Transmasculine Voice Modification: A Case Study

Voice Pitch Shaping and Genderization: New Needs of Cosmetic Phonoplastic Surgery

Voices can convey content, emotion, and essential information about an individual's gender and social information. Closely related to gender identification and sexual attraction, voices also positively affect many psychological factors of individuals. Surgeries have evolved from treating congenital diseases to fulfilling an individual's aesthetic needs for voice. Voice shaping is emerging as the next cosmetic surgery hotspot after skincare and appearance and body shaping. This paper summarizes the development of voice pitch shaping and genderization procedures out of the cosmetic need. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .

Clinician and Consumer Perspectives on Gender-Affirming Voice Services

INTRODUCTION

A significant portion of the transgender, nonbinary, and gender-expansive community experiences gender-related voice issues. However, barriers exist to accessing gender-affirming voice care, and most existing voice research does not include the gender-nonbinary population. Our study aimed to examine transgender, nonbinary, and gender-expansive consumer/potential consumer (hereafter referred to as consumer) engagement and compare/contrast consumer and speech-language pathologist perspectives on gender-affirming voice services. A secondary aim was to assess possible voice impairments in transgender, nonbinary, and gender-expansive individuals.

METHODS

Two surveys were distributed via listservs for SLPs and flyers and social media posts for consumers. Surveys included items regarding experience with and accessibility of gender-affirming voice services and clinician competence. Consumers and clinicians answered the same questions from their respective positions. Consumers additionally completed the Voice Handicap Index-10 (VHI-10).

RESULTS

Forty-eight consumer and 54 clinician responses were collected. Twenty (41.7%) consumers were trans women, 15 (31.2%) were trans men, 12 (25%) were gender-nonbinary, and one (2.1%) was gender fluid. VHI-10 responses were in the abnormal range for 61.4% of consumers, and 68.8% indicated desire to receive gender-affirming voice services, including 58.3% of gender-nonbinary respondents. However, only 6.25% of consumers considered themselves as having a voice disorder and 29.2% reported that their voice impairs communication. In contrast, 24.1% of clinicians felt consumers seeking gender-affirming voice services have a voice disorder and 51.2% felt they have an impaired communication ability. Consumers indicated positive perceptions of voice services/providers but reported a variety of barriers to access. SLPs indicated mixed confidence in accessibility of services. Both groups perceived an affordability barrier.

CONCLUSIONS

This study demonstrates the desire and need for gender-affirming voice services and is the first to our knowledge to explicitly include gender-nonbinary individuals' perspectives on them. Understanding how consumer and clinician perspectives differ can help focus provider efforts in improving experiences with, access to, and visibility of gender-affirming voice services.

Androgenic induction of penile features in postnatal female mouse external genitalia from birth to adulthood: Is the female sexual phenotype ever irreversibly determined?

Female mice were treated for 35 days from birth to 60 days postnatal (P0, [birth], P5, P10, P20 and adult [∼P60]) with dihydrotestosterone (DHT). Such treatment elicited profound masculinization the female external genitalia and development of penile features (penile spines, male urogenital mating protuberance (MUMP) cartilage, corpus cavernosum glandis, corporal body, MUMP-corpora cavernosa, a large preputial space, internal preputial space, os penis). Time course studies demonstrated that DHT elicited canalization of the U-shaped clitoral lamina to create a U-shaped preputial space, preputial lining epithelium and penile epithelium adorned with spines. The effect of DHT was likely due to signaling through androgen receptors normally present postnatally in the clitoral lamina and associated mesenchyme. This study highlights a remarkable male/female difference in specification and determination of urogenital organ identity. Urogenital organ identity in male mice is irreversibly specified and determined prenatally (prostate, penis, and seminal vesicle), whereas many aspects of the female urogenital organogenesis are not irreversibly determined at birth and in the case of external genitalia are not irreversibly determined even into adulthood, the exception being positioning of the female urethra, which is determined prenatally.

Readability Analysis and Accessibility of Online Materials About Transgender Voice Care

OBJECTIVE

To determine readability, understandability, and actionability of online health information related to transgender voice care.

STUDY DESIGN

Review of online materials.

SETTING

Academic medical center.

METHODS

A Google search of "transgender voice care" was performed with the first 50 websites meeting inclusion criteria included. Readability was assessed using the Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), and the Simple Measure of Gobbledygook (SMOG). Understandability and actionability were measured by 2 independent reviewers using the Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P). Unpaired t tests were used to compare clinician- and patient-oriented sites, surgical and nonsurgical sites, and sites that discuss nonbinary indications for voice care. Analysis of variance was used to compare sites that discuss voice feminization, masculinization, both, or neither.

RESULTS

Average scores across the cohort for FRES, FKGL, and SMOG were 43.77 ± 13.52, 12.14 ± 2.66, and 11.30 ± 1.93, respectively, indicating materials were above a 12th-grade reading level. PEMAT-P scores for understandability and actionability were 64.95% ± 15.78% and 40.55% ± 23.86%, respectively. Patient-oriented sites were significantly more understandable and actionable than clinician-oriented sites (P < .02). Websites that discussed only voice feminization were significantly more readable according to objective metrics (FKGL, SMOG) than websites that discussed both feminization and masculinization or those that did not differentiate care types (P < .05).

CONCLUSION

Online information written about transgender voice care is written at a level above what is recommended for patient education materials. Providers may improve accessibility of transgender voice care by enhancing readability of online materials.

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.

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.

Voice and Speech Changes in Transmasculine Individuals Following Circumlaryngeal Massage and Laryngeal Reposturing

PURPOSE

The purpose of this study was to measure the short-term effects of circumlaryngeal massage and laryngeal reposturing on acoustic and perceptual characteristics of voice in transmasculine individuals.

METHOD

Fifteen transmasculine individuals underwent one session of sequential circumlaryngeal massage and laryngeal reposturing with a speech-language pathologist. Voice recordings were collected at three time points-baseline, postmassage, and postreposturing. Fundamental frequency (f o), formant frequencies, and relative fundamental frequency (RFF; an acoustic correlate of laryngeal tension) were measured. Estimates of vocal tract length (VTL) were derived from formant frequencies. Twelve listeners rated the perceived masculinity of participants' voices at each time point. Repeated-measures analyses of variance measured the effect of time point on f o, estimated VTL, RFF, and perceived voice masculinity. Significant effects were evaluated with post hoc Tukey's tests.

RESULTS

Between baseline and end of the session, f o decreased, VTL increased, and participant voices were perceived as more masculine, all with statistically significant differences. RFF did not differ significantly at any time point. Outcomes were highly variable at the individual level.

CONCLUSION

Circumlaryngeal massage and laryngeal reposturing have short-term effects on select acoustic (f o, estimated VTL) and perceptual characteristics (listener-assigned voice masculinity) of voice in transmasculine individuals.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19529299.

Testosterone therapy masculinizes speech and gender presentation in transgender men

Voice is one of the most noticeably dimorphic traits in humans and plays a central role in gender presentation. Transgender males seeking to align internal identity and external gender expression frequently undergo testosterone (T) therapy to masculinize their voices and other traits. We aimed to determine the importance of changes in vocal masculinity for transgender men and to determine the effectiveness of T therapy at masculinizing three speech parameters: fundamental frequency (i.e., pitch) mean and variation (f_o and f_o-SD) and estimated vocal tract length (VTL) derived from formant frequencies. Thirty transgender men aged 20 to 40 rated their satisfaction with traits prior to and after T therapy and contributed speech samples and salivary T. Similar-aged cisgender men and women contributed speech samples for comparison. We show that transmen viewed voice change as critical to transition success compared to other masculine traits. However, T therapy may not be sufficient to fully masculinize speech: while f_o and f_o-SD were largely indistinguishable from cismen, VTL was intermediate between cismen and ciswomen. f_o was correlated with salivary T, and VTL associated with T therapy duration. This argues for additional approaches, such as behavior therapy and/or longer duration of hormone therapy, to improve speech transition.