In part one of this interview with speech and vocal pathologist Dr. Anita Kozan, we focused on general voice and vocal health practices. In part two, we focus more explicitly on transgender vocal health for both the speaking and singing voice.

K: So I’d love to know more about the transitioning voice and how it impacts the vocal chords, since you’ve really focused on that in your life’s work.

A: When we as cisgender females mature, our vocal folds are 3/4 inch to an inch long. A biological cis male will have an inch to an inch and a 1/4 long vocal fold post puberty. With children up to the age of 10, the voices and larynxes are very similar and the acoustic measures are very similar. In terms of transitioning male to female post-puberty, men take estrogen (or another female hormone) and nothing happens to the larynx. Every change they make must be made with training, therapy, and hard work, because the muscles need to adapt to a higher range. Generally, vocal chords lengthen for higher pitches and thin out for lower pitches, and the muscles adapt to the pitch range we adapt most frequently. Our highest pitches have just the inside margins (mesial margins), where the vocal chords form a V when we’re breathing, but when we speak, the vocal folds come together and the inside edges vibrate. A smaller portion of the vocal fold vibrates as we get into higher pitches. Trans women have to condition their voices- learn pitch inflection, a higher range, and other aspects of speech that make them sound more “female.” Women transitioning to men, or a trans man, takes male hormones which then enact a number of changes on the vocal chords. We had a trans vocal health day about ten years ago, and I remember a client saying that “You take testosterone, and you just don’t know what you’re going to get in terms of your voice, your appearance, and the biological changes.” It affects everyone differently, but what does happen is that muscles grow. Trans male vocal folds grow and thicken but the cartilage of the larynx which contains the vocal folds, cannot grow. The cartilage is already ossified and can’t adapt to the vocal fold size change- some men run into trouble and quickly injure their voice if they’re trying to force the voice lower or louder, which can be extremely frustrating. In the literature, it usually says that trans men don't have any vocal problems, but I can remember being a reviewer for an article like that, and this is simply not true for transitioning men. Men might say that they they feel like their voice is stuck or heavy, or that there’s some constriction, and I think they’re reacting to the vocal folds’ expansion into the cartilaginous restriction, and the greater mass means they will vibrate at a lower pitch but less comfortably than they used to. I’ve done consultations at health fairs promoting LBGTQ health, and a number of people have approached me where they are already singers in the process of transitioning, hoping to maintain their singing voice as well as they can. And this is where Dr. Alexandros N. Constansis comes in, because he was the first person internationally to study himself (he is a classically trained singer), transition F to M, and dial down the amount of testorone, building up the dosage more gradually over time. He was very careful about the process and also continued to vocalize throughout the process, studying himself and what he was able to do, and he has since created a whole set of exercises and approach to handling the transition. For some people, under even the best of circumstances, you might only have a few notes in your range for a period of time, or you’ll constantly be breaking and cracking, because the vocal folds aren’t stable enough to vibrate consistently. In the US, more people are becoming familiar with his work and how important it is to transition gradually, titrating the dosage carefully.

K: Interesting- I’ll definitely check out his work. It seems like slow adaptation and change is really the key to vocal health for the transitioning voice.

A: Yes- absolutely. So what else can I tell you?

K: One thing that is really compelling is the rich psychological element to this work, which I think is different than your average speech therapy work, but the combination of gender identity and "self" adds another layer of challenge and meaning to working with this population.

A: Yeah- that’s beautifully put. I think the only other group that I have felt as emotional about is the singers who have had injured voices and couldn’t sing. There is a psychological aspect that is multi faceted, but if you think about someone who for their whole life (before they transitioned) was trying to use their voice in a way that society was dictating them to use it, based on the gender assigned at birth rather than gender identity. Men, who may feel in their heart of hearts that they are women, try for all of their lives to present a masculine image, and then finally come to me as their true selves, realizing and seeing all of these things that she did to pass as a man for 20,30, 40 years. It affects everything- what they think they were supposed to sound like in their birth assigned gender, it affects their worries about how others perceive them in their true gender, and they want to express themselves well with a new corresponding voice. I work a lot with my clients on self-talk; how clients handle the change and the self criticism that often arises. It can be a very important way of managing the large scale changes in their body and voice, especially if the physiological changes are not as rapid or quite as desired. The work I do is a way to continue their journey in loving themselves, appreciating themselves as they are, and it starts with “what am I saying to myself and how is it affecting me?” Trans clients can get disheartened and frustrated with the changes that go on, especially if they’re not as rapid as they wish they were. It’s a huge change, but it’s also incredibly joyful to see people get to become themselves more fully. They almost go through a new gender adolescence, finding new things to be excited by and interested by. There's a new recognition of how women interact with one another versus how men interact. I’ve heard from trans women on how shocked they are that women can be so kind to one another, and go out of their way for one another. They’ll talk about being in a public bathroom and someone will say hello and admire a garment or purse or something. The trans men notice the body language cues between men that they had never noticed before, whether it be from standing farther from one another or making less eye contact. It’s really a fascinating process- but almost all of my trans clients do work with a psychologist and sometimes with a psychiatrist too. The changes can be large scale in their family and personal life, and I’m honored to be supporting that process.

K: Yes- absolutely. It’s such an amazing process that you’ve become involved in, and from my viewpoint, it’s so exciting to see that someone much older than me has seen the value of this work for so long, not only its potential from a physiological level, but also the deeper psychological, social, and emotional value. It’s spectacular work that you do.

This image is from a 2015 news article on Anita and her work in the trans community, "Expert coaches help people find a new voice."

A: Yeah, it just hit me- I am forty years older than you! But yes, I feel blessed to have found this rich profession that will inspire me for the rest of my life. My hope as I look to 70 is to create a new choral group in Minnesota that supports this work- I don’t want to be the director, but I'd like to get it started and the director of One Voice Mixed Chorus has expressed an interest in supporting it. (Note: There are currently 7 trans choirs in the USA, as well as many choirs open to the LBGTQ community). There is someone in my area who is studying choral conducting who is a trans male, and who might be interested in leading a trans choir for us. One Voice is a very organized non profit, and it would be great to be an umbrella group with them. I just want to help people with their voice, and maybe compose a song for trans voices, but I really want to help them condition their voices. It’s so exciting what’s happening in our country; the recognition, acknowledge, and acceptance for people who are trans.

K: I think it’s so exciting to see the change, even within my life span, for those who might identify as “other,” whether that be via race, gender, orientation, nationality, religion, or otherwise, there’s more and more awareness and evolution of viewpoints. There are still terrible things happening every day, but I do think things are changing, and that the arts can be a portal for change, self-expression, interpersonal connection, and growth as a culture.

A: It is- my mother, shortly before she passed away, was asking me about what I’d do when I retire, and I said I’d always continue my work with those who are transgender, that I feel it is really God’s work for me. She was born in 1920, grew up in a small midwestern town, and she certainly expanded her horizons and viewpoints. She said in response, “You have made your work God’s work,”

K: That is truly a gift. Thank you so much for all of the work that you do- it is very much needed in both the trans and musical communities.

You can connect with Anita at www.kozanclinic.com and her practice in Minnesota, where she is the director and founder. Also read this article from the Star Tribune about Anita and her support of the trans voice, as evidenced by the interviews.

To learn more about Dr. Alexandros Constansis, check out his website Changing Voice.

NOTE: The St Paul public school system is one of the few schools in the country that has someone full time who addresses LBGTQ issues in the schools. The district was getting so many different calls from parents that they can barely keep up. The schools have become more and more progressive in their policies towards supporting students, allowing students to assume other names and genders within the schools. To learn more about their work and read their gender inclusion policy, read here.

Supporting Transgender Voices: Interview Part 2 with Dr. Anita Kozan

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