Musicians' Health Collective

Musicians' Health Collective: Supporting the health of musicians

Supporting All Voices: Interview Part 1 with Dr. Anita Kozan

Dr. Anita Kozan is a Minnesota-based speech and language pathologist whose focus has been on the care of the speaking and singing voice.  She's worked with a wide range of clients, from children diagnosed with autism to older clients to transexuals.  I first heard about her work in the context of supporting the transexual voice, and I'm so thrilled that she made time to speak to me the day before she had rotator cuff surgery.  

Kayleigh: So how did you begin in speech pathology?

Anita: It’s a fascinating field, and honestly, I had never heard of it growing up.  I was from a small town where we didn’t have a speech pathologist or speech therapist in our community, but a man I had dated told me about it, saying that I liked helping people and I might like this field.  So I started taking classes as a sophomore in college, and had never ever really seen what it was until I transferred to the University of Minnesota my junior year, and I instantly thought, “Oh my gosh, I love this!”  I feel really lucky that I have found a profession that I have loved my whole career- I’m 69 and I’ve been practicing since I was 22.  Just celebrated my 47th anniversary in the field.  I’ve worked with all different ages too- never babies, but I’ve done preschool children all the way through the ages to geriatric clients who have had strokes, with an emphasis on voice, often working with people after accidents or illness.  But voice is really my favorite thing to do.  I finished my bachelors in 1969, and went back to work on my masters in 1970, finishing in 1972, and at some point in that year, I went to a regional conference where there was a speech and language pathologist working with a transexual woman, demonstrating the outcome of the work she had done with this woman.  I was fascinated and I really thought, “I want to do that- I think I can do a good job,” and that was really the beginning of looking for opportunities to learn more about the trans community.

K: That’s amazing because you figure 44 years ago, transgender sexual identity was rarely if ever talked about or discussed.

A: Yes, you’re right.  I grew up in a town where a female neighbor dressed up as a man, but I thought that was just her and never thought much about it.  I thought that was just who she was.  I don’t remember seeing anyone in school or in public who was openly trans.  So that was really the beginning in 1972- it took a while to find things and resources, but by the eighties, clients were being referred to me by their physician who were having trouble with their voices; hoarseness, etc., but the real issue was that they were transitioning and they didn’t know what to do with the changes in their voice.  People started to find me, trickling down from other sources, and because of my interests and in putting my energy out there, I continued to be sought out more and more.  It’s a difficult speciality- it’s some of the hardest work that I’ve ever done, in terms of people that I’ve worked with.  The hardest is when singers are transitioning, because I want to preserve their voice as much as possible while expanding and evolving their range.  By the 1990’s, people were being referred to me fairly frequently, it was becoming more acceptable to seek out help during transition, and insurance companies were beginning to pay for it and acknowledge the health challenges it posed.  But still, there were people who did not want to be seen, who did not want to use their insurance, did not want to be seen in a public hospital setting.  I had always had a private practice, but that was also when i began melding singing and voice exercises for those who were not singers, who were also transitioning.  I had worked for many years at Northwestern Hospital where I had a voice labarotory, and was studying people’s larynxes underendoscopic light. The Sister Kenny institute, which was part of the hospital, also had an instrumentalist clinic, and they saw a lot of people who were professionals having difficulties, and so I very much respect your interest in overuse injuries and musculoskeletal problems, especially since I got trigger finger from playing saxophone once!

Note: I had never heard of Sister Kenny before, and she's been really interesting to learn about.  

Note: I had never heard of Sister Kenny before, and she's been really interesting to learn about.  

K: Yes.

A: But I also wanted to tell you about some interesting research at Sister Kenny that changed the wayI work with all voices and injured voices.  Sister Kenny was an Australian nurse who pioneered rehabilitation with polio in Minnesota, and was trying to help patients recondition their muscles.  The work wasn’t highly thought of at first, but she continued on with her work, and the center continued with a rehabilitative model.  Some of the people who were involved as physicians with the clinic began to do research on people who had been diagnosed with polio as children or teenagers, and they were having a post-polio syndrome, where they began having muscle weakness long after treatment. (Note: PPS is a condition that affects polio survivors long after the initial attack of the poliomyelitis virus on the nervous system )  The physicians did a controlled study where they had people with this syndrome divide into two groups.  One group did muscle testing before they began and then they had them engage in a specific exercise for X minutes, and then tested their strength again.  The experimental group had the same testing process, but the exercise was done in an interval training model, where they did the exercise for a minute or two, then rested, and then exercised again, repeating the cycle.  What they found was that the people who exercised continuously were weaker on the post test, and that the people who did interval training, were stronger in their post test.  I used that research and applied it to two singers who both were performers with post-polio syndrome, and I used this technique as part of their healing process.  I had them working on speaking and singing using interval training models, but they both regained their abilities to sing, and one of them just had an incredible voice by the end of it.  I extrapolated from that experience and generalized the model to singers who did not have post-polio syndrome, and then generalized to singers who had injured voices, and then I applied it to people who were transgender, and in the midst of that, starting using singing voice exercises with all of my clients, irregardless of whether they were singers.  With all of those different populations, I used interval training models and singing exercises to help condition muscles that hadn't been used before or hadn't been used efficiently, especially with male to female transitions, who are learning to use a range of their voice that they’ve maybe never used.  They may have played around with falsetto or head voice, but it’s not something they’ve used regularly.  I started using really simple vocal exercises and interval training with people who were singers and who were trans, and then with people who were trans and non vocalists.  But I could see that if we wanted people to speak in a higher range, we want them to sing as well.  It’s a melding of techniques that has worked well for a variety of people.

K: Did you train yourself as singer?

This image from does an excellent job of showing the nasal pathway of studying the vocal folds.  

This image from does an excellent job of showing the nasal pathway of studying the vocal folds.  

A: Yes,  I have sung my whole life.  I've done some solo work, but mostly choirs, barbershop quartets, and then after high school I played in bars and bands.  I also play keyboards, and have played and sung in weddings, funerals, and churches.  I played in a rock band from 1978 to 1981, and then I realized that singers of all genres really need help in not injuring their voices.  That was the extra push in seeking out the singing voice.  By 1987, I started work on my PhD at the same time I opened the first voice laboratory in Minnesota, examining vocal cords endoscopically through the nose or through the mouth.  I've continued to sing throughout my life, but I always need a gig or concert to work towards in order to be motivated to practice.  But when I am singing, I try to do all of the things I teach my students in warming up, practice duration, and most importantly, cooling down- that’s why I had gone back to work on my dissertation.  Cooling down was mentioned in Etude magazine in the 1950’s, originally called “warming down,” but very little research had been doing on vocal cool downs.  One of my colleagues, Dr Alfred Lavarado had told me about it - he had been a speech pathologist and singer, and I was at the International Voice Symposium at Juilliard.  He had worked with singers prone to overuse on warming up and cooling down, and had helped them reduce the swelling of the vocal folds enough so that they could speak and sing, even if they had overused their voice.  My dissertation had been studying the effects of the vocal warmups on singers, but I certainly had a special interest in the “cool down” process as well..

K: You’ve already illuminated some of the crux of your dissertation work, mainly that warmups are a critical part of vocal health and maintenance, but what were some of the other aspects of the research that came up?

A: Cooling down has still not been studied within the research model that I used, but with warmups, the study was the impact on perceptual judgments of the effects of vocal warmups on the singing voice.  I had twenty year olds: ten were classical trained singers and ten had no training.  The same was true for the older age group- I had wanted post-menopausal women, and once again I had ten classical trained singers and ten non trained.  I had three different singing tasks- one was to sustain a note five steps down from the top of their range, then sing a one octave scale, and third was to sing the star spangled banner.  I had them do those tasks, and then led them through a 17 minute task, and then repeated the vocal tasks.  I took recorded samples, across the passagio, the high pitch, the one octave scale, and then one particular passage of the star spangled banner, and then randomized the tracks, and played them for vocal judges, who did not know what the focus of my research was.  Their job was instead to pick out if the before/after recordings were different, and if so, how was clarity and uniformity impacted.  Over the 40 singings, judges correctly picked out 39/40 singers- the warmed up voice vs. the unwarmed up voice, especially with the sustained high pitch.  The one singer that was indistinguishable had told me that it took her 40 minutes to warm up her voice, and between her wide vibrato and instability, I knew it wasn’t a healthy singing voice.  Of course it wasn’t my place to say that, but it was an interesting aspect of the research.  So at the time, my final vocal advisor had said that I could make a career of testing singers and conducting research- I took it as a compliment, but I knew that just wasn’t what I wanted to do. I wanted to be out in the field helping people. 

K: Of course- more connection.  More importantly, you proved that warming up was such an integral part of vocal care, which has become more mainstream in vocal and choral teaching.

A: Yes- absolutely.  For now, I’m going to work for one more year, maintain a small private practice, and go from there.  I’m also interested in supporting youth, specifically homeless and LBGTQ youth, who are often homeless as a result of their identities.  An opportunity came up to be a speech a language pathologist in a high school, working with autistic and non autistic students.  I left the hospital and research environment a few years ago, even though I loved having a vocal research laboratory, but it was such an amazing opportunity to change my focus.  Being around teenagers has put me closer to youth and the singing voice. Within my client base in the last 9-10 years, over 50% have been singers, whether it was for enjoyment in private all the way up to semi professional singers.  

K: Fantastic!

*In the second part of this interview, we delve more into the care and keeping of the transitioning voice, and how the support of the trans voice has changed in the last 35 years.*

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