Perception of Voice in the Transgender Client

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.

Exploring the Relationship Between Acoustic Measurements and Self-Perception of Voice in Trans Women

OBJECTIVE

This study aimed to explore the strength and direction of the relationship between spectral cepstral-based, time-based acoustic measures and the self-perception of voice in trans women.

METHODS

Forty-eight trans women were included in the study. Analysis of the sustained vowel phonation was performed using Multidimensional Voice Profile Analysis (MDVP), and spectral-cepstral analyses of the sustained vowel phonation, all-voiced weighted sentence, and spontaneous speech were made via Analysis of Dysphonia in Speech and Voice (ADSV) software. For self-perceptual evaluations, the Trans Woman Voice Questionnaire (TWVQ) and the Self-perception of Voice Femininity Scale (SPVF) were used. The correlation between MDVP, spectral-cepstral parameters, and TWVQ and SPVF scores was calculated.

RESULTS

The present study found a positive relationship between F0, SPVF, and TWVQ. Among the perturbation parameters, the jitter was the only one found to correlate with SPVF and TWVQ. The CPPF0 parameter was found to be associated with a more feminine voice perception and a higher voice-related quality of life in all speech samples in the present study. In addition, higher CPP values achieved from vowel phonation were associated with less feminine voice perception and lower voice-related quality of life. The present study also suggests a weak correlation with the SPVF and Cepstral Peak Prominence Standard Deviation (CPPF0 SD) of the spontaneous speech sample in a negative direction.

CONCLUSIONS

This study found weak and moderate levels of correlations between F0, jitter (%), CPP, CPPF0, CPPF0 SD parameters, and self-perceptual measures. These findings suggested that such a level of relationship is attributable to the fact that these tools evaluate different aspects of voice in accordance with the International Classification of Functioning System. According to this pioneering study, it would be beneficial to incorporate spectral-cepstral measures into the objective assessment protocol for trans women's voices.

Perceptual-Auditory and Acoustic Analysis of Breathiness in Cis and Transgender Men and Women

OBJECTIVE

To verify breathiness in the cisgender and transgender men and women's voices, compare values of acoustic and perceptual indicators of breathiness and fundamental frequency (f0) between groups, and compare them between the voices attributed as female and male.

STUDY DESIGN

Cross sectional retrospective study.

METHODS

The study was approved by the Research Ethics Committee (4,937,140). Sustained vowel /a/ and continuous speech recordings of 21 cisgender men (CISM), 31 transgender men (TM), 32 cisgender women (CISW), and 31 transgender women (TW) were analyzed. Three judges conducted a perceptive-auditory analysis regarding the degree breathiness, using a visual analog scale, and attributed gender (female or male). The ABI (Acoustic Breathiness Index) was extracted using the PRAAT software (6.1.16). The f0, Harmonic-Noise Ratio (HNR), Voice Turbulence Index (VTI), and Soft Phonation Index (SPI) were analyzed using the Multi-Dimensional Voice Program (KayPentax).

RESULTS

The ABI value for CISM was lower than for TM and CISW. CISW had a higher f0 than; TM had a higher f0 than CISM; and TW had a higher f0 than CISM. The groups did not differ for HNR and VTI. Regarding the SPI, CISM had higher values than CISW. Regarding the auditory perception, TM presented more intense breathiness than CISM in the vowel. Regarding gender attribution by voice, the voices CISM and CISW were 100% identified as male and female. On the other hand, in the vowel analysis, 45.2% of the TM voices were perceived as female, and 59.4% of TW voices as male.

CONCLUSION

Breathiness occurs differently between groups and the voices perceived as male and female. Even when TM is submitted to the use of testosterone and undergoes vocal changes, the transglottal airflow remains, which is a female characteristic of phonation.

Incorporating Mobile App Technology in Voice Modification Protocol for Transgender Women

PURPOSE

Motivated by practice and feedback principles of motor learning, a hybrid clinic-home protocol for voice feminization was developed to minimize the role of SLPs to 1 of supervision and professional guidance and to maximize learning during independent practice apart from intervention sessions. The purpose was to explore the effectiveness and acceptability of the innovative service delivery.

METHOD

This single-subject changing criterion design included four transgender women who completed a 10-week hybrid clinic-home voice intervention program delivered via 30 -minute weekly in-clinic sessions and a technology-supported home program. The program was client-centered and capitalized on principles of motor learning in that it incorporated frequent practice with intermittent, knowledge-of-result feedback. Participants' desired outcomes were measured using acoustics, self and listener ratings of audio samples, and a program evaluation questionnaire.

RESULTS

Average speaking fundamental frequency of phrases and picture descriptions gradually increased into the 170-220 Hz range for all except one participant. All four transgender women were perceived to sound more feminine following treatment compared to baseline. Participants found the in-clinic sessions useful, the app easy to use, and noted limited fatigue or discomfort.

CONCLUSION

Four transwomen met their goals using this hybrid clinic-home service delivery format. Further investigations may elucidate key factors of the success achieved in the current study by designing comparison delivery models and including people from other populations.

The Patient Experience: The Relationship Between Vocal Handicap, Congruency, Perceived Present Control, and Mood Across Four Voice Disorders

OBJECTIVE

The potential for negative sequalae in psychosocial well-being presents clinical importance to the assessment of voice disorders. Despite the impairment voice disorders cause in the psychosocial domain, the clinical assessment of these disorders relies heavily on visual perceptual judgments of the larynx, audio-perceptual, as well as acoustic and aerodynamic measures. While these measures aid in accurate diagnosis and are necessary for standard of care, they present little insight into the patient experience of having a voice disorder.

DESIGN

Retrospective between-subject, non-experimental design.

METHODS

Data from 335 patients from the University of Pittsburgh Voice Center were collected from scores of the Voice Handicap Index-10 (VHI-10) and two recent questionnaires, the Voice Present Perceived Control scale (VPPC), and the Vocal Congruency Scale (VCS). Examining how these voice-specific scales related to three mental health screeners for stress (Perceived Stress Scale-4), anxiety (Generalized Anxiety Disorder-7) and depression (Patient Health Questionnaire-9) were also examined. Patient diagnoses included primary muscle tension dysphonia (pMTD), unilateral vocal fold paralysis (UVFP), vocal fold atrophy, and mid membranous vocal fold lesions.

RESULTS

There were significant differences in scores from the voice-specific scales between diagnostic groups with UVFP being the highest (worst) in VHI-10 and UVFP being the lowest (worst) in VCS compared to healthy controls. There was no significant difference in VPPC scores between diagnostic groups. Results showed statistically significant inverse relationships between the VHI-10 and the VPPC and between the VHI-10 and VCS for all diagnostic groups. A significant direct relationship was found between the VPPC and the VCS for patients diagnosed with MTD, UVFP and Lesions. In sum, patients with UVFP presented with the most frequent and sometimes strongest relationships between voice and mental health measures.

DISCUSSION

This study marks an initial investigation into the nuanced patient experience of having a voice disorder. Three theoretically unrelated voice constructs: handicap, perceived control, and sense of self, were measured via self-report. Results from this study describe the patient experience correlating to these constructs with weak correlations to stress, anxiety, and depression. Findings also clearly suggest that patient experience varies among diagnostic groups, as well as varying constructs. Measures of multiple constructs of patient perception provide valuable insight into a patient's experience of their voice disorder, guidance on the direction of voice treatment, and justification for such treatments.

Meta-Analysis of Validated Quality of Life Outcomes Following Voice Feminization in Transwomen

OBJECTIVES

For transwomen undergoing voice feminization interventions, fundamental frequency (F 0 ; vocal pitch) is a commonly reported functional outcome measure in the literature. However, F 0 may not correlate well with improvement in quality of life (QoL). Several validated voice-related QoL instruments have been used to assess QoL improvement in these patients, yet there is no consensus on the most appropriate instrument. This systematic review and meta-analysis aimed to assess the relationship between change in F 0 and QoL improvement following voice feminization, and to compare validated QoL instruments commonly used in this population.

DATA SOURCES

PubMed, Cochrane, and Embase.

REVIEW METHODS

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary studies of transwomen undergoing voice feminization, reporting validated QoL outcomes were included. Meta-analyses for associations between mean change in QoL score and mean change in F 0 , as well as variations in mean change in QoL score by QoL instrument, were performed using a multilevel mixed effects model.

RESULTS

No statistically significant correlation was found between change in F 0 and QoL score improvement post-intervention. Different validated instruments showed statistically significant variation in QoL score change, with the Trans Women Voice Questionnaire (TWVQ) capturing a greater improvement in QoL score relative to other instruments.

CONCLUSIONS

Lack of correlation between changes in F 0 and QoL improvement further supports that F 0 alone is insufficient to assess the efficacy of voice feminizing interventions. Validated QoL measures are useful adjuncts. Of these, the TWVQ appears to be the most sensitive for measurement of QoL improvement following voice feminization.

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.

Outcomes of Gender-Affirming Voice and Communication Modification Training for Non-binary Individuals: A Case Series

OBJECTIVES

There is currently no research reporting solely on outcomes of voice and communication modification training (VCMT) in individuals who identify as non-binary and genderqueer (NBGQ) in the English literature. This study aimed to describe the objective and subjective impact of VCMT on the voice of NBGQ individuals undergoing a 12-week gender-affirming VCMT program.

METHODS

A retrospective consecutive case series of NBGQ individuals enrolled in a VCMT program was performed. Demographics, Transgender Self-Evaluation Questionnaire (TSEQ), fundamental frequency (F0), and frequency range were collected before and after the program.

RESULTS

Four NBGQ individuals enrolled between January 2019 and June 2021; the mean age was 27.0 years. While all four participants represented in this case series showed improvement in at least one of their initial goals, only one improved both their F0 and TSEQ scores; the other three participants had mixed results.

CONCLUSION

NBGQ individuals experienced improvements in self-reported outcomes and changes in acoustic measures after completing VCMT in our case series. Individuals experienced significant improvement in subjective outcomes despite small changes in acoustic measures, and vice versa. More research is needed to better understand the voice and communication needs of NBGQ individuals, along with their outcomes with VCMT.

LEVEL OF EVIDENCE

Level 4.

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.

Visual biases in evaluation of speakers' and singers' voice type by cis and trans listeners

Introduction

A singer's or speaker's Fach (voice type) should be appraised based on acoustic cues characterizing their voice. Instead, in practice, it is often influenced by the individual's physical appearance. This is especially distressful for transgender people who may be excluded from formal singing because of perceived mismatch between their voice and appearance. To eventually break down these visual biases, we need a better understanding of the conditions under which they occur. Specifically, we hypothesized that trans listeners (not actors) would be better able to resist such biases, relative to cis listeners, precisely because they would be more aware of appearance-voice dissociations.

Methods

In an online study, 85 cisgender and 81 transgender participants were presented with 18 different actors singing or speaking short sentences. These actors covered six voice categories from high/bright (traditionally feminine) to low/dark (traditionally masculine) voices: namely soprano, mezzo-soprano (referred to henceforth as mezzo), contralto (referred to henceforth as alto), tenor, baritone, and bass. Every participant provided voice type ratings for (1) Audio-only (A) stimuli to get an unbiased estimate of a given actor's voice type, (2) Video-only (V) stimuli to get an estimate of the strength of the bias itself, and (3) combined Audio-Visual (AV) stimuli to see how much visual cues would affect the evaluation of the audio.

Results

Results demonstrated that visual biases are not subtle and hold across the entire scale, shifting voice appraisal by about a third of the distance between adjacent voice types (for example, a third of the bass-to-baritone distance). This shift was 30% smaller for trans than for cis listeners, confirming our main hypothesis. This pattern was largely similar whether actors sung or spoke, though singing overall led to more feminine/high/bright ratings.

Conclusion

This study is one of the first demonstrations that transgender listeners are in fact better judges of a singer's or speaker's voice type because they are better able to separate the actors' voice from their appearance, a finding that opens exciting avenues to fight more generally against implicit (or sometimes explicit) biases in voice appraisal.

Effect of Endoscopic Glottoplasty on Acoustic Measures and Quality of Voice: A Systematic Review and Meta-Analysis

INTRODUCTION

The voice is an important marker of the transition process to the new gender identity of the transgender person. For 20% of patients seeking voice feminization, voice therapy is not completely satisfactory, and surgery should be considered, with endoscopic glottoplasty being the current practice. While the increase in fundamental frequency (F0) after glottoplasty has been well described, no systematic review of the literature or meta-analysis regarding other acoustic parameters and quality of voice has been performed yet.

OBJECTIVE

To define the effect of endoscopic glottoplasty on acoustic measures and quality of voice by assessing F0, maximum phonation time (MPT), frequency range, and grade of dysphonia.

METHODS

A literature review was performed in Medline/PubMed, Cochrane, Science Direct, LILACS, and Google Scholar, following PRISMA guidelines, with no constraints on publication date. We included studies in English, Portuguese or Spanish that assessed transgender women who underwent endoscopic glottoplasty. All the included articles were measured in terms of their methodological quality.

RESULTS

The PRISMA approach yielded 14 studies, totaling 566 patients. There was significant heterogeneity between studies regarding follow-up time, surgical technique and perioperative care. Thirteen studies were submitted to meta-analysis. The results showed significant changes in pre- to postglottoplasty mean differences of F0 = 78.49 Hz (95%CI: 75.69-81.30), MPT = -1.11 seconds (95%CI -1.67 to -0.54), frequency range = -3.55 semitones (95%CI -5.74 to -1.36) and grade of dysphonia on the GRBAS scale = 0.44 (95%CI 0.27-0.61).

CONCLUSION

Glottoplasty is effective in significantly increasing fundamental frequency, but slightly decreases MPT, frequency range and vocal quality measured by the grade of dysphonia on the GRBAS scale.

Gauging Stakeholder Perspectives on Artificial Intelligence in Gender-Affirming Voice Care

BACKGROUND

As the main objective outcome measure used in gender-affirming voice care (GAVC), fundamental frequency (f₀ ) often fails to accurately reflect patient perceptions of their voice. Our team developed an artificial intelligence (AI) program that provides an alternative objective outcome measure that has the potential to more accurately align with patient perceptions.

OBJECTIVE

To gauge stakeholder receptivity to the use of AI in GAVC before employing a novel outcome measure in transgender and nonbinary communities.

METHODS

This prospective qualitative study used online focus groups composed of speech-language pathologists (SLPs), transgender men (TGM), transgender women (TGW), and nonbinary (NB) individuals. Participant age, race, gender, and geographic location were recorded. Each cohort participated in a series of two focus group sessions. The first session focused on participant experiences in GAVC, whereas the second ascertained participant perspectives on the use of AI in GAVC. Transcripts of each discussion were coded using Nvivo to perform inductive thematic analysis.

RESULTS

Seven SLPs, seven TGW, three TGM, and two NB individuals (mean [range] age, 35.5 [26-48] years) participated. Transgender and nonbinary participants were generally amenable to the technology, whereas SLPs were more hesitant about its use. Positive findings included appreciation for AI as an objective outcome measure and enthusiasm for its potential to longitudinally track progress. Hesitations concerned the actionability of using the AI and unease about the black box nature of the AI's analysis.

CONCLUSION

Transgender and NB individuals were receptive to the use of AI technology in GAVC, whereas SLPs were more apprehensive about using AI.

LEVEL OF EVIDENCE

NA Laryngoscope, 2022.

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.

Inferential Statistics Is an Unfit Tool for Interpreting Data

Null hypothesis significance testing is a commonly used tool for making statistical inferences in empirical studies, but its use has always been controversial. In this manuscript, I argue that even more problematic is that significance testing, and other abstract statistical benchmarks, often are used as tools for interpreting study data. This is problematic because interpreting data requires domain knowledge of the scientific topic and sensitivity to the study context, something that significance testing and other purely statistical approaches are not. By using simple examples, I demonstrate that researchers must first use their domain knowledge—professional expertise, clinical experience, practical insight—to interpret the data in their study and then use inferential statistics to provide some reasonable estimates about what can be generalized from the study data. Moving beyond the current focus on abstract statistical benchmarks will encourage researchers to measure their phenomena in more meaningful ways, transparently convey their data, and communicate their intellectual reasons for interpreting the data as they do, a shift that will better foster a scientific forum for cumulative science.

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.

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.

Outcomes of Gender-Affirming Voice and Communication Modification for Transgender Individuals

OBJECTIVES

Transgender individuals' voices are closely related to gender identity. A primary goal of gender-affirming voice modification is to help individuals alter their voices to improve gender congruence; however, there is a paucity of research to support this approach. This study aimed to evaluate the outcomes of a 12-week gender-affirming voice and communication modification program.

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective consecutive case series of transgender women enrolled in a voice and communication modification program was performed. Demographics, Trans Woman Voice Questionnaire (TWVQ), fundamental frequency (F₀ ), and frequency range were collected before and after the program. A Wilcoxon signed-rank test assessed changes in outcomes. Spearman's rank-order correlation coefficients quantified associations between self-reported outcomes and acoustic measures.

RESULTS

A total of 16 trans women individuals were enrolled. The mean age was 31.5 years. After program completion, TWVQ improved 20.4 points, F₀ increased 26.5 Hz (spontaneous speech) and 25.7 Hz (reading), and the range increased 24.7 Hz (spontaneous speech) and 0.1 Hz (reading). None of the changes in acoustic measures significantly correlated with improvement in TWVQ scores in the cohort.

CONCLUSION

Trans women experience improvements in self-reported outcomes and changes in acoustic measures after completing a gender-affirming voice and communication modification program. Individuals may experience significant improvement in subjective outcomes despite small changes in acoustic measures and vice versa.

LEVEL OF EVIDENCE

Level 4 (case series) Laryngoscope, 2021.

Listening to Gender-Diverse People of Color: Barriers to Accessing Voice and Communication Care

Purpose The purposes of this study are to gather and analyze perspectives of people from racial and gender minority groups in order to identify barriers to voice and communication services for these populations. Method In focus groups facilitated by community members, 11 people in racial and gender minority groups discussed their gender-related goals and accessibility of voice and communication services. Salient themes were derived using a grounded theory approach and analyzed using an access to care framework. Results During discussion of voice and communication as it relates to gender presentation, most utterances were speculations on the processes and potential outcomes of interventions for voice and communication; the majority of these were characterized as uninformed or misinformed. Conclusions Future studies will need to overcome barriers related to health literacy and beliefs in order to thoroughly assess potential interest or intentions regarding voice and communication services. Additional study is expected to provide valuable information that can be interpreted using the Levesque et al. (2013) framework of access to care and eventually eliminate barriers to voice and communication services for all.

Listener Age and Gender Diversity: Effects on Voice-based Perception of Gender

OBJECTIVE

An important clinical outcome of voice masculinization treatments in transmasculine speakers is voice-based perception of gender. Rigorous assessments of voice treatment that utilize ratings of perception of gender typically do not control for demographic characteristics of the listeners. The objective of the present study was to determine the effect of listeners' age and gender diversity on voice-based judgments of speaker gender.

METHODS

Speech stimuli were produced by a single transmasculine individual over approximately one year of hormone replacement therapy, during which he experienced significant changes in his voice. Three groups of listeners rated speech stimuli on a visual analog scale with anchors ranging from "definitely male" to "guessing male" to "guessing female" to "definitely female." Listener groups were N = 10 cisgender young adults, N = 10 cisgender older adults, and N = 10 gender diverse individuals.

RESULTS

All groups rated the speaker as consistently female through week 14 of hormone replacement therapy and consistently male after week 28. Mean responses of the three groups of listeners were highly correlated (Pearson's correlations all r > 0.97).

CONCLUSION

Given reasonable group sizes, average ratings of gender perception of a transmasculine speaker are not highly influenced by varying listener age and gender minority status.

Acoustic Measures of Brazilian Transgender Women's Voices: A Case-Control Study

Objective: This study aims to compare the acoustic vocal analysis results of a group of transgender women relative to those of cisgender women. Methods: Thirty transgender women between the ages of 19 and 52 years old participated in the study. The control group was composed of 31 cisgender women between the ages of 20 and 48 years old. A standardized questionnaire was administered to collect general patient data to better characterize the participants. The vowel /a/ sounds of all participants were collected and analyzed by the Multi-Dimensional Voice Program advanced system. Results: Statistically significant differences between cisgender and transgender women were found on 14 measures: fundamental frequency, maximum fundamental frequency, minimum fundamental frequency, standard deviation of fundamental frequency, absolute jitter, percentage or relative jitter, fundamental frequency relative average perturbation, fundamental frequency perturbation quotient, smoothed fundamental frequency perturbation quotient, fundamental frequency variation, absolute shimmer, relative shimmer, voice turbulence index (lower values in the cases), and soft phonation index (higher values in the cases). The mean fundamental frequency value was 159.046 Hz for the cases and 192.435 Hz for the controls. Conclusion: Through glottal adaptations, the group of transgender women managed to feminize their voices, presenting voices that were less aperiodic and softer than those of cisgender women.

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.

A Comparison of an Artificial Intelligence Tool to Fundamental Frequency as an Outcome Measure in People Seeking a More Feminine Voice

OBJECTIVES/HYPOTHESIS

An artificial intelligence (AI) tool was developed using audio clips of cis-male and cis-female voices based on spectral analysis to assess %probability of a voice being perceived as female (%Prob♀). This program was validated with 92% accuracy in cisgender speakers. The aim of the study was to assess the relationship of f_o on %Prob♀ by a validated AI tool in a cohort of trans females who underwent intervention to feminize their voice with behavioral modification and/or surgery.

STUDY DESIGN

Cohort study.

METHODS

Fundamental frequency (f_o ) from prolonged vowel sounds (f_o /a/) and f_o from spontaneous speech (f_o -sp) were measured using the Kay Pentax Computerized Speech Lab (Montvale, NJ) in trans females postintervention. The same voice samples were analyzed by the AI tool for %Prob♀. Chi-square analysis and regression models were performed accepting >50% Prob♀ as female voice.

RESULTS

Forty-two patients were available for analysis after intervention. f_o -sp post-treatment was positively correlated with %Prob♀ (R = 0.645 [P < .001]). Chi-square analysis showed a significant association between AI %Prob♀ >50% for the speech samples and f_o -sp >160 Hz (P < .01). Sixteen of 42 patients reached an f_o -sp >160 Hz. Of these, the AI program only perceived nine patients as female (>50 %Prob♀).

CONCLUSION

Patients with f_o -sp >160 Hz after feminization treatments are not necessarily perceived as having a high probability of being female by a validated AI tool. AI may represent a useful outcome measurement tool for patients undergoing gender affirming voice care.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Associations Between Voice and Gestural Characteristics of Transgender Women and Self-Rated Femininity, Satisfaction, and Quality of Life

Purpose Client-based subjective ratings of treatment and outcomes are becoming increasingly important as speech-language pathologists embrace client-centered care practices. Of particular interest is the value in understanding how these ratings are related to aspects of gender-affirming voice and communication training programs for transgender and gender-diverse individuals. The purpose of this observational study was to explore relationships between acoustic and gestural communication variables and communicator-rated subjective measures of femininity, communication satisfaction, and quality of life (QoL) among transfeminine communicators. Method Twelve acoustic and gestural variables were measured from high-fidelity audio and motion capture recordings of transgender women (n = 20) retelling the story of a short cartoon. The participants also completed a set of subjective ratings using a series of Likert-type rating scales, a generic QoL questionnaire, and a population-specific voice-related QoL questionnaire. Correlational analyses were used to identify relationships between the communication measures and subjective ratings. Results A significant negative relationship was identified between the use of palm-up hand gestures and self-rated satisfaction with overall communication. The acoustic variable of average semitone range was positively correlated with overall QoL. No acoustic measures were significantly correlated with voice-related QoL, and unlike previous studies, speaking fundamental frequency was not associated with any of the subjective ratings. Conclusions The results from this study suggest that voice characteristics may have limited association with communicator-rated subjective measures of communication satisfaction or QoL for this population. Results also provide preliminary evidence for the importance of nonverbal communication targets in gender-affirming voice and communication training programs.

Laser Reduction Glottoplasty for Voice Feminization: Experience on 28 Patients

OBJECTIVES

Laser reduction glottoplasty is a relatively new surgical procedure for voice feminization on transgender women. This study aims to determine long-term voice results of glottoplasty on transwomen.

METHODS

Nonrandomized, retrospective, cohort. Tertiary referral center. Endoscopic laser reduction glottoplasty was performed on 28 transwomen. Voice Handicap Index (VHI-30), Transsexual Voice Questionnaire (TVQ), acoustic analysis with /a/ for F₀, jitter, shimmer, noise to harmonic ratio and acoustic analysis for speaking F₀ were measured before and after surgery. Patients self-evaluated their postoperative voices and medical students and 2 voice experts scored patients' pre- and postsurgery voice samples as masculine, feminine or neither.

RESULTS

Mean total VHI and TVQ scores improved significantly postoperatively (P < .001). Pre- and postsurgery mean F₀ were 132 and 198 Hz and mean speaking F₀ were 123 and 194 Hz, respectively; these variations were found statistically significant (P < .001). Postoperative mean jitter, shimmer and NHR increased significantly compared to preoperative values (P < .05). Nine patients (32%) were not happy with their postsurgery voice result and were offered anterior glottic web formation as secondary procedure. MFT women's self-ratings of their postsurgery voices showed 3 masculine, 19 feminine and 6 neither outcomes, leading to patient gratification score of 68%. Medical students evaluated 79% of postsurgery voice specimens as feminine. Voice experts evaluated 75% of postsurgery voice specimens as feminine.

CONCLUSIONS

Laser reduction glottoplasty is an accomplished and satisfying operation for feminizing voice of transwomen. Its voice outcome appears to be durable for 5 years. However, secondary operation may be needed to further gratify transwomen.

Voice And Gender Incongruence: Relationship Between Vocal Self-Perception And Mental Health Of Trans Women

OBJECTIVE

To verify the association between vocal perception and Common Mental Disorders (CMD) suspicion in trans women.

METHODS

Cross-sectional observational study including 24 adult trans women with a minimum time of presentation as a woman of six months. The sampling of the subjects was supported by the "Snowball" technique. Three questionnaires were applied for data collection: sociodemographic and health data, Self-Reporting Questionnaire (SRQ-20) and Trans Woman Voice Questionnaire (TWVQ). The sociodemographic and health data collected were: age, marital status, education, smoking habits, speech therapy, use of hormones, and whether they had undergone Sex Reassignment Surgery (SRG). SRQ-20 was used for suspicion of CMD evaluation, such as depressive and anxiety symptoms. TWVQ is a vocal self-report questionnaire for trans women living the full-time gender role in which they self-identify. TWVQ has a minimum score of 30 points and a maximum of 120 points. Higher scores are associated with perceptions of a higher frequency of voice-related difficulties and psychosocial impacts. For statistical analysis, data were analyzed descriptively and statistically using Fisher's and Mann-Whitney's exact tests, both with a significance level of 5%.

RESULTS

The average participants' age in this study was 28.2 years old (SD = 6.5 / minimum = 21 and maximum = 48); 83.3% were single; most (41.7%) were high school graduates; and most (95.83%) had not undergone Sex Reassignment Surgery. All subjects reported using hormones; 37.5% were smokers; 4.2% had undergone speech therapy; and the average number of years of experience in the female role was 8.8 years (SD = 7.2). The average TWVQ score was 55.4 points (SD = 4.3). Through SRQ-20, it was verified the prevalence of suspected CMD in 58.3% of the participants. The study results indicated that communicative dissatisfaction in trans women due to inconsistent voice with the recognized gender is associated with probable CMD such as depression and anxiety (P= 0.001).

CONCLUSION

Trans women who reported greater difficulties and voice-related effects in their lives had more symptoms of anxiety and depression. Although more research is needed, results indicate the need for inter-professional preventive and therapeutic actions directed towards assisting trans women. This fact encourages reflection on the care of this population and the role of health professionals, enhancing scientific production, clinical practice and the inclusion of the "transsexuality" theme in Speech Language and Hearing Sciences.

Translation, Cross-Cultural Adaptation, and Preliminary Validation of the Transsexual Voice Questionnaire for Male-to-Female Transsexuals (I-TVQMtF) Into Italian

OBJECTIVE

To perform a cross-cultural adaptation into Italian and to analyse reliability and validity of the Transsexual Voice Questionnaire for male-to-female transsexuals (I-TVQ^MtF).

STUDY DESIGN

Cross-sectional nonrandomized survey study.

METHODS

For item-generation, a cross-cultural adaptation and translation process was performed following standard guidelines. Transgender women were consecutively recruited and asked to fill out the I-TVQ^MtF and a form on social, demographic and transition-related variables. Firstly, data collected from participants were used to perform confirmatory factor analysis, and to evaluate internal consistency and test-retest reliability Subsequently, convergent validity was evaluated comparing I-TVQ^MtF total scores with the two extra items addressing self-perception (SPVF) and aspiration (AVF) of voice femininity. To evaluate convergent validity, scores of the Italian version of the Voice Handicap Index were considered for comparisons. A correlation analysis was performed to verify potential association between I-TVQ^MtF scores and social, demographic and transition-related variables.

RESULTS

Confirmatory factor analysis demonstrated that a two-factor model fits data better than the unidimensional one. Both internal consistency and test retest reliability of the I-TVQ^MtF were satisfactory. Negative correlations were highlighted between I-TVQ^MtF scores on one side and self-perception vocal functioning and aspiration vocal functioning on the other. Positive correlations between I-TVQ^MtF and Italian version of the Voice Handicap Index scores were also found. Finally, negative correlations were demonstrated between I-TVQ^MtF scores and time spent living in the female role.

CONCLUSION

The I-TVQ^MtF appears to be a reliable and valid instrument for the assessment of voice-related quality of life in transgender women.

Examining the voice of Israeli transgender women: Acoustic measures, voice femininity and voice-related quality-of-life

BACKGROUND

Transgender women may experience gender-dysphoria associated with their voice and the way it is perceived. Previous studies have shown that specific acoustic measures are associated with the perception of voice-femininity and with voice-related quality-of-life, yet results are inconsistent.

AIMS

This study aimed to examine the associations between specific voice measures of transgender women, voice-related quality-of-life, and the perception of voice-femininity by listeners and by the speakers themselves.

METHODS

Thirty Hebrew speaking transgender women were recorded. They had also rated their voice-femininity and completed the Hebrew version of the TVQ^MtF questionnaire. Recordings were analyzed to extract mean fundamental frequency (F0), formant frequencies (F1, F2, F3), and vocal-range (calculated in Hz. and in semitones). Recordings were also rated on a voice-gender 7-point scale, by 20 naïve cisgender listeners.

RESULTS

Significant correlations were found between both F0 and F1 and listeners' as well as speakers' evaluation of voice-femininity. TVQ^MtF scores were significantly correlated with F0 and with the lower and upper boundaries of the vocal-range. Voice-femininity ratings were strongly correlated with vocal-range, when calculated in Hz, but not when defined in semitones. Listeners' evaluation and speakers' self-evaluation of voice-femininity were significantly correlated. However, TVQ^MtF scores were significantly correlated only with the speakers' voice-femininity ratings, but not with those of the listeners.

CONCLUSION

Higher F0 and F1, which are perceived as more feminine, jointly improved speakers' satisfaction with their voice. Speakers' self-evaluation of voice-femininity does not mirror listeners' judgment, as it is affected by additional factors, related to self-satisfaction and personal experience. Combining listeners' and speakers' voice evaluation with acoustic analysis is valuable by providing a more holistic view on how transgender women feel about their voice and how it is perceived by listeners.

Voice and Stroboscopic Characteristics in Transgender Patients Seeking Gender-Affirming Voice Care

OBJECTIVE

Understanding transgender voice is in nascent stages. This study describes voice characteristics in treatment-seeking trans women by comparing two validated questionnaires-Voice Handicap Index-10 (VHI-10) and Transsexual Voice Questionnaire (TVQ^MtF )-and reports incidence of abnormal stroboscopy findings and acoustic characteristics.

METHODS

Retrospective review of transgender patients presenting to tertiary-care laryngology center between February 2018-February 2019. Mean VHI-10, TVQ, and Singing VHI-10 (SVHI-10) scores; audio-perceptual grade; acoustic measures; and stroboscopy findings were analyzed. VHI-10 and SVHI-10 vs TVQ^MtF were compared.

RESULTS

Sixty-one trans female patients (mean age: 32 ± 11 years) were analyzed. Mean duration since start of transition was 41.5 ± 61 months. Sixty-nine percent presented full-time female in all contexts. Pathologic stroboscopy findings were found in 5%. Mean questionnaire scores were 16 ± 10 (VHI-10), 19 ± 13 (SVHI-10), and 81 ± 22 (TVQ^MtF ). Correlation between VHI-10 and SVHI-10 versus TVQ^MtF was weak, R = 0.47 (P = .053) and R = 0.35 (P = .17), respectively. Mean audio-perceptual grade was 0.27 ± 0.15. Mean Cepstral Spectral Index of Dysphonia (CSID, sustained vowel) was 8.5 ± 21.9. Mean Cepstral Peak Prominence (CPP) Fo and CPP Fo SD in rainbow passage were 157.3 ± 16 and 59.4 ± 15.9, respectively.

CONCLUSION

Trans women report perceived voice handicap in speaking and singing, which appears separate from gender-related voice/communication concerns. This study is the first to report stroboscopy findings in transgender individuals, with 5% being abnormal. Stroboscopy is encouraged before initiating voice intervention in transgender patients. Preliminary evaluation suggests weak correlation between VHI-10 or SVHI-10 and TVQ^MtF but requires further investigation. TVQ^MtF may provide information which more specifically reflects voice concerns of trans women as compared to VHI-10 and SVHI-10.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1071-1077, 2021.

Investigating Validity and Reliability of the Turkish Version of Transsexual Voice Questionnaire (Male to Female)

OBJECTIVE

The problems faced by trans women with regard to their voice may affect their quality of life. For the evaluation of trans women's voice, tools assessing their self-perception are very important, with the Transsexual Voice Questionnaire (TVQ^MtF ) being one of the most frequently used. The purpose of this study was to investigate the validity and reliability of the Turkish version of the TVQ^MtF (TVQ^MtF -TR), which was previously translated into 12 languages.

STUDY DESIGN

Cross-sectional study.

METHOD

A total of 41 trans women participated in this study. The participants filled out the TVQ^MtF -TR, the self-perceptions of voice femininity questionnaire, and the World Health Organization Quality of Life Questionnaire-Short Form (WHOQOL-BREF-TR). Additionally, 58.5% of the participants filled out the TVQ^MtF -TR again two weeks after the first interview.

RESULTS

The total Cronbach's-α value of the TVQ^MtF -TR was 0.972, and the item-total correlation values were found to be between 0.323 and 0.876. The intraclass correlation coefficient value was 0.931. There was a strong negative correlation between TVQ^MtF -TR and self-perceptions of voice femininity. There was a significant negative correlation between TVQ^MtF -TR and the psychological and environmental domains of WHOQOL-BREF-TR. However, there was no significant relationship found between the social and physical domains.

CONCLUSION

According to the results of the study, the Turkish version of TVQ^MtF -TR was considered a valid and reliable tool.

Contributions of Voice and Nonverbal Communication to Perceived Masculinity-Femininity for Cisgender and Transgender Communicators

Purpose The purpose of this study was twofold: (a) to identify a set of communication-based predictors (including both acoustic and gestural variables) of masculinity-femininity ratings and (b) to explore differences in ratings between audio and audiovisual presentation modes for transgender and cisgender communicators. Method The voices and gestures of a group of cisgender men and women (n = 10 of each) and transgender women (n = 20) communicators were recorded while they recounted the story of a cartoon using acoustic and motion capture recording systems. A total of 17 acoustic and gestural variables were measured from these recordings. A group of observers (n = 20) rated each communicator's masculinity-femininity based on 30- to 45-s samples of the cartoon description presented in three modes: audio, visual, and audio visual. Visual and audiovisual stimuli contained point light displays standardized for size. Ratings were made using a direct magnitude estimation scale without modulus. Communication-based predictors of masculinity-femininity ratings were identified using multiple regression, and analysis of variance was used to determine the effect of presentation mode on perceptual ratings. Results Fundamental frequency, average vowel formant, and sound pressure level were identified as significant predictors of masculinity-femininity ratings for these communicators. Communicators were rated significantly more feminine in the audio than the audiovisual mode and unreliably in the visual-only mode. Conclusions Both study purposes were met. Results support continued emphasis on fundamental frequency and vocal tract resonance in voice and communication modification training with transgender individuals and provide evidence for the potential benefit of modifying sound pressure level, especially when a masculine presentation is desired.

Vocal Congruence: The Voice and the Self Measured by Interoceptive Awareness

Voices are, by nature, idiosyncratic representations of individuals because they possess anatomical, physiological, and psychological characteristics that are unique to them, which contribute to vocal output, and thus, establish the voice as a salient marker of their individuality. The areas of experimental psychology and cognitive neuroscience have examined the psychological and neurological constructs that form one's sense of self and have employed measures of interoceptive and exteroceptive abilities to discover the underlying constructs of the sense of self. This study employed measures of interoceptive awareness to assess level of vocal congruence. Forty-one participants analyzed in this study underwent a heartbeat detection task designed to assess the level of interoceptive awareness and were placed into two groups: those high in interoceptive awareness and those low in interoceptive awareness. They completed two tasks, a speaking task, which included structured passages and conversation, and a listening task, where they listened to themselves in the speaking task. Following each task, they completed a Vocal Congruence Scale designed to assess the level of identification they have within themselves related to the sound of their voice. Individuals scoring high in interoceptive awareness scored significantly higher in vocal congruence than those scoring lower in interoceptive awareness. Additionally, when analyzed with other measures of personality, anxiety, mood, and voice handicap, the Vocal Congruence Scale appears to measure a unique aspect of vocal identity with one's self that encompasses interoceptive awareness.

Health considerations for transgender women and remaining unknowns: a narrative review

Transgender (trans) women (TW) were assigned male at birth but have a female gender identity or gender expression. The literature on management and health outcomes of TW has grown recently with more publication of research. This has coincided with increasing awareness of gender diversity as communities around the world identify and address health disparities among trans people. In this narrative review, we aim to comprehensively summarize health considerations for TW and identify TW-related research areas that will provide answers to remaining unknowns surrounding TW's health. We cover up-to-date information on: (1) feminizing gender-affirming hormone therapy (GAHT); (2) benefits associated with GAHT, particularly quality of life, mental health, breast development and bone health; (3) potential risks associated with GAHT, including cardiovascular disease and infertility; and (4) other health considerations like HIV/AIDS, breast cancer, other tumours, voice therapy, dermatology, the brain and cognition, and aging. Although equally deserving of mention, feminizing gender-affirming surgery, paediatric and adolescent populations, and gender nonbinary individuals are beyond the scope of this review. While much of the data we discuss come from Europe, the creation of a United States transgender cohort has already contributed important retrospective data that are also summarized here. Much remains to be determined regarding health considerations for TW. Patients and providers will benefit from larger and longer prospective studies involving TW, particularly regarding the effects of aging, race and ethnicity, type of hormonal treatment (e.g. different oestrogens, anti-androgens) and routes of administration (e.g. oral, parenteral, transdermal) on all the topics we address.

Acoustic Features of Transfeminine Voices and Perceptions of Voice Femininity

The purpose of this study was to evaluate the relationships between acoustic measures of transfeminine voices and both self- and listener ratings of voice femininity. Connected speech samples were collected from 12 transfeminine individuals (M = 36.3 years, SD = 10.6 years) and a control group of five cisgender (cis) women and five cis men (M = 35.3 years, SD = 13.3 years). The acoustic measures of fundamental frequency (f_o), f_o variation, formant frequencies, and vocal intensity were calculated from these samples. Transfeminine speakers rated their own voices on a five-point scale of voice femininity. Twenty inexperienced listeners heard an excerpt of each speech sample and rated the voices on the same five-point scale of voice femininity. Spearman's rank-order correlation coefficients were calculated to measure the relationships between the acoustic variables and ratings of voice femininity. Significant positive correlations were found between f_o and both self-ratings (r = 0.712, P = 0.009) and listener ratings of voice femininity (r = 0.513, P < 0.001). Significant positive correlations were found between intensity and both self-ratings (r = 0.584, P = 0.046) and listener ratings of voice femininity (r = 0.584, P = 0.046). No significant correlations were found between f_o variation or formant frequencies and perceptual ratings of voice femininity. A Pearson's chi-square test of independence showed that the distribution of self- and listener ratings differed significantly (χ² = 9.668, P = 0.046). Self- and listener ratings were also shown to be strongly correlated (r = 0.912, P < 0.001). This study provides further evidence to support the selection of training targets in voice feminization programs for transfeminine individuals and promotes the use of self-ratings of voice as an important outcome measure.

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.

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.

"My Voice Is My Identity": The Role of Voice for Trans Women's Participation in Sport

OBJECTIVE

This study explored trans women's experience and awareness of their vocal communication and voice use within sporting environments.

STUDY DESIGN

Mixed methods study.

METHODS

Twenty trans women were interviewed about their voice use and vocal communication during sport and its impact on their level of participation. The participants also completed the Transsexual Voice Questionnaire for Male-to-Female Transsexuals.

RESULTS

Three core themes emerged from analysis of the interview data. These were: importance of voice in a sport setting, voice production in sporting environments, and psychosocial moderators of voice within the sporting environment. Trans women perceived their voices to be the main barrier to their participation in sport. These women reported that the strong gendered environment of sport made them anxious that they would not be identified as women because their voice was not always congruent with their physical appearance. However, maintaining feminine voice was deemed less critical if participants felt comfortable at their sporting club and had strong relationships with their teammates and coaches. Findings from the Transsexual Voice Questionnaire for Male-to-Female Transsexuals supported the interview data as to the impact that voice has in the lives of trans women.

CONCLUSION

Voice is critical for trans women who wish to integrate and be accepted as women in sporting environments. Participants suggested that voice training should target achieving a gender congruent voice and include minimalizing perceived barriers such as vocal fatigue and maintaining adequate breath support.

Developing Trans-Affirming Health Services in an Underserved Area: An Intersectional Approach

Purpose: Gender-nonconforming patients are at higher risk for medical problems that require prompt medical and mental health intervention. Barriers to healthcare for transgender individuals have been well characterized in the literature, but not in low resource settings. The purpose of this paper is to present the barriers encountered when bringing healthcare to transgender children, adolescents, and adults in a medically underserved, predominantly Hispanic area of the United States. Methods: In this medically underserved area on the U.S.-Mexico border, there is a severe shortage of medical expertise for transgender individuals at both the primary- and specialty-care levels. Further, given the mainly Hispanic population, there is an additional culturally based barrier to obtaining medical care for transgender patients. Results: It is important for academic centers in these regions to collaborate to overcome these barriers through a multidisciplinary approach that includes providing education for medical students and physicians in training and identifying medical providers who are able and willing to provide transgender-competent care adapted to local culture and gender norms. Conclusion: In this manuscript, we will describe the efforts of various groups to address the needs of the transgender community in the region.

Masculine Voices Predict Well-Being in Female-to-Male Transgender Individuals

Voices convey important social information about an individual's identity, including gender. This is especially relevant to transgender individuals, who cite voice alteration as a primary goal of the gender alignment process. Although the voice is a primary target of testosterone therapy among female-to-male (FTM) trans people, little research has explored the effects of such changes on their psychological well-being. Here, we investigated how FTMs' vocal gender related to their well-being. A total of 77 FTMs (M _age = 25.45 years, SD = 6.77) provided voice samples and completed measures of their well-being and psychological health. An independent group of 32 naïve raters (M _age = 22.16 years, SD = 8.21) subsequently rated the voice samples for masculinity. We found that FTMs whose voices sounded more congruent with their experienced gender (i.e., sounded more masculine) reported greater well-being (better life satisfaction, quality of life, and self-esteem; lower levels of anxiety and depression) than FTMs with less gender congruent (i.e., more feminine) voices (β = .48). The convergence between outwardly perceived vocal gender and gender identity brought about through hormone replacement therapy may therefore support greater well-being for FTMs.

Efficacy of intensive voice feminisation therapy in a transgender young offender

Research suggests that transgender young offenders are a uniquely vulnerable caseload that may benefit from speech pathology intervention to help bring their voice into alignment with their gender identity. However, no previous studies have investigated treatment efficacy in this population. This study investigated the impact of intensive voice feminisation therapy targeting fundamental frequency and oral resonance in a 17 year old transgender individual within a youth justice institution. Acoustic analysis, listener and self-ratings of vocal femininity, self-ratings of vocal satisfaction, a post-treatment structured interview, and pre- and post- treatment completion of the Transsexual Voice Questionnaire (TVQ^MtF) were utilised to determine treatment impact. Outcome measures indicated therapy was effective at increasing the client's vocal pitch and perceptually femininity without compromising vocal quality. However, the client was still not consistently perceived as female post-intervention and had difficulty implementing feminine speech strategies in discourse. This case study provides preliminary evidence for the effectiveness of intensive voice feminisation therapy in a youth offending population. This research also highlights the potential utility of speech pathologists working in youth justice settings, even when the timeframe for intervention is limited. Furthermore, this research paper validates the use of perceptual outcome measures in transgender voice work, by replicating previous findings in which significant correlations were found between perceptual ratings of vocal gender and client satisfaction.