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Therapeutic Techniques

Therapy may take place in an individual or group setting. The most common focus in transgender voice therapy is pitch raising or lowering; however, other gender markers may be more important for the client to work on. Clients and clinicians should discuss goals of therapy to ensure that they are working together toward the voice that most fits the person's gender identity.

In a review of speech literature, Davies and Goldberg (2006) were unable to find any clear protocols for treating the female to male (transgender man) voice. Based on the protocols they found for treating the male to female (transgender woman) voice, they proposed the following therapeutic techniques for both voice feminization and masculinization:

1. Imitation of non-transgender people observed in daily life.

2. Progressively complex practice while maintaining good voice quality.

3. Vocal flexibility exercises to maintain vocal range and voice quality.

4. Motor training.

5. Identifying and altering voice qualities when coughing, laughing, and clearing the throat.

6. Experimentation with a broad range of voice styles.

While there is some evidence for the effectiveness of voice therapy for transgender people, it is still weak. In a 2012 review by Oates (as referenced in Davies, Papp, and Antoni, 2015) of the literature on transgender voice therapy, 83% of studies were found to be at the lowest level of the evidence hierarchy for evidence-based practice, and the remaining 17% were also at low levels. However, research does show that transgender clients who have had voice therapy have high satisfaction with the results, and there is a strong consensus among speech language pathologists (SLPs) as to what are strong markers of speaker gender in voice.

Non-Verbal Communication

Non-verbal communication may have more of an effect on a transgender person's readability than verbal factors such as pitch or resonance. Regardless of what is most effective, congruency between a person's visual and auditory gender presentation contributes greatly to their perceived authenticity. Non-verbal communication includes posture, gesture, movement, and facial expressions. In a discussion of the differences between masculine and feminine non-verbal behaviour, Hirsch and Boonin (2012) describe feminine communication as generally more fluid and continuous. Examples of feminine non-verbal communication behaviours include more smiling, expressive and open facial expression, more side-to-side head movement, and more expressive finger movements than men. Deborah Tannen's book, You Just Don't Understand (1990) is referred to by the authors as a seminal work on the difference in male and female non-verbal communication.

Within the speech therapy context, non-verbal communication may be targeted through encouragement of focused observation, offering feedback on the client's self-defined non-verbal goals, offering information about the differences between male and female non-verbal communication, and/or referring to peer support or expert services.

Psychosocial Factors

While some specific psychosocial issues faced by transgender people are often addressed through psychotherapy, there are psychosocial factors that can influence transgender voice therapy. For example, some clients feel that hormone therapy for transitioning changes concentration and emotional stability, which could affect receptiveness to speech therapy. Davies and Goldberg (2006) also note that an altered voice may feel inauthentic, and it may take time for the client to feel as if their new voice is an expression of their true self.

Trans erasure describes systematic, individual, or organizational discrimination against transgender people. Informational erasure and institutional erasure were identified in a 2009 Canadian study of health care for transgender people as being the most prominent barriers to care. Informational erasure involves a lack of knowledge, or a perceived lack of knowledge, about transgender health care. This may manifest itself in health care providers being more reluctant to treat transgender clients because of an unwillingness to find information about their specific population. Institutional erasure describes policies that do not accommodate transgender identities or bodies. For example, forms, texts, or prescriptions may refer to a person by an unpreferred name or pronoun. Issues of erasure may hinder a transgender person's ability to find speech therapy services, or may affect the person's comfort with speech therapy.

In addition to paying attention to problems of erasure, Adler and Christianson (2012) suggest that a clinician should be sensitive to the following areas when working with a transgender client:

• Gender attribution and discrimination
• Possible feelings of shame and guilt
• Consequences of the coming out process
• Spouse, partner, or family attitudes
• Employment issues
• Incidence of HIV/AIDS
• Racial and cultural differences

The authors note that this is not an exhaustive list of possible psychosocial factors, and that every client is different. Psychosocial factors such as these may affect a transgender client's progress and prognosis in speech therapy.

Controversy

There are two major areas of controversy for professionals working on transgender voice. The first is regarding vocal surgery, and the second is regarding bigender voice therapy.

Professional opinion is mixed regarding the use of vocal surgery. There is currently a lack of outcome data, particularly longitudinal data, for pitch-elevating surgery, and outcomes have not been well-monitored over time. Because of this, some SLPs do not think that phonosurgery is a viable treatment option. Others believe it is, and still others believe it should be considered only as a "last resort" after the desired pitch change has not been seen in therapy. Critics cite variability in outcome, lack of outcome data, and reported negative effects like compromised voice quality, decreased vocal loudness, adverse impact on swallowing/breathing, sore throat, wound infection, and scarring as reasons to avoid vocal surgery. Proponents argue that surgery may protect a person's voice from damage caused by repetitive strain to elevate pitch in therapy. Ultimately, the decision to undergo surgery is up to the patient, with input from a knowledgeable physician and SLP.

There is also some controversy regarding the use of a bigender voice. A person may want to have both a masculine and a feminine voice in their vocal repertoire, possibly to fit with their own bigender identity, or to read as a different gender in different contexts. Many clinicians will not train bigender voice, arguing that it decreases the opportunity for practice, and it may be difficult or even damaging to the vocal folds for the person to switch from one voice to another. However, Davies, Papp and Antoni (2015) reference the ability of actors to use different accents and dialects, and people to learn different languages as a sign that training a bigender voice may be a viable treatment goal.

Bibliography for Transgender Voice Therapy Article

Oates J & Dacakis G (1983). "Speech pathology considerations in the management of transsexualism: a review." British Journal of Disorders of Communication 18(3).

Spencer, L. (1988). "Speech characteristics of male-to-female transsexuals: a perceptual and acoustic study." Folia Phoniatrica 40.

Wolfe V, Rutusnik D, Smith F, & Northrop F. (1990). "Intonation and fundamental frequency in male-to-female transsexuals." Journal of Speech and Hearing Disorders 55(1).

Brown M, Perry A, Cheesman A & Pring T (2000). "Pitch change in male-to-female transsexuals: has phonosurgery a role to play?" International Journal of Language & Communication Disorders 35:1.

^crico-thyroid surgery

Dacakis, Georgia et al. (2012) Development and Preliminary Evaluation of the Transsexual Voice Questionnaire for Male-to-Female Transsexuals. Journal of Voice Volume 27,( 3): 312 - 320

Gelfer, M. and K. Schofield (2000). "Comparison of acoustic and perceptual measures of voice in male-to-female transsexuals perceived as female versus those perceived as male," Journal of Voice 14(1).

Davies, S., Papp, V. G., & Antoni, C. (2015). Voice and Communication Change for Gender Nonconforming Individuals: Giving Voice to the Person Inside. International Journal Of Transgenderism, 16(3), 117-159. doi:10.1080/15532739.2015.1075931

See also:

http://www.wpath.org/ World Professional Association for Transgender Health

http://transhealth.ucsf.edu/ University of California, San Francisco Center of Excellence for Transgender Health

Notes

difficult to find meta-analyses and reviews. Look into possibly controversy re: surgery, therapy, etc.

To add to page: better structure, pictures? More information about therapy, and specific surgery techniques. Clear, referenced information.

Davies, S., Papp, V. G., & Antoni, C. (2015). Voice and Communication Change for Gender Nonconforming Individuals: Giving Voice to the Person Inside. International Journal Of Transgenderism, 16(3), 117-159. doi:10.1080/15532739.2015.1075931