How does gender-affirming voice therapy work?

For many transgender, gender nonconforming, and nonbinary people, changing your voice is a key part of the gender-affirmation experience. The process can involve medical intervention, vocal training, or both, depending on your goals and preferences. Many gender-diverse people, in fact, will choose not to pursue voice therapy. If you do wish to change your voice, there are experts and resources available to help you understand your options and guide your care.

What providers might I seek for voice therapy?

You may try to change the sound of your voice on your own. It’s important to realize, though, that doing so without professional help could lead to vocal fatigue, strain, or discomfort over time. This can happen as you put stress on the muscles around your vocal cords (also known as vocal folds). If you have access to the appropriate providers, there are a variety of specialists who can help you achieve your goals.

You might work with a vocal coach, a singing or theater teacher, or a medical doctor such as a laryngologist. Speech-language pathologists (SLPs) are often go-to providers. These specialists are trained to address overall vocal health, as well as behavioral changes related to voice and communication. Look for an SLP with experience working with gender-diverse people who also understands the various dimensions of gender-diverse physical and mental health.

“By finding a certified SLP, designated by ‘CCC-SLP’ after their name, you can be sure that you are being taught evidence-based, effective, and safe strategies by a licensed professional who can help assist you in your vocal transition while ensuring you aren’t straining or hurting your voice,” says Jessica Schwartz, MS, CCC-SLP, a speech-language pathologist and owner of Resonate Voice and Speech Services in Philadelphia, specializing in gender-affirming voice therapy. (The CCC indicates a certificate of clinical competence in the field.)

What are the main approaches to voice training?

Depending on your gender-affirmation goals, you may pursue masculinizing, feminizing, or androgynous voice therapy.

Voice feminization

If you’re taking feminizing gender-affirming hormone therapy (GAHT), you shouldn’t expect to experience substantial changes to your voice as a result. The estrogen typically used in feminizing GAHT does not affect vocal quality. Vocal training (with surgery, if needed) is thus the primary approach to feminizing one’s voice.

The aspects of your voice that an SLP will typically address include:

• Pitch (how high or low your voice sounds)
• Pitch range, or intonation (how much of a change in pitch you show during normal speech)
• Vocal resonance (the location from which your voice mostly vibrates, such as the chest, throat, lips or nose, and how you shape the sound of your voice in those areas)
• Prosody (the melody of your speech, which involves changes in loudness, pitch, and the stress placed on certain words)
• Articulation and speech rate (how clearly you say each word and how quickly or slowly you speak)
• Non-verbal communication, such as facial expressions, eye contact, and posture

Each of these factors can play a role in how you and others perceive your voice. Generally speaking, voices considered conventionally feminine have higher pitch and greater variability in pitch, while conventionally masculine voices are associated with lower pitch and greater use of stress or loudness.

Voice masculinization

If you’re taking masculinizing hormone therapy (testosterone), you might find that the thickening of your vocal cords that results from the hormones lowers the pitch of your voice to a level that meets your goals.

An estimated 84 percent of transgender men are satisfied with their voice changes after testosterone therapy, according to a 2018 review of research published in the International Journal of Transgenderism. If you feel you would also benefit from vocal training, an SLP experienced in working with transmasculine clients can help you adjust additional aspects of your voice, such as your breathing, resonance, and speaking patterns.

Androgynous vocal training

You may desire a voice that is neither conventionally masculine nor feminine. This is typically achieved using masculinization and/or feminization voice strategies shaped and guided by your goals. The approach may also focus on achieving communication characteristics perceived as gender-neutral, such as an average speaking pitch range.

Schwartz notes that while most clinicians who specialize in this area are familiar with voice training across the gender spectrum, it may be beneficial to speak to potential providers about their comfort level and experience with androgynous vocal training before beginning therapy.

Insurance coverage for voice therapy differs across insurers, so check with your provider before beginning therapy to find out how much, if any, of your therapy will be covered.

What can I expect at my first voice training appointment?

Intake appointments typically involve a four-stage assessment to enable your SLP to understand your situation and how best to work with you. (Depending on the healthcare practice, a laryngologist may also be involved in an initial examination.)

Step 1: Oral-motor examination: The SLP will examine your face, mouth, and throat muscles to check for weaknesses or coordination problems. Most people will have no issues here, but it is important that your SLP knows about anything that could affect your training before you begin.

Step 2: Voice evaluation: The SLP will test the current state of your voice, including your pitch, pitch range, resonance, articulation, intonation, and breathing.

Step 3: Communication skills assessment: The SLP will assess your current verbal and non-verbal speech behaviors during conversation. This can help you pinpoint the areas you’d like to change.

Step 4: Identification of goals: This is a conversation that helps the SLP determine what training elements you will need. A good SLP will take the time to understand what you want, create a plan that can get you there safely, and ensure that they stay true to your goals along the way.

You’ll typically set up a schedule of regular visits with your SLP. Voice therapy, particularly feminizing voice training, usually entails weekly sessions with an SLP over months or even years, depending on your goals and circumstances.

“It’s important to recognize that changing your voice is a process, and that it doesn’t happen overnight,” says Schwartz. “It takes time, practice, motivation, and mindset to make lasting behavioral changes.”

What about surgical options?

While the primary approach to changing your voice is typically voice therapy, surgery is also an option if therapy alone does not yield desired results. Surgeries for voice feminization tend to focus on raising pitch by making adjustments to the size, length, or tension of the vocal cords. Surgeries for voice masculinization are less common, and typically involve relaxing the vocal cords.

Feminizing laryngoplasty, for example, although rare, is becoming more popular as an alternative to feminizing voice training. This is appealing for some, because it can result in a bigger change in pitch and doesn’t require months of training or practice.

As with any surgery, there are risks to consider, such as the chance of permanent damage to your vocal cords. It can also be expensive, ranging from $5,000 to $10,000. Unfortunately, health insurance plans rarely view this surgery as “medically necessary,” so few will provide coverage for it. It’s also important to recognize that because voice feminization surgery will only change your pitch, it’s likely you will still need to work with an SLP on adjusting other vocal behaviors, such as intonation, prosody, and articulation.

If you’d like to pursue the surgical option, speak with your SLP about the potential benefits and risks.

Resources to explore

The best way to start on a course of voice therapy is to get a recommendation for an SLP from a knowledgeable and trusted primary care provider. If you need additional help identifying experienced and affirming voice providers, there are several online resources that can help:

• The American Speech-Language-Hearing Association offers a general database that allows you to search for people with specific experience in gender-affirming care.
• The WPATH Provider Directory is a comprehensive database of gender-affirming providers that includes speech and voice specialists.
• The voice page on Transgender Map offers information on several aspects of voice practice, including lists of voice therapists and teachers.