Sexologies (2008) 17, 271276

Disponible en ligne sur www.sciencedirect.com

journal homepage: http://france.elsevier.com/direct/sexol

ORIGINAL ARTICLE / ARTICLE ORIGINAL

Working with the transgender voice: The role of the

speech and language therapist
Travailler avec la voix transgenre : rle de
lorthophoniste
El trabajo sobre la voz del transgnero : el papel del
logopeda y de la terapia de lenguaje
J. Thornton (B.Sc (Hons))

Speech and Language Therapy Department, Royal Hallamshire Hospital, Glossop Road, Shefeld S10 2JF, Yorkshire, England, UK

Available online 6 November 2008

KEYWORDS Summary How do we perceive speaker gender? What marks a voice as male or female? Most
Transsexual; nave listeners would say it is the pitch of a voice that determines the perceived gender of the
Transgender; speaker. However, research has shown that although fundamental frequency is important, non
Voice; verbal communication, linguistic and phonetic features are also signicant. Within individual
Speech; cultures there will be expected patterns of communication that are gender specic and it is
Therapy these areas that the therapist is advised to attend to during therapeutic intervention. This
article outlines the role of speech and language therapy with the trans population looking at
these aspects in detail, based on peer agreed practise and research ndings, which relate mainly
to English speaking populations. Addressing these aspects enables the individual who presents
well physically to complete the package and achieve a more gender specic communication
style.
2008 Elsevier Masson SAS. All rights reserved.

Rsum La participation une thrapie orthophonique et de communication joue un grand

MOTS CLS rle dans le succs de la transition de certains transgenres. Divers degrs de changements sont
Transsexuels ; possibles permettant chacun de dcider comment et quand employer ces nouvelles habilets
Transgenres ; [Logoped Phoniatr Vocol 33 (2008) 2534]. Le temps ncessaire la ralisation et au maintien
Voix ; du changement de voix et de la communication dsirs est variable. Dacakis [J Voice 14 (2000)
Orthophonie 549556] pense que la ralisation fondamentale du changement de frquence et la russite de
son maintien dpendent du nombre de sessions de thrapie. Sderpalm et al. [Logoped Phoniatr

722, Prince of Wales Road, Shefeld, S9 4EU, Yorkshire, England, UK.

E-mail address: Jane.thornton@sth.nhs.uk.

1158-1360/$ see front matter 2008 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.sexol.2008.08.003
272 J. Thornton

Vocol 29 (2004) 1830] ne retrouvent pas ce lien. Le changement de voix continue souvent aprs
la n du traitement lorsque la personne sapproprie son nouveau genre, avec une acceptation
croissante de la nouvelle voix permettant plus de exibilit vocale et de conance dans la
communication. Enn, le bon fonctionnement dans la vie de ces personnes sera dtermin par
leur perception individuelle satisfaisante de communication dans diffrentes situations plutt
que ladoption dun seul style de communication.
2008 Elsevier Masson SAS. All rights reserved.

Resumen Participar en una terapia de lenguaje y comunicacin es una tcnica que facilita
PALABRAS CLAVE el xito de la transicin de un gran numro de personas transgnero. Existen varios grados de
Transexuales; cambios posibles que permiten decidir cmo y cundo utilizar estas nuevas tcnicas [Logoped
Transgneros; Phoniatr Vocol 33 (2008) 2534]. El tiempo necesario para realizar y mantener el cambio de
Voz; voz y de comunicacin deseados es variable. Dacakis [J Voice 14 (2000) 549556] piensa que
Logopedia la realizacin fundamental del cambio de frecuencia y el xito de su mantenimiento dependen
del nmero de sesiones de terapia. En cambio, Sderpalm et al. [Logoped Phoniatr Vocol 29
(2004) 1830] no establece este vnculo. A menudo, el cambio de voz sigue evolucionando,
a medida que la persona va adaptndose a su gnero y aceptando su nueva voz, lo que le
conere una mayor exibilidad vocal y una mayor conanza a la hora de comunicarse. Al nal,
el nivel individual de satisfaccin a la hora de comunicarse en distintas situaciones, ms que la
adopcin de un simple estilo de comunicacin, es lo que determina el xito del funcionamiento
psicosocial de los pacientes.
2008 Elsevier Masson SAS. All rights reserved.

Version abrge exemple lorsquils parlent des enfants ou lorsquils lisent

Introduction
Les orthophonistes travaillent sur les contraintes
anatomiques an de faciliter sans risque le change-
ment qui permettra un transsexuel dacqurir un style
de communication exible en rapport avec son identit de
genre. Tout en reconnaissant que le son est fondamental
Van Borsel et al., 2000 et Byrne et al., 2003, entre autres,
ont constat que les caractristiques linguistiques, phon-
tiques et non verbales sont signicatives de la perception
du genre dun orateur et que ces domaines devraient
galement tre au centre de lattention de la thrapie. En
principe, lorthophoniste doit disposer dune exprience
considrable des troubles de la voix et travailler au sein
dune quipe largie et coordonne de traitement des
troubles de lidentit de genre (TIG).
valuation
Les troubles prexistants de la voix doivent faire lobjet
dune investigation et dun traitement appropris avant
que ne commence le travail sur la voix spcique un
genre. On effectue une analyse de la voix, des mesures
perceptuelles, objectives et dautovaluation, ainsi quune
discussion portant sur les attentes du patient. Les essais
thrapeutiques indiquent le degr de changement que
lon peut attendre, compte tenu de la rponse physique
et psychologique aux interventions de thrapie diagnos-
tique. Si cela na pas encore t fait, il est conseill
dobserver les personnes de mme ge, culture et milieu
social dans un contexte familial. Des tentatives initiales
dexprimentation vocale peuvent sembler fausses et non
convaincantes et ce stade il est utile de discuter avec les
patients de la variation naturelle de leur propre voix, par
voix haute.
Intervention
Gnralement la thrapie concide avec la transition mais
dans certains cas, la modication de la voix peut se pro-
duire plus tt pour faciliter le processus de transition. Le
Tableau 1 dtaille des zones spciques de focalisation pour
ce groupe de patients. La communication non verbale et
laltration des fonctions vgtatives telles que la toux peu-
vent galement tre prises en charge en fonction de besoins
spciques sociaux ou professionnels.
Fin des soins
La thrapie normale prend n lorsque le patient a atteint
tous les objectifs convenus ou lorsquil ny a plus de progrs
attendre. Dans lidal, cela doit tre une dcision com-
mune et une rvaluation constante, pendant la thrapie,
permettra de vrier que les points les plus importants pour
la personne ont t traits.
Full version
Introduction
The role of speech and language therapy (SLT) in the trans
population is to facilitate change by enabling the individual
to acquire a exible communication style that is congruent
with their core gender identity, enabling them to pass in
all social and occupational situations. For the trans female,
this should enable the person to sound more feminine with-
out sounding effeminate and for the trans male to enable a
natural lowering and stabilisation of the voice (aided by hor-
mones) with a more masculine speech style. Van Borsel et
Working with the transgender voice: The role of the speech and language therapist
al., 2000, amongst others, found a combination of communi-
cation features to inuence listeners perception of speaker
gender. Byrne et al., 2003, also found that although fun-
damental frequency is important in perception of speaker
gender; linguistic, phonetic and nonverbal characteristics
are all signicant in marking the speaker as male or female.
This in effect means working within anatomical constraints
to adapt voice and communication style. Most trans people
will present for gender conrmation in middle age, after
many years of trying to live their biologically determined
life. This will undoubtedly necessitate challenging estab-
lished, often exaggerated, styles of communication.
The combination of habit and anatomical constraints can
make changes in communication the most frustrating part
of the transition process. Amount of practice required to
effect and maintain change cannot be underestimated and
should be emphasised at the very start of therapy. For many,
it is the icing on the cake to be able to not only look the
part but to avoid listener doubt in all situations, including
the most challenging of all, the telephone.
What can voice therapy offer individuals who wish to
develop their voice and communication skills? Like any other
method of intervention the case history is the starting point.
Ideally, the SLT will have considerable experience working
with disordered voices and will be working within a compre-
hensive and coordinated gender dysphoria team. They will
be skilled at voice analysis, both perceptual and objective,
and be mindful at all times of the natural capabilities of
the voice. The aim of therapy is to facilitate safe develop-
ment and habitualisation of a gender-appropriate voice and
communication style that is comfortable for the person to
use on a daily basis without vocal fatigue. Individuals who
are able to evaluate their success in exercises away from the
therapy session are likely to show a faster rate of progress
than those who, for a variety of reasons, are hindered by
their listening skills.
Assessment
If a pre-existing dysphonia (i.e. voice disorder) is identied
at initial assessment, it must be properly investigated and
treated before commencing any gender-specic work. Per-
ceptual, objective and self-evaluation measures together
with discussion of client expectations would be carried out
in addition to general medical and drug information. Specic
areas of focus for this client group include pitch, reso-
nance, articulation, intonation, language, prosody, rate of
speech, nonverbal communication and clients social and
occupational voice use. Therapy goals will be set and agreed
between the clinician and the individual and will, wherever
possible, be evidence based.
The clients goals may not be in agreement with the
clinicians and this should be explored in full. Individuals
present at different points along the transition continuum
and some will be more aware of communication differ-
ences than others. Most have spent many years preparing for
their transition and may already be aware of male/female
differences with many hours spent observing others and
experimenting with different voices. If, however, they have
not, this should be the rst step in any voice therapy work.
Observation of people who are of their chosen gender, age,
273
culture and social class in familiar contexts is a good starting
point. Some will be self conscious of experimenting with the
voice which may initially sound false and unconvincing. It is
helpful at this point to discuss and demonstrate the different
voices they may already use e.g. with children, authoritative
gures, reading aloud, etc to illustrate the natural variation
of their voice.
For those individuals who present with an already altered
voice quality that is dysfunctional or unstable, it is the
responsibility of the clinician to advise the individual of this.
It may be that the trans man (especially the younger
one who has lived as male since puberty) has lowered his
voice prior to hormones in a way that may be causing vocal
abuse and may ultimately strain or damage the vocal mech-
anism. Similarly, the trans woman may be talking in a very
quiet, almost inaudible whisper, as she believes the natural
female voice to be quieter than the male. These patterns
will be causing vocal abuse and should be eliminated before
beginning any gender work.
Therapeutic probing and trials give an idea of how much
change can be anticipated given the physical and psycholog-
ical response to diagnostic therapy interventions.
Intervention (Table 1)
Most transgendered people will require some assistance with
their voice and/or communication skills. It is usual prac-
tice for communication and voice therapy to coincide with
transition. This is viewed as the most successful time to con-
centrate on altering voice and communication as it gives the
individual continuous practice opportunities without having
to revert to the biological role. However, in some cases voice
modication may occur earlier to facilitate the transition
process.
Therapy may take place either on an individual basis, in
a group setting or a mixture of the two dependent on the
needs of the individual. The rst aim of any intervention is
for the clinician and client to agree upon shared aims, expec-
tations and responsibilities. Frequency of therapy sessions
will vary dependent on the needs of the individual.
Not all the following areas will need to be addressed
but in current practice these are the ones that have
been found to be markers of male/female communication.
There are many excellent texts and resources available to
practising clinicians working with this client group to sup-
plement their existing clinical skills including e.g., Adler et
al., 2006, Andrews (1999) and Davies and Goldberg, 2006.
Although addressed separately, many of the areas described
below will be worked on simultaneously by a more general
approach to mimic natural usage. The development of com-
puter software programmes for voice analysis is also proving
invaluable for home practice.
Pitch and intonation
Most individuals identify this as the most obvious differ-
ence between male and female speakers and some may
have already experimented with a new pitch. Most trans
women have a personal goal of speaking in a higher pitch and
trans men at a low pitch. Often the trans male population is
neglected due to the therapists assumption that hormones
274 J. Thornton

Table 1 Goals of intervention.

Buts de lintervention.

Area Trans female Trans male

Pitch and intonation
Resonance
Speech and language
Articulation and speech rate
Increased pitch to at least neutral range Stabilisation of post hormonal voice
145-165Hz (Oates, 1997)
Therapy pre and post pitch changing
surgery to maximise surgical results
Dynamic pitch contours with gentle onset Narrower band of intonation with
and ending of utterance sharp drop at end of utterance
More head resonance, increasing the 3rd More chest resonance
formant to produce a lighter voice
More use of tag questions (isnt it?) More direct speech
More use of intensiers (very)
More descriptive words
Slower, lighter and more precise Harsher, clipped articulation with
articulation (Andrews, 1999) short vowels and omission of nal
Palatalisation of articulation phonemes

Domaine Trans femme Trans homme

Ton et intonation Augmenter le ton au moins jusqu la Stabilisation de la voix

Rsonance
locution et langage
Articulation et dbit dlocution
* Le timbre est dtermin par des formants. Ce sont les endroits du spectre sonore dun son qui prsentent les plus grandes accumu-
plage neutre de 145165 Hz (Oates et posthormonale
Dacakis, 1997)
Thrapie pr- et postchirurgie de Bande dintonation plus troite avec
changement de ton pour maximaliser les chute brusque la n de llocution
rsultats chirurgicaux
Contours de ton dynamique avec
dclenchement et n progressifs de
llocution
Plus de rsonance de tte, augmentant le Plus de rsonance de poitrine
f3 , (3e formant* ) pour produire une voix
plus lgre
Plus dutilisation de questions tag (nest-ce Plus dlocution directe
pas ?)
Plus dutilisation dintensicateurs (trs)
Plus de mots descriptifs
Articulation plus lente, plus lgre et plus Articulation plus hache, segmente
prcise (Andrews, 1999) avec de courtes voyelles et omission
Palatalisation de larticulation des phonmes naux

lations de pression sonore. f3 est corrl avec la conguration des lvres pour les voyelles antrieures.

alone will establish a male voice. Whilst administration of
androgens leads to an increase in vocal cord mass thereby
lowering pitch, other features of masculinisation communi-
cation are not automatically adopted and in some cases the
pitch change is limited.
Pitch changes through life, with the main change in the
biological male being at puberty, when the larynx lowers
thereby increasing the vocal tract length by as much as
15%. There is smaller, though signicant, change following
the menopause in women and in the elderly male resulting
from decreasing hormone levels. Different cultures will have
varying pitch differences with e.g. Dutch male and female
being very close whereas the Japanese male and female
pitch levels are much wider. Dependant on the age at refer-
ral, we can use these facts to aid voice change. Male and
female pitch range overlaps between 145165 Hz (Oates and
Dacakis, 1997) and historically clinicians have focused on
trans people achieving a voice within this gender ambigu-
ous range. Indeed, some authors (Wolfe et al., 1990 and
Spencer, 1988) have suggested that the pitch alone (of
an English speaker) will be deemed female if it is above
160/165 Hz.
Manipulation of vocal tract length by altering laryngeal
height whilst keeping an open and relaxed internal laryngeal
posture allows the individual to focus on a reduced, more
gender-specic pitch range. The importance of achieving an
Working with the transgender voice: The role of the speech and language therapist
acceptable voice that is appropriate to both the age and
physique of the person cannot be overstated.
If the trans person is to undergo pitch changing surgery,
therapy both before and after the procedure is recom-
mended to counsel on the effects of surgery on voice and
help with the stabilisation of the voice postsurgery.
Patterns of intonation and intonation contours (i.e. the
tune of the utterance) are often easier to adapt in a more
natural pattern than concentrating on pitch alone and
often lead to an overall increase in pitch. Certain accents
are recognised as being more tuneful than others. In
general, English-speaking female voices are judged to
be more dynamic, lively and generally use more upward
inections than English speaking male voices. Therapy will
focus on developing uent intonation without dramatic
shifts in pitch. Encouraging gentle onset and nishing of
phrases/utterances in trans women and a narrower, though
not monotone, pitch in trans men. In trans women, this
helps to eradicate the perceptually aggressive style of the
male speaker which may be characterised by a sharp
drop in intonation at the ends of phrases. Instrumentation
which provides visual representation during speaking tasks
enables immediate biofeedback to facilitate change in the
therapy session.
Resonance
The trans woman will be aware of the need not to use a deep
rumbling chest voice and to create more head resonance.
In practice, we talk of shifting the balance of resonance (i.e.
adapting the formant frequencies), avoiding elimination of
chest resonance completely, as this is required for a robust
and healthy speaking voice quality. Imagining the voice as
lighter and lifting the voice in association with obtaining
tactile sensation from the chest and face, altering lip and
tongue placement are often sufcient to achieve a redistri-
bution in resonance and an increase in formant frequency
values (Carew et al., 2007).
Speech and language differences
Language is constantly evolving and the language style of
the young will not be the same as that of elders within their
community. In the eld of linguistics, it is recognised that
there are certain learned styles of communication that are
gender-specic, which are socially determined e.g. conver-
sational role of the speaker, use of tag questions (e.g. isnt
it?) and intensiers (e.g. very). Society is changing and the
traditional roles are being challenged. However, there
are gender-specic linguistic features that the trans person
can adopt to achieve congruence with chosen gender and
societys expectations of that gender. Role play is often used
to demonstrate this aspect.
Articulation and speech rate
Andrews (1999), amongst others, describes gender differ-
ences between male and female articulatory patterns with
female speech tending to be slower, with articulation being
lighter and more precise than male articulation. Male speech
275
tends to be harsher and more clipped with shortening of
words by dropping nal phonemes. It is hypothesised that
this is related to the female traditionally being the model for
child speech development thereby necessitating the need
for clear speech. Females tend to have palatalised speech
i.e. the tongue blade and sides have a closer approxima-
tion to the molars giving it a raised setting, resulting in a
change to the third formant which is signicant in the per-
ception of the female voice. Encouraging an elevated tongue
position during therapy tasks will also result in a shortening
of the entire vocal tract thus working on both pitch and
articulation simultaneously.
Nonverbal communication and vegetative functions
Whilst being mindful of cultural factors and practices, there
are some aspects of nonverbal communication (i.e. posture
and positioning, use of gesture, turn taking, eye contact
and facial expression) that are gender-specic. The use of
video recording during the session accompanied by sensi-
tive feedback is useful. People watching and television
viewing to look for appropriate role model behaviour is
encouraged. Natural functions including coughing, sneezing
and laughing may need special attention towards the end of
therapy if they have not already adapted through general
assimilation.
Discharge
Termination of therapy is dependent on many factors. It
is generally agreed that regular therapy will cease when
the client has achieved all goals or no further progress is
likely. Ideally, this should be a joint decision and constant
re-evaluation throughout the course of therapy would have
ensured the areas most relevant to the individual have been
addressed.
Conclusion
Voice and communication therapy have a vital part to play in
the successful transition of some trans people. Some, gen-
erally those transitioning early or late in life, will have less
need for specic therapy for reasons stated earlier but, for
the majority, undertaking successful and complete transi-
tion to their chosen gender, some assistance will be needed.
Speech and language therapy will enable safe experimen-
tation within a relaxed environment. If appropriate, all
areas above will be addressed in order for the individuals
communication style to be perceived appropriately. There
is, unfortunately, little research into the length of therapy
required and the long term benets of voice modication.
Dacakis (2000), details a decrease in group fundamental fre-
quency for trans women following discharge from 168.1Hz to
146.5Hz, with a suggestion that the fundamental frequency
shift achieved and the successful maintenance of change is
dependant on the number of therapy sessions. Sderpalm et
al. (2004), however, does not nd a link between number of
therapy sessions and outcome.
Voice change often continues following discharge as
the person becomes more settled in their core gen-
276
der, with increasing acceptance of the new voice enabling
more vocal exibility and condence in communication.
Amount of change is specic to the individual and some may
decide not to alter their voice/communication. Ultimately,
it is the individuals perception of satisfaction with their
communication in different situations, rather than a single
communication style, which will determine successful func-
tioning in their lives. Speech and Language Therapists work
with the trans person to experiment with varying degrees of
change to enable the individual to decide how and when to
use these new skills (Pasricha et al., 2008).
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