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For many transgender women assigned male at birth, voice can be a major source of gender dysphoria. Helping these women align the sound of their voice with their gender identity can be a big step towards gender affirmation. Michelle Adessa, BM, MS, CCC-SLP, joins from Cleveland Clinic's Voice Center to discuss voice modification techniques.

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Learning About Gender-Affirming Voice Modification Techniques

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 in our Head and Neck Institute. You can follow me on Twitter at @PaulCBryson, and you can get the latest updates from our Institute by following @CleClinicHNI. Today, I'm looking forward to talking with my friend and colleague, Michelle Adessa, a speech language pathologist who I've been working with in the Cleveland Clinic Voice Center for a number of years. Michelle, welcome to Head and Neck Innovations.

Michelle Adessa: Thanks so much for having me.

Paul Bryson: Well, let's start by having you share some background information to our listeners. Where you're from, where you trained, how you came to Cleveland Clinic and also your journey to becoming a speech language pathologist.

Michelle Adessa: Sure thing. I joined Cleveland Clinic in 2016 after doing my fellowship here in Cleveland. I trained at MGH Institute in Boston and I did my clinical training at the MGH Voice Center. My background prior to becoming a speech pathologist was in music. I was a classical singer. So I kind of came to the profession a bit late in life. So I started again and I retrained and now I specialize in voice, swallowing, and upper airway disorders.

Paul Bryson: Well, we're really lucky to have you and sort of the background and the empathy and the experience that you provide to your patients with your care is just fabulous.

Michelle Adessa: Thanks so much.

Paul Bryson: Oh, you're welcome. And as you might expect, our listeners on the podcast really specialize in a lot of different fields across medicine and surgery. Can you give, if possible, a general overview of the overall role of a speech language pathologist? And I'll educate the listener a little bit. Just as there's many specialties within medicine and surgery, I think what you'll be surprised about is the specialization within speech language pathology.

Michelle Adessa: That's right, Paul. So speech pathologists work in a wide variety of settings. So we work across educational settings and medical settings. So many people think of speech pathologists just working with children on articulation disorders. And a good portion of us do, about 60% of us. About 40% of us work in the medical professions. And so that includes skilled nursing facilities. That includes long term care facilities and also outpatient facilities, as well as inpatient.

Both of those services, we have here at Cleveland Clinic main campus. And so I work in the outpatient area. So speech pathologists work across such a broad range of communication disorders. The ones that we work most closely with in head and neck are voice, swallowing, upper airway. We also work with cognitive linguistic communication issues. Often we think of these after stroke or a traumatic brain injury. We also work with fluency, issues with stuttering.

We work with articulation problems in children and adults. So we actually kind of encompass a lot more variety than people may realize. And sometimes patients come in and they think, "Why am I seeing a speech pathologist?" if they're here for, let's say, chronic cough. And so we specialize in vocal chords. And so we do behavioral cough suppression therapy. So there's a lot of things that we do that patients don't even realize that are actually being serviced by a speech pathologist. So swallowing is probably the biggest one inpatient. So our inpatient speech pathologists are doing swallowing assessments to make sure that patients are swallowing safely while they're in house. And then we're seeing patients outpatient for speech and swallowing as well.

Paul Bryson: I also wanted to highlight some of the very important sort of pre-treatment and post-treatment work that speech language pathology performs as part of the team. We see such a broad range of patients undergoing surgery for benign conditions of the upper airway and vocal folds to patients getting complex, reconstructive surgery, radiation and chemotherapy for head and neck cancer. And partnering with our speech language pathologist is really critical for not only having the patients recover and hopefully meet their post-treatment functional potential, but even trying to identify opportunities before treatment begins to try to optimize patients as they embark on a treatment plan.

Michelle Adessa: We call that prehabilitation, to get patients ready for their course of treatment so we can exercise and make sure that their function doesn't decline with regard to speech, swallowing, breathing, all of the things that really connect us to being human. I think that's special about what we do.

Paul Bryson: Well, I appreciate the diversity of patients that we treat and I wanted to spend some time today highlighting our work with gender affirming voice care. For many transgender women assigned male at birth, voice can be a major source of gender dysphoria. Helping these women align the sound of their voice with their gender identity can be a major step towards gender affirmation and really a part of the journey.

Can you share some of the insight into the work that we do here and also a recent study you were a part of to identify the most effective therapies and strategies for these patients who come to our voice center as part of our broader transgender care team here.

Michelle Adessa: Sure. There's lots of things to dive into there. So the first thing I would say is we're lucky here at Cleveland Clinic to provide really comprehensive gender affirming care. We work in partnership with our transgender surgical medicine group and our surgical group, so we have a nice alliance of providers to provide to our LGBTQ community, specifically our trans community.

So patients coming here can be directed by a patient navigator. And so we have a nice alliance of providers. So patients who come to see us often meet with myself and one of my partners, Emma Laurash. She and I provide gender affirming voice care and voice training. We also have a surgical voice component, which you're providing. And then we have the other specialists and surgical providers who are also part of this care team. So, luckily, we're really grateful to have this team of people so we can provide really comprehensive support.

So what does it mean for someone to come in and seek gender affirming care? So for our transgender women, specifically, that we looked at in this study, so we really decided to do this work, to provide this care and we, personally, I really wanted to make sure that we were providing the best high-quality care for our patients. So kind of looking at what are the outcomes in terms of using gender affirming voice therapy alone, or gender affirming voice therapy and surgical intervention?

And so patients come in and they have specific goals about their voice. The care is really patient driven, so we're working on a variety of things, variety of components of the voice, I should say. So the first thing we think of, of course, is if a person's voice is being feminized, that maybe that the pitch is raised higher than their baseline.

Well, certainly that's a component of it, but there's a broad envelope of other things that we work on in voice training. And so we work on resonance, which is how the throat shapes the sound. We work on articulation, so how the articulators, the lips, the tongue and the teeth, shape each sound of English. We work on speech rate, how fast or slow somebody speaks. Parsing out phrasing. Where can they breathe to make the voice sound more feminine? And so I would also see that there's a lot of variability with goals. Some patients want some flexibility. They want to be able to have increased pitch, more feminine sounding voice, but they may also still want flexibility, depending on what their communication goals are.

So we work together to their personal goal and that is very different for each patient. And so in the study that we looked at most recently, we did a retrospective study of about 16 patients who received care here. We looked at whether patients receiving voice therapy only, or surgical intervention plus voice therapy, had any difference in their outcomes. And I would say my disclaimer about this is that the outcomes we chose may be limiting in the sense that we're not capturing their full experience. So we used two outcomes.

The first was increase in speaking fundamental frequency. And the second is a quality of life measure. It's called the trans woman voice questionnaire that was given at the initial visit and then after, at the discharge. So we looked at the scores on that and compared them pre and post. And very interestingly, we didn't necessarily see a statistical difference in whether somebody had voice therapy only or voice therapy plus surgery. So how that may translate clinically is that I think that the patients are really the ones driving the treatment plan. We're here to guide them, but if they want to have surgery or they only want to have therapy because surgery is just not something that they're particularly interested in for their voice, they can have equal success, at least based on those variables.

I would say those variables are pretty finite and people's total communication is very diverse. So I think, as we look ahead to continuing this work and providing better quality care, it's going to be how do the patients define their success in voice therapy? That's what I'm really interested in finding out. So I think some qualitative work on how do patients best define what is success for them? I think they're reassured when they hear that they can go either path because sometimes it doesn't work out that they're able to do multiple sessions of therapy.

And I'm going to answer a question that you haven't asked me yet, which is a lot of patients ask me, "Well, how long is it going to take me to get the voice that I really want?" And I say, "I don't know", which is maybe a bad answer. I see patients for any number of sessions of therapy that it takes them to reach their goals. That can be three sessions. That can be 10 sessions. That was the average number of sessions that patients had in our study. Or it could be 26 sessions or even more. So I don't think it's prescriptive. I think it's super individualized and very much driven by the patient's experience and where they want to go with their voice.

Paul Bryson: Would you say that's the most surprising thing that you found is sort of the heterogeneity of the patients in this journey?

Michelle Adessa: Yeah, I think it was interesting for me to see that kind of in an objective way in the data. Because, in some of the literature, we look at the surgical data and some of those studies only had patients doing, let's say, three sessions of voice therapy. So what I think is interesting about what we found is that the only thing that was correlated with a greater increase in speaking fundamental frequency was a greater number of voice therapy sessions.

So there may be a ceiling in terms of how much pitch elevation you can get from, let's say, a Wendler glottoplasty, which is one of the surgeries that you do for voice feminization. And I also think if we're talking about doing this work, if we're just talking about voice feminization only, there is another component where we have a lot of patients who may be non-binary, who want to work on their voice and it's not so much about sounding very female.

It may be sounding different. And for them, they have to figure out how they want to sound different. So that's part of the journey as well. I think what's really interesting about doing this work is I get to know people very well. And so it's really an honor to work with them and serve this population. So I feel really grateful to be part of their journey, such hardworking patients who come to the sessions, really invested and prepared in their work. So it's so vital to them. And so it's a real honor to work with them. There's so many discoveries that patients make along the way. And the longer that I do this work, it helps me ask better research questions and hopefully serve them better.

Paul Bryson: As you look at the field and in this sort of area of the specialty, what are some research opportunities? What are some things that you're interested in or have become interested in as you've done this work?

Michelle Adessa: So a couple of things have come up. I think the first is what I just already mentioned is kind of finding out from patients their more qualitative experience with their journey, and also maybe how that looks in terms of a transition across specialties. So we think about patients who may be receiving multiple procedures. At what time point do they have those procedures and what part of their gender affirmation process is voice part of that? Is it starting from the beginning? Is it the first thing?

There's no right answer with that. I think it's interesting to find out their journey and I would love to do some more qualitative interviews with patients to develop some better tools for our field to help guide our practice so that we can be as all-inclusive as possible in terms of the communication training that we're providing. So sometimes we even work on things like nonverbal communication.

We work on word choice, things like that. So those things may be surprising to our listeners. How people move their face or move their hands or how they move across a room, all of those things can be really meaningful for communication. And we sometimes work on those. Sometimes patients don't want to work on those or they already turned the page on that. So I think also for our transmasculine patients, we didn't look at them in this particular study, and our non-binary patients, but I do see some patients training for transmasculine voice as well. So that's something also I would love to look more at with our research. Certainly, we're not as big of a place as New York or San Francisco, let's say, but I think we have quite a robust program here to offer northeast Ohio.

Paul Bryson: Yeah, no, I would agree. It's been a real privilege to be part of a larger multispecialty team. And I agree with you. It seems like we learn constantly and we try to really create an individualized experience for patients as we're part of the journey, as we say.

Michelle Adessa: Well, the other thing I think that's important to identify is that a lot of the people who are doing my job are cisgender white women. So when we look at the field of speech pathology, we don't see the largest group of most diverse care providers. So I think my hope for our field is, in general, we become more diverse. And as we become more diverse, I think that can only improve our patient care. So I think, as we have some trans women and men themselves providing this care, I think that would provide additional insight for patients. And I think that that could be really valuable for patients.

Paul Bryson: I mean, it would be a whole other level of empathy sort of brought to bear, brought to the table for treatment.

Michelle Adessa: Yeah.

Paul Bryson: Well, I just wanted to thank you for your time today. And as we kind of wind down this installment of Head and Neck Innovations, any take home messages for our listeners? Can be anything really. Can be about our voice affirming care program or your practice in general.

Michelle Adessa: Sure. One thing I deal with on a daily basis, working with people and their voices, is how important your inner voice is. And so in work with gender affirming care, but also in my work in general, just as a voice pathologist, your inner voice and your outer voice are connected. And when that connection is not working smoothly, whether the signal, it sounds rough or hoarse, or that it doesn't sound light or maybe it doesn't sound dark, or whatever it is that is not pleasing to you, or it doesn't feel good when you use your voice, whatever that connection is between the inner self and the expression, that is the work that we do here.

And I think that no matter what, the training that I'm providing, I think it's always about providing the most easy connection, the most ease and the most comfort when somebody uses their voice, that it's pleasing, it makes them happy to hear their voice and that they can communicate freely. So I think that's the work and that the take home message is that inner voice and that outer voice need to be connected in a really strong way in order for the person to be happy.

Paul Bryson: Well, I so appreciate that. You've said that so eloquently, I get to see it every day and know you bring so much passion. The team brings so much passion to trying to help bridge that gap or have that synergy between the inner and the outer voice.

Michelle Adessa: Yeah. And when that's blocked, patients feel really frustrated, no matter what the reason. And I think a lot of the work we do in the Voice Clinic is listening with empathy. I mean, our job is to make the voice clear and strong, easily produced, but it's also validating for patients to be able to express their frustrations with their voice in a safe place. And I think that we hopefully do that here. I think we do, and we're always continuing to improve that.

But I think that's the biggest take home message. And I think we all experience frustrations with our communication and we can't express ourselves clearly. Sometimes that's in the written word, sometimes that's when we're talking. So I think we don't focus on the written word, but we do focus on the signal, the sound of the voice and also the content of what we're saying. And so speech pathologists work with both of those things and laryngologists as well.

Paul Bryson: Well, thanks, Michelle.

Michelle Adessa: Yeah.

Paul Bryson: To learn more about Cleveland Clinic's Voice Center, please visit ClevelandClinic.org/Voice. That's ClevelandClinic.org/Voice. And to speak with a specialist or submit a referral to our Head and Neck Institute, please call 216.444.8500. That's 216.444.8500. Michelle, thanks for joining Head and Neck Innovations.

Michelle Adessa: Thank you so much.

Paul Bryson:

Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website at clevelandclinic.org/podcasts, or you can subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. Don't forget, you can access realtime updates from Cleveland Clinic Head and Neck Institute experts on our consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.

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Head and Neck Innovations

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.
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