Transgender voice therapy and surgery

Transgender individuals who seek transgender voice therapy and surgery want to adapt their voices to communicate in a way that matches their gender identity. Transgender voice care can help lessen the discomfort or distress that might accompany a difference between gender identity and sex assigned at birth or sex-related physical characteristics (gender dysphoria).

Having a voice that doesn't match your gender identity can also cause safety issues including harassment, in certain circumstances.

Transgender voice therapy and surgery isn't right for all transgender individuals. You might prefer your current voice or a gender-neutral voice to signal your distinct identity. Some desire a gender expansive voice, which means they can alternate between masculine, gender-neutral and feminine voices.

Voice, speech and communication changes involve using the voice production mechanism in new, nonhabitual and often unfamiliar ways. Your speech-language pathologist or specialist will work with you to help avoid vocal trauma.

Transgender voice surgery typically focuses on pitch change. For voice feminization, the focus of surgery is to raise habitual speaking pitch and reducing the ability to produce a low-pitched voice. This means that surgery will reduce the overall pitch range of your voice. There is also a risk that surgery could cause your voice to become too high or so rough, hoarse, strained or breathy as to make communication difficult. Results of most voice feminization surgery are permanent.

Because voice feminization surgery will only change your pitch, you may still need to work on other vocal behaviors.

Voice masculinization surgery isn't as common as voice feminization surgery. It focuses on lowering the pitch of the voice by decreasing the tension of the vocal folds. The surgery can't be reversed.

If you're considering gender affirming voice care, ask your health care provider to refer you to a speech-language pathologist or specialist. Look for a specialist with training in the assessment and development of communication skills in transgender and gender-diverse clients.

Professionals such as vocal coaches and singing teachers, and some online resources also might play a helpful role.

Your speech-language pathologist will talk to you about your goals. What communication behaviors, vocal and nonverbal, do you want to acquire? If you don't have specific goals, your speech-language specialist will explain and help you explore options.

Using this information, you and your specialist will come up with a treatment plan.

Gender affirming voice care can include speech therapy aimed at feminizing, neutralizing, or masculinizing your voice and speech. Voice care with a speech pathologist is highly recommend for both before and after laryngeal surgery.

For transgender men, adequate voice deepening may be achieved through masculinizing hormone therapy. Gender affirming voice care may be helpful in addressing communication style and the rhythm and the way words are stressed (prosody) that allow for more masculine outcomes.

Feminizing hormones don't modify the voice for transgender women. Anti-androgens and estrogens have no effect on the voice.

Targets of speech therapy might include:

• Pitch. The average speaking fundamental frequency of adult cisgender males — males whose gender identity correspond with their birth sex — is about 107 to 120 hertz (Hz). For cisgender females, it's 189 to 224 Hz. To be perceived as female, it may be helpful for vocal frequency to stay above around 165 Hz. To be perceived as male, it's helpful for vocal frequency to stay below 165 Hz.
• Prosody. Prosody is the melody of speech and includes loudness, pitch and stress changes. For example, men tend to use stress or loudness for emphasis, while women often use greater pitch variability.
• Vocal resonance. This term often refers to the perception of vibrations when using one's voice. The location of vocal resonance isn't fully dependent on your gender. You can have a throaty resonance, where vibrations are focused in the throat or chest, or a forward resonance, where vibrations are experienced around the lips and nose. A speech-language specialist can help you find a healthy resonance that reflects who you are. This takes practice, exploration and experimentation with your voice.

Therapy may also address:

• Voice quality
• Articulation
• Speech rate and phrasing
• Nonverbal communication, such as eye contact, use of hand gestures, facial expression, posture and head nodding

During a session, you'll learn and practice techniques to modify your voice. A keyboard or piano may be used to help you target pitches, and visual frequency tracing software can help measure progress in real time and for reassessment.

The frequency and duration of treatments will depend on your needs. Treatment can involve individual or group sessions.

You might also consider talking with a surgeon about ways to modify the speaking pitch of your voice. Your surgeon will explain expected voice changes following surgery and can also discuss potential risks.

Voice surgery doesn't require the referral of a mental health provider. However, talking to a surgeon, mental health provider and speech language specialist can help you make a fully informed decision about the timing and implications of the surgery in the context of your social transition.

Two surgical options used most frequently to raise voice pitch include:

• Anterior glottal web formation. This surgery creates a web or scar band at the front of the V of the vocal cords (anterior commissure). This shortens the vocal cords to help raise voice pitch. Anterior glottal web formation affects frequency range by eliminating the ability to produce lower pitches. It also narrows the airway to some degree. As a result, this surgery might be less appropriate for vocal professionals and, perhaps, serious athletes.
• Cricothyroid approximation (CTA). This surgery increases vocal cord tension. This results in a higher speaking pitch and a reduction in the ability to lower pitch. However, studies have found that this technique doesn't have a lasting effect.

Voice masculinization surgery is less common than voice feminization surgery, but it may be an option for transgender men who aren't satisfied with the pitch of their voice after hormone therapy. This surgical option can lower the pitch of the voice:

• Thyroplasty type III. This surgery lowers the fundamental frequency of the voice by decreasing the vocal fold tension.

After surgery, you'll have follow-up visits with a speech-language pathologist to make the most of your surgery, protect your vocal health and learn to use your changed voice.

Finding a voice that matches your gender identity and feels true to you is an individual process. Gender affirming voice care and surgery are tools that can help your voice sound more like your authentic self.

Your results will partly depend on the techniques used, as well as the effort you put into practicing changing your voice. But keep in mind that a pitch modification alone doesn't guarantee being perceived as your preferred gender, especially in the absence of visual cues, such as on the phone. Some people also report that it can be hard to maintain their new voice with loved ones or people who knew them before transitioning.