• The word transgender is an umbrella term used to describe people who are living as a gender other than that which was assigned at birth.  There are numerous terms used to represent an individual's identity.
  • More definitions on transgender terms and pronouns can be found on: https://www.plannedparenthood.org/learn/sexual-orientation-gender/trans-and-gender-nonconforming-identities/transgender-identity-terms-and-labels

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• As of 2016, an estimated 1.4 million people identify as transgender in the United States. ​

• The largest survey of transgender people available, the 2015 U.S. Transgender Survey, was available as an online and anonymous survey. 27,715 people from all the U.S. states and surrounding territories responded​. 

  • The full report can be accessed at: https://www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF​

• The findings revealed:​​

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• ​​​Our voices do so much more than just communicating information to others! Our voice communicates our feelings, temperament, and personal identity. 

• Transgender people often feel as though their voice does not represent their true identity, how they feel or look before, during, or after their transition. Transgender people often experience negative situations when others hear their voice and make assumptions about their gender and personality. ​

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• A Speech-Language Pathologist (SLP) treats a variety of communication problems, including voice, speech, and language. An SLP is an essential health provider and best equipped to facilitate treatment for transgender clients who seek to match their voice to their gender. SLP's deliver care specific to each individual and administer evidence-based treatment to help their clients achieve their goals.​

  • The key responsibilities of the SLP are to complete a voice evaluation and provide voice treatment.

• When you meet with your SLP, you can expect to work with someone who is compassionate, understanding, and open-minded. The SLP's main goal is to create a safe and trusting therapeutic relationship with each client.  The SLP can be a source of strong psychological support.

• It is best to find an SLP who specializes in transgender voice. Recommendations are made on the Community and Referral Sources on this website.

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• Adults transitioning from male-to-female (also known as male-to-female transgender) often seek out voice and communication therapy to obtain a more gender-appropriate voice. These people are hoping to find a more feminine voice that aligns with their identity. 

  • Generally speaking, male-to-female transgender people tend to seek therapy more frequently than do female-to-male people. This is because male-to-female patients often don't achieve the voice change they want during hormone therapy. Therefore, male-to-female transgender people will need professional services to learn and acquire feminine speech.

• As a result of voice changes, professional services from a speech-language pathologist (SLP) will also help transgender individuals improve their quality of life.

• While voice and communication interventions for TG individuals have been proven efficacious, treatment does not come without challenges for both the SLP and the TG client. SLPs are essential providers for TG clients who seek to have a voice authentic to their identity. In order to provide the support necessary for this population, SLPs must obtain adequate knowledge, deliver culturally competent care, and administer evidence-based treatment.

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• Case History  

  • The SLP will gather a variety of information during an interview and/or with a printed intake form, including: 

    • Description of the client's  complaints to understand how the client wishes to present their voice at home, work, and in social situations

      • Gathering this subjective analysis from the client's perspective is a critical component of assessment to add to documentation and use during progress analysis. Seeing old video or audio recordings from these interviews or informal assessments may also be a source of motivation and proof of success.

    • Medical history 

      • Medications

      • Includes ​​information that pertains to any hormone therapies; the SLP will need to know this to determine the possible influence on the voice and voice mechanism

        • ​​​For example, testosterone generally adds mass to the vocal folds, causing a lower pitch. Also, surgeries can impact the structure and functioning of structures along the vocal tract.

    • Prior voice treatment and their outcomes

    • Consult with other medical professionals for any additional information

• Self-Rating or Self-Assessment Scales

  • The SLP uses these to get a better understanding of how the individual perceives their voice problem and how it affects their emotions, self-image, and ability to communicate effectively in a variety of settings. This is an effective guide to setting goals that fit how the client wants to use their voice.

  • Along with these formal measures/scales, the SLP will complete informal interviews to gain a comprehensive look at the impact of the client's voice on their everyday life.

  • Examples:

    • The Voice Handicap Index (VHI)​ can be administered before and after therapy is completed to illustrate therapy success

• The "Voice Part" of the Voice Evaluation

  • The SLP will use instruments or tasks to measure the voice and it's perceptual qualities and acoustic/aerodynamic function. These are the formal measures to evaluate voice.

    • Examples:

      • The Consensus Auditory Perceptual Evaluation of Voice (CAPE-V)​ was designed to elicit various voice behaviors and qualities

      • Use of KayPentax, specifically Visi-Pitch, is used to record and measure the client's voice then produce a visual representation of the sound qualities

• Laryngoscopic Exam 

  • Typically performed by the SLP and ENT

  • Videostroboscopy or laryngoscopy is a minimally invasive clinic procedure

  • It allows professionals to assess the details of vocal structures and function

  • This may be recommended if a client has a hoarse voice or if there is concern about their ability to safely or effectively modify their voice.

• Stimulability Testing or "Trial Therapy"

  • The SLP guides the treatment plan by learning about what voice techniques or approaches produce immediate vocal improvement​.

• Depending on the areas of need, the SLP may focus on or administer additional assessments on:

  • Vocal Health 

  • Resonance - the "color" of one's voice

  • Voice: Pitch, Intonation, and Volume (Fundamental Frequency) 

  • Voice characteristics - Jitter, shimmer, noise-to-harmonic ratio, voice-turbulence index 

  • Articulation - how words are pronounced

  • Language - the words we use and how

  • Nonverbal Communication - gestures, posture, facial expressions

  • Real-life experiences/authenticity/safety 

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• As mentioned above, research shows that Voice and Communication Therapy (VCT) parameters include all of the following:

  • fundamental frequency (FF),

  • breathing/phrasing, intonation,

  • resonance, rate,

  • volume

  • articulation

  • vocabulary,

  • pragmatics & nonverbal communication

• These parameters have been the most represented in VCT for transgender clients.

• FF and resonance are often used as primary targets in VCT with additional goals in communication changes, such as body language, vocabulary changes, and volume. 

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• Fundamental Frequency

  • FF is a measure of how high or low the frequency of a person's voice sounds.

  • The average FF of adult males is approximately 107–120 Hz, while the average FF of females is 189–224 Hz. This difference is almost one octave and is typically large enough to eliminate confusion as to a speaker’s gender.

  • Studies have shown that in order for biological males to be perceived as female, FF must increase to at least 155–165 Hz.

  • The “gender-ambiguous range”, or where a speaker’s gender is not immediately clear based on voice alone. Working toward a gender-ambiguous pitch may be initially confusing, as the recommended range might fall short of the expected female pitch.

    • Although this range is considered “ambiguous”, it is targeted because it is important to develop a “natural” voice, rather than merely developing a “high” voice.

  • Sometimes clients are not completely satisfied with a FF in range of 155-165 Hz.  Research shows that this is the most realistic starting phase of therapy and pitch is only one aspect of the feminization process.

  • A popular method used to increase FF is Stemple’s vocal function exercises (VFE's)

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• Resonance

  • The goal of resonant voice therapy is to bring the resonation/vibrating feeling to the front of the face and mouth. 

    • These actions reduce "chestier" or heavier sounds that are associated with the male voice.

    • This aspect of therapy may be considered to be the most difficult part of therapy because it requires the client to hear their voice in a different way and pay attention to how it feels to produce voice. 

 

• While one-on-one therapy is important to teach strategies and techniques, therapy outcomes heavily rely on the work that is put in outside of the therapy room. 

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