Voice Masculinization Surgery

What is voice masculinization (deepening) surgery?

Voice masculinization surgery (thyroplasty type III) permanently deepens your voice. It’s a type of gender-affirmation surgery that changes your vocal cords to lower your pitch, or how low your voice sounds.

Voice qualities, including pitch, contribute to information about gender identity. During puberty, people assigned male at birth (AMAB) experience an increase in testosterone that thickens their vocal cords and enlarges their voice box (larynx). This produces a lower pitch (deeper voice) than in people assigned female at birth (AFAB). If you’re a transgender (trans) man or transmasculine person, having a higher voice may make you feel as if there’s a mismatch between your gender and how you sound (gender incongruence).

Taking testosterone as a part of masculinizing hormone therapy causes your voice to naturally deepen as it does for people AMAB during puberty. But if hormones alone don’t lower your pitch enough, surgery may help.

Why is voice masculinization surgery done?

Voice masculinization surgery may be an option if you’re dissatisfied with your pitch after a year or two of hormone therapy. Up to 20% of transgender men report having a pitch that’s too high to align with their gender identity, even after a year of taking testosterone.

Still, for most trans men and transmasculine people, the next step is voice therapy — not surgery. Working with a speech-language pathologist (SLP) with expertise in trans care can help you work on different voice qualities to better align with your gender. Testosterone and voice therapy together lead to gender congruence for most people.

Voice masculinization surgery is usually a last resort in the rare instance when both hormones and voice therapy still leave you feeling as if your voice isn’t the right fit for your gender.

How common is voice masculinization surgery?

Voice masculinization surgery is much less common than voice feminization surgery, and research into this area is still new.

Taking testosterone naturally lowers pitch in trans men, but feminizing hormone therapy doesn’t raise pitch for trans women. This is why trans women are much more likely to need surgery if alternatives, like voice therapy, don’t produce the desired results.

How should I prepare for voice masculinization surgery?

The most important first step is ensuring that your surgery goals align with your goals as you transition. This usually involves meeting with an SLP. They can explain what surgery can and can’t do.

For example, many people think that voices express gender primarily through pitch — highs and lows. But lots of other things matter, too. These include how often you vary your pitch, how loudly or fast you speak and even your word choices. These are gender cues you learn in voice therapy.

If you decide that surgery is right for you, you’ll meet with a laryngologist. They’ll examine your voice box (larynx) to ensure you don’t have a voice disorder that may make surgery unsafe.

What happens during voice-deepening surgery?

The main procedure for voice masculinization surgery is thyroplasty type III. Your surgeon will:

1. Administer anesthesia. You may get general anesthesia, which puts you to sleep. Or, you may get local anesthesia that numbs the area. With local anesthesia, your surgeon may ask you to speak during the operation so they can gauge changes in your voice. Either way, you won’t feel pain during the procedure.
2. Make an incision. They’ll make a tiny horizontal incision above your voice box so that they can access your vocal cords. Whenever possible, they’ll cut into an already-existing neck fold to minimize scarring.
3. Remove tissue. They’ll remove 1 to 3 millimeters (mm) of the thyroid cartilage housing your vocal cords. Your thyroid cartilage supports your voice box and sits just above your thyroid gland. Your surgeon will suture the remaining edges of the thyroid cartilage together to ensure stability. Removing some of the tissue loosens your vocal cords, which lowers your pitch.
4. Suture the wound. You’ll need sutures to seal the area.

Voice-deepening surgery should only take about an hour or two.

What happens after voice masculinization surgery?

You’ll go home the day of your surgery. You’ll need to ask a loved one to drive you home because you’ll still have the anesthesia in your system. You may have a small drain at the site of the incision.

Before you’re discharged, your care team will monitor you to ensure you’re safe to leave. They’ll explain how to care for the wound and tell you when to return for a follow-up visit. For example, you may need to return within a week to have your sutures removed. You may need additional follow-up visits within the next few weeks to check on how you’re healing.

What are the benefits of this procedure?

Voice masculinization surgery is a safe procedure that can permanently lower your pitch. On average, surgery reduces pitch by about 50 to 60 hertz (Hz).

For reference, pitches greater than 160 Hz are perceived as feminine, while pitches between 95 to 175 Hz are perceived as masculine. Pitches between 160 to 180 Hz may be perceived by others as gender neutral or gender ambiguous. Depending on your pitch before surgery, your voice may fall within a range that others more quickly perceive as masculine.

It’s important to remember, though, that there are many other elements to communication, like resonance, speech rate and inflection, which also aid in being perceived as male by listeners.

What are the risks or complications?

Risks of voice masculinization surgery include:

• Too little change in pitch.
• A voice that sounds hoarse or raspy (although some people like this change).
• Not being able to speak as loudly as before.
• Not being able to speak in a falsetto (exaggeratedly high) voice.
• Having less of a vocal range.
• Changes to the quality or “character” of your voice that may affect your public speaking or singing voice.

Is voice-deepening surgery reversible?

Voice masculinization surgery isn’t reversible, which means its effects are permanent. Your care team will help you understand potential risks and likely outcomes of surgery to ensure it’s the right choice for you before proceeding.

How long does it take to recover from voice masculinization surgery?

It may take up to three months for your voice to heal fully and settle into your final pitch. It’s common to notice changes in your voice even within a few days of surgery, but keep in mind that things like swelling impact how you sound.

Try to be patient as you wait for the changes. You’ll be able to hear the difference once your vocal cords have fully healed.

What is the recovery process like?

You’ll need to rest your voice for a few days up to a few weeks after surgery. This means limiting how much you talk and taking care not to strain your voice. Your laryngologist will advise you on how to care for yourself.

They may provide guidance on:

• Eating: You may need to stick with soft foods for the first few days after surgery.
• Showering: You may need to avoid showering until you have your sutures removed.
• Managing pain: Most people manage pain with over-the-counter (OTC) pain medications. Some come in liquid form that may go down more easily while your voice box heals. You can also apply ice packs to the wound to numb the pain and keep the swelling down. Make sure you wrap ice packs in a dish cloth or towel before applying them to your skin.
• Engaging in activities: You may need to wait a few weeks before you become active again. It may take a month or more before strenuous activities, like weightlifting or contact sports, are safe.

It’s a good idea to work with a speech-language pathologist during and after recovery. They can help you care for your voice as you heal. They can teach you how to make the most of your new instrument so that you feel as confident as possible that your voice sounds right for you.

When should I call my healthcare provider?

Before you leave the hospital, ask your healthcare provider about what side effects are normal and which are signs of a complication.

Go to the emergency room (ER) if you:

• Have signs of an infection (fever or chills).
• Have trouble breathing.
• Have trouble swallowing water or soft foods. (This puts you at risk of aspiration pneumonia, which can be serious or even deadly without treatment.)

A note from Cleveland Clinic

If you’re self-conscious about your pitch after hormone therapy, reach out to a speech-language pathologist with expertise in trans-affirming care. Chances are, the voice exercises they teach you, combined with the changes in your vocal cords from the hormones, will leave you feeling more confident in your voice. If this isn’t the case, they can talk you through the pros and cons of voice-deepening surgery. They can also refer you to a trans-affirming laryngologist who can help.