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Diaphragmatic Breathing in Transgender Gender Affirming Voice Therapy

Embarking on the complex yet profound journey as a speech-language pathologist with a specialized focus on voice therapy, I have been intimately intertwined with the myriad of experiences that reveal the deeply transformative power of voice work, particularly within the diverse and rich tapestry of the transgender community. The individuals within this community often encounter a unique, multifaceted voyage in exploring and molding their voice, a journey not merely of physiological modification but one deeply tethered to the intrinsic and authentic expression of self. Voice, in its multifaceted resonance, is not just an audible reflection of self, but acts as an indispensable conduit through which gender identity is expressed, perceived, and socially navigated. Therefore, its role in gender presentation, and more significantly, in reinforcing and affirming one’s true gender identity, is indescribably pivotal.

In light of this, numerous transgender individuals, with their courageously embarked-upon journeys, often find solace and empowerment in voice therapy. Here, they seek not only the alignment of their vocal expressions with their authentic gender identity but also a supportive space wherein their vocal transitions become a harmonious blend of technical, physiological, emotional, and psychological evolution. In this delicate and transformative process, one fundamental technique stands out in its foundational importance yet is sometimes overshadowed by more overtly perceptible aspects of voice work. This technique is diaphragmatic breathing – an elemental, yet profoundly impactful practice, that not only fortifies the voice with strength and endurance but also serves as a keystone upon which the myriad of vocal modifications, essential for gender-affirming voice work, are solidly built.

The Importance of Diaphragmatic Breathing

Diaphragmatic breathing refers to breathing that is deep, originating from the diaphragm, rather than shallow breaths that come from the chest. This type of breathing is crucial for various reasons:

  1. Supports Phonation: Deeper breaths offer sustained airflow, crucial for modulating pitch and volume (Hancock & Gross, 2005).
  2. Enhances Resonance: Improved airflow allows for better resonance, a key element in voice quality.
  3. Reduces Strain: It prevents undue tension in the vocal folds, promoting voice health (Van Stan, Roy, Awan, Stemple, & Hillman, 2015).

Exercises to Foster Diaphragmatic Breathing

  1. Balloon Breathing: Imagine your belly is a balloon. As you inhale, envision the balloon expanding, and as you exhale, imagine it deflating.
  2. Book on Belly: Lie down with a book on your stomach. Inhale deeply and try to lift the book using only your breath. Exhale and watch the book lower.
  3. Sss Counting: Take a deep breath in and exhale while producing a prolonged “sss” sound. See how long you can maintain this, aiming to increase your time with practice.
  4. Breath Pausing: Inhale deeply, then exhale half of your breath, pause for two seconds, and then exhale the rest. This helps in controlling airflow.
  5. Paced Breathing: Use a metronome or app. Set it to 60 beats per minute. Inhale for 4 beats, hold for 4 beats, then exhale for 4 beats.
  6. Hissing & Speaking: After a deep inhale, produce a hissing sound for a few seconds and then switch to speaking a sentence. This transition helps to connect controlled airflow with phonation.
  7. Humming with Variance: Inhale deeply and as you exhale, produce a humming sound, modulating from low to high pitch. This not only reinforces diaphragmatic breathing but also trains pitch control.

Integration in Gender Affirming Voice Therapy

When working on voice feminization or masculinization, the above exercises can act as foundational practices. For instance:

  • For individuals aiming for a higher pitch, controlled airflow through diaphragmatic breathing can support sustaining those pitches without strain (Adler, Hirsch, & Mordaunt, 2012).
  • For those targeting a deeper resonance, diaphragmatic breathing ensures a steady and strong airflow, essential for achieving and maintaining those resonant qualities (Dacakis, 2002).

Concluding Thoughts

The journey towards voice modification and adaptation, particularly in male-to-female (MTF) transition, often intertwines closely with an individual’s pursuit of authentic self-representation and the external perception thereof. For those engaged in MTF transitions, where the adaptation from a typically lower to a higher pitch is commonly sought, there is not only a physical but also an emotional, social, and psychological implication tightly knitted with voice and communication (Dacakis, 2002). The echo of one’s voice essentially becomes a continual affirmation of identity, which is notably significant in the path of transgender voice adaptation.

Diaphragmatic breathing becomes an ally in this journey, affording the ability to produce, sustain, and manage desired vocal pitches and qualities in a healthy and feasible manner. This technique, while seemingly simple, forms the bedrock upon which the voice can be modulated, adapted, and cared for, particularly in the context of elevating pitch and modifying resonance, which are frequently encountered facets of MTF voice work (Adler, Hirsch, & Mordaunt, 2012). Through strategic, consistent, and mindful practice of diaphragmatic breathing, individuals can craft a voice that is not only affirming to their gender identity but also sustainable and healthful for their vocal apparatus in the long term.

Moreover, the essence of voice in shaping social interactions and affirming gender identity, especially for transgender women, cannot be overstated. The voice is often a primary factor by which gender is perceived and interacted with, offering either a pathway to seamless social gender affirmation or potential for misgendering and dysphoria (Hancock & Gross, 2005). Thus, the investment in healthy vocal practices, especially those that revolve around sound foundational techniques like diaphragmatic breathing, not only contributes to vocal health but also becomes an integral part of the journey towards consistent gender affirmation and, by extension, emotional and psychological well-being.

In this context, diaphragmatic breathing not only ensures a robust and healthy vocal function but serves as a vessel through which the voice, a powerful instrument of identity and self-expression, can mirror the internal landscape of one’s gender identity. For many undergoing the MTF transition, crafting a voice that aligns with their identity becomes a pillar in their journey, and the cultivation of sustainable, healthy vocal practices through diaphragmatic breathing can provide both the practical and symbolic support needed in that beautifully complex journey.


  1. Hancock, A. B., & Gross, H. E. (2005). Voice perceptions and quality of life of transgender people. Journal of Voice, 19(3), 553-558.
  2. Van Stan, J. H., Roy, N., Awan, S., Stemple, J., & Hillman, R. E. (2015). A taxonomy of voice therapy. American Journal of Speech-Language Pathology, 24(1), 101-125.
  3. Adler, R. K., Hirsch, S., & Mordaunt, M. (2012). Voice and communication therapy for the transgender/transsexual client: A comprehensive clinical guide. Plural Publishing.
  4. Dacakis, G. (2002). The role of voice therapy in male-to-female transsexuals. Current Opinion in Otolaryngology & Head and Neck Surgery, 10(3), 173-177.
  5. T’Sjoen, G., Van Caenegem, E., & Wierckx, K. (2011). Transgenderism and reproduction. Current Opinion in Endocrinology, Diabetes, and Obesity, 18(6), 315-322.
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Emiko Lee, Writer

Emiko (Emi for short) loves to write about issues in gender. She researches and writes stories and guides the support, uplift and share trans voices and trans lives. She has 2 ferrets (Wilbur and Lulu) who make her days wonderful and horrible, and loves coffee more than water!
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