Update on Voice Therapy for Transmen and Transwomen

Susan Clark

MPhil Speech Therapist. Royal Victoria Infirmary, Newcastle
Gendys Conference, 2004


Voice Therapy Update

The aim of this paper is to review the principles of feminising voice and the developments that have taken place since my first presentation at this conference in 1998.


Transmen criticise voice therapists for not giving them therapy routinely. This is because they are spared the problems of transwomen. Testosterone enlarges the larynx, (voice box), thickens the vocal cords so that the voice becomes deeper. Therapy should be offered at this time to stabilise the voice. To improve vocal hygiene, and emphasise male gestures.

Male voice needs to be assertive, but without excessive tension or conditions such as vocal nodules may develop. It may be necessary to concentrate on the basics for voice hygiene - relaxation, good breath support, good posture, projecting the voice and minimising excessive hard attack, and reducing intake of alcohol, and cigarettes. Excessive throat clearing or coughing are voice irritants and can also lead to vocal nodules.

Male body language involves more expansive leg and arm movements, less eye contact, different sitting and standing positions, and taking bigger strides. Men like more personal space


Oestrogen has no effect on the voice at all. Not all transwomen consider a female voice to be a priority, but for some it is the most important aspect of femininity. But to be called "Sir" on the telephone can wreck someone's confidence. Transgendered individuals do not just need to be totally committed to adjusting to their preferred gender, they need robust personalities!


The time that a client is referred for therapy is not necessarily the time for therapy intervention for the following reasons:

  • Unable to dress full time in the female role
  • Following discussion the client decides that voice is not a priority to feminisation
  • Other issues need to be sorted out before the client can concentrate on therapy.

How can voice therapy assist feminisation?

Occasionally they will need therapy if they are misusing their existing voice, and this must be corrected first, and vocal hygiene has already been discussed.

Areas to focus on:


The aim is to reduce chest resonance and increase oral resonance, which gives the illusion of raising the pitch. Place your finger tips on your chest and make an "AH" sound. You will feel the chest vibrating. Now make the "AH" sound focusing on making the sound from the front of your mouth. You should feel less chest vibration. The aim is to minimise vibration in the chest and maximise vibration in the mouth and forehead,


Women use more intonation than men who tend to be more monotone. Listen to how women speak, particularly those in their own peer group. Note the inflexions women use. Reading poetry aloud and monitoring feedback on an audio tape recorder is good practice.


Softening the voice involves controlling the breath so that the air is let out slowly in a controlled way when you are speaking, Men use harder attack. Women use softer attack. To achieve softer attack practice words and phrases that begin with "t" "d" "n" such as "dig down deep" using light tongue tip, elongate vowel sounds without hard attack

Voice Quality

A breathy voice quality can make the voice sound more feminine, but the listener must be able to hear what is being said, and too breathy a voice may be an ineffectual voice and it must have energy and reflect the person's personality.

Different Ways Men And Women Speak

  • Women use more evaluative adjectives e.g. brilliant, wonderful
  • Women are less direct in conversation using such words as "perhaps", "well maybe"
  • Women have different topics of conversation "fashion" "people"
  • Women interrupt less than men in conversation are more verbose than men, and are better listeners.
  • They talk more slowly and vocabulary is characterised by more words implying feelings and psychological state.

Female Non Verbal Communication

  • Women use more eye contact than men
  • They touch their hair and clothing more than men
  • Women smile and use more gestures than men
  • Women walk with small strides, swing their hips and tuck their elbows in.
  • Women cross their legs more than men
  • Trans women need to emphasise their femininity more than heterosexual women e.g. jewellery, makeup


Why have I left pitch to the end, as most transwomen regard it as the most important aspect of voice feminisation? Yes, it is important, but achieving a feminine pitch will not make the voice sound feminine on its own. The aspects of voice just discussed are equally important

The first point to remember is that female voice is not necessarily high pitched, Particularly older women and women who smoke. The pitch must match the person's physique.

Some older women sound similar to their male counterparts. Do not try to use a falsetto voice. It will sound ridiculous and can damage the larynx.

The aim is to raise the pitch to a realistic level.

Tongue position affects the height of the larynx. The larynx rises when we produce high notes, or when we swallow to close the airway. If you place the tip of your fingers onto your larynx and make an "ee" sound the larynx will go up. Follow this with an "ah" sound and you will feel the larynx go down. The tongue needs to be positioned high and forward in the mouth, and the back of the tongue should be pushed up against the molars, as for "ng". You need to imagine what it is like to hold a denture in place.

Most transwomen can achieve acceptable voice through therapy alone and surgery should only be used as a last resort.

But not everyone achieves acceptable pitch, after conscientiously practising the exercises outlined. A transwomen may be hard of hearing, tone deaf, or lack perception of pitch.

Criteria For Voice Surgery

Voice surgery may help transwomen who meet the following criteria.

  • Living in role
  • Have had a psychological evaluation
  • ENT examination
  • Must have had therapy which has been unsuccessful
  • Clients must be unhappy about their pitch
  • Must agree to therapy post surgery

Surgical Technique

Cricothyroid Approximation

This is the surgical technique most commonly used on clients who meet the above criteria. It is not the only technique, but is the one most commonly used here and in the United States.

The characteristic fundamental pitch of a male voice is between 100 and 150Hz: and for a female voice the range is between 170 to220 Hz: The lower pitch of the male voice is due to the greater mass and length of the male vocal cords, and the length of the male upper airways (throat, mouth, nose and sinuses) affecting the resonance

In this technique the thyroid cartilage - Adams apple - is pushed against the cricoid cartilage that lies below it. The two cartilages are then sutured together. The approximation of the thyroid and cricoid cartilages anteriorly increases the tension of the vocal cords by stretching them posteriorly . This raises the pitch at which the cords will vibrate. The operation mimics normal physiology: When we speak at the upper end of our pitch range we do so by contracting the cricothyroid muscle which pulls the two cartilages together and increases the tension in our vocal cords. Following surgery voice rest is essential. for two to three weeks, not whispering but using the voice as little as possible and no vocal abuse such as shouting.

Voice therapy should once again concentrate on the following areas:

  • Breath support
  • Resonance
  • Intonation
  • Quality of voice
  • Prevention of vocal abuse


The same surgical incision for cricothyroid approximation is used for chondroplasty or tracheal shave, for aesthetic reduction of the thyroid cartilage or Adams apple. The two procedures can be done at the same time.


General points to remember:

Total commitment is vital to achieving a feminine voice

Practice for short periods but frequently

Do not be afraid to exaggerate when working on these exercises

Learn to use your voice in a high position ALL the time

Voice therapy is unlikely to be successful if you are not living full time in your preferred role

Important attributes are self-confidence, and to be satisfied with the way you perceive your voice. It is not how other people perceive your voice.

Have you succeeded? Telephone a store and ask for the shoe department!


Lawrence A. (2004) Voice Feminising Surgery: A critical Overview

Citation:Clark. S., (2004),Update on Voice Therapy for Transmen and Transwomen, GENDYS 2004, The Eighth International Gender Dysphoria Conference, Manchester England.
Web page copyright GENDYS Network. Text copyright of the author. Last amended 09.02.11