The Department of Communication Sciences and Disorders of the College of Saint Rose in Albany, N.Y., offers a voice modification program for individuals in the transgender community, focusing on enhancing communication for male-to-female (MTF) transsexuals. The program was initiated in October 2007 in response to a local mental health counselor who requested voice therapy for two of her clients. At that time there were no formal voice services for this clinical population in this region. Since the program's inception, 15 women in the transgender community have taken part, suggesting that we are meeting an important need.
The program's structure includes weekly two-hour sessions that involve both group and individual intervention; student clinicians (all female to date) team up with clients to complete several activities during each session. Among the activities is an ongoing project in which clients and student clinicians collaborate to develop and implement presentations to raise awareness of the transgender experience (e.g., societal perceptions of transsexuals, the challenges inherent in transitioning from male to female, and the important distinction between gender identity and sexual orientation). The presentations are discussed and planned as part of each session, providing a context for generalizing skills learned during the intervention process.
Sessions begin with discussion of participants' positive and negative communication interactions and their future vocal needs. Clients have the opportunity to share their experiences in a safe environment, with student clinicians acting as reflective listeners and supportive communication partners. The open dialogue points out challenges faced by individuals in the transgender community: building relationships during transition, gender discrimination at work, and misidentification. These challenges are often incorporated into the presentation project. The initial dialogue also serves as an opportunity for women (clients and clinicians) to engage in conversation that is sometimes limited in our clients' lives, as many have not yet completed their transition and spend time throughout the day in a male role.
The initial discussion is followed by vocal warm-up and exercise, including the application of vocal function exercises to increase vocal strength and flexibility (Stemple, Glaze, &Klaben, 2000). Exercise is a prerequisite to voice modification, as building strength and flexibility will increase the likelihood of success and reduce the chance of vocal stress and strain. Next, clients complete vocal skills activities that address each client's individual needs. These activities focus on modifying voice quality, pitch, inflection, loudness, resonance, and/or other characteristics that facilitate the perception of female voice. The small but growing list of resources on transgender voice is used to guide the development and implementation of these activities (e.g., Adler, Hirsch, &Mordaunt, 2006; Carew, Dacakis, & Oates, 2007; Gallena, 2007; Gorham-Rowan & Morris, 2006; Stemple, 2000).
Typically, broader aspects of language and communication are emphasized next, with attention to linguistic differences between men and women, the use of nonverbal communication, and the influence of physical appearance on gender perception. Our clients have also suggested that we attend to behaviors such as coughing, sneezing, and throat-clearing, because these often affect listener perception of gender (Adler, Hirsch, &Mordaunt, 2006). Clients recite movie monologues that serve as a connected speech context; these videotaped monologues are used to evaluate each client's application of communication skills. The monologues provide an opportunity for student clinicians to serve as coaches; clinicians and clients are encouraged to provide supportive, critical feedback on the monologues. During the last 10 minutes of each session, we discuss the strengths and weaknesses of the session and make a plan for the next meeting.
Just prior to this important feedback activity, we work on the classroom presentation project. At the College of Saint Rose, a project-oriented approach to intervention is often used during the clinical education of speech-language pathology students, in part because it provides a means of contextualizing intervention in our on-campus clinical facility. This approach has been effectively applied in clinical areas other than voice, including traumatic brain injury and literacy (Feeney & Capo, 2002; Feeney &Ylvisaker, 2000; Frank, 2001; Spielman, 2001). Given the success of project-based intervention in other clinical populations, we decided to apply it to the voice modification program.
The project choice was a collaborative decision among clients and student clinicians, who suggested that presentations to clinical and mental health college classes would provide a context for practicing voice and increase awareness about the important issues of people in the transgender community. Planning classroom presentations became a structured part of each session. Presentation scheduling is completed first. Matching client schedules with classroom presentations is a functional challenge negotiated between student clinicians and clients. Clients who are unable to present during a class period can still take part in the preparation and rehearsal.
Once clients are scheduled, classroom presentations (including introductions) are scripted. The women in the voice modification program rehearse their introductions, questions, and responses over several sessions; the result is a series of connected speech samples, some of which are videotaped. Student clinicians evaluate voice during the session and in the videotaped samples. They also provide supportive feedback relative to individual client needs.
When the clients go into a classroom, they introduce themselves, respond to scripted questions, and then respond to spontaneous questions from the audience. We collect audience feedback: what they learned, how the presentation will enhance their clinical skills, and their impressions of the speakers' voices.
To date, the clients in the voice program have visited approximately 150 students in seven classrooms, including undergraduate and graduate courses in voice disorders, graduate courses on counseling for speech-language pathologists, and a graduate class for community counselors. Audience feedback has been extremely positive, focusing not only on the relationship between voice and the transgender community, but also on the way the presentations helped students in the audience understand an aspect of cultural diversity of which they were relatively unaware. Similar feedback has been expressed by the 16 student clinicians who have served the program over the past year.
Client outcomes are being gathered on vocal function exercises, voice-related quality of life, and listener perception of communication change. Evaluation of the program and the classroom project reveals benefits for clients and student clinicians.
Client-reported benefits include:
- A chance to practice vocal skills in a conversational context
- Increased confidence in a safe, inviting environment
- The opportunity to share information about the transgender community
- An occasion to interact with other women around shared experiences
Student clinicians also report benefits:
- A chance to gain clinical experience in voice and resonance
- Increased confidence in a supportive, supervised environment
- The opportunity to collaborate with clients who have considerable motivation to improve
- An occasion to interact with other women around a shared experience
This project and the voice program have benefited us as clinicians, teachers, and, most importantly, as human beings. We are constantly reminded of the important interaction between skill-building and relationship-building in the therapeutic process. We also see the benefit of collaboration in establishing client goals and ownership for the program. Over time we have observed increased levels of confidence and self-advocacy in our transsexual clients and student clinicians. These are all benefits that inform our other clinical work and supervision.
Finally, our classroom presentation project has become a valuable way to establish transfer of learning to a meaningful connected communication activity, one that creates a fabulous series of "teaching moments" for all involved.