The World Professional Association for Transgender Health (WPATH)

Medical providers and others working in the area of transgender and gender-expansive services often look to the World Professional Association for Transgender Health (WPATH), which is one of the most highly recognized organizations for creating policy and providing essential communication and training for transgender service providers worldwide. They issued the “Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7” in 2011 [5], which is available free to the public at www.​wpath.​org. Of particular relevance to pediatrics and to voice and communication services are the sections entitled “Voice and Communication Therapy” and “Assessment and Treatment of Children and Adolescents with Gender Dysphoria” [5].

While we generally consider pediatrics to include people under the age of 18, a discussion of pediatric voice and communication services is primarily limited to a discussion of adolescents who have begun pubertal changes. Prior to the onset of puberty, our speech-language pathology services will likely be limited to consultation, education, and monitoring, as voice changes will not have occurred.

When discussing physical interventions used for adolescents, much consideration is given to whether the intervention is fully reversible, partially reversible, or irreversible [5]. The WPATH Standards of Care states that “A staged process is recommended to keep options open through the first two stages. Moving from one stage to another should not occur until there has been adequate time for adolescents and their parents to assimilate fully the effects of earlier interventions.” [5] Some physical interventions can impact voice, including use of agents to suppress puberty and hormone therapy to masculinize or feminize the body. A positive outcome of puberty suppression when undertaken for transfeminine individuals is that some of the physical changes that pubertal testosterone causes to voice will not occur [7–9]. Considerations for hormone therapy include that taking the masculinizing hormone testosterone will deepen the voice and the physical changes are not considered reversible [5, 10]. However, feminizing hormone therapy for transfeminine clients is not expected to raise pitch [9, 11, 12]. Risks of interventions must be carefully weighed with the risks of not providing an intervention [5]. If intervention for adolescent or preadolescent voice and communication is undertaken, the status of pubertal changes and any hormone interventions should be carefully considered [9]. WPATH reports that “Increasing numbers of adolescents have already started living as their desired gender role upon entering high school” [5, 13] and providing comprehensive care and support to these adolescents is crucial.

In some areas of the USA, multidisciplinary medical and support teams have been established to provide comprehensive and coordinated services to transgender and gender-expansive people. Of note, multiple children’s hospitals and clinics across the country have developed coordinated clinical care programs for transgender and gender-expansive children [14]. These multidisciplinary programs generally include pediatricians, psychologists, psychiatrists, endocrinologists, urologists, surgeons, nurses, and social workers. Some programs incorporate other professionals, such as ethics consultants, school consultants, or legal consultation services on their teams. Speech-language pathologists are directly involved in some programs and will likely become increasingly included as part of these multidisciplinary teams over time. The demand for transgender and gender-expansive services for youth will likely soon push the need beyond these established programs to other hospitals, university clinics, community clinics, private practices, and schools.

Research

There are limited evidence-based research studies published for transgender and gender-expansive voice and communication services, with the field being further limited by the fact that research that currently exists is primarily based on transgender women clients and is almost exclusively based on adult participants. There are limited randomized controlled trials (RCT), and most published studies have limited sample sizes. Limited evidence-based information exists for effectiveness of communication services for aspects of communication beyond voice, such as language and nonverbal communication, and there is little data on the optimal dose for frequency and duration of sessions.

While there are limited data to support other communication parameters, some clinicians may include work on semioccluded vocal tract exercises, speech rate, vocal quality or intensity, articulation, and other areas of language and nonverbal communication as targets of overall communication modification. Published research is available on potentially feminine and masculine characteristics of some of these parameters, but clinicians should be wary of stereotypes and discuss goal areas with clients carefully and openly [15, 16].

Evaluation/Assessment

As previously discussed, speech-language services are optimally delivered as part of an overall team of providers, supporting each individual in their medical, psychological, and social needs [16]. While ASHA guides speech-language pathologists that prior to initiating voice therapy, “All patients/clients with voice disorders are examined by a physician, preferably in a discipline appropriate to the presenting complaint,” [28] transgender and gender-expansive individuals seeking voice modification are considered to be non-disordered populations, and a screening for voice disorder is generally accepted, with referral provided for further examination only if needed [16]. However, the practice of screening versus requiring a physician examination is debated, with some SLPs in this practice area requiring the physician exam prior to initiating services.

Davies, Papp, and Antoni state, “To date there are no minimal standards for the assessment of voice and communication in transgender clients. The field of practice is recent and the evidence base, is still weak” [15]. Evaluations should be comprised of multiple assessments spanning various voice and communication parameters. Careful attention needs to be paid to client goals as they relate to measures undertaken in an initial evaluation.

An initial interview should include a discussion of client goals including the client’s perception of their voice and communication use. SLPs need to be aware that some clients may be open to discussing their past, while some may not. Questionnaires, such as the Transsexual Voice Questionnaire for Male-to-Female Transsexuals (MtF)-TVQ(MtF), may be used to gain further insight into impact that voice presentation has for clients [29]. Acoustic measurements should include “average SFF, SFF range, maximum phonation range, and the first, second and third formants of vowels, in particular the corner vowels /a/, /i/, and /u/” [15] elicited across a variety of speaking tasks including phonation of prolonged vowel, oral reading, picture description, and conversational speech [16, 30–32]. Video or audio recording may be used to aid in assessment of voice and communication [15].

Hancock and Helenius Study

Adrienne Hancock and Lauren Helenius published a study in the Journal of Communication Disorders in 2012 documenting results of an adolescent’s response to a speech-language voice and communication intervention [9]. In the only peer-reviewed case study of a pediatric transgender client for voice and communication services, the paper by Hancock and Helenius provides rationale, procedures, and outcomes for one 15-year-old MtF transgender client, who attended 15 sessions conducted over 7 months in a university clinic. The client had strong family support, no history of voice issues or abuse, and no previous work with SLP on transgender voice and communication, but she had attempted some voice modifications on her own. The client participated in sessions which included many elements of a typical transgender voice and communication program, including work on: vocal hygiene, relaxation techniques, breath support, fundamental frequency, intonation, resonance, vocal quality, and rate [9]. Positive results were reported across multiple domains and included client report of increased self-confidence as result in change in communication and progress during SLP services. Perceptually, improvements were documented in multiple areas, including breathiness; pitch, which increased to within typical female limits; increased use of feminine intonation (greater pitch contours); forward-focused resonance in oral cavity; relaxed and aligned posture; and use of primarily abdominal-diaphragmatic breathing. Unfamiliar listeners gave high ratings for the femininity and “softness” of the client’s voice [9]. The conclusions of the study indicated that voice and communication services helped the client to achieve feminine voice and communication, using both objective and subjective data, and that methods used for MtF transgender adults were effective for a younger voice [9]. Though the scope of this study was limited, it is an important start to our understanding of the ways in which voice and communication methods that are used for the adult population can be effective for adolescent clients as well.