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Logoped Phoniatr Vocol. 2011 October ; 36(3): 128–136. doi:10.3109/14015439.2011.587447.

Gender differences affecting vocal health of women in vocally

demanding careers
Eric J. Hunter, PhD1,2,3,4, Marshall E. Smith, MD2, and Kristine Tanner, PhD2,3
1National Center for Voice and Speech, The University of Utah, Salt Lake City, UT

2Division
of Otolaryngology – Head and Neck Surgery, University of Utah School of Medicine,
The University of Utah, Salt Lake City, UT
3Department of Communication Sciences and Disorders, The University of Utah, Salt Lake City,
UT
4Department of Bioengineering, The University of Utah, Salt Lake City, UT

Abstract
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Studies suggest that occupational voice users have a greater incidence of vocal issues than the
general population. Women have been found to experience vocal health problems more frequently
than men, regardless of their occupation. Traditionally, it has been assumed that differences in the
laryngeal system are the cause of this disproportion. Nevertheless, it is valuable to identify other
potential gender distinctions which may make women more vulnerable to voice disorders. A
search of the literature was conducted for gender-specific characteristics which might impact the
vocal health of women. This search can be used by healthcare practitioners to help female patients
avoid serious vocal health injuries, as well as to better treat women who already suffer from such
vocal health issues.

Keywords
Occupational groups; occupational voice disorder; risk; singers; teachers

INTRODUCTION
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Many studies have focused on the vocal health issues of occupational voice users, or those
whose professional performance depends on good vocal quality and health 1. While many
occupational voice users are at risk for vocal health issues 2–5, much of the current research
has focused on school teachers. One survey of teachers in the United States (N=237) found
that over 50% of teachers experienced three or more voice symptoms that negatively
affected their teaching ability 6. In a survey of 550 school teachers in Ireland, only 20% of
teachers reported no voice concerns, with 27% reporting voice issues and 53% reporting
‘intermittent’ voice issues 7.

Preliminary research suggests that women have more voice disorders than men. Women
may be nearly twice as likely to report a history of voice problems as men 8 and represent up
to 76% of voice clinicians referrals 9. Moreover, 10% more women than men (regardless of
occupation) reported a history of a prolonged voice disorder, or a voice problem lasting
more than four weeks 10. This gender distinction extends to occupational voice users (e.g.,

Corresponding Author (for reprints): Eric J. Hunter, National Center for Voice and Speech, 201 Presidents Circle, Rm 210 / Salt Lake
City UT 84112-9011, [email protected].
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teachers 11, 12, customer service workers 13, and singers 14), a distinction which becomes
particularly significant for such professions that are predominantly female (e.g., teaching,
aerobic instructors, telemarketers).
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METHODS
The information in this discussion paper was collected by first examining studies and reports
published in English using the PubMed database through July 2009. Key words that were
used, either in combination or singly, included: voice, gender, laryngeal anatomy,
occupational, voice disorders, vocal health, hormones, endocrine, puberty, contraception,
menses, menopause, blood flow, and laryngopharyngeal reflux. The reference list in each of
these papers was then examined to identify additional references and key words. For
example, when conducting the initial review of the effect of hormones on the laryngeal
system, one identified paper included a reference for a study examining the effects of
hormones on the voice in individuals who have undergone gender reassignment. The key
words “gender reassignment” had not been initially included in the search parameters, but
were subsequently included based on the identified reference. In this particular example, this
methodology of expanding search parameters facilitated the inclusion of key words and
references that would have been otherwise excluded, providing valuable insight into the
effects of isolated hormones on various physiological systems. Thus, it should be noted that
the purpose of this paper was not to conduct a traditional, replicable literature review. Such a
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review would likely be limited in scope due to the initial restriction of key words. Rather,
this study was undertaken to ultimately identify as many potential factors as possible that
might influence the female voice.

RESULTS
Voice production and vocal health is a complex issue with a range of physiological and non-
physiological risk factors. A general lack of awareness of these risks may ultimately
increase an occupational voice user’s vulnerability to voice disorders 15. However, there has
not yet been a comprehensive presentation of gender differences from the perspective of
voice production and vocal risk. To answer why women are more vulnerable to vocal health
issues than men, the anatomical differences in their respective laryngeal systems will be
highlighted. Second, differences in less obvious systems, beginning with the impact of the
endocrine system, will be explored. Next, other non-laryngeal related differences, many of
which are influenced by these endocrine differences, will be examined. Finally, gender-
related non-physiological and behavioral differences which may cause vocal health issues to
be more predominant in women will be surveyed.
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LARYNGEAL DIFFERENCES
The pre-puberty laryngeal systems (Figure 1) of males and females are quite similar.
However, the influx of testosterone during puberty creates structural changes to produce the
male vocal gender. This rapid structural growth during puberty is a key source of teenage
male vocal instability. Gender differences in laryngeal geometry affect many aspects of
voice production such as the intensity of the voice 16, 17, pitch 18, 19, and voice onset and
offset 20.

Elongation of the male thyroid cartilage during puberty without an equal widening narrows
the angle between the thyroid lamina and forms the distinctive laryngeal prominence (i.e.,
Adam’s apple) seen in the male thyroid cartilage 21, 22 (Figure 2). Because the female
thyroid cartilage changes much less during puberty compared to the male, the adult female
thyroid cartilage is approximately 20% smaller anteriorly-posteriorly than the male 23, 24.
The vocal folds, which reside within the thyroid cartilage, show similar gender differences.

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The female vocal folds are on average 60% shorter anteriorly-posteriorly 25 which is one of
the primary reasons for women’s higher average fundamental frequency (F0) (190 Hz,
female, vs. 120 Hz, male) 26. Simply put, smaller structures correlate with higher vibratory
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frequencies, as do shorter structures, like strings or beams. Additionally, shorter structures

increase the effect of material bending contributions that can result in further increases in
string-like vibratory frequency 27. This difference in F0 may increase women’s risk for voice
disorders because a higher F0 results in more vocal fold oscillations and collisions for an
equal amount of voicing (on average, 70 more collisions per second, or 190 cycles per
second minus 120 cycles per second). In addition to being longer, the male vocal folds are
also thicker, primarily because the muscle within the vocal folds (i.e., thyroarytenoid
muscle) is thickened by testosterone during puberty (Figure 3). In contrast, female vocal
folds thicken only slightly during puberty, making them about 20–30% thinner than male
vocal folds25. This difference in thickness also contributes to the difference in average
fundamental frequency difference and its corresponding increased risk for voice disorders.
Further, thinner vocal folds may increase women’s risk because there would be less tissue to
damp/absorb vibratory forces 10, 24.

While the primary reason for the gender difference in pitch is vocal fold length and
thickness, the primary mechanism for pitch control is the variation in elongation of the vocal
folds. Higher tensile stress on the vocal fold mucosa and vocal ligament, which lies along
the medial edge of the vocal folds parallel with the thyroarytenoid muscle, correlates with
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higher pitch. Studies have uncovered gender differences in the amount and density of
collagen, the primary tensile stress bearing structure 28 , within the vocal fold. Female vocal
folds have been shown to have less tensile stress than a male for a given percent elongation
(from 2 to 5 times less) 29, possibly because they have approximately 59% of the collagen
found in adult male vocal folds 30,31. Thus, with the female vocal fold significantly less stiff
during equal elongation or strain, the female tissue may require a larger percent elongation
in order to obtain an equivalent stiffness range and thus an equivalent pitch range. This
difference would require increased effort and, likely, more fatigue.

Within the vocal fold extracellular matrices is hyaluronic acid (HA), and its distribution
appears to also vary based on gender. Found throughout the body, HA is important in
developing tissues such as the vocal folds, as well as non-laryngeal tissues like the umbilical
cord, dermis, subcutaneous tissue, and cartilages. Significantly, it is usually found in high
concentrations in the body in areas of high shock absorption 32. Further, it controls viscosity
and stiffness of the extracellular matrix, possibly by regulating the water content 32–34.
Studies suggest that HA also plays a vital role in the laryngeal system specifically; for
example, HA has been shown to be important in preventing vocal fold scarring 35.
Therefore, the presence of HA potentially affects the damping and absorption of vocal fold
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collisions, likely helping to protect the vocal folds from phonotrauma during high vocal
demand and excessive vibration as well as aiding in vocal recovery. While men seem to
have a fairly stable distribution of HA throughout the depth of the vocal folds’ lamina
propria, women have less HA in the superficial layer and more in the deep layer 36. Thus,
reduced amounts of HA in the superficial layer may predispose females to increased vocal
fold injury and increased scarring.

ENDOCRINE DIFFERENCES
As discussed above, most structural gender differences appear as the male laryngeal system
changes with the onset of puberty. However, studies examining the effects of hormone
therapy during gender reassignments provided details about the impact on the voice of
isolated hormones. The primary goals of such therapy are to diminish the hormonally
induced secondary sexual characteristics of the original gender, while inducing the
secondary sexual characteristics of the intended gender. For example, one study showed that

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androgen therapy altered the adult female larynx, lowering the mean F0 from a pretreatment
of 228.45Hz to 116.52Hz between the 3rd and 4th month of treatment 37. However, in male-
female gender reassignment procedures, hormone therapy and voice coaching alone
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produced only minimal pitch changes because the male laryngeal structure was already
altered at puberty. Such studies once again underline the gender-based physiological
differences.

A key reason for the impact of hormones on the laryngeal system is the location of hormone
receptors in the cytoplasm and nucleus of vocal fold cells 38. Studies suggest that these
receptors make the human laryngeal system significantly responsive to variations in gonadal
hormones. For example, the laryngeal system is affected by hormone fluctuations during
menses and menopause 39–44. Indeed, epithelial swabs taken from the larynx during menses
and menopause appear to mimic the fluctuations seen in the vagina 45.

Specifically, studies have found a variety of vocal health issues associated with hormone
fluctuations during menses, including increased vocal fatigue, decreased range, and loss of
vocal power and high harmonics. Some studies suggest that the new generation of oral
contraceptives, which reduce hormonal fluctuations during menses, also seem to increase a
female’s vocal stability (e.g., lower jitter and shimmer values) when compared to women
not using any oral contraceptives 46–48. Perhaps even more significantly, the impact of these
hormone fluctuations during menses is reported to be greater in occupational voice users
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versus non-occupational voice users 49. Further, studies of vocal fold changes during menses
have suggested that non-optimal voice use or even vocal misuse (e.g., excessive vibration,
poor vocal hygiene, inadequate breath management) may exacerbate the effect of
menstruation on the voice 50.

The negative effects of menopause on the female voice have also been documented
perceptually and acoustically (e.g. Raj, et al.51), supporting the positive effects of estrogen
on voice quality in post-menopausal women. The lower amount of estrogen also causes a
breakdown in their connective tissues, precluding optimal vocal health43. In a review of the
potential effects of these hormone changes during menopause on the female larynx,
D’haeseleer, et al.52 gives more detail than can be discussed here.

OTHER NON-LARYNGEAL PHYSIOLOGICAL DIFFERENCES

Gender differences in other major physiological systems may also impact the laryngeal
system directly or indirectly. Some are systems tightly integrated with voice, such as the
respiratory system, while others are more independent, such as the cardiovascular system.

Nervous System—Responses to pain sensitivity seem to have gender-related

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differences 53, 54. Pain is the body’s way to identify real or potential tissue damage. While
sensitivity to painful stimuli appears to fluctuate during the menstrual cycle, women appear
to be more sensitive to pain than men after the onset of puberty. Studies suggest that men
have a greater pain threshold (i.e., the point at which a person becomes aware of pain) and
tolerance for pain, while women generally report painful stimuli as more painful than
men 55–57. Chronic pain is also more frequent in females than males 58,59, and changes with
the hormone cycle 60,61. Gender reassignment studies have highlighted how hormones affect
the experience of pain. In an examination of changes in chronic pain (e.g., headache) in two
groups undergoing gender reassignment (with estrogen and anti-androgens administered to
male-female subjects and androgens administered to female-male subjects), approximately
50 percent of the female-male subjects who had previously experienced chronic headaches
experienced an improvement in their pain after receiving testosterone therapy, while 33
percent of the male-female subjects who were given estrogen and anti-androgen therapy
experienced an onset in chronic pain 62. Whether women actual experience more pain or are

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more sensitive to pain generally, the gender difference in the pain experience could also
account for a portion of the higher incidence of reported voice problems by women over
men.
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Respiratory System—Because sufficient and coordinated respiratory control and breath

management (e.g., adequate sub-glottal pressure and airflow) is required to manage voice
production, the respiratory system is also crucial in vocal health. During phonation, air
pressure acts upon the vocal folds to help start and maintain their oscillation 63, control
changes in vocal loudness 17, and affect vocal fold vibratory modes 64. For maximum
aerodynamic-to-acoustic energy conversion and minimum disturbance of the natural
vibratory patterns of the vocal folds, the interaction between respiratory support and
vocalization should be optimized. Generally, a breathy voice results when the average
airflow is excessive, and a pressed voice results when there is insufficient airflow. Neither
are optimal healthy vocalization styles 65. In a comparison of laryngeal function and
respiratory system coordination between the genders 66, the male lungs were reported to
have a higher static recoil during exhalation. This finding suggests that women require a
higher percentage of lung volume use to create an equivalent lung pressure, a necessary
driving force vocal fold vibration. Further, females in the study 66 generally used a higher
initial percentage of rib cage volume than males for comfortable speech possibly to try to
compensate for the difference in lung volume or to create more equivalent static recoil.
Thus, women may use more inhalation respiratory effort to vocalize on par with men. This
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pattern would likely either fatigue the respiratory muscles in females earlier than males or
require the females to use increased respiratory muscular effort during speaking, which
would also speed fatigue as well as require more breaths per words than males.
Alternatively, women who did not compensate in one of these two ways but instead used a
comparable initial percentage of rib cage volume as men would have insufficient airflow.
Then to maintain voicing with insufficient airflow, these women would then have to
compensate with increased laryngeal adduction, creating more contact force per unit area on
the medial edges of the folds, which is ultimately a less healthy vocalization style. The
consistent use of unusually low lung volumes in speech may be a risk factor for nodules due
to the link between vocal fold adduction and impact stress during vibration 67,68.
Specifically, women with vocal nodules have been shown to initiate and terminate speech
breathing at lower lung volumes than healthy control subjects 69. Therefore, differences in
the respiratory system could be one of the factors contributing to the higher instance of vocal
nodules in female compared to male teachers 70.

Digestive System—Gender differences in the digestive system may also increase the risk
for laryngeal health problems in women. The average ambulatory gastric residence time
(i.e., time necessary for food to pass from the stomach to the small intestine) has been
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measured to be longer for females: 4.6 hours compared to 3.4 hours 71. This may be
important as many patients with voice problems that precipitate a visit to a voice clinic are
also diagnosed with laryngopharyngeal reflux 72,73, which is the backflow or regurgitation
of stomach gasses up the esophagus into the pharynx. Such voice problems include minor
throat irritations, chronic throat clearing or cough, hoarseness or sore throat (particularly in
the morning), and laryngospasm 73,74. While it has been traditionally assumed that more
males suffer from reflux, more females actually suffer from endoscopy-negative reflux
disease, whose symptoms are similar but without visible endoscopic evidence 75,76. Further,
in an examination of emergency room patients at Brigham & Women's Hospital in Boston,
57% of patients with Non-Cardiac Chest Pain (NCCP) were diagnosed with
Gastroesophageal Reflux Disease, with more women than men presenting with NCCP.
These women tended to have reflux both during supine (sleeping) and upright (awake)
periods whereas men tended to experience the symptoms when upright 77. If these results

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are substantiated and could be expanded to included laryngopharyngeal reflux, such

conditions could impede nightly vocal recovery 78 for a female occupational voice user (i.e.,
reflux while both supine and upright) more than a male (i.e., reflux while upright).
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Whole Body Hydration—Gender differences in the body’s water content may also play a
role. The adult female body’s water content is lower (female=50%; male= 59%). This
difference is related to the disparate fat levels 79. Systemic tissue hydration is vital to healthy
vocal performance and, to some extent, self-perceived vocal effort 80–83. Studies suggest
that laryngeal tissue viscosity may decrease and vocal fold thickness increase with adequate
systemic hydration 84,85. Therefore, if all other things were equal, the lower water content in
females may make them more vocally at risk. This disparity might be somewhat mitigated
as, when systemic hydration levels are low, the vocal tract, as well as the respiratory system
at large, seems to preserve hydration levels longer than other parts of the body 86. However,
subclinical systemic dehydration is not uncommon in the general population as hydration
levels fluctuate and returning hydration levels to optimal is gradual. Thus, because females
have a lower water content percentage than males, they may be more sensitive to these
common fluctuations leaving ample windows for voice performance reduction.

Interestingly, higher F0 may also increase sensitivity to hydration. For example, in a

fatiguing singing task with non-professional karaoke singers, the effect of hydration and
short (1-minute) vocal rests on vocal health was examined 87. The female subjects in the
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non-hydration/non-rest group had a significant decrease in the highest sustained F0 (i.e.,

pitch) which could be sung; this decrease was not seen in the other study groups (female
hydration/rest, male non-hydration/non-rest, male hydration/rest). While no attempt was
made to explain this gender distinction, the absence of vocal rests was probably not the sole
cause of the loss of F0; likely hydration played at least a partial role. The potential influence
of dehydration at higher pitches is substantiated by a hydration study conducted by
Verdolini et al. which used phonation threshold pressure and perceived phonatory effort to
demonstrate a progressive sensitivity to dehydration with increasing F0 83. Although this
point was not made by the authors of the paper, such a result could imply a greater
sensitivity to dehydration (and, thus, increased effort) in females more than males because of
their generally higher pitch.

NON-PHYSIOLOGICAL AND BEHAVIORAL DIFFERENCES

Non-physiological and behavioral differences might be another source for women’s
increased risk. For example, one aspect which would obviously affect vocal health is gender
differences in amount of vocal vibration exposure from vocalizing. Traditionally, women are
believed to speak more although no study to date can be found which substantiate this claim
with statistical significance. For example, in a widely reported study of 396 university
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students, no statistically significant gender difference was found: women spoke

approximately 16,215 words daily and men spoke approximately 15,669 words 88. However,
the dynamics of young adults in university classrooms and social situations may not
accurately reflect a typical adult population. Additionally, one recent preliminary study
conducted by Hunter and Titze 89 reported a similar trend with teachers, again without
statistical significance. Phonation time dose, average loudness, and F0 were calculated using
the National Center for Voice and Speech voice dosimetry databank. Occupational voice use
(9am–3pm) and non-occupational voice use (4pm–10pm, weekends) were compared from
two-week study portions for each subject (8400+ hours). Two key gender-related
vocalization trends were presented. First, female teachers vocalized 10% more than males at
work. Further, female teachers’ non-occupational vocalization was 7% more than male
teachers, reinforcing the need to quantify women’s additional non-occupational vocal load,
particularly as the primary caregivers for children in their homes 90.

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Another potentially non-physiological difference[1] which may explain the gender disparity
in voice disorders is a higher reported incidence of symptoms of depression and anxiety in
females in the general population 91–93. Research contends that these symptoms appear to
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begin at puberty and continue through the child-bearing years 94,95. Wilhelm et al. tracked a
group of professional voice users for 30 years (1978 n=170; 2003 n=154) and found that the
women reported significantly more “social, simple and combined anxiety disorders” during
the study 95. Such stress, anxiety, and depression may have a direct effect on voice
production 96. Clinicians have been urged to recognize emotional factors to certain
nonorganic voice disorders, which may be caused in part by increased muscle tension from
vocal misuse and emotional stress 96. For example, high stress level is one factor
contributing to muscle tension dysphonia, associated with tissue changes that affect the
biomechanical properties of the vocal folds 97. Muscle tension dysphonia can be
experienced as laryngeal discomfort and may lead to other harmful vocal behaviors in the
belief they will “clear” the voice (e.g., coughing, throat clearing). Further, emotional stress
often causes whole-body musculoskeletal tension, which often extends to the extrinsic
laryngeal muscles (neck strap muscles); this tension can change the position of the larynx
and/or vocal folds, which would result in a non-optimal position or mechanical stress
distribution of the vocal folds 15,98,99. Baker suggests that studies must be conducted to
determine the “degree to which the underlying emotional stresses contribute to onset and
perpetuation of the excessive laryngeal tension” 100.
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Another behavioral difference which may play into gender vocal health differences is the
preponderance of eating disorders in females as compared to males: approximately 90–95%
of all cases of anorexia nervosa, 80% of bulimia nervosa, and 65% of binge-eating (as
opposed to overeating) disorders. Although few studies have examined the direct impact of
such disorders on the voice, voluntary vomiting negatively impacts the larynx and studies
have demonstrated the increased risk for reflux caused by eating disorders 101,102. As
mentioned, many voice problems stem from various types of reflux, including minor throat
irritations, chronic throat clearing or cough, hoarseness or sore throat (particularly in the
morning), and laryngospasms 73,74. Another result of anorexia is a patulous (or chronically
open) Eustachian tube 103, which is likely the reason other studies suggest that anorexia
causes autophonia, the hyperperception of one's own voice and breathing 104. With such an
effect changing aural feedback of one’s voice, this could impact how often and in what
manner one’s voice is used by modifying the type and loudness of phonation—potentially
changing to a less optimal production.

Finally, it is possible that gender differences in vocal disorders may reflect the well-
documented tendency for women to report vocal symptoms more than men 8, 10, as well as
distinct gender approaches to reporting symptoms and completing questionnaires generally.
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In the 30-year study conducted by Wilhelm et al. described above, while there were no
gender differences in the number and type of significant life events were reported, there was
a significant difference in how these events were experienced: female subjects judged
“unpleasant life events” as more unpleasant than their male counterparts 95. Such a study
suggests that it may be possible that some portion of the reported female propensity for
voice disorders might be caused by males underreporting their voice issues.

CONCLUSIONS
Throughout voice literature, evidence has accumulated that women are more inclined to
vocal health issues than men. In this review, potential causes for this gender difference were

1While we recognize that depression and anxiety may have a physiologic basis, they also have such a vast array of potential causes –
both non-physiologic and physiologic – that we have chosen to place it with the non-physiologic category for convenience sake alone.

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reviewed using both voice-specific literature and general medical and biological literature.
These causes included differences related to laryngeal physiology, hormone differences,
other non-laryngeal physiology, and non-physiological and/or behavioral characteristics.
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Thus, the voice, with its close proximity and connections to the major lifelines of the body,
seems to be susceptible to many physiological systems and functions which on first glance
would appear unrelated to the voice.

This review is intended to increase awareness of gender differences as they relate to voice
disorders to guide clinical care. Further, it is meant to identify potential avenues of future
gender-based studies. Specifically, gender-specific studies of risk factors for various types of
voice disorders, treatment development and response, and voice disorder prevention are
required. To this end, specific terms commonly used in describing vocal health (e.g., vocal
fatigue or phonotrauma) and vocal behaviors (e.g., vocal abuse and misuse, or inadequate
breath support) also need to be more rigorously defined with specific, widely accepted
characteristics. These research priorities are necessary steps toward improving vocal health
in women.

Acknowledgments
Funding for this work was in part provided by the National Institute on Deafness and Other Communication
Disorders, grant number 1R01 DC04224. We express appreciation to The University of Utah Vice President for
Research for support of the National Center for Voice and Speech.
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Figure 1.
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Elongation of the male thyroid cartilage results in a longer vocal fold (after Titze, 1989).
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 Hunter et al. Page 14
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Figure 2.
The muscle within the male vocal folds is enlarged by testosterone during puberty
thickening the vocal fold (after Titze, 1989).
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