The Highs and the Lows: The Issue of Puberphonia

Generally speaking, cases of puberphonia do not present frequently at the Voice clinician’s door. When they do, our interventions tend to be short and satisfying for both patient and clinician as successful outcomes often come quickly. 

What is puberphonia?

Puberphonia occurs in males whose voices remain high after they have gone through the other physiological changes associated with puberty. The condition is also referred to as mutational falsetto. Physical laryngeal exercises are often the main type of treatment. However, exploration of psycho-social factors may also form part of the treatment.  

The high road

Typically, individuals present with very high pitched voices, often a falsetto quality which may be strained and prone to fatigue. Their voices seem locked into a track of high and narrow  pitch range.   In most cases, the males describe feelings of embarrassment and social discomfort. Although these cases appear severe in nature (and would be graded as severe in a perceptual SLT or ENT assessment), the restoration to a lower more appropriate pitch is usually relatively simple with the help of an experienced Voice specialist SLT. Connecting the client to their lower voice can proceed with the SLT guiding and supporting  the individual through a series of exercises firstly  to help find   their lower voice and then to establish it more securely. 

However, some  cases may prove a little more complex.  

The case of Steven 

Recently, I saw a young man,  18 years old, who presented with a very high pitched voice. Unlike most puberphonics, he was not particularly embarrassed about his voice but he was aware that the pitch was high,  that his voice fatigued easily and that he could not project his voice.  Unusually, he could produce a lower pitched voice  but he felt both physically and psychologically uncomfortable in the lower voice.  I asked what his friends thought about his higher voice and he said that they were used to it.  The real issue was that Steven was used to his higher voice.  We humans tend to be most comfortable with what we are used to even if what we are used to is inappropriate or limiting for us. 

We humans tend to be  most comfortable with what we are used to even if what we are used to is inappropriate or limiting for us. 

Christella Antoni
Puberphonic baseline recording

The low road

Because Steven could already access a lower pitch, establishing this more securely was not the main challenge of therapy for me.  The goals centred around increasing his vocal  stamina in lower voice and to assist the process of lower voice use habituation and his ability to project his voice. 

It took 3 treatment sessions to reach all our therapy goals. The last of these sessions took place after a gap of 2 months, to serve as a review and final check that the patient had not reverted to the higher pitch puberphonic voice.  Fortunately, Steven had remained in the lower voice and, in the course of three months, had become accustomed to it.

Puberphonia Session 3

There are cases where learning to use a higher pitch can be the goal and it is very possible to do this safely and effectively and to generalise this  such that the higher voice  becomes the client’s habitual voice. This is the kind of work I do routinely for example with transgender women seeking a female sounding voice. Voice modifications in trans women can enhance their social comfort and well being but in the cases of puberphonia –  mainly young males locked into an inappropriately  high voice – their social functioning may be limited. Fortunately, successful voice therapy  outcomes with puberphonics  are common in speech and language therapy and the well being effects can be life-lasting  for our clients.