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 examina tions 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, behav ior, or dress vary from traditional gender norms, including transsexuals, transgenderists, Transgender Voice 367 CHAPTER 10 • Voice Disorders Related to Self and Identity 366 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 TAB L E 10.7 DSM-IV-TR Diagnostic Criteria for Gender Identity Disorder gender side (Gold, 1999). . '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) SEX REASSIGNMENT SURGERY advantages of being the other sex). In c 1 ren, of the following: . ] l ' Despite nonsurgical lifestyle options now open to transgendered people, transsexuals tend d' b . insistence lhal he or sh.e IS, t le t lei seX to view sex reassignment surgery (SRS) as the treatment of choice (Denny, 2004). It has been 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 estimated Lh at arolu,d 1 in 30,000 adult males and 1 in 100,000 adult females elect to undergo . \ 'I oty[ ical masculine c O\lll1g . sex rea signmenl urgery (Levy, 2000). Surgery for changing one's natal gender is not some Ing on y s ere I " 1 make-belIeve play or persistent 3. Strong and persislent preferences for cross-sex ro es \1 thing that is done lightly, and 010 t physicians and psychiatrists require a person to live for fantasies of being the other sex . d astimes of the other sex 1-2 years as a member of the target gender before undergoing the surgery (Verdolini et al., 4. Intense desire to participate in the stereotypICal games an p 2006). Internationally adopted guidelines contain built-in time restraints and safeguards for £ f playmates of the other sex the potential transsexual patient. The first version of this document was published in 1979. 5. Strong pre erence or f' ropriateness in the gender role of that Originally called the Harry Benjamin Guidelines for Standards of Care, the name was changed B. Persistent discomfort with his or her sex or sense 0 mapp in 2001 to the Harry Benjamin International Gender Dysphoria Association's Standards of sex. . h h ical intersex condition. Care for Gender Identity Disorders, 6th Version (February 2001). In 2009 the Harry Benjamin ~'. ~~: ~~::::~::~: ~a::~sc:l~~~:~~;::~\fi:~,tY;istress or impairment in social, occupational, or International Gender Dysphoria Association (HBIGDA) was renamed the World Professional Association for Transgender Health (Cohen-Kettenis & Pfaftlin, 2010). other important areas of functionmg. 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 vari ance throughout the world; diagnostic terminology and ICD-lO classification of gender identity disorders; responsibilities of the mental health professional; aSSessment and treat 2004) The trans gender model views transsexual- cross-dressers, and drag queens (Denny, . If s of human variability rather than as ment of children and adolescents; psychotherapy with adults; requirements for and effects d . nce as natura orm ism and other forms 0 f gen er vana \". an'i researchers have argued lhal gender of hormone therapy for adults; the real-life experience; different forms of surgery includ . d (D 2004) Some c 100CIan5 ( , d' ing sex reassignment surgery, breast surgery, and other cosmetic surgeries (e.g., reduction a mental (llsor er enny, " II . d' t psychialric diagnosis, but rather a me 1- incongruen e hould not aulomahca y mabn ,\ e. dto describe variations in gender thyroid chondroplasty); and post-transition foHow-up. The entire document may be accessed All' 2010) Terms have een f r pose . d at www.wpath.org/publications_standards.cfm. cal Olle (e,g" Ison, .. . f d' 'd e The e include gellder dyspf'lOrw, gell 'r without categorizing them ill terms /0 I'll' 1~0l r. \ or gender incongruence (Allison, 2010; Most individuals who complete sex reassignment surgery are male-to-female transsexu discordance, gender dissonl11'1ce, gem er (, ISCO n '.1 or , als. 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. 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 enllty However, the so-called "trans woman" is often left with a voice that is perceived as masculine, , fl' t ' th their blO OgIC, sex, . I at odds with her new appearance. The person's pitch levels, intonational patterns, voice quality, is fundamentally In co n IC WI . ) Tl . d'y'dual feels strong disc roforl WIll with th Ilon-n, Lal gender (Denny, 2 00~ : le 1-: ~x~ ec l a lion s and attitude thai sO i and overall communicative characteristics often remain in the masculine domain, Mainstream the biological idenUty and ~ e COrr~ S? Ol~ llO g ~, ~d female ge nd~ r s, Lt is nol uncomm n culture does tend to penalize people whose voices do not match their gender, body type, and ety expects in accordance wi th tradltlol1 -l m.a e ' tl the cictal rules for the natal gend.e.r build. This is troublesome to many patients who have undergone the surgery. Reportedly, ' f ' years m aceord ance WI 1 • , r 93% of participants at a transgender conference rated voice as at least somewhat important in fO l' t.he person to Ilve 0 1 I I (MFT) seeking the serVlceS d th I -to-fema e transsexua (Tho rnLOn 2008). In d ee, .e I~ a~ e middle-a ed, married or previou. ly m~r - the transition process, and around 25% rated voice and nonverbal communication as playing a speech-language patholOgIst I. hkely to b G I~ , 19;9' Thornton 2008). It is Iikev,r)se the most important role in the individual's success in "passing" as a female (Johnson, 2008). ried, and the rather of one o~ m, I:e c ~Id.r e. ~ (vee(o~'i,ave I~ad) tradjti ~ nal1y male-oriented Many trans women turn to speech-language therapists for help in achieving a more femi 110t unu ual for Ln\nssexual tndlVLdu s to lad . tb" lUlTltarv r have workecl in law en- nine voice. Clinicians working with this population are faced with some unique challenges. A . If 1999) Many have serve LJ1.! I . . 'd , I's clinician may be reluctant to work with a transgender client for moral, ethical, and/or religious rea occupatIOns (Ge er, . ' . e t ically mascuJi.ne field. The mdiVl U3 forcement, constructIOn, or some ~theI ster :r: ress the ender dysphoria (Brown & sons, yet ASHA's Principles of Ethics state that all clients must be treated with respect. Clinicians masculine lifestyle may represent hiS attempt tOkSt~P and ma~ lecide to lll1dergo surgica l need to be aware of their own biases and perspectives and take care that these do not negatively ee ROlll1s1ey, (996) . Eve~ tu a\l )' lhe p,e rso~ mait r~~e~s of ch an ging one' gender is a L ng impact the therapeutic process. Speech-language pathologists must ensure that they are familiar procedures f r changmg gender Iden Ity. k 1e ~ s and involves stages f counseling an~ with the guidelines for treatment of all transgendered clients and are cognizant of appropriate gen and challenging o ~ e, The process m;YI ta e ye;rgender enduring the surge ry ilsell', [\1' der terminology. Table 10.8 provides terminology currently used in the transgender community. psych therapy, UV1I1 g as :l person 0 Ile large , 368 CHAPTER 10 • Voice Disorders Related to Self and Identity Transgender Voice 369
TAB L E 10,8 Terminology Related to Sexual Orientation TABLE 10.9 C H' and Gender Identity Disorder ase .story Questions Pertaining to Transgender and/or Transsexual Clients TERM DEFINITION Gender Role Information Gender identity Diagnostic category referring to individuals with a strong and persistent disorder cross-gender identification Which name do you prefer to be called? Is this the name t b d C Queer Umbrella term that includes gender identities and sexual orienta o e use tor contact outside the clinic? tions and applies to anyone who does not identify as straight/gender What stage are you' th d In e gen er reaSSignment process? normative :ow o;ten do you present yourself as male? (estimate percentage of time) Sexual orientation (SO) External, sexual attraction to others; spectrum from straight ow 0 ten do you present yourself as female? (estim t to bisexual to gay (Queer SO) Ar d' . a e percentage of time) e you un ergolng hormone treatment? Gender identity (GI) Internal, perception of self; spectrum from male to androgynous to Are d h female (Queer GI) you un er t e care of a mental health specialist? Cisgender Gender identity consistent with the gender one is identified as at birth Do you plan to transition to full-time immersion in th f, I I If so, when? e ema e ro e? Transgender 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 What kind of woman do you wish to be? gender transition How SUppor t'Ive are your friends, colleagues, and family? Transsexual An individual who desires to live full-time in the opposite gender; describes a person whose external genital anatomy has been changed to Voice Information resemble that of the opposite sex :ow ;OUld you rate your present female voice? (poor, fair, good, excellent) Cross-dresser Individual who identifies on the gender spectrum but who does not ow 0 ot h ers react to your female voice? (transvestite) wish to fully transition and presents as the opposite gender less than halftime 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) Transition The process one goes through to live as the opposite gender How' , , , ge rom your male to female voice? Important IS a femlnll1e voice to you? (not at all h Gender community Cultural group where gender roles are not strictly defined Wh t ,somew at, very) by anatomical physical attributes a are your goals for voice therapy?
Passing Ability of a TG or TS individual to be perceived by others as belonging SOllrces: 'n(ofma.lloll from IJroll'n el nJ (2 ), ' Momn CI 31. (200$) • 000, DacakIs (2006); Gelfer (1999) ' Johnson (2008) K' to the target gender group , , , ; mg et al. (1999);
Sources: Information from Johnson (2008); King 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 EVALUATION to be called and whether this is als' tJ , d ask the clien t whkh name be/she prefers 2006; J 999; bnson 200S )o r, ed for conta cL ol:llside the cJjnic (Dacakis As with any voice disorder a comprehensive evaluation is essential. In the case of a transgen eifel', J loer l:ann:e tl~ ~)de 1I ' 1 I". 11" ' , l'« me: IVl . U'U who" t, ", , • dered individual, the case history becomes even more important because of unique concerns 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 ma le and female versions of hl"s/ involving privacy issues, terminology, evolving treatment goals, and unusual social circum , ' ,l • 1111 portanl lOr the eli ' , stances (King, Lindstedt, & Jensen, 1999). Table 10.9 presents questions pertaining specifi name and the appropriate personal 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, cally to transgenderltranssexual clients that should be incorporated in the overall case history , d' S e eva uator sbould 1' " " f' , reg If mg wllere lhe indivl'd ual' , 1 e Ie It III ormation F/'Om th e cJjeJlt interview. , d " ' IS 111 t l C gender re -' In order to establi -h professional redibllity, trust, and rapport with the client, the un crgo rng hormone lreatment, and whelbeJ" he/she i ~ssignmellt pro ess, whether he/she is speech-language path logist must demonstrate a high level of pragmatic appropriateness dur mental heallh profeSSional (Geller 1999) TI ' d" S wlder the CaJ'C of a psycJtia lrist Or oth r ing the initial interview. ongoing evaluation. and the entire therapeutic process. When dealing degree of Uppc)I'[ he/she is l'eCeivil;g or is·I'k 1~ III IVla~lal shoul d be questi oned regarding the ( clfer, 1999; f(jng et al.. 1999) The lev J 'f ~ Y to re~c l ve fr rn fami ly, G'iends, and co fleaglles , , e 0 support IQ the client's everyday en vi 1'011111 'nL can 370 CHAPTER 10 • Voice Disorders Related to Self and Identity Transgender Voice
371 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 al.h l i~lc r eased Use oj' to uch (Parker, 2008) A " . . the new voice (Johnson, 2008), what percentage of time he/she is currently living as a woman, J1 lca tlOn work is for ,he el i at' to spend u' g~() d 1;~rutIl11 I JnUor gencler-spe ifr com rn u and when he/she plans to make the transition to full-time immersion in the female role. It is age, cu lture, ,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 ' likely that as the individual transitions from a more masculine role to a more feminine role, the gen er- pecin work begins, allY exis ling d . I . 0 II on, -0 8). Howev r, before an}' communication situations in his/her environment will change, signaling the need for ongoing be trent 'el (Th rn l 11 , 2008), and any l11e d i!a~P lO~~ ,. ajl d vocally tnmma tic hchavi J'S must communication assessment and evaluation (Dacakis, 2006; King et al., 1999). be addressed. con IIJon . such as GERD or ll 11 ergi S sbou ld 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 Voice Thel·apy. Behaviora l voi e them ' la .' , feminine voice will sound like (Gelfer, 1999). This could jeopardize the therapeutic process develop a percepillally more fe min i Il e ;'~j:e «~~d\~ Il,IC~ P~l't. in help ing lb e trans spea ker and negatively impact the person's perception of therapeutic success. The client's perspec ! herapy fo.eu es not nly 0.0 ra ising pit h but on (eU ' I ~ .el?ll1lJ ne c . m l~ u nka li n patterns. ZU1 tive regarding what kind of woman she wishes to be is another important issue, as many of :eson3nce, rn lon<1 lional patterns, arti cul ator I att r ,l1l 111 I g ~h e ellen l S VOCR!. quality and the verbal and nonverbal behaviors suggested in the literature for transsexual clients reflect a IS also empl) aS ized <1 ' the individu allea m / p .Ils. and no n, verbal gc, ltl res. Voca l hycriene female stereotype, which is rejected by many modern women but forms the target for some laryngeal strai n or vocal hype l'ful1eti n (T ':b~e ~~ ~ ~ ~~ ~ e and l1l <1 ll1t ai n the targct pitch wi ~'01l1 clients (Moran, Hague, & Roper, 2008). In addition to specific items related to transgender issues the client's medical history Pitch. FO is the most salient cue to ender iden ' . should be explored. Particular attention should be paid to conditions that may affect the voice, biological men and women (Gelfer &gM 'k 200 hficatlOn for trans speakers as well as for such as a history of GERD, any neurological problems, cardiac problems, hearing difficul has typically been targeted as the most ' lOS, 5), Therefore, raising the individual's pitch Important goal of treatment. Research has established ties, 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. TAB L E 10.10 Feminizing Strategies for Trans Speakers As with all individuals who present for voice therapy, the speech-language patholo FO and Pitch gist should determine the client's level of daily vocal usage, vocal technique, vocal needs, and Determine target PO level 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. Es~ablish a star~ing PO slightly above the male habitual pitch An individual may have tried to raise pitch by using excessive laryngeal tension, thereby creat RaIse PO levels In small increments while maintaining good voice ' ing the conditions for a possible MTD (Brown, Perry, Cheesman, & Pring, 2000). Quality of Begin each PO level with isolated vo I d qualIty and appropriate intonation life questionnaires such as the VHI are an important means of gaining insight into the impact , . we s an progress to longer utterances PractIce USIng each new PO level in different phon t' of the client's voice on his/her everyday life. U e IC contexts and with v ' , se more upward pitch inflectio d f, . aryIng Intonational patterns In addition to the extensive case history, the client should undergo laryngeal examination ns an ewer downward pitch inflections by an otolaryngologist to rule out any laryngeal abnormalities of structure or function. Acoustic Voice Quality analysis is also a critical part of the assessment process. It is important to determine the client's Eliminate glottal fry and hard glottal attacks 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 Avoid falsetto register program is helpful in documenting the person's habitual average fundamental frequency in Use a slightly breathy quality sustained phonation, reading, and spontaneous speech. Use a resonant forward focus Articulation TREATMENT Use more anterior ton I Treatment for individuals wishing to develop a more feminine communication style is Use light and more pr~~:ePa:t~::::;;~:~::c::reading to raise formant frequenCies multifaceted and may include voice therapy, surgery, counseling, articulation therapy, assis tance with nonverbal communication patterns, and focus on physical appearance. The goal Paralinguistic and Nonverbal of treatment is to emphasize and highlight the markers of female speech. Markers include Use feminine nonverbal patterns such as increased e e contact a a higher pitch, greater intonational range and pitch variability, increased vocal expression, Increase use of tags at the end of utterances Y nd use of gestures 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 373 CHAPTER 10 • Voice Disorders Rel ated to Self and Identity 372 than the female, and the male pharynx is proportionally larger than the female (Rammage 1 . I seal crs are perceived as male and above et aI., 2001). The male vocal tract resonates more strongly to lower frequencies while the a cutoff;O [nroun.d 150-17 Hz, b 'low wB~C 1 ~; .y' heesl11an, & Pdng, 2000; Gelfcr & . da. tCl11a le(eg lown, .ren, . female vocal tract resonates to higher frequencies. These formant fr equency differences also wh ich speaker arc perceive ,s. .' ., N rthro), 1990). The range bet ween approXl- contribute to the perception of a person's voice as m ale or female (Gelfer & Schofield, 2000; Schotleld, 2000; Wolfe, Rattl sml , Snulh, & °FO zO:le 'io which the s eal: ef's gender is not Rammage et al., 2001). The first formant frequency (F1) is related to tongue height and the mutely 14"- 165 l iz fonns a ge~der ~ alUbl~~~8) This zone forms the initial target for pitch identifiable (MordalUlt, 2006; rhornton, . 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, & raising exercises. " FO level as dose as possible to that f . t" to acb leve a 111C,1I1 ' . Oates, 2007). Teaching the speaker to articulate with the tongue in a more forward posi 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 tion raises F2 frequency and may facilitate the perception of a "thinner" and more feminine adul. l female speakers. W uc' ypl . . '·aL' ta"gel tbattilkes II1to ace unt \le • . 1 I ' i,t lunmg an appropl l' e • voice (Gorham-Rowan & Morris, 2006; T hornton, 2008). Teac.hing the clien t to Lalk wi th lips raising Ll1e client S pItch ~ve IS ~ ~ er,l ' . u t' oses. Pilch ,ra ising protocol typical1ye t, b- slightly spread can ra L~e F3 ( arew et aI. , 2007). arew ct a l. (2007) reported U1at the com speal er's ~\bi l ity to vary pilch [01 \n fl ecbonal P P . ductions of v wels or nasal consonantl bination of increased forward tongue carriage and increased use of lip spreacling n t only lish a startil1g FO by having the cUcnL pTo~~ce ~~sy P:~at a frequency slightly above t11e speak increased formant value, but ill addition had the effect of rai ing FO by up to 30 Hz. Percep voweJ c · mbinali us such as /al ,./ma/, 01 un: mro 2006) The client is p~'ov i ded a model of GeHer 1999' M I dallnt, . f lb I tual ratings of femininity of voice following treatment increased for 70% of participants, and er's typical male Ieve I (e.g., , . , 1 .hc instrumentati.on for visual eel ac < 't Most pro LoCO S lise acOUSu . d participant self-ratings of both satisfaction and femininity of voice were significantly higher a light. clea.r voca I qu,al I y. . 1 WI, Lh eli nl becomes abl.e to hablluale ,)11 . d"f, . audilory fee db ac L~. !1.el1 e · "d . t after treatment (Carew et al., 2007). 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 . . the 1evel ll1 lJ)crements 0, . . Intonation. Pitch range and variability are aspects of intonation that are strong markers of (2006) recontmcn d e d raising ' . I " the 11 igh er level in different sllllalt ns I I . uah ty IS ab e Lo use . 1 gender identity. Female speakers typicaUy liS a wider range of FO and n more varied pattern maintains an acceptil) e vmce q L' e the u ward intonational pallerns lhat give t.)e f pitch infiecti n , while male speakers tend to use a more reslricted FO rang and fewer an d wiLh prtch level1llust anow lbe speaker to vat'yi~g l ~ ll ?neSS ~~:e~s~~~~dfi:;~ ~~Sired ensl 1 ~ in ft ecti nal patterns (Ferrand & Bloom, 1996). Sludies hnve demon trated thaI trans speak speech a more leml\11ne qua It).. . \ . OSC$ As the client conlinue t progress ers voice iden till d as female ,u'e ch ara terized by more pi tch inHeclions b th upward and access the upper pitch ranges for l\1tolnlaLJoJll~:'~aI 1PI Y be' g'illS with isolated vow.cis, extending . hi 1 . fce aI' ea 1 eve 'I. K ' · . chI \ down ward, less extensive downward shift., CHAPTER 10 • Voice Disorders Related to Self and Identity 374 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 maintained more than a year after therapy, although not at the level attained immediately after tolward th e fema le size range. Glottopla v.oc,,1 th u slill'ring the v ca l s Lerm I yefla~( 1 ,1~a.lllent , n! IreaLmen t (pretesLSFF 11 HI'.• posHest 178 Hz, long- DS Hz). t lC postsurgica" ' l CTA mea n 0 f approximate( 1OWlI1g58 H CIA was .rep rte (It 0 'Incr ease FO from There is retnllve1y strong consensuS among experts as \'0 recommended approathes lo .appl, I oX ll11atcJy 20 H ing from eTA ranging from 16 to 13 1 Hz (e. g., Brown et a1., 2000; Debruyne, De Jong, & TREATMENT PRETHERAPY Pos - OllOW-UP sterlinck. 1995; De Tong & Norbarl, 1996; Kanagalingam et a1.. 2005; Kocak et a1., 2009; Dacakis (2000) Voice therapy 125 Hz 168 Hz 146 Hz Neuman, Welzel, & Berghaus, 2002). The advantages of T A include th lower degree of effort for th. patienllo keep up Lhe Carew et al. (2007) Oral resonance 119 Hz 133 Hz high FO and the rise or the lowest pitch level (Soderpalm eta\., 2004). However, complicali ns therapy have been repolted in luding decrea ea vocal range, decreased dynamiC range and 10lldness, Gross (1999) Surgery 117 Hz 201 Hz and worsened vocal quality (e.g., Netunann & Welzel; 2004; Spiegel, 2006). Mayer & Gelfer (2008) Voice therapy 119 Hz 178 Hz 138 Hz Brown et al. (2000) Surgery 142 Hz 174 Hz 185 Hz 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 Yang et al. (2002) Surgery 133 Hz 185 Hz and reducing the vibrating P rtion in rder to rai e the FO. La er-a isled anterior commiS Van Borsel et aL (2008) Surgery 118 Hz 169 Hz sure placalion is de.signcd. to create a web between the anterior edges of the v cal fo ld , The Neumann & Welzel (2004) Surgery plus voice 117 Hz 155 Hz 162 Hz mucosal lining of the anterior quarter of lhe i Ids is vaporized with a 0 1 laser, and the therapy denuded folds are sutured together (Rammage et al., 2001). A similar technique, called el'l Kocak et aL (2009) Surgery 158 HZ 203 Hz (post • ,,"'pi, "",I fold sn'" en ing, was described by Gro. (1999). roSS (1999) pre"n"d re.ul~ (post CTA) glottoplasty) demonstrating not only an average increase of 9.2 s 111itones in piLCh, but also a r ductionr Remade et al. (2011) Surgery ISO Hz 194 Hz in range in the lower frequencies. lotto-plasty is another techniql\e that involves ulu - ins th, d"pith,I/.""d ,n' 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 1. How are self-concept, identity, and personality linked to voice production and vocal . Use natural vocalizations such as cou h' h gOing t rough adolescence e f h g Ing to s ape a lower pitch self-perception? . none 0 t e above 2. Explain the role of stress in generating and/or maintaining specific voice disorders. 380 CHAPTER 10 • Voice Disorders Related to Self and Identity Preparing for the Praxis 381 4. An excessively high pitch such as that exhibited by Phillip may be due to 3. Which .Of the following questions are appropriate for the speech professional to ask Alexis during the evaluation? a. longitudinal tension exerted by the cricothyroid muscles a. Which name do you prefer to be called? b. vibration of only the membranous portion of the vocal folds b. Is this the name to be used for contact outside the clinic? c. elevation of the larynx due to excessive contraction of the suprahyoid muscles c. What stage are you in the gender reassignment process? d. inappropri ately high tongue carriage that affects vocal tract resonance d. What kind of woman do you wish to be? e. all of the above e. all of the above 5. An appropriate referral for Phillip would be to a 4. Which of the following treatment goals (if any) is NOT appropriate for Alexis? a. psychiatrist a. pushing technique to facilitate a strong falsetto voice b. physical therapist b. developing a higher pitch audiologist c. c. increasing intonational variability d. gastroenterologist d. developing a slightly breathy voice quality e. social worker e. All of the above are appropriate treatment goals. CASE STUDY 10.2: Transsexual Voice 5. The range of FOs between around 145-165 Hz is called "gender neutral" because Directions: Please read the case study and answer the five questions that follow. The answers can be found at the bottom a. it is a range very seldom used by either men or women of the page. b ..m .en who speak in that rang e sound female, and women who speak in that range sound male Alexis Carter is a 25-year-old individual who has recently undergone gender reassignment surgery (male to c. It IS the range In which the speaker's gender is not identifiable female). She is happy with the surgery and her new lifestyle as a woman, and she is taking the recommended d. it ~s the range in which different emotions such as happiness, sorrow, and annoyance are neutralized hormones. Her voice, however, is creating problems for her, as it still sounds like a male voice. You work at a clinic e. It IS the range that best lends itself to a confidential voice that obscures the person's gender 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