Forces Affecting Voice Function in Gender Diverse People Assigned Female at Birth

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Forces Affecting Voice Function in Gender Diverse People Assigned Female at Birth *David Azul, †Adrienne B. Hancock, and ‡,§Ulrika Nygren, *Bendigo, Australia, yWashington, District of Columbia, and zxStockholm, Sweden

Summary: Objectives. The purpose of this study was to explore the factors and practices that have acted as facilitators or barriers to voice function in gender diverse people assigned female at birth (GD peopleAFAB) from a participant-centered perspective and to inform the role of speech-language pathologists in supporting GD peopleAFAB with developing and maintaining functional voice production. Methods. Transcripts of semistructured interviews with 14 German-speaking GD peopleAFAB were analyzed for the study objectives using a consensual approach to qualitative content analysis. The interviews and their interpretation were conceptualized as co-constructions of participants and researchers who were regarded as experts in their own right. Results. Professional practices (testosterone treatment, professional voice support), speaker practices (self-care and voice use practices, self-evaluation of voice function), conversation partner practices, and supraindividual biocultural forces (vocal demands, normative practices, other biocultural forces) were identified as having influenced the participants’ voice function. Professional voice support, a range of phonation practices, and general self- and voice care practices were frequently cited facilitators of functional voice production. The most frequent barriers to voice function included testosterone treatment, slouched posture, excess muscle tension, forceful voice use, and avoidance practices. Conclusions. Voice function in GD peopleAFAB is influenced by interactions of several forces, most of which may be shared by voice users of all genders. Professional practices should follow a person-centered approach to care in which all parties are well informed of the limitations and possibilities for any intervention, including the often-unquestioned contribution of testosterone treatment. Key Words: Interviews−Qualitative content analysis−Conceptual research−Communication−Transgender −Transmasculine.

INTRODUCTION Gender diverse people assigned female gender at birth (GD peopleAFAB) but who do not identify with this classification have recently received increased attention in the voice literature. While the view has been widespread that members of this population do not experience any voice problems and do not need attention from voice specialists due to the effects of testosterone treatment on their voices, a range of studies have been published in the last 20 years that challenge these assumptions. Specifically, research has demonstrated that GD peopleAFAB may present with various kinds of voice problems independent of whether they have been treated with testosterone or not and may seek or be recommended to seek professional voice support (eg,1−8). In addition, there are a range of indications that the forces that Accepted for publication January 6, 2020. From the *Discipline of Speech Pathology, Rural Department of Allied Health, La Trobe Rural Health School, College of Science, Health and Engineering, La Trobe University, Bendigo, VIC, Australia; yDepartment of Speech, Language, and Hearing Sciences, The George Washington University, Washington, District of Columbia; zDivision of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; and the xFunctional Area Speech & Language Pathology, Karolinska University Hospital, Stockholm, Sweden. Address correspondence and reprint requests to David Azul, Discipline of Speech Pathology, Rural Department of Allied Health, La Trobe Rural Health School, College of Science, Health and Engineering, La Trobe University, PO Box 199, Bendigo 3552, VIC, Australia. E-mail: [email protected] Journal of Voice, Vol. &&, No. &&, pp. &&−&& 0892-1997 © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvoice.2020.01.001

influence GD peopleAFAB’s voices are not limited to testosterone treatment alone but are more diverse and complex than traditionally assumed (eg,1,2). We use “force” in this study as an overarching term to refer to living processes, nonliving factors, and human practices that are attributed the “power to influence [or] affect” (Oxford English Dictionary Online9) voice function. We will predominantly use the term “sociocultural positioning” instead of “identity” for the following reasons. One, positioning can be used in an active (positioning oneself in terms of sociocultural categories, eg, gender, age, sexuality, and ethnicity) and in a passive sense (being positioned by others in terms of sociocultural categories) and thereby refers to the two types of meaning making practices that are enacted in vocal encounters between speakers and listeners. Two, positioning is understood in a flexible sense as something that may change repeatedly and in various ways during a person’s life whereas identity is defined as “the sameness of a person . . . at all times or in all circumstances”9 and tends to be conceptualized as stable, persisting, and unchangeable. So far, there has not been a systematic evaluation and synthesis of more in-depth and comprehensive conceptualizations of the different forces that impact on voice and communication to guide practitioners in advising and serving GD peopleAFAB. For this reason, there is a need to return to a position of not knowing and to explore in detail, which forces are contributing to shaping GD peopleAFAB’s vocal situations, what their specific effects on voice are and

ARTICLE IN PRESS 2 how the identified forces can best be addressed in clinical practice. Challenging traditional assumptions about testosterone as the main force affecting GD peopleAFAB’s voices When GD peopleAFAB are defined as “biological females who desire to appear male,”10 (p. 189) and it is suggested that “[v]irtually all female-to-male transsexuals experience virilization as a result of hormonal therapy” (ibid.), which will “improve congruence between their voice and their selfidentity and [. . .] avert negative societal responses,”11 (p. 49), two assumptions are implied. First, that all GD peopleAFAB position themselves as male and therefore wish to be treated with testosterone. Second, that voice-related problems GD peopleAFAB experience will resolve if they have testosterone treatment. With the help of testosterone treatment, so it is claimed, the mismatch between desired and actual voice, the need to take steps to vocally and otherwise embody the male gender, and the discomfort or distress that may have been associated with these experiences and practices will disappear. There are several problems with this traditional view on the vocal situations of GD peopleAFAB. First, it has been recognized over the years that GD peopleAFAB are a diverse group whose members position themselves variously in terms of gender and other categories of sociocultural belonging. In particular, not all GD peopleAFAB identify as male, wish to present with a male voice, or are dissatisfied with their current voice because it does not represent the gender with which the speaker identifies (eg,5,12,13). Second, the methods GD peopleAFAB may use to present themselves are now seen to be diverse. As has been acknowledged in the World Professional Association of Transgender Health “Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People,”14 (p. 5), professional support for gender diverse people should be individualized: “[W]hile many individuals need both hormone therapy and surgery to alleviate their gender dysphoria, others need only one of these treatment options and some need neither.” And indeed, there are examples of GD peopleAFAB who have participated in voice research and who had not been treated with testosterone at the time of the study (eg,3,15,16). There are also case reports of GD peopleAFAB who have not been interested in hormone treatment but have sought professional voice support (eg,5) or pitchlowering laryngeal surgery instead.17 It follows that not all GD peopleAFAB are receiving or wish to receive testosterone treatment. Third, up until recently, studies have been focused on testosterone treatment as the main factor shaping GD peopleAFAB ’s voices. In three recent reviews of the voice literature on GD peopleAFAB, the following percentages of included studies were focused on testosterone treatment: 82%1; 86%2; 100%.8 However, studies exploring the effects of testosterone treatment have often not been controlled well for the influence of other forces on GD peopleAFAB’s voices (eg,

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self-positioning practices, speaker’s vocal demands). Therefore, there is a need to critically examine the position of testosterone treatment as the main factor and to pay close attention to other forces that may impact on GD peopleAFAB ’s voices. In addition, there have been reports of permanent restrictions to voice function in speakers assigned female at birth (participants of these studies are commonly referred to as “women” without providing information about their self-identified gender) as a result of treatment with testosterone-containing medications (eg,18−21) or due to endogenous production of androgens.22,23 Restrictions that are mentioned in the literature include loss of high frequencies, vocal instability, hoarse voice quality, and difficulties to project the voice. These findings challenge the view that it can be taken for granted that testosterone treatment will necessarily and only have a beneficial effect on voice in GD peopleAFAB. Voice function in GD peopleAFAB In this study, a distinction is made between two perspectives from which voice can be examined, however, it is acknowledged that these aspects of vocal communication are entwined and influence each other. On the one hand, one can explore the voice’s contribution to positioning the speaker in sociocultural contexts and on the other hand, one can look at the speaker’s capacity to meet their vocal demands. We will refer to the latter as “voice function” in this paper. The voice’s influence on the speaker’s sociocultural positioning is considered in terms of whether or not the speaker identifies with their own voice and whether or not the attributions the speaker receives from others match with the speaker’s self-positioning regarding, eg, gender, age, sexuality, cultural background, religion, and dis/ability. For instance, speakers who self-evaluate their voices as not masculine enough or speakers in their 40s or 50s who tend to be heard and addressed as adolescents over the phone present with problems related to the voice’s contribution to positioning the speaker in alignment with the speaker’s own wishes or identification. The forces involved in GD peopleAFAB’s sociocultural positioning in vocal encounters will be the focus of another study. In this paper, the focus will lie on the forces that influence GD peopleAFAB’s voice function. Voice function is defined as comprising “the areas of assessment and treatment voice clinicians would consider with every voice client . . . and which are not primarily gender related,”2 (p. 261.e9). In assessing a speaker’s voice function, voice specialists examine whether or not speakers can meet their everyday vocal demands in a functional manner, that is, “without having to increase vocal effort, experiencing vocal fatigue or changes to voice quality that draw attention to their voice in terms of attributions of impairment.”24 Phrased in positive terms, functional voice production allows the speaker or singer to feel good while making vocal sounds, achieve maximum control over their voice and to maximize the longevity of vocal production by minimizing muscular effort and facilitating the most

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efficient vocal output.25 Voice quality, vocal power, pitch range, and pitch variability are aspects of voice function that have been explored in GD peopleAFAB in previous research (eg,2). When identifying forces that affect voice function in GD peopleAFAB, it is important to recognize that GD peopleAFAB are in the first instance voice users just like speakers of all genders. The implication of this understanding is that all forces that might influence any person’s voice function could also potentially affect a GD personAFAB’s voice function. Examples of forces generally seen as having an effect on voice function include: voice care practices (eg,26,27); life style factors (eg,28,29); environmental factors (eg,30,31; Nybacka et al, 201232); vocal demands (eg,33,34); psychosocial forces (eg,35); biophysiological conditions and effects of professional interventions on voice, such as, voice therapy, laryngeal or other surgery to head and neck, or medication (see contemporary text books on voice disorders, eg,25,36). In addition, certain forces are assumed to more likely and more frequently impact on GD peopleAFAB’s voice function as compared to on the voices of speakers who do not belong to this population. These forces are related to anything a GD personAFAB might request from others or do themselves for the purpose of presenting their sense of sociocultural belonging in alignment with their own positionings and preferences. For example, a GD personAFAB may use a binder to shape chest contour and, as a result of the binder, experience difficulty achieving adequate breath support for loud voice (eg,2,5). The current lack of knowledge about the forces that may affect voice function in GD peopleAFAB is problematic, because it hampers a detailed understanding of the vocal situations of members of this group. It prevents the provision of specific and accurate informational counseling, and hinders the development of comprehensive and evidence-based approaches to professional voice support aimed at enhancing facilitators and reducing barriers to functional voice production in this population. The purpose of this study was to address aspects of the above-mentioned knowledge gap via an in-depth exploration of GD peopleAFAB’s own accounts of factors and practices that shaped their voice function. The co-constructed accounts utilized in this qualitative study were examined in terms of the following research questions: 1. Which types of forces influenced the participants’ voice function? 2. Which (aspects) of the identified forces contributed to promoting the participants’ capacity for functional voice production (facilitators)? 3. Which (aspects) of the identified forces contributed to hindering the participants’ capacity for functional voice production (barriers)? 4. Which (aspects) of the identified forces having affected functional voice production can be influenced in speech-language pathology practice with GD peopleAFAB?

3 METHODS Methodological perspective We used interviews in this study in order to explore our participants’ perspectives on their own voice function. The interviews were conceptualized explicitly as “interactional events in which interviewer(s) and interviewee(s) make meaning, co-construct knowledge, and participate in social practices,”37 (p. 2) so the analysis includes contributions of researchers’ and participants’ meaning making practices. This understanding does not imply that it would be possible to consider every potential way in which knowledge production could have been shaped during planning, conducting, and representing this study. Rather, the advantage of theorizing research interviews as co-constructions of meaning between people who are regarded as experts in their own right is to highlight that knowledge production of any kind is always already mediated by a range of forces, including conscious and unconscious signification practices on the part of the interviewers and the interviewees and supraindividual sociocultural forces (eg, gender norms, linguistic rules, understandings of voice, health and disorder). In this study, these influences were not conceptualized as bias, which the interviewer needed to minimize in order to avoid distorting the data.38 Instead, to the extent that they could be identified, influencing forces were considered as part of the data and it was seen as the researchers’ role to explore any contributions these forces may have had for the conceptualization of voice function of our participants and to suggest the scope for and limitations to supraindividual generalization of findings. Data collection F edPTag ourteen German-speaking participants at 19;5 to 42;8 years (years; months) who all self-classified as GD peopleAFAB were recruited via nationwide volunteer sampling. Thirteen participants had started testosterone treatment prior to the beginning of the study (duration of hormone treatment at the time of the study: 2.5 months to 9.3 years, M = 22.6 months). The participants were notified that the interviewer (DA) was the primary researcher and also a participant in the study. Approval for the study was obtained from the local ethics committee and all participants provided written informed consent to take part. Thirteen interviews were conducted in-person by the first author (DA), who grew up in Germany, has German as their first language, self-classifies as a GD personAFAB and was a certified practicing speech-language pathologist and Master’s research student at the University of Aachen, Germany, at the time of the data collection. A cisgender female, German-speaking certified practicing speech-language pathology colleague who was familiar with the interview guide but not an investigator on the research project conducted the interview with the first author in the role of participant. The interviews, followed a topic guide, were conducted individually, audio recorded, and transcribed verbatim (see Appendix 1 for example questions). The

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Speaker psychosocial situation

neuromotor processes

Biophysiological conditions

Vocal demands

Professional interventions

Voice care practices

Self-presentation practices

cognitive-emotional practices

FIGURE 1. Conceptualization of the forces affecting voice function in GD peopleAFAB that informed the data collection.

interview guide was used flexibly; not every participant was asked all questions, in the same order, or using the same wording, and participants were given the opportunity to elaborate in their responses on points that were relevant to them. The interview guide was informed by the following general conceptualization of voice production: “Voice is the result of a highly complex interplay of cerebral activities, sub-cortical control loops, emotional components and muscular effort, including respiration, phonation, articulation and upright posture,”39 p. 6, our translation). Speaker psychosocial situation, vocal demands, voice care practices, biophysiological conditions, and professional interventions affecting voice were also conceptualized as factors shaping functional voice production (Figure 1). In addition, questions were included about the impact on voice function of practices in which individual participants may have engaged in order to position themselves in social encounters in alignment with the gender with which they identified and other aspects of sociocultural belonging that were important to them (“self-presentation practices”) (Figure 1).

Data analysis The sections of the interview transcripts that referred to the participants’ voice function were extracted for this study and further divided into accounts pertaining to the participants’ current voice function (ie, participant self-evaluations of their voice function at the time of the interview) and those pertaining to the forces affecting voice function (ie, processes, factors, or practices that were seen as having shaped the participants’ voice function in supportive, hindering, or neutral ways). A mixed-methods examination of the participants’ current voice function has been presented elsewhere.4 The focus of this paper was to explore the forces affecting voice function based on an integration of the perspectives of the interviewees, the first author who combined the roles of

interviewer, interviewee, researcher, and voice clinician, and the second and third authors who were cisgender women with dual roles of researcher and speech-language pathologist (AH grew up and lives in the USA and has American English as her first language; UN grew up and lives in Sweden and has Swedish as her first language). Following previous publications reporting on other parts of the same research project,3,4,12 the interview transcripts were examined in this study according to a combination of deductive and inductive approaches to qualitative content analysis.

Conceptualization of voice function used for data analysis The analysis of the interview transcripts followed a conceptualization of the notion of functional voice production that is different from the one we used during data collection and which also constitutes a reworking of conceptualizations that are commonly presented in the voice literature.24 The reason for this reconceptualization was recent advances in social sciences and humanities discourses that had not yet been applied to voice research at the time of the data collection (eg,40−44). According to this new conceptualization we used for data analysis, voice function is not understood as either predominantly dependent on the bio- and neurophysiological condition and anatomical dimension of the speaker’s vocal mechanism (as suggested, eg, by the category organic voice disorders) or as dependent on how efficiently the speaker gestures with their body and voice organ (as suggested, eg, by some understandings of functional voice disorders). In addition, the different types of forces impacting on voice function depicted in Figure 1 are no longer understood as acting in isolation from each other or as being assessable and treatable individually. Instead, voice function is conceptualized as the outcome of an inextricable assemblage of diverse types of forces that are beyond individual control (Figure 2).24

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5 that are provided for employees to do their job (eg, amplification devices, headsets, ear protection; see also46).

FIGURE 2. Conceptual model of voice function informing the data analysis (Azul and Hancock, in press). Following this model, the capacity to act (“agency”) on voice function can be attributed to individuals (“individualized agency”), such as, speakers (“speaker practices”), conversation partners (“conversation partner practices”), or to professionals whose support speakers have been receiving (“professional practices”) (Figure 2). Examples of these individualized practices include speakers gesturing with their vocal mechanisms to produce voice, conversation partners evaluating the speaker’s voice, and professionals who provide the speaker with medical or voice-specific intervention. The contributions from each of these categories of people to the production of speaker voice function are not conceptualized as actions in the sense of a doing that is consciously and intentionally controlled. Rather, the agency of individuals in the production of voice function is understood as mediated by a fusion of sociocultural and material forces (“supraindividual biocultural mediation”) (Azul and Hancock, in press) (Figure 2). The notion of work-related vocal demands, which include “vocal loading (speech and song), background noise, poor room acoustics, long speaking distance, air quality, dryness, dust, stress, and inadequate equipment,”34 (p. 123), is an example of how voice function can be conceptualized as being bioculturally mediated by forces that are beyond individual control. Work-related vocal demands are on the one hand shaped by sociocultural aspects of workplace culture, which is defined as “a set of shared meanings, expectations, values, and assumptions that governs behavior in a workplace and how it is interpreted,”45 (p. 343). These immaterial aspects of workplace culture include, eg, duration of voice use per day, periods of voice rest, and access to training in voice care. On the other hand, work-related vocal demands also have a material side that pertains to physical forces and objects that are part of the workplace, such as the location and architectural setup of the workplace (affecting, eg, acoustics, size of rooms, air quality) and the tools

Within-case analysis In order to identify the types of forces that could have affected the participants’ voice function, the first author analyzed the individual interview transcripts into the four domains of the conceptual model24 of speaker practices, professional practices, conversation partner practices, and supraindividual biocultural forces (Figure 2). This application of the model of a bioculturally mediated production of voice function to the analysis of the interview transcripts constituted the deductive part of the qualitative content analysis. The sections of text that had been allocated to the different domains of the model were then further explored following a combination of inductive qualitative content analysis47,48 and consensual analysis as described in Hill.49 The accounts were divided into meaning units, which were then condensed, abstracted, and coded.47 The abstraction of material into codes also included a translation from the German language (interview transcripts) into English (categories and subcategories). The codes constituted draft categorizations of the forces that have affected individual participants’ voice function within the four different domains (research question 1). In a second step, the material that had been analyzed into the different types of forces that could have affected the participants’ voice function was categorized into the interviewees’ evaluations of whether voice function had been influenced in a positive or negative way (research questions 2 and 3). Cross-analysis The first author compiled the draft categorizations and associated excerpts from individual transcripts into one document per domain and revised the categories and subcategories until commonalities across and differences between cases had been considered and a category structure had been developed that captured the data within the domain as comprehensively as possible. All three authors conducted the cross-analysis of the participant accounts at group level individually to identify categories and subcategories that were shared across individual participant accounts and to decide which of the identified forces having affected voice function in our participants had potential to be influenced in speech-language pathology practice (research question 4). Differences between the analyses of individual research team members were discussed until consensus was reached regarding which types of forces to include, how to label overarching categories, which forces to categorize as facilitators or barriers of the participants’ voice function and which to classify as amenable to change in professional voice support. RESULTS In order to illustrate categorizations, quotations from the participants’ accounts translated from the original German into English will be provided. “P1-14” refer to the number of the quoted participant and “I” to the interviewer. Comments in

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square brackets are added to clarify content as necessary. Material that was considered not essential to illustrate categories or subcategories was excluded and presented as “- - -.” Types of forces having affected voice function Forces that were interpreted as having affected the participants’ voice function were categorized and sorted to align with the model used in analysis (see Figure 3). The accounts associated with the domain “Speaker Practices” were analyzed into two categories of forces: Self-evaluation of voice function and Self-care and voice use practices (accounts of how participants were looking after their health and wellbeing and how they used and cared for their voice). The accounts associated with the domain “Professional practices” were analyzed into four categories of forces: Professional voice support; Medications (testosterone treatment and other medications); Surgery (mastectomy); and Other professional support (physiotherapy, massage). Specific types of medications other than testosterone treatment, surgery and other professional support participants had been receiving, had shaped the participants’ voice function in an idiosyncratic manner. In order to avoid overinterpreting accounts that pertained only to one participant but that constituted a separate category of professional practices,48 (p. 124), we will not further discuss these accounts in more detail. Instead we will focus on an analysis of the impact of professional voice support and testosterone treatment on

voice function, which were the only practices included in the accounts of more than one participant. The accounts associated with the domain “Supraindividual biocultural mediation” were analyzed into three categories of forces: Vocal demands; Normative practices; and Other biocultural forces affecting voice function. The category Normative practices refers to the application of standards of voice function to the speaker’s voice, such as, evaluations of a speaker’s voice function as restricted or unrestricted. These evaluations may be attributed to the speaker by the speaker themselves or by their conversation partners who may be laypeople or professionals. The accounts associated with the domain “Conversation partner practices” were analyzed into the category Evaluation of speaker voice function. As above, due to the idiosyncratic nature of conversation partner evaluations of the participants’ voice function and low numbers of accounts pertaining to this category, these practices will not be analyzed in detail but addressed as part of the category “normative practices” that belongs to the Supraindividual biocultural mediation domain. Types of forces having acted as facilitators and barriers In the following section, we will present the results of the analysis pertaining to the direction of the effect different types of forces were seen to have had on different aspects of voice function across our group of participants. In addition,

FIGURE 3. Results: categories of forces that were identified as having affected the participants’ voice function.

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we will provide an estimate of how frequently the different types of forces were co-constructed as facilitators or barriers to voice function (number and percentage of participants affected) based on the participant accounts. The frequency data constitute minimum numbers due to the understanding that if a participant did not mention specific types of forces or their effects on voice function during the interview this did not necessarily imply that this participant had not experienced the effect of these forces on their voice. Instead, there could have been a range of other reasons why a participant did not mention specific forces or their effects on voice (eg, interviewer did not specifically ask about this force, participant was not aware of or did not remember specific forces that have impacted on their voice, etc). Professional practices Testosterone treatment. Of the 13 participants who had been treated with testosterone at the time of the interviews (P1 was not treated with testosterone), five had been undergoing testosterone treatment for shorter than 1 year (P2-6) and eight for longer than 1 year (P7-14). Some of the participants who had been receiving testosterone for longer than 1 year included comments on the perceived restrictions to voice function at the beginning of their testosterone treatment. These comments were included in the results pertaining to the time period within 1 year of initiating testosterone treatment (Table 1). Seven participants (54%) reported restrictions to at least one aspect of voice function within the first year of testosterone treatment (Table 1). There were no reports of testosterone

acting as a facilitator of voice function during this time. Voice quality (38%), vocal control/stability (38%), pitch range (31%), vocal endurance (23%), and vocal power/projection (23%) were the aspects of voice function most frequently reported to be restricted as a result of testosterone treatment. P4: I cannot remember that I was previously [prior to testosterone treatment] hoarse or that I found it tiring [to speak] but this is definitely the case now.

Half of the participants who had been treated with testosterone for longer than 1 year reported restrictions to at least one aspect of voice function (Table 1). Voice quality (38%) and pitch range (25%) were the aspects most frequently reported to be restricted beyond 1 year of testosterone treatment. Thirty-eight percent of participants reported that taking testosterone for longer than 1 year had led to improvement in their voice function, in particular in terms of vocal power (38%) and vocal control/stability (25%). I: Do you experience problems with your voice when you are at work? P10: No, not any more, I think this has improved with [taking] the hormones - - - I have got a notion that it [P’s voice] has become more resilient.

In summary, 85% of participants reported barriers to at least one aspect of voice function independent of the duration of testosterone treatment, 23% perceived testosterone to be a facilitator of some aspects of voice function, and 15% reported a neutral effect of testosterone treatment on their voice function (Table 1).

TABLE 1. Effect of Testosterone Treatment on Participants’ Voice Function Duration of Testosterone Treatment

Direction of Effect* Barrier

Facilitator

Effect on

Within first year

7/13 (54%)

N/A

Beyond 1 year

5/13 (38%) 5/13 (38%) 4/13 (31%) 3/13 (23%) 3/13 (23%) 2/13 (15%) 1/13 (8%) 4/8 (50%)

N/A N/A N/A N/A N/A N/A N/A 3/8 (38%)

3/8 (38%) 2/8 (25%) 1/8 (13%) N/A 1/8 (13%) 11/13 (85%)

1/8 (13%) 1/8 (13%) 1/8 (13%) 3/8 (38%) 2/8 (25%) 3/13 (23%)

At least one aspect of voice function (cumulative) Voice quality Vocal control/stability Pitch range Vocal endurance Vocal power/projection Throat comfort Pitch variability At least one aspect of voice function (cumulative) Voice quality Pitch range Vocal endurance Vocal power/projection Vocal control/stability At least one aspect of voice function at any time during treatment (cumulative)

Summary: Independent of duration

Neutral or no Effect

Not Mentioned

N/A

6/13 (46%)

N/A N/A N/A N/A N/A N/A N/A N/A

8/13 (62%) 8/13 (63%) 9/13 (69%) 10/13 (77%) 10/13 (77%) 11/13 (85%) 12/13 (92%) 2/8 (25%)

N/A N/A N/A N/A N/A 2/13 (15%)

4/8 (50%) 5/8 (62%) 6/8 (75%) 5/8 (62%) 5/8 (62%) N/A

* indicates number of participants who mentioned that voice function was affected by this force/total number of participants exposed to this force (percentage of participants who mentioned that their voice function was affected by this force).Abbreviation: N/A, not applicable.

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TABLE 2. Types of Self-Care and Voice Use Practices Interpreted as Facilitators of Voice Function (Participant Perspective) Types of Self-Care and Voice use Practices Interpreted as Facilitators of Voice Function

Frequency*

Phonation practices Use of soft volume Using comfortable pitch range/levels Leaving out higher notes in singing Singing with others Throat clearing Body conditioning/Posture practices Relaxation techniques

6/14 (43%) 3/14 (21%) 3/14 (21%) 2/14 (14%) 1/14 (7%) 1/14 (7%) 5/14 (36%) 2/14 (14%)

Binding practices

2/14 (14%)

Upright posture

2/14 (14%)

Physical activity

1/14 (7%)

General self- and voice care practices Voice rest

4/14 (29%) 3/14 (21%)

Focus on posture, breathing, speaking during voice production Humidification No smoking Respiration practices Breath support No attempt at consciously influencing breathing

2/14 (14%) 2/14 (14%) 1/14 (7%) 2/14 (14%) 1/14 (7%) 1/14 (7%)

Aspect of Voice Function Particularly Affected if Mentioned

Vocal endurance Vocal power

Breathing Muscle tension Posture Muscle tension Posture Muscle tension Muscle tension Posture Voice quality Throat comfort

Breathing

* indicates number of participants who mentioned that voice function was affected by this force/total number of participants exposed to this force (percentage of participants who mentioned that their voice function was affected by this force).

Professional voice support. Four participants had received professional voice support at the time of the interviews provided by speech-language pathologists. They all reported beneficial effects on a range of aspects of voice function, eg, muscle tension, breathing, throat comfort, voice quality, vocal power, and voice function in general. P6: I know this voice when it is relaxed and rested and it is able to move downwards [towards lower pitch levels] really nicely after practicing for 45 minutes with the speech pathologist - - - wonderful. I have this in my ear and can feel it in my throat. This is how I would love to be able to speak all day long.

Speaker practices Self-care and voice use practices. The transcripts of all participants contained manifest accounts of self-care and voice use practices. We analyzed these accounts into two categories: Self-care and voice use practices that were interpreted by the participants as facilitating voice function (Table 2) and those that were interpreted as hindering voice function (Table 3). Facilitators of voice function. Self-care and voice use practices interpreted by the participants as facilitating voice

function affected, eg, muscle tension, posture, breathing, voice quality, and vocal endurance and were analyzed into four first level subcategories (second level subcategories in parentheses; Table 2): (1) Phonation practices (Use of soft volume, Using comfortable pitch range/levels, Leaving out higher notes in singing, Singing with others, Throat clearing); (2) Body conditioning/posture practices (Relaxation techniques, Binding practices, Upright posture, Physical activity); (3) General self- and voice care practices (Voice rest, Focus on particular aspect during voice production, Humidification, No smoking); and (4) Respiration practices (Breath support, No attempt at consciously influencing breathing). Overall, Phonation practices were perceived as facilitators of voice function by the highest percentage of participants (43%), followed by Body conditioning/Posture practices (36%), General self- and voice care practices (29%), and Respiration practices (14%) (Table 2). P12: I have tried to - - - never sing higher or lower than I could without problems — and also to hold off in terms of loudness. I think that was quite good [for P’s voice function]. P12: I have not tried to press it [P’s voice] down forcefully or - - - to smoke especially much - - - I knew that I would destroy it [P’s voice] with this [these practices] in the long term.

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TABLE 3. Types of Self-Care and Voice Use Practices Interpreted as Barriers to Voice Function (Participant Perspective) Types of Self-Care and Voice use Practices Interpreted as Barriers to Voice Function

Frequency*

Body conditioning/Posture practices: Slouched posture

11/14 (79%) 10/14 (71%)

Binding practices

5/14 (36%)

Lack of physical activity

3/14 (21%)

General self- and voice care practices Excess duration voice use

Smoking Lack of focus on singing Forceful voice use (phonation, articulation) Forceful lowering of voice pitch

6/14 (43%) 3/14 (21%)

2/14 (14%) 1/14 (7%) 6/14 (43%) 4/14 (29%)

Forceful use of higher pitches

2/14 (14%)

Restricting speech melody

2/14 (14%)

Restricting jaw opening Forceful control of speech Forced masculine speech Excess tension on larynx Avoidance practices Avoiding loud voice use Avoiding use of higher pitch levels Loud voice use

1/14 (7%) 1/14 (7%) 1/14 (7%) 1/14 (7%) 6/14 (43%) 5/14 (36%) 2/14 (21%) 5/14 (36%)

Access to voice use techniques Difficulties with register transition singing

5/14 (36%) 2/14 (14%)

Difficulties with breath support, costoabdominal breathing Difficulties with implementing SLP recommendations

2/14 (14%)

Aspect of Voice Function Particularly Affected if Mentioned Posture Body tension Pain Breathing Body tension Freedom of movement Breathing Body tension Voice quality Vocal control Vocal endurance Vocal power Voice quality Breathing Vocal control/stability Voice quality Vocal endurance Voice quality Vocal endurance Self-presentation Pitch range Self-presentation Throat comfort Self-presentation Throat comfort Vocal power Pitch range Voice quality Vocal control Throat comfort Pitch range Vocal control Voice quality Breathing Vocal power

1/14 (7%)

* indicates number of participants who mentioned that voice function was affected by this force/total number of participants exposed to this force (percentage of participants who mentioned that their voice function was affected by this force).

Barriers to voice function. Self-care and voice use practices interpreted by the participants as hindering voice function affected, eg, body tension, breathing, voice quality, vocal control, vocal power, vocal endurance, and self-presentation and were analyzed into six first level subcategories (second level subcategories in parentheses; Table 3): (1) Body conditioning/ Posture practices (Slouched posture, Binding practices, Lack of physical activity); (2) General self-and voice care practices (Excess duration voice use, Smoking, Lack of focus on

singing); (3) Forceful voice use (Forceful lowering of voice pitch and use of higher pitches, Restricting speech melody and jaw opening, Forceful control of speech, Forced masculine speech, Excess tension on larynx); (4) Avoidance practices (Avoiding loud voice use and use of higher pitch levels); (5) Loud voice use; and (6) Access to voice use techniques (Difficulties with register transition singing, breath support, costoabdominal breathing, and with implementing SLP recommendations). Overall, Body conditioning/Posture practices

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TABLE 4. Effect of Speaker Self-Evaluation Practices on Participants’ Voice Function Aspect of Voice Function

Not Mentioned* Self-Evaluation

Body tension

N/A

Voice quality

N/A

Breathing

N/A

Throat comfort

N/A

Singing voice

2/14 (14%)

Vocal power/ projection 1/14 (7%) Vocal endurance

2/14 (14%)

Vocal control/stability

N/A

Pitch range

5/14 (36%)

Pitch variability

12/14 (86%)

Restricted Not restricted Restricted Not restricted Restricted Not restricted Restricted Not restricted Restricted Not restricted Restricted Not restricted Restricted Not restricted Restricted Not restricted Restricted Not restricted Restricted Not restricted

Frequency (All Participants)* 12/14 (86%) 2/14 (14%) 10/14 (71%) 4/14 (29%) 9/14 (64%) 5/14 (36%) 9/14 (64%) 5/14 (36%) 9/14 (64%) 3/14 (21%) 8/14 (57%) 5/14 (36%) 8/14 (57%) 4/14 (29%) 7/14 (50%) 7/14 (50%) 7/14 (50%) 2/14 (14%) 2/14 (14%) 0/14 (0%)

Frequency (T1)* Frequency (T2)* 5/6 (83%) 1/6 (17%) 6/6 (100%) 0/6 (0%) 5/6 (83%) 1/6 (17%) 5/6 (83%) 1/6 (17%) 3/6 (50%) 1/6 (17%) 5/6 (83%) 0/6 (0%) 5/6 (83%) 1/6 (17%) 6/6 (100%) — 3/6 (50%) — 1/6 (17%) —

7/8 (88%) 1/8 (13%) 4/8 (50%) 4/8 (50%) 4/8 (50%) 4/8 (50%) 4/8 (50%) 4/8 (50%) 6/8 (75%) 2/8 (25%) 3/8 (38%) 5/8 (63%) 3/8 (38%) 3/8 (38%) 1/8 (13%) 7/8 (88%) 4/8 (50%) 2/8 (25%) 1/8 (13%) —

* indicates number of participants who self-evaluated their voice function/total number of participants (percentage of participants who evaluated their voice as restricted or unrestricted); T1 is participants treated with testosterone for shorter than 1 year or not at all; T2 is participants treated with testosterone for longer than 1 year; — represents no manifest accounts in participants’ transcripts.Abbreviation: N/A, not applicable.

were perceived as barriers to voice function by the highest percentage of participants (79%), followed by General self- and voice care practices, Forceful voice use, and Avoidance practices (each 43%), Loud voice use and Access to voice use techniques (each 36%; Table 3).

P13: I have never called out loudly — Maybe it is just a psychological issue. Maybe I am capable of shouting but somehow I think I am inhibited to express myself loudly. It is a problem that I speak so softly.

P8: I am quite tense due to sitting in front of the computer for long stretches of time - - - I am anyway very much bent forward in the shoulders - - -

Self-evaluation of voice function. The participants evaluated a range of aspects of their voice function as either restricted or not restricted (Table 4). Body tension (86%), Voice quality (71%), Breathing (64%), Throat comfort (64%), Singing voice (64%), Vocal power/projection (57%), and Vocal endurance (57%) were self-evaluated as restricted by the majority of participants. In the subgroup of participants who had been treated with testosterone for shorter than 1 year (T1), the percentage of participants reporting restrictions to the different aspects of voice function were especially high: Vocal control/stability and Voice quality (100%); Body tension, Breathing, Throat comfort, Vocal power/projection and Vocal endurance (83%). In the subgroup of participants who had been treated with testosterone for longer than 1 year (T2), a majority reported restriction in Body tension (88%) and Singing voice (75%) and no restriction in vocal control/stability (88%) and vocal power/projection (63%) as not restricted.

I: Is this [the slouched posture] also because of your chest? P8: Yes, it is somehow a habit - - - the shoulders fall forward automatically. P7: If you wear this horrible rip injury binder belt daily for more than one year because you cannot tolerate yourself - - - I wore a belt that is thick and totally hard, not at all flexible, and hot - - - I would say I had about 45 percent of my normal breathing available. P1: A few years ago - - - I looked in the internet for tips how to train my voice down myself [in order to speak and sing at lower pitches] and I have tried it for two months and it drove me crazy - - - it sounded totally unnatural - - - and it totally affected my voice [restricted P’s voice function]. It was somehow okay for two minutes - - - but as soon as I had to speak more loudly and I spoke for a longer time, it was just hell.

Supraindividual biocultural forces Vocal demands. The transcripts of all participants contained manifest accounts of their everyday vocal demands.

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Forces Affecting Voice Function

TABLE 5. Effect of Vocal Demands on Participants’ Voice Function Vocal Demands

Direction of Effect on Voice Function

Voice task

Phonation time

Conversation Conversation Conversation Spare time voice use Oral presentation Choir singing

5 mins Longer duration — — Occasionally Once per week

Tree worker

Occasionally

Singing Aged-Care Nursing Telephone counseling Lecturing/teaching Choir leader

Regularly Part-time Full-time Full-time 3−4 times per week, 90 −120 min per rehearsal Total

Voice use setting/type of voice use Quiet room — High background noise — — 3−4 times per week/ 90−120 min per rehearsal Loud voice use, Covering longer distances with voice — Loud voice use — Loud voice use Loud voice use (speaking and singing)

Barrier*

Neutral or no effect*

1/22 2/22 3/22 N/A 2/22 1/22

N/A N/A N/A 2/22 1/22 1/22

N/A

1/22

N/A 2/22 1/22 N/A N/A

2/22 N/A N/A 2/22 1/22

12/22 (55%)

10/22 (45%)

* indicates number of participants whose voice function was affected by this type of vocal demands/total number of types of vocal demands identified in the participants’ accounts (percentage of types of vocal demands classed as barrier or neutral); — represents no manifest accounts in participants’ transcripts. Abbreviation: N/A, not applicable.

We identified 22 different types of vocal demands and categorized and analyzed the accounts into voice task, phonation time, and voice use setting or type of voice use whenever sufficient detail was reported (Table 5). Some participants reported on more than one type of vocal demands. A wide variety of vocal demands were mentioned, ranging from short conversations in quiet settings to full-time occupational voice use requiring prolonged loud voice production in speaking and singing. Out of 22 different types of vocal demands, 12 (55%) were reported to be barriers to voice function and 10 (45%) were reported to have a neutral or no effect on voice function. Out of the 14 participants, five (36%) could meet all of the vocal demands they mentioned in the interviews while maintaining functional voice production. Among these was one participant (P12) who worked as a full-time secondary school teacher in training, was a leader of four choirs and sang regularly in their spare time. Seven participants (50%) could meet none of the vocal demands they mentioned without experiencing restrictions to voice function. Among these was one participant (P1) who reported that even a 5-minute conversation in a quiet room led to vocal fatigue. Two participants (14%) were able to maintain functional voice production when attempting to meet some of their vocal demands (eg, singing in a choir) but were struggling to meet other vocal demands (eg, speaking in a room with high background noise). I: How do you go with your voice then [when P gives occasional oral presentations]?

P6: At the end of a working day [full-time telephone counseling] my voice sounds constricted, forced, jammed. This is also what I feel in my throat. After five, six hours - - I have the impression that I have a chain around my neck and I notice that it is simply hard to speak. P14: I shout a lot and often [when working as an aged care nurse]. I: How does shouting work [for P’s voice]? P14: After ten minutes, I have to call it a day [stop speaking]. A conversation with someone who is hard of hearing is then not possible any more - - - It [P’s voice] escapes then. That is, I can try and say something but it comes out at random pitch levels - - - it [P’s voice] is simply overstrained.

Normative practices. We identified a range of normative practices on which researchers, participants, and their conversation partners (as reported by the participants) had drawn in their evaluations of speaker voice function. They were divided into three subcategories: standards of voice function; standards of health and illness; and standards of normal male voice. Standards of voice function. When participants were asked to self-evaluate their voice function during the interview, they were at first encouraged to compare their voice function at the time of the interviews to their own internal standards. I: How would you describe your voice as it is now? . . .

P1: It [P’s voice] declines rapidly. After I have spoken for a bit longer or a bit louder my voice gets rough and becomes softer.

P1: Mickey mouse. That means, I personally perceive it to be distorted.

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Journal of Voice, Vol. &&, No. &&, 2020 P6: Hoarse and strained. Tense or something like that. It sounds very much gentler and more relaxed on Sunday mornings.

In many cases, the interviewer followed up with specific questions about the participants’ self-evaluation of different aspects of voice function as they are commonly assessed in clinical practice. In order to facilitate participant responses, the interviewer related the clinical categories to everyday voice use practices and provided participants with a binary choice of perceptual terms that referred to the aspect of voice function in question. I: Would you say that your voice sounds hoarse or clear? [voice quality] P7: When I speak normally, as loudly as I speak now, I would say that it is a clear voice. I: Do you speak loudly or softly? [vocal power] P7: When I sit with someone in a room, then I speak softly, but I was never asked by teachers to speak up. I: Is your voice powerful or weak? [vocal power/ projection] P13: What do you mean by powerful? I: Are you capable of covering distances with your voice or cutting through background noise? P13: Well, then, it is very weak.

Here, the participant responses were interpreted in terms of clinical categories (in square brackets) and standards of voice function. A few participants reported that their voice had been evaluated by conversation partners in terms of specific aspects of voice function in ways that did not match the participants’ self-evaluation. P1: It was explained to me by others . . . that I don’t sing but produce a kind of melodious sprechgesang [intermediate between speaking and singing]. P3: My voice sounds normal to me but for others it sounds hoarse.

In these instances, the participants’ voice function was evaluated based on their conversation partners’ standards of voice function. Standards of health and illness. When participants reported on their own or other people’s spontaneous evaluations of speaker voice function (ie, evaluations that were not guided by clinical categories and standards), the perception of hoarseness was frequently used as a proxy for evaluating the speaker’s voice function as restricted. Participants who had just started their testosterone treatment and conversation partners who were not aware that a speaker was treated with testosterone, tended to interpret the perception of

hoarseness as an indication that the speaker’s voice had been affected by a cold. P10: After three weeks or one month [on testosterone] . . . I noticed that my voice sounded rough, just like having a cold. At first, I thought, I am having a cold again . . . but then I thought it cannot be because it feels differently. . . eventually it was clear that it must have been the effect of the hormones. P5: A colleague with whom I had not been in contact for a while said to me on the telephone after I had been on testosterone for 2−3 months: Oh my god, what a bad cold you have caught.

Standards of a male-sounding voice. Varied sociocultural standards for what constitutes a functional male-sounding voice influenced whether a speaker’s voice function was classified as restricted, preliminarily restricted, or unimpaired. Some participants indicated that what would be called a restricted voice quality according to clinical standards was part of how they wanted their own voice to sound. I: How would you like your voice to sound? P1: Low pitched and smoky. Not deep like a booming bass voice but . . . a normal male voice that comes across as distinctive by sounding smoky. P14: My ideal [voice] was, so to speak, it does not matter how it sounds, the main thing is that it is low pitched. It could have been much worse, it could have sounded much rougher . . . and much more brutal . . . if I had had the choice between a horrible voice like this or my old voice, I would have taken the new horrible voice.

Some participants interpreted perceived restrictions to their voice function by comparing their vocal situation to that of cisgender male adolescents who experience voice change as part of puberty. Based on the participants’ understanding of vocal mutation they saw restrictions to voice function as a preliminary phase that will eventually be completed and automatically yield a fully functional voice. P11: Once I asked an ENT [Ear, Nose, and Throat Specialist] - - - how long should voice change usually take in normal boys and he said, well, half a year, then it should be done. I have been taking testo [testosterone] for more than two years now and it [the voice change and restrictions to voice function] is not done yet. This is quite strange.

Other biocultural forces. We analyzed the accounts associated with other biocultural forces that had affected the participants’ voice function into the following subcategories: Excess muscle tension, Asthma, Cold air temperature, Musicality, Musculoskeletal conditions, Whiplash injury, Hay fever, Stress, and Low air quality (Table 6). With the exception of musicality (which was rated as having no specific effect on voice function when present),

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Forces Affecting Voice Function

TABLE 6. Effect of Other Biocultural Forces on Participants’ Voice Function Type of Biocultural Force Excess muscle tension

Barrier*

Effect on

Neutral or no Effect

Not Mentioned

10/14 (71%)

Muscle tension Body comfort Breathing Breathing Muscle tension

1/14 (7%)

3/14 (21%)

N/A N/A

10/14 (71%) 10/14 (71%)

Asthma Cold air temperature

4/14 (29%) 4/14 (29%)

Musicality Musical Lack of musicality Musculoskeletal conditions

N/A 3/14 (21%) 1/14 (7%)

Whiplash injury Hay fever Stress Low air quality

1/14 (7%) 1/14 (7%) 1/14 (7%) 1/14 (7%)

4/14 (29%) Singing Posture Muscle tension Muscle tension Breathing Breathing Breathing

7/14 (50%) N/A N/A

13/14 (93%)

N/A N/A N/A N/A

13/14 (93%) 13/14 (93%) 13/14 (93%) 13/14 (93%)

* indicates number of participants who mentioned that voice function was affected by this force/total number of participants exposed to this force (percentage of participants who mentioned that their voice function was affected by this force).Abbreviation: N/A, not applicable.

these biocultural forces were classified as barriers to muscle tension, body comfort, posture, breathing, and singing.

Facilitators and barriers of different aspects of voice function Table 7 provides an overview of the forces that were interpreted as having acted as facilitators or barriers to different aspects of voice function. Individual vocal demands and use of loud voice were not included in Table 7. Instead, a speaker’s capacity to meet their vocal demands and to produce voice as loudly or softly as appropriate for a particular voice use setting was considered as an essential feature of functional voice production itself. Similarly, speaker self-evaluations of aspects of voice function as “restricted” were not listed in Table 7 because speaker self-evaluations of the different aspects of voice function would be expected to be limited to “nonrestricted” ratings for speakers with functional voice production. While our participants described barriers to all 12 aspects of voice function that were reported in this study, there were no manifest accounts of facilitators of voice function in relation to singing, pitch variability, and self-presentation. Speaker practices were identified as facilitators of the highest number of aspects of voice function (seven), followed by professional voice support and testosterone treatment beyond 1 year (facilitators of five aspects of voice function each; Table 7). A participant with the highest level of regular vocal demands in our group of participants (P12 worked as a full-time teacher in training and as a leader of four choirs at the time of the interview) describes in the account below how he looked after his voice at the beginning of testosterone treatment so that he could continue most of

his work as a choir leader and his own singing for pleasure. P12: At no time [during the beginning of testosterone treatment] did I stop singing completely. But I was careful in terms of my roles as choir leader. At the time, I led a choir - - - and this was quite exhausting because I had to sing along a lot. I stopped leading this choir for six to eight weeks - - - I continued leading the other choirs, but I tried to limit my speaking and stopped model singing completely - - - instead I played passages on the piano or whistled. I continued singing in the chamber choir throughout [testosterone treatment] - - - depending on the piece we were rehearsing I could only sing half of the notes - - - I was careful that I did not take a leading role so that there were enough other people [singing the same part].

Speaker practices were also identified as barriers to the highest number of aspects of voice function (11), followed by testosterone treatment (barrier to seven aspects of voice function) and supraindividual forces (barriers to four aspects of voice function; Table 7). A participant describes in the account below how their voice function deteriorated as a result of changes to their self-care and voice-use practices during a day of working as a telephone counselor. P6: During normal working weeks the mornings are always quite pleasant, because I still remember quite well simple things like sitting upright, changing [posture], standing up, holding the handset at times in the left, at times in the right hand. From noon onwards things change and if it is stressful I tend to get totally tense. I have the PC in front of me, hold the mouse in the hand, squeeze the handset in [between ear and shoulder] and try to speak on top of this and then everything is at the end of the line [P and their voice cannot function any more].

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TABLE 7. Facilitators and Barriers of Different Aspects of Voice Function Aspect of Voice Function

Facilitators

Barriers

Muscle tension

Speaker practices (Relaxation techniques; Binding practices; Upright posture; Physical activity) Professional practices (voice support)

Supraindividual forces (Excess muscle tension; Musculoskeletal conditions; Whiplash injury; Cold air temperature) Speaker practices (Binding practices; Slouched posture; Lack of physical activity)

Posture

Speaker practices (Binding practices; Upright posture, Physical activity)

Supraindividual forces (Musculoskeletal conditions) Speaker practices (Slouched posture)

Breathing

Speaker practices (Relaxation techniques; No attempt at consciously influencing breathing) Professional practices (voice support)

Supraindividual forces (Asthma; Hay fever; Stress; Cold air temperature; Low air quality) Speaker practices (Lack of voice use technique breathing; Smoking; Binding practices; Lack of physical activity)

Throat comfort

Speaker practices (Voice rest) Professional practices (voice support)

Speaker practices (Forceful voice use) Professional practices (Testosterone treatment (WFY))

Voice quality

Speaker practices (Voice rest) Professional practices (voice support, Testosterone treatment (BOY))

Speaker practices (Lack of voice use technique register transitioning singing; Forceful voice use; Smoking; Excess duration voice use) Professional practices (Testosterone treatment (WFY, BOY))

Vocal control/Stability

Professional practices (Testosterone treatment (BOY))

Speaker practices (Lack of voice use technique register transitioning singing; Lack of focus on singing; Excess duration voice use) Professional practices (Testosterone treatment (WFY, BOY))

Vocal power/Projection

Speaker practices (Singing with others) Professional practices (voice support; Testosterone treatment (BOY))

Speaker practices (Excess duration voice use; Lack of voice use technique breathing; Avoiding loud voice use) Professional practices (Testosterone treatment (WFY))

Vocal endurance

Speaker practices (Using comfortable pitch range/levels) Professional practices (Testosterone treatment (BOY))

Speaker practices (Forceful voice use; Excess duration voice use; Lack of voice use technique) Professional practices (Testosterone treatment (WFY, BOY))

Singing

Pitch range

Supraindividual forces (Lack of musicality) Speaker practices (Avoidance of higher pitch levels; Lack of voice use technique register transitioning singing) Professional practices (Testosterone treatment (BOY))

Speaker practices (Lack of voice use technique register transitioning singing; Avoiding use of higher pitch levels; Forceful voice use) Professional practices (Testosterone treatment (WFY, BOY))

Pitch variability

Professional practices (Testosterone treatment (WFY))

Self-presentation

Speaker practices (Forceful voice use)

Abbreviations: BOY, testosterone treatment beyond 1 year; WFY, testosterone treatment within first year.

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Forces Affecting Voice Function

Forces appropriate for addressing in speechlanguage pathology practice with GD peopleAFAB The research team classified a range of forces that had been interpreted as having affected voice function in our participants as amenable to change in professional voice support for GD peopleAFAB provided by speech-language pathologists. Given that the main focus of professional voice support is to work with the speaker’s selfcare and voice use practices (eg,50), voice clinicians target the very practices that were found to have affected the highest number of aspects of voice function in our participants. General self-care and voice use practices, body condition, posture, respiration, phonation, articulation, and singing practices are discussed in the literature on voice support for gender diverse people as being within the scope of speech-language pathology practice (eg,51−53). Accordingly, the following speaker practices that had been identified as facilitators of voice function in our group of participants were deemed to be suitable for being fostered in speech-language pathology practice: Provision of access to professional voice support for GD peopleAFAB; education in regulation of body tension and assuming an upright posture; encouragement of gentle physical exercise and preparation of body and mind for extended voice use; voice care education in terms of gentle voice use practices that do not exceed the speaker’s capacity for voice production, humidification, and other general self-care practices. The following speaker practices that had been identified as barriers to voice function in this study were deemed to be suitable for being removed, reduced, or replaced with alternatives in speech-language pathology practice: Replacement of forceful voice use practices with gentle voice use practices that are based on a balanced interplay of the components of the vocal mechanism; support for developing safe, efficient, and controlled approaches to loud voice use, pitch variability, singing, and self-presentation; provision of training in voice use techniques speakers need to overcome specific difficulties with their voice function (eg, smooth register transitioning in singing; costoabdominal breathing and breath support); discouraging self-care practices with negative effects on voice function (eg, smoking; slouched posture; using binders that are harmful to the body and restrict breathing too much) and replacing them with alternative behaviors (eg, giving up smoking; assuming an upright posture when bound; choosing a binder that is tight enough to hide chest but loose enough to allow for efficient breathing). Avoidance practices are commonly addressed by speechlanguage pathologists who work with people who stutter (eg,54). These skills were seen as transferable to working with the avoidance practices reported by our participants, for instance, by exploring avoidance practices for the purposes they serve and replacing them with active approach coping strategies (eg, use of amplification to increase vocal power and projection; working with hierarchy of difficulties

15 and systematic desensitization against feelings of discomfort in relation to voice use). In addition, professional support for developing functional voice production might also be applied to the clients’ everyday voice use settings (eg,30). Voice clinicians can address issues clients experience in relation to vocal demands via training in specific voice use techniques clients need to fulfill particular voice tasks and advocacy for clients at their workplaces and at places of recreational voice use. In regard to other biocultural forces identified as having affected voice function, such as cold air temperature, low air quality, and high levels of background noise, professional voice support was seen as suitable for advising speakers how to manage these often-immutable forces by strategically protecting voice function in their presence or avoiding their influence by changing voice use location. The effects of normative practices on classifying voice function as restricted or unrestricted were seen to be a suitable topic for informational counseling with GD peopleAFAB, in which the following could be discussed. Each encounter with other people (whether they be health professionals, friends, or unfamiliar conversation partners) may involve the use of normative practices to evaluate voice function. The results of these evaluations may be diverse and may deviate from the speaker’s self-evaluation. Attributions of restricted or unimpaired voice function to the speaker from others are informed by conversation partners’ standards of voice function that may intersect with standards of health and illness or gender. Differences in opinion about whether or not a person presents with functional voice production are not limited to GD speakersAFAB but are a commonly occurring and unavoidable event in vocal encounters (eg,55). Attributions of restrictions to voice function to a speaker by others do not hold more truth about the speaker’s voice function than the speaker’s own observations and evaluations. In cases in which speakers feel uncomfortable or distressed when being confronted by others with attributions of voice problems, speech-language pathologists can provide opportunities for clients to explore their habitual reactions to negative attributions from others and to practice replacing these reactions with responses that have been proven helpful for dealing with inevitable and uncontrollable stressors in life, such as mindfulness and self-compassion (eg,52,56−59). Biophysiological conditions affecting voice (eg, asthma, musculoskeletal conditions) were seen as requiring collaboration between voice clinicians and medical or other allied health practitioners to be addressed effectively. Forces requiring a change in speaker practices that exceed an explicit focus on voice use practices (eg, giving up smoking and avoidance practices, developing mindful and self-compassionate responses to stressors) were seen as potentially benefitting from being addressed in collaboration between voice clinicians and counselors or psychologists.

ARTICLE IN PRESS 16 Testosterone treatment was identified as a force affecting voice function for which more research is required before it can be decided how to best manage its effects on voice. At this stage, the role of speech-language pathologists was seen to be as transparent as possible (preferably before a client starts hormone treatment) about what is and what is not known about the effects of testosterone on voice in order to enable clients an informed decision of whether or not they would like to be treated with hormones.6 DISCUSSION The purpose of this study was to explore forces that affected voice function in a group of GD peopleAFAB in order to inform the role of speech-language pathologists in supporting functional voice production in this population. These aims had arisen out of findings from previous research that demonstrated that GD peopleAFAB might experience restrictions to voice function and seek professional voice support, while what had led to the identified voice problems and how they could be addressed was not well understood and had not been the explicit focus of research studies so far. We analyzed our participants’ perspectives on how their voice function was facilitated or hindered based on a conceptual model of voice production that is suited to identify different forces and their capacity to act on voice function.24 Overall, a range of different forces were co-constructed as having influenced voice function in our group of participants. Agency in shaping functional voice production in GD peopleAFAB was found to be dispersed among speaker, conversation partner, and professional practices, which are entwined with each other and mediated by supraindividual biocultural forces. Implications of viewing forces affecting voice function in GD peopleAFAB as diverse and interacting These findings have a range of implications. First, functional voice production in GD peopleAFAB is not under the control of an individual force. This is consistent with recent literature questioning the traditional assumption that testosterone alone is generally sufficient intervention for voice needs of GD peopleAFAB.1,2,6 From this it follows that it is not appropriate to consider any treatment in isolation from other forces when conceptualizing how voice function in GD peopleAFAB is produced and how it can be improved. Rather, future research needs to be widened in its scope to consider forces impacting on GD peopleAFAB’s voice function to include complex interplay with mutual interaction. Second, voice function in GD peopleAFAB is not under the speaker’s control or under that of professionals working with the speaker. Thus, self-initiated attempts by the speaker or support the speaker might receive from

Journal of Voice, Vol. &&, No. &&, 2020

professionals directed at producing voice in an enjoyable, effortless, and efficient manner must be reconceptualized in a manner that acknowledges fundamental limitations to speakers’ and voice clinicians’ agency in ensuring functional voice production or fixing voice problems. On the other hand, when professional practice options include interventions common in other areas of speech-language pathology practice, many avenues for improving the speaker’s vocal function and wellbeing do exist. Examples of forces that were interpreted as impacting on speaker voice function but which cannot entirely be controlled or avoided by the speaker or professionals working with the speaker include: conversation partner evaluations of speaker voice function; diverse and contradicting normative understandings of what constitutes functional voice production; and material and sociocultural aspects of everyday vocal demands that are of structural nature. However, these have some potential to be improved in long-term, collaborative efforts (eg, advocating at workplaces to develop voice friendly schedules, equipment, and expectations of employees; changes to room acoustics). Third, most, but not all, of the forces that were interpreted as having affected voice function in our participants are not specific to GD peopleAFAB but may be shared by voice users of all genders. Testosterone treatment and binding practices were the only identified practices that could be regarded as specific to GD peopleAFAB who wish to use these practices as a method to shape their self-presentation according to their wishes and positionings. While slouched posture was reportedly used by a number of participants to hide their chest, this practice was also interpreted by some participants as resulting from long periods of sitting down at a desk or habitual ways of assuming a relaxed position. Similarly, while some participants have used forceful phonation practices and smoking to influence their vocal self-presentation (eg, in order to control pitch levels and pitch variability or to shape voice quality), forceful voice use and excess tension in the perilaryngeal region are also generally observed in speakers who present with hyperfunctional vocal behaviors (eg,60) and smoking is a lifestyle choice that potentially affects voice function in people of all genders.

Facilitators and barriers of voice function Forces explored in this study were not consistently interpreted by participants as facilitators, barriers, or neutral to their voice function. In addition, in the case of throat clearing and smoking habits, which were perceived as neutral to voice function by the majority of participants and are seen as barriers to voice function in the clinical voice literature (eg,28,61) we found examples of a disagreement between speakers and researchers/clinicians in terms of the appraisal of the direction in which speaker practices were understood

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Forces Affecting Voice Function

to affect voice function. These findings imply that forces affecting functional voice production need to be explored and discussed with each client individually in clinical practice, in order to work toward an agreement on the forces that would need to be fostered and those that would need to be reduced or eliminated. According to a large majority of participants, testosterone treatment was perceived as a barrier to functional voice production. All participants who had been treated with testosterone at the time of the interviews reported on restrictions to at least one aspect of voice function, which they associated with the effects of testosterone treatment on their voice. This finding presents on the one hand a challenge to accounts in the voice literature, in which testosterone treatment is conceptualized as having a solely positive effect on GD peopleAFAB’s voices and wellbeing (eg,15,62,63). On the other hand, the finding provides support for studies in which voice problems as a result of testosterone treatment were reported for some GD peopleAFAB.2,4,6−8 Testosterone treatment is an example of a force that has been identified as influencing voice function in GD peopleAFAB whose effect on voice is not under professional or the speaker’s control. Once the testosterone has been applied to the speaker’s body at a dose the professional has selected and the speaker has agreed to, it depends on the body’s physiological response to the testosterone whether and in what way the tissues and structures that constitute the vocal mechanism change in their capacity to work together in a functional manner. While claims have been made in the clinical voice literature that the physiological response to testosterone treatment in GD peopleAFAB is comparable to the processes causing vocal mutation in cisgender male adolescents during puberty (eg,64), these claims have not yet been explored in controlled, longitudinal studies in which these responses have been measured and compared between the two groups of speakers. Given this research gap and growing indications that testosterone treatment does not necessarily have beneficial effects for all GD peopleAFAB, we recommend that testosterone should only be prescribed to GD peopleAFAB with considerable informational counseling about the fact that it is currently not possible to say whether or not and in which cases testosterone treatment can be regarded as safe for a person’s voice function. In addition, we recommend that a referral to a voice specialist be offered for GD peopleAFAB who wish to have their voice function examined, monitored, and potentially treated behaviorally with a speech-language pathologist, regardless of whether testosterone treatment is pursued. Professional voice support provided by speech-language pathologists was unanimously described as helpful for promoting functional voice production by the participants who had already received it. In addition, current speech-

17 language pathology practices are well suited to address the identified forces associated with speaker self-care and voice use practices and with a range of supraindividual forces.

Limitations and future directions Among the members of the research team, the first author had the biggest influence on data collection and analysis because the interviews were conducted in German and the other members of the research team do not speak German. Opportunities for taking a consensual team approach to the qualitative content analysis were limited to discussing categorizations of the interview transcripts that had been suggested by the first author. In addition, participants were not invited to view the results and comment on whether the results resonated with their experiences. In future research, it would be beneficial to take a team approach to all parts of the research project and to share interview transcripts, draft categorizations, final results and the completed publication with the participants in order to increase the diversity of perspectives and to ensure that participants feel represented by the research and can benefit from the work to which they have contributed. The number of participants reporting on the different forces that were interpreted as having acted as facilitators or barriers to voice function was small. Therefore, the findings have to be treated with care and should not be interpreted as more than indications of forces affecting voice function, which need to be explored in more detail and with other and higher numbers of participants in future research. Future voice research needs to attend very carefully to the question of what it is that participants who are grouped together in terms of gender or other sociocultural categorizations actually have in common and which of these characteristics that are shared across a group of participants are influencing voice function. For instance, in our group of participants there was not a single force interpreted as having affected voice function that was shared among all participants. Further, some forces were interpreted as being facilitative for some individuals while hindering other individuals. The self-identification as GD peopleAFAB was the only communality among all participants and this aspect of their sociocultural positioning by itself does not constitute a force affecting voice function. CONCLUSIONS Voice function in GD peopleAFAB is influenced by interactions of several forces, most of which may be shared by voice users of all genders. Professional practices should follow a person-centered approach to care in which all parties are well informed of the limitations and possibilities for any intervention, including the often-unquestioned contribution of testosterone treatment.

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APPENDIX 1. EXAMPLE INTERVIEW QUESTIONS Forces That Could Influence Voice Function in GD PeopleAFAB Body tension/posture

Respiration Phonation Articulation Biophysiological conditions Voice care practices Vocal demands

Self-presentation practices Speaker psychosocial situation Professional interventions

Example Questions  Would you describe your body as generally tense or relaxed?  Do you bind your chest? If yes, which effect does binding have on your body tension, posture or physical wellbeing?  Have you ever had problems with breathing? If yes, please describe these problems.  Do you bind your chest? If yes, does it have an effect on your breathing?  Have you ever had any voice problems? If yes, please describe these problems.  How does your voice sound to you?  Have you ever had any speech problems? If yes, please describe these problems.  Do you take any medications? If yes, have you noticed an effect on your voice?              

How do you respond to situations when you experience problems with your voice? Do you smoke? Do you clear your throat often? Do you use your voice professionally? Please describe your voice function at the end of a (working) day. Do you need to produce loud voice on a regular basis? What do you do to present your gender to others? Have you ever changed the way you speak/how you use your voice in order to present your gender to others? How satisfied are you currently with your psychosocial wellbeing? Do you currently see a counselor/psychotherapist or would you like to receive psychological support? Are you taking or would you like to take hormones? Which effects has the testosterone treatment had on your voice? Have you had or would you like to have chest surgery? Have you ever seen or would you like to see a voice professional?

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