Transgender Voice Therapy

Published: October 16th, 2020

Category: Local News, UAD Student Blog

TG therpay image

By: Macarena Gonzalez, Louie Gross, and Amy Meltzer

Speech language pathologists (SLPs) play a vital role in helping transgender individuals achieve voicing congruent with their gender identity. Clinicians can work with patients to modify an array of speech parameters relevant to gender perception in communication, including vocal pitch, resonance, rate of speech, volume of speech, intonation, articulation, pragmatics, semantics, syntax, and nonverbal communication (McCready et al., 2011). Clinicians counsel patients in how their voice may change as a result of hormone therapy or surgical interventions. They may also help patients address the slew of emotions that can accompany vocal changes. Throughout the voice transition process, SLPs promote healthy vocal behaviors and preventing vocal injury (Babajanians, 2019).

Glossary

Sex: the set of biological characteristics that define an individual, including chromosomes and hormones

Gender: the set of socially constructed characteristics that define an individual’s role in society, including norms, roles, and relationships

Transgender: individuals whose gender does not match the sex they were assigned at birth

Female to Male (FtM): individuals who were assigned female at birth whose gender identity is male

Male to Female (MtF): individuals who were assigned male at birth whose gender identity is female

Gender Dysphoria: a medical diagnostic term referring to a conflict between an individual’s assigned gender and the gender which they identify with (American Psychiatric Association, 2016)

Why should SLPs be concerned with treating transgender voice?

Research shows that transgender individuals experience heightened risk for eating disorders, harassment, victimization, medical discrimination, anxiety, depression, and suicide due to gender dysphoria (Cooper et al, 2020). Best practice in treating gender dysphoria is to facilitate an individual’s comfort in their gender expression (American Psychiatric Association, 2016). Studies suggest that a speaker’s voice is one of the strongest markers of gender (ASHA, n.d.).

Voice feminization and masculinization yield reductions in gender dysphoria, improvements in mental health, and enhanced quality of life (Davies, Papp, & Antoni, 2015). Specially trained SLPs are the professionals most equipped to provide this treatment alongside medical management (Schneider and Courey, 2016).  Ethically, SLPs should show the same level of concern for this population as any other in our field.

What treatments can SLPs implement?

There are a number of vocal exercises an SLP might employ during therapy sessions. Vocal function exercises strengthen the larynx and increase vocal flexibility. For example, pitch gliding low to high can target stretching, and pitch gliding high to low can target contracting. Resonant voice therapy can make a voice more authentic by reducing vocal effort through a sequence of humming, sighing, and chanting (McCready et al., 2011).

Feminization of voice can be encouraged by increasing upward inflections, as well as having more varied inflections within utterances. Feminization of nonverbal communication can be shaped by increasing the fluidity of hand gestures, incorporating whole body movements, nodding the head while listening, maintaining eye contact, and smiling in conversations. Meanwhile, masculinization of nonverbal communication can be shaped by keeping the head static, listening in a backward position, having more reserved gestures, breaking eye contact, and using more aggressive facial expressions. (McCready et al., 2011).

Overall, voice therapy is an intensive process. It initially involves extensive practice and effort, but ultimately results in generalization of an authentic voice (Babajanians, 2019).

What other treatments can transgender patients pursue?

Often, transgender individuals are not satisfied alone with speech therapy to alter their voice. For MtF patients looking to feminize their voice, surgical interventions are another option for achieving a vocal pitch closer to their gender identity.

Wendler’s Glottoplasty
This involves connecting the anterior 1/3 of vocal folds with sutures. The remaining 2/3 then act as female length vocal folds and yield a slightly higher pitch after healing.

 Pros Cons
– Patients achieve higher pitch with Wendler’s comparatively after also undergoing a CTA.
– Reported feminization lasting up to 4 years after surgery.
– No scarring in the neck
-Excessive feminization of the voice may result from the creation of a laryngeal membrane that is too large
– Mixed self-reported satisfaction
– Granulomas may appear in the suture zone.

(Casado, et al. 2016)

Feminization Laryngoplasty
Laryngoplasty shortens the vocal cords using an endoscopic, minimally-invasive laser-assisted procedure. It is best to combine with Cricothyroid Approximation (CTA), which sutures the cricothyroid muscle into a permanent position of contraction.

Pros Cons
– Ideal for those with an already high pitch, androngynous voice

– Pitch can be increased 50 Hz in some cases.

– Dynamic voice range, optimal for singers.

– Not ideal for those with low or average male speaking pitch
– More natural lower pitch range is preserved, which can be undesirable for some clients.
– Cannot stretch, thin, or tighten vocal folds.

(Center for the Care of The Professional Voice, 2020)

Overall, counseling should be implemented prior to the surgery to discuss realistic expectations. Furthermore, voice rest and post-surgical voice therapy modulation treatment should be conducted in order to achieve an optimal result in the feminization of the voice in MtF transgendered clients.

References

Babajanians, T. (2019). Giving Voice to Gender Expression. The ASHA Leader, 24(2), 54–63. https://doi.org/10.1044/leader.FTR2.24022019.54

Casado, J., Rodriguez, M., & Adrian J.. (2016) Voice feminization in male-to-female transgendered clients after Wendler’s glottoplasty with vs. without voice therapy support.
https://link.springer.com/article/10.1007/s00405-016-4420-8

Crutchley, S., Adler, R., Pickering, J., & McCready, V. (2010). The Role of the SLP in Transgender Communication. https://www.asha.org/events/convention/handouts/2010/1569-crutchley-sena/

Davies, S., Papp, V. G., & Antoni, C. (2018). International Journal of Transgenderism Voice and Communication Change for Gender Nonconforming Individuals: Giving Voice to the Person Inside. https://doi.org/10.1080/15532739.2015.1075931

Feminization (2020). Center for the Care of The Professional Voice
https://professionalvoice.org/feminization.aspx

Gray, M. L., & Courey, M. S. (2019). Transgender Voice and Communication. In Otolaryngologic Clinics of North America (Vol. 52, Issue 4, pp. 713–722). W.B. Saunders. https://doi.org/10.1016/j.otc.2019.03.007

Nolan, I. T., Morrison, S. D., Arowojolu, O., Crowe, C. S., Massie, J. P., Adler, R. K., Chaiet, S. R., & Francis, D. O. (2019). The role of voice therapy and phonosurgery in transgender vocal feminization. Journal of Craniofacial Surgery, 30(5), 1368–1375. https://doi.org/10.1097/SCS.0000000000005132  https://journals-lww-com.lp.hscl.ufl.edu/jcraniofacialsurgery/Fulltext/2019/07000/The_Role_of_Voice_Therapy_and_Phonosurgery_in.16.aspx

[Temple University Transgender Voice Therapy]. (n.d.). https://whyy.org/articles/temple-voice-therapy-program-speaks-to-transgender-women/

TG Voice Therapy. (n.d.). Transgender voice therapy [Pinterest post]. Pinterest. Retrieved October 3, 2020, https://www.pinterest.com/pin/226728162477806501/

What Is Gender Dysphoria? (2016). American Psychatric Association. https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria

Voice and Communication Services for Transgender and Gender Diverse Populations: Key Issues. (n.d.). Retrieved October 3, 2020, from https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589944119&section=Key_Issues