Transgender voice is a difference, not a disorder, said Richard Adler, PhD, CCC-SLP, of Minnesota State University, Moorhead. Speech-language pathologists require a high level of cultural competence to work with transgender clients. They also need to be aware that some transgender individuals come for voice and communication therapy and have been diagnosed with a voice disorder by their ENT physician.
"You shouldn't just immediately say, 'Sure, I'll help you.' You really need to understand voice therapy protocols as well as voice evaluation parameters first before agreeing to work with someone who is coming to your clinic for voice and communication therapy as part of their overall transition from male to female (MtF) or female to male (FtM)," advised Dr. Adler, who is a professor of speech, language and hearing sciences and dean of Graduate Studies at the university and an ASHA Fellow.
Speech-language pathologists cannot discriminate in seeing patients for any reason, according to the American Speech-Language-Hearing Association (ASHA) Code of Ethics. Clinicians who don't understand or want to work with clients in the transgender population are obligated to refer them elsewhere.
One of the biggest misunderstandings about people in the transgender community is that the changes they want to make are linked directly to sexual orientation. "For example, people think if you're going from male to female you must be gay," he told ADVANCE. "A majority of MtF clients are not. They're coming from a culture that says, 'I'm different to you and I feel this way.' You don't have to understand this client, but you should be able to at least empathize with the person. After all, you are a speech-language pathologist, and you are there for the client-you must leave your biases and cultural differences behind."
Many of his male-to-female patients are married men who have reached the point where they feel like they have no choice but to go through with the transition. The desire to go from one gender to another has nothing to do with sexual activity and everything to do with the gender that an individual identifies with, often from early childhood.
Transgender individuals often enlist the help of psychologists to help them understand who they really are and find out how far they're willing to go in the transition process. The American Psychological Association uses the term "gender variant" for these individuals.
"Gender variant refers to an expression of gender-masculinity or femininity-that does not conform to the dominant gender norms of our culture," said Dr. Adler. "Your gender identity is totally separate from your sexual orientation."
In the best case scenario, the person's spouse is understanding and accepting and offers a helping hand and guidance throughout the process. On the opposite end of the spectrum, the spouse wants nothing to do with the person, who may need to search for a support system in the transgender community or the general gay, lesbian, bisexual, transgender (GLBT) community.
"They have to be careful who they choose for a support system," said Dr. Adler. This may include their speech-language pathologist, psychologist, psychiatrist and other professionals.
Families generally become more accepting over time, he noted. "About 50 percent get a lot of support from their spouse, family or children. Transgender is a concept that's more in the open than it used to be, but acceptance is still far off in our society, he said.
The workplace also can be a tricky area. When individuals who are transitioning from male to female decide to start coming out at work, they typically start in small steps, like growing their hair longer or wearing clear nail polish. As they become more comfortable, they approach the director of human resources and/or their boss. "Sometimes they're told, 'I don't think you should do this because you could be fired or not totally accepted by your colleagues.' Saying that to a transgender individual unfortunately is legal in many states," said Dr. Adler.
People in the transgender community want to "pass" as a member of their desired gender. In order to achieve this, they have to change not only their voice but nonverbal communication such as how they sit, stand and gesture.
Most people who see Dr. Adler think the only aspect of the voice they need to work on is pitch. While some MtF individuals often have an "androgynous" pitch (140-145 Hz), which makes it difficult at times for the average listener to tell whether the person is male or female, others can bring their pitch into the 180-200 Hz range, which is a very obvious female pitch. It often takes some time to convince a transgender individual that their voice passes as either female or male.
"The person's perception of voice is key," he said. "Someone's pitch might not be acceptable to their ears, but as a professional I will say, 'You will pass. This is an appropriate pitch level and it's perfectly acceptable.' Sometimes it's hard to convince people."
But pitch is only part of the overall package. "While a deep low-pitched voice might give you away, many other vocal parameters must be taken into consideration, such as nonverbal communication, resonance, intonation, volume, rate and articulation. There are certain male and female markers, and we talk about those and work on them," he said. It is not uncommon for patients to tell him that they want to look and sound like a certain celebrity. "I say, 'We'll work on your voice and communication as much as we can, and we'll get you to where you'll be satisfied." Promising a client that he or she will actually "sound" like a particular celebrity would be unethical.
The importance of vocal hygiene during the transition process cannot be overstated. Clients need to achieve their goals without damaging their voice.
One of the main components of good vocal hygiene is breath support for speech and voice production. The focus is on keeping the throat, vocal fold area and larynx in good shape. Dr. Adler usually prescribes herbal tea with honey to soothe the laryngeal tissue area. If the person talks a lot at their job, he recommends that they keep chamomile and honey lozenges on hand in the winter months. They also should drink as much water as possible and avoid anti-histamines, caffeine and smoking. These are drying agents and can lead to unwanted phonotrauma.
"People say, 'I get really tired at the end of the day after practicing what I've learned. My voice gets fatigued.' That's naturally going to happen because you're using your laryngeal muscles in ways you normally don't," he said. He teaches patients how to cough and clear their throats carefully so they don't put extra stress on the vocal folds.
Occasionally, people leave the program because they feel the speech techniques are not working quickly enough. Dr. Adler said an average of one or two weekly sessions for a minimum of six to 12 weeks are needed for clients to see noticeable improvements. He also requires his clients to practice twice daily. "I can't tell people how long it's going to be because they might need more pitch work or some other kind of work," he explained. "I go as fast as I can and make sure I don't harm the vocal folds or the throat."
The local TriState Transgender organization, which serves Minnesota, North Dakota and South Dakota, as well as Manitoba, Canada, offers informal support groups where transgender adults can talk about anything and feel free to be who they are. "For instance, they'll go around the room at the beginning of the meeting and fill everyone in on what happened since the last time they met," said Dr. Adler. "They might say some wonderful things or some really sad things, but it's really helpful because they know that support is there and they can call each other any time they want." Dr. Adler attends these group meetings monthly to offer support and answer questions about voice and communication issues.
The groups that Dr. Adler works with sometimes meet for two hours on Saturdays and interact with people in the community. To practice their voice skills group members may call or go to bookstores, doctor's offices or other local businesses and ask for specific products or go out to lunch and order food. Clients keep journals about their interactions and write about how they are received in person or on the phone.
Both individual and group therapy have their benefits. Individual therapy is useful because the speech-language pathologist can concentrate on specifics and offer tips and new techniques, while group therapy provides encouragement and crucial feedback. In group therapy "they feed on one another" under the supervision of the speech-language pathologist, Dr. Adler said. "Someone who is doing well will say, 'Do this, this is what I've done.' It means a lot to them when it comes from somebody who's in their shoes."
- Adler, R.K., Hirsch, S., Mordaunt, M. (2006). Voice and Communication Therapy for the Transgender/Transsexual Client: A Comprehensive Clinical Guide. San Diego: Plural Publishing Inc.
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Jason Mosheim is a Senior Associate Editor for ADVANCE. He can be contacted at firstname.lastname@example.org.