Endoscopic and Stroboscopic Presentation of the Larynx in Male-to-Female Transsexual Persons

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.

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.

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

PURPOSE

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

METHOD

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

RESULTS AND CONCLUSIONS

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

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.

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.

Perceptual-Auditory and Acoustical Analysis of the Voices of Transgender Women

Voice is an important gender marker in the transition process as a transgender individual accepts a new gender identity. The objectives of this study were to describe and relate aspects of a perceptual-auditory analysis and the fundamental frequency (F0) of male-to-female (MtF) transsexual individuals. A case-control study was carried out with individuals aged 19-52 years who attended the Gender Identity Program of the Hospital de Clínicas of Porto Alegre. Vocal recordings from the MtF transgender and cisgender individuals (vowel /a:/ and six phrases of Consensus Auditory Perceptual Evaluation Voice [CAPE-V]) were edited and randomly coded before storage in a Dropbox folder. The voices (vowel /a:/) were analyzed by consensus on the same day by two judge speech therapists who had more than 10 years of experience in the voice area using the GRBASI perceptual-auditory vocal evaluation scale. Acoustic analysis of the voices was performed using the advanced Multi-Dimensional Voice Program software. The resonance focus and the degrees of masculinity and femininity for each voice recording were determined by listening to the CAPE-V phrases, for the same judges. There were significant differences between the groups regarding a greater frequency of subjects with F0 between 80 and 150 Hz (P = 0.003), and a greater frequency of hypernasal resonant focus (P < 0.001) in the MtF cases and greater frequency of subjects with absence of roughness (P = 0.031) in the control group. The MtF group of individuals showed altered vertical resonant focus, more masculine voices, and lower fundamental frequencies. The control group showed a significant absence of roughness.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

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

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

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

Transgender Voice and Communication: Introduction and International Context

Transgender voice and communication is a growing area of clinical service delivery in the United States and around the world; however, many clinicians are unsure where to begin if they are interested in working with people who are transgender, transsexual, or gender nonconforming/gender variant. Recently, at the Biennial Symposium of the World Professional Association for Transgender Health (WPATH) in Bangkok, Thailand, a group of speech-language pathologists (SLPs) and speech-language therapists (SLTs) from around the world gathered to discuss ways of disseminating information about transgender voice and communication to clinicians interested in serving this underrepresented and misunderstood clinical population. The symposium participants also brainstormed ways of reaching out to students so they would have an increased awareness of this area of clinical service delivery. In order to address these goals, this article introduces transgender voice and communication with a focus on: (a) key terminology for practicing SLPs and SLTs, (b) the role of WPATH in voice and communication intervention, and (c) a group therapy program for people in the transgender community.