Vol. 15 Issue 24
Feminization of Voice and Communication
Therapy for transgender clients
Transgender individuals face numerous challenges when they undergo a gender identity transition, and speech-language pathologists can play a crucial role in this process.
Voice therapy for a transgender client does not revolve solely around pitch and voice, according to Michelle Mordaunt, MS, CCC-SLP, a private practitioner based in Seattle, WA, and formerly a clinical lecturer in the Department of Speech and Hearing Sciences at the University of Washington (UW) in Seattle. "It really is total communication," she told ADVANCE.
Mordaunt designed and developed the group and individual therapy program for male-to-female (MTF) clients at the UW Speech & Hearing Clinic. A primary aim of group therapy is to view the client as a whole and target nonverbal communication, lexical features and vocabulary choice in addition to the voice.
"A woman's voice is not just a higher male voice," she said. "Changing the voice is not just talking in a higher pitch."
The primary goal of an MTF client is to be experienced as female, according to Connie Dugan, MA, CCC-SLP, a private practitioner in Chicago, IL. "And that's my goal, too."
"It's a very important safety issue because people in the transgender population are often terribly mistreated," said Dugan, who leads a volunteer voice therapy group for transgender clients at the Howard Brown Health Center in Chicago. "If they are appearing as women, it's important that they are convincing."
Group and individual therapy helps clients target their overall voice and feminine communication needs. This type of therapy is particularly well suited to the skills of the speech-language pathologist, said Dugan. "Our natural and highly honed skill is to build a hierarchy of difficulty for our clients, whether it's stuttering, articulation, swallowing or feminine communication style."
The group therapy model utilized by the UW Speech & Hearing Clinic serves as an introduction to the voice therapy approach at the university and lets clients know the detailed and involved nature of the voice feminization process as a whole.
"It gives them a sense of what to expect from individual therapy and is a prerequisite for individual therapy at our clinic," Mordaunt explained.
The UW group generally consists of five or six clients. Targeted topics include vocal hygiene, resonance, intonation, lexical features, nonverbal communication and pitch range.
"Putting it all together in a very natural, convincing way allows a person to be perceived as feminine or at least gender ambiguous," she said.
The sessions are led by graduate students and supervised by a clinical instructor. The group model benefits clinicians by allowing them to observe how patients communicate in therapy and allows them to gauge client expectations and how receptive a client is to feedback.
"At the end of group, we want them to be able to come away with a place they can practice because there usually is a waiting time between group and individual therapy," she said.
Though some individuals may come to group focused solely on changing pitch, many clients have a broad understanding of the voice/communication feminization process, Mordaunt said. "Through experience, they have found that just making their male voice higher is not working. They recognize that just changing pitch isn't enough."
Clients who enjoy the most success in group therapy tend to be those who have no preconceived notion of pitcha "clean slate" approach.
Clients who come to the clinic speaking in an artificially high voice can create more work for themselves and their clinician, she said. "It's almost like we have to undo a bad habit and replace it with a new one."
When a client begins individual therapy, Dugan initially focuses on vocal stamina. When people first start to change their vocal style, they can fatigue easily. It's important to build up their endurance gradually so they don't harm the vocal folds.
Once her client understands the importance of vocal stamina, she gradually begins working on other areas, such as pitch and resonance. She continues to reinforce endurance and vocal stamina throughout the course of therapy.
A large part of voice therapy centers on inflection, which is key to a convincing feminine presentation, Dugan said. "In American English, men tend to emphasize loudness in their speech, while women tend to put more emphasis on pitch change. It's the ups and downs and the music of the language that read as feminine."
To help clients achieve feminine inflection, she uses single-word drills and adapts exercises from teaching materials for accent modification that focus on individual words.
"Single-syllable words tend to have a glide in them," she said, citing the word "home" as an example. "It sounds much more feminine, and there's much more melody."
One of the most valuable tools for patient learning in group therapy is doing the homework assigned each week. Mordaunt provides patients with homework packets that correspond to the voice therapy topic the group is addressing that week. She requests that patients do their homework exercises at least once a day for five days a week. Patients then evaluate their practice in a journal and discuss their progress at the next group session.
"There's an increasing awareness of their voice production," she said. "A lot of what group is is increasing their awareness of what they can do."
Dugan records a tape for clients to use for practice between sessions.
"I'm only with them for a short time, and they need a lot of practice to make this change," she said.
Another important area of therapy is alerting clients to the difference in lexicon between the genders. The words commonly used by men and women are different, she explained. Women tend to use more "feeling" words, such as "lovely." Dugan will emphasize the differences in male and female language and word usage to clients in therapy.
"For example, in the United States it's very unusual to hear a man say 'lovely,' so I tell my ladies that that is not a 'guy' word," she said.
Dugan tries to use therapy activities that are socially beneficial to clients but keep the nature of the therapy "playful." She often incorporates sociolinguistics into therapy sessions.
"We may pass around pictures and talk about how a woman would describe the picture," she explained. "Then we do negative practice and talk about how a guy might describe it. Women give women a lot more compliments than women give men, so we also practice complimenting each other."
In addition to employing voice therapy techniques, Mordaunt emphasizes the importance of nonverbal communication in voice/communication feminization. Focusing on nonverbal communication is especially helpful for clients who are struggling with verbal communication.
"Nonverbal communication doesn't involve the voice, which tends to give away the client with the 110 Hz voice," she said. "Therefore, working on nonverbal communication can be safer, but it's not easy; and successful nonverbal communication can't always be accomplished right away."
She cautioned that clients still must learn how to differentiate between the gestures, posture and facial expressions of men and women. They also must learn how to implement feminine aspects of nonverbal communication as well as understand when and why they are used.
She urges clients to go to the mall and observe how women and men talk to one another, how men talk to each other, how women talk to each other, and how women talk to children. Clients compare and contrast the gestures and facial expressions of people and record the observations in a journal.
One client adopted a higher pitch when talking to men. Despite recognizing the problem, the client was unable to control it.
"She gets a lot of falsetto intonation, and it's really artificial," Mordaunt said. "But when she talks to me, she talks almost in her male pitch."
She asked the client to think about why she changed her pitch when she communicated with men and if she could find some kind of nonverbal communication that would have the same impact, such as leaning forward or placing a hand on the person's shoulder or forearm.
"If you shake someone's hand, usually you just use one hand," she explained. "But if you put one hand on top of it, it's more endearing, comforting and personal. A lot of people don't do that unless they really are genuinely involved. Those are things that are very difficult for clients to look at and implement."
Dugan emphasizes the importance of hand gestures and facial expressions to clients during therapy by calling attention to their actions. "If they make a gesture that looks feminine to me, I tell them it looked fantastic and read as completely feminine," she said.
She uses cards with emotions written on them to help clients practice facial expression and then acts out the emotions with them.
"Women make a lot more expression with their whole face, while men tend to make a lot more facial expression below the nose, so we work on that," she said. "We work on the whole face."
Speech-language pathologists who work with MTF clients need to be aware of the specific needs of the transgender population, Mordaunt said. "This is a clientele that has gone through a lot in their life. Not that other clients haven't, but there's a lot of sensitivity to what you're doing."
The voice often is the last thing MTF clients are changing about themselves, and it usually is one of the most difficult, she noted. "I've had more than one client tell me that it's the most difficult part [of the process]. Everything else is 'do this, go to a surgeon, have plastic surgery here.' The voice is not that easy, but there is a fix for it. Voice is process, and there's an actual effort to make a change. The voice is like a blueprint of who we are."
She always seeks the permission of clients to contact their counselor or psychologist to keep them abreast of their progress and any emotional issues that may arise.
"It's a very emotional process," Mordaunt said. "As speech-language pathologists, we have the counseling skills; but at some point we need help to get clients through what is a very emotional thing for them."
It also is vital for speech-language pathologists to perceive the clients as they perceive themselves, Dugan said. "If you were in a room with my ladies, you would spiritually feel that they were women. Let them tell you who they are. I see them as women, and they feel like women."
For More Information
• Connie Dugan, online: www.conniedugan.com
• University of Washington Speech and Hearing Clinic, online: http://www.depts.washington.edu/sphsc/clinic_about.htm
Alyssa Banotai is an Assistant Editor at ADVANCE. She can be reached at firstname.lastname@example.org.