Voice feminization in Transgender Women

Objective of Voice feminization in Transgender women

Voice feminization aims to turn a 90 to 150-hertz male vocal pitch into a 160 to 220-hertz female vocal pitch.1 Normally, the larynx size is fully developed, and the voice becomes deeper when men turn 12-15 years old. There are currently two medical methods of voice feminization:

Speech Therapy

Performed by speech therapists, this method increases the vocal pitch and adjusts gestures, rhythms, and intonation to develop a more authentic feminine voice. It involves the control of mouth and tongue movement and breath. It is recommended to those who wish to avoid surgery. However, it requires regular practice while the natural voice remains masculine. Alternatively, this therapy can be used in conjunction with voice feminization surgery to ensure a naturally feminine voice quality.

Male-to-female voice surgery

This method is recommended only when the individual’s larynx has fully developed, and when patients have a female appearance. Two types of surgery are commonly used in Thailand:

Cricothyroid approximation surgery

This surgery brings the thyroid cartilage close to the cricoid cartilage with sutures to increase tension of the vocal cords and thereby raise vocal pitch. This method requires an anterior neck incision, through which a concurrent tracheal shave to reduce the Adam’s apple for a more feminine appearance of the neck, could be performed. While this technique rarely results in scarring of the vocal cords, a disadvantage is that after initial results, the pitch elevation may fade back to the baseline pitch in long-term follow-up.

Anterior web formation or reapproximation of anterior commissure

This surgery, either a transoral endoscopic surgery or open surgery (via an anterior neck incision), brings the anterior commissures into approximation with sutures to reduce their length. Alternatively, it may use a laser to fuse the vocal cords. This method offers a permanent pitch elevation because of surgical fusion. However, the voice quality may change or vocal range maybe limited. For example, patients may experience hoarseness after surgery until the wound is healed.

Preoperative and postoperative preparation

Before surgery, an ENT doctor completes a detailed preoperative exam through a laryngostroboscopy in the clinic. Different surgical interventions and their specific benefits and disadvantages are discussed in detail at that time. The patient can then be referred to a speech therapist to prepare for postoperative vocal cord rehabilitation. Transoral endoscopic surgery requires general anesthesia. Prior to any surgery type, smoking cessation and avoidance of excessive voice usage is recommended. The patient should also stop taking medicine or supplements that may affect blood coagulation for at least 1 week preoperatively. After surgery, the doctor makes follow-up appointments every 1-2 weeks initially, then every 3-6 months for a year, depending on the type of surgery. After surgery, it takes at least a few months until the pitch elevation becomes stable, depending on several factors like surgery method, age, postoperative practice, and pronunciation practice.

Postoperative instructions

1. Total voice rest is recommended for at least a week. Thereafter, minimal usage is permitted for at least two to four weeks.
2. Avoid harsh coughing, sneezing, or throat clearing for at least a week.
3. Avoid eating food that stimulates reflux for at least two weeks.
4. Start speech therapy rehabilitation with a speech therapist one or two months after surgery (depending on the type of surgery).
5. Avoid general anesthesia (where endotracheal intubation is needed) one to three months after surgery to prevent inflammation of the larynx secondary to intubation.

Reduction Thyroid Chondroplasty

Laryngeal prominence, or Adam’s apple, is a cartilaginous structure wrapped around the larynx. In males, the left and right portions of the cartilage form a more acute angle than in females. Thus, their Adam’s apple appears to be more prominent. Reduction thyroid chondroplasty is a surgical intervention that reduces Adam’s apple size by cutting off the cartilage’s edges to make them smoother. This procedure will not increase pitch for a more feminine voice, but may temporarily result in a softer voice due to postoperative vocal cord edema, which usually self-resolves in three to four weeks.

One standard precaution that must be considered for reduction thyroid chondroplasty is if the patient is more than 30 years old, the cartilage of their Adam’s apple will be more calcified, which hardens the structure. The surgery may require special instruments, such as a surgical drill and general anesthesia. For patients with an extremely hard Adam’s apple, reducing their Adam’s apple size may be difficult, and their Adam’s apple may not appear as smooth.

Refer: Voice Feminization in Transgender Women - The Thai Handbook of Transgender Healthcare Services, Center of Excellence in Transgender Health, Chulalongkorn University