When I began applying to speech-language pathology graduate programs I knew I wanted to work with the queer population. Specifically, I wanted to perform gender- affirming voice therapy. This type of therapy is provided when a client would like to achieve more gender-alignment, which is the agreement of gender-expression and gender-identity. This alignment has been proven to be successful and to have positive effects on individuals’ mental health status, which makes this type of therapy all the more rewarding and enticing for a clinician (Hancock & Garabedian, 2012; Davis & Colton, 2014). Without it, many individuals could feel gender dysphoria (the internal conflict between gender and sex) or could be misgendered. Misgendering is when one’s gender is misidentified, potentially based upon physical characteristics like one’s voice, and this would mean that they are not “passing” or being identified as the gender they are expressing(McLemore, 2014). This can lead to internal turmoil as well as possible violence against the individual. Other factors that could impact the mental health of a trans individual are the use of their “dead name” (the name they were called prior to transitioning, and it may appear on their paperwork, along with potentially incorrect gender/sex information) or gendered-language that is commonly used. For example, some of the language we commonly use (i.e., “preferred pronouns”, “you guys”) can be deemed as offensive to some individuals. It is best to stray from any language you think could make any client uncomfortable, especially the population you’re working with.
Using this language, one’s dead name, or misgendering an individual can all be interpreted as microaggressions, which is the use of a comment or action that, although often unconscious, suggests a prejudiced attitude towards a marginalized group. These can be detrimental to anyone’s mental health, and as a clinician working with this population it is essential to be aware of how these can impact your client. Thus, as I began my journey in working with trans clients I knew it was critical that I be well aware of these facets of their lived experience. However, despite the intersection of mental health, the queer population, and speech-language pathology being the perfect concoction for my future career, I had yet to discover the speedbumps I would encounter and the many directions this type of therapy could take me.
Before Graduate School
Given the knowledge from my undergraduate classes, I was aware that voice could be analyzed in five domains: respiration, phonation, resonance, pitch/prosody, and articulation. Initially, I had assumed voice therapy was tailored to clinicians who were more musically inclined. Since I can’t carry a tune in a bucket, I told myself to focus on only the basics. We were taught that these domains can be adjusted to better suit clients such as singers, individuals with voice disorders, and even the transgender population. When I heard that my ears perked up. I was unaware that I would be able to help the this population, and being an LGBT Studies minor and a member of the queer community I immediately knew this was what I wanted to do.
Thus, I applied to graduate programs that I knew would provide exposure to this type of therapy. To learn more about what my education could look like, I set up a meeting with the advisor in charge of voice clients in the University of Maryland (UMD) Hearing and Speech Clinic. She was happy to meet with me regarding the transgender clients, and had a clear passion for this work. This meeting taught me several things I had yet to consider:
- Though this therapy may be considered ‘elective’ it can be life-saving for individuals who lack gender-alignment, have mental health concerns, and need to “pass” in society without the threat of transphobic violence (Stotzer, 2009),
- most transgender voice clients are trans women because when trans men take their hormone treatments their voices naturally deepen (Davis & Colton, 2014),
- I would need to become a solid voice model for my clients, which would mean training my voice and ears in ways I had never used them before, and
- being a man could be complicated when I am teaching a woman how to sound more like a woman.
The last lesson made me feel deflated. I did not want to do a disservice to this population by underperforming or making my clients feel uncomfortable in our sessions; especially considering that solid rapport and comfort in sessions evidently provide better therapeutic outcomes, particularly with transgender voice therapy (Romijnders, Wilkerson, Crutzen, Kok, Bauldry, & Lawler, 2017).
When I was accepted to the University of Maryland Speech-Language Pathology program, I was unsure of whether or not this therapy would be possible for me. Despite my uncertainty, that same advisor scheduled me a transgender voice client and my journey in transgender voice therapy began.
Graduate School: Year 1
Preparing for my First Client
After I was assigned my first client I made it my mission to find the most current research on transgender voice therapy. The articles I read revealed that voice qualities like pitch, prosody, and resonance of an individual’s voice are highly attended to when confirming assumptions of a speaker’s gender (Schneider & Courey, 2016). Additionally, I read up on current voice therapy practices through Joseph Stemple’s work, who taught me vocal function exercises which included:
- sustaining /i/ and /s/ for as long as possible,
- stretching the vocal folds by using the word “knoll” and gliding from low to high notes,
- contracting the vocal folds by using the word “knoll” and gliding from high to low notes, and
- sustaining a note for as long as possible on the word “ole”.
Along with this research I found it was also necessary to better understand gender, as the concept of gender can be taken for granted or ignored by individuals, like myself, who are cisgender (meaning they identify as the gender they were assigned at birth).
Rapport is Key
Once I sat down with my client , putting my therapeutic training into practice became my main focus for our first few sessions. When I began to feel more comfortable with modelling vocal function, meeting pitch in the “feminine range”, and practicing different voice strategies I began to feel myself, and my client, relax into our routine. We grew more comfortable with each other, and considering we were both noticeably nervous initially I was glad to feel a shift in the tone of our sessions.
In the middle of one session, approximately half way through our time together, my client’s voice cracked. It was not the first time this happened, but she was more upset by it than usual. She began to tell me how she had been misgendered by a stranger earlier that week and how much it upset her, and that she felt that our sessions weren’t working. This was the first time she had been so candid, and the first time I had been this position. Instinctually, I began to tell her of the obvious progress she had made and how this stranger was not the judge of her – she was. I also recommended she listen to some recordings of herself from the beginning of our time together just to hear the difference. We spent the rest of the session talking this out.
After leaving that session I felt completely unsure of my counseling skills, and my skills as a clinician. I feared in our next session she would be even more defeated and would cancel her treatment. When our next session came, we sat in our seats and were about to begin our exercise routine. Before we began, she told me something that made my heart stop; she had indeed found old recordings of herself and she wanted me to listen. As she played them, I knew that we were both hearing the same thing. Undeniable change.
Her voice on the recordings was monotone, and clearly lower pitch. She had made evident improvement towards her goals, and the smile on her face confirmed it. Most importantly, she had found the proof herself. This was the just what we both needed to keep going, and her voice grew closer where she wanted it with each of our sessions together. I believe it was that pivotal moment that made our client-clinician relationship so strong, and I like to think our bond helped in her voice’s progress.
Graduate School: Year 2
Externship in Voice
For my second clinical outplacement I was chosen to work in the John’s Hopkins Department of Otolaryngology: Head and Neck Cancer. This department focused on dysphagia and voice therapy for clients with a wide variety of diagnoses; including clients undergoing transgender voice therapy. When I began in this position, my advisor asked me what I knew about the therapy and immediately I gave her Stemple’s vocal function exercises as well as the chart of “masculine” and “feminine” pitch ranges. She nodded along to the vocal function exercises and when I began talking about the pitch ranges her eyebrows raised. After I had finished explaining, she had flipped through her clipboard filled with resources and showed me that very chart. She told me that this was just a jumping off point, but I had not yet truly experienced what she meant.
As I observed her working with her clients I soon realized the difference. I had been using this chart as a strict guideline, she used it as a suggestion. When working with my first client at the UMD clinic, I kept watch of how her pitch changed on a guitar-tuning app, and her goals were based on her ability to maintain certain pitches. This was not the case with my Hopkin’s advisor. She just listened. To be fair, she was very musically-inclined and had perfect pitch which essentially made her ear a tuning app. However, she would only comment on the pitch; it was never the goal.
The goal, was based on the client’s satisfaction. With my UMD client, I had chosen her goal based upon what the chart said was appropriate. With the clients at Hopkins, their goals were based on what they wanted from their voices. Some clients only wanted more intonations in their voice. Some wanted to be able to project their voices, and could not coordinate their pitch and volume. One client did not want to sound like their mother, so they chose to avoid the traditionally “feminine” range altogether. The prescriptive, rigid way I was thinking was barring me from realizing what voice therapy truly should be; whatever makes the client feel that their gender-identity and gender-expression are in alignment.
Additionally, my Hopkin’s advisor utilized her medical knowledge of voice in ways I could not conceptualize before. She would propose techniques based on what she heard in order to get the client’s voices really working. She understood the vocal anatomy, and thus, could use treatment strategies that could manipulate mechanisms for better voice production. The ease with which she built rapport with her clients lent itself well to them being receptive to whatever suggestion she threw at them.
Previously, I had only had my routine of the same vocal function exercises, with the same pitch drills, with the same prompts. My advisor had created an ingenious set up. The clients were very comfortable, and she was able to propose any “silly” strategy or exercise that were anatomically-based and she would even explain the mechanisms to the clients. It was the way she infused this partnership within her therapy plan that astounded me, and was clearly effective for her clients on many levels.
Candidacy Research and Future Plans
When it came time to do research on a topic in the speech-language field, my choice was clear. Based on my experience, there was a facet of trans voice I had yet to explore: group therapy. I had seen the positive effects of group therapy with other populations I had worked with, including people who stutter and people with aphasia, and I could predict the same positive effect with the transgender population. I also wanted to think of the mental health implications of voice therapy with transgender individuals, considering my first client’s experience and current research both confirm that mental health is intrinsically intertwined in the transitioning and gender-alignment process (Bouman, Davey, Meyer, Witcomb, & Arcelus, 2016). My research had revealed that mental health of trans people is connected to their perceptions of their voice, and whether or not it is aligned with their gender (Hancock, 2017). It also indicated that there is a correlation between social acceptance and the mental health of trans individuals (Romijnders et al., 2017).
Although I did not actually conduct a study on the real-time effects of a transgender voice group, I have spoken with clinicians who lead such groups and they report excellent results. I truly believe this will be the path I take my career; working with transgender clients and providing both individual and group sessions. Keeping in mind to build a strong relationship with my clients, to base their goals on what they would like their voices to sound like, and to utilize a plethora of different techniques and strategies based on anatomy and research that will get them to achieve their goals.
Bouman, W. P., Davey, A., Meyer, C., Witcomb, G. L., & Arcelus, J. (2016). Predictors of psychological well-being among treatment seeking transgender individuals. Sexual and Relationship Therapy, 1–17. doi: 10.1080/14681994.2016.1184754
Davis, S. A., & Meier, S. C. (2014). Effects of Testosterone Treatment and Chest Reconstruction Surgery on Mental Health and Sexuality in Female-To-Male Transgender People. International Journal of Sexual Health, 26(2), 113–128. doi: 10.1080/19317611.2013.833152
Hancock, A. B. (2017). An ICF Perspective on Voice-related Quality of Life of American Transgender Women. Journal of Voice, 31(1). doi: 10.1016/j.jvoice.2016.03.013
Hancock, A. B., & Garabedian, L. M. (2012). Transgender voice and communication treatment: a retrospective chart review of 25 cases. International Journal of Language & Communication Disorders, 48(1), 54–65. doi: 10.1111/j.1460-6984.2012.00185.x
McLemore, K. A. (2014). Experiences with Misgendering: Identity Misclassification of Transgender Spectrum Individuals. Self and Identity, 14(1), 51–74. doi: 10.1080/15298868.2014.950691
Romijnders, K. A., Wilkerson, J. M., Crutzen, R., Kok, G., Bauldry, J., & Lawler, S. M. (2017). Strengthening Social Ties to Increase Confidence and Self-Esteem Among Sexual and Gender Minority Youth. Health Promotion Practice, 18(3), 341–347. doi: 10.1177/1524839917690335
Schneider, S., & Courey, M. (2016). Transgender voice and communication – vocal health and considerations. UCSF Transgender Care. Retrieved from https://transcare.ucsf.edu/guidelines/vocal-health
Stemple, J. C., & Hapner, E. R. (2019). Voice therapy: clinical case studies. San Diego, CA: Plural Publishing.
Stemple, J. C., Roy, N., & Klaben, B. (2020). Clinical voice pathology: theory and management. San Diego, CA: Plural Publishing Inc.
Stotzer, R. L. (2009). Violence against transgender people: A review of United States data. Aggression and Violent Behavior, 14(3), 170–179. doi: 10.1016/j.avb.2009.01.006
About the Author
Michael Pensabene is a graduate student in the department of Hearing and Speech Sciences at the University of Maryland. He is a member of the Cultural-Linguistic Diversity Emphasis Program (CLD-EP) and has interned in multiple medical settings including Mt. Washington Pediatric Hospital and Johns Hopkins Department of Otolaryngology. His clinical interests include gender-affirming voice therapy with the transgender population.