Gender-Affirming Voice Therapy

What is gender-affirming voice therapy?

Gender-affirming voice therapy, previously called transgender voice therapy, is a specialized form of voice training that can align your voice with your gender identity.

A type of gender-affirming care, this treatment can help you raise or lower your vocal pitch (how high or low your voice sounds) and shape your sound to express yourself the way you’d like. Some people successfully modify their voices solely through voice therapy, while others prefer vocal cord surgery or a combination of both.

Who needs gender-affirming voice therapy?

Your experience of your voice, including your desire to change it, is profoundly personal. There isn’t a “right” or “wrong” way to sound like your gender.

Most transgender, nonbinary or gender-nonconforming people who seek voice therapy do so because they feel there’s a mismatch between their voice quality and how they — or others — perceive their gender. Biological sex characteristics determine vocal pitch. People assigned male at birth (AMAB) tend to have larger and longer vocal cords. As a result, they have lower, or “deeper,” voices than people assigned female at birth (AFAB). These differences don’t often cause distress if you’re cisgender.

These biological characteristics can lead to misgendering and psychological distress. Having your gender misrecognized by others may even be dangerous if you’re in a hostile, transphobic environment.

You may decide to receive voice therapy if you think that changing your voice will allow you to express your gender more authentically.

Types

The type of gender-affirming voice therapy you need depends on your goals. They include:

• Voice feminization therapy.
• Voice masculinization therapy.
• Gender expansive or gender diverse voice therapy.

Voice feminization therapy

Voice therapy may be a part of gender-affirming care if you’re a transgender woman or a nonbinary person assigned male at birth (AMAB) who feels that your voice is incongruent with your gender identity. Voice feminization therapy can train you to use your voice muscles to adjust pitch so that your voice sounds higher. Generally, people perceive vocal pitches greater than 160 Hz as feminine. The range is from 160 to 315 Hz and above, with 200 Hz as the average pitch.

Transgender women seek voice therapy more often than any other trans-identified population because common treatments like feminizing hormone therapy won’t change pitch.

Still, voice feminization therapy isn’t just about pitch. You may also learn tools like:

• More pitch variability: Adjusting your pitch so that you’re speaking across the highs and lows of your vocal range more frequently.
• Resonance: Shaping your sound so that it sounds brighter and lighter instead of darker and heavier.
• Articulation: Placing a lighter emphasis on each sound to reduce the intensity.

Voice masculinization therapy

Voice therapy for transgender men and nonbinary people AFAB focuses on making the voice sound more masculine. Generally, people perceive vocal pitches between 95 to 175 Hz (with an average of approximately 120 Hz) as masculine.

Unlike feminizing hormone therapy, taking testosterone as part of masculinizing hormone therapy usually changes your pitch.

Still, hormone therapy may not lower your voice to a pitch you’re comfortable with. In this case, you may need voice therapy. Masculinizing voice therapy can also help you adapt to changes in your vocal cords that result from taking testosterone. For example, your vocal cords may get bigger, but your voice box may not get bigger proportionally. This can lead to muscle tension and vocal problems that voice therapy can address.

You may receive masculinizing voice therapy because you’d like to lower your voice but don’t want to take testosterone.

Part of therapy may also include learning other vocal qualities. For example, you may develop:

• Less pitch variability: Staying in a narrower pitch range, so your voice has less pitch variability.
• Greater intensity: Speaking louder with changes in rhythm and rate of speech.

Gender expansive or gender diverse voice therapy

Gender-ambiguous voices fall within the range of approximately 155 to 187 Hz. You may wish to target this range if you’re nonbinary or uncomfortable having a vocal pitch that others associate with specific genders.

This type of therapy trains you to switch between pitches to control when you sound more feminine (higher pitch) or masculine (lower pitch). Voice training can help you find the voice qualities that accurately reflect your gender identity. It may allow for the flexibility that your voice requires.

Who provides gender-affirming voice therapy?

You’ll meet regularly with a voice specialist, such as a speech therapist (speech-language pathologist).

Treatment success will depend on your choice of healthcare provider. It’s essential to vet the provider you work with carefully so that you choose someone who understands and respects your treatment needs.

What happens before gender-affirming voice therapy?

You’ll meet with a healthcare provider to decide on voice therapy goals, and you’ll make a plan to achieve them. To start, your provider will analyze your voice, including how you use your breath, vocal cords and other speaking muscles. They’ll note your baseline voice pitch. This starting point will help them determine how much change is needed to reach your target pitch.

They’ll also ensure your voice is healthy, so you don’t risk injury during therapy.

How does gender-affirming voice therapy work?

You’ll meet regularly with a provider on a timeline that makes sense for your goals. Many programs involve multiple sessions over eight weeks, but there’s no standard timeline. You’ll connect on your progress throughout therapy and adjust training as needed.

Adjusting your pitch will likely be a primary focus during therapy. Still, the specific training you receive depends on your unique goals. You may develop skills in:

• Pitch modification: Lowering or raising your pitch. You’ll start with a slight pitch change before gradually progressing to higher or lower pitches, depending on your goals. You may begin with vowel sounds before gradually progressing to words, phrases, sentences and conversations in your desired pitch range.
• Vocal hygiene: Practicing good habits to keep your vocal cords healthy and free from injury. This includes doing vocal warm-ups, practicing good posture and performing breathing and relaxation exercises.
• Articulation: Using your speaking muscles to form sounds in a way that accurately reflects your gender identity. This may mean lightening the constriction between your lips, tongue and teeth/palate or using greater intensity depending on your goals.
• Resonance: Using the air-filled cavities in your throat, mouth and nose to color the sounds your vocal cords make. Working on your resonance can help create a unique tone that feels authentic to you. Training may involve learning how to control your sound better, so you can anchor sounds in your chest (chest voice) or in your head (head voice).
• Prosody: Modifying the tone and emphasis you place on sounds, words and phrases, creating a rhythmic quality (or flow) to your speech.
• Word choice: Choosing words that reflect gendered ways of speaking.
• Pragmatics: Adjusting your communication style to fit changing social situations.
• Nonverbal communication: Using visual cues like body language and facial expressions to convey messages without speaking.

An important part of gender-affirming voice therapy involves applying the skills you learn to real-world situations. Across settings, you’ll reflect on how you feel when using your voice across a range of purposes: speaking, laughing, singing and more. You can share your response with your provider to adjust voice therapy to your needs.

What are the benefits of gender-affirming voice therapy?

Voice therapy can help you change your voice without surgery. Most people who receive gender-affirming voice therapy see it as a positive experience. In addition to helping you change your pitch, voice therapy can offer you the space to reflect on the vocal qualities that sound and feel true to you.

Still, there are no guarantees regarding how much higher or lower your voice becomes during therapy. Many people reach their desired pitch, but it’s not possible in all cases. Much depends on the anatomy of your vocal cords and your ability to use them.

What are the risks or complications of gender-affirming voice therapy?

Your vocal cord anatomy may not allow the pitch adjustments you’d like to achieve. It’s important to remember that pitch is just one vocal quality people hear regarding gender. You can work closely with your provider on other aspects of your communication style to convey your gender.

If you’re unsatisfied with your results, talk with your healthcare provider about the possibility of surgery to change your voice.

When should I see my healthcare provider?

Contact your provider if you notice signs of vocal cord strain, including:

• Hoarseness.
• Vocal fatigue.
• Pain when you speak.

It shouldn’t feel unpleasant to use your voice. Get guidance from your provider on whether you should adjust your therapy, rest your vocal cords or try other treatments.

How long does voice feminization training last?

You’ll need to continue vocal exercises to maintain the gains you make during vocal therapy. Over time and with consistent practice, you’ll gain better control over your voice muscles.

How long does voice masculinization training last?

Whether you’re on hormone therapy or not, the voice exercises you learn in voice therapy can help you maintain better control of your voice. The effects of testosterone on your vocal cords are permanent, which means your voice will remain lower even if you stop taking testosterone.

A note from Cleveland Clinic

Choosing an experienced speech-language pathologist who works with transgender, nonbinary and gender-nonconforming people will make the difference in your treatment success. Many healthcare providers can help you adjust your pitch. It’s important, though, to find a provider who can tailor treatment to the changes you’d like to hear so that your voice expresses your gender. These changes may involve more than changing how high or low your voice is. You may not know what changes feel right inside your body when you’re speaking without the guidance of a provider who’s attuned to your needs. Work with a provider who understands how voice and gender identity are related.