Aligning voice and identity.
About
The Vocal Congruence Project (VCP) is a collection of free and accessible resources to help you find an affirming and congruent voice.
Congruence is defined as "agreement or harmony; compatibility." Our mission is to help people find vocal congruence — the sense that their voice and speech accurately reflect who they are — which has a proven positive impact on mental wellbeing.
VCP is a collaboration between Leah B. Helou, PhD, CCC-SLP, and Connor Mahon, MS, CF-SLP. It draws from Dr. Helou's 20+ years of experience working with the transgender and gender diverse community as a speech-language pathologist, and is additionally informed by community input.To stay up to date on the Vocal Congruence Project, join our mailing list.
Provider Map
This map includes gender affirming voice and communication providers of all disciplines, as well as providers of gender affirming voice surgery.How to use the map:
Select a pin to learn more about each provider. Please note that locations are approximate.
Select a state to see all Speech-Language Pathologists offering virtual services there. Most providers that are not SLPs offer services nationally or globally.
Select the icon in the top left to sort by provider type and browse entries as a list.
Select the icon in the top right or the button below to open the map in a new tab and search by name.
Need help finding the perfect provider for you? Contact us.
Resources
These resources are designed to help you navigate the process of finding vocal congruence, independently or with a provider. They were written with the transgender and gender diverse community in mind, but can be used by any person seeking vocal congruence. Have feedback or a request? Connect with us.
Gendered Voice & Effects of Hormone Replacement Therapy
Learn how your voice works, which aspects are relevant to gender perception, and how HRT and transitioning can change your voice.
Independent Practice & When to Seek Support
Learn about changing your voice on your own and the resources that can support you, as well as when and how a provider can help.
Finding Practice Partners & Opportunities
See common ways to practice in private or with a partner, and guidance on overcoming obstacles like dysphoria, limited time, or lack of motivation.
Types of Gender-Affirming Voice Provider
Read about the most common categories of gender affirming voice and communication training providers, including potential benefits and considerations of each.
Choosing a Gender-Affirming Voice Provider
Review common red flags and green flags when searching for a voice and communication provider, including questions you can ask to find the best fit.
What to Expect Working With a Speech-Language Pathologist
Learn more about Speech-Language Pathology and when an SLP might be the right choice for you, as well as what to expect from your first appointment.
Overview of Gender Affirming Phonosurgery
Discover how surgery to change the voice works and when it might be right for you, as well as common surgical approaches and tips for finding and selecting a surgeon.
Identity-Affirming Voice & Communication Training
Explore how a voice and communication provider can support all people and their individual needs, including cisgender speakers and non-gender related goals.
More Content Coming Soon!
Wondering where to start, have feedback, or want to suggest a resource? Connect with us.
Outreach
Help us reach those who would benefit from our resources! If you are connected to organizations or individuals serving the trans and gender diverse community, we would greatly appreciate you sharing VCP with them.
Inquire with local gender affirming care providers, mental health providers, and staff at LGBTQ+ centers or other community spaces about adding VCP to digital and print resource lists and handouts.
Share VCP on social media to reach your personal network.
Research voice providers in your area and invite them to check out and join our Provider Map.
Share on social media:
Downloadable materials:
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Mailing List
Join our mailing list to learn about updates, new resources, and more. Emails are infrequent and you can opt out at any time.
Support
VCP does not currently accept direct donations. We ask that anyone interested in supporting us financially instead donate to one of the following causes affiliated with the VCP team. Please indicate in your donation comments if you came from VCP.
LGBTQ+ Communication Sciences & Disorders Student Association - national nonprofit providing community, mentorship, and advocacy for LGBTQ+ students of speech-language pathology and audiology. Co-founded by Connor Mahon.
Camp Lilac - nonprofit summer camp for trans and gender diverse youth, ages 13-17. Co-directed by Connor Mahon.
How VCP Uses Your Donations
As a community-centered initiative, we aim for maximum financial transparency. Donations and grant support are applied to the following operational expenses in the order presented:
Website Hosting - Includes annual costs of our domain name and website builder.
Map Hosting - Includes licensing the Google Maps API, which is priced per view.
Outreach & Promotion - Includes print materials, postage, and registration for relevant events and conferences.
Third Party Labor - Includes development of the Provider Map, or contributions to resources beyond the knowledge of the VCP Team. When possible, transgender/gender diverse community members will be selected for paid opportunities.
VCP Team Labor - Includes development of resources, administrative tasks, etc.
Donations are accepted via Ko-Fi. Ongoing donor-supported projects and goals are highlighted there.
Support
Donations support a range of operational costs, from web hosting to outreach. Please consider supporting VCP so that we can continue to provide resources at no cost to the community.
Independent Practice & When to Seek Support
What Can I Do Independently?
Finding an identity-affirming voice can be a daunting task. Fortunately, there is no “right” way to go about this process.Some individuals find they can achieve a congruent voice entirely on their own, with or without the support of online resources. In keeping with the language used by WPATH, we call this “self-initiated change”. Others may find it difficult to even begin without the support of a voice training provider.One thing anyone can do is try to explore their voice on their own. There is no right way to explore. Some ways to start include using an accent, character voice, or celebrity impression. You can also try to isolate and adjust a single element, like pitch or nasality. You might try singing and then moving that way of using your vocal instrument into the realm of speech. Try to do anything but your default voice.While exploring, pay attention to how sounds feel, both physically (e.g., tense, open) and emotionally (e.g., affirming). As you familiarize yourself with your instrument, pick and choose areas to explore more deeply if they feel affirming or productive. This will help you build skill in manipulating your voice, as well as develop your goals. Try to not get hung up on what you do not like. Self criticism can be degrading to not just self esteem but also to the possibility of change.
Resources Supporting Self-Initiated Change
Beyond exploration, many resources offer instruction on how to achieve a more congruent voice. They may provide information about acoustics and voice production, gender perceptions, and exercises to practice manipulating certain characteristics of your voice.Broadly, these may include:
Video Tutorials – Such as those offered by TransVoiceLessons on YouTube, or Renée Yoxon on Instagram.
Mobile Applications – Such as Voice Tools, which analyzes audio recordings to display information on pitch, resonance, volume, and more. Applications with an instructional focus, like Christella VoiceUp or PRYDE Voice and Speech Therapy, are also available.
Forums or Community Groups – Such as the r/TransVoice subreddit. Communities commonly invite users to share audio for feedback from other users.
Benefits of Self-Initiated Change
Self-initiated change has a number of benefits:
Free or low cost
Unaffected by legislative forces limiting access to gender affirming services
Able to be done from home or anywhere else, allowing for confidentiality and privacy
Allows for easy exposure to many perspectives, techniques, explanations, etc
Commonly created by members of the trans and gender diverse community with lived experience changing their own voices
Often include opportunities for comments by other users, which can enrich the resources and flag problematic resources
Additional Considerations for Self-Initiated Change
Due to the nature of self-initiated practice, it is important to note the following considerations:
There is no single formula, approach, or set of exercises that will result in a congruent voice, and online resources are not individualized.
No one technique can possibly work for every user. If something seems attractive but just doesn’t work for you no matter how hard you try, be prepared to just drop it and move along.
Next steps may not always be apparent and motivation may be difficult to maintain.
With new vocal habits comes the risk of developing a vocal pathology, which almost always works against gender-affirming voice and communication goals. Read on to learn more.
When to Seek Support
Uncertain Beginnings
If you’re uncertain of how to begin or how to move through the process of vocal change, a voice and communication training provider can assist by providing tailored guidance. This may be especially true if you find the process of exploration (described above) feels out of reach.
Anxiety & Overwhelm
If stress or anxiety are obstacles for you, a provider can provide a safe and affirming space for your first steps. If you are feeling overwhelmed by the amount or variety of resources supporting self-initiated change, it is okay to start working with a provider immediately. Independent efforts are not a prerequisite.
Accountability & Structure
If you find it difficult to commit time or find opportunities to practice, a provider can offer accountability and a structured checkpoint each session. This may motivate you to practice between sessions, and provides a dedicated time for intentional practice. They can also work with you to develop a home practice schedule, troubleshoot ways to practice discreetly, or other tailored approaches.
New Techniques
If you have explored your voice or engaged in practice on your own, you likely have a growing list of ways to change your voice. If you feel these aren’t enough to reach your goals, a provider can provide new exercises or methods for you to try.
Troubleshooting
If you are not making progress or cannot find your most congruent voice despite effort and practice, there may be another factor at play. A voice training provider can assist you in identifying and addressing obstacles, and offer individualized feedback and suggestions.
Feedback & Awareness
If you have difficulty hearing changes in pitch, resonance, or any other component of voice you are seeking to change, a voice provider can provide useful feedback. They can also help you build your auditory awareness to hear the components yourself, which can facilitate home practice.
Vocal Pathology
A voice disorder can affect how your voice sounds, feels, or functions. Those with a voice disorder may experience sensations of vocal fatigue, strain, effort, pain, or similar. They may have a rough, breathy, or hoarse-sounding voice. They may lose the ability to use a loud or a quiet voice, to access certain parts of their pitch range, or to use their voice for extended periods of time. Voice disorders may emerge during training as a result of unhealthy practice patterns, or they might characterize one’s baseline voice.A voice disorder will make it more difficult to achieve a congruent voice. A voice-specialized Speech-Language Pathologist can assist you in establishing a healthy baseline voice and addressing practice patterns that may have contributed to a voice disorder. If you experience any of the symptoms above, we recommend seeking out a speech-language pathologist with expertise in voice disorders. For assistance finding one, see our provider map.
What to Expect Working With a Speech-Language Pathologist
About SLPs
Speech-Language Pathologists (SLPs) are medical professionals who evaluate and treat a variety of speech, language, voice, and swallowing disorders. They can additionally provide elective services, like gender affirming services.SLPs hold a Masters Degree, must be licensed by the state(s) they practice in, and most are certified by the American Speech-Language-Hearing Association which requires that they engage in regular diversity training. This means that multiple mechanisms help to ensure that your SLP will practice ethically.SLPs are also formally trained in helping individuals make behavioral changes to the way they communicate. Voice is a niche specialty, meaning most SLPs do not receive extensive training in it. SLPs with expertise are available, most commonly employed at specialized “voice centers” or in private practice. Many SLPs working in this speciality area have a background in singing or performance, in addition to their clinical training.
Is an SLP right for you?
While many people can independently find an affirming voice, an SLP or other voice provider can help provide guidance about exploring your voice, using a variety of techniques, troubleshooting if you aren’t making satisfactory progress, and adding structure and accountability to your practice.An SLP may be an especially good fit if:
You suspect you are hurting your voice through your practice
You have other medical conditions that may affect your voice and communication training, e.g., reflux or chronic pain
You are neurodivergent and want someone trained in working with neurodivergent people
Your insurance covers their gender affirming voice and communication services
See our other resource, Types of Gender-Affirming Voice Provider.
What to Expect From Your First Appointment
History
Your first session is likely to begin with a conversation about your history and goals. Questions may cover:
The sound, feel, and function of your present voice. SLPs should screen for the presence of and risk factors for voice disorders when they engage in gender affirming work.
Your voice use habits. For example, your SLP may want you to describe how you use your voice at work, home, and socially.
Past and future surgeries to the head and neck, or any planned surgeries that will require intubation (breathing tube)
Difficulties with swallowing, breathing, allergies, reflux, or other relevant medical concerns
Your goals for voice training, and any independent practice to date
You may also be asked to complete standardized questionnaires about your voice. These commonly include the Voice Handicap Index or questionnaires relating to voice and gender identity. It is always okay to decline to respond or to ask for an explanation of questions that feel irrelevant or overreaching.
Voice Recording
You may be asked to record your speaking voice. This recording may be useful in measuring progress before and after training. Other data can be gathered from this recording, such as your average speaking pitch. If hearing your voice is a dysphoria-inducing experience, you can request that the SLP not play back the recording.
Instrumental Evaluation
You may be asked to complete a laryngoscopic exam to view your larynx (voice box). This exam assesses for vocal issues (such as nodules, polyps, or excess tension), and allows for confirmation that your voice is healthy and ready for training. It also may be a requirement for insurance coverage. It likely will not occur on the same day as your visit with the SLP, and it might be required that you complete it before you can complete your intake visit with the SLP.This test is performed using a thin tube that contains a camera and light. A flexible laryngoscope is guided through your nose, or a rigid laryngoscope is guided through your mouth. Only a small portion of the scope enters your nose or mouth. Either may be mildly uncomfortable, but should not be painful. Topical anesthetic is often used to reduce discomfort.
Finding an Experienced SLP
Referrals from your local Voice Center
Referrals from your local LGBTQ+ Health Center or Community Center
Referrals from community social media groups or pages
Referrals from friends and others in the community
Types of Gender-Affirming Voice Provider
When to Seek Support
Finding an affirming voice can be a daunting task. While many people can independently find an affirming voice, a voice and communication provider can help provide guidance about exploring your voice, using a variety of techniques, troubleshooting if you aren’t making progress, providing structure and accountability for your practice, or helping redirect your efforts if you suspect you are hurting your voice through independent practice.For more information, see our other resource, Independent Practice & When to Seek SupportSeveral types of providers offer gender-affirming voice and communication training.
Speech-Language Pathologists
SLPs hold a Masters Degree, license from the state(s) they practice in, and [most] are certified by the American Speech-Language-Hearing Association. Voice is a niche specialty, meaning most SLPs do not have extensive training in it. SLPs with expertise are available, most commonly employed at specialized “voice centers” or in private practice. Many SLPs working in this speciality area have a background in singing or performance, in addition to their clinical training.Possible benefits include:
Most likely to be covered by insurance
Trained to recognize, prevent, and treat vocal pathology, a risk of voice training
Oriented to medical conditions that may impact voice, such as reflux, chronic pain, etc.
Connected to other medical providers and can refer you as needed
Formally trained in supporting people who are neurodivergent
Additional Considerations:
Voice specialists may be hard to find, especially outside of major cities
The SLP field historically trains students in a deficit/pathology model, meaning that clients are viewed as having something wrong that must be fixed. Good gender affirming providers will not subscribe to this perspective.
The SLP field is comprised primarily of white cisgender women
For more information, see our other resource, What to Expect Working With a Speech-Language Pathologist.
Vocal Pedagogues / Singing Instructors
Vocal pedagogues, coaches, instructors, or those with a background in music, theater, or performance may additionally offer GAVC services. They can come from a variety of formal educational backgrounds. They may be members of professional organizations, however, there is no credentialing, licensing, or other such oversight of their work.Possible benefits include:
Toolkit may include more diverse, whole-body techniques
Often more culturally attuned to gender diversity
Often experienced in singing instruction, if singing is a goal
Additional Considerations:
Likely private pay only
Formal training unlikely to have included gender-affirming voice instruction
Not professionally regulated
Likely not trained to recognize or prevent vocal pathology, and not trained to resolve it
Nontraditional Gender-Affirming Voice Trainers
This category of providers refers to those who, through their lived experience or through independent work, feel they gained unique and useful insight that could be useful to others. Providers who fall into this category may have little or no formal education in voice, voice disorders, or vocal pedagogy, however, those with lived experience bring valuable insights from their own voice work that may be less common among those with formal education and training.“Nontraditional” is used here for lack of a better term. We acknowledge that the predominant viewpoints on who has the authority to perform gender affirming voice and communication services center cisgender narratives. This includes cisgender providers, as well as formal training pathways that may be inaccessible for many transgender and gender diverse community members seeking to offer voice training.Possible benefits include:
Likely basing their training on their own lived experience
Not limited by the dogma of a field of training, which may result in different approaches
May be tapped into a provider network based on word-of-mouth in the transgender / gender diverse community
Additional Considerations:
Private pay only
May have little to no “formal” training
Not professionally regulated
Not trained to recognize, prevent, or resolve vocal pathology
May not be tapped into a relevant network of professionals
Which is Right for Me?
There is no one field that “owns” this work. The WPATH Standards of Care outline a set of skills and knowledge that providers should have, rather than endorsing any individual profession or credential. As no profession’s training pathway includes extensive education gender affirming voice and communication, providers across any of these categories may be equipped to help you meet your voice needs. There is likely to be high variability between the approaches of different providers, and all should be assessed on an individual basis. The right professional is one that clicks with you and helps you meet your goals.Questions you can ask before working together:
Can you share your personal philosophy or approach to gender affirming voice?
What specific training or education have you completed?
Tell me about your advocacy within the community.
If we don’t meet our goals, what are some potential next steps or referrals that you could make?
For more information, see our other resource, Choosing a Gender-Affirming Voice Provider.
Finding a Provider
Referrals from your local Voice Center
Referrals from your local LGBTQ+ Health Center or Community Center
Referrals from community social media groups or pages
Referrals from friends and others in the community
Choosing a Gender-Affirming Voice Provider
Introduction
Once you’ve determined that you would like the support of a voice and communication provider and learned about the types of providers available to you, the next step is selecting an individual to begin working with.Providers across fields have a range of experience and training and should be assessed on an individual basis. The right provider is one that clicks with you and helps you meet your goals. Not all of these may be important to you - please pick and choose.
Red Flags
Using Outdated Language
Pay special attention to marketing materials and intake forms.
If the provider does not ask about your preferences or match the terminology you use, that is a red flag.
Q: “How do you personally keep up with evolving culture and terminology relating to gender diversity?”
Lack of Training or Experience
Gender affirming voice and communication work is not extensively covered by any profession’s training pathway. It may be important to you that a provider has independently completed additional training.
Q: “What specific training or continuing education have you completed?”
Q: “What percentage of your clientele is seeking gender affirming services?”
Q: “What are your key metrics of success for this work, and what have your outcomes been?”
Q: “What kind of training do you have that will help ensure that my voice will stay healthy as I make changes to the way I use it?”
Prescriptive Approach
When a provider is prescriptive, they have a defined goal of their own and might not seem quite as interested in your own personal goal(s) for your voice. They might lean heavily on normative data or allow their own social biases to guide their work.
When a provider makes you feel that there is a “right way” to engage in the process of voice and communication change, they might be applying a more prescriptive approach.
Q: “Can you share your personal philosophy or approach to gender affirming voice work? How has that evolved over time as you have done more of this work?”
Defensive to Feedback
Feedback is often not given early in a relationship, which is the best time to determine whether a provider will be open to it. Try to give feedback early on and see how they respond. If you are not met with openness and humility, that’s a red flag.
Q: “If something you suggest isn’t really working for me, how would you like for me to give you feedback about it?”
Gatekeeping
When a provider tells you that they cannot work with you if you have not initiated hormone treatment, if you have not socially transitioned to a certain degree, or if you are not currently working with a psychologist, that is a red flag.
Some providers, especially speech-language pathologists, may feel ethically bound to require that an Ear, Nose, and Throat doctor assess your vocal fold health prior to beginning treatment. This requirement could be because of their commitment to gold standard practice in their field, because something in your voice or case history concerns them about the possibility of a voice disorder, or because the exam is necessary for insurance coverage or institutional policy.
Q: "Are there any prerequisites for beginning training? If so, what is the rationale for each?"
Green Flags
Personality Compatibility
The fit matters. Feeling free to be yourself while training can be a critical factor in making progress.
Flexibility and Responsiveness
Goals can change over time as you explore your voice. A provider should check in, solicit feedback, and be prepared to meet your shifting needs.
Engagement with the Community
Engagement and allyship are often facilitated by a deeper connection to the trans community. Your provider should be engaging with the trans community outside of the gender affirming work that they do, to demonstrate that they seek and value community voices.
Q: “Tell me about your engagement with and advocacy within the community.”
Understanding of Their Limitations
Providers should be willing to admit when they do not know something and know how to seek answers to help you best meet your needs.
Strong Network
A provider that is well connected to other relevant professionals (e.g., endocrinology, mental health, etc) can help you meet a range of needs related to your voice.
Q: “If we don’t meet our goals, what are some potential next steps or referrals that you could make?”
Discontinuing Services
If you find that you are no longer interested in working with a provider, there is no shame in discontinuing services. While there is never an obligation to offer feedback, sharing your perspectives can help the provider improve their services for future clients. In some cases, it can also help them advocate for institutional improvements. For example, if you had a negative experience with a front desk staff member, telling the provider can help them push for staff training.As a starting place for generating feedback, you can reflect on these questions:
Did they use appropriate terminology and language?
Was the venue and its staff supportive of you and your needs?
Did they treat you with courtesy and respect?
Did they keep questions and comments about your identity related to voice?
Did they seek detailed information about your goals?
Did they check in frequently to make sure you were moving in a positive direction?
Did you understand the purpose of the exercises that you were asked to do?
Did you feel like you knew how to apply techniques outside of training?
Overview of Gender Affirming Phonosurgery
Introduction
For those seeking vocal congruence, phonosurgery (surgery to change the voice) is one option. Surgery is most often considered after goals were not met through voice training alone.However, surgery is not an instant, easy, or complete pathway to vocal congruence. In most cases when surgery is chosen, it is done so in conjunction with voice training to modify a variety of vocal features.Phonosurgery should be performed by a specialized physician called a laryngologist. This is a subspeciality of otolaryngology (or Ear, Nose, and Throat - ENT) specializing in the larynx, or your voice box. Laryngologists support a range of voice and upper airway needs.
How Does Surgery Change My Voice?
While voice training helps change how you use your voice, surgery can change the structures underlying voice production.Our voice begins with our breath. As we relax our diaphragm, we exhale air, which passes our vocal folds. These are two side by side muscles that remain open in a V shape when we breathe and that come together and vibrate to produce sound.The pitch (how high or low our voices sound) is determined by the thickness, length, and tightness of the vocal folds. This is the primary feature of the voice that is changed by phonosurgery.Sound generated at the vocal folds is shaped by our throat, mouth, and nose on its way out of our mouths. Resonant quality (how bright or dark our voices sound) is determined by the size, shape, and material of these spaces. It is claimed that some phonosurgery approaches modify the resonance, but evidence is limited.Finally, we use our tongues, lips, teeth, and more to form sound into speech. All of these elements (and more, such as the rate and volume we speak at) work together to inform how others perceive our voice.Learn more in our other resource, "Gendered Voice & Effects of Hormone Replacement Therapy"
When is Surgery Right for Me?
Surgery is most often considered if goals are not met by voice training alone. In many cases, your surgeon may recommend (or your insurance may require) a course of voice training prior to surgery. A voice provider, especially a voice-specialized speech-language pathologist, can discuss surgical options, walk you through the research supporting them, and help you develop realistic expectations for your post-operative voice. In the immediate post-operative phase, you will likely need to engage in a few sessions of voice therapy to support optimal healing. You may also benefit from voice therapy or training to supplement surgical pitch change for a cisgender-assumed voice.If you are completing voice training and finding it does not meet your goals, surgery is still unlikely to be an immediate next step. Progress can stall for many reasons including incompatibility with the provider or their approach, the amount you are able to practice on your own, or other life situations limiting your ability to make meaningful change right now. These barriers can be addressed in numerous ways including taking a break from training, finding a new provider, or utilizing the services of other professionals such as mental health professionals to overcome barriers. For transmasculine individuals, it is important to note that the full effects of testosterone on the voice can take upwards of two years. A discussion with your provider regarding HRT dosage may be warranted. Learn more in our other resource, "Gendered Voice & Effects of Hormone Replacement Therapy."The process of accessing gender-affirming phonosurgery can be complex. If you feel phonosurgery is something you would like to pursue, we recommend taking initial steps as soon as possible, such as contacting your insurance company for coverage criteria, and researching and contacting surgeons of interest. While highly recommended, presurgical voice training is not required according to the WPATH Standards of Care.
Common Surgical Approaches for Voice Feminization
Cricothyroid Approximation (CTA)
This procedure elevates pitch by increasing tension of the vocal folds. This procedure is performed through an incision in the throat. Sutures are placed to replicate the contraction of the cricothyroid muscle, the primary muscle of pitch elevation. Pitch change in isolation is unlikely to result in a feminine-perceived voice. This procedure has been in use since 1986 and outcome data is mixed. Magnitude of increased pitch ranges significantly, and some studies report decreased pitch over time following surgery in some patients.
Wendler’s Glottoplasty / Anterior Glottic Web Formation
This procedure elevates pitch by shortening the length of the vocal folds. This does not require an incision because the vocal folds are accessed through the mouth. This procedure includes exposing the inner surfaces of part of the vocal folds using a laser, then stitching these surfaces together to create an overall shorter vibrating surface. In a systematic review of multiple phonosurgical methods, procedures that shortened the vocal folds resulted in the largest increase in pitch. However, pitch change alone is unlikely to result in a feminine-percieved voice.
Laser-Assisted Voice Adjustment (LAVA) / Laser Reduction Glottoplasty (LRG)
These procedures elevate pitch by decreasing the mass of the vocal folds. This does not require an incision because the vocal folds are accessed through the mouth. Scarring caused by these procedures can also stiffen the vocal folds, and may contribute to elevated pitch. While sharing these qualities, LAVA and LRG differ in that LAVA evaporates only the first layer of vocal fold tissue, while LRG evaporates the first layer and deeper tissues. As with other procedures, pitch change in isolation is unlikely to result in a feminine-percieved voice.
Feminization Laryngoplasty
This procedure aims to alter pitch and resonance by combining vocal fold modification and thyrohyoid elevation. Due to the removal of cartilage during vocal fold modification, this procedure additionally produces aesthetic results similar to chondrolaryngoplasty. It involves separating and repairing the thyroid cartilage, which provides the structural frame of the larynx. This procedure is the least commonly performed and has the least outcome data available. The term is also used inconsistently, and exact approaches may vary between surgeons. Change in both pitch and resonance can result in a more consistently feminine-perceived voice, however, this surgical approach does not guarantee that outcome. Many other factors can also contribute to gendered voice perception, and postoperative voice therapy and training is likely still necessary.
Common Surgical Approaches for Voice Masculinization
Type III Thyroplasty
This procedure lowers pitch by decreasing tension of the vocal folds. It is presently the only surgical option available for vocal masculinization, however, is not widely available. Vertical cuts are made in the thyroid cartilage, in which the vocal folds are housed. A segment of the cartilage is removed, and the opening is sutured closed. This smaller space reduces tension on the vocal folds, which results in lower pitch. However, pitch change in isolation is unlikely to result in a masculine-perceived voice.
Additional Surgical Approaches of Note
Chondrolaryngoplasty
Also called a tracheal shave, this procedure removes mass from the thyroid cartilage, which makes up the adam’s apple, for purposes of a more feminine neck appearance. This is most often done through an incision in the throat but can be done through the mouth as well.Chondrolaryngoplasty may be performed by a plastic surgeon or a laryngologist and should not affect the voice. No published data compares voice outcomes of this procedure based on whether the provider was a plastic surgeon or laryngologist. However, laryngologists possess a high level knowledge of the vocal anatomy and physiology, which theoretically reduces risk of complications affecting the voice in their hands. Regardless, complication rates are low when performed by any specialty.
Finding a Surgeon
The Vocal Congruence Project Provider Map includes surgeons, including the types of procedures offered and other relevant information.
Referrals from your local Voice Center
Referrals from an LGBTQ+ Health Center
Referrals from community social media groups or pages
Referrals from friends and others in the community
Choosing a Surgeon
Choosing a surgeon can be based on many factors. This might include geography, insurance coverage, procedures offered, reputation, and more.The WPATH Standards of Care recommend a surgeon performing gender-affirming surgical procedures have the following credentials:
Training and documented supervision in gender-affirming procedures
Maintenance of an active practice in gender-affirming surgical procedures
Knowledge about gender diverse identities and expressions
Continuing education in the field of gender-affirmation surgery
Tracking of surgical outcomes
When selecting a surgeon, asking questions is an important. You can start with the following:
What surgical options do you offer?
Do you collect or publish outcome data? Can I see it, or hear recordings of prior patients?
What risks are involved in this procedure?
Is voice training a prerequisite for the procedure? If so, does this need to be with the SLPs on your team?
Are pre-/post-operative voice therapy required?
What can I expect from the recovery process?
Will I need to complete voice rest?
If I am unhappy with my voice post-operatively, what next steps are available?
Glossary of Terms - Provider Map
Introduction
This list compiles many of the common terms, acronyms, and organizations you may see on our Provider Map. The purpose of this list is to help you understand these terms and their relevance to gender affirming voice work. Note that the majority of terms are specific to North America, and terminology likely varies internationally.This guide is designed as a companion to supplement our other resources, Types of Gender-Affirming Voice Provider and Choosing a Gender-Affirming Voice Provider.Did we miss something, or do you have additional questions? Connect with us.
Tip: use Ctrl + F to search for a specific term.
Degrees & Credentials
Clinical (Speech-Language Pathologists)
MA - Master of Arts
An MA (in Speech-Language Pathology) is one of several accepted entry-level degrees of clinical practice as an SLP. It indicates completion of graduate level coursework and clinical training across the scope of practice for SLPs.MS / MSc - Master of Science
An MS (in Speech-Language Pathology) is one of several accepted entry-level degrees of clinical practice as an SLP. It indicates completion of graduate level coursework and clinical training across the scope of practice for SLPs.MEd - Master of Education
An MEd (in Speech-Language Pathology) is one of several accepted entry-level degrees of clinical practice as an SLP. It indicates completion of graduate level coursework and clinical training across the scope of practice for SLPs.MClSc - Master of Clinical Science
An MClSc (in Speech-Language Pathology) is one of several accepted entry-level degrees of clinical practice as an SLP. It indicates completion of graduate level coursework and clinical training across the scope of practice for SLPs.SLPD - Doctor of Speech-Language Pathology
Per the American Speech-Language-Hearing Assocation (ASHA), a clinical doctorate in speech-language pathology is an advanced clinical practice degree. An individual with an SLPD has completed the entry-level master’s degree in SLP, and opted to continue their training in preparation of an advanced professional role, such as master clinician, clinical educator, clinical administrator, or leader in a clinical setting or area of specialization. A clinical doctorate in SLP may also be awarded as a ClinScD, CScD, or DSLP.PhD - Doctorate of Philosophy
A Doctorate of Philosophy is the most common doctoral degree. Philosophy does not refer to the discipline of study, but to the nature of the degree as having a research focus. This distinction differentiates the PhD from a clinical/professional doctoral degree such as a SLPD or an MD. A PhD can be awarded for many disciplines. A Speech-Language Pathologist’s PhD is most commonly (but not exclusively) in the field of Communication Sciences & Disorders, which is the umbrella term for SLP and related disciplines. Individuals with PhDs often conduct research in academic settings and/or teach at the university level.SLP - Speech-Language Pathologist
Speech-Language Pathologists are medical professionals trained to support communication and swallowing needs across the lifespan. To learn more about SLPs, see our resources, “Types of Gender-Affirming Voice Provider” and “What to Expect Working With a Speech-Language Pathologist”.SLT - Speech and Language Therapist
Equivalent to a Speech-Language Pathologist, this terminology is used in some countries, including the UK and Australia.CCC-SLP - Certificate of Clinical Competence in Speech-Language Pathology
The Certificate of Clinical Competence is awarded by the American Speech-Language-Hearing Association to a Speech-Language Pathologist following graduation from an accredited graduate program and completion of a one-year supervised Clinical Fellowship Year. (See also, CF-SLP)CCC-SLP/L - Certificate of Clinical Competence in Speech-Language Pathology, Licensed
This refers to state licensure. Lack of a /L does not mean the provider is not licensed. In most cases, licensure is not explicitly stated and can be assumed.CF-SLP - Clinical Fellow in Speech-Language Pathology
A Clinical Fellow in Speech-Language Pathology has graduated from an accredited graduate program in SLP, and is now completing a supervised one-year fellowship to further their training. Upon successful completion, they will be awarded the Certificate of Clinical Competence.S-LP(C) - Speech-Language Pathologist, Certified
Indicates the provider is a certified Speech-Language Pathologist through Speech-Language & Audiology Canada (SAC)Reg. CASLPO - Registered, College of Audiologists and Speech-Language Pathologists of Ontario
Indicates the provider is a registered Speech-Language Pathologist through College of Audiologists and Speech-Language Pathologists of Ontario (Canada)RSLP - Registered Speech-Language Pathologist
Indicates the provider is a registered Speech-Language Pathologist through the College of Speech and Hearing Health Professionals of British Columbia (Canada)BCS-S - Board Certified Specialist in Swallowing and Swallowing Disorders
Offered by the American Board of Swallowing and Swallowing Disorders, this indicates a Speech-Language Pathologist has completed advanced training specializing in swallowing and swallowing disorders (dysphagia), one of many areas within the speech-language pathology scope of practice. It is common for a voice-specialized SLP to also specialize in swallowing, and they may be based in a “Voice & Swallowing Center.”CBIS - Certified Brain Injury Specialist
Offered by the Brain Injury Association of America, this indicates that the provider has completed advanced training specializing in brain injury and cognitive rehabilitation. Supporting cognitive communication needs is one of many areas within the speech-language pathology scope of practice.
Clinical (Surgeons)
MD - Doctor of Medicine
MD is a professional doctoral degree for the practice of medicine. It is distinct from a PhD, which has an emphasis on research. Following completion of an MD degree, physicians complete years of additional training in the form of a residency, and have the option to complete even further specialized training through a fellowship. (See also, Fellowship Trained)DO - Doctor of Osteopathic Medicine
DO is a professional doctoral degree for the practice of medicine. It is an equivalent professional doctoral degree to an MD, with identical post graduate training through residency, and the option to complete a fellowship (See also, Fellowship Trained). One notable difference between MD and DO training is that DOs complete additional training in osteopathic manipulative medicine, a system of alternative medicine that emphasizes physical manipulation of the body's muscle tissue and bones.FACS - Fellow of the American College of Surgeons
Per the American College of Surgeons website, “Fellows are board-certified surgeons whose education, training, professional qualifications, surgical competence, and ethical conduct are reviewed and consistent with the high standards of the ACS. Not all surgeons are accepted as Fellows, and some surgeons choose not to become Fellows.”Fellowship Trained
Fellowship is the highest level of specialty training for a physician. A fellowship trained physician has a deep level of knowledge in a particular clinical area. The length of a fellowship varies by specialty. Many surgeons on the VCP Provider Map will have completed a fellowship in laryngology, equipping them with highly specialized skills related to evaluation and medical/surgical management of voice and upper airway needs.
Singing / Performance
BFA - Bachelor of Fine Arts
Undergraduate degree in fine arts fields, including but not limited to visual art, creative writing, theater, musical theater, and dance.MFA - Master of Fine Arts
The terminal degree (meaning it is considered the highest degree in its field) for fine arts fields. Providers with an MFA will have training in performing arts, such as dance, theater, and musical theater, or visual arts, such as photography or graphic design.BM - Bachelor of Music
Undergraduate level degree in music with training in music theory, music history, performance, and pedagogy. Concentrations of study can include musicology, composition, performance, and education. Performance practice and training are traditionally classically focused, but some degree programs include cross-training in contemporary styles, including genres such as musical theater, jazz, and commercial music. You may also see specializations reflected in the degree abbreviation, such as BM-VP (Vocal Performance) or BM-ME (Music Education).MM - Master of Music
Masters-level degree in music with advanced training in music theory, music history, performance, and pedagogy. Concentrations of study can include musicology, theory, composition, performance, pedagogy, conducting, and education. Performance practice and training are traditionally classically focused, but some degree programs include cross-training in contemporary styles, including genres such as musical theater, jazz, and commercial music.DMA - Doctor of Musical Arts
Doctoral-level degree that combines advanced studies in an applied area of specialization, such as music performance, music composition, or conducting, with graduate-level academic study in subjects such as music history, music theory, or music education.Singing Voice Specialist
Traditionally, a singing voice specialist is a singing voice teacher with training in the anatomy and physiology of phonation, voice disorders and rehabilitation, and knowledge of laryngological interventions, in addition to performance and pedagogy training. A singing voice specialist may also be a speech-language pathologist, but this is not a requirement. The qualifications of each singing voice specialist may vary.
Multidisciplinary / Other
CYVT - Certified YogaVoice Teacher
Indicates a provider is trained in YogaVoice, a voice training method incorporating yoga.MMT - Master of Music Therapy
An advanced degree held by a Music Therapist, a professional who uses music interventions for a variety of goals including cognitive, emotional/psychological, and communication goals.MT-BC - Music Therapy Board Certification
Administered by the Certification Board for Music Therapists, this credential “demonstrates advanced clinical competence” in music therapy.LPC - Licensed Professional Counselor
Provider of mental health services that focus on behavioral, emotional and mental issues in various healthcare or private practice settings.PAVA-RV - Pan American Vocology Association Recognized Vocologist
Per their website, “PAVA Recognition indicates that one has demonstrated knowledge and experiences across vocology disciplines but does not constitute an evaluation or endorsement of the application of this knowledge. It will not train or certify you in voice habilitation, rehabilitation, or any other vocology discipline.” (See also, PAVA)
Professional Organizations
Clinical (Speech-Language Pathologists)
_SHA or _SHLA - [State] Speech-Language-Hearing Association
An acronym ending in either of the above is likely a state association for Speech-Language Pathologists. For example, CSHA is the California Speech Language Hearing Association.ASHA - American Speech-Language-Hearing Association
The national professional organization for Speech-Language Pathologists. ASHA oversees national certification for SLPs, including ethical oversight and scope of practice. (See also, CCC-SLP)NBASLH - National Black Association for Speech-Language and Hearing
A professional and scientific association addressing the communication interests and concerns of Black communication science and disorders professionals, students and consumers.RCSLT - Royal College of Speech and Language Therapists
The professional organization for Speech-Language Pathologists in the United Kingdom.SAC - Speech-Language and Audiology Canada
The national professional organization for Speech-Language Pathologists in Canada. SAC oversees certification for SLPs in Canada. (See also, SLP(C)).
Clinical (Surgeons)
AAO-HNS - American Academy of Otolaryngology - Head and Neck Surgery
An organization representing specialists who treat the ears, nose, throat, and related structures of the head and neck. The AAO-HNS publishes clinical practice guidelines, among other advocacy, awareness, and research initiatives.ABEA - American Broncho-Esophageal Association
A society of physicians, researchers and allied professionals who specialize in the airway and esophagus.ABO-HNS - American Board of Otolaryngology--Head and Neck Surgery
The ABO-HNS oversees board certification in Otolaryngology - Head and Neck Surgery, a process completed by physicians after residency, consisting of written and oral examinations.ALA - American Laryngological Association
Professional society for laryngologists. This is a subspeciality of otolaryngology (or Ear, Nose, and Throat - ENT) specializing in the larynx, or your voice box. Laryngologists support a range of voice and upper airway needs.AOCOO-HNS - The American Osteopathic Colleges of Ophthalmology and Otolaryngology – Head and Neck Surgery
Professional organization representing ophthalmologists and otolaryngologists. (See also, DO - Doctor of Osteopathic Medicine)IATVS - International Association of TransVoice Surgeons
An association of laryngologists dedicated and experienced with gender affirming phonosurgeries. The association serves as a forum for surgeons to exchange information and raise awareness of gender affirming voice surgery and its outcomes.Triological Society
Formally known as the American Laryngological, Rhinological and Otological Society, the Trilogical Society is an organization of Ear, Nose, and Throat (ENT) physicians that hosts conferences and publishes the scientific journal The Laryngoscope.
Singing / Performance
NATS - National Association of Teachers of Singing
An organization consisting of teachers of singing that provides professional development opportunities, publishes the Journal of Singing, and hosts biannual conferences.
Multidisciplinary
PAMA - Performing Arts Medical Association
An organization of medical professionals, artists, educators, and administrators with the common goal of improving the health care of the performing artist. PAMA offers education for professionals, including a certificate in “Essentials of Performing Arts Medicine.”PAVA - Pan American Vocology Association
An organization consisting of speech-language pathologists, ear nose and throat (ENT) doctors,, professional dingers, voice teachers, acting coaches, music directors, stage directors, and others who work with human and animal vocalization. PAVA hosts an annual symposium, and offers a Recognized Vocologist designation. (See also, PAVA-RV)TVF - The Voice Foundation
An organization consisting of surgeons, scientists, speech-language pathologists, voice teachers, and performing artists known for hosting an annual symposium, and for publishing the Journal of Voice. Some countries or states have dedicated chapters.VASTA - Voice and Speech Trainers Association
An international organization for voice and speech professionals of any discipline, encompassing publishing, mentorship, and advocacy.
Gender Affirming Care
AusPATH - Australian Professional Association for Trans Health
AusPATH is a professional organization for "professionals involved in the health, rights and well-being of all trans people"TPATH - Transgender Professional Association for Transgender Health
TPATH is an organization designed to represent the needs of trans members of the World Professional Association for Transgender Health and its regional offshoots, and to provide a space for these members. Membership in TPATH is open only to those who self-identify within the trans and gender diverse spectrum. (See also, WPATH)USPATH - United States Professional Association for Transgender Health
United States based chapter of the World Professional Association for Transgender Health (WPATH). (See also, WPATH)WPATH - World Professional Association for Transgender Health
WPATH is an international interdisciplinary professional and educational organization devoted to transgender health. WPATH publishes the Standards of Care (SOC) for the Health of Transgender and Gender Diverse People, currently on its 8th edition. These “articulate a professional consensus about the psychiatric, psychological, medical, and surgical management of gender dysphoria and help professionals understand the parameters within which they may offer assistance to those with these conditions.” The SOC are cited throughout VCP resources to provide information about what is currently viewed and applied as best practice. We recognize the history of the SOC as a gatekeeper to medically necessary gender affirming care. We additionally acknowledge that WPATH leadership, SOC contributors, and providers of gender affirming care are not exempt from transphobia, and may promote and perpetuate harmful ideas. (See also, USPATH, TPATH)
Specialty Areas / Trainings
Clinical
CSCFT - Casper-Stone Confidential Flow Therapy
A therapy approach designed to reduce laryngeal tension/hyperfunction and increase airflow, supporting voice production.CTT - Conversation Training Therapy
A therapy approach that focuses on voice awareness and production in conversational speech from the very start of treatment (as opposed to a hierarchical approach, where a target may be practiced in sounds, words, sentences, and so forth, increasing in complexity).LSVT - Lee Silverman Voice Treatment
A therapy approach primarily used to improve speaking volume for those with parkinson's disease and other neurological conditions.Manual Therapy / Circumlaryngeal Massage
A therapy approach including hands on manipulation of the muscles of the head and neck, often to reduce muscle tension and support voice production.PhoRTE - Phonation Resistance Training Exercises
A therapy approach used to rehabilitate the vocal mechanism and improve vocal endurance for older adults experiencing age-related voice changes.RVT - Resonant Voice Therapy / LMRVT - Lessac-Madsen Resonant Voice Therapy
A therapy approach used to optimize the vibratory pattern of the vocal folds, primarily used for those with voice disorders.
Singing / Performance
Alexander Technique
An alternative therapy approach that seeks to make adjustments to movement and posture, which practitioners believe addresses a range of health problems, including voice.EVT - Estill Voice Training
A voice training approach for gaining isolated control of individual anatomical structures within the voice production system, thought to give greater control over the voice when speaking and singing.Fitzmaurice Voicework
A voice training approach that “combines adaptations of classical voice training techniques with modifications of yoga, shiatsu, bioenergetics, energy work, and many other disciplines.”SVW - Somatic Voicework / The LoVetri Method
An “organized method of vocal training for Contemporary Commercial Music (CCM) styles, based upon somatic (physical) awareness and aural discernment.”
Multidisciplinary
SVI - Summer Vocology Institute
An intensive training program for the science and practice of voice habilitation, hosted at the University of Utah. Individuals from various disciplines, including speech-language pathology and vocal pedagogy, may engage in this training. A graduate of this course may refer to themselves as an SVI-Trained Vocologist.
Gender Affirming Voice & Communication
Gender Affirming Voice Training: A Course for Voice Clinicians (Sandy Hirsch, MS CCC-SLP, Leah Helou, PhD CCC-SLP, & Christie Block, MA MS CCC-SLP)
This multi-day training workshop was offered annually from 2013-2023. Authored and presented by field leaders Hirsch (retired as of 2023), Helou, and Block, this course was the first and leading training opportunity in gender-affirming voice work. Read more about Leah and Christie on the VCP Provider Map.Learn to Teach Trans Voice Alteration in 5 Weeks (Renée Yoxon)
Course for singing teachers and other voice professionals to learn to teach trans voice alteration.Medbridge: Hirsch’s Acoustic Assumptions: Nuancing Resonance for a Gender-Affirming Voice (Sandy Hirsch, MS CCC-SLP)
A course covering one approach to modification of resonance and articulation. “Practitioners will gain an understanding of resonance challenges, learn to disentangle multiple physiologic variables affecting voice and speech output, and learn how to train their clients to execute desired resonance changes using systematic modifications applicable to a wide spectrum of unique vocal goals.” This course is hosted on SLP continuing education platform Medbridge. Read more about Sandy Hirsch on her Medbridge profile.Medbridge: Gender Affirmative Voice Training: Approach and Technique (Leah Helou, PhD CCC-SLP & Wynde Vastine, MA CCC-SLP)
A course encompassing the “main target areas that a transgender person may wish to address in their voice and some foundational approaches for targeting these areas. Guidance will be provided on how to avoid enforcing a clinician's own gender bias and other forms of microaggressions throughout the therapy and assessment process for truly patient-centered care.” This course is hosted on SLP continuing education platform Medbridge. Read more about Leah and Wynde on the VCP Provider Map.Medbridge: Cultural Humility With Transgender and Nonbinary People (Leah Helou, PhD CCC-SLP & Wynde Vastine, MA CCC-SLP)
A course including terminology, “how transgender and nonbinary people are often harmed in traditional allied health settings despite the good intentions of all parties,” and strategies for personal and professional reflection and growth. This course is hosted on SLP continuing education platform Medbridge. Read more about Leah and Wynde on the VCP Provider Map.Trans Voice Elective (CREDIT Institute / Transplaining / AC Goldberg, PhD CCC-SLP)
Course for SLPs including “everything they need to know about gender expansive voice care for transgender and gender nonconforming (TGNC) patients, clients and students, from policy to technique through a culturally responsive lens.” Read more about AC on the VCP Provider Map.TVI - Trans Voice Initiative
A group of transgender, nonbinary, and gender non-conforming speech-language pathologists who offer training in gender affirming voice and communication to TGNC speech-language pathologists.
Finding Practice Partners & Opportunities
Introduction
Finding the time, place, and people needed to practice can be one of the most difficult parts of developing a congruent voice. However, devoting significant time to practice is necessary to make changes to your voice, even when you are working with a provider.This advice may or may not apply to you depending on your transition timeline, access to supportive people, and other factors. Pick and choose what strategies feel most useful to you.
Practicing in Private
Practicing in private can be a great way to explore your voice before sharing it with the world. However, finding privacy can be difficult and many individuals need to create private practice spaces for themselves. Here are some common places and methods that may offer some privacy:
In your car, especially while parked in a comfortable, safe location
On a walk or hike where the setting affords some privacy
The most private space in your home, such as the garage or basement
A rentable meeting room, sometimes available at libraries and co-working spaces
A rentable music practice room, sometimes available at music stores or universities
Using a portable voice dampener, such as the Belt Box
Soundproofing & Masking
Soundproofing areas of your home or a room can help maintain privacy when practicing. Placing furniture against walls can make a space more soundproof. Tapestries and wall hangings, fabric furniture like couches, and rugs can also help reduce the transfer of sound. Stepping into a closet filled with clothes, or speaking under a duvet, can both provide quick sound reduction.While DIY approaches may help, you are unlikely to achieve true soundproofing without products designed for this purpose. Sound dampening material such as acoustic paneling can be effective but expensive. Cheap foam panels are rarely adequate to soundproof a space.In addition to these approaches, music, noise of a TV, or other audio can be used to cover the sound of your voice. You can also practice while doing a loud activity or chore, like vacuuming or cutting the grass.
Practicing with Partners
Speaking with another person helps build confidence in using your voice. A practice partner can also provide feedback and insight that is not apparent to you.
Practicing with a Provider
A gender affirming voice and communication training provider is a valuable practice partner as they can offer the most specific advice and feedback to help you meet your voice goals. You can also set expectations and discuss what sorts of feedback you are looking for. Learn more about how a provider can support you in our resource, “Independent Practice & When to Seek Support.” It is important to note that one session per week will almost certainly not be all it takes to change your voice. Home practice both alone and with others is typically necessary to apply and develop the skills you develop in sessions.
Practicing with Friends
Supportive friends make great practice partners as they provide a low pressure environment where conversation is easy. This allows you to focus less on what to say and more on how you’ll say it.Playing games with friends is another great way to practice your voice. Tabletop Role Playing Games, such as Dungeons & Dragons, normalize the use of character voices, which can be helpful to explore and experiment. However, it is important that your target voice feels like you and not a character. Think about what elements of your chosen character voice are appealing, and how you can adapt them into a speaking voice for daily use.
Practicing with Strangers
If your goals include developing a cis-assumed voice, practicing with strangers will provide the most accurate feedback. While engaging in practice with strangers, remember to be kind to yourself. If the risk of being misgendered is too great of a barrier, think about this type of practice approach as just for skill development and try not to put too much emphasis on how others respond.Feedback from strangers is most useful when your voice is perceived in isolation. For example, you might try calling a restaurant to inquire about their menu or hours. The use of gendered language like “sir” or “ma’am” is common, especially among high-end establishments, and can provide valuable information about how your voice is perceived.Another opportunity for using your voice with strangers is online gaming with a voice chat feature. Note that many gaming communities are toxic. For those with feminine voice goals, misogyny prevalent in some gaming communities may mean that regardless of your success in achieving your goals, reactions can be negative.Not all online communities are toxic, however. There are many LGBTQ+ gaming communities, as well as several online gender affirming voice-focused communities that welcome submissions for feedback from other members. Learn more about these in our other resource, “Independent Practice & When to Seek Support.”Across all of these situations it is important to acknowledge that being misgendered or receiving negative feedback can be difficult and discouraging. Make sure you are in a suitable headspace before intentionally seeking out this kind of interaction.
Overcoming Obstacles
Dysphoria
Some people may experience vocal dysphoria hearing the sound of their own baseline voice. Others may not mind the sound of their baseline voice but are deeply affected by the misgendering associated with using it. Regardless of your experience with vocal dysphoria, it is important to acknowledge how difficult it can make practicing a new target voice. While there is no simple fix, here are some strategies that may allow you to make progress in spite of the effects of dysphoria.
Positive Headspace - The right headspace can make practice more manageable and productive. Set an intention to not bully yourself, and to be open to learning everything that your vocal instrument can do. Prepare yourself for the possibility that some sounds might come out of your mouth that you find unnatural or unattractive, and that you will try to accept your voice in all its forms.
Auditory Masking - Speaking while wearing headphones with masking noise (e.g., white noise). This prevents you from hearing your own voice. You can rely on the feedback of a practice partner, or record your voice for review at a later date. Or, you can just use auditory masking to get used to the physical sensations of voice production, with no pressure on how you sound. Note that masking may result in you speaking louder than you intend.
Silent Practice - Some elements of voice, such as resonance, can be practiced without using your voice at all. Exercises targeting laryngeal or oral posture can be explored using only a whisper. Additionally, it is always beneficial to practice strong breath support, using full breaths to fill your abdomen.
Affirming Facilitators - Buffer practice with things that make you feel confident and affirmed. For example, wear a favorite outfit, a new outfit, or makeup that helps you feel confident. Speak to supportive friends or family or plan to independently practice prior to a therapy session, so that you can debrief your feelings. Think about your sources of gender euphoria. How might you layer your voice practice into those things?
Ultimately, there is no avoiding using your voice unless you are willing to accept some pretty massive social trade-offs. Remember that your efforts are working toward a long term reduction of vocal dysphoria and finding vocal euphoria. Just as you don’t expect physical change immediately after any given workout session, be patient with yourself and trust the process of committed practice.
Finding the Time to Practice
It can be difficult to find both the time and space for regular practice. The easiest way to accomplish this is by building practice into your existing routines. For example:
Practice while in the shower
If you drive, talk to yourself on your commute. Or, thank the bus driver using your target voice.
If you go to the gym regularly, trade time on the treadmill for an outdoor walk for an added practice opportunity.
Practice while doing the dishes, folding laundry, or for added privacy, during a loud chore like vacuuming or cutting the grass.
Once you start to settle on a voice you are happy with and begin using it publicly, every time you talk becomes an opportunity to practice and hone it further.
Developing a Practice Hierarchy
A practice hierarchy is a list of situations that you encounter in your life and that require use of your voice, ordered from the easiest to the most difficult. This can help guide practice, explore your emotions around using a new voice, and help make the leap from practicing in private to using a congruent voice publicly. A hierarchy can include as many situations as you can think of. A short example, ordered from easiest to most difficult, looks like this:
Easiest to use my target voice
Practicing privately at home
Talking to pets and plants
Spending time at a friends house
Ordering a coffee
Having a low-stakes conversation
Giving a presentation to a client at work
Going on a first date
Hardest to use my target voice
To put situations in order, think about people, place, priority, and preparation.
| People | Who is the conversation with? A stranger, a friend, a boss, a partner? |
| Place | Where is this conversation happening? In private? In public? |
| Priority | What are the stakes of the conversation? Additionally, is a cis-assumed voice necessary for safety in this situation? |
| Preparation | What opportunities will you have to prepare? Can you practice exactly what you’ll be saying in your target voice? |
Practicing privately at home - speaking with no audience in a private place is the easiest situation to speak in.
Spending time at a friend's house - speaking with supportive people in a private environment results in relative ease.
Ordering a coffee - speaking with a new person (cashier) in a public environment increases the difficulty.
Having a low-stakes conversation - even if a conversation is low-stakes, it can be a challenging balancing act to simultaneously think about what you’re saying and how you’re saying it
Giving a presentation to a client at work - speaking with new people you’d like to impress makes this difficult, however, you had the opportunity to prepare your script beforehand.
Going on a first date - speaking with a new person you’d like to impress in a public setting makes this very difficult, and spontaneous conversation means direct preparation is not possible.
Once you’ve established an order, pick your starting point. This is a situation you feel you can use your target voice in today. It can be as high or low on the hierarchy as you feel comfortable with, but will likely be near the easy end to start. This week, find an opportunity to intentionally use your voice in that situation.Before you engage in this task, think through the situation.
What thoughts and emotions arise?
Is there anything you can practice in advance to help you feel more confident in another moment? (For example, rehearsing your coffee order in your target voice.)
Anything else that you can do to feel more comfortable? (For example, recruiting a friend to accompany you.)
Afterwards, think through the situation again.
Did it go the way you predicted? Why or why not?
Were there any cognitive distortions present in your thinking? (For example, did you catastrophize and see only the worst possible outcome?)
Did your voice feel authentic and good to use?
What changes might you make for next time?
The next week, move up your hierarchy to a slightly more difficult situation. Small, regular steps up the hierarchy promote meaningful and measurable progress toward confident use of a congruent voice in all situations. If you find a situation too difficult, that’s okay! Return to the question of what is needed to feel confident in that situation. If it feels like too big of a leap, think about a middle ground option between it and the prior level on your hierarchy. Success does not always mean perfection. Instead, success can mean better understanding yourself and your needs, clarifying your goals or next steps based on feedback, or simply committing to and following through on a goal.
What If I Don't Practice?
Without regular practice, it is unlikely that you will make significant progress toward finding a congruent voice. However, voice can’t always be a priority. Practicing voice change may get in the way of other goals, like maintaining safety and privacy. If you truly are unable to find opportunities to practice, it may not be the right time to work on your voice. You can always return to your voice goals in the future.You can consider your options using a decisional balance sheet that looks like this:
| Advantages | Disadvantages | |
|---|---|---|
| No Change | - | - |
| Change | - | - |
Your decisional balance sheet should be based on your individual goals and life context. A hypothetical example might look like this:
| Advantages | Disadvantages | |
|---|---|---|
| No Change | No added time commitment. No effort to modify and monitor my voice. | Continued vocal dysphoria. Not cis-assumed in public, decreasing feelings of safety. Misgendered frequently on the phone. |
| Change | Vocal dysphoria reduced in the long term. Possibility of experiencing vocal euphoria. No longer misgendered on the phone. Contributes to being cis-assumed in public, increasing safety and reducing misgendering. | Time commitment of practice. I find practicing embarrassing. Self-monitoring and use of voice in public can increase my feelings of dysphoria in the short term. Financial costs of working with a provider. |
Gendered Voice & Effects of Hormone Replacement Therapy
Overview of Voice Production
Respiration
Our voice begins with our breath. We contract our diaphragm and other muscles of inspiration to bring air into the lungs. As we relax our diaphragm, we exhale air, which passes up through the airway and vocal folds.
Phonation
The vocal folds are two side-by-side muscles that remain open in a V shape when we breathe, close when we swallow, and come together to vibrate when we speak and sing. This vibration is called “phonation.”The pitch (how high or low our voices sound) is determined by the thickness, length, and tightness of the vocal folds. The resting length and thickness of our vocal folds increase during puberty. Testosterone-driven puberty experienced by people Assigned Male at Birth (AMAB) increases the mass and length of the vocal folds significantly. This structural change results in a large decrease in pitch. Those Assigned Female at Birth (AFAB) also experience a decrease in pitch during puberty, although it is much smaller.Following puberty, the size and length of the vocal folds generally do not change substantially. However, some people experience voice changes later in life. AMAB people may develop a higher pitch and other changes in voice quality due to age-related muscle atrophy, changes in breath support, and more. Some AFAB people develop a lower pitch due to hormonal shifts during menopause.When speaking and singing, pitch is actively controlled by the cricothyroid muscle, which adjusts the tightness of our vocal folds. Other small muscles in the voicebox also help to “tune” and control the sound. As an analogy for the effects of size, length, and tightness on sound production, imagine an acoustic guitar. The thickest string produces the lowest pitch, while the thinnest string produces the highest pitch. When a finger is placed on a string to shorten it, the sound gets higher in pitch. Additionally, when the guitar is tuned, a knob is turned to wind or release the string, increasing or decreasing tension. When wound tighter, the pitch is increased, and vice versa. The vocal folds also change pitch as their tension changes.
Resonance
Sound generated at the vocal folds is shaped by our throat, mouth, and nose on its way out of our mouths. Resonant quality (how bright or dark our voices sound) is determined by the size, shape, and material of these spaces. A larger resonating space results in a darker sound, typically perceived as more masculine. A smaller resonating space creates a brighter sound, typically perceived as more feminine.All resonating chambers will grow alongside our bodies as we develop and age. Changes in resonant quality accompany changes in pitch during puberty, resulting in our adult voices. AMAB people typically develop larger resonating chambers.When speaking and singing, we actively adjust the size and shape of our resonating chambers using a variety of muscles. For example, count to five with your mouth first in a more “eeee” position, like you’re smiling, and then in more of a “oooo” position. The difference in sound is created by adjusting resonance through tongue placement and lip shape.To put these concepts together, return again to the image of an acoustic guitar. The resonating chamber is the body of the guitar. Now imagine the difference in sound made by a ukulele. The smaller body and shorter strings results in a higher, brighter sound.
Resonance
Finally, we use our tongues, lips, teeth, and more to form sound into speech. All of these elements and more work together to inform how others perceive our voice. While pitch and resonance are generally considered the most important, other notable features can include volume, inflection, nonverbals, and more.
Anatomical Effects of Hormone Replacement Therapy (HRT)
Feminizing HRT
Feminizing HRT refers to the use of exogenous (not produced in the body) estrogen and/or an antiandrogen (e.g., spironolactone). Feminizing HRT has no effect on the structures underlying voice production. The increase in length and mass of the vocal folds and size of the resonating chambers caused by testosterone-driven puberty in AMAB people is permanent. Surgical approaches are the only way to modify the vocal anatomy.However, our control over the many muscles of speech production allow us to modify the pitch, resonance, and other features of voice and communication. Vocal feminization is possible through training and practice.
Masculinizing HRT
Masculinizing HRT refers to the use of exogenous testosterone. Testosterone can cause changes to the vocal folds at any age. These changes primarily include thickening the vocal folds, resulting in a permanent reduction in pitch.The effect of post-pubertal exogenous testosterone on the length of the vocal folds is poorly understood. As we age, cartilages including our larynx, or voice box, become less flexible. Thus, HRT may have lesser effects on vocal fold length, especially when started at later ages. For similar reasons, significant changes in resonance are unlikely to be seen from HRT alone.Changes depend on many factors, including baseline pitch, method of administration, dosage, and more. The first changes to the voice may occur as early as a few weeks on testosterone. Deepening of the voice to a cismasculine range is expected in approximately 1 year. However, research indicates that 21% of people may not reach a cismasculine pitch range, and 16% were unsatisfied with their voices after these changes had plateaued (Ziegler et al., 2018). Further change to pitch and resonance can be achieved through practice and training.A slower rate of change may be desirable for some, including singers and those who have not yet socially transitioned. Individuals seeking slower voice changes may opt for a lower HRT dose to facilitate this, however, it is not possible to predict the exact ways an individual’s voice will respond at any dose.
Socially Influenced Vocal Characteristics
No aspects of voice are purely a product of the underlying anatomy. Rather, voice is a product of the conscious and unconscious ways that we use that anatomy.Significant evidence reveals that gendered aspects of voice have a socially learned component. For example, the vocal tracts of children are largely identical prior to changes occurring during puberty, yet listeners can tell the gender of boys and girls by voice alone. Various languages and cultures show wide differences in many vocal characteristics. Finally, aspects of identity with no associated anatomical differences (e.g., sexual orientation, socioeconomic status) influence the voice. These voice changes are largely unconscious.Consider also how your voice changes across situations and settings. Does your voice sound the same when talking to a child as it does an adult? How about a colleague versus a best friend? Or when you are excited versus sad? A wide range of vocal expression is possible regardless of anatomy.
Effects of Identity, Transition, and HRT on Socially Influenced Vocal Characteristics
For transgender and gender diverse people, there is little known about how these socially influenced features develop or how they change with transition. One study found children ages 5-13, assigned male at birth and diagnosed with gender identity disorder (GID, a now-outdated term referring to gender dysphoria) sounded less masculine to listeners than same age boys without a diagnosis of GID (Munson et al., 2015). This indicates that those with an awareness of gender dysphoria in childhood develop socially influenced vocal characteristics differently.The gender exploration process accompanying transition, as well as emotional effects of HRT, may work to deconstruct internalized social norms that influence voice. For example, a transfeminine person may no longer feel pressured to “perform” masculinity, resulting in an unconscious shift in speaking voice. Some trans women say that their ability to access an “emotional self” increased with feminizing HRT, making it easier for them to access ways of talking that are more expressive and aligned with classic notions of femininity.Another study found that the speaking pitch of some transgender men on HRT lowered as expected, but then increased. As the changes caused by testosterone are irreversible, this indicates a “conscious or unconscious fine-tuning” to better align voice and identity (Papp, 2011). Some trans men also report purposefully trying to effect a “nice” way of speaking–this typically involves one or more voice and speech changes that are aligned with more feminine voice–so that it is clear to listeners that they can be trusted and are safe.
Socially Influenced Vocal Characteristics
The sound of each person's voice is uniquely formed through both their vocal anatomy and how they use that anatomy, the latter being informed by identity and other social influences. There is no singular way to sound masculine, feminine, androgynous, etc. Expanding vocal expression can be a physical and emotional process, influenced by HRT and social transition.
Identity-Affirming Voice & Communication Training
Options for Cisgender Speakers and Non-Gender Related Goals
Introduction
Voice can feel inseparable from our identity in countless ways. Based on voice alone, many listeners make assumptions about gender, race, age, body size, sexual orientation, personality, and much more. These assumptions can be conscious but they are most often unconscious. When listener assumptions made about one’s voice fail to accurately align with the speaker’s sense of self, the social results may be distressing to the speaker.While it is common for a transgender or gender diverse person to seek the services of a voice provider in aligning their voice with their gender identity, this is not the only situation in which a provider offering affirming voice services can help. People of all identities and backgrounds can benefit from voice training targeting their individual goals. For this reason, some providers prefer the umbrella term “Identity Affirming” over “Gender Affirming.”Regardless of terminological choice, providers engaged in this work should be expected to respect and incorporate all intersectional identities and fully customize their services to your needs. While it is less common to see a provider’s website or marketing mention broader identity affirming services, there is a high probability that they are willing and able to offer services supporting a wide range of goals, including the examples below.
Example: Gender-Affirming Care for Cisgender People
Numerous medical conditions can cause cisgender women to develop a deeper voice. For example, hyperandrogenism is commonly caused by Polycystic Ovary Syndrome and involves the circulation of excess androgens (such as testosterone) in the body. Some women will use voice training to try to behaviorally counteract changes to the voice caused by hormones.Another cause for voice deepening in cisgender women is Reinke's Edema, which involves changes to the structure of the vocal folds (typically caused by smoking). When smoking cessation and/or surgery are not utilized or not effective at restoring a higher pitch, voice therapy with a speech-language pathologist may include pitch raising techniques.Cisgender men may want to deepen their voices for a variety of medical reasons. One example is mutational falsetto, also known as puberphonia, a functional voice disorder characterized by the use of a high-pitched voice after puberty. Voice therapy with a speech-language pathologist can utilize a variety of pitch lowering and manual therapy techniques to establish a voice more congruent with age and gender.Cisgender men and women can also seek voice training for non-medical reasons, such as to feel affirmed in their masculinity or femininity. Any individual may benefit from the wide availability of gender affirming care, regardless of their gender identity.
Example: Addressing Age-Related Voice Changes
While the majority of voice changes happen over several years during puberty, many people also experience voice changes later in life. People assigned male at birth (AMAB) may notice higher pitch and other changes in voice quality due to age-related muscle atrophy, changes in breath support, and more. Some people assigned female at birth (AFAB) people develop a lower pitch due to hormonal shifts during menopause. Anyone might feel they sound older than they feel, and want their voice to reflect this.Voice and communication providers can use a variety of technique to facilitate vocal congruence. As age-related voice change is often the result of a change to the structures used for voice production, a voice-specialized Speech-Language Pathologist is the best choice of provider. Learn more in our resource, “What to Expect Working With a Speech-Language Pathologist.” Therapy approaches are tailored to the specific cause of the voice change.
Example: Accent Modification
Accent modification is an elective service provided by some voice and communication providers that teaches the sounds, intonation patterns, word pronunciation, and other features of a language to an individual with an accent, a pattern of speech that is common among individuals from a certain region or who share a common first language. An individual may seek accent modification services to reduce the impact of linguistic discrimination, or to be better understood by others. As accent is connected to culture and heritage, some voice and communication providers morally object to the provision of accent modification services on the grounds that it denies identity and perpetuates a system of linguistic discrimination. Others view accent modification services as adding an additional layer to identity without denying the connection to culture. This may affirm identity as an immigrant or citizen. While a nuanced topic, for some individuals, accent modification can constitute identity affirming voice and communication training.
Finding a Provider
As previously mentioned, most providers are likely willing and able to offer services supporting a wide range of goals beyond gender-affirming services, even when not explicitly mentioned on their website or marketing. You can start your search in the following places:
Referrals from your local Voice Center (typically a practice where voice-specialized Ear, Nose, and Throat doctors and SLPs practice together)
Referrals from community social media groups or pages
Provider Map - Playground
This map includes gender affirming voice and communication providers of all disciplines, as well as providers of gender affirming voice surgery.