Transgender Voice - COE

Transgender Voice 365

pitch. Chernobelsky (2002) used electroglottography with deaf adolescents who exhibited an abnormally high pitch with an average FO of 436 Hz. Using the technique of voiced coughing to lower the FO into the modal register, the boys were able to compare the electroglottographic waveforms produced in modal versus falsetto registers. Posttherapy, the average FO of these boys lowered to 184 Hz.

Several researchers have reported successful outcomes of behavioral voice therapy with long-term maintenance of the lower pitch (e.g., Dagli, Acar, Stone, Dursun, & Eryilmaz, 2008; Lim et a!., 2007). Lim et al. (2007) treated 15 patients with mutational falsetto using manual compression of the larynx. The authors conducted acoustic and aerodynamiC tests before and after treatment. Reportedly, before treatment the voices of all patients were abnormally high pitched, weak, and breathy, and no patient could phonate at low pitches. Laryngeal examinations showed normal development of the larynx in the majority of cases, although many boys demonstrated a narrow thyrohyoid space, elevation of the larynx, and severe contraction of the suprahyoid muscles during phonation. Vocal fold mobility was normal in all cases. FO was 193.41 Hz for /a/ and 198.85 Hz for connected speech. Following therapy FO for /a/ decreased to 113.49 Hz and for connected speech to 115.62 Hz. Jitter and shimmer levels also decreased, reflecting increased vocal stability.

Counseling or psychotherapy may be helpful for some individuals who are able to lower their FO with voice therapy, but who are strongly resistant to voice change (Remacle et a!., 2010).

Surgery. For those cases that are unresponsive to voice therapy due to excessive muscular contraction of suprahyoid and/or cricothyroid muscles, Botox injection has been proposed (e.g., Lim et aI., 2007; Woodson & Murry, 1994). Woodson and Murry (1994) described a case study of a 47-year-old man with an above-average FO and thin voice quality for whom voice therapy was unsuccessful. The researchers injected Botox into the cricothyroid muscles, with a resulting drop in FO to a normal level (around 100 Hz). Woodson and Murry (1994) proposed that Botox injection in conjunction with voice therapy should be attempted prior to considering surgical alteration such as Type III thyroplasty for individuals who do not respond to voice therapy alone. Type III thyroplasty, also called relaxation thY1'Oplasty, is designed to manipulate the thyroid cartilage in a way that shortens the vocal folds and reduces vocal fold tension (Remacle et aI., 2010). Using this procedure Remacle et al (2010) reported a decrease in FO from an average of 187 Hz to 104 Hz postsurgery and a substantial improvement on the VHI for patients with mutational falsetto.

Transgender Voice The term transsexual was coined in the 1960s and defined in various versions of the DSM as a condition in which an individual wishes to manifest the primary and secondary sex characteristics of the non-natal sex and live as a member of that sex, and who modifies his or her body with hormones and surgery to achieve that end (Denny, 2004). In the mid-1990s the diagnostiC category Transsexualism was replaced with the more general category Gender Identity Disorder (DSM -IV -TR, 1994) and specifies four criteria for diagnosis (Table 10.7). In this version the term transsexual was subsumed under the more inclusive term transgellde1'. The term transgender describes all persons whose identities, behavior, or dress vary from traditional gender norms, including transsexuals, transgenderists,

366 CHAPTER 10 • Voice Disorders Related to Self and Identity

TAB L E 10.7 DSM-IV-TR Diagnostic Criteria for Gender Identity Disorder

. 'fication (not merely a desire for any perceived cultural A. Strong and persistent cross-gender Iden~\d the disturbance is manifested by four (or more)

advantages of being the other sex). In c 1 ren,

of the following: . ] l ' d' b . insistence lha l he or sh.e IS, t le t lei seX

I. Repealedly stated eSl!e to e,ol. " ulating feruale attire; in girls, insislen eon ivear-2. In boys, preference for cross-dress\mgj ~r sun

. \ 'I oty[ ical masculine c O\lll1g . Ing on y s ere I " 1 make-belIeve play or persistent 3. Strong and persislent preferences for cross-sex ro es \1

fantasies of being the other sex . d astimes of the other sex 4. Intense desire to participate in the stereotypICal games an p

£ f playmates of the other sex 5. Strong pre erence or f' ropriateness in the gender role of that

B. Persistent discomfort with his or her sex or sense 0 mapp

sex. . h h ical intersex condition.

~'. ~~: ~~::::~::~: ~a::~sc:l~~~:~~;::~\fi:~,tY;istress or impairment in social, occupational, or

other important areas of functionmg.

2004) The trans gender model views transsexual-cross-dressers, and drag queens (Denny, . If s of human variability rather than as

f d . nce as natura orm ism and other forms 0 gen er vana \". an'i researchers have argued lhal gender

. d (D 2004) Some c 100CIan5 ( , d' a mental (llsor er enny, " II . d' t psychia lric diagnosis , but rather a me 1-

incongruen e hould not aulomahca y mabn ,\ e. d to describe variations in gender All' 2010) Terms have een f r pose . d

cal Olle (e,g" Ison, .. . f d' 'd The e include gellder dyspf'lOrw, gell 'r wi thout categorizing them ill terms /0 I'll' 1~0l r.e\ or gender incongruence (Allison, 2010; discordance, gender dissonl11'1ce, gem er (, ISCO n '.1 or ,

Cohen-Kettenis & Pfafflin, 2010). , ' nl refers La individuals whose gender id e nl~t! As currenlly used, the Lerm Il all:sse~ uI . ill and who unambigllously icl enll ty

, fl ' t ' th their blO OgIC, sex, . I is fund amentally In con IC WI . ) Tl . d 'y'dual feels strong disc roforl WIll

with th Ilon-n, Lal gender (Denny, 200~ : le 1-: ~x~eclalions and at titude thai sO ithe biologica l idenUty and ~e COrr~S?Ol~ llOg ~, ~d female gend~rs, Lt is nol uncomm n ety expects in accordance wi th tradltlol1

d-l m.a e ' tl the cictal rul es for the natal gend.e.r

I' f ' years m aceor ance WI 1 • , r fO l' t.he person to lve 0 1 I I (MFT) seeking the serVlceS

d d th I -to-fema e transsexua (Tho rnLOn 2008) . In ee, .e I~a~ e middle-a ed, married or previo u. ly m~r-a speech- language patholOgIst I. hkely to b G I~ , 19;9' Thornton 2008). It is Iikev,r)se ried, and the rather of one o~ m, I:e c~Id.re.~ (vee(o~'i,ave I~ad) tradjti~nal1y male-oriented 110t unu ual for Ln\nssexual tndlVLdu s to lad . tb" lUlTltarv r have workecl in law en-

. If 1999) Many have serve LJ1.! I . . 'd , I's occupatIOns (Ge er, . ' . e t ically mascuJi.ne field. The mdiVl U3

forcement, constructIOn, or some ~theI ster :r: ress the ender dysphoria (Brown & masculine lifestyle may represent hiS attempt tOkSt~P and ma~ lecide to lll1dergo surgica l

ROlll1s1ey, (996) . Eve~tua\l )' lhe p,e rso~ maitee r~~e~s of ch an ging o ne' gen der is a L ng

procedures f r changmg gender Iden Ity. k 1e ~ s and involves stages f counseling an~ and challenging o~e, The process m;YI ta e ye;rgender enduring the surge ry ilsell', [\1' psych therapy, UV1I1g as :l person 0 Ile large ,


becoming accepted as a person of the desired gender. The treatment of the transsexual client has been described as a process of phases that one travels through to get to the other gender side (Gold, 1999).

SEX REASSIGNMENT SURGERY

Despite nonsurgical lifestyle options now open to transgendered people, transsexuals tend to view sex reassignment surgery (SRS) as the treatment of choice (Denny, 2004). It has been estimated Lh at arolu,d 1 in 30,000 adult males and 1 in 100,000 adult females elect to undergo sex rea signmenl urgery (Levy, 2000). Surgery for changing one's natal gender is not something that is done lightly, and 010 t physicians and psychiatrists require a person to live for 1-2 years as a member of the target gender before undergoing the surgery (Verdolini et al., 2006). Internationally adopted guidelines contain built-in time restraints and safeguards for the potential transsexual patient. The first version of this document was published in 1979. Originally called the Harry Benjamin Guidelines for Standards of Care, the name was changed in 2001 to the Harry Benjamin International Gender Dysphoria Association's Standards of Care for Gender Identity Disorders, 6th Version (February 2001). In 2009 the Harry Benjamin International Gender Dysphoria Association (HBIGDA) was renamed the World Professional Association for Transgender Health (Cohen-Kettenis & Pfaftlin, 2010).

The Standards of Care is an extensive document that covers introductory concepts describing the purpose and standards of care; epidemiological considerations such as the natural history of gender identity disorder and cultural differences in gender identity variance throughout the world; diagnostic terminology and ICD-lO classification of gender identity disorders; responsibilities of the mental health professional; aSSessment and treatment of children and adolescents; psychotherapy with adults; requirements for and effects of hormone therapy for adults; the real-life experience; different forms of surgery including sex reassignment surgery, breast surgery, and other cosmetic surgeries (e.g., reduction thyroid chondroplasty); and post-transition foHow-up. The entire document may be accessed at www.wpath.org/publications_standards.cfm.

Most individuals who complete sex reassignment surgery are male-to-female transsexuals. Often, the surgery is extremely successful in terms of visual appearance, with the help of appropriate hormone treatment, breast augmentation, electrolysis, and facial plastic surgery. However, the so-called "trans woman" is often left with a voice that is perceived as masculine, at odds with her new appearance. The person's pitch levels, intonational patterns, voice quality, and overall communicative characteristics often remain in the masculine domain, Mainstream culture does tend to penalize people whose voices do not match their gender, body type, and build. This is troublesome to many patients who have undergone the surgery. Reportedly, 93% of participants at a transgender conference rated voice as at least somewhat important in the transition process, and around 25% rated voice and nonverbal communication as playing the most important role in the individual's success in "passing" as a female (Johnson, 2008).

Many trans women turn to speech-language therapists for help in achieving a more feminine voice. Clinicians working with this population are faced with some unique challenges. A clinician may be reluctant to work with a transgender client for moral, ethical, and/or religious reasons, yet ASHA's Principles of Ethics state that all clients must be treated with respect. Clinicians need to be aware of their own biases and perspectives and take care that these do not negatively impact the therapeutic process. Speech-language pathologists must ensure that they are familiar with the guidelines for treatment of all transgendered clients and are cognizant of appropriate gender terminology. Table 10.8 provides terminology currently used in the transgender community.


TAB L E 10,8 Terminology Related to Sexual Orientation

and Gender Identity Disorder

TERM DEFINITION

Gender identity disorder

Queer

Sexual orientation (SO)

Gender identity (GI)

Cisgender

Transgender

Transsexual

Cross-dresser (transvestite)

Transition

Gender community

Passing

Diagnostic category referring to individuals with a strong and persistent cross-gender identification

Umbrella term that includes gender identities and sexual orientations and applies to anyone who does not identify as straight/gender normative

External, sexual attraction to others; spectrum from straight to bisexual to gay (Queer SO)

Internal, perception of self; spectrum from male to androgynous to female (Queer GI)

Gender identity consistent with the gender one is identified as at birth

Gender identity not consistent with the gender one is identified as at birth; used as an umbrella term for all queer GIs; describes persons in gender transition

An individual who desires to live full-time in the opposite gender; describes a person whose external genital anatomy has been changed to resemble that of the opposite sex

Individual who identifies on the gender spectrum but who does not wish to fully transition and presents as the opposite gender less than halftime

The process one goes through to live as the opposite gender

Cultural group where gender roles are not strictly defined by anatomical physical attributes

Ability of a TG or TS individual to be perceived by others as belonging to the target gender group

Sources: Information from Johnson (2008); King et al. (1999).

EVALUATION

As with any voice disorder a comprehensive evaluation is essential. In the case of a transgendered individual, the case history becomes even more important because of unique concerns involving privacy issues, terminology, evolving treatment goals, and unusual social circumstances (King, Lindstedt, & Jensen, 1999). Table 10.9 presents questions pertaining specifically to transgenderltranssexual clients that should be incorporated in the overall case history interview. ,

In order to establi -h professional redibllity, trust, and rapport with the client, the speech-language path logist must demonstrate a high level of pragmatic appropriateness during the initial interview. ongoing evaluation. and the entire therapeutic process. When dealing

Transgender Voice

TABLE 10.9 C H' ase .story Questions Pertaining to Transgender

and/or Transsexual Clients

Gender Role Information

Which name do you prefer to be called?

Is this the name t b d C o e use tor contact outside the clinic? What stage are you' th d

In e gen er reaSSignment process?

:ow o;ten do you present yourself as male? (estimate percentage of time)

ow 0 ten do you present yourself as female? (estim t Ar d' . a e percentage of time)

e you un ergolng hormone treatment? Are d h you un er t e care of a mental health specialist?

Do you plan to transition to full-time immersion in th f, I I If so, when? e ema e ro e?

What kind of woman do you wish to be? How t' SUppor Ive are your friends, colleagues, and family?

Voice Information

:ow ;OUldh

you rate your present female voice? (poor, fair, good, excellent) ow 0 ot ers react to your female voice?

How much of a strain is it to use your female voice (not at all somewh t What strategies do you use to chan ti ,a , very) How' , , , ge rom your male to female voice?

Important IS a femlnll1e voice to you? (not at all h Wh t ,somew at, very)

a are your goals for voice therapy?

SOllrces: 'n (ofma.lloll from IJroll'n el nJ (2 ), ' Momn CI 31. (200$) • 000, DacakIs (2006); Gelfer (1999) ' Johnson (2008) K' , , , ; mg et al. (1999);

W~~l individuals with sexua l ol' ienta ti,on Or gender identi " _ " " paRle cllrrcu t termJnology and t!1 ' 'I" d l' , ty I sues, It lsntJcal to use appro-

, , ,e .tnUVI ua s preferred /" r" dd ' pel SO.n s confidence aod trust. The evaluator s11 ul OJ l~ 0 a ress 111 order to win the to be called and whether this is al ' tJ , d ask the clien t whkh name be/she prefers 2006; eifel', J 999; J bnson 200S

s)o r, loer l:ann:e tl~ ~)de 1I ed for contacL ol:llside the cJjnic (Dacakis

' 1 I". 11" ' , l'« me: IVl . U'U who" t, ", , • 10 e to I U -tune h~malc rule th cJient willliJ eJ ' b IS I aJ1SJ UOllJl1g from fu ll-time male her name (Dac,lki,s 2006) ' t is ' r< '>' lise oth the male and female versions of hl"s/

, ' ,l • 1111 portan l lOr the eli ' , name and the appropriate persona l PI' nouns . ~ICll'l n 10 re~pc:: t and Lise the preferred

1. uring tbe inlerview proces ' th ' I ' aCCOldll1g to the cJJent's wishes, , d' S e eva uator sbould 1' " " f' ,

reg If mg wllere lhe indivl'd ual' , 1 e Ie It III ormation F/'Om the cJjeJlt d " ' IS 111 t l C gender re -'

un crgo rng hormone lreatment, and whelbeJ" he/she i ~ssignmellt pro ess, whether he/she is mental heallh profeSSional (Geller 1999) TI ' d" S wlder the CaJ'C of a psycJtia lrist Or o th r degree of Uppc)I'[ he/she is l'eCeivil;g or is·I'k 1~ III IVla~lal sho uld be ques tioned regarding the ( clfer, 1999; f(jng et al.. 1999) The lev J 'f ~ Y to re~clve fr rn fami ly, G'iends, and cofleaglles

, , e 0 support IQ the client's everyday en vi 1'011111 'nL can

369


impact the degree to which he/she is able to apply techniques learned in the clinic to functional situations in his/her life. Information should be obtained about when the client must pass with the new voice (Johnson, 2008), what percentage of time he/she is currently living as a woman, and when he/she plans to make the transition to full-time immersion in the female role. It is likely that as the individual transitions from a more masculine role to a more feminine role, the communication situations in his/her environment will change, signaling the need for ongoing communication assessment and evaluation (Dacakis, 2006; King et al., 1999).

Identifying the client's goals for voice treatment is important to maximize the potential for a successful treatment outcome. A client may have unrealistic expectations about what her feminine voice will sound like (Gelfer, 1999). This could jeopardize the therapeutic process and negatively impact the person's perception of therapeutic success. The client's perspective regarding what kind of woman she wishes to be is another important issue, as many of the verbal and nonverbal behaviors suggested in the literature for transsexual clients reflect a female stereotype, which is rejected by many modern women but forms the target for some clients (Moran, Hague, & Roper, 2008).

In addition to specific items related to transgender issues the client's medical history should be explored. Particular attention should be paid to conditions that may affect the voice, such as a history of GERD, any neurological problems, cardiac problems, hearing difficulties, respiratory issues, and seasonal or other allergies. It is important to note whether the individual has undergone any nongender or gender-related surgeries, and whether he/she was intubated for the procedure. Any prescribed or over-the-counter medications should be noted, as these can affect voice production. Attention should also focus on the client's use of tobacco, alcohol, and recreational drugs.

As with all individuals who present for voice therapy, the speech-language pathologist should determine the client's level of daily vocal usage, vocal technique, vocal needs, and vocal habits. Vocally traumatic behaviors should be identified. It is also important to note whether and how the person has attempted to change the voice during the transition process. An individual may have tried to raise pitch by using excessive laryngeal tension, thereby creating the conditions for a possible MTD (Brown, Perry, Cheesman, & Pring, 2000). Quality of life questionnaires such as the VHI are an important means of gaining insight into the impact of the client's voice on his/her everyday life.

In addition to the extensive case history, the client should undergo laryngeal examination by an otolaryngologist to rule out any laryngeal abnormalities of structure or function. Acoustic analysis is also a critical part of the assessment process. It is important to determine the client's habitual speaking frequency level in the male role (Mordaunt, 2006), as well as maximum phonational frequency range, intensity levels, and intonational patterns. An acoustic analysis program is helpful in documenting the person's habitual average fundamental frequency in sustained phonation, reading, and spontaneous speech.

TREATMENT

Treatment for individuals wishing to develop a more feminine communication style is multifaceted and may include voice therapy, surgery, counseling, articulation therapy, assistance with nonverbal communication patterns, and focus on physical appearance. The goal of treatment is to emphasize and highlight the markers of female speech. Markers include a higher pitch, greater intonational range and pitch variability, increased vocal expression, rising intonation on statements, breathier voice quality, feminine patterns of phrasing, as well as nonverbal visual markers such as increased eye contact, increased hand/arm gestures,

Transgender Voice

371

al.h l i~lc reased Use oj' to uch (Parker, 2008) A " . . J1 lca tlOn work is for ,he el i at' to spend u' g~()d 1;~rutIl11 I JnUor gencler-spe ifr com rn uage, culture, ,1no oeial class in t:' lll '1' l11e () el'vlIlg people who nrc of lhe chosen gender

d " l Iar co nte. ts crh I' t ') 0 ' gen er- pecin work begins, allY exis ling d . I . 0 II on, -0 8). Howev r, before an}' be trent 'el (Th rn l 11 , 2008), and any l11ed i!a~P lO~~,.ajld vocally tnmma tic hchavi J'S must be add ressed. con IIJon. such as GERD or ll 11ergi S sbou ld

Voice Thel·apy. Behaviora l voi e them ' la .' , develop a percepillally more fe min i Ile ;'~j:e «~~d\~ Il,IC~ P~l't. in helping lbe trans spea ker ! herapy fo.eu es not nly 0.0 ra ising pit h but on (eU'I ~ .el?ll1lJ ne c .m l~ unka li n pat terns. :eson3nce, rn lon<1 lional patterns, articulator I att r ,l1l 111 IZU1g ~he ellen l S VOCR!. quality and IS also empl)aS ized <1 ' the individuallea m / p .Ils. and no n,verbal gc, ltl res. Vocal hycriene laryngeal strain or vocal hypel'ful1eti n (T':b~e ~~~ ~~~ ~e and l1l <1 ll1tai n the targc t pitch wi ~'01l1

Pitch. FO is the most salient cue to ender iden ' . biological men and women (Gelfer &gM 'k 200 hficatlOn for trans speakers as well as for has typically been targeted as the most ' lOS, 5), Therefore, raising the individual's pitch

Important goal of treatment. Research has established

TAB L E 10.10 Feminizing Strategies for Trans Speakers

FO and Pitch

Determine target PO level

Es~ablish a star~ing PO slightly above the male habitual pitch

RaIse PO levels In small increments while maintaining good voice ' Begin each PO level with isolated vo I d qualIty and appropriate intonation

, . we s an progress to longer utterances PractIce USIng each new PO level in different phon t ' U e IC contexts and with v ' ,

se more upward pitch inflectio d f, . aryIng Intonational patterns

Voice Quality ns an ewer downward pitch inflections

Eliminate glottal fry and hard glottal attacks

A void falsetto register

Use a slightly breathy quality

Use a resonant forward focus

Articulation

Use more anterior ton I

Use light and more pr~~:ePa:t~::::;;~:~::c::reading to raise formant frequenCies

Paralinguistic and Nonverbal

Use feminine nonverbal patterns such as increased e e contact a Increase use of tags at the end of utterances Y nd use of gestures


1 . I seal crs are perceived as male and above a cutoff;O [nroun.d 150-17 Hz, b 'low wB~C 1 ~; .y' heesl11an, & Pdng, 2000; Gelfcr &

. da . tCl11a le(eg lown, .ren, . wh ich speaker arc perceive ,s. .' ., N rthro), 1990). The range bet ween approXl-Schotleld, 2000; Wolfe, Rattl sml , Snulh, & °FO zO:le 'io which the s eal: ef's gender is not

mutely 14"- 165 l iz fonns a ge~der~alUbl~~~8) This zone forms the initial target for pitch identifiable (Mo rdalUlt, 2006; rhornton, .

raising exercises. " FO level as dose as possible to that f . t" to acb leve a 111C,1I1 ' .

The goal of mterven I.on IS b _ 180-230 Hz An U1'1nortant fiJ'st step In . . l ' I L . cally ranges elween .. t'. . I

adul.l female speakers. W uc' ypl . . '·aL' ta"ge l tbattilkes II1to ace unt \le • . 1 I ' i,t lunmg an appropl l' e • raising Ll1e client S pItch ~ve IS ~ ~ er,l ' . u t' oses. Pilch ,ra ising protocol typical1ye t, b-speal er's ~\bi l ity to va ry pi lch [01 \n fl ecbonal P P . ductions of v wels or nasal consonantl lish a startil1g FO by having the cUcnL pTo~~ce ~~sy P:~at a frequency slightly above t11e speakvoweJ c · mbinali us such as /al ,./ma/, 01 un: mro 2006) The client is p~'ov ided a model of

I I ( GeHer 1999' M I dallnt, . f lb I er's typical male eve e.g., , . , 1 .hc instrumentati.on for vis ual eel ac <

I al't Most pro LoCO S lise acOUSu . d a ligh t. clea.r voca qu, I y. . 1 WI, Lh eli nl becomes abl.e to hablluale ,)11

. d"f, . a udilory feedbac L~. !1.el1 e · "d . t 3.l1daudlOrecor tngs 0,1 . d ' ' 1'ty Lbetarg -tisraisedagal.O.Mol MUl

. I: I I ' h . level With goo VOICe qua ,I , . k mail1tain the sl lg lty 11g el . . . . j: '10 Hz while en uring that the pea er

d d . . the 1evel ll1 lJ)crements 0, . . (2006) recontmcn e raising ' . I " the 11 igh er level in different sllllalt ns

I I . uah ty IS ab e Lo use . 1 main tains an acceptil) e vmce q L' e the u ward intonational pallerns lhat give t.)e

an d wiLh vat'yi~g l~ ll?neSS ~~:e~s~~~~dfi:;~ ~~Sired prtch level1llust anow lbe speaker to ensl1~ speech a more leml\11ne qua It).. . \ . OSC$ As the client conlinue t progress access the upper pitch ranges for l\1tolnlaLJoJll~:'~aI1PIY be' g' illS with isolated vow.cis, extending

. hi 1 . fce aI' ea 1 eve 'I. K ' · . chI \ LO higher PltC eve s, pi ac I d l at US'l llg Lhe new pitch. The new plt eve LI. • o" d 1 become more a ep , . gf 1 utterances as ulC Ifi , IVI ua . . armng levels of meanU1 u ne.

. . d' U;. t · honetic contexts, usmg v I' . d 'houl l be pracllced Il'l L el n p , '\1" abollt '''1 'ullportan l- issue), read.mg, an

f· 'h 'k versus la ,lllg <u . (e.g., reciLing the days 0 t .e wee h ' k .' ene uraged to express dIfferent

. A tr > e~l' nce level, t e spea eI ,1 " , ·tb I answering quesllons. t 1t: S 1 . " , . " that he/she can experiment WI t lC emotions Sll b as happiness, sorrow, and anl1oy.u1 e, so

feminine voice (Gelfer, 1999).

. 's em hasized both be for the pilCh work begins and through-Vowl Quality. ood vo a.l quality I . P i t li' 'Ula te any instances of harshness,

Th ' d' 'ci al is tallg 1t 0 e 111 . Olll lhe treal1nent process. , e In tVl 1I ks d o'l t'aged to lise a sligh tly luwer intenSIty

,._. 1 f d l ' ·d gloltal altac an enc , . hoarseness, glotlal ry, an 1M . f al £en1'lninity (Gorham-Rowan & Morns,

I' " . 'c the perception 0 voc · . I . " and breathy qua J.ty to I\1creas , I) , ., d l1ab·t"llatlllg a "contidentla VOlce

M i t 2006) racuell1g an ( I • - . ,

2006; Holmberg et ,,1.,2009; ore aun,. . ali Resonant voice th rC\py can also be helphu may create the ?csired sligh tly breat~lYv l~t~~' J~dUCe '~l1l1d wilh a forwa rd foclIs and ~w~y in achieving this goal. Thc peak~r Ils,~aug 1 .Pb tiO ll ~ I'roduced dming speech prirmtrlly 111

1 . ' d Lo lee ule om VI ra '" d from the laryngea al ea, an '. t' g fil ly lhroughollt the v cal Lract all the mask f tl1e face. This f~cilitaLeH lh~ ~~Ice r.~~~: ~~lY ~ rt or tension (e.g., Hirsch, 2006). lncreaslng vocal power, c1anty, ,Uld n.ex-Ibl 1;' w~ thaC are more cOlDmonly used by males, such

lnd ivlduals should aVOld ce.rtalil voca Olc 5 d hi g (Deem & M iller, 2000). Also . 1 1 alized pallses an coug n I

as throal clearing, low-pltc lee voc . ' 1 . ili in reedy quali ty that d es I10l sound ?altu'a to be av ided is Lhe use oE fa lsetto. wluch :as]a r. ' I . Y use thi s I' gister Ul the mlstal<el1

or pleasant. Speaker ' wis~ng t~ be percetvet as lema e ma

belief that the very high pilch Will be h elpful.

• ., . J owel forman t frequencies has been C\ ta rget .ill Vocal tact Formallt f'rcqucncl.Cs. RaIS1l1dg.~· COrn1"llt f"'eqtleI1CY related to the sIZe

. . h Tl . . . ilierences m l " . .., . 1 • r some intervention appro,\c es. lei e t\l e ll females The male v cal tracl 15 1 ng

e

aDd configllration of the vocal t ract III ma es ane ,.


than the female, and the male pharynx is proportionally larger than the female (Rammage et aI., 2001). The male vocal tract resonates more strongly to lower frequencies while the female vocal tract resonates to higher frequencies . These formant fr equency differences also contribute to the perception of a person's voice as m ale or female (Gelfer & Schofield, 2000; Rammage et al., 2001). The first formant frequency (F1) is related to tongue height and the second formant frequency (F2) is associated with anterior/posterior tongue placement. The third formant frequency (F3) is correlated to degree of lip spreading (Carew, Dacakis, & Oates, 2007). Teaching the speaker to articulate with the tongue in a more forward position raises F2 frequency and may facilitate the perception of a "thinner" and more feminine voice (Gorham-Rowan & Morris, 2006; T hornton, 2008). Teac.hing the clien t to Lalk wi th lips slightly spread can raL~e F3 ( arew et aI. , 2007). arew ct a l. (2007) reported U1at the combination of increased forward tongue carriage and increased use of lip spreacling n t only increased formant value, but ill addition had th e effect of rai ing FO by up to 30 Hz. Perceptual ratings of femininity of voice following treatment increased for 70% of participants, and participant self-ratings of both satisfaction and femininity of voice were significantly higher after treatment (Carew et al., 2007).

Intonation. Pitch range and variability are aspects of intonation that are strong markers of gender iden tity. Female speakers typicaUy liS a wider range of FO and n more varied pattern

f pitch infiecti n , while male speakers tend to use a more reslricted FO rang and fewer in ftecti na l patterns (Ferrand & Bloom, 1996) . Sludies hnve demo n trated tha I trans speakers voice iden till d as female ,u'e ch ara terized by more pi tch inHeclions b th upward and down ward, less extensive dow nward shift., <l greater proportion of upward shifts, and fewer level intonation pa tterns (e.g., Gelfer & Schofield, 2000; Wolfe et aI., 1990). Women's intonational patterns differ from men's not only in range, but in phrase endings. Women tend to use more rising inflections at the end of utterances, often giving their speech a somewhat tentative sound. In fact, a speaker who uses a lower pitch , but a more feminine intonational pattern and style will sound more feminine than one who uses a higher pitch but fewer feminine patterns.

Outcomes of Voice Th erapy. Many studies have demonstrated that voice therapy can be effective in helping the trans speaker achieve a more feminine sounding voice. Soderpalm, Larsson, and Almquist, (2004) evaluated a group of speakers before and after therapy. The therapy approach included vocal hygiene and pitch raising exercises, improving the clarity of articulation, and encouraging more anterior articulation. The authors reported that fewer than half the patients produced an FO above 15S Hz at the close of therapy, but some patients reached this level at follow-up. They suggested that one of the benefits of voice therapy may be the improved vocal technique tha t prevents fatigue and sore throat. Mayer and Gelfer (2008) stlldi.ed the effects of voice therapy in shifting listener perceptions of gender in trans speakers from male to female, and the acollstic parameters accompanying that change. Each client received 16 sessions of group voice treatment. Intervention focused on raising pitch to an individually determined leve.l using a light, breathy quality and good breath support, improving articulatory precision, and increasing intonational variability. A group oflisteners rated pre- and post-therapy voices as male or female, as well as rating the voices on a scale o f pleasantness, masculinity, and femininity. Acoustic m easures included speaking fundamental frequency (SFF) , upper and lower limits of SFF, and Fl , F2, and F3. Samples were analyzed prior to therapy, immediately following 8 weeks of therapy, and 15 months after termination of therapy. The results showed that prior to therapy only 2% of voices were rated as female , while 51 % of post-therapy voices were rated as female. Gains in SFF m ade in therapy were


maintained more than a year after therapy, although not at the level attained immediately after

IreaLmen t (pretesL SFF 11 HI' .• posHest 178 Hz, long-Lerm

DS Hz). There is retnllve1y strong consensuS among experts as \'0 recommended approathes lo

voi e therapy ( ates, 2006). studie indi ate thaI v ic therapy can be bend! i<11 . althmtgh th~re is very liule guidance as to prognostic indlcat rs or predictors of successful interventi n ( ates. 2006). However. lue reports provi,de anecdotal uggestion5 as to who may benefit m t from voice therapy. The lrans client who i living full timc in the female role will havc n str ng need to develop a voice can i tent wiLh her gender and will ill ely be more motivated to pructi c and comply with LheJ'apy regi roes (Gel fer 1999; Gold, 1999). Speakers wb. arc prone to vocall y traumatic behavior I' suffer fr ro allergies or ul1treatecL GERD arc likely to be Less

successful.

Surgical Treatments. Surgical treatments are available LO raise FO as well as to feminize laryngeal appearance. Pitch-raising surgery aims to raise the fundamenral frequency by in rea sing vocal fold tension, decreasing vocal fold masS, or modifying vocal fold con istency (Remade. Matar, Morsom

me• Verduyckt. & Lawson. 20 U ). A thorough as essmenl of the individual's

suitability for surgery is imp rtant and 11. uld be carried oul by a. multidi ciplinary team including the can ul tanl psy hialri l, speech-Janguage pathologist, and otolaryngolog

i t

(Parker, 2008).

Cricothyroid Approximation. Cricothyroid approximation (CTA) is Lhe most commonly used proceduret increase PO (Remacie et al .• 2011). In this technique the cricoid cartilage is tilted backwal'd and the thyroid artilage is tilted forward. 1'h vocal folds are thuS elongated and stretched, resulti ng in a higher FO and l'erceptuaHy higher pitch. By means of computed tom graphy Pickuth el al. (2000) calculated thaI PO increased approximately L8 Hzlor ever)' millimeter of approximation of cricothyroid distance. The surgery can be performed either under general or I cal anesthetic. Local nne thesia has the benefit of patient participation in determining the optimal pit h leyel. Many researchers have reported FO increases resulting from eTA ranging from 16 to 13 1 Hz (e.g., Brown et a1., 2000; Debruyne, De Jong, &

sterlinck. 1995; De Tong & Norbarl, 1996; Kanagalingam et a1.. 2005; Kocak et a1., 2009;

Neuman, Welzel, & Berghaus, 2002). The advantages of T A include th lower degree of effort for th. patienllo keep up Lhe high FO and the rise or the lowest pitch level (Soderpalm eta\., 2004). However, complicali ns have been repolted in luding decrea ea vocal range, decreased dynamiC range and 10lldness,

and worsened vocal quality (e.g., Netunann & Welzel; 2004; Spiegel, 2006).

Anterior Commissure Surgeries. Several surgical techniques have been described that modify the vocal folds at the anterior commissure. This has the effect of shortening the vocal folds and reducing the vibrating P rtion in rder to rai e the FO. La er-a isled anterior commiSsure placalion is de.signcd. to create a web between the anterior edges of the v cal fold , The mucosal lining of the anterior quarter of lhe i Ids is vaporized with a 0 1 laser, and the denuded folds are sutured together (Rammage et al., 2001). A similar technique, called el'l

• ,,"'pi , "",I fold sn'" en ing, was described by Gro. (1999). roSS (1999) pre"n"d re.ul~ demonstrating not only an average increase of 9.2 s 111itones in piLCh, but also a r duction in range in the lower frequencies. lotto-plasty is another techniql\e that involves ulu

r-

ins th, d"pith,I/.""d ,n'<fior p ,·tion or 'h' vu,.! fold> " 'h' .nteri r "",",issu" in , V _ hal'. Using this proceduro, R .n"cl"t ru. (20 ll) reportod • siS

nifi,"" in'''''' in PO

from a median r 150 Hz pre llrgery LO L94 111. P stsurgery. Kocak et a1. (2009) used laser


redu Lion gl ttoplaSI)' in patlenls who w . . reduces the bulkorthe lhyrovocal i SJ11UsC~IC n~1 salisued with 'TA results. Th.is Lech.ni ue tolward the fema le size range. Glottopla I yefla~( v.oc,,1 1,1~a.lllent, th u s lill'ring the v ca l n! s t lC postsurgical CTA f OWlI1g CIA was rep rte It ' " ' mea n 0 approximate( 158 H . ( 0 Increase FO from appl oXll11atcJy 20 H I, y , z to the poslsllrgi 31 I t I . , I z. <os",u,·serY'o;ce qu,I;ty d I · · go, p "ty menn I ~ '." ne-y.ar follow up. 1I0w,v.,., "Iy' of th ";; y~p ,omc, but impr ved .ub.""ti.lly

er, vA;~~ ou'rom~ wbil. Iwo wer .• only p'eli,lI; al~~:lS wer·, rompl,t,ly "ti ned with

. ough the e procedures c'ln be ffi . .. ' vOice qu31 ' t r ,e ecllve lI1 mcre' " FO N 'Y, requ.nry mng., 'nd in"asity I I as~g . , u'her f.alu,·" sueh " eum~nn ~Welzel . 2004; Parker, 200 ; Rema~~ee I ~~ay dctenoratc (e.g., Kocak ·t aI., 2009j

lrrglcal lecllJliqlles ca n b ' e eL,2011) . . d' 'd ' e an Il11p rtanl [ . 10 IVI .llal 's voice, because cven when beh"I'viO .meall~ 0 Hleren ing the feminini.ty of the ~~etatlve v calizations (e.g., ISlighing ou~h' Lal v01~e therapy is effective, uncontrolled ~ste: (Gross. 1999). Even with the rel ~fve mg, yaWom n.g) may still occur in the male re -llldicales thnt the surgeJ'\I d' 1 Iy sub tanlml ID reases in PO I}o g • J oes not neccssaril . I ' ' wever, research vOice. Neuman eL aJ (2002) ·bad a J f Y resu t 111 the p rception of a wl'olly fi " l. j . pane 0 J'udg t tl' ell1Jllll1e },IC undergone TA compared with bioi 'c es ra e le f~l~al~ness or trao peakers who the po~operative voices as marc femnle th~n al m~es aJ~d blologlcnl females. Listener raled oftl1e bIological females. Further paUe t the,bIOloglcal males, but less femal than th the FO in rease, il does not conform :1exp:cta.tl~ns l1~ay be ex1remely high, that ~Itho~se (Rema Ie t 31. 20 I l ). Tab! lO LId I." 1 til IndiVidual s percepLion of a wholly female vo,gh and ft . . I ' ,~p ays average FO I I ' Ice a el PltC l-l'alsing treatment. eve. s reported in the literatw'e before

TABLE 10.11 Average Fundamental Frequencies (FO) . Male-to-Female Transsexu I S k Reported In the Literature for

T

a pea ers before and ft . reatment, and on Long-T F II a er PItch-Raising

erm 0 ow-Up

Dacakis (2000)

Carew et al. (2007)

Gross (1999)

Mayer & Gelfer (2008)

Brown et al. (2000)

Yang et al. (2002)

Van Borsel et aL (2008)

Neumann & Welzel (2004)

Kocak et aL (2009)

Remade et al. (2011)

TREATMENT

Voice therapy

Oral resonance therapy

Surgery

Voice therapy

Surgery

Surgery

Surgery

Surgery plus voice therapy

Surgery

Surgery

PRETHERAPY Pos -

125 Hz 168 Hz

119 Hz 133 Hz

117 Hz 201 Hz

119 Hz 178 Hz

142 Hz 174 Hz

133 Hz 185 Hz

118 Hz 169 Hz

117 Hz 155 Hz

158 HZ 203 Hz (post (post CTA) glottoplasty)

ISO Hz 194 Hz

OllOW-UP

146 Hz

138 Hz

185 Hz

162 Hz


Other urgical procedures such as thyroid chondroplasty ("laryngeal shave") may be performed for cosmetic reason. Thyroid chondroplasty is designed to feminize the appearance of the neck by removing tbe upper parts of the thyroid laminae (Matal, Cheesman, &

Clarke, 2003; Parker, 2008).

ClIENT SATISFACTION Outcomes studies have demonstrated that surgical and behavioral voice th rapy can be effective in facilitating a more feminine voice for trans peakers. However despite reported successes in raising pitch there is not universal satisfaction am ng lients wi lh their feminine voice. There is often a discrepancy bel-ween the client', and clinkian' perception r a satisfactory voice, particularly when success is defined solely r primarily in term of p r cep tual ratings and a o ustic measUJem nts of the voice (Dacakis. 2000; Pasricha, Dacakis, & Oates, 2008). Yang, Palmer, Murray, Meltzer, and Cohen (2002) rep rled Lhat 50% of their patients fe lt their voice after urgery n w titted with th Lr elf-perception, 20% fell neutral about their new voice, and 29% responded negatively. Wagner et al. (2003) 11 ted that 11 oftbeir patients experienced a postsurgery improvemenl in -0 and some expres ed satisfaction. However. the measured improvement in FO did n t always coO"espond with patienl satisfaction. M eUl, wilso.n, Clark. and Deakin (2008) investigaLed the relationship between FO, perceived femininity of vic, and happiness with voice in transsex ual individuals- Speakers also completed the VHl. Voice rec rdings were evaluated by speech langu<\ge pathologists and na-ive observers. Most participanls described situali n where d1ey felt Lheir voice let them UOWll, including speaking Olllhe telephone, coughing. and laughing. McNeill et al. (200 ) caution d that patic11tl' happines with their voice is not dil"cctly related to Fa and may not correlate with perceplions of the clinician or tbe by public. Pi twth el al. (200 ) reported lhat despite the incrca e in PO, not all the palien t were satisfied with their current vo ice. nly 58% indicated lheywere satisfied, whil 33% were eli saLi fied, and 8% were neutral. Vocal pilch wns rated as feminine by half the respondents, masculine by one-quar ter. and neutral by the remainder. Pickulh et al. (2000) reported that when asked how w'eU the individual's new voice fit witb her currenl self-perception. 1% rcsp nded positively, 29% responded negatively. and 20% felt it to be neutral. Neumann and Wel~el (2004) reported Lhat approximately 85% of their patienLs wh underwent w-gery were satisfied with the result. Pasricha et at. (2008) hell [! Cllsed interviews with tr.U1S speakers wbo had lmderg

one various types of therapy. ParLlcipant rcported that voice was the feature r

communicati n with which tbcy were th least saLislied and was the principal (ealurc lik Iy to betray their biologica.! gender. Dacakis (2000) foll wed up on trans speakers sev ral years aIler lherapy and obtained a ouslic meaSures as well as measures of satisfa timl wi Lh voice and pitch level. Reportedly, the more Lherapy session attended, the better the maintenan e oHO gaios acbieved in therapy. A a grollp. the subject maintained a higher FO at followup (han at the initinl evaluaLion al lho llgh there waS variability in the actual amounl of FO increase. The l11ajorily of the clients, including 3 whose mean FO had returned to prctherapy levels. expressed a h igh level of satisfaction wilh their pitch level. This JUay J" fleet a clieL1l's

ability to "pass" despite the lower pitch. These studie hlghlighlth' fact that intervention should focus not only 0 11 lhe clien

l'S

v ice, but on other important a pects f cOJUmunication includ ing articulation, rate of speech,

vocabulary, and body language. The client sbould learn t articula te more gently. yet wilh m re preci'io

n than is lypical f l1'1al (Thornton. 2008). Nonverbal gender markers such as

maintaining eye conlact ancl using l uch and gestures more frequenUy should also be targeted

Chapter Summary 377

in th~rapy. Female speakers tend to use more t day, Isn't it?"), and this is a straightCorwal.d ags at

f ~he end of sentences (e.g., "It's a lovely

, I' , n1eans 0 In· . h son s communication. Cleas1I1g t e feminineness of the per-

Physical appearance is anotber important facto -Cuypere, and den Berghe (2001) repo t db" r to take 111to account. Van Borsel De Ire t at t 1e perc f f '

sexua as male or female was modified d d. ep IOn 0 a male-to-female trans-cha~acteristics. They suggested that vocalefren .1l1g on bo~h physical appearance and vocal conJuncti~n with appearance factors such :;n:ng t? femll1lZe the voice should be done in less fem1111l1e-sounding voice may sfll b 10thll1g and makeup. An individual with a

con vindngly [,male, Thu" "" tm,n; foe' t:~~:~"d " a woman if h" phy,i"l '1'1''',,"00 ;; With emphasis not only on vocal character. f p~akers IS best provided in a holistic context style and presentation. IS lCS, ut on the person's overall communicativ~

A CHARACTERIS~IC OF MOST voice disorders relate . . . . that the larynx IS structurally normal d h _ d to persona!Jty and Identtty issues is

basi~ for the problem. cal fUJ1cLion , hO~\f:~er t. e~-e IS ~o detectable organic or neurologic Whde tbere are many different SYll1ptOlt d h' IS unpaIred 111 terms of quality or capacity

d.d . lSan c aracte( f f - . an 1 entity, there are also certain conIDlon I't- S IS ICS 0 vOIce problems related to self voice disorders. a l ies. tress may play an important role in certain

Muscle tension dyspbonia (MTD)· d· th . t. _ IS a Isorder that· It f , em nnslc and extrinsic laryngeal muscles as well I es~ s rom hypercontraction of )l\w, tongue, neck, and sboulders M I _ as muscles 111 other areas such as the face P . . usc e tensIOn dysph· b '

nmary MTD results from many interactin ,oma may e primary or secondar ality factors that induce tension psy h ~ fla~tors, 1I1cluding psychological and/or perso:~ h. h. ' c osoCla Issues poor' I I·

Ig_ occupatIOnal and/or social voice usage. Seconda ' , \ oca tec_1mque, and excessively which results from compensation co. d I _ LJ MTD IS aSSOCIated with vocal tension

I. I' I un er y111g glott I· ffi - '

ma Ignant vocal tumors vocal t Id b . a ll1SU IClency caused by benign b h- ' 0 owmg. or vocal fold . I - or

reat mess, hoarseness, strain effortful h. pala YSlS. Symptoms ofMTD include and reduction in vocal range Vocal tractPd?natlO:1, vocal fatigue, pitch breaks, voice arrests , . I ., Iscomlort ha I b ' mg, ttgltness, dryness aching tick!. s a so een reported including burn-

d. " 111g, soreness and lb·

spasmo IC dysphonia share many perceptual t ' . ~ o. us sensatIon. Because MTD and the two conditions. Stress and excessive m I e~tl~res, It IS Important to differentiate between

treatment typically focuses on relaxation o:t~U t ~nsl~n are strongly related to MTD. and therapy has been used successfully for MTD. e ea an neck muscles. Cognitive behavioral

ConversIOn disorders are cate o· d suggest a physical etiology such as ga nze

d, aS

I soma.t~form disorders in whicb symptoms

P

h . I' ' me lca condItion d- , . YSlca cause IS evident and the co d-t.. ' Isease, or IllJury. However no

tl tId- .d ' n I Ion IS actually -m e -' f ' IC. n IVI uals with conversion disol-d t d ,xplesslOn 0 psychological con-a .. ers en to suffer ac t h -,nger, unmatunty and dependency. a histor ' of f ~I e or c romc stress, suppressed to-moderate depression. Patients report ~)\" requent mlllor health problems, and mildweaknesses, and attach great importanc tee ll1

gltense and overburdened, cannot admit to

. .. e 0 socIa conventi A IS Important 111 order to rule out any p .bl _ ons. comprehensive evaluation Treatment focuses on both restorin OSSI ~ organic ~r neurologiC causes of the problem.

g norma vocalizatIOn and exploring the ps I I - I yc 10 oglCa

378 CHAPTER 1 a • Voice Disorders Related to Self and Identity

issues that underlie or contributed to the voice problem. Counseling techniques are important to help the patient uncover and deal with the conflict in more open and productive ways.

Functional dysphonia (FD) is strongly related to internal and external stressors and to personality characteristics. Individuals with FD have been reported to demonstrate higher scores than controls in terms of specific anxiety symptoms related to health concerns and somatic complaints; to be cautious, careful, tense, fearful, apprehensive, nervous, timid, doubtful, discouraged, and passive; to feel insecure, victimized, resentttl\, and p imistic; and l exp rience life a stressful and disturbing. Vocal symptoms tend to be nonspecific and includ varying degree f breathiness, hoarseness, and roughness. Individuals with l-iD respond well to voice therapy focusing on direct treatment techniques such as vocal and breathing exercises, indirect techniques such as education, vocal hygiene, and nondirective counseling, as well as cognitive behavioral therapy.

Mutational falsetto, also called puberphonia or mutational dysphonia, occurs primarily in postadolescent males. Occasionally, despite normal laryngeal growth, a male's pitch level does not lower. This is often due to psychological reasons, such as resistance to the responsibilities of adulthood, embarrassment at the pitch changes and voice arrests that often occur during the change, or desire to identify with a female role model. The abnormal pitch may also be the result of the boy's attempt to stabilize the unsteady pitch and quality of the changing vocal mechanism. Other causes of the patient's high pitch such as endocrine problems, hearing loss, or neurological problems should be ruled out and/or addressed. Behavioral treatment is effective in helping the individual lower his pitch and can include laryngeal massage, shaping vegetative vocalizations, and manual compression of the larynx. Counseling or psychotherapy may be helpful for some individuals who are able to lower their FO with voice therapy, but who are strongly resistant to voice change. Botox injection may be used in cases that are unresponsive to voice therapy due to excessive muscular contraction of suprahyoid and/or cricothyroid muscles.

The term transgender describes all persons whose identities, behavior, or dress vary from traditional gender norms, including transsexuals, transgenderists, cross-dressers, and drag queens. The term transsexual refers to individuals whose gender identity is fundamentally in conflict with their biological sex, and who unambiguously identify with the non-natal gender. Transsexuals tend to view sex reassignment surgery (SRS) as the treatment of choice. Often, the surgery is extremely successful in terms of visual appearance, but the person's voice is perceived as masculine in terms of pitch levels, intonational patterns, voice quality, and overall communicative characteristics. A comprehensive evaluation is essential. In the case of a transgendered individual, the case history becomes even more important because of unique concerns involving privacy issues, terminology, evolving treatment goals, and unusual social circumstances. Treatment for individuals wishing to develop a more feminine communication style is multifaceted and may include voice therapy to raise pitch and increase intonational variability, surgery such as cricothyroid approximation, counseling, articulation therapy, assistance with nonverbal communication patterns, and focus on physical appearance.

1. How are self-concept, identity, and personality linked to voice production and vocal self-perception?

2. Explain the role of stress in generating and/or maintaining specific voice disorders.

Preparing for the Praxis

379

3. Compare and contrast primary and seconda mi' symptomatology, and treatment approaches: usc e tenSIOn dysphonia in terms of etiology,

4. Identify and describe similarities and differenc b dysphonia. es etween conversion disorders and functional

S. Why is behavioral voice therap ft fi" . yo en very e fectIve m treating mutational falsetto?

6. Explam the importance of using appro riate te . der identity differences. p rmmology when dealing with clients with gen-

7. ~escribe behavioral and surgical pitch-raisin techni . pItch are important in voice feminization. g ques, and explam why factors other than

. . CASE STUDY 10.1: Mutational Falsetto Directions: Please read the case stud d . of the page. yan answer the five questions that follow. The answers can be found at the bottom

~hilip Gaynes is a 23-year-old college student. He is 6 feet 2 inches tall wei h Ing. However, When he starts talki " g s 21 a pounds, and is very good look-

. . ng, you are startled by the sound of h" ' . weak In Intensity, and hoarse. He reports th t h h IS VOice, which IS extremely high pitched ~ a w en e speaks on the telephon h' II ' emale, and he is sick of it. He wants to kn 'f h " eels Usua y mistaken for a young

ow I t ere IS anything he can do to change his voice 1. Based on the above sympt h . .

oms, t e most likely diagnOSis for Philip is a. mutational falsetto b. conversion disorder

c. muscle tension dysphonia d. functional dysphonia

e. transsexual voice problem

2. The most appropriate way of evaluating Phillip's voice is

a. acoustic analYSis of Fa and electroglottography b. aerodynamic analysis of air pressures and airflows c. pulmonary function testing d. high-speed digital imaging e. all of the above

3. The most appropriate clinical course of action is to

a. refer Phillip to a psychiatrist to determine the ossibilit . b. implement a program of vocal hy . d P y of an underlYing personality disorder

glene an vocal education c. contact Phillip's parents to find out if he h d d a any unusual difficulties . h

. Use natural vocalizations such as cou h' h gOing t rough adolescence e f h g Ing to s ape a lower pitch . none 0 t e above


4. An excessively high pitch such as that exhibited by Phillip may be due to

a. longitudinal tension exerted by the cricothyroid muscles

b. vibration of only the membranous portion of the vocal fold s

c. elevation of the larynx due to excessive contraction of the suprahyoid muscles

d. inappropriately high tongue carriage that affects vocal tract resonance

e. all of the above

5. An appropriate referral for Phillip would be to a

a. psychiatrist

b. physical therapist

c. audiologist

d. gastroenterologist

e. social worker

CASE STUDY 10.2: Transsexual Voice

Directions: Please read the case study and answer the five questions that follow. The answers can be found at the bottom

of the page.

Alexis Carter is a 25-year-old individual who has recently undergone gender reassignment surgery (male to

female). She is happy with the surgery and her new lifestyle as a woman, and she is taking the recommended

hormones. Her voice, however, is creating problems for her, as it still sounds like a male voice. You work at a clinic

that specializes in transsexual voice, and you assure her that there are techniques and strategies that can help to

make her sound more feminine.

1, The term transgender

a. refers to a challenging mental illness best treated by pharmacologic means

b. is a category in the DSM-IV that describes all persons whose identities, behavior, or dress vary from traditional

gender norms

c. should be used exclusively to refer to individuals whose gender identity is fundamentally in conflict with their

biological sex, and who unambiguously identify with the non-natal gender

d. is a synonym for gender dysphoria, gender discordance, gender dissonance, gender discomfort, or gender

incongruence

e. all of the above

2. The fact that Alexis recently underwent sex reassignment surgery means that

a. she is really serious about living her life as a woman

b. she has always dressed as a woman and held traditionally female jobs

c. she probably lived for 1- 2 years as a woman before undergoing the surgery

d. she felt that all other options for a happy life were closed to her unless she had the surgery

e. all of the above

Preparing for the Praxis

381

3. Which .Of the following questions are appropriate for the speech professional to ask Alexis during the evaluation? a. Which name do you prefer to be called?

b. Is this the name to be used for contact outside the clinic?

c. What stage are you in the gender reassignment process? d. What kind of woman do you wish to be? e. all of the above

4. Which of the following treatment goals (if any) is NOT appropriate for Alexis?

a. pushing technique to facilitate a strong falsetto voice b. developing a higher pitch

c. increasing intonational variability

d. developing a slightly breathy voice quality

e. All of the above are appropriate treatment goals.

5. The range of FOs between around 145-165 Hz is called "gender neutral" because

a. it is a range very seldom used by either men or women

b .. m.en who speak in that range sound female, and women who speak in that range sound male c. It IS the range In which the speaker's gender is not identifiable

d. it ~s the range in which different emotions such as happiness, sorrow, and annoyance are neutralized

e. It IS the range that best lends itself to a confidential voice that obscures the person 's gender

Documents

Transgender Voice - COE