Innovations in Gender-Affirming Voice Care

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology - head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on X, formerly Twitter, @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following @CleClinicHNI on X. That's @CleClinicHNI. You can also find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology.

Today I'm joined by my colleague Bethany Beckham, a speech-language pathologist in our Voice Center. Bethany, welcome to the Head and Neck Innovations podcast.

Bethany Beckham: Thank you.

Paul Bryson: Well, as a new guest on the podcast, let's start by having you share some background on yourself, where you're from, where you trained, and how you came to Cleveland Clinic.

Bethany Beckham: Sure. So I was born and raised in Memphis, Tennessee. I was raised in a very voice-centric singing, music-centric family. I grew up doing that. And then as part of my speech pathology training, I did actually two clinical fellowships. So I did the first in inpatient rehab in Des Moines, Iowa where I met my spouse, and then I moved to Nashville, Tennessee where I did a second voice-centered clinical fellowship at Vanderbilt Voice Center, and got a lot of training with singing voice, and gender affirming voice, and just all of the voice world there. And then I came to Cleveland Clinic for this job. And I have to say I was a little bit swayed to come here by someone who I trained with while I was at the Vanderbilt Voice Center, Dr. Will Tierney, who is one of our colleagues, one of the other laryngologists at the Cleveland Clinic Voice Center. We had the pleasure of doing our fellowships at the same time at Vanderbilt. And so he finished up a little before me and was a big part of the reason that I came and got this job.

Paul Bryson: Well, he's definitely a good ambassador for our program. He's a great guy. He's a friend of the podcast and been just great to have as part of the team. So we're grateful to him and grateful that it brought you here to us here in Cleveland. And it's really been great to have you as part of the team and lending your expertise for so much of what we're doing here.

I wanted to highlight a couple of things and congratulate you on your recent participation at the Fall Voice Conference. For those that are listening, this has really become one of the larger specialized voice conferences in the United States and really even has a flavor of an international meeting. At this point, I wanted to highlight a presentation that you gave on gender-affirming voice care. Can you give the listener just some background on the presentation and maybe some of the highlights from the work that you presented?

Bethany Beckham: Yeah, absolutely. So I mean, I have to start off by crediting my speech pathology colleague Michelle Adessa, who really was the brains behind this original research. She did the original dataset where she looked at trans women's outcomes for surgery versus therapy, versus therapy plus surgery, just in terms of what increases in pitch are they getting pre and post-treatment, and then also what does their quality of life look like? So we have a questionnaire that has been standardized that we used to measure that. And so the original work that she did was from 2017 to 2019, looking at women that came through the Voice Center. And at that time retrospectively there were 16 women.

And so 2019 is a while ago. And so we had the question earlier this year, of is this probably the fastest growing group that we see as speech pathologists and laryngologists at the Voice Center. So how many women have we treated at this point and how do the outcomes look different now than they may have from that original study? So I started on that work including the original dataset, and we came out with over 150 trans women, which is a significant jump. And so I analyzed the data of about 90 trans women after applying exclusionary criteria. And interestingly, but maybe not so interestingly, it showed that therapy, and therapy plus surgery, and surgery only all had statistically significant outcomes in terms of pitch increase. And we didn't have enough data for the surgery only group for the questionnaires. That's something that we hope to look at in the future, but for the therapy and therapy plus surgery group also showed that there was a significant quality of life increase after those treatments as well.

And so I really think that just shows that patient preference is so important in this. If a patient comes to you and they're particularly interested in one type of treatment, it's our job to support them in that and guide them through that. And also now though, this gives us a little something up our sleeve for when they want that medical guidance, is this going to be effective? Because obviously that's big, that tells us a lot about patient compliance as well.

Paul Bryson: Yeah, it's a really nice study, congrats on it. It's a really nice opportunity for us to provide education and outcomes and have just a very transparent conversation with people about what they might expect and what we've seen in our group to date. I think it's a powerful tool for patients so they understand what the options are, they understand what the outcomes have been and how things might look for them. So yeah, it's really great. And I think as a corollary to that, just in your own experience, it sounds like you're right. I think we all kind of are aligned on meeting people where they are. We try to customize care certainly. But what are some of the most effective strategies for people that practice gender-affirming voice care? What do you do and what have you observed over time?

Bethany Beckham: That's such a hard question because every single person that comes to see me has a little bit of a different goal. And that's something that we spend a lot of time, particularly in our first session in our evaluation discussing. And so what we've seen a lot with the gender affirming voice care population, not only trans women, I know that's what this research set was on, but also trans men, non-binary folks, gender queer folks, we really see them across the board and they obviously have a lot of different goals. And one of the things that we've seen with this population is that it is definitely in the minority for them to come in with absolutely no knowledge or research of these things, even if it's just that they've watched some videos on YouTube and came away saying, I'm a little bit more confused about this after watching it, and I really think that I would like a professional here.

Some people have done a voice surgery before they see us, some people have done voice therapy elsewhere before they see us, or worked with a voice coach or done work with friends on Discord or Reddit. There's so many resources now. And so I think discussing that with the patient is very important in figuring out where they want to start because there's not a one size fits all recipe for this. Some people are very concerned about it, and for very good reasons. Their primary goal is safety and being identified as cisgender by people that are in their group or at their workplace or things like that. And so we may choose to say, oh, well, we need to start with pitch with you for that reason, just for safety reasons. Or sometimes they might not be as concerned about pitch and they want to focus more on the weight of their voice, how heavy or how light does it come off the forward resonance versus the darker resonance or even nonverbal cues or the language that they're choosing. There are so many different outcomes and tools in your toolbox that go in to make a voice sound feminine or masculine or androgynous. And so I think for me and my colleagues as speech pathologists, it's really listening to the patient and giving them the tools that we have. And then session to session, just kind of molding that, figuring out do we want it to be 20% that we focus on this and 5% that we focus on this? And it really is just about creating their specific recipe.

Paul Bryson: I mean, it probably takes a little bit of time to get to know people and it requires a lot of listening and empathy and understanding. So I could imagine that where you start may not be totally where you end and you might learn stuff as you go along. That changes the recipe a little bit.

Bethany Beckham: Yeah, absolutely. I think it's really important that patients feel comfortable with me and with themselves between practice sessions when they can try on these new voices, even if it's just doing a certain accent or something that feels very out of the realm, can sometimes get you to notice things about a voice that you might like more. And I always tell patients, you're not married to this voice that you're doing in here in this moment. And if you could try on this one thing and then we can talk about what do you like or what do you not like about it? There are definitely people that I've learned from, and some titans in the gender-affirming voice field that I've learned a lot of things from, one of them being what I believe Sandy Hirsh, Christie Block, and Leah Helou call “voice drafts,” where basically if patients are comfortable with it, we will have them record a voice draft that could be a phrase, or a sentence, or however long the time that we're working on isn't what they feel comfortable with.

And then we listen back to it and I let them pick one thing that they like or dislike. And that way, first of all, it is limiting this of feeling super overwhelming. It's like we're not talking about your voice as a whole. We're talking about this one moment in time. What is one thing that you like or one thing that you dislike about your voice? And I think that takes some of the pressure off them. And then the other part of it is, and this is not just a gender-affirming patient care thing, this is all patients that I see for voice therapy, and I know we've probably known this too. It is so different to hear your voice back than it is what you hear in your own head. There's definitely that cognitive dissonance. And so sometimes being able to listen back to that voice, they're like, oh, this sounds a lot more feminine, or a lot more masculine or a lot more androgynous than I thought it did in my head. And so that can be a conversation to have too. It's like, well, what if we're hearing back is more of what other people are hearing? And being able to adjust that too has been a really helpful tool that I found.

Paul Bryson: Yeah, that's great. I mean, it's really clever and it utilizes the technology that a lot of us possess. So I like the idea of drafts and probably using things on the smartphone and the concept of we're seeing people just for a moment in time during the day, but we're not catching people maybe in the work environment when they could record a draft or maybe even in a social or casual environment where a draft could be taken. So that's really clever and I think it really gives you insight into what the day-to-day might look like for folks.

Bethany Beckham: Yeah, absolutely.

Paul Bryson: Yeah, this is great. I really appreciate you coming on. Any other new treatments or strategies like you shared that you wanted to highlight or anything?

Bethany Beckham: I think that there's always new ways of looking at treatment. For me personally, I always enjoy when I can go to a conference like Fall Voice and hear people from other centers who are doing more research, innovative techniques, and also just they do some of these roleplay things where they have a patient come up on the stage and have a clinician up and just seeing how other people operate, even if it's not a new technique or treatment. It's just something that maybe I haven't thought of in a while or haven't thought of reframing it in that way.

I think as far as innovations, I love seeing AI, it is very interesting for a lot of different reasons, and I enjoy seeing it in the context of speech pathology and laryngology, particularly as it can make patients more comfortable. Last year we saw something with patients being more comfortable in the OR when they can have an Oculus or something like that, like a virtual reality for the surgeries that they have to be awake for in the or just to make them more comfortable during it. There's all sorts of things that I am excited to see in coming years too, if we can include technology in terms of increasing patient comfort and satisfaction and buy-in as well.

Paul Bryson: Yeah, that's great. I mean, it is a little rejuvenating to be able to get out of town for a little bit and be with some like-minded folks. I'm glad that you find value in that. It does sort add to the creative juices hopefully when you return home. So I feel like all of us on the team really try to do a good job about customizing care for patients, whether it's our gender-affirming population, or teachers that are getting vocally beat up at school, or I feel like we try our best to kind of meet people where they are and come up with practical solutions. Often that doesn’t involve surgery, sometimes involves medical management or other therapeutic strategies. So I think that's a really cool thing about our team. Sometimes you have strategies that I certainly don't think of, or you have awareness of technologies that are really supportive or different that make a big difference for patients. And so when I think about take homes and things, the thing that I really like about our center is that I don't think any of us are so dogmatic that we can't be open to finding things that are going to maybe work for people.

Bethany Beckham: Yeah, I think that's really the importance of, I love the environment that we work in and the fact that we have such an interdisciplinary clinic. I may work with you guys 1.5 days a week in a joint clinic, which that in and of itself is great, but I also love the fact that we are always there for each other no matter which location we're at, whether you guys are in surgery or in another clinic, I think it really is the best that it could possibly be for patient outcomes because a patient may see you once and then see me for some therapy and then see you back after, but the patients don't always see what's going on behind the scenes and the fact that we are constantly in communication with each other to better their experience and to get things moved around and things like that. We really just am so grateful to be a part of what a wonderful team it is.

Paul Bryson: Well, it's good to hear and it's great to have you as a part of the team, and it's great to have you on the pod, so I'm sure it's the first of hopefully a few more appearances for you.

Well, thanks for coming and for the listener, for more information on Voice Services at Cleveland Clinic, please visit ClevelandClinic.org/Voice, that's ClevelandClinic.org/Voice, and to connect directly with a specialist or to submit a referral, call 216.444.8500. That's 216.444.8500.

Bethany, thanks for joining Head and Neck Innovations.

Bethany Beckham: Thanks for having me.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website clevelandclinic.org/podcasts. Or you can subscribe to the podcast on iTunes, Google Play, Spotify, BuzzSprout, or wherever you listen to podcasts. Don't forget, you can access realtime updates from Cleveland Clinic experts in otolaryngology – head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.