When a person speaks, the sound of their voice, their gestures and speaking style help convey a sense of their gender. For transgender men and transgender women, specialized therapy and vocal cord surgery can help them communicate in a way that is more aligned with their gender identities.

Otolaryngology surgeons Lee Akst, M.D., and Simon Best, M.D., join speech language pathologist Ashley Davis, M.S., assistant of otolaryngology–head and neck surgery, to review this important aspect of gender affirming care. 

What is transgender voice therapy and voice surgery?

Gender-affirming voice treatment is designed to help transgender people who feel the sound of their voices or their ways of speaking do not align with their gender identity.

For some people, the sound of their voice can aggravate gender dysphoria: the feeling of distress caused by physical traits not matching a person’s gender identity. A voice or speaking style that misgenders a person can put them at risk for mental health issues, discrimination or even violence.

Voice Therapy for Transgender and Gender-Diverse People

Aligning a person’s voice with their gender identity begins with voice therapy. Treatment can include nonsurgical interventions such as exercises, feedback, recording and practice, either with a therapist or on one’s own with videos.

Therapy can address aspects of the voice and speaking style such as:

• Voice pitch: how high or low the person’s voice is, and how it varies as they speak
• Resonance: how space in the nose, mouth and throat affect the sound of the voice and impart traits often perceived by the listener as masculine or feminine
• Intonation: the flow of louder or softer sounds when speaking
• Air flow and breathing, which can affect “breathiness” in a person’s voice
• Articulation: how clearly the person creates distinct sounds and words
• Nonverbal cues such as gestures and mannerisms of the head and hands

Candidates for Transgender Voice Care

“Voice therapy can be appropriate for nearly anybody, regardless of the individual’s age or where they are in the process of their journey,” Davis says. “Voice therapy is a way to explore identity that can be as fluid as the individual as they discover their voice. Unlike surgery, the modifications in therapy offer a varied menu of options, so it’s a safe place to begin or return to.”

She points out that voice treatment can be challenging, since a person’s progress isn’t always linear. “There will be moments where somebody achieves the voice they desire and then struggles to replicate it later, but with guidance the momentum is hopefully always forward.

“While therapy or surgery cannot automatically ‘fix’ extreme vocal dysphoria [discomfort with one’s voice], having a supportive multidisciplinary team can make the person feel less vulnerable through the process.”

Davis notes that surgery may be an option for people who have been working on their voice and have good intonation, but who may notice that their preferred voice occasionally “drops,” such as when they are laughing, shouting or responding with emotion. 

First Steps

The initial evaluation of the patient may include a medical history and examination of the vocal cords by the speech language pathologist and the laryngologist. The team can help the patient understand the relationship between the voice box anatomy and what the voice sounds like.

“The pitch of a person’s voice is determined by both anatomy and function,” explains Best, a laryngeal surgeon. “Speaking is a complex neuromuscular process, similar to swallowing. The larynx and vocal cords are controlled by nerves and muscles. The thicker and longer the vocal cords, the lower the pitch.”

Stroboscopy

The doctor may recommend a test called a stroboscopy, which is a medical examination of the vocal cords. It is a simple test, performed in the doctor’s office to examine both the anatomy and function of the vocal cords.

Here is what happens:

• The doctor sprays a numbing medication into the patient’s nose and throat.
• The patient leans forward and holds their tongue with gauze.
• The doctor inserts an endoscope (a narrow tube) into the mouth. The endoscope is equipped with a camera and a flashing (strobing) light that helps the practitioner see the vibration of the vocal cords in slow motion.
• The patient follows prompts to make certain vocal sounds so the doctor can see how the vocal cords function.

Determining Goals

Next is determining what the patient hopes to achieve from treatment. A candid conversation helps the team get a sense of the person’s ideal voice and its characteristics.

When it comes to pitch, 165 hertz is the approximate dividing line for gender difference. Voices below this level are most often heard as male; above this level, female. But these metrics aren’t for everyone, and Davis and her team offer a more fluid array of options.

“A person may not want to sound typically masculine or feminine,” she says. “There are more neutral, nonbinary options. In addition to pitch, other voice qualities, such as lightness, crispness, dialect, resonance and melody are considered.”

The treatment plan also addresses the patient’s overall vocal health. “If a patient has spent years working to modulate the voice, it can become strained, weak or raspy,” Davis observes.

Voice Surgery for Gender Affirmation

Some patients opt for voice surgery ― surgery on the vocal cords ― to help create a voice that is aligned with their gender identity. Best says nearly 50% of patients who come to the clinic choose a surgical procedure.

Most of these operations are endoscopic. Surgeons insert a tube (endoscope) into the patient’s mouth to gain access to the larynx (voice box). They use different techniques to make the vocal cords thinner, tighter or shorter to raise the pitch the voice. The main side effect from surgery is a sore throat, tongue or jaw.

Other procedures, such as voice deepening, may involve an incision (cut in the skin of the neck) to gain access to the larynx.

Who may benefit from gender-affirming voice surgery?

For transgender people who wish to present with a feminine voice, procedures can shorten the vocal cords or make them thinner to raise the pitch of the voice so the person does not have to strain to speak at a higher register. Anti-androgen and estrogen therapy do not affect the voice, so surgery may be necessary to achieve a voice that sounds more feminine.

“Since transgender people who wish to present with a masculine voice are likely to achieve voice modification with hormone treatment, most surgical patients are those who wish for a voice that presents as more feminine,” says Akst, a laryngeal surgeon. However, if a patient wants a lower voice after hormone treatment, there are options including therapy and a procedure to loosen the vocal cords to achieve a lower pitch.

The results of voice surgery are permanent. A prospective patient deciding to undergo a procedure can speak with other patients who have undergone the operation. “Connecting with people who have gone through the surgery can help prospective surgery patients understand what to expect,” Davis says. 

Voice Feminization Surgery

To create a higher, more feminine voice, surgery can tighten or reduce the thickness of the vocal cords. “Think of a guitar string,” Akst says. “A thinner string, or one wound more tightly, will vibrate at a higher pitch.”

Wendler Glottoplasty Procedure for Vocal Feminization

Most patients choose glottoplasty to raise the pitch of the voice so it feels more natural and causes less strain. This is a minimally invasive endoscopic technique. Endoscopic means it is performed with an endoscope, a lighted tube that is inserted in the mouth.

• The glottoplasty takes place in an operating room, and the patient is given general anesthesia.
• The procedure itself takes about an hour and a half.
• Surgeons use small instruments, guided through the endoscope, to reach the larynx and create scar tissue on the fronts of the vocal cords.
• As the scar contracts over time, the vocal cords shorten, resulting in a higher pitch for the voice.
• Patients usually go home the same day after recovering from the anesthesia.

LAVA for Vocal Cords

A procedure called laser-assisted voice adjustment (LAVA) may be used as a first procedure or a follow-up to a Wendler glottoplasty to further raise the pitch of the voice. It can also be performed at the same time as the glottoplasty.

With the patient asleep under anesthesia, the surgeon accesses the larynx with the endoscope through the mouth, then applies laser beams to the front of the vocal cords to reduce their mass (make them thinner).

Cricothyroid Approximation (CTA)

is another voice feminization approach to tightening the vocal cords that is no longer commonly used. Sutures (stitches) are placed in the cartilage to shorten the distance between the top and bottom, shortening the vocal cords. The operation can twist the voice box and make a trans woman’s Adam’s apple more prominent, calling for a tracheal shave or other facial feminization procedure.

Voice-Masculinizing Surgery

Most transgender people who wish to present with a masculine voice find the hormone therapy that is part of their treatment sufficiently lowers their voices to an acceptable level. But for those patients who desire a deeper voice, a procedure called thyroplasty type III can help. This is a rare procedure performed by a relatively small number of laryngeal surgeons, according to Best.

He explains the procedure starts with an incision in the front of the neck in a natural crease where a scar will not be obvious. The surgeon then relaxes the muscle that contracts the vocal cords so it can't raise the pitch of the voice. Changing the position of the voice box cartilage relaxes and shortens the cords and makes them vibrate at a lower frequency. Patients who have this procedure will notice a reduction in the top end of their voice range. 

After Surgery

Healing takes several weeks, and for the first week, the surgeons advise voice rest — using the voice as little as possible while the inflammation goes down. “It’s important to rest your voice for the first week,” says Akst, “so do not yell or whisper.”

• Most patients follow up with the surgeon about three weeks after surgery.
• Voice therapy can continue if the person is healing well.
• The last follow-up appointment is at six months to assess final results.

Side Effects and Complications of Voice Surgery

After surgery, patients may experience some side effects:

• A sore throat (relieved by acetaminophen)
• A sore tongue or jaw from having the mouth open during the procedure
• Temporary roughness of the voice before the inflammation in the area is fully healed

Vocal cord surgery for gender affirmation is mostly safe, and complications are rare. However, some have been reported, including:

• Problems from the anesthesia
• Vocal cords that are too tight, resulting in a voice pitch that is higher than desired
• A cracked or chipped tooth from insertion of the endoscope
• Numbness of the tongue, which may be temporary or persistent 

Post-Surgical Care and Therapy

Surgery makes structural changes in the patients’ vocal cords, but Davis says that is only the beginning. The team recommends therapy after a surgical procedure.

“The voice the patient hears immediately after surgery is not the final result,” she says, noting that there may be temporary weakness or rasp.

It takes time for patients’ voices to become natural and effortless; practice pays off. “Muscle memory is a big part of the recovery,” Davis says, and adds, so is the mental aspect. “The new voice, over time, matches with the internal voice ― how a person speaks to themselves mentally.” 

Singers, Announcers, Actors and Vocal Artists

Davis notes that patients who use their voices as part of their professions, such as vocal artists or voice-over professionals, should understand that there are no shortcuts for rehab time.

“They have a new instrument and need to understand how to play it. A person may need to adjust airflow and learn to ‘hit the gas’ so the voice is loud enough,” she says. “But a couple of artists we have treated have been able to take their musicianship to a new level, with a more reliable pitch.” 

Speaking Up: Improved Quality of Life

Best says voice surgery make a positive difference in patients. He explains, “Our voices determine how we present ourselves in the world and how we're perceived by others. It’s a set of treatment options that may be overlooked in gender affirmation but that can be very beneficial.”

Although it can take a while for patients to adjust to their new voice after surgery, Davis says patients report feeling happier and more relaxed. Transgender and gender-diverse people who have held back speaking up may feel freer to express themselves. “When the dysphoria eases, the person’s comfort and willingness to extend themselves and gets reinforced with positive feedback,” she says.

“People realize how much they have to say.”