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Joe (he/they) is a healthy 30-year-old transgender male undergoing testosterone therapy for their transition from female to male. Joe is seeking out the services of a communication professional to learn how to use their voice in a more masculine way. In particular, Joe wants to work on pitch, resonance, and how to express different emotions.

This case study centers around gender-affirming voice therapy. What does a communication professional need to know in order to best serve Joe?

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Characteristics of Communication in Transgender FTM Voice

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Characteristics of Communication in Transgender FTM Voice

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Pitch --> Typically, women speak at a higher pitch than men, around an octave higher. For adult women, the average pitch range is between 165 - 255 Hz, while an adult man's pitch is 85 - 155 Hz. This difference in pitch is caused by the presence of testosterone, which can thicken the vocal folds resulting in a deeper-sounding pitch.

Intonation -->

T-voice: A well-known event that commonly occurs in those undergoing testosterone therapy.

It can cause a buzzy/strained sound that is a result of one's vocal folds experiencing a change in the form of the folds thickening, but not lengthening yet.

Paralanguage --> How people use nonverbal language to emphasize the point they are trying to convey.

Women tend to use paralanguage in communication much more than men do. However, there are key aspects that can make communication more masculine.

Common paralanguage used by men includes...

Gestures --> Men often use sharp and direct motions, while women tend to use more fluid motions with their hands. Men also tend to nod less than women during communication

Facial expressions/Body language--> Women tend to smile more when communicating while men tend to maintain a stronger sense of eye contact.

While there is no exact role of paralanguage for each gender, males and females tend to follow subconscious patterns of communication. For individuals who wish to modify their communication style, gender-affirming care may be advantageous.

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A survey conducted by Matthews et al. of over 350 working SLP’s and SLP students assessed that around 80% of those surveyed believe transgender care to be part of their practice, yet only around 20% had received any training for doing so, and an even smaller percentage had actually worked with transgender clients.

Cultural Competence in Transgender Care

SLP Practitioners should be able to respond to the needs of diverse clients.

Knowledge Skills and Attitude (Van De Bergh & Crisp, 2004)

When working with LGBTQ clients, acquiring knowledge includes learning the history of the community, knowing relevant terms and kinesics, understanding the discrimination the community has faced, and the policies that may work for or against the community.

‘Skills’ means having the ability to create a safe environment for any given client and providing affirming services.

‘Attitude’ involves self-reflection and understanding implicit biases one may have towards a certain group of people.

By building knowledge, skills, and attitude, a practitioner can work towards building cultural competence.

Perception of LGBT+ youth can be affected by factors such as geographic location and socio-economic status

According to the survey, the amount of SLP’s and students who believe gender affirming voice therapy to be a medical necessity is larger in number in the west (75%) than in the south (61%)

Based on the survey, while many SLP students and practitioners believe that transgender care is an important part of the job, there has been lack of training towards this topic and a majority of SLP's do not possess the knowledge necessary to properly care for transgender individuals.

Matthews et al. have proposed training methods including

Graduate courses that cover the extent of the issue such as multicultural issues

Including sessions about the topic at conventions or conferences

Seminars for both graduate students and practicing professionals.

Above all, cultural competency should be prioritized when serving transgender clients.

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Discrimination - "the transgender community faces more discrimination, misunderstanding, and cultural missteps than the larger community, with over 70% of transgender and gender nonconforming people surveyed by Lambda Legal reporting at least one experience of discrimination in health care, including being refused care and experiencing physical or verbal abuse (Lambda Legal, 2010)."

Barriers to Quality Care –

Gatekeeping - Healthcare professionals block access to care due to stigma and/or unfair judgments made

Finances - Lack of income, insurance does not cover voice therapy, lack of insurance

Access to Care - Lack of access to the service, limited access to quality care

Approach to Therapy

clients often have goal of "passing" which is problematic due to reinforcing the belief that people perceived to be the gender they were assigned at birth are better than those who are transgender.

Metatherapy - clients can create their own goals as they think about therapy and their communication goals. They have the opportunity to define their identity "and their communication and gender expression in relationship to that identity."

Modeling - client-led therapy, chosen from diverse options presented. Clients practice a continuum of expressive techniques to determine their preferences.

Clinical program at NCCU followed Two Clients

Both clients struggled with some level of both:

dysphoria due to their assigned gender and how they have been perceived and

distrust of the medical community

So, trust was built through empathy and allowing the clients to lead or slow down the therapy as needed.

In addition, clients had plenty of time to process their identities and determine how they wanted to express their gender going forward.

Both clients decided on the pronouns they wanted to use during the therapy process, as inititially one was very unsure and accepted all pronouns while the other initially wanted he/him and switched to they/them.

Mental health, including anxiety, depression and social anxiety are important to address, especially in group therapy settings before the client can gain comfortability.

The client's support network should also be considered, in imagining how the client will present themself going forward. One client ultimately needed to cut ties with multiple people in order to confidently move forward in their chosen identity.

Singing was the key for both clients to finally reach their goals. JR reached an average of 130 Hz with chest resonance and masculine intonation, without testosterone therapy. Their goal was to get consistently gendered male over the phone and this was achieved successfully through the program.

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The connection between voice and quality of life is well documented ( Hancock et al., 2011; Murry et al., 2004). Transgender people have frequently reported that their voices do not represent their gender, and they would feel safer and more confident with gender-affirming voice modification ( Söderpalm et al., 2004). Voice and communication therapy may help alleviate gender misidentification and be a positive, motivating step toward achieving gender role expression goals ( Adler et al., 2012).

Despite constituting 4.5% of the U.S. population, the lesbian, gay, bisexual, transgender, queer+ (LGBTQ+) community is still a culture with much uncertainty for much of the service community and the health care community in particular ( Powell, 2018; The Williams Institute, UCLA School of Law, 2019). Yet, the transgender community faces more discrimination, misunderstanding, and cultural missteps than the larger community, with over 70% of transgender and gender nonconforming people surveyed by Lambda Legal reporting at least one experience of discrimination in health care, including being refused care and experiencing physical or verbal abuse ( Lambda Legal, 2010). Understanding the narrow intricacies of this culture is critical to providing high-quality, mentally safe, gender-affirming care.

When a medical professional wields the power of prescription to discriminate toward a transgender individual, it is called "gatekeeping." Gatekeeping has been identified as one of the most significant barriers to successful transgender health care ( Safer et al., 2017). Other barriers include financial issues-including insurance not covering voice therapy, lack of insurance, and lack of income-inadequate service access, and limited access to culturally competent service. Gatekeeping may be stigma against transidentified individuals, but it may also manifest not only as a form of exclusionary practice but also as blocking individuals who do not seem ready to transition ( Williams, 2015). This can result in medical professionals making transition decisions for transgender individuals, and it can impact the statistics of individuals who feel that they have experienced discrimination. This is ultimately a barrier to individuals seeking care.

Clinicians working with transgender clients will encounter a number of gender identities on a spectrum. These identities range from transmen and transwomen who are binary, which would be individuals who identify as the opposite gender as their assigned gender at birth, to a wide variety of nonbinary genders, who identify as genders in between male and female, agender, or beyond the gender binary. At birth, babies are assigned sex without chromosomal testing, and for many people, anatomical structure matches chromosomal structure and the later development of gender identity, which is a social construct. However, with the rise of visibility of transgender and intersex individuals, many professionals now acknowledge that, given that underlying chromosomal factors are rarely known, anatomical sex is no longer a meaningful aspect of identity. The correct terminology is now "assigned male at birth" or "assigned female at birth" in the place of "sex" to identify physical characteristics of sex. Gender identity, on the other hand, reflects an inner sense of gender, and it can manifest in many different ways ( Kelly & Robert, 2018). When seen through a culturally competent lens with a focus on client affirmation, gender identity and gender expression become very individualized and highly nuanced, and the path to guiding a client to a new communication method in expressing that identity becomes a carefully crafted puzzle, specialized for the unique goals and features of the client's voice, sense of self, and desire to be understood as an individual.

"Passing," "stealth," and "clocking" are defined by the idea of being perceived and accepted in society at large as being the opposite sex and whether one is "clocked" or identified as transgender ( Smith & Hao, 2018). However, these concepts and language are considered problematic because they are cisnormative and fortify the idea that only individuals consistently perceived as assigned at birth as their affirming gender are valid ( GLAAD, n.d.). Nonetheless, many clients still approach therapy with the target of passing, and this mentality is reinforced by the literature that focuses on safety, mental health, and quality of life issues related to misgendering, which is directly related to passing ( Smith & Hao, 2018). The findings of these studies still stand, in spite of the outdated constructs. Current approaches, however, encourage identity-affirming communication presentation ( Davies et al., 2015).

According to Hancock and Haskin's (2015) study, although transgender communication is within the speech-language pathologist's (SLP) scope of practice, only 47% of speech-language pathology practitioners indicated that such services were addressed in their master's program and 51% of SLPs were unable to describe transgender communication therapy ( Hancock & Haskin, 2015). Training and education must be expanded for all SLPs in order to adequately serve this population, especially one that can highlight a cultural model. On the website for the World Professional Association for Transgender Health, only 30 voice and speech clinicians in the United States are listed ( World Professional Association for Transgender Health, 2014). This is not enough to meet the clinical needs of this population.

The Office of Multicultural Affairs (OMA) for the past 50 years has been providing the resources to facilitate the clinically and culturally competent care. The course of OMA has run parallel to the progression of increased regard for LGBTQ+ populations in the United States, engendering the communities that work to maintain trust and empathy in the field. The Special Interest Group 14: Cultural and Linguistic Diversity has embraced the LGBTQ+ community as a cultural group. SIG 3: Voice and Upper Airway Disorders and SIG 10: Issues in Higher Education produces research on clinical practice with gender-nonconforming individuals and personnel preparation to help SLPs provide top-of-license (TOL) services for transgender clients. All of this has been done under the purview of the OMA, which also provides resources to help SLPs provide transgender voice services ( American Speech-Language-Hearing Association, 2019). Thus, we recognize the OMA's prevailing focus on diversity of expression and opportunity for all, which supports a culturally competent approach to care that can be achieved for every community.

Therefore, a clinical program was implemented at North Carolina Central University to provide voice modification therapy integrated within a framework for cultural competence for this unique population. The mission was to provide excellence in transgender voice and communication therapy through education, research, and evidence-based clinical service.

This program utilized modeling and metatherapy to maximize opportunities to facilitate achieving the identity that represents the clients. This program avoided all prescriptive models in modification therapy and employed descriptive approaches only. These techniques were achieved via describing commonly perceived gendered features, examples, and wide ranges of communication strategies consistent with reported chosen gender presentation, allowing clients to make judgments on how they felt about models and what they would like to emulate. Furthermore, clients were given opportunities to practice extreme and subtle aspects of targeted-gender communication ( Smith & Hao, 2018). By practicing along this continuum, clients could decide for themselves over time what kind of communication pattern matched their gender expressions. For most clients, no target feels natural at first, and clients often feel as though they are "faking" (Kasi, personal communication, 2019). Practice can be provided until a natural expression emerges.

Therapy was provided via group and individual therapy options. Group therapy provides for generalization and social and emotional support during an intensely vulnerable process. It is also an opportunity to practice and observe the spectrum of gendered communication in real time by talking to each other. Individual therapy implements teaching and drill practice to work toward the client's individualized goals, which gave each client an opportunity to communicate about themselves in a more secure, one-on-one context. This article will present the methodology of applying culturally competent care to transgender clients in a clinical context and analyze the results in two case studies: Kasi, a transfeminine client, and RJ, a transmasculine client.

Method

A model of adapting the unique cultural circumstances of this community must be integrated into this clinical model. Methodologically, a focus on adapting this clinical technique for a culturally competent approach is the gap the health care world must cross in transgender communication care ( Mills et al., 2019). In an effort to decrease gatekeeping in transgender health care, the methods employed for this program highlighted building trust and demonstrating empathy, with the goal that this may construct trust with the larger medical world and increase access to broader health care. Furthermore, by employing focus on self-expression, a secondary goal was to increase the client's ability to communicate themselves in professional, health care, and casual settings ( Mills & Stoneham, 2017). The communication setting focus of therapy follows the client's primary goals, because this can also go a long way in increasing access to environments that gatekeeping can obstruct.

In addition to emphasizing trust and empathy, this program highlighted unique client needs. Clients were exposed to wide varieties of options in their communication modification to meet the heterogeneous needs of this diverse community. These needs are in parallel with the methods of communication among cisgender individuals, with wide spectrums spanning from socially gender conventional behaviors to unorthodox patterns, all differing in millions of microscopic manners. Similarly, transgender voices will have such variety of self-expression, seeking various points along the continuum of femininity, masculinity, and neutrality.

In order to accomplish these twin approaches, the first approach is to listen to what the client wants in terms of their expression as they evolve ( Adler, 2017). Homework and therapy sessions often consist of reflection and observation of their own expressive strategies and those of others as they construct a new approach for themselves. The second approach is to let targets develop and change progressively as client self-understanding and ability changes. This population can be vulnerable to lack of trust in their providers and low self-confidence. Also, unlike most voice practice, these clients come to therapy as part of a larger attempt to modify their presentation ( Davies et al., 2015). Therefore, how the client will communicate with their therapist at the beginning of therapy should be incredibly different from a few months into therapy. Goals must therefore be able to adapt to these changes.

Each of the clinical methods utilized are designed specifically to incorporate the client's cultural background into therapy. Metatherapy highlights the client's opportunities to define their identity as it evolves over time and their communication and gender expression in relationship to that identity. Metatherapy is the practice of thinking about therapy and thinking about communication goals ( Helou, 2017). Therefore, clients can use this method to determine their own fates. Modeling is used to capture a client-led model by not imposing the clinician's values on the clients and giving the clients an opportunity to select their targets from a diversity of option ( Rogers, 1951). Also, by practicing a continuum of expression techniques, clients can refine all of these aspects simultaneously, until the targets do in fact feel natural.

Results

Case Study 1: Kasi

Kasi was a 57-year-old transfeminine client. When they came to therapy, they did not identify with a clearly defined gender identity, a specific pronoun set, or a coherent voice target. They requested to start in group therapy, but as a result of their dysphoria and social anxiety, they clashed with both the other members of the group and the graduate student clinicians working with them. To adapt Kasi's plan of care to a more culturally appropriate model that fit their needs, the first step in their care required listening to their needs. Based on Kasi's circumstances and need for additional opportunities to explore themselves, they were transitioned to individual therapy, not as a method of isolation but as a method of giving customized care. Kasi was struggling with some aspects of transition, and the presence of other people was overwhelming them and triggering anxiety responses, which was causing much of the personality clashes. They were uninterested in pursuing mental health therapy, so it became clear that they required individualized time. As they adapted to the treatment, they were invited to group events to maintain social inclusion, while keeping them focused during individual therapy. Kasi's sense of self started to expand from this individualized approach. By the end of therapy, they still had a very nebulous sense of gender identity and were still accepting most pronouns, but they had a stronger preference for they/them pronouns and had a few clear voice targets and experienced gender euphoria from achieving their goals ( Wiktionary, 2019). As Kasi's treatment approaches changed, their targets naturally shifted as well. This adaptability was very important in Kasi's treatment. At the beginning, Kasi could barely manage vocalizations above 160 Hz and could not achieve feminine resonance, no matter what strategies were tried. Kasi's initial focus was increasing a fairly low fundamental frequency and modification of intonation, because those aspects came most naturally to them through an interest in acting. As Kasi's interest in singing grew, however, they found a new avenue into resonance and their confidence in higher frequencies grew, opening new, more feminine-sounding voices up to them that culminated into a breadth of options from which to choose.

After therapy, Kasi reported being more confident and sure of themselves in their access to quality of life. After therapy, they joined a choir, freed themselves of negative relationships, and made a point to communicate their identity consistently, instead of letting people speak for them metaphorically or literally. Kasi approached voice therapy expecting to be given a voice. Giving Kasi a chance to choose their voice gave them a power that rippled throughout their communication and interactions in all of their life. They found determination and flexibility to adapt, and together with the therapy team, they found a voice that belonged to them.

Case Study 2: JR

Research reveals that administration of testosterone has successfully lowered the vocal pitch of individuals who are assigned female at birth ( Mészáros et al., 2005; Söderpalm et al., 2004). However, there are many transmasculine individuals who may seek voice therapy services for other reasons. Some seek therapy to supplement the effects of the testosterone and to facilitate a smooth vocal pitch decline without tightness, roughness, or "T-voice" (an underresearched but well-known phenomenon in the transgender community characterized as a "strange" and "whiney" sound in the first few months of testosterone use, likely due to fundamental frequency dropping prior to the client learning to achieve a chest resonance, creating the distinctive T-voice sound). Many transmasculine people seek voice therapy to assist in transitioning their singing voice. Many seek communication therapy to transition communication strategies such as intonation, paralinguistics (gestural, nonverbal communication), vocabulary, and resonance. Many transmasculine individuals seek voice therapy because they do not pursue hormone replacement therapy. For one reason or another, testosterone is not an option for many individuals, and these are the most common transmasculine clients seen by SLPs ( Azul, 2014; Block, 2017; Dorman, 2018).

JR was one such client, a 44-year-old individual who described themselves alternatively as nonbinary, agender, and a transman. Like Kasi, JR struggled with a great deal of repressed dysphoria that they could not fully accept in therapy. Gender dysphoria is the feeling of unhappiness as a result of one's gender identity is in conflict with one's gender presentation. When they first started, JR stated that they would like to be called "he/him," but they said they knew that would probably never happen, because they would never "be a man," as they were not on testosterone or attempting a full social transition. Despite this, JR started therapy being addressed with he/him pronouns because of this stated preference. However, as therapy progressed, JR's preference for they/them seemed to assert itself more strongly, so the clinicians discussed pronouns with JR again, and as a result of their evolving preferences, the clinician switched to they/them. JR maintained that they accepted both pronouns throughout the course of treatment.

JR was highly distrustful of medical professionals at the beginning of therapy and remained guarded throughout the course of treatment, never revealing their last name. They did not trust mental health professionals either, so speech pathology was working with them exclusively. They requested to come only once every 2 weeks, partially due to their busy schedule, but partially due to low confidence in the value of this service. The providers listened to JR's needs and adapted to meet their need for privacy, flexibility, empathy, and trust. Over the course of treatment, JR opened up more, spoke about their family, shared about their job, laughed, and requested more sessions with motivation.

Like Kasi, JR truly realized their goals through singing and caught on very quickly. When they found that they could stretch their voice range and master an effective chest resonance through singing their beloved songs in the car on their long drives, JR started practicing relentlessly. Therapy goals were modified from listening to men and drill practice while reflecting and journaling about communication strategies to singing and integrating their control of resonance, intonation, and pitch in song and then doing the same in speech.

By the end of therapy, JR was speaking at an average of 130 Hz with chest resonance and masculine intonation and could consistently get gendered male on the phone, which was their goal upon entering therapy. Mastering 130 Hz at conversation level without testosterone is a notable achievement. This evinces that the voice is more flexible and more adaptable than is often acknowledged, and practice and dedication can harness that flexibility. However, it is only via genuine trust between clinician and client that such dedication can ever result.

Discussion

Both of these clients responded to the techniques used in therapy. By the end of therapy, they had improved their physical and technical abilities, which is the most well-understood goal of therapy. Both Kasi and JR were able to improve their ability to communicate in alignment with their gender presentation. However, additionally, both clients were able to express their cultural background and let their experiences and identity evolve in an open environment. Also, they were able to develop a sense of gender euphoria at times, instead of only the oppressive dysphoria that had been their shadow for so long. Both clients left therapy feeling as though they had accomplished something and that their process had been validated.

Both Kasi and JR responded more to the culturally based interventions than the technical ones. It was more important to them to have an integrated sense of presentation that could sound feminine or masculine than it was to achieve a certain number on the scale. This is particularly notable in Kasi, who always struggled with the high pitches but still managed to achieve a feminine vocal quality that made them happy. Both clients responded to singing in the end. This may not work for every client, but it works for many clients because it is a simple principle of dynamic voice use, and it should be euphoric in and of itself for the client. When therapy is its own reward, clients will participate. Access to quality voice therapy provided by SLPs practicing TOL (i.e., practicing to the full extent of education; Institute of Medicine, 2011) care, however, is extremely low. There are not enough clinicians who are clinically competent in providing care to transgender populations, the cost of care is far too high, and there are not enough clinicians who are trained in culturally competent care with transgender populations ( Hancock & Haskin, 2015).

These three components are inextricably tied to one another and essential to TOL practice ( Vega-Barachowitz, 2019). As long as this culture is poorly understood, transgender care will be treated as a fringe therapy population, and there will be a perpetual clinical training deficit. As long as financial barriers are in place due to voice therapy not being recognized as medically necessary, gatekeeping will persist. Thus, until transgender people recognize the speech pathology community as one of abundant allyship, there will be misinformation, distrust, and those going without ( Hancock & Haskin, 2015).

However, by building trust and empathy through engaging the clients on both an individual and cultural level, one can have wide-ranging effects on building larger trust ( Vega-Barachowitz, 2019). Through these offices, scholarly work, GLAAD and other national LGBTQ+ organizations, and local LGBTQ+ centers, clinicians have resources at hand to learn about these communities. However, the most essential resources available to them are the clients once they walk in the door. Every client is unique, and it is the job of the clinician to give the client time and space to talk and share that experience. Then, the clinician will truly learn cultural competence.

Conclusion

Voice and communication therapy can be crucial for the health and safety of these clients. This therapy decreases the risks associated with gender dysphoria by reducing misgendering, reduces physical safety risks from being identified as transgender, and reduces the risks of vocal harm that may occur from trying to perform vocal modification without skilled care. As can be seen in the cases of Kasi and JR and so many other cases like theirs, voice and communication therapy can profoundly impact quality of life in a positive way. Essentially, voice therapy for this population, like any other, is transformative. See Appendix for further information on terms and concepts discussed.

References

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

Dorman, K. (2018). Speech-language pathology and transgender voice therapy. Presented at North Carolina Central University, Durham, NC, Unites States.

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. National Academy of Sciences.

Kelly, F., & Robert, H. (2018). Why removing sex from birth certificates matters to gender diverse people. Phys.org. https://phys.org/news/2018-10-sex-birth-certificates-gender-diverse.html

Mills, M., & Stoneham, G. (2017). The voice book for trans and non-binary people: A practical guide to creating and sustaining authentic voice and communication. Jessica Kingsley.

Oliver, W. (2018). Gender and grammar: The singular 'they.', Journal of Dance Education, 18(1), 1-2.

Powell, A. (2018, March 23). The Harvard Gazette: Health and Medicine.The problems with LGBTQ health care.

Rogers, C. (1951). Client-centered therapy: It's current practice, implications and theory. Constable.

Smith, C. J., & Hao, G. J. (2018). Incorporating cultural competence in clinical approaches to transgender voice and communication therapy in a university clinic setting. Presented at the American Speech-Language-Hearing Association Annual Convention, Boston, MA, United States.

The Williams Institute, UCLA School of Law. (2019). LGBT demographic data interactive.

Vega-Barachowitz, C. (2019). Top of the license. Presented at the ASHA Faculty Development Institute, Rockville, MD, United States.

Williams, R. (2015). The ethics of gatekeeping in trans healthcare. https://www.philpercs.com/2015/11/the-ethics-of-gatekeeping-in-trans-healthcare.html Philosophical Percolations.

Footnotes

¹As a transaffirming article, this author has chosen to utilize singular generic they/them pronouns in place of singular generic he/she pronouns throughout the article. To learn more about the use of singular they/them pronouns in practice and in writing, see MyPronouns.org (2019), and Oliver (2018).

² Names and identifying information have been changed to protect client identities.

³ North Carolina Central University was a free clinic with no billing, and as a trans-affirming provider, only chosen names were used on all documents when possible. Therefore, no one was required to disclose any name or portion of a name against their will.

Author Notes

Financial: Carey J. Smith has no relevant financial interests to disclose. Nonfinancial: Carey J. Smith has no relevant nonfinancial interests to disclose.

Editor: Mary Sandage

Publisher Note: This article is part of the Forum: Celebrating the 50th Anniversary of ASHA's Office of Multicultural Affairs.

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Culturally Competent Care for Transgender Voice and Communication Intervention

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Purpose Despite constituting 4.5% of the population, the lesbian, gay, bisexual, transgender, queer+ community is poorly understood by the health care community. Seventy percent of transgender individuals report discrimination in health care, and 51% of speech-language pathologists do not know clinical techniques for transgender clients.

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Literature relating to voice therapy in transmasculine clients is very sparse since hormone therapy directly changes the voice.

Hormone therapy does not any other aspect of speech besides pitch, though, and the clients laryngeal muscles may not be well suited to fully utilize the changes in pitch, which could lead to hyperfunction in the larynx

This article focuses on vocal function exercises, or VFE's to provide acoustic and perceptual changes to the voice prior to hormone therapy.

These exercises, which include stretching the vocal chords, practicing masculine intonation, and sustaining notes at lower pitches alongside circumlaryngeal massage to increase laryngeal mobility, led to both acoustic and perceptual changes in provided case.

Client J.P., 18, has not yet started hormone therapy, yet during the 4 month treatment period, he saw a 30 hz decrease in his speaking fundamental frequency (206hz - 175 hz)

Voice was perceived as primarily feminine prior to therapy and 'somewhat masculine' post-therapy. Additionally, he reported strangers perceiving him as male, showing improved voice-related quality of life

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This YouTube video was created by an SLP who specializes in transgender voice therapy. The media focuses on changing resonance by "opening the throat," lip rounding, and how to effectively employ masculine intonation patterns. This media is relevant because it provides further information about the process of voice masculinization and how SLPs can use several techniques in the form of exercises to help clients produce a masculine voice both in and out of session.

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Considerations for Speech, Language, or Hearing Assessment

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Considerations for Speech, Language, or Hearing Assessment

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·        It’s important for clinicians to be aware that they may encounter multiple gender identities on a spectrum:

o   From binary transwomen and transmen (who identify as the gender opposite to the gender assigned to them at birth

o   To nonbinary genders, who identify in between male and female, agender or beyond the gender binary

o   anatomical sex is no longer a meaningful aspect of identity

o   correct terminology in place of “sex” = “assigned male at birth” or “assigned female at birth” (identifies physical characteristics of sex)

§  binary classification system, does not account for intersex

§  cisgender vs transgender

o   Gender identity reflects an inner sense of gender – outwardly expressed in various ways

o   Thus, gender expression is unique to the individual and clinicians helping a client express this (potentially new) identity must consider the “goals and features of the client’s voice, sense of self, and desire to be understood as an individual.”

·        Clinicians must be aware of any biases, judgments, or preconceived ideas they may hold regarding transgender individuals. In addition, recognize their power as a healthcare professional to avoid discriminatory practices.

·        Clinicians must ensure they allow clients to make their own decisions, and not decide for them if they are “ready” to transition or not.

·        Training and education are recommended to support SLP’s in becoming comfortable and confident with effectively treating this population.

o   Only 30 voice and speech clinicians in the U.S. are listed on the World Professional Association for Transgender Health – not enough for the population.

o   Office of Multicultural Affairs (OMA) “provides resources to help SLP’s provide transgender voice services.”

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Considerations for Speech, Language, or Hearing Intervention

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Considerations for Speech, Language, or Hearing Intervention

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·        Therapy techniques to employ – modeling, metatherapy

·        Avoid prescriptive models in modification therapy

·        Use descriptive approaches only – providing many examples to clients and allowing them to choose based on how they feel about them “and what they would like to emulate.”

·        Provide opportunities for clients to practice both “extreme and subtle aspects of targeted-gender communication.”

·        Allow client to practice “until a natural expression emerges.”

o   Clients will often feel as though they are “faking” at first.

o   Practice along a continuum allows the client to determine which communication pattern matches their gender expression.

·        In general:

o   Trust and empathy are keys to success.

o   Listen to what the client wants.

o   Allow targets to emerge and change throughout therapy as client’s “self-understanding and ability changes.”

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FtM Voice Training. (2023). YouTube - Jordan Ross Communication . Retrieved 2024, from https://youtu.be/z8GD2twTgys?si=xPfbN1yel9uyp2Qq.

Matthews, J. J., Olszewski, A.,  Petereit, J. (2020). Knowledge, Training, and Attitudes of Students and Speech-Language Pathologists About Providing Communication Services to Individuals Who Are Transgender. American Journal of Speech-Language Pathology, 29(2), 597-610. https://doi.org/10.1044/2020_AJSLP-19-00148

Myers, B.,  Bell, T. (2020). Adapting Vocal Function Exercises for Voice Masculinization. Perspectives of the ASHA Special Interest Groups, 5(4), 861-866. https://doi.org/10.1044/2020_PERSP-20-00076

Smith, C. J. (2020). Culturally Competent Care for Transgender Voice and Communication Intervention. Perspectives of the ASHA Special Interest Groups, 5(2), 457-462. https://doi.org/10.1044/2020_PERSP-19-00117