Transgender Voice Care: Feminization, Modification and Surgery

For transgender and gender non-binary persons, experts at the Grabscheid Voice and Swallowing Center of Mount Sinai specialize in helping them to find the voice that is uniquely theirs. Our laryngologists and dedicated voice and speech therapists work with each of our patients to fine-tune their voices to comfortably and effectively do their jobs, and live their lives. Our team members all have specialized interest and training in evaluating and working with transgender patients to provide behavioral and medical/surgical interventions, including tracheal shave surgery and Wendler glottoplasty. Additional we are part of Mount Sinai’s Center for Transgender Medicine and Surgery and work together to ensure seamless care for each patient.

Voice Feminization and Masculinization

Voice feminization makes use of a team approach involving you, a laryngologist, and a voice therapist. As a team (patient, physician, therapist) we determine how to help you achieve your voice and communication goals. Our specially-trained voice and speech therapists help you to learn those communication patterns that signal a feminine speaker. After these new behaviors have been maximized, then consideration can be given to surgery to alter pitch. While the surgery is designed to eliminate the lowest portions of a voice’s pitch range and elevate the common speaking pitch closer to an average feminine range, the behaviors learned in the voice therapy are necessary to communicate gender identity. Physicians at the Grabscheid Voice and Swallowing Center can also perform voice box modification to alter the appearance of the Adam’s apple.

Voice masculinization is often achieved to a satisfactory level due to the effects of testosterone on the vocal fold mucosa. Most trans men develop a low enough pitch; hence, further intervention is not necessary. However, voice therapy may be helpful to adjust patterns of speaking, and surgical intervention by a laryngologist - should it be required - can reduce the tension on the vocal folds in order to eliminate the higher pitches of the voice.

Transgender Voice Evaluation at Mount Sinai

At the initial evaluation, you will meet with the laryngologist and the voice/speech therapist. They will listen to you and come to an understanding of the type of voice that you wish to communicate with the world. We will ask about your medical history, medications, and other issues related to your health. Measurements will be made of your vocal capabilities, deficits, and strengths. A videostroboscopy will be done to allow us to evaluate your vocal folds in vibration. This involves the use of a small scope that is placed in your mouth or through your nose to view the voice box. Acoustic measurements will also be made of your voice. By the end of this first session, you should have a treatment plan that may involve several components, such as voice therapy, vocal fold surgery, and/or a modification of your Adam’s apple.

Voice Therapy for Feminization

Most of what makes a voice ‘feminine’ sounding has little to do with the pitch of the voice. Some feminine sounding voices are lower in pitch than are some very masculine sounding voices. Our voice therapists will help you make subtle changes to parts of your voice such as the resonance and breathiness. Speech changes may include speed, fluidity, inflection, and stresses within the sentence. Other things that can signal a male or female voice may also include attention, eye contact, head gestures, and timing or turn taking in a conversation. These aspects of gender are subtle, and require you to be able to make them a habitual part of your communication. We will help you do that.

Wendler Glottoplasty/Endoscopic Vocal Fold Shortening

While most of what makes a voice sound feminine involves how you use it, shortening the vocal folds through surgery can help by raising the pitch and eliminating the lowest parts of your range. One of the most successful of these procedures is called the Wendler glottoplasty, also called endoscopic vocal fold shortening. This involves connecting the anterior 1/3 of your vocal folds with sutures. The remaining 2/3 then act as female length vocal folds, and yield a slightly higher pitch after healing. There is no scar in the neck as the entire procedure is done through the mouth while you are asleep under general anesthesia.

Tracheal Shave/Modification of the Adam’s Apple

The male larynx (voice box) has a more prominent Adam’s apple versus a woman’s larynx. This is called the laryngeal or thyroid prominence. Frequently, the thinner your neck, the more prominently this stands out. We perform a surgical procedure, the tracheal shave, which reduces the size of this area by carefully removing only that portion of the thyroid cartilage that is on the outside. This involves a small incision that is placed in a natural crease in your neck, and is minimally visible after healing.

What to Expect of the Vocalization Process

Changing the way you make use of your voice can be difficult. Just like it takes a little time to adjust to new physical appearances, a new voice can seem strange at first. We help you through this process and guide you to a voice that reflects who you are and what you need to do with your voice. The therapy usually takes 4-6 sessions over 8-10 weeks, but this schedule can be accelerated. Many voice patients are happy with their voices after the initial therapy, and choose to not undergo the Wendler glottoplasty.

For those who opt for the procedure, you can expect to have an average of six months after surgery for healing of the tissue. You will need to be quiet for a week, and then return to the clinic so we can see how you are healing. Depending on your healing, we will start you on some gentle exercises to help the gradual reintroduction of your voice. If you elect to have the tracheal shave, this can be done at the same time as the Wendler glottoplasty. This would involve a small incision. After the glottoplasty, some additional therapy may be helpful in learning how to make use of your new vocal instrument.