Many transgender females report that
passing as the feminine sex is very difficult because of the voice. Aronson
(1980) classifies the voice of the transsexual as a "psychogenic voice
disorder" in the subcategory of psychosexual conflict. In the author's
own experience, these individuals often hesitate to use the phone, talk to
new people, or speak in public. They are constantly afraid of embarrassment
because of a low-pitched voice. Unfortunately, neither surgery nor hormone
therapy will raise the pitch of the voice in the male-to-female transsexual.
Once the vocal folds are thickened and lengthened during mutation and
puberty, they cannot be reversed. Recently, however, there has been some
evidence that the pitch of the male-to-female transsexual voice can be
raised with voice therapy (Bralley, Bull, Core, and Edgerton, 1978). This
perceived change may be the result of an increase in vocal fundamental
frequency (fo) and/or a combination of speech, language, and nonverbal
behaviors (Aronson, 1988; Lakoff, 1975; Thorne and Henley, 1975).
Changing speech, language, and nonverbal
behaviors may ultimately be more beneficial to the transsexual than changing
the pitch of the voice. Many women have low pitched voices, yet are
unquestionably female (Boone, 1977). Kline (1978) describes many sex
differences in communication. These include pitch, intonation, resonance,
loudness, articulation rate, speech quantity, word choice, syntax, vocal
behaviors, body posture, and other nonverbal behaviors. She recommends that
the clinician make the transsexual aware of the female characteristics of
speech and language in order to have communication match the desired body
image.
The purpose of this paper is to present a
case study of a preoperative male-to-female transsexual in order that the
speech and language behaviors that differentiate sexes may be outlined. In
addition, therapy techniques that can be used to teach these behaviors are
discussed. This client achieved moderate success with voice therapy, but
there were other aspects of speech and language that aided in her
self-concept as a female, as well as listeners' identification of her as a
female.
CASE PRESENTATION
The client, O.R., contacted an urban
community hearing and speech center by mail seeking professional help with
her speech. Her original request was for, "help with speech muscles
insofar as learning how to better modulate my speech as a woman does."
The diagnostic evaluation was performed soon after receipt of the letter and
the local managing hospital sex reassignment committee was contacted. Her
committee case manager, a licensed clinical psychologist, approved of speech
therapy if I deemed it appropriate.
O.R. had been a 26-year-old male who had
received hormone treatment for six months as prescribed by the Gender
Identity Clinic of an urban teaching hospital. It was reported that prior to
his decision for SRS, he had dressed as a female off and on for years, had
always felt like a female, and once was addicted to heroin as an escape from
being unable to be a female. The lifestyle-change year began with the onset
of hormone therapy and she (the candidate for SRS) lived with her mother who
supported her emotionally and financially. O.R. reported that she had
studied music during the two years she attended college and hoped to give
piano lessons to support herself after sex reassignment surgery. Her long
range goals were to be a successful piano teacher, get married, and adopt
children. The hospital psychologist reportedly was proceeding very
cautiously with O.R. because of her previous heroin addiction and suspected
schizophrenia--a condition which is one of those previously discussed in
Gender dysphoria syndromes (Benjamin, 1966; Meyer, 1974). O.R. had been in
psychotherapy previous to the speech and language evaluation and continued
during treatment.
THE DIAGNOSIS
O.R. presented herself at the diagnostic
session as a female. She was trying very hard to pass as a female, wearing a
long black wig, facial makeup, a dress, heels, and carrying a purse. It was
the examiner's subjective opinion that she was a bit "overdone,"
but was reasonably acceptable as a female.
Voice
An oral examination revealed normal
structure and function of a male larynx. The pitch ranged from approximately
90-350 Hertz (Hz), a range typical of a male tenor depressed at the upper
range (Boone, 1977). In vowel production a "normal" /e/ was
produced at a fundamental frequency (fo) of 145 Hz and an /i/ produced in a
falsetto voice was 280 Hz. As recommended by Cooper (1973) she was requested
to say "um hum" several times to determine the modal pitch. The
"um" portion was between 140 and 150 Hz and the "hum"
portion was between 160 and 180 Hz with rising intonation. Thus, her modal
pitch, roughly analogous to speaking fundamental frequency averaged between
140-160 Hz. Spectrograms were made of the voice for documentation purposes.
Fo was calculated according to the method recommended by Lieberman (1977).
This method utilizes a narrow band, scale magnified spectrogram (0-2000 Hz)
to calculate the fo from the fifth harmonic.
Loudness and voice quality were appropriate
in the conversational situation. The client reported that she did not speak
as loudly in group situations since adopting the female gender. This is
reportedly a female characteristic (Markel, Prebor, and Brandt, 1972).
Phonetic Structure
The client had no phonetic structure
(articulation) disorders, but did exhibit articulatory patterns that
characterize some male speakers. The patterns, as described by Freeman and
Clayman in Kline (1978) may be attributable to the larger tongue and oral
cavities of men. They include hypocorrect phonetic forms, such as /d/ for /
/, and /In/ for /I /. In addition to these, O.R. exhibited imprecise
productions at the ends of many words which may be described best as
clipping the ends of words.
Prosody
Other than clipping the ends of words,
O.R.'s prosody was normal. She reported that she did interrupt in mixed-sex
conversations—a characteristic that is more typical of males than females
(Thorne and Henley. l975).
Language Behavior
Language behaviors typically associated
with one sex or the other were informally assessed during the diagnostic
session and the first therapy session. She did not exhibit many of the
typical (Kline, l978) female syntactical or semantic patterns, such as
hypercorrect grammar, tag questions, confirmation words, or polite requests.
Nonverbal Behavior
Nonverbal behaviors, as described in
Birdwhistell (1970) and Thorne and Henley (1975), were assessed to determine
if O.R. exhibited more female than male characteristics. The following were
assessed:
Behavior of client was characterized
by:
vocal behaviors: female soft laugh, no
harsh coughing, sneezing, throat clearing
body posture: male open leg crossing,
foot movement, pelvis rolled back in walking, swinging arms, hand and arm
gesturing more forceful, angular
facial: pleasantness female smiles, nods of
approval
eye contact: male decreased eye contact
touching: male little touching
Diagnostic conclusions and management
goals
O.R. did not exhibit a speech or language
disorder in the traditional sense of a male speaker. She did, however,
exhibit more male than female speech and language behaviors. Therapy was
recommended with the following goals:
Goal A: Raise the modal pitch of her voice
as much as possible without creating vocal abuse or a falsetto range;
Goal B: Make O.R. aware of the
characteristics of speech and language that are associated with a (feminine)
woman so that she may choose from these to fit her own needs.
THERAPY
O.R. was seen two hours per
week for lO weeks. She returned for follow-up sessions three months and six
months after the conclusion of therapy. Spectrographic measurements were
made of her voice from high quality tape recordings taken in a sound treated
room. These measurements were made after the diagnostic session, fourth
therapy session, and final therapy session. In addition, O.R.'s speech and
language characteristics were informally evaluated by another certified
speech-language pathologist at the fourth and tenth sessions.
First Therapy Session
Session one consisted of a discussion of
her new vocal image (Cooper, 1973) in terms of its psychological
desirability and the mechanics involved in establishing a locus of resonance
that would lead to a voice that would be perceived as higher in
pitch. She concentrated on a tone focus that would create forward resonance
(e.g., focus the sound behind the nose). She used the "um hum" and
"hello?" techniques to establish the higher resonance. O.R. had an
excellent understanding of the pitch/resonance issue and was aware of the
importance of avoiding abusive vocal habits. Although she smoked 1.5
packages of cigarettes per day, she voluntarily decided to stop smoking
after the first therapy session because of its suspected lowering of pitch.
Sessions 2-4
In these sessions the new resonance pattern
(pitch) was monitored and attention was given to concepts of volume and
breath support. She, O.R., began with easy words for the new pitch
(/h/-words) and progressed to more difficult vowel/consonant words. Whenever
she needed to establish the new pitch, she thought of a "spot"
behind the bridge of her nose. O.R. reported that she liked her new pitch
and that it made her feel more feminine. All activities were tape recorded
and replayed for 0.R.'s monitoring.
As soon as O.R. consistently used the new
pitch in single words, she was ready to learn how to alter her inflection
and intonation in phrases. It was at this point (session three) that the
clinician re-introduced concepts discussed during the diagnostic session,
i.e., femininity is more than higher pitch (resonance). In sessions three
and four, the goals included work on feminine intonation, hyperarticulation,
rapid rate, and fewer interruptions during conversations.
To develop her sense of awareness of
male-female intonation differences, O.R. listened to women's voices on her
home tape recorder. These voices were low pitched yet obviously female. O.R.
was instructed to hum the melody pattern of the voices, as recommended by
Thorne and Henley (1975). Extensive practice and monitoring of intonation
were necessary. Careful selection of stimulus material enabled O.R. to
develop a greater pitch range and to relay varied emotions. The clinician
selected drill materials often used in modifying foreign accent. After those
drills were mastered, the clinician and O.R. practiced role playing, using
scenarios written by O.R.
To develop O.R.'s ability to
hyperarticulate, the clinician called her attention to male/female
differences in phonetic forms. A very effective technique to achieve this
goal was the simultaneous viewing by O.R. and the clinician of a few minutes
of a well known "soap opera." Characters tended to be ultra female
or ultra male. O.R. practiced a quick, precise, and light pattern of
articulation by using smaller jaw movements, using a higher-than-usual
tongue position, and practicing word lists containing / /, and / /, and
final consonant clusters. While working on articulation, O.R. was instructed
to note the increase in rate which automatically occurred. She was
discouraged from speaking too rapidly for fear of sacrificing gains made in
pitch and phonetic structure.
To decrease O R 's speech interruptions in
male/female conversations, she was assigned to monitor her own conversation
with men. She reported that she did indeed have a tendency to interrupt, but
was reducing this behavior now that she was aware of it.
O.R.'s fundamental frequency was measured
at the conclusion of the fourth therapy session. Her fundamental frequency
by this time was between 160-180 Hz as compared to the 140-160 Hz measure at
the time of the diagnosis, as determined by a spectrographic measure
recommended by Lieberman (1977). The subjective evaluation by a second
speech-language pathologist (a male) of her phonation was that the voice
"sounds lower than appropriate for a feminine voice." He was aware
that she was a transsexual. Another speech-language pathologist (a female),
who was unaware that the client was a transsexual, was asked to judge the
voice. She reported that phonation was normal but commented that the pitch
was "a bit low."
Sessions 5-10
In these sessions, work on the previous
areas was continued and the introduction of female language characteristics
was begun. The client was made aware of these differences as described by
several authors (Thorne and Henley, 1975; and Lakoff, 1975). In addition, a
very helpful book (Word Play, by Peter Farb) was read and discussed.
Portions of this book describe female intensifiers, qualifiers, expletives,
nonspeech vocal modifiers, pronouns, verbs, conjunctions, interjections,
swear words, jokes, and word choice. Some of this information is not current
because of females using language previously described as male.
To make O.R. aware of the characteristic
female nonverbal behaviors, she was asked to review the information by
Birdwhistell (1970). This information included body posture and movement,
hand and arm gesturing, facial pleasantness, eye contact, touching, and
space. Also discussed were clothing, make-up, and accessories, which are
considered to be forms of nonverbal communication.
At the conclusion of the tenth therapy
session, fundamental frequency was again measured. It was identical to the
measure made after the fourth session, or 160-180 Hz. The same male
speech-language pathologist who knew that O.R. was a transsexual
re-evaluated her and reported that although she "appeared to be a
female" she still had a low pitched voice. Interestingly, he reported,
"I don't see how you can work with her--it makes me nervous."
Follow-up sessions
O.R. came back three months and six months
after the conclusion of therapy. She had stabilized the new voice and
exhibited most of the female speech and language characteristics covered in
therapy. She reported that she still interrupted conversation in mixed sex
situations. Her nonverbal communication was female and her clothing was less
"overdone." O.R. was accepted as a female on the telephone about
50% of the time, according to her report. This was aided by the fact that
she answered the telephone with her female name, and not "hello."
She reported that the Gender Identity Clinic had decided that she should not
yet have sex reassignment surgery. She was very upset that the committee did
not approve her after one year.
CASE DISPOSITION
Six months after the
conclusion of therapy, O.R. received sex reassignment surgery from a private
physician without the knowledge of the Gender Identity Clinic. According to
her psychologist, she had a postsurgical psychotic episode, but has now
stabilized. She is living a "marginal life" with friends and is
back in psychotherapy as an outpatient at the Gender Identity Clinic. This
case history supports the view of Lothstein (l980) who strongly recommends
postsurgery psychotherapy to treat the conflicts often released by SRS.
SUMMARY AND CONCLUSION
This report introduces the reader to some
of the sex differences in speech and language that are of benefit to a
transsexual client. Although an increase in the fundamental frequency of
voice may be minimal in the male-to-female transsexual, many other therapy
goals may be attained--including more appropriate resonance characteristics.
Any therapist considering work with this population should work in
cooperation with a gender identity clinic or a psychological treatment team.
The importance of the adoption
of the appropriate gender role in these patients should not be
underestimated. Appropriate speech and language are suggested as major
facilitators for social-psychological adjustment in the transsexual. Not
only will others accept the patient's new gender role, but the patient’s
gender identity may be more easily self-accepted.
ACKNOWLEDGEMENT
The author would like to express her
appreciation to Dr. Lesie M. Lothstein of University Hospital, Cleveland,
Ohio, for his assistance and information regarding Gender Dysphoria
Syndromes and Dr. Alex F. Johnson, of the Cleveland Hearing and Speech
Center, for administrative assistance.
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Citation: This
work was based upon the clinical work of Celia
Routh Hooper, Ph.D., with the University Hospitals Gender Dysphoria Clinic
and the Cleveland Hearing and Speech Center. Acknowledgments to the
professional staff at both institutions at that time...the 1980s, especially
Alex F. Johnson, Ph.D. and Leslie Lothstein, M.D.
