acoustic correlates of pitch, loudness, voice quality, and vocal tract length, as well as perceptual measures of voice quality and gender. Speaking fundamental frequency (f_o) lowered from 183 Hz to 134 Hz. Phonatory frequency range (ie, minimum and maximum singing range) shifted from a range of D#3-E6 to a range of A2-A5. Perceptual measures of voice quality indicated no negative changes. Naïve listeners reliably rated the participant's speech samples as male after 37 weeks on testosterone. Few studies document in detail the variety of voice changes that occur during cross-sex hormone therapy, focusing instead on f_o alone. This study adds to the literature a comprehensive case study of speech and voice changes experienced by one transmasculine participant undergoing testosterone therapy.

Intervención logopédica en la feminización de la voz en transexuales: revisión bibliográfica

La transexualidad es un trastorno en el cual entran en conflicto el sexo fisiológico y el género de una persona. Las personas transexuales sienten el deseo de pertenecer al sexo con el que realmente se identifican y esto les lleva a realizar ciertas acciones para cambiar su apariencia. La mujer transexual no alcanzará la feminización de su voz mediante el tratamiento hormonal, siendo sus opciones: la cirugía de las cuerdas vocales y/o la intervención logopédica.La presente revisión bibliográfica tiene como objetivo exponer aspectos relevantes y proporcionar información amplia sobre el trabajo logopédico en el tratamiento de la feminización de la voz, en transexuales de hombre a mujer, como intervención única, no complementaria a la intervención quirúrgica. Para llevar a cabo una revisión bibliográfica descriptiva se realiza la búsqueda de artículos científicos en las fuentes secundarias PubMed y Scopus. Utilizando una metodología cualitativa, se obtiene un listado de 25 artículos, en cada una, que se acota con filtros y criterios de inclusión y exclusión, dando como resultado una lista de 7 artículos finales. En cuanto a los resultados, todos los artículos concluyen con resultados positivos de la terapia vocal en mujeres transexuales, destacando especialmente los objetivos relativos al aumento de la frecuencia fundamental y al aumento de las frecuencias formantes.En conclusión, se halla información que demuestra que la terapia logopédica puede ser eficaz en la feminización de la voz en la población transexual. Sin embargo, el escaso número de artículos impide hacer generalizaciones universales.

Do Transmasculine Speakers Present With Gender-Related Voice Problems? Insights From a Participant-Centered Mixed-Methods Study

PURPOSE

The purpose of this study was to investigate whether there are indications of gender-related voice problems in our transmasculine participants and to analyze how discrepancies between participant self-evaluations and researcher-led examinations can be best negotiated to ensure a participant-centered interpretation.

METHOD

We conducted a participant-centered mixed-methods study combining qualitative content analyses of semistructured interviews, acoustical voice analyses, and an examination of gender attributions to voice. Fourteen German-speaking transmasculine people, 14 cisfemale control persons, and 7 cismale control persons participated. The data were examined for indications of gender-related voice problems pertaining to vocal gender presentation and gender attribution to voice received from others.

RESULTS

Eleven participants (79%) presented with indications of gender-related voice problems. Problems included dissatisfaction with gender-related voice features, difficulties with control of vocal gender presentation, and mismatch between desired gender attribution and gender attributions received from others. Discrepancies between participant self-evaluations and researcher-led examinations were observed in a number of cases.

CONCLUSION

Transmasculine speakers may experience a range of gender-related voice problems. Research and clinical practice with transmasculine people need to be adapted to better match the diversity of the population and the complexity of the processes that shape the production of speaker vocal gender in interaction.

Trans Male Voice in the First Year of Testosterone Therapy: Make No Assumptions

PURPOSE

The purpose of this study was to prospectively examine changes in gender-related voice domain of pitch measured by fundamental frequency, function-related domains of vocal quality, range, and habitual pitch level and the self-perceptions of transmasculine people during their first year of testosterone treatment.

METHOD

Seven trans men received 2 voice assessments at baseline and 1 assessment at 3, 6, 9, and 12 months after starting treatment.

RESULTS

Vocal quality measures varied between and within participants but were generally within normal limits throughout the year. Mean fundamental frequency (MF0) during reading decreased, although to variable extents and rates. Phonation frequency range shifted down the scale, although it increased in some participants and decreased in others. Considering MF0 and phonation frequency range together in a measure of habitual pitch level revealed that the majority of participants spoke using an MF0 that was low within their range compared with cisgender norms. Although the trans men generally self-reported voice masculinization, it was not correlated with MF0, frequency range, or habitual pitch level at any time point or with MF0 note change from baseline to 1 year of testosterone treatment, but correlations should be interpreted with caution due to the heterogeneous responses of the 7 participants.

CONCLUSION

In trans men, consideration of voice deepening in the context of objective and subjective measures of voice can reveal unique profiles and inform patient care.

Gender-related aspects of transmasculine people's vocal situations: insights from a qualitative content analysis of interview transcripts

BACKGROUND

Transmasculine people assigned female gender at birth but who do not identify with this classification have traditionally received little consideration in the voice literature. Existing analyses tend to be focused on evaluating speaker voice characteristics, whereas other factors that contribute to the production of vocal gender have remained underexplored. Most studies rely on researcher-centred perspectives, whereas very little is known about how transmasculine people themselves experience and make sense of their vocal situations.

AIMS

To explore how participants described their subjective gender positionings; which gender attributions they wished to receive from others; which gender they self-attributed to their voices; which gender attributions they had received from others; and how far participants were satisfied with the gender-related aspects of their vocal situations.

METHODS & PROCEDURES

Transcripts of semi-structured interviews with 14 German-speaking transmasculine people served as the original data corpus. Sections in which participants described the gender-related aspects of their vocal situations and that were relevant to the current research objectives were selected and explored using qualitative content analysis.

OUTCOMES & RESULTS

The analysis revealed diverse accounts pertaining to the factors that contribute to the production of vocal gender for individual participants and variable levels of satisfaction with vocal gender presentation and attribution.

CONCLUSIONS & IMPLICATIONS

Transmasculine people need to be regarded as a heterogeneous population and clinical practice needs to follow a client-centred, individualized approach.

Voice and endocrinology

Voice is one of the advanced features of natural evolution that differentiates human beings from other primates. The human voice is capable of conveying the thoughts into spoken words along with a subtle emotion to the tone. This extraordinary character of the voice in expressing multiple emotions is the gift of God to the human beings and helps in effective interpersonal communication. Voice generation involves close interaction between cerebral signals and the peripheral apparatus consisting of the larynx, vocal cords, and trachea. The human voice is susceptible to the hormonal changes throughout life right from the puberty until senescence. Thyroid, gonadal and growth hormones have tremendous impact on the structure and function of the vocal apparatus. The alteration of voice is observed even in physiological states such as puberty and menstruation. Astute clinical observers make out the changes in the voice and refer the patients for endocrine evaluation. In this review, we shall discuss the hormonal influence on the voice apparatus in normal and endocrine disorders.

Transmasculine People's Voice Function: A Review of the Currently Available Evidence

OBJECTIVES

This study aims to evaluate the currently available discursive and empirical data relating to those aspects of transmasculine people's vocal situations that are not primarily gender-related, to identify restrictions to voice function that have been observed in this population, and to make suggestions for future voice research and clinical practice.

METHODS

We conducted a comprehensive review of the voice literature. Publications were identified by searching six electronic databases and bibliographies of relevant articles. Twenty-two publications met inclusion criteria. Discourses and empirical data were analyzed for factors and practices that impact on voice function and for indications of voice function-related problems in transmasculine people. The quality of the evidence was appraised.

RESULTS

The extent and quality of studies investigating transmasculine people's voice function was found to be limited. There was mixed evidence to suggest that transmasculine people might experience restrictions to a range of domains of voice function, including vocal power, vocal control/stability, glottal function, pitch range/variability, vocal endurance, and voice quality.

CONCLUSIONS

More research into the different factors and practices affecting transmasculine people's voice function that takes account of a range of parameters of voice function and considers participants' self-evaluations is needed to establish how functional voice production can be best supported in this population.

On the Varied and Complex Factors Affecting Gender Diverse People's Vocal Situations: Implications for Clinical Practice

Gender diverse people who do not or do not only identify with the gender category assigned to them at birth may experience various difficulties with their vocal communication. In this paper, I will explore the different needs and expectations with regards to professional voice support in this population and outline the implications for clinical practice. In my discussion, I will draw on an understanding of gender diverse people's vocal situations that is informed by constructionist theories of gender and by changes to the conceptualization of gender diversity included in the seventh version of the Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People (Coleman et al., 2012). This theoretical perspective calls attention to a range of factors voice clinicians need to consider when planning and implementing intervention with gender diverse people. The most important of these factors are the client's subjective gender positioning or identity, the client's preferences for and against treatment options, and the extent to which the different treatment options can be regarded as suitable for developing the client's vocal gender presentation and improving the agreement between how the client wishes to be perceived and addressed in terms of gender and the gender attributions the client receives from others.

Transgender Voice and Communication: Research Evidence Underpinning Voice Intervention for Male-to-Female Transsexual Women

Transsexual clients seek speech-language pathology services to achieve voice characteristics congruent with their true gender. Male-to-Female Transsexual Women (MtF women) make up the majority of transsexual clients on clinicians' caseloads. For many MtF women, achieving gender congruent voice is critical to psychosocial and financial wellbeing and quality of life. It is incumbent on clinicians who offer voice services to MtF women to use the best evidence available for effective voice training. There is strong evidence that voice feminization should target increasing fundamental frequency to approximately 180 Hz and increasing formant frequencies close to biological female (cisfemale) levels, as well as some evidence that increasing fundamental frequency variability and minimum and maximum fundamental frequency, decreasing vocal effort and intensity, and increasing breathiness are an important focus of intervention. While further research is required, the evidence base is increasing. It is encouraging that studies indicate that most MtF women achieve vocal improvements and that most are satisfied with voice training. Important next steps are to increase the quality of research designs, increase sample sizes, and measure long-term voice outcomes. Expert clinicians in collaboration with MtF women's self-advocacy groups will then be able to develop clinical guidelines for this expanding area of practice.