The Role of Voice Therapy and Phonosurgery in Transgender Vocal Feminization

Abstract

Objective: Nonsurgical and surgical options are available for transgender vocal feminization. This systematic review explores the efficacy of feminizing voice therapy and phonosurgery. Methods: A systematic review was performed using PubMed, Cinahl Plus, Ovid SP, Web of Science, Science Direct, and Google Scholar with terms related to transgender phonosurgery and voice therapy. Included studies were outcomes-based vocal feminization interventions for transgender women. Data were collected on pre- and postintervention fundamental frequency (F0), externally measured vocal femininity, patient satisfaction, and complications. Results: Two hundred twelve studies were identified and 20 met inclusion criteria. Postintervention patient satisfaction was approximately 80% to 85% for voice therapy, endoscopic shortening, and cricothyroid approximation. Complications were reported for each phonosurgery technique, most commonly decreased mean phonation time and loudness. Of the 20 studies, 17 were used for meta-analysis of F0 change. F0 increased by 31 Hz with voice therapy alone, 26 Hz with laser reduction glottoplasty, 39 Hz with cricothyroid approximation, and 72 Hz with endoscopic shortening. Conclusion: The literature supports both voice therapy and phonosurgery, depending on a patient's magnitude of desired pitch change and tolerance for cost and potential complications. Most will likely benefit from voice therapy, as it is highly satisfactory, raises vocal pitch, and is noninvasive. However, endoscopic shortening is also highly satisfactory and provides the greatest absolute increase in vocal pitch. If surgery is chosen, postoperative voice therapy may additionally increase F0, stabilize the voice, and create a more female timbre. However, further studies will be necessary to provide definitive clinical recommendations.

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

“…A large load of literature regarding feminizing voice therapy is often nonstandardized and analyzed unreliably. 56 And also, there are many variations of technique and strategies to feminize voice. One article identified these variations are in part due to the complex nature of an individual's baseline and voice goals as well as a lack of standardized treatment among speech language pathologists.…”

“…In the literature, voice therapy has focused on raising the pitch of speaking, cadence, intonation, resonance, speech rate, phrasing patterns, voice quality, and nonverbal communication patterns. 56 Based on gender difference of phonatory organ, voice therapy for feminizing the voice successfully should make more biomechanical changes than physiological movement of vocal folds to raise the pitch to a higher level than its own voice range. Voice therapy should also make changes of vocal tract dimensions to modify oral and pharyngeal resonance.…”

“…As mentioned earlier, in many studies, voice therapy is being applied to patient with various therapy goals and techniques. 26,54,56,[58][59][60][61] However, given that there are morphometric differences between male and female phonatory organs, voice therapy should focus on changes in resonance frequencies that are related to oral cavity volume and length as well as pharyngeal volume. Oral cavity volume and length are mainly controlled by tongue motion that also affects hyoid motion with modification of laryngeal movement.…”

“…54 Eventually, postoperative voice therapy may raise F0, stabilize the voice pitch, and increase femininity of the voice. 56 Another importance of postoperative voice therapy is to prevent reverse adaptation of resonance frequency. Preoperative old phonatory pattern before the surgery has a low male fundamental frequency and adjusted resonance frequency.…”

Applying concurrent multidisciplinary care to gender affirmation in transgender women: A case series

“…The endoscopic approach has been found to have high patient satisfaction rate and ability to increase the fundamental frequency of the voice by creation of an anterior web and fusion reducing vibratory length. 5 The patients were intubated with a small endotracheal tube, internal diameter of 5.5 mm or less, allowing for easier manipulation of the vocal folds and causing less disturbance of their natural position than a larger tube. Using an operating laryngoscope, a potassium titanyl phosphate (KTP) laser was used to remove the epithelium from both sides of the anterior commissure of the vocal folds, extending back approximately 40% of the glottal length.…”