Speech-Language Pathology

Gender-Affirming Voice Modification for Transgender Women: Characteristics and Outcomes

The primary aim of this study was to define the characteristics of transgender women seeking gender- affirming voice modification at Cleveland Clinic Voice Center. The secondary aim was to evaluate outcome measures, comparing (a) behavioral voice training alone, (b) surgery alone, and (c) combination of behavioral voice training + surgery.

Patients who sought care for gender-affirming voice modification were seen over a 30-month period and were included if they were assigned male at birth and identified as female. Patient demographic information, patient quality of life index scores, Trans Woman Voice Questionnaire (TWVQ), and acoustic data were collected before and after intervention.

Sixteen patients met inclusion criteria. The majority of patients were (a) undergoing hormone replacement therapy at initiation of treatment, (b) were presenting in public for more than 2 years as female, and (c) had a history of psychological disorders (i.e., gender dysphoria, anxiety, depression, or attention deficit hyperactivity disorder [ADHD]). Increased speaking fundamental frequency (sf0) and decreased Trans Woman Voice Questionnaire (TWVQ) scores were evident and statistically significant within both the behavioral voice training cohort and behavioral voice training + surgery cohort. Treatment groups appear similar with respect to average changes; pre- and post-data were not available for surgery-only patients. Greater change in sf0 was directly correlated with increased number of voice training sessions.

There is variability in the treatment course for patients seeking gender-affirming voice modification; however, treatment type may not impact outcomes. Increased patient quality of life and increased speaking fundamental frequency were found in this patient cohort.

Concurrent clinical comorbidities in the study cohort
N (%)
Psychological disorders14/16 (87.5%)
Neurological disorders4/16 (25%)
Voice disordersᵃ1/16 (6.25%)
Head and neck cancer0/16 (0%)
Hearing loss0/16 (0%)

ᵃOther than incongruence between gender identity and voice.

Change in average fundamental frequency and transsexual Voice Questionnaire Scores by Treatment Cohort

Treatment cohort

Change in average sf0 (

Hz) (SD)


Change in TVQ score

(points) (SD)


Voice therapy63.14 (25.50)0.001ᵃ-40.83 (22.80)0.007ᵃ
Voice therapy + surgery65.20 (41.83)0.025ᵃ-51.00 (5.66)0.050

ᵃStatistically significant = p-value < 0.05.

SD, standard deviation; TVQ, Transsexual Voice Questionnaire.

Individual Patient Data: Speaking Fundamental Frequency and Trans Woman Voice Questionnaire Scores
Tx only (N = 7)63.14 hz +/- 25.50 HzP = 0.001
Tx + Sx (N = 5)65.20 Hz +/- 41.83 HzP = 0.025
Tx + Sx vs Tx onlyP = 0.93

Behavioral voice training + surgery subjects bolded. Number indicates time point data were taken after surgical intervention.

TWVQ, Trans Woman Voice Questionnaire.