IVLUTION

My Diagnosis: A Psychogenic Voice Disorder – Puberphonia
By Steven J Dennis

First and foremost, I would like to thank everyone who has read my piece, it means so much to me! When deciding to write and publish this piece I never envisioned this response. I was apprehensive before sharing it, but since then it has been read internationally, and the overall response is positive and overwhelming; It is more than I ever anticipated. I have now decided to continue documenting and publishing content and turn – Pitch Imperfect into a series.

So far, I have shared the history of the issues and problems I have faced with my voice. But from this point, I will be sharing and documenting the process I now face. A new era into this journey is beginning and for the first time, I am excited to see where this will lead.

February 18^th

To continue from my last piece, I had an appointment with an ENT (ear, nose and throat) specialist at the Royal National Throat, Nose and Ear Hospital in London, on February 18th, 2019.

I was very nervous about this appointment but equally excited. It felt like I was going to finally have the answers I have been seeking all these years. I was expecting to have extensive tests and examinations, as the appointment letter stated that I would be at the hospital for 2-3 hours. However, the appointment was shorter than expected; I must have been there for less than an hour. It began by going over the medical notes from previous doctors and going over the concerns I have with my voice. After this discussion, the specialist took me over to perform a laryngoscopy and shortly after, it was all over.

This procedure involves a scope; a thin flexible tube that is inserted through the nose and guided to the throat to directly inspect the nose, throat, and larynx for abnormalities. It is not painful, but it is uncomfortable as it is guided through the nasal cavity and into the throat. Once the camera had a clear image of my larynx, the specialist asked me to make different sounds and cough to see how my larynx moves. Fortunately, no alarming irregularities were detected, but the specialist could identify what is causing my voice to be high-pitched.

The Diagnosis

After the laryngoscopy, the specialist informed me of the condition that is causing my voice to be high-pitched, and it is called puberphonia. I was overcome with relief as he was talking about the condition; it was like it was rushing through my body as he was talking. It felt like a huge leap forward. The unknown and wonder with what is causing my voice to be high-pitched immediately disappeared. I finally knew the name. I finally had the answer.

Puberphonia

There are limited resources available online on the condition. So, I am informing you all with notes from the specialist and mainly what I can find on old faithful – Wikipedia.

Puberphonia is a psychogenic voice disorder. Defined as the persistence of a high-pitched voice during puberty and continues into adulthood if not treated. The condition becomes permanent as there is strong tension surrounding the larynx as well as no muscle control/memory, and poor breath control. Also, characterised by a higher pitch that would be inappropriate for the age and gender of the patient.

Puberphonia in general population is 1 in 900,000 (Bannerjee et al., 1995).

During puberty, anatomical changes in the larynx typically result in a decrease in pitch in both males and females. However, the larynx descends and grows significantly larger in males which often results in a visible laryngeal prominence on the neck – commonly known as an Adam’s Apple. Additionally, male vocal folds become longer and thicker, and these changes contribute to the deepening of the voice in pubescent males. Puberphonia is the failure to transition into the lower pitched voice during puberty. In conjunction with an atypically high-pitch, common symptoms include a weak, breathy, or hoarse voice, as well as low vocal intensity, pitch breaks, and shallow breathing.

The specialist explained that in the laryngoscopy he could see that I am capable of producing a lower pitch. My vocal folds had developed during puberty, but the habitual use of a higher pitch has caused tension in the muscles surrounding the vocal folds – resulting in a higher pitch. But my larynx is incapable of supporting a lower pitch as the tension in the muscles is restricting, and the muscles are too weak to resist and maintain a lower pitch. This condition explains why I have a prominent Adam’s Apple but a high-pitched voice. Also, why I can’t annunciate and project my voice.

Puberty Paradox

The direct cause of puberphonia is unknown but it is heavily linked to psychological disorders and can be influenced by:

Emotional stress
Delayed development of secondary sex characteristics
Resistance to pubertal changes
Self-consciousness resulting from an early breaking of the voice
Self-consciousness resulting from emerging adulthood
Excessive admiration of another male or sibling

If you have read my previous piece, you’ll see that I can probably tick a few boxes. It’s ironic that the thing I yearned for most during puberty is also the thing I didn’t allow myself to have. And now it is stuck. However, I was unaware of the damage I was inflicting to myself. Puberphonia is not a disorder that is likely to go away on its own, and without treatment, the higher pitch will be permanent.

My Treatment

Previously, I have had speech therapy, but it was unsuccessful. The specialist read through the notes from the speech therapist and said I had been receiving the wrong treatment. Rather than techniques to relieve the tension in my larynx, the methods they were teaching me were to control and improve my breathing. As well as articulation techniques such as vocal warm-ups and lip movement; to improve my vocal articulation. However, as the tension still surrounds my vocal folds, I was experiencing little change in the pitch. When I would attempt a deeper voice, it would sound unnatural. Due to the muscles in the larynx retracting as it is unable to maintain the deeper registry and the pitch would break, and sound forced and breathy.

As much as I had hoped for surgery, the specialist elaborated that the surgical procedure may not give the voice I desire. Although it is a quicker way to relieve the tension, it is invasive, and the recovery process may still require speech therapy.

The outcome of the specialist appointment is to undergo speech therapy again. However, it will be different; this therapy will be intense, and the therapists specialise in puberphonia cases. There is a three-month waiting period, but I’m hoping that speech therapy this time will have a greater impact and I’ll achieve a deeper voice. I assume that if the specialised speech therapy remains unsuccessful, I will then undergo the surgical procedures to resolve the tension in my larynx.

If you would like to read more on the conditions, here are the sites I found useful:

http://www.jaypeejournals.com/eJournals/ShowText.aspx?ID=954&Type=FREE&TYP=TOP&IN=&IID=83&isPDF=YES

http://www.jorl.net/otolaryngology/puberphonia-conservative-approach-a-review.pdf

http://www.laryngologyandvoice.org/article.asp?issn=2230-9748;year=2012;volume=2;issue=1;spage=26;epage=29;aulast=Desai

https://en.wikipedia.org/wiki/Puberphonia

[GRAPHIC CONTENT] http://www.jorl.net/otolaryngology/relaxation-thyroplasty–a-classical-surgical-approach-for-puberphonia.pdf

The Secret Struggles of Having a High-Pitched Voice
By Steven J Dennis

For those of you who know me may be aware that my voice is my biggest affliction and for those who don’t, Hello, my name is Steven Joseph Dennis, I am 23 years old and I have a high-pitched voice. My voice has always been the epicentre of my insecurities throughout my life. It is the thing I love to hate and hate to love. I have struggled with having a high-pitched voice, since adolescence and it continues into my adulthood. Always fearing that I will be judged or mocked for sounding different and I fear people will not take me seriously in a working environment. People also perceive me younger than I am due to my voice and it doesn’t help that I look young too.

This piece isn’t meant to be a pity party! I’m trying to write engaging content to build my portfolio. People always say, “write what you know” and I know nothing more than the struggles of having a high-pitched voice. There isn’t much content on this subject, and I feel it is important to share my experiences with my voice. So people can see how something so minor to some can have monumental control over someone’s life. What you will be reading, is my version of events and how I remember it. I cannot speak on behalf of others but this is how I felt growing up, this is my story.

Growing Up With My Voice

I first noticed I was different in primary school. People would seem to treat me differently. I was a shy and effeminate child in comparison to the other boys. Often feeling singled out and pushed aside because I didn’t enjoy the same activities. Feeling like something was wrong with me but I was too young to understand. The girls saw me as one of their own and welcomed me into their circles until the dynamic shifted when we grew older. I slowly became an infiltrator, trespassing on girl territory then once again, being exiled.

My voice became a target of ridicule during my final year of primary school. I remember the first comment I received vividly; a boy in my year asked if I was gay. At that age, I had no idea what that meant so my immediate reaction was “no!” and this became a running theme of my life until the day I came out.

High school for some is a hellish experience. I was unfortunate enough to be burnt by the metaphorical flames of hell. I already felt like an outcast as I was experiencing bullying already. Starting a new school terrified me and I wasn’t naive; I knew it would get harder and certainly a lot worse. As predicted the disparagement and taunting began, although it wasn’t as bad at first. My sister was a few years above me, so I had comfort knowing I had a protector. Once she left school, that’s when I felt alone. It was already a confusing time for me as I was coming to terms with my sexuality. People would tell me I was gay, but I didn’t feel or know I was gay (at that time). Whenever somebody mocked my voice I would say; “I’m not gay, I just sound like it”. I would introduce myself to people saying that, to acknowledge my voice before they had a chance to comment.

Plot twist, I was GAY! I remember I started coming to terms with my sexuality when I would watch porn. I realised I was focusing on the man rather than the woman overcompensating with her screams. At the time, it was a shocking revelation but now I look back and laugh that I ever thought I made a convincing heterosexual. It was a lot easier once I finally burst through the doors of the closet because people wouldn’t make as many comments on my voice, as it no longer had power over me.

My life after high-school was significantly better. The hierarchy of the popularity system had fallen and my college and university years were some of the best times of my life! Although it is a cliché to say, it did get better once I left school! To this day, I often face comments about my voice. The only difference is, I am strong enough now to ignore the comments.

A list of some of the remarks I have endured regarding my voice:

Squeaky
Are you gay?
Do you breathe helium?
Have your balls dropped?
Are you a girl/woman?
You sound like a girl/woman
Do you put that on?
Is that your real voice?
Why is your voice so high?
You have a big Adam’s Apple for your voice to be that high

My Experiences with Having a High-Pitched Voice

My voice is the epicentre of my insecurities. Even the days I am not thinking about it, there will be a subconscious feeling that will be feeding my anxiety. All I have ever wanted is to have a deep voice or a voice that wouldn’t be so high-pitched. It seems stupid that something so mediocre like a voice can have power over one’s life. Mine can inhibit me, hindering me to avoid situations to protect myself.

The situation I mostly avoid is being on the phone. I know the majority of people dislike their voice on the phone. However, I feel the phone emphasises the pitch and makes mine higher. As a result, I am misgendered frequently on the phone. The tone will shift once they realise I am not female and I am male, usually once I say my name. It’s like the voice they hear doesn’t “fit” the name. I try to avoid phone calls as much as possible unless it is crucial. If I am on the phone, I feel so uncomfortable that I will speed through the conversation to finish the call. Although there are a few exceptions, a few close friends’ I am comfortable being on the phone to.

My bank accounts have been blocked due to my voice. I have called and been denied access to my accounts because they do not believe that I am, who I say I am. Although the calls were very stressful and embarrassing, the worst part is going into the branch to unblock the accounts. Standing in the queue and struggling to piece a sentence together to explain what had happened. “Hello, I have been blocked from my account because I sound feminine.” – It feels humiliating! Even saying it felt strange and I can see the confusion on the clerks face as they couldn’t fathom what I was saying. They were apologetic and sympathetic for the trauma it had inflicted, but it still seemed disingenuous. I now have a footnote attached to my accounts, so when I call, it will pop up, informing the person I am calling that my voice is different. I find this more embarrassing than being blocked access as I must make sure they have seen the note before I begin my inquiry because I am fearful it will happen again.

When it happened for the third time, I was so angry. I was enraged and on the warpath. All telephone manner went out of the window, and I lost it. I regret it now but at the time I was so upset and angry, I couldn’t believe it was happening again. I remember seeing the same thing happened to a trans-woman with the same bank and I was a bull seeing red, I was like an inferno of rage. In that rage, I emailed out my story and later sold it to The Sun. The article was not what I had hoped it would be, it seemed to be a parody of events rather than telling my story, but It seemed a good idea at the time. It felt like I was part of an exposé and if you want a good lol, I’d recommend reading it.

Phone calls are easy to avoid, but it’s difficult to avoid meeting new people. I have always been self-conscious when I meet new people and always fear their reaction when they hear me for the first time. I find it easier to talk to women than I do men, maybe it is a comfort thing as I have grown up mainly surrounded by women. It wasn’t until I moved for uni that I would interact with more men, particularly straight men. Although I purposely chose Brighton for uni as it is known as the gay capital of the UK, I knew I would feel more at ease being in a place that was very accepting.

Alcohol plays a key part in my social life. I am comfortable talking to people when I drink. I become confident; my anxieties demise and I feel temporarily freed. However, I will overcompensate when I talk to people. I’ll do silly voices and impersonations to try and make them laugh, but it is to distract them from my insecurities with my natural voice. Ironically, the only voice I can’t do is a deep one. I’m infamously known for my impersonation of Catherine Tate’s character – Nan. I will almost certainly do it when I am drunk. I become possessed by these voices, and I can’t stop myself, even when I am aware it’s becoming irritating. It’s like that scene in Mean Girls where Cady can hear people become bored with her, but she can’t stop, it keeps coming up like “word vomit”. That is what it’s like when I do these voices, I know people are growing tired of it, but I can’t stop doing it. I feel comfortable talking as somebody else than I do talking normally.

It goes without saying that I also hate being recorded too. I will avoid it like the plague. Whenever people start recording around me, I become paralysed with fear. Fearing that they will record me talking and I will have to hear it back. However, it is public speaking I fear most and presentations are mortifying for me. Standing in front of what feels like a sea of people, is terrifying. My insecurities with my voice will be in full force during situations like this. It’s fear that they will start laughing or making comments about my voice. Even though these people knew me and didn’t have an issue with my voice, they felt less like friends and more like critics. One presentation during my third year at uni, my presentation partner and I were so anxious about our presentation that she got stoned and I got drunk. I came into class with cans of gin & lemonade, and everyone thought it was hilarious! But for me, it was to feel that confidence I have when I am drinking. Surprisingly, we passed the presentation, even in our states but a pass was good enough for me.

Little Voice Box of Horrors

Over the years, I have done many things to attempt to lower the pitch of my voice. Currently, none have worked. Even the inevitable didn’t work, the day my voice broke. Believe it or not, my voice was even higher than it is now. I joke about it and say, “it was like a chipmunk on helium” to mask my insecurities. I was overcome with joy and excitement when it started breaking. I thought this would be the start of me, and all the comments would stop and I would finally be/feel normal. I remember calling my mother and sister to the top of the stairs to show them, “nature is finally taking its course” I would repeat over and over in my excitement. However, once my voice settled, there was not much change and was still high-pitched. I became very disappointed and depressed that the thing I had been waiting for [puberty] had let me down, so I did other things to try and lower the pitch of my voice.

Looking back on the things I tried to lower the pitch of my voice, they seem insane. Before situations like interviews, I would cough excessively, trying to force damage to my voice so it would sound lower; like it does when you have a cold. I would drink boiling water to burn my throat to try and make my voice have hoarseness. The most memorable thing I tried was hypnotherapy. I remember watching an episode of Friends and Chandler attempts to quit smoking. He is listening to a tape while he is sleeping, and this helps him to quit smoking. I saw this and thought it would be the answer to my prayers. So, I recorded a passage to put on repeat while I slept. I can’t remember the full passage, but I remember it ended with “you will sound like a boy”. I would sleep with earphones in, listening to myself; telling myself that I would wake up with a deeper voice. However, after many nights attempting hypnotherapy, my dreams of a deep voice never materialised.

The longest one was smoking, although this one correlates with my desperate need to fit in during high-school. I was smoking to lower the pitch of my voice. I remember seeing those smoking adverts that would inform the dangers of smoking and damage to the larynx was one of them. Smoking from a very young age, I must have been around 13, and I can confirm after 8 years of smoking my voice never changed.

Another thing I do to lower the pitch of my voice is talking with a vocal fry. I was watching Ugly Betty, and the actress who plays Amanda spoke with a vocal fry. So, I began speaking with one. It seemed to lower the pitch of my voice and added a distraction at the same time. It was blissful. I thought no one would notice the pitch of my voice as they would be distracted by the vocal fry.

Change is a Powerful Thing

It is not all doom and gloom. In 2015, I began my journey to get what I’ve always wanted, a deep voice. I waited for my 20th birthday as instructed by a previous doctor. The doctor told me I needed to be this age to have hormone tests, as the hormone levels are stable after puberty. I later found out by a new doctor that this was not the case and I could’ve started whenever; it felt like I had wasted time, but I was determined to begin now. He issued me to have hormone tests, and the results of my first one showed that I had high levels of the female hormone – progesterone. I felt relieved. It was like I had an answer to my problems and I had an excuse for sounding feminine. However, after 2 follow up tests, my hormone levels were normal.

Following the results of my hormone tests, I had speech therapy. This was an exciting chapter of my life, before being a great disappointment. I began optimistically, thinking it would be a new beginning of my life. Prior to this, I was severely depressed and in a downward spiral, but as I was becoming mentally stable again, it felt like a fresh start and the emergence of a new version of myself. Several sessions later, there was little to no change. On my last session, I was played the recording from my first session, and I could hear there was not much of a difference. Although, a few noticed a difference in my voice and saw a growth in my confidence; it still didn’t feel like a permanent solution as my voice was still high-pitched.

Through speech therapy, I have become more accepting of my voice, even if I do feel insecure about it. I don’t let it inhibit me as much as it did growing up. Working in an LGBTQ+ venue helped my confidence too, surrounded by people in the same community and by people who cared for me was comforting. I felt protected and safe whenever I was there – it felt like home. I never imagined growing up that I would’ve had a job as public as hospitality, as I couldn’t see myself interacting with people. But I am glad I did because I wouldn’t have the confidence I have now.

The next step is to see a specialist, and I am on February 18th, 2019. I am hoping this will result in a thyroplasty, a surgery to cut the tight muscles surrounding the larynx resulting in a deeper voice. This journey has been a long one, but I finally feel it is coming to an end. This affliction I’ve had since adolescence could be gone, and I’ll finally have the voice I’ve always dreamed of.