Many transgender men and women experience gender dysphoria (distress). Many seek help to reduce this.
A particular group, who identify as transsexual and have a firm belief their sex at birth is the opposite of their gender identity, frequently request help to transition to a gender presentation that matches their gender identity and experience. This commonly includes genital re-assignment surgery, cross-sex hormone therapy, voice and communication training, and social care.
One of the primary ways people express their gender is through their voice. Voice features such as pitch, voice quality and inflection signal the person's gender to others. Female-sounding voices, for example, are generally perceived as being higher pitched, slightly breathier and with more varied inflection than male-sounding voices.
A gender-nonconforming voice not only has impacts on a person's gender identity, but holds the potential to betray the individual's gender assigned at birth and to attract a great deal of negative societal reaction and stigma.
Voice change approaches
Many transsexual women and men seek specialised services to assist them to feminise or masculinise their voices. Feminisation or masculinisation of the voice can be achieved through voice training, cross-sex hormone therapy and/or laryngeal surgery.
Female-to-male men are fortunate in that their gender transition involves cross-sex hormone (testosterone) therapy that normally results in considerable masculinisation of the voice through increasing the size of the vocal cords and consequently lowering the pitch.
Although the lower pitch achieved through testosterone therapy may be sufficient for them to be perceived as male speakers, that is not always the case. Some will require voice training from a speech pathologist to help them access their altered pitch range, to habituate their new pitch into everyday speech and to masculinise their voice quality, resonance and intonation patterns.
Male-to-female women, in contrast, do not benefit vocally from cross-sex hormone therapy with oestrogens. Oestrogen therapy cannot feminise the voice in male-to-female women. Many therefore request voice feminisation training from a speech pathologist who is skilled in voice assessment and training for transsexual individuals.
The aim of voice training is to assist the woman to modify her voice so it becomes congruent with her gender identity and the altered voice sounds authentic to others.
Laryngeal surgery (surgery on the voice box) may also assist male-to-female women and female-to-male men achieve a more gender-conforming voice. This is particularly the case for those who can't achieve sufficient voice feminisation through voice training. For male-to-female women, surgical voice feminisation methods involve shortening the vocal cords and/or reducing their mass and/or increasing the tension on the vocal cords.
Each of these approaches is designed to increase the speed of vocal cord vibration and therefore increase the voice's pitch. More extensive surgery to the framework of the larynx and the pharynx (throat) can also enlarge the cavities of the larynx and the vocal tract above the larynx so that the voice sounds more masculine.
For female-to-male men, surgical voice masculinisation involves reducing the tension on the vocal cords so they vibrate at a lower rate. This lowers the voice's pitch.
While voice feminisation and masculinisation surgery is available worldwide, it is not routinely offered. This is because, although such surgeries can result in substantial pitch change, research shows outcomes are variable. Some are left with a gender-incongruent voice.
Laryngeal surgery can also lead to unwanted side-effects, such as poor voice quality, vocal fatigue, difficulty projecting the voice and reduced ability to vary the pitch of the voice in both speaking and singing.
However, surgical procedures are being refined. Research is under way to determine which surgical procedures are most effective, who is likely to benefit most from surgery, and whether the outcomes are enhanced with voice training before and/or after the procedure.
Voice training for male-to-female women
Targets for voice training are based on the woman's personal goals, the findings of the speech pathologist's assessment of the woman's current voice and vocal capabilities, and how research says people perceive gender from voice.
Training goals typically focus on increasing pitch into the average range for non-transsexual women. Other goals include decreasing vocal effort and loudness, and increasing breathiness (allowing a small amount of air escape between the vocal cords).
In some cases, feminising vocalised pauses (such as "mmm" and "oh"), throat clearing, coughing and laughing will be necessary.
Educating the client about the lifestyle, diet, exercise and vocal habits that maximise vocal health are also important, especially given the woman's vocal structures remain anatomically male and that voice change is therefore highly vocally demanding.
Voice training usually involves about ten individual sessions of 40 minutes to one hour supplemented by a small number of group sessions. This training aims to maximise transfer of the new voice into everyday communication and to facilitate compliance with the relatively demanding vocal practice regime.
The practice is not painful, but can be tiring. The fatigue is mainly mental – the person has to consciously control their voice whenever they talk, especially early in the training process.
Voice training methods include imitation of female voice models, instruction on how to alter the position of the larynx in the neck, the tightness of the vocal cord muscles, the rates and ranges of movement of the vocal cords, lips, tongue and jaw, and exercises that promote increased vocal flexibility.
Specialised apps such as Sonneta Voice Monitor are now available, so users can monitor their own development. Ongoing and extensive practice of the new voice skills outside of voice training sessions is essential.
Further studies are required to reach unequivocal conclusions. But it's particularly encouraging that all studies published to date show most male-to-female women achieve substantial vocal improvements following training. Virtually every client is satisfied with their voice outcomes.
This article first appeared in The Conversation