Perception of Voice in the Transgender Client

Voice challenge in transgender women: trans women self-perception of voice handicap as compared to gender perception of naïve listeners

ABSTRACT Purpose: to analyze the self-perception of transgender women’s voice handicap in comparison to the voices’ gender perception by naïve listeners. Methods: 31 transgender women, who were first submitted to vocal acoustic assessment and had their voices recorded to measure fundamental frequency and standard deviations, were eligible to the study. Next, they answered to the Voice Handicap Index protocol, from which, at the end of data collection, the most suited questions to the daily demands of this population were selected. Subsequently, 50 naïve blindfolded listeners were exposed to the recordings and had to identify the voices as males, females or undefined. Descriptive statistics were applied to speakers’ characteristics and the Spearman's correlation coefficient was applied to the protocol scores and the speaker's voice identifications. Results: the mean fundamental frequency found was 172.40 Hz (SD=4.8Hz) and one third of the transgender women reported being satisfied with their voices. A moderate positive significant correlation was found in voices considered as males, and strongly significant and negative in voices considered as females. For the voices considered undefined, however, no significant correlation was found. Conclusion: transgender women’s self-perception of voice handicap is directly related to naïve listeners' perception of their voice gender.

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.

Associations between the Transsexual Voice Questionnaire (TVQMtF ) and self-report of voice femininity and acoustic voice measures

BACKGROUND

The Transsexual Voice Questionnaire (TVQ^MtF ) was designed to capture the voice-related perceptions of individuals whose gender identity as female is the opposite of their birth-assigned gender (MtF women). Evaluation of the psychometric properties of the TVQ^MtF is ongoing.

AIMS

To investigate associations between TVQ^MtF scores and (1) self-perceptions of voice femininity and (2) acoustic parameters of voice pitch and voice quality in order to evaluate further the validity of the TVQ^MtF . A strong correlation between TVQ^MtF scores and self-ratings of voice femininity was predicted, but no association between TVQ^MtF scores and acoustic measures of voice pitch and quality was proposed.

METHODS & PROCEDURES

Participants were 148 MtF women (mean age 48.14 years) recruited from the La Trobe Communication Clinic and the clinics of three doctors specializing in transgender health. All participants completed the TVQ^MtF and 34 of these participants also provided a voice sample for acoustic analysis. Pearson product-moment correlation analysis was conducted to examine the associations between TVQ^MtF scores and (1) self-perceptions of voice femininity and (2) acoustic measures of F0, jitter (%), shimmer (dB) and harmonic-to-noise ratio (HNR).

OUTCOMES & RESULTS

Strong negative correlations between the participants' perceptions of their voice femininity and the TVQ^MtF scores demonstrated that for this group of MtF women a low self-rating of voice femininity was associated with more frequent negative voice-related experiences. This association was strongest with the vocal-functioning component of the TVQ^MtF . These strong correlations and high levels of shared variance between the TVQ^MtF and a measure of a related construct provides evidence for the convergent validity of the TVQ^MtF . The absence of significant correlations between the TVQ^MtF and the acoustic data is consistent with the equivocal findings of earlier research. This finding indicates that these two measures assess different aspects of the voice-related experience.

CONCLUSIONS & IMPLICATIONS

Evidence supporting the validity of the TVQ^MtF is strong and indicates that it is a sound measure for capturing the MtF woman's self-perceptions of her vocal functioning and how her voice impacts on her everyday life.

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.

The Evidence Behind the Practice: A Review of WPATH Suggested Guidelines in Transgender Voice and Communication

Voice and communication change for gender-divergent people is a rapidly growing specialty within the practice of speech-language pathology. In 2015, the World Professional Association for Transgender Health (WPATH) published an article to support clinicians, researchers and educators in this emerging field. This “Companion Document” expands on WPATH's Standards of Care in Transgender Voice and Communication. What follows here is a brief summary of the document's content.

Pretreatment Acoustic Predictors of Gender, Femininity, and Naturalness Ratings in Individuals With Male-to-Female Gender Identity

PURPOSE

The purpose of this study was to describe the pretreatment acoustic characteristics of individuals with male-to-female gender identity (IMtFGI) and investigate the ability of the acoustic measures to predict ratings of gender, femininity, and vocal naturalness.

METHOD

This retrospective descriptive study included 2 groups of participants. Speakers were IMtFGI who had not previously received communication feminization treatment (N = 25). Listeners were members of the lay community (N = 30). Acoustic data were retrospectively obtained from pretreatment recordings, and pretreatment recordings also served as stimuli for 3 perceptual rating tasks (completed by listeners).

RESULTS

Acoustic data generally were within normal limits for male speakers. All but 2 speakers were perceived to be male, limiting information about the relationship between acoustic measures and gender perception. Fundamental frequency (reading) significantly predicted femininity ratings (p = .000). A total of 3 stepwise regression models indicated that minimum frequency (range task), second vowel formant (sustained vowel), and shimmer percentage (sustained vowel) together significantly predicted naturalness ratings (p = .005, p = .003, and p = .002, respectively).

CONCLUSIONS

Study aims were achieved with the exception of acoustic predictors of gender perception, which could be described for only 2 speakers. Future research should investigate measures of prosody, voice quality, and other aspects of communication as predictors of gender, femininity, and naturalness.

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.

The Role of Cultural Competence in Serving Transgender Populations

Recent research indicates that our professions could improve in Lesbian, Gay, Bisexual, and Transgender (LGBT) cultural competency. As indicated by Turner, Wilson, and Shirah's (2006) model of cultural competency, one can begin by increasing knowledge of transgender (TG) culture and improving sensitivity and attitudes foundational to serving these populations appropriately. This article sheds light on the factors influencing quality of life for many TG people, including voice. Readers are encouraged to include appropriate measures of voice-related quality of life in treatment outcomes and are provided with suggestions for developing LGBT cultural competency.

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

BACKGROUND

Transmasculine people assigned female sex at birth but who do not identify with this classification have traditionally received little consideration in the voice literature. Some voice researchers and clinicians suggest that transmasculine people do not need attention because testosterone treatment leads to a satisfactory masculinization of their voice organs and voices. Others, however, argue that transmasculine people are a heterogeneous group whose members might not share the same body type, gender identity or desire for medical approaches to gender transitioning. Therefore, testosterone-induced voice changes may not necessarily meet the needs and expectations of all transmasculine people.

AIMS

To evaluate the gender-related discursive and empirical data about transmasculine people's vocal situations to identify gaps in the current state of knowledge and to make suggestions for future voice research and clinical practice.

METHODS & PROCEDURES

A comprehensive review of peer-reviewed academic and clinical literature was conducted. Publications were identified by searching seven electronic databases and bibliographies of relevant articles. Thirty-one publications met inclusion criteria. Discourses and empirical data were analysed thematically. Potential problem areas that transmasculine people may experience were identified and the quality of evidence appraised.

MAIN CONTRIBUTION

The extent and quality of voice research conducted with transmasculine people so far was found to be limited. There was mixed evidence to suggest that transmasculine people's vocal situations could be regarded as problematic. The diversity that characterizes the transmasculine population received little attention and the complexity of the factors that contribute to a successful or unsuccessful vocal communication of gender in this group appeared to be under-researched. While most transmasculine people treated with testosterone can expect a lowering of their pitch, it remains unclear whether the extent of the pitch change is enough to result in a voice that is recognized by others as male.

CONCLUSIONS & IMPLICATIONS

More research into the different factors affecting transmasculine people's vocal situations that takes account of the diversity within the population is needed.

Combined type IIIB with bilateral type I thyroplasty for pitch lowering with maintenance of vocal fold tension

To evaluate type IIIB thyroplasty using the excised larynx bench apparatus and determine how altering vocal fold contour by performing bilateral medialization of the inferior vocal fold affects phonation. This procedure could be performed in patients for whom pitch lowering is desirable, such as female-to-male transsexuals or male patients with mutational falsetto in whom intensive voice therapy was insufficient. Aerodynamic, acoustic, and high-speed videokymographic data were collected for nine larynges at three subglottal pressure inputs for each of three conditions: normal; type IIIB thyroplasty; and combined type IIIB with modified bilateral type I thyroplasty intended to create a more rectangular glottal configuration. Each larynx served as its own control. Phonation threshold flow (p = 0.005), phonation threshold power (p = 0.031), and airflow varied across conditions with highest values for type IIIB thyroplasty and lowest for the combined procedure. Fundamental frequency was significantly different (p < 0.001), decreasing by approximately 100 Hz from control to type IIIB trials, and then by approximately 15 Hz from IIIB to combined procedure trials. Vibratory amplitudes and intrafold phase difference were highest for type IIIB trials. Addition of bilateral inferior medialization to type IIIB thyroplasty provided some further decrease in frequency, but mostly served to increase tension, reduce airflow, and produce a vibratory pattern which more closely mirrored control trials. Exploration of this combined procedure in patients may be warranted if not completely satisfied with the results from type IIIB thyroplasty alone.

Adolescent male-to-female transgender voice and communication therapy

Current research to describe and evaluate effectiveness of voice and communication therapy for male-to-female transgender people is limited to adults. This paper provides rationale, procedures, and outcomes from voice and communication therapy for a male-to-female transgender adolescent 15 years of age. Treatment addressed vocal hygiene, breath support, fundamental frequency, intonation, resonance and vocal quality, and rate. Positive acoustic, perceptual, and client self-report outcomes confirm treatment effectiveness for this adolescent.

LEARNING OUTCOMES

The reader will be able to recognize common aspects of transgender voice and communication therapy provided by a speech-language pathologist. The reader will also be able to explain the effectiveness of therapy provided to an adolescent speaker.