Changing the Speech and Language of the Male to Female Transsexual Client: a case study

Changing the Speech and Language of the Male to Female Transsexual Client: a case study



Celia Routh Hooper, Ph.D., CCC-SLP, ASHAF
Journal of the Kansas Speech-Language-Hearing Association. 25, 1-6.
[Abstract] Full Text [PDF]




Many transgender females report that passing as the feminine sex is very difficult because of the voice. Aronson (1980) classifies the voice of the transsexual as a “psychogenic voice disorder” in the subcategory of psychosexual conflict. In the author’s own experience, these individuals often hesitate to use the phone, talk to new people, or speak in public. They are constantly afraid of embarrassment because of a low-pitched voice. Unfortunately, neither surgery nor hormone therapy will raise the pitch of the voice in the male-to-female transsexual. Once the vocal folds are thickened and lengthened during mutation and puberty, they cannot be reversed. Recently, however, there has been some evidence that the pitch of the male-to-female transsexual voice can be raised with voice therapy (Bralley, Bull, Core, and Edgerton, 1978). This perceived change may be the result of an increase in vocal fundamental frequency (fo) and/or a combination of speech, language, and nonverbal behaviors (Aronson, 1988; Lakoff, 1975; Thorne and Henley, 1975).

Changing speech, language, and nonverbal behaviors may ultimately be more beneficial to the transsexual than changing the pitch of the voice. Many women have low pitched voices, yet are unquestionably female (Boone, 1977). Kline (1978) describes many sex differences in communication. These include pitch, intonation, resonance, loudness, articulation rate, speech quantity, word choice, syntax, vocal behaviors, body posture, and other nonverbal behaviors. She recommends that the clinician make the transsexual aware of the female characteristics of speech and language in order to have communication match the desired body image.
The purpose of this paper is to present a case study of a preoperative male-to-female transsexual in order that the speech and language behaviors that differentiate sexes may be outlined. In addition, therapy techniques that can be used to teach these behaviors are discussed. This client achieved moderate success with voice therapy, but there were other aspects of speech and language that aided in her self-concept as a female, as well as listeners’ identification of her as a female.

The client, O.R., contacted an urban community hearing and speech center by mail seeking professional help with her speech. Her original request was for, “help with speech muscles insofar as learning how to better modulate my speech as a woman does.” The diagnostic evaluation was performed soon after receipt of the letter and the local managing hospital sex reassignment committee was contacted. Her committee case manager, a licensed clinical psychologist, approved of speech therapy if I deemed it appropriate.
O.R. had been a 26-year-old male who had received hormone treatment for six months as prescribed by the Gender Identity Clinic of an urban teaching hospital. It was reported that prior to his decision for SRS, he had dressed as a female off and on for years, had always felt like a female, and once was addicted to heroin as an escape from being unable to be a female. The lifestyle-change year began with the onset of hormone therapy and she (the candidate for SRS) lived with her mother who supported her emotionally and financially. O.R. reported that she had studied music during the two years she attended college and hoped to give piano lessons to support herself after sex reassignment surgery. Her long range goals were to be a successful piano teacher, get married, and adopt children. The hospital psychologist reportedly was proceeding very cautiously with O.R. because of her previous heroin addiction and suspected schizophrenia–a condition which is one of those previously discussed in Gender dysphoria syndromes (Benjamin, 1966; Meyer, 1974). O.R. had been in psychotherapy previous to the speech and language evaluation and continued during treatment.

O.R. presented herself at the diagnostic session as a female. She was trying very hard to pass as a female, wearing a long black wig, facial makeup, a dress, heels, and carrying a purse. It was the examiner’s subjective opinion that she was a bit “overdone,” but was reasonably acceptable as a female.

An oral examination revealed normal structure and function of a male larynx. The pitch ranged from approximately 90-350 Hertz (Hz), a range typical of a male tenor depressed at the upper range (Boone, 1977). In vowel production a “normal” /e/ was produced at a fundamental frequency (fo) of 145 Hz and an /i/ produced in a falsetto voice was 280 Hz. As recommended by Cooper (1973) she was requested to say “um hum” several times to determine the modal pitch. The “um” portion was between 140 and 150 Hz and the “hum” portion was between 160 and 180 Hz with rising intonation. Thus, her modal pitch, roughly analogous to speaking fundamental frequency averaged between 140-160 Hz. Spectrograms were made of the voice for documentation purposes. Fo was calculated according to the method recommended by Lieberman (1977). This method utilizes a narrow band, scale magnified spectrogram (0-2000 Hz) to calculate the fo from the fifth harmonic.
Loudness and voice quality were appropriate in the conversational situation. The client reported that she did not speak as loudly in group situations since adopting the female gender. This is reportedly a female characteristic (Markel, Prebor, and Brandt, 1972).

Phonetic Structure
The client had no phonetic structure (articulation) disorders, but did exhibit articulatory patterns that characterize some male speakers. The patterns, as described by Freeman and Clayman in Kline (1978) may be attributable to the larger tongue and oral cavities of men. They include hypocorrect phonetic forms, such as /d/ for / /, and /In/ for /I /. In addition to these, O.R. exhibited imprecise productions at the ends of many words which may be described best as clipping the ends of words.

Other than clipping the ends of words, O.R.’s prosody was normal. She reported that she did interrupt in mixed-sex conversations—a characteristic that is more typical of males than females (Thorne and Henley. l975).

Language Behavior
Language behaviors typically associated with one sex or the other were informally assessed during the diagnostic session and the first therapy session. She did not exhibit many of the typical (Kline, l978) female syntactical or semantic patterns, such as hypercorrect grammar, tag questions, confirmation words, or polite requests.

Nonverbal Behavior
Nonverbal behaviors, as described in Birdwhistell (1970) and Thorne and Henley (1975), were assessed to determine if O.R. exhibited more female than male characteristics. The following were assessed:
Behavior of client was characterized by:
vocal behaviors: female soft laugh, no harsh coughing, sneezing, throat clearing
body posture:  male open leg crossing, foot movement, pelvis rolled back in walking, swinging arms, hand and arm gesturing more forceful, angular
facial: pleasantness female smiles, nods of approval
eye contact: male decreased eye contact
touching: male little touching

Diagnostic conclusions and management goals
O.R. did not exhibit a speech or language disorder in the traditional sense of a male speaker. She did, however, exhibit more male than female speech and language behaviors. Therapy was recommended with the following goals:
Goal A: Raise the modal pitch of her voice as much as possible without creating vocal abuse or a falsetto range;
Goal B: Make O.R. aware of the characteristics of speech and language that are associated with a (feminine) woman so that she may choose from these to fit her own needs.

O.R. was seen two hours per week for lO weeks. She returned for follow-up sessions three months and six months after the conclusion of therapy. Spectrographic measurements were made of her voice from high quality tape recordings taken in a sound treated room. These measurements were made after the diagnostic session, fourth therapy session, and final therapy session. In addition, O.R.’s speech and language characteristics were informally evaluated by another certified speech-language pathologist at the fourth and tenth sessions.

First Therapy Session
Session one consisted of a discussion of her new vocal image (Cooper, 1973) in terms of its psychological desirability and the mechanics involved in establishing a locus of resonance that would lead to a voice that would be perceived as higher in pitch. She concentrated on a tone focus that would create forward resonance (e.g., focus the sound behind the nose). She used the “um hum” and “hello?” techniques to establish the higher resonance. O.R. had an excellent understanding of the pitch/resonance issue and was aware of the importance of avoiding abusive vocal habits. Although she smoked 1.5 packages of cigarettes per day, she voluntarily decided to stop smoking after the first therapy session because of its suspected lowering of pitch.
Sessions 2-4
In these sessions the new resonance pattern (pitch) was monitored and attention was given to concepts of volume and breath support. She, O.R., began with easy words for the new pitch (/h/-words) and progressed to more difficult vowel/consonant words. Whenever she needed to establish the new pitch, she thought of a “spot” behind the bridge of her nose. O.R. reported that she liked her new pitch and that it made her feel more feminine. All activities were tape recorded and replayed for 0.R.’s monitoring.
As soon as O.R. consistently used the new pitch in single words, she was ready to learn how to alter her inflection and intonation in phrases. It was at this point (session three) that the clinician re-introduced concepts discussed during the diagnostic session, i.e., femininity is more than higher pitch (resonance). In sessions three and four, the goals included work on feminine intonation, hyperarticulation, rapid rate, and fewer interruptions during conversations.

To develop her sense of awareness of male-female intonation differences, O.R. listened to women’s voices on her home tape recorder. These voices were low pitched yet obviously female. O.R. was instructed to hum the melody pattern of the voices, as recommended by Thorne and Henley (1975). Extensive practice and monitoring of intonation were necessary. Careful selection of stimulus material enabled O.R. to develop a greater pitch range and to relay varied emotions. The clinician selected drill materials often used in modifying foreign accent. After those drills were mastered, the clinician and O.R. practiced role playing, using scenarios written by O.R.

To develop O.R.’s ability to hyperarticulate, the clinician called her attention to male/female differences in phonetic forms. A very effective technique to achieve this goal was the simultaneous viewing by O.R. and the clinician of a few minutes of a well known “soap opera.” Characters tended to be ultra female or ultra male. O.R. practiced a quick, precise, and light pattern of articulation by using smaller jaw movements, using a higher-than-usual tongue position, and practicing word lists containing / /, and / /, and final consonant clusters. While working on articulation, O.R. was instructed to note the increase in rate which automatically occurred. She was discouraged from speaking too rapidly for fear of sacrificing gains made in pitch and phonetic structure.

To decrease O R ‘s speech interruptions in male/female conversations, she was assigned to monitor her own conversation with men. She reported that she did indeed have a tendency to interrupt, but was reducing this behavior now that she was aware of it.
O.R.’s fundamental frequency was measured at the conclusion of the fourth therapy session. Her fundamental frequency by this time was between 160-180 Hz as compared to the 140-160 Hz measure at the time of the diagnosis, as determined by a spectrographic measure recommended by Lieberman (1977). The subjective evaluation by a second speech-language pathologist (a male) of her phonation was that the voice “sounds lower than appropriate for a feminine voice.” He was aware that she was a transsexual. Another speech-language pathologist (a female), who was unaware that the client was a transsexual, was asked to judge the voice. She reported that phonation was normal but commented that the pitch was “a bit low.”

Sessions 5-10
In these sessions, work on the previous areas was continued and the introduction of female language characteristics was begun. The client was made aware of these differences as described by several authors (Thorne and Henley, 1975; and Lakoff, 1975). In addition, a very helpful book (Word Play, by Peter Farb) was read and discussed. Portions of this book describe female intensifiers, qualifiers, expletives, nonspeech vocal modifiers, pronouns, verbs, conjunctions, interjections, swear words, jokes, and word choice. Some of this information is not current because of females using language previously described as male.

To make O.R. aware of the characteristic female nonverbal behaviors, she was asked to review the information by Birdwhistell (1970). This information included body posture and movement, hand and arm gesturing, facial pleasantness, eye contact, touching, and space. Also discussed were clothing, make-up, and accessories, which are considered to be forms of nonverbal communication.
At the conclusion of the tenth therapy session, fundamental frequency was again measured. It was identical to the measure made after the fourth session, or 160-180 Hz. The same male speech-language pathologist who knew that O.R. was a transsexual re-evaluated her and reported that although she “appeared to be a female” she still had a low pitched voice. Interestingly, he reported, “I don’t see how you can work with her–it makes me nervous.”

Follow-up sessions
O.R. came back three months and six months after the conclusion of therapy. She had stabilized the new voice and exhibited most of the female speech and language characteristics covered in therapy. She reported that she still interrupted conversation in mixed sex situations. Her nonverbal communication was female and her clothing was less “overdone.” O.R. was accepted as a female on the telephone about 50% of the time, according to her report. This was aided by the fact that she answered the telephone with her female name, and not “hello.” She reported that the Gender Identity Clinic had decided that she should not yet have sex reassignment surgery. She was very upset that the committee did not approve her after one year.
Six months after the conclusion of therapy, O.R. received sex reassignment surgery from a private physician without the knowledge of the Gender Identity Clinic. According to her psychologist, she had a postsurgical psychotic episode, but has now stabilized. She is living a “marginal life” with friends and is back in psychotherapy as an outpatient at the Gender Identity Clinic. This case history supports the view of Lothstein (l980) who strongly recommends postsurgery psychotherapy to treat the conflicts often released by SRS.

This report introduces the reader to some of the sex differences in speech and language that are of benefit to a transsexual client. Although an increase in the fundamental frequency of voice may be minimal in the male-to-female transsexual, many other therapy goals may be attained–including more appropriate resonance characteristics. Any therapist considering work with this population should work in cooperation with a gender identity clinic or a psychological treatment team.
The importance of the adoption of the appropriate gender role in these patients should not be underestimated. Appropriate speech and language are suggested as major facilitators for social-psychological adjustment in the transsexual. Not only will others accept the patient’s new gender role, but the patient’s gender identity may be more easily self-accepted.

The author would like to express her appreciation to Dr. Lesie M. Lothstein of University Hospital, Cleveland, Ohio, for his assistance and information regarding Gender Dysphoria Syndromes and Dr. Alex F. Johnson, of the Cleveland Hearing and Speech Center, for administrative assistance.


American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (DSM-III). Washington, D.C.
Aronson, A.E. (198O). Clinical Voice Disorders. New York: Thieme-Stratton, Inc.
Barlow, D.H., Abel, G.G., and Blanchard, E.B. (1979). Gender identity change in transsexuals. Arch. Gen. Psychiat., 36, 1001-1007.
Benjamin, H. (1966). The Transsexual Phenomenon. New York: The Julian Press.
Birdwhistell, R. (1970). Masculinity and femininity as display. In Kinesthetics and Content, Philadelphia: University of Pennsylvania Press, 39-46.
Boone, D.R. (1977). The Voice and Voice Therapy. Englewood Cliffs, N.J.: Prentice-Hall.
Bralley, R.C., Bull, J.L., Gore, C.H., and Edgerton, M.T. (1978). Evaluation of vocal pitch in male transsexuals. J. Com. Dis., 11, 443-449.
Cooper, M. (1973). Modern Techniques of Vocal Rehabilitation. Springfield, IL.: Charles C. Thomas.
Farb, P., (1973). Word Play–What Happens When People Talk. New York: Alfred A. Knopf.
Fisk, N. (1973). Gender dysphoria syndrome. In Laub, D.R., and Gandy, P. (Eds.) Proceedings of the Second Interdisciplinary Symposium on Gender Dysphoria Syndrome. Palo Alto, California: Stanford University Medical Center.
Kirkpatrick, M., and Friedman, C. (1976). Treatment of requests for sex change surgery with psychotherapy. Am. J. Psychiat., 133, 1194-1196.
Kline, P. (1978). Sex differences in communication: a therapy framework for the male to female transsexual client. Unpublished paper, Philadelphia: Temple University.
Lakoff, R., (1975). Language and Women’s Place. New York: Harper and Rowe.
Lieberman, P. (1977). Speech Physiology and Acoustic Phonetics: An Introduction. New York: MacMillan Publishing Co., Inc.
Lothstein, L.M. (1977). Psychotherapy with patients with gender dysphoria syndromes. Bulletin of the Menninger Clinic, 41, 563-582.
Lothstein, L.M., (1979). Group therapy with gender-dysphoric patients Am. J. Psychotherapy, 33, 67-81.
Lothstein, L.M., (1980). The postsurgical transsexual: empirical and theoretical considerations. Ar. Sexual Behavior, 9, 547-564.
Markel, N., Prebor, L., and Brandt, J., (1972). Bio-social factors in dyadic Communication–sex and speaking intensity. Journal of Personality and Social Psychology, 23: 11-13.
Meyer, J. (1974). Clinical variants among applicants for sex reassignment.  Arch. Sex. Behav., 3, 527-558.
Morgan, A.J., (1978). Psychotherapy for transsexual candidates screened out of surgery. Arch. Sex. Behav., 7, 273-283.
Thorne, B., and Henley, N., (Eds.) (1975). Language and Sex: Difference and Dominance. Rowley, Mass.: Newbury House Publishers, Inc.”


Citation: This work was based upon the clinical work of Celia Routh Hooper, Ph.D., with the University Hospitals Gender Dysphoria Clinic and the Cleveland Hearing and Speech Center. Acknowledgments to the professional staff at both institutions at that time…the 1980s, especially Alex F. Johnson, Ph.D. and Leslie Lothstein, M.D.