Download The Role of the SLP in Transgender Communication

Sena Crutchley, MA, CCC-SLP
The University of North Carolina at Greensboro
Richard Adler, PhD, CCC-SLP
Minnesota State University Moorhead
John Pickering, Jr., PhD, CCC-SLP
College of Saint Rose
Vicki McCready, MA, CCC-SLP
The University of North Carolina at Greensboro
Richard Adler &
Jack Pickering
 Multicultural
Approach: Overt and Covert
 Transgender Culture




Ida Stockman: ―…culture can be viewed… as the
socially constructed and learned ways of
believing and behaving that [identifies] groups of
people.‖
What beliefs or behaviors identify a culture?
Culture is not just about race or ethnicity.
Overt: Food, music, dance, body language, nonverbal language; that which is passed down or
learned from others in the culture
 Covert:
Intangible learned behaviors; body
language, vocab, gestures, tone, pitch, voice
quality. Here is a Gender Continuum








Sex: Genetic
Male…………………………………………..Female
Gender
Woman……………………………………….Man
Sexual Orientation
Heterosexual……………………………..Homosexual
Presentation/Social Role
Masculine……………………………………Feminine
 Hispanic
 African-American
 Asian-Pacific
Islander
 Native American
 Asian-Indian
 GLBT Community
 Deaf Community
 SLPs
in other countries were working with
Transgender Clients since the 70’s.
 1980’s saw some breakthrough research from
Jenni Oates and Georgia Ducakis in Australia.
 Was beginning to catch on in the U.S. in the
mid 80’s.
 I began seeing TG clients after leaving Emory
University…I began a private practice.
 TG Voice and Communication Therapy has
evolved over the past three decades.
 Before
evidence-based practice came into
the limelight, therapy was basically to raise
pitch for MtF clients; FtM clients were not
seen at most clinics in the U.S.
 Early 90’s saw an emergence in several
aspects of voice including pitch, resonance,
intonation, volume, and rate…realizing that
it was not just pitch that made a difference.
 Late 90’s more FtM clients were seeking help
most often with non-verbal communication,
articulation, and syntax/pragmatics.
 Throughout
the 80’s and 90’s, more research
was ―coming out‖ that indicated it was not
just pitch that needed to be changed but all
voice aspects as well as basic communication
aspects.
 Research was published to show that there
were subtle and yet some blatant differences
in gender communication; ―gender-benders‖
were recognized.
 More MtF and some FtM clients were more
public about rights, needs, and visibility.
 Throughout
these decades, the main
international organization, The Harry
Benjamin International Gender Dysphoria
Association, published several Standards of
Care for Transgender Health.
 The 6th Edition came out in 2001. Nothing
was included in Voice and Communication
standards.
 At the start of the new century in 2000,
voice and communication were recognized in
this country as a total program for the TG
client.
 Freidenberg,
Oates, Ducakis, Gelfer and
others were publishing evidenced based
research that gave credibility to what could
be done for the MtF and FtM client.
 In Canada, Joshua Mira Goldberg and Shelagh
Davies were writing programs for TG clients
in British Columbia.
 Much work was being done in England
(Christella Antoni), New Zealand, Germany,
and other EU countries…ENT physicians were
taking the lead to establish this in Europe.
 In
the early 2000’s, HBIGDA was changed to
the World Professional Association for
Transgender Health (WPATH). Its
international headquarters are located at the
University of Minnesota Human Sexuality
Program in the Medical School in the Twin
Cities…Minneapolis/St. Paul.
 Harry Benjamin is still honored as the
―father‖ of transgender healthcare but the
new WPATH more clearly incorporates the
mission of this organization…a total
healthcare approach.
 In
2009, WPATH executive committee formed
a Standards of Care Committee to update the
Standards for Version 7 to come out in late
2011….First time an SLP was appointed to be
on that committee (after many
correspondences and interactions with the
president).
 The 2011 SOCs will include Voice and
Communication Standards for the first time
in HBIGDA’s or WPATH’s history. I have to
give credit to the SLPs in the U.S., Australia,
and England for advocating for this for years.
A
total program is most beneficial.
 Voice: Pitch, Intonation, Resonance, Rate,
and Volume
 Vocal Health (Hygiene)
 Articulation
 Language: Both Pragmatics and Syntax
including vocabulary
 Non-verbal communication
 Real-Life Experiences/ Authenticity
 Why






SLPs?
We have training in voice disorders, both
assessment and treatment.
We can look objectively at TG voice issues as a
difference or disorder.
TG Voice and Communication is a ―Modification‖
type of therapy program.
It is not a ―pure therapy‖ type of approach.
SLPs are qualified to know the difference.
SLPs are trained in voice care, the laryngeal
mechanism, vocal health, vocal hygiene
principles, and work closely with ENT physicians.
 Other
professionals work with TG clients
Actors/Actresses
 Singers
 Other performers
 Public speaking professionals
 VASTA: Voice and Speech Trainers’ Association
 Singing/Voice Teachers
 Theatre Personnel
 Choir Directors
 Clergy—Preaching, Sermons

 Code



of Ethics-- Principle of Ethics I, Rule C
We must be non-discriminatory with respect to
[CLD] culturally and linguistically diverse persons
in the delivery of professional services or in the
conduct of research or scholarly activities.
Rules A and B stress emphasis on competent
service delivery.
Cannot discriminate in clinical service delivery or
in academic settings and person or persons who
come under a CLD category: Native American,
African American, Hispanic/Latino, Asian Pacific
Islander, Asian Indian, and GLBT
 It
is a developing process.
 Requires a commitment
 Requires continuous understanding and
enhancement of Knowledge
 Gain knowledge: information we need about
a culture to become culturally competent
 Skills: what to do with our gained knowledge
and how to apply it to our therapy plans
 What
kind of professional do we want to be?
 Develop awareness, application, and
advocacy
 Identify your own ―culture(s)‖ including
beliefs, stereotypes, values
 Take knowledge about cultural diversity and
apply that to skills that impact therapy.
 Don’t become someone you are not—


You do not have to have a stroke in order to treat
a patient with aphasia.
You do not have to be Trans to work in this area.
 Many
transgender persons come to a clinic
with a voice disorder and also wish to have
voice modification.
 Is Transgender Voice and Communication a
voice disorder or a voice difference?
 Why voice? Why communication?
 Differences between genders in vocabulary
choice, syntax, etc.
 Think about this: Your voice is kind of a
―Blueprint‖ of who you are….if you are an
MtF…you would want your voice to be
modified.
 Hormone







therapy
MtF individuals take testosterone blockers and
add estrogen.
Does not change voice
May change emotions and communication style
FtM individuals take estrogen blockers and add
testosterone
Does have an effect on the voice
Often does not change other voice aspects like
intonation, sometimes resonance, rate and
volume
Does not have an effect on non-verbals
 Many
MtF and a few FtM individuals choose
vocal fold surgeries to change their voices.
 MtF often need ―Adam’s apple‖ shaving
through surgery; some individuals do not
have a prominent ―Adam’s apple‖ or thyroid
notch.
 Some MtF individuals choose fold surgery to
―thin out‖ and ―shorten‖ the folds to achieve
a higher pitch.
 It can work well; often leaves a client with a
―Minnie Mouse‖ sounding voice; client is not
pleased with it.
 Development
of the W-PATH SOC, Version 7
necessitated a review of the literature.
 Research completed over the last decade or so
provides insight into intervention for:




Vocal characteristics
Resonance and articulation
Language and non-verbal communication
Female-to-male transsexuals
 Client
self-perception and voice-related quality
of life have been an important focus of recent
research.
 Raising f0 can
facilitate the perception of female
voice for MtF transsexuals.1-9





The target is gender neutral or higher.
f0 can be increased safely.
Number of sessions seems to affect generalization.
Higher f0 may not correspond to increased client
satisfaction.
f0 change may affect or be affected by other areas
of communication (resonance, appearance, etc.).
 So,
clearly a higher f0 is important, but not the
only thing…
 Other
areas of voice to consider to enhance the
perception of female voice




A
Breathy voice quality
Reducing glottal fry
More inflections, more upward inflections
Not a lot about loudness in the transgender
research, but lower volume may support perception
recent gender study be Hillebrand and Clark10
suggests that changing f0 and resonance can
have a greater impact on gender perception
than just changing one of these characteristics.
 Modifying
resonance involves changing speech
sound production.11-15


Focus on forward tongue carriage and lip spreading
Articulation changes affect resonance frequencies
and contribute to f0 increase.
 Authorities
suggest improving the continuity of
speech (reducing ―choppy-ness‖), but there is
little research support at this time.
 Modifying speech rate does not seem to affect
perception.16
Quite a bit of gender research, but less in the
transgender arena17-26
 Features of spoken language facilitate perception
(tag questions, adjectives/adverbs).
 Vicki and Sena published a case study that
emphasizes the importance of language and nonverbal communication – more to come…
 Physical appearance contributes to gender
perception and client self-perception.
 Client satisfaction is influenced by voice, resonance,
language (including pragmatics), and non-verbal
communication (remember – it’s not one thing!).

Limited research exists. 27-31
 We know that voice changes in response to
hormone therapy and the relationship between
voice and physical appearance appears strong.
 However,
 other aspects of speech and communication are
not affected by hormone treatment.
 some clients have a problem adjusting to voice
change.
 Adler & Van Borsel (2006) and Van Borsel et al
(2000) provide ideas for intervention.
 Constansis (2008) writes about FtM singers, vocal
warm up and exercise.





1-10 Vocal Characteristics: Dacakis (2000); Soderpalm, et al.
(2004); Wolfe, et al. (1990); Gelfer & Schofield (2000); McNeill
et al. (2008); Hancock et al. (2009); Holmberg, et al. (2010);
Gorham-Rowen & Morris (2006); Mordaunt (2006); Hillenbrand
& Clark (2009)
11-16 Resonance and Articulation: Mount & Salmon (1988);
Gelfer & Mikos (2005); Carew, et al. (2007); Van Borsel & De
Maesschalck (2008); Boonin (2006); Hirsch (2006a)
17-26 Language and Non-verbal Communication: Byrne, et al.
(2003); Hirsch (2006b); Hirsch & Van Borsel (2006); Hooper
(2006); Hooper & Hershberger (2006); McCready et al. (2010);
Schwartz & LaSalle (2008); Pasricha, et al. (2008); Kayajian
(2005); Baker (2010)
27-31 FtM Transsexuals: McNeill (2006); Adler & Van Borsel
(2006); Van Borsel et al. (2000); Van Borsel et al. (2009);
Constansis (2008)
Jack Pickering &
Richard Adler
 Maintaining
vocal health is essential to
continuous voice improvement.
 What do you do daily that would be harmful
to your voice? Smoke, Drink, scream etc.
 Phonotrauma
 Suggestions to relieve laryngeal tension
 Suggestions to relieve vocal fold strain
 Suggestions to maximize our safe use of our
respiratory system
 Suggestions for continuous hydration
 Suggestions to relieve vocal fatigue
Biological differences
between genders in
the vocal folds and
vocal tract:


Do not change with
hormone therapy for
MtF clients
Are difficult, if not
impossible, to modify
surgically
So, our goal for
MtF clients:
Play the flute so it
sounds like a piccolo
 Use
the recent research and consider:
 Fundamental frequency
 Fundamental frequency change (inflection)
 Vocal tract resonance
 Voice quality and loudness
 Client self-perception and goals
 Apply intervention from voice disorders
 Vocal Function Exercises
 Resonant Voice Therapy
 The ultimate goal: An authentic voice
Goal of VFEs (Stemple, Glaze & Klaben, 2010): To
strengthen and balance the laryngeal
mechanism in order to increase vocal flexibility
and variability. For MtF transsexuals, it
provides a context for safely exploring tones
that are consistent with a female speaker. May
also work with FtM clients
VFEs:
1. Warm-up: Nasal ―eee‖ on F note
2. Stretching: Gliding on comfort pitch low to high
3. Contracting: Gliding on comfort pitch high to low
4. Isometric strength: Musical notes C-G or E-B
Client
SM
C3
D3
E3
F3
G3
A3
B3
C4
D4
E4
131
147
164
175
196
220
245
262
294
328
22
30
35
37
26
31
44
49
53
44
38
37
32
34
31
41
46
45
40
33
45
50
44
34
31
35
51
45
35
30

Goal of RVT: To produce
voice with forward,
resonatory focus and as
little vocal effort as
possible, consistent
with female speakers
Steps:
 Humming
 Molming
 As a sigh
 Varying rate and
loudness
 Like speech
Steps (cont.)
 Chanting
 ―Mamapapa‖
 Varying rate, loudness
 Like speech
 More Chanting
 Producing sentences
and conversation
 Effective for MtF and
FtM clients
 Males
and females use inflection differently.
Females use:
More upward inflections
 More varied inflections
 More continuous articulation (more fluid)

 Really?
Really!
 Walk-jump-step fall…
Client
Walk
Jump
Step
Fall
AZ (3 mo.)
182 Hz
264 Hz
161 Hz
147 Hz
AO (6 mo.)
178 Hz
283 Hz
174 Hz
146 Hz
RP (6 mo.)
213 Hz
290 Hz
230 Hz
182 Hz
SA (9 mo.)
137 Hz
226 Hz
123 Hz
109 Hz
TJ (9 mo.)
227 Hz
242 Hz
235 Hz
165 Hz
 Program
components: The big picture
 Work on voice and resonance


Group intervention to introduce techniques
Individual intervention to customize for the
client (goal setting w/the client)
 Measuring




change
Phonation time for VFEs
Visipitch for visual feedback and data collection
On-going perceptual measures
Providing conversational speech activities
(monologues, poetry, class presentations)
Vicki McCready
 The
claim is that 65-90% of human messages
come through nonverbal communication
(Hirsch & Van Borsel, 2006; Wood, 2009).
 Within
30 seconds of meeting someone,
―…we draw an average of six to eight
conclusions about a person before a single
word is uttered‖ (Nelson & Golant, 2004).
 NVC reflects both gender and culture (Wood,
2009).
 Many
transgender clients ―initially have no
idea of the communicative power of their
biological gender habits‖ (Hirsch & Van Borsel, 2006).
 Responsiveness:
Women are socialized to be
responsive and use NVC behaviors to show
engagement, emotional involvement and
empathy with others.
 Liking: Women are socialized to form
relationships and be nice to other people.
 Power or Control: Men exceed women in use
of NVC efforts to control conversations, e.g.,
through vocal qualities, touch and use of
space.
 According
to Hirsch & Van Borsel (2006), NVC
is defined as ―any nonverbal behavior that
may be interpreted as having meaning for a
receiver, even if not intended as such by the
sender‖ (p. 284).
 Typical categories include:





Kinesics (body motion)
Proxemics (personal space)
Haptics (touching/tactile communication)
Oculesics (use of the eyes)
Facial Expression
Men





Listen with head in
static position
Use closed fingers in
gestures
Maintain a backward
position when listening
Display more reserved
posture and movement>
move trunk less
Move on a linear plane
Women





Mirror partner’s
movements, tilt and
move the head
Use fluid gestures with
open finger motions
Lean in while talking or
listening
Use entire body in
movements
Use swinging,
undulating movements
(Hirsch & Van Borsel, 2006;
Wood, 2009; Davies &
Goldberg, 2006)
Men



Take up more space
when sitting or standing
and use more personal
space
Enter women’s spaces
more often than women
enter men’s spaces and
more often than men
enter men’s spaces
Refuse to yield territory
more often
Women



Sit, stand, talk closer
together
Condense bodies to take
up less space
Cede personal territory
and accept the invasion
more often
(Wood, 2009; Hirsch & Van
Borsel, 2006)
Men


When young, are
touched less frequently
by parents
Use touch to assert
power, direct people &
express sexual interest
Women



When young, are
touched more often and
more gently by parents
Use hugs & touches to
express affection &
support
Display self-referential
touching
(Hirsch & Van Borsel, 2006;
Wood, 2009)
Men
Use eye contact to
express dominance
 Do not sustain eye
contact in a
conversation
 Look at others from
an angle

Women
Engage in more eye
contact
 Use eye contact to
relate to others or
express submission
 Are more comfortable
with use of eye
contact

(Davies & Goldberg, 2006;
Hirsch & Van Borsel, 2006;
Wood, 2009)
Men
Smile less and frown
more in conversations
 Use facial expressions
in an aggressive
manner more often

Women
Smile more often
 Communicate with all
senses to listen
empathically and pick
up details
 Display a wider
variety of expressions
 Nod head when
listening

(Davies & Goldberg, 2006;
Hirsch & Van Borsel, 2006;
Wood, 2009)
 Analysis
of three to five minute videotaped
conversational sample for clients who are MtF
(McCready, et al., 2011).



Quantitative ratings of 16 nonverbal behaviors
Qualitative comments and observations about
client’s nonverbal behaviors
Rating scale of client’s use of feminine nonverbal
characteristics:
Excessively
Feminine
5
Overly
Feminine
4
Feminine
3
Somewhat
Masculine
2
Masculine
1


A menu of choices/client preferences (McCready et al.,
2011) that are authentic to the client (Hirsch, 2006)
Example of a short-term objective for a beginning
voice and communication group for clients who are
MtF (McCready et al., 2011):


Use of at least 6 of 15 feminine nonverbal behaviors with
comfort and fluidity two times each during a 5-minute
conversation over 3 consecutive sessions.
Sequence of activities





Knowledge about and observation of NVC in men and
women (via handouts, published video samples, and
homework)
Modeled practice of two to three nonverbal behaviors in
functional role plays per session
Practice of nonverbal behaviors combined with spoken
language behaviors
Combined practice of nonverbal and spoken language
behaviors with voice
Practice outside the clinical setting
Sena Crutchley
―Language not only expresses cultural views of
gender but also constitutes individuals’ gender
identities‖ (Wood, 2009, p. 137).
 The language behaviors of males and females are
a result of the different, subtle ways in which
they are socialized (as cited in Wood; McCready et al., 2011).
 Men and women exhibit differences in
communication goals, interpretations, and styles
of speaking, and these differences may influence
communicative partners (Hannah & Murachver, 1999).
 We may not be able to identify the specifics of
how men and women use language differently,
but we are instinctively aware that differences
exist (Wood, 2009).

A
considerable amount of evidence indicates
that there are gender-based differences in
articulation.
 Researchers have empirically demonstrated
that the speech of women tends to be more
precise than that of men.
 Boonin states that ―…gender-linked
articulation behaviors need to be seen as
significant and appropriate matters for
evaluation and exploration when engaging in
the clinical endeavor of gender-appropriate
speech modification‖ (p. 228).
Men





Establish control &
status
Talk to achieve
practical objectives
Lead the conversation
Direct and assert
themselves
Respect others’
independence
Women







Establish and build
relationships
Establish equity
Provide support
Maintain conversation
Are responsive
Provide details and
disclosures
Speak tentatively
Women:
 Use tentative language (e.g., I think, kind of)
 Use traditionally polite phrases more readily
 Invite the partner to speak more frequently
 Pause longer to allow partner talking time
 Interact in conversations more frequently
 Compliment others more frequently
 Express empathy more frequently
 More likely to self-disclose
 Say more apologies
 Listen actively
Men:
 Offer advice more quickly
 Refrain from self-disclosure
 Use ―feeling‖ language less often
 Brag and verbally spar more often
 Aim to direct conversational topic
 Talk more in public environments but less in
intimate environments
 Use direct statements with a tone of authority
 Express ideas more abstractly and conceptually,
less from personal experience
 Interrupt the conversational partner more readily
Women:
 Use a variety of descriptive adjectives (e.g.,
beautiful) and adverbs (e.g., painfully slow)
 Say ―so‖ more often (e.g., ―I was exhausted,
so I took a nap.‖)
 Express nurturing & empathy (―I can relate.‖)
 Use many terms of affection (e.g., adore)
 Use inclusive pronouns such as us and we
 Discuss feminine topics (e.g., makeup) with
related vocabulary
gorgeous
sweltering
passionately
admire
Men:
 Use ―I‖ more frequently
 Curse and use crude language more
frequently
 Use language that is less descriptive (e.g.,
―That tastes good.‖
funny
nice
great
hot
fast
Women:
 Use more adverbial clauses (e.g., ―I would be
happy to help if I new how to do it.‖)
 Use conjunctions (e.g., and) to connect
sentences more frequently
 Use more tag questions (e.g., ―, isn’t it?‖)
 End sentences with such clauses as unless,
provided that, as long as, whenever
 Ask questions rather than make statements
of wants/needs (e.g., ―Are you thirsty?‖)
I went to the store, and I found this beautiful blouse, and then I
met my sister for lunch, and we had the most delicious Thai food.
Men:
 Ask questions less frequently when in public
 Start sentences with adverbial clauses (e.g.,
―If I could help, I would.‖)
 Don’t connect sentences with transition
words as frequently as females (e.g., ―I went
to the store. I bought some paper towels.‖)
 Use contractions (e.g., wouldn’t, I’d) more
often than females
 Speak in briefer utterances
I went to the store. I found this shirt.
Then I met my sister for lunch.
Women:
 Prolong vowels more frequently

Also related to a slower speaking rate in women
 Speak
more precisely with crisp articulation
 Pause more frequently
 Pause with longer duration
Example for MtF:
 Analysis of five to ten minute videotaped
conversational sample (McCready, et al., 2011)


Quantitative ratings of 10 spoken language
behaviors
Qualitative comments and observations about
client’s spoken language and articulation
 Rating
scale of client’s use of feminine
spoken language characteristics:
Excessively
Feminine
5
Overly
Feminine
4
Feminine
3
Somewhat
Masculine
2
Masculine
1


A menu of choices/client preferences (McCready et al., 2011)
Example of a short-term objective for a beginning voice
and communication group (McCready et al., 2011):


Use of at least 6 of 10 feminine spoken language
characteristics two times each during a 5-minute conversation
over 3 consecutive sessions.
Sequence of activities





Knowledge about and observation of spoken language in men
and women (via handouts, published video samples, and
homework)
Modeled practice of two to three spoken language behaviors in
functional role plays per session
Practice of spoken language behaviors combined with
nonverbal behaviors
Combined practice of spoken language and nonverbal
behaviors with voice
Practice outside the clinical setting
 Prolonging
vowels
 Producing vowels with easy onsets
 Practicing specific phonemes and phoneme
combinations to achieve more precise
productions
 Practicing ―light‖ contact
 Using legato speaking style - Connecting
words to increase smoothness and reduce
glottal attacks
 Opening mouth wider and rounding lips more
 Women
typically have slower speech rate
 According to Mordaunt, females tend to
speak in short bursts, while males typically
speak at a steady pace (Norton as cited in Boonin).
 Focus in training of MtF clients:



Increasing frequency of pauses
Increasing length of pauses
Prolonging duration of vowels and continuants
Nooooo waaaayyy! Reeeaaally?! Absoluuuuutely!
Sena Crutchley
Richard Adler
Jack Pickering
Vicki McCready






Boonin, J. (2006). Articulation. In R.K. Adler, S. Hirsch, & M. Mordaunt (Eds.),
Voice and Communication Therapy for the Transgender/Transsexual Client A
Comprehensive Clinical Guide (pp. 225-236). San Diego: Plural Publishing.
Boonin, J. (2006). Rate and volume. In R.K. Adler, S. Hirsch, & M. Mordaunt
(Eds.), Voice and Communication Therapy for the Transgender/Transsexual
Client A Comprehensive Clinical Guide (pp. 237-252). San Diego: Plural
Publishing.
Davies, S. & Goldberg, J. (2006). Transgender speech
feminization/masculinization: Suggested guidelines for BC clinicians.
Retrieved January 27, 2008, from
http://www.vch.ca/transhealth/resources/library/tcpdocs/guidelinesspeech.pdf
Hannah, A., & Murachver, T. (1999). Gender and conversational style as
predictors of conversational behavior. Journal of Language and Social
Psychology, 19(2), 153-174.
Hirsch, S. (2006). Nonverbal communication: Assessment and training. In R.K.
Adler, S. Hirsch, & M. Mordaunt (Eds.), Voice and Communication Therapy for
the Transgender/Transsexual Client A Comprehensive Clinical Guide (pp. 317343). San Diego: Plural Publishing.
Hirsch, S. & Van Borsel, J. (2006). Nonverbal communication: A Multicultural
View. In R.K. Adler, S. Hirsch, & M. Mordaunt (Eds.), Voice and Communication
Therapy for the Transgender/Transsexual Client A Comprehensive Clinical
Guide (pp. 283-316). San Diego: Plural Publishing.





Hooper, C. (2006). Language: Syntax and semantics. In R.K. Adler,
S. Hirsch, & M. Mordaunt (Eds.), Voice and Communication
Therapy for the Transgender/Transsexual Client A Comprehensive
Clinical Guide (pp. 253-268). San Diego: Plural Publishing.
Hooper, C. & Hershberger, I. (2006). Language: Pragmatics and
discourse. In R.K. Adler, S. Hirsch, & M. Mordaunt (Eds.), Voice
and Communication Therapy for the Transgender/Transsexual
Client A Comprehensive Clinical Guide (pp. 269-282). San Diego:
Plural Publishing.
McCready, V., Campbell, M., Crutchley, S. & Edwards, C. (2011).
Doris: Becoming who you are: A voice and communication group
program for a male-to-female transgender client. In S. Chabon &
E. Cohn (Eds.), The Communication Disorders Casebook: Learning
by Example (pp. 518-532). Upper Saddle River, NJ: Pearson
Education, Inc.
Nelson, A. & Golant, S. K. (2004). You don’t say: Navigating
nonverbal communication between the sexes. New York:
Prentice-Hall.
Wood, J. T. (2009). Gendered lives (8th ed.). Boston: Wadsworth
Cengage Learning.