1. Introduction to Transgender Communication: Assessment and treatment Karen Kochis Jennings, Ph.D., CCC-slp California state university, Northridge * From ‘Voice and Communication Therapy for the Transgender / transexual Client’ (2004) richard K. adler, Sandy Hirsch and michelle mordaunt
Lecture 16 Introduction to Transgender Communication: Assessment and Treatment
In this lecture, I present a very basic introduction to transgender communication, including voice training.

2. Transgender Terminology
Transgender – ‘umbrella’ definition for person living in a gender other than his/her biological gender
Gay – term used to describe men who are attracted to other men
Lesbian – term used to describe women who are attracted to other women
Passing – when a person is addressed in a manner congruous with his/her appearance in the new gender
GCS –gender confirmation surgery and genital reconstructive surgery
Gender Dysphoria – extreme discomfort w/ one’s socially, biologically, or culturally assigned gender role.
Sex – what you were born as
Gender – what you identify as
2. Transgender terminology. Always ask your client how they would like to be addressed.

3. What does ‘transgender’ mean?
Transgender is the state of one's gender identity or gender expression not matching one's assigned sex.[1]
Transgender is independent of sexual orientation; transgender people may identify as heterosexual, homosexual, bisexual, etc; some may consider conventional sexual orientation labels inadequate or inapplicable to them. The definition of transgender includes:
"Of, relating to, or designating a person whose identity does not conform unambiguously to conventional notions of male or female gender roles, but combines or moves between these."[2]
"People who were assigned a sex, usually at birth and based on their genitals, but who feel that this is a false or incomplete description of themselves."[3]
"Non-identification with, or non-presentation as, the sex (and assumed gender) one was assigned at birth."[4]

4. Transgender Across Cultures – one of many examples
North America
In the United States and Canada, many Native American and First Nations peoples recognized] the existence of more than two genders, such as
the Zuñi male-bodied Ła'mana,
the Lakota male-bodied winkte
the Mohave male-bodied alyhaa and female-bodied hwamee.[
Such people are referred to as Two-Spirit, and their spouses would not necessarily have been regarded as gender-different.
In Mexico, the Zapotec culture includes a third gender in the form of the Muxe.

5. Harry Benjamin International Gender Dysphoria Association (HBIGDA)
Center for Human Sexuality at the University of Minnesota Medical School, Minneapolis – St. Paul
International organization that establishes standards of care within the medical, psychological and other parameters of care in the area of Transexual medicine
RLT – ‘real life test’ is living full time as the gender of choice for 1 year prior to SRS or GCS. This is required prior to surgery
3. All gender confirmation surgery candidates must live full time as their gender of choice for 1 year prior to the surgery. The Harry Benjamin Association is an excellent resource for information on gender dysphoria.

6. Insurance Coverage
MANY insurance companies now cover gender re-assignment surgeries and / or medical and surgical transgender treatment
Many times speech and voice services are covered.

7. The Treatment Team Surgeons – specialty surgeons, ENT surgeons
Endocrinologist
Mental Health professionals (psychologist /psychiatrist)
Social Worker
Nurses
Speech Pathologists
4. The treatment team working with a transgender client includes specialty surgeons, possibly ENTs, an enocrinologist for hormone management, mental health workers, social workers, nurses and speech pathologists.

8. Role of the SLP Voice and Speech Assessment
Voice, Speech and Language Training
Counseling, but only those areas w/in our scope of practice
Appropriate referrals
5. The role of the SLP is to conduct a voice, speech and language assessment, conduct voice, speech and language training and counsel. Transgender communication training has become a specialty within our field.

9. Voice Assessment Voice History Medical History
Rule out pre-existing voice problems that are unrelated to transgender voice issues
Vocal hygiene history
Assess for laryngeal, neck, tongue, jaw and shoulder muscle tension
Assess breath support and breathing pattern
6. The voice assessment should be conducted with two goals in mind. First, to determine if there are current voice problems. And second, to assess the client’s voice regarding pitch range, habitual pitch, inflection/intonation pitch range, etc.

10. Voice Assessment – Instrumental
Acoustic Assessment:
1. Habitual pitch during sustained phonation, counting, reading, and spontaneous speech
2. Optimal pitch –
a) mmhm b) uh huh c) throat clear
3.Pitch range – lowest and highest pitches
4. Spectrogram – assess formant frequencies
5. Intonation – assess conversational pitch range
7. Assessing pitch range and habitual pitch as well as optimal pitch is important because you will likely train a ‘new’ habitual pitch. A spectrogram must be obtained to measure the formant frequencies of a number of vowels because formant frequencies differ between men an women.

11. Articulation Assessment
Assess for presence of hard glottal attacks on vowel initial words
Assess vowel durations
Light versus heavy articulation
Articulatory precision
Assess speech rate and intensity
8. It will also be important to assess articulation because there are differences in articulation between men and women. For example, women have been found to have a more precise articulation with longer vowel and consonant durations.

12. Additional Areas of Assessment
Language, Syntax and Semantics
Pragmatics and Discourse
Nonverbal communication
9. Men and women also differ in the type of language they use, pragmatics, discourse and nonverbal communication.

13. Voice Training Speaking Pitch Adjustments Conversational Pitch Range
Intonation
10. Voice training will involve habitual pitch adjustments, conversational pitch range and inflection / intonation patterns.

14. Female to Male Transgender Voice
Voice – typically, hormone treatments will lower the voice
Surgical procedure to shorten vocal folds: will lower pitch but often results in weaker voice. Voice tx can help to strengthen
Establish ‘chest’ resonance
Yawn-sigh technique lowers larynx, eliminates laryngeal tension and may create a ‘darker’ timber
Resonant voice for chest resonance
11. Female to male transgender clients will typically experience a lowering of habitual pitch due to hormone therapy treatment. A chest resonance must be established. Typically, lengthening the vocal tract, and this can be accomplished by allowing the larynx to lower via yawn sigh techniques, will create a darker resonance. This technique can be combine with resonant voice techniques.

15. Training: Pitch for Male to Female Transgender Clients
Adjusting Speaking fundamental frequency (sFo)
Goal:
Achieving gender ambiguous sFo without strain or
excess muscle tension
Gender ambiguous pitch range 155 Hz – 185 Hz
However, a higher sFo is not in itself sufficient to create the perception of a female voice !
Average male sFo = 110 Hz
Average female sFo = 220 Hz
12. Research has shown that there is a ‘gender neutral’ pitch range and this range is between 155 – 185 Hz. Care must be taken to find and establish a habitual pitch that is gender neutral and not so high that voice production will not cause muscle tense or strain. Also, an artificially high speaking pitch, one that is too high, will often reveal the original gender. However, raising habitual pitch alne is not sufficient to create the perception of a female voice.

16. Training: Pitch Technique to adjust pitch Resonant Voice Tx
Begin with a pitch between 150 – 185 Hz that is comfortable
Starting at Hz is reasonable
Pitch can be gradually increased until final sFo target is achieved w/o vocal strain or laryngeal muscle tension
13. Use resonant voice tx an start with a pitch between Hz. Pitch can gradually be increase until the target Fo is reached w/o vocal strain or muscle tension.

17. Training: Voice
Address and correct any unfavorable vocal behaviors, such as
Hard glottal attacks
Breathiness
Glottal fry
Hoarseness
Use traditional techniques such as easy onset, resonant voice tx, vocal function exercises
14. Elimination of hard glottal attacks and glottal fry is essential. Glottal attacks and fry can pull the voice out of a higher pitch and resonant voice placement, making it very hard to maintain the new habitual pitch.

18. Training: Pitch Range
Establish a Range for sFo – usually 1 semitone above and 1 semi tone below the target sFo
Conversational Pitch range – 12 semitones
female: 165 – 311 Hz (total 146 Hz)
male: 93 – 175 Hz (total 82 Hz)
gender ambiguous: 131 – 247 Hz (total)
15. Training an appropriate speaking pitch range, i.e. inflectional range, is also important to avoid dropping into glottal fry or very low pitches at the end of sentences. A gender ambiguous pitch/inflectional range is 131 Hz – 247 Hz. This is 11 semitones.

19. Training: Intonation Male versus female intonation:
* Females use intonation more than stress to emphasize meaning
* Males are more monotone and may use increased loudness to emphasize meaning
Male to female clients must learn to use greater pitch range and intonation to promote successful voice feminization
16. Training intonation is important. Females use intonation mre than stress to emphasize meaning, while men ten to use a narrower speaking pitch range, are somewhat more monotone and use loudness to emphasize meaning.

20. Therapy: Resonance
Feminine Resonance – bring tone from chest resonance into facial-mask and head resonance
Forward tone focus – facial-mask resonance
Vowel Formants – high, front, spread vowels tend to have higher formant frequencies and are perceived more feminine. Start w/ unvoiced consonant plus high front vowels and progress to back, low vowels
‘ee’ – ification of vowels
Use Lessac Masden Resonant Voice Therapy
17. Resonant Voice Therapy or other frontal tone focus approaches work well to establish a feminine resonance. In particular high front vowels such as ‘ee’ or ‘ay’ are quite useful.

21. Training: Articulation
Vowels – easy onsets
Vowel prolongation – females tend to elongate their vowels
Consonant precision – females pronounce words with greater articulatory precision
‘Light Contact’ = light articulation
Linking and blending: ‘smooth or legato speech’
Oral motor – greater mouth opening and lip rounding in women
18. Training feminine articulation involves elimination of hard glottal attacks and training vowel prolongations, consonant precision, light contact, linking, etc.

22. Training: Rate and Intensity
Males are typically louder than females
Males speak faster than females
Females tend to pause more frequently and longer and prolong individual phonemes
19. There are also differences between men and women in intensity an speech rate. These must also be addressed.

23. Training: Language Syntax and Semantics - Gender Differences
20. Men and women also differ in use of syntax and semantics.

24. Training: Language Syntax example:
Females use more adverbial or ‘tag clauses’
‘I did a good job on the test, I believe.’
Females also use more ‘conditional’
clauses
‘ She’s going, unless she changes her mind.
Females show more ‘classic’ proper speech than males
21. For example, females use more adverbial and conditional clauses.

25. Training: Language
Semantics - Men and women use different words for different purposes and have different meanings for the same word
Women use the intensifier ‘so’ more often and show greater use of adjectives and adverbs and use less slang and swear words
22. There are also differences in semantics. As you can see, there is a great deal more to transgender communication training than adjusting vocal pitch.

26. Training: Pragmatics and Discourse
Females
are more elaborative,
communicate to share thoughts/feelings
give more disclaimers and qualifiers
communicate to build consensus
use nurturing phrases
are more emotionally expressive
use more terms of affection
use self disclosure
23. There have been many studies that have examined the communication differences between men and omen. Some characteristics of female pragmatics and discourse are listed in this slide.

27. Training: Pragmatics and Discourse
Males
communicate as a means to establish a place in a hierarchy
communicate to acquire information
are less likely to ask questions in public
24. The intention for male communication is different.

28. Training: Pragmatics and Discourse (Tannin, 2007)
Women desire intimacy in conversation, to feel connected to others.
Men desire to give information while remaining independent of the other party.
Women try to avoid the appearance of “superiority.”
Men are comfortable telling others what to do and appearing “superior.”
25. Pragmatics and discourse are also important components of the communication training.

29. Training: Pragmatics and Discourse (Tannin, 2007)
Women want to reach consensus and consult with others before deciding.
Men want to get straight to the bottom line and choose without consulting.
Women communicate to build relationships.
Men communicate to give information, solve problems and show expertise. 
26. Understanding and training components of gender appropriate pragmatics and discourse for both male to female and female to male transitions.

30. Training: Pragmatics and Discourse (Gray, 2004)
Women use more words to make a point & express more feelings.
Men use fewer words and express fewer feelings.
Women use conversation to think through a problem and work toward a solution.
Men think through a problem privately, then express the solution as the bottom line.
Women give feedback with tact, tentativeness and sensitivity.
Men give feedback directly and with bluntness, without the intention that it should be taken personally. 
Women often change the topic in the middle of a conversation, then return to it later.
Men tend to finish one topic before going on to the next. 
27. No notes

31. Training: Nonverbal Communication
‘During the initial 30 secs. of an interaction, we draw 6-8 conclusions about a person BEFORE a single word is uttered ..’ Audrey Nelson (2004)
28. Men and women also differ in terms of non verbal communication !

32. Training: Nonverbal Communication
Nonverbal behaviors include:
kinesics (body movements)
haptics (touching behaviors)
proxemics (distance between people)
occulesics (use of the eyes)
olfaction (smell)
physical appearance
chronemics (use of time)
paralanguage or vocalics
29. Nonverbal behaviors include many things, including use of eyes, touching, an body movements.

33. Proxemics or ‘personal space’
Women take less personal space, sit w/ legs crossed, arms in
Men take greater personal space, sit the legs stretched out and apart or out with legs crossed at the ankles and arms out
Women sit face to face and stand closer
Men sit side by side or stand at a greater distance
30. Men and women also differ in amount and use of personal space.

34. ‘Occulesics’ or use of the eyes
Women maintain greater eye contact, hold contact longer and ‘gaze’
Men show less eye contact overall
Men show ‘visual dominance’ – greater and longer eye contact when speaking than when listening
Men stare rather than gaze
31. Men and women differ in eye contact

35. CULTURE OF YOUR CLIENT
Many of these studies were performed in the United States
Speech, Language, Pragmatics and Nonverbal Communication varies by culture
You must not only consider the transgender culture of your client but their ethic and racial cultures as well
32. Remember that in addition to being transgender, your client also has a racial and ethnic culture, a speech community culture etc. You must take this into consideration as well. Transgender communication training is a specialty and requires that you acquaint yourself with all the differences in communcation, speech and voice production between men and women.

36. Sources
1. Gay and Lesbian Alliance Against Defamation. "GLAAD Media Reference Guide - Transgender glossary of terms", "GLAAD", USA, May Retrieved on
2. Author unknown, (2004) "...Transgender, adj. Of, relating to, or designating a person whose identity does not conform unambiguously to conventional notions of male or female gender, but combines or moves between these..." Definition of transgender from the Oxford English Dictionary, draft version March Retrieved on
3. USI LGBT Campaign - Transgender Campaign". Retrieved 11 January 2012.
4. Stroud District Council "Gender Equality SCHEME AND ACTION PLAN 2007"