User:Kp23/sandbox

Working Bibliography

Suggestions for sources to be used:

Adler, R. K., Hirsch, S., & Mordaunt, M. (2012). Voice and communication therapy for the transgender/transsexual client: A comprehensive clinical guide.

Davies, S. & Goldberg, J. M. (2006) Clinical Aspects of Transgender Speech Feminization and Masculinization, International Journal of Transgenderism, 9:3-4, 167-196, DOI: 10.1300/J485v09n03_08

Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., Fraser, L., Zucker, K. (August 01, 2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism, 13, 4, 165-232.

Hancock, A. B. & Garabedian, L. M. (2013). Transgender Voice and Communication Treatment: A Retrospective Chart Review of 25 Cases. International Journal of Language and Communication Disorders. 48, 54-65, DOI: 10.1111/j.1460-6984.2012.00185.x

Hancock, A. B. & Helenius, L. (2012). Adolescent male-to-female transgender voice and communication therapy. Journal of Communication Disorders. 45, 313-324.

Irwig, M. S. (2016). Testosterone therapy for transgender men. Lancet Diabetes and Endocrinology, The. Elsevier Ltd

Mastronikolis, N. S., Remacle, M., Biagini, M., Kiagiadaki, D., & Lawson, G. (2013). Wendler Glottoplasty: An Effective Pitch Raising Surgery in Male-to-Female Transsexuals. Journal of Voice. 27, 516-522.

Orloff, L. A., Mann, A. P., Damrose, J. F., & Goldman, S. N. (2006). Laser-assisted voice adjustment (LAVA) in transsexuals. The Laryngoscope. 116, 655–660. DOI: 10.1097/01.mlg.0000205198.65797.59

Van Damme S., Cosyns, M., Deman S., Van den Eede, Z., & Van Borsel, J. (2016). The Effectiveness of Pitch-raising Surgery in Male-to-Female Transsexuals: A Systematic Review. Journal of Voice. Article in Press.

Yang. C. Y., Palmer, A. D., Murray. K. D., Meltzer. T. R., & Cohen. J. I. (2002). Cricothyroid approximation to elevate vocal pitch in male-to-female transsexuals: results of surgery. Annals of Otology, Rhinology & Laryngology. 111, 477-485.

Plan to Improve article:

New Structure of Article: Voice Feminization, Voice Masculinization , Therapeutic Techniques , Surgical Techniques, Controversy, Effect of Hormones - might be able to merge into feminization/masculinization

Other things to fix: Change title of article to "Transgender voice therapy". It does not make sense for the title to be Voice Therapy in general, if only transgender voice therapy is being discussed, Terminology? Are feminization and masculinization the most up-to-date terms?, Revise “See Also” section - take out yodelling, Improve sources & citations, More material relevant to topic, Link to phonation article, take out paragraph explaining it, Add pictures

My Contribution:

All of the group members will contribute to the therapeutic techniques section of the article as it is the most important part of the article and the most relevant to us. I will work on the Surgical techniques section of the article. I plan to look up what each of these surgeries entail and write about the procedures briefly. Then I will write how these surgeries affect or are suppose to affect the voice qualities of transgender people. Then I will try to find evidence that supports these surgeries (ie. is there any research that shows that these surgeries are actually effective in voice feminization and voice masculinization).

Voice Therapy

Raising Pitch

The most common concern for male-to-female transgender individuals is their pitch and speaking fundamental frequency (SFF) (the average frequency produced in a connected speech sample) because they typically perceive a feminine voice as using a higher pitch. Although pitch is the not the most essential element of voice change for these individuals, it is necessary to raise the SFF to a gender appropriate pitch to help with vocal feminization. A Speech-Language Pathologist will work with the individual to raise their pitch and provide therapeutic exercises.

The first step in therapy is determining the habitual speaking fundamental frequency of the individual using an acoustic analyzing program. This is accomplished through several tasks including sustained phonation of the vowels /i/, /a/ and /u/, reading a standardized passaged and producing a spontaneous speech sample. Then the therapist and the individual determine what the target pitch should be, based on the gender acceptable range for women (i.e. a socially acceptable pitch based on the average female vocal pitch range). When therapy begins, they establish a starting frequency to work on, that is slightly above the client's SFF. The point is to choose a starting pitch that can be produced without strain or excessive vocal effort. As therapy progresses, the target SFF will gradually increase until the goal has been reached. Progression moves from using the target pitch in a sustained vowel to using it in a 2-5 minute conversation.

Semi-occluded vocal tract (SOVT) techniques may be used to facilitate voice production in the higher pitch range. SOVT techniques include phonating into straws, lip or tongue trilling, and producing multiple speech sounds such as nasals /m/, /n/, voiced fricatives (i.e. /z/, /v/), and high vowels such as /u/ and /i/. There are two exercises that are often used: producing a pitch glide that goes from the middle of the pitch range to the upper pitch range; and a messa di voce exercise, where the voice goes from soft to loud to soft again. SOVT techniques have the individual prolong their voice at a higher pitch, which may help make voice production at a higher, non-habitual pitch easier and more efficient.

Vocal surgeries

While hormone replacement therapy and gender reassignment surgery can cause a more feminine outward appearance for male-to-female transgender individuals, they do little to alter the pitch of the voice or to make the voice sound more feminine. The existing vocal structure can be surgically altered to raise vocal pitch by shortening the folds, decreasing the whole mass of the folds, or by increasing the tension of the folds . Male-to-female transgender individuals can undergo surgery to raise their vocal pitch (as measured by fundamental frequency F0), to increase their pitch range and to remove access to lower frequency ranges in their voice. The current pitch-raising vocal surgeries include:

• Cricothyroid approximation (CTA) (The most common procedure)
  • This surgery tenses and elongates the vocal folds in order to increase vocal pitch. This is done by bringing the cricoid cartilage closer to the thyroid cartilage with sutures or metal plates. The cricoid cartilage is shifted backward and upward and the thyroid cartilage is moved forward and downward. This mimics cricothyroid muscle contraction that tenses and elongates the vocal folds which causes the pitch to increase. .
• Anterior Glottal Web Formation or Anterior Commissure Advancement
  • This surgery shortens the vibrating length of the vocal folds to raise vocal pitch. The tissue of the anterior part of the vocal folds is removed, and then this tissue is sutured together to form a nonvibrating anterior web.
• Laser assisted voice adjustment (LAVA)
  • In this procedure, microlaryngoscopy (a surgical procedure that looks at the vocal folds in great detail) is done in conjunction with a carbon dioxide (CO₂) laser that vaporizes small portions of the vocal folds. When the vocal fold tissue is in the process of healing and scaring, the vocal folds decrease in mass and increase in stiffness. This results in a rise in vocal pitch.
• Laser Reduction Glottoplasty (LRG)
  • This procedure involves using a CO₂ laser to vaporize the anterior part of the vocal folds. Then the vocal folds are tensed with sutures, causing the pitch to increase.

Usually, male-to-female transgender people consider vocal surgery when they feel dissatisfied with voice therapy results, or when they want a more authentic sounding female voice. However, it is important to note that vocal surgery alone may not produce a voice that sounds completely feminine, and voice therapy may still be needed. . Although there has been evidence to show that all these surgeries can be effective in increasing vocal pitch as measured by F0, results have been mixed. However, many patients do report being satisfied with the results. Negative effects from these surgeries have been noted, including reduced voice quality, reduced vocal loudness, negative effects on swallowing and/or breathing, sore throat, infections and scarring. A positive effect of surgery can be protecting the voice from damage due to the strain of constantly elevating pitch while speaking. Because of the risks, vocal surgery is often considered a last resort after vocal therapy has been pursued.

As for female-to-male transgender individuals, it is generally presumed that hormone therapy does successfully masculinize the voice and lower vocal pitch. However, this may not be the case for all female-to-male transgender individuals. Although it is far less common, surgery to lower vocal pitch does exist, and may be considered if traditional hormone therapy did not adequately lower it. Medialization laryngoplasty (or masculinization laryngoplasty) is a procedure where the vocal fold contours are medially augmented with the injection of silastic implants. This mimics the changes that the vocal folds go through during male puberty, which causes a lower sounding voice.