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Gender-affirming voice training aims to assist transgender and gender-diverse clients in reaching a voice in better alignment with their gender identity. We describe the development and evaluation of the Auditory-Perceptual Assessment of Gender Expression in Voice (PAGE-V) protocol for assessing voice and speech features commonly targeted in gender-affirming voice training. Features previously identified to influence the perception of femininity and masculinity were evaluated in two steps. First, seven speech and language pathologists (SLPs) reviewed PAGE-V based on their experience in providing gender-affirming voice training. Second, six SLPs completed listener training and assessed 45 voice samples with varying gender expressions using PAGE-V. The results showed that individual SLPs rated items relatively consistently; agreement among SLPs was lower. The PAGE-V was concluded to provide a clinically useful tool, and the insights gained support further development of PAGE-V. Listener training sessions are needed to strengthen SLPs’ internal representations and consensus on protocol items.

Despite an increasing amount of research related to gender-affirming treatment (GAT) outcomes among transgender and gender-diverse (TGD) people (ie, people who experience discomfort or distress in the misalignment between their gender and sex assigned at birth) in recent years, the evidence base for current recommendations is suboptimal. One contributing factor is the heterogeneity in the outcomes and outcome measures used. This study seeks to address this challenge by developing a foundational core outcome set (COS) to be used for TGD adults receiving GAT in Sweden.

Methods: Recommendations from the Core Outcome Measures in Effectiveness Trials initiative will be used to address this aim in four phases. Phase 1, an umbrella review of peer-reviewed literature and international guidelines in GAT will be conducted to identify relevant outcomes. In phase 2, we will solicit input from TGD individuals through the review of patient and interest organisations' reports and an anonymous survey to identify outcomes of personal significance. In phase 3, using the Delphi method, 2-3 rounds of assessment will be conducted where researchers, healthcare professionals, policy-makers and TGD adults rate the identified outcomes by perceived importance. In phase 4, a consensus meeting will convene representatives from all stakeholder groups to finalise the COS.

Analysis: The results of this study will consist of a COS for GAT regarding TGD adults in Sweden. Participant survey responses will be evaluated using interpretive analysis to identify core outcomes. During each of the Delphi rounds, Likert-type scale ratings will be aggregated for outcomes to advance or be eliminated in each round.

Ethics and dissemination: The study has received ethical approval by the Swedish Ethical Review Authority (Umeå medicine department, Registration number: 2024-04672-01). The results of this study will be published open-access and disseminated through TGD interest organisations and a Swedish research network for gender dysphoria.

Trial registration number: COMET registration number 3223.

Context: There is a considerable diagnostic delay in acromegaly, contributing to increased morbidity. Voice changes due to orofacial and laryngeal changes are common in acromegaly.

Objective: Our aim was to explore the use of digital voice analysis as a biomarker for acromegaly using broad acoustic analysis and machine learning.

Methods: Voice recordings from patients with acromegaly and matched controls were collected using a mobile phone at Swedish university hospitals. Anthropometric and clinical data and the Voice Handicap Index (VHI) were assessed. Digital voice analysis of a sustained and stable vowel [a] resulted in 3274 parameters, which were used for training of machine learning models classifying the speaker as “acromegaly” or “control.” The machine learning models were trained with 76% of the data and the remaining 24% was used to assess their performance. For comparison, voice recordings of 50 pairs of participants were assessed by 12 experienced endocrinologists.

Results: We included 151 Swedish patients with acromegaly (13% biochemically active and 10% newly diagnosed) and 139 matched controls. The machine learning model identified patients with acromegaly more accurately (area under the receiver operating curve [ROC AUC] 0.84) than experienced endocrinologists (ROC AUC 0.69). Self-reported voice problems were more pronounced in patients with acromegaly than matched controls (median VHI 6 vs 2, P < .01) with higher prevalence of clinically significant voice handicap (VHI ≥20: 22.5% vs 3.6%).

Conclusion: Digital voice analysis can identify patients with acromegaly from short voice recordings with high accuracy. Patients with acromegaly experience more voice disorders than matched controls.

Introduction: Gender dysphoria describes the stress and discomfort that transgender and gender diverse (TGD) people may experience when their gender identity is not aligned with their birth-assigned sex. A mismatch between voice and gender identity, voice dysphoria, can be a prominent part of gender dysphoria and may lead to limited participation in social life. Gender-affirming voice training provided by speech and language pathologists (SLPs) aims to assist TGD voice clients to reach their preferred gender expression in voice. The training is mainly based on research on voice and speech features most influential for the perception of femininity and masculinity in cisgender naive listeners, that is, people whose gender identity aligns with their birth-assigned sex and who have no professional training in voice assessments. The overall purpose of this thesis was to adopt a client-centred perspective by focusing on TGD people’s perception of voices and voice modification.

Method: To increase the understanding of TGD people’s motives and perceived barriers to voice modification, semi-structured interviews were conducted with 15 TGD voice clients considering gender-affirming voice training (Study I). To explore TGD people’s perceptions of voices in relation to cisgender naive listeners and SLPs, a listening experiment was constructed in which 132 voices representing a variety of gender expressions were rated according to the degree of femininity and masculinity, respectively. (Study II). The listener ratings were combined with a comprehensive set of acoustic voice and speech features using a penalized regression model to identify the relative strength of acoustic features most salient for listeners’ perception of femininity and masculinity in voice (Study IV). A rating protocol for standardised auditory-perceptual assessment of voice and speech features influencing the perception of gender expression in voice was developed and evaluated regarding consistency and agreement in six SLP listeners (Study III).

Results: Study I: The interviews showed that the TGD voice clients’ expected gains of modifying the voice included increased well-being, participation in social life, and control over the voice. Anticipated barriers included fears of not reaching one’s set goals and that the modified voice would no longer be an efficient tool for communication. Study II: The results of the listening experiment indicated that while TGD and cisgender naive listeners did not differ in their perceptions of femininity and masculinity, SLPs rated the voices as less feminine, and less masculine compared to the other two groups. Study IV: The acoustic models that best predicted the listener ratings explained 89% and 86% of the variance of the rated femininity and masculinity in voices, respectively. While fundamental frequency was seen to be the single most influential acoustic feature, the results verified the co-contribution of 222 other acoustic properties of articulation, intonation and resonance. Study III: The evaluation of the auditory-perceptual rating protocol provided support for structured clinical ratings within gender-affirming voice training to be meaningful. The protocol items were rated overall in a consistent manner by the SLPs, but the level of agreement among SLPs was lower.

Conclusions: The project places the TGD voice client in focus, taking a stance on the importance of applying a client-centred approach in both voice training and research. The results showed the need to address motivational and constraining factors for voice modification as these may affect TGD clients’ adherence to voice training and their satisfaction with training results. SLPs should be attentive to how their professional training may influence their perception of voices and encourage explorations of the TGD voice client’s perceptions of femininity and masculinity to ensure that goal setting and evaluation of training outcomes reflect the perceptions of the client. The voice training should consider the combined influence of pitch, intonation, resonance and articulation to target the client’s preferred gender expression in voice, measures which are also possible to analyse acoustically. To promote consensus among SLPs when performing auditory-perceptual assessments of these voice and speech aspects, joint listener training is recommended on a regular basis.

The project provides methodological alternatives for how listener experiments can be conducted to lessen the impact of normative assumptions about gender expression in voice as binary and equalled with the gender categories man and woman. The project advocates for a non-binary presentation of femininity and masculinity to be considered in future research on the perception of voices.

Introduktion: Könsdysfori innebär stress och obehag som transpersoner kan uppleva när könsidentiteten inte överensstämmer med det kön personen tilldelats vid födseln. Personer med könsdysfori kan i varierande grad uppleva negativa känslor inför röstens könsuttryck, röstdysfori. Att könsidentiteten inte speglas i rösten kan göra att personen av andra inte uppfattas och bemöts i enlighet med sin könsidentitet, vilket kan leda till försämrat psykiskt mående och att personen undviker samtalssituationer. Könsbekräftande röstbehandling hos logoped syftar till att patienten ska nå en röst som bättre överensstämmer med könsidentiteten. Röstbehandlingen baseras till stora delar på forskning som försökt kartlägga vilka egenskaper i röst och tal som inverkar på lyssnares uppfattningar av femininitet och maskulinitet i rösten. I dessa studier har deltagarna främst varit otränade lyssnare och cispersoner, d v s personer vars könsidentitet överensstämmer med det kön de tilldelats vid födseln. Det övergripande syftet med den här avhandlingen var att sätta patienternas perspektiv i centrum genom att fokusera på transpersoners uppfattningar av röster och av könsbekräftande röstbehandling.

Metod: För att öka förståelsen kring transpersoners förhoppningar och eventuellt upplevda hinder för att förändra rösten genomfördes semi-strukturerade intervjuer med 15 transpersoner inför könsbekräftande röstbehandling (delstudie I). För att utforska transpersoners uppfattning av röster utfördes ett lyssnarexperiment där ett stort antal röster med varierande könsuttryck skattades utifrån upplevd grad av femininitet respektive upplevd grad av maskulinitet. Utöver transpersoner deltog även cispersoner utan träning i att bedöma röster och logopeder för att utforska eventuella skillnader mellan de tre lyssnargruppernas skattningar (delstudie II). Därtill kombinerades lyssnarnas skattningar med ett stort antal akustiska mått som i tidigare forskning visats påverka uppfattningen av femininitet och maskulinitet i rösten. En regressionsmodell skapades för att identifiera akustiska mått med störst inverkan på lyssnarnas uppfattningar av femininitet respektive maskulinitet (delstudie IV). Vidare utvecklades och utvärderades ett bedömningsverktyg för auditivt-perceptuella röstanalyser att användas inom könsbekräftande röstbehandling (delstudie III).

Resultat: Intervjuerna visade att deltagarnas mål med att förändra rösten inkluderade ett förbättrat mående och ökat deltagande i sociala sammanhang, samt att kunna kontrollera vad rösten kommunicerar om den egna personen. Upplevda hinder för att påbörja röstbehandling inkluderade rädslor för att inte nå sina uppsatta mål, att rösten skulle låta konstlad, svag eller på andra sätt inte längre vara ett välfungerande kommunikativt verktyg.

Resultaten från lyssnarexperimentet visade att transpersoner och cispersoner inte skiljde sig åt i sina skattningar av femininitet respektive maskulinitet i röster. Logopederna visade däremot en tendens till lägre skattningar av både femininitet och maskulinitet jämfört med de andra två lyssnargrupperna.

De akustiska modellerna som bäst predicerade lyssnarskattningarna innefattade 223 akustiska mått och förklarade 89% och 86% av variansen i femininitetsrespektive maskulinitetsskattningarna. Grundtonsfrekvensen i rösten var den akustiska egenskap som främst inverkade på lyssnarnas uppfattningar av både grad av femininitet och grad av maskulinitet. Även andra akustiska mått relaterade till artikulation, intonation och resonans bidrog till att förklara lyssnarnas skattningar.

Utvärderingen av det kliniska bedömningsverktyget visade att de inkluderade röst- och talaspekterna skattades på ett konsekvent sätt av logopederna, men att samstämmigheten mellan logopedernas bedömningar var lägre.

Slutsatser: Genom att utgå från transpersoners uppfattningar och erfarenheter förordar avhandlingen ett patientcentrerat perspektiv i både kliniskt arbete och forskning. Avhandlingen visar på behovet av att både motiverande och hindrande faktorer uppmärksammas då dessa kan påverka patienternas genomförande av röstträningen liksom nöjdhet med behandlingsresultaten. Vidare bör logopeder reflektera över hur deras medicinska utbildning och träning kan medföra att uppfattningen av röster skiljer sig något mot transpersoners uppfattningar. Logoped och patient bör därför tillsammans utforska patientens uppfattning av femininitet och maskulinitet i rösten för att säkerställa att behandlingsmål och utvärderingen av röstträningen baseras på patientens uppfattningar. Vidare behöver träning av både röstläge, intonation, resonans och artikulation övervägas i röstbehandlingen för att nå patientens önskade uttryck i rösten. För samstämmiga och tillförlitliga auditivt-perceptuella bedömningar av dessa röstoch talaspekter rekommenderas logopeder regelbundet genomföra gemensamma lyssnarövningar.

Avhandlingen visar på alternativa metoder för hur lyssnarexperiment kan genomföras för att undvika normativa och binära antaganden om könsuttryck i rösten som likställda med könskategorierna man och kvinna. Projektets utgångspunkt att femininitet och maskulinitet är relaterade men separata aspekter i rösten bör övervägas även i framtida forskning om könsuttryck i röster.

The perceived level of femininity and masculinity is a prominent property by which a speaker’s voice is indexed, and a vocal expression incongruent with the speaker’s gender identity can greatly contribute to gender dysphoria. Our understanding of the acoustic cues to the levels of masculinity and femininity perceived by listeners in voices is not well developed, and an increased understanding of them would benefit communication of therapy goals and evaluation in gender-affirming voice training. We developed a voice bank with 132 voices with a range of levels of femininity and masculinity expressed in the voice, as rated by 121 listeners in independent, individually randomized perceptual evaluations. Acoustic models were developed from measures identified as markers of femininity or masculinity in the literature using penalized regression and tenfold cross-validation procedures. The 223 most important acoustic cues explained 89% and 87% of the variance in the perceived level of femininity and masculinity in the evaluation set, respectively. The median fo was confirmed to provide the primary cue, but other acoustic properties must be considered in accurate models of femininity and masculinity perception. The developed models are proposed to afford communication and evaluation of gender-affirming voice training goals and improve voice synthesis efforts.

Objective: To explore whether cisgender naive listeners, transgender and gender diverse (TGD) listeners, and speech-language pathologists (SLPs) experienced in providing gender-affirming voice training differ in their perception of femininity and masculinity in voices.

Methods: Samples of spontaneous speech were collected from 95 cisgender, and 37 TGD speakers. Three listener groups of cisgender naive (N = 77), TGD (N = 30), and SLP (N = 14) listeners, respectively, rated the voices on visual analog scales in two randomly ordered blocks, in which the perceived degree of femininity was rated separately from the perceived degree of masculinity.

Results: The three listener groups showed similar patterns in their distribution of ratings on the femininity and masculinity scales. The TGD listeners’ mean ratings did not differ from the cisgender naive listeners’, whereas SLPs showed a small, but significant, difference in their ratings compared with both TGD and cisgender naive listeners and rated the voices lower on both the femininity and masculinity scales.

Conclusion: The results differ from previous studies as TGD, and cisgender naive listeners rated the voices very similarly. The lower ratings of femininity and masculinity by the SLPs were likely influenced by their awareness of the complexity in the perception of voices. Therefore, SLPs providing gender-affirming voice training should be attentive to how their professional training may influence their perception of femininity and masculinity in voices and encourage discussions and explorations of the TGD voice client's perceptions of voices.

Purpose: To date, transgender and gender-diverse voice clients' perceptions and individual goals have been missing in discussions and research on gender-affirming voice therapy. Little is, therefore, known about the client's expectations of therapy outcomes and how these are met by treatments developed from views of vocal gender as perceived by cisgender persons. This study aimed to explore clients' individual motives and perceived barriers to undertaking gender-affirming voice therapy.

Method: Individual, semistructured interviews with 15 transgender and gender-diverse voice clients considering voice therapy were conducted and explored using qualitative content analysis.

Results: Three themes were identified during the analysis of the participants' narratives. In the first theme, “the incongruent voice setting the rules,” the contribution of the voice on the experienced gender dysphoria is put in focus. The second theme, “to reach a voice of my own choice,” centers around anticipated personal gains using a modified voice. The third theme, “a voice out of reach,” relates to worries and restricting factors for not being able to reach one's set goals for voice modification.

Conclusions: The interviews clearly indicate a need for a person-centered voice therapy that starts from the individuals' expressed motives for modifying the voice yet also are affirmative of anticipated difficulties related to voice modification. We recommend that these themes should form the basis of the pretherapy joint discussion between the voice client and the speech-language pathologist to ensure therapy goals that are realistic and relevant to the client.

Gender-affirming voice training aims to assist transgender and gender diverse clients in reaching a voice in better alignment with their gender identity. We describe the development and evaluation of the formal rating protocol Auditory-Perceptual Assessment of Gender Expression in Voice (PAGE-V) for assessing voice and speech features commonly targeted in gender-affirming voice training. Features previously identified to influence the perception of femininity and masculinity were included in the protocol and reviewed for their relevance by seven Speech and language pathologists (SLPs) with experience in providing gender-affirming voice training. The included 21 items were evaluated using 45 voice samples with varying gender expressions. Six SLPs rated the samples after completing a listener training session using the PAGE-V. The results show that individual SLPs rated items consistently overall while agreement among SLPs was lower. The PAGE-V was concluded to provide a clinically useful tool, and insights gained strengthen further development of the PAGE-V. Listener training sessions are needed to strengthen SLPs internal representations and consensus on the items.