Voice feminizing therapy and surgery

Overview

Voice feminizing therapy involves treatments to help transgender women (male to female) adapt their voices, resulting in communication patterns that match their gender identity. Treatments can help you change vocal characteristics, such as pitch and intonation, and nonverbal communication patterns, such as gestures and facial expressions. Surgery to raise your pitch also might be an option.

The way people speak, including their style, voice and choice of words, is highly personal. You'll choose which communication behaviors you want to acquire in agreement with your gender identity. Voice therapy shouldn't counsel you to adopt behaviors that aren't right for you. Also, keep in mind that changing your voice can take years and these changes can feel uncomfortable or inauthentic at first.

Voice feminizing therapy treatments depend on your needs. A specialist can help you determine your goals and create an individualized therapy plan, as well as show you how to prevent vocal damage as you change your voice.

Why it's done

Trans women who seek voice feminizing therapy want to adapt their voices and communicate in a way that matches their gender identity. This can help lessen the feeling of discomfort or distress that might accompany a difference between gender identity, 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, such as harassment, in certain circumstances.

While voice deepening sought by transgender men can typically be achieved by masculinizing hormone therapy, feminizing hormone therapy doesn't have the same impact on transgender women's voices. Anti-androgens and estrogens have no effect on the voice.

Voice feminizing therapy isn't right for all transgender women. You might prefer a non-normative voice to signal your distinct transgender identity. The decision is up to you.

Risks

Feminizing the voice involves using the voice production mechanism in a new, nonhabitual way. Your speech-language pathologist will work with you to help prevent vocal misuse and vocal damage.

Surgeries for voice feminization focus on raising habitual speaking pitch by 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 (dysphonic) as to make communication difficult. Because voice feminization surgery will only change your pitch, you may still need to work on other vocal behaviors.

How you prepare

If you're considering voice feminizing therapy, ask your doctor to refer you to a speech-language pathologist. Look for a specialist with training in the assessment and development of communication skills in transsexual, transgender and gender-nonconforming clients, and who has a basic understanding of transgender health, treatments and psychosocial issues. Professionals such as vocal coaches or 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 pathologist can explain some options.

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

What you can expect

Voice feminizing therapy can include speech therapy aimed at feminizing your voice or laryngeal surgery with therapy before and after surgery.

Targets of voice feminizing therapy might include:

• Pitch. The average speaking fundamental frequency of adult males is approximately 107 to 120 hertz (Hz), while for females it's 189 to 224 Hz. To be perceived as female, it's helpful for the voice to stay above around 165 Hz.
• Prosody. Prosody is the melody of speech and includes loudness, pitch and stress changes. 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 pathologist can help you find a healthy resonance that reflects who you are. This takes practice, exploration and experimentation with your voice.

Therapy will 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 feminize 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 also might consider surgery to raise the average speaking pitch of your voice. Your surgeon will explain how much surgery can be expected to change your voice and the possible risks.

Voice surgery doesn't require the referral of a mental health provider. However, talking to a surgeon and mental health provider 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 fixes the cricoid cartilage to the thyroid cartilage, elongating the vocal cords. 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.

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.

Keep in mind that surgery to minimize the thyroid cartilage or Adam's apple (tracheal shave) isn't considered a voice feminizing procedure.

Results

Finding a voice that matches your gender identity and feels true to you is an individual process. Voice feminizing therapy and surgery are tools that can help your voice sound more feminine.

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 higher pitch doesn't guarantee being perceived as female, 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. You might even fear comments about your new voice. Try to focus on enjoying what you're doing for yourself. This can help you weather feelings of anxiety and self-consciousness.