Voice Feminization Surgery for MtF transgender patients

gender dysphoria transgender symbol

Voice feminization surgery or feminization laryngoplasty is an important step in male to female (MtF) transition; a voice that is not congruent with the gender identity might make the patient feel as if their voice betrays theirselves.

The voice is a very important component of a person’s identity. It is used on a daily basis, continuously, it allows for socializing and communicate with others, to express and understand emotions, to sing, to scream, to cry and to laugh. And right from the voice, without the need of being able to physically see someone, we are able to deduce their gender and approximate age.

The voice is produced by three main components:

  • The lungs and diaphragm, which allow for the expiration of air
  • The vocal folds, which vibrate very fast while the air passes through them and create a sound
  • The pharyngeal, oral and nasal cavities which work as resonance chamber and amplify the sound.

Moreover, other components such as the tongue, palate, teeth, cheeks, lips, etc. which allow for articulation of the words and modification of the sounds produced by the abovementioned anatomical structures.

Differences between male and female voices

Due to the anatomical differences between the two biological genders, the voices have different characteristics which are common to the same gender. Here are some of the differences between a male and female voice:

Pitch

The pitch determines how high or low the sounds are. It is measured in Hertz (Hz), the unit of measurement of frequency. The higher the frequency, the higher the pitch.

Women on average have a pitch of about 196-224 Hz, with frequencies that vary between 145 Hz and 275 Hz.

Men on average have a pitch of about 107-132 Hz, with frequencies that vary between 80 Hz and 165 Hz.

Formant

The formant indicates the acoustic resonance of the vocal tract.

Men have lower formants and women have higher ones.

Intonation

The intonation indicates the variability in pitch while articulating sounds such as words and sentences and which allows for the attribution of different meanings or functions to such elements. For example, in western languages it is possible to express emotions, or a regional accent through intonation; and intonation makes the difference between a simple statement and a question. In Asian languages the intonation changes the meaning of the same syllable.

Women tend to have a more varying and higher intonation when they speak. Men tend to have a monotonous intonation (using always the same tone) with a tendency to using lower tones.

Besides these three main characteristics considered as typical and distinctive of the two biological genders there are many more verbal and non-verbal features of language that can suggest the biological gender; these further features though are not unique traits belonging to any gender so their expression is not uniquely related to one gender or the other.

Further verbal and non-verbal features of language

The volume of the voice: it is measured in decibel (dB) and defines how intense or loud a sound is. Women voices average 68-74 dB, while men average 68-76 dB; there is no significative difference between the intensity of the two voices, although women ones tend to be perceived as louder.

Breathiness: women, contrary to men, tend to have a breathy voice (more air escaping while articulating words).

Non-verbal language: women tend to move more the arms and use more gestures when compared to men, they tend to touch the person they are speaking to, sit closed to them and to keep eye contact, looking in the eyes the person they are talking to.

Anatomical differences between male and female vocal tract and vocal organs

vocal folds diagram

To qualitative differences between a male and female voice correspond anatomical differences in the vocal apparatus.

Thyroid cartilage is about 20% bigger in males.

Vocal folds are longer in men, measuring about 17-25 mm compared to 12-17 mm in women (60% difference).

Vocal folds are also thicker in men, about 20-30% more than women, as well as being denser and more resistant, with differences in the composition of their tissue.

Vocal tract length, which is the distance between the vocal folds and the lips, measures about 16-17 cm in men and about 14,5 cm in women, which creates a different resonance and formant.

The effects of hormone replacement therapy on voice

Contrary to transgender men and androgen hormone replacement therapy which is able of modifying their voice by increasing the volume of the vocal folds, transwomen on feminizing hormone replacement therapy only experience minimal changes of the vocal folds and laryngeal structures and no change at all in the vocal tract that after adolescence is already fully developed. Hence, the changes induced by HRT don’t modify the unique traits of male voice and transgender women, although having a higher pitch, still possess other features that reveal their biological gender.

From studies conducted over the years, it appears that even after completing the transition from male to female, a transwoman might still be mistaken for a man, especially over the phone, due to the male features of their voice, with social and psychological consequences that this incongruity causes to the individual.

Methods for feminizing the voice in MtF transgender patients

Due to the reasons explained above and the impact the voice has, like other physical features, in signaling the biological gender, there has been research in the field of voice change with development of medical and surgical techniques specifically tailored to the transgender population.

To modify the voice of transgender woman the following are the options and can be pursued singularly or combined, depending on the individual case:

  • Vocal fold volume reduction
  • Vocal fold tension increase
  • Vocal fold length reduction

Triamcinolone acetate injection in the vocal folds

Triamcinolone acetate is a potent and long acting corticosteroid. Among its effects there is also the atrophy of the tissues in the region of injection. This atrophy, when the injection is made in the vocal folds, determines loss of volume of the vocal folds to which corresponds an increase in the vibration frequency of about 25-40 Hz.

The injection of triamcinolone acetate is a simple and minimally invasive procedure, requiring only topical anesthesia and performed with a microlaryngoscope or fiber endoscope. The effect of this treatment is temporary, and the results are inconsistent and not accurately foreseeable.

Thyroplasty type 4 or Cricothyroid approximation

approssimazione crico-tiroidea tiroplastica

Cricothyroid approximation also known as lengthening of the vocal folds is one of the most performed voice feminization procedures on transgender women and is generally done in combination with a second surgical procedure which is the feminizing laryngoplasty or Adam’s apple reduction.

The surgery is performed under general anesthesia. It is done by placing synthetic or metal non resorbable sutures between the cricoid and the thyroid cartilages, causing them to shift closer in the same way it happens when the cricothyroid muscles are involved; this action increases the tension of the vocal folds as well as lengthens them, causing a rise in the pitch.

Anterior commissure advancement or glottoplasty

avanzamento commessura glottica anteriore

The anterior commissure advancement is a procedure performed under general anesthesia.

The surgeon first removes the epithelium of 30-50% of the anterior region of the vocal folds; then, these areas are carefully sutured together. This process shortens the vibrating and functional part of the vocal folds, which in turn raises the pitch.

Adam’s apple reduction

The Adam’s apple reduction is a surgery often coupled with the thyroplasty and performed during the same surgery right after that procedure. Once the thyroid cartilage is exposed, the surgeon shapes it to straighten the curve it normally creates on the anterior region of the neck, excising its frontal bulging where it surrounds the larynx. It is a simple procedure to perform and it has an high satisfaction rate among patients. This surgery leaves a small scar in the anterior region of the neck, but an expert surgeon will make sure to make the incision in one of the natural folds of the neck, so that it will be mostly hidden.

Further information on voice feminization surgeries

The final results of voice feminization surgeries can be observed after a couple of weeks from surgery. There will be continuous and progressive changes to the voice, until its final stabilization some months after surgery (up to 8 months).

Right after surgery the patient might experience a decrease in pitch, but that is due to the swelling caused by the procedure. Moreover, some hoarseness might be experienced up to 10 weeks post-op.

During the first week post-op, the patient is not allowed to talk, not even whispering, paying attention to not cough to avoid traumas to the operated area. After this first period there will be a gradual increase in the amount of talking.

Speech therapy for the transgender patient

There aren’t just surgical options to modify the voice, on the contrary it is usually advised to start with speech therapy or to pair the surgery with a well-studied therapeutic plan defined by a speech therapist specialized in transgender patients in order to maximize the results. Speech therapy can and is often used as the only therapy to modify the voice, without undergoing any surgery, but it is very important to resort to a specialized professional: modifying the way of talking and using the vocal organs, over time, if done inappropriately, can lead to long term damage with negative results on the voice and the need of surgical procedures to correct the damage.

While surgery is able to modify only specific qualities of the voice, speech therapy is capable to change many more features of the speech. Here’s what speech therapy focuses on in the specific case of the transgender patient:

  • The pitch, that can be modified and raised
  • The formants, which can be modified and raised too
  • The speech therapist teach the proper techniques to modify the voice and correct the patient when doing so, in order to not cause excessive vocal cords strain and not to fatigue too much the muscles involved in phonation; this stress could otherwise cause injury or the formation of nodules on the vocal folds.
  • By observing people in their daily life, the speech therapist will help in working on non-verbal language too: facial expressions, posture, arm movements, respiration, …
  • Moreover, the speech therapist will work on the word choice, the articulation of the words, the intonation and other features of verbal language
  • There will be focus on getting the patient used to these speech modification techniques: it is easy to learn and use such techniques within a clinic; the hard part is using the techniques learned on a daily basis, in stressful situations, when feeling emotions, when lost in thought, when tired after a long day, … so there will be some practice on common expressions used on a daily basis to train for an automatic response (hi, good morning, thank you, yes, no, etc).

As reference timeline, in general a 1-hour session once weekly for at least 15 weeks is required; sometimes it takes up to 1 year of speech therapy to achieve satisfactory results.

Before beginning speech therapy, it is important to understand what the expectations are: some patients might want to achieve a very feminine voice. The professional will have to make sure the expectations are realistic and achievable: some patients might want to achieve an unrealistically high pitch for example. For this reason, there is the need of a specialized professional who will be able, after some practice with the patient, to tell what is achievable, but also what is necessary and what not.

Both surgery and speech therapy will lead to a change in the pitch and in general in the voice of the patient. This changes though, don’t necessarily mean that strangers will surely perceive the voice as absolutely feminine; in general, from published studies, patients report satisfaction after undergoing such therapies.


Sources
  • Physiologic and acoustic differences between male and female voices.
    Titze IR – The Journal of the Acoustical Society of America, Apr 1989
  • Gender differences affecting vocal health of women in vocally demanding careers.
    Hunter EJ, Smith ME, Tanner K – Logopedics Phoniatrics Vocology Journal, Ott 2011
  • Voice, Speech and Gender: Male-Female Acoustic Differences and Crosslanguage Variation in English and French Speakers.
    Pepiot E – Xvèmes Rencontres Jeunes Chercheurs de l’ED 268, 2012 Paris France
  • Pitch Elevation in Trangendered Patients: Anterior Glottic Web Formation Assisted by Temporary Injection Augmentation.
    Andreson JA – Journal of Voice, Nov 2014
  • Voice, articulation, and prosody contribute to listener perceptions of speaker gender: a systematic review and meta-analysis.
    Leung Y, Oates J, Pang Chan S – Journal of Speech, Language, and Hearing Research, Feb 2018
  • Management of Gender Dysphoria – A Multidisciplinary Approach
    C Trombetta, G Liguori, M Bertolotto – Springer, 2015
  • Principles of Transgender Medicine and Surgery – 2nd edition
    Ettner R, Monstrey S, Coleman E – Routledge 2016
  • Transgender Medicine – A multidisciplinary Approach
    Poretsky L, Hembree WC – Springer 2019

 

 

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