Speech pathologist Adrienne Hancock holds a model of the vocal tract (Marvin Joseph/The Washington Post)

A soft-spoken, middle-aged woman slides into a chair in a small, bare room at George Washington University’s Speech and Hearing Center, then smiles at the clinician sitting across from her. After a few minutes of chitchat, they begin their hour-long session, during which the woman repeats sentences and answers seemingly random questions:

“Why do you go to school?”

“Why do we have stop lights?”

“Why do we use clothes hangers?”

As it turns out, it’s not the answers that matter. It’s the sound of those answers. The woman is transgender, and she is here to learn a new voice.

“We’re not just changing their voice pitch,” said Adrienne Hancock, an associate professor at George Washington and a pioneer in the field, according to many of her professional peers. “We’re changing how they express themselves.”

It is vital to transgender women to find the feminine voice that matches their gender identity, gives them confidence and helps prevent harassment.

Dena, the woman undergoing the training session — she asked that her last name not be used — explained the danger of being a transgender woman with a man's voice in the company of strangers.

“Passing is a safety thing for transgender people, and the voice is part of that,” she said. “It’s not just for me to be comfortable, but to protect me.”

The problem for transgender women is that finding a feminine voice is no easy task. As The Washington Post reported, testosterone, which transgender men take to build up their muscles and grow facial hair, also increases the size of their vocal folds, making their voices deeper. Estrogen, however, which most transgender women take, can’t shrink the vocal cords.

Most of the differences between male and female voices are not biologically determined, but are learned from a very young age, which means they can also be relearned.

“There is a subtle, but very significant psychological barrier to speaking too femininely,” Dena said. “I did not realize for a long time that many of the speaking patterns I would keep falling back into were unconsciously ingrained in me from childhood as to what a boy and a young man sound like.”

That's where voice training comes in, and it focuses on five parts of speech: pitch, intonation, volume, articulation and resonance. The vocal tract that produces sound travels from the larynx and vocal cords up through the head and out the nose and mouth. A female voice is typically breathier and usually emanates more from the face and nasal cavity. The male voice typically originates in the lower part of the throat or chest. Voice training for transgender women focuses particularly on three of those five speech characteristics: Pitch, which they want to raise; oral resonance, which is the sound felt and heard in the front of the face and mouth; and intonation, which is usually more varied and has more upward patterns for women, as opposed to men, who are more monotone and have downward intonation.

Of the five parts to speech, resonance often takes the longest to retrain, according to Josie Zanfordino, who was a speech language pathologist long before she came out as a transgender woman.

A person has to use “the entire toolbox — trachea, nasal passages and where you’re aiming the voice,” said Zanfordino, who is also the co-founder of the transgender voice and communication clinic at Ithaca College in New York. “The nuance of it, and then taking that voice out into the world where you need to use it, that’s not easy.” 

One of the reasons it’s not easy is that learning a new voice also means learning how the voice varies in different situations.

“Think about [talking to a] a romantic partner, a kid or an employer. Your style of communication is not one-dimensional,” said Nicholas Palomares, who teaches in the communications department at the University of California at Davis. “It’s not as predictable as our stereotypes would have us believe.”

Dena's voice is already quite feminine after nearly two dozen training sessions, and the difference between now and when she started at the center is discernible on a videotape of her first visit.

“It had a throaty resonance, low pitch and narrow intonation pattern,” said Linda Siegfriedt, who directs the Clinical Transgender Voice Program and the Voice Disorders Clinic. “There was a heaviness to it.”

Over the course of the past year, according to Siegfriedt, Dena has lifted her pitch almost an octave.

“I am going to say [my new voice] is an 8.5 out of 10,” Deena said. “I may never say it is a 10 because I do feel like there are always things to work on.”

A few of those things, she said, are laughing and coughing more femininely, or using a more falsetto voice when she wants to express strong feelings.

“It’s really important not to impose what I think they would sound like as a woman or what I think makes that voice sound really pretty,” Hancock said. “We have to let the patient say what they like, and then once they find it, help them develop it.”

Hancock often sits in on training sessions and says she is continually astounded by the determination of the women she meets.

“You think about all the things that we never consider as being meaningful,” she said. “Like how your voice sounds when someone calls you ‘sir’ and you’re actually a 'ma’am,' and just how heart-wrenching and disturbing that can be.”

There are only a handful of voice training programs for transgender women in the United States. But they’re needed, experts say, with more and more transgender people wanting to express their identity in the public sphere. That increased openness has been seen in TV shows and movies featuring transgender characters, high-profile transgender actresses such as Laverne Cox appearing on the cover of Time magazine, civil rights cases, college athletes and celebrities. Tolerance and acceptance of transgender people is higher than in the past. A  2015 survey from the National Center for Transgender Equality reported that two-thirds of 27,715 transgender respondents who were out to co-workers said their colleagues were supportive.

The United States has had a nearly fourfold increase in the number of gender affirmation surgeries between 2000 and the beginning of 2015, according to a February study in the Journal of the American Medical Association, and more than a dozen states, plus the District of Columbia, have instituted laws or mandates against the blanket exclusion of gender-affirming surgeries from insurance benefits packages. Federally, Section 1557 of the Affordable Care Act, known as the Health Care Rights Law, prohibits most insurance companies and health-care providers from discriminating on the basis of gender identity. The Trump administration may be about to roll back some rights for LGBT people. On its website the Department of Health and Human Services has deleted references to gender identity and sexual orientation in its list of protected groups.

Insurance for voice training has always lagged, even under the ACA, because companies could classify speech therapy as “optional.” Being part of a university department, Hancock said, allows the Speech and Hearing Center at George Washington to offer clients a sliding scale.

At the start of Dena’s recent session, her trainer, graduate student Hannah Abel, asked her to sit up straight, back against the chair, feet on the ground, because good posture puts less strain on the voice. Abel stood behind her client and massaged her voice box muscles to release tension, assuring the best possible production of sound.

What followed were exercises in which Dena was asked to briefly reply to questions about her life, then repeat again several lists of short sentences. She was also asked to vocalize the sounds “ewww” and “ahhh.” Called glides, the vocalizations were meant to loosen up her vocal muscles so she could focus on oral resonance by moving the vibrations of the sound to the lips and the front of the face, and away from the chest and throat.

Abel recorded Dena's responses for each part of the program using an app on her iPhone that scored the exercises for pitch, intonation and resonance. Each time Dena vocalized, a score would pop up telling the trainer if her client was in the range of an average feminine voice. Dena has the app on her own phone and between sessions at George Washington practices at home.

During one of the final exercises of the day, Abel asked Dena to again answer several questions.

“Why do we have pets?”

“For companionship and comfort,” Dena answered.

“That was outstanding for resonance!” Abel said, after looking at her phone and seeing the score fall perfectly in the feminine zone.

Clearly pleased, Dena's face relaxed, and she smiled broadly.

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