Guidance for Research with Trans and Gender-Diverse People.

When engaging in research with marginalized communities, it is important for researchers to reflect on their practice and consider what steps they can take to avoid perpetuating inequality or causing harm. This article provides guidance for researchers working with trans and gender-diverse individuals from the perspective of two speech-language pathologists. Key considerations presented by the authors include the importance of engaging in reflexive research practices-thinking deeply about and acknowledging impacts of one's personal beliefs, values, and practices on one's research-and developing an awareness of factors that contribute to the trans and gender-diverse community's ongoing minority stress. Specific suggestions to redress power imbalance between the researcher and the researched community are provided. Finally, practical methods for implementing the guidance are presented: the community-based participatory research model and an example in speech-language pathology research with trans and gender-diverse individuals.

Perceptions of Gender and Femininity Based on Language: Implications for Transgender Communication Therapy.

Recent research presents a picture of diminishing gender differences in language. Two experiments examined whether language use can predict perceptions of gender and femininity; one included male and female speakers telling a personal narrative, the other also included male-to-female transgender speakers and analyzed an oral picture description. In each experiment, raters read transcribed samples before judging the gender and rating the femininity of the speaker. Only number of T-units, words per T-unit, dependent clauses per T-unit, and personal pronouns per T-unit emerged as different between gender groups. As none of the variables were strongly correlated with perceptual judgments, regression analysis was used to determine how combinations of linguistic variables predict female/feminine ratings. Results from these two studies demonstrate that gender-related differences in language use for these two contexts are limited, and that any relationship of language to perceptions of gender and femininity is complex and multivariate. This information calls into question the utility of training key language features in transgender communication therapy.

Transgender voice and communication treatment: a retrospective chart review of 25 cases.

BACKGROUND: People transitioning from male to female (MTF) gender seek speech-language pathology services when they feel their voice is betraying their genuine self or perhaps is the last obstacle to representing their authentic gender. Speaking fundamental frequency (pitch) and resonance are most often targets in treatment because the combination of these two voice characteristics can account for the majority of how listeners perceive a speaker's gender. Intonation, voice quality, pragmatics and non-verbal communication contribute to a lesser extent but are usually recommended in treatment guidelines. There are few examples of effective treatment with male-to-female transgender individuals in the literature. Due to a small number of reports, it remains unclear how closely clinical practice follows recommended approaches and the extent to which gains may be expected. AIMS: The purpose of this study was to examine retrospectively 5 years' worth of cases of voice feminization treatment at a university clinic in order to describe a unique clinical population and report treatment techniques and outcomes. METHODS & PROCEDURES: Demographic information and treatment outcome data (e.g. acoustic measures) were available for collection from 25 of the 32 cases discharged from a university clinic between 2006 and 2010. Behavioural targets of treatment goals also were examined. OUTCOMES & RESULTS: Clients were in various stages of male-to-female gender transitions during treatment; at discharge, 80% of them presented as female 100% of the time. A majority (88%) had a history of feminizing hormone treatment and 28% presented with a voice disorder separate from gender presentation concerns. Treatment goals included the following (listed in order of percentage of cases that addressed the topic): forward resonance, increased fundamental frequency or pitch, physical and mental relaxation, intonation, phonotraumatic behaviours, breath control, non-verbal communication, pragmatics, and vocal hygiene. After treatment, clients had increased speaking fundamental frequency in sustained vowel, reading, and monologue tasks by five to six semitones, which is statistically significant. Gains in fundamental frequency correlated significantly with total number of sessions, but no other correlations were significant. CONCLUSIONS & IMPLICATIONS: Treatment goals for clients included in this study were consistent with those goals most often recommended in the research literature regarding voice and communication treatment for transgender clients. Voice and communication treatment resulted in gains in areas important to listeners' perception of gender. Further research is warranted to determine efficacy of specific treatment protocols and potentially influential factors such as initial voice and communication status.

Gender Attributions by Cisgender and Gender Diverse Listeners Rating Vowels, Reading, and Monologues.

OBJECTIVES: To determine if listeners' attributions of speakers' gender vary by linguistic context and/or the listeners' gender identity. METHODS: Seventeen self-identified transgender adults assigned male at birth were audio-recorded prolonging /a/, reading sentences, and saying spontaneous monologues. Eighteen adults (10 cisgender and 8 gender-diverse individuals) listened and used a 1-5 scale (1: very masculine, 2: somewhat masculine, 3: androgynous, 4: somewhat feminine, and 5: very feminine) to rate the gender attribution of each speech sample. RESULTS: The intra-rater reliability was moderate to excellent (0.62-1.00). Ratings by cisgender and gender-diverse listeners were not significantly different. Ratings were not significantly different between different speech contexts of vowel, reading, and spontaneous monologue speech samples. CONCLUSIONS: Transwomen have many variables available to consider and use in their communication. The linguistic context (eg, reading a speech versus spontaneous monologue) or listener's gender does not appear to be highly influential factors in how listeners attribute gender.

Supporting Well-Being in Gender-Diverse People: A Tutorial for Implementing Conceptual and Practical Shifts Toward Culturally Responsive, Person-Centered Care in Speech-Language Pathology.

PURPOSE: Gender dysphoria is commonly conceptualized as a mental disorder in gender-diverse people who do not identify with the gender assigned to them at birth. Direct support for well-being tends to be delegated to the field of mental health (MH), whereas speech-language pathology (SLP) practice is charged with modifying gender-diverse people's voice and communication in the belief that well-being will improve as a byproduct. However, with the introduction of the minority stress model, gender dysphoria is now understood as the result of sociocultural processes of stigmatization, pathologization, coping, and resilience, and it is to be addressed by all professions providing transgender health services. The purposes of this tutorial are to examine practices in SLP in light of the current conceptualization of gender dysphoria and guide speech-language pathologists in their role in supporting the well-being of gender-diverse people. METHOD: We reviewed the SLP and MH literature in the topic area to compare the two disciplines' conceptualizations and approaches to professional support for gender-diverse people. RESULTS: We propose a transdisciplinary, person-centered, and culturally responsive approach to SLP practice that directly attends to minority stress, microaggressions, coping skills, and resilience factors. CONCLUSIONS: It is not sufficient for speech-language pathologists to delegate support for well-being in gender-diverse people to MH practitioners. Rather, speech-language pathologists need to be proactive in taking responsibility for supporting their clients' well-being based on each individual clinician's knowledge, skills, and capacity to do so. We recommend addressing barriers and facilitators of gender-diverse people's well-being both within SLP as a professional culture and by adapting the clinician's own professional practice.

Listening to Gender-Diverse People of Color: Barriers to Accessing Voice and Communication Care.

Purpose The purposes of this study are to gather and analyze perspectives of people from racial and gender minority groups in order to identify barriers to voice and communication services for these populations. Method In focus groups facilitated by community members, 11 people in racial and gender minority groups discussed their gender-related goals and accessibility of voice and communication services. Salient themes were derived using a grounded theory approach and analyzed using an access to care framework. Results During discussion of voice and communication as it relates to gender presentation, most utterances were speculations on the processes and potential outcomes of interventions for voice and communication; the majority of these were characterized as uninformed or misinformed. Conclusions Future studies will need to overcome barriers related to health literacy and beliefs in order to thoroughly assess potential interest or intentions regarding voice and communication services. Additional study is expected to provide valuable information that can be interpreted using the Levesque et al. (2013) framework of access to care and eventually eliminate barriers to voice and communication services for all.

Incorporating Mobile App Technology in Voice Modification Protocol for Transgender Women.

PURPOSE: Motivated by practice and feedback principles of motor learning, a hybrid clinic-home protocol for voice feminization was developed to minimize the role of SLPs to 1 of supervision and professional guidance and to maximize learning during independent practice apart from intervention sessions. The purpose was to explore the effectiveness and acceptability of the innovative service delivery. METHOD: This single-subject changing criterion design included four transgender women who completed a 10-week hybrid clinic-home voice intervention program delivered via 30 -minute weekly in-clinic sessions and a technology-supported home program. The program was client-centered and capitalized on principles of motor learning in that it incorporated frequent practice with intermittent, knowledge-of-result feedback. Participants' desired outcomes were measured using acoustics, self and listener ratings of audio samples, and a program evaluation questionnaire. RESULTS: Average speaking fundamental frequency of phrases and picture descriptions gradually increased into the 170-220 Hz range for all except one participant. All four transgender women were perceived to sound more feminine following treatment compared to baseline. Participants found the in-clinic sessions useful, the app easy to use, and noted limited fatigue or discomfort. CONCLUSION: Four transwomen met their goals using this hybrid clinic-home service delivery format. Further investigations may elucidate key factors of the success achieved in the current study by designing comparison delivery models and including people from other populations.

Forces Affecting Voice Function in Gender Diverse People Assigned Female at Birth.

OBJECTIVES: The purpose of this study was to explore the factors and practices that have acted as facilitators or barriers to voice function in gender diverse people assigned female at birth (GD peopleAFAB) from a participant-centered perspective and to inform the role of speech-language pathologists in supporting GD peopleAFAB with developing and maintaining functional voice production. METHODS: Transcripts of semistructured interviews with 14 German-speaking GD peopleAFAB were analyzed for the study objectives using a consensual approach to qualitative content analysis. The interviews and their interpretation were conceptualized as co-constructions of participants and researchers who were regarded as experts in their own right. RESULTS: Professional practices (testosterone treatment, professional voice support), speaker practices (self-care and voice use practices, self-evaluation of voice function), conversation partner practices, and supraindividual biocultural forces (vocal demands, normative practices, other biocultural forces) were identified as having influenced the participants' voice function. Professional voice support, a range of phonation practices, and general self- and voice care practices were frequently cited facilitators of functional voice production. The most frequent barriers to voice function included testosterone treatment, slouched posture, excess muscle tension, forceful voice use, and avoidance practices. CONCLUSIONS: Voice function in GD peopleAFAB is influenced by interactions of several forces, most of which may be shared by voice users of all genders. Professional practices should follow a person-centered approach to care in which all parties are well informed of the limitations and possibilities for any intervention, including the often-unquestioned contribution of testosterone treatment.

Who or what has the capacity to influence voice production? Development of a transdisciplinary theoretical approach to clinical practice addressing voice and the communication of speaker socio-cultural positioning.

Purpose: The purpose of this conceptual study was to develop a transdisciplinary theoretical approach to clinical practice in the area of voice that is informed by contemporary clinical and social sciences theories of voice production.Method: We used theoretical sampling to survey the clinical voice literature for different conceptualisations of forces that contribute to voice production and analysed these forces' capacity to act ("agency") on voice. We classified the selected conceptualisations according to wider theoretical perspectives that informed them and evaluated their capacity to account for the complexity of voice production.Result: We identified biological determinist, constructionist, and socio-cultural mediation theories as informing the various conceptualisations of voice production and agency. Finding all theories identified in the clinical voice literature inadequate, the conceptualisation of agency as a bioculturally mediated capacity to act was explored and found to be most suitable for a new transdisciplinary theoretical approach to clinical practice in the area of voice.Conclusion: The inextricable interplay between speaker, professional, and listener practices and supra-individual biocultural forces in voice production must be acknowledged. Clients need to be prepared to deal confidently with the multi-faceted, dynamic, and unpredictable nature of how voice function and socio-cultural positioning is produced in social encounters.

An ICF Perspective on Voice-related Quality of Life of American Transgender Women.

PURPOSE: The factors and correlates of voice-related quality of life (vQOL) in American transgender women (ie, male-to-female) were examined using two questionnaires and were reviewed in the context of the International Classification of Functioning, Disability, and Health (ICF) model. This information will assist clinicians to be culturally and clinically competent providers of voice and communication feminization services. METHODS: A diverse group of 81 transgender women completed a survey to report relevant demographic information, as well as the Voice Handicap Index and the Transgender Self-evaluation Questionnaire (TSEQ). Descriptive statistics for the overall levels of vQOL were calculated. Items from the TSEQ were sorted to correspond to the ICF components to allow for description and ranking of factors impacting health function. Spearman correlations were used to examine the relationships between questionnaire scores and to select demographic and gender transition characteristics (ie, personal factors in the ICF). RESULTS: These transgender women reported a wide range of vQOL; some are severely restricted by their voice and communication, whereas others are not. The most common concerns are emotional reactions to activity limitations and participation restrictions. Personal factors related to demographics and gender transition generally were not significant contributors to the vQOL scores. CONCLUSIONS: In addition to addressing the physiological functions of the voice, speech language pathologists should cultivate cultural competence and consider transgender clients' emotional reactions to voice function impairments and related life participation restrictions.

Trans Male Voice in the First Year of Testosterone Therapy: Make No Assumptions.

Purpose: The purpose of this study was to prospectively examine changes in gender-related voice domain of pitch measured by fundamental frequency, function-related domains of vocal quality, range, and habitual pitch level and the self-perceptions of transmasculine people during their first year of testosterone treatment. Method: Seven trans men received 2 voice assessments at baseline and 1 assessment at 3, 6, 9, and 12 months after starting treatment. Results: Vocal quality measures varied between and within participants but were generally within normal limits throughout the year. Mean fundamental frequency (MF0) during reading decreased, although to variable extents and rates. Phonation frequency range shifted down the scale, although it increased in some participants and decreased in others. Considering MF0 and phonation frequency range together in a measure of habitual pitch level revealed that the majority of participants spoke using an MF0 that was low within their range compared with cisgender norms. Although the trans men generally self-reported voice masculinization, it was not correlated with MF0, frequency range, or habitual pitch level at any time point or with MF0 note change from baseline to 1 year of testosterone treatment, but correlations should be interpreted with caution due to the heterogeneous responses of the 7 participants. Conclusion: In trans men, consideration of voice deepening in the context of objective and subjective measures of voice can reveal unique profiles and inform patient care.

Utility of virtual reality environments to examine physiological reactivity and subjective distress in adults who stutter.

PURPOSE: Virtual reality environments (VREs) allow for immersion in speaking environments that mimic real-life interactions while maintaining researcher control. VREs have been used successfully to engender arousal in other disorders. The purpose of this study was to investigate the utility of virtual reality environments to examine physiological reactivity and subjective ratings of distress in persons who stutter (PWS). METHOD: Subjective and objective measures of arousal were collected from 10PWS during four-minute speeches to a virtual audience and to a virtual empty room. RESULTS: Stuttering frequency and physiological measures (skin conductance level and heart rate) did not differ across speaking conditions, but subjective ratings of distress were significantly higher in the virtual audience condition compared to the virtual empty room. CONCLUSION: VREs have utility in elevating subjective ratings of distress in PWS. VREs have the potential to be useful tools for practicing treatment targets in a safe, controlled, and systematic manner.

Real enough: using virtual public speaking environments to evoke feelings and behaviors targeted in stuttering assessment and treatment.

PURPOSE: Virtual reality environments (VREs) are computer-generated, 3-dimensional worlds that allow users to experience situations similar to those encountered in the real world. The purpose of this study was to investigate VREs for potential use in assessing and treating persons who stutter (PWS) by determining the extent to which PWS's affective, behavioral, and cognitive measures in a VRE correlate with those same measures in a similar live environment. METHOD: Ten PWS delivered speeches-first to a live audience and, on another day, to 2 virtual audiences (neutral and challenging audiences). Participants completed standard tests of communication apprehension and confidence prior to each condition, and frequency of stuttering was measured during each speech. RESULTS: Correlational analyses revealed significant, positive correlations between virtual and live conditions for affective and cognitive measures as well as for frequency of stuttering. CONCLUSIONS: These findings suggest that virtual public speaking environments engender affective, behavioral, and cognitive reactions in PWS that correspond to those experienced in the real world. Therefore, the authentic, safe, and controlled environments provided by VREs may be useful for stuttering assessment and treatment.

Acoustic and aerodynamic measures of the voice during pregnancy.

BACKGROUND: Known influences of sex hormones on the voice would suggest pregnancy hormones could have an effect, yet studies using acoustic measures have not indicated changes. Additionally, no examination of the voice before the third trimester has been reported. Effect of pregnancy on the voice is relatively unexplored yet could be quite relevant to female speakers and singers. OBJECTIVES/HYPOTHESIS: It is possible that spectral and aerodynamic measures would be more sensitive to tissue-level changes caused by pregnancy hormones. DESIGN/METHODS: In this first longitudinal study of a 32-year-old woman's pregnancy, weekly voice samples were analyzed for acoustic (fundamental frequency, perturbation ratios of shimmer and jitter, Harmonic-to-Noise Ratio, spectral measures, and maximum phonation time) and aerodynamic (average airflow, peak flow, AC/DC ratio, open quotient, and speed quotient) parameters. RESULTS: All measures appeared generally stable during weeks 11-39 of pregnancy compared with 21 weeks postpartum. Slight decrease in minimum airflow and open speed quotient may reflect suspected vocal fold tissue changes. CONCLUSIONS: It is recommended that future studies monitor and test correlations among hormone levels, visual analyses of vocal fold mucosa, aerodynamic function, and glottal efficiency.

Script training treatment for adults with apraxia of speech.

PURPOSE: Outcomes of script training for individuals with apraxia of speech (AOS) and mild anomic aphasia were investigated. Script training is a functional treatment that has been successful for individuals with aphasia but has not been applied to individuals with AOS. Principles of motor learning were incorporated into training to promote long-term retention of scripts. METHOD: Three individuals with AOS completed script training. A multiple-baseline, across-behaviors design examined acquisition of client-selected scripts. Errors and speaking rates were also analyzed. Random practice and delayed feedback were incorporated into training to promote motor learning. Probes for long-term retention were elicited up to 6 months after treatment. RESULTS: All clients successfully acquired their scripts, and probes demonstrated script retention 6 months after treatment. Errors generally decreased but remained variable even during maintenance and retention probes. Speaking rate increased for 2 clients but also remained variable. CONCLUSIONS: Script training was successful and functional for clients with AOS. Clients reported increased confidence, speaking ease, and speech naturalness. Although scripts did not become errorless, clients retained their scripts and reported using them frequently. Whether principles of motor learning may have promoted the long-term retention of scripts exhibited by participants must be determined through future research.

Voice perceptions and quality of life of transgender people.

Despite the plethora of research documenting that the voice and quality of life (QoL) are related, the exact nature of this relationship is vague. Studies have not addressed people who consider their voice to influence their life and identity, but would not be considered to have a voice "disorder" (e.g., transgender individuals). Individuals seeking vocal feminization may or may not have vocal pathology and often have concerns not addressed on the standard psychosocial measures of voice impact. Recent development of a voice-related QoL measure specific to the needs of transgender care (Transgender Self-Evaluation Questionnaire [TSEQ]) affords opportunity to explore relationships between self-perceived QoL and perceptions of femininity and likability associated with transgender voice. Twenty male-to-female transgender individuals living as a female 100% of the time completed the TSEQ and contributed a speech sample describing Norman Rockwell's "The Waiting Room" picture. Twenty-five undergraduate listeners rated voice femininity and voice likability after audio-only presentation of each speech sample. Speakers also self-rated their voices on these parameters. For male-to-female transgender clients, QoL is moderately correlated with how others perceive their voice. QoL ratings correlate more strongly with speaker's self-rated perception of voice compared with others' perceptions, more so for likability than femininity. This study complements previous research reports that subjective measures from clients and listeners may be valuable for evaluating the effectiveness of treatment in terms of how treatment influences voice-related QoL issues for transgender people.

Formative feedback, rubrics, and assessment of professional competency through a speech-language pathology graduate program.

Professional competencies independent of discipline-specific knowledge and skills are addressed by most allied health professions. This paper presents the process of developing and testing a Graduate Student Development Profile (GSDP) in rubric format. In addition to documenting behaviors, a rubric system provides formative feedback helpful to student learning and development as a professional. A rubric for rating responsibility for learning, critical thinking, cognitive flexibility, professionalism, and communication, each with specific subcategories, was created, developed, and implemented by faculty and clinical staff to guide the three sequential evaluations each master's level student receives during the five-semester speech-language pathology program. Pilot scoring of master's students was used to calibrate and refine the GSDP before official implementation. Two evaluations were completed during faculty meetings to familiarize users with the GSDP. A third evaluation was conducted via a secured website. In each case, resulting scores and specific comments for each student were shared during a faculty meeting before being presented to students individually. The GSDP documents the speech-language pathology student's professional competency demonstrated across academic, clinical, and interpersonal settings. The web-based version brings convenience and efficiency to the often formidable, but fundamentally necessary, process of providing formative and summative feedback to students.

Public speaking attitudes: does curriculum make a difference?

In light of infamous levels of fear associated with public speaking, businesses are training staff in communication effectiveness and universities are requiring courses in public speaking. A variety of approaches to individual training are available, but few studies have assessed effectiveness of group instruction, as in academic curricula. The specific purpose of this study was to compare changes in scores on measures of self-perceived confidence, competence, and apprehension associated with public speaking after two types of courses: one focused on knowledge of the vocal mechanism and mastering vocal characteristics (pitch, volume, rate, quality), and one addressing general communication theory and public speaking. Seventy-one undergraduate students enrolled in "Voice and Diction" at George Washington University (GWU) and 68 enrolled in "Fundamental Speech" at Florida State University completed questionnaires before and after the courses. Scores on Self-Perceived Communication Competence Scale, Personal Report of Confidence as a Speaker, and Personal Report of Communication Apprehension-24, were compared within subjects (ie, prepost course) and between courses. Significant differences (p<0.05) were found on all measures: students reported less apprehension and more confidence and competence after the courses. No differences were found between the two courses when comparing the mean changes from pre- to postscore. Traditional public speaking curriculum of how to design and deliver a speech and curriculum tailored to the voice and speech mechanism succeeded in reducing public speaking apprehension and increasing feelings of confidence and competency for these undergraduate students.