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.

Voice and Communication in Transmasculine Individuals One Year Under Testosterone Therapy: A Qualitative Study.

OBJECTIVES/HYPOTHESES: The purpose of this study was to investigate voice and communication difficulties in transmasculine individuals to develop evidence-based voice and communication training programs. STUDY DESIGN: Qualitative study. METHODS: Eight transmasculine individuals, who had received testosterone therapy (TT) for at least 1year, were included in this study. Semistructured interviews were conducted by two experienced voice clinicians. The software program NVivo was used for transcribing and coding the interviews. Data were processed using a thematic analysis. RESULTS: The thematic analysis resulted in the identification of five major themes. Most transmasculine individuals experienced a pitch decrease during the first year of TT and encountered voice-related problems, with a higher incidence during the initial period. Additionally, some participants experienced increased satisfaction with how others attributed their gender after 1year of TT. However, others still experienced a discrepancy between external gender attribution, self-attribution, and their desired attribution by others. Many participants did not receive voice and communication training. In many cases, voice had a significant impact on their well-being and daily life. CONCLUSIONS: It's difficult to generalize the results of the current study, since the population of transmasculine individuals is heterogeneous in terms of their subjective gender positioning, desired gender attribution, gender attribution received from others, and gender-related aspects of their vocal situation. Some clients may express dissatisfaction with specific aspects of their voice and communication and may require professional support. Therefore, clinical practice for transmasculine individuals should adopt an individualized approach based on a comprehensive examination of the client's perspective.

Voice Outcome of Glottoplasty in Trans Women.

PURPOSE: This study investigates the short- and longer-term effects of glottoplasty up to six months after surgery on acoustic voice parameters, listener perceptions, and client's satisfaction in trans women. Secondly, the impact of chondrolaryngoplasty and voice therapy on the glottopasty outcomes was investigated. METHOD: A prospective longitudinal non-controlled trial was used. Thirty-five trans women undergoing glottoplasty or a combination of glottopasty and chondrolaryngoplasty were included in this study. A voice assessment was conducted before surgery and 1 week, 1 month and 6 months after surgery. The following outcome parameters were measured: fundamental frequency (fo), intensity, frequency and intensity range, Dysphonia Severity Index (DSI), Acoustic Voice Quality Index (AVQI), Voice Handicap Index (VHI), Trans Woman Voice Questionnaire (TWVQ), and visual analogue scales (VAS) measuring client's satisfaction. Listener perceptions of masculinity-femininity were collected using a listening experiment. RESULTS: Significant differences over time were found for all fo and intensity parameters, DSI, AVQI, VHI and TWVQ scores. Listener perception and self-perception of femininity was higher after surgery. Significant differences in evolution of listener perceptions were found between the groups with and without voice therapy. CONCLUSION: Glottoplasty improves voice related quality of life and is an effective method to increase the fo and associated perceptual femininity. After glottoplasty an immediate and short-term decrease in voice quality, vocal capacity and frequency range was measured with a progressive recovery on the longer term. Long term side effects of glottoplasty are a reduction in speaking intensity and intensity range. Voice therapy seems to improve the outcomes of glottoplasty, but should be further investigated in future studies.

Intonation Parameters in Gender Diverse People.

OBJECTIVES/HYPOTHESIS: Although intonation is often addressed in speech training for gender diverse individuals, the relationship between intonation and femininity/masculinity ratings remains unclear. The aim of this study was to examine differences in intonation parameters in gender diverse individuals. Moreover, the relationship between acoustic intonation parameters and femininity/masculinity ratings was investigated. METHODS: Speech samples of semistructured speech were elicited from cisgender (cis) (107 ciswomen, 104 cis men), transgender (trans) (19 trans women, 10 trans men), and non-binary (n = 11) individuals using a prosody protocol. An objective acoustic analysis was performed to compare intonation parameters (upward/downward/flat intonation shift, general and final intonation shift, general fundamental frequency range, fundamental frequency variation index) between groups. In addition, a listening experiment was conducted, consisting of a cis and gender diverse listening panel (n = 41). The listeners were asked to rate the femininity/masculinity of speech samples (n = 57) using a visual analogue scale. Correlational analyses were used to examine the relationship between intonation parameters and femininity/masculinity ratings. RESULTS: Similarity was found in the intonation parameters of participants with a similar gender identity. In non-binary speakers, no significant differences in acoustic intonation parameters were found between these speakers and the cisgender speakers. In addition, no significant correlations were found between the acoustic intonation parameters and the femininity/masculinity ratings in the groups with cis men, cis women, and non-binary participants. However, moderate to strong significant correlations were found between acoustic intonation parameters and femininity/masculinity ratings in the trans participants. CONCLUSIONS: Intonation is a "speech marker" that distinguishes between groups with a different gender identity. No relationship was observed between intonation and femininity/masculinity ratings for cisgender and non-binary speakers. However, the significant relationship between these parameters for transgender participants (trans men and trans women) provides evidence for intonation exercises in gender affirming voice, speech, and communication training, and therefore contribute to evidence-based intonation training in transgender persons.

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.

EASE-NL: Cross-Cultural Adaptation and Validation of the Dutch Version of the Evaluation of Ability to Sing Easily.

OBJECTVES: The Evaluation of the Ability to Sing Easily (EASE) is a self-rating tool that is used to assess the singer's perceptions of the current singing voice status. The purpose of this study was to develop and validate a Dutch translation of the EASE. METHODS: The original version of the EASE was translated and adapted to Dutch according to the recommendations of the Quality of Life Special Interest Group - Translation and Cultural Adaptation group. Subsequently, the questionnaire was individually completed by 70 singers with a mean age of 35.2 years before and after a singing activity, together with a demographic questionnaire and the Dutch Singing Voice Handicap Index 10 (SVHI-10-NL). Two groups of singers were included between September and June 2020: a group of healthy singers (n = 54) and a group of dysphonic singers (n = 16). Internal and external consistency, construct and criterion validity, test-retest and split-half reliability were calculated using Cronbach's alpha coefficients, Student's t-test, the paired Wilcoxon tests and Pearson correlation coefficients. Furthermore, the impact of sex and age and the diagnostic accuracy of the EASE-NL was measured using the Mann Whitney U-test, the One Way ANOVA and the Brown Forsythe ANOVA-test. RESULTS: The internal consistency of the EASE was considered good. For the external consistency, the Pearson correlation coefficient showed a positive correlation between the total score of the EASE-NL and the SVHI-10-NL. Dysphonic singers scored significantly higher compared to singers without voice problems and no differences were found between the pre and post singing condition in both groups. Pearson correlations coefficients showed a strong positive correlation between the test and retest condition and between the subscales. A ROC-curve analysis showed a cut-off score of 12.5, with a sensitivity level of 75.0% and a specificity level of 74.1%. No differences for sex and age were found. CONCLUSIONS: The original English version of the EASE was translated and validated in Dutch. The EASE-NL is found to be a valid and reliable self-reported tool to assess singer's perceptions of the current status of their singing voice.

Experiences of Transgender Women with Speech Feminization Training: A Qualitative Study.

This study investigated the experiences of transgender women after following sessions for speech feminization using semi-structured face-to-face interviews. Transgender women who completed a clinical trial were invited for an interview and 12 accepted the invitation. Interviews were conducted using an interview guide and were recorded and transcribed verbatim. NVivo 12 was used for qualitative data analysis, applying an inductive thematic approach. Four main themes were identified: communication, therapy experiences, impact on mental health, and external factors associated with the outcomes. For most participants, fear of speaking in public decreased after the training and all participants mentioned improved vocal characteristics. Though, reactions ranged from needing more speech therapy to being satisfied with the results. Coping strategies during misgendering occasions differed a lot between participants. More emotive counseling during speech feminization sessions is necessary to help clients in managing possible negative emotions.

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.

Age and Gender Differences in Belgian Dutch Intonation.

PURPOSE: This study investigated whether intonation is influenced by age and gender and obtained normative data for the intonation of Flemish (Belgian Dutch) speaking cis women and cis men in Flanders, Belgium, per age group. METHOD: A total of 105 cis women and 102 cis men were included and equally spread in five age groups by gender. Semi-structured speech samples were elicited using a prosody protocol. An objective acoustic analysis was performed to determine four intonation parameters (general intonation shift, general fundamental frequency range, final intonation shift, and fundamental frequency variation index). RESULTS: Cis women used a higher percentage of general upward and downward intonation shifts than cis men. Cis men generally used more flat intonation shifts than cis women. A larger mean value was observed in cis women as compared to cis men for each of the continuous intonation parameters per sentence type. In terms of age, differences in continuous intonation parameters were found between younger and older age groups, mostly with the 46-55-year-old age group, in which the younger age groups showed smaller mean values for all parameters. CONCLUSIONS: Cis women use a more expressive intonation than cis men. In terms of age, older persons showed a more expressive intonation in a number of sentences compared to younger persons. The prosody protocol and the normative data from this study can be used to determine speech therapy goals.

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.

Acoustic and Perceptual Effects of Articulation Exercises in Transgender Women.

PURPOSE: This study measured the impact of articulation exercises using a cork and articulation exercises for lip spreading on the formant frequencies of vowels and listener perceptions of femininity in transgender women. METHODS: Thirteen transgender women were recorded before and after the cork exercise and before and after the lip spreading exercise. Speech samples included continuous speech during reading and were analyzed using Praat software. Vowel formant frequencies (F1, F2, F3, F4, F5) and vowel space were determined. A listening experiment was organized using naïve cisgender women and cisgender men rating audio samples of continuous speech. Masculinity/femininity, vocal quality and age were rated, using a visual analogue scale (VAS). RESULTS: Concerning vowel formant frequencies, F2 /a/ and F5 /u/ significantly increased after the lip spreading exercise, as well as F3 /a/, F3 /u/ and F4 /a/ after the cork exercise. The lip spreading exercise had more impact on the F2 /a/ than the cork exercise. Vowel space did not change after the exercises. The fundamental frequency (fo) increased simultaneously during both exercises. Both articulation exercises were associated with significantly increased listener perceptions of femininity of the voice. CONCLUSION: Subtle changes in formant frequencies can be observed after performing articulation exercises, but not in every formant frequency or vowel. Cisgender listeners rated the speech of the transgender women more feminine after the exercises. Further research with a more extensive therapy program and listening experiment is needed to examine these preliminary findings.

Effects of speech therapy for transgender women: A systematic review.

Background: For transgender women, communication and speech characteristics might not be congruent with their gender expressions. This can have a major influence on their psychosocial functioning. Higher quality of life scores were observed the more their voice was perceived as feminine. Speech language pathologists may play an important role in this, as the gender affirming hormone treatment for transgender women does not affect the voice. Aim: This systematic review aimed to provide speech and language pathologists with the current literature concerning the effects of speech therapy in transgender women in terms of acoustic and perceptual outcomes. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used for reporting this systematic review. The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (using the PubMed interface) and Embase (using the embase.com interface) were used as electronic databases. All individual studies which measured the effects of speech therapy in transgender women were evaluated with a risk of bias assessment tool and levels of evidence. Relevant data were extracted from these studies and a narrative synthesis was performed. Results: 14 studies were identified through the databases and other sources. These studies show positive outcome results concerning pitch elevation, oral resonance, self-perception and listener perception. However, methodological issues contribute to problems with generalization and reproducibility of the studies. Conclusion: There is an urgent need for effectiveness studies using RCT designs, larger sample sizes, multidimensional voice assessments, well-described therapy programs, investigators blinded to study process, and longer-term follow-up data. Speech and language pathologists who work with transgender women may find these results essential for defining therapy goals.

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.