There’s plenty of talk about the Johns Hopkins Voice Center — by members of the transgender community thrilled with their new voices.

At the center, a multidisciplinary team, including laryngeal surgeons Lee Akst and Simon Best and speech-language pathologist Ashley Davis, provides options for gender-affirming voice care to some 100–150 patients a year.

“Voice is one of those things that is uniquely human and individual,” Akst says. “It is how we present to the world, and the dysphoria that occurs when that vocal presentation is incongruent with how you wish to be perceived and how you wish to present yourself is real.”

Patients looking to alter their voice first meet with both a surgeon and speech-language pathologist to discuss treatment options, which range from speech therapy to medication to surgery. The appointment begins with a medical history and examination of the vocal cords, along with a discussion about what the patient would like to achieve.

“It’s very much a patient-driven process, where we are there to facilitate the journey,” Davis says. For example, if a person is studying to be a lawyer or is a professional singer, the team keeps those goals in mind when suggesting strategies to alter voice. They also can work to attain a neutral voice for individuals who identify as nonbinary.

For transgender women looking for a higher vocal range, Best and Akst can perform a Wendler glottoplasty. This minimally invasive endoscopic procedure, performed on an outpatient basis, involves creating a web between the front of the vocal cords to shorten the portion of the vocal cords that vibrate. As the anterior web matures over the next month, patients will find a higher vocal range to work with.

Transgender men in search of a lower vocal range can often achieve that as a side effect of taking testosterone therapy and from working with a speech therapist. For those looking for additional vocal masculinization, Best and Akst can perform a type III thyroplasty, a procedure done through an incision in front of the neck to reduce the tension in the vocal cords and achieve lower pitch.

Even when patients opt for surgery, they usually follow with voice therapy.

“It really optimizes the surgical outcomes as to create the voice and the persona that most matches their gender identity,” Akst says. “Even if somebody said, ‘I want to be as feminine as you can make me,’ and surgery gets them part of the way there, behaviors get them the rest of the way.”

During voice therapy sessions, Davis and others help patients adjust their pitch, intonation, air flow and breathing, as well as nonverbal cues like gestures. The appointments are spread out to allow patients time to practice at home. There is no prescribed timeframe for how long an individual may participate in voice therapy, says Davis: “The goal is always a consistent, functional voice that represents the individual.”

“It’s incredibly rewarding” working with patients to find the voice that matches their identity, she adds, likening the process to watching a butterfly emerge from its cocoon. “People realize how much they have to say.”

For more information or to refer a patient, see hopkinsmedicine.org/health/treatment-tests-and-therapies/transgender-and-gender-diverse-voice-care and affirm.blogs.hopkinsmedicine.org/2021/03/09/gender-affirming-voice-therapy.