Alex Ahmed is a trans woman and a PhD student at Northeastern University. She is working with fellow students, speech therapists, and people in the trans community to develop a new voice training app that is inclusive to all trans and gender nonconforming people, individualized to each person’s goals, and freely accessible to anyone who wants to use it. I spoke with her over the phone about the process of developing her app, what healthcare providers need to know about voice training, and the broader intersection between medicine and the trans community.

Jamie Moffa: I wanted to ask about the voice modification app you’re developing.

Alex Ahmed: Okay, I guess I can talk about how it started. I’m a PhD student in Computer and Health Science at Northeastern University in Boston. I joined the program because at the time I was getting into programming, and I was looking for something to do, and I also felt that I wanted to do something that was helpful to people. So I settled on this program for its focus on health technology and how to use technology for health.

JM: Yeah.

AA: So I joined the program as a PhD student in 2014, so quite a few years ago now. Early on in the program I had the idea to do a voice training app. I was at the time just coming out as trans in early 2015, so it was closely on my mind at the time. So [over] the next few years I started to explore the problem, trying to understand the experiences people were having. So I interviewed 10 trans people, kind of a mix of trans men and trans women, but mostly trans women. Tried to understand, if I did want to do this, how to do it, how to do it correctly, and what would be most useful to folks.

I also over the years looked at existing apps¹. There are a few apps that exist for voice training. Most of them are made by speech therapists, branded with their own style of voice training. A lot of them feature videos of themselves giving lessons and whatnot. Those apps are pretty expensive to download, and I saw a lot of ways that they could be improved. One of the more obvious ones was that the apps currently are very heavily gendered, and I guess the initial response to that would be: “Of course they’re gendered, the whole thing is about gender.” But at the same time it’s pushing down a very stereotypical notion of what it means to be a man or a woman, and it erases nonbinary identities, and implies that if you are a trans woman you want your voice to be a certain kind of way. So I tried to think about how could an app not do that. Is it possible to build something that is more open to experimentation? Maybe more open to the user of the app having a bit more control over what the app is doing, or what the app is giving to you in terms of either feedback on your voice, how it sounds, the pitch, or even just how the app looks. It could be something basic, like if you open one of these apps that is made for trans women they’re like all pink, and the background of the app there’s an image of a person with lipstick on, and it’s very in your face.

JM: All the trappings of femininity.

AA: Right, and on the other hand, apps for trans men are separate, of course, and there’s an app for trans men with a blue color screen, and the image you see when you first click on the app is this person who’s masculine presenting and wearing a suit. Like, what are we showing here with these images? I’m trying to pull in a lot of different types of analyses to talk about it. I’m not just talking about the design of an app functionally, but what are the social forces at play? What are the stereotypes and what are the social consequences of having apps like this? So I was thinking about that while also building an app from scratch. I’m not doing that alone, I’m actually partnering with a lot of other people.

So the premise of the project is that it’s open source, anyone can download it for free, anyone can modify it. And I and several other volunteers who have contributed to the project over the past year have helped with the design of how it looks, what it does functionally, and also just the work of building it has been distributed across many people. Which has been really cool to see. It presented many challenges. Building software like this with a group of people for free has been a thing for a long time, but it was very new to me, so I was figuring it out on my own. I can talk in detail about what the app does and everything if that’s helpful.

JM: Yeah, I’d like to know: What goes into building a voice training app for trans and gender non-conforming individuals?

AA: I can’t speak generally but I can speak about our process. Like I said, it started with the interviews, and I did 10 interviews, and I wrote a paper about the responses and I can send that to you if you like. But essentially I drew conclusions from these interviews where I asked them about their experiences.

For more day-to-day, it varies, but we talk almost every week about the design of the app. I am primarily responsible for the visual look, but we’ve had a lot of support from others, like a graphic designer, a visual designer. It’s her job to do things like this, and she volunteered her time to help us craft how the app would look. So I really am just building off what she started. She uses a program called Adobe XP, which is like Photoshop but for app screens. So we use that to build out the screens and what they’re supposed to look like.

Prior to that we talked to several voice training experts, some of whom are institutionally recognized speech therapists, and some of whom are trans people who have studied this. So we’re kind of looking at how there’s institutional knowledge about how trans voices work, and what the medical establishment, speech therapy, the licensed practitioners do, and what trans people do, and it’s often times not the same. Trying to reconcile that difference has been a challenge.

I meet with speech therapists too, and my work is trying to negotiate these different systems and understanding how speech therapists have their own way of doing things, and they may disagree with the things that trans people do. I’m lucky that the people working with me are aware of that, they’re aware that this is a very new field and that trans people have been doing what we’re doing for a very long time. Since passing has been required or desired or needed for safety, we’ve been altering our behavior, perhaps even more so than we want to, to try to pass or blend in. It’s just recently that this industry has been created, and there are now experts to help trans people. And what I’ve noticed, especially from my perspective as a trans person, is that there’s a tendency for medical professionals to have a savior complex, an “I’m doing this for the community” type thing. Which is in many ways good, because medical professionals do not have the richest and most positive history dealing with trans people. It is, even today, hard, depending on who you are and where you are and what your identity is, racially, ability wise, etc. There’s also good things going on. All of that is to say that it is now an industry that is medically recognized, and there is this body of research now we can draw from. We can say: “Ok, it seems to be commonly useful to do this, or that,” and you can build that into the app, and say that we consulted with experts who have been doing this for their living. But at the same time, that’s not all there is to it. So that’s just part of it.

From the technical side, we’re trying to build up the app from scratch. Like I said, we’re not building off of anyone’s existing work, except where there’s publicly existing code that does what we want to do, like calculate the pitch of someone’s speech sample. A lot of those exist already, but we’re not taking someone’s app and adding to it, were doing something new. And part of the reason for doing that is we wanted to retain our creative autonomy, we wanted to present options to users, that’s something that hasn’t been in many apps so far. So, for example, when users open the app for the first time they can decide what they want to do with their voice. Like, do they want to prioritize something that is in the traditionally feminine pitch range, or masculine, or not, neither, somewhere in the androgynous range? Do they have a specific pitch in mind that they want to aim for? This is something some people want. The idea is that you don’t have to align yourself with any gender label in order to use the app, you can just sort of log onto the app and use it. And you can even say that you don’t want any gendered markers to be shown to you. This is something that a lot of apps assume by default, that you want your voice pitch to be placed alongside the gender label ranges.

So if you log onto the internet, all sorts of research has been done on this. You can find data on the ranges of male and female voices from many languages. The linguistics and audio, this type of research is very obsessed with gender, but in a very sort of cisnormative way. So you’ll get data on pitches, but it’s very “male and female,” of course. They want to reduce any complexity to it. So a lot of data we have is skewed in this way, and doesn’t take into account trans people at all. So the idea that we could show that without giving people the option is kind of silly, we thought. So what I’m aiming for is the idea that we can’t pretend that the gender ranges don’t exist, we can’t pretend that there are not these tendencies and norms in this society. Norms exist and we can’t escape them. We can be aware that they exist, and name that they exist, and be aware that they are tendencies but not anything set in stone.

So the question then becomes how do we create an app that is mindful of that, how do we present information in ways that doesn’t chain people or judge people for not identifying with this? Giving people the option to opt into these things rather than assuming that they’re interested in conforming to some certain ideal. So, we’re building that out, like I said. It sort of flows like: the decision is given to you as to what you want to do with your voice, and then that carries through to what kind of information the app shows you later. So, for example, there’s a function where you can speak into the microphone, and it does this thing that speech therapists do where they ask you an open ended question and you just speak naturally. […] After users say what they want to say, they say that they’re done and you get a readout where [the app] shows you their average, it shows you their minimum and maximum. Except if you’ve indicated in the app that you want to be looking at the gender ranges, it will show you them, and if you indicate to the app that there’s some specific pitch you’re interested in, it will show you that alongside your range and your average through a line graph. However, if you haven’t set any of those things, it will just show you your pitch and your average, and it won’t show you anything else you haven’t expressly said that you want. So that’s kind of the idea.

JM: Yeah. I know that there are other dimensions of speech therapy that trans people consider, not just the pitch of your voice, but what words you use and how your inflection goes up or down at the end of sentences. Does the app take that into consideration as well?

AA: Not really, no. This is something I’ve been thinking about a lot, not only just in terms of pitch and word choice, but also where those norms come from. It’s really interesting, especially because we are trying to release this globally, so anything about word choice…it would be very difficult to make that applicable across languages. Also, in my opinion, and I’m not speaking for the entire team, basically it’s tricky to put that in an app form, I think, and it’s a bit problematic. Not just because of the English dominance of how apps are built, and we’re trying to make this accessible and translated. It’s really hard to say how useful that is to people and what the consequences of that would be. There’s more than enough stuff out there that’s like, “Well, if you want to sound like a woman, make everything sound like a question and stuff.” And we don’t need to be replicating that. If people want to seek out that information, it’s really available. There’s something to be said for training things that are applicable no matter what you’re trying to do. And, drilling down into habitual stuff and expression stuff, I kind of consider that your expression. If you want to sound a certain kind of way that’s totally up to you, but I don’t think our app should be elevating certain ways of existing and expressing as more legitimate than others. So, yeah, that’s kind of where I stand on it.

JM: That makes a lot of sense. I’ve been researching a lot of the current apps out there, and some have information on that, some don’t.

AA: Oh yeah? Can I ask which ones you looked at?

JM: The main one was called EVA, I think?

AA: Right, yeah, we looked at EVA for sure.

JM: This also sounds like it’s really great for nonbinary people, because like you said a lot of the current apps are very gendered, so if you want an androgynous voice range, it’s difficult.

AA: Yeah, and that’s something I’ve heard specifically from people. One of the things I struggle with is that I don’t want to build something that will further marginalize and cause harm. Which is so easy to do if you’re building an app that a lot of people will use. You can’t just ignore that some people exist.

JM: Yeah. I wanted to go back for a second. You said that there was some discrepancy in practices between speech therapists and trans people. Can you talk a little bit more about specifics there?

AA: Definitely. So there’s an idea out there around voice training forums online around larynx height modification. So this idea that if you have testosterone dominance in your system at some point in your life around puberty, then your larynx descended, and the idea is that a more feminine sounding voice can happen if you consciously elevate your larynx. If you have control of it you can sort of elevate it so that it changes the sound of your voice, like the quality of it. Instead of sounding deeper and darker then it becomes a bit more, like, I guess the word is bright. So there’s this kind of light metaphor, even though it’s kind of hard to put into words. But basically, your voice gets a little bit more, like, let me see if I can do it…this is really difficult…but basically you can try to…ok, I don’t think I’m going to be able to do it.

JM: That’s ok. I understand the concept of bright versus dark.

AA: Yeah, you get the concept.

JM: Being a musician you talk about that kind of “dark versus light” sound all the time.

AA: So, you’ll see people on YouTube talking about this², you see people on message boards talking about this. However, I went to the speech therapist that I’m working with, and she was like “I would never tell anyone to do that.” Your larynx goes up and down naturally all the time, that’s just how it is. According to her, you just want to aim for your larynx being in a neutral position. But you know, a lot of these trans folks have trained themselves to have a consistently high larynx. And a speech therapist might tell you that that can cause strain. But these folks might respond that actually no, it doesn’t cause strain if you do it correctly. And that’s a disagreement that came out in the process of building this app out. I eventually decided to include a larynx exercise in the app, even though that’s not something a speech therapist would do. In a way it was a values based decision, like I wanted to respect that knowledge. It’s no less real knowledge even though it’s not generally agreed upon. The other thing to note is that it’s also disagreed upon within speech therapists. Other speech therapists might be like: “Oh, yeah, I train people to control their larynx,” or whatever. But everyone does it differently and there’s not really a consensus because the field is so new. It’s kind of hard to say. But basically larynx modification or larynx control is something that came up around this.

JM: That’s really interesting, I didn’t know that.

AA: Yeah it’s interesting.

JM: That got me thinking about professional singers who specifically speak in a particular range to protect their voices. I don’t know if you’ve worked with anyone who works with professional singers, or how applicable that is, but that reminded me of that.

AA: Yeah, so I sing…

JM: Oh, awesome!

AA: Yeah so I’m in an a capella group, and I see a singing coach once every couple weeks. We try to figure out how I want to sing. It’s been a challenge. And a lot of similar things come up around trans stuff as singing stuff, especially when they overlap. Trans singers often struggle with this. A few people in my a capella group are also trans, and have talked about how their voices have changed, and how they have dealt with or understood changes in their voices, and I think it’s really fascinating because it’s tied to our identities in so many ways. I mean, not necessarily, but for a lot of people it is. One thing that’s really interesting about that is how singing is taught is really gendered a lot of the time. So, this idea that if you’re in your head voice as a “male” then it’s your falsetto because it’s false, but if you’re in your head voice as a “female” person then that’s intentionally how you should be singing, and you don’t want to be in your chest voice ever. I’m being taught in a way from my singing coach that’s making me think about where we place the sound. I’m trying to think about placing the sound more in my head, but not necessarily not being able to access those low frequencies. So it’s more about being able to change the resonance of it, being conscious of the resonance, which is really fucking hard. But, yeah, I’m lucky that my singing coach […] will tell you that “I would teach everyone how to sing the same way, regardless of who they are.” Because it’s not so much about getting people to sing in a certain way, it’s just about getting people to be aware of their instrument, basically, and I love that.

JM: Yeah, you wouldn’t teach someone to play the trumpet or saxophone differently because of their gender.

AA: Yeah, right.

JM: So, kind of building off of something you mentioned: Are there any adverse risks or health effects of doing voice training improperly?

AA: I’ve been talking to a lot of my speech therapist’s contacts around this, and we eventually decided that we wanted vocal health to be one of the main functions of the app. Like, we wanted the app to impart some information about how to do these things in a way that doesn’t hurt your voice, because it definitely can. If you don’t warm up, if you do these exercises more often, if your voice starts to feel strained or tight or uncomfortable and you keep going, you are going to get hoarse, you are going to get strained. And people who I interviewed told me that, because they don’t have access to that information, and they try to do stuff, then they end up having a sore voice for a couple days. In the beginning, when you first open the app, we show hints and best practices, and we try to have reminders as you use it to just “Remember to take a break” or “Remember to do certain exercises like this so often per day and not more than that.” I don’t know, I think everyone has a different capacity, so we just wanted to encourage awareness about like “this is actually not feeling good” rather than causing the app to stop working if you do something too many times. So it will let you do stuff more, but it will tell you if you’ve done something that is more than is recommended.

JM: What are the current resources online or in person for trans or gender nonconforming voice training that health care providers should be aware of?

AA: It’s kind of like what I was saying: people seek out this information, you know? If people want it then they look for it, and a lot of it is online. Like, YouTube, endless people have posted videos of voice training. Some of them describe themselves as experts and I think that they are, in the fact that they’ve lived it, and they’ve dedicated a lot of their life to understanding the science behind it. As always, there is no 100% true or most effective method. People have their own ways of doing things just like people have different ways of expressing themselves. You can go on YouTube to find a ton of that. There are forums online that I’ve talked about. There’s Discord, have you heard of that?

JM: Oh, yeah.

AA: There’s Discord channels for trans voice. I haven’t so much gone on traditional old school message boards, but I’m sure those exist too. There’s books about it³, there’s academic texts about it, but I feel like those aren’t so often accessed by regular people. There are also, like I was saying before, professionals now who charge for their services. You can find them online, you can book sessions with them remotely, like over Skype. There’s also folks on Discord who advertise their services there and you can book sessions with them. There’s a lot of resources. There’s really no shortage of them. And they’re often really variable, in my experience. People have a lot of different ways of approaching this.

JM: What do you see as the future directions of voice training technology for trans people?

AA: Well, if I’m being honest, I think that the medical industrial complex is very invested in providing services for trans people, because it is for the benefit of society to want to push trans people towardπs a certain limited way of being. And I’m not saying that it’s good or bad, really, I’m saying that medical transition, while it’s accessible for a lot of people, is in many ways part of this structure of the system where the outcome is that there’s now these very delineated paths: if you’re going to transition, you do XYZ. And I’m drawing from some queer theory, some of the more humanities-based thinking around this. So, this writer Jasbir Puar wrote this book called ‘The Right to Maim’⁴, where she talks about disability and transness. She talks about this idea called ‘transnormativity,’ which is: there are these social structures built around creating normative trans people who check all the boxes and become assimilated and integrate into society. Her analysis of the outcome is that you have people who are now ready and willing to participate in capitalist society. They are now able to take part in capitalism, they are able to get a job, to create value, to create labor, etc. So it’s a more social constructionist approach, more grounded in understanding capitalism.

So I feel like the future of voice training is that there’s going to be more and more research, there’s going to be more and more resources available. And I think that technology allows these speech therapists, if they so wish, to create their own brand of app, and they can charge for them, and they all have their own various methods, and they can put themselves on the market. And people have all sorts of options, like “Do I want to get this one, do I want to get this one?” Overall, these passing guides, these “how tos” for gender and stuff, they don’t come from nowhere, they’re not value neutral, they’re in a social context. And…where was I going with this?

JM: No, this is really interesting.

AA: And technology is serving that purpose, and it’s profitable. That’s kind of the whole thing behind the medical industrial complex is that it’s an industry. Now, gender affirmation for trans people is placed within the medical system, and in order to obtain that you have to have insurance, you have to jump through all these hoops, you have to participate in capitalism. Unless you don’t need to and you don’t want to, and that’s obviously totally fine, but I think that the overall result is that transness is now placed in this context of “If you want to be trans, you gotta have resources. If you don’t have resources, you’re not going to be able to access the things that you might need.” Which is, obviously, capitalism. At this point I’m rambling.

JM: This is interesting rambling, I like it. I’ve thought about this a lot being a medical student, and how medicine intersects–

AA: Oh, you’re in med school.

JM: Yes. This whole web site⁵ is directed at providing medical providers with information so that they can treat their trans and LGBT patients better, with more understanding and compassion.

AA: Oh, I see, I see.

JM: So, I don’t know where our site fits into this whole discussion, but generally, this discussion intersects with talking about the diagnosis of gender dysphoria and how that’s been placed in a medical context…

AA: Right, exactly.

JM: I’ve heard both sides of the argument, with some people saying: “We need this diagnosis to access health care”, and then on the other hand, you can say: “Well, you only need the diagnosis to access health care because that’s how the insurance system tells you to do it.”

AA: Exactly. People have this idea that we need the diagnosis, but, I mean, that’s a product of the system in which we live. If the diagnosis [of gender dysphoria] didn’t exist, and we didn’t need it to access resources, then what would it be used for? It’s premised on this idea that our brains are fundamentally different, that we have some disorder. And it’s like, actually, maybe society is disordered, how about that?

JM: Yeah. This is just a normal variant of human experience, and you’re telling lots of people that before they can do what they want to do to feel most comfortable in their bodies, they need to have a diagnosis and all sorts of evaluations.

AA: Yeah. Exactly. Have you heard of this YouTuber called Contrapoints?⁶

JM: Oh my god, I love Contrapoints.

AA: So her video on dysphoria is really interesting. She talks about it recently in one of her [videos]. Yeah, I like her position on it. She sort of shows off the positions and their contradictions.

JM: I like how she does it, too, I think I remember which one you’re talking about because she plays two different characters–

AA: Exactly.

JM: –who hold opposing viewpoints. And, she’s such a good philosopher, first of all.

AA: Yeah. I think it was on “Transtrenders”.⁷

JM: Yes.

AA: Yeah, I would say that medical providers need to become aware of these things. They need to understand really what they’re doing when they interact with a trans person, and the social context in which that interaction takes place. It’s not just that they’re here as a benevolent medical provider here to dispense services. Often times people are here under duress, like they have to do this in order to get what they want. And they probably at some point would lie to you about what we are and what we need just so we can get through this fucking situation.

JM: Yeah. If you go to therapy to talk about your gender identity and transition, you can either be honest about all the fears and doubts you have about transition, and what you question about your identity, or you can just check off all the boxes you need to check off, say “yes I have dysphoria, I don’t like this, I don’t like this.” I think I want to go into psychiatry, and that idea really bothers me that you can’t be open. Because my ideal as a provider would be to have a patient be as open with me as they feel comfortable, because then that deepens the relationship and you can talk more specifically about individualized medicine and what might work best for you. But if it’s tied up in gatekeeping about “well you don’t meet all the criteria for dysphoria so you can’t get top surgery even though you really want top surgery.” Like, that just really frustrates me because I know if I go into psychiatry and work with trans patients, they will probably lie to me about…yeah.

AA: Because despite your best intentions as a provider you’re not going to be able to escape the context in which the interaction is happening. Even if you want to create the best environment for a trans person, you’re not the only provider they’re going to interact with. You could be great at what you do, but you can’t escape from that system. It is a harmful system, ultimately, to more people.

JM: Yeah, and all of that is especially frustrating in that this is about ten levels beyond what most providers understand about trans health. Like, you can’t even start on the implications of what we’ve just been talking about when you’re trying to just get people to understand that trans people exist, and you’ll see them in your office, and you need to know how to talk to them and treat them without being a dick.

AA: Yeah, the bar is so low.

JM: Yeah.

AA: The bar is so fucking low.

JM: We had people within our own institution at WashU write a letter to the editor at some journal about the dangers of transgender therapy.⁸ And people like to scare monger particularly in relation to transgender youth and “they’re being pushed into transition, and we shouldn’t be allowing this,” and I’m so frustrated by that.

AA: Yikes. So I probably should go within the next 5 or so minutes, is there anything else you wanted to ask about?

JM: No, I just wanted to clarify before you go, what your pronouns are so I can refer to you properly in the article.

AA: Yeah, she/her.

JM: Great. So that’s about it, this has been a great conversation, thank you so much.

AA: Yeah, you’re welcome.

JM: Have a good day.

Footnotes

¹Some examples of existing voice training apps for trans people: Voice Analyst, Christella VoiceUp, EVA (Exceptional Voice App) MtF and FtM

²Video example of larynx elevation by TransVoiceLessons

³Adler, R; Hirsch, S; Pickering, J. Voice and Communication Therapy for the Transgender/Gender Diverse Client: A Comprehensive Clinical Guide.

⁴Puar, J. The Right to Maim.

⁵Interview initially intended for the website PrideinPractice.org, which educates healthcare professionals on LGBTQ+ health.

⁶Contrapoints YouTube Channel

⁷“Transtrenders” | ContraPoints

⁸Michael K Laidlaw, Quentin L Van Meter, Paul W Hruz, Andre Van Mol, William J Malone, Letter to the Editor: “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline”, The Journal of Clinical Endocrinology & Metabolism, Volume 104, Issue 3, March 2019, Pages 686–687, https://doi.org/10.1210/jc.2018-01925