Voice Feminization Surgery

What is voice feminization surgery?

Voice feminization surgery is a type of gender affirmation surgery to raise the pitch of your voice (how high or low it sounds). Surgery permanently changes your vocal cords so your voice sounds higher.

Your vocal cords (also called vocal folds) are bands of soft tissue in your larynx (voice box). Qualities like how thick or long your vocal cords are control their pitch. On average, men and people assigned male at birth (AMAB) have vocal cords that produce lower pitches than women and people assigned female at birth (AFAB).

During voice feminization surgery, a laryngologist shortens, thins or tightens your vocal cords permanently to give you a higher pitch.

Why is voice feminization surgery done?

Voice feminization surgery helps some transgender women and transfeminine people raise their pitch so their voices better align with their gender identity.

You may also choose to have surgery to raise your pitch if you:

• Have a disorder of sex differentiation.
• Have disorders that require androgen (male sex hormone) therapy as treatment.
• Have ovarian cancer or another disorder where tumors produce androgens.

Can you change your voice without surgery?

You can. Voice feminization therapy can help you raise or lower your vocal pitch and shape your sound to express yourself the way you’d like. It’s an alternative to surgery, which changes your voice by changing your vocal cord structure. Typically, therapy is recommended before surgery because it’s low-risk and reversible. It helps people manifest their vocal gender identity on its own or in combination with surgery.

Most trans women who have surgery work with a speech-language pathologist to receive voice therapy beforehand. It’s also a good idea to continue therapy after surgery to help adjust to your voice changes.

How common is voice feminization surgery?

About 1% of transgender women have voice feminization surgery. More people (about 14% of transgender women) choose nonsurgical voice feminization therapy instead.

How should I prepare for voice feminization surgery?

Most people do voice feminization therapy before surgery. A speech-language pathologist (SLP) works with you on:

• Vocal function exercises: Expanding and contracting your vocal cords several times daily helps them move more easily. Exercises also strengthen the muscles in your voice box. This can help your recovery process.
• Vocal hygiene: Good vocal hygiene means keeping your voice as healthy as possible, especially before surgery. Your SLP may ask you to drink plenty of water and help you stop smoking, if you smoke. They might also want you to avoid alcohol and caffeine, which can dry out your vocal cords.

Your surgeon and SLP will also make sure you don’t have any existing voice disorders that could prevent a successful surgery.

What happens during voice feminization surgery?

For some procedures, your laryngologist operates using a thin, lighted tube (laryngoscope) that goes into your mouth and reaches back to your larynx. Other procedures require incisions (cuts) on the outside of your throat.

You’ll receive general anesthesia no matter the procedure. This medicine puts you to sleep so you don’t feel pain during surgery.

There are different approaches to voice feminization surgery, including:

• Anterior glottal web formation (Wendler glottoplasty): Removes several layers of tissue from the vocal cords at the front of your voice box. Your laryngologist uses stitches to join the vocal cords in this area, shortening the overall length of your voice box. This is the most common type of voice feminization surgery.
• Laser reduction glottoplasty (LRG): Destroys the outermost tissues of your vocal cords with light energy from a laser, increasing the tension in your vocal cords. It’s a type of laser-assisted voice adjustment (LAVA).
• Cricothyroid approximation (CTA): Stitches together cartilage from the top and bottom of your voice box, increasing the tightness of your vocal cords. This was the first procedure for voice feminization surgery. Laryngologists use it less and less because studies show its effects aren’t as long-lasting as other types of surgery.
• Feminization laryngoplasty: Removes cartilage from your thyroid (a gland in your neck) and parts of your vocal cords. Surgery lifts your voice box and shortens your vocal cords. Your laryngologist may perform a single procedure or a combination of them to raise your pitch.

How long does surgery take?

The time you’re in surgery depends on the specific procedure. The most common type, anterior glottal web formation, typically takes one to three hours.

What happens after voice feminization surgery?

Your laryngologist and SLP care team will follow you closely after your procedure. Depending on the procedure you choose with your care team, you may have additional minor procedures to get the best results. You’ll likely need a period of voice rest (no speaking) immediately after the surgery for five to 14 days. You may also need to do additional SLP therapy to maximize the effect of the procedure.

Voice feminization surgery is usually outpatient. This means you’ll likely get to go home the same day as your procedure.

What are the benefits of voice feminization surgery?

The major benefit of voice feminization surgery is that you can achieve a pitch that more closely matches your gender identity. Many people who have the procedure consider it an important part of transitioning.

Unlike voice therapy alone, surgery can:

• Help you maintain your pitch more consistently. It’s less likely your voice will drop when you’re making an involuntary sound, like coughing or clearing your throat. You can rely on your pitch remaining constant when your voice tires. Additionally, surgery requires no conscious effort on your part to maintain these effects.
• Prevent you from getting misgendered based on pitch alone. It’s less likely you’ll get misgendered in situations where people assume gender based only on how high or low your voice is, like over the phone.

How successful is this surgery?

Voice feminization surgery can successfully raise your pitch. Of the different procedures, anterior glottal web formation raises pitch the most. The final results will depend on how high or low your pitch is before surgery.

Still, success depends on your treatment goals. How high or low someone’s voice is only accounts for about 40% of how we perceive gender based on speech and communication. The other 60% comes from things you learn in voice therapy, like loudness, resonance, pitch variation and nonverbal cues.

This is why it’s so important to talk with your laryngologist and SLP before surgery so everyone’s on the same page about what a successful voice transition means for you.

What are the risks or complications of voice feminization surgery?

Risks of voice feminization surgery include:

• A voice that sounds weak or strained, especially in the upper range.
• A voice that sounds hoarse, breathy, rough or raspy (dysphonia).
• Too much pitch increase (voice is unnaturally high).
• No change in pitch or too little change in pitch.
• Voice breaks or tremors.
• Voice lowering over time.
• Needing a second surgery.

Although it’s rare, surgery can lead to conditions like:

• Vocal cord dysfunction.
• Vocal cord lesions.
• Vocal fold paralysis.
• Abscesses in your airway.

Working with a laryngologist who regularly performs voice feminization surgery reduces your risk of complications. Ask your healthcare provider about potential risks based on the type of procedure they recommend for you.

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

It may take six months to a year for your vocal cords to fully heal and your voice to adjust. Don’t feel frustrated if your voice doesn’t sound as you hoped right away. In time, you’ll be able to hear the full results of your higher pitch.

What is the recovery process like?

After voice feminization surgery, you’ll need to be on vocal rest for five to 14 days. This means no talking (not even whispering!), laughing, singing or coughing. Be prepared to communicate with text messages or notes.

During recovery, you may need acetaminophen (Tylenol®) to help with pain from common side effects like a sore throat. You may need to eat soft foods only for the first few weeks.

Usually, within two to three weeks after surgery, you’ll meet with your laryngologist to see how you’re healing. They can advise you on next steps during this appointment, like when it’s safe to continue voice therapy. They’ll let you know when you need your next check-up.

Most people notice major changes in how they sound within the first six months and then again at the one-year mark.

When should I call my healthcare provider?

Before leaving the hospital, make sure you know what side effects to expect and which changes are signs of a complication or an emergency.

Go to the emergency room (ER) immediately if you’re:

• Noticing signs of an infection (like fever, chills or pus at the incision site).
• Having trouble breathing.
• Having trouble swallowing water or soft foods. (Food falling into your windpipe can lead to aspiration pneumonia, a serious condition.)