What Is Voice Surgery for Transgender Individuals?

Voice surgery for transgender individuals may be an option for individuals who experience dysphoria about their voice and have not been helped enough by the practice of voice therapy.

Purpose

Voice therapy can be helpful for people who are learning to speak in a way that is read as more masculine or more feminine. It can also help people, to a degree, make their speaking voices sound a certain way. However, it does not adjust the fundamental pitch of the voice.

Transmasculine individuals often experience a deepening of their voice when on testosterone-driven gender-affirming hormone therapy. This is because testosterone causes lengthening of the vocal cords.

In contrast, transfeminine people do not experience a shortening of their vocal cords when they take estrogen. Therefore, if they are uncomfortable with the pitch of their voice, or feel as though it is not congruent with their gender, they may seek voice surgery.

Voice surgery is generally not recommended until people have tried voice therapy, which is a less invasive way to address voice dysphoria or discomfort.

Types of Transgender Voice Surgery

Most transgender voice surgery performed is feminizing voice surgery. In order to affect pitch, voice surgery is used to modify the physical characteristics of the vocal cords that determine pitch. These are vocal fold tension, length, and mass. There are a number of different procedures that can be used to adjust these characteristics.

Cricothyroid Approximation

Criciothyroid approximation (CTA) increases tension in the vocal cords by tilting the larynx and sewing the lower border of the thyroid to the Adam's apple cartilage. This has been shown to increase voice pitch.

It also makes the thyroid notch more prominent, which is an undesirable side effect. As a result, many individuals combine voice surgery with a reduction in the size of the Adam's apple. This surgery is not recommended for individuals under 30 because younger patients do not yet have solid thyroid cartilage.

Anterior Commissure Advancement

Anterior commissure advancement is another tension-modifying surgery. It was initially developed to treat medical conditions that affect tension in the vocal cords. However, it generally does not affect pitch enough to be useful for transgender women.

Anterior Glottic Web Formation

Anterior glottic web formation describes procedures that are used to shorten the length of the vocal folds. This can be done using a number of different techniques. These include both external procedures, performed through the neck, and endoscopic procedures, performed from inside the throat.

Laser Reduction Glottoplasty

Laser reduction glottoplasty uses a laser to vaporize parts of the vocalis muscle and surrounding structures in order to change the density of the vocal folds. Originally used for cases where CTA had failed, it is now sometimes used in combination with CTA to take advantage of both density and tension changes and increase the magnitude of the pitch effects of surgery.

Who Performs Transgender Voice Surgery

Voice surgery procedures should only be performed by surgeons who are specifically trained in the modification of the voice, and ideally the modification of the transgender voice.

When surgery is performed by people who lack appropriate training, outcomes may be undesirable. People may lose range in their voice or experience other undesired vocal effects, including hoarseness.

Voice surgery is most often performed by ear, nose, and throat specialists, otherwise known as otolaryngologists. Such surgeons have advanced training in working with the structures of the throat.

However, not all otolaryngologists have experience with pitch modification. It is reasonable to ask doctors about their experience performing this surgery and if they can share samples of voice changes they have achieved using their work.

Eligibility

Unlike many other gender-affirming surgeries, there are no specific eligibility requirements for accessing gender-affirming voice surgery. However, most ethical surgeons will encourage patients to work with a voice therapist before undergoing surgery.

Voice therapy can address gendered aspects of the voice and may affect people's desire to undergo surgical modification of the vocal folds. Voice therapy may also be required after vocal surgery, in order for individuals to learn to use the changed structures of their throat.

People who are unable or unwilling to engage with voice therapy and see surgery as a quick fix may not be appropriate candidates, because, where recommended, voice therapy is an important part of surgical recovery.

Association of Voice With Gender

Voices are, quite literally, the first way that most people communicate with the world. Whether talking on the phone or calling out to a friend across the room, our voices are a big part of how we are perceived.

Indeed, many of the assumptions we make about people's identities reflect our perceptions of the way they speak. These assumptions are not only those related to gender, People often think they can determine other characteristics by hearing someone's voice—including their race.

What about a person's voice is associated with gender? Although we think of women as having higher voices than men, pitch is only the most obviously gendered aspect of the voice. Gender is also associated with volume of speech as well as the ways people pronounce different vowels.

The fact that perception of vocal gender is multifaceted is why vocal surgery is rarely performed in the absence of therapy for vocal technique, because pitch change alone is unlikely to affect whether a person's voice is heard as male or female.

A Word From Verywell

Having a masculine voice is a predictor of improved well-being for transmasculine people. The same is true for transfeminine people, and various aspects of the voice have been found to be associated with quality of life. Not every transfeminine person is interested in voice therapy or surgery. However, for some people it can be very important for their well-being.

This may be particularly true for women who spend a lot of time using their voice—such as teachers or phone support providers—because being repeatedly misgendered can take an emotional toll. Vocal surgery may also have the potential to reduce the risk of other forms of transphobia and discrimination.