(NOTE: This story contains references to suicide. If you or someone you know is thinking of suicide, call the National Suicide Prevention Lifeline at 800-273-8255 or text TALK to the Crisis Text Line at 741741.)
PHILADELPHIA -- When Fenix Cobbledick speaks in an unfamiliar place for the first time, they often feel scared.
They have spent countless hours and thousands of dollars on hormone therapy, laser facial hair removal, and growing out a feminine haircut to make their appearance more accurately reflect their identity.
But even as they changed their body, Cobbledick, a 31-year-old nonbinary trans woman, felt at risk when they opened their mouth to talk.
"I love my singing voice. It's beautiful; it's just deep. And maybe one day we'll live in a world where I don't have to hide that voice," Cobbledick said. "But we don't live in that world."
Trans individuals are at higher risk for suicide and for becoming victims of violence. While not for everyone, gender-affirming care can help trans people feel comfortable in their own skin and safe in the community, LGBTQ advocates and researchers say.
Voice therapy may be valuable for addressing the mental health challenges many transgender people experience. As a common identifier of gender, voice can contribute to gender dysphoria — an unease that arises from one's gender not matching the sex they were assigned at birth.
"Voice is really integral to identity and that listeners assume a lot about a person by their voice alone," said Alyssa Giegerich, a speech-language pathologist at Einstein MossRehab, who specializes in gender-affirming voice therapy. "Our voice goals are to align the way that someone is perceived with their identity."
Hormone therapy, voice coaching, or surgery can help an individual when their gender identity doesn't match the sex they were assigned at birth. They are among the interventions known as gender-affirming care.
First on Cobbledick's to-do list was laser facial hair removal about three years ago. While the process was expensive, and painful, Cobbledick felt relieved by the removal of unwanted hair on their face. After that, they started taking hormones.
"It's just tiny steps that you take in the same direction," they said. "Everything just goes a little bit toward helping."
Earlier this year, they began working with a speech-language pathologist at MossRehab. The therapy is in partnership with Einstein's Pride Program, where Cobbledick receives gender-affirming care.
Every other week, for 10 sessions, Cobbledick met Giegerich in a small room at MossRehab's Elkins Park campus for voice therapy. Insurance covered some of the cost.
First, Giegerich assessed Cobbledick's voice and discussed what Cobbledick wanted to change about it. This therapy requires understanding perceived barriers — for instance, a fear of public speaking causing a patient's voice to crack.
"You could focus just on the mechanics of voice, and you would be missing a big part of what it means to have an authentic voice, to really identify with your voice, because that is so psychologically rooted," Giegerich said.
During their sessions, Giegerich asks Cobbledick to repeat sounds or words, or build sentences using specific phrases spoken into a microphone. Together, they listen back to the recording to analyze the pitch, range, the cadence of a sentence, and the inflection with which the sentence ends. They make note of voice characteristics they liked.
"Airy" is the voice characteristic that Cobbledick is focusing on.
"Learning how to push the air out in a way that was smooth felt 'airy' to me and that's where that term came from," they said.
More than half of transgender and non-binary individuals between ages 13 to 24 have seriously considered attempting suicide, according to a 2021 national survey of the Trevor Project, an LGBTQ suicide prevention nonprofit. About 1 in 5, the survey found, has made an attempt.
Gender-affirming care can help young transgender people, studies show. Transgender women seeking to feminize their voice have expressed satisfaction with voice therapy.
Other stressors come from fears of violence against trans individuals.
"If I was perfectly safe being a woman with just a deep voice, I wouldn't have to do this," Cobbledick said. "This trans-affirming care is not just to make me feel better."
Last year saw a record of at least 57 murders of trans and non-binary individuals in the United States, according to the Human Rights Campaign, the nation's largest LGBTQ rights group. The majority of victims were Black and Latinx trans women.
Last month, a trans woman was beaten and her sister and friend were shot in Kensington after the assailant reportedly yelled homophobic slurs. The incident is under investigation as a hate crime. Nationwide, Pride Month celebrations saw threats of violence.
Naiymah Sanchez understands the fear of becoming a target when in public. A trans woman, she worries that a recent wave of legislation nationwide taking aim at trans rights has heightened the risks.
"A lot of the times we don't leave our house, we don't speak, we don't do things," said Sanchez, who is the trans justice coordinator of the ACLU of Pennsylvania. Being trans, she said, means taking protective steps: "Just so that we can fly under the radar. Just so that we can make it home."
In Pennsylvania, legislators passed, and the governor was expected to veto, a ban on trans athletes that experts call discriminatory. According to an ACLU tracker, many states are similarly considering trans-related restrictions — including about 20 states where bills banning gender-affirming care for youth were introduced.
Sanchez says that not every trans person necessarily wants gender-affirming care, but for those who do, access provides a way to minimize the harm.
Cobbledick hopes that more cisgender people, whose gender identity corresponds with their sex at birth, will support trans people — especially youths and young adults at risk of suicide. "Give them the care they need and make them feel accepted and heard," they said.
The path isn't always easy. Gender-affirming care is expensive, some procedures are painful, and therapy can have uncomfortable moments.
For instance, lots of people dislike hearing their own voice played back, but for people with gender dysphoria, the experience can lead to tremendous distress.
Before speech therapy, Cobbledick winced at the masculine voice they heard on recordings. They say that getting their desired "airy" quality when talking still takes a lot of effort, but they are learning to control and recognize their voice.
"I like hearing it a lot more now," Cobbledick said.
