“I always thought it was normal to hate hearing yourself talk, but at some point you realize that other people don’t think ‘I want to vomit’ after hearing themselves speak,” Lilian Primrose told me.

Primrose, a 30-year-old computer programmer, began her transition from male to female in September of 2017. I met her in February at a coffee shop in Greenwich Village. She sat across from me, proudly presenting as her authentic self and eager to speak about her gender transition journey. Sporting dark lipstick and shoulder-length wavy brown hair, Primrose explained how she had come a long way from the confused, isolated boy she used to be.

She enthusiastically told me about the many changes she had experienced over the past year and a half. As a trans woman myself, I understood the relief of hormone treatments softening her skin, forming her breasts, and thinning her body hair. But one thing hadn’t changed: her voice.

Her discomfort with her voice even hindered a very important step in her transition. “I would put off phone calls for months if I could,” she said. “Getting my legal name change done was mostly delayed by the fact that I didn’t want to call the law office.” Her voice was a reminder of her gender dysphoria: a feeling of disconnect between one’s assigned sex and their gender identity.

For Primrose, like other trans women who transition after enduring male puberty, testosterone elongated and thickened her vocal cords, deepening her voice. Achieving a higher voice can be essential to embracing a female identity, so she considered the two options trans women like her have: vocal training, which requires weekly sessions over months or years, and thousands of dollars, or feminizing laryngoplasty surgery, which has increased in popularity even though it risks permanent damage to the vocal cords and is also expensive (the procedure ranges from $5,000 to $10,000 in the United States).

Vocal cord surgery simply provides a patient with a new instrument by diminishing the lower end of their vocal register, but it doesn’t teach them how to effectively use it. If a trans woman undergoes vocal cord surgery but continues to speak with the same vocal tendencies as before, her voice may still sound more masculine. This is why, even for many trans patients who do opt for vocal cord surgery, voice therapy is usually recommended, and it has proven to be successful. Last year, researchers at New York University compared the voices of 12 trans women and 19 cisgender men. The trans women initially produced nominally higher voices than the men, but the difference was negligible. After training, including altering the movement of the mouth, the trans women were able to produce significantly higher frequencies.

Neither voice training nor surgery are typically covered by medical insurance because they are viewed as elective processes, making the ability to alleviate what for many trans women is a source of discomfort a luxury accessible to only a few.

But a different voice is not just a luxury, it’s also a means of protection. For trans women, voice is often times the most significant indicator of their transness to the outside world. In 2018, LGBTQ advocates documented at least 26 homicides of trans people in the United States. Two murders of trans women have already been reported in 2019. For trans women, achieving a feminine voice can serve as a cloak of protection from bias and bigotry.

Christie Block, a speech pathologist at the New York Speech & Voice Lab, keeps this in mind. “Vocal training can help trans women deal with situations where they’re in danger,” Block said. “I work with clients to show them how they can use their voices and what they can say in dangerous situations as an actual vocal task to practice.”

She began working with Primrose in February of 2018. Block, who also works with clients who have vocal issues such as hoarseness, vocal fatigue and weak voice. “A typical lesson is the combination of a singing lesson, psychotherapy session and physical therapy session,” Block told me. During sessions, Block and Primrose discussed her progress utilizing her trained voice in daily life, then Primrose would do vocal warm-ups like lip trills (blowing out allowing the lips to vibrate) and humming to help to stretch the vocal folds. Then Primrose would read and recite sentences using her feminine voice.

Block recorded Primrose’s progression by having Primrose read what is called “The Rainbow Passage”– a paragraph developed by speech pathologists, to assess vocal nuances because it contains many sound combinations found in the English language.

Throughout my own transition, I’ve often wondered whether my voice, which is deeper than that of the typical cisgender woman, diminished my value as a woman. Hormones and surgical alterations had feminized my exterior, however, my voice had not changed and was a persistent source of frustration and angst for me. At times, I wished for nothing more than a voice that was considered “pretty” and “passable”, wanting to change every aspect of my identity in order to live up to what society expects women to be: submissive, subdued, sensual and feminine.

Over time, I’ve realized that there is no one way for a woman to sound. Block agrees. She says that there is no single target voice for her clients, and no set number of sessions.

“The concept of an ideal female voice is something that is associated with the concept ideal female, cis or trans,” Block told me. “I think it’s very much linked to sexism and what we expect women to be like.”

Like me, Primrose has veered away from the the goal of “passing” as a cisgender woman. Instead, she is working towards achieving a voice that is personally fulfilling. “I want to be the person that I’m comfortable being,” Primrose said. “I don’t necessarily want to have a high voice because it makes you approximate cis women. I don’t care about that. I feel no shame about being trans. It’s who I am. It’s my life’s journey. It’s my identity.”

When beginning her voice training with Block, Primrose was met with early frustrations. She initially found it difficult to reach a higher pitch and her voice would get tired easily. Primrose also felt self-conscious about speaking in a new voice at first. “You feel silly at first doing some of the voice exercises,” she said. “Anyone who’s ever done it is very familiar with this.”

Block says it’s common for trans women to feel shy or self-aware at first. Voice training is an extremely intimate process and trans women’s voices are often fraught with feelings of inadequacy and otherness. Block says it’s important to develop trust with each client so they feel as comfortable as they can when doing the exercises. She’s developed methods to put her clients at ease.

“I just act stupid myself,” Block laughed. “It comes very naturally. Nobody’s averse to doing it at all, otherwise they wouldn’t be coming. But there are some people who can’t do it with me yet.” Others are afraid of the thin walls in their apartment and so they won’t practice at home. Block has been working with two people recently who are doing exercises in their cars.

According to Block, each trans woman has their own respective restrictions based on their physiology. In order to attain the best results, feminizing one’s voice entails unlearning a lifetime of habits and tendencies and adopting entirely new strategies.

“When somebody works on their voice, they’re limited by what their vocal mechanism can do for them,” Block said. “We’re basically playing the vocal instrument differently, but we’re not changing its anatomy. We’re only going to be able to help that person achieve their individual voice with the body and behavior skills that they have.”

A trans woman’s vocal structure remains anatomically male without surgical intervention, meaning that persistent vocal alteration can be highly demanding.

During her first week speaking in a higher register, Primrose overstrained her voice. “It would just suck for the rest of my first week out,” she said, letting out a sigh of frustration. “I was going too hard too fast trying to maintain a femme voice for too long. You want everything to be ready and working and going immediately, but voice is one of those things, kind of like hormones in that way where it just takes time and you can’t make it go faster.”

As Primrose continued her sessions with Block, she gradually learned how to raise the pitch of her voice without putting excessive amounts of stress on her vocal cords. She also began to focus on other aspects of her voice that bothered her, like her breath patterns and speaking style. Primrose said that it’s a misconception that the only part of feminizing your voice is raising your pitch.

The voice feminization process also focuses on allowing patients to speak more fluidly. Primrose’s tendency, which developed through her male upbringing, was to speak in a more staccato style, which is typically associated with male speech patterns. She now actively works towards speaking in a more seamless manner, allowing words and sentences to gently flow into one another.

Primrose has been seeing Block for voice therapy on and off for about a year. Her voice has progressively become increasingly feminine as she has continued to perform her exercises. The progression of her voice has been gradual and subtle. Primrose realized how much her voice had changed when she recently called her bank to update her information on her credit cards. She says that it was the first time she had been gendered correctly on the phone by someone who didn’t know her and was not aware of her trans identity.

“It felt really good,” she said.

Throughout her transition, Primrose says that she felt like she had personally failed whenever someone would misgender her, or refer to her by male pronouns. She felt like she had made a mistake and was not authentically representing her female identity, a frustration that resonated with me. But with her voice training, Primrose has experienced less and less misgendering, which is a welcome relief.

“Before voice training, I always felt like I was holding people at arm’s length,” she said. “I now have more confidence and I’m more outgoing. I enjoy meeting people and talking to people and feeling good enough to reach out and connect with people in a deeper way.”