What is gender-affirming vocal care? The medical field helping people find their voice

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When Mattie Kimberly “Kimi” Klauser was growing up, singing was an escape. But by the time the professional opera singer hit her late 20s, she could barely listen to herself.

“Since I was a kid, my voice has always been my protection ... so this thing that protected me and represented me started to become my enemy,” Klauser, who is a transgender woman, recalls.​​

Now 37, Klauser has undergone facial feminization surgery, hormone therapy and a tracheal shave, which reduces the size and appearance of the Adam’s apple. She’s also been in vocal therapy for years for both singing and as part of her gender transition, and while she feels she’s come a long way, she still has some discomfort with her voice.

“Sometimes, when I’m a passing trans person, if I speak in a way that’s too deep or masculine, that’ll be the thing that outs me,” says Klauser. “When I’m having vocal dysphoria, sounds will come out of my mouth and I’ll just feel so bad. ... There was about a year where I couldn’t talk on the phone because I was so frequently getting misgendered.”

When a person’s voice doesn’t align with their gender identity or how they want to be perceived, also known as vocal dysphoria, it can be distressing for transgender and nonbinary individuals and even jeopardize their safety, experts say.

Rare but on-the-rise procedures referred to as gender affirming vocal surgery can help trans and nonbinary individuals with this problem. About 1% of trans women have had it, the Cleveland Clinic estimates.

Due to an issue with her voice box, as well as the time away from singing the recovery would require, Klauser was not a candidate for the procedure — which, in trans women, shortens, thins or tightens the vocal cords to raise the pitch of the voice. So, she’s continuing with voice therapy with a specialized speech-language pathologist.

While not all transgender or nonbinary people want to change their voice, gender-affirming vocal care, from surgery to speech therapy and medication, can be a life-changing part of transitioning.

Gender and how you speak

When you speak, air from your lungs blows through your vocal cords, causing them to vibrate. The size and shape of your vocal cords, throat and mouth affect the volume, pitch and tone of your voice, the National Institutes of Health explain.

Your voice changes over time, depending on your sex assigned at birth and exposure to hormones.

For example, when the body is exposed to testosterone, either during puberty or through gender-affirming care, the throat, voice box and vocal cords grow larger and thicker, causing them to vibrate at a lower frequency than they would if exposed to estrogen, Dr. Mark Courey, a laryngologist and director of the Grabscheid Voice and Swallowing Center at Mount Sinai, tells TODAY.com.

The shorter and thinner the vocal cords, the higher the pitch — “just like a violin has a higher pitch than a cello,” Dr. Brandon Baird, otolaryngologist and co-director of the University of Chicago Medicine Voice Center, tells TODAY.com.

Additionally, people tend to shape their speech according to their environment and how they want to be perceived, says Courey. “There are physical differences, and there are learned differences. I refer to these as a male or a female accent,” he adds.

However, there is a large amount of variability in voice. “Everyone’s voice is unique,” AC Goldberg, Ph.D., visiting assistant clinical professor at Northeastern University and the founder of the CREDIT Institute, tells TODAY.com.

Many transgender and nonbinary individuals are happy with the way their voices sound. Others may feel that their voice does not align with their gender identity or how they want to be perceived, known as vocal dysphoria, says Goldberg.

Safety is another reason many people seek gender-affirming vocal care. A 2021 study found that transgender people were four times more likely than cisgender people to be victims of violent crime.

“I felt tremendously anxious when my voice and gender presentation weren’t aligned because people would stare, misgender me, and I felt unsafe,” Goldberg, who is transgender and uses he/him pronouns, explains.

There are many different types of gender-affirming voice care, from voice therapy to hormones or surgery to alter the pitch of the voice. Care may focus on masculinization or feminization of the voice, or achieving a gender-ambiguous voice.

Gender-affirming speech therapy

Gender-affirming vocal care often starts with speech therapy or voice training from a specialized speech-language pathologist.

“Transgender people who’ve tried to modify their voice on their own, without guided instruction, often do it in inefficient, tense ways that can make the voice worse,” says Courey.

A speech language pathologist may work on how to safely change things like pitch, resonance, intonation and even people’s word choices and ways of signaling their genders verbally, says Goldberg.

“We want to make sure that we’re doing it in a way that’s healthy, and not going to be straining or damaging. We’re aiming for a pitch that’s comfortable and sustainable,” Dana Hayes, an advanced speech-language pathologist with University of Chicago Medicine, tells TODAY.com.

Patients seeking voice feminization may work on pitch elevation, says Hayes, or techniques to lighten the voice or brighten the resonance, for example.

Not everyone who gets gender-affirming voice therapy is looking to develop one new, habitual voice. “There are non-binary people who might want to be read as feminine ... in some situations (but) not in others, and want a multitude of voices to express the full breadth of their gender identity,” says Goldberg.

The goal of gender-affirming vocal therapy is to give patients the tools to achieve an authentic voice that they can safely maintain on their own, says Hayes. This can take anywhere from weeks to years, says Goldberg.

“After patients finish their course of voice therapy, about 95% of them are very happy with the result, and 5%, maybe 10% feel they’re having trouble meeting their goals or sustaining them,” says Baird. These patients may seek out medical or surgical interventions.

Voice masculinization treatments

Transgender and nonbinary people seeking to lower their voice may try hormone therapy.

“(Patients) are able to take testosterone either by injection or gel, and there’s a significant pitch alteration,” says Baird. Testosterone will have its full effect on the voice within six months of continuous administration, Courey adds.

Esti Blanco-Elorrieta, a 33-year-old professor of psychology and neuroscience based in New York City, says hearing their voice had always irked them. Blanco-Elorrieta, who identifies as nonbinary, started speech therapy, but testosterone only took a few months to dramatically drop their pitch. “My voice started breaking after about one month. By (six months) it was much, much lower. ... It was fast.”

But hormone therapy alone doesn’t always help people achieve the results they want, Goldberg notes.

For example, many trans men seek vocal treatment after going through puberty, so they’re starting with a smaller voice box and throat, Courey explains. In these cases, testosterone may not make their voice as low-pitched as they want, so combining testosterone with speech therapy can help them further deepen their voice to be perceived as more masculine, he adds.

Vocal masculinization surgery is less common, but it is an option for those unsatisfied with hormone and voice therapies. One version is called thyroplasty type III, where the voice box is shortened, loosening the vocal cords and preventing them from reaching higher pitches. Injecting fat into the vocal cords can also bulk them up to help them go deeper.

Vocal masculinization surgery can help some patients, but it has risks. These include a major drop in volume or the voice sounding breathy and hard to hear in loud environments, Courey adds.

Vocal feminization surgery

Suppressing testosterone and administering hormones like estrogen can result in physical changes, but these will not alter a person’s pitch, Goldberg notes. Vocal feminization surgery can create a higher, more feminine voice by shortening, thinning or tightening the vocal cords.

There are a number of approaches done by different providers around the world, says Baird. These include:

  • Wendler glottoplasty or endoscopic vocal fold shortening

  • Feminization laryngoplasty

  • Laser-assisted vocal fold surgery

  • Cricothyroid approximation

The most common gender-affirming vocal surgery performed by laryngologists is the Wendler glottoplasty, says Baird. During this surgery, which is performed through a tube inserted in the mouth, a laryngologist sutures together the very front of the vocal folds to form a scar (called an anterior glottic web), which shortens the vocal cords and raises the pitch.

Vocal feminization surgery is an evolving field, the experts note, and there have been many advancements in recent years. But results vary.

“We can (typically) get patients into the top of the gender neutral or bottom of the feminine pitch range,” says Courey. Speech therapy following surgery can help further elevate pitch and feminize speech.

A major risk of shortening the vocal folds is that it can decrease the amount of air that can go through the voice box, which can create a quieter voice, says Baird. Other risks include a weakened voice, a hoarse voice or an unnaturally high-pitched voice.

Gender-affirming voice surgery, especially the Wendler glottoplasty, is typically well-tolerated, says Baird. However, it may not be recommended depending on a patient’s health status or anatomy, like in Klauser’s case.

The recovery after gender-affirming vocal surgery varies, but it usually takes about two to three months. It may take patients longer, though, to attain their desired voice, and speech therapy is usually necessary, like “when you get a hip replacement and need physical therapy,” Goldberg explains.

Finally hearing yourself

Klauser says voice therapy has been one of the most challenging parts of her transition, especially as a singer. She is still working with a team to find a voice that makes her feel at peace.

For Blanco-Elorrieta, finally sounding the way they wanted came with a sense of “relief.”

“Earlier, when I would hear my voice in the loudspeakers or recordings ... there was a nagging feeling of discomfort. I would be confident in what I was saying, but not how it sounded,” says Blanco-Elorrieta.

“The moment in which I started to sound the way I wanted to sound … it felt so good,” they explain. “Voice in particular was one of those things that you don’t realize how heavy of a burden it is until you’re no longer carrying it, and suddenly you feel extremely light.”

“When it started changing my voice, it felt like I was starting to hear myself for the first time.”

This article was originally published on TODAY.com