<p>Vocal Feminization for Transgender Women: Current Strategies and Patient Perspectives</p>

Abstract

Voice feminization for transgender women is a highly complicated comprehensive transition process. Voice feminization has been thought to be equal to pitch elevation. Thus, many surgical procedures have only focused on pitch raising for voice feminization. However, voice feminization should not only consider voice pitch but also consider gender differences in physical, neurophysiological, and acoustical characteristics of voice. That is why voice therapy has been the preferred choice for the feminization of the voice. Considering gender difference of phonatory system, the method for voice feminization consists of changing the following four critical elements: fundamental frequency, resonance frequency related to vocal tract volume and length, formant tuning, and phonatory pattern. Voice feminizing process can be generally divided into non-surgical feminization and surgical feminization. As a non-surgical procedure, feminization voice therapy consists of increasing fundamental frequency, improving oral and pharyngeal resonance, and behavioral therapy. Surgical feminization usually can be achieved by external approach or endoscopic approach. Based on three factors (length, tension and mass) of vocal fold for pitch modulation, surgical procedure can be classified as one-factor, two-factors and three-factors modification of vocal folds. Recent systematic reviews and meta-analysis studies have reported positive outcomes for both the voice therapy and voice feminization surgery. The benefits of voice therapy, as it is highly satisfactory, mostly increase vocal pitch, and are noninvasive. However, the surgical voice feminization of three-factors modification of vocal folds is also highly competent and provides a maximum absolute increase in vocal pitch. Voice feminization is a long transition journey for physical, neurophysiological, and psychosomatic changes that convert a male phonatory system to a female phonatory system. Therefore, strategies for voice feminization should be individualized according to the individual's physical condition, the desired change in voice pitch, economic conditions, and social roles.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

“…Two types of laryngeal surgeries are relevant for TGD populations: those for raising voice pitch (e.g., glottoplasty with retro-displacement of the anterior commissure, cricothyroid approximation (CTA), feminization laryngoplasty, laser-assisted voice adjustment (LAVA)) (Anderson, 2007 ; Anderson, 2014 ; Brown, 2000 ; Casado, 2017 ; Geneid, 2015 ; Gross, 1999 ; Kelly et al., 2018 ; Kanagalingam, 2005 ; Kim, 2017 ; Kim, 2020 ; Kocak, 2010; Kunachak, 2000 ; Mastronikolis, 2013 ; Mastronikolis et al., 2013 ; Matai, 2003 ; Meister, 2017; Mora, 2018 ; Neumann, 2004; Nuyen et al., 2022 ; Orloff, 2006 ; Pickuth, 2000 ; Remacle, 2011 ; Thomas & MacMillan, 2013 ; Tschan, 2016 ; Van Borsel, 2008 ; Wagner, 2003 ; Wendler, 1990 ; Yang, 2002 ) and for lowering voice pitch (e.g., thyroplasty type III, vocal fold injection augmentation) (Bultynck et al, 2020 ; Isshiki et al., 1983 ; Kojima, et al. 2008 ; Webb et al., 2021).…”

Pathology-Related Influences on the VEM: Three Years’ Experience since Implementation of a New Parameter in Phoniatric Voice Diagnostics

“…Within this 36-month acquisition period, the sample consisted of mainly adult patients with vocal problems, but also of smaller amounts of children, transgender patients, and healthy participants who presented to receive a vocal fitness examination (control group). All children and transgender subjects were excluded from further analysis to avoid distortion of results considering the well-known effects of vocal mutation and maturation [ 17 , 18 ] as well as conservative or phonosurgical gender-transforming procedures [ 19 , 20 ] on acoustic and aerodynamic measures. The study was conducted in accordance with the Declaration of Helsinki and approved by the local ethical review board (reference number: EA4/140/10).…”

Readability Analysis and Accessibility of Online Materials About Transgender Voice Care

“…15 In cases where voice therapy alone does not achieve the desired voice, laryngologists can perform a variety of procedures to change fundamental properties of the larynx, including length (ie, Wendler glottoplasty), tension (ie, cricothyroid approximation, Isshiki thyroplasty type III), and mass (laser reduction glottoplasty) of the vocal folds with resulting change in pitch. 12,16,17…”