This handbook is written for transgender people, their families and friends; for professionals who in their day-to-day job may encounter transgender people; and for students, teachers, educators, academics, and members of the public at large with an interest in transgender people.
This handbook gives an in-depth overview on a wide spectrum of issues encountered by transgender people, from childhood to later on in life. Key topics addressed include medical and surgical treatments, access to transgender health care, sexuality, mental health issues, fertility, education, and employment.
This practical guide is written in a clear and concise manner by more than 40 international specialists in the field of transgender health and well-being.
This essential text is extensively referenced and illustrated, and informs the reader on a broad range of important gender-affirming issues.
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Frequently Asked Questions
Q: Can I begin voice feminization if i am currently living as a man?
A: Yes. Voice feminisation can begin prior to full time gender transition. Some individuals live dual role and wish to develop a female voice for when they present female. Some individuals have a specific transition date in mind but are currently living in male role and want to start their voice modification as soon as they can. Other clients may have made their gender social transition but have not had any previous speech therapy and seek this out after the social transition. there is no specific right way of beginning voice feminization. It is recommended that the the patient is fairly close to transition so that motivation for voice change remains high, particularly for clients seen in the NHS as sessions are usually limited in number and the timing of treatment becomes mire important so that the client can get the most out of the sessions.
Experienced Speech & Language Therapists (SLT’s) can guide each individual client according to their individual circumstances and for this reason, attendance at an Initial SLT Consultation is recommended. The timing of the follow up treatment sessions can be planned /suggested at the Initial Consultation.
Q: Can voice therapy begin before hormones?
Q: What effect does oestrogen hormone therapy have on the voice?
A: None. Unfortunately, oestrogen has no significant impact on the voice as once a person born male has gone through puberty, the larynx will have lowered in the body, increased in size. In addition, the testosterone that influences other bodily changes during puberty also thickens the vocal cords which makes the voice sound deeper. This cannot be revered with oestrogen after a person has gone through puberty.
Q: How long does voice feminization therapy take?
A: This varies from individual to individual. People learn at their own pace. In addition, many factors can influence progress such as their ability to commit to therapy, their motivation to improve and their personal circumstances. It can also depend heavily on the the skill and experience of the Speech & Language Therapist. As a general guide, approximately 12 sessions are required to feminize a voice. Like all therapy, voice feminization is a process with stages of development and an experienced clinician can guide you through the process from beginners level to feminized voice.
Q: Will my female voice sound natural?
A: The goal is to achieve a natural /authentic sounding female voice. that fits the person. The modifications made will be by adjustments to each individuals vocal tract so the ‘essence’ of the person should not be totally lost by developing their female voice. It is normal for clients to have doubts about their voice or how well they are doing in the early stages of therapy. – this is the case whenever we embark on acquiring a new skill or are going through change. However, most individuals are inspired by the small initial changes which eventually increase to achieve the goals of treatment.
In the early stages, the learning is a very conscious activity but as the treatment progresses, with the tasks used by the Slt and the guidance given, conscious learning becomes unconscious.
Q: Will I need voice surgery as well as speech therapy to achieve a female voice?
A: The majority of clients achieve at least a well feminised or at least a reasonably feminised voice without the need for voice feminization surgery. Voice feminization surgery is carried out to achieve pitch elevation. Pitch is an important marker for distinguishing between male and female voices. However, it is just one aspect and pitch elevation alone is not usually enough to achieve a female voice. Many other aspects of voice such as intonation are important for voice feminization and these aspects need to be learnt and practiced to achieve natural and authentic sounding voice.
From clinical observation, it appears that in the U.K, approximately 20 % of male to female individuals in the U.K may seek voice feminization surgery.
My clinical observations over 15 years working with pre and post voice feminization surgeries have strongly indicated to me that the individuals who have better pitch and voice outcomes with voice feminization surgery are theses individuals who have first had a course of Speech & Language Therapy.. This is because the muscles involved in voice change have already adapted prior to surgery which supports the surgery and prevents the pitch dropping or changing after surgery. In addition, pitch surgery cannot address other aspects of female voice and communication such as intonation and speech style features. Prior to deciding to proceed to voice feminization surgery, the client should have undergone a pre-surgical assessment with an e SLT and an ENT Consultant.
Q: What is the recommended process for accessing voice feminization therapy?
A: The strongly recommended approach is:
1. Voice therapy with a suitably qualified SLT
2. pre- surgical assessment with an SLT which will involve accurate pitch measurements being made by the therapist and discussed with the client. The possible benefits and possible limitations of surgery will also be discussed (not all SLT’s have experienced with pitch elevation surgery so they may refer you to an experienced SLT). An explanation of the surgery will also be given to the client.
3. Referral to an experienced Ear, Nose & Throat (ENT) doctor foran assessment.
4. If surgery is carried out, post surgical review with the SLT is very important. This is to give post surgical exercises and guidance and to review the voice quality. If the person had a course of speech therapy prior to the surgery, fewer sessions are required post surgically – sometimes only 2 – 3 are required.
Q: Is Speech & Language Therapy available on the NHS?
A: Yes. Your GP can refer you to your local service for this. If you are under a Gender Identity Clinic (GIC, there may be an in-house SLT that the psychiatrists or psychologists can refer you to. The West London Gender Identity Clinic (known as Charing Cross GIC) can offer Speech & Language Therapy for clients under their care IF the client is a London area patient. For individuals living outside of London, they will need to seek referral to their local adult Voice SLT service.
Unfortunately, not all areas of the UK have a service for transgender individuals. Voice feminisation therapy has traditionally been very niche and specialist not least due to the small numbers of clients within the population as a whole. However, as the rates of referral have increased so have the number of treating clinicians. Since 2002, I have run training courses for SLT’s role to ensure carry over of skills and broaden the availability of this specialist kind of Voice therapy.and am happy to see that more SLT’s now wish to acquire skills in this area and continue to attend the 3 day courses I run. From 2008, I developed the junior developing specialist role at the West London GIC, offering full training within that role to the developing specialist with a view to succession planning.
Q: Can I refer myself for private speech and language therapy?
A: Yes. You can do this at any point in your transition.
Q: Can I start voice feminization with a private speech & language therapist while I am waiting to be seen by an NHS therapist?
A: Yes. Many individuals seek therapy with a suitably experienced SLT prior to seeing their NHS therapist.
Q: Can I have treatment with a private speech & language therapist as well an NHS therapist?
Y: Yes. It is possible to continue with a private SLT whilst having NHS speech & language therapy. However, the private SLT and the NHS SLT must not be the same person. If your private SLT also works in your local NHS voice service, you should be discharged from their private caseload first and then transferred to their NHS caseload.
Q: Is it possible to achieve a fully feminized voice?
A: YES! I have over 20 years experience of achieving this for a very wide range of clients using my established treatment model. The key elements required for success is motivation for change, an ability to comment to the therapy sessions, some practice time and development of social confidence. The skill and experience of the therapist can play a vital role both in the treatment model offered and in guiding the client through the process of voice change.