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When Emma McFadden hit puberty, the nightmares started. Night after night, she dreamed��that someone had stolen her voice.

In her waking life, McFadden’s voice had deepened. It sounded alien to her ears.

Years later, after coming to realize that her gender identity didn't match her assigned gender at birth, McFadden sought out , assistant professor of communication science and disorders in the , for support training her voice to match her identity as a woman.

For McFadden, working with a voice-specialized clinician like Helou was a necessary step toward addressing her gender dysphoria — her overwhelming feeling of distress at the discrepancy between her gender and how others perceived her.

“When I came out, transition became my only option,” said McFadden.

She said that learning to speak how she wanted to sound was one piece of the puzzle toward feeling like her whole self.

“Every day of our lives, we do things to communicate who we are,” said Helou, founder of the Transgender Voice and Communication Training Program at the UPMC Voice Center and a leading voice clinician in the U.S. “From the clothes we wear to the car we drive, we express who we are in society. The most dynamic, accessible way we communicate is with our voice. For those trans people whose voice doesn’t match their identity, moving through a social space that doesn’t affirm their identity can feel like death by 1000 cuts.”

In 2013, she worked with McFadden to address her voice pitch, speech pattern and body language. Nine years later, McFadden said the lessons of Helou’s training are second nature.

Helou instructed her on how to make her voice resonate in her head rather than her chest and to open her mouth wider to better enunciate. With Helou’s coaching, McFadden also adopted a different gait and posture.

While practicing the techniques, McFadden recorded herself speaking a soliloquy from “Macbeth” and critiqued it thousands of times to land on the sound she sought. The passage’s sing-song cadence helped McFadden practice a legato rhythm — the kind of inflection typically associated with feminine speech patterns.

Helou noted that in working with training clients, clinicians must examine their explicit and implicit biases when providing gender-affirming care. The work must be guided by the client rather than dictated by the clinicians' stereotyped definitions of what men and women “should” sound like.

“One thing I would like to figure out is how to take a person’s speech sample and, with their help, manipulate the features to the point to where when they’re listening to it, they can say, ‘If my voice sounded like this, I would like it better,’” said Helou.

“The goal is to derive targets for congruency — like raising the pitch and changing the resonance, for example,” she added. “We would then have empirically driven goals for the work.”

Gaining a sense of security

Trans people experiencing an incongruence between their gender and their voice may experience consequences that go beyond gender dysphoria — it also can be a matter of personal safety.

“When in public, I try not to draw attention to myself. I want to blend, so people don’t know I’m trans,” said McFadden. “In the early stages of my transition, my voice gave me away.”

For some trans people, blending — the act of not calling attention to their transness — can be critical to gaining and keeping employment and housing and avoiding transphobic aggression.

Brett Welch, a doctoral student who studies philosophy in communication science and disorders and works with Helou, is quick to point out that the problem lies with mainstream culture’s enforcement of rigid gender binaries and not the actions of trans people.

“A lot of cisgender women have low voices, and a lot of cisgender men have high voices. It’s only when you’re trans that it becomes a safety concern,” said Welch. “I want to live in a world where everyone is able to focus on using a voice that feels congruent with who they are.”

, Helou and Welch drew a more concrete link between the voice and its psychological effects. It also showed that cisgender people can experience voice dysphoria, too.

The study focused on mostly cisgender people without voice disorders. Participants evaluated recordings of their voices and reported experiences of communicative congruence and communicative dysphoria — how in line their communication is with their sense of self and identity — and the ramifications on their psychosocial well-being.

According to the study, participants who reported higher levels of incongruence were more likely to report depression symptoms.

“This is the first bit of evidence that explicitly links congruence and dysphoria with depression,” said Helou.

Their work lends scientific backing to a correlation already supported by anecdotal clinical evidence — and it could lay the groundwork for clinical voice therapy services to be recognized by health care organizations as an essential component to supporting an individual’s mental health.

Shifting tides

In her 20-year career of offering voice training services to trans people, Helou said she’s witnessed a notable shift in the ages and attitudes of her clients.

“Most people I saw, when I started out, were trans women in their 50s and 60s who were newly out because they had reached a breaking point,” she said.

“They were like — I’m either going to live my true self, or I’m not going to live.”

These days she sees less shame and internalized transphobia and instead “a coalesced kind of pride in trans existence and shared identity.”

That assessment resonates with McFadden.

She said that being openly trans and educating the public feels like her obligation to future generations.

“Many people made it better for me, and I want to see things better for them.”

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Illustration by Amy Kleebank