“I’m really sick of you doing that.”
Jessie Buckley sighed, shifting a curtain of dark red hair from her face. Inside a small, windowless room on the University of Maryland’s campus in College Park, she glanced across the table at Katie Aveni, a speech-language pathology master’s student, who nodded encouragingly.
Again, Buckley sighed.
“I’m really sick of you doing that,” she said, injecting frustration into every word.
For the last six months, Buckley, a 26-year-old trans woman who lives in Annapolis, has been developing a new voice with the university’s Hearing and Speech Clinic. The voice is much higher than the voice she had after going through male puberty. It’s slower and smoother, and is sweet and warm, even when she’s feeling shy. It’s brighter now.
She’s still learning how to adjust it when she’s sad or angry — the skill she was working on last fall when she practiced saying she was “sick” of someone doing something. But for the first time in her life, she’s starting to feel like her voice reflects who she is.
While not every trans or nonbinary person needs gender-affirming voice therapy, experts say it’s necessary health care for some people experiencing gender dysphoria. That’s the condition defined by the American Psychiatric Association as a feeling of disconnect between a person’s gender identity and the gender they were assigned at birth.
It’s less physically invasive than other procedures, like chest masculinization or facial feminization surgery. But it can take months of consistent, sometimes emotionally painful practice for changes in a person’s voice to become a habit. Meanwhile, the patient has to go to work or school, make calls, and order from restaurants with one of the most visible signs of their gender in flux.
“You can choose how to dress on a given day, you can choose how you act on any given day. The voice is much harder to choose to be different,” Buckley said. “It’s a lot of effort to change a part of yourself that’s very impactful to how people perceive and interact with you.”
How to change a voice
Ask a voice expert to explain how humans produce sound and, sooner or later, they’ll bring up a musical instrument. Dr. Lee Akst, director of the Johns Hopkins Voice Center, chooses a guitar.
Your vocal cords are two muscular bands that sit in your larynx, above your windpipe. When you inhale, they open in a V shape, allowing air to pass between them and down to your lungs. When you speak, they close and vibrate together in the air flow created as you exhale.
And just like when you pluck a guitar string, Akst said, that vibration is the foundation for sound production.
Also like a guitar string, the thicker and larger a person’s vocal cords are, the deeper their baseline pitch is. That’s why people who go through male puberty typically have deeper voices than those who experience female puberty.
As a surgeon, Akst can adjust that baseline pitch for a trans woman by tightening or reducing the mass of the vibrating portion of her vocal cords. For trans men, he can relax their vocal cords, since thicker cords produce a lower-pitched sound. Those procedures are less common, since many trans men find that taking testosterone sufficiently lowers their voice.
While surgery can change the pitch, there are other elements that influence how someone speaks. There’s intonation: how their voice rises and falls; and resonance: the sound quality of their voice, which is influenced by how they shape their mouth and throat and position their tongue.
Voice therapy teaches people to manipulate these aspects, Akst said. Many trans and nonbinary people who see speech pathologists achieve their goals without surgery. A good candidate for further intervention is someone who has advanced in voice therapy to the point that they’re happy with their voice and are able to use it without strain, Akst said, but find they fall out of their new voice if they’re not always thinking about it.
Under Maryland’s Trans Health Equity Act, which went into effect Jan. 1, Medicaid covers gender-affirming voice therapy and surgery, among other services.
Ashley Davis, a Johns Hopkins speech pathologist who specializes in gender-affirming voice therapy, hopes the new law makes voice therapy more accessible to Maryland’s estimated 94,000 trans and nonbinary people. However, most commercial insurers, including Cigna — which Buckley has — don’t cover voice therapy. Buckley paid $1,400 for the therapy she received at the University of Maryland over the course of the fall.
To reduce barriers to care, Davis kept her telemedicine practice going after the pandemic so people don’t have to leave home for appointments.
“When someone achieves what they’re seeking, it’s such a rewarding moment,” she said. “I can’t imagine what that is like — other than having the feedback of people coming back to me and saying, ‘I never knew I had so much to say.’”
Coming out
Two years after the fact, Buckley’s fiancee, Brittney Keys, laughs when she remembers how Buckley realized she was trans. She’d dressed as Little Red Riding Hood for Halloween as a joke, but when she put the dress and heels on, it didn’t feel goofy. It felt right.
Looking back, Buckley said she lived in an almost constant state of dissociation before realizing she was trans. She’d look in a mirror and struggle to comprehend that she was the person staring back.
“It was probably just way too overwhelming of how bad I would feel, if I let myself feel bad,” Buckley said. “And so, I just wouldn’t let myself feel anything to stop that from happening.”
She found a therapist about three months after that Halloween and a few months later, she began taking estrogen. Within a week, she noticed something: For the first time in her life, she’d feel randomly happy, even if nothing special had happened.
But as she moved along in her transition, her voice started bothering her more. She tried to follow online videos posted by voice therapists, but wasn’t sure if she was doing the exercises correctly. She wasn’t much of a singer, so she didn’t have experience manipulating her voice.
In January 2023, she applied to receive gender-affirming voice therapy at the University of Maryland. She started sessions with Aveni over the summer.
Every trans and nonbinary person has different goals, but Buckley has always wanted a stranger’s first impression of her to be that she is a woman, rather than a trans woman. She’d like to choose whether to come out to someone.
She said she always knows when someone notices she’s trans. No matter what they do — whether they look at her with disgust and pull a child away from her, or if they smile as they walk by — to her, the first look is the same. And it hurts every time.
“Here I am, trying my best to present femininely,” Buckley said, “and clearly, it’s not working the way I wanted.”
Behind the glass
With 15 minutes left in one of Buckley’s voice therapy sessions, the conversation turned to phone calls — and Buckley’s distaste for them.
As an engineer for a Baltimore company, she doesn’t make many calls for work. It’s also rare for her to call a friend just to chat. But one of her goals is to be consistently gendered correctly on the phone, so she knows she has to practice.
“Can we prank call someone right now?” Aveni joked.
A few doors down from the practice room, Kristin Slawson watched a stream of Buckley’s session. Slawson, a certified speech language pathologist and director of clinical education in speech language pathology at the University of Maryland, supervises graduate students during their clinical hours.
The number of people interested in receiving gender-affirming care from the clinic has increased since Slawson started at the hearing and speech sciences department 12 years ago. Now, they almost always have a waiting list.
When a new patient starts, Slawson and at least one graduate clinician meet with them. They measure the person’s baseline vocal abilities and explain how adaptable voices can be. They also ask lots of questions, from what a person’s goals are to what their social support system looks like.
Although Slawson doesn’t require it, she prefers clients to have a therapist. While she and her students are trained to provide some counseling related to voice and communication, feelings related to those subjects often bleed into tricky areas, like family dynamics, relationship issues and body dysphoria.
“Voice is very core to who we are,” Slawson said. “I don’t think everybody appreciates that until you’ve cracked the can of worms.”
Nobody walks out of the speech clinic with a fully evolved voice. Instead, Slawson’s students help clients find the words to describe how they’d like their voice to sound, then give them the tools to make changes.
For many trans and nonbinary people, Slawson said, the hardest part isn’t figuring out how to adjust their resonance or raise their pitch without unnecessary tension. It’s learning to like a part of themselves that has distressed them in the past.
“Just because your voice changes doesn’t mean your thinking changes,” she said. “And that’s the hard part. It’s reconnecting with your voice. Bringing it back into the fold.”
Jessie in color
Thanksgiving was a turning point for Buckley.
When she came for her therapy session the next week, she couldn’t wait to play Aveni the recordings she’d made of her voice over the holiday. Before then, Aveni recalled, getting Buckley to say anything positive about her voice was like pulling teeth. The change seemingly happened overnight.
Buckley agreed. Before, she could tell her control over her resonance and pitch was improving. But it wasn’t until all of the elements of her voice clicked together that she was happy with how she sounded.
“I was very much holding myself to a quite high standard,” she said, of her earlier dissatisfaction. “And if I’m not reaching the standards that I’ve set, why would I be happy with it?”
During the next few months, Buckley plans to check in occasionally with Aveni, but they will no longer meet every week. She has the tools — the evolution of her voice is now in her hands.
Lately, Keys has noticed a distinct change in her partner’s confidence. When she compliments Buckley’s makeup or tells her she looks cute, Buckley scrunches up her face and replies, “I know.”
She’s more quickly frustrated than before she realized she was trans — back when she felt detached from life — but she’s more quick to laugh, too.
Buckley’s wardrobe formerly consisted mostly of gray and black T-shirts. Now, it’s full of color.
“She’s just,” Keys stopped and stared at Buckley, who stared back, eyes full of tears, “brighter now.”
