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Health & Wellness

Transgender Voice Therapy: What Is It and How To Start It?

Megan P.

Speech therapy for transgender individuals is also referred to as communication therapy or speech therapy and serves the purpose of alleviating the anxiety caused by gender dysphoria.

By receiving voice therapy, non-binary, transgender, and gender-expansive people can make adaptations to the pitch and tone of their voice to better reflect their gender identity. Voice therapy can be used to increase gender satisfaction and confidence. Voice and communication therapy is not necessarily limited to altering transgender and non-binary people’s voices to fit a certain binary gender but can be tailored for specific goals that best fit the individual’s gender identity.

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Voice therapy includes a range of non-surgical interventions to change certain elements of a person’s voice. Voice and communication play a large role in gender perception, and voice training can help trans, non-binary and gender-expansive people establish a new voice that affirms their gender.

A qualified speech-language pathologist who offers transgender voice therapy can help trans people feminize or masculinize their voice quality and reduce the extent to which they are misgendered. Voice quality often entails gender cues which could add to the frustration of gender dysphoria in that it does not always accurately reflect a person’s gender identity.

Communication treatment often approaches this procedure by focusing on resonance, vocal hygiene, vocal pitch, and role-playing scenarios to assess voice production.

Hormone Therapy vs. Voice Therapy

When it comes to the intervention of hormone therapy, it is worth noting that testosterone therapy is much more prone to change someone’s voice than estrogen is. Testosterone leads to voice masculinization by directly causing the vocal cords to drop the pitch of a voice. Estrogen does not have such a great impact on voice quality.

Many factors contribute to the effects that hormones can have on voice sound. These include the age at which a person starts receiving hormone therapy as well as the pitch range of the person’s original voice. Hormone replacement therapy does not always bring about the desired effects, but voice and speech therapy can substantially improve one’s authentic voice.

Non-binary and transgender patients may seek voice services to ensure that their communication is congruent with their gender identity or -expression. Studies have conclusively shown that a mismatch between voice and gender identity can lead to depression and anxiety concerning gender dysphoria.

Speech-language pathologists collaborate with their clients to assess and evaluate many aspects of both verbal and nonverbal communication. This includes the voice itself and factors such as intonation, fluency, articulation, laughing, and coughing.

The speech-language therapy involves the client’s family and implements strategies such as cultural awareness and sensitivity training to ensure full clarity among loved ones. This includes sharing updated knowledge on respectful, inclusive, and appropriate terminology. As terminology continuously evolves, it is important to stay informed about the client’s pronouns and when to use them. The speech-language pathologist will always be conscious of the potential obstacles that the client faces every day, impacting their communication skills.

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Who Can Get Voice Therapy?

Really anyone can receive voice and communication therapy. However, it is very common for transgender and non-binary people to see a speech pathologist because they simply do not feel comfortable in their communication patterns and wish to improve on their auditory gender presentation.

How Do I Get Started With Voice Therapy?

Starting with voice therapy means investing in your vocal health. There are so many options out there, but consulting a speech-language pathologist with experience in voice and communication is the best way to go.

Online platforms are great in offering a starting point for exploring your communication style, but health care providers can customize therapy techniques to reach your individual goals better than anyone else.

What is transgender voice surgery?

Voice therapy is more often than not fundamentally required before surgery can be considered. After a speech-language pathologist meticulously worked with a patient in attempting to establish a new voice, an otolaryngologist might attempt vocal fold surgery only if speech therapy could not produce the desired outcome.

Vocal surgeries are most common among transgender women simply because voice feminization is a greater challenge for a person with a male voice, and voice feminization surgery relieves this burden. Transgender women’s voices can be altered to achieve a more feminine voice by performing pitch-raising surgery. Voice masculinization for transgender men surgeries is less common largely due to the impact of hormone therapy alone, making surgical intervention unnecessary.

Hormone replacement therapy can do wonders in feminizing a transgender women’s outer appearance, but it is not as useful in feminizing a voice. Unless hormone replacement therapy immediately follows puberty blockers, the structure of the vocal cords is pretty much fixed. It can only be changed by surgically shortening the vocal folds, decreasing the entire mass of the folds, or raising the tension in the folds.

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Trans women can raise their vocal pitch and restrict or completely remove access to lower frequency ranges. Some of the existing pitch-raising surgeries available today include:

Cricothyroid approximation (CTA)

During this procedure, the vocal folds are elongated and tension is created, increasing vocal pitch. Metal plates or sutures are used to bring the thyroid cartilage and the cricoid cartilage closer together. The backward and upward shift of the cricoid cartilage and the forward and downward movement of the thyroid cartilage mimic cricothyroid muscle contraction. This elongates and tenses the vocal folds, raising the pitch.

Anterior glottal web formation or anterior commissure advancement

This procedure aims to shorten the vocal folds’ length of vibrations, which raises the vocal pitch. The tissue of the anterior area of the vocal folds is removed, and then sutured together to create an anterior web that cannot vibrate.

Laser-assisted voice adjustment (LAVA)

Microlaryngoscopy is performed in conjunction with a carbon dioxide laser that removes small parts of the vocal folds. During the healing process of this tissue, the folds increase in stiffness and decrease in mass. This will raise the pitch of the voice.

Laser reduction glottoplasty (LRG)

This laser procedure involves vaporizing the anterior part of the vocal folds with a carbon dioxide laser. Tension is then created with sutures in the vocal folds, increasing the pitch.

Voice Feminization

This is fundamental to the vocal health of male to female transsexuals. Because changing a voice to a much higher speaking pitch is especially challenging, research in this sector of transgender health is very advanced.

Because of sufficient this research, modifications in voice resonance and fundamental frequency have proved to be very effective in feminization.

The fundamental frequency of the average male voice ranges from approximately 107 to 120 hertz. The average female voice lies between 189 and 224 hertz. Evidently, the female pitch range is substantially higher. Altering the fundamental frequency is consequently the most effective way of feminizing a male voice.

It is worth noting that people’s perspectives of speech and voice characteristics vary widely, and therefore raising the vocal pitch alone is not sufficient in affirming many people’s gender identity.

Based on current evidence, fundamental frequency and voice resonance are the two factors that have the greatest effects on the feminization of the voice. Other factors include speech rate, intonation patterns, articulation, and loudness.

Raising pitch

Pitch and speaking fundamental frequency are typically the topics of concern for transgender women because they perceive a feminine voice as having a higher frequency. Specialists of speech-language pathology will assess the individual and determine which elements will be most beneficial to the feminization of their voice.

The first step is to use an acoustic analyzing program to determine the habitual speaking fundamental frequency of the transgender woman. This is done by having the patient read a standard passage and a spontaneous speech sample. The therapist and patient can then decide on the target pitch they wish to accomplish. This is usually based on the typical range of cis women.

Pitch raising is done gradually, starting with a pitch just a bit higher than the patient’s original voice. No strain or excessive effort should be experienced during the initial stages. The patient will eventually use the target pitch in a sustained vowel during a short conversation as progression occurs.

Another helpful aid is exercising semi-occluded vocal tract techniques. This will improve voice production in a higher pitch. Some exercises may include producing much different speech sounds like nasals, vowels, and fricatives. Tongue and lip thrilling and phonating into straws will also enable the patient to stabilize an authentic voice.

Two common exercises include a pitch glide where the voice is taken from the middle of the pitch range all the way to the top. The second exercise included going from soft to loud and back to soft.

Pitch can also be improved by oral resonance therapy. The resonance of the vocal tract is highly affected by the length of the tract. Because cis men have larger vocal tracts than cis women, they have a lower vocal tract resonance and a lower pitch. To create an authentic voice in male to female transsexuals, patients can practice shortening the vocal tract by retracting the lips when making “s” sounds, among other techniques.

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Voice masculinization

Modifications to be made to masculinize a voice involved lowering the fundamental frequency. The effects of testosterone on the larynx are often sufficient in lowering voice pitch. Many transgender men, however, have reported that hormone replacement therapy alone does not deepen their voice to the level they would like it to. Voice masculinization therapy is a safe and efficient strategy in any communication program.

Testosterone therapy can cause overdevelopment of vocal folds, leading to entrapped vocality. Entrapped vocality is characterized by persistent hoarseness and insufficient passing. The length of the larynx can be modulated by exercise. Larynx length is a useful tool for trans males getting a passing voice.

Apart from vocal exercises, trans men can also reap some valuable benefits from training their lips and keeping a high quotient of how long vibrations last to how long vocal cords touch.

According to the World Professional Association for Transgender Health, overall vocal health should always be prioritized when assessing the voice goals of transgender men. Common therapy techniques include exploring different pitch ranges to find to most comfortable frequency for the individuals. Therapy also involves:

  • Using relaxation exercises and breath support.
  • Initiating voice strengthening exercises.
  • Improving posture stability to increase chest resonance.

Lowering pitch

Communication services can offer patients exercises to use their new voices without tension with the proper training. Some guidelines can be followed to help patients find their optimal speaking pitch.

Firstly, achieving a much lower pitch can sometimes be straining. It is much better to find your individual optimal pitch that feels comfortable and tension-free. To maintain fluency while altering a transgender voice, diaphragmatic breathing patterns can be of great help. Find a stable speaking posture and practice controlling and using your breathing to optimize pitch.

Always warm-up before practicing the maintenance of your pitch to prevent vocal fatigue. Resting after such a session is just as important. Tension releasing techniques must be implemented to relax your jaw, neck, tongue, and laryngeal area. Where head resonance is typically applicable to women, chest resonance is highly important for transgender men. Chest resonance can be improved by lowering the larynx and expanding the chest area.

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Therapeutic techniques

Therapy sessions can occur in individual and group sessions depending on the division of speech-language pathology at hand. When considering transgender voice alterations, the lowering and raising of a voice is commonly the main focus in discovering all the aspects of voice and communication.

In group sessions, more general topics such as speech sound articulation can be discussed. In contrast, individual sessions will be centered around more intricate methods of expressing gender identity through communication patterns.

Clear protocols for transgender voice therapy for men were a little harder to outline than protocols for treating the voices of transgender women. The following therapeutic techniques have proven to be helpful applications in such services:

  • Imitating non-transgender individuals after observing their common voice and communication patterns
  • Participating in voice practice that progressively gets more challenging
  • Training motor skills
  • Altering the quality of the voice in nonverbal communication such as laughing and coughing
  • Experimenting with a wide variety of voice styles

Although research on communication services suggests relatively weak evidence on the effectiveness of voice therapy, it still suggests that transgender women and men who have had this therapy are highly satisfied with the results.

There is also a strong concurrence between speech-language pathologists about the strong markers of speaker gender.

Risks Involved In Voice Therapy

Feminizing or masculinizing a voice involves manipulating the mechanisms of your voice in a very non-habitual and unusual way. It is important to avoid misusing and damaging your voice in the process.

Consistently pushing your voice to its limits without taking the necessary precautions can lead to permanent hoarse and rough voices that can become strained and breathy. This is referred to as dysphonia.

How To Prepare

It is always wise to consult and have a transparent relationship with a speech-language pathologist. It goes without saying that a specialist with training in assessing and developing communication patterns of transgender, transsexual and gender-nonconforming patients will be the best option. It is always advantageous that they have a basic understanding of the psychosocial issues of transgender individuals.

During your conversations with such a specialist, you will create a clear outline of your goals and expectations whereby you can proceed to receive treatment.

What To Expect

You can expect a treatment that focuses on reaching your goal pitch. To be perceived by others as a female, you can aim to raise your pitch to above 189 Hz. To be perceived as a male, aim you reach a pitch below 120 Hz. These are, of course, only general guidelines, and you may have very different goals.

Prosody refers to the melody of speech which is determined by pitch, emphasis, and loudness. This will be developed according to your goals during the course of treatment. Your vocal resonance is often referred to as the perception of vibrations in your voice. This concept does not rely on gender per se. You may discover that your resonance is focused in your chest or throat, whereas others might have a more forward resonance.

Your therapist will guide you in discovering a healthy resonance that fits your needs. There will be a lot of experimentation and practice involved in this discovery.

Other factors that will be addressed include the quality of your voice, articulation, speech rate, and nonverbal communication such as your body language while speaking.

Aids like a keyboard or a piano will be used to practice and help you reach your target pitch. Your therapist may even make use of frequency tracing software to be able to measure your progress in real-time, allowing you to reassess and make adjustments where necessary.

Whether you participate individual sessions, groups sessions, or both, your progress and rate of improvement will depend entirely on your individual needs and goals. Therefore, there is no accurate timeframe to describe how long you will need to receive treatment.

If you feel like you are not meeting your own expectations, you might consider surgery. This is more applicable to trans women as hormone therapy does not have a major effect on the pitch of your voice if you are transitioning from a male to a female. Your surgeon will outline his/her/their recommendations and all possible risks involved.

It is worth noting that minimizing the thyroid cartilage or Adam’s apple surgically is not considered a voice-related procedure.

Results

Transgender voice therapy is a tool that can be used to learn how to express your true self accurately. This will boost your confidence and authenticate your gender identity. It is important to manage your expectations while receiving voice therapy. The results will depend on the treatment regime that was followed as well as your individual efforts.

At first, it may be a challenge to maintain your new voice in everyday life, especially when conversing with people that knew you before you started transitioning. Do not stress or worry too much about the little obstacles that you will inevitably overcome, and enjoy the journey!

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