Attending the 31st World Congress of the International Association of Logopedics and Phoniatrics (IALP) this August was most definitely one of my 2019 highlights. Not only did it give me the opportunity to be ‘trans-vocal’, it also gave me the chance to co-present with fellow voice specialist professionals; attend a range of presentations about voice; meet up with old friends and colleagues and make new connections.
It was great to receive the IALP Voice Committee’s invitation to present a 90 min workshop presentation on transgender voice. Myself and two Australian colleagues, Professor Jennifer Oates and Dr Georgia Dacakis from La Trobe University in Melbourne presented: ‘Speech-Language Pathology practice with trans and gender diverse clients: Foundations and best practice’.
My voice work remains broad and I work with a wide range of clients. I saw my first transgender voice client in 1997. However, it was since my appointment as the transgender voice specialist at Charing Cross Hospital in 2001, that being what I call trans-vocal began to form a significant part of my work. The need to increase awareness of transgender voice aspects and treatment for both clients, SLP/SLT clinicians and students was needed then and now. Over the years, I have received hundreds of queries from all over the world which continue to increase. It was a wonderful opportunity to present to an audience which exceeded 100 attendees. We had not been able to estimate how many likely attendees there would be and the volume far exceeded our expectations but it accurately reflected the reality of the continuing growing interest in this field from both SLPs/SLTs and SLP/SLT students.
Presenting at conferences takes energy and preparation. With a 90 minute time allocation involving 3 speakers in total from two continents, it takes a fair bit of co-ordination too. Within the presentation title above, we had prepared seven topics in total. To start with, Professor Oates engaged the audience in some live polling so that they could select in order of their preference, the five topics they most wanted to hear about. We had anticipated that the ‘Voice Training’ and Voice Assessment’ talks would be high on the list and indeed they were the top two topics selected respectively. These were the talks allocated to me to prepare and in both of my talks and those given by my colleagues, we had the chance to discuss some of the many misconceptions about voice work and voice change in transgender and gender diverse people.
One misconception is that most trans women (individuals assigned male at birth who have a female gender identity) seeking voice modification will require vocal surgery to feminize their voice. This is far from the truth. Voice feminisation is highly possible with specialist voice therapy alone, especially with a suitably trained clinician following a secure and staged process of therapy. (Several pre and post treatment voice examples can be heard on my website’s transgender voice page). Voice training with an SLP/SLT remains the most common way a client may seek to change their voice and this is the recommended initial course of action. However, some clients remain unaware of the role voice clinicians can play to assist with voice change and may seek surgery in the first instance. The increasing wait to access SLP/SLT services in many clinics may also be an influencing factor.
Another misconception is that only limited vocal outcomes are possible with voice therapy. Pre and post treatment voice examples demonstrate the level and range of possible outcomes. As for any voice presentation I give, I included voice samples at the recent IALP congress. The level of surprise from the audience regarding the degree of voice change was very apparent yet these therapy outcomes are more the norm rather than the exception in my voice work and this is the case for other experienced SLTs who work with transgender voice. My colleague Georgia Dacakis reminded me that during a presentation at the World Professional Association for Transgender Health (WPATH) conference several years ago, I stated that playing pre and post treatment voice samples was crucial to enhancing knowledge, interest and awareness in transgender voice and I stand by that comment to this day. In smaller specialist voice fields such as transgender voice, this is still especially important.
A further misconception is that SLTs/SLPs who work with trans women stick rigidly to stereotypical binary gender voice and speech markers. The reality, in best practice therapy, is that the treatment is highly individualised, client centred and driven by the goals of the clients themselves, not by the goals of the clinician.
Whilst many individuals cite voice modification as a crucial part of their social transition, it is always important to remember that not all trans clients wish for, or seek, voice change. Some may seek a mildly modified voice or more fluid voice depending on gender presentation whilst many others will seek more extensive voice change. The latter generally involves more stages of treatment. Part of our work involves helping clients adjust and manage their own feelings about their voice and voice change and the reactions of others. The emotional support role provided by SLPs/SLTs is generally highly valued by clients.
Traditionally, the bulk of the SLPs/SLT’s work has been with voice feminisation and our interventions with trans females tend to be longer. This is because oestrogen hormone treatment given to trans females has no impact on the sound of the voice or the structure of the vocal folds. In contrast, trans men (individuals assigned female at birth who identify as male), experience a lowering of pitch many are satisfied with due to vocal fold thickening following testosterone treatment. More trans men are now coming forward for voice training, sometimes due to less lowering of pitch than desired.
In our IALP presentation, Dr Georgia Dacakis, gave a brief overview of the role of hormones for trans individuals as well as describing some of the facilitators and barriers for clients and clinicians. Dr Jennifer Oates described the evidence base in the field of transgender voice. As a relatively new field of voice work, the evidence is correspondingly low. However, evidence continues to grow, particularly for voice feminisation where SLTs have traditionally had an increased level of input.
It is always welcome when people approach the presenters’ desk at the end of the conference with comments and questions. It was especially heartening to have local SLTs/SLPs come forward to express thanks and ask for advice with their own cases and for local students to express a strong interest to work in the field. The day before I departed for Taipei, a student had observed two transgender voice practice support groups I ran at my treatment rooms. Demand for transgender voice therapy currently far outweighs supply. As if to highlight that even further, all through my time at the congress, new clients have contacted seeking appointments.
In the way that synchrony often mysteriously joins past and current experiences in our lives, I finished answering student questions post presentation at the conference and returned to my hotel room to find emails from U.K SLTs seeking advice regarding some aspect of their work with transgender clients; and a request from a student association to give a presentation to them about working with transgender voice. The synchrony was enhanced in this situation by the cross-continent duality of requests.
Working with transgender voice can touch the lives of many trans individuals seeking voice modification to assist them to achieve enhanced social comfort and functioning. It can also enhance the experience of the lives of professionals already heavily active in the field and the lives of clinicians and students looking to work in the field in the future.
Seemingly random coincidences can often resonate with particular events in our life. A few days after the conference, I found myself in a Buddhist temple, and picked up a few book marks on offer… I asked my guide Kai to make a general translation of the Chinese characters of one of them and I think it’s message was in pure resonance with the trans-vocal message of our presentation. The translation goes something like this:
Thank you IALP for the opportunity to be trans-vocal in Taipei, Taiwan, August 2019.