Voice therapy or voice training refers to any non-surgical technique used to improve or modify the human voice. Because voice is a gender cue, transsexual women frequently undertake voice therapy as a part of gender transition in order to make their voices sound female, and therefore increase their passability as females in society. Transgender people and crossdressers who present as women may also desire to feminize their voices and therefore undertake voice therapy.
- 1 Overview
- 2 Differences between male and female voices
- 3 Vocal surgeries
- 4 See also
- 5 Discuss
Voice feminization is the desired goal of changing a perceived male sounding voice to a perceived female sounding voice. The term voice feminization is used to describe what the desired outcome of surgical techniques, speech therapy, self-help programs and a general litany of other techniques to acquire a female-sounding voice. The methods used for voice feminization vary from professional techniques used for vocal training, speech therapy by trained speech pathologists and several Pitch altering surgeries.
Vocal sound is produced by air traveling upwards from the lungs through the opening of the larynx called the glottis where the vocal folds vibrate and phonation or voicing occurs. The vibrating vocal folds produce a sound that is modified by chambers (like rooms) of the throat and mouth creating resonance frequencies. The size of the chambers directly affects these frequencies. As the size of the chambers increase the deeper (or lower) the formant frequencies become. These chambers play a very important role in the perception of the timbre (rich, nasal, flat) of the voice. The articulators (tongue, lips, jaw, and soft palate etc.) shape the sound into recognizable speech. Then it is the prosodic features (speaking rate, inflection, pauses) which makes unique speech patterns.
There are several frequencies or harmonics produced at the lips. The fundamental frequency (F0) or the number of times per second that the vocal folds vibrate (in hertz), the conversational fundamental frequency is approximately 200 Hz for adult women and 125 Hz for adult men. Many of the voice feminization techniques, including those of surgeons, focus on the fundamental frequency but do little to address the how the sound is modified by the articulators or prosodic features. Speech therapists and professional voice coaches offer training in both changing the fundamental frequency and how to change the perception of voice quality.
Voice masculinization is the opposite of voice feminization, being the change of a voice from feminine to masculine. Voice masculinization is not generally required for transsexual men as the masculinising effects of testosterone on the larynx are usually sufficient to produce a masculine voice.
Differences between male and female voices
Pitch.: Females usually have higher-pitched voices than males. Many people believe that this is the only essential difference between male and female voices; however, that is not the case. The fundamental frequency (F0) of male voices typically ranges from 100 to 150 Hz while ranging from 170 to 220 Hz in females. In a 1988 study in which listeners identified the sex of a speaker by voice alone, all individuals identified as male had an average F0 of 160 Hz or less; all identified as female had an average F0 above 160 Hz.
Resonance, also known as timbre, is another important voice characteristic. According to Melanie Anne Phillips, resonance is more significant in "gendering" one's voice than pitch. One TS woman who raised her average F0 from 110 Hz to 205 Hz over four months was still frequently identified as male on the telephone, which may have been due to the resonance of her voice. However, Anne Lawrence believes that pitch is a more significant gender cue than resonance. An additional factor is the different size of the average vocal tract of males and females.
- Intonation: men tend to speak in a more monotonous tone, while women tend to use a wider range of tones when speaking.
- Pronunciation: Some theories believe that men and women tend to pronounce words differently.
- Discourse patterns: According to Melanie Anne Phillips, men tend to use words, sentence structures, and pragmatic features in which they are assertive, while women are more submissive.
Like other gendered characteristics, considerable overlap exists between male and female vocal characteristics, especially the psychological ones.
Transsexual women who go through puberty as males will usually develop voices characteristic of males. Hormone therapy does not alter a trans woman's voice once it has masculinized therefore, trans women who intend to pass as females need to have help with vocal training to feminize their voices.
Vocal training is done formally with the help of several types of professionals and privately by the use of self-help resources including audio or video tapes programs, books, information garnered from websites or chat groups that shares this particular interest. Some trans women, such as Lynn Conway have feminized their voices with no assistance.
The advantage of going through a speech pathologist instead of many of the other professionals that offer training or trying to learn on your own with self-help programs is that vocal cords can easily become irritated and even develop callous-like growths called vocal fold nodules as the result of incorrect use of the voice and from modifying oneâ€™s voice too quickly. Individuals who participate in a voice feminization program are trained to self-monitor and become more aware of their vocal quality. They learn to recognize where and how they produce sound, how they are resonating that sound, and how they physically carry themselves and their voice. Related aspects of communication are also addressed including: breathing patterns, gender related non-verbal communication and vocal hygiene.
Some trans women find voice training to be difficult, while others consider it unnecessary. While most trans women would prefer to have completely feminine voices, many are unable to achieve this goal. Some post-transition trans women have masculine voices, and many have peculiar female voices that may draw attention.
Voice scientists, speech pathologists, language pathologists and ENT physicians (otolaryngology) organize voice production into five components. They are:
- Respiration - power source
- Phonation - sound source
- Resonance - sound modifier
- Articulation - speech modifier
- Prosody - melodic aspects of speech
In training for a feminine voice, all five components are usually included.
Things that help make a voice feminine
- Pitch Feminine voices are higher; this may be the most important concern.
- Pitch Range Men tend to be more monotone, varying the pitch helps feminize the voice.
- Speech Rate - Men typically speak at a steady rate, while women tend to speak in shorter bursts followed by pauses.
- Language patterns - The language that women use differs from that of men, although the degree of variation can be quite different from one language to the next (relative to English, it is extremely pronounced in Japanese, for instance).
- Tag Questions - Example: "It's a beautiful day, isn't it?" A man, on the other hand, would be more likely to simply declare, "It is a beautiful day." 
- Supportive environment - As with any skill, speaking with a feminine voice may be easier without the stress of extreme consequences for failure (for example, being identified as a transsexual by someone to whom one is not out.) Additionally, opportunities to use the feminine voice in conversational situations (as opposed to speech-therapeutic ones) may be helpful in polishing the skill.
NB: These suggestions are based on literature from language and gender scholarship such as Lakoff (1975) and the work of Deborah Tannen. However, this work has been critiqued heavily for representing only stereotypes of how women speak, rather than how women actually speak, and additionally for representing middle-class white heterosexual women to the exclusion of all others. 
While hormone replacement therapy and gender reassignment surgery can cause a more feminine outward appearance, they do little to alter the pitch or sound of the voice. The existing vocal structure can be surgically altered using procedures that include
- Cricothyroid approximation (CTA, the most common, reduces lower range of voice)
- Laryngoplasty (surgical placement of an implant that increases tension of the vocal cords)
- Thyrohyoid approximation (surgical manipulation of the larynx to a higher position which in turn, shortens the pharyngeal chamber, does not raise pitch)
- Laryngeal reduction surgery (surgical shortening of the vocal cords)
- Laser assisted voice adjustment (LAVA, laser reduction of vocal cord tissue, known to cause scaring of the folds)
While these surgeries exist and can elevate the vocal pitch, there is limited evidence to their overall effectiveness at raising the fundamental frequency over the course of several years. All of these surgeries have little or no effect on resonance or any other vocal characteristic. After successful voice surgery, speech therapy is recommended if not required for at least 3 months after the surgery recovery time. Many in the transsexual community regard voice surgery as inadvisable. Anecdotal evidence suggests that voice surgery often raises pitch above female norms and that it may result in raspiness, or rarely, complete loss of voice. Deirdre McCloskey is one trans woman who experienced complications from voice surgery.
Cricothyroid approximation in detail
Patient prep depends on age and if any other procedures are being performed at the same time. Older clients and patients undergoing concurrent surgical procedures, (may) require general anesthesia with intubation because of the ossification of the thyroid cartilage. An advantage to using local anesthesia is that vocal function can be assessed intraoperatively.
It starts with an approximately 2 centimeter incision in a neck fold above the larynx. the skin tissues atop the thyroid and cricoid cartilages is separated to provide a field for the surgeon to work in. Next a monofilament wire is installed by penetrating (using a drill if necessary) the cricoid cartilage, under the cricothyroid and back in a square loop, If necessary, it can be doubled into 2 parallel loops if failure of the wire is a possibility. A miniplate can be used if reinforcing the cartilage is desired. Afterward, the skin is sutured back up once the surgeon is satisfied with the results.
Results and complications of CTA surgery
After surgery, the average increase (in the study group of 59) in fundamental frequency was by one fourth. (approximately five to six semitones) The range of increase was one semitone to more than one octave. 30% of the group had a normal female pitch range and 32% has a borderline pitch range. There was a couple cases of deepening of the voice pitch and general dissatisfaction with results.
The only complications noted were in a few cases of infection or incompatibility of the suture material. (delaying healing) There was 1 patient who required revision surgery from complications and 10 who chose to have revision. 7 of those 10 did not achieve further raising of pitch with revision. And finally 1 patient reverted the surgery.
In six cases, the skin adhered to underlying tissue, resulting in aesthetic issues. 25% of the patients had temporary swelling and bruising of the wound area, no medical intervention was required. All patients has some postoperative hoarseness lasting less than 4 weeks post surgery.
The over satisfaction rate is 80% with passing voices after maintenance speech therapy. Aesthetically, most (90%) were happy with the lack of visible scarring.
- Transsexual Voice for the Tone Deaf
- TS Roadmap - Transsexual Voice Resources
- How to Develop a Female Voice by Melanie Ann Phillips
- James P. Thomas: Surgery on the larynx or voice box
- TS Woman's Resources - Voice Feminization Surgery
References and further reading
- Abitbol, J.; B. Abitbol, P. Abitbol (September 1999). "Sex hormones and the female voice". J. Voice 13 (3): 424â€“446. Mosby. PMID 10498059. Retrieved on 2007-04-10.
- Lawrence, MD, Anne A. (January 2004). Voice Feminization Surgery: A Critical Overview. Retrieved on 2007-03-16.
- Lawrence, MD, Anne A. (1998). Selected References: Speech Therapy and the Transsexual Voice. Retrieved on 2007-03-16.
- James, Andrea (March 2007). Hormonal therapy for women in transition. TS Roadmap. Retrieved on 2007-03-16.
- Acoustic and perceptual implications of the transsexual voice by Deborah GÃ¼nzburger (Archives of Sexual Behavior, Volume 24 Number 3, June 1995)
- Speech Characteristics of Male-to-Female Transsexuals: A Perceptual and Acoustic Study by Linda E. Spencer (Folia Phoniatrica et Logopaedica, Vol. 40, No. 1, 1988)
- Development of a Femininity Estimator for Voice Therapy of Gender Identity Disorder Clients by Nobuaki Minematsu and Kyoko Sakuraba (Lecture Notes in Computer Science, Volume 4441, 2007)
- Operative voice pitch raising in male-to-female transsexuals by K. Neumann, C. Welzel and A. Berghaus (European Journal of Plastic Surgery, Volume 25 Number 4, September 2002)
- Voice change surgery in the transsexual by Paul J. Donald (Head & Neck Surgery, Volume 4 Issue 5, Jul 2006)
- Thyroid cartilage and vocal fold reduction: A new phonosurgical method for male-to-female transsexuals by Kunachak, Somyos; Prakunhungsit, Supawadee; Sujjalak, Kanjalak (Annals of Otology, Rhinology & Laryngology, November 1, 2000)
- Speech Therapy in the Management of Male-to-Female Transsexuals by M.D. de Bruin, M.J. Coerts, A.J. Greven (Folia Phoniatrica et Logopaedica, Vol. 52, No. 5, 2000)
- Cricothyroidopexy in Male-to-female-Transsexuals â€“ Modification of Thyroplasty Type IV by Kerstin Neumann, Cornelia Welzel and Alexander Berghaus (IJT Volume 6, Number 3, 2002)
- Laver, John (1984). Principles of Phonetics. Cambridge University Press. ISBN 978-0-521-45031-7 (hb), ISBN 978-0-521-45655-5 (pb).
- Benninger, Michael. Vocal Arts Medicine: The Care and Prevention of Professional Voice Disorders. Thieme Medical Publishers, Inc.. ISBN 978-0-86577-439-1.
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