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

Impact of Wendler glottoplasty on acoustic measures and quality of voice in transgender women: a systematic review and meta-analysis

PURPOSE

Since new evidence regarding the impact of Wendler glottoplasty (WG) on the voice in transgender women became available in the literature in recent years, we aimed to perform an updated systematic review and meta-analysis to determine the actual safety and efficacy of WG in the process of vocal feminization.

METHODS

PubMed, Embase, and Cochrane were searched for English-language articles published until July 4, 2023. Studies were found eligible if they evaluated the impact of WG on the acoustic-aerodynamic measures and quality of voice in transgender women.

RESULTS

Twenty-three studies were identified. After exclusion of three studies due to incomplete data, 20 studies including 656 patients were included in the meta-analysis. After WG, there was a significant increase of fundamental frequency, speaking fundamental frequency, and lower limit of the frequency range (p < 0.001). Concurrently, a significant reduction of frequency range and maximum phonation time was observed (p < 0.001). No significant differences were found between the pre- and postoperative values regarding the Grade, Roughness, Breathiness, Asthenia, and Strain scale score (p = 0.339). The overall score in the Trans Woman Voice Questionnaire (TWVQ) significantly improved after WG (p < 0.001).

CONCLUSIONS

WG is an effective voice feminization method in transgender women, associated with a high procedural success and low risk of postoperative complications. Significantly improved TWVQ score after surgery suggests its positive impact on the voice-related quality of life. Postoperative decrease of maximum phonation time and frequency range does not seem to significantly impact the effectiveness of voice production.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

SUPPLEMENTAL MATERIAL

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

Reframing transgender communication in gender-affirming communication care: Comfort and confidence are the main goals

PURPOSE

To understand the communicative participation experiences of transgender people through a qualitative inquiry, and to address similarities and differences in experiences across genders.

METHOD

This study was a secondary analysis of interview data gathered for modifying the Communicative Participation Item Bank for use with transgender populations. Fourteen transgender participants attended individual qualitative interviews. During the interview, participants shared their communication experiences in various situations and the availability of social supports related to communication. Qualitative content analysis was used to develop themes and subthemes from the data.

RESULT

Three themes emerged from the data: the participants' priorities for comfort, safety, and authenticity; the use of an internal "checklist" to optimise their communication; and changes in attitudes towards communication over time. Across themes, participants shared core communication experiences regardless of gender identities.

CONCLUSION

The findings support prior research on voice-related communication experiences of transgender people. A key finding is the notion that communication success is influenced by sociocultural contexts and the physical environment beyond their communication presentation. To achieve targeted comfort and satisfaction in communication, healthcare professionals need to consider the transgender client's communication contexts, and incorporate a life-participation approach to gender-affirming voice and communication training.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Experiences of Transgender Women with Speech Feminization Training: A Qualitative Study

This study investigated the experiences of transgender women after following sessions for speech feminization using semi-structured face-to-face interviews. Transgender women who completed a clinical trial were invited for an interview and 12 accepted the invitation. Interviews were conducted using an interview guide and were recorded and transcribed verbatim. NVivo 12 was used for qualitative data analysis, applying an inductive thematic approach. Four main themes were identified: communication, therapy experiences, impact on mental health, and external factors associated with the outcomes. For most participants, fear of speaking in public decreased after the training and all participants mentioned improved vocal characteristics. Though, reactions ranged from needing more speech therapy to being satisfied with the results. Coping strategies during misgendering occasions differed a lot between participants. More emotive counseling during speech feminization sessions is necessary to help clients in managing possible negative emotions.

Effect of Anchor Term on Auditory-Perceptual Ratings of Feminine and Masculine Speakers

BACKGROUND

Studies investigating auditory perception of gender expression vary greatly in the specific terms applied to gender expression in rating scales.

PURPOSE

This study examined the effects of different anchor terms on listeners' auditory perceptions of gender expression in phonated and whispered speech. Additionally, token and speaker cues were examined to identify predictors of the auditory-perceptual ratings.

METHOD

Inexperienced listeners (n = 105) completed an online rating study in which they were asked to use one of five visual analog scales (VASs) to rate cis men, cis women, and transfeminine speakers in both phonated and whispered speech. The VASs varied by anchor term (very female/very male, feminine/masculine, feminine female/masculine male, very feminine/not at all feminine, and not at all masculine/very masculine).

RESULTS

Linear mixed-effects models revealed significant two-way interactions of gender expression by anchor term and gender expression by condition. In general, the feminine female/masculine male scale resulted in the most extreme ratings (closest to the end points), and the feminine/masculine scale resulted in the most central ratings. As expected, for all speakers, whispered speech was rated more centrally than phonated speech. Additionally, ratings of phonated speech were predicted by mean fundamental frequency (f _o) within each speaker group and by smoothed cepstral peak prominence in cisgender speakers. In contrast, ratings of whispered speech, which lacks an f _o, were predicted by indicators of vocal tract resonance (second formant and speaker height).

CONCLUSIONS

The current results indicate that differences in the terms applied to rating scales limit generalization of results across studies. Identifying the patterns across listener ratings of gender expression provide a rationale for researchers and clinicians when making choices about terms. Additionally, beyond f _o and vocal tract resonance, predictors of listener ratings vary based on the anchor terms used to describe gender expression.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19617564.

Barriers and Motives for Physical Activity and Sports Practice among Trans People: A Systematic Review

This study aimed to analyze the research conducted between 2016 and 2021, regarding barriers and motives for the practice of physical activity (PA), physical exercise (PE), and sports among trans individuals. The searches were carried out in the PubMed, Scopus, and Web of Science databases between January 2022 and April 2022, and included papers published between October 2016 and December 2021. After reading the full text of the studies, and according to the eligibility criteria previously defined, only six studies met the inclusion criteria. Internal barriers were related to body dissatisfaction and discomfort, discrimination, and fear of other people’s reactions. Regarding external barriers, sports environment, PE environment, and sports participation policies and regulations are the main factors expressed by trans individuals that hinder the practice of sports and PE. The desire to achieve a specific physical form and the role that PE plays in the preparation and/or replacement of gender-confirming surgery are the most important motives for the practice. This study highlights the importance of continuing to fight the barriers encountered in the practice of PE and sports, suggesting the main motives that could help create better interventions, plans, and inclusive policies that may help promote its 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.

Effect of Wendler glottoplasty on voice and quality of life of transgender women

OBJECTIVE

To investigate the effect of Wendler glottoplasty on voice feminization, voice quality and voice-related quality of life.

METHODS

Prospective interventional cohort of transgender women submitted to Wendler glottoplasty. Acoustic analysis of the voice included assessment of fundamental frequency, maximum phonation time formant frequencies (F1 and F2), frequency range, jitter and shimmer. Voice quality was blindly assessed through GRBAS scale. Voice-related quality of life was measured using the Trans Woman Voice Questionnaire and the self-perceived femininity of the voice.

RESULTS

A total of 7 patients were included. The mean age was 35.4 years, and the mean postoperative follow-up time was 13.7 months. There was a mean increase of 47.9 ± 46.6 Hz (p = 0.023) in sustained/e/F0 and a mean increase of 24.6 ± 27.5 Hz (p = 0.029) in speaking F0 after glottoplasty. There was no statistical significance in the pre- and postoperative comparison of maximum phonation time, formant frequencies, frequency range, jitter, shimmer, and grade, roughness, breathiness, asthenia, and strain scale. Trans Woman Voice Questionnaire decreased following surgery from 98.3 ± 9.2 to 54.1 ± 25.0 (p = 0.007) and mean self-perceived femininity of the voice increased from 2.8 ± 1.8 to 7.7 ± 2.4 (p = 0.008). One patient (14%) presented a postoperative granuloma and there was 1 (14%) premature suture dehiscence.

CONCLUSION

Glottoplasty is safe and effective for feminizing the voice of transgender women. There was an increase in fundamental frequency, without aggravating other acoustic parameters or voice quality. Voice-related quality of life improved after surgery.

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.