Voice and Communication Across the Gender Continuum

Editor’s note: This text-based course is a transcript of the webinar, Voice and Communication Across the Gender Continuum, presented by Gwen L. Nolan, MS, CCC-SLP.

Introduction: Cultural Awareness

I am delighted to be presenting today on the topic of modifying voice and communication across the gender continuum. If you have never treated anyone for voice modification, it's important to remember gender identity is not binary for everyone. Gender identity is a continuum, with masculine on one end and feminine on the other end. Some people will fall on either end of the continuum, whereas others are more in the middle, or gender-neutral. Another thing to keep in mind is that we cannot assume that everyone who identifies as transgender will transition. Some who do transition will undergo one or more surgeries, and others will not. It's highly variable because it's an individual journey. No two people's journeys are alike, just as no two people are alike. 

Pronoun Preferences

The first thing we want to think about are pronouns. You don't want to make gender binary assumptions about a person's pronoun preferences. In fact, I have clients who identify as transwomen, and yet they'll continue to use masculine pronouns, either because they haven't transitioned or it's just their choice. I always like to ask for pronoun and name preferences right out of the gate. Sometimes, if a person makes contact with me via email, underneath their signature at the bottom of the page, it will often indicate their pronoun preferences. It's okay to ask, but be sensitive about it. 

Why People Seek Therapy

The reasons why people seek therapy is a personal choice. Not all people who identify as transgender seek therapy. Some feel very strongly that how they look and how they sound is completely up to them. The people that tend to seek services from us do so for the most part because they want a voice and communication style that is more congruent with their gender identity, regardless of where they identify on the continuum. In other words, they want their voice to match the person that they feel like inside; they want to sound the way that they look. Some people will want to be able to code switch based on communication settings and partners. Perhaps they will only need that feminine or masculine voice when they're outside a work environment. Many people want to build confidence in the use of that new modified voice and approaching groups of their peers. Sadly, sometimes a person's motivation for seeking therapy is fear-based. I have heard people say that they are afraid of getting beat up because their voice doesn't match their outward appearance. However unfortunate, we need to be aware that this does happen. There is a lot of discrimination in the community, even given that people are considerably more aware than they once were.

Influences on Gender Perception and Voice Communication

Gender perception is influenced by several factors:

• Pitch and pitch range
• Resonance
• Anatomical and hormonal differences
• Cultural gender differences

When treating people, remember to keep the continuum in mind. Some people will come to us with more gender-neutral characteristics at baseline. Others will be more comfortable moving toward a more gender-neutral presentation rather than one that strongly leans masculine or feminine.

Pitch and pitch range. Generally, feminine pitch is higher, and the pitch range is typically broader, at around 200 Hz (depending on age). Masculine pitch typically has a lower, more constricted range (around 125-130 Hz). Gender-neutral is going to fall right around the 150-155 Hz range. Based on pitch alone, if a listener hears a voice above that 150-155 Hz range, they might perceive the speaker as feminine; below 150-155, they might perceive the speaker as more masculine.

Resonance. Deep, chest resonance is generally perceived as more masculine. Forward, oral, more head resonance is perceptually more feminine.

Anatomical and hormonal differences. Smaller versus larger anatomy is going to impact pitch, pitch range, resonance, and breath support. When taken over time (usually about one year), testosterone generally does lower pitch. At around the 12-month mark, people taking male hormones will definitely notice changes and lower pitch. Conversely, it is important to note that taking estrogen does not elevate pitch. When working with clients who are taking feminine hormones, it is critical that we educate them that those hormones will not have an impact on their pitch.

Cultural influences. Feminine voices and communication styles tend to have greater pitch variation. In addition, word attack is softer with more articulatory precision. Often, it is perceived as feminine when a person incorporates greater use of gestures, varied facial expressions, and open body postures. Furthermore, the inclusion of more colorful word choices and indirect language can be perceived as feminine. In terms of masculine perception, there is less pitch variation and more word stress for emphasis, as well as a harder onset and articulatory contact, especially with plosives. In addition, a person perceived as masculine will not use as many gestures, their body posture may be more closed, they will likely use less touching, and use a more direct language and communication style.

Initial Visit: Evaluation Components

When I begin treating a client, I always start with an evaluation. I find that evaluating is a good way to break the ice and get people comfortable with therapy. It also gives me a good sense of their level of commitment and insight into how well they might do. You might wonder why we evaluate when we're modifying gender perception, as the person does not have a speech or language disorder, per se. I like to do it because it helps to rule out any vocal fold pathology and allows me to recommend a consult if someone presents with suspected signs and symptoms of vocal fold dysfunction (e.g., nodules). The evaluation also allows me to establish baseline function, and to educate the client about therapy and expectations: both their expectations and ours.

Evaluation involves several components:

• Initial Contact
• Initial Visit and Evaluation
  • Obtain Medical History and Medicine List
  • Conduct Formal/Informal Voice-Communication and Vocal Hygiene Assessment
  • Administer Self-Ratings
  • Probe Pitch
  • Provide Education

Initial Contact

In terms of initial contact, that can be done via phone, email or in person. Sometimes, meeting with someone before you schedule the initial session makes sense. It allows us to provide a brief overview of what is involved with therapy and estimate how long we might expect it to take. It is also a good chance to find out a little about the client, what they're looking for, and allows them the opportunity to ask questions. I find that people are very nervous about this process, and we don't want that. Sometimes just sitting down and meeting with me, either by phone or in person before that initial session allows them to decide, "Yes, this is for me," or, "Maybe I need to wait a while." It's important because it also lets me know that they're committed to therapy. For a client who wants to change the way they sound and present, their commitment is as critical as the therapy itself. It also gives me an initial snapshot of a client's voice, how they sound now, and I can establish pronoun and name preferences early in the relationship.

Initial Visit: Interview

In the initial visit, we always do an interview. Primarily, we want to establish rapport, as well as confirm name and pronoun preferences (which may change as therapy advances and people progress through their transitions). People who are transwomen, still presenting as male but are going to be transitioning, may want to start out with male pronouns and change to female as they go along. You want to get a good medical history, looking for things like seasonal allergies and reflux that can affect the vocal mechanism. Also, consult with other professionals involved in the transition process, such as endocrinologists who might be managing hormones, or counselors and psychiatric professionals, because these are the people who are providing a support. In addition to medical support, you want to get a sense of the person's support system outside of the medical realm. Are they a part of any group in the community? Obtain a current medication list. Are they taking any medications for depression or anxiety? Often, people will not self-reveal depression and anxiety, which are common in this population. Find out about any prior treatment or self-help that they may have tried. I find that the vast majority of my people have gone online to self-help websites and YouTube. These methods tend not to work well and sometimes people will come in with bad habits (e.g., speaking in falsetto, vocal hyper-function). It's always helpful to find out if they've been online seeking to try to make that change on their own.

Evaluation: Informal

Also, during the initial interview, ascertain what the client hopes to accomplish. What do they want to sound like when they're done? If you're just going to do an informal evaluation, listen to that present voice for signs and systems of strain, harshness, hoarseness, any sign of potential vocal fold dysfunction or pathology. If you're concerned that there might be nodules or another condition, be prepared to refer that individual to another provider, if necessary. Collect subjective and objective data on pitch and loudness from word to conversation level. Assess that the client has sufficient oral motor function and breath support. It is important to observe nonverbal communication behaviors to get a sense of whether they use more masculine behaviors or more feminine behaviors?

Formal Instruments

I would recommend the use of formal instruments if there's any sign or system of vocal fold pathology perceived during the interview. When in doubt, refer. It's better to have someone scoped to rule out a problem than to just attribute it to poor vocal hygiene. We certainly don't want to make things worse. 

Don't skip the instrumental evaluation! Some instrumental evaluations include Visi-Pitch, Sona‑Speech, and PRAT. Because I'm a practicing clinician, in addition to working in a university training clinical skills, I tend to focus on things that most speech pathologists in the field will have access to and can afford. You can also use computer or tablet-based assessments. I use an iPad app called Voice Analyst because it provides great visual feedback during the evaluation and treatment, and it's effective in measuring pitch and pitch range and loudness. 

During an evaluation, I typically use the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). I work with a lot of students, and they are easily trained in using the CAPE-V. CAPE-V is available on the ASHA website along with the instructions. I also use a vocal hygiene questionnaire, such as The Voice-Related Quality of Life (VRQL). I also like the Voice Handicap Index (VHI) because it gives me physical, functional, and emotional parameters. Sometimes, the Transgender Voice Questionnaire by Davies and Johnston is a good choice, but I tend to use the VRQL and the VHI the most. I also use a vocal hygiene questionnaire that asks questions about GERD, how much water they drink, do they drink a lot, do they smoke, and habits that I may need to address. The majority of the people that I see don't give me any indication that I might need to move on to something like the Voice Assessment Protocol. 

Pitch Probes

In the initial visits, I always do pitch probes. You want to have a keyboard or a keyboard app to cue. I've downloaded a free keyboard app onto the iPad, and it does a great job of cuing for pitch. It allows me to use that keyboard to probe higher and lower pitch and pitch range so I can establish a point of strain. I don't want to go beyond what someone can tolerate because our focus is always a good quality voice. I'll cue them using that keyboard app, and then make adjustments as I hear strain. This process also allows me to temper expectations. One thing that I notice the most with transgender women is that they often tend to not sound high enough to themselves, so they really want to get up into those higher pitch ranges. However, when I record them and play it back, they can hear how strange and harsh that sounds. Then, I can reduce pitch so that it's still in a feminine range, but they have a better understanding and expectation of how it sounds. 

Education

We also like to educate about the vocal mechanism and gender-influenced voice and communication characteristics so that people have a sense of the things that we'll be working on during therapy. Appropriate vocal hygiene is also important to train. This includes making sure that people limit alcohol and caffeine intake, and try to refrain from smoking. Although we can't control their behavior, we can let them know that those things are harsh on the vocal folds. We also train relaxation exercises, and give them handouts on that. Often, we'll let them go home and practice the target pitch that we're going to establish, but we always want them to do their relaxation exercises and vocal warmups before they do any kind of practice with pitch or pitch glides.

We also talk about timeline and expectations. How well someone is going to do with this type of therapy depends on where they are at baseline, how many times a week they're being seen, and whether or not they commit to that extra clinical practice. Practice outside the clinic is critical, as is attending therapy twice a week, preferably. For people who have voices outside the range where they want to be, we can work toward that goal and we can get better, but it requires showing up for therapy and practicing outside the therapy room.

Goal Setting

Make sure you're setting realistic goals. For example, if I have a 50-year-old transgender woman who's speaking fundamental frequency is 130 Hz, it would be totally unreasonable to try to set a target of 220 Hz. We want to try to temper those expectations, set realistic goals, and remind ourselves and the client that what really matters is a good quality voice with no sign of strain that reflects the client's perception of self. We want to involve the client to make the therapy more relevant and meaningful. They may indicate that they don't want to work on the language piece, and that's okay. Knowing that helps us focus on the things that they do want to work for, the things that matter most to them.