Transgender voice therapy

Procedure undertaken by transgender people

"Voice therapy" or "voice training" refers to any non surgical technique used to improve or modify the human voice. Because voice is a social cue to a person's sex and gender, transgender people may frequently undertake voice training or therapy as a part of gender transitioning in order to make their voices sound more typical of their gender, and therefore increase their likelihood of being perceived as that gender. Having voice and speech characteristics align with one's gender identity is often important to transgender individuals, whether their goal be feminization, neutralization or masculinization. Transfeminines trying to feminize their voice represent the largest group seeking speech therapy services, therefore, most studies regarding transgender voice have focused on voice feminization, as opposed to voice masculinization. Therapy has been shown to be effective in voice feminization, and the modification of certain voice characteristics, such as fundamental frequency, vocal weight and voice resonance, can help in that effect. Fundamental frequency, closely related to pitch, was initially thought to be the characteristic most effective in voice feminization. Raising the fundamental frequency can help towards voice feminization. However, each person might have different perspectives regarding speech and voice, and therefore the salient characteristics, and their relative impact on femininity, can vary from person to person, and many people are not satisfied with only a change in fundamental frequency. What is considered a feminine or a masculine voice varies depending on age, region, and cultural norms. However, testosterone replacement therapy does not always deepen the voice to the person's desired level, and others choose to not undergo masculinizing hormone therapy at all. Overdevelopment of vocal folds in an undescended, small larynx can result in a condition named "entrapped vocality" with permanent hoarseness, and lack of passing. Other areas that transgender men may benefit from training are embouchure and maintaining high CQ (closed quotient, a quotient of how long the vocal folds are touching to how long the cycle of vibration lasts), responsible for "heavy" or "buzzy" voice quality.

In the case of AI vocal gender identification examples, key features noted to effect gender perception included fundamental frequency and formant frequency as well as further source related measures including cepstral peak prominence (a rough measure of harmonicity in voice with low values indicating a higher likelihood of dysphonia) and rolloff in energy between the first and second harmonics. A 2020 study in the International Journal of General Medicine noted other factors being involved in gender perception, saying: "a minimum F0 value of 180 Hz required for a voice to be perceived as feminine". Vocal gender presentation can be assigned by speakers even as things like fundamental frequency stay the same, especially where we see formant frequencies changing, which is noted as important for gender presentation alongside fundamental frequency.

Therapy may take place in an individual or group setting. The most common focus in transgender voice therapy is pitch raising or lowering; however, other gender markers may be more important for an individual to work on.

A lack of training on how to use their new voice may cause some transgender men to have increased muscle tension. Informational erasure and institutional erasure were identified in a 2009 Canadian study of health care for transgender people as being the most prominent barriers to care. During adolescence, there is an increase of both vocal tract size and vocal fold length, especially for those assigned male at birth, which affects the voice and pitch. Because of these physical changes and hormonal changes, it is difficult to focus on pitch. Previous studies have shown that therapy shaped from adult therapy can be effective.

There are two major areas of controversy for professionals working on the voices of transgender people. The first is regarding vocal surgery, and the second is regarding genderfluid and bigender voice therapy. Professional opinion is mixed regarding the use of vocal surgery. There is currently a lack of outcome data, particularly longitudinal data, for pitch elevating surgery, and outcomes have not been well monitored over time. Because of this, some SLPs do not think that phonosurgery is a viable treatment option. Others believe it is, and still others believe it should be considered only as a "last resort" after the desired pitch change has not been seen in therapy. Critics cite variability in outcome, lack of outcome data, and reported negative effects like compromised voice quality, decreased vocal loudness, adverse impact on swallowing/breathing, sore throat, wound infection, and scarring as reasons to avoid vocal surgery. Proponents argue that surgery may protect a person's voice from damage caused by repetitive strain to elevate pitch in therapy. Ultimately, the decision to undergo surgery is up to the patient, with input from a knowledgeable physician and SLP. There is also some controversy regarding the use of a genderfluid voice. A person may want to have both a masculine and a feminine voice in their vocal repertoire, possibly to fit with their own genderfluid identity, or to read as a different gender in different contexts. Some clinicians will not train genderfluid voice, arguing that it decreases the opportunity for practice, and it may be difficult or even damaging to the vocal folds for the person to switch from one voice to another. However, Davies, Papp and Antoni (2015) reference the ability of actors to use different accents and dialects, and people to learn different languages as a sign that training a genderfluid voice may be a viable treatment goal.