Summary
Introduction
Gender affirming voice training is a service provided by speech language pathologists
to members of the trans and gender diverse community. While there is some evidence
to support the effectiveness of this training, the evidence base is limited by a lack
of prospective studies with large sample sizes. Finally, there has been only limited
research investigating the effectiveness of this training when delivered on intensive
(compressed) schedules, even though such schedules are used in clinical practice and
may have practical benefits such as increasing service access for this vulnerable
population.
Methodology
This study aimed to investigate and compare the effectiveness gender affirming voice
training among 34 trans individuals presumed male at birth aiming to develop a perceptually
feminine/female-sounding voice. Among these 34 participants, 17 received their training
on a traditional schedule (one 45-minute session per week over 12 weeks) and 17 on
an intensive scheduled (three 45-minute sessions per week over 4 weeks). Building
on a previous mixed methodological study which indicated that these two training groups
were equally satisfied with training outcomes, the current study utilised a wide range
of self-report, acoustic, and auditory-perceptual outcome measures (including self-ratings
and listener-ratings of voice) to investigate training effectiveness.
Discussion
Results from this study indicated that both training programs were similarly effective,
producing positive statistically significant change among participants on a range
of outcome measures. Participants in both groups demonstrated significant auditory-perceptual
and acoustic voice change and reported increased satisfaction with voice, increased
congruence between gender identity and expression, and a reduction in the negative
impact of voice concerns on everyday life. However, as has been the case in past studies,
training was not sufficient for all participants to achieve their goal of developing
a consistently feminine/female-sounding voice.
Conclusion
This study provides evidence to suggest that gender affirming voice training for transfeminine
clients may be similarly effective whether delivered intensively or traditionally.
This study provides evidence to support the practice of using a wide range of outcome
measures to gain holistic insight into client progress in gender affirming voice training
programs.
Key Words
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References
World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender-nonconforming people [7th version]; 2012. https://www.wpath.org/publications/soc
- Guidelines for psychological practice with transgender and gender nonconforming people.Am Psychol. 2015; 70: 832-864https://doi.org/10.1037/a0039906
- Introducing trans terminology.Transgender Health : A Practitioner's Guide to Binary and Non-Binary Trans Patient Care. Jessica Kingsley Publishers, 2018: 17-38
- Non-binary or genderqueer genders.Int Rev Psychiatry. 2016; 28: 95-102https://doi.org/10.3109/09540261.2015.1106446
- On the varied and complex factors affecting gender diverse people's vocal situations: implications for clinical practice.Perspect Voice Voice Disord. 2015; 25: 75-86https://doi.org/10.1044/vvd25.2.75
- Who or what has the capacity to influence voice production? Development of a transdisciplinary theoretical approach to clinical practice addressing voice and the communication of speaker socio-cultural positioning.Int J Speech Lang Pathol. 2020; 0: 1-12https://doi.org/10.1080/17549507.2019.1709544
- Navigating identity: Experiences of binary and non-binary transgender and gender non-conforming (TGNC) adults.Int J Transgenderism. 2019; 20: 181-194https://doi.org/10.1080/15532739.2018.1426074
- Global health burden and needs of transgender populations: a review.Lancet. 2016; 388: 412-436https://doi.org/10.1016/S0140-6736(16)00684-X
- A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States.Clin Psychol Rev. 2018; 66: 24-38https://doi.org/10.1016/j.cpr.2018.03.003
- A review of lesbian, gay, bisexual, trans and intersex (LGBTI) health and healthcare inequalities.Eur J Public Health. 2019; 29: 974-980https://doi.org/10.1093/eurpub/cky226
- On the limits of “Trans Enough”: authenticating trans identity narratives.Gend Soc. 2018; 32: 613-637https://doi.org/10.1177/0891243218780299
- Breaking down barriers and binaries in trans healthcare: the validation of non-binary people.Int J Transgenderism. 2019; 20: 132-137https://doi.org/10.1080/15532739.2018.1534075
- Expanding the evidence: Developments and innovations in clinical practice, training and competency within voice and communication therapy for trans and gender diverse people.Int J Transgenderism. 2017; 18: 328-342https://doi.org/10.1080/15532739.2017.1329049
- Voice therapy with a transsexual.in: Gemme R Wheeler CC Progress in Sexology: Selected Papers from the Proceedings of the 1976 International Congress of Sexology. Plenum Press, 1977: 77-84
- Evidence-based practive in voice training for trans women.in: Adler R Hirsch S Pickering J Voice and Communication Therapy for the Transgender/Transsexual Client: A Comprehensive Clinical Guide. 3rd ed. Plural Publishing, 2019: 87-103
- Effects of speech therapy for transgender women: a systematic review.Int J Transgender Heal. 2021; 0: 1-21https://doi.org/10.1080/26895269.2021.1915224
Oates J, Dacakis G. Submission to the senate inquiry: prevalence of different types of speech, language, and communication disorders and speech pathology services in Australia.; 2014. http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Speech_Pathology
- Service delivery and the challenges of providing service to people who are transgender.Perspect Voice Voice Disord. 2015; 25: 59-65https://doi.org/10.1044/vvd25.2.59
- The experiences of trans and gender diverse clients in an intensive voice training program: a mixed-methodological study.J Voice. 2021; (Published online)https://doi.org/10.1016/j.jvoice.2020.12.033
- Optimal intervention intensity.Int J Speech Lang Pathol. 2012; 14: 401-409https://doi.org/10.3109/17549507.2012.700323
- Optimal intervention intensity in speech-language pathology: Discoveries, challenges, and unchartered territories.Int J Speech Lang Pathol. 2012; 14: 478-485https://doi.org/10.3109/17549507.2012.717967
- Speech rate in males, females, and male-to-female transsexuals.Clin Linguist Phon. 2008; 22: 679-685https://doi.org/10.1080/02699200801976695
- Differential treatment intensity research: a missing link to creating optimally effective communication interventions.Ment Retard Dev Disabil Res Rev. 2007; 13: 70-77https://doi.org/10.1002/mrdd.20139
- Considerations for intake and assessment.in: Adler R Hirsch S Pickering J Voice and Communication Therapy for the Transgender/Transsexual Client: A Comprehensive Clinical Guide. 3rd ed. Plural Publishing, 2019: 105-126
- My Life as a Woman: Placing Communication Within the Social Context of Life for Transsexual Women.La Trobe University, 2007 (Dissertation)
- Investigating the social integration and wellbeing of transgender individuals: a meta-synthesis.Int J Transgenderism. 2018; 19: 46-58https://doi.org/10.1080/15532739.2017.1364199
- Is more intensive better? Client and service provider outcomes for intensive versus standard therapy schedules for functional voice disorders.J Voice. 2014; 28: 652.e31-652.e43https://doi.org/10.1016/j.jvoice.2014.02.005
- Feasibility and cost analysis of implementing high intensity aphasia clinics within a sub-acute setting.Int J Speech Lang Pathol. 2014; 16: 250-259https://doi.org/10.3109/17549507.2014.887777
- Clinicians’ perceptions of delivering new models of high intensity aphasia treatment.Aphasiology. 2017; 31: 406-426https://doi.org/10.1080/02687038.2016.1236359
- Optimal dose–response relationships in voice therapy.Int J Speech Lang Pathol. 2012; 14: 419-423https://doi.org/10.3109/17549507.2012.686119
- Good practice guidelines for the assessment and treatment of adults with gender dysphoria.Sex Relatsh Ther. 2014; 29: 154-214https://doi.org/10.1080/14681994.2014.883353
International Commission of Jurists. The Yogyakarta principles plus 10 - additional principles and state obligation on the application of international human rights law in relation to sexual orientation, gender expression and sex characteristics to complement the Yogyakarta principles; 2017. http://yogyakartaprinciples.org/wp-content/uploads/2017/11/A5_yogyakartaWEB-2.pdf
- Efficacy of intensive voice feminization therapy in a transgender young offender.J Commun Disord. 2018; 72: 1-15https://doi.org/10.1016/J.JCOMDIS.2018.02.001
- Temporal variables in voice therapy.J Voice. 2015; 29: 611-617https://doi.org/10.1016/j.jvoice.2014.12.001
- Voice, articulation and prosody contribute to listener perceptions of speaker gender: A systematic review and meta-analysis.J Speech Lang Hear Res. 2018; 61: 266-297https://doi.org/10.1044/2017_JSLHR-S-17-0067
- The Accent Method of Voice Therapy. 1. Singular P., 1995
- Voice training and therapy with a semi-occluded vocal tract: rationale and scientific underpinnings.J Speech Lang Hear Res. 2006; 49: 448-459https://doi.org/10.1044/1092-4388(2006/035
- Efficacy of vocal function exercises as a method of improving voice production.J Voice. 1994; 8: 271-278https://doi.org/10.1016/S0892-1997(05)80299-1
- A systematic review of resonant voice therapy.Int J Speech Lang Pathol. 2017; 19: 17-29https://doi.org/10.1080/17549507.2016.1226953
- Handbook of the International Phonetic Association: A Guide to the Use of the International Phonetic Alphabet.Cambridge University Press, 1999
Australian/New Zealand Standard. Acoustics - Recommended design sound levels and reverberation times for building interiors; 2016. https://infostore.saiglobal.com/en-au/Standards/AS-NZS-2107-2016-1882409/
- Recommended protocols for instrumental assessment of voice: American speech-language-hearing association expert panel to develop a protocol for instrumental assessment of vocal function.Am J Speech-Language Pathol. 2018; 27: 887-905https://doi.org/10.1044/2018_AJSLP-17-0009
- Tutorial and guidelines on measurement of sound pressure level (SPL) in voice and speech.J Speech Lang Hear Res. 2018; 61: 441-461https://doi.org/10.1044/2017_JSLHR-S-17-0095
Audacity [Computer software]. Version 2.2.2. Audacity Team; 1999-2018. http://audacity.sourceforge.net/
Stachler RJ, Francis DO, Schwartz SR, et al. Clinical Practice Guideline: Hoarseness (Dysphonia) (Update). Vol 158.; 2018. https://doi.org/10.1177/0194599817751030
- The acoustic voice quality index: toward improved treatment outcomes assessment in voice disorders.J Commun Disord. 2010; 43: 161-174https://doi.org/10.1016/j.jcomdis.2009.12.004
- Acoustic analysis.in: Podesva RJ Sharma D Research Methods in Linguistics. Cambridge University Press, 2014: 375-398
- Version 7.10.0 (R2010a). Natick.The MathWorks Inc., Massachusetts2010
RecVox [Computer software]. Version 0.0.0.20. Tolvan Data; 2020.
- Praat, a system for doing phonetics by computer.Glot Int. 2001; 5: 341-347https://doi.org/10.1097/AUD.0b013e31821473f7
- The voice in transsexuals.Logop Foniatría y Audiol. 2014; 34: 40-48
- Voice in female-to-male transsexual persons after long-term androgen therapy.Laryngoscope. 2014; 124: 1409-1414https://doi.org/10.1002/lary.24480
- Sex differences in frequency and intensity in reading and voice range profiles for Taiwanese adult speakers.Folia Phoniatr Logop. 2006; 59: 1-9https://doi.org/10.1159/000096545
- Freddie Mercury—acoustic analysis of speaking fundamental frequency, vibrato, and subharmonics.Logop Phoniatr Vocol. 2017; 42: 29-38https://doi.org/10.3109/14015439.2016.1156737
- The improvement of internal consistency of the acoustic voice quality index.Am J Otolaryngol - Head Neck Med Surg. 2015; 36: 647-656https://doi.org/10.1016/j.amjoto.2015.04.012
- A comparison of dysphonia severity index and acoustic voice quality index measures in differentiating normal and dysphonic voices.Eur Arch Oto-Rhino-Laryngology. 2018; 275: 1-10https://doi.org/10.1007/s00405-018-4903-x
- External validation of the Acoustic Voice Quality Index version 03.01 with Extended Representativity.Ann Otol Rhinol Laryngol. 2016; 125: 571-583https://doi.org/10.1177/0003489416636131
- Diagnostic accuracy of dysphonia classification of DSI and AVQI.Laryngoscope. 2019; 129: 692-698https://doi.org/10.1002/lary.27350
- The Acoustic Voice Quality Index: toward improved treatment outcomes assessment in voice disorders.J Commun Disord. 2010; 43: 161-174https://doi.org/10.1016/j.jcomdis.2009.12.004
- Voice and Articulation Drillbook.2nd ed. Harper and Row, 1960
- The effectiveness of oral resonance therapy on the perception of femininity of voice in male-to-female transsexuals.J Voice. 2007; 21: 591-603https://doi.org/10.1016/j.jvoice.2006.05.005
- Adolescent male-to-female transgender voice and communication therapy.J Commun Disord. 2012; 45: 313-324https://doi.org/10.1016/j.jcomdis.2012.06.008
- Further evidence of the construct validity of the transsexual voice questionnaire (TVQMtF) using principal components analysis.J Voice. 2017; 31: 142-148https://doi.org/10.1016/j.jvoice.2016.07.001
- Measuring transgender individuals’ comfort with gender identity and appearance: development and validation of the transgender congruence scale.Psychol Women Q. 2012; 36: 179-196https://doi.org/10.1177/0361684312442161
- Development of a new self-report questionnaire to measure self esteem.Psychol Med. 1989; 19: 513-518https://doi.org/10.1017/S003329170001254X
- Life satisfaction in 18-to 64-year-old Swedes: In relation to gender, age, partner and immigrant status.J Rehabil Med. 2002; 34: 239-246https://doi.org/10.1080/165019702760279242
- Life satisfaction in 18-to 64-year-old Swedes: In relation to education, employment situation, health and physical activity.J Rehabil Med. 2003; 35: 84-90https://doi.org/10.1080/16501970306119
- A global measure of perceived stress.J Heal Soc Behav. 1983; 24: 385-396https://doi.org/10.2307/2136404
- The hospital anxiety and depression scale.Acta Psychiatr Scand. 1983; 67: 361-370
- Perceived gender and client satisfaction in transgender voice work: comparing self and listener rating scales across a training program.Folia Phoniatr Logop. 2021; (Published online): 1-16https://doi.org/10.1159/000521226
- Short-term effect of two semi-occluded vocal tract training programs on the vocal quality of future occupational voice users: “resonant voice training using nasal consonants” versus “straw phonation.J Speech Lang Hear Res. 2017; 60: 2519-2536https://doi.org/10.23959/sfahrj-1000001
- Mixed-Effects Models in S and S-PLUS.Springer, 2010
- [R software package].R Core Team, 2021 (Pinheiro J, Bates D, DebRoy S, Sarkar D)
R: A language and environment for statistical computing [Computer Software]. Versions R3.6.3-R4.1.12. R Core Team; 2020-2021.
Estimated Marginal Means, aka Least-Squares Means (emmeans). [R software package]. Lenth R, Buerkner P, Herve M, Love J, Riebl H, Singmann H; 2021. https://cran.r-project.org/web/packages/emmeans/index.html
- Least-squares means: the R package lsmeans.J. Stat. Softw. 2016; 69: 1-33https://doi.org/10.18637/jss.v069.i01
- Perceptual and acoustic outcomes of voice therapy for male-to-female transgender individuals immediately after therapy and 15 months later.J Voice. 2013; 27: 335-347https://doi.org/10.1016/j.jvoice.2012.07.009
- A preliminary study on the use of vocal function exercises to improve voice in male-to-female transgender clients.J Voice. 2013; 27: 321-334https://doi.org/10.1016/j.jvoice.2012.07.008
- Long-term maintenance of fundamental frequency increases in male-to-female transsexuals.J Voice. 2000; 14: 549-556https://doi.org/10.1016/S0892-1997(00)80010-7
- Transgender voice and communication treatment: a retrospective chart review of 25 cases.Int J Lang Commun Disord. 2013; 48: 54-65https://doi.org/10.1111/j.1460-6984.2012.00185.x
- Efficacy of conservative voice treatment in male-to-female transsexuals.Folia Phoniatr Logop. 2005; 57: 111-118https://doi.org/10.1159/000083572
- Evaluation of a consecutive group of transsexual individuals referred for vocal intervention in the west of sweden.Logop Phonatrics Vocology. 2004; 29: 18-30https://doi.org/10.1080/14015430310021618
- Cognitive load in voice therapy carry-over exercises.J Speech Lang Hear Res. 2017; 60: 1-12https://doi.org/10.1044/2016_JSLHR-S-15-0235
- Objective assessment of pediatric voice disorders with the acoustic voice quality index.J Voice. 2012; 26: 672.e1-672.e7https://doi.org/10.1016/j.jvoice.2012.02.002
- Voice perceptions and quality of life of transgender people.J Voice. 2011; 25: 553-558https://doi.org/10.1016/j.jvoice.2010.07.013
- Perception of voice in the transgender client.J Voice. 2008; 22: 727-733https://doi.org/10.1016/j.jvoice.2006.12.010
- Phonetograms, aerodynamic measurements, self-evaluations, and auditory perceptual ratings of male-to-female transsexual voice.J Voice. 2010; 24: 511-522https://doi.org/10.1016/j.jvoice.2009.02.002
- The role of self- and listener perceptions of femininity in voice therapy.Int J Transgenderism. 2010; 12: 272-284https://doi.org/10.1080/15532739.2010.550767
- Self perception of speaking pitch levels.J Speech Hear Disord. 1978; 43: 3-8https://doi.org/10.1044/jshd.4301.03
- Clinical Anxiety.Elsevier Science & Technology, 1971
- Voice-related Experiences of Nonbinary Individuals (VENI) development and content validity.J Voice. 2021; (Published online)https://doi.org/10.1016/j.jvoice.2020.12.037
- Associations between speaking fundamental frequency, vowel formant frequencies, and listener perceptions of speaker gender and vocal femininity–masculinity.J Speech Lang Hear Res. 2021; 64: 2600-2622
- Influence of listener characteristics on perceptions of sex and gender.J Lang Soc Psychol. 2017; 36: 599-610https://doi.org/10.1177/0261927X17704460
- The effect of task on determination of habitual pitch.J Voice. 2000; 14 (In press): 484-489https://doi.org/10.1016/S0892-1997(00)80005-3
Article info
Publication history
Published online: April 07, 2022
Accepted:
March 2,
2022
Publication stage
In Press Corrected ProofIdentification
Copyright
© 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
