Perceived gender and client satisfaction in transgender voice work: comparing self and listener rating scales across a training program

Can acoustic measurements predict gender perception in the voice?

PURPOSE

To determine if there is an association between vocal gender presentation and the gender and context of the listener.

METHOD

Quantitative and transversal study. 47 speakers of Brazilian Portuguese of different genders were recorded. Recordings included sustained vowel emission, connected speech, and the expressive recital of a poem. Subsequently, four scripts were used in Praat to extract 16 acoustic measurements related to prosody. Voices underwent Auditory-Perceptual Assessment (APA) of the gender presentation by 236 people [65 speech and language pathologist (SLP) with experience in the area of the voice (SLP), 101 cisgender people (CG), and 70 transgender and non-binary people (TNB)]. Gender presentation was evaluated by visual analogue scale. Agreement analyses were executed among quantitative variables and multiple linear regression models were generated to predict APA, taking the judge context/gender and speaker gender into consideration.

RESULTS

Acoustic analysis revealed that cis and transgender women had higher median fundamental frequency (fo) values than other genders. Cisgender women exhibited greater breathiness, while cisgender men showed more vocal quality deviations. In terms of APA, significant differences were observed among judge groups: SLP judged vowel samples differently from other groups, and TNB judged speech samples differently (both p<0.001). The predictive measures for the APA varied based on the sample type, speaker gender, and judge group. For vowel samples, only SLP judges had predictive measures (fo and ABI Jitter) for cisgender speakers. In number counting samples, predictive measures for cisgender speakers included fomed and HNR for CG judges, and fomed for both SLP and TNB judges. For transgender and non-binary speakers, predictive measures were fomed for CG and SLP judges, and fomed, CPPs, and ABI for TNB judges. In the poem recital task, predictive measures for cisgender speakers were fomed and HNR for both SLP and CG judges, with additional measures of cvint and sr for CG judges, and fomed, HNR, cvint, and fopeakwidth for TNB judges. For transgender and non-binary speakers, the predictive measures included a wider range of acoustic features such as fomed, fosd, sr, fomin, emph, HNR, Shimmer, and fo peakwidth for SLP judges, and fomed, fosd, sr, fomax, emph, HNR, and Shimmer for CG judges, while TNB judges considered fomed, sr, emph, fosd, Shimmer, HNR, Jitter, and fomax.

CONCLUSIONS

There is an association between the perception of gender presentation in the voice and the gender or context of the listener and the speaker. Transgender and non-binary judges diverged to a higher degree from cisgender and SLP judges. Compared to the evaluation of cisgender speakers, all judge groups used a greater number of acoustic measurements when analyzing the speech of transgender and non-binary individuals in the poem recital samples.

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

INTRODUCTION

Gender affirming voice training is a service provided by speech language pathologists to members of the trans and gender diverse community. While there is some evidence to support the effectiveness of this training, the evidence base is limited by a lack of prospective studies with large sample sizes. Finally, there has been only limited research investigating the effectiveness of this training when delivered on intensive (compressed) schedules, even though such schedules are used in clinical practice and may have practical benefits such as increasing service access for this vulnerable population.

METHODOLOGY

This study aimed to investigate and compare the effectiveness gender affirming voice training among 34 trans individuals presumed male at birth aiming to develop a perceptually feminine/female-sounding voice. Among these 34 participants, 17 received their training on a traditional schedule (one 45-minute session per week over 12 weeks) and 17 on an intensive scheduled (three 45-minute sessions per week over 4 weeks). Building on a previous mixed methodological study which indicated that these two training groups were equally satisfied with training outcomes, the current study utilised a wide range of self-report, acoustic, and auditory-perceptual outcome measures (including self-ratings and listener-ratings of voice) to investigate training effectiveness.

DISCUSSION

Results from this study indicated that both training programs were similarly effective, producing positive statistically significant change among participants on a range of outcome measures. Participants in both groups demonstrated significant auditory-perceptual and acoustic voice change and reported increased satisfaction with voice, increased congruence between gender identity and expression, and a reduction in the negative impact of voice concerns on everyday life. However, as has been the case in past studies, training was not sufficient for all participants to achieve their goal of developing a consistently feminine/female-sounding voice.

CONCLUSION

This study provides evidence to suggest that gender affirming voice training for transfeminine clients may be similarly effective whether delivered intensively or traditionally. This study provides evidence to support the practice of using a wide range of outcome measures to gain holistic insight into client progress in gender affirming voice training programs.

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.

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.

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.

Exploring Motives and Perceived Barriers for Voice Modification: The Views of Transgender and Gender-Diverse Voice Clients

PURPOSE

To date, transgender and gender-diverse voice clients' perceptions and individual goals have been missing in discussions and research on gender-affirming voice therapy. Little is, therefore, known about the client's expectations of therapy outcomes and how these are met by treatments developed from views of vocal gender as perceived by cisgender persons. This study aimed to explore clients' individual motives and perceived barriers to undertaking gender-affirming voice therapy.

METHOD

Individual, semistructured interviews with 15 transgender and gender-diverse voice clients considering voice therapy were conducted and explored using qualitative content analysis.

RESULTS

Three themes were identified during the analysis of the participants' narratives. In the first theme, "the incongruent voice setting the rules," the contribution of the voice on the experienced gender dysphoria is put in focus. The second theme, "to reach a voice of my own choice," centers around anticipated personal gains using a modified voice. The third theme, "a voice out of reach," relates to worries and restricting factors for not being able to reach one's set goals for voice modification.

CONCLUSIONS

The interviews clearly indicate a need for a person-centered voice therapy that starts from the individuals' expressed motives for modifying the voice yet also are affirmative of anticipated difficulties related to voice modification. We recommend that these themes should form the basis of the pretherapy joint discussion between the voice client and the speech-language pathologist to ensure therapy goals that are realistic and relevant to the client.

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.

A Study on Reliability and Validity of the Simplified Chinese Version of the Trans Woman Voice Questionnaire

PURPOSE

This study aims to translate the English version of the Trans Woman Voice Questionnaire (TWVQ) to simplified Chinese (TWVQ-SC) and to examine its reliability and validity.

METHOD

Standardized translation procedures were strictly followed for the translation of the TWVQ. Two hundred sixty trans woman and 128 cis woman subjects completed sociodemographic investigation, the TWVQ-SC, and the Voice Handicap Index-10 (VHI-10) online. Internal consistency was examined by Cronbach reliability coefficient (Cronbach α). Test-retest reliability was quantified by intraclass correlation coefficient (ICC). Content validity, structural validity, and discriminant validity were examined by expert panel's judgment, factor analysis, Spearman's rank correlation coefficient, and the Mann-Whitney U test.

RESULTS

The Cronbach α of the TWVQ-SC was .969 and the ICC was .841, indicating excellent internal consistency and good test-retest reliability. The four principal factors explained 21.345%, 18.592%, 13.551%, and 12.027% of the variance respectively with the cumulative contribution rate 65.514%. There was a strong correlation between the total score of the TWVQ-SC and that of the VHI-10 (r = .858, p < .001), indicating good structural validity. The total score of the TWVQ-SC of the trans woman subjects was significantly higher than that of the cis woman subjects (z = 14.590, p < .05), indicating good discriminant validity.

CONCLUSION

The TWVQ-SC exhibits overall high reliability and validity, qualified to be applied as a reliable clinical tool to evaluate trans women's voice in mainland China.

Inferential Statistics Is an Unfit Tool for Interpreting Data

Null hypothesis significance testing is a commonly used tool for making statistical inferences in empirical studies, but its use has always been controversial. In this manuscript, I argue that even more problematic is that significance testing, and other abstract statistical benchmarks, often are used as tools for interpreting study data. This is problematic because interpreting data requires domain knowledge of the scientific topic and sensitivity to the study context, something that significance testing and other purely statistical approaches are not. By using simple examples, I demonstrate that researchers must first use their domain knowledge—professional expertise, clinical experience, practical insight—to interpret the data in their study and then use inferential statistics to provide some reasonable estimates about what can be generalized from the study data. Moving beyond the current focus on abstract statistical benchmarks will encourage researchers to measure their phenomena in more meaningful ways, transparently convey their data, and communicate their intellectual reasons for interpreting the data as they do, a shift that will better foster a scientific forum for cumulative science.

Masculinization Laryngoplasty

A description of pitch reduction thyroplasty has been around for decades, primarily used for high-pitched voice disorders in cisgendered men. Currently, the application of an Isshiki type III thyroplasty and its modifications is mainly used in transgendered men who fail to achieve sufficient pitch reduction from speech therapy and masculinizing gender-affirming hormone therapy. The current state of the procedure with a description of commonly used modifications is reviewed.