The Effectiveness of Gender Affirming Voice Training for Transfeminine Clients: A Comparison of Traditional Versus Intensive Delivery Schedules

Gender-Affirming Voice Training for Trans Women: Acoustic Outcomes and Their Associations With Listener Perceptions Related to Gender

OBJECTIVES

To investigate acoustic outcomes of gender-affirming voice training for trans women wanting to develop a female sounding voice and to describe what happens acoustically when male sounding voices become more female sounding.

STUDY DESIGN

Prospective treatment study with repeated measures.

METHODS

N = 74 trans women completed a voice training program of 8-12 sessions and had their voices audio recorded twice before and twice after training. Reference data were obtained from N = 40 cisgender speakers. Fundamental frequency (fo), formant frequencies (F1-F4), sound pressure level (Leq), and level difference between first and second harmonic (L1-L2) were extracted from a reading passage and spontaneous speech. N = 79 naive listeners provided gender-related ratings of participants' audio recordings. A linear mixed-effects model was used to estimate average training effects. Individual level analyses determined how changes in acoustic data were related to listeners' ratings.

RESULTS

Group data showed substantial training effects on fo (average, minimum, and maximum) and formant frequencies. Individual data demonstrated that many participants also increased Leq and some increased L1-L2. Measures that most strongly predicted listener ratings of a female sounding voice were: fo, average formant frequency, and Leq.

CONCLUSIONS

This is the largest prospective study reporting on acoustic outcomes of gender-affirming voice training for trans women. We confirm findings from previous smaller scale studies by demonstrating that listener perceptions of male and female sounding voices are related to acoustic voice features, and that voice training for trans women wanting to sound female is associated with desirable acoustic changes, indicating training effectiveness. Although acoustic measures can be a valuable indicator of training effectiveness, particularly from the perspective of clinicians and researchers, we contend that a combination of outcome measures, including client perspectives, are needed to provide comprehensive evaluation of gender-affirming voice training that is relevant for all stakeholders.

Puberty Assessment and Consideration of Gonadotropin-Releasing Hormone Agonists in Transgender and Gender-Diverse Youth

Transgender and gender-diverse (TGD) youth may pursue gender-affirming medical therapy in the form of gonadotropin-releasing hormone analogues (GnRHa), or "puberty blockers," if pubertal changes result in the development or worsening of gender dysphoria. GnRHa monotherapy can allow TGD youth to explore gender without the distress of unwanted secondary sexual characteristics. However, given the potential effects of GnRHa on growth, skeletal development, neurodevelopment, fertility, and future surgical outcomes, it is critical to accurately assess pubertal status to facilitate fully informed conversations with TGD youth and families about risks, benefits, and unknown consequences of GnRHa monotherapy. The focus of this discussion will be on the approach to puberty assessment in TGD youth as well as the different effects of GnRHa monotherapy that may be important to TGD youth and their families. [Pediatr Ann. 2023;52(12):e462-e466.].

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.

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.

A speech therapy for transgender women: an updated systematic review and meta-analysis

BACKGROUND

We systematically reviewed the literature and performed a meta-analysis on the effects of speech therapy and phonosurgery, for transgender women, in relation to the fundamental frequency gain of the voice, regarding the type of vocal sample collected, and we compared the effectiveness of the treatments. In addition, the study design, year, country, types of techniques used, total therapy time, and vocal assessment protocols were analyzed.

METHODS

We searched the PubMed, Lilacs, and SciELO databases for observational studies and clinical trials, published in English, Portuguese, or Spanish, between January 2010 and January 2023. The selection of studies was carried out according to Prisma 2020. The quality of selected studies was assessed using the Newcastle-Ottawa scale.

RESULTS

Of 493 studies, 31 were deemed potentially eligible and retrieved for full-text review and 16 were included in the systematic review and meta-analysis. Six studies performed speech therapy and ten studies phonosurgery. The speech therapy time did not influence the post-treatment gain in voice fundamental frequency (p = 0.6254). The type of sample collected significantly influenced the post-treatment voice frequency gain (p < 0.01). When the vocal sample was collected through vowel (p < 0.01) and reading (p < 0.01), the gain was significantly more heterogeneous between the different types of treatment. Phonosurgery is significantly more effective in terms of fundamental frequency gain compared to speech therapy alone, regardless of the type of sample collected (p < 0.01). The average gain of fundamental frequency after speech therapy, in the /a/ vowel sample, was 27 Hz, 39.05 Hz in reading, and 25.42 Hz in spontaneous speech. In phonosurgery, there was a gain of 71.68 Hz for the vowel /a/, 41.07 Hz in reading, and 39.09 Hz in spontaneous speech. The study with the highest gain (110 Hz) collected vowels, and the study with the lowest gain (15 Hz), spontaneous speech. The major of the included studies received a score between 4 and 8 on the Newcastle-Ottawa Scale.

CONCLUSION

The type of vocal sample collected influences the gain result of the fundamental frequency after treatment. Speech therapy and phonosurgery increased the fundamental frequency and improved female voice perception and vocal satisfaction. However, phonosurgery yielded a greater fundamental frequency gain in the different samples collected. The study protocol was registered at Prospero (CRD42017078446).

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.