Who or what has the capacity to influence voice production? Development of a transdisciplinary theoretical approach to clinical practice addressing voice and the communication of speaker socio-cultural positioning

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.

Considerations for Voice and Communication Training Software for Transgender and Nonbinary People

Transgender and gender diverse people often experience voice-gender incongruence, which is inversely correlated with health and quality of life. Such incongruence could be reduced with voice and communication training, but expert-administered training is often inaccessible while self-guided training is difficult and potentially risky. Training could alternatively be provided through software (eg, smartphone apps), but such software is at an early stage. This qualitatively driven mixed-methods study thus includes surveys and interviews with 21 transfeminine, transmasculine and nonbinary people to identify general views of voice and communication training software as well as most desirable features of such software. Participants were positive about the general idea and described ways to effectively implement four critical features: feedback, accountability, automated goal setting, and training characteristics other than pitch. They also discussed optional or undesirable features. These findings may inform development of voice and communication training software, thus improving health and quality of life for gender minorities.

Perception of Femininity and Masculinity in Voices as Rated by Transgender and Gender Diverse People, Professional Speech and Language Pathologists, and Cisgender Naive Listeners

OBJECTIVE

To explore whether cisgender naive listeners, transgender and gender diverse (TGD) listeners, and speech-language pathologists (SLPs) experienced in providing gender-affirming voice training differ in their perception of femininity and masculinity in voices.

METHODS

Samples of spontaneous speech were collected from 95 cisgender, and 37 TGD speakers. Three listener groups of cisgender naive (N = 77), TGD (N = 30), and SLP (N = 14) listeners, respectively, rated the voices on visual analog scales in two randomly ordered blocks, in which the perceived degree of femininity was rated separately from the perceived degree of masculinity.

RESULTS

The three listener groups showed similar patterns in their distribution of ratings on the femininity and masculinity scales. The TGD listeners' mean ratings did not differ from the cisgender naive listeners', whereas SLPs showed a small, but significant, difference in their ratings compared with both TGD and cisgender naive listeners and rated the voices lower on both the femininity and masculinity scales.

CONCLUSION

The results differ from previous studies as TGD, and cisgender naive listeners rated the voices very similarly. The lower ratings of femininity and masculinity by the SLPs were likely influenced by their awareness of the complexity in the perception of voices. Therefore, SLPs providing gender-affirming voice training should be attentive to how their professional training may influence their perception of femininity and masculinity in voices and encourage discussions and explorations of the TGD voice client's perceptions of voices.

Design and usability evaluation of a web-based pitch control training app for transgender women

Transgender people often experience dysphoria because the way their voice is perceived does not match their gender identity. Such dysphoria negatively affects mental health and quality of life, and is particularly an issue in trans women. Dysphoria can be reduced via gender-affirming voice and communication training provided by human experts, but the accessibility of such training is often limited. As a supplement or alternative to human-guided training, our team has thus developed an early prototype of voice training software for transfeminine users (i.e., trans women and nonbinary users who were assigned male at birth). The software is accessible via a web browser and provides three vocal pitch exercises together with real-time feedback about the user's pitch relative to a desired target pitch curve. This paper presents the main technical features and results of a single-session usability evaluation with 5 transfeminine participants. We further present future plans for expansion to other exercises and voice aspects (particularly resonance) as well as plans for clinical trials.

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.

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.

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.

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.

Auditory free classification of gender diverse speakersa)

Auditory attribution of speaker gender has historically been assumed to operate within a binary framework. The prevalence of gender diversity and its associated sociophonetic variability motivates an examination of how listeners perceptually represent these diverse voices. Utterances from 30 transgender (1 agender individual, 15 non-binary individuals, 7 transgender men, and 7 transgender women) and 30 cisgender (15 men and 15 women) speakers were used in an auditory free classification paradigm, in which cisgender listeners classified the speakers on perceived general similarity and gender identity. Multidimensional scaling of listeners' classifications revealed two-dimensional solutions as the best fit for general similarity classifications. The first dimension was interpreted as masculinity/femininity, where listeners organized speakers from high to low fundamental frequency and first formant frequency. The second was interpreted as gender prototypicality, where listeners separated speakers with fundamental frequency and first formant frequency at upper and lower extreme values from more intermediate values. Listeners' classifications for gender identity collapsed into a one-dimensional space interpreted as masculinity/femininity. Results suggest that listeners engage in fine-grained analysis of speaker gender that cannot be adequately captured by a gender dichotomy. Further, varying terminology used in instructions may bias listeners' gender judgements.

Gender Attributions by Cisgender and Gender Diverse Listeners Rating Vowels, Reading, and Monologues

OBJECTIVES

To determine if listeners' attributions of speakers' gender vary by linguistic context and/or the listeners' gender identity.

METHODS

Seventeen self-identified transgender adults assigned male at birth were audio-recorded prolonging /a/, reading sentences, and saying spontaneous monologues. Eighteen adults (10 cisgender and 8 gender-diverse individuals) listened and used a 1-5 scale (1: very masculine, 2: somewhat masculine, 3: androgynous, 4: somewhat feminine, and 5: very feminine) to rate the gender attribution of each speech sample.

RESULTS

The intra-rater reliability was moderate to excellent (0.62-1.00). Ratings by cisgender and gender-diverse listeners were not significantly different. Ratings were not significantly different between different speech contexts of vowel, reading, and spontaneous monologue speech samples.

CONCLUSIONS

Transwomen have many variables available to consider and use in their communication. The linguistic context (eg, reading a speech versus spontaneous monologue) or listener's gender does not appear to be highly influential factors in how listeners attribute gender.

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.

Short-term effects of a speech feminization program for transgender women: listener perceptions, self-perception and satisfaction of the voice

Purpose: This study measured and compared the short-term impact of pitch elevation training (PET) and articulation-resonance training (ART) in transgender women, on self-perception, satisfaction and masculinity-femininity perceptions of listeners. Methods: A randomized controlled study with cross-over design was used. Thirty transgender women were included and received fourteen weeks of speech training. All participants started with sham training (four weeks), after which they were randomly assigned to one of two groups: one group continued with PET (five weeks), followed by ART (five weeks), the second group received both trainings in opposite order. Participants were recorded four times, in between the training blocks: pre, post 1 (after sham), post 2 (after training 1) and post 3 (after training 2). Participants did a self-evaluation through the Trans Woman Voice Questionnaire (TWVQ) and visual analogues scales (VAS) concerning their self-perception and satisfaction. Two listening experiments (n = 75) were conducted researching the continuous masculinity-femininity rating (through a VAS) and categorical masculinity-femininity attribution. Results and conclusions: Transgender women perceive their voices more feminine after the training and experience a positive impact on the vocal functioning and the voice-related impact on their daily life. However, a lot of the participants acknowledge that they need more speech training after ten weeks. Listeners rate the participants' voices more feminine after training, both during the continuous and categorical questions. Higher femininity scores were detected during self-perception and listener perceptions after the combination of both ART and PET, compared to the separate trainings. No order effects were detected between ART and PET, both for self-perception and listener perceptions. Defining outcome predictors is crucial in future research.

Voice Outcome of Glottoplasty in Trans Women

PURPOSE

This study investigates the short- and longer-term effects of glottoplasty up to six months after surgery on acoustic voice parameters, listener perceptions, and client's satisfaction in trans women. Secondly, the impact of chondrolaryngoplasty and voice therapy on the glottopasty outcomes was investigated.

METHOD

A prospective longitudinal non-controlled trial was used. Thirty-five trans women undergoing glottoplasty or a combination of glottopasty and chondrolaryngoplasty were included in this study. A voice assessment was conducted before surgery and 1 week, 1 month and 6 months after surgery. The following outcome parameters were measured: fundamental frequency (fo), intensity, frequency and intensity range, Dysphonia Severity Index (DSI), Acoustic Voice Quality Index (AVQI), Voice Handicap Index (VHI), Trans Woman Voice Questionnaire (TWVQ), and visual analogue scales (VAS) measuring client's satisfaction. Listener perceptions of masculinity-femininity were collected using a listening experiment.

RESULTS

Significant differences over time were found for all fo and intensity parameters, DSI, AVQI, VHI and TWVQ scores. Listener perception and self-perception of femininity was higher after surgery. Significant differences in evolution of listener perceptions were found between the groups with and without voice therapy.

CONCLUSION

Glottoplasty improves voice related quality of life and is an effective method to increase the fo and associated perceptual femininity. After glottoplasty an immediate and short-term decrease in voice quality, vocal capacity and frequency range was measured with a progressive recovery on the longer term. Long term side effects of glottoplasty are a reduction in speaking intensity and intensity range. Voice therapy seems to improve the outcomes of glottoplasty, but should be further investigated in future studies.

Intonation Parameters in Gender Diverse People

OBJECTIVES/HYPOTHESIS

Although intonation is often addressed in speech training for gender diverse individuals, the relationship between intonation and femininity/masculinity ratings remains unclear. The aim of this study was to examine differences in intonation parameters in gender diverse individuals. Moreover, the relationship between acoustic intonation parameters and femininity/masculinity ratings was investigated.

METHODS

Speech samples of semistructured speech were elicited from cisgender (cis) (107 ciswomen, 104 cis men), transgender (trans) (19 trans women, 10 trans men), and non-binary (n = 11) individuals using a prosody protocol. An objective acoustic analysis was performed to compare intonation parameters (upward/downward/flat intonation shift, general and final intonation shift, general fundamental frequency range, fundamental frequency variation index) between groups. In addition, a listening experiment was conducted, consisting of a cis and gender diverse listening panel (n = 41). The listeners were asked to rate the femininity/masculinity of speech samples (n = 57) using a visual analogue scale. Correlational analyses were used to examine the relationship between intonation parameters and femininity/masculinity ratings.

RESULTS

Similarity was found in the intonation parameters of participants with a similar gender identity. In non-binary speakers, no significant differences in acoustic intonation parameters were found between these speakers and the cisgender speakers. In addition, no significant correlations were found between the acoustic intonation parameters and the femininity/masculinity ratings in the groups with cis men, cis women, and non-binary participants. However, moderate to strong significant correlations were found between acoustic intonation parameters and femininity/masculinity ratings in the trans participants.

CONCLUSIONS

Intonation is a "speech marker" that distinguishes between groups with a different gender identity. No relationship was observed between intonation and femininity/masculinity ratings for cisgender and non-binary speakers. However, the significant relationship between these parameters for transgender participants (trans men and trans women) provides evidence for intonation exercises in gender affirming voice, speech, and communication training, and therefore contribute to evidence-based intonation training in transgender persons.

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.

Innovation in speech-language pathology research and writing: Transdisciplinary theoretical and ethical perspectives on cultural responsiveness

In this paper, we offer three paths for the development of innovation in speech-language pathology (SLP), which enhance the discipline's capacity to address issues of diversity, inclusion and cultural responsiveness: transdisciplinary theoretical research, researcher reflexivity, and changes in ethical standards. First, we engage in a reflective conversation to identify facilitators and barriers to innovation we have encountered as academics who speak and write from personal and professional positionings that move between the privileged and the marginalised. Second, we present the results of a critical discourse analysis of the 2020 revisions to Speech Pathology Australia's Code of Ethics and characterise recent changes in the field's expanding understanding of ethical research and clinical practices. Third, we discuss how speech-language pathologists might reconsider their modes of engagement with clients and research populations in our shared area of specialisation-transgender voice. Together, these insights can support speech-language pathologists in further developing a contemporary, self-reflective, culturally humble and responsive professional culture.

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.

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.

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.

Voice-Gender Incongruence and Voice Health Information-Seeking Behaviors in the Transgender Community

Purpose Voice-gender incongruence has predominantly been investigated in the past through the perspective of feminine-identifying individuals seeking feminine-sounding voices. The purpose of this study was to determine the prevalence of self-reported voice-gender incongruence in the transgender, nonbinary, and gender-nonconforming (TNG) community and to describe health information-seeking behaviors exhibited when individuals attempt to address their voice and communication challenges. Method An online survey was designed with questions targeting the self-reported prevalence of voice-gender incongruence, characteristics of this complaint, and health information-seeking behaviors. Valid standardized measures, including the Voice Handicap Index and the Barriers to Help-Seeking Scale, were also included. Results Four hundred five participants were sorted into three groups based on gender identity (feminine, masculine, gender-neutral) to facilitate comparative analysis. Ninety-six percent of participants reported the experience of voice-gender incongruence in the past, and 88% reported that they currently experience voice-gender incongruence. There were no significant differences in reported voice-gender incongruence between groups. Voice Handicap Index scores were significantly higher for those who currently experience voice-gender incongruence (p < .0001) and reflected differences in how much this concern bothers participants, as rated on a Likert scale, ranging from no problem to a very big problem (p < .0001). Barriers to Help-Seeking Scale scores indicated that the masculine group perceived greater barriers to seeking help as compared to the feminine group. Discussion We present foundational evidence for the prevalence of voice-gender incongruence within the TNG community and barriers encountered when individuals attempt to access care. Future work should investigate the specific needs of subgroups within the TNG community and whether those who desire feminine-, masculine-, and/or androgynous-sounding voices experience voice-gender incongruence and access to services differently. Supplemental Material https://doi.org/10.23641/asha.12462422.

Forces Affecting Voice Function in Gender Diverse People Assigned Female at Birth

OBJECTIVES

The purpose of this study was to explore the factors and practices that have acted as facilitators or barriers to voice function in gender diverse people assigned female at birth (GD people^AFAB) from a participant-centered perspective and to inform the role of speech-language pathologists in supporting GD people^AFAB with developing and maintaining functional voice production.

METHODS

Transcripts of semistructured interviews with 14 German-speaking GD people^AFAB were analyzed for the study objectives using a consensual approach to qualitative content analysis. The interviews and their interpretation were conceptualized as co-constructions of participants and researchers who were regarded as experts in their own right.

RESULTS

Professional practices (testosterone treatment, professional voice support), speaker practices (self-care and voice use practices, self-evaluation of voice function), conversation partner practices, and supraindividual biocultural forces (vocal demands, normative practices, other biocultural forces) were identified as having influenced the participants' voice function. Professional voice support, a range of phonation practices, and general self- and voice care practices were frequently cited facilitators of functional voice production. The most frequent barriers to voice function included testosterone treatment, slouched posture, excess muscle tension, forceful voice use, and avoidance practices.

CONCLUSIONS

Voice function in GD people^AFAB is influenced by interactions of several forces, most of which may be shared by voice users of all genders. Professional practices should follow a person-centered approach to care in which all parties are well informed of the limitations and possibilities for any intervention, including the often-unquestioned contribution of testosterone treatment.