When Alice was growing up in the Midwest, she rarely saw her grandmother, who lived on the East Coast. Usually, they'd just keep in touch over the phone.

"Every time I called her in high school, she would say, 'Oh, your voice is getting deeper, you sound like you're growing into such a nice man, you're going to be like your dad,'" Alice said.

Those were painful words to hear. Alice remembers artificially raising the pitch of her voice to thwart her grandmother's comments.

It wasn't until years later that Alice realized she was transgender. She started to publicly transition during her senior year in college. She's 23 now and recently graduated from a speech therapy program that helps transgender people safely adjust how they speak, so they can sound more like themselves.

"I'm at a point where for like 90 plus percent of the time, I'm happy with how I sound and how I'm perceived by other people," Alice said. "This is something I never expected to be in a position of. And it's really exciting."

Vocal training for transgender people is becoming more widely available as the community becomes more visible. But it can be fraught because each individual needs to decide the mannerisms they want to adopt, some of which may be considered stereotypical or even sexist.

Alice asked to be referred to by just her middle name because she's moving across the country to start a new life and wants to have control over whether she tells people she's transgender.

She has worked on construction sites and in food service. It was at work that she noticed she was straining her voice as she competed with heavy machinery and other workplace noise. By the end of the week, her voice would be shot.

"I wanted to have a voice that was sustainable and that I could feel comfortable using all day, talking with people I'd never met before and would probably never meet again, but have them still recognize me as a woman without me having to have that conversation every single time," Alice said.

She went to see Alison Weinlaeder, a speech pathologist at Courage Kenny Rehabilitation Institute at United Hospital in St. Paul. Weinlaeder was trained in how to help transgender people use different parts of their voices to sound like they want.

Some transgender patients reach out to Weinlaeder for speech therapy at the beginning of their transition. Some contact her later in life. But they're often wary.

"I often will have people first contact me only by email, saying, 'I'm too nervous to call you on the phone, I just want some information,'" Weinlaeder said. "There can be some hesitancy, and it takes a lot of trust building to get these relationships going."

Alice's insurance initially declined to pay for her treatment. But Weinlaeder argued that Alice's voice was being damaged by the strain of talking at her jobs, which she said is not uncommon for transgender women who haven't learned healthy techniques to make them sound like they want. Trying to force one's voice to sound much higher or lower than its natural range can actually damage a person's vocal chords. The insurance company eventually agreed to cover the sessions.

Most transgender speech therapy patients are women. Transgender men who take testosterone will often experience a deepening of their voices. But even transgender women who take estrogen don't experience a change in their vocal chords.

Weinlaeder said masculine- or feminine-identified voices are about more than whether they sound high or low.

"The way we resonate the sound in our body, whether it's in our chest, our throat, our lips, our nose, all of those pieces can really shape masculinity or femininity in someone's communication style," Weinlaeder said. "So it's so much more than pitch."

Weinlaeder trains speech therapy clients on how to learn to use different parts of their voices. One tool she uses is a kazoo. Her students use the kazoo, humming and chanting to help them get used to feeling their faces vibrate as they learn to project their voices differently.

"Someone who's going from male to female transition, we're moving from usually a chesty or throaty resonance up into a nasal or forward-focused resonance," Weinlaeder said.

There are other little tricks that speech therapists can use. Masculine and feminine voices are associated with other characteristics too: asking versus telling, using arms when they speak, how they stand.

"We're not promoting stereotypes, but it is information that people should have," Weinlaeder said. "So I say, 'This is your toolbox. I'm going to tell you what would make a more masculine style, a more feminine style. You decide if you want to use it or not.'"

Alice did adopt some behaviors, such as using her hands differently when she spoke. But she refused to fall in line with gender norms she thought were antiquated or offensive.

"I am a feminist. I'm going to act like it. Just because this is a typical feminine behavior, if it is just a very patriarchal, like trying to silence and subdue women, I'm not going to do that," Alice said. "It's not worth it."

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Speech therapy for transgender people didn't used to be widely available. Leah Helou, a speech language pathologist and assistant professor, founded the Transgender Voice and Communication Training Program at the University of Pittsburgh in 2011.

When Helou completed her master's degree in 2004, there were few clinicians who saw transgender clients, she said.

"I committed to that being one of my areas of clinical focus, and I couldn't find anyone to train me, I couldn't find anyone to observe," Helou said. "So I just did my best and learned as I went."

The clients seeking therapy have also changed. They used to be older, she said, and now many younger transgender people are looking for assistance.

"While it used to be niche, what I say at conferences is, 'This is knocking on your door,'" Helou said. "If you're a speech pathologist, you better figure out how to do trans voice, because trans people are everywhere and they deserve good services."

Her profession has also been shifting away from just teaching transgender people that there's just one correct way to speak, and has focused more on helping individuals communicate more effectively and authentically.

While Helou wishes that transgender people wouldn't feel pressure to adjust their speech, she understands that sometimes these gendered cultural behaviors might be things transgender clients may want to adopt.

"Some of these really feminine behaviors that we might want to reject are the same things that somebody might need to call upon to maintain their safety in certain situations," Helou said. "It's OK to not choose it, but it's not OK to not have tools to choose from."

Of course, the therapy is not a requirement for transgender people. Some choose not to change their voices at all.

Ellie Krug, 62, transitioned a decade ago. It's always been extremely important to Krug to "pass," meaning to have people perceive her as a woman. She's slight in stature, even in heels, with long blond hair that she tucks behind her ear.

Ellie Krug Courtesy of Ellie Krug

Krug said she looks feminine, but "sounds like a 6-foot-2, 225-pound guy with the five o'clock shadow at three o'clock. That causes problems for me — interacting with humans."

But for Krug and other transgender people, passing can sometimes be an issue of safety. She knows that transgender people, especially people of color, are frequent targets of violence. Krug is white, and fears what could happen as she walks down the street.

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"Let's just say that somebody wants to mug me and take my phone," Krug said. "But as soon as they hear my voice, my fear is that it would turn then into a hate crime."

Krug said she knows she could work more on her voice. But therapy can be expensive. She still has some anxiety about how she sounds, but she's learned to accept it, and to even use it to her advantage in her work as a radio host and trainer on inclusivity.

"For the most part, I'm good with it because I'm not hearing a man's voice in my head right now, I'm just hearing Ellie," Krug said. "And I like her a lot."