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.

Immediate effects of a semi-occluded water-resistance ventilation mask on vocal outcomes in women with dysphonia.

INTRODUCTION: Semi-occluded vocal tract exercises (SOVTEs) are frequently used exercises in voice therapy. An important shortcoming to most SOVTEs is the inability to include continuous speech in these exercises. A variation of water-resistance therapy (WRT), during which a patient phonates through a resonance tube ending in water, was developed to include continuous speech: the semi-occluded water resistance ventilation mask (SOVM-WR). The current study investigated the immediate effects of this innovative technique on vocal outcomes of women with dysphonia. METHODS: A pretest-posttest randomized controlled trial was performed. Twenty female participants were randomly assigned to the experimental SOVM-WR group or the WRT (control) group. A blinded multidimensional voice assessment was conducted before and after a 30-minute therapy session with the assigned technique. RESULTS: No significant changes were found in acoustic or auditory-perceptual vocal outcomes in either of the groups, except for a significant increase in lowest frequency in both groups. Patient-reported outcomes (PROMs) showed significant improvements of vocal comfort, vocal effort, and voice quality in both groups, and participants indicated that they would use the techniques at home. CONCLUSIONS: The similar results of the SOVM-WR to WRT and promising PROMs confirm its suitability as an alternative to the latter technique. Potential reasons for a lack of improvement of objective and auditory-perceptual vocal outcomes are vocal fatigue, tube dimensions and immersion, and the small sample size. Large-scale and longitudinal research is needed to examine whether the SOVM-WR has a higher transfer to spontaneous speech than WRT after a full therapy program.

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.

Longitudinal Vocal Outcomes and Voice-Related Quality of Life After Selective Bilateral Laryngeal Reinnervation: A Case Study.

PURPOSE: Bilateral vocal fold paralysis (BVFP) is a severe disorder that can result in respiratory, swallowing, and voice-related problems. Most surgical treatments do not restore laryngeal function and often need to compromise voice quality to preserve respiratory function. Laryngeal reinnervation (LR) may offer a solution to this problem, but literature on longitudinal outcomes of this procedure is scarce. This study aims to report the longitudinal vocal outcomes of BVFP after LR and subsequent voice therapy. METHOD: The case of a 23-year-old man with BVFP after a traumatic dissection of both recurrent laryngeal nerves is described. Selective bilateral LR of both adductors and abductors was performed 5 months after the onset of BVFP. Voice therapy was provided after the LR procedure. Multidimensional voice assessments, including acoustic, perceptual, and patient-reported outcome measures (PROMs), were conducted 2, 5, 6.5, 8, and 31 months after LR. RESULTS: An improvement of vocal capabilities and voice quality was noticed 6.5 months after LR, after 4.5 months of voice therapy, with normative values after 2.5 years. PROMs showed an improvement of voice-related quality of life, but some limitations to activities of daily living were still present. Inspiratory arytenoid abduction was not observed on laryngeal videostroboscopic findings in this patient, but tracheostomy was not required. CONCLUSIONS: Voice therapy after LR helps establish healthy and efficient voice use without increasing compensatory hyperfunctional behavior. More research is needed to examine potential merits of voice therapy in the rehabilitation of vocal and respiratory functions after LR.

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, Symptoms, and Habits in Musical Theater Actors.

PURPOSE: The purpose of this study was to measure and compare the voice characteristics and vocal complaints and habits of musical theater actors and musical theater students. METHOD: Thirty participants were included in the study, 18 musical theater students and 12 professional musical theater actors. Vocal quality was measured by the multiparameter indices Dysphonia Severity Index (DSI) and Acoustic Voice Quality Index (AVQI). A perceptual evaluation of the speaking voice was performed using the GRBASI scale. All participants completed the Voice Handicap Index (VHI), the VHI adapted to the singing voice, the Vocal Tract Discomfort (VTD) Scale and the Corporal Pain Scale. RESULTS: Excellent scores for DSI (resp. 7.3, 7.1) and AVQI (resp. 2.6, 2.5) were found in the musical theater actors and students. All participants reported at least two symptoms of VTD and the mean scores for the VHI adapted to the singing voice were located in the clinical zone. Musical theater students reported significantly more VTD and pain symptoms compared to the professionals. No significant differences in perceptual and objective voice characteristics were found between musical theater actors and students. A higher presence of vocal misuse and stress in the students was observed. CONCLUSION: Musical theater students and actors are elite vocal performers with comparable excellent objective vocal measures (DSI, AVQI). In both groups, an increased number of VTD and complaints of the singing voice were reported. Especially students were vulnerable for stress, vocal misuse, VTD, and pain symptoms. The findings suggest that musical theater actors are a risk group for developing voice disorders requiring multidimensional voice assessment and voice care.

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.