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Do you sound like you? Gender-affirming voice therapy allows people to speak authentically

Why is it important to offer gender-affirming voice therapy or surgery? We spoke with experts on all sides of the equation.

Do me a favor and read one of these sentences aloud. Are you pleased with the sound of your voice? Many people aren't. Perhaps it's too nasally, or passive, or the intonation seems wrong. Now imagine that the sound coming out of your mouth isn't just mildly irritating, but that it betrays your fundamental identity.

"Changing my voice was one of the most important parts of my transition," said Gabriella Gonzalez, a 38-year-old software engineer in San Jose, California. "I had hated my voice my entire life. But now hearing my voice as I am speaking delights me. I can't stop thinking, 'That's my voice.' Finally, I feel like me when I am speaking."

Gonzalez worked with speech language pathologist Betsy Stickels at the Palo Alto Medical Foundation to achieve her new voice. Stickels recently joined Stanford Health Care as one of three speech language pathologists versed in gender-affirming voice therapy. Together with clinical assistant professor of otolaryngology Brian Nuyen, MD, who specializes in gender-affirming vocal cord surgery for transgender or gender non-conforming people, they help transform patients' voices to reflect their authentic selves.

I spoke with Stickels, Nuyen and Gonzalez to learn more about the process and what Stanford Health Care can offer.

Why is it important to offer gender-affirming voice therapy or surgery?

Nuyen: Vocal gender affirmation is not often thought about as part of gender-affirming care. But the voice is very gendered, and voice training or vocal surgery is cited by the World Professional Association for Transgender Health as one of the most powerful ways to effect change and help transgender or gender non-conforming people be perceived accurately by the outside world. Betsy and I work closely with people to help them achieve a voice that authentically reflects their identity, whether through surgery, voice therapy or a combination of approaches.

Stickels: Our voice is our calling card, and we don't realize how many ways we use our voice every day. Many of us can only imagine how upsetting it would be if the sound you heard while speaking was not yourvoice, that it didn't reflect your identity. I've worked with people who have reported taking more risks at work, speaking up more, feeling more authoritative after achieving their new voice. One person got back into dating after successful voice therapy; another became more comfortable with public speaking engagements. The advantage with voice therapy is that we can target almost any aspect of a person's voice. Some people want two voices -- one for work and one to use with friends. Others want one voice that they are comfortable using in every situation.

Gonzalez: It's important to note that not all transgender or gender non-conforming people want to change their voice. Some are fine with their voice. But for me, it was a very important and emotional experience, and I am excited and happy when I hear myself speak. I think people underestimate the extent to which you can change your voice. They don't understand what a flexible instrument the voice is.

How do you help a person change their voice? What roles do speech therapy and surgery play?

Stickels: There are many aspects to a person's voice other than pitch. For gender-affirming therapy we think of things like resonance -- an umbrella term about voice quality - as well as inflection and intonation, which I think of as a melody that underscores the pitch. Typical feminine voices are light, bright and sweet, while masculine voices tend to be heavier and darker. There are also differences in volume and articulation, and even facial expressions and gestures and non-verbal aspects including coughing, laughing and sneezing.

I help people decide what they want their voice to sound like, then teach them how to manipulate their voice to achieve their goals. I encourage people to view their voices as their own personal sound mixing board. We're here to help you sound like you.

Nuyen: Although some people can achieve their goals with voice therapy alone, others want a change in pitch that will require surgery. If you think about the vocal cords, or folds, like guitar strings, their fundamental frequency is determined by their mass, tension and length. Deeper voices come from lower tensions and longer lengths, while higher pitched voices arise from vocal folds that are shorter and held at a higher tension. We can raise the pitch of a person's voice, making the voice sound more feminine, by shortening the vocal folds in a procedure called glottoplasty.

Transgender men on testosterone often experience a deepening of their voice due to the hormone's effect on the vocal folds, but if a lower pitch is desired we can achieve this surgically with a procedure called thyroplasty that loosens the tension of the vocal folds. It's important to note that surgery is irreversible, and that even those people who choose surgery will work intensively with a voice therapist like Betsy or her colleagues to address the many other aspects of voice that affect a person's perceived gender.

Gonzalez: Voice therapy got me to my goal without surgery. But it took three to six months of regular appointments and a total of about a year to a year and a half to feel confident and comfortable with my new feminine voice. Before I started working with Betsy, I tried to train myself using YouTube videos and practicing at home. But after a while I realized that I was straining my voice, and I learned that could cause permanent damage. Betsy taught me to reduce strain by generating enough airflow to have a higher pitch while also reducing strain on my vocal folds.

This also helped my voice sound more natural and relaxed, which is very important because I give a lot of presentations at conferences, when I need to speak uninterrupted for up to an hour. At first I couldn't maintain my new voice for more than a minute, so it took a lot of practice to get to where I am now. It's also important to practice speaking in different contexts. When I first began training, sometimes I could speak just fine at home, for example, but I might lose my feminine voice if someone in public tapped me on the shoulder and asked me a question.

What motivates you?

Nuyen: As with many gender-affirming procedures, vocal surgery can be an emotional process for patients and their health care team. The demand for gender-affirming voice services is high but these services are not easy to find, so we often have a sizable waiting list. It's such a privilege to see my patients come into their own and experience a change they've been wanting for such a long time. As a surgeon and a human being, my core value is authenticity. I have never and I will never take away someone else's right to live authentically. That's why I do what I do.

Stickels: Trying to change your voice is like trying to change how you blink. It's a reflex we don't think about, and that can be a significant point of frustration for transgender or gender non-conforming people. We want to help people achieve their goal in the healthiest, most sustainable way possible so they can use their new voice all day, every day.

Photo: BrAt82

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