Transgender voice therapy

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"Voice therapy" or "voice training" refers to any non-surgical technique used to improve or modify the human voice. [1] [2] Because voice is a social cue to a person's sex and gender, [3] transgender people may frequently undertake voice training or therapy as a part of gender transitioning in order to make their voices sound more typical of their gender, and therefore increase their likelihood of being perceived as that gender. Having voice and speech characteristics align with one's gender identity is often important to transgender individuals, whether their goal be feminization, neutralization or masculinization. [4] Voice therapy can be seen as an act of gender- and identity-affirming care, in order to reduce gender dysphoria and gender incongruence, improve the self-reported wellbeing and health of transgender people, and alleviate concerns over an individual being recognized as transgender. [3]

Contents

Voice feminization

Voice feminization refers to the perception of voice change from masculine to feminine. It is considered an essential part of care for transfeminine people. [4] Transfeminines trying to feminize their voice represent the largest group seeking speech therapy services, therefore, most studies regarding transgender voice have focused on voice feminization, as opposed to voice masculinization. [5]

Therapy has been shown to be effective in voice feminization, and the modification of certain voice characteristics, such as fundamental frequency, vocal weight and voice resonance, can help in that effect. Fundamental frequency, closely related to pitch, was initially thought to be the characteristic most effective in voice feminization. Raising the fundamental frequency can help towards voice feminization. However, each person might have different perspectives regarding speech and voice, and therefore the salient characteristics, and their relative impact on femininity, can vary from person to person, and many people are not satisfied with only a change in fundamental frequency. [6]

What is considered a feminine or a masculine voice varies depending on age, region, and cultural norms. [5] The changes with the greatest effects towards feminization, based on current evidence, are fundamental frequency, vocal weight and voice resonance. Other characteristics that have been explored include intonation patterns, loudness, speech rate, speech-sound articulation and duration. [5]

Voice masculinization

Voice modifications for transgender men typically involve the lowering of the speaking fundamental frequency. [4] Voice therapy is generally not required for transgender men as the effects of testosterone on the larynx result in a deeper pitch. [7] However, testosterone replacement therapy does not always deepen the voice to the person's desired level, and others choose to not undergo masculinizing hormone therapy at all. [4] Voice masculinization therapy can help to further lower the pitch of transgender men and address voice problems associated with hormone therapy. [4]

In testosterone replacement therapy vocal folds change faster than larynx. [8] Overdevelopment of vocal folds in an undescended, small larynx can result in a condition named "entrapped vocality" with permanent hoarseness, and lack of passing. [8] Larynx length can be controlled via exercise, making lowering the larynx a useful tool for transgender men in obtaining a passing voice. [9] Other areas that transgender men may benefit from training are embouchure and maintaining high CQ (closed quotient, a quotient of how long the vocal folds are touching to how long the cycle of vibration lasts), responsible for "heavy" or "buzzy" voice quality. [9]

A speech-language pathologist (SLP) may be involved in aiding transmaculine people to achieve their desired voice goals, while usually prioritizing the overall health of the voice. [10] Therapy techniques may involve finding a person's most comfortable pitch range, using breath support and relaxation exercises, introducing voice strengthening warm-ups, stabilizing posture and increasing chest resonance. [10]

Another option for transgender men who wish to further lower their speaking pitch is to undergo vocal surgery. [10]

Gender perception in voice

In the case of AI vocal gender identification examples, key features noted to effect gender perception included fundamental frequency and formant frequency as well as further source related measures including cepstral peak prominence (a rough measure of harmonicity in voice with low values indicating a higher likelihood of dysphonia) and rolloff in energy between the first and second harmonics. [11] [12] A 2020 study in the International Journal of General Medicine noted other factors being involved in gender perception, saying: "a minimum F0 value of 180 Hz required for a voice to be perceived as feminine". [13]

Modifying gender presentation of voice on a selection of vowels including a, i, e and o.

Vocal gender presentation can be assigned by speakers even as things like fundamental frequency stay the same, especially where we see formant frequencies changing, which is noted as important for gender presentation alongside fundamental frequency. [14]

Vocal surgeries

While hormone replacement therapy (HRT) and gender reassignment surgery can cause a more feminine outward appearance for transgender women, they typically do nothing to alter the pitch of an adult voice or to make the voice sound more feminine, [15] unless HRT is started immediately after puberty blockers during teenage years. The existing vocal structure can be surgically altered to raise vocal pitch by shortening the vocal folds, decreasing the whole mass of the folds, or by increasing the tension of the folds. [5] Transgender women can undergo surgery to raise their vocal pitch as measured by fundamental frequency (F0), to increase their pitch range and to remove access to lower frequency ranges in their voice. [5] The current pitch-raising vocal surgeries can be split-up into several categories:

Additionally, some other procedures are currently being employed in an attempt to provide the patient a more feminine resonance, or timbre, in their voice. These include Thyrohyoid Elevation (commonly performed as part of Feminization Laryngoplasty), which raises the larynx in the neck, and Pharyngeal Narrowing, which removes a strip of tissue from the back of the mouth in order to reduce the size of the pharyngeal resonance cavity. [24]

Usually, transgender women consider vocal surgery when they feel dissatisfied with voice therapy results, or when they want a more authentic sounding feminine voice. However, vocal surgery alone may not produce a voice that sounds completely feminine, and voice therapy may still be needed. [25] Although there has been evidence to show that all these surgeries can be effective in increasing vocal pitch as measured by F0, results have been mixed. [15] However, many patients do report being satisfied with the results. [15] Negative effects from these surgeries have been noted, including reduced voice quality, reduced vocal loudness, negative effects on swallowing and/or breathing, sore throat, infections and scarring. A positive effect of surgery can be protecting the voice from damage due to the strain of constantly elevating pitch while speaking. Because of the risks, vocal surgery is often considered a last resort after vocal therapy has been pursued. [5]

As for transgender men, it is generally presumed that hormone therapy does successfully masculinize the voice and lower vocal pitch. [26] However, this may not be the case for all transgender men. Although it is far less common, surgery to lower vocal pitch does exist and may be considered if traditional hormone therapy did not adequately lower it. Medialization laryngoplasty (or masculinization laryngoplasty) is a procedure where the vocal fold contours are medially augmented with the injection of silastic implants. This mimics the changes that the vocal folds non-transgender men go through during puberty, which causes a lower sounding voice. [27]

Therapeutic techniques

Therapy may take place in an individual or group setting. The most common focus in transgender voice therapy is pitch raising or lowering; however, other gender markers may be more important for an individual to work on. [5] Clients and clinicians should discuss goals of therapy to ensure that they are working together toward the voice that most fits the person's gender identity. [4]

In a review of speech literature, Davies and Goldberg (2006) were unable to find any clear protocols for transgender men's voice therapy. Based on the protocols they found for treating transgender women's voices, they proposed the following therapeutic techniques for both voice feminization and masculinization: [4]

While there is some evidence for the effectiveness of voice therapy for transgender people, it is still weak. In a 2012 review by Oates (as referenced in Davies, Papp, and Antoni, 2015) of the literature on transgender voice therapy, 83% of studies were found to be at the lowest level of the evidence hierarchy for evidence-based practice, and the remaining 17% were also at low levels. [5] However, research does show that transgender people who have had voice therapy have high satisfaction with the results, and there is a strong consensus among speech-language pathologists (SLPs) as to what are strong markers of speaker gender in voice. [5]

Raising pitch

The most common concern for transgender women is their pitch and speaking fundamental frequency (SFF) (the average frequency produced in a connected speech sample) because they typically perceive a feminine voice as using a higher pitch. Although pitch is not the most essential element of voice change for these individuals, it is necessary to raise the SFF to a gender-appropriate pitch to help with vocal feminization. [10] A speech-language pathologist will work with the individual to raise their pitch and provide therapeutic exercises.

The first step in therapy is determining the habitual speaking fundamental frequency of the individual using an acoustic analyzing program. This is accomplished through several tasks including sustained phonation of the vowels [ i ], [ a ] and [ u ], reading a standardized passage and producing a spontaneous speech sample. Then the therapist and the individual determine what the target pitch should be, based on the gender acceptable range for cis women (i.e. a socially acceptable pitch based on the average woman's vocal pitch range). When therapy begins, they establish a starting frequency to work on, that is slightly above the individual's SFF. [10] The point is to choose a starting pitch that can be produced without strain or excessive vocal effort. [5] As therapy progresses, the target SFF will gradually increase until the goal has been reached. Progression moves from using the target pitch in a sustained vowel to using it in a 2-5 minute conversation. [10]

Semi-occluded vocal tract (SOVT) techniques may be used to facilitate voice production in the higher pitch range. SOVT techniques include phonating into straws, lip or tongue trilling, and producing multiple speech sounds such as nasals (e.g., [ m ] and [ n ]), voiced fricatives (e.g., [ z ] and [ v ]), and high vowels (e.g., [u] and [i]). There are two exercises that are often used: producing a pitch glide that goes from the middle of the pitch range to the upper pitch range; and a messa di voce exercise, where the voice goes from soft to loud to soft again. SOVT techniques have the individual prolong their voice at a higher pitch, which may help make voice production at a higher, non-habitual pitch easier and more efficient. [5]

Pitch can also be altered through voice resonance modification. The length of the vocal tract affects the resonance of the vocal tract, which in turn affects the pitch. Cis men tend to have vocal tracts that are 10-20% larger than those of cis women, and therefore cis men have a lower vocal tract resonance, and a lower pitch, than cis women. Modifying the length of a vocal tract results in a change in resonance and in pitch, as can be shown by pronouncing a prolonged [ s ] while protruding and retracting the lips. Transgender women can use techniques, such as retracting the lips, to shorten the vocal tract and sound more feminine. [28]

Lowering pitch

A lack of training on how to use their new voice may cause some transgender men to have increased muscle tension. [10] Therefore, a speech-language pathologist can give individuals vocal exercises to help find their optimal speaking pitch and maintain overall vocal health. [10] Adler, Hirsch, & Mordaunt (2012), describe the following therapy techniques for transgender men:

Non-verbal communication

Non-verbal communication may have more of an effect on a transgender person's readability than verbal factors such as pitch or resonance. [10] Regardless of what is most effective, congruency between a person's visual and auditory gender presentation contributes greatly to their perceived authenticity. [10] Non-verbal communication includes posture, gesture, movement, and facial expressions. [4] In a discussion of the differences between masculine and feminine non-verbal behaviour, Hirsch and Boonin (2012) describe feminine communication as generally more fluid and continuous. Examples of feminine non-verbal communication behaviours include more smiling, expressive and open facial expression, more side-to-side head movement, and more expressive finger movements than men. [10] Deborah Tannen's book, You Just Don't Understand (1990), is referred to by the authors as a seminal work on the difference in men and women's non-verbal communication. [10]

Within the speech therapy context, non-verbal communication may be targeted through the encouragement of focused observation, offering feedback on the client's self-defined non-verbal goals, offering information about the differences between men and women's non-verbal communication, and/or referring to peer support or expert services. [4]

Psychosocial factors

While some specific psychosocial issues faced by transgender people are often addressed through psychotherapy, there are psychosocial factors that can influence transgender voice therapy. For example, some clients feel that hormone therapy for transitioning changes concentration and emotional stability, which could affect receptiveness to speech therapy. [4] Davies and Goldberg (2006) also note that an altered voice may feel inauthentic, and it may take time for the client to feel as if their new voice is an expression of their true self. [4]

Transgender erasure describes systematic, individual, or organizational discrimination against transgender people. [29] Informational erasure and institutional erasure were identified in a 2009 Canadian study of health care for transgender people as being the most prominent barriers to care. [29] Informational erasure involves a lack of knowledge, or a perceived lack of knowledge, about transgender health care. This may manifest itself in health care providers being more reluctant to treat transgender clients because of an unwillingness to find information about their specific population. [29] Institutional erasure describes policies that do not accommodate transgender identities or bodies. For example, forms, texts, or prescriptions may refer to a person by an inappropriate name or pronoun. [29] Issues of erasure may hinder a transgender person's ability to find speech therapy services, or may affect the person's comfort with speech therapy.

In addition to paying attention to problems of erasure, Adler and Christianson (2012) suggest that a clinician should be sensitive to the following areas when working with a transgender client: [10]

The authors note that this is not an exhaustive list of possible psychosocial factors and that every client is different. Psychosocial factors such as these may affect a transgender client's progress and prognosis in speech therapy.

Transition in childhood and adolescence

Few studies have considered the potential repercussions of age on therapy. Currently, there is no consensus regarding speech therapy for adolescents. [30] During adolescence, there is an increase of both vocal tract size and vocal fold length, especially for those assigned male at birth, which affects the voice and pitch. Because of these physical changes and hormonal changes, it is difficult to focus on pitch. [31] Previous studies have shown that therapy shaped from adult therapy can be effective. [31]

Transition in aging populations

Few studies have looked into the transition in the elderly. A survey has shown that many elderly members of the LGBT community do not disclose their LGBT status to their clinicians, including members that receive speech therapy; they choose not to disclose this information because they are afraid it would negatively affect their access to services. [32]

Controversy

There are two major areas of controversy for professionals working on the voices of transgender people. The first is regarding vocal surgery, and the second is regarding genderfluid and bigender voice therapy.

Professional opinion is mixed regarding the use of vocal surgery. [5] There is currently a lack of outcome data, particularly longitudinal data, for pitch-elevating surgery, and outcomes have not been well-monitored over time. [4] Because of this, some SLPs do not think that phonosurgery is a viable treatment option. [4] [5] Others believe it is, and still others believe it should be considered only as a "last resort" after the desired pitch change has not been seen in therapy. [4] Critics cite variability in outcome, lack of outcome data, and reported negative effects like compromised voice quality, decreased vocal loudness, adverse impact on swallowing/breathing, sore throat, wound infection, and scarring as reasons to avoid vocal surgery. [5] Proponents argue that surgery may protect a person's voice from damage caused by repetitive strain to elevate pitch in therapy. [5] Ultimately, the decision to undergo surgery is up to the patient, with input from a knowledgeable physician and SLP.

There is also some controversy regarding the use of a genderfluid voice. A person may want to have both a masculine and a feminine voice in their vocal repertoire, possibly to fit with their own genderfluid identity, or to read as a different gender in different contexts. [5] Some clinicians will not train genderfluid voice, arguing that it decreases the opportunity for practice, and it may be difficult or even damaging to the vocal folds for the person to switch from one voice to another. However, Davies, Papp and Antoni (2015) reference the ability of actors to use different accents and dialects, and people to learn different languages as a sign that training a genderfluid voice may be a viable treatment goal. [5]

See also

Related Research Articles

<span class="mw-page-title-main">Vocal cords</span> Folds of throat tissues that help to create sounds through vocalization

In humans, the vocal cords, also known as vocal folds, are folds of throat tissues that are key in creating sounds through vocalization. The length of the vocal cords affects the pitch of voice, similar to a violin string. Open when breathing and vibrating for speech or singing, the folds are controlled via the recurrent laryngeal branch of the vagus nerve. They are composed of twin infoldings of mucous membrane stretched horizontally, from back to front, across the larynx. They vibrate, modulating the flow of air being expelled from the lungs during phonation.

<span class="mw-page-title-main">Human voice</span> Sound made by a human being using the vocal tract

The human voice consists of sound made by a human being using the vocal tract, including talking, singing, laughing, crying, screaming, shouting, humming or yelling. The human voice frequency is specifically a part of human sound production in which the vocal folds are the primary sound source.

Vocal cord nodules are bilaterally symmetrical benign white masses that form at the midpoint of the vocal folds. Although diagnosis involves a physical examination of the head and neck, as well as perceptual voice measures, visualization of the vocal nodules via laryngeal endoscopy remains the primary diagnostic method. Vocal fold nodules interfere with the vibratory characteristics of the vocal folds by increasing the mass of the vocal folds and changing the configuration of the vocal fold closure pattern. Due to these changes, the quality of the voice may be affected. As such, the major perceptual signs of vocal fold nodules include vocal hoarseness and breathiness. Other common symptoms include vocal fatigue, soreness or pain lateral to the larynx, and reduced frequency and intensity range. Airflow levels during speech may also be increased. Vocal fold nodules are thought to be the result of vocal fold tissue trauma caused by excessive mechanical stress, including repeated or chronic vocal overuse, abuse, or misuse. Predisposing factors include profession, gender, dehydration, respiratory infection, and other inflammatory factors.

Vocal fold cysts are benign masses of the membranous vocal folds. These cysts are enclosed, sac-like structures that are typically of a yellow or white colour. They occur unilaterally on the midpoint of the medial edge of the vocal folds. They can also form on the upper/superior, surface of the vocal folds. There are two types of vocal fold cysts:

  1. Sub-epithelial vocal fold cysts- located in the superficial lamina propria of the vocal folds.
  2. Ligament vocal fold cysts- located within the deeper layers of the lamina propria or on the vocal ligament.
<span class="mw-page-title-main">Reinke's edema</span> Medical condition

Reinke's edema is the swelling of the vocal cords due to fluid (Edema) collected within the Reinke's space. First identified by the German anatomist Friedrich B. Reinke in 1895, the Reinke's space is a gelatinous layer of the vocal cord located underneath the outer cells of the vocal cord. When a person speaks, the Reinke's space vibrates to allow for sound to be produced (phonation). The Reinke's space is sometimes referred to as the superficial lamina propria.

<span class="mw-page-title-main">Adam's apple</span> Feature of the neck

The Adam's apple is the protrusion in the neck formed by the angle of the thyroid cartilage surrounding the larynx, typically visible in men, less frequently in women. The prominence of the Adam's apple increases in some men as a secondary male sex characteristic during puberty.

Gender-affirming surgery for male-to-female transgender women or transfeminine non-binary people describes a variety of surgical procedures that alter the body to provide physical traits more comfortable and affirming to an individual's gender identity and overall functioning.

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Chondrolaryngoplasty is a surgical procedure in which the thyroid cartilage is reduced in size by shaving down the cartilage through an incision in the throat, generally to aid those who are uncomfortable with the girth of their Adam's apple.

<span class="mw-page-title-main">Bogart–Bacall syndrome</span> Voice disorder caused by abuse or overuse of the vocal cords

Bogart–Bacall syndrome (BBS) is a voice disorder that is caused by abuse or overuse of the vocal cords.

A hoarse voice, also known as dysphonia or hoarseness, is when the voice involuntarily sounds breathy, raspy, or strained, or is softer in volume or lower in pitch. A hoarse voice can be associated with a feeling of unease or scratchiness in the throat. Hoarseness is often a symptom of problems in the vocal folds of the larynx. It may be caused by laryngitis, which in turn may be caused by an upper respiratory infection, a cold, or allergies. Cheering at sporting events, speaking loudly in noisy situations, talking for too long without resting one's voice, singing loudly, or speaking with a voice that is too high or too low can also cause temporary hoarseness. A number of other causes for losing one's voice exist, and treatment is generally by resting the voice and treating the underlying cause. If the cause is misuse or overuse of the voice, drinking plenty of water may alleviate the problems.

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Vocal cord paresis, also known as recurrent laryngeal nerve paralysis or vocal fold paralysis, is an injury to one or both recurrent laryngeal nerves (RLNs), which control all intrinsic muscles of the larynx except for the cricothyroid muscle. The RLN is important for speaking, breathing and swallowing.

Puberphonia is a functional voice disorder that is characterized by the habitual use of a high-pitched voice after puberty, hence why many refer to the disorder as resulting in a 'falsetto' voice. The voice may also be heard as breathy, rough, and lacking in power. The onset of puberphonia usually occurs in adolescence, between the ages of 11 and 15 years, at the same time as changes related to puberty are occurring. This disorder usually occurs in the absence of other communication disorders.

LGBT linguistics is the study of language as used by members of LGBTQ communities. Related or synonymous terms include lavender linguistics, advanced by William Leap in the 1990s, which "encompass[es] a wide range of everyday language practices" in LGBT communities, and queer linguistics, which refers to the linguistic analysis concerning the effect of heteronormativity on expressing sexual identity through language. The former term derives from the longtime association of the color lavender with LGBT communities. "Language", in this context, may refer to any aspect of spoken or written linguistic practices, including speech patterns and pronunciation, use of certain vocabulary, and, in a few cases, an elaborate alternative lexicon such as Polari.

<span class="mw-page-title-main">Voice therapy</span> Used to aid voice disorders or altering quality of voice

Voice therapy consists of techniques and procedures that target vocal parameters, such as vocal fold closure, pitch, volume, and quality. This therapy is provided by speech-language pathologists and is primarily used to aid in the management of voice disorders, or for altering the overall quality of voice, as in the case of transgender voice therapy. Vocal pedagogy is a related field to alter voice for the purpose of singing. Voice therapy may also serve to teach preventive measures such as vocal hygiene and other safe speaking or singing practices.

<span class="mw-page-title-main">Trans woman</span> Woman assigned male at birth

Transgender women are women who were assigned male at birth. Trans women have a female gender identity and may experience gender dysphoria. Gender dysphoria may be treated with gender-affirming care.

Gender-affirming hormone therapy (GAHT), also called hormone replacement therapy (HRT) or transgender hormone therapy, is a form of hormone therapy in which sex hormones and other hormonal medications are administered to transgender or gender nonconforming individuals for the purpose of more closely aligning their secondary sexual characteristics with their gender identity. This form of hormone therapy is given as one of two types, based on whether the goal of treatment is masculinization or feminization:

Muscle tension dysphonia (MTD) was originally coined in 1983 by Morrison and describes a dysphonia caused by increased muscle tension of the muscles surrounding the voice box: the laryngeal and paralaryngeal muscles. MTD is a unifying diagnosis for a previously poorly categorized disease process. It allows for the diagnosis of dysphonia caused by many different etiologies and can be confirmed by history, physical exam, laryngoscopy and videostroboscopy, a technique that allows for the direct visualization of the larynx, vocal cords, and vocal cord motion.

<span class="mw-page-title-main">Feminization laryngoplasty</span>

Feminization laryngoplasty is a reconstructive surgery surgical procedure that results in the increase of the pitch of a patient, making the voice sound higher and more feminine. It is a form of Open Laryngoplasty and effectively reaches its goals via a Partial Laryngectomy of the anterior portion of the larynx, thereby diminishing the size of the larynx to cisgender female proportions. It also changes the vocal weight or resonance quality of the voice by diminishing the size of the larynx. It is a type of voice feminization surgery (VFS) and an alternative to vocal therapy. Feminization laryngoplasty is performed as a treatment for both transgender women and non-binary people as part of their gender transition, and women with androphobia. The surgery can be categorized into two main steps: Incision and vocal fold modification followed by thyrohyoid elevation. Risks and complications include granuloma, dysphonia and tracheostomy. Patients are recommended to follow perioperative management such as voice rest to hasten recovery.

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  26. ↑ Spiegel, Jeffrey H. (2006). "Phonosurgery for Pitch Alteration: Feminization and Masculinization of the Voice". Otolaryngologic Clinics of North America. 39 (1): 77–86. doi:10.1016/j.otc.2005.10.011. PMID   16469656.
  27. ↑ Hoffman, Matthew R.; Devine, Erin E.; Remacle, Marc; Ford, Charles N.; Wadium, Elizabeth; Jiang, Jack J. (2013-11-16). "Combined type IIIB with bilateral type I thyroplasty for pitch lowering with maintenance of vocal fold tension". European Archives of Oto-Rhino-Laryngology. 271 (6): 1621–1629. doi:10.1007/s00405-013-2798-0. ISSN   0937-4477. PMC   4013228 . PMID   24241252.
  28. ↑ Carew, Lisa; Dacakis, Georgia; Oates, Jennifer (2007-09-01). "The effectiveness of oral resonance therapy on the perception of femininity of voice in male-to-female transsexuals". Journal of Voice. 21 (5): 591–603. doi:10.1016/j.jvoice.2006.05.005. ISSN   0892-1997. PMID   16822646.
  29. 1 2 3 4 Bauer, Greta R.; Hammond, Rebecca; Travers, Robb; Kaay, Matthias; Hohenadel, Karin M.; Boyce, Michelle (2009). ""I Don't Think This Is Theoretical; This Is Our Lives": How Erasure Impacts Health Care for Transgender People". Journal of the Association of Nurses in AIDS Care. 20 (5): 348–361. doi:10.1016/j.jana.2009.07.004. PMID   19732694. S2CID   12586015.
  30. ↑ de Vries, Annelou L. C.; Cohen-Kettenis, Peggy T. (2012-01-01). "Clinical management of gender dysphoria in children and adolescents: the Dutch approach". Journal of Homosexuality. 59 (3): 301–320. doi:10.1080/00918369.2012.653300. ISSN   1540-3602. PMID   22455322. S2CID   11731779.
  31. 1 2 Hancock, Adrienne; Helenius, Lauren (2016-10-01). "Adolescent male-to-female transgender voice and communication therapy". Journal of Communication Disorders. 45 (5): 313–324. doi:10.1016/j.jcomdis.2012.06.008. ISSN   1873-7994. PMID   22796114.
  32. ↑ Kelly, Rebecca J.; Robinson, Gregory C. (2011-05-01). "Disclosure of Membership in the Lesbian, Gay, Bisexual, and Transgender Community by Individuals With Communication Impairments: A Preliminary Web-Based Survey". American Journal of Speech-Language Pathology. 20 (2): 86–94. doi:10.1044/1058-0360(2011/10-0060). ISSN   1058-0360. PMID   21393619.
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