As a transmasculine voice coach who’s worked with hundreds of people on testosterone, I am frequently asked how to keep the voice healthy on HRT! I have lots of advice to share on this topic, but it’s helpful to start with a deeper understanding of why and how testosterone therapy may impact the vocal health of those who take it.
Testosterone therapy can impact vocal health in three major ways:
During the period of transition, vocal cords may become inflamed and swollen. This makes the voice more vulnerable to fatigue or misuse.
After voice drops occur, registration issues (problems with “vocal registers”) can put unnecessary strain on the voice.
During and after voice change, people on testosterone often experience significant muscle tension while speaking or singing.
Let’s unpack these points, starting with vocal cord inflammation during transition.
Hormonal fluctuations in the body may cause a short-term reaction of water retention, swelling, and inflammation in the vocal cords and larynx.
We might refer to these as “laryngitis symptoms,” since laryngitis is defined by inflammation and swelling in the larynx and vocal cords.
Many people experience laryngitis symptoms while transitioning with testosterone therapy. Importantly, these symptoms are not permanent! They are caused by changes in hormone levels, so they resolve over time as hormone levels stabilize.
There’s a lot of variation in how people experience these laryngitis symptoms. Typically, symptoms do not last for the entire period of transition — instead, there may be occasional flare-ups of symptoms during transition, which might resolve within a couple of days or within a couple of weeks. In some cases, symptoms may last for up to 2-3 months at a time, although this is less common.
There are a few specific events that may cause a flare-up of laryngitis symptoms:
Starting testosterone
Restarting testosterone after taking a break from it
Increasing testosterone dosage
Testosterone levels in the bloodstream building up over time and reaching certain levels which trigger more changes in the body
Voice drops
If the testosterone dosage is fairly high, it’s possible that laryngitis symptoms may become severe. On a relatively lower dose, most people only experience moderate or mild symptoms, and some people experience no symptoms at all.
Mild laryngitis symptoms may cause the voice to feel slightly “off,” similar to what happens when you’re starting to come down with a cold. High notes may feel tight or unstable. The “break” in the voice may seem more pronounced, and the notes right around the break might feel unpredictable or clumsy.
Moderate laryngitis symptoms may cause more pronounced vocal instability and clumsiness. This may include difficulty with register coordination, causing more frequent voice cracks. Vocal tone may be darker, thicker, or less resonant. Sometimes, vocal cord inflammation slightly lowers vocal pitch, similar to what happens when vocal cords get irritated from a bad cold. The voice may feel less powerful, less able to project, and more easily fatigued. Vocal range may appear to shrink, with higher ranges becoming temporarily inaccessible.
Severe laryngitis symptoms may cause the voice to feel even more clumsy and unmanageable. Vocal range may appear extremely limited, and the head voice register (sometimes called the “falsetto”) may become completely inaccessible. With severe vocal cord swelling, it may be impossible to produce a clear tone, and the voice may sound husky, breathy, or hoarse. In this condition, vocal stamina is shockingly low, and the voice fatigues very easily.
To maintain vocal health through transition, it’s important to know how to react — and how NOT to react — to laryngitis symptoms:
DON’T “push” your voice or “force” it to do anything while it’s inflamed. Don’t push out a high note that you can’t reach without pushing. Don’t push to add volume, power or projection. Vocal cords are much more sensitive when they are swollen, and anything that further irritates them can make laryngitis symptoms worse.
DO be very gentle with your voice when singing and speaking. Pay close attention to your body sensations — if you’re doing something that’s harsh on your voice, it will feel uncomfortable. Make adjustments as needed.
DON’T wear yourself out. Laryngitis makes the voice much more susceptible to fatigue, so your voice will get tired much more easily. Don’t keep going when you already feel tired — if you sing or talk for too long while your vocal cords are swollen, it can make laryngitis symptoms worse.
DO rest your voice when it feels tired. Vocal rest is the best medicine and will speed up the healing process. Without enough rest, laryngitis may take significantly longer to heal. Take breaks from talking when you can, and limit singing if necessary.
DON’T be ambitious with your voice while it’s recovering from inflammation. Save the flashy vocal acrobatics for a time when you’re feeling better.
DO be prepared to be flexible with song arrangements while your voice is under the weather. This may include transposing songs, re-phrasing a melody as needed, replacing high notes with lower-note alternatives, or octave-jumping through a song.
DON’T get mad at your voice for being uncooperative during transition — it’s doing its best to process a lot of changes really quickly, and it’s actually pretty amazing when you think about it.
DO use SOVT exercises to recover from vocal inflammation and to bounce back faster from vocal fatigue. These are very gentle exercises that help voices heal and promote healthy vocal functioning. We’ll talk more about SOVT exercises later on in this article!
Fortunately, testosterone-related laryngitis symptoms really do resolve over time. Testosterone only causes laryngitis symptoms during the period of transition, so you won’t be stuck with laryngitis forever.
(For those who use testosterone therapy intermittently or inconsistently, laryngitis symptoms may reappear anytime testosterone is restarted after taking a break.)
When the period of transition reaches its natural conclusion — or if you stop using testosterone altogether — these short-term laryngitis symptoms will completely go away. At that point, other unrelated vocal challenges may emerge. This brings us back to the other two major ways that testosterone can impact vocal health.
To protect your voice after starting testosterone therapy, you may need to adjust vocal registration after voice drops and manage muscle tension during and after transition.
Testosterone therapy, when used consistently over time, causes vocal cords to grow thicker. The result of abruptly thickening vocal cords is that the voice “drops,” which is a shorthand way of saying that the overall vocal range drops into a lower pitch range. Unlike the laryngitis symptoms discussed above, voice drops are permanent changes to the voice.
Voice drops occur very quickly — often within less than a week, and sometimes within just a few days. This makes it difficult to observe the voice dropping in real time, as it’s actually happening. By the time we notice a voice drop, it may already be over.
Voice change via testosterone therapy is a lengthy process that typically includes three separate voice drops. In a faster transition, these voice drops may occur very close together, making it harder to see them as separate events. In a slower transition, there may be long periods of vocal stability — periods of time where the voice is not changing — lasting for months, or even years, in between voice drops.
By the end of the transition process, the vocal range typically will have dropped by about one octave in total.
When voice drops occur, they cause new low notes to emerge, and vocal registers and passages also drop lower in pitch. This is profoundly disorienting for many singers, who may feel misled by muscle memory of where notes used to be before their voices changed!
A “vocal register” is a range of notes where the sound is produced by a specific mechanical action. For example, the mechanics of “chest voice” are slightly different than the mechanics of “mix voice” or “head voice.”
To preserve vocal health, singers need to use appropriately supportive vocal registers for each pitch. Many songs require us to use more than one register to navigate the melody, so we need to be able to move smoothly (and often instantaneously) from one register to another.
When talking about vocal registers, we might also use the term “passages” to refer to transitions between registers. Or, we might identify “passages” between different parts of the vocal range (for instance, between the “lower voice” and “middle voice,” or between the “middle voice” and “upper voice”).
By the end of the transition process, the vocal registers and passages typically will have dropped by about a half an octave. That being said, vocal registers are strongly shaped by how we habitually use them, and surprisingly flexible in how they can be developed through voice training.
Because voice drops cause vocal registers and passages to move lower in pitch, many people benefit from voice (re)training to adapt to these changes.
This may include a process of getting reacquainted with your own voice, observing which pitches can now be accessed within each register, and identifying the pitch range of any noticeable passages.
Over time, voice (re)training can help rebalance vocal registers and adjust to new registration patterns if necessary. This may include improving access to some registers, developing previously under-developed registers, expanding the ranges within each register, and smoothing register transitions. These steps will also improve access to the entire vocal range and may significantly increase vocal stamina.
During or after voice change, many people who use testosterone develop a significant passage somewhere around middle C (potentially anywhere between Ab3-F#4) that may feel perplexingly difficult to manage. Mix voice, improving breath support, and releasing excess muscle tension are the keys to building new technique in this range as well as moving the break higher over time with more practice.
Unfortunately, if we do not complete this (re)training process, we may be prone to straining our voices by trying to do certain things in the “wrong” register. Or, we may occasionally fumble a necessary register transition, causing us to accidentally do something harsh on our voices.
This register disorientation, along with general confusion about how to use our newly changed voices, may contribute to significant muscle tension and muscle over-engagement while speaking or singing.
Here are a few common examples of how these issues can manifest:
Bringing chest voice too high instead of transitioning into mix voice when appropriate – high notes feel “pushed” or strained
Getting “stuck” in mix voice and having difficulty finding chest voice – feels like “my voice never dropped” because lowest notes are inaccessible
Using a too-high register position when speaking – voice feels tight, voice sounds high
Lifting the larynx very high in the neck – muscles feel tense, voice sounds high or overly nasal
Over-engaging the tongue muscle and/or the jaw muscles when singing or speaking – muscles work harder than necessary, singing and speaking feel effortful, voice fatigues easily, voice sounds quiet
Clenching the swallowing muscles and/or other muscles around the throat and larynx – voice sounds overly nasal
Shoving too much breath through the larynx while singing or speaking – voice feels “forced”
Vocal cords pull apart while singing or speaking due to severe muscle tension around the larynx — voice hurts, voice often feels tired, voice sounds breathy, hoarse, or raspy — this is actually a description of a common voice disorder called Muscle Tension Dysphonia (I’ll give a bit more info on this below)
All of the issues on this list are common among people who use testosterone. These issues often improve through voice training that includes therapeutic vocal exercises, such as SOVT exercises. These are sort of like “physical therapy” exercises for the voice, designed to gently teach the voice to function in a healthier and more sustainable way.
You can learn to do SOVT exercises on your own, or work through these issues with a voice teacher or voice coach. Or, you can get help for these issues from medical providers like speech therapists, voice therapists, voice pathologists, or laryngologists (these medical services are often covered by insurance).
Nonmedical bodywork practices may also help with these vocal issues, including Alexander Technique, Body Mapping, or Feldenkrais’s Awareness Through Movement exercises.
Muscle Tension Dysphonia is a common voice disorder that occurs frequently among people who use testosterone, and also among the mainstream (mostly cisgender) population. Because this disorder is so common, voice therapists already have therapeutic tools, including SOVT exercises, to help people improve and sometimes even totally resolve this issue.
This article began by naming three major challenges to vocal health during and after transition with testosterone. Luckily, SOVT exercises can help with all three of these challenges!
SOVT exercises are an invaluable tool for supporting vocal health while using testosterone.
SOVT exercises have the following therapeutic benefits:
Reducing vocal cord inflammation
Accelerating recovery from vocal fatigue
Smoothing register transitions
Developing healthy habits for making sounds
Reducing muscle tension during vocalization
“SOVT exercises” stands for Semi-Occluded Vocal Tract exercises. The term “vocal tract” refers to all of the resonating space above the vocal cords (including the throat, mouth, and sinus cavities) which helps shape the sounds and colors of your voice. The term “semi-occluded” means partially closed.
In other words, Semi-Occluded Vocal Tract exercises involve making sounds with our voices while the vocal tract is partly closed.
For example, SOVT exercises may use any of the following sounds: “mm,” “nn,” “ng,” “oo,” “vv,” “zz,” “jj,” or a voiced “th.” Lip trills and tongue trills are also SOVT sounds. Humming through a straw is a popular SOVT exercise called “straw phonation.”
When the vocal tract is partially closed, some of the airflow is blocked from exiting the mouth while we make sound. This airflow then cycles back towards the top of the vocal cords and neutralizes the pressure from the airflow coming up from the lungs. As a result, we are able to exercise our voices very gently and practice healthy vocalization while also receiving therapeutic benefits from these exercises.
Here’s a set of easy SOVT exercises to help you get started:
Step 1: Before we begin making sounds, let’s take a moment to connect with our breath by taking three breaths with the following intentions:
Breathe in, and notice any sensations of movement you feel in your body with that breath. Breathe out, and invite any tense muscles to soften and release.
Breathe in, and feel your torso expand like a balloon. Breathe out, and feel the balloon deflate until it’s completely empty.
Breathe in, and keep breathing in until your lungs feel completely full. Breathe out, and notice how your body feels.
If you like, you can stretch, wiggle, or shake things out. Invite your body to relax, and notice how it responds.
Step 2: Take a new breath in, and exhale while articulating this sound: “shh.” Keep the sound going for the entire length of the exhale. Is the “shh” sound consistent and steady, or inconsistent and shaky? Notice how the sound matches the movement of your exhaled breath. When you exhale smoothly, with a consistent stream of air, the “shh” sound flows equally smoothly at a consistent volume.
Experiment with your airflow and listen to the “shh” sounds that you can make with different amounts of air. Check in with the muscles in your face, jaw, mouth, tongue, throat, neck, and abdomen to make sure you’re not clenching anything while making the “shh” sound. Repeat this step as many times as you want, aiming for smoothness in your sound, until you feel ready to move on to Step 3.
Step 3: Now, let’s try a simple SOVT sound: humming. Breathe in, and as you exhale, lightly close your lips and hum on any comfortable pitch, sustaining the “mm” sound. Try holding one pitch for the length of an entire exhale, and notice how this compares to the experience of sustaining the “shh” sound in Step 2. Again, a smoother exhale will result in a smoother sound. Keep an eye out for muscle tension, paying special attention to the outer abdominal muscles, and encourage any tense muscles to soften and release.
Experiment with sustaining the hum on different pitches, and notice any vibrations of resonance that you feel in your body on these pitches. If you like, you can use a piano, keyboard, or pitch analyzing app to track which pitches feel easiest and most natural for you to hum.
Step 4: Repeat Step 3 with any or all of the following SOVT sounds: “nn,” “ng,” “vv,” “zz,” “jj,” or a voiced “th.” If you can, try using a lip trill or a tongue trill. You may notice that some of these sounds feel easier and more intuitive to you, while other sounds might feel more difficult to articulate or sustain. Choose your favorite SOVT sounds, and spend more time on those sounds that you like best!
Optional: You can also try “straw phonation” by humming through a straw, using an average-sized straw of any material. Place one end of the straw lightly between your lips and hold it there. With your lips closed around the straw, your mouth is now almost completely closed, with only a very small opening. The straw temporarily extends your vocal tract but only provides a very narrow channel for air to flow out of your mouth, so most of your exhaled breath is redirected back towards the top of your vocal cords. Make a humming sound through the straw for the length of a full exhale.
For a more advanced straw phonation, place the free end of the straw into a glass of water, just under the surface of the water. As you hum through the straw, this will blow bubbles in the water and add resistance to your exhale. This is called “bubble phonation.” Over time, with more practice, you can try putting the end of the straw deeper into the water to create even more resistance.
Step 5: Now that you’ve warmed up with sustained pitches on SOVTs, let’s try sliding through your whole vocal range. This type of sliding exercise is sometimes called a “siren,” or “sirening.” Using any of your favorite SOVT sounds, start on a pitch near the bottom of your range and slide up in pitch, going as high as you comfortably can without forcing anything. Then, try starting on a pitch near the top of your range and sliding all the way down. Try this a few times with different SOVT sounds, and see what you notice.
For example, as you slide through your range, do you feel yourself moving between registers? What do these movements feel like – are they smooth, or kind of clunky? Can you slide through most pitches along your range, or are there parts of your range where you abruptly jump over a bunch of notes? As you slide up and down, do you find one of those directions easier than the other? Do you feel vibrations of resonance moving into different parts of your body (perhaps into your chest, throat, mouth, face, sinus cavities, or top of your head) while you slide up and down through your range?
Repeat Step 5 by sirening a few times on the “oo” sound, if you haven’t already done so. This is a good one to end on before proceeding to Step 6.
Step 6: Using the “oo” sound, slide up and down over the “break” in your voice. This will likely be the most noticeable register transition in your range: the transition between chest voice registers and head voice registers. (If you can’t access your head voice, feel free to skip Step 6.) Practice sliding over the break repeatedly in both directions on the “oo” sound. Experiment with making this transition at different speeds, sometimes jumping quickly over the break and sometimes sliding slowly through the break.
If this feels a bit awkward, or you don’t like the way your break sounds, that’s actually pretty normal! Keep in mind that this register transition will get smoother and easier to control with more practice (and will also sound smoother when your voice is more warmed up).
Repeat Step 6 with other SOVT sounds. Then, try sliding through the break on open vowels such as “ah,” “oh,” and “eh.” Reflect on how these different sounds create different sensations while transitioning between registers. Does this transition feel easier or smoother on any particular SOVT sound, or on any specific vowel?
Optional: Consider any other register transitions that you may have noticed in your range while sirening in Step 5. Repeat Step 6 on any other transitional spot between registers that you can identify. What else do you notice about these registers, and the transition between them? Reflect on whether this transition feels natural to you, or whether it feels tricky or complicated. Sticky register transitions often smooth out over time with more practice.
Step 7 (Optional): Sing a 5-note scale (12345), or a 5-note ascending and descending scale (123454321), on any SOVT sound. Repeat this scale as many times as you like, moving the key up or down by half steps with each repetition. (If you need a little guidance on the 5-note scale, you can find it in a free app called Appcompanist — after you download the app, go to “Playlists,” click on “Top 50 exercises,” then choose “Exercise 1 - Scales.”)
You can try these scales in any range, perhaps starting with the most comfortable part of your range before working your way into more challenging ranges. Then, sing these same 5-note scales on made-up syllables that pair SOVT sounds with open vowels, such as “ma ma ma ma ma” on a 12345 scale, etc.
Step 8 (Optional): If you have a song that you’re currently working on, or a favorite karaoke song, or a song that you’ve been struggling with, try singing the entire song on SOVT sounds in place of the song’s lyrics. Then, sing the song again on made-up syllables that pair SOVT sounds with open vowels, such as “nga,” “ni,” “vo,” etc. Investigate which vocal registers you are using to navigate the song’s melody, and consider whether any registration adjustments might make the song feel physically easier to sing. Experiment as needed.
Step 9 (Optional): Let us know in the comments how this exercise went for you, and what you learned in the process!
Peter Fullerton (he, him) is a transmasculine singer, voice coach, and trans voice specialist. He offers voice training and consulting services in Portland, Oregon and over Zoom. peterfullerton.com
For more information about voice change on testosterone therapy, check out Peter’s other resources on this topic:
What actually happens during transgender voice change from testosterone therapy? (YouTube video)
Vocal transition on testosterone therapy (Infographic)
For more information about vocal registers, including vocal exercises to help develop each register, check out Justin Stoney’s Vocal Register World Tour, produced by New York Vocal Coaching:
How To Sing Chest Voice (YouTube video)
How To Sing Head Voice (YouTube video)
How To Sing Mix Voice (YouTube video)
For more guidance on SOVT exercises, check out these resources:
Phonatory Exercises Handout: Semi-Occluded Vocal Tract Exercises from San Diego Voice and Accent (Handout)
7 vocal exercises for easier high notes from Dr. Nick Klein (Instagram reel)
Transmasc Tension Reducers from Quinn Dinsmore (YouTube video)
Bubble phonation from Diana Orbelo, PhD CCC-SLP at Mayo Clinic Otolaryngology (YouTube video)