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Voice and Communication Change for Gender Nonconforming Individuals: Giving Voice to the Person Inside

July 2015
International Journal of Transgenderism 16(3):117-159

July 2015
16(3):117-159

DOI:10.1080/15532739.2015.1075931

Authors:

University of British Columbia

In the seventh version of their Standards of Care, WPATH recognizes that, as each person is unique, so is the person's gender identity. The goal of speech-language therapists/pathologists is to help transgender people develop voice and communication that reflects their unique sense of gender. When outer expression is congruent with an inner sense of self, transgender people may find increased comfort, confidence, and improved function in everyday life. Transgender voice and communication is a relatively new area of practice within speech-language pathology/therapy and this document is intended to support clinicians and researchers working in this field. It begins with a review of the evidence-based literature in transgender voice and communication. The paper then discusses these clinical topics: trans-specific voice-and-communication assessment, voice feminization protocols and voice feminizing surgeries. There is also a section on speech and voice masculinization—an area that has received little previous attention. As minimal standards have yet to be established in this field the paper concludes with recommendations for good clinical care.

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International Journal of Transgenderism

ISSN: 1553-2739 (Print) 1434-4599 (Online) Journal homepage: http://www.tandfonline.com/loi/wijt20

Voice and Communication Change for Gender

Nonconforming Individuals: Giving Voice to the

Person Inside

Shelagh Davies, Viktória G. Papp & Christella Antoni

To cite this article: Shelagh Davies, Viktória G. Papp & Christella Antoni (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

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Voice and Communication Change for

Gender Nonconforming Individuals: Giving Voice

to the Person Inside

Shelagh Davies

Vikt

oria G. Papp

Christella Antoni

ABSTRACT. In the seventh version of their Standards of Care, WPATH recognizes that, as each

person is unique, so is the person’s gender identity. The goal of speech-language therapists/

pathologists is to help transgender people develop voice and communication that reﬂects their unique

sense of gender. When outer expression is congruent with an inner sense of self, transgender people

may ﬁnd increased comfort, conﬁdence, and improved function in everyday life. Transgender voice

and communication is a relatively new area of practice within speech-language pathology/therapy

and this document is intended to support clinicians and researchers working in this ﬁeld. It begins

with a review of the evidence-based literature in transgender voice and communication. The paper

then discusses these clinical topics: trans-speciﬁc voice-and-communication assessment, voice

feminization protocols and voice feminizing surgeries. There is also a section on speech and voice

masculinization—an area that has received little previous attention. As minimal standards have yet to

be established in this ﬁeld the paper concludes with recommendations for good clinical care.

KEYWORDS. Communication, transgender, voice

This companion document discusses in more

detail the position outlined by WPATH’s

Standing Committee for Voice and Communi-

cation. In the seventh version of the Standards

of Care, WPATH recognizes that, as each per-

son is unique, so is the person’s gender identity.

The role of speech-language pathologists/thera-

pists

is to help individuals ﬁnd and develop

voice and communication that reﬂects the

individual’s sense of gender, so the outside

expression reﬂects the person inside. A discrep-

ancy between outward gender presentation and

the felt sense of gender is not trivial; it can

impair conﬁdence in communication, comfort

with gender presentation, and function in the

everyday world. A number of studies indicate

that speech-therapy intervention is useful in

helping gender nonconforming individuals

Shelagh Davies is afﬁliated with the University of British Columbia, School of Audiology and Speech

Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Vikt

oria Papp is afﬁliated with the Department of Linguistics, University of Canterbury, Christchurch,

New Zealand. Christella Antoni is a speech-language therapist in independent practice.

Address correspondence to Shelagh Davies, University of British Columbia, School of Audiological and

Speech Sciences, Faculty of Medicine, 2177 Wesbrook Mall, Vancouver, British Columbia, V6T 1Z3

Canada. E-mail: sd@shelaghdavies.com

117

International Journal of Transgenderism, 16:117–159, 2015

ISSN: 1553-2739 print / 1434-4599 online

DOI: 10.1080/15532739.2015.1075931

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portray their gender identity through speech

(Carew, Dacakis, & Oates, 2007; Dacakis,

Oates, & Douglas, 2012; Gelfer & Tice, 2013;

Hancock & Garabedian, 2013; M

esz

aros et al.,

2005). Such changes to communication are not

simply superﬁcial; they can reduce gender dys-

phoria and improve mental health and quality

of life.

The goal of the Standing Committee on

Voice and Speech is to encourage the highest

standards of research and practice in the ﬁeld

of transgender voice and communication. In

creating this document we wish to make cur-

rent evidence available to speech-language

therapists internationally and foster excellence

in this ﬁeld around the world. However,

research and practice constantly evolve, and

by the time this document is published, our

knowledge will already have advanced beyond

it. We hope simply to provide guidance for

current practice and stimulate more and better

guidelines and research in the future.

SCOPE

This document is intended for speech-lan-

guage therapists who have already taken trans-

gender sensitivity/awareness training or have

experience working with the transgender com-

munity and are seeking more advanced guid-

ance on how to be clinically effective in

working with transgender-speciﬁc aspects of

voice and communication. Gender noncon-

forming people who feel that their speech and

voice are not congruent with their gender do

not have voice disorders, and the protocols

used to address this issue are not designed to

treat voice disorders. However, it is possible to

have both a voice disorder and gender incon-

gruence in voice and speech. A discussion of

voice disorders in transgender clients is found

in the section “Vocal Health, Voice Habilita-

tion and Voice Rehabilitation.”

It is our intention to provide a useful sum-

mary and interpretation of the research litera-

ture on voice, speech, and communication for

transgender people. To do this we consulted

the following databases: Medline, CINAHL,

LLBA, ERIC, PubMed, and PsycINFO.

With the exceptions noted, this document

was based on studies using transgender individ-

uals rather than cisgender (gender-sex congru-

ent) subjects. In some areas we could uncover

almost no literature discussing transgender par-

ticipants. These areas include nonverbal com-

munication (e.g., nodding/shaking head, facial

expressions); language and syntactic choices

(e.g., more/less emotionally laden word

choices, use of tag questions and qualiﬁers);

and body movements, postures and gestures.

While we do not dismiss the importance of

these aspects of communication, the paucity of

evidence using transgender subjects did not

allow us to do more than mention these aspects

in this document. Besides studies of cisgender

participants, this companion document also

contains instances of expert opinion about a

given topic.

It should be noted that recent studies (both

on cis- and transgender participants) high-

light the context- and identity-driven varia-

tion of these communication parameters and

shift the focus on the interaction of the (gen-

dered and nongendered) identities in the

communicative situation (cf. Grainger &

Dunbar, 2009; Hogg, 1985; Papp & Town-

send, 2012; Podesva, 2007, 2011; Townsend

& Papp, 2012).

LIMITATIONS

We are still in the early stages of under-

standing gender markers in voice and com-

munication and how to affect their change in

transgender people. The corpus of literature

is small and many studies involve small

numbers of participants and lack of control

groups. Some of the literature is based on

expert opinion rather than on well-designed

studies. Oates reminds us that the evidence

for effectiveness of voice therapy for trans-

gender clients is weak, with 83% of the stud-

ies being “at the very lowest level on the

evidence hierarchy. The remaining 17% of

publications in this ﬁeld provide only mar-

ginally stronger evidence” (Oates, 2012,

p. 59). No studies compare speciﬁc interven-

tions or the effectiveness of targeting

118 Davies, Papp, and Antoni

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particular parameters of voice and speech.

Johnston (2007) notes that “the most compel-

ling information will come from review

articles, with or without quantitative meta-

analysis” (p. 12). Until recently there have

been few review articles that summarize the

primary literature on transgender voice and

communication.

Currently there are almost no studies that

investigate effectiveness of voice-and-com-

munication therapy protocols with transgen-

der people. In the absence of evidence-based

studies we have elected to discuss two kinds

of protocols: those used with transgender

people that include standard outcome meas-

ures and those modeled on evidence-based

protocols from the voice therapy literature

with cisgender people.

The literature we uncovered was found to be

further biased in two ways:

1. Research and therapy have been con-

ducted primarily with transsexual

women, who are only one subgroup under

the umbrella of those who identify as

transgender.

2. The literature is chieﬂy concerned with

voice. Oates (2012) references Pasricha

et al. (2008), saying, “The voice was of

primary concern [for transsexual women]

and that it was the feature of their com-

munication with which they were least

satisﬁed” (p. 30).

This lack of strong evidence does not mean

the practice is poor but simply that the ﬁeld has

not been fully and rigorously explored. It is

important to remember that practice, especially

in the medical ﬁeld, always precedes evidence.

In examining the literature on clinical practice,

Oates (2012) noticed

high levels of satisfaction among transgen-

der clients;

fairly strong consensus among speech-lan-

guage therapists as to vocal parameters

that are strong markers of speaker gender;

and

ways to approach voice therapy with this

population.

VOICE AND COMMUNICATION IN

TRANSGENDER PEOPLE: THE

EVIDENCE THAT SUPPORTS THE

PRACTICE

“If we are to provide the highest quality care,

our clinical decisions must reﬂect an integra-

tion of current high quality research evidence

...with practitioner expertise and client prefer-

ences and values” (American Speech-Lan-

guage-Hearing Association, 2005, p. 1).

Notwithstanding the limitations discussed ear-

lier, the past 10 years have seen a dramatic

expansion of both clinical practice and the col-

lection of evidence in the following areas:

1. We have established that therapy can be

effective in feminizing the voice in trans-

sexual women (Dacakis, 2012b; Descloux

et al., 2012; Gelfer & Tice, 2013; Han-

cock & Garabedian, 2013; M

esz

aros

et al., 2005; S€

oderpalm, Larsson, & Alm-

quist, 2004).

2. We are beginning to determine the

parameters of voice that are most impor-

tant to target in feminization/masculiniza-

tion (Adler, Hirsch, & Mordaunt, 2012;

Carew et al., 2007; Dacakis et al., 2012;

Gelfer & Mikos, 2005; Holmberg, Oates,

Dacakis, & Grant, 2010; King, Brown, &

McCrea, 2011; M

esz

aros et al., 2005;

Owen & Hancock, 2010; van Borsel &

De Maesschalck, 2008; van Borsel, Van

Eynde, Cuypere, & Bonte, 2008).

3. Our assessments of goals and outcomes

have gone beyond the measurement of

acoustic data to include the clients’ own

perception of their voice and their experi-

ences of voice in their real lives (Adler,

Hirsch, & Mordaunt, 2012; Constansis,

2008; Davies & Goldberg, 2006a; Han-

cock, Krissinger, & Owen, 2011; McNa-

mara, 2007; McNeill, Wilson, Clark, &

Deakin, 2008; Owen, 2009; Owen

& Hancock, 2010; Papp, 2011a; Papp &

Townsend, 2012; Pasricha et al., 2008;

Zimman, 2010, 2012).

4. We are beginning to investigate the proto-

cols in voice surgery and voice therapy for

their efﬁciency and effectiveness (Adler,

INTERNATIONAL JOURNAL OF TRANSGENDERISM 119

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Hirsch, & Mordaunt, 2012; Chung, Tsuji,

Sennes, & Imamura, 2007; Gelfer & Van

Dong, 2013; Gorham-Rowan & Morris,

2006; Hancock & Garabedian, 2013;

Kocak et al., 2010; Orloff, Mann, Dam-

rose, & Goldman, 2006; Palmer, Dietsch,

& Searl, 2012; Remacle, Matar, Mor-

somme, Verduyckt, & Lawson, 2011;

Wagner, Fugain, Monneron-Girard, Cor-

dier, & Chabolle, 2003).

A full review of the history of research in

transgender voice and communication is

beyond the scope of this document. Extensive

reviews of the literature from 1978 to the pres-

ent are found in Freidenberg (2002), Pickering

and Baker (2012), and Oates and Dacakis

(1983). Much of the early literature focused on

single-case studies or small-group studies that

report the outcomes of speech therapy and pho-

nosurgery. Parameters of change targeted in

speech therapy included pitch, resonance,

inﬂections, loudness, articulation, and voice

quality; speaking rate; and nonverbal commu-

nication (Bralley, Bull, Gore, & Edgerton,

1978; Coleman, 1983; G€

unzburger, 1989,

1993; Oates & Dacakis, 1983; Spencer, 1988;

Wolfe, Ratusnik, Smith, & Northrop, 1990).

Oates and Dacakis (1997) expanded the discus-

sion beyond research and therapy outcomes to

discuss philosophy of treatment. They discuss

the importance of working in a collaborative

process with the client and outline the impor-

tance of designing a treatment plan that takes

into account the client’s changing gender

identity, goals, and real life communicative

situations.

During this period there was a concurrent lit-

erature looking at issues of communication and

gender in nontransgender people. They include

studies on average speaking fundamental fre-

quency (Andrews, 1999; Biemans, 2000; Hud-

son, de Jong, McDougall, Harrison, & Nolan,

2007; Iseli, Shue, & Alwan, 2007; Traunm€

uller

& Eriksson, 1995); voice quality (Andrews &

Schmidt, 1997; Mendoza, Valencia, Munoz, &

Trujillo, 1996; van Borsel, Janssens, & de Bodt,

2009); resonance and resonance-source interac-

tions (Smith & Patterson, 2005; Turner & Pat-

terson, 2003); language and syntax (Eckert &

McGonnell-Ginet, 1999, 2003; MacAulay,

2001; Mondorf, 2002; Schumann & Ross,

2010); phonetics (Diehl, Lindblom, Hoemeke,

& Fahey, 1996; Robb, Gilbert, & Lerman, 2005;

Simpson, 2009); and nonverbal aspects of com-

munication (Briton & Hall, 1995; Hall, Coats,

& Smith, 2005; Hess, Adams, & Kleck, 2004;

LaFrance, Hecht, & Paluck, 2003). Further

references on cisgender-based studies are found

in the references in the appropriate chapters of

Adler, Hirsch, and Mordaunt (2012).

As the understanding of issues in transgen-

der voice and communication grew the litera-

ture became more reﬁned. Comprehensive

summaries of recent work are found in Dacakis

et al. (2012); Gelfer and Tice (2013); Hancock

and Garabedian (2013); and Pickering and

Baker (2012).

ACROSS THE GENDER SPECTRUM

Many people identify as being under the

gender nonconforming “umbrella” and there

is great variation in the extent to which

voice and communication changes are under-

taken or desired by gender nonconforming

individuals. Some gender nonconforming

persons seek to develop two speech patterns

(one more masculine and one more femi-

nine) either because they identify as bigen-

dered or because external pressures (family,

employment, cultural community, friends)

prevent living full time in a way that is con-

sistent with their felt sense of self. Some

people may have a sense of gender that is

not at either pole of the cismale/cisfemale

scale but is on the continuum of masculine

and feminine. They would like a more ﬂexi-

ble gender presentation to reﬂect this gender

identity.

Further, most current transgender speech and

voice protocols do not support bimodal speech

as a treatment goal, based on the belief that to

achieve maximal change it is necessary to have

a consistent single speech pattern. Switching

back and forth between two speech/voice pat-

terns may be too difﬁcult for some clients and

inconsistent use decreases practice opportuni-

ties to acquire the new speech/voice habits.

120 Davies, Papp, and Antoni

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However, the human capacity to learn and speak

more than two languages or dialects, develop a

speciﬁc accent for an acting role, and develop a

singing voice that is different from the speaking

voice suggests it may be possible to develop

bigender speech/voice. We encourage speech-

language therapists to be open to this possibility

and not to routinely exclude clients who have

two speech/voice patterns as their treatment

goal. We recommend that speech services be

made available to the full spectrum of the gen-

der nonconforming community.

As was discussed earlier, the majority of

gender nonconforming clients seeking speech

therapy services are transsexual women wish-

ing to maximize their feminine voice and com-

munication. Speech and voice feminization is

widely recognized as a vital component of care

for transgender women (Adler, Hirsch, & Mor-

daunt, 2012; Andrews, 1999; Kalra, 1977; Neu-

mann & Welzel, 2004; Wollitzer, 1994). The

weighting of studies in transgender communi-

cation is far from balanced, with almost all

research being on transsexual women.

Much less attention has been paid to speech

masculinization (Oates & Dacakis, 1997; van

Borsel, Cuypere, Rubens, & Destaerke, 2000)

and this lack of investigation may be obscuring

concerns of transgender men. The study by van

Borsel et al. (2000) of 16 female-to-male (FtM)

transsexuals found that 88% of participants con-

sidered masculinization of communication to be

as important or more important than sex reas-

signment surgery. While many transgender men

ﬁnd that they develop an acceptably masculine

voice as a result of androgen therapy, some do

encounter difﬁculties. We will discuss voice-

and-communication change for transgender

men in the section “Masculinizing Speech:

Physiology and Identity.”

VOICE AND COMMUNICATION

THROUGH THE LIFE SPAN AND

GENDER TRANSITION

Childhood and Adolescence

Speech and voice feminization in adoles-

cents was ﬁrst examined in 2012 in a

single-subject study by Hancock and Helenius.

They found that voice therapy based on princi-

ples established with adults was effective but

caution that the implications of age on the ther-

apy effectiveness have not been examined. As

the need to transition is now being recognized

earlier, more research into helping youth

develop gender-appropriate communication is

needed. We may wish to consider whether there

is a role for the speech-language therapist in

monitoring the communication needs of trans-

gender adolescents.

Through the Gender Transition Process

Transsexual people’s perception of both

their gender identity and their voice may

change as they move through transition. In her

doctoral thesis, Byrne (2007) notes that some

transsexual women feel less pressure to femi-

nize their voice after gender reassignment sur-

gery has been completed. She hypothesizes that

once there is congruence between the physical

body and gender identity, the need to sound

completely female may be less important. It is

important for speech-language therapists to

remain sensitive to their clients’ (possibly

changing, evolving) wishes rather than follow

their own assumptions about voice-and-com-

munication goals.

Voice, Speech, and Sense of Self

Initial studies on the transgender voice

looked chieﬂy at speaking fundamental fre-

quency. More recently the scope of study has

expanded to explore the intimate and complex

relationship between voice/communication,

sense of self, and function in the world. It is

important to understand the client’s perspective

around speech and voice change (Andrews,

1999; Byrne, 2007; Dacakis, 2002; Dacakis,

Davies, Oates, Douglas, & Johnston, 2013;

Gelfer, 1999; McNeill et al., 2008; Oates &

Dacakis, 1997; Owen & Hancock, 2010;

S€

oderpalm et al., 2004). A study by McNeill

et al. (2008) found that in male-to-female

(MtF) transsexual clients, the happiness with

voice was not directly related to speaking

fundamental frequency. Another 2008 study

INTERNATIONAL JOURNAL OF TRANSGENDERISM 121

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looked at 12 MtF transsexuals and found that

happiness with voice was not directly related to

speaking fundamental frequency, but rather

was signiﬁcantly correlated with perception of

femininity—both the participants’ self-percep-

tions and the perceptions of listeners (McNeill

et al., 2008). In 2010, in a study of 20 transgen-

der women, Owen and Hancock conﬁrmed this

ﬁnding. In their study they found that the

speaker’s perception of her own femininity was

strongly correlated to both the mean fundamen-

tal frequency of the voice and to her own feel-

ing of femininity. Speakers who rated

themselves as more feminine were also judged

as more feminine by listeners. Another study

by Hancock, Krissinger, and Owen (2011)

extends the investigation, suggesting that

exploring the client’s own perception of the

voice may be useful for evaluating the effec-

tiveness of voice therapy. This is an important

corroboration and veriﬁcation that outcome

measurements need to expand beyond the eval-

uation of acoustic parameters, such as speaking

fundamental frequency.

In an attempt to gather information on the

effect of voice in everyday life, Davies

adapted the Vocal Handicap Index (Jacobson

et al., 1997) to be trans-speciﬁc and created

the Transsexual Self-Evaluation of Voice

Questionnaire (Davies & Goldberg, 2006a).

This questionnaire was further developed,

and psychometric evaluation was undertaken

by Dacakis, Davies, et al., resulting in the

TVQ

MtF

(Transsexual Voice Questionnaire,

Male to Female) (Dacakis et al., 2013). This

is the ﬁrst instrument with established psy-

chometric properties that assesses a transsex-

ual woman’s experience of her own voice in

real-life situations. The version for female to

male transsexuals is still under development.

The TVQ

MtF

is available as a free download

from www.shelaghdavies.com or by contact-

ing Georgia Dacakis at G.Dacakis@latrobe.

edu.au. The questionnaire has been translated

into Swedish, Portuguese, German, and Dan-

ish and these versions are also available on

the website. Translations into a number of

other languages are ongoing and, when ﬁn-

ished, will be added to the website and avail-

able for downloading at no cost.

GENDERED VOICE AND

COMMUNICATION

The following is a discussion of feminization

in voice, speech, and communication. The pro-

cess of masculinization is discussed in the sec-

tion “Masculinizing Speech: Physiology and

Identity.”

Feminizing Voice, Speech and Other

Aspects of Communication

Current evidence suggests that the largest

feminization effects come from changing both

the speaking fundamental frequency and the

resonance of the voice. Other parameters that

have been targeted for change are inﬂectional

patterns and excursions, voice quality, speech-

sound articulation and duration, average speak-

ing intensity, and speech rate.

Average Speaking Fundamental

Frequency

S€

oderpalm, Larsson, and Almquist (2004)

established that MtF transsexuals were able to

raise their speaking fundamental frequency

without strain or vocal damage. This is reassur-

ing but there is no consensus in the literature as

to how high the speaking fundamental fre-

quency (SFF) should be for a transgender wom-

an’s voice to be perceived as female. It is

generally accepted that the SFF must move out

of cismale speaking range (roughly 100–

140 Hz) into either a gender neutral range

(145–175 Hz) or cisfemale range (roughly

180–220 Hz). After that, opinion varies widely,

and has been summarized by Hancock & Gara-

bedian (2013). Studies have suggested a mini-

mum SFF of 155 Hz (Wolfe et al., 1990),

165 Hz (Oates & Dacakis, 1983), 172 Hz

(Owen & Hancock, 2010), and 180 Hz (Gor-

ham-Rowan & Morris, 2006). Dacakis, Oates,

and Douglas (2012) say:

Despite the fact that an increase of F0

(fundamental frequency) into the female

F0 range may not routinely result in per-

ceptions of the speaker as female, the

122 Davies, Papp, and Antoni

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evidence indicates that this is likely to

increase listener perceptions of the voice

as containing female attributes. (p. 167)

It is perhaps not surprising that something as

complex and close to the human heart as voice

cannot be modiﬁed by simply altering one

parameter. We also recall that contributions

from the larynx (F0 and harmonics) are inextri-

cably linked to contributions from the vocal tract

(vowel formants, resonance effects) (Baken &

Daniloff, 1991). Perceptually they are difﬁcult

to separate and indications are that they both

must rise for the voice to be perceived as female.

In any therapeutic work involving SFF it is

important to use norms that are age appropriate

and culturally appropriate for the individual.

As an example, the mean SFF is different

across biological age (Brown, Morris, Hollien,

& Howell, 1991; Hollien & Paul, 1969; Lin-

ville & Fisher, 1985; Michel, Hollien, &

Moore, 1966; Nishio & Niimi, 2008; Torre III

& Barlow, 2009); across dialects of the same

language (Awan & Mueller, 1996; Deutsch,

Le, Shen, & Henthorn, 2009; Dolson, 1994);

between monolingual and bilingual speakers of

the same language (Abu-Al-Makarem & Petro-

sino, 2007; Altenberg & Ferrand, 2006; Ullako-

noja, 2007); and naturally, between languages

(Loveday, 1981; Mennen, Schaefﬂer, & Doch-

erty, 2007; Muta, 1994; Natour & Wingate,

2009; Ohala, 1983; Ohara, 1992; van Bezooi-

jen, 1995; Yuasa, 2008).

Resonance

The word resonance has many meanings but

in this context its meaning is highly speciﬁc.

We refer to the ﬁlter function of the vocal tract

on the sound wave produced by the larynx.

Because of the interdependence of these

organs, it is difﬁcult to perceptually separate

the contributions of source (larynx) and ﬁlter

(vocal tract) in the gender perception of a voice

(Carew et al., 2007). Research evidence shows

that a voice may sound low even though the

SFF is reasonably high and vice versa (Hillen-

brand & Clark, 2009).

There is a 10% to 20% difference in length

between the vocal tracts of cismen and

ciswomen (Titze, 2000) and this difference in

length produces acoustic differences in the

sound wave that disseminates from the lips.

Typically vocal tract resonances are higher for

ciswomen and children and lower for cismen.

These resonance effects are found in unvoiced

as well as voiced sounds, as can be demon-

strated by saying the voiceless fricative /s/ and

protruding and retracting the lips.

Vowel formants—the ﬁrst, second, and often

third resonances of the vocal tract (F1, F2, and

F3, respectively)—are frequently calculated to

measure the effect of the vocal tract ﬁlter on

the voice. While the ﬁrst and second formants

determine the vowel identity and quality, all

three formants reﬂect the overall length of the

vocal tract (Carew et al., 2007). Carew et al.

(2007) developed a protocol of oral resonance

therapy for transsexual women that used a

slight retraction of the lips to shorten the reso-

nance tract during speech. They found that all

three vowel formants were higher, with F3

being most signiﬁcantly affected. Participants

and listeners both perceived the voices as more

feminine after treatment. Interestingly, there

was a concurrent spontaneous increase in fun-

damental frequency although this was not tar-

geted in therapy. In an early study, Mount and

Salmon (1988) found that a transsexual woman

was able to raise her SFF to 210 Hz but was

not perceived as female until she raised her

vowel formants. Gelfer and Mikos (2005) and

Pasricha et al. (2008) found that both SFF and

vowel formants were important for gender per-

ception. Finally, a study of ciswomen and cis-

men by Hillenbrand and Clark (2009) looked at

the role of SFF and formant frequencies in dis-

tinguishing the voices of men and women.

They found that shifting either SFF or formants

alone was usually ineffective in changing the

perceived gender of the speaker but when the

speaker changed both together, the person was

perceived to be the opposite gender 82% of the

time. Although the researchers found that shift-

ing the SFF was somewhat more important

than shifting the formants, they concluded that

both speaking fundamental frequency and

vowel formants are needed to specify the

gender of a speaker. This ﬁnding is further cor-

roborated by the formant- and SFF-scaling

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research in Patterson, Smith, Dinther, and Wal-

ters (2007); Smith and Patterson (2005); and

Smith, Patterson, Turner, Kawahara, and Irino

(2005).

Inﬂections

The use of more upward gliding inﬂections

and more frequent inﬂections (i.e., a more

dynamic intonation contour) are generally con-

sidered to be feminine characteristics of voice

production, while the use of a ﬂatter speaking

style has been considered to be more masculine

(Pickering & Baker, 2012). Gelfer and Scho-

ﬁeld (2000) found that using both a higher

upper limit of SFF and a higher SFF facilitated

the perception as female. However, two recent

studies suggest that the use of a narrower

inﬂectional range is perceived to be more femi-

nine (Owen, 2009; Owen & Hancock, 2010). In

2014, Hancock, Colton and Douglas (2014)

looked at intonation differences between trans-

sexual women who passed as cisfemale and

those who did not. The researchers found that

the women who passed as cisfemale used more

upward gliding intonations and a larger utter-

ance semitone range than those who did not

pass. The authors suggest that further, culture-

speciﬁc study is needed of this important aspect

of speech and voice production.

Voice Quality

In a study of ciswomen, van Borsel et al.

(2009) found that breathiness was perceived to

be a feminine characteristic of voice and sug-

gested that this study needed to be replicated in

transgender women. The adoption of a slightly

breathy, or softer, quality is a frequent goal in

many voice therapy protocols for transgender

women (Davies & Goldberg, 2006a). The

understanding is that this breathy quality may

replicate the voice quality of ciswomen because

of a small posterior gap between the vocal folds

during vibration (Biever & Bless, 1989; Lin-

ville, 1992; S€

odersten & Lindestad, 1990).

Palmer et al. (2012) undertook endoscopic and

stroboscopic examination of nine transsexual

women and noted that those who reported a

“passing” female voice had a glottal closure

pattern with a posterior glottal gap. In another

study the mean SFF and semitone range, but

not perturbations (noise to harmonics ratio,

vocal turbulence index, jitter percent, shimmer

percent), were strongly related to the perception

of femininity (Owen & Hancock, 2010). Yet

other studies found further, conﬂicting results

on the production and perception of breathiness

and creakiness in speech (Henton & Bladon,

1985; Henton, Bladon, Hyman, & Li, 1988;

Kreiman, Gerratt, & Antonanzas-Barroso,

2007). More work is needed to conﬁrm the

effect of voice quality on the perception of

voice in transgender women.

Articulation

Female speakers may speak with more preci-

sion than male speakers (Oates & Dacakis,

1983) and modiﬁcation of articulatory patterns

is frequently included in speech/voice therapy

protocols for transgender women. In their study

with transsexual women, Free and Dacakis

found that speech was perceived to be more

feminine when the consonants were rated as

“more precise” rather than “less precise”

(Dacakis et al., 2012; Free & Dacakis, 2007).

Speaking Intensity

Women are generally considered to speak

more quietly than men (Boonin, 2012). In one

study of four transsexual women, the speaking

loudness was the sole factor that accounted for

gender perception (Holmberg et al., 2010).

While this suggests that a moderate reduction

in average speaking intensity, perhaps corre-

lated with a slight increase in breathiness, may

feminize the voice.

Some transgender individuals who are self-

conscious about speech may use insufﬁcient

vocal intensity as a means of minimizing atten-

tion to their voice and some transwomen may

speak quietly to try to “soften” the voice (Daca-

kis, 2002). To be functional in all situations,

particularly with background noise, trans-

women need to learn how to produce a strong

voice that still maintains a feminine vocal

quality.

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Speech Rate and Prosody

Studies on speech rate in cismen and cis-

women have been inconclusive (Dacakis et al.,

2012). Van Borsel and De Maesschalck (2008)

looked at the speech rate of 28 transsexual

women and found no signiﬁcant differences

when compared with the rates of nontranssex-

ual men and women. On the basis of these

results it appears that speech rate is not a useful

parameter to target in speech/voice change.

Oates remarks: “Communication manage-

ment for [transgender/transsexual] clients may

[also] require a focus on ... vocabulary, prag-

matic behaviours, conversational topics and

style, and nonverbal communication”(Oates,

2012, p. 50). Although there is some psycholin-

guistic literature on cisgender speakers that

supports this statement, we were not able to

uncover literature using transgender speakers.

RESPONSIBILITIES OF THE

VOICE-AND-COMMUNICATION

PROFESSIONAL

Throughout the world, feminization/mascu-

linization services are delivered primarily by

speech-language therapists (speech therapy)

and laryngologists (vocal surgery). While

speech-language therapists do not need to be

experts in every realm of transgender care to

work with transgender clients, it is expected

that those providing speech feminization/mas-

culinization services have a basic understand-

ing of the processes involved in gender

transition, the potential impact of testosterone

on FtM speech, and trans-speciﬁc psychosocial

issues that shape clients’ goals and treatment

options. Understanding of basic sensitivity pro-

tocols such as use of preferred gender pronoun

and name is essential but is outside the scope of

this article.

To assist in greater understanding of trans-

gender voice and communication issues, the

client’s permission should be sought to share

anonymous assessment data with other speech

professionals and for research purposes. Over

the past 10 years the literature on transgender

voice and communication has substantially

increased but there is still a paucity of evidence

in many areas, particularly in evidence-based

clinical practice (Dacakis et al., 2012; Hancock

& Helenius, 2012). As with all research, it is

important that transgender clients’ involvement

in research be fully voluntary—that is, it is not

ethical to make service contingent on agree-

ment to be studied.

As with other transgender care, we recom-

mend that voice and communication services

be offered in the context of a complete

approach to transgender health that includes

comprehensive primary care and a coordinated

approach to psychological and social issues

(Adler, Hirsch, & Mordaunt, 2012; Coleman

et al., 2011; S€

oderpalm et al., 2004). Speech

services must be individualized based on the

individual’s goals and identity, the risks and

beneﬁts of treatment options, and consideration

of social and economic issues.

In the following two sections we provide an

overview of existing good practice in the

assessment and treatment of the transgender

voice. While the two sections are largely

geared toward the needs of transwomen,

many of the considerations and concerns also

apply to the FtM voice.

TRANS-SPECIFIC SPEECH/VOICE

ASSESSMENT

Change in a transgender person’s voice and

communication starts with a thorough assess-

ment. For a comprehensive discussion the

reader is referred to Dacakis (2012a),

“Assessment and Goal Setting Revisited” in

Adler, Hirsch, and Mordaunt (2012).

Components of the initial assessment are

1. Establishing therapeutic rapport

2. Collecting the history

a. Psychosocial history

b. Voice use and vocal health

c. Medical history

3. Clinical assessment of speech and voice

a. Client’s subjective assessment

b. Acoustic/aerodynamic measurement

c. Speech-language therapist’s subjec-

tive analysis

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d. Developing goals and assessing

potential for change

e. Assisting the client in understanding

therapeutic options

The following recommendations relate to the

general initial assessment that should be con-

ducted as part of a therapeutic evaluation and

treatment plan. Clients who wish to pursue

pitch-elevating surgery must undergo addi-

tional evaluation prior to surgery; this is dis-

cussed in the section “Surgical Feminization of

the Larynx and Voice.”

Establishing Therapeutic Rapport

The relationship between client and clinician

begins with the ﬁrst interactions. In the initial

session, the speech-language therapist is not

only assessing the client, the client is also

assessing the knowledge and supportiveness of

the clinician. A relationship grounded in mutual

respect, trust, and genuine care for the client’s

well-being facilitates open communication and

encourages active engagement in therapy; con-

versely, it can be difﬁcult to build therapeutic

rapport if conﬂicts arise in initial sessions.

Many transgender people have had negative

experiences with ill-informed or unempathetic

health professionals, and there may be wariness

about entering unreservedly into a relationship

around communication, which is by its nature

highly personal. Because the assessment pro-

cess sets the stage for all future interaction, it is

extremely important to make the client feel

respected and safe, and to create a feeling of

positive anticipation for the therapy process.

One report identiﬁed storage of information,

privacy issues in setting appointment times,

client name preference, use of the client’s pre-

ferred pronouns, and therapist bias and

judgments about gender transition issues that

speech-language therapists need to consider in

the intake process (King, Lindstedt, Jensen, &

Law, 1999).

Collecting the History

Clients come to voice therapy with different

backgrounds, goals and knowledge bases about

voice and communication change, so the

speech-language therapist should match the

input to the needs of the client. Client history

should include information about both trans-

speciﬁc concerns and general issues that may

impact therapeutic options and potential out-

comes. An initial open-ended question like,

“What brings you to see me?” or “How can I

help you?” may elicit a great deal of informa-

tion. While some transgender individuals are

very comfortable talking about their history,

others are more private. In some cases it may be

appropriate to revisit sensitive questions after

therapeutic rapport has been well established.

Psychosocial History: Voice, Speech and

Sense of Self

Our goal as speech-language therapists is to

help the client develop voice and communica-

tion that is congruent with the person’s own

sense of gender. While many may wish to pass

as cismale or cisfemale, others may feel more

comfortable with a presentation somewhere

between these polarities of gender. A sensitive

exploration of what best ﬁts the client’s self-

perception is necessary in determining goals in

therapy. This question of “right ﬁt” may be

easy for the client to answer right away, or may

be answered over time with experimentation,

introspection, practice, and observation of role

models. A self-evaluation questionnaire like

the TVQ

MtF

(Dacakis et al., 2013: 21) can be

useful in exploring and quantifying how well

the voice ﬁts the sense of self and how well it

works in everyday life.

Vocal Health, Voice Habilitation, and

Voice Rehabilitation

The process of voice feminization and mas-

culinization is different from a rehabilitation

process to treat a disordered voice, but there

are three goals common to both:

1. training efﬁciency in voice production

2. helping clients achieve vocal ease endur-

ance in all voice-use situations

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3. supplying information clients need to

maintain their vocal health (Adler &

Antoni, 2012; Dacakis, 2000, 2002; Gold,

1999; Kaye, Bortz, & Tuomi, 1993;

Mount & Salmon, 1988; Oates & Daca-

kis, 1997, 1983; S€

oderpalm et al., 2004;

Titze & Verdolini Abbot, 2012).

If during the assessment, the speech-lan-

guage therapist uncovers evidence of a voice

disorder, such as roughness, limited range, dif-

ﬁculty projecting, rapid vocal fatigue, or effort-

ful voice production, the usual protocols of

investigation should be followed, beginning

with referral to an otolaryngologist.

In their review of 25 cases of voice-and-

communication change Hancock and Garabe-

dian (2013) found that “28% presented with a

voice disorder separate from gender presenta-

tion concerns.”

If a client has a voice disorder it is important

to determine if it existed before any speech/

voice change was undertaken or if it resulted

from attempts to change the voice. Previous

attempts to feminize/masculinize speech should

be investigated, including techniques used,

duration of self-directed or professionally

directed therapy, and the client’s subjective

feelings about the outcome (Adler & Antoni,

2012; Andrews, 1999; Dacakis, 2002; Gelfer,

1999; Perez, 2004). Modifying habitual pitch,

adopting unfamiliar articulatory postures or

producing the voice in nonhabitual ways can be

fatiguing and potentially damaging for some

people. Clients who developed dysphonia and

vocal fatigue from previous attempts at voice

feminization or masculinization may ﬁnd this

disappears when they adopt a more effective

protocol. Others may require a traditional voice

rehabilitation program before they undertake

further voice change (Davies & Goldberg,

2006a).

Voice Use

A full history of the client’s voice use

should be collected, including professional and

recreational use of the voice (e.g., involvement

in singing/acting). This history is useful for

exploring any areas of concern and

determining whether previous training could

be tapped during therapy. Teachers, singers,

and clients with heavy voice demands or difﬁ-

cult speaking situations will need maximally

efﬁcient voice-production habits to sustain

their gender-modiﬁed voice and avoid phono-

trauma. As in traditional voice therapy, creat-

ing a list of voice-use situations is useful in

generalizing the new voice into everyday life

and creating a hierarchy of practice (Dacakis,

2012a; Davies & Goldberg, 2006a).

Medical History

In some clinics a laryngological examination

is performed as a matter of course by an otolar-

yngologist. In others it is performed with a

referral when there are symptoms of dysphonia

or other signs of abnormal laryngeal function.

As in the assessment of any voice client, a

full history of medical information relevant to

the voice and speech should be recorded. This

includes information about respiratory disease,

upper respiratory tract infections, laryngophar-

yngeal reﬂux disease, thyroid function, head/

neck surgeries or trauma, hearing loss, and

other medical information relevant to speech

and voice change. This includes problems

stemming from self-directed attempts to mod-

ify voice, high vocal load, or any other condi-

tions that could impact speech (de Bruin,

Coerts, & Greven, 2000; Gelfer, 1999;

S€

oderpalm et al., 2004). To assist in the coordi-

nation of care, other health professionals

involved in the client’s general and trans-spe-

ciﬁc care should be noted (de Bruin et al.,

2000; S€

oderpalm et al., 2004). All current med-

ications (including feminizing or masculinizing

hormones) should be recorded. As previously

stated, clients who present with difﬁculty swal-

lowing or symptoms that may suggest a voice

disorder should be referred for laryngological

examination (Dacakis, 2012a).

Lifestyle habits that may negatively impact

speech and voice, such as smoking (tobacco,

cocaine, marijuana) and more than moderate

use of alcohol, should be explored. Because

the stigma associated with substance abuse

can make it difﬁcult to get accurate

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information, a gentler question could be,

“Have you ever used ... ?”

While female hormones have no effect on

the voice of a transgender woman, some

women report emotional changes that may

affect the way they communicate so it can be

useful to know if a transgender woman has

been taking hormones and for how long. It is

likely that androgens affect the voice of trans-

gender men by thickening the vocal folds thus

deepening the voice. Depending on the method

of testosterone intake, this process can take up

to 2 years to complete (cf. Papp, 2011a), so it

is important to know the length of time a trans-

gender man has been undergoing androgen

therapy, the dose he is taking, and possibly also

his recent serum testosterone levels.

There is some discussion around whether

a speech-language therapist should ask if the

client has undergone genital reassignment/

reconstruction surgery (GRS). While this

procedure has no impact on speech/voice

production it may affect a transperson’s feel-

ings about voice change, so it is important

information for the speech-language therapist

to have. Byrne (2007) notes that after gender

reassignment surgery, some transwomen feel

a comfort that their physical body is now

congruent with their gender identity and

developing a completely female voice is less

important. However, some speech-language

therapists may feel this is an intrusive, per-

sonal question and not necessary since it

does not affect voice production. Further, not

all transgender clients wish to undergo GRS,

whether or not they live full time as women.

Sensitivity and tact are important when

approaching this question.

Trans-speciﬁc history should also include

information about other feminization/masculin-

ization treatments that relate directly to speech

and voice (e.g., facial feminization surgery in

MtFs, chest binding in FtMs) and any noted

impact on speech following these treatments

(Andrews, 1999; Gelfer, 1999; King et al.,

1999; S€

oderpalm et al., 2004). It is not neces-

sary to inquire speciﬁcally about trans-speciﬁc

treatments that are unlikely to directly impact

communication.

Clinical Assessment of Speech and Voice

Parameters Associated With Gender

A complete clinical analysis should include

a variety of investigations with input from both

the client and the clinician. The objective is to

gain a thorough understanding of how well the

speech and voice currently function in every-

day life, how well they reﬂect the client’s own

sense of gender, and what potential there may

be for speech and voice feminization (Andrews

& Schmidt, 1997; Byrne, 2003; Coleman,

1983; Dacakis, 2002; Dacakis et al., 2013; de

Bruin et al., 2000; Gelfer, 1999; Gelfer &

Schoﬁeld, 2000; Gold, 1999; Oates & Dacakis,

1997; Wollitzer, 1994).

The following is a summary of a comprehen-

sive trans-speciﬁc speech and voice assess-

ment. For a full discussion the reader is

referred to Dacakis (2012a).

Client’s Subjective Assessment

Clients’ feelings about their current voice

and communication and their goals for change

are related to self-perception, feelings about the

perceptions of others, and function in day-to-

day life. These can be assessed both formally

and informally.

Formal Evaluation. The Transsexual Voice

Questionnaire (TVQ

MtF

) has recently been

developed by Dacakis et al. (2013). The FtM

version is still under development. This ques-

tionnaire explores a transsexual woman’s feel-

ings about her voice and how well her voice

functions in the real world. It can be used as an

intake instrument and as an outcome measure-

ment. The Transsexual Voice Questionnaire

may be acquired free of charge at www.shelagh

davies.com and from Georgia Dacakis. For

translation, authorization from the authors is

required and WHO protocols for translation

must be followed. Please contact Georgia

Dacakis at La Trobe University, Melbourne,

Australia, for further information

(g.dacakis@latrobe.edu.au).

Informal Evaluation. Asking clients for

three things they would like to change about

speech and voice or three situations in which

they would like to sound more masculine or

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feminine gives a brief insight into the clients’

goals and can be reviewed at the end of voice

therapy as a rough outcome measurement

(Davies & Goldberg, 2006a). Dacakis (2012a)

suggests other useful probes such as asking if

the client wants to change communication in all

speaking situations or if the client has a particu-

lar vocal image in mind. Questions about previ-

ous attempts to change speech and voice can

yield information about the client’s familiarity

with the process and his or her stimulability for

change. It may also alert the client to any poten-

tially harmful vocal hyperfunction resulting

from undirected voice change (Adler, Hirsch, &

Mordaunt, 2012; Davies & Goldberg, 2006a).

Acoustic Analyses

An assessment of the client’s voice and

speech gives a baseline against which to mea-

sure change and provides information about

which changes would be most useful (Andrews

& Schmidt, 1997; Kaye et al., 1993; King

et al., 1999). The parameters of speech and

voice relevant to gender perception of voice

have been discussed earlier and will simply be

mentioned here. They include the following:

speaking fundamental frequency (SFF);

speaking fundamental frequency range

and variability;

total physiological frequency range (or

maximum phonation range, cf.);

formants of vowels, in particular, the

corner vowels /a/, /i/, and /u/; and

average speaking intensity.

These may all be measured using a number

of acoustics analysis software programs cur-

rently available. Some, such as Praat (http://

www.fon.hum.uva.nl/praat/) or SFS/WASP

(http://www.speechandhearing.net/laboratory/

wasp.htm) may be downloaded free of charge.

Some commercially available programs can be

obtained through Kay-PENTAX, Tokyo, Japan,

and LingWAVES, a program manufactured by

WEVOSYS, Forchheim, Germany.

Speaking intensity may be measured using a

sound level meter. Care should be taken to

measure in dBC and to conform to the standard

distance from lip to sound level meter, as this

varies throughout the world (Gramming &

Sundberg, 1988). The total physiological and

intensity ranges may also be measured and dis-

played in a vocal range proﬁle, or phoneto-

gram. This graph displays vocal intensity,

usually on the vertical axis, against fundamen-

tal frequency on the horizontal axis, providing

a clear picture of the maximal extent of these

vocal parameters (Sulter, Wit, Schutte, &

Miller, 1994).

It is useful to record the fundamental fre-

quency in sustained vowels and the speaking

fundamental frequency in various tasks such as

sustained vowels, reading, picture description,

and spontaneous speech. A variety of samples

give a broader base and differences among

them may reﬂect a voice in transition. There is

generally less mental energy required to sustain

a vowel, read, or describe a picture than to gen-

erate language in spontaneous conversation. If

the SFF is higher in reading than in conversa-

tion this may suggest that the client needs high

levels of concentration on voice production and

cannot maintain this when required to think of

the words as well (Dacakis, 2012a; Davies &

Goldberg, 2006a). However, the difﬁculty

among these tasks may also reﬂect other factors

such as educational level or comfort with oral

reading.

Audio or Video Recordings. Following

standard practice in a speech/voice evaluation,

audio or video recordings of the assessment

should be made. These are useful for analyzing

current communication patterns and setting

goals for therapy. They also serve as a baseline

against which to measure change and (with the

consent of the client) as a resource to train stu-

dent speech-language therapists. Some speech-

language therapists videotape the assessment

session and review the tape with the client,

looking at speech/voice parameters and also

nonverbal communication features such as ges-

tures, movement, and facial expressions. Other

speech-language therapists prefer not to use

video footage as clients report ﬁnding it intru-

sive and intimidating (Davies & Goldberg,

2006a). Both audio and video recordings allow

comparisons to be made during trial therapy, as

is discussed later.

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Speech-Language Therapist’s Perceptual

Analysis. As in a traditional speech and voice

assessment, an experienced speech-language

therapist can supplement the objective analysis

by making perceptual assessments of voice qual-

ity, intonation patterns, speaking style (legato

vs. staccato), and speech sound articulation.

Trial Therapy to Assess Potential

for Change

Once the assessment is complete the speech-

language therapist can share the ﬁndings with

the client, explain any technical details, and dis-

cuss possible parameters of change. This estab-

lishes a collaborative process, with client and

clinician working together to establish goals.

At this point, trial therapy is useful to get a

sense of how the voice and speech could

change. For example, if the client wishes to

feminize her voice, some words or short senten-

ces can ﬁrst be recorded at the habitual pitch.

Then the speech-language therapist can assist

the client to produce them efﬁciently at a higher

pitch or at several higher pitches. The trials can

be recorded and compared with the original

one at the habitual pitch. This practice gives

useful information about what feels comfort-

able and acceptable to the client and what may

be possible. It also affords an opportunity to

discuss the nature of the process of change.

Change to any motor habit will feel unfamiliar

and possibly uncomfortable simply because it

is nonhabitual. However, this is a sign that

things are moving and this movement is neces-

sary to develop new habits. While the ﬁnal

decision about the nature of voice and commu-

nication change rests with the client, the clini-

cian can assist this process by suggesting the

client remain open to experimenting with what

is unfamiliar (Adler, Hirsch, & Mordaunt,

2012; Davies & Goldberg, 2006a).

Assisting the Client in Understanding

Therapeutic Options

Two options open to the transgender client

wishing voice feminization are voice therapy

or phonosurgery. They may be available singly

or together and the availability of both varies

widely throughout the world. The speech-lan-

guage therapist should be familiar with options

in his or her location, including the possibility

of distance voice therapy through the Internet

and be able to discuss the pros and cons with

the client in a knowledgeable and unbiased

way. Phonosurgery is discussed in more detail

in the section “Surgical Feminization of the

Larynx and Voice.”

Should the client choose voice and commu-

nication therapy, the speech-language therapist

should communicate clearly about what is

involved in the therapy program, including

length of practice time, the nature of the exer-

cises, and frequency of practice sessions. This

allows the client to make adjustments to daily

routines to accommodate practice.

Timing of Therapy

While there are no hard and fast rules about

the timing of voice therapy, we should remem-

ber that a client’s perception of voice may

change as the person progresses through the

transition process, so it is important to evalu-

ate voice and communication near the begin-

ning of any therapy program (Byrne, 2003,

2007; Dacakis, 2012a). The ability to progress

in a speech/voice therapy program can be

affected by a variety of factors and a frank dis-

cussion about choosing the optimal timing of a

therapy program is useful. The impact of any

planned surgeries on the timing of voice and

communication therapy should also be

considered.

Some psychosocial factors to investigate are

the following:

1. Motivation for change: For a client begin-

ning a new job in his or her desired gen-

der, the stress and motivation can be very

high. Others who talk only with support-

ive family and friends may not feel the

same need to work hard on speech/voice

change.

2. The amount of time spent in the desired

gender role: Gelfer (1999) and Gold

(1999) suggest that a transsexual woman

living full time is likely to do better in

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voice therapy. However, the transition

process is a personal journey that varies

widely among clients. Some clients may

wish to feminize/masculinize the voice

before they begin to present publicly at

all. Others may feel more comfortable

with a gender-neutral presentation while

they work on their voice and communica-

tion. As with all aspects of the transgen-

der process, the client’s wishes should be

respected.

3. Availability of practice opportunities:

Does the client have sufﬁcient time to

devote to a structured exercise pro-

gram? Is the client socially isolated or

have a wide network of family, friends,

and acquaintances with whom to

practice?

Mental Health and Stability

Transitioning is, by deﬁnition, a time of

great upheaval and psychosocial stress. Before

entering speech/voice therapy a client should

reﬂect on whether they have the time and sta-

bility in life to undertake it. Issues of mental ill-

ness or substance abuse will obviously affect

compliance with any therapy program. If

psychosocial issues are signiﬁcantly impacting

treatment, referral to a trans-competent mental

health professional may be useful.

Minimal Standards

To date there are no minimal standards for

the assessment of voice and communication in

transgender clients. The ﬁeld of practice is

recent and the evidence base, still weak. It is

recommended that once the evidence is sufﬁ-

ciently strong international minimal standards

be developed. The establishment of minimal

standards not only supports best practice

among clinicians around the world but also,

when standard assessment procedures are

used, facilitates the collection of data. How-

ever it must be stressed that clients need to

give their explicit permission for this data col-

lection and distribution.

COMPONENTS OF A PROGRAM TO

FEMINIZE VOICE AND

COMMUNICATION

In this section we will recount evidence- and

practice-based approaches to feminizing voice

and communication. For information on mascu-

linization of voice and communication see

the section “Masculinizing Speech: Physiology

and Identity.”

Preparing for the Process of Voice-and-

Communication Feminization

Most expert speech-language therapists

agree that feminizing voice and communica-

tion is a long process requiring considerable

work on the client’s part (Davies & Goldberg,

2006a). While therapy outcomes cannot be

predetermined, the estimated amount of daily

practice time and expected duration of the

course of therapy should be discussed, as

should the factors that can inﬂuence the course

of therapy (Byrne, 2003). The process requires

altering deeply ingrained communication hab-

its and behaviors, which can be challenging to

modify. It may be useful to use the Stages of

Change model (Prochaska, DiClemente, &

Norcross, 1992; Zimmerman, Olsen, & Bos-

worth, 2000) or other behavioral change tools

to assist in anticipating and addressing barriers

to implementing change. If pitch-changing sur-

gery is sought, there should be discussion of

the parameters of speech and voice that may

still need work after surgery, as well as an

estimation of the healing time involved and

the time required to stabilize the new pitch

(Dacakis, 2002; Neumann & Welzel, 2004;

Wagner et al., 2003).

Some clients are interested primarily in an

assessment of their speech and a professional

opinion on what would be involved in

changing it. Information about therapeutic

options can help with decisions regarding

the timing of gender transition. Speciﬁc

objectives relating to voice modiﬁcation

depend on what is feasible to produce with-

out strain, what ﬁts with the client’s self-

image, and how important passing is to the

client (some clients may be comfortable with

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gender-neutral speech, while others will want

to aim for a voice that is perceived by listen-

ers as cismale or cisfemale).

Education and Information

Clients undergoing speech feminization

need information in a number of areas, such

as:

how the voice is produced;

physiological differences in biological

male and female voice production

systems;

how these differences affect voice produc-

tion and listener perception;

gender-salient parameters of voice and

communication speciﬁc to each client’s

(linguistic and cultural) community;

treatment options, outcomes and risks; and

strategies to prevent vocal fatigue or vocal

injury.

While some transgender individuals are

extremely well informed, others have no

knowledge or have been exposed to inaccu-

rate information via the Internet or peer

groups.

Pretherapy Voice Conditioning

In a pilot project Dacakis (2012b) used

Stemple’s Vocal Function Exercises (Stem-

ple, Lee, D’Amico, & Pickup, 1994) with a

group of 19 participants recruited from a

voice therapy waiting list. This voice exer-

cise program included four sessions over a

7-week period. There were statistically sig-

niﬁcant improvements in a number of voice

parameters and the clients perceived the

therapy to be effective. Initial results suggest

that this kind of pretherapy conditioning may

be useful, particularly for distance therapy,

as it is easy to monitor over online audio-

video telecommunication software, such as

Skype, for transwomen not yet presenting as

femaleandforwomenonavoicetherapy

waiting list or without ready access to

weekly therapy.

Treatment Format: Individual and Group

Sessions

Traditionally voice and communication ther-

apy has been delivered in a 1:1 setting to facili-

tate the personalized intervention necessary to

modify and monitor change in target behaviors.

Determining appropriate average speaking

pitch, working with aspects the client ﬁnds

especially challenging, and dealing with dys-

phonia are all best conducted in a 1:1 setting.

However, there can be advantages to conduct-

ing therapy, at least partially, in a group setting.

A group format is ideal for participants to share

observations, insights, and practical advice. A

group can facilitate peer support and reduce

self-consciousness that a client may experience

when working alone with a therapist (Davies &

Goldberg, 2006a). Information about voice

care and voice change can also be given efﬁ-

ciently in a group.

Some programs incorporate both group and

individual formats. Examples are found in

Davies and Goldberg (2006a) and in Mordaunt

(2012). Group therapy may be used before 1:1

therapy for education purposes and to introduce

participants to the process of change or after

1:1 therapy to offer support and further practice

opportunities. In Davies and Goldberg (2006a),

group therapy and 1:1 sessions are interspersed.

Length of Treatment Time

The length of treatment for transwomen gen-

erally ranges from a minimum of 15 hr to a

maximum of 1 year of weekly sessions. Studies

investigating optimal length of therapy time

have shown mixed results. Some studies sug-

gest that longer time in therapy correlates with

higher SFF (Dacakis, 2000; Hancock & Gara-

bedian, 2013). Two other studies demonstrated

improvement after intervention of 5 weeks and

8 weeks, respectively (Carew et al., 2007; Gel-

fer & Tice, 2013). In the Gelfer study these

changes lasted, at least in part, for up to

15 months after treatment.

Optimal treatment time for each individual

will vary, depending on the degree of change

sought, the client’s natural abilities, the amount

of time and energy the client devotes to

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practice, and the presence of co-occurring psy-

chosocial difﬁculties. A short program may

promote increased focus and motivation while

a longer course of treatment allows more time

for habituation and generalization.

Psychosocial adjustment is an important part

of changing speech and voice. Participants may

require time to get in touch with what sort of

voice best matches the person within. This is by

necessity a process that takes time and profes-

sional input to assess what is desirable and pos-

sible. Many transgender individuals begin with

the goal of having a pitch that is unrealistically

high (MtF) or low (FtM); only with experimen-

tation and practice will it become apparent that

this is probably not achievable, necessary, or

even desirable. Additionally, it can take time to

feel that an altered voice is an authentic expres-

sion of self rather than an artiﬁcial “mask.”

Speech and Voice Therapy Protocols

Speech-language therapists are in the difﬁ-

cult situation of having to provide service in

speech/voice feminization in the absence of

evidence-based protocols. In this section we

have chosen protocols that include standard

outcome measures and those modeled on evi-

dence-based protocols from the voice therapy

literature with cisgender people.

Examples of two complete protocols for

speech/voice feminization may be found in

Voice and Communication Therapy for the

Transgender/Transsexual Client: A Compre-

hensive Clinical Guide (Adler, Hirsch, & Mor-

daunt, 2012) and in Davies and Goldberg

(2006a). These protocols should be used advis-

edly as their efﬁcacy and effectiveness have

not been established in the literature.

Perceptual-Motor Learning Principles

In their recent book, Vocology, Titze and

Verdolini Abbot (2012, pp. 217–238) discuss

perceptual-motor learning principles and how

they apply to the remediation of voice disorders

(pp. 217–238). These apply equally well to

voice and communication feminization and

the reader is referred to this book for a compre-

hensive discussion of the principles underlying

speech and voice change. The principles

include the following:

using target sensations or images as input,

rather than instructions;

the need for attention and concentration on

producing and reproducing the target

sensation;

progressing from simple tasks to more

complex ones; and

performing and learning behaviors

together (such as breathing and voicing) if

they should be performed together.

Vocal Stretching, Vocal Conditioning

Voice training protocols frequently begin

with vocal ﬂexibility exercises.

Vocal Function Exercises

Stemple’s Vocal Function Exercises (Stem-

ple et al., 1994) have been used to facilitate a

wider pitch range and train efﬁciency of voice

production (Dacakis, 2012b; Gelfer & Van

Dong, 2013). Dacakis used them for pretherapy

voice conditioning and found they were beneﬁ-

cial. Gelfer and Van Dong used vocal function

exercises along with their standard voice femi-

nization program. They found that while listen-

ers rated posttreatment voice recordings as

more feminine, the addition of vocal function

exercises did not improve outcomes, as

compared with previous literature.

Semi-Occluded Vocal Tract Techniques

Semi-occluded vocal tract (SOVT) techni-

ques may be used to facilitate voice production

in the upper part of the pitch range; train a

“head voice” or “mixed registration”; encour-

age efﬁcient vocal fold vibration; and stimulate

a forward sensation of the voice, or a high voice

placement (Verdolini-Marston, Burke, Lessac,

Glaze, & Caldwell, 1995). SOVT techniques

include phonating into straws or tubes, lip or

tongue trilling, the use of nasals /m/, /n/, voiced

fricatives, e.g., /z/, /v/, and closed vowels, e.g.,

/u/, /i/. Two exercises are often used: a pitch

glide throughout the middle and upper pitch

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range and a messa di voce exercise, going from

soft to loud and then soft again (Titze, 2000;

Titze & Verdolini Abbot, 2012). Prolonging

the voice at a higher pitch through a semi-

occluded vocal tract may develop efﬁciency of

voice production at a higher nonhabitual pitch

(Davies, 2012; Davies & Goldberg, 2006a).

Raising the Speaking Fundamental

Frequency

These techniques have been used by experi-

enced speech-language therapists to train an

efﬁciently produced higher average speaking

pitch.

1. Using trial therapy in the assessment ses-

sion the clinician and client ﬁnd a speak-

ing pitch that is either in gender neutral

or low cisfemale range and can be pro-

duced without strain. This is used as a

training pitch and is prolonged using

semi-occluded-vocal-tract techniques.

Speech sounds, words then longer utter-

ances are intoned then modulated in a

natural way, always keeping the voice

easily produced without the need for

excessive vocal effort (Dacakis, 2012a;

Davies & Goldberg, 2006a; Gelfer & Van

Dong, 2013; Gelfer & Tice, 2013).

2. The client starts near the habitual speak-

ing pitch and slowly raises the average

speaking pitch throughout the therapy ses-

sions. This continues until both the client

and the clinician feel the pitch is appropri-

ate and manageable (Mordaunt, 2012).

3. The speech-language therapist asks the

client to sing “do re mi” then hold the

pitch of “mi” and use that as a target for a

higher, easier voice (Bennett, 2010).

4. The client uses a pitch well into cisfemale

range, such as 220 Hz, as a target for

pitch training (Perez, 2004).

Raising Vocal Tract Resonance

Frequencies

1. Instruct the client to use a forward tongue

carriage and slightly spread lip posture

during speech. This technique was found

to be effective in a clinical study of 10

transsexual women (Carew et al., 2007).

2. Use /i/ as a target mouth shape for high,

forward tongue placement in other vow-

els (Mordaunt, 2012).

3. Use smaller jaw excursions during

speech.

High Voice Placement

1. Using /m/, /v/, and other semi-occluded–

vocal tract sounds to cue a high, maxi-

mally forward voice placement (Davies

& Goldberg, 2006a; Mordaunt, 2012;

Titze & Verdolini Abbot, 2012).

2. Draw attention to sensations of vibration

or resonance moving from the chest or

throat into the mouth or front of face

Davies & Goldberg, 2006a; Mordaunt,

2012; Titze, 2001).

Language and Discourse Pragmatics

While there are strong social stereotypes

about gender norms and language (e.g., use of

slang, intensiﬁers, and tag questions), gender-

associated norms of language and discourse

are so dependent on an ever-shifting social

context that ﬁndings from studies conducted in

past decades may not be reﬂective of current

trends in the client’s speech community (Frei-

denberg, 2002; Oates & Dacakis, 1983). Addi-

tionally, there is strong interplay between

gendered language norms and norms relating

to culture, class, and age (Hasegawa & Hata,

1995; Linville, 1998; Moran, McCloskey, &

Bady, 1995; Morris & Brown, 1994), so norms

appropriate for one client would not be appro-

priate for another. If there are habits relating

to vocabulary and syntactic choices, such as

the use of modiﬁers, qualiﬁers, indirect versus

direct speaking style, that the client ﬁnds dis-

comforting or the clinician feels may contrib-

ute to perceptions that don’t ﬁt the client’s

self-image, we recommend that the speech-

language therapist offer feedback in these

areas, encouraging the client to weigh research

ﬁndings or the clinician’s suggestions against

personal experience.

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We recommend that modiﬁcation of lan-

guage and discourse be based on the client’s

own observations of gender markers in the

speciﬁc environmental context of concern to

the client (e.g., work, home, cultural commu-

nity, social setting). Clients with strong beliefs

about “appropriate” language may beneﬁt

from the speech-language therapist’s assis-

tance to explore stereotype versus actual

observed behavior of peers.

A discussion of gender-dependent communi-

cation variables in cisgender people, together

with exercises, can be found in chapters 13

(Frazier & Hooper) and 14 (Crutchley, Hooper,

& McCready) in Adler, Hirsch, and Mordaunt

(2012).

Nonverbal Communication: Facial

Expressions, Posture, and Movement

Norms relating to posture, gestures, and

other nonverbal aspects of communication are

strongly inﬂuenced by many things including

cultural, class, and age norms. These behaviors

also constantly change depending on many var-

iables such the speaker’s mood and conversa-

tional partner or situation. It is not within the

normal scope of practice of a typical speech-

language therapist to provide a detailed assess-

ment of nonverbal communication behaviors.

If a client wishes input that the clinician feels

unable to give, it may be possible to refer

to a trans-competent–speech-language therapist

who has training in nonverbal communication.

Other options include a discussion of the non-

verbal parameters of communication, together

with structured observations to be conducted

within the client’s community. This can help

foster awareness and sensitivity to subtle

changes in nonverbal communication, which

could be more useful than learning and follow-

ing rigid patterns of behavior.

A discussion of nonverbal communication

and therapy protocols is found in Adler, Hirsch,

and Mordaunt (2012): Hirsch and Van Borsel

(chapter 15) and Boonin and Hirsch (chapter

16). These chapters are based on the authors’

experience and observations and on literature

of cisgender men and women.

Habituation and Generalization

The ability to use a feminine voice in every-

day life is a signiﬁcant achievement and also

the goal of many transwomen who embark on

speech/voice change. Some strategies can pro-

mote carryover into everyday life:

practicing words that are typically part of

daily conversation (e.g., hi, bye, yes, no);

in clinical practice of conversational

speech, focusing on situations/topics

related to the client’s life and engaging in

role plays suggested by client to match

real-life situations that pose the most difﬁ-

culty (e.g., job interview, coffee shop

interaction; e.g., Hooper, 1985);

experimenting with emotional intensity by

practicing sentences expressing feelings

like joy, sorrow, irritation or anger; and

mindful practice outside the clinic setting

in a wide variety of real-life settings,

depending on comfort level

The process of habituation of any new motor

act takes mindful practice over a period of time

(Adams, 1971). Maintaining change outside the

clinical setting is challenging and until recently

has not been measured. In 2007, Ma et al. used

Soundswell’s computerized real-time phoneto-

gram Phog 1.0 (Hitech Development AB, T€

aby,

Sweden) to record voice in everyday situations

among cisgender subjects with dysphonia (Ma

et al., 2007). In 2009, S€

odersten, Hertega

rd,

Larsson, and Holmberg (2009) researched the

use of a portable dosimeter called the Ambula-

tory Phonation Monitor (APM) in one MtF client

to monitor voice use outside the clinic. When her

fundamental frequency decreased under a certain

threshold level a tactile feedback signal was

given to remind her about raising her fundamen-

tal frequency. Also the portable Voxlog system

can provide tactile feedback when the speaker

exceeds or goes below a certain fundamental fre-

quency threshold level. This could be useful for

transgender speakers. Dacakis et al. (2012)

also suggest such a device may prove useful

in a clinical context. In North America the

dosimeter that is commercially available is

the Ambulatory Phonation Monitor (APM),

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developed collaboratively by Kay PENTAX and

speech-language therapists from Massachusetts

General Hospital.

Follow-Up Sessions

Follow-up sessions after the initial treatment

has ﬁnished, or facilitated support groups for

ongoing practice, may be useful in maintaining

and entrenching changes made in therapy. Clini-

cally supervised follow-up also provides an excel-

lent opportunity to gather much-needed data

about the effectiveness of a program over time.

Follow-Up Sessions (Group/Individual)

There is as yet no empirical evidence regard-

ing the optimum frequency for follow-up ses-

sions, the optimum content, or the criteria for

termination. In the absence of data, we suggest

that refresher sessions could be initially offered

3 months after treatment and then at 4- to 6-

month intervals or as the clinician and client

deem appropriate.

Follow-up sessions can include a discussion

of successes, problems, strategies, and difﬁcul-

ties the client has experienced since the end of

therapy; a review of the core exercises of the

program (to ensure the client is practicing cor-

rectly and to determine if the exercises are still

appropriate); and time to address any concerns

that have arisen since the end of treatment. Ide-

ally, follow-up would include re-evaluation of

the same parameters measured in the pretreat-

ment assessment, both to assess the mainte-

nance of the desired changes and also to

evaluate the effectiveness of refresher sessions.

If the initial therapy was provided in a group

setting, a group setting is a natural forum for

refresher sessions. As with group format for

initial therapy, group format for refresher work

offers valuable opportunities for clients to com-

pare experiences. In our experience this can be

most useful and encouraging, especially for

those in the early stages of their transition. Indi-

vidualized follow-up may be more appropriate

than the group format if the client has numer-

ous concerns or unusual concerns that require

individual attention or if the client feels uncom-

fortable in a group setting.

Client-Run Voice and Communication

Support Groups

Self-help groups may be useful for transgen-

der individuals who have completed clinical

treatment and are seeking peer support to

maintain or strengthen voice and communica-

tion changes. Client-run voice and communica-

tion groups can provide motivation to maintain

practice, a forum to practice and to share ideas

and concerns, and an opportunity to socialize

and undertake speciﬁc role playing. Client-run

groups can also foster the client’s sense of own-

ership and control of speech and voice produc-

tion so that he or she feels less dependent on

the therapist.

In any self-help group there is a danger that

an individual may inappropriately assume a

professional clinical role. In a communication

group, this could be circumvented by providing

group facilitation training to members, by hav-

ing the speech-language therapist as guest visi-

tor from time to time, and by having self-help

sessions along with therapist-run refresher

sessions.

IMPROVING ACCESS TO SERVICE

Distance Assessment and Therapy

At the time of writing, online applications

and forums such as the ones provided by Skype

and Google Hangouts offer opportunities for

interactive distance voice and communication

therapy. These recent technological advances

have the potential to greatly expand access to

voice and communication services—one of the

main difﬁculties experienced by many trans-

gender people. However, speech-language

therapists should be mindful of possible con-

cerns with a lack of conﬁdentiality inherent in

Internet communication.

In her presentation at the WPATH 2011

symposium, Dacakis (2011) outlined a protocol

for this kind of service delivery. Video confer-

encing is being used with increasing frequency

in many health care settings. It has the potential

to provide good visual and audio contact

between speech-language therapists and geo-

graphically isolated clients and could also serve

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as a training modality for speech-language

therapists in the care of transclients.

Improving Accessibility and Utility to

Clients With Access Barriers

The transgender community is tremendously

diverse, and protocols must be ﬂexible enough

to address this diversity of service needs and

issues relating to access. In the transgender

voice and communication literature reviewed

for this project, there was little discussion of

modiﬁcation to address the needs of clients

who have difﬁculty accessing the typical set-

ting or format of voice and communication

services—including individuals who have

speech, hearing, cognitive, or learning disabil-

ities, are not highly ﬂuent in the primary lan-

guage spoken where they live, or are not

literate or who are geographically isolated or

cannot leave a residential facility, such as a

prison or long-term care home. Without empiri-

cal evidence to guide practice, we offer the fol-

lowing suggestions based on our experience

providing services to a diverse range of trans-

gender clients.

For individuals who do not speak the speech-

language therapist’s language, an information

package could be translated into a variety of

languages. Providing voice and communication

services in another language is not possible

unless the speech-language therapist speaks the

client’s language well, as subtleties of inﬂec-

tions, inﬂectional range, word stress, and

semantic and syntactic choices require a thor-

ough knowledge of the language. The only

direct therapeutic input that could perhaps be

given would be in changing the speaking fun-

damental frequency and formant characteris-

tics. Speech-language therapists who are

multilingual could be supported to take trans-

speciﬁc training, perhaps working in consulta-

tion with a more trans-experienced speech-lan-

guage therapist to provide service in the

client’s primary language. If the client is par-

tially ﬂuent in the primary language of their

community, wishes speech therapy in that lan-

guage, and will be using it in everyday life,

therapy delivered in that language can be

beneﬁcial as the client has the opportunity of

learning more-feminine/masculine patterns of

speech as they acquire the language. For indi-

viduals who are only partially ﬂuent in the lan-

guage used in therapy, the therapeutic process

will likely be longer and will require much

more 1:1 input.

Transgender clients with speech or hearing

disabilities who are able to attend voice and

communication therapy sessions may ﬁnd great

beneﬁt from using visual input during speech

therapy. This has been used with good success

with other populations (e.g., using palatography

and ultrasound to work with phonological dis-

orders in people with hearing impairments).

For transgender clients, there are a number of

software programs that record fundamental fre-

quency and allow the creation of a “model

voice wave.” The speech-language therapist

can record a desired average speaking pitch or

an intonation pattern and the client could then

use the visual input to copy it; alternatively, the

speech-language therapist could record the

lowest (MtF)/highest (FtM) desirable frequency

and the client could use the visual input to keep

the speaking pitch above (MtF) or below (FtM)

this line.

Online and/or ofﬂine free pitch-measuring

programs can be useful for clients’ home

practice. Speech-language therapists should

be alert for other emerging applications for

electronic communication devices. Some cur-

rently available programs include the

following:

Seventh String Tuner: http://www.seventh

string.com/tuner/tuner.html

Praat: http://www.praat.org

Mintleaf software: http://mintleafsoftware.

com/voice-monitor.html

Sonneta Voice Monitor: http://appstore.

com/sonnetavoicemonitor

Voice Analyst: https://play.google.com/

store/apps/details?id Dco.speechtools.

voiceanalyst

If a client has cognitive or learning disabil-

ities, depending on the nature of the disability

it may be useful to include a loved one or care

aide in the therapeutic process. This person

could help the client establish a regular practice

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schedule and give input to the exercises, under

the guidance of the speech-language therapist.

A different format may be useful for the client

who has difﬁculty processing the information

necessary to change speech habits. Rather than

using an approach that requires introspection

(e.g., “How does that sound? Am I feeling my

voice in my face?”), the speech-language thera-

pist may be more directive in determining

which exercises would most useful and could

be performed appropriately by the client; the

clinician and client together would draw up a

practice schedule and the client would simply

practice the motor movements outlined. Indi-

vidualized attention is likely to be more effec-

tive than group work for providing the client

with more intensive input. To be successful,

this kind of format would require regular clini-

cal intervention and support outside the therapy

room.

Self-Guided Speech Feminization

There are many videos, websites, CDs, and

other materials available for self-guided speech

feminization. We cannot comment on the efﬁ-

cacy or safety of these materials, but we are

concerned that (a) many are not produced by

speech-language therapists and (b) there are

risks associated with attempting to change the

voice without professional assistance. Speech

feminization/masculinization involves substan-

tial changes in habitual production and so has

the potential to cause a voice disorder or aggra-

vate an existing one. It is strongly recom-

mended that anyone seeking to feminize or

masculinize speech ﬁrst be assessed by a

speech-language therapist, that a speech-lan-

guage therapist be involved in monitoring prog-

ress, and that a speech-language therapist be

consulted if there are any symptoms of vocal

fatigue or negative changes to vocal quality.

Additionally, we recommend that consumers

be cautious of any materials promoting a rigid

set of speech norms, as speech is highly indi-

vidualized and culturally driven and cannot be

guided solely by a set of generic rules.

Over the past 10 years, study and practice in

the area of transgender voice and communica-

tion has expanded and deepened. We look

forward to greater understanding and better

practice as this ﬁeld continues to grow.

SURGICAL FEMINIZATION OF THE

LARYNX AND VOICE

Transgender people wishing to feminize

their voice or appearance through surgical

means may choose to undergo two different

kinds of surgical procedures:

1. A thyroid chondroplasty, which is a cos-

metic procedure that reduces the size and

angle of the thyroid cartilage to resemble

the ﬂatter, smaller cisfemale thyroid carti-

lage. It has no feminizing effect on the

voice (Sandhu, 2007).

2. Phonosurgery, which can raise the speak-

ing fundamental frequency and eliminate

lower frequencies in the cismale speaking

range (Spiegel, 2006).

Thyroid Chondroplasty

A thyroid chondroplasty, also called a tra-

cheal shave, laryngeal shave or Adam’s apple

reduction, may be performed alone or in addi-

tion to a phonosurgical procedure. This surgery

may be performed by an otolaryngologist or

plastic surgeon. The surgeon makes the incision

in a crease at the front of the neck, directly over

the larynx. In Sandhu’s opinion “Unless there

is a history of keloid scar formation, the inci-

sion is not easily visible after a few weeks. The

advantage of this technique is that it allows for

the dimensions of the larynx to be measured

accurately for maximal and safe removal of the

laryngeal prominence” (Sandhu, 2007, p. 196).

An alternative scar location is a small incision

high on the midline of the neck. Although the

advantage is that the scar is hidden under the

chin, the scar cannot be placed in a natural

crease and the patient is more likely to develop

adhesions between the skin and the larynx so

that there is “puckering” of the skin with swal-

lowing. Sandhu (2007) notes there may be a

small risk of detaching the vocal cords anteri-

orly, with an associated risk to the voice and

airway. Spiegel (2006) notes that during this

procedure it is important to preserve the

138 Davies, Papp, and Antoni

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anterior attachment of the true vocal folds, oth-

erwise an undesirable lowering of pitch can

result. A summary of outcome data is found in

Matai, Cheesman, and Clarke (2003).

Voice Feminization Surgery

As was discussed in the section “Average

Speaking Fundamental Frequency,” a higher

speaking fundamental frequency (SFF) is con-

sidered to be one of the most important compo-

nents of a feminine voice and transwomen may

undergo phonosurgery to raise both the SFF

and frequency range, as well as to eliminate

access to lower frequency ranges (Remacle

et al., 2011; Spiegel, 2006; Wagner et al.,

2003). Van Borsel found that the “perception

of femaleness signiﬁcantly correlated with the

average fundamental frequency” (Adler & van

Borsel, 2006). However, as was also discussed

earlier, there are a number of voice characteris-

tics that are believed to combine to produce a

feminine voice. These include resonance char-

acteristics, articulatory contacts, voice quality,

and intonation contours. Adler and van Borsel

(2006) noted that while a pitch-raising surgery

may be a viable option to increase the speaking

pitch in MtFs, this surgery alone may not be

sufﬁcient to produce a voice that is perceived

as totally female.

A number of reasons support the use of pho-

nosurgery to feminize the voice in transgender

women. The availability of speech-language

therapists with this particular clinical compe-

tency may be limited in the area where the indi-

vidual lives. Treatment outcomes may be

inﬂuenced by the client’s commitment to ther-

apy, level of practice outside of the therapy ses-

sions, social conﬁdence level, and emotional

health. Whilst some clients show an aptitude

for voice work and possess a “good ear,” which

aids their skill acquisition, other clients ﬁnd

voice work challenging on a physical and/or

emotional level. Some clients struggle with

vocal fatigue, and to maintain a raised pitch,

even with sustained voice therapy, progress

may be limited (Adler, Constansis, & van Bor-

sel, 2012).

Antoni (2007) notes, “Limited data exist

regarding the formal outcomes of vocal surgery

with transsexuals” (p. 144). There is a paucity

of outcome data for pitch-elevating surgery,

particularly longitudinal data to monitor out-

comes over time. In general, professional opin-

ion is mixed about voice surgery, with some

clinicians stating that it is not a viable treatment

option (Andrews, 1999; Koufman, 2007), and

others recommending and others recommend-

ing that voice surgery be considered a treatment

of last resort for MtFs who have not experi-

enced satisfactory increase in pitch following

speech therapy (Lawrence, 2004; Oates &

Dacakis, 1997; Wagner et al., 2003). Certainly

the reported negative effects (compromised

voice quality, diminished vocal loudness,

adverse impact on swallowing or breathing,

sore throat, wound infection, and scarring) and

variable outcomes are a concern (Brown, Perry,

Cheesman, & Pring, 2000; Dacakis, 2002;

Koufman, 2007; Lawrence, 2004; Neumann &

Welzel, 2004; Oates & Dacakis, 1997; Thomas,

2003; Wagner et al., 2003; Yang, Palmer, Mur-

ray, Meltzer, & Cohen, 2002).

However, some proponents of voice surgery

suggest that surgery can protect the voice from

damage caused by strain to elevate pitch

through nonsurgical means (Brown et al.,

2000; Neumann & Welzel, 2004; Yang et al.,

2002). Given this, while there are clear risks of

voice surgery and the decision to pursue it

should be carefully considered, the decision

about risk-beneﬁt ratio and preferred technique

is best left to the patient, with input from both a

trans-experienced surgeon and a trans-experi-

enced speech-language therapist.

Presurgical Assessment

In addition to the standard screening con-

ducted prior to any surgery (assessing for risks

relating to anesthesia, infection, etc.), assess-

ment prior to pitch-elevating surgery should

include an anatomical and functional assess-

ment of the larynx, the client’s subjective

assessment of the client’s voice, an acoustic

analysis, audio or video recordings, and the

clinician’s perceptual analysis.

Particular

attention should be paid to the measurement of

speaking fundamental frequency and frequency

range and of voice quality (Neumann &

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Welzel, 2004; Yang et al., 2002). Any dyspho-

nia present before surgery should be addressed

through standard voice therapy protocols prior

to voice surgery. Care should be taken to ensure

that the patient understands the risks and antici-

pated outcome of the technique that will be

used.

After ﬁnding that some subjects have

strained and unnaturally elevated voices fol-

lowing surgery, attributed to habitually speak-

ing at an artiﬁcially elevated pitch for sustained

periods of time prior to surgery, one surgical

group reported testing for ability to phonate at

a pitch within the masculine range as part of

preoperative consultation. Clients who are

unable to do this were felt to have the equiva-

lent of a muscle tension dysphonia and were

referred for preoperative voice therapy to

recover the ability to produce relaxed phona-

tion (Yang et al., 2002).

Estrogen is associated with risk for deep vein

thrombosis and pulmonary embolism. If the

patient will be immobilized for a prolonged

period during or following surgery, consulta-

tion with the prescribing physician is necessary

to discuss the advisability of tapering estrogen

use before surgery.

Smoking increases the risk of complications

from anesthetic and impairs healing, and there

is evidence that smoking following voice sur-

gery can negatively impact voice quality and

pitch (Wagner et al., 2003). Patients should be

made aware of the risks associated with smok-

ing and of smoking cessation resources and and

should be strongly encouraged not to smoke

prior to or immediately following surgery.

Postsurgical Care

Postsurgical care depends on the speciﬁc

surgical technique employed. The surgeon

should review aftercare instructions with the

patient as part of informed consent prior to

surgery, as well as provide written informa-

tion to be consulted before and after surgery.

The surgeon should also be easily accessible

for questions relating to postoperative com-

plications. If surgery is performed away

from the patient’s hometown, the patient’s

local primary care provider should consult

with the surgeon to determine appropriate

follow-up.

Follow-up evaluation by the surgeon (or

postoperative care coordinator if the surgeon is

in a different location) is recommended at 1

week, 4 weeks, 12 weeks, and 6 months after

surgery to monitor healing and recovery.

Immediately following surgery, temporarily

decreased pitch, diminished voice quality, and

edema were commonly reported, with sponta-

neous recovery in most cases. Less-common

complications that required medical interven-

tion included mild emphysema, neck abscess,

negative response to the sutures/plates used in

cricothyroid approximation (requiring removal

of the material), and loosening of the sutures

used in cricothyroid approximation (requiring

additional surgery) (Neumann & Welzel, 2004;

Wagner et al., 2003).

For most techniques, it is recommended that

patients not use their voice at all for 1 to 7 days

after surgery and then to use the voice cau-

tiously until any discomfort (e.g., due to post-

operative edema) has passed (Brown et al.,

2000; Neumann & Welzel, 2004). For the more

invasive, combined thyroid cartilage and vocal

fold reduction, 2 weeks vocal rest is suggested

(Kunachak, Prakunhungsit, & Sujjalak, 2000).

Following cricothyroid approximation, steam

inhalation may be recommended to hydrate and

lubricate the vocal cords to promote healing

(Brown et al., 2000).

Speech therapy is recommended following

surgery to help the patient adapt to and stabilize

the new voice (Neumann & Welzel, 2004;

Wagner et al., 2003). If pitch-elevating surgery

was performed before other components of

speech had been satisfactorily altered, other

aspects of voice such as resonance, intonation,

and articulation may also need to be addressed

through speech and voice therapy (Dacakis,

2002; Neumann & Welzel, 2004).

Voice Feminization Surgeries

With one exception, the thyrohyoid approxi-

mation, the voice feminization surgery

described in the literature addresses only pitch

change.

140 Davies, Papp, and Antoni

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Surgical techniques to elevate pitch are

based on the physiological components of pitch

(Kunachak et al., 2000):

F0 D1

2£ﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃ

mean vocal fold tension

vocal fold density

Fundamental frequency can thus be raised by

shortening the folds, by decreasing the total

mass of the folds, or by increasing the tension

of the folds (Neumann, Welzel, & Berghaus,

2002; Pickuth et al., 2000; Yang et al., 2002).

Surgical techniques to achieve this include

anterior commissure advancement; creation of

an anterior vocal web,; cricothyroid approxima-

tion; induction of scarring along the vocal

folds; and vocal-fold reduction by intracordal

steroid injection, laser evaporation of the vocal

fold, or composite reduction/reconstruction of

the vocal fold (Brown et al., 2000; Kunachak

et al., 2000; Neumann, Welzel, & Berghaus,

2002; Neumann, Welzel, Gonnermann, &

Wolfradt, 2002; Neumann & Welzel, 2004;

Oates & Dacakis, 1997; Pickuth et al., 2000;

Wagner et al., 2003; Yang et al., 2002). To

date, there has been very little literature discus-

sing outcomes of any procedures other than the

cricothyroid approximation. Based on the liter-

ature review, cricothyroid approximation is the

only method that has been assessed with sufﬁ-

cient rigor to be considered a viable treatment

option (Brown et al., 2000; Neumann, Welzel,

& Berghaus, 2002; Neumann, Welzel, Gonner-

mann, & Wolfradt, 2002; Neumann & Welzel,

2004; S€

oderpalm et al., 2004; Yang et al.,

2002; Wagner et al., 2003).

Pitch-Elevating Surgical Procedures

Cricothyroid approximation (CTA) is the

most common voice feminization surgery and

the only one that has a body of outcome data. It

is also one of the few procedures that does not

involve surgical alteration of the vocal folds

themselves. In this procedure, “the cricoid car-

tilage is moved backward and upward and the

thyroid cartilage is ... moved forward and

downward. Then the two cartilages are closer,

and the vocal cord tension is increased.”

(Wagner et al., 2003, pp. 1158–1159). This

mimics the contraction of the cricothyroid mus-

cle that tenses and elongates the vocal folds,

causing the pitch to increase. The cartilages are

then secured in place by stitches and/or metal

plates. This procedure, in effect, puts the vocal

folds on permanent stretch. The surgery is car-

ried out through a small skin excision over the

larynx and may be performed at the same time

as a thyroid chondroplasty.

In theory, CTA is reversible, but in some

cases scar tissue has permanently fused the car-

tilages together. Where this fusion has not hap-

pened, the stitches/plates can loosen over time,

causing the cartilage to move back to its origi-

nal position and the pitch to drop. Because the

vocal folds aren’t directly surgically changed

by this technique, it may be possible to perform

additional surgery if the CTA is not sufﬁcient.

While several studies have described an

increase in SFF after CTA (Brown et al., 2000;

Kanagalingam et al., 2005; Neumann, Welzel,

& Berghaus, 2002; Neumann & Welzel, 2004;

Yang et al., 2002), the amount of the pitch

increase was variable and the subjective out-

comes to the surgery were mixed. Yang et al.

reviewed 20 patients and found a mean change

in SFF of 57 Hz (from a mean of 145 Hz pre-

operatively to 202 Hz postoperatively). In

2004, Neumann & Welzel (2004) looked at 67

patients and found that a year post-CTA, 30%

of the voices were within cisfemale pitch range

and 32% were in a gender neutral range.

Patient satisfaction with post-CTA voice was

also mixed. In Yang et al. (2002), 58% of the

patients expressed satisfaction and 33%

expressed dissatisfaction; 42% described their

postoperative voice as “rough or hoarse.”

When describing how well their voice worked

on the phone, 31% said they were never per-

ceived as male, 47% reported being occasion-

ally taken as male, and 22% said they were

frequently considered to have a masculine

voice. At a follow-up a year or more after sur-

gery, 29% of the subjects reported dysphagia

with liquids. A review of CTA surgery by

Kanagalingam et al. (2005) found that 79% of

patients were satisﬁed with the results and 71%

had increased fundamental frequency both in

reading and speaking.

INTERNATIONAL JOURNAL OF TRANSGENDERISM 141

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The variability of outcomes after a CTA may

result from anatomical differences in the crico-

thyroid joint itself (Storck et al., 2011; Wind-

isch, Hammer, Prodinger, Friedrich, &

Anderhuber, 2010). In 2011, Storck and col-

leagues sought to determine why a CTA

worked well in some patients and not others

and to see if there was a way of predicting how

successful a CTA would be. Using high-resolu-

tion computerized tomography and three-

dimensional imaging software, they examined

24 cadaver larynges of transsexual women who

had undergone CTA. They found that the ana-

tomical structure of the CTJ [cricothyroid joint]

inﬂuences directly (1) the position of the effec-

tive rotation axis and (2) the elongation of the

vocal folds. “Based on the location of this

effective rotation axis, we could distinguish

three groups. In group I (N D13), the rotation

axis was located in the lower third; in group II

(N D5), it was located in the middle third; and

in group III (N D6), it was located in the upper

third of the cricoid. The elongations of the

vocal fold were 12%, 8%, and 3%, in groups I,

II, and III, respectively” (Storck et al., 2011,

p. 632).

Shortening the Vocal Folds

Other phonosurgeries are available to trans-

gender women; however, these are more inva-

sive than the cricothyroid approximation and

there is sparse literature on both the surgical

procedures and the outcomes.

There are a number of reported surgical

techniques used to shorten the vocal folds,

allowing them to vibrate at a higher frequency

(e.g., Gross, 1999). One such procedure is

called the anterior commissure advancement.

The epithelial tissue of the anterior third of the

true vocal folds is ablated, then this tissue is

sutured together to form a nonvibrating anterior

web (Remacle et al., 2011). An example of a

variation of this procedure, in which no sutures

are used, is described on the Yeson Voice Cen-

ter website (http://www.yesonvc.net/disease/

feminization_surgery.asp).

Another example of a voice feminization lar-

yngoplasty technique is described by Thomas

and Macmillan (2013). In this procedure, a 10- to

14-mm wide segment of the anterior thyroid car-

tilage is removed. The true and false vocal folds

are split in the anterior midline and the anterior

portions of both are excised. The true vocal folds

are then sutured together to create a new anterior

commissure and the thyroid alae are brought

back together to create a smaller larynx.

Other Procedures

In some more recent patients of Dr. Thomas,

an additional surgery, a thyrohyoid approxima-

tion, was performed. The thyroid cartilage was

raised and sutured to the hyoid bone to dimin-

ish, as much as possible, the thyrohyoid space.

The goal in this procedure is to create more

feminine resonance characteristics by shorten-

ing the vocal tract.

In discussing outcomes Thomas and Mac-

millan (2013) note that the feminization laryng-

oplasty elevated SFF into cisfemale range and

resulted in a permanent loss of bass notes. They

also provide references for online voice record-

ings of patients who had undergone both of

these surgeries. However, we could uncover no

further literature discussing these surgical pro-

cedures and would advise caution in undertak-

ing a highly invasive surgery for which there is,

as yet, little outcome data.

Another phonosurgery available to transgen-

der women is Laser-Assisted Voice Adjustment

or LAVA. In this procedure a CO2 laser is used

to vaporize portions of the vocal folds, resulting

in a decrease in mass and increase in stiffness.

The scarring resulting from this procedure pro-

duces a signiﬁcant rise in pitch (Orloff et al.,

2006). Orloff et al. conducted a retrospective

review of 31 patients, with a mean follow-up

time of 23 weeks. While pitch increases averag-

ing 26 Hz were reported, the evaluation also

showed decreased vocal quality, loudness, and

vocal range. In 2010, Kocak et al. described

the use of a modiﬁed LAVA procedure in a

small study of 3 patients whose voices were not

improved by cricothyroid approximation. After

the vocal folds had been vaporized with a CO2

laser they were tensed medially and stabilized

with sutures. The authors reported higher SFF

and improved patient satisfaction after surgery

(Kocak et al., 2010).

142 Davies, Papp, and Antoni

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In summary, there is a variety of phonosurgi-

cal procedures available to transgender women

wishing to increase the pitch of the voice. How-

ever, variable outcomes and paucity of outcome

data suggest that these procedures be approached

with caution and that they should be coupled

with voice therapy to address other gendered

aspects of speech and voice production (Dacakis,

2002, 2012b; Orloff et al., 2006; Spiegel, 2006).

MASCULINIZING SPEECH:

PHYSIOLOGY AND IDENTITY

Introduction

The lacuna in both the global research

efforts on and therapeutic treatment of the FtM

vocal changes does not make it possible to pro-

vide a summary of current good practice.

Instead, this section of the companion docu-

ment attempts to summarize and interpret the

results of the existing evidence-based research

and give an overview of gendered voice and

speech issues that a speech practitioner work-

ing with FtM people needs to be aware of.

Although the effects of sex hormones on the

human voice have been widely documented, up

until recently very few studies addressed trans-

gender individuals directly. Instead, practi-

tioners had to rely on studies that explored the

vocal maturation of biological males (e.g.,

Titze, 1994), women’s voices changing due to

endocrine problems or the treatment of their

symptoms (e.g., Pattie, Murdoch, Theodoros,

& Forbes, 1998), and the ageing voice (e.g.,

Titze, 1994).

A small number of recent studies have begun

to document the effects of exogenous androgen

hormones in transgender men, or FtM transsex-

uals (Adler & van Borsel, 2006; Constansis,

2008; Damrose, 2009; Papp, 2011a; van Borsel

et al., 2000; van Borsel, Cuypere, & van den

Berghe, 2001). Although other researchers

have presented pitch change data for transition-

ing transgender men, longitudinal studies are

still scarce, especially ones that interpret the

changes using a psycho-acoustic pitch-scale for

accurate within- and between-subject compari-

sons. As it will be shown below, besides the

changes in the speaking fundamental frequency

(SFF), it is important to also monitor the

changes in the available maximum phonational

range (MPR)—that is, the distance between the

lowest and highest phonational frequencies (cf.

p. 49). In addition to documenting the amount

of change during the ﬁrst year on testosterone,

it is important to characterize the timing of the

changes and following the changes for possibly

multiple years. The motivation behind this is

that some of the most frequent questions from

FtMs commencing testosterone therapy address

(a) how soon the changes are noticeable, (b)

how low their SFF may reach, (c) how long it

takes for the mean fundamental frequency to

reach its lowest and settle, and (d) how their

singing voice might be impacted by the

changes.

Several newer studies on the FtM voice

challenge existing assumptions about the

FtM vocal transitioning process. Speciﬁcally,

results in Papp (2011a) and Zimman (2012) do

not support some theories of transitioning

(e.g., Heath, 2006) that view the FtM transi-

tioning process as striving for an unambigu-

ously masculine end result. Similarly, Papp’s

and Zimman’s results are not consistent with

theories of gender that deﬁne gender in terms

of a binary opposition of male and female

categories and of transgenderism as the

“switching” from one feature set to another.

Instead, their data suggest that many transgen-

der men view gender as a continuum and they

are often comfortable with (a) moving in gen-

eral toward a more masculine, as opposed to

unambiguously masculine, self-representation

and (b) keeping their vocal gender ﬂuid and

adjusting features of it to circumstances, which

may even call for demasculinizing vocal

descriptors.

The difference between habitual and

“passing” pitch is of special interest in trans-

sexual and transgender populations. In the case

of MtF transsexuals who went through puberty

as males, the question is how speech-language

therapists can safely retrain speakers to use a

potentially very different range in their reper-

toire for everyday communication without

voice quality deteriorating or becoming apho-

nic, without losing intonational variety and pro-

jecting power, and without developing vocal

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pathologies. The little documentation available

on the hormonal transitioning of FtMs usually

shows substantial lowering of the fundamental

frequency (Adler, Constansis, & van Borsel,

2012; Papp, 2011a; Zimman, 2010). There is

little information, however, on whether speak-

ers’ actual habitual pitch lowers in tandem with

the predicted habitual or optimal speaking pitch

(usually calculated with reference to the pitch

ﬂoor or the Maximum Phonation Range).

Negotiating the distance between a “passing”

pitch versus the actual speaking fundamental

frequency is very likely a task for the speech-

language therapist. As there is evidence that lis-

teners are able to locate a speaker’s SFF within

their phonational range without having been

exposed to the speaker’s entire range (Bishop

& Keating, 2012; Honorof & Whalen, 2005),

speech practitioners need to be aware that the

gendered perception of speech is not a trivial

matter that purely depends on the SFF and

speaking range of the SFF but depends on a

host of other acoustic descriptors that we still

know fairly little about.

Related to the accurate measurement of the

acoustic correlate of the speaking pitch, the

fundamental frequency, is the issue of the psy-

choacoustic representation—that is, the com-

parability of the values, both within and

between clients. It is often convenient to mea-

sure absolute frequencies in Hz when pitch or

change in pitch is studied. But while the pro-

duction of frequency is linear by nature, the

perception of frequency is largely logarithmic.

As a result, logarithmic or other nonlinear

auditory scales of frequency representation are

required to accurately characterize perceptual

changes in the speaking fundamental fre-

quency. One such recommended scale is the

semitone (ST) scale. On one hand, being one

of the few commonly used scales both in clini-

cal practice and musicology, the results are

easily interpretable for the widest possible

audience. Additionally, the ST scale is the

only scale with only one agreed-upon formula

that has remained virtually unchanged in the

past many centuries, unlike the Bark, Mel, and

Equivalent Rectangular Bandwidth (ERB)

scales (Miller, 2002).

Speaking Fundamental Frequency

There is substantial evidence that andro-

gens in adolescent cismen, ciswomen with

hyperandrogenism (excessive production and/

or secretion of androgens in women), and

MtF clients who went through adolescence as

males not only lower the SFF, but they do so

permanently. The change in SFF is interpreted

to be caused by the increase of vocal fold

mass with possible contribution from vocal

fold stiffness as well. The irreversibility of

this change has been amply documented in

the literature on cismen, ciswomen with

hyperandrogenism, and MtF transsexuals. As

an example, case studies of females in andro-

gen therapies establish that this noticeable

deepening of the habitual pitch happens in

the ﬁrst 3 months of the therapy, and is per-

manent and irreversible even on cessation of

the androgens (Baker, 1999; Barbieri, Evans,

& Kistner, 1982; Boothroyd & Lepre, 1990;

Mercaitis, Peaper, & Schwartz, 1985; New-

man & Forbes, 1993; Pattie et al., 1998; War-

dle, Whitehead, & Mills, 1983).

Evidence on SFF changes in FtM individuals

is more scarce though. Van Borsel et al. (2000)

and Adler, Constansis, and van Borsel (2012)

present longitudinal data of two FtMs,

with data points collected about every

2 months. Damrose’s (2009) subject was a

33-year-old semi-professional jazz singer,

recorded monthly for 20 months. Papp (2011a)

recorded seven subjects fortnightly during the

ﬁrst year of testosterone therapy and measured

SFF and formant changes. Zimman (2012)

recorded 10 transgender men eight times during

a window of about 40 to 60 weeks, most of

them in the ﬁrst or second year of transitioning.

The changes in SFF in the above studies seem

to be following an S-curve: after the initiation

of the androgen therapy there is a marked drop

in SFF that plateaus out after a number months.

The majority of the changes are completed

within a year, but Papp (2011a) observed fur-

ther lowering during the second year on testos-

terone, and also as a result of oophorectomy

(the removal of the ovaries) and the onset of

menopause. Papp also found previously

144 Davies, Papp, and Antoni

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undocumented patterns in which some trans-

gender men show a reverse J-pattern in pitch

changes: after the initial drop and plateau, the

habitual pitch slightly rises. As an upward shift

is deemed impossible on purely physiological

bases, Papp hypothesizes that this is due to

transgender men ﬁne-tuning their habitual SFF

to match their gender identity and express

nuances (gender expression and sexual orienta-

tion) within their gender.

In Papp’s experience some transgender men

have actively or passively resisted speaking in

a lower (chest) voice. In LW’s account, when

he felt a strange “rumbling” in his chest he usu-

ally recalibrated himself to a higher pitch,

unless it was a formal situation demanding

authoritative behavior, in which he maintained

the low pitch. As another example, TJ would

often ask whether his voice had changed during

the course of the androgen therapy—by that he

meant an observable change in the mean funda-

mental frequency, which he himself did not

perceive as changing. He was indeed correct:

over 1 year on testosterone his mean habitual

pitch changed from 200 to 170 Hz, which is a

change of 3 ST. At the same time, however, his

pitch ﬂoor lowered from 130 to 80 Hz, or more

than 8 ST. If his habitual pitch had recalibrated

to a predicted 4 ST over his pitch ﬂoor he

would have been speaking at around 100 Hz,

which is an unambiguously masculine pitch.

When asked if he tried to play with his voice

and speak lower, TJ’s answer was that he had

tried and since “it sounded weird” he reverted

(close) to his pretestosterone habitual pitch.

It has been observed that some transgender

men have problems “passing” as males well

into their time on testosterone when their pre-

dicted optimal pitch based on their available

pitch ﬂoor (cf. Awan, 1993; Britto & Doyle,

1990; Cooksey, 2000; Boone, McFarlane,

Berg, & Zraick, 2009) and/or their habitual

pitch was unambiguously masculine (Nygren,

2014; Papp, 2011a; S€

oderpalm et al., 2004; van

Borsel et al., 2000). These ﬁndings make a

strong case for including a speech-language

therapist in the routine medical care of trans-

gender men. The role of a speech-language

therapist could include both mapping the

habitual speaking fundamental frequency and

intensity within the available pitch range of

transgender men and facilitating behavioral

changes or making referrals to other professio-

nals, such as endocrinologists and ear-nose-

throat specialists (ENTs), as a trained specialist

is able to make distinctions between transgen-

der men reporting temporary, developmental

phenomena versus potentially acute problems

relating to the habitual speaking fundamental

frequency.

One type of problem encountered in practice

is when transgender men exhibit little or no

lowering of the habitual fundamental frequency

and the pitch maxima, even though they have

been on testosterone for over a year. This is

likely a physiological-hormonal problem,

which needs to be investigated with the help of

a speech-language therapist, an ear-nose-throat

specialist, and/or an endocrinologist. Another

kind of problem is reported by individuals who

demonstrably have access to cismale-normative

fundamental frequencies (which they may or

may not know about) but do not seem to be

able to speak at those frequencies habitually.

These transgender men would then need to be

retrained to realize the existence of and then

adjust to frequency ranges that are conducive

to presenting as the desired gender. Naturally, a

speech-language therapist would not need to

work with the third group of individuals who,

while having access to a cismale SFF, exhibit

higher-than-cismale habitual frequency values

and are happy with the way they are read (be it

gay, queer, androgynous, effeminate, or on

occasion, female).

Maximum Phonation Range

Maximum phonation range is the physical

range where an individual is able to phonate

audibly (cf. Hallin, Fr€

ost, Holmberg, &

S€

odersten, 2012; Holmberg et al., 2010; San-

chez, Oates, Dacakis, & Holmberg, 2014; Sul-

ter et al., 1994). At its simplest it is used as a

diagnostic tool to document changes in the

voicing source, but given the importance of the

speaking fundamental frequency in trans popu-

lations, it is very useful to monitor the voice

changing as a result of testosterone therapy.

The lowest available frequency (also known as

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the Minimum F0) is elicited by asking the cli-

ent to glide or scale down as low as they can

and sustain the lowest note. The highest avail-

able frequency is usually elicited by asking the

client to glide or scale up as high as they can,

with no regard to voice quality. Musically

untrained clients usually ﬁnd it easiest if they

imagine they are on a roller coaster ride and

they imitate the sharp rises and deep falls of the

roller coaster with their voice. It is up to the

speech-language therapist to record and audito-

rily evaluate the client’s production during the

assessment/elicitation session in order to get

the true extremes of the phonatory range. Then

the results of the acoustic measurement should

be expressed in a psychoacoustic scale (e.g.,

semitones, ERB) and it could be recorded as

one of the indicators of vocal change.

The correct interpretation of the MPR results

is crucial in giving good feedback to transgen-

der men. Results in Damrose (2009) and Adler,

Constansis, and van Borsel (2012) seem to doc-

ument a marked change in the maximum pho-

nation range (MPR) of transgender men

transitioning on testosterone. They conclude

that as a result of testosterone therapy the

three transgender men’s MPR has decreased

when expressed in Hz. Building on their work,

Papp (2011a) converted their original results

into semitones and found that, by the end of the

documented vocal transitioning, the MPR of

Damrose’s subject shrank by 1.3 ST, but the

MPR of the two subjects in Adler et al.’s study

not only did not shrink but in fact expanded by

a trivial 0.3 ST. A net change in the range of 1

ST over 12 months is a perceptually insigniﬁ-

cant change that is well within the ranges of

documented time-of-day ﬂuctuations (Lehto,

Laaksonen, Vilkman, & Alku, 2008; van Mers-

bergen, Verdolini, & Titze, 1999), longitudinal

ﬂuctuations over a month (Gelfer, 1989), and

on par with within-day versus across-day dif-

ferences (Murry, Brown, & Morris, 1995). As

such, it indicates no perceptual narrowing of

the available pitch range. On the contrary, the

consistency of the size of the ranges is quite

remarkable considering the time span of over

one year between the ﬁrst and last measure-

ments. This reanalysis of the ﬁndings of previ-

ous studies indicates only a relocation of the

entire pitch range to a lower fundamental fre-

quency interval.

The results in Papp (2011a) also lend further

support to the temporariness of the range reduc-

tion: transitioning did indeed lead to loss of

range (as measured in semitones) around 150 to

200 days into the testosterone therapy, but by

the end of the ﬁrst year on testosterone most

subjects not only regained but actually largely

surpassed their original range. As pointed out

in Adler, Constansis, and van Borsel (2012),

this “bottleneck” is due to the steadily lowering

pitch ﬂoor, which is concurrent with a tempo-

rary lack of access to the upper range.

Papp’s overview of the changes of the pitch

descriptors during the ﬁrst year of testosterone

therapy shows that the sentential mean funda-

mental frequency decreased substantially in

some subjects. On average the 1-year SFF

means are about 3 to 11 ST lower and the SFF

minima about 6 to 12 ST lower than the pretest-

osterone values. SFF maxima changed differ-

ently among subjects. Some speakers lost about

8 to 9 ST from their upper range, while others

gained 4 to 10 ST in the upper range by the end

of their ﬁrst year on testosterone. In Papp’s

study, two speakers experienced a slight

decline in pitch range (3–4 ST), while the

others experienced that their pitch range wid-

ened over the ﬁrst year on testosterone by more

than an octave (12CST). A hitherto unexam-

ined ﬁnding in Papp (2011a) is that the location

of the mean SFF value within the MPR also

changed. Speakers’ mean SFF before transi-

tioning was higher than the predictable 3 to 4

ST above the pitch ﬂoor. This distance grew in

the case of every transgender man in this study.

In the case of two speakers, this means that

they spoke a full octave (12 ST) above their

pitch ﬂoor. This “buoyancy” of the mean pitch

over the pitch ﬂoor is observable in the subjects

in the study by Adler, Constansis, and van Bor-

sel (2012) as well, whose mean SFF was about

7 to 8 ST over their pitch ﬂoor.

Introspection from Papp’s study participants

seems to raise the point that the speed, but not

necessarily the magnitude, of the mean SFF

decrease might correlate with the amount or

ratio of hormones in the body. Subjects who

took larger amounts of testosterone, or whose

146 Davies, Papp, and Antoni

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estrogen production was (virtually) nonexistent

(cf. postmenopausal and postoophorectomy

transgender men) felt they demonstrated a

faster, more hyperbolic change. This, however

is not borne out (yet) by empirical evidence:

Nygren (2014) found no or only weak correla-

tions between hormone levels and fundamental

frequency values over the ﬁrst 18 months of

the testosterone therapy.

Surgical Lowering of the Fundamental

Frequency

While it is not common, surgical interven-

tion is available to lower the speaking funda-

mental frequency using techniques developed

by Isshiki, Taira, and Tanabe (1983). The vocal

fold relaxation technique has been used in cases

of mutational falsetto and hypogonadic males

as well as transgender men (Hoffman et al.,

2014; Kocak et al., 2008; Remacle, Matar, Ver-

duyckt, & Lawson, 2010).

Vocal Tract Resonances

The growth of the vocal tract length in bio-

logical males is usually accounted for by the

growth spurt during adolescence and the

descent of the larynx. However, a change in

transgender men’s height or laryngeal descent

is not reported in the studies so far. This sug-

gests that no physiological (as opposed to

behaviorally conditioned) changes are to be

expected as a result of the androgen therapy.

However, the results of Papp’s longitudinal

study (2011) reveal previously undocumented

lowering in the vowel formant values over the

ﬁrst year of testosterone therapy. The ﬁrst three

formant values, which had been previously not

considered a factor during the vocal transition-

ing, were signiﬁcantly lower during the ﬁrst

year of hormone therapy. This trend was lent

further support by Zimman (2012).

There are a few physiological changes in the

bony or cartilaginous structures around the

vocal tract in transgender men. Antoszewski,

Zadzinska, and Foczpanski (2009) found that

the size of FtM transsexuals’ maxillary and

mandibular canines and the ﬁrst molars is

between those of cismales and cisfemales.

Informal introspection by transgender men in

Papp (2011a) indicates that the angle between

the posterior part of the mandible and the lower

border of the ramus changes noticeably during

transitioning, creating a more masculine jaw-

line. Some transgender men experience the

growth of the bony protrusion of an Adam’s

apple, which may be accompanied with other

laryngeal cartilage shifts and growths. All these

phenomena indicate that these structures in and

around the vocal tract may remain sensitive to

androgens comparatively late in life.

Papp’s ﬁndings based on two subjects fol-

lowed for multiple years strongly suggest that

besides physiological forces, behavioral modi-

ﬁcations may also lie behind the observed for-

mant changes. This is evidenced by steady

progress toward more-masculine formant val-

ues, followed by the reversal of the values a

number of years into the androgen therapy,

much like the inverse J-curve observed in the

SFF of these men. This increased ability to

make behavioral choices, which is facilitated

by the physiologically altered structures, pro-

vides further evidence of the relative ﬂexibility

of speech features that were previously thought

of as largely ﬁxed. The slow ﬂuctuation and

sometimes reversal of the values further sup-

port the idea that speakers continually ﬁne-tune

features as they repeatedly relocate themselves

along the gender continuum.

Breathing

Binders

Transgender men who have gone through

hormonal adolescence as females often wear a

compressing layer of clothing in order to cre-

ate a more masculine looking chest. The

binders may range from ACE bandage and

(multiple, layered) sports bras to tight tops and

specially-made binders covering the whole

torso. Introspection among transgender men

holds that the strong chest compression that

especially larger-chested transgender men

need to employ often leads to shortness of

breath, inadequate breath support for voicing

and physical exercise, and, in especially severe

cases, fainting and cracked ribs.

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While wearing binders is a non-negotiable

part of many no-surgery or pre-surgery trans-

gender men, it might be useful to help clients

monitor their pulmonary/spirometric values

(such as descriptors of the (forced) inspiratory

and expiratory vital capacity maneuvers, and

total lung capacity) by comparing in-binder

and no-binder tidal breathing, especially at the

beginning of the social transitioning, which

often coincides with the onset of habitually

wearing a binder. As proper pulmonary support

is necessary for good laryngeal valving efﬁ-

ciency; also phonation intensity should be

checked in transgender men—that is, whether

they can project in a sustained manner.

Hormones

Hormone therapy might affect ventilatory

responses to obstructive lung problems (such as

asthma, chronic obstructive pulmonary disease

(COPD), bronchitis), as testosterone, progester-

one and estrogen are known to alter ventilatory

control. Moreover, gender differences exist in

lung function and metabolic demand, both of

which may affect the ventilatory compensatory

responses to airway obstruction. We recom-

mend surveying and monitoring a history of

pulmonary or ventilatory problems in clients on

hormones.

Sleep-Disordered Breathing

A lack of consistent results is found in stud-

ies of ventilatory responses in men and women.

However, there are a number of observed risk

factors that were not well understood prior to

the publication of population-based studies that

included both genders. Although the gender

differences are less striking than once thought,

there still appears to be a higher prevalence of

both sleep-disordered breathing (SDB) and

obstructive sleep apnea (OSA) in men than in

(premenopausal) women. OSA is a relatively

common condition often characterized by snor-

ing, recurrent episodes of cessation of breath-

ing, disrupted sleep, and daytime somnolence.

Associated serious complications are hyperten-

sion, increased risk of heart disease, stroke, and

increased susceptibility to industrial and motor

vehicle accidents (Park, Ramar, & Olson,

2011; Ramar & Guilleminault, 2007).

The reason for the male predominance

remains uncertain. Because testosterone con-

tributes to fat deposition in the neck and upper

body and reshapes the mandible and possibly

the pharyngeal cavity, it may contribute to the

development of OSA through reduced or

altered upper airway size. In support of the

hypothesis connecting testosterone with OSA

is the increased prevalence, induction, or wors-

ening of OSA in these groups:

postmenopausal women (Bixler et al.,

2001; Shahar et al., 2003; Young, Finn,

Austin, & Peterson, 2003);

women with high endogenous levels of

testosterone and/or polycystic ovarian syn-

drome (PCOS) (Dexter & Dovre, 1998;

Fogel et al., 2001; Vgontzas et al., 2001);

women with exogenous testosterone

administered (Johnson, Anch, &

Remmers, 1984);and

hypogonadal, elderly, or obese men

through administration of testosterone

(Hoyos, Killick, Yee, Grunstein, & Liu,

2012; Killick et al., 2013; Liu et al., 2003;

Matsumoto et al., 1985; Sandblom et al.,

1983; Schneider et al., 1985).

Most of these studies controlled for the

effects of age and weight/BMI, as both have

been found to show positive correlation with

the prevalence of OSA. For documented and

possible risk factors of OSA see Ramar and

Guilleminault (2007); for further testosterone-

induced risk factors consult the WPATH Stand-

ards of Care E. Coleman et al. (2011).

Because OSA may be worsened or

unmasked by androgen therapy in FtM individ-

uals, and since it may be a risk factor for a

number of further health problems, we recom-

mend that the speech-language therapist should

regularly ask the clients about changes in qual-

ity of sleep and snoring.

SUMMARY AND OUTLOOK

As shown above, during the process of vocal

masculinization, hormonal and psychosocial

148 Davies, Papp, and Antoni

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forces often work in tandem in order to create a

voice that represents not only the true gender

but the true complete identity of transgender

men, which includes expressions of age, ethnic-

ity, sexual orientation, and ﬂuidity in and

around gender. As such, voice and speech goals

may change during transitioning, whether the

transgender man is taking testosterone or not.

In order to gauge the goals and the vocal satis-

faction, it is recommended to survey the clients

before, during, and after the therapy provided

by the speech and language therapist. The sur-

vey should preferably include (among other

information) client expectations, vocational

demands on voice, current satisfaction with

voice and communication, age, menopause/

ooporectomy status, amount of testosterone

taken and method of administration, current

SFF descriptors, use of chest binders, snoring

and sleep-disordered breathing, and if the client

is comfortable with sharing such information,

the current gender identity and/or sexual orien-

tation. This information, taken together with

culturally appropriate sociolinguistic usage will

help the speech-language therapist recommend

pitch, formant, breathiness, and creakiness

goals that give a voice to the person within.

While transitioning on androgens is very fre-

quent among FtMs, it is not the only way to

reshape the voice and speech by any means.

Many no-hormone or prehormone transgender

men may seek out a speech-language

therapist’s help in order to reshape their voice

and speech. According to Papp’s large-scale

survey (Papp, 2011b), a large proportion of

transgender men have started smoking or have

considered starting smoking in order to lower

their SFF. While evidence suggests (e.g., Gil-

bert & Weismer, 1974) that smoking might

indeed lower the SFF, speech-language thera-

pist should promote alternative, sustainable,

nondamaging ways to reshape a transgender

man’s voice.

Finally, as suggested above, there is much

to learn about the perception of the trans-

male voice, both accompanied by or in

absence of visual clues. Observations by

transgender men, such as “I sound weirdly

nasal,” “People keep asking if I have a

cold,” “People say I sound like a young gay

man, but I’m straight and in my 40s,” indi-

cate outstanding issues. These issues were

quantiﬁable in Nygren’s (2014) dissertation:

She found that in her pool of 50, for nearly

a quarter of transgender men, voice and

communication therapy was needed due to

problems with vocal fatigue and instability,

insufﬁcient lowering of pitch and projecting

power, and problems with the voice sound-

ing too young.

These issues might include the source-ﬁl-

ter mismatch in some transgender men possi-

bly caused by the combination of cismale-

like SFF and cisfemale-like resonances;

altered resonances possibly due to changing

bone and cartilage structures; or temporary

dysphonia during the ﬁrst year on testoster-

one while the SFF, much like in cismale

adolescence, is still in ﬂux.

All these further emphasize the importance

of (gender(ed)) sensitivity, good training in

speech-language therapists, and continued

focused research in order to better serve this

invisible, but sizeable, population.

SUMMARY OF RECOMMENDATIONS

Voice and Communication Intervention

for Gender Nonconforming Individuals

1. Transgender voice and communication

services should be offered in the context

of a complete approach to transgender

health that includes comprehensive pri-

mary care and a coordinated approach to

psychological and social issues.

2. In working with gender nonconforming

clients, the speech-language therapist’s

primary goal is to help the client develop

voice and communication that more

closely approximates the client’s sense of

self.

3. Feminizing/masculinizing voice involves

nonhabitual use of the voice-producing

mechanism. To prevent the possibility of

vocal damage, professional evaluation

and assistance are essential.

4. Self-guided voice and communication

change without professional supervision

INTERNATIONAL JOURNAL OF TRANSGENDERISM 149

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is not recommended. Clients intending to

pursue self-guided voice change should

be encouraged to, at a minimum, have an

initial professional assessment and then

to consult with their primary care pro-

vider if they develop symptoms of vocal

fatigue or negative changes to vocal qual-

ity. Self-help voice and communication

groups should have appropriate clinical

support.

Clinical Competence

1. Voice and communication professionals

working with transgender individuals

must have a basic understanding of trans-

gender health (including hormonal and

surgical feminization/masculinization)

and trans-speciﬁc psychosocial issues;

they must be familiar with basic sensitiv-

ity protocols such as use of preferred gen-

der pronoun and name.

2. Gender nonconforming individuals who

are seeking voice and communication

services for reasons other than speech

feminization/masculinization can be

treated by trans-sensitive speech-lan-

guage therapists using standard

voice and communication protocols.

voice and communication feminization/

masculinization requires additional clini-

cal expertise and special clinical

protocols.

Client Inclusion and Exclusion

1. Voice and communication services

should be available to the full spectrum

of the transgender community, including

MtF and MtF transsexuals and others

who are gender nonconforming.

2. The need for voice and communication

services should not be evaluated based on

hormonal use, pursuit of sex reassignment

surgery, or length or percentage of time

living in the desired gender role.

3. Services should be adapted as needed to

ﬁt a client’s individual needs, including

accommodation relating to speech or

hearing disability, mental illness, cogni-

tive disability, learning disability, physi-

cal disability, geographic isolation, or

incarceration.

Treatment Decisions

1. The client is responsible for treatment

decisions, supported by the clinician’s

informed professional opinion, assess-

ment data, and any allies the client wishes

to be involved.

2. To support fully informed treatment deci-

sions, clients should be informed of the

following:

a. potential risks and beneﬁts associated

with treatment options

b. estimated duration of treatment;

factors that can inﬂuence the out-

come or duration of treatment

3. Existing protocols for voice and commu-

nication feminization should be reviewed

and considered when developing individ-

ualized treatment plans. As there are no

established protocols for speech mascu-

linization, FtMs seeking this service

should be informed that the protocol is a

trial.

4. While modiﬁcation of existing protocols

is encouraged, all treatment plans (includ-

ing those using new or experimental tech-

niques) are expected to be based on a

clearly articulated, logical, and valid clin-

ical rationale. Departure from existing

protocols should be explained as such to

the client as part of fully informed con-

sent and should be documented in detail

to facilitate evaluation.

Assessment

1. Assessment prior to voice and communi-

cation feminization/masculinization

should include the following:

a. psychosocial, voice use, voice health,

and medical history

b. clinical assessment of speech and

voice including:

1. the client’s subjective assessment

150 Davies, Papp, and Antoni

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2. instrumental measurement

3. the clinician’s subjective analysis

4. an assessment of potential for

change

5. assistance with understanding

therapeutic options

2. As there is evidence that behavioral

changes (of pitch, inﬂection, resonance,

etc.) may degrade over time, periodic re-

evaluation is recommended following

treatment with further clinical assistance

as needed.

Voice and Communication Therapy

1. Voice and communication therapy should

be individualized based on each person’s

goals and identity, the risks and beneﬁts

of treatment options, and consideration of

social and economic issues.

2. Rather than adopting a rigid and artiﬁcial

set of voice and communication norms, it

is recommended that clients be assisted to

develop an individualized and context-

speciﬁc set of norms based on communi-

cation patterns in their own social, cul-

tural, work, and home environments.

3. It is clinically optimal to be able to offer

both individual sessions and group treat-

ment, with the proportion of time in each

format depending on the client’s thera-

peutic needs and goals.

Pitch-Elevating Surgery

1. As there is no professional consensus

regarding the effectiveness and risk-

beneﬁt ratio of pitch-elevating surgery,

care should be taken to ensure that cli-

ents are fully informed of potential

risks, postoperative care requirements,

and possible outcomes (including

decreased pitch).

2. Assessment by both a laryngologist and

speech-language therapist is recom-

mended prior to surgery.

3. Prior to surgery, the laryngologist should

discuss after-care instructions with the

patient and provide written after-care

instructions.

4. Voice therapy should be offered follow-

ing phonosurgery to help the patient adapt

to and stabilize the new voice.

Outcome Evaluation

1. Outcomes should be rigorously evaluated

and documented.

2. At minimum, the baseline assessment

should be repeated immediately follow-

ing the end of therapy. Ideally, re-evalua-

tion would take place at 6 months,

1 year, 5 years, and 10 years after

treatment.

3. Evaluation should include client satisfac-

tion with the treatment outcome and with

the quality of care provided, as well as

perceptual and objective measures of

voice and communication change.

4. Informal or formal sharing of outcome

data (with colleagues, at conferences, in

publications, etc.) must occur only if the

client has provided fully informed and

voluntary written consent.

Research

1. There is a paucity of data relating to

speech feminization/masculinization.

Further research in this area is eagerly

anticipated.

2. To ensure that participation in research is

voluntary, services should not be offered

solely as part of a research protocol.

ACKNOWLEDGMENTS

This article was written by Shelagh Davies,

Vikt

oria G. Papp (female-to-male considera-

tions), and Christella Antoni and Shelagh

Davies (phonosurgery), with research assis-

tance provided by Charlotte Beck and Leah

McKeil; content editing by Vikt

oria G. Papp

with contributions by Jennifer Oates, Richard

Adler, and Colin Davies Contributions from:

INTERNATIONAL JOURNAL OF TRANSGENDERISM 151

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Joshua Goldberg and Judith Johnston Final

formatting and copy editing of document:

Vikt

oria G. Papp.

FUNDING

Preparation of this document was generously

supported by a grant to Shelagh Davies from

the Transgender Health Information Program

of British Columbia, Canada.

NOTES

1. For the rest of the document we will use speech-

language therapist (SLT) and clinician as umbrella terms

for speech-language therapists and pathologists. Other

speech and voice specialists, such as singing teachers and

speaking voice trainers may also be involved in discrete

areas of the voice and communication needs of the trans-

gender population.

2. The sections “Presurgical Assessment,”

“Postsurgical Care” to “Voice Feminization Surgeries”

were reproduced from Davies and Goldberg (2006b).

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Wendler Glottoplasty for Transfeminine Voice

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Apr 2024

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Akustička analiza glasa transrodne žene uslijed vokalne terapije − prikaz slučaja

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GOVOR

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Apr 1996
J Voice

The goal of this study was to determine if there are acoustical differences between male and female voices, and if there are, where exactly do these differences lie. Extended speech samples were used. The recorded readings of a text by 31 women and by 24 men were analyzed by means of the Long-Term Spectrum (LTAS), extracting the amplitude values (in decibels) at intervals of 160 Hz over a range of 8 kHz. The results showed a significant difference between genders, as well as an interaction of gender and frequency level. The female voice showed greater levels of aspiration noise, located in the spectral regions corresponding to the third formant, which causes the female voice to have a more "breathy" quality than the male voice. The lower spectral tilt in the women's voices is another consequence of this presence of greater aspiration noise.

Feminisation of the larynx and voice

Chapter

Sep 2017

Guri Sandhu

Female-to-Male Transsexuals and Gay-Sounding Voices: A Pilot Study

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Lal Zimman

A great deal of work has now been published on the perception of men’s sexual orientation on the basis of phonetic characteristics. In this paper, I present a pilot study focusing on a population that sheds new light on this topic: female-to-male transsexuals. As individuals who were raised as girls but self-identify as men, trans men (as they are also called) are often perceived as gay-sounding after undergoing the drop in vocal pitch that is typically brought on by testosterone therapy. Using recordings of read speech from three trans men and five non-trans men who were each rated as gay- or straight-sounding by listener subjects, the analysis presented here shows that trans men are perceived in much the same way as gay-sounding non-trans men, despite a number of differences in the acoustic features of their voices. Ultimately these findings lend credence to the notion that there is no single gay-sounding phonetic style, but rather multiple styles that are lumped together perceptually as gay-sounding on the basis of their deviation from norms for straight-sounding voices.

Evidence based practice in voice therapy for transgender/transsexual clients

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Jennifer Oates

Assessment and goal setting: Revisited

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Georgia Dacakis

Vocology: The Science and Practice of Voice Habilitation

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Satisfaction of MtF transsexuals with operative voice therapy - A questionnaire-based preliminary study

Article

Oct 2002

After having undergone successful sexual reassignment surgery male-to-female (MtF) transsexuals are very often negatively affected by their unchanged masculine voice, which contrasts with their feminine appearance and this interferes considerably with their social integration as women. Since hormonal treatment or logopedic therapy alone will not achieve a permanent increase in voice pitch, the development of a phonosurgical technique to achieve a permanent elevation of the voice pitch is of great importance. Since 1993, 67 MtF transsexuals have undergone cricothyroidopexy at the department of otorhinolaryngology, in the university hospital in Halle, according to Berghaus and Neumann (1996). Increased tension of the vocal cords results in a permanent elevation of the fundamental frequency range by five to six semitones on average. While pre-operatively none of the patients had a feminine speaking voice pitch, after the surgery, about 30 percent attained a voice pitch within the feminine range, and 38 percent attained at least a neutral voice pitch. In the long-term, mostly combined with further voice training, the results proved to be of a permanent character, and in 45 percent of the cases, a further increase was observed. The operation technique in question has proved to be generally successful with a minimum of risk factors. The effect that voice therapy can have on the social integration of the persons in question and to what extent they were satisfied with the results of voice treatment was assessed by means of a questionnaire, which was developed with the Institute of Psychology at the Martin-Luther University of Halle-Wittenberg. Twenty-eight questionnaires were evaluated, and in most cases, the feminisation of the voice had improved and facilitated better social integration was achieved by the MtF transsexuals who had undergone treatment.

Voice change in transsexuals

Article

Jan 1997
Venereol Interdiscipl Int J Sex Health

Because the voice characteristics of transsexuals are frequently incongruent with their desired gender role, particularly for male-to-female transsexuals, voice training is integral to the gender reassignment process. This paper reviews the available research evidence on voice differences between males and females, voice training procedures for transsexuals, laryngeal surgery for voice change, and the efficacy of both voice training and laryngeal surgery. Training in other aspects of communication including speech sound articulation, vocabulary, and communication topic and style is also discussed. This review is concerned mainly with voice change for male- to-female transsexuals, but the need for change in communication behaviour for female-to-male transsexuals is briefly outlined.

Principles of Voice Production, Second Printing

Article

Jan 2000

Ingo R Titze

Transgendered voice: considerations in case history management

Article

Jan 1999

D. Elise Lindstedt Judith B. King

Standard voice case history forms used by speech language pathologists do not appropriately address the needs of clients in the transgender process. A group of transgendered clients assisted the authors in identifying important considerations for effective interviewing and case history management. These considerations include: 1) appropriate interview terminology; 2) pragmatics in questioning; 3) knowledge of pre- and post-operative phases of treatment; 4) identification of voice treatment goals; 5) attitudes of family, friends and co-workers; 6) time-frame considerations for changes in gender role; 7) effects of medical intervention options on vocal function; 8) potential for negative clinician-bias; and 9) psychosocial factors. This report identifies items for effective interviewing and case history management.

Voice and Communication Change for Gender Nonconforming Individuals: Giving Voice to the Person Inside

Abstract

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