Emily Hornack, MA, CCC-SLP, estimates that when she became a speech-language pathologist at MetroHealth fourteen years ago, she had five or six patients a year come to her for help with gender-affirming voice therapy.
Now, alongside Erin Nutt, MS, CCC-SLP, and Carey Wentzel, MS, CCC-SLP, scores of patients per year are finding their voice at the MetroHealth Rehabilitation Institute. The trio serves patients virtually and in three locations across Cuyahoga County: the ENT clinics at Main Campus and Parma and the speech office in Cleveland Heights.
“We see patients at many points during their transition, from two weeks after starting hormone therapy to people who have been out for 40 years,” says Hornack. “A person’s voice transition has to adapt to their overall transition. So, we have to be sensitive and adaptive to where they are.”
Comprehensive Care: All One Voice
While gender-affirming care is often wrongly reduced to discussions about genitalia and hormones, a person’s voice is a major part of how they present themselves. In reality, gender-affirming care must be comprehensive—and that includes voice therapy.
“Without gender-affirming voice therapy, patients run the risk of never finding their true voice, the voice that sounds like themselves,” says Nutt.
Gender-affirming voice therapy is a behavioral-based therapy that helps a person communicate in a way that matches their gender identity. While surgery is available, Hornack estimates that 90-95% of patients at MetroHealth meet their goals with voice therapy—a less invasive treatment method.
For patients using gender-affirming hormone therapy, there are significant considerations. While testosterone will lower a person’s voice, estrogen does not feminize the voice. Other patients are seeking to become more androgynous on the gender spectrum. So, while changes may be happening with a person’s body to match their gender identity, those changes don’t always show up in the voice. And even when they do, there are paralinguistic differences between a feminine and a masculine voice that voice therapists can address.
“Males are typically raised to be monotone, and their register goes down at the end of sentences,” explains Hornack. “Women tend to have a sing-songy quality. It’s about listening to the patient’s goals and helping them achieve those goals in a healthy way.”
Gender-affirming voice therapy isn’t just about meeting goals, it’s also a safety issue. If a person’s voice does not match their outward gender identity, they could out, themselves and be susceptible to the abuse and attacks prevalent in the trans community.
“Gender-affirming voice therapy isn’t just physically demanding, it’s mentally and socially demanding, too,” explains Nutt. “At MetroHealth, we put special focus on connecting patients to resources that may help them throughout their transition and beyond.”
Anatomy of a Visit
While gender-affirming voice therapy has very few specific protocols and bodies of research, therapists at MetroHealth lean on adapting existing research to address specific patient goals.
“There are a few particular experts that have been doing this work since the 1980s,” says Wentzel. “But we’ve also adapted what we’ve learned from puberphonia, singing voice therapy and accent modification services to meet patient needs.”
In a patient’s first visit, MetroHealth therapists focus on setting goals and good vocal hygiene.
“We focus on breathing, resonance and pitch,” says Wentzel. “In visits that follow, we can work on making sounds and exercises that give patients the freedom to access a wider range of their voice.”
And those exercises are important to meeting a patient’s goals—and staying healthy.
“Sometimes a patient’s true voice is on the edge of what it was built for,” says Hornack. “So we continue to reemphasize voice hygiene throughout: staying hydrated, avoiding clearing your throat, maintaining good breath support and avoiding smoking.”
Through hour-long visits, a typical patient sees a MetroHealth voice therapist five to ten times over six months.
“But we continue to be accessible to patients throughout their journey,” says Nutt. “It’s important that patients know we’re still here for them if they develop vocal fatigue or other voice issues.”
One Voice in Care
Most patients find their way to a gender-affirming voice therapist at MetroHealth through the MetroHealth Pride Network.
“The Pride Network can connect patients to the whole gamut of wraparound care—and that includes voice therapy,” says Hornack. “Because MetroHealth has the longest-standing LGBTQ+ clinic in the region, it’s been a great place to develop a practice.”
And, because the Pride Network has set the standard for LGBTQ+ care in the area, patients sometimes live further from Cleveland than the typical MetroHealth patient. That’s why the team also offers virtual visits.
The standard set by the Pride Network has also driven the MetroHealth team to continue to learn and adapt.
“While I’d like to see us develop more specific gender-affirming voice therapy standard protocols, the number of patients we’ve been able to help makes me more comfortable with the process I’ve adapted from other well-known and researched voice exercises,” says Nutt.
In the end, though, it’s all about the patient.
“There’s no wrong time to refer someone to voice therapy,” says Nutt. “Whatever is right for the patient drives us.”
