Gender-affirming (transgender) voice therapy and surgery

Gender-affirming voice therapy and surgery help transgender and gender-diverse people adjust their voices to communication patterns that fit their gender identity. These treatments also are known as transgender voice therapy and surgery. They may be called voice feminization therapy and surgery or voice masculinization therapy and surgery.

These treatments can help change voice characteristics, such as pitch and resonance, as well as voice quality. They also may address nonverbal communication, such as eye contact, hand gestures and facial expressions.

The type of gender-affirming voice care you get depends on your needs. Your healthcare team can help you decide on your goals and create a plan. The team also can show you how to avoid vocal fatigue and damage as you expand your voice and speech.

Voice and style of speech are highly personal. You may not feel comfortable or familiar with the changes at first. Keep in mind that modifying how you speak takes time.

People who seek gender-affirming voice care often want their voices to better fit their gender identity. The treatments may ease discomfort or distress due to differences between a person's gender identity and sex assigned at birth. That condition is called gender dysphoria.

Gender-affirming voice therapy and surgery also may be done for safety reasons. Some people whose voices don't match their gender identity have concerns about possible bullying, harassment or other safety issues.

Not all transgender and gender-diverse people choose to have voice therapy or surgery. Some are happy with their current voice and do not feel a need to get this treatment.

Long-term voice, speech and communication changes involve using the body's ability to make sound in new ways. If not done correctly, making those changes can lead to vocal fatigue. A speech-language specialist can work with you to help avoid vocal discomfort.

Gender-affirming voice surgery usually focuses only on changing pitch. For voice feminization surgery, the focus is to raise speaking pitch. The surgery also reduces the ability to make a low-pitched voice. That means the overall pitch range is smaller. The surgery reduces the voice's loudness too. That may make it hard to shout or yell.

There is a risk that the surgery could cause the voice to become too high or not high enough. The voice also may become so rough, hoarse, strained or breathy as to make communication hard. The results of most voice feminization surgeries are permanent. Your healthcare team may recommend voice therapy before and after surgery.

Voice masculinization surgery isn't as common as voice feminization surgery. This surgery focuses on lowering the pitch of the voice. It does this by decreasing the tension of the vocal folds. The surgery may change voice quality, and it cannot be reversed.

If you're considering gender-affirming voice therapy or surgery, ask your healthcare professional to refer you to a speech-language specialist. That specialist should have training in the assessment and development of communication skills in transgender and gender-diverse people.

Before you start treatment, talk with the speech-language specialist about your goals. What communication behaviors do you want? If you don't have specific goals, your speech-language specialist can help you explore the options and make a plan.

A voice coach or singing teacher also may play a role in helping you reach your goals. If you decide to work with this type of professional, look for one who has experience working with transgender and gender-diverse people.

Gender-affirming voice therapy

Gender-affirming voice care can include speech therapy aimed at making your voice and speech more feminine, gender neutral or masculine. Or it may help you change between masculine, gender-neutral and feminine voices. This is called a gender-expansive voice.

For transgender men and others who want a deeper voice, some voice deepening may be achieved with masculinizing hormone therapy. Gender-affirming voice therapy along with masculinizing hormone therapy may be helpful to:

• Learn communication styles that match gender identity.
• Work on the rhythm of words, the way words are stressed, and the melody and emotion of speech. This is called prosody.
• Understand how airflow and vocal techniques can help with the change to more bulky vocal folds.

Feminizing hormone therapy that includes anti-androgens and estrogen doesn't change the voice.

Speech therapy may focus on:

• Pitch. Pitch is how high or low a voice sounds. The frequency of a sound controls its pitch. Voice frequency is how fast the vocal cords vibrate when a sound is made. The faster the frequency, the higher the pitch.

  Frequency is measured in hertz (Hz). In general, for voices that sound female, vocal frequency stays above about 165 Hz. For voices that sound male, vocal frequency stays below 165 Hz.

• Prosody. Prosody is the rhythm of words and the way words are stressed, along with the melody and emotion of speech. Prosody may differ by gender. For example, men tend to use stress or loudness for emphasis. Women often use changes in pitch for emphasis.

• Vocal resonance. Vocal resonance is where you feel vibrations when using your voice. The location of vocal resonance isn't fully dependent on gender.

  For example, in a throaty resonance, the vibrations are focused in the throat or chest. In a forward resonance, the vibrations are felt around the lips and nose. A speech-language specialist can help you find a resonance that reflects who you are.

• Ear training. This training can help you hear differences in your voice and define vocal targets that are right for you.

Speech therapy also may address:

• Voice quality.
• How you speak and pronounce words. This is called articulation.
• How fast you speak and phrases you use.
• Nonverbal communication. That may include eye contact, hand gestures, facial expression, posture, head nodding and other movement.

During a speech therapy session, you learn and practice ways to modify your voice. You may use a phone app, keyboard or piano to help find the target pitch. Computer software that can detect the pitch, loudness and quality of your voice also may be used. This technology can help measure your progress and provide feedback.

How often you have gender-affirming voice therapy sessions and how long they last depend on your needs. A typical session lasts about 20 to 40 minutes. They may be individual or group sessions.

Gender-affirming voice surgery

Gender-affirming voice surgery can modify voice pitch. Talking to a surgeon, a mental health professional and a speech-language specialist before surgery may be useful. These healthcare professionals can help you make a well-informed decision about the timing of surgery and the effects the surgery may have.

For voice feminization surgery, the two options used most often to raise voice pitch include:

• Anterior glottic web formation. This surgery creates a web or a band of scar tissue at the front of the V of the vocal cords. The medical term for that structure is the anterior commissure. The surgery shortens the vocal cords to raise voice pitch. It affects a voice's frequency range by eliminating the ability to make lower pitches. It also narrows the airway somewhat. Because of that, the surgery might not be a good choice for professional singers or others who use their voices professionally.
• Cricothyroid approximation (CTA). This surgery raises vocal cord tension. The result is a higher speaking pitch and less ability to lower pitch. But studies have found that the effects of this approach are not long-lasting.

Voice masculinization surgery to lower the voice is less common than voice feminization surgery. But it may be an option for people who aren't happy with the pitch of their voices with hormone therapy alone. Surgery to lower the pitch of the voice includes:

• Thyroplasty type 3. This surgery lowers the frequency of the voice by decreasing the vocal fold tension.

Your healthcare team may suggest that you have voice therapy before and after surgery. The therapy focuses on aspects of your voice and speech that surgery can't change.

Finding a voice that feels true to you is an individual process. Gender-affirming voice therapy and surgery are tools you can use to help you meet the goals you have for your voice.

The results of gender-affirming voice therapy and surgery depend on the treatments used. The amount of time and effort you put into voice therapy can make a difference too. Voice changes take time and commitment.

Gender-affirming voice therapy requires practice and exploration. Be patient with yourself. Allow time for the changes to happen. Talk to people you trust about your experiences and feelings. Continue to work with your speech-language specialist to meet goals that reflect who you are.