Feminine after cricothyroid approximation?

Prosodic Differences in the Voices of Transgender and Cisgender Women: Self-Perception of Voice - An Auditory and Acoustic Analysis

INTRODUCTION

The voice is an important parameter for identifying the speaker's gender. Transgender people seek to adapt their bodies to gender identity, and transgender women have greater difficulties in achieving vocal acceptance. In this context, the evaluation of the various parameters of the voice of transgender and cisgender women is essential to make it possible to propose appropriate intervention measures.

OBJECTIVES

To identify the differences in vocal characteristics of transgender and cisgender women.

METHODS

An sectional study was conducted. The sample comprised 20 transgender women and 20 cisgender women who underwent evaluation of acoustic parameters, emotional prosody, self-perception, and perception of gender by lay listeners.

RESULTS

The vocal characteristics of transgender and cisgender women differ in terms of the following parameters: f0, glottal noise excitation (GNE), vocal intensity, speech range profile (SRP), the first three formants of the vowel /a/, and in terms of emotional prosody, including duration and melodic contour. Higher values ​​were mostly found in the cisgender population, except for noise level and vocal intensity. In addition, in most cases lay listeners identified the voices of transgender women as belonging to the male gender. There was a negative correlation between vocal dissatisfaction and f0 among transgender women.

CONCLUSIONS

Even though they perform vocal adjustments, the voices of transgender women are different from cisgender women in terms of acoustic parameters, vocal extension, and emotional prosody including duration and melodic contour. These differences have repercussions on the perception of gender by listeners.

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.

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).

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.

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.

Transgender Phonosurgery: A Systematic Review and Meta-analysis

Objectives

Different surgical techniques have been described in the literature to increase vocal pitch. The purpose of this study is to systematically review these surgeries and perform a meta-analysis to determine which technique increases pitch the most.

Data Sources

CINAHL, Cochrane, Embase, Medline, PubMed, and Science Direct.

Review Methods

A systematic review and meta-analysis of the literature was performed using the CINAHL, Cochrane, Embase, Medline, PubMed, and Science Direct databases. Studies were eligible for inclusion if they evaluated pitch-elevating phonosurgical techniques in live humans and performed pre- and postoperative acoustic analysis. Data were gathered regarding surgical technique, pre- and postoperative fundamental frequencies, perioperative care measures, and complications.

Results

Twenty-nine studies were identified. After applying inclusion and exclusion criteria, a total of 13 studies were included in the meta-analysis. Mechanisms of pitch elevation included increasing vocal cord tension (cricothyroid approximation), shortening the vocal cord length (cold knife glottoplasty, laser-shortening glottoplasty), and decreasing mass (laser reduction glottoplasty). The most common interventions were shortening techniques and cricothyroid approximation (6 studies each). The largest increase in fundamental frequency was seen with techniques that shortened the vocal cords. Preoperative speech therapy, postoperative voice rest, and reporting of patient satisfaction were inconsistent. Many of the studies were limited by low power and short length of follow-up.

Conclusions

Multiple techniques for elevation of vocal pitch exist, but vocal cord shortening procedures appear to result in the largest increase in fundamental frequency.

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.

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.

Conversational topics in transsexual persons

Abstract In general, speech language therapy for transsexual persons focuses on pitch and pitch variation and more recently also on resonance. Other communicative aspects are dealt with far less often, especially language. This study investigated to what extent conversational topics might need attention in therapy for transsexual persons. A total of 111 males, 116 females, 28 male-to-female and 18 female-to-male transsexuals were asked to indicate on a list with 34 topics how often they speak about each topic (never, sometimes, often) in conversations with males, with females and in a gender mixed group. Results showed that transsexual persons behave in accordance with the desired gender. However, they also tend to adopt a position depending on the gender of their conversational partner. It can be concluded that in general it is not necessary to pay attention to conversational topics in therapy for transsexual persons.