Voice masculinization surgery for FtM transgender

gender dysphoria transgender symbol

Voice masculinization defines the medical and surgical therapies, as well as speech therapy, aimed at changing an individual’s voice into one with more masculine features.

We already talked about:

  • How the voice is produced
  • What are the features of male and female voices
  • What are the anatomical differences between the male and female vocal tract and vocal organs

All of this can be found in our voice feminization surgery blog post.

Voice masculinization therapies and surgeries can be sought both by cisgender males unsatisfied with their voice and by transmen as part of their transition. There are three main ways of masculinizing the voice:

  1. Increasing the volume of the vocal folds, which in turn decreases the pitch. This can be done for example injecting fillers directly in the vocal folds.
  2. Decreasing the tension of the vocal folds, which decreases the pitch. This can be done for example with Type 3 Thyroplasty or Relaxation Laryngoplasty
  3. Speech therapy which can address not only the pitch, but also several other features of the human voice such as the resonance, intonation, intensity and non-verbal communication.

A common and widespread misconception on voice and transmen

There is a widespread belief that hormone replacement therapy with testosterone is sufficient in inducing changes to the vocal organs, causing a lowering and masculinization of the voice. It is certainly true that testosterone can cause a thickening of the vocal folds and that this is correlated to a lower pitch; however, the degree of change and in general the changes determined by testosterone are not the same for everyone. It is estimated that 10-25% of transmen are unsatisfied with their voice.

To this we can add the fact that not all transgender males want to take hormone replacement therapy with testosterone. As reiterated several times by the World Professional Association for Transgender Care (WPATH) there is no standard and universal path for all the individuals who have a gender assigned at birth which is different from their gender identity. The possible medical and surgical interventions are different among individuals and must be individualized; the requests, goals and personal characteristics of each individual are some of the many factors considered. For this reason, some transmen might not be interested in HRT, but might want a change in their voice to reflect their gender identity.

Lastly, an objective measurement that depicts a voice change with more masculine features doesn’t necessarily relate to the patient’s perception of their voice and overall satisfaction; hence some individuals might experience an objective voice change, with lower mean fundamental frequency (MF0) and decrease in phonation frequency range (PFR), but nonetheless be subjectively dissatisfied with the results.

Vocal folds injection or injection augmentation

One of the ways to masculinize the voice is to thicken the vocal folds via a vocal fold injection, a minimally invasive procedure known also as injection augmentation. To do this the surgeon injects a substance directly into the vocal folds, usually a hyaluronic acid filler, collagen or autologous fat tissue.

The advantage of this procedure is that is relatively cheap, it is easy and fast to perform, and carries low risks.

The disadvantage is that the filler is usually resorbed over time and that the results are not predictable in terms of how much filler should be injected and how low will the voice be after the injection.

Pay attention to the use of alloplastic fillers which we always discourage and are not recommended.

Relaxation Laryngoplasty or Type 3 Thyroplasty

Relaxation laryngoplasty and type 3 thyroplasty refer to the same type of surgeries aimed at lowering the tension of the vocal folds. The different names are based on the classification system which is followed by the clinic or surgeon. There are mainly 3 variations of this technique all of which start with an incision on the neck to gain access to the thyroid cartilage and then proceed with:

  • The resection of one (monolateral) or two (bilateral) vertical strips of cartilage. There are two margins with a void in between created by the excision; the margins are moved close together and sutured. This leads to decreased tension of the vocal folds. (Fig. 1)
  • A linear vertical incision on one of the two sides of the cartilage. Instead of removing a strip of tissue, the two margins are overlapped, again causing a decrease in tension to the vocal folds. (Fig. 2)
  • The anterior commissure retrusion. A bilateral incision of the thyroid cartilage is performed, and the anterior commissure is retrodisplaced. All margins are then secured with sutures. This determines a decrease in tension of the vocal folds.
Voice masculinization surgery
Fig. 1 – Source: https://doi.org/10.1016/j.jvoice.2013.05.001
Voice masculinization surgery
Fig. 2 – Source: https://doi.org/10.1016/j.jvoice.2013.05.001

Speech therapy for the FtM transgender patient

An effective option which does not require surgery is speech therapy. With it, it is not only possible to lower the voice (pitch), but it is also possible to address several other features of human voice, including non-verbal communication. It is of utmost importance to approach a professional with specific knowledge and experience in speech therapy for transgender individuals. An amateur and incorrect approach to the subject could put a strain on the vocal organs, muscles and vocal tract which can lead to negative modifications of the voice and to lesions which might need surgical repair.

Further information on speech therapy can be found in our blog post on voice feminization.

  • Effectiveness of testosterone therapy for masculinizing voice in transgender patients: A meta-analytic review.
    Ziegler A, Henke T, Wiedrick J, Helou LB – International Journal of Transgenderism, Mar 2018
    DOI: https://doi.org/10.1080/15532739.2017.1411857
  • Transgender Medicine – A multidisciplinary Approach
    Poretsky L, Hembree WC – Springer 2019
  • Transmasculine people’s vocal situations: a critical review of gender-related discourses and empirical data.
    Azul D – International Journal of Language & Communication Disorders, Jan 2015
    DOI: https://doi.org/10.1111/1460-6984.12121
  • Trans Male Voice in the First Year of Testosterone Therapy: Make No Assumptions.
    Hancock AB, Childs KD, Irwig MS – Journal of Speech, Language, and Hearing Research, Sep 2017
    DOI: https://doi.org/10.1044/2017_jslhr-s-16-0320



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