Long-term Acoustic Effects of Gender-Affirming Voice Training in Transgender Women.

OBJECTIVES: One role of a speech-language pathologist (SLP) is to help transgender clients in developing a healthy, gender-congruent communication. Transgender women frequently approach SLPs to train their voices to sound more feminine, however, long-term acoustic effects of the training needs to be rigorously examined in effectiveness studies. The aim of this study was to investigate the long-term effects (follow-up 1: 3months and follow-up 2: 1year after last session) of gender-affirming voice training for transgender women, in terms of acoustic parameters. STUDY DESIGN: This study was a randomized sham-controlled trial with a cross-over design. METHODS: Twenty-six transgender women were included for follow-up 1 and 18 for follow-up 2. All participants received 14weeks of gender-affirming voice training (4weeks sham training, 10weeks of voice feminization training: 5weeks pitch elevation training and 5weeks articulation-resonance training), but in a different order. Speech samples were recorded with Praat at four different time points (pre, post, follow-up 1, follow-up 2). Acoustic analysis included fo of sustained vowel /a:/, reading and spontaneous speech. Formant frequencies (F1-F2-F3) of vowels /a/, /i/, and /u/ were determined and vowel space was calculated. A linear mixed model was used to compare the acoustic voice measurements between measurements (pre - post, pre - follow-up 1, pre - follow-up 2, post - follow-up 1, post - follow-up 2, follow-up 1 - follow-up 2). RESULTS: Most of the fo measurements and formant frequencies that increased immediately after the intervention, were stable at both follow-up measurements. The median fo during the sustained vowel, reading and spontaneous speech stayed increased at both follow-ups compared to the pre-measurement. However, a decrease of 16 Hz/1.7 ST (reading) and 12 Hz/1.5 ST (spontaneous speech) was detected between the post-measurement (169 Hz for reading, 144 Hz for spontaneous speech) and 1year after the last session (153 Hz and 132 Hz, respectively). The lower limit of fo did not change during reading and spontaneous speech, both directly after the intervention and during both follow-ups. F1-2 of vowel /a/ and the vowel space increased after the intervention and both follow-ups. Individual analyses showed that more aspects should be controlled after the intervention, such as exercises that were performed at home, or the duration of extra gender-affirming voice training sessions. CONCLUSIONS: After 10 sessions of voice feminization training and follow-up measurements after 3months and 1year, stable increases were found for some formant frequencies and fo measurements, but not all of them. More time should be spent on increasing the fifth percentile of fo, as the lower limit of fo also contributes to the perception of more feminine voice.

Effect of a Group-Based Narrative Language Training in Typically Developing Turkish-Dutch Children.

INTRODUCTION: Due to the heterogeneity in language trajectories and differences in language exposure, a lot of bilingual children could use some extra support for the acquisition of the school language to reduce the risk of language problems and learning difficulties. Enhancing bilingual children's narrative abilities in the school language could be an efficient approach to advance the general school language abilities as well. Therefore, this study aimed to investigate whether a narrative intervention could improve both general and narrative school language abilities of typically developing bilingual (Turkish-Dutch) children. METHODS: Nineteen Turkish-Dutch bilingual children (6-9.9 years) were enrolled in this single-arm early efficacy study. The intervention procedure was administered in the school language (Dutch) and based on a test-teach-retest principle with two baseline measurements. At baseline 1, the expressive, receptive, and narrative language abilities were determined. The second baseline measurement consisted of a second measurement of the narrative abilities. Subsequently, a weekly 1-h group-based intervention was implemented during 10 sessions. After the intervention phase, the expressive, receptive, and narrative language abilities were tested again. RESULTS: After the intervention, the children produced significantly more story structure elements compared to both baseline measurements. No significant differences were found for microstructure narrative measures. The participants had significantly higher scores on the expressive and receptive language measurements post-intervention. CONCLUSION: These findings suggest that the intervention could be an efficient approach to stimulate the second language development of bilingual children.

Attitudes of Teachers toward Multilingualism, Heritage Language Maintenance, and Second Language Learning at School.

INTRODUCTION: Providing an adapted language input in a multicultural classroom is often challenging to educators. Teachers are frequently the parents' first contacts for language counseling and educational support, and therefore, they may influence the language exposure not only in the classroom but at home as well. This study aimed to investigate the cognitive, emotional, and behavioral attitudes of teachers toward multilingualism in Flanders. The effects of contextual teacher- and school-related properties on the attitudes of teachers were also considered. METHODS: An online survey questioning the cognitive, emotional, and behavioral attitudes of teachers was developed and distributed to all schools in Flanders. 710 preschool, primary, and secondary teachers completed the questionnaire. RESULTS: The results showed rather positive attitudes toward heritage language maintenance and multilingualism. However, there are still some misconceptions about multilingual language learning strategies. Teachers are interested in extra training, as they find it hard to use the languages of their pupils as a resource in their teaching practice. DISCUSSION: Teachers mostly consider multilingualism an added value. Supplementary training and extra advice given by speech-language therapists could be helpful to inform teachers about the importance of their students' proficiency in the heritage language and could give teachers insight into the principles of second language acquisition.

Short-Term Acoustic Effects of Speech Therapy in Transgender Women: A Randomized Controlled Trial.

PURPOSE: This study measured and compared the acoustic short-term effects of pitch elevation training (PET) and articulation-resonance training (ART) and the combination of both programs, in transgender women. METHOD: A randomized controlled study with cross-over design was used. Thirty transgender women were included and received 14 weeks of speech training. All participants started with 4 weeks of sham training; after which they were randomly assigned to one of two groups: One group continued with PET (5 weeks), followed by ART (5 weeks); the second group received both trainings in opposite order. Participants were recorded 4 times, in between the training blocks: pre, post 1 (after sham), post 2 (after training 1), and post 3 (after training 2). Speech samples included a sustained vowel, continuous speech during reading, and spontaneous speech and were analyzed using Praat software. Fundamental frequency (f o), intensity, voice range profile, vowel formant frequencies (F 1-2-3-4-5 of /a/-/i/-/u/), formant contrasts, vowel space, and vocal quality (Acoustic Voice Quality Index) were determined. RESULTS AND CONCLUSIONS: Fundamental frequencies increased after both the PET and ART program, with a higher increase after PET. The combination of both interventions showed a mean increase of the f o of 49 Hz during a sustained vowel, 49 Hz during reading, and 29 Hz during spontaneous speech. However, the lower limit (percentile 5) of the f o during spontaneous speech did not change. Higher values were detected for F 1-2 of /a/, F 3 of /u/, and vowel space after PET and ART separately. F 1-2-3 of /a/, F 1-3-4 of /u/, vowel space, and formant contrasts increased after the combination of PET and ART; hence, the combination induced more increases in formant frequencies. Intensity and voice quality measurements did not change. No order effect was detected; that is, starting with PET or ART did not change the outcome.

Voice Quality of Choir Singers and the Effect of a Performance on the Voice.

BACKGROUND: The voice use of choir singers is understudied despite the imbalance of high vocal demands versus low vocal education, and consequently increased risk for voice problems. Also, there is a lack of information on the effects of a performance on choristers' voices. Available studies included performances of at least one hour. To date, no studies investigated the effects of a choir performance with a duration resembling vocal warm-ups. PURPOSE: The first purpose of this study was to determine the voice quality, capacities, symptoms and voice-related quality of life of choir singers. Secondly, the effect of a short choir performance, resembling warm-up duration (15 minutes), on the choristers' voices was investigated. METHODS: A randomized controlled trial was used. Thirty adult choir singers (25 women, 5 men; mean age: 32 years) were assigned randomly to an experimental group or a control group. Participants in the experimental group sung in choir for 15 minutes immediately after their pre voice assessment, whereas the control group was instructed to have standard voice use (one-on-one conversation with the investigator, no singing) across that time span. A second voice assessment was repeated afterwards. RESULTS: The choir singers showed excellent voice quality and capacities with mean scores on the Dysphonia Severity Index and Acoustic Voice Quality Index of 7.5 and 2.0, respectively. Auditory-perceptually, the mean grade score was 5/100 corresponding with a normal to mildly deviant voice quality. Patient-reported outcome measures showed mean deviant scores, indicating a considerable singing voice handicap. The choir singers seem vulnerable for stress with a high occurrence rate of 76.7% (23/30). Compared with the control group, the Dysphonia Severity Index significantly improved, whereas the self-perceived presence of vocal fatigue and complaints increased after 15 minutes of choir singing. Fundamental frequency increased in both groups, being more outspoken in the experimental group. CONCLUSIONS: Choir singers show excellent voice quality and capacities, that further improve after a short choir performance of 15 minutes. Vocal fatigue and complaints, on the other hand, already increased after that short time span. Realizing that vocal load is much higher in real-life rehearsals, competitions and performances, choristers deserve and need a qualitative voice training and a strict follow-up. Future research should focus on effective vocal warm-up and cool-down programs for this population.

Vocal Quality After a Performance in Actors Compared to Dancers.

STATE OF THE ART: Theater actors are a high risk group for developing voice disorders. AIMS: The first purpose of this study was to examine and compare the objective and subjective vocal quality between professional theater actors, non-professional theater actors and a control group of professional dancers. Secondly, the impact of one theater performance on the objective and subjective vocal quality was investigated within and between the groups. It is hypothesized that actors will experience vocal fatigue and a deteriorated vocal quality compared with dancers as a result of the vocal load during the performance. Dancers will face more general fatigue and smaller vocal changes due to the impact of a performance including stress, decompensation and physical fatigue. METHODS: Recordings of 27 professional actors, 19 non-professional actors and 16 professional dancers were collected before and after a performance using the PRAAT software. Voice samples included sustained vowel phonation, continuous speech, aerodynamic measurements and voice range profile. Both Acoustic Voice Quality Index and Dysphonia Severity Index were computed. For auditory-perceptual evaluations the GRBASI scale was used. Several questionnaires were completed pre and post performance to capture vocal risk factors. RESULTS: Vocal quality between groups showed lower fundamental frequency (fo) values (female), larger fundamental frequency (female) and intensity ranges and a longer maximum phonation time (female) in professional actors compared to non-professionals. Professional dancers showed higher Acoustic Voice Quality Index values compared to non-professional actors. Dysphonia Severity Index, Voice Handicap Index, Vocal Tract Discomfort Scale and GRBASI results did not differ between groups at the baseline. Both objective measurements and questionnaires did not show significantly different results post performance. Questionnaires revealed poor vocal habits in professional actors. CONCLUSION: Professional actors have better vocal capacities than non-professionals. Dancers' vocal quality is worse than actors. The results show no impact of one performance on the vocal quality in theater actors and dancers. The long-term impact of performing, however, is subject for further research.

Language Development in Turkish-Dutch Bilingual Children.

INTRODUCTION: In the current literature, there is a well-established necessity for the improvement of bilingual language diagnostics. Nowadays, the majority of clinicians in Belgium still rely on standardized tests with monolingual norm samples. It is therefore fundamental to have a detailed knowledge of the performance of bilingual children on these monolingual normed tests. Furthermore, there is also a need for unambiguous longitudinal research on the language performances of bilingual children. Therefore, this study aims to investigate the language skills of 25 Turkish-Dutch successive bilinguals compared to 25 age- and gender-matched monolingual Dutch children. In 9 bilinguals and 13 monolinguals, longitudinal data of 3 years (at 6 years and at 9 years) were collected and compared. METHODS: The subject group consisted of 25 bilingual Turkish-Dutch children with a mean age of 9 years and 6 months (SD 0.26 years, min. 8 years and 11 months to max. 9 years and 10 months) with Turkish as the dominant home language. Language exposure to Dutch was at least 3 years. An age- and gender-matched control group of 25 monolingual Dutch children with same educational backgrounds was compiled. Language skills were investigated using the Dutch version of the CELF. In 22 children, language skills were reassessed 3 years later in a follow-up study. Data were compared using the Mann-Whitney U test and Wilcoxon matched-pairs signed-rank test. RESULTS: Language comprehension and production were significantly lower in the bilingual children compared to the monolinguals. After 3 years, the language delay in bilingual Turkish-Dutch children remained the same. Language production in the bilingual children was mainly influenced by the profession of the mother and the home language. CONCLUSION: The low performances of typically developing Turkish-Dutch children on language batteries are worrying and have clinical implications. The same language gap was found at the age of 6 and 9 years in Turkish-Dutch bilingual children compared to monolingual Dutch children, implying that the bilingual children did not catch up with their peers.

Articulation skills in bilingual children with a migration background: a comparison between bilingual Turkish-Dutch, Arabic-Dutch and monolingual Dutch children.

BACKGROUND/AIMS: There is a lack of studies investigating articulation skills in bilingual children with a migration background. Therefore, the present study compared articulation skills in bilingual Turkish-Dutch/Moroccan Arabic-Dutch children with migration background and monolingual Dutch children without migration background. Moreover, possible factors influencing articulation skills were determined. METHODS: 15 bilingual Turkish-Dutch, 15 bilingual Moroccan Arabic-Dutch and an age and gender matched group consisting of 15 monolingual Dutch children, all aged between 6 and 7 years and living in Flanders, were included in the present study. Articulation was evaluated using a picture naming test. Speech samples were transcribed phonetically and articulatory analysis, including a phonetic inventory and phonetic and phonological analyses, was performed. The phonetic analysis made a distinction between distortions, substitutions, additions, and omissions. For the phonological analysis, a distinction between syllable structure processes, substitution processes and assimilation processes was made. Moreover, parents were administered a self-report questionnaire to determine possible factors influencing articulation skills. RESULTS: A statistically significant difference in additions was found when comparing the three groups. Interestingly, both the Turkish-Dutch and Moroccan Arabic-Dutch groups used additions that were not present in the Dutch group (i.e. respectively addition of the [ə] and [ər]). Concerning phonological analysis, it was found that deletions of final consonants were more present in the bilingual groups compared to the monolingual group. Moreover, statistically significant effects of origin, home language, and language preference of the child were found on presence of both phonetic errors and phonological disorders. CONCLUSION: Findings of the present study showed that some phonetic errors and phonological processes were more present in the group of bilingual children with migration background compared to the group of monolingual children without migration background. Interestingly, phonetic errors and phonological processes were more present when (1) the child had a Turkish origin, or (2) when the dominant language at the home environment was Turkish, or (3) when the preferred language of the child was Turkish. Given the increased attention to migration, findings of the present study are highly important for speech-language pathologists, teachers, and more generally, all professionals working with bilingual populations with a Moroccan Arabic or Turkish migration background.

Immediate Effects of a Semi-Occluded Water Resistance Ventilation Mask on Objective and Subjective Vocal Outcomes in Musical Theater Students.

Background Traditional semi-occluded vocal tract exercises (SOVTEs) are restricted to single-phoneme tasks due to the semi-occlusion at the mouth, which hinders full articulation, continuous speech, and singing. Innovative SOVTEs should overcome this limitation by creating the semi-occlusion outside the oral cavity. Purpose The purpose of this study was to investigate the immediate effects of a semi-occluded water resistance ventilation mask, which allows for continuous speech and singing, on objective (voice range, multiparametric voice quality indices) and subjective (auditory-perceptual, self-report) vocal outcomes in musical theater students. Method A pre-/posttest randomized controlled trial was used. Twenty-four musical theater students (16 women and eight men, with a mean age of 21 years) were randomly assigned into a study group and a control group. The study group received a vocal warm-up session with the innovative water resistance ventilation mask (tube attached to the mask "outside" the mouth), whereas the control group received the traditional water resistance approach (tube "inside" the mouth). Both sessions lasted 30 min and were similar with respect to vocal demand tasks. A multidimensional voice assessment including objective and subjective outcomes was performed pre- and posttraining by an assessor blinded to group allocation. Results The Dysphonia Severity Index significantly and similarly increased (improved) in both the study and control groups, whereas the Acoustic Voice Quality Index solely decreased (improved) in the control group. The intensity range significantly decreased (worsened) and the semitone range significantly increased (improved) in the study group, whereas no differences in voice range profile were found in the control group. Auditory-perceptually, a more strenuous speaking voice was noticed after the use of the traditional water resistance approach. The subjects perceived both SOVTEs as comfortable vocal warm-up exercises that decrease the amount of effort during speaking and singing, with a slight preference for the water resistance ventilation mask. Conclusions Both the innovative water resistance ventilation mask and the traditional water resistance exercise seem effective vocal warm-up exercises for musical theater students. The additional articulatory freedom of the mask might increase the phonatory comfort and the practical implementation of SOVTEs in the daily vocal warm-up of (future) elite vocal performers. The hypothesis of a higher transfer to continuous speech or singing in the mask condition has not been supported by the current study. Larger scale investigation and longer term follow-up studies are needed to confirm these preliminary results. Supplemental Material https://doi.org/10.23641/asha.11991549.

The Impact of a Teaching or Singing Career on the Female Vocal Quality at the Mean Age of 67 Years: A Pilot Study.

OBJECTIVES: The purpose of this study was to measure the objective and subjective vocal quality in women aged between 60 and 75 years. Secondly, the impact of a teaching or singing career on the vocal quality was investigated by comparing the vocal quality of retired women with different careers. STUDY DESIGN: This is a case-control study. METHODS: Seventy-three retired women between 60 and 75 years (mean age: 67 years, standard deviation: 4.49) participated in the study and were divided into three groups: women with a teaching career (n = 21), choir singers with a singing career (n = 12), and women with a non-vocal career (n = 40). All subjects underwent the same assessment protocol consisting of objective (aerodynamic, maximum performance, vocal range, acoustic measurements, and the Dysphonia Severity Index) and subjective (the Voice Handicap Index, auditory-perceptual evaluations by three listeners) voice measurements. RESULTS: In all three groups, objective and perceptual voice analysis showed a mild dysphonia. No differences in the Dysphonia Severity Index were found between the three groups. The voices of choir singers with a singing career were perceived significantly less rough than voices of the women with a non-vocal career. Additionally, the lowest frequency of the frequency range was significantly lower in the retired teachers and choir singers than in the controls. CONCLUSION: The results of this study prudently suggest that a singing or a teaching career compared with a non-vocal career has a positive impact on the vocal frequency range, and that singing has a positive impact on the perceptual vocal quality of the older female voice.

Vocal Quality in Theater Actors.

OBJECTIVES: The purpose of this study was to investigate vocal quality, vocal complaints, and risk factors for developing voice disorders in theater actors. Secondly, the impact of one vocal performance on the voice was investigated by comparing objective and subjective vocal quality before and after a theater performance. STUDY DESIGN: Prospective study of the actors' voice prior to and after a performance METHODS: Speech samples of 26 theater actors (15 men, 11 women, mean age 41.9 years) were recorded before and after a theater performance of one and a half hour and analyzed using the software program Praat. Speech samples consisted of the combination of sustained phonation and continuous speech. For each speech sample, the Acoustic Voice Quality Index was calculated. Auditory perceptual evaluations were performed using the GRBASI scale. Questionnaires were used to inventory vocal symptoms and influencing factors. RESULTS: Acoustic analysis showed a mean Acoustic Voice Quality Index (AVQI) of 3.48 corresponding with a mild dysphonia. Fifty percent of the theater actors reported having (sometimes or regularly) vocal complaints after a performance. The questionnaire revealed a high presence of vocally violent behavior and poor vocal hygiene habits. Objective vocal quality, measured by the AVQI, did not change after a theater performance. The auditory perceptual evaluation of the overall grade of dysphonia showed a subtle amelioration of the vocal quality. CONCLUSIONS: The results of this study showed the presence of mild dysphonia, regular vocal complaints, and poor vocal hygiene habits in theater actors. A theater performance did not have an impact on the objective vocal quality.