Gender-Affirming Voice Therapy
Gender Affirming Voice Modification aims to give non-binary and transgender individuals the tools to use their vocal instrument in any way that feels most affirming to them to improve their quality of life. This may vary from day to day, and that is why truly understanding how YOUR vocal instrument works is a vital step in finding your most comfortable voice. Having a skilled therapist to teach those techniques and provide feedback is invaluable.
As speech-language pathologists who specialize in voice rehabilitation, we have a unique and in-depth understanding of how voice is made. The way a person’s voice sounds has to do with so many different elements from the airflow to vocal fold closure/vibration to how we shape our throats and mouths. Believe it or not, we have control over every individual element that goes into creating a voice. Modification of one or more of these individual elements can greatly change how a speaker sounds. This is what transgender voice therapy is for.
Our aim as voice therapists and speech pathologists is not to tell you how you SHOULD sound, but to help you learn to use the vocal instrument you already have to sound the way you WANT while maintaining your vocal health and being true to your gender identity.
There are societal norms that exist that are traditionally deemed “feminine” vs. “masculine” voice characteristics. While these norms are not necessary to follow, it is helpful to understand how they play into vocal quality to inform a client’s decision about their voice modification.
The Benefits of Gender Affirming Voice Therapy
- Gender affirming voice therapy can help transgender individuals find their most authentic voice and feel more comfortable with how they sound.
- Through gender affirming voice therapy, speech therapists can educate transgender individuals on how to use their vocal cords in order to achieve the desired pitch and resonance they are looking for.
- With a personalized treatment plan, gender affirming voice therapy can give transgender women the tools to further express themselves through their voice and improve their quality of life.
- By understanding the different elements that go into creating a voice, transgender individuals can learn how to modify one or more elements in order to change how they sound without damaging their vocal cords or putting undue strain on them.
- Gender affirming voice therapy helps transgender individuals gain confidence in their own voices by giving them control of how they sound, allowing them to move away from traditional gender norms and create a unique and individualized vocal quality that suits their identity best.
The Role of a Speech-Language Pathologist in Gender Affirming Voice Therapy
A speech-language pathologist (SLP) is an important part of providing gender affirming voice therapy. SLPs are trained to assess and treat communication disorders, including vocal disorders. They have the knowledge and skills necessary to provide transgender clients with the vocal techniques they need to reach their voice goals safely.
When a transgender person is looking for gender affirming voice modification, they should find a healthcare provider who specializes in this area specifically and has experience working with transgender clients. An initial evaluation will be conducted where the SLP will assess the client’s current vocal techniques and determine what changes should be made in order to achieve the desired result. From there, the SLP can develop a personalized treatment plan for the client that includes appropriate vocal techniques and strategies for practice outside of therapy sessions.
During voice therapy sessions, SLPs can give transgender individuals feedback on how to modify their voices safely in order to reach their desired pitch and resonance while maintaining their vocal health. The goal of these sessions is for clients to gain understanding of how their vocal instrument works so that they can use it as effectively as possible.
Gender affirming voice modification requires patience and dedication on behalf of both the therapist and the client, but it also has great potential for improving a transgender individual’s quality of life by allowing them to express themselves through their own unique voice without compromising their safety or health.
There are many ways one can be perceived as more feminine when speaking. Research has been conducted on speech to determine what listeners deem as feminine-perceived speech in various situations. The following outlines the main categories that have been shown to lend toward feminine perceived speech in Standard American English.
While voice pitch is not the only feature used to achieve a more feminine-sounding voice, it is often one of the most important factors. Studies show that the average cisgender feminine speaking pitch is about an octave higher than the average cisgender masculine speaking pitch.
If you are a person who is AMAB (assigned male at birth) and has gone through puberty, the hormone testosterone has caused physical changes that thicken the vocal folds and thus deepened the voice. These physical changes in the voice box are irreversible without surgery. Taking estrogen and suppressing testosterone as part of hormone replacement therapy does not typically have an impact on vocal changes.
Transgender Voice Therapy can help you learn to use the muscles of the voice to adjust pitch so that your voice sounds higher. It is important to learn to do this in an efficient and healthy way from a trained clinician so that you do not cause vocal fatigue or lasting vocal injuries.
The definition of resonance is the reverberation of sound in space. When humans speak, resonance occurs in our chest, neck, and head. If you naturally have a larger head and neck, your voice may naturally sound large and full and booming. If you have a smaller head and neck, your voice may sound smaller and younger. A commonly used analogy is the difference in sound between a violin and a cello. They are very similar instruments but with different body sizes, making the same note on each instrument sound different (due to resonance).
Fortunately, resonance is not only created by our born bodily features. We can also shift where the reverberation of the voice is most prominent by how we shape our throat and mouth. Having a brighter, smaller, more forward resonance can give a sound that is more often deemed feminine, regardless of pitch. A skilled voice therapist can help you learn to isolate different muscles of the throat and face and figure out how to shape your resonant filter to create the resonance that feels most suitable to you.
In addition to resonance and pitch, various other communication characteristics can be modified to achieve a more feminine voice such as articulation, intonation, loudness level, nonverbal communication choices, word choice, and even facial expression. Each of these characteristics can be addressed with a skilled voice therapist to find a voice and communication style that feels most comfortable to you as a transgender woman.
AFAM individuals (individuals assigned female at birth) whose gender identity does not correspond with that, may choose to undergo testosterone hormone therapy. The current literature reports that testosterone deepens pitch by about an octave within the first 6-12 months due to an increase in vocal fold mass/vocal fold thickening. This tends to result in a low habitual pitch that is concurrent with a cisgender masculine pitch average. Any deepening of pitch is permanent whether testosterone is continued or ceased due to the non-reversible change in vocal fold mass.
Due to this effect of testosterone on the voice, voice/speech therapy for individuals wishing to masculinize their voice tends to be less sought out. But it is not without its benefits.
In addition, to pitch alone, like voice feminization, there are other aspects that make a voice sound more masculine. These include intonation, resonance, articulation, non-verbal communication, and loudness level.
Even if hormone replacement therapy alone has deepened the pitch of an individual’s speaking voice, working on these other aspects of communication can help an individual feel more comfortable and more in control of their vocal instrument.
NON-BINARY AND GENDER NON-CONFORMING SPEAKERS
If you are a gender-diverse person who does not feel that your gender aligns with either female or male and you wish for your voice to reflect a non-binary self, understanding the various aspects of traditionally gender-based norms in communication and learning to control your vocal instrument is the most effective way to find a voice quality that feels congruent with your gender identity.
Gender-Affirming Voice Telehealth
Telehealth services are offered to patients seeking gender-affirming voice care services. These services have been shown to be just as effective as in-person therapy without the barriers that come with an in-person office visit. With telehealth, your SLP will work with you to sound like your most authentic self. This is done through exercises targeting:
- Vocal Resonance
- Pitch range
- Tension release
- Musicality/ inflection
Advantages of telehealth
- Eliminates the need for travel
- Can be more cost-effective
- Saves time
- Can be conducted anywhere
- Improves access to care
Telehealth services can be delivered in several different formats. The American Speech-Language-Hearing Association (ASHA) defines these services as:
Synchronous— Services are conducted with real-time audio and/or video connection to create an experience similar to that achieved in an in-person traditional encounter. Synchronous services may include, for example, connecting a client or a group of clients with a clinician, or they may include consultation between a clinician and a specialist. Telehealth visits, virtual check-ins, e-visits, or virtual consultations are examples of synchronous services.
Asynchronous— Information, images, video, or data are saved and transmitted for viewing or interpretation at a later time. Examples include transmission of voice clips, audiological testing results, patient education materials, or outcomes of independent client practice. Store-and-forward or chat-based interactions are examples of asynchronous services.
Hybrid— A combination of synchronous, asynchronous, remote patient monitoring (e.g., wearable sensors, mobile apps), and/or in-person services are implemented to meet the needs of the individual client. An example includes using an online or a mobile app to share asynchronous information between the client and the clinician between synchronous in-person or virtual sessions.
At Becker ENT, we generally use a synchronous or hybrid approach.
Research has shown that acoustic measurements can be measured accurately via a telehealth interface. The use of an interface will vary by organization and may also vary by the patient and/or SLP internet connection. Some commonly used interfaces include Zoom, Microsoft Teams, Facetime, or Google Hangouts. Additionally, medical providers often use HIPPA-compliant interfaces including Doxy or BlueJeans so patient information remains protected.
It is important to conduct a telehealth session in a safe and quiet environment. For safety reasons, your provider may ask where you are conducting the session in case of an emergency.
To ensure you get the most out of your appointment, it is best to conduct the session in a quiet, well-lit private space. This will ensure minimal distractions. If you are conducting the session somewhere outside of your home, please be sure you are stationary and with a good internet connection.
Your SLP will walk you through the steps of each exercise from the comfort of your own home. So long as you have a stable internet connection, effective and efficient healthcare is just a click away!
GENDER-AFFIRMING SINGING VOICE CARE
Do you want to be able to sing higher or lower? Maybe you want to sing without tension and strain or have a wide range? Perhaps your goal is to develop a different vocal register/mode, and you have never sung in M1 (chest voice) or M2 (head voice/falsetto) before and want to develop these areas. Or do you want your singing voice to sound more gender-neutral, fluid, masculine, or feminine?
We can help with that!
With gender-affirming singing voice care, our team of voice-specialized Speech-Language Pathologists will evaluate your speaking and singing voice quality and work with you to develop customized vocal exercises and meet your voice goals.
Some goals may include:
- Establishing a daily singing voice warm-up routine
- Decreasing body tension through musculoskeletal release through circumlaryngeal massage and stretches
- Coordinating the vocal subsystems (respiration, phonation, and resonance) through evidence-based exercises including SOVTEs (semi-occluded vocal tract exercises)
- Understanding/training the different registers/modes of the voice such as M1 (sometimes referred to as “chest”), M2 (sometimes referred to as “head/falsetto”), or using a “mix” of these modes while singing.
- Vocal exercises and techniques to alter vocal tract shaping (sometimes called acoustics or resonance) in order to be perceived as more/less feminine, masculine, or non-binary.
- Finding a comfortable pitch range in which to sing as well as repertoire (songs) that fits that range.
Challenges and Potential Risks of Gender Affirming Voice Therapy
Gender-affirming voice therapy is a specialized form of speech-language pathology that focuses on helping transgender individuals to develop voice and communication patterns that accurately reflect their gender identity. This is a complex process that involves in-depth medical history review, in-depth evaluation of current communication patterns, and working in close collaboration with other healthcare providers. As with any type of medical treatment, gender-affirming voice therapy carries risks including vocal strain or damage due to overuse, difficulty transitioning to a new pitch range or mode due to lack of training or practice, and the potential need for transgender voice surgery if the desired goals are not achieved. It is important for transgender individuals considering this type of therapy to work closely with experienced voice specialists who understand the complexity of these issues and can help them safely navigate through this process.
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