Intervention for a Female-to-Male Transgender Individual:
A Case Study
Jack Pickering, PhD., CCC-SLP and Reverend Diane Berdan
The College of Saint Rose, Albany, New York
Introduction
Intervention
Data Regarding Voice Change
Over the past 2 decades, literature about voice and communication
modification for male-to-female (MtF) transsexuals has provided a
blueprint that can guide SLPs working with MtF clients; however, there
is very little information about voice and communication therapy for
female-to-male (FtM) transsexuals, so SLPs have little guidance.
Baseline data taken in early May indicated a fundamental frequency of
174 Hz, high frequency perturbation (jitter), and a moderately rough voice
quality. Some laryngeal tension was also noted upon palpation. The initial
focus of therapy (once per week for 1.5 hours per session) was to: a)
decrease laryngeal tension using laryngeal massage and b) produce
connected speech with forward resonatory focus. In the summer 2009,
Ian took part in Vocal Function Exercises (VFEs) at a frequency range of
C3-G3 in order to increase laryngeal strength and tone (Stemple, Glaze,
and Klaban, 2010).7 Inflection was also targeted.
Data collected during the early part of treatment indicated an
interesting decline in fundamental frequency (see below),
occurring in a stair-step manner. A decline in frequency from May
to June (174-152 Hz) was followed by several weeks of limited
change. Then, another decline took place around June 29 (152141 Hz) that was followed by another period of little change. By
the beginning of the fall, Ian’s fundamental frequency dropped to
125 Hz, which has remained relatively consistent. Each time
fundamental frequency changed, roughness and increased back
tone focus was noted, even when fundamental frequency
dropped into a male frequency range.
One reason for the lack of information is that most FtM transsexuals
achieve a desired voice with hormone therapy because testosterone
contributes to a thickening of the vocal folds, facilitating a lower
fundamental frequency, consistent with male speakers.1 Also, the
relationship between voice and physical appearance seems strong for
FtM individuals, which facilitates passing.2
While most FtM transsexuals do not need voice and communication
intervention, some individuals have trouble adjusting to their voice
change and may require therapy.3-4.
Van Borsel et al.4 suggested that SLPs have a role in: a) assessing
. FtM individuals before hormone therapy, b) assisting FtM clients in
developing realistic expectations of voice change, and c) providing
therapy for FtM clients who struggle adjusting to their voice change.
Adler & Van Borsel5 described a 10-step voice therapy program for
FtM transsexuals who require intervention because of excessive
muscle tension. They also described a surgical option, Type III
thyroplasty, for lowering the f0 of FtM transsexuals.
Since FtM singers may also experience difficulty during their
transition, readers are directed to Constansis6, who described his own
personal account and the results of a study involving vocal warm up
and exercise for eight FtM transsexual singers.
The Case
This poster describes a case of a FtM client (Ian) who was seen at the
College of Saint Rose during the summer and fall, 2009. Ian is a 48
year old pastor who began transition in February 2009, and hormone
therapy in April 2009. After starting hormone therapy, he noticed a
dramatic change in his voice that was having a significant effect on his
ability to perform duties as a pastor in an upstate New York church. His
primary complaints included hoarseness, vocal instability, vocal fatigue,
difficulty singing, and reduced inflection during conversation.
Since the most relevant perceptual features of Ian’s voice included a
rough voice quality and back tone focus, intervention emphasized
Resonant Voice Therapy (RVT), as described by Stemple, Glaze and
Klaban (2010).7 During the fall 2009 (September-December), intervention
was devoted to the improvement in resonance; RVT facilitated this
improvement. As the fall semester went on, it was noted that laryngeal
tension decreased without massage and inflection improved, although
there continues to be a concern that Ian uses intonation patterns (e.g.,
upward inflections) that may be perceived as feminine. In addition,
singing did not improve over this time. Sermons served as a functional
context for working on voice and resonance.
Resonant Voice Therapy
Ian’s Reflections (and a call for further study!)
Goal of RVT: To produce voice with
forward, resonatory focus and as little
vocal effort as possible.7
I have “a need to have a voice and be empowered once again. I still cannot sing, and I miss
that. Answering questions about a cold...people who have not seen me for awhile still ask.
Steps:
•Humming
•Molming
•As a sigh
•Varying rate and loudness
•Like speech
•Chanting sentences
•“Mamapapa”
•Varying rate and loudness
•Like speech
•More Chanting
•Producing sentences
•Overinflected
•Natural Speech
•Additional sentences and
conversation
Jack Pickering, 2010
People need to be respected and listened to. The medical field is political, suspicious, fearful
and often incompetent and disrespectful when providing medical care for transgender people.
Voice treatment is one place I did not have to worry about being considered to be stupid or
treated as less than human.
There is a behavioral change, an adolescent phase that comes with transitioning. Patience
with that process is pivotal...for patient and treatment providers.”
References
1 McNeill, E. J. M. (2006). Management of the transgender voice. The Journal of Laryngology & Otology, 120, 521-523.
2 Van Borsel, J., de Pot, K., & De Cuypere, G. (2009). Voice and appearance in female-to-male transsexuals. Journal of Voice, 23(4), 494-497.
3 Adler, R. K., Hirsch, S., & Mordaunt, M. (2006). Voice and Communication Therapy for the Transgender/Transsexual Client: A Comprehensive
Clinical Guide. San Diego, CA: Plural Publishing, Inc.
4 Van Borsel, J., De Cuypere, G., Rubens, R., & Destaerke, B. (2000). Voice problems in female-to-male transsexuals. International Journal of
Language and Communication Disorders, 35(3), 427-442.
5 Adler, R.K. & Van Borsel, J. (2006). Female-to male considerations. In R.K. Adler, S. Hirsch, & M. Mordaunt (Eds.), Voice and Communication
Therapy for theTransgender/Transsexual Client A Comprehensive Clinical Guide (pp. 139-167). San Diego: Plural Publishing.
6 Constansis, A.N. (2008). The changing female-to-male voice. Radical Musicology, 3, 1-18.
7 Stemple, J.C., Glaze L.E., and Klaben, B. (2010). Clinical Voice Pathology: Theory and Management (4th ed.). San Diego: Plural Publishing.
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