This is a transcript from our podcast episode published November 8th, 2021. The podcast episode is offered for .1 ASHA CEU (introductory level, related area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime.
A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible.
[00:01:39] Kate Grandbois: We are so excited to welcome today's guests, two lovely individuals who have been on the show with us before welcome AC Goldberg and Barb Worth.
[00:01:48] Barb Worth: Thank you.
[00:01:50] AC Goldberg: Thanks for having us.
[00:01:52] Amy Wonkka: So AC and Barb, you are here to discuss diving into gender, aligning, voice work, underlying principles and [00:02:00] practice. And before we get started, can you tell us in our listeners a little bit about yourself?
[00:02:04] Barb Worth: Sure. I am Barb and I have been doing, uh, this type of work for the last 10 years or so. And I've been a speech pathologist for a little bit longer, like going on 27 years, which is absolutely crazy. And so I I'm so happy to be here because this is something that I feel incredibly passionate about.
And I, uh, started, uh, gender aligning voice work about 10 years ago and in a medical setting, but I have switched and I now work at Emerson college, both as a clinical and an academic instructor, and I focus almost exclusively in the area of gender aligning voice work. So I am, I think about myself as sort of teaching and training the next generation.
[00:02:50] Kate Grandbois: That's so awesome. What about you AC?
[00:02:54] AC Goldberg: Uh, where should I start? I am AC Goldberg. I'm a speech language pathologist, [00:03:00] and I have 17 years of experience now over 17 years of experience, which is so alarming at this point. And I have just made the transition from being a school clinician with a private practice on the side to working for a private practice full time where I'm doing mostly gender voice modification.
And I am the founder of transplaining, which is a cultural responsiveness training platform where I offer intersectional educational opportunities to speech language pathologists, and other clinicians who want to learn more about how to best serve the people that we see as SLPs in our, in any setting that we work in.
[00:03:40] Kate Grandbois: And for our listeners who may or may not have, who may or may not have heard you on our show before, do you want to tell us a little bit about transplaining and the resources that you have available? Cause I feel like it really is a wealth of information. And anybody, everybody who's listening should, should know that it's out there.
[00:03:57] AC Goldberg: A short, well Transplaining is now [00:04:00] a a, an interactive educational website that offers both live and prerecorded continuing education opportunities where you can come and listen to me, talk about gender and considerations for working with trans and gender nonconforming people. In the whole field of being a speech language pathologist, whether you're encountering us in a voice setting or you're encountering.
And I say us because I am, I am a trans person, but whether you're encountering a trans person in a voice setting or just, you know, as a student in your school how to best how to best be responsive and make sure that your space is microaggression free. And in that vein, I offer this intersectional education on my platform where I invite SLP speakers of all backgrounds to come and speak about their experiences and how to best serve people from their populations as an SLP. For example. Recently I had Joshua Alison Burbank who is Navajo SLP. And that was incredible. And I would highly recommend anyone who [00:05:00] is tuning in to listen to that. I've had Vivian TC come on and talking about being an autistic SLP. I have had so many different, I can't shout out to everyone, but what I would love to any listeners to do is actually I've sent, um a discount code for 50% off monthly memberships to keep me me over here.
So, you'll find it in the notes of this episode and you can subscribe for a low monthly fee and have access to all of this continuing education. It's all intersectional. And you know, really, it's gonna make you a better clinician to learn about the people that we work with.
[00:05:32] Kate Grandbois: Thank you so much. You, you talk to us a little bit in a previous episode and give a discount to our listeners and it's just so incredibly generous.
And having, you know, really gone through your website thoroughly, myself, I can't say enough about how many resources you really have on there. And one of the things that we're passionate about doing here is connecting people with resources to continue their learning. So thank you for everything that you do and all the resources that you have.
So we're really excited about today. For those of you who are listening and[00:06:00] hearing AC and Barb for the first time they have been with is with us here. Once before the last time you guys were here, your focus was on cultural responsiveness, and today is sort of the second installment of that. And your focus is going to be more diving further into voice mod, the voice modification aspects of what you do.
And we're really excited about it. We've had lots of listeners write in looking for this information. Before we get started, I do have to read our financial and nonfinancial disclosures as well as our learning objectives for the day. People do write in and ask me to skip this part. I can't, ASHA makes me read it so I will get through it as fast as I can.
AC Goldberg's financial disclosures: AC is employed full-time as a speech pathologist working primarily in gender voice modification and is the founder and co-owner of Transplaining.info AC Goldberg's nonfinancial disclosures AC as a person of transgender experience, which gives him personal perspective.
Barb Worth's financial disclosures. Barb is a clinical and academic instructor of communication, sciences and disorders and Emerson college. She instructs students in [00:07:00] the delivery of voice services to all populations, Barb, its nonfinancial disclosures. Barb has a decade of experience working with the TGNC population.
Kate that's made my financial disclosures. I'm the owner and founder of Grandbois therapy and consulting LLC and co-founder of SLP nerd cast my nine financial disclosures. I'm a member of ASHA SIG 12 and serve on the AAC advisory group for Massachusetts advocates for children.
I'm also a member of the Berkshire association for behavior analysis and therapy Mass ABA, the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis special interest group.
[00:07:32] Amy Wonkka: Amy's financial disclosures. I am an employee of the public school system and co-founder of SLP nerd cast.
And my non-financial disclosures are that I'm a member of ASHA SIG 12, and I serve on the AAC advisory group for Massachusetts advocates for children.
[00:07:46] Kate Grandbois: Okay. Slightly more fun than financial and nonfinancial disclosures, learning objectives. Learning objective number one, identify at least two steps you can take towards cultural and clinical competency in the area of gender affirming, voice and [00:08:00] communication training
Learning objective number two, describe at least two components of gender affirming, voice and communication, evaluation. And learning objective number three, describe at least three potential therapy target areas for a client receiving gender affirming, voice and communication.
Okay. All the boring stuff is over. We got through it.
[00:08:18] Amy Wonkka: The good stuff begins now. AC and Barb, why don't you start us off by telling us just a little bit more about cultural responsiveness within gender affirming, voice and communication training.
[00:08:28] AC Goldberg: So, you know, I think that if you're listening to this episode right now, it would really be a great idea to go back and listen to our first episode because we really covered a lot in that episode that, you know, we don't necessarily have to cover again, but that really, if, if this were courses in order and there were a prerequisite that would be the prerequisite to this and you know, it's something that you can't just learn once it's an ongoing practice.
So the practice of cultural responsiveness is a lifelong commitment to learning and [00:09:00] continuing to learn about other people. You know, not just a one-time course about, you know, issues in bilingualism but really learning about every single population you could serve to the best of your ability.
So that you're able to bring what you know about that person's history into your treatment, so that you actually are able to form a better clinical relationship because you actually understand where the person is coming from. So, you know, it's really important that you go ahead and engage in the practice of cultural responsiveness and that you go ahead and listen to our first episode.
It's really important to learn all of the most current terminology, but terminology that Barbara and I use today might be outdated by the time you listen to this episode, that's something that happens. You know, I I'll write an article, it'll get published by the time it's published. The terminology is outdated.
That is one of the things I love most about language is that it's dynamic [00:10:00] and changes over time. And this language is rapidly evolving. Uh, There's so many resources that you can kind of dive into in the area of cultural responsiveness. You can join me on my, on my Transplaining platform. There's what is the Facebook page called Barb?
[00:10:20] Barb Worth: Gender spectrum, voice and communication.
[00:10:23] AC Goldberg: There are books that you can, that you can purchase. And you know, you can do some, some learning just about the trans population in general by you know, visiting a site like listen or gGLAAD, or even the Trevor project. Just to kind of get some background information, if you haven't listened to our first episode,
[00:10:41] Kate Grandbois: thank you for that reminder.
I think that's really important. And for anybody who's interested in listening to that it was published a ways back. Got to take a listen.
[00:10:49] AC Goldberg: So I'm going to, I'm going to talk a little bit about some terminology.
I'm going to give some reminders. So, Gender is not something that you can tell by looking at them. And, you know, it's never something that you [00:11:00] should assume you know, people have a sex assigned at birth. And along with that comes a gender that's assumed at birth, which is a set of societal constructs that somebody kind of puts on them as a set of expectations that somebody puts on them based on sex that they're assigned at birth. So, you know, you've got a sex assigned at birth, gender assumed at birth. And when you are transgender that means that you don't feel comfortable conforming to those conforming, to those expectations that people place on you based on your gender assumed at birth or your sex assigned at birth you might be gender nonconforming which means that you don't fit squarely into sort of any gender box.
You might have a non binary gender which can be defined really broadly. It's just a gender that, you know, is neither male nor female. It could be something that has nothing to do with either of those, or it could be a combination of any of those things. You know, that's very unique and individual but you know, all of [00:12:00] what's most important is that if you're dealing with a patient client or student who describes themselves as transgender or having a sort of gender that is neither male nor female, that should mirror their language. You know, and if you mis-gender someone it's really important just to, just to move on. You know, don't apologize profusely.
This kind of looks like this, you know, I met Barb the other day. He went, she came into the clinic and it just is, it's a really quick correction. If you can catch yourself, I don't say, oh my gosh, I'm sorry. I'm sorry. I'm sorry, because that really puts the burden on Barb to be like, oh no, it's okay. When really, you know, Barb doesn't want attention called to that.
Barb just wants to be gendered correctly. And I modeled that I knew the correct pronoun and then I moved on and that's what you really have to do. If that happens. It's important reminder.
[00:12:50] Barb Worth: So one of the questions that I get a lot is, wow, it's so cool what you're doing that sounds so interesting. How can I start doing [00:13:00] that? You know, I really would like to delve into this area of our field, which is a relatively newer area and, you know, just like any other area of our, of, of our profession, it's so important to develop competency and we've talked about cultural competency and responsiveness, but how will we become clinically competent in this area?
So, you know, i think first and foremost, it's really important to understand the function of the voice. You know, I come from a medical background. I was, I was lucky in that I, you know, I had training in voice and anatomy physiology, but also in voice disorders. And so, you know, I, I performed laryngo-video stroboscopy and, uh, comprehensive evaluations.
So I come from that perspective and I have to say that I, I really appreciate that. I, I had all that training because I think that it really helps me. To [00:14:00] understand, you know, what, we're, what we may be doing. When we are asking someone to make some modifications to this beautiful, beautiful structure and function of the larynx.
So I, you know, I think that, you know, first and foremost, dive into your, your voice textbooks, go back to, you know, uh, Voice 101 that you took and take some courses. And we're going to talk later on about specific courses and things that you, that you might, uh, choose to do in this specific area.
You know, one thing that people ask is, you know, how do I find a mentor? How can I find somebody to help me along the way? And, you know, I have to say that most of us in this area are thrilled to help others. And that's part of the reason why AC and I are doing this today is because we want to spread the good news and what we also want people to, and to, to appreciate what a wonderful area of our field this is, but also really [00:15:00] impress upon people how it's important, you know, to really know what you're doing.
Right. So, you know, finding a mentor is not always easy, but, you know, AC I don't know if you want to sort of tell our story how we met.
[00:15:11] AC Goldberg: Oh, my goodness. Well, we met over at Emerson.
[00:15:15] Barb Worth: We met over at Emerson, right? So Emerson AC was interested in, in, you know, learning a little bit more about this area and you know, had done some observations of my work and you know, we pay it forward now, AC is doing this, this type of work a hundred percent of the time.
You know, I'm not only mentoring other, uh, other uh, graduate students, but I'm also mentoring peers.
[00:15:39] AC Goldberg: And I think it's really important that, you know, there's, there's transgender clinicians now who are doing this work full-time, which is wonderful, but we have a lot of cisgender clinicians who, you know, did kind of come, you know, before us and start this work as it was.
And I think that very oftentimes [00:16:00] people are afraid to ask for a mentor in this work. And you know, I identified Barb as someone who I knew was an ally. We had met before. You know, I said like, Hey, you know, I'm going to dive into this work. I've been doing a little bit of it on the side, but I need to see it formally.
I need to talk to you. I need to be in the booth with you. And you know, you were like, oh yeah, come on down. Like, you know, I'll see you Tuesday afternoon. And you know, you were so welcoming to me as, you know, as a peer and as someone who who you were just like, oh yeah, that's great. You know, fantastic.
Let's do it. And I think that people shouldn't be afraid to kind of dive in and say, you know, I want mentoring in this specific type of work. And there are cisgender and transgender clinicians who are willing to mentor you. So that you have sort of the, like the best lens to, to do this work. And there's, there's plenty of people out there now who know how to do this work, but you know, you shouldn't try to do it unless you actually have experience.
[00:16:58] Barb Worth: So one of the things that, you know, I did, [00:17:00] uh, oh, maybe five or six years ago is we sort of developed, uh, a peer group. So some of us that were doing this work would meet on a monthly or every other month basis. Uh, we would share resources. We would, with clients' permission, we would, uh, we would share a voice samples and sort of having another, another pair of ears to listen and say, Hey, I'm sort of stuck here.
What should I do? What would you do if this was your client? And then fast forward to a few months ago, uh, one of my colleagues who I had not met at an area hospital contacted me and said, you know, I'd really like to get into this area. And I said, great, what have you learned so far? And so she, you know, through email and, and eventually a phone call, we started talking and we've reformed our group.
And so, you know, we're now going to be meeting on a monthly or quarterly basis. And just again, sharing experiences and supporting one another[00:18:00]
[00:18:00] Kate Grandbois: So I love what, you're what you're saying about mentorship. I love mentorship.
I think it's so important. I think that it's something that our field in general has not embraced enough across all disciplines and all areas of practice. And another reminder, this is something that we talk about a lot here is how scope of competency is the ethical choice. So based on our code of ethics, you are really required to gain competency in an area before practicing and mentorship is one of the best ways to do that.
And I'm just so thrilled that you mentioned that this just like my tiny little soap box about mentorship, I'll get off of it now. So as a person, as a clinician, I have zero experience with voice. It is not my area of competency. I took my one graduate school class, and that was it at Emerson, which was a wonderful, uh, but you were not there at the time.
So I'm wondering if either of you can tell me a little bit about, I mean, this is a very generic question, but, but what [00:19:00] is it, what is it like, what kind of work are you doing? In, in this, in this world of voice modification,
[00:19:07] AC Goldberg: Oh, it's so fun. I mean, anyone of any gender can seek gender, voice modification, you know, sometimes you've got older cis-gender women whose vocal register has changed who are feeling, you know, uncomfortable, maybe they're being mis-gendered, maybe they don't, they want their voices to send younger.
You've got, you know, people who are, you know, trans feminine, who want to be coded in all of their interactions as female. They don't, you know, they don't want to be mis-gendered. You've got, you know, trans masculine folks. You've got non binary folks. You know, you've got people who are, who are gender fluid, who want to be able to have different sets.
But you know, really it's fascinating because everyone's voice is completely different. And I am going to dive in and tell you a little bit about the types of people who you might see because you know, people, when they oftentimes see, like you hear like trans feminine voice care or trans masculine voice care, they kind of assume that, you know, all female voices are gonna sound the [00:20:00] same.
You know, you're going to have a higher pitch, more frontal residents, that sort of thing, which we're going to get into, but, you know, people who I see could range from, you know, a butch lesbian trans woman who, you know, doesn't want to doesn't, you know, doesn't want to seem, you know, traditionally feminine, but doesn't want to be mis-gendered to someone who is I, uh, trans, masculine and gay, and doesn't want to be accidentally read as female.
You know, I've got there's a lot of crossover there. I've got, you know, people on my caseload who, you know, their primary goal is to not be mis-gendered in any interaction, but others who care less about that and more about how they feel about their voice. So, you know, people come to for a gender voice modification or gender affirming voice modification, because there's a discrepancy between their gender presentation, their outward gender presentation and how what's manifested in their voice and communication.
Some people complain about like [00:21:00] strain, fatigue, a lot of effort. Their voices sound thin. They have a hard time projecting you know, people don't want to don't want to be read as the wrong gender in any circumstance. And, you know, you have to talk to clients about phone, voice, and how phone voice is always a little extra you know, believe it or not, you all listeners can hear my, my voice.
I am still mis-gendered on the phone sometimes because I default to, you know, my old habitual, polite phone voice. And you know, uh, I got locked out of my bank account the other day and I'm getting, I was getting texts that some, someone was trying to hack into my bank account. And, and it was because I was using my phone polite voice from my old habitual voice, not my current voice that I'm using now.
And people try to modify their voices on their own. And they have difficulty because they don't know the proper techniques and they get harmful advice on YouTube a lot of the time. And. Barb, do you want to jump in? So I'm, if [00:22:00] anything, no,
[00:22:01] Barb Worth: no, I, I think you covered it. I, uh, I think that, you know, our clients will talk a lot about the anxiety that they feel that they may feel.
Not everybody has anxiety about their voice, but some people do. We hear about people who say I, and I, and I'm using air quotes here. I pass because that's a, that's a word that I, as a cis person, I wouldn't use unless someone uses it first, one of my clients uses it first. So they might say, you know, I I'm, I, I pass until I open up my mouth.
And so this is really creating a lot of issues for me. You know, people, some people are, I hate to say this, but in all areas of our country, you know, people are feeling unsafe. And so, it may, uh, they really might need some help with their voice because they want to feel safe. And some people feel like that they just don't [00:23:00] even want to be communicating or talking because the voice that's coming out, it's just, they don't connect with, with this voice.
It doesn't match it. Doesn't align with who they are
[00:23:12] AC Goldberg: You can see gender voice alignment clients anywhere. You know, you can see them in private practice.
You could see someone in a medical setting. You know, you can see them over zoom, telepractice and schools and camps are even getting in on the action. So if you're a school SLP, go for it.
[00:23:28] Barb Worth: You know, I wouldn't know. One question is people always ask about insurance. You know, uh, I love to say that the more I'm in doing this sort of work, the more I see that insurance companies are covering the service.
Uh, so it's really important to have an understanding of people's, uh, medical insurance to see if it is a covered service. What I think I cannot say enough about is that we, as, as practitioners must be licensed in [00:24:00] this state in which we are practicing and the person resides. Okay.
[00:24:06] Amy Wonkka: That's an important technicality.
[00:24:08] Barb Worth: Yes, it is very important. And I know that there are people who don't either don't know that, or maybe perhaps are not conforming to that. So I'll say it again. We need to be prac, you need to be licensed in the state in which you are residing and you are, you are practicing you're in which your client is practicing.
Kate.
[00:24:33] Kate Grandbois: I have a question that might be a little controversial or maybe an interesting question. It recently came to my attention that there are SLPs who are engaging in this work with this community and calling it coaching. Yes. And not clinical service. And by calling it coaching, they are, sir, they're skirting around a lot of the liability.
Well, supposedly [00:25:00] skirting around this issue of licensure and liability. I'm wondering if there is any, if you have any like, perspective on that.
[00:25:08] Barb Worth: Well, AC and I were talking about this yesterday and you know, I, I, yes, it is happening, right. You do not need to be a speech language pathologist to do this work.
Okay. So many of the people who were doing this way before I was doing this in the way before AC was doing this were not speech pathologists. A lot of them were actually singing teachers
[00:25:29] AC Goldberg: And actors and voice coaches. And they’re all also qualified to do this work, but we can't un-be SLPs in order to do this work.
So we have to act within our ethical code. At least I feel that way. In terms of where sort of that boundary is you know, and I, I would feel uncomfortable. If I would not practice in a state where I'm not [00:26:00] licensed because I am an SLP.
[00:26:04] Kate Grandbois: Thank you for answering my question. I think it's an interesting intersection, but, but moving on, so I'm dying to hear more about as again, as a person who knows zero about, I want to say, I know zero about the larynx. I know more than the average, but very little in that part of my brain has, has, you know, I've made room for other knowledge.
[00:26:25] Barb Worth: All right. So Kate, I want to ask you, do you remember about the three sub-systems speech production?
Okay.
[00:26:32] Amy Wonkka: I'm really glad you're asking Kate. Oh my God.
[00:26:37] Kate Grandbois: You love it. I'm just, oh no. Okay. Listening. Please. Don't take my license when I can't answer this question.
[00:26:42] Barb Worth: So it's power source and filter.
[00:26:47] Kate Grandbois: Oh, I wouldn't have said that. I would've said like resonance. I don't know what I would have said. I'm just going to write my mouth here.
[00:26:52] Barb Worth: Right? So power respiration source the larynx, the vibrating, the vibrating source of the larynx and the filters, the resonance. So you, [00:27:00] you got a third of it, right? Yeah.
So, you know, when we're doing this type of work, there are other things that we addressed, but those are the three sort of foundational areas. So, you know, looking first at respiration, you know, the respiration is the gas for our voice, right? So, you know, in our practice, we may be depending upon, you know, our, what our assessment entails, we may be addressing sort of, you know, some breathing mechanics, some breathing behaviors.
We certainly are going to be addressing the source, which is the larynx. And I think it's important to, to remind our listeners or to educate our listeners. Cause they, they may not know this about, uh, the effect of testosterone specifically on the larynx. Okay. So, you know, a person who has undergone testosterone guided or [00:28:00] related puberty right.
Will have some changes to their larynx. So it will, the testosterone will thicken the vocal folds, will lengthen the vocal folds. And actually the larynx itself will, will change slightly in angles so that there's a sharper sort of angle at the front. And it will widen in the back. And that are, those are some of the effects of testosterone for a person who has yes.
A you're putting your hand up. Okay.
[00:28:32] AC Goldberg: I'm putting my finger up because I just want to remind our listeners that this is someone who has gone through a testosterone-driven puberty at an age where they're still growing. And this is not something that occurs with when a person who might be transgender non-binary takes testosterone.
Yes, the thickening of the vocal folds occur occurs, but the sort of change to the structure is there's no evidence that that [00:29:00] occurs at this point which can actually result in this thing called in chopped F to M locality, which is, you know, something that we see a lot of the time in the clinic.
So, you know, you get, you get a little bit, you get the thickening but you don't actually get the structural differences. Now Amy's got her hand up.
[00:29:17] Amy Wonkka: Well, I have a question because I've never heard of that entrapped FTM. And what does that do? I assume that that's a result of the smaller laryngeal structure and the larger vocal folds.
[00:29:28] Kate Grandbois:
Got it a description of what that is. Cause that was way above my wheelhouse right now.
[00:29:33] AC Goldberg: So you got it
[00:29:34] Kate Grandbois: above my pay grade.
[00:29:34] Barb Worth: Yeah. So the thickening of the vocal folds, but, but but you know, you have the say th th th the carriage is the same. So what is holding the vocal folds hasn't changed.
So that can lead to some, uh, and I think that there is this misconception, perhaps that if an individual [00:30:00] undergoes hormone therapy and takes testosterone, that, that, that voice change will sort of happen and there'll be a hundred percent satisfied. And so there can be some issues with voice projection and the testosterone doesn't change the resonance structures.
And we're going to talk about residents. So this is probably a really good segue into talking about resonance. So what is resonance? Resonance is, you know, sort of, I like to think that it's the color of the voice. All right. So you have this vibrating source. These vocal folds are vibrating, you know, 100, 200, 300, 400 times a second.
Right. And as the, that's the source, and as that sound comes through, the cavities certain, that's a complex sound and certain sounds are amplified and certain sounds are dampened. And so I love to give the example of it's the [00:31:00] difference between, ah, ah, oh, that was good. Wow. I heard two completely different sounds, but then if you were to measure the pitch of that, that would be the same.
Okay. Two completely different sounds. So, you know, so with some of our trans men or people who are trying to masculinize their voices after undergo, after having, having hormone therapy, sometimes we work with them with regards to their resonance because their pitch might be satisfactory to them, but we changed some of the resonant qualities.
Yes. Amy, you have your hand up
[00:31:46] Amy Wonkka: and if you can just explain, because it's a podcast, if you can just explain for the listeners kind of what you did there with your facial structure to change that resonance.
[00:31:56] Barb Worth: Well, did I change my facial structure, but actually I'm going to do it again and not [00:32:00] change facial structure.
So, ah,
[00:32:09] AC Goldberg: what do you think she's doing Amy? I'm so curious as to what your take is because I know exactly what's happening
[00:32:15] Amy Wonkka: No, I mean, I, I feel like it's something happening in like. The soft palate area. I don't know. I don't know.
[00:32:25] Kate Grandbois: nasopharynx is, is moving back and forward
[00:32:28] Barb Worth:. So I was changing some of the you're right.
I was, yes. And I also was changing the tongue. So my tongue for, as my tongue is higher, it's closer to the EE sound. Okay. And when we're feminizing voices, sometimes we look it's called eiffication. So we're actually trying to get that brighter quality by changing the, the, the the, the, the height of the tongue.
I was also probably changing my laryngeal position as well. I was probably [00:33:00] raising my larynx slightly.
Kate Grandbois: That's a lot of things to keep track of.
Barb Worth: It is a lot of things to, to keep track of. And can you imagine getting into sort of, you know, voice training, imagine trying to take something that is so habituated that you've been doing one way for so long and not even thought about it and then coming for, you know, to see a voice clinician.
Kate Grandbois: No.
Barb Worth: And having to start literally at the phoning level.
Kate Grandbois: Right, right.
Barb Worth: And make these adjustments so that you can achieve the desirable voice.
[00:33:39] Amy Wonkka: Oh, what, what does the, what does the evaluation process look like? Like what do you, how, how do you get started?
[00:33:48] Kate Grandbois: So what do you do? I'm very overwhelmed by all of these tiny pieces.
So many muscles in there
[00:33:53] AC Goldberg: At the evaluation, you know, we, we evaluate to, it's not to [00:34:00] pathologize a trans person, but it's just to get baseline data on, you know, where they are, ask them where they want to go and screen them for a voice, voice disorder. You know, sometimes you get someone who, you know, you're like is, is that a polyp I'm hearing?
Or, you know, is that GERD like, what's what's, do you have some muscle tension? Dysphonia sometimes we get a lot of that and we refer to an ENT. If we think that there's anything going on prior to starting treatment, we need to see that strobe. Because you know, you really just never know. You don't want to do any harm to, to someone's voice by saying, you know, okay, you should implement these strategies, you know, in order to modify your voice, but you have an underlying voice disorder you want to, you need to know and treat and deal with that underlying voice disorder before before you start and you can get some instrumentals but they're not necessary.
Amy, here, you have your hand up.
[00:34:48] Amy Wonkka: Sorry, I'm trying to remember something that I may be remembering wrong. If I go way, way back into my grad school days, I do feel like voice is the one area where you kind of [00:35:00] always need that ENT opinion before you treat, or is that, is that something I'm inventing
[00:35:06] Barb Worth: if someone has a voice disorder and you are as a speech language pathologist,seeing them for a voice disorder that has been diagnosed by an ENT.
Yes. However actually ASHAs, uh, practice preferred practice pattern is that someone needs to be seen by an MD or a medical profession professional, but it actually does not specify an ENT.
Amy Wonkka: Okay. Okay.
Barb Worth: So, but, but in the area of voice modification, the individuals, the individuals not need to see a medical doctor.
However, some insurance companies may require a referral from a medical doctor. So, but that's between the person and their insurer. Not. Does not direct our, does that guide our care, but you know, I, I do want to say that I came from, you know, a, sort of a medical background. And so we did an instrumental exams on our, our clients who were [00:36:00] receiving, uh, gender affirming voice therapy.
And I have to say, because I came from that sort of mindset, it was really helpful for me as a clinician to see their larynx in action. And I will, and I will say that we did end up diagnosing a lot of people with any, anything from MTD muscle tension dysphonia, to nodules, polyps, you know, what have you.
So I guess I would just caution and say that while instrumental exam is not necessary, really use your ears and, you know, gather your information. And we're going to talk more about what else goes into the evaluation, but, you know, use that information. And when in doubt, refer out. Right. When in doubt refer out.
[00:36:50] Kate Grandbois: I like that always. And one other thing it's making me think of is though is the important intersection between those clinical referrals and the, hopefully the [00:37:00] training that you've done in cultural, responsiveness and competency, so that you don't pathologize the individual that you're working with and you don't, you know, oh, this is disordered or in any way advertently or inadvertently.
Because I think that I, I assume that that can be a very sensitive or that can be a discussion that takes some, some competency.
[00:37:24] AC Goldberg: Well, it can be sorry, Barb. Did I cut you off?
[00:37:28] Barb Worth:No, no, no, no. I was just going to wait. We just went through. Uh, is that it's also, you know, those, those relationships that you have with other providers are really important.
And it's also super important that if you're referring your trans clients to a provider that you know, that you're referring them to a trans friendly provider and safe space, I'm sorry.
[00:37:47] AC Goldberg: I see nicely, precisely what I was going to say. So mind-meld as usual you know, you just have to make sure that, that you're not referring someone because, you know, trans people come with a lot of trauma into these clinical spaces.
You know, we [00:38:00] are, we have a lot of medical trauma related to just trying to get, you know, competent care. So we might be resistant to a referral. So if you say like, you know, this is my, you know, this is my colleague. Like they, they see all of my trans patients, like, you know, that you will be treated fine in this office.
Like then, you know, that person might be more likely to actually follow through and then see you back in your clinic, as opposed to someone who you're just referring out for something. And they don't really know what they're, where they're going or what they're getting, but you know, more, more evaluation components, you know, you want to do, do your intake and interview and you have to have that culturally responsive lens.
You know, you don't, you need to have consent for all sorts of, for the whole interaction. May I ask you some questions, you know, will you tell me a little bit more about your voice use? You, you, you can't. You know, informed consent is not like a one-time sheet of paper that people sign. Informed consent is an ongoing conversation between a client and [00:39:00] clinician that guides a collaborative goal setting agreement.
That's extremely important when you're dealing with individuals who come from backgrounds that may have experienced trauma having your client collaborate with you and set their goals, tell you what their, what they want their voice to sound like.
So with regard to the intake, like we talked about in the, in our first appearance here on SLP nerd cast, you obviously have to come at things through a culturally responsive lens with regards to your intake in your interview. And I'm not going to relive that whole podcast because you really should listen to it.
Barbara, you want to take this one?
[00:39:37] Barb Worth: Sure. So I, you know, there have been some published quality of life measures that I think can be very helpful to get some information, you know, from your clients. There's, uh, something called the trans woman voice questionnaire. It used to be called the TBQ. There is the trans voice questionnaire which is F to M, which is outdated terminology, but that is one that we are using for our transmasculine folks.[00:40:00]
Unfortunately, there are no published nonbinary measures, hopefully that will happen in the, in the future that they will be a quality of life measure. That's more appropriate for someone who is non binary. And then there is something called the voice handicap index, which helps to screen for any kind of a voice disorder and something called the reflux sensitivity index, which also can be helpful to screen for, uh, symptoms of reflux.
Super important when you're doing this work that you invest in a good quality microphone that you have some sort of, uh, an app or whatever to, to do your recordings. There is a free acoustic analysis software program called Praat P R A T that I currently use. As again, I said free, but it's clunky, so you have to play with it.
And I put a shout out to Christy Knickerbocker who on her website actually has a little tutorial on how to use Praat. And you know, something like a [00:41:00] stopwatch and, and beyond that, you don't really need a whole lot of equipment to do this work. The typical things that we, uh, measure or, uh, is, uh, maximum phonation time.
So you'll probably remember that from grad school, uh, as long as you can on a habitual pitch. The S to Z ratio, again, you know, you probably learned that in grad school, but just as a reminder, how long somebody can sustain the skinny S is a guesstimate or, uh, somebody's vital capacity, and then how long they can sustain the Z sound zzzs is, is a guesstimate of of glottal, glottal, sufficiency.
So you're looking, you want that estimate and that Z to be, uh, pretty much one-to-one meaning, you know, the same amount of time on the S as the Z. And that's a screening. And if, if it's not one-to-one and the Z is shorter you might want to think about that there could be a vocal pathology that's causing the vocal folds not to completely close.
[00:42:00] So we take with our sophisticated software, uh, programs, we're taking the average fundamental frequency, we're recording during conversations, reading tasks, you're going to do some sort of a perceptual, uh, measurement. So if you were, again, you remember from, from, from grad school, something called the Cape V, which is a perceptual tool to use.
And I also really like to do some of my own sort of informal judgment on things like intonation and things like resonance. So as you get dive deeper into this sort of work, you get to you, you start to think about somebody's intonation patterns. I think a lot about stereotypes, unfortunately, in this, uh, area of our profession.
But a, a stereo it's stereotypically a more feminine presentation is to have more rising and falling of your voice. And with regards to resonance, we talk about, and again, beyond what we can talk about today, but things like chest resonance and [00:43:00] head resonance, which are sort of, again, going back to that sort of qualitative aspects of a voice.
So we listen for those sorts of things. And then there are other acoustic measures that you can take. If you, again, going back to grad school, like a jitter and shimmer and that sort of things, not necessarily as important, unless you're suspecting some sort of a voice disorder. And then, you know, finally, sometimes we look at some non-verbal communication.
So we may look at things like body language and gestures, and also important to pay attention to nonverbal reflexive, voicings, such as throat clearing and laughing and those types of types of things. So after we gather all of this information, I know you want to know what do you do in a therapy session? So if you go back to that sort of power source and filter that we talked about, so we may do things like working on, and I hate the word diaphragmatic breathing, but I, and I prefer the term lower focused breathing.
So making sure that, you know, [00:44:00] people are expanding their upper abdominal muscles when they're breathing. They're not using a lot of chest movement. This is going to be helpful for all of our clients. It's really sort of the, again, it's the foundation of the voice. And then with regards to looking at the source.
So this is when we start to talk about things like pitch. So there is normative data with regards to how we gender a voice and how that matches someone's pitch. So again, going back to sort of, you know, grad school and things like fundamental frequency is how many times the vocal folds are vibrating per second, 200 times a second is the typical pitch for someone to be gendered as female, but really it's a range and it's anywhere from about 150 to about 225.
So this, this really [00:45:00] huge range that we will going to listen to a voice and say, Hmm, I think that that person might be feminine. They may be female. And then when we're thinking about a more masculine sounding voice, we're talking about a voice that's really anywhere from about a hundred to 110 to about 140, 150, but there's this really huge area.
That is what we call sort of the gender neutral area. And that's when all of those other aspects of voice come into play and communication come into play that are, we start to say, Hmm, why do I gender that voice as more masculine or more gender neutral or more feminine? And that's when we start to talk about things like resonance, we start to talk about things like intonation we talk about is the voice [00:46:00] choppier, or is it more blended?
And again, a more stereotypical masculine sounding voice is not going to be as blended from one word to another. I was just very blended going from one word to another, which we think about as a more feminine presentation. So these are the types of activities and tasks that we do in our therapy session to help our clients achieve their desired vocal quality.
And going back to what AC was saying about the evaluation, that is the time when we really need to listen to our clients. And ask them what they want in their voice. It is not about my perception. It is not about society's perception. It is about their desires for their communication style. And Kate has her hand up.
[00:46:58] Kate Grandbois: I do, I have a question. [00:47:00] We talk a lot about data collection on here. Cause that's very ethical, making sure that what you're doing is, is aligned with perspectives and values of your client. Cause that's evidence-based practice. And I'm wondering if you ever use a recording and have the person listened back to it as like a biofeedback to say, yes, this is what I like.
Or I don't like this aspect to give you that feedback about what they would like to change, because I say that because I'm a speech pathologist and the nuance and subtlety and specifics of what you're talking about. It is a lot. I mean, those tiny little subtle things can make a big difference.
[00:47:34] Barb Worth: And Kate, I'm going to ask you a question.
Oh no.
Barb Worth:When you hear, and Amy, I'm going to ask you when you listen to your voices back,
Amy Wonkka: I hate it.
[00:47:46] Kate Grandbois: That it doesn't I've
[00:47:47] AC Goldberg: I think it's universal. Yeah. Oh my gosh.
[00:47:51] Barb Worth: That doesn't bother me.
[00:47:54] Kate Grandbois: Am I, am I weird I can listen to my voice? Cause I edit all these audio files. I've just, I just listen to it.
[00:47:58] Amy Wonkka: [00:48:00]
[00:48:00] Barb Worth: You are really in the minority.
Most people hate. Why is that? Well, first of all, what did you remember from back in grad school that we hear ourselves through bone conduction, right? So we're actually not even hearing other people right here. And then we have all the limitations of our recording equipment. Right. Right. So, so that's really multifaceted.
But the other thing that I do want to bring up is that there is a certain percentage of our clients who have vocal dysphoria. And so for some people listening, it's hard enough for them to practice right. Their voice, but to listen back can be really challenging. And so that is something that I really use discretion and would only do following a, uh, a conversation.
You are agree AC?
[00:48:56] Kate Grandbois: you are wise. I never would have thought that
[00:48:59] AC Goldberg: [00:49:00] when I, when I ask my clients, I say, you know, are you comfortable recording your voice? Are you comfortable recording your voice, sounding in this new pattern? So you can tell me whether you like the way, it sounds, don't think of it as your voice.
Think of it as, you know, is that a voice you can, you can listen to because I, a lot of clients really, you know, do experience a tremendous amount of vocal dysphoria and hearing their voice can, can trigger that. And even though your recorded voices and the voice that you hear in your head, it's still can really be like murky territory.
And you know, there, I do take recordings of my clients so that I can, you know, measure progress. But I frequently have clients who don't want that shared with them until they feel like they've achieved where they are, or where, where they are, where they want to head with their voice.
[00:49:50] Barb Worth: I think to answer your question though, Kate, with regards to, so how do we collect data and AC might have a different response to this, but one of the things that I [00:50:00] think is really hard for my graduate students is that we do a lot of Likert scales.
And so, because it really is ultimately about the client's perception and their desirability and satisfaction. So we do a lot of like on a zero, zero to five, five, meaning this is, you know, sort of, yes, this, this is, this is it. This is what you want, where are you today? Or where were you in that segment?
Right. And, and I think there's probably a little bit different than, than, than other aspects of our field. Do you agree?
[00:50:31] AC Goldberg: Oh yeah. I mean, I say you know, how did that feel? And I, you know, usually there's a numeric scale. How did that feel? Do you want my feedback? You know, and then I might tell them if they say, you know, that only felt like a seven, how do I, how do I take it to a 10?
And I, I talked to tell them something like, you have to over cue you in order to get there and then fall back into where you were trying to get to.
[00:50:55] Barb Worth: So with regards to sort of like, you know, therapy techniques that we use you know, [00:51:00] we do a lot of the techniques that you learned in voice class or that, that, that people who work with voice, people with voice disorders do use.
So things like resonant voice therapy, which is a, which is, uh, a technique to help to get a more forward resonance. We do things like sending occluded vocal tract exercises, meaning [lip trill] and I think AC has a straw.
Yeah. So phonating through a straw. We do, you know, laryngeal massage. So, yeah. So one of the things that we teach our clients to do, we may do first and then we may teach our clients only with permission obviously is to, to reduce any tension that they might feel, because you could imagine that, you know, this takes some retraining and I, I like to use sports analogies, you know, that you have to warm up in order to, to do this type of work.
You don't go run a marathon without stretching and [00:52:00] in theory, right. And that also that there might be some, some small amount of muscle fatigue asking your, your, your, your muscles to do something different. And so things like laryngeal massage can be super helpful for the clinician to apply to the client and also for the client to learn themselves I think I also, you know, briefly mentioned, we do work on things like word choice or body language we work at on, you know, non-verbal vocal aspects like laughing, sneezing, coughing.
We have sessions where we, you know, turn on a funny, uh, comedian and practicing laughing.
[00:52:39] AC Goldberg:, The best. practicing laughing, also practicing loud voice practicing phone voice, practicing polite voice you know, sort of, you never think about all those sets to your voice until you're doing this type of work.
And you're like, oh, I have a different voice for, you know, when I'm ordering food at the drive through versus when I'm calling to make a doctor's appointment. Versus when I am talking to a friend or when I'm [00:53:00] raising my hand in class, they're all different sets and people need to, you know, make sure that they're comfortable falling into their new habitual voice in each of those sets.
[00:53:09] Barb Worth: And I think, uh, you know, we start very much, you know, at sort of at the word level and then we sort of move along and I think. It's also really important to remember the cognitive load that it takes in order to be thinking about your voice and formulating language at the same time. So I'll give you an example.
I'm so proud of my graduate students, because they have formed this really incredible group of, of actually as a, it's an interesting group because it's actually people working on masculinizing their voice and feminizing their voice. And they work together on work-related tasks and do work presentations.
And so these are people who have been in therapy for a while. Let's say like six plus months and they get together and they work on their workf voice. [00:54:00] So, uh, it, it, and, and it takes a huge amount of skill to be able to talk at such a high level. I mean, we have a PhD students who were talking about, I don't even know, like astrophysics, right?
I don't even know what they're talking about, but it is incredible at this level using their new voice.
[00:54:24] AC Goldberg: Imagine me as a speech pathologist, speaking as a speech pathologist, using a new voice, it's a thing. We still have to, I do still have to center myself and call my attention to it. I'll find my resonance creeping all the way up, especially at the end of the day, like I'm right here.
And like, I just have to kind of like, be like, okay, you know, get, get yourself back down there.
[00:54:46] Kate Grandbois: That's a tremendous amount of things to focus on all at once. Not to mention any environmental variable or any, I don't know. Other social cues you're picking. I mean, communication is complex on the best of days.
[00:54:57] Amy Wonkka: So to try and think about [00:55:00] shifting something that's so automatic that we don't, I mean, even just the points that you were making about all of the different vocal registers that you're using in all of these different contexts, I don't, i’ve never thought of that, but then you set it in it completely makes sense.
But to be thinking about all of those vocal changes all the time, plus your message I don't even.
[00:55:19] AC Goldberg: think about just spelling your last name. When you're, when, when you're, uh, you know, over the phone, you know, like, okay, you know, what's your last name? Can you spell that? And then, you know, when you have to spell something over the phone, it's like G O L and you know, if you're spelling something in your new habitual voice and you're like, oh my gosh, I have to make all of these strange sounds and this new voice, I mean, even spelling can be, can be burdensome.
When you're, when you're using any voice. We love to empower people to use their new voices across all settings. You know, I, sorry, go ahead, Barb.
[00:55:55] Barb Worth: I was going to say, I know that we are running out of time and I know that we love to empower [00:56:00] the speech language pathologists who want to do this type of work.
[00:56:03] AC Goldberg: Yes. This type of work, this type of work is re uh, it's. You know, for me as a transgender person, it feels so full circle for me to come back and help people in my community, feel more comfortable with their vocal presentations, as someone who was so uncomfortable with my vocal presentation for so much of my adult life.
You know, I feel like there was, I did a lot of work on my voice and I know what's involved in it. And so having the lived experience of modifying my own voice and knowing what goes into it, knowing the feelings behind it, knowing that somebody can come away and feel like, wow, like I can just walk down the street and talk to someone and not have them know.
And that was a big thing for me, is that like, I just, I didn't want that to be the focus of my conversation. Like, oh yes, I'm trans. And you know, I would like to order a coffee. I never wanted that to be the focus of my conversation. And I [00:57:00] understand when my clients come to me with the sort of like, I just, I want my voice to go unnoticed.
I want it to be aligned with the way that I look. I want to feel good when I use it. I want to be able to laugh in public with my friends. I want to be able to feel comfortable communicating across all settings. And I love nothing more than empowering members of my own community to use their voice, their most powerful instrument to speak up for themselves in all in all settings.
And I love SLPs who provide this work and do it competently because they're helping people like me who, you know, may not have had access to this service years ago. You know, it really wasn't something that we, that we had that we offered as a field. So I'm just so grateful to clinicians like Barb, who, who started this work, you know, kind of in our field way before you know, I came along and, and knew that it was even a thing in our field.
[00:57:54] Barb Worth: And I, I feel so privileged to have walked this journey. I know it sounds super cliche, but [00:58:00] I do feel privileged. You know, when, when a client comes to my office and asks me to help them and such an incredibly personal, private, intimate part of their, intimate but yet outward presenting, right, part of themselves and the absolute joy that people feel as they're achieving their goals.
And when they say things like, wow, like I am feeling so much more aligned. And I'm not afraid anymore, or I'm, I'm not reluctant anymore to use my voice across all [00:59:00] of these different aspects of my life. And I have to say that it, you know, out of my, as I said, 27 years of, of work in this field, I have to say it's the most personally rewarding for me.
And hence why I think that AC and I want to help to educate others on how to do this type of work.
[00:59:27] Kate Grandbois: Well, I can't say anything after that, that was moving and inspiring. And I think speaks to just your level. You, both of you, your level of knowledge, your level of passion about this topic.And we're so grateful that, that you agreed to come back and hang out with us because this is just such a wealth of information. So thank you so much for all of this.
[00:59:47] Barb Worth: Well, Kate, it was such a pleasure and, you know, we, we didn't get a chance to talk about, you know, resources. So I know that we're going to put some information up on the website that will have, you [01:00:00] know, books that AC I would call them our Bibles. I mean, they're the Bible, the green Bible.
Yeah. These are, these are resources that we use all the time. Various journal articles, uh, websites, and what have you that sort of have helped us along the way.
[01:00:17] Kate Grandbois: We will put all of that in the show notes. So if you're listening and you're out on a run or drive. Rest assured that a list of resources and links will all be available in the show notes.
So, if you, again, for anyone listening who wants to use this for ASHA CEUs, you can go over to our website and purchase access to the quiz. The link to AC’s platform, Transplaining.info with a code for the discount will also be listed in the show notes. Guys, this was awesome. Thank you so much for being here with us today.
And we are just very grateful for your time.
[01:00:48] Barb Worth: Thank you.
[01:00:49] AC Goldberg: Thank you so much for having us.
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