Speaking From the Heart

Middlesex Health helps transgender patients build a voice to match their identity

By Carol Latter / Photography by CT HEADSHOTS

For transgender patients, transitioning is often a journey fraught with numerous challenges. For each individual, the hurdles may include any or all of the following – coming out to family, friends and coworkers, finding skilled medical guidance and support, assessing insurance coverage, managing hormonal treatments, undergoing surgery, obtaining new identity documents, and changing their outward physical appearance and wardrobe to better match their gender identity.
Yet even after all of this, for many people, another issue remains: having the voice and mannerisms that match the male or female they know themselves to be.
“Sometimes, transgender people are outed because of their voice, or they won’t speak because their voice is not as feminine [or masculine] as they would like. That’s an unfortunate situation,” says Rebecca Burrell, MS, CCC-SLP. Burrell is inpatient therapy manager at Middlesex Health, where speech therapy to help transgender patients change their voice and mannerisms to become consistent with their gender identity has been offered since May 2018.
She says in addition to personal preference, having a voice that matches their appearance can be a safety issue for a patient, especially given the ongoing spate of violent attacks on transgender individuals seen across the country.
Burrell says while testosterone therapy usually lowers the voice of a person transitioning from female to male to a range that is typical for a man, not all female-to-male transgender patients choose to undergo hormonal therapy – either because they hope to have children in the future, or for other reasons.
Also, explains Burrell, unlike testosterone, estrogen does not affect voice pitch or tone in male-to-female transgender patients, which can tempt them to consider vocal surgery.
Burrell doesn’t recommend that, and she says most of her patients are not pursuing this type of surgery, for a number of reasons. First, there are not many physicians in the United States who perform surgery to alter the vocal tract to increase the pitch of the patient’s voice. And those who do are usually reluctant to perform voice surgery until all other surgeries associated with transition have already taken place, since the intubation required for the other procedures can ruin the results of the voice surgery.
Even more importantly, she says, “Voice surgery has not been perfected and the outcomes are not great at this point.” While there have been some successes, “I don’t think that it’s a good enough surgery yet. I don’t bring up surgery unless they [patients] do because at the moment, I don’t have anyone that I would recommend.”

An Effective Alternative
The good news is that Burrell and her fellow speech therapist at Middlesex Health, Meghan Wright, MS, CCC-SLP, are now offering speech therapy that can help patients change not only their mannerisms and the way they speak but their actual voices. Burrell and Wright treat both male-to-female and female-to-male transgender patients and non-binary patients.
The therapy begins with an evaluation and 12 one-hour follow-up sessions. “I teach them about pitch and resonance,” Burrell says.
The pitch of someone’s voice – whether it’s a deep, more masculine voice or a higher, more feminine voice – depends on the vibration of the vocal folds, also known as vocal cords. The larger a person’s larynx is, the longer and thicker their vocal folds are, the lower the number of vibrations per second, and the lower the pitch of their voice. Women tend to have shorter, thinner vocal folds, more vibrations per second, and a higher voice. Typical male voices range in pitch from 85 to 180 hertz while female voices are usually 165 to 255 hertz.
“Some of my patients have done some research, so they’ll say, ‘I have to have 180 Hertz or higher to be in that female range.’ And while it’s been scientifically kind of shown that a trans female is often in the 150 to 180 range, if she has all the other things going for her – the resonance, the nonverbals – then that can make her voice sound just as feminine as someone who is a true 180.”
Overall, she says, “I look at voice as a package. It’s not just pitch. Resonance and intonation are also important.”
And what does she mean by resonance? Simply put, the sound created by a person’s vocal cords is changed and amplified by their throat, mouth cavity, and nasal passages, creating their recognizable voice. “Females tend to speak more from the front of their face,” Burrell says, “whereas males are more chesty and more in their throat” when they speak.
For male-to-female transgender patients, she says, “we teach them the processes that bring the resonance forward for them.” For female-to-male patients, “we work with them to promote more chest resonance.”
When it comes to intonation, “females have an upward trend to their voices; sometimes we sound like we’re asking questions, whereas the male voice is more direct. And males use less colorful language – fewer adjectives and less descriptive terms. A male might describe something as red, whereas a female might call it magenta.”
Burrell and Wright also teach general mannerisms, including hand gestures and the way people sit. “Occasionally, we get to singing and yelling, but that doesn’t mean that every patient is interested in those things.”
Each course of treatment is tailored to each individual patient and their needs – how their voice and mannerisms are currently, their preferences for what they want their voice to sound like, and even what kind of work they do. For instance, college professors and customer service representatives may use their voices a lot, whereas other patients don’t talk much in their day-to-day lives. “Those are the more challenging ones,” says Burrell. “They don’t have as many opportunities to use what you’ve taught them.”
Key to a successful voice transition is a commitment by the patient to do the exercises taught by Burrell and Wright. Patients learn to do certain voice exercises during their appointments and are then asked to practice them at home.
“And I always have them do some sort of integration exercise, like call somewhere and ask for something. A lot of my [male-to-female] patients get ‘sirred’ a lot. People call them ‘sir,’ especially on the phone. They’ll come back and tell me, ‘I got [called ma’am] for the first time.’ It’s a really great moment for them. And this usually happens anywhere between sessions six and nine. I always think that that’s a huge victory for them. And for me, I’m like, ‘Oh my gosh, I hate it when people call me that. Don’t call me ma’am!’” she says, laughing.

A Life-Changing Treatment
Burrell, a trained speech-language pathologist, became involved in transgender care a few years ago, when a colleague at Middlesex Health, who also sat on the hospital’s transgender committee, raised the need for transgender voice therapy. Burrell joined the committee and was tasked with building the program.
She notes that voice therapy for transgender patients has transitioned from a rather rare situation to something that is becoming much more common. “When I was in grad school, it was kind of a boutique thing,” Burrell says. Although health insurance companies in some states consider it “cosmetic” and won’t cover the cost, that’s not the case in Connecticut.
Now, she is eager to spread the word. “I’d like for patients to know that when they’ve gone through their physical transformation, there’s something that can be done when it comes to their voice,” she says.
For many patients, voice therapy is truly a life-changing treatment, raising patients’ self-esteem, allowing them to “fit in” in social situations, and making them feel accepted and safe. All of this makes Burrell’s job tremendously rewarding.
“I actually recently had an experience where I was giving a presentation at a program that we held for transgender people [and supporters] here at Middlesex Health. I was waiting to present and one of our psychiatrists, Dr. Shelton, came up to me and said he had referred a patient to me,” she recalls.
“I had been seeing her since July and she had just finished with me. We went through the 12 sessions and she did amazing – her pitch, her mannerisms. I mean, you would not even know that any masculinity was left in her voice. She was an optimal patient. She went home and practiced every night for an hour. Dr. Shelton told me he had seen the patient the other day and it was amazing how much her confidence level, the way she carries herself, and how happy she is with herself had all improved now, with her voice change.”
Needless to say, Burrell was thrilled.
“That just really touched me, that he as a physician had noticed the positive changes in this particular patient. When I first met her, she barely talked. She was reluctant to talk on the phone; she would text all the time. She was reluctant to even talk to people in her circle: her mom, her grandmother. And now she’s out there, and she wants to tell her story. Whereas I think before she wasn’t able to tell her story because her voice wasn’t there. She didn’t feel comfortable. She didn’t feel confident. So, I think that the voice can be incredibly important.”
For loved ones, a change in voice – especially a significant one – can be something that takes a little getting used to. Some patients have shared that their parents were having a difficult time adjusting to the change. For others, it’s the delay in voice transition that’s causing a problem. One patient brought their spouse into therapy, “and I think it was emotional for them” because the patient’s voice did not match her appearance and she didn’t want to use her voice as much around her spouse.
Burrell says that while her best outcomes have been among people in their 20s, success can come at any age. Her patients range from teenagers to people in their 60s. Most are between the ages of 20 and 40.
Another of her success stories involves an “extremely dedicated” teenaged musician. “I think having a musical background is helpful in this case, because a lot of what I do is self-reflection on their voice. We’ll record [voices] and I’ll say, ‘Which one do you like better? A, B, or C? Why do you like that one better, and what can we do to get you closer to that?’”
For someone who initially wanted to be an attorney specializing in elder law – and found speech pathology through a somewhat serendipitous route when a professor introduced her to the field – she is enjoying her career immensely.
She’s also grateful for the close-knit team of healthcare professionals at Middlesex Health who work together to ensure that transgender patients – and all LGBTQ patients – receive the highest level of care and attention possible.
The job is not without its challenges. She has had cases where patients find they can’t commit to regular practice of the voice-altering exercises, or have unrealistic expectations, wanting a voice that they aren’t able to achieve. So, what to do? In the first instance, she may need to give the patient space, and allow them to take the required steps when they’re ready. In the second, “I have them bring in clips of people that they like. And through our process, we find the voice that is achievable. I would say that in the end, it’s about finding your ideal voice.”