The Vocal Congruence Project (VCP) is a collection of free resources to help people find vocal congruence — the sense that their voice and speech accurately reflect who they are. This has a proven positive impact on mental wellbeing.

VCP is a collaboration between voice-specialized speech-language pathologists Nora Mahon, MS, CF-SLP and Leah B. Helou, PhD, CCC-SLP. Based in lived and professional experience, VCP was created for the transgender and gender diverse community, but can support anyone.

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Our guides are designed by voice experts to help you navigate the voice training process and get the most out of your time and effort. Select an option below to see the resources most relevant to you.

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The map is opt-in. Submit a request to join using the button below. Before joining, please view the map to see how information will appear on your profile. The entrance form takes approximately 10-15 minutes to complete.

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Please notify us of small edits (e.g., changes to 1-2 fields, or additions to your affiliations, locations, etc.) by emailing vocalcongruence@gmail.com.For more significant edits, or to delete your listing, please submit a new form.

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Who Can Become a VCP Ambassador

Anyone is welcome to become a VCP Ambassador, but this opportunity is especially well suited for students and early career professionals in voice professions who are interested in expanding their own networks and learning more about gender-affirming voice and communication.

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How VCP Uses 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:

Donations are accepted via Ko-Fi. Ongoing donor-supported projects and goals are highlighted there.

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.

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-Esophagological 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.

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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.

Vocal Exploration

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:

Benefits of Self-Initiated Change

Self-initiated change has a number of benefits:

Additional Considerations for Self-Initiated Change

Due to the nature of self-initiated practice, it is important to note the following considerations:

Will I Hurt My Voice?

TLDR: It’s possible, but preventable.It is possible to hurt your voice by practicing independently. However, this should not discourage you from exploring or practicing on your own, especially when services with a provider are not accessible. Rather, it simply means that your independent practice should include regular reflection on how your voice sounds and feels to see if these may indicate a potentially unhealthy practice pattern.Signs of a voice disorder may include:

Both masculinizing and feminizing techniques can lead to voice difficulties, and a voice disorder will make it more difficult to achieve a sustainable and congruent voice.If you suspect you are practicing in an unhealthy way, or if you suspect you may have a voice disorder before beginning to practice, 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 and filtering by “Speech-Language Pathologist.” Depending on the results of their evaluation, an SLP may provide clinical voice therapy, which is more likely to be covered by insurance even when gender affirming voice training is not.

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

As discussed above, a voice disorder can affect how your voice sounds, feels, or functions. Voice disorders may emerge during training as a result of unhealthy practice patterns, or they might characterize one’s baseline voice.For a list of symptoms that may indicate a voice disorder, see above.If you suspect you are practicing in an unhealthy way, or if you suspect you may have a voice disorder before beginning to practice, we highly encourage you to seek the services of a voice provider.A voice-specialized Speech-Language Pathologist is most equipped to assist you if this is the case. For assistance finding one, see our provider map.

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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:

See our other resource, Types of Gender-Affirming Voice Provider.

What to Expect From Your Evaluation Appointment

Depending on where you are seeking services, your first appointment may be with a speech-language pathologist alone, or with an SLP and a laryngologist (a physician specialized in the voice). This is especially common at a "Voice Center." Laryngologists work in collaboration with the SLP to assess your vocal health and readiness for therapy. Many laryngologists perform gender-affirming voice surgeries, and can provide additional information about these options. Regardless, you can expect the following.

History

Your first session is likely to begin with a conversation about your history and goals. Questions may cover:

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.

What to Expect From Your Training Appointments

Every providers approach will differ, however, you can likely expect the following:

In order to make progress, you are encouraged to practice often on your own. As you develop your skills, your SLP may recommend spacing out your therapy sessions, leaving you added time to practice between appointments. Learn more about finding practice opportunities and overcoming barriers to practice here.

Before Training Begins

There may be a wait before your first training session. The following resources can help you get a head start.

Finding an Experienced SLP

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When to Seek Support

Finding an affirming voice can be a daunting task. 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 Support

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:

Additional Considerations:

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:

Additional Considerations:

Theater / Acting Coaches

Coaches with a specific background in acting or theater may additionally offer GAVC services. They can come from a variety of formal educational backgrounds. Similarly to Vocal Pedagogues/Singing Instructors, they may be members of professional organizations, however, there is no credentialing, licensing, or other such oversight of their work.Possible benefits include:

Additional Considerations:

Nontraditional Gender-Affirming Voice Trainers

This category of providers refers to those who, through their lived experience and 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 exclusively 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:

Additional Considerations:

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:

For more information, see our other resource, Choosing a Gender-Affirming Voice Provider.

Finding a Provider

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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

Lack of Training or Experience

Prescriptive Approach

Defensive to Feedback

Gatekeeping

Endless Sessions

Green Flags

Personality Compatibility

Flexibility and Responsiveness

Engagement with the Community

Understanding of Their Limitations

Strong Network

Discontinuing Services

If you’re currently working with a voice provider, and looking for permission to break up with them, here it is.Whether it's due to incompatibility or any other reason, 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 deciding to discontinue services, and for generating feedback, you can reflect on these questions:

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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, Voice Fundamentals & 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-specialized speech-language pathologist (often in collaboration with a laryngologist) 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.

Troubleshooting Training

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, Voice Fundamentals & Effects of Hormone Replacement Therapy.

Accessing Surgery

The process of accessing gender-affirming phonosurgery can be complex. If you feel phonosurgery is something you would like to pursue, begin the initial steps as soon as possible, such as contacting your insurance company for coverage criteria, researching and contacting surgeons of interest, and beginning voice training (if desired or required). While highly recommended, presurgical voice training is not required according to the WPATH Standards of Care, but may be a requirement of your surgeon or for insurance coverage.

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 one of the only options 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.

Injection Augmentation

Injection augmentation is the process of injecting filler material (including fat or synthetical filler materials) into the vocal folds to increase vocal fold mass. The additional vocal fold mass can result in a lower pitch, however, pitch change in isolation is unlikely to result in a masculine-perceived voice. This procedure is most commonly used for those with vocal paralysis or reduced muscle mass to bring the vocal folds closer together and improve vocal fold vibration. The vocal folds may be accessed via the mouth, or an injection through the neck. The augmentation may be temporary or permanent, based on the filler material used.

Additional Surgical Considerations

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.On the other hand, some insurance providers may more readily cover chondrolaryngoplasty if done by a plastic surgeon in conjunction with Facial Feminization Surgery. Regardless, complication rates for this procedure are low when performed by any specialty.

Surgical Intubation

Intubation is the process of inserting a tube through the mouth or nose and the trachea. The tube keeps the airway open, and can connect to a machine that delivers air. Intubation is done in emergency situations, but can also be necessary for some surgeries, including gender affirming surgeries unrelated to the voice.Because the breathing tube passes through the larynx (or voice box), there is a risk of damage to the voice during any procedure requiring intubation. Ask your surgeon about these risks and recovery instructions.

Finding a Surgeon

The Vocal Congruence Project Provider Map includes surgeons, including the types of procedures offered and other relevant information.

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:

When selecting a surgeon, asking questions is important. You can start with the following:

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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:

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.

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:

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

Hardest to use my target voice

To put situations in order, think about people, place, priority, and preparation.

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.

Afterwards, think through the situation again.

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:

Your decisional balance sheet should be based on your individual goals and life context. A hypothetical example might look like this:

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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.

Articulation

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.

In Conclusion

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.To learn more about this topic, we suggest reading our resource "Exploring Your Voice Goals."

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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.

Examples

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.

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.

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:

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What’s your “Why?”

Like many aspects of the voice training process, there is no single or correct way to start thinking about your goals. However, asking “why change?” can be a solid first step. Here are some common answers:

You can have more than one reason for wanting to change your voice. However, some may not overlap. For example, if you are seeking a voice that contributes to a cis-assumed presentation, you might find that your “most feminine” or “most masculine” voice is not the same voice that brings you the most vocal euphoria. Conflicts like this are something you might uncover as you explore your voice.You might also read this list and reflect on this topic only to realize you don’t have a reason or motivation to change your voice. That’s okay too! No one is obligated to voice train or present in any specific way.

Exploration

Vocal exploration is something everyone can and should try, to get a sense of their own abilities and gain valuable information about goals. There is no right way to explore. If you aren’t certain where to start, try a character voice or celebrity impression, and reflect on the following questions:

When trying something new with your voice, ask yourself the question: “Was that a step forward, a step backwards, or did I not move?”If you feel like you took a step forward (toward your “goals,” even if we aren’t sure what those are yet), take another step. For example, if you raised your pitch and felt it was a productive step forward, raise your pitch even more. Maybe you’ll find that you’re continuing to head in the right direction, or maybe it’s a step too far. Either way, you are learning more about your voice goals and abilities. If you feel it was a step backwards, reverse course. If you don’t feel you moved at all, try modifying a different component of your voice.Throughout this, pay attention to how sounds feel both physically (e.g., tense, open) and emotionally (e.g., affirming). Pick and choose areas to explore more deeply if they feel useful. As you explore your voice, you might find that your initial goals change. This is okay and expected - finding your voice is unlikely to be a straightforward journey.

Framing Your Goals

There are a number of ways we can think and talk about voice goals. Here are some possible framings that might click with you:

Acoustics

Acoustics refers to the actual sound of your voice, including the qualities of pitch, resonance, and more. You can learn more about each of these qualities here. This can be a conveniently objective and concrete approach to thinking about goals.Goals related to acoustics might read like this:

You may encounter resources and research that refer to a specific pitch range for cisgender men and cisgender women, or a pitch range for when a voice is perceived as a specific gender. When interpreting this information, it is important to note that our voices are not a single pitch. We fluctuate based on a variety of features, including who we are talking to, the emotions we are conveying, the culture we are from, and much more.Additionally, there is a large variety of voices among cisgender people. Take for example the lower feminine voices of actresses Emma Stone or Scarlett Johansson, or the higher masculine voice of athlete David Beckham. There is no singular “masculine” or “feminine” target for any acoustic feature, only broad ranges that vary with culture and context.

Congruence

Vocal congruence is the feeling that your voice matches who you are. Goals related to vocal congruence might read like this:

To find a voice that is truly “you,” it can be helpful to set aside acoustics for a moment and consider your voice as an extension of your personality. What qualities about you do you want your voice to convey? What parts of your personality and identity came through in your default voice, and which do you want to keep? This can be a foundation to build a new voice that is still uniquely yours, beyond an acoustic target.

Function

Another metric for examining if your voice has met your goals is its function, or how using your voice plays out in your life. Goals related to function might read like this:

If you don’t feel safe, or don’t feel confident, this can impact your daily life by reducing the amount you speak with others, try new things, etc, and you might not consider it a “functional” voice for your needs. Likewise, if you have achieved vocal congruence or an acoustic target, but using that voice is painful, strained, or otherwise unsustainable for long periods of time, that is not a functional voice.

Putting It All Together

If you’d like, you can draw from all of these to craft a goal. For example,:

What if I Can’t Choose A Goal?

There is no reason that you need to have a singular, specific voice goal. You can practice as many voice modalities as you would like, with the caveat that each one requires its own exploration and training to perfect and use. If you’re exploring multiple distinct voices and are looking for the best match, look for what they have in common.

A Note on Passing & Terminology

Historically, many providers and researchers of gender affirming voice and communication services operated under the assumption that passing, a term for when a transgender person is perceived as cisgender, was the primary or exclusive goal of someone seeking such services.More recently (from the perspective of the authors, who are speech-language pathologists) the field has shifted away from this mindset to be inclusive of a wide range of goals and expressions. With this, there has been a shift away from the term passing, mirroring that seen in other clinical and media contexts discussing transgender people.In place of passing, the term “cis-assumed” is used by many providers and here to describe when a transgender person is perceived as cisgender, without an associated value judgment or implication of dishonesty or deception, common criticisms of the term “passing.”This is not to imply that one should not use the term passing to describe their own goals and experiences, but note that most providers engaging in culturally informed practice will only use the term when mirroring a client’s language.

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Vocal Development

Voice Changes During Puberty for Children Assigned Male at Birth (AMAB)

For those assigned male at birth (AMAB), puberty is expected to begin between ages 9 and 14. During this time, the voice changes significantly, commonly beginning around age 12. Testosterone, a hormone released during puberty, results in an increase in the mass and length of the vocal folds, decreasing pitch. At the same time, the larynx (or “voice box”) descends and grows larger. This commonly results in a visible Adam’s apple, and increases the size of the resonating chambers, resulting in a more masculine-perceived voice quality.Changes take place over a period of several years. Voice “cracks” and instability are common, and may be the first things noticed, but the voice will become more stable over time as the body becomes accustomed to the growing larynx. It may take several years for all changes to conclude, with small changes continuing into early adulthood.

Voice Changes During Puberty for Children Assigned Female at Birth (AFAB)

For those assigned female at birth (AFAB), puberty is expected to begin between ages 8 and 13. The voices of AFAB people change some during puberty. Slightly lower pitch and darker resonant quality can be expected due to changes in the size and shape of vocal anatomy. However, changes are to a much smaller degree than in AMAB people.

Puberty Blockers

Puberty blockers will delay or suspend the onset of puberty and associated voice changes. Some minor changes to the voice can still be expected from the effects of overall growth and body size, but will not resemble the changes seen in puberty. Anecdotally, transfeminine and transmasculine adolescents who begin puberty blockers before the onset of voice changes and continue with Hormone Replacement Therapy can expect to develop cis-assumed voices. However, there is limited research on this population.For more information on the science of voice, development past puberty, and effects of HRT, see our other resource: “Voice Fundamentals & Effects of Hormone Replacement Therapy”

Voice Training for Children & Teens

There is no age or milestone required to begin independent vocal exploration or voice training with a provider. Voice can be an important goal at any time. However, much of the information and many of the resources available were created with the assumption that the reader has a fully developed voice. VCP is no exception. Keep in mind when engaging with content here and elsewhere that certain concepts, techniques, and considerations may not be fully accurate or applicable to someone pre-puberty or who is currently going through puberty.

Goals

Figuring out voice goals is a difficult process no matter what age you are starting the voice training process. Many young people share an experience of feeling "this voice isn't right, but I don't know what is." The voice training process is likely to include learning to sit with that uncertainty, and developing a willingness to explore.Vocal exploration is something everyone can and should try. There is no right way to explore. Some common ways to start include attempting a character voice, or celebrity impression.

Try something new and ask one simple question: “Was that a step forward, a step backwards, or did I not move?” If you feel like you took a step forward (toward your “goals” even if we aren’t sure what those are yet), take another step. For example, if you raised your pitch and felt it was a productive step forward, raise your pitch even more. Maybe you’ll find that you’re continuing to head in the right direction, or maybe that it’s a step too far. Either way, you are learning more about your voice goals. If you feel it was a step backwards, reverse course. If you don’t feel you moved at all, try modifying a different component of your voice.Throughout this, pay attention to how sounds feel both physically (e.g., tense, open) and emotionally (e.g., affirming). Pick and choose areas to explore more deeply if they feel useful.Voice is also affected by age. If attempting character or celebrity voices, try to find examples close to you in age, or pay extra attention to the voices of friends or classmates. This can help you develop a voice that feels congruent for both gender and age.For more information on developing goals, see our other resource, "Exploring Your Voice Goals"

Self-Initiated Practice

Self-initiated, or independent practice means changing your voice without the assistance of a voice provider. This is likely the most available option for transgender and gender diverse youth, especially those not yet out or who lack parental support.Online resources supporting self-initiated voice change, like those found on YouTube, TikTok, or Instagram, are unlikely to have been developed with children and teenagers in mind, and assume the user has a fully developed voice. If using these resources, it is important to keep in mind that not all information will be fully accurate or applicable.Online resources also commonly emphasize technical knowledge, such as anatomy, physics of sound, or other advanced concepts. While children and teenagers can learn and may benefit from this knowledge, it can also be overwhelming and discouraging. This technical knowledge is not necessary to make meaningful voice changes. If feeling discouraged, a provider can help. Learn more in our other resource: “Independent Practice & When to Seek Support”Still, independent voice practice and online resources can support voice change through many obstacles. Someone pursuing independent practice may benefit from the resources here.

Parent / Caregiver Involvement

Parents and other caregivers can support the voice training process in several ways. First, by creating a home environment that is supportive of vocal exploration. This means accepting that a child may want to use their voice in a variety of ways, and providing support and motivation as needed. Additionally, this means refraining from commentary or feedback unless requested.Vocal exploration and training is a highly personal process for many, and may give rise to feelings of vulnerability and embarrassment. Parents and caregivers should be prepared for their child to want to engage in this process privately, and offer up space to do so. However, when desired, parents can serve as a dependable practice partner, who can give respectful and requested feedback.Parents and caregivers can also aid in the voice training process by finding and funding services with a voice provider, when the child has decided this is something they would like to pursue. Learn more about the types of providers and choosing a provider, and browse local providers on the VCP Provider Map.

Legislative Barriers

In the United States in recent years, many states have enacted legislation and regulatory policies limiting and criminalizing gender affirming care for minors. These may limit the use of puberty blocking medication and HRT, both of which can be used to develop or maintain a target vocal quality. These laws also commonly prohibit gender affirming voice surgeries for minors, however, this is largely redundant as gender-affirming phonosurgery is not performed on minors.Some states additionally limit social transitioning, which includes non-medical aspects of transition such as changing one’s name and clothing, and may be interpreted to encompass vocal transition. While the specific wording of these laws generally does not specify gender-affirming voice and communication services, some providers, especially Speech-Language Pathologists (SLPs), may not offer services to minors out of an abundance of caution. SLP services may also be affected by state bans on insurance coverage of gender affirming services for minors and adults. An overview of state laws is provided by the American Speech-Language-Hearing Association (ASHA).

Additional Considerations

Voice at School

Many trans and gender diverse students experience difficulty at school due to their voice. It is common for students to experience social anxiety or withdraw from social opportunities due to vocal dysphoria. It can also make some assignments, like oral presentations, even more difficult.Depending on state of residence in the United States, the educational impact of an incongruent voice may (in theory) qualify trans and gender diverse youth for services with a school-based SLP. However, it is uncommon for a school-based SLP to provide gender affirming services, and few school-based SLPs are experienced in this niche area. Significant advocacy on behalf of the student is likely required to pursue these services in the school setting.

Finding Community

Finding a community of people with similar experiences can be uplifting and impactful. While we do not currently know of any voice-specific community groups for children and teens, there are many youth-centered programs and spaces where transgender and gender diverse youth can find community.Any such community space should also be welcoming of a range of vocal expression and exploration, and be an affirming environment to try new things, or even discuss shared experiences with others on their own voice journeys. We are happy to assist anyone looking for local organizations serving queer youth. Please contact us.

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Benefits of Documenting Your Progress

Documenting your vocal transition through regular recording offers a range of benefits:

While there are many benefits to documenting your progress, for some, listening to a voice recording can also cause dysphoria. If this is the case for you, it is okay to not record yourself. For more on addressing dysphoria during voice training, see our resource “Finding Practice Partners & Opportunities.”

Recording Process

Schedule

We recommend recording yourself at least every other week. Recordings should be taken far enough apart that you can realistically achieve change between them. This may vary based on your practice habits. For example, if you practice every day, you may choose to record weekly or even more frequently.

Equipment

For most people, a phone microphone is high enough quality to monitor progress over time. If you are using your phone, hold it no closer than 6 inches from your face for the best sound quality. Be sure that the microphone is not obstructed while recording.To obtain a higher quality recording suitable for in depth analysis, an external microphone is a better choice. If using an external microphone, follow the manufacturer's recommendations for achieving the highest quality recording.You can also improve your recording quality by minimizing reverberations and background noise. Placing furniture against walls can make sound reverberate less in a space. 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 an improvised sound booth.

Software

In most cases, the voice recording application pre-installed on your phone will be sufficient for your needs. You can also use Audacity, a free audio editor and recording application available for Windows, MacOS, and Linux.For analysis of speech samples, additional software is needed. AcousticGender.space is a free and easy to use web-based application that analyzes recordings for pitch and resonance. Praat is another popular and free software that can be used to analyze pitch, resonance, intensity, and more. Praat can be difficult to use, but many tutorials are available.Real-time information about pitch, resonance, and intensity can be analyzed using a mobile application like Voice Tools, however, this software does not analyze recordings.

What To Say

The content of your recording can be anything! However, it is important to note the difference between reading a passage and spontaneous speech, and why it can be beneficial to record both.

Read Speech
For many individuals, reading can take away a lot of the thought work required for spontaneous speech. We may also add inflection, stress specific words, or change other characteristics of our voices to convey the message of the passage. Read speech allows for repeating the same passage each time you record, making it easier to compare across time points.Several standardized passages are used commonly in research and clinical practice. Several of these are listed below. There is no significant benefit to either. Do not feel limited to these scripts. Some people also opt for a passage that is personally meaningful, such as a poem or passage from a book.

Spontaneous Speech
When having a spontaneous conversation, we devote cognitive resources to what we are saying as well as how we say it. Compared to a reading passage, this resource allocation can make it more difficult to maintain a target voice. One tradeoff is that practicing your voice in spontaneous speech makes your practice more like day to day voice use. Compared to readings, it may be a bit more difficult to compare spontaneous recordings against one another. You may also find your performance varies when using your voice alone versus out and about, or with a conversation partner, adding another variable that makes comparison difficult. Try the following:

Additional practice prompts include:

Observer Effect

When recording, it is important to be aware of the observer effect. This is when performance changes in response to the act of recording. For an accurate picture of your progress, try to remain as calm and natural as possible. You can also try turning on your recorder and putting your phone down during a meeting or a conversation with a friend (with the consent of the other people present). In time, you will likely forget you are recording, reducing the observer effect. While this method may not result in the highest quality recording, it can provide the most authentic record of your everyday voice.

Reviewing Your Recordings

The amount you review your recordings depends on your goal. One method is to listen immediately after recording, to get an accurate sense of how you sound and to be able to troubleshoot in the moment. This can mean recording the same phrase, listening, and recording the same phrase again with slight modifications to fine tune.A less frequent review of your recordings is important for gaining perspective. By comparing your current voice to your baseline voice, you can hear the full range you’ve covered. You might also have no intent to listen to your recordings, but just want to maintain a record. That is totally fine, and there is no obligation to listen back.Regardless, when reviewing your recordings, it is best to do so with an open mind and kind intent. You are learning a new and difficult skill, and it is important to not let perfectionism get in the way of progress.

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Insurance

Insurance coverage of gender affirming voice and communication training is highly dependent on your specific plan. In most cases, only services provided by a Speech-Language Pathologist (SLP) are eligible for insurance coverage. Learn more about types of voice provider and how they differ.

Determining Coverage Criteria

We recommend contacting your insurance company to inquire about their specific coverage criteria for gender affirming voice and communication services. You may be asked to provide the relevant CPT (treatment) codes. These include 92524 (voice evaluation) and 92507 (voice therapy sessions).Your insurance company may inform you of ICD (diagnostic) codes you will need for coverage. This will likely include F64.0 or F64.9 (Gender Dysphoria), diagnosed by a mental health provider, and possibly R49.0 (Dysphonia) or R49.9 (Unspecified voice and resonance disorder), diagnosed by a speech-language pathologist or ENT.

Insurance Requirements

In some cases, insurance coverage may be conditional upon certain transition milestones or other requirements. For example, a certain amount of time on HRT, or a letter from a mental health provider reaffirming the medical necessity of voice services.A template mental health provider letter is available here.It is important to note that requirements such as these are not in alignment with the WPATH Standards of Care or current evidence for best practices among voice professionals. If they are required by the voice provider prior to services (outside of reasons of obtaining insurance coverage), this is a red flag.

Finding Covered Providers

Your insurance company may provide a directory for browsing in-network providers. However, gender-affirming voice services are niche and are not offered by all speech-language pathologists.Therefore, we recommend starting with the VCP Provider Map. Select “I am looking for a Trainer”, then filter Professional Area by “Speech-Language Pathologists,” and by your state. Select one of the providers. If they have provided information about costs or insurances accepted, the heading “Financial Information” will be present on their profile. Select it to read more.

Medicaid

Twenty-six state Medicaid agencies cover “medically necessary” gender affirming services. These services are generally inclusive of surgery, hormone therapy, and mental health treatment. However, voice services are rarely explicitly mentioned but still may be covered under the concept of “medical necessity.”Per the American-Speech-Language-Hearing Association (ASHA), state Medicaid agencies that cover gender-affirming care but do not mention whether voice therapy is a covered service include: California, Colorado, Connecticut, Hawaii, Illinois, Maine, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New York, Oregon, Pennsylvania, Rhode Island, Washington, and Wisconsin.State Medicaid agencies that include gender affirming care generally but exclude coverage for voice therapy for gender affirmation services include: District of Columbia, Maryland, and Vermont.Ten states’ Medicaid policies specifically exclude gender-affirming care, including: Arizona, Florida, Idaho, Kentucky, Missouri, Nebraska, Ohio, South Carolina, Tennessee, Texas.As gender-affirming healthcare legislation has been evolving rapidly, the information here may become out of date. The Movement Advancement Project Medicaid Coverage Map provides more up to date information, but may not include voice-specific information. We recommend contacting your state’s Medicaid agency directly with questions. Please feel free to let us know if you become aware of an error in the information here.

Self Pay

If your insurance coverage does not include gender affirming voice services and you would still like to proceed with training, you will need to pay out of pocket. Fortunately, there are several ways to reduce these costs.

Self Pay Discounts

If you are not using or do not have insurance, you will likely be charged a lower rate than what the provider would charge an insurance company. This is known as a self pay or private pay discount, and can often be a substantial reduction. Be sure to inquire about self pay rates wherever you seek services.

Sliding Scale Pricing

Sliding scale pricing means rates are adjusted based on your ability to pay. Depending on the provider, this may factor in your income, number of individuals in your household, or other financial information.

Superbills

Your insurance coverage may include out-of-network benefits. A superbill is an itemized list of services provided by an out-of-network provider that you can use to request reimbursement for the cost of the services. You will need to inquire with (a) your insurance company regarding your out-of-network benefits and if prior authorization is needed, and (b) your provider to see if they offer superbills.

Payment Plans

Some providers may offer payment plans to distribute costs over a greater period of time, reducing the immediate financial burden.

Outreach Script

Consider sending the following message to potential providers, which encompasses the above options:Hello! I am interested in working with you for gender-affirming voice services. I would be grateful if you could share your policies and information regarding costs and payment options. Specifically, do you accept any insurance plans? Do you offer self pay-discounts, sliding scale pricing, superbills, payment plans, or any other ways to make services more affordable?

University Clinics

Free or reduced cost services may be available in university-based speech-language pathology clinics. In these clinics, services are typically provided by a masters-level student of speech-language pathology under the supervision of a licensed SLP.Students at this level will have completed an undergraduate degree and prerequisite coursework in speech, language, and hearing. They may or may not have completed a graduate course on voice. The SLP curriculum and the time spent on gender-affirming voice services varies across programs.If you do not see providers representing your local universities on the VCP Provider Map, you can find all schools offering SLP programs on the ASHA website (filter by “Master’s Degree in Speech-Language Pathology” and your state). Then, you can search online or contact your local schools to determine (a) if they have a campus SLP clinic, (b) if they offer gender-affirming voice services, and (c) the costs of those services (commonly sliding scale or free).

Grants

Limited funding opportunities exist for gender affirming voice services. Please reach out if you discover additional grants or funding opportunities so that we can add them to our list.

Observation & Open Groups

Certain providers, most commonly nontraditional voice trainers, will offer a discount if you allow others to observe your training session. You can also observe others’ sessions for free or a small fee and follow along with the exercises yourself.These same providers may also host free group courses in their virtual venue of choice, such as a Discord Server. Learn more about gender-affirming voice forums and community groups in our resource Independent Practice & When to Seek Support

Independent Practice

If none of the above options are available to you, you may want to begin practicing without the support of a voice provider. To learn more, see our Independent Practice Resource Hub.

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Mental Health Provider Letters

In some cases, insurance coverage of gender affirming voice services may be conditional upon certain transition milestones or other requirements. This may include a letter from a mental health provider reaffirming the medical necessity of voice services.This template letter (modified from the UCSF Gender Affirming Health Program template) is intended to aid mental health professionals in writing a letter for clients seeking voice services with a speech-language pathologist.Be sure to review the specific requirements of the insurance plan and make any adjustments as needed prior to submission.

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Template Letter

[Date]
[Patient Name]
[Legal name, if different]
[Date of birth]To Whom It May Concern,Regarding the above named patient: I am a [title] practicing at [practice name]. I have worked with this patient since [month, year]. I am appropriately qualified to perform evaluations in accordance with the criteria described in the World Professional Association for Transgender Health (WPATH) Standards of Care 8th Edition (SOC8).During our patient-provider relationship ([DATE – DATE]), I have evaluated the above-named patient and diagnosed [him/her/them] with Gender Dysphoria (F64.0) in line with DSM-5 criteria. [He/She/They] have experienced the desire to live and be accepted as a member of her chosen gender since [year]. [He/She/They] have additionally [comments on medical, social, and/or legal gender-affirmation steps].Despite these interventions, [he/she/they] continue[s] to experience significant gender dysphoria, emotional distress, and decreased social and occupational participation due to the misalignment between voice and gender identity. [Additional comments, if any, on client’s experience with vocal dysphoria and related challenges.] Rectifying voice incongruence is expected to provide marked relief of the distress experienced and improve life participation.Based on my assessment and experience working with [patient name], I recommend gender-affirming voice therapy as the next appropriate step to allow [him/her/them] to continue living as [his/her/their] true identified gender, provided the treating speech-language pathologist and/or laryngology provider reaffirm their candidacy for voice therapy from a medical standpoint after consultation. [Patient name] is fully capable of making an informed decision about this treatment, is aware of possible benefits and challenges, and has reasonable expectations with regards to treatment outcomes.It is my clinical opinion that [patient name] meets the criteria for a persistent, well-documented diagnosis of gender dysphoria (F64.0), and that [pt name]’s gender dysphoria related to the voice causes emotional distress and impairment in social, occupational, and other important areas of functioning. Thus, it is medically necessary for this patient to undergo voice therapy for the purpose of gender affirmation.If you have any questions, please contact me at [phone, email].Sincerely,[NAME]
[Credentials]
[Practice Name]
[Contact info]

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