Voice and Communication in Transgender and Gender Diverse Individuals : Evaluation and Techniques for Clinical Intervention

This book serves as a guide to any patient, clinician, or person who desires to understand how transgender and gender diverse individuals can be assisted in achieving voice and communication congruity with gender. Voice and communication style serve as intricate links to one’s identity and are central aspects of the gender transition process. Guiding a transgender or gender diverse patient through this transition is complex, requiring an understanding of the patient’s desires, the ability to identify and work with patients to achieve sustainable patterns of behavioral modification that affect voice in a positive manner, and an understanding of the role of newly emerging surgical techniques. This is best addressed by an interdisciplinary team, and this book makes this material available in one source. The first section of the book consists of introductory chapters written by primary care physicians, endocrinologists, and psychiatrists addressing the complex nature of transition from the medical standpoint. A review of hormonal replacement therapies, psychological evaluations, and potential effects of hormone replacement on voice is included. The second section describes the behavioral techniques available in speech and voice therapy for voice change and addresses outcomes that can be expected from behavioral intervention. Each chapter addresses the physiologic principles of therapeutic techniques for effecting change, techniques of instruction, nuances for transgender and gender diverse patients, methods of generalization, and methods of maintenance. Finally, the third section of the book details the surgical techniques available to assist patients in voice transition and their expected outcomes for voice modification. Each chapter includes an introduction, preoperative assessment, role of preoperative therapy, surgical technique, postoperative management, and expected outcome. This section also includes a surgical atlas. This is an ideal guide forotolaryngologists, speech-language pathologists, primary care providers, as well as psychiatrists and endocrinologists caring for transgender and gender nonconforming patients. Preface Disclaimer Contents Contributors Part I: Background: Patient History and Evaluation Chapter 1: Introduction to the Care of Transgender Persons References Chapter 2: Medical Management for Transgender Patients Introduction Diagnosis and Decision to Begin Treatment The Management of Children and Adolescents Fertility Preservation Hormone Therapy for Transgender Individuals Hormone Therapy for Transgender Women: Male to Female (MTF) Perioperative Hormone Management Hormone Therapy for Transgender Men: Female to Male (FTM) General Health Surveillance and Screenings Conclusions References Chapter 3: Strategies for Evaluating Patients’ Readiness for Surgical Intervention: From a Psychiatric Perspective Behavioral and Surgical Treatment for Gender Dysphoria Due to Voice The Role of a Pre-Surgical Psychiatric Assessment Conducting a Pre-Surgical Psychiatric Assessment Conclusion References Chapter 4: Barriers to Care and Cultural Responsiveness in Transgender and Gender Nonconforming Voice Modification Introduction Language What Is “Voice Feminization”? Brief Historical Considerations for the Transgender and Gender Nonconforming Community in the United States Service Providers Discrimination in Healthcare and Disparities in Health Outcomes in TGNC Community Trauma-Informed Practice with TGNC Individuals Adapting TIC Considerations to Institutional Settings [10, 11] Consent Common Issues when Interacting with TGNC Individuals Misgendering or Deadnaming Triggering Topics Responding When Someone Is Triggered Considerations for Note and Report Writing Receiving Negative Feedback Ideally... References Chapter 5: Patient-Reported Outcomes and Data Collection in Treatment-Seeking Transgender and Gender Nonconforming Individuals Introduction What Are Patient-Reported Outcomes? Data Collection Clinician-Perceived Dysphonia Normophonic Voicing Patient-Reported Outcome Measures (PROMs) Acoustic, Aerodynamic, and Auditory-Perceptual Evaluation Limitations in Determining Gender-Affirming Voice Targets from Cisgender Voice Norms (as Described in Table 5.3) Using Acoustic/Aerodynamic/Perceptual Analysis for Pre- and Post-Operative Gender-Affirming Voice Surgery Conclusion Appendix References Part II: Behavioral Interventions to Aid Transition Chapter 6: Applying Flow Phonation in Voice Care for Transgender Women, Nonbinary, and Gender Nonconforming Individuals Introduction Background Airflow Considerations with Transgender and Gender Nonconforming Individuals Exploring Techniques to Facilitate Phonatory Airflow From Structured Tasks to Generalization Hierarchy Using Stretch and Flow Phonation Pitfalls When Working with Flow Phonation Practice and Maintenance Conclusion References Chapter 7: Resonant Voice Care Introduction Background Resonance Considerations with Transgender and Gender Nonconforming Individuals Techniques to Facilitate Forward Resonance From Structured Tasks to Generalization Resonant Hum Transition to Speaking Voice Hierarchy of Tasks for Forward Resonance Practice and Maintenance Considerations Pitfalls When Working with Resonance Conclusion References Chapter 8: Working with Pitch in Transgender and Gender Nonconforming Voice Care Introduction Research on Pitch and Pitch Range Therapies Role/Rationale for the Use of Pitch Range Therapies in Voice Modification Training with TGNC Individuals Determining with Patients, Which Pitch to Begin with and/or Target, and Methods to Achieve This Antoni Method Approach and Protocol for Transfeminine and TGNC Work [The Antoni Method Protocol Is Outlined in Appendix 2] Exercise 1: Resonance and Pitch Contrast Exercise Specific Techniques for Pitch-Based Instruction Lightening the Vocal Tone Emotional Tone of Voice Range Voice Onset Practice Twang Voice Quality Recommendations for Facilitating the Patient’s Ability to Achieve the Desired Pitch Appendix 1 Appendix 2 References Chapter 9: Nonverbal Communication Rationale for and Role of Training Research on Nonverbal Communication and Gender Expression Techniques to Facilitate Nonverbal Communication Generalization to Communication Situations Pitfalls and Considerations References Chapter 10: The Singing Voice Introduction Background Singing and the Singer: A Holistic Approach to Vocal Training Initial Sessions Rapport-Building Consultation/Vocal Counseling Expectations and Outcomes: Emphasizing Function over Sound Social Vocal Transition Technical Vocal Transition Paths to Technical Vocal Transition The Unmodified Voice The Hybrid Voice The Modified Voice Sample Exercises (Table 10.2) Balancing Sustainable Singing with Gender-Affirming Modification Onset Vocal Fatigue Warm-Up/Cool-Down Laryngeal Positioning Tension and Functional Disruption Challenges and Other Considerations Estrogen-Based HRT and The Singing Voice Anxiety and Mental Health Management Laryngologist, SLP Recommendations, and Access to Care Conclusion Appendix 1 Initial Vocal Intake Protocol References Chapter 11: Behavioral Management for Masculinization of Voice and Communication Across the Gender Spectrum Introduction Effects of Testosterone on the Voice Vocal Dissatisfaction in Individuals Post-Testosterone Masculine Voice and Communication Pitch Resonance and Articulation Intonation, Pitch Variation, and Volume Language and Nonverbal Communication Treatment: Techniques and Strategies for Communication and Voice Masculinization Pitch Resonance Intonation, Pitch Variation, and Language Respiration Generalization of Voice and Communication Techniques Additional Treatment Considerations Conclusion References Part III: Surgical Techniques to Aid Transition Chapter 12: Surgical Concepts in Transgender Voice Change References Chapter 13: Cricothyroid Approximation Introduction Preoperative Assessment Role of Preoperative Therapy Surgical Technique Postoperative Management Expected Outcomes Conclusion References Chapter 14: Laser-Assisted Voice Adjustment (LAVA) Introduction Preoperative Assessment Role of Preoperative Voice Therapy Surgical Technique Postoperative Management Expected Outcomes Healing Phase Return to Voice Production Durability of Procedure Conclusion References Chapter 15: Laser Reduction Glottoplasty: Vocal Fold Reduction Surgery for Feminine Voice Quality in Transgender Women Introduction Preoperative Assessment Voice Assessment Voice Analysis Stroboscopy High-Speed Laryngoscopy and Digital Kymography Subjective Voice Evaluation Patient Selection Role of Preoperative Therapy Surgical Technique Postoperative Management Healing Phase Expected Outcomes Conclusions References Chapter 16: Modified Wendler Glottoplasty: Endoscopic Bilateral Partial Cordectomy with Primary Closure Introduction Preoperative Assessment Role of Preoperative Therapy: Is it Indicated? Is there a Role? Surgical Technique Postoperative Management Expected Outcome: Healing Phase, Return to Voice Production, and Durability of the Procedure Healing Phase Return to Voice Production Durability of the Procedure References Chapter 17: Feminization Laryngoplasty Introduction Preoperative Assessment Vocal Examination Role of Preoperative Therapy: Is it Indicated? Is there a Role? Surgical Technique Postoperative Management Recovery Room Initial 3 Days Voice Use Expected Outcomes: Healing Phase, Return to Voice Production, and Durability of the Procedure Healing Phase: Voice Durability of the Procedure Conclusions Further Reading Chapter 18: Type III Thyroplasty: Voice Masculinization Introduction Background Preoperative Assessment Voice Questionnaires Informed Consent Preoperative Voice Therapy: Is There a Role? Surgical Technique: Type III (Relaxation) Thyroplasty Postoperative Management Expected Outcome: Healing Phase, Return to Voice Production and Durability of the Procedure References Chapter 19: Thyroid Cartilage Reduction Introduction Preoperative Assessment Role of Preoperative Therapy Surgical Technique Postoperative Management Expected Outcomes Conclusion References Index