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286 The Voice and Voice Therapy
aid the patient’s comprehension. We use age-appropriate descriptive terminology to discuss the
mechanics of normal voice and vocal abuse. Some examples we use are discussing the soreness and
redness of palms after clapping hands forcefully and asking the child to describe what their vocal
folds would feel like if they clapped all day. We attempt to video-record the child interacting with
the child’s family in free play or discussion. We review the video and discuss pitch, loudness, and
vocal quality. This audio and video feedback indirectly draws everyone’s attention to the distinctive qualities of voice, and the child and the family can begin to talk about voice using the same
language. The importance of family involvement in voice intervention cannot be overestimated.
Sonbay Yilmaz and colleagues (2021) studied two groups of children aged 8 to 12 years with
bilateral vocal nodules. One group received voice therapy only, and one group received voice
therapy with their mothers. Acoustic measures and scores on the p-VHI were collected before and
after therapy. Results revealed no acoustic differences between the two groups, but post-treatment
p-VHI scores for the group that received therapy with their mothers was significantly lower. These
are important findings, especially considering earlier findings in this section that suggest children
with dysphonia exhibit lower quality of life scores than their nondysphonic peers (Petrović-Lazić
et al., 2023).
A specific approach that we have found successful with children is making every attempt
to pair child voice clients in therapy (Von Berg & McFarlane, 2002a). This arrangement has
been found to be conducive to early and lasting success. At the beginning of the therapy session,
unstimulated acoustic measures are collected. If the clinic does not have this type of instrument,
a digital voice recorder or smartphone application is sufficient. The children listen to their voices
and discuss any changes from the previous session. The children discuss vocal parameters using the
same terminology developed during the audio and video recording of the family session discussed
earlier. Each child is challenged to describe techniques that might move the voice closer to a just
right voice. VFAs are introduced, and each is followed by a child production, using a novel phrasegenerating task. The children analyze each other’s productions, which is a powerful way to increase
each child’s understanding of their dysphonia and how to improve vocal quality. We often audio
record and immediately replay these sessions because the children are motivated to critique and
repair their own dysphonia (see Video 8–2).
Video 8–2. We often pair children in therapy
because it encourages them to actively listen
to and describe each other’s vocal quality in
terminology that is easy to understand and
generalize outside of the clinic. This video
shows how children engage in constructive
feedback of each other’s vocal quality. Grand
Rounds: Describe one biofeedback activity
that you might implement for a child dyad
voice therapy session.
CHAPTER 8 Therapy for Specific Patient Populations 287
In Chapter 7, we identify the various biofeedback technologies currently available to support
voice intervention in the general population; these technologies are also available for pediatric
voice intervention. Readers are encouraged to investigate innovative approaches that employ
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virtual reality (Hapner & Johns, 2004; King et al., 2011) and video self-modeling (Bandura,
1997). See Adriaansen and colleagues (2022) for a systematic review of existing literature on the
effects of voice therapy in children with vocal nodules.
Professional Voice Users
The professional user of voice exerts unusual demands on respiration, phonation, resonance,
and articulation. We use the term professional voice user for the actor, singer, teacher, salesperson,
minister, telemarketer, politician, broadcaster — people whose primary occupational competence
(and probable success) is shaped by their voices. Their success in using their voices is always
competing with demands of excessive phonation, background noise, and environmental pollution (Bovo et al., 2007). The SLP-voice clinician may begin a vocal hygiene program designed
for awareness of avoiding excessive phonation time and making attempts to reduce competing
background noise. However, Holmberg and colleagues (2001) have found that a vocal hygiene
program alone is not always associated with a good voice. It appears that a vocal hygiene program
needs to be coupled with some vocal instruction provided by a vocal coach, singing teacher, or
voice clinician to help the professional voice user maintain a functional professional voice (Hazlett
et al., 2011; Vermeulen et al., 2022).
One of the obstacles we experience in working with the professional voice user is the relative
“performance innocence” of the SLP-voice clinician. The professional uses their voice often
beyond the normal limits we generally associate with heavy voice use. The SLP-voice clinician
who has never performed beyond these supposed limitations may experience difficulty convincing
the performer about what to do to correct a voice problem. Like the voice clinician who wants to
communicate with the voice scientist or the scientist who likes to dabble clinically, the SLP-voice
clinician’s “performance naiveté” may be revealed to the professional performer once the SLP strays
beyond their zone of training and competence.
Another obstacle to working successfully with the professional voice user is the lack of meaningful language between the performer and the SLP. For example, the actor or singer may have
been taught a way of breathing for performance that is at variance with new voice science findings
specific to respiration. Imagery abounds with performers, and the clinician cannot take away this
imagery without replacing it with descriptions that will enhance performance and encourage using
vocal mechanisms in a healthy manner. The skillful clinician can often use performers’ imagery
about what they are doing by not attacking it directly but by modifying it by demonstration of less
muscle effort producing similar vocal output. Excesses in muscle tension while performing have
been categorized by Koufman and colleagues (1996), finding that much unnecessary supraglottic
muscle tension occurs, particularly among “bluegrass/country and country/western and rock/
gospel singers.” When excessive muscle tension appears to cause laryngeal problems, voice therapy
directed toward decreasing the excessive glottal and supraglottal muscle tension can be effective
(Lowell et al., 2012; Sataloff, 2017). Excessive muscle tension can be reduced by using VFAs such
as auditory feedback, change of loudness, chant talk, chewing, counseling, focus, changing glottal
attack, laryngeal massage, open-mouth, relaxation, and yawn-sigh (see Chapter 7) (see Video 8–3).
288 The Voice and Voice Therapy
Video 8–3. This video shows that the act
of chewing encourages an overall relaxation
of the jaw, neck, and laryngeal muscles for
those patients with vocal hyperfunction.
Many patients consider it a one-size-fits-all
tension reducer. Grand Rounds: Investigate
Brodnitz’s and Froeschel’s reflexive chewing
theory.
Most professional voice users have auditory recordings of their voices. At the first meeting
between the performer and the SLP, an audio recording is made. It is sometimes useful to compare
the client’s previous recordings with the new one made at the time of evaluation. Part of the initial
voice evaluation requires close listening to playback, possibly stopping and restarting to identify
possible problem areas. Auditory feedback may play an important role in helping the performer
identify what needs to be accomplished in future voice therapy situations. The SLP-voice clinician may use helpful auditory modeling in future therapy sessions (Boone, 1998), employing one
or more applications available for playback listening and imitation. Perhaps the most effective
auditory feedback is providing the client with real-time playback of what the client just said
and then comparing it with some kind of desired voice target. Fortunately, myriad personal and
clinical acoustic instrumentation offers the performer many visual and auditory feedback applications that may be recommended by the SLP-voice clinician (Filipa & Fiuza, 2022; van Leer &
Connor, 2012). In many professional voice situations, the performer must speak above unreasonable background sound levels. Clinically, it has been found that hard rock concert performers and
classroom teachers are the two performer groups who most frequently use their voices in excessive
noise background settings. Among the many research studies looking at noise-level impact on
vocal performance, Ferrand (2006), Stathopoulos and Sapienza (1993), and Grillo and colleagues
(2010), have found that excessive noise may compromise respiratory function, pitch changes, voice
quality, and overall phonatory stability.
When actors, public speakers, politicians, and broadcasters consult with the SLP-voice
clinician for problems with voice, the SLP-voice clinician should have them first complete questionnaires regarding their use of voice and their perceived voice-related quality of life (Portone
etal., 2007; Zraick & Risner, 2008) (see also Chapter 6). Questionnaire and voice evaluation data
should be reviewed to determine what type of voice therapy is indicated. The services of either the
SLP-voice clinician or the vocal coach (Sadoway, 2021) may then be provided. A blend of both
specialties is often an ideal combination for the professional user of voice who is experiencing
some vocal difficulties (Hazlett et al., 2011; Sataloff, 2017, pp. 11–14; Zeine & Walter, 2002).
Consideration is often given to providing vocal hygiene counseling and information along with
voice therapy, although there is some research that finds equivocal value of vocal hygiene alone
CHAPTER 8 Therapy for Specific Patient Populations 289
(Roy et al., 2001) However, combining vocal hygiene and voice exercises for teachers with selfreported voice symptoms has been found to produce significant voice improvement (Faham et al.,
2016; Gillivan-Murphy et al., 2006; Pasa et al., 2007; Vermeulen et al., 2022). Following vocal
hygiene guidelines often produces immediate benefit for the professional user of voice.
Singers often experience functional and organic problems of voice, and they are often referred
to the SLP-voice clinician for consultation and possible voice therapy (Boone & Wiley, 2000).
Aspecial voice handicap scale for singers (Cohen et al., 2007; Sobol et al., 2020) provides information relative to the constancy and impact of the problem on singing performance. For better
understanding and more effective communication between the singer and the SLP-voice clinician,
it is recommended that the clinician become familiar with some of the technical terminology
of this population. Tessitura (the range in which most notes of a vocal part fall), leggiero (light,
graceful), and vibrato (to vibrate, meaning the note changes subtly and quickly) are examples.
An increasing number of SLP graduate programs are adding vocology programs to prepare
SLPs for this specialty area (Sataloff, 2017, p. 76). For the voice clinician with a limited background in music performance and singing, consideration should be given to consultation with a
singing teacher (Sadoway, 2021). The SLP-voice clinician often finds with professional singers that
their vocal problems seem to originate from things they do when not singing, such as excessive
throat clearing, smoking, lack of hydration, or talking too much before and after performance
(Boone, 1997).
Of all professional performance groups, teachers appear to be the professional group experiencing the most vocal problems (Assad et al., 2019; Ferrand, 2012; Martins et al., 2014; Munier
& Farrell, 2016; Ramos et al., 2022). Looking at voice disorders in a population of 550 primary
school teachers, Munier and Kinsella (2008) found that “27% suffered from a voice problem, 53%
reported an ‘intermittent’ voice problem, while only 20% had no voice problem.” Summarizing
multiple studies on voice problems in teachers, Grillo and Fugowski (2011) reported that “between
15% and 32% of teachers reported experiencing a voice disorder in their teaching careers” (p. 149).
Roy and colleagues (2004, 2005) have found an overwhelming prevalence of voice disorders in
teachers compared with other adults in the same-age population. A large epidemiological study
in Brazil (Behlau et al., 2012) of 1,651 teachers compared with 1,614 nonteachers found the
prevalence of voice disorders among teachers was 11.6% versus 7.5% for nonteachers. Huston
and colleagues (2024) analyzed 1,522 responses from a survey pertaining to voice use and voice
disorders from a representative sample of the U.S. population. Approximately 8.6% of the total
number surveyed were teachers. Most teachers felt that they use their voice more than other
people; they were also more likely to use a voice-assisted device and teleconferencing technology.
When compared with nonteachers, teachers were much more likely to report voice issues, with
43% of teachers reporting that they had or currently have a voice disorder, with almost 75% of
these having seen a physician or therapist for these problems.
Dysphonia risk factors for teachers include extensive working hours, frequently longer than
40 hr a week, excessive number of students per classroom, environmental noise, inappropriate
classroom facilities, and chalk powder (Bottalico et al., 2023; Martins et al., 2014). Outside of
the classroom, teachers are engaged in teleconferencing as well, placing additional demands on
the vocal load (Huston et al., 2024). Tracy and colleagues (2020) reported that vocal effort and
sound pressure levels were increased when using remote audio and remote audiovisual communication in comparison to in-person communication. This is another factor that may contribute
290 The Voice and Voice Therapy
to dysphonia in teachers. The SLP-voice clinician who hears high noise levels in the classroom
(Cutiva & Burdorf, 2015, 2016) may recommend that the teacher use a voice amplifier (Nusseck
et al., 2017). Assad and colleagues (2019) found that use of an amplification device allowed the
teachers to maintain the same phonation time but reduced the number of vocal fold oscillations
and total distance traveled over vibratory cycles. Also, the teacher may benefit from an approach
that combines indirect methods (such as changing the physical teaching environment) with direct
methods (such as vocal hygiene education and/or voice therapy). The individual teacher, when
consulting with the SLP, sometimes benefits from a classroom visit by the SLP to see and hear
the teacher in action. The SLP may find the teacher in the classroom using much vocal hyperfunction while teaching, in sharp contrast to normal voicing efforts observed in the voice clinic.
Vocal hyperfunction is associated with dysphonia, and studies have found reduced intelligibility
in students when the classroom teacher is dysphonic. (Bottalico et al., 2023). These researchers
suggested that better acoustic conditions are needed for children to reach a good level of intelligibility, as children with dysphonic teachers show poorer performance and greater listening difficulty
compared with those children with nondysphonic teachers.
Among research studies looking at effectiveness of voice disorder prevention programs for
teachers, Duffy and Hazlett (2004), Bovo and colleagues (2007) and Keder and Sielska-Badurek
(2024) have reported significant voice improvement for experimental subjects (vs. control groups)
in the programs. However, large systematic literature reviews on voice therapy for teachers have
not found sufficient evidence to conclude voice training is effective in preventing dysphonia in
teachers (Hazlett et al., 2011, Ramos et al., 2022). But just because comparison studies of large
groups of teachers have not revealed significant differences does not mean that a given individual
teacher might not benefit from working with a SLP-voice clinician. Teachers with clinical voice
problems require a full medical and SLP diagnostic evaluation, followed by appropriate medical
management and individualized voice therapy designed by the SLP for that particular teacher. It
is clear that more robust research should be performed (Richter et al., 2016) to determine which
persons are the best candidates for therapy and which kind of therapy is most effective.
Deaf and Hard of Hearing
Voice production is controlled by auditory feedback that takes place within the central nervous
system. Any disturbance in this feedback results in alterations in acoustic voice parameters. Hearing
loss greatly impacts children’s access to speech input and places deaf and hard of hearing (DHH)
children in dramatically different speech and language situations than peers with normal hearing
(Abu-Zhaya et al., 2019). Szkiełkowska and Myszel (2021) described the specific characteristics
related to deaf and hard-of-hearing voice, including alterations in fundamental frequency, variations of fundamental frequency, formant frequency transitions, phonation range, vocal intensity,
and phonation time. Changes in speech include difficulties with articulatory placement and
precision, prolonged vowel durations, excessive nasality, reduced speaking rate, and deviations in
voice-onset timing (Allegro et al., 2010; Szkiełkowska & Myszel, 2021).). These alterations are
known as audiogenic dyslalia. The earlier the onset of deafness or profound hearing loss, the more
severe the aforementioned voice and speech symptoms are likely to be (Guerrero Lopez et al.,
2013). Therefore, it is imperative that voice clinicians employ best practices to work with DHH
CHAPTER 8 Therapy for Specific Patient Populations 2 91
children and their teachers to provide best practices to support their linguistic and educational
needs (Secora & Shahan, 2023).
DHH children are frequently fitted with hearing aids (HAs) or cochlear implants (CIs),
depending on the severity of the hearing loss. CIs are surgically implanted electric prosthetic
devices that provide electric stimulation to the auditory nerve fibers of the cochlea. This effectively
bypasses damaged inner ear hair cells to deliver a signal to the brain, which is then interpreted as
sound (ASHA, 2023). In an early study of pediatric CI users, Seifert and colleagues (2002) found
positive changes in voice pitch, elevated second formant, resonance, and rate of speech in older
children who underwent CI. Campisi and colleagues (2005) identified unique voice characteristics
in pediatric unilateral CI recipients related to the long-term control of vocal pitch and intensity.
Their study cohort contained both pre- and postlingually deafened users of CIs. They reported
that long-term control of amplitude variation improved to normal levels postimplantation, but
long-term control of F0 variation remained impaired. No significant differences were found
between the results of the pre- and postlingually deafened CI users (see also Allegro et al., 2010).
Arias-Vargara and colleagues (2022) found no advantages concerning speech prosody in adults
between unilateral and bilateral CIs. Holler and colleagues (2010) reported a similar finding in
their study of children with bilateral CIs.
With respect to adult CI users, Svirsky and colleagues (1992) used an on-off study of auditory
deprivation on voice. They found that when the CI was turned off for 24 hr, participants demonstrated elevated fundamental frequency (F0), increased intraoral pressures, and lowering of the
second formant. With the restoration of auditory input via the CI, these voice parameters began
to normalize. Ubrig and colleagues (2011) compared the vocal characteristics of postlingually
deaf adults before and after CI. These clinical researchers reported a significant reduction in
perceived overall voice severity, strain, loudness, and instability; a significant reduction in F0 in
male speakers; and F0 variability in both genders. Pastore and colleagues (2021) studied eight
patients with single-sided deafness and cochlear implant (SSD-CI) with respect to sound localization. For patients with SSD-CI with their CI turned off, head rotations substantially reduced
front-back reversal, and the combination of turning on the CI with head rotation led to almost
full resolution of front-to-back sound source location.
Although elevated voice pitch and excessive pitch variability are common findings in those
with severe hearing loss, the anatomy and physiology of the larynx and vocal folds are the same as
those of the normal hearing population. DHH children profit from developing an awareness of
other voices as well as an awareness of their own pitch levels by using visual and auditory feedback
and instrumental tracings of pitch. Instrumental and software programs that provide clear visual
feedback of pitch and pitch variability may play primary roles in voice training. Such computer
programs provide real-time feedback relative to excesses in voice loudness (too loud or not
loud enough). Czap (2018) described a system to assist the speech production improvement of
hard of hearing (HOH) children by the visualization of speech sound and articulation. The sound
transcoder also features a prosody display and automatic assessment and knowledge-based system
display that allow the user individual practice on home computers and mobile devices.
It is important to note that the personal contributions of specialized teachers and the voice
clinician cannot be replaced. A useful voice training method by the SLP-voice clinician is to provide
“cue arrows” pointing in the desired direction of pitch change. For a DHH child attempting to
292 The Voice and Voice Therapy
lower the voice, for example, cards can show a down arrow. These cards and their digital correlates
on smartphones should be placed wherever possible in the child’s environment — in the backpack,
on the bureau or desk, smartphone, and so on. Also, caregivers, the classroom teacher, and voice
clinician can give the child hand cues by pointing toward the floor. Another method for developing
an altered pitch level is to place the fingers lightly on the larynx and feel the downward excursion
of the larynx during lower pitch productions and the upward excursion during higher ones. The
ideal or optimum pitch is produced by minimal vertical movement of the larynx. Any noticeable
upward excursion of the larynx, except during swallowing, immediately signals that the voice may
be at an inappropriately high pitch level. Once an appropriate pitch level has been established,
the child may read aloud for a specified time, placing the fingers lightly on the thyroid cartilage
to monitor any unnecessary vertical laryngeal movement.
Beyond targeted voice and speech therapy, it is essential to recognize the importance of
psychosocial-based interventions for this population. Young DHH children who use HAs or
CIs experience disruptive behaviors at rates at least as high as typically developing children, but
their access to evidence-based psychosocial interventions is limited. Ronner and colleagues (2020)
introduced several principles and approaches that aim to reduce inequities and improve quality
of life in DHH children. Among them are integration of behavioral parent training into the
standard of care of DHH children. Secora and Shahan (2023) also reported on best practices for
educating teachers of the deaf and SLPs with respect to the DHH population. Recommendations
include joint classroom experiences, co-teaching, and explicit instruction and practice in conflict
management and perspective taking.
The typical voice of a DHH child who has had no training reveals a voice that is characterized by alterations in nasal resonance (Baudonck et al., 2015), often accompanied by excessive
pharyngeal resonance, which produces a cul-de-sac voice (Kim et al., 2012). The major contributing factor to these resonance alterations is the excessive posterior posturing of the tongue in the
hypopharynx, which markedly lowers the second format (Monsen, 1976; Wirz, 1986). The tongue
is drawn back into the hypopharynx and creates the peculiar resonance heard in DHH speakers;
this back resonance sounds similar to the resonance sometimes heard in speakers with athetoid
cerebral palsy or oral verbal apraxia. The cul-de-sac voice has a back focus to it. In addition, the
DHH child or adult may demonstrate marked variations in nasal resonance: too much nasal focus
(hypernasality) or insufficient nasal resonance (hyponasality). Such nasal resonance variations
may be due in part to the posterior carriage of the tongue as well as to the inability to monitor
acoustically the nasalization characteristics of the normal speaker.
Altering the tongue position to a more forward carriage and tongue protrusion (see Chapter7)
can contribute greatly to establishing more normal oral resonance in the voice. In addition to
the procedures outlined in Chapter 7 for altering tongue position, more detailed procedures
and therapy materials for both children and adults are available in The Boone Voice Program
for Children (Boone, 1993) and The Boone Voice Program for Adults (Boone & Wiley, 2000).
Once the tongue has been placed in a more neutral setting, the child needs to practice making
vocal contrasts between back pharyngeal resonance and normal oral resonance. The child is
encouraged to develop an awareness of what it feels like to use the lips, the tongue against the
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alveolar processes, the tongue on the hard palate, and other front-of-the-mouth postures. Such
front focus seems to develop only after intensive practice doing tasks that encourage anterior
tongue carriage.
CHAPTER 8 Therapy for Specific Patient Populations 293
Gender-Affirming Voice Therapy
Individuals may seek voice and communication services when their voice and/or other aspects of
their communication are not consistent or congruent with their gender identity and/or gender
presentation. These individuals include those who identify as transgender, gender fluid, gender
diverse, gender nonconforming, or other gender identities (ASHA, 2019). Gender-affirming voice
therapy supports gender diverse individuals as they explore and develop a healthy voice that feels
congruent with their gender and sense of self (Merrick et al., 2022).
The World Professional Association for Transgender Health (WPATH) is an international,
interdisciplinary professional and educational organization devoted to transgender health. Its
members conduct clinical and academic research to develop evidence-based quality of care for
transexual, transgender, and gender-nonconforming individuals. In the eighth edition of Standards
of Care for the Health of Transgender and Gender Diverse People (Coleman et al., 2022), the authors
outline clinical guidelines to assist health care professionals in helping provide transgender and
gender diverse (TGD) individuals with strategies to achieve personal comfort with their gendered
selves and optimize their overall physical health, psychological well-being, and fulfillment. In this
section, we use the WPATH acronym of TGD for those individuals seeking a healthy voice that
feels congruent with their gender and sense of self.
Gender does not exist in isolation, rather it intersects with other aspects of human diversity,
such as ethnicity, race, sexuality, faith and spirituality, and language (Coleman et al., 2022;).
Not every TGD person experiences challenges with or wants professional support for their voice
and communication. However, for those TGD individuals who do seek to modify their voice and
communication, the SOC-8 document lists practices amenable to behavioral change, including
speaking and singing voice, mindfulness, relaxation, respiration, pitch and pitch range, voice
quality, resonance and timbre, loudness, projection, facial expression, gesture, and posture, among
others (Coleman et al., 2022, p. S138).
Gender-Affirming Intervention for Transwomen
Numerous studies have suggested that aspects of voice and speech most salient to the perceptions
of the speaker’s gender are average speaking frequency, resonance, intonation, vocal quality, articulation, speaking rate, and intensity (Davies, 2017; Hancock & Garabedian, 2013; Hardy etal.,
2020; da Cruz Martinho & Constantini, 2024; Oates & Dacakis, 2015). Leyns and colleagues
(2021) conducted a systematic review of 14 studies aimed at providing voice clinicians with the
current literature concerning the effects of speech therapy in transwomen in terms of acoustic
and perceptual outcomes. The authors reported that these studies showed positive outcomes
concerning pitch elevation, oral resonance, self-perception, and listeners’ perception of voice.
Schwarz and colleagues (2023) analyzed 16 studies on the effects of speech therapy and phonosurgery for transwomen between the years 2010 and 2023. Results revealed that phonosurgery was
significantly more effective in terms of fundamental frequency gain compared with speech therapy
alone. Among several surgical procedures available for altering fundamental frequency reported
in the study were the cricothyroid approach and the modified laryngoplasty technique known as
feminization laryngoplasty. Endoscopic approaches reported included glottoplasty and CO
laser
2
techniques (Schwarz et al., 2023). See WPATH’s SOC-8 (Coleman et al., 2022, pp. S140–S141)
for a full description of phonosurgical approaches for transwomen.
294 The Voice and Voice Therapy
Merrick and colleagues (2021) reviewed the charts of 62 transwomen and/or nonbinary individuals who attended either individual or hybrid (group and individual training) gender-affirming
voice and communication at a single facility from 2012 to 2019. Results revealed that both
groups achieved significant pitch elevation and lower scores on the Transexual Voice Questionnaire (TVQMtF) (Dacakis and colleagues, 2013), with the hybrid participants demonstrating
significantly higher goal achievement and therapy adherence. The authors suggested that hybrid
training may provide valuable support for these populations.
Considering these positive outcomes, several researchers note the need for effective studies
using randomized controlled trial designs, larger samples, and multidimensional voice assessment
(Leyns et al., 2021). Indeed, incorporating voice and speech markers into training programs for
transwomen that meet rigorous levels of evidence has proved elusive. In an extensive literature
review of voice training programs for transwomen, Adler and colleagues (2019), found that of
29 publications analyzed, only eight (28%) could be considered to yield evidence stronger than
single case reports or expert opinion (Adler et al., 2019, p. 97). Nevertheless, these authors did
suggest that clinicians working with transwomen can be encouraged by (a) the relatively strong
evidence as to voice markers of gender (Davies, 2017; Oates & Dacakis, 2015), (b) consensus
among experts as to recommended approaches to voice training, and (c) the high client satisfaction
with voice training. Indeed, much of what is done clinically is related to positive outcome data
in which the client performs more like the target gender, and the transwoman is pleased by the
therapy outcome (Dacakis et al., 2016, 2017). Popular self-report voice tools designed to collect
transwomen’s perceptions of their vocal functioning and its impact on their lives are the VHI
and VRQOL (described in Chapter 6); the Utah Gender Presentation Scale for Communication (Myers and colleagues, 2024) and the Transexual Voice Questionnaire TVQMtF (Dacakis
etal., 2017). These instruments not only measure pre- and post-therapy self-perceptions of transwomen regarding their voice, but the responses help the clinician and the client identify goals
for intervention.
Our clinical experience with markers that convey gender cues align closely with those suggested
by the WPATH’s SOC-8 document (Coleman et al., 2022), Davies (2017), and Adler (2019).
Figure 8–1 portrays communication behaviors that, in our clinical experience, may be of interest
to the transwoman. The behaviors listed in this scale are by no means exhaustive, rather they
provide a starting point for the transwoman and the voice clinician to begin considering goals for
therapy. As reported by Boone and colleagues (2019), scores on the left represent a more masculine
presentation, and scores on the right represent a more feminine presentation. After the variables
have been selected, the client and the voice clinician begin therapy, watching and listening to the
voice and speech using audio and visual feedback.
Of those voice and speech behaviors included in Figure 8–1, it appears that the behaviors
most salient to the perceptions of a speaker’s gender are pitch and resonance (Adler et al., 2019,
pp.91–92; ASHA, 2019; Carew et al., 2007; Leyns et al., 2021; Oates & Dacakis, 2015). We
explore these two behaviors next and identify VFAs designed to help the voice clinician and transwoman achieve the desired changes. The VFAs are discussed in full detail in Chapter 7.
Pitch: Mean pitch ranges have been reported to be 180 to 267 Hz for cisgender females
(biological females), 100 to 154 Hz for cisgender males (biological males), and 155 to 220 Hz
for those in the androgynous frequency range (Davies et al., 2015; Saggio & Costantini, 2022).
There are no universally accepted targets for SFF for transgender women or men (Leung and
Date:
Comments
F
Target
Name:
M
123456789
AlteredLexicon
1 2 3 4 5 6 7 8 9
Breathiness
123456789
1 2 3 4 5 6 7 8 9
Facial Expression
Gesture
123456789
Intonation
1 2 3 4 5 6 7 8 9
123456789
1 2 3 4 5 6 7 8 9
123456789
1 2 3 4 5 6 7 8 9
Pitch
PitchFlexibility
Rate
Volume and Loudness
VowelProlongation
Summary/Plan:
FI GUR E 81. Gender speech–voice presentation.
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