ORIGINAL ARTICLE
The Role of Voice Therapy and Phonosurgery
in Transgender Vocal Feminization
Ian T. Nolan, BM, Shane D. Morrison, MD, MS,y Omotayo Arowojolu, MD, PhD,
Christopher S. Crowe, MD,y Jonathan P. Massie, MD,z Richard K. Adler, PhD, CCC-SLP,§
Scott R. Chaiet, MD, MBA,jj and David O. Francis, MD, MSjj
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
From the New York University School of Medicine, New York, NY;
yDivision of Plastic Surgery, Department of Surgery, University of
Washington School of Medicine, Seattle, WA; zDivision of Plastic
Surgery, Department of Surgery, Feinberg School of Medicine, North-
western University, Chicago, IL; §Emeritus Faculty, Speech Language
and Hearing Sciences Department, Minnesota State University Moore-
head, Moorehead, MN; and jjDivision of Otolaryngology—Head and
Neck Surgery, Department of Surgery, University of Wisconsin School
of Medicine and Public Health, Madison, WI.
Received July 30, 2018.
Accepted for publication October 2, 2018.
Address correspondence and reprint requests to Shane D. Morrison, MD,
MS, Division of Plastic Surgery, University of Washington Department
of Surgery, 7CT73.1 Harborview Medicine Center, 325 9th Avenue,
Mailstop #359796, Seattle, WA 98104; E-mail: shanedm@uw.edu; Ian
T. Nolan, BM, New York University School of Medicine, New York,
NY 98104; E-mail: ian.nolan@nyumc.org
ITN and SDM contributed equally to this work.
The authors report no conflicts of interest.
Supplemental digital contents are available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web site (www.jcraniofa-
cialsurgery.com).
Copyright # 2019 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000005132
1368 The Journal of Craniofacial Surgery  Volume 30, Number 5, July 2019
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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.
Key Words: Gender affirmation, phonosurgery, transgender, vocal
feminization, voice therapy
(J Craniofac Surg 2019;30: 1368–1375)
M any transgender people experience incongruence between
the biologic sex they were assigned at birth and their gender
identity. This incongruence often causes gender dysphoria, which
can cause significant psychological burden.1 – 3 Gender-affirming
treatments have proven effective in relieving this dysphoria.4,5 An
important aspect of gender affirmation for many transgender
women is vocal feminization, which can ease voice-related gender
dysphoria and improve how well others perceive a transgender
woman as her identified gender.4 The primary goal of voice-
related gender-affirming treatment options is to reduce gender
dysphoria by creating congruency between a patient’s voice and
their gender identity. For transgender women, this can be achieved
by modifying a number of vocal parameters, including raising the
pitch of the speaking voice to a typical adult female range and
increasing the ease with which patients can be identified as female
while speaking. Thus, interventions aim to increase the habitual
pitch or speaking fundamental frequency (F0) from the adult male
range of 80 to 120 Hz to above the threshold range of 155 to
160 Hz, approaching the adult female range of 160 to 220 Hz.6,7
Additional measures of how ‘‘feminine’’ a patient’s voice is
perceived include cadence, intonation, resonance, speech rate,
phrasing patterns, voice quality, and nonverbal communication
patterns.8
Options for vocal feminization include phonosurgery and non-
surgical management with voice therapy.9 Voice therapy typically
involves several iterative sessions designed to teach patients how to
use their voice in a way that is congruent with their identified gender.
It has also proven to be effective in raising the pitch of the speaking
voice, increasing patient satisfaction, and increasing externally-rated
vocal femininity.10,11 Unlike phonosurgery, voice therapy also
addresses nonpitch related aspects of vocal femininity.12
Phonosurgery techniques for vocal feminization include cri-
cothyroid approximation to increase vocal cord tension, endoscopic
shortening to decrease the length of vocal cords, and laser reduction
glottoplasty to reduce the mass of vocal cords.9 Recent systematic
reviews have shown that all 3 are effective in raising the pitch of the
speaking voice, increasing patient satisfaction, and increasing
externally-rated vocal femininity, with the largest increase in F0
achieved by endoscopic shortening.9
The Journal of Craniofacial Surgery  Volume 30, Number 5, July 2019 Transgender Vocal Feminization

There is currently no standardized treatment protocol for vocal RESULTS

feminization, and various permutations of voice therapy and pho- Study selection: The initial search and reference review yielded 212
nosurgery exist.7,12 Patients may be satisfied with voice therapy unique studies, of which 20 met inclusion criteria (Fig. 1). Six
alone, may only desire phonosurgery, may undergo phonosurgery studies provided data for feminizing voice therapy and 14 papers
after having voice therapy, or may begin voice therapy as part of provided data for phonosurgery; however, the use of voice therapy
their postsurgical rehabilitation. prior to or after surgery was not standardized.10,11,14–20 Interven-
Currently, transgender women seek and undergo voice therapy tion, study design, sample size, mean age, length of follow-up, and
at a much higher rate than phonosurgery. Per the 2015 US Trans- mean F0 pre- and postintervention are reported in Tables 1 and
gender Survey, 14% of transgender women have undergone voice 2.10,11,14– 31 Subjective patient satisfaction, externally rated femi-
therapy whereas only 1% have undergone phonosurgery.13 More- ninity results, and complications by study are reported in Table 3.
over, 48% of transgender women desired voice therapy, while only Details of voice therapy regimens are included in Table 4. Seven-
18% desired phonosurgery. teen of the 20 included studies reported pre- and postintervention F0
To date, there has been no comprehensive review of the with high data quality, qualifying them for inclusion in a meta-
literature regarding the effectiveness of voice therapy and various analysis of this outcome (Fig. 2). Six of these 17 studies fell outside
phonosurgery techniques. To fill this gap, our study compares the 95% confidence interval, suggestive of the presence of publi-
subjective patient satisfaction, external ratings of vocal cation bias (see Figure, Supplemental Digital Content 1, http://
femininity, change in F0, and complications following links.lww.com/SCS/A391). Data from all 20 studies were included
treatment with voice therapy, endoscopic shortening, laser reduc- in our discussion of gender perception and patient satisfaction
tion glottoplasty, and/or cricothyroid approximation phonosur- outcomes.
gery techniques. The results should provide insight into the Patient Satisfaction: For voice therapy, 1 study reported a 65%
efficacy of voice therapy compared with various phonosurgery increase in self-rated femininity while another reported a patient
techniques. satisfaction score of 80 out of 100 on follow-up (Table 3).11,14
Regarding endoscopic shortening, 1 study reported that 82.5% of
patients gave satisfactory ratings for voice-related quality of life
METHODS and another reported increased scores on a self-reported percep-
The systematic review followed PRISMA guidelines and was tion measure for voice quality, from 40 before treatment to 70.3
registered on the online PROSPERO database under following treatment.18,19 Regarding laser reduction glottoplasty,
CRD42017070232. The following databases were searched: 1 study reported no net change in satisfaction following
Pubmed, Cinahl Plus (EBSCO Host, LGBT Life, Humanities Full surgery, while another reported 66.7% complete satisfaction
Text, Humanities Source, Medline), Ovid SP (Ovid MEDLINE, and 33.3% partial satisfaction.21,22 Regarding cricothyroid
Ovid MEDINE Daily Update, Ovid MEDLINE In-Process, Psy- approximation, 1 study reported 58% satisfaction rate and another
chInfo, EMBASE), Web of Science (all databases), Science Direct 85% satisfaction.23,24
(Elsevir, EMBASE), and Google Scholar. In Pubmed, MeSH
keywords searched were ‘‘(Transgender person OR transgender
OR transgendered person OR transgendered OR 2-spirit person
OR 2 spirit person OR transsexual person OR transsexual OR
gender-variant person OR gender-variant OR gender variant
person OR gender variant OR gender queer person OR gender-
queer person OR gender queer OR genderqueer OR gender non-
conforming OR gender nonbinary OR transsexualism OR
transgenderism) AND (Speech therapy OR voice training). In
other databases, equivalent terms, including ‘‘Voice therapy,
speech therapy, and/or speech training’’ were used in compatibil-
ity with each database’s search algorithms. Studies were included
if they met the following criteria: relevant to voice therapy with or
without phonosurgery for transgender women, outcomes-based,
primary literature with original data, and originally published in
or translated to English. Articles were excluded from meta-
analysis if they were clinical reports with fewer than 2 patients,
did not report standard deviations, or used more than 1 phono-
surgery technique. Additional articles were identified via refer-
ence review of initially included studies. Five authors (ITN, SDM,
JPM, OA, CSC) were involved in the study selection and data
extraction process. At least 2 authors reviewed each paper, and
consensus was reached.
Data extracted from studies meeting criteria included patient
characteristics, details of phonosurgery procedure and/or voice
therapy regimen, change in voice pitch (F0, Speaking Fundamental
Frequency, or Habitual Pitch) immediately after completion of
treatment, externally rated vocal femininity, subjective patient
satisfaction, and complications. RevMan v5.3 software (Cochrane) FIGURE 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses
was used for analysis of publication bias and calculation of F0 effect (PRISMA) Flow Diagram. Of 212 unique studies identified by initial search, 20
met inclusion criteria of outcomes-based vocal feminization interventions
size between treatment conditions. For all other measures, differ- consisting of voice therapy and/or phonosurgery for transgender women, of
ence of means and t test analyses was performed when possible. which 17 reported data of sufficient quality to be included in meta-analysis of F0
Statistical significance was held at P < 0.05. effect size.

# 2019 Mutaz B. Habal, MD 1369

Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Nolan et al The Journal of Craniofacial Surgery  Volume 30, Number 5, July 2019

TABLE 1. Overview of Selected Studies Evaluating Effect of Treatment on Fundamental Frequency (F0)

Study Sample Mean Preintervention Postintervention F0

Study First Author and Year Intervention Design Size Age F0 F0 Change

Voice Therapy
Dacakis 200011 Voice therapy Retrospective 9 45 125.5 168.1 42.6
Meszaros et al 200517 Voice therapy Prospective 3 23 150.7 191.3 40.6
Carew et al 200714 Voice therapy Prospective 10 40 119.4 133.3 13.9

Gelfer and Tice 201310 Voice therapy Prospective 5 46 126 210 84

Gelfer and van Dong 201315 Voice therapy Prospective 3 43 115.5 152 36.5
Hancock and Garabedian 201316 Voice therapy Retrospective 25 43 124 156 32
Endoscopic Shortening
Gross 199929 Anterior web formation Retrospective 10 40.5 116.9 201 84.1
(‘‘endolaryngeal vocal fold
shortening’’)
Postoperative voice therapy
Remacle et al201120 Wendler’s glottoplasty Retrospective 15 42.5 150 194 44
Postoperative voice therapy
Mastronikolis 201328 Wendler glottoplasty Retrospective 31 38.3 135.8 206.3 70.5
Postoperative voice therapy (93% of
patients)
Anderson 201430 Anterior web formation and Retrospective 10 42 127.8 238 110.2
Radiesse injection augmentation
Postoperative voice therapy not
reported
Casado et al 201618 Wendler’s glottoplasty Retrospective 10 39.9 137 243 106
Postoperative voice therapy
Meister et al201626 Wendler glottoplasty Retrospective 21 43 131 174 43
Postoperative voice therapy
Kim 201719 Vocal Fold Shortening and Retrospective 313 34.4 144.1 190.3 46.2
Retrodisplacement of Anterior
Commissure (VFSRAC)
Postoperative voice therapy
Laser Reduction
Orloff et al 200621 CO2 laser vocal fold vaporization Prospective 18 44 142 168 26
Postoperative voice therapy
,y
Koçak 201022 CO2 laser vocal fold vaporization. Prospective 3 29 165.67 209.33 43.66
All patients had failed
cricothyroid approximation.
Postoperative voice therapy not
reported
Cricothyroid Approximation
Brown et al 200031 Feminizing laryngoplasty Prospective 14 37.5 152.2 154.8 2.6
Postoperative voice therapy not
reported
Yang et al 200223 Cricothyroid approximation Retrospective 20 46 144.5 202.4 57.9
Postoperative voice therapy (36% of
patients)
Neumann and Welzel200424 Cricothyroid approximation Retrospective 67 39 117.2 155.2 38
Postoperative voice therapy (prospective
follow-up)
Kanagalingam et al 200527 Cricothyroid approximation and Retrospective 15 39 118 175 57
subluxation
Postoperative voice therapy
Van Borsel et al 200825 Cricothyroid approximation Prospective 7 43 118.5 169.8 51.3
Postoperative voice therapy
,y
Koçak 201022 Cricothyroid approximation Prospective 3 29 130 165.67 35.65
Postoperative voice therapy


Studies excluded from F0 analysis due to poor F0 data quality.
y
Single study with data for both laser reduction and cricothyroid approximation.

Externally-rated femininity: Eight studies reported this outcome
as rated by trained observers (Table 3). Two studies evaluating voice
therapy reported increases in the percentage of the time patients’
voices were interpreted as female. In the first, external observers
identified the voice as female in 1.9% of participants preintervention
and 50.8% of participants immediately postintervention.10 Moreover,
33% of participants maintained a ‘‘female’’ voice at 15-month
follow-up. The second voice therapy study reported a change from
0% to 7.4% recognition of voice femininity from pre- to posttreat-
ment. One endoscopic shortening study reported that on a ‘‘very
masculine’’ to ‘‘very feminine’’ scale, patients’ voices converted
from ‘‘somewhat masculine’’ pre-treatment to ‘‘somewhat feminine’’
posttreatment. One laser reduction glottoplasty study reported an
increase in female perception from 1.5 to 8.5 on a 10-point scale and a
reduction in male perception from 6.7 to 1.0 following treatment.22
One cricothyroid approximation study reported postoperative

1370 # 2019 Mutaz B. Habal, MD

Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery  Volume 30, Number 5, July 2019
TABLE 2. Demographics and F0 Change by Intervention
Treatment Sample Size (n)
Voice therapy 47
Endoscopic shortening 410
Laser reduction 18
Cricothyroid approximation 123
femininity ratings of 42.38 (P < 0.001) on a scale of 0 (very male)
to 100 (very female), which was an intermediate score between
nontransgender men (14.51/100) and nontransgender women
(79.38/ 100).25
TABLE 3. Overview of Selected Studies Evaluating Qualitative Measures and Complications
Study Patient Satisfaction
Voice therapy
Dacakis 200011 Score of 78 on discharge, score of 80 on
follow-up.
Carew et al 200714 65% increase in self-rated femininity.
Gelfer and Tice 201310
Gelfer and van Dong 201315
Endoscopic shortening
Remacle et al 201120
18
Casado et al 2016 Self-reported perception measure for
voice quality (TSEQ) rating: 40
before treatment to 70.3 following
treatment.
Meister et al 201626 On visual analog scale: ‘‘satisfaction
with voice’’ ¼ 6.1/10 (range 0–9);
‘‘femininity with voice’’ ¼ 5.3/10
(0–9.2). Strongly correlated with
degree of F0 increase.
Kim 201719 Self-reported voice-related quality of
life: 82.5% satisfactory, 12.6% needs
improvement, 4.9% worse.
Laser reduction
Orloff et al 200621 Self-satisfaction questionnaire (0–30
pts with 30 being best):
preintervention 18.67 and
postintervention 18.67 (no change).
Kocack 201022 66.7% completely satisfied (4/6),
33.3% partially satisfied. All
reported self-perceived change in
vocal pitch.
Cricothyroid approximation
Yang et al 200223 Satisfaction: 58% satisfied, 33%
dissatisfied. Self-reported quality:
42% clear, 23% rough, and 34% fair.
Femininity: feminine 50%, masculine
25%, neutral 25%.
Neumann and Welzel 200424 85% patient satisfaction.
Van Borsel et al 200825
# 2019 Mutaz B. Habal, MD
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Transgender Vocal Feminization
Mean Age, y F0 Effect Estimate, Hz (95% CI)
37.8 30.9 (44.3, 17.5)
40.1 72.2 (95.1, 49.4)
44 26 (50.4, 1.6)
40.9 39.5 (62.9, 16.0)
Complications: No complications of treatment were reported for
voice therapy alone (Table 3). Endoscopic shortening complica-
tions included reduced mean phonation time (61%), pitch instability
(1.9%), decreased loudness (1.7 to 6%), dysphonia (1.7%),
Externally Rated Femininity Complications
Patients perceived as female 1.9% of the time
before treatment, 50.8% of the time
immediately following treatment, and
33.1% at 15-month follow-up.
Patients all perceived as male before
treatment, as female 7.4% of the time
following treatment.
Decreased mean vocal
range.
Visual analogue scale: ‘‘somewhat Decreased mean phonation
masculine’’ before treatment and time (61.1%).
‘‘somewhat feminine’’ following treatment.
Pitch instability (1.9%),
decreased loudness
(1.7%), dysphonia
(1.7%).
6/10 had voices perceived as female by blind
listeners. 3/10 had voices perceived as
mixed, and 1/10 had voice perceived as
male.
Increase in female perception ratings (mean
1.5 to 8.5 out of 10), with a reduction in
male perception ratings (mean 6.7 to 1.0).
47% occasionally mistaken as male, 31% 6% reduction in loudness,
never, and 22% always. 6% vocal fatigue, 3%
hoarseness, 29%
dysphagia immediately
after surgery.
Scale from 0 (very male) to 100 (very female).
Audio only: subjects mean score 42.38,
versus nontransgender male (14.51) and
nontransgender female controls (79.38), all
P < 0.001. Audiovisual: subjects mean
score 46.33 versus nontransgender male
(13.53) and nontransgender female controls
(81.23), all P < 0.001.
1371
Nolan et al The Journal of Craniofacial Surgery  Volume 30, Number 5, July 2019

TABLE 4. Details of Voice Therapy Regimens

Mean Total Mean Duration

Time of Voice of Voice
Study Therapy Sessions (h) Therapy (d) Goals of Voice Therapy Methods of Voice Therapy

Voice therapy alone

Dacakis 200011 20 (range 10–90) No details No details No details
Meszaros 200517 41 290 Development of female pitch. Use of first articulation zone.
High pitch vocalization Costoabdominal breathing
technique to lengthen time of
expiration.
Decreased laryngeal muscle
tension.
Increased head resonance compared
with chest resonance.
Special attention to formation of
soft tones and precise
articulation.
Increasing intensity of phonation.
Carew 200714 3.75 35 Improved oral resonance Increased use of lip spreading
during speech.
Increase forward tongue carriage.
Practice with progressively more
complex facets of speech, from
isolated vowels to words to
sentences and conversation.
Gelfer, Tice 201310 16 56 Increased F0 of speaking voice. Individualized F0 goal for each
Preservation of vocal flexibility. patient.
Vocal flexibility exercises.
Emphasis on quality (smooth and
light), intonation (female
pattern), pitch range, emotional
expression.
Practice with progressively more
complex facets of speech, from
isolated vowels to words to
sentences and conversation.
Gelfer, Dong 201315 12 42 Increased F0 of speaking voice. Individualized F0 goal for each
Preservation of vocal flexibility. patient.
Vocal flexibility exercises.
Emphasis on quality (smooth and
light), intonation (female
pattern), pitch range, emotional
expression.
Practice with progressively more
complex facets of speech, from
isolated vowels to words to
sentences and conversation.
Hancock and 22 n/a Decreased phonotraumatic behavior. Practice speaking at increased F0
Garabedian 201316 Vocal hygiene. with feedback.
Relaxation techniques. Forward oral resonance with fade
Fundamental frequency. modelling.
Intonation. Practice of upward intonation and
Resonance. expressive intonation.
Vocabulary. Laryngeal massage and whole body
Pragmatics. relaxation techniques.
Nonverbal communication. Increased diaphragmatic breathing.
Respiration. Decreased glottal attack.
Endoscopic shortening
Gross 199929 No details. No details. No details. No details
Remacle 201120 No details. No details. No details. No details
Mastronikolis 201328 No details. No details. ‘‘Normal voice therapy.’’ ‘‘Normal voice therapy.’’
Anderson 201430 No therapy
regimen
reported.
Casado 201618 18 56–94 Vocal hygiene. No details
Relaxation.
Breathing.
Emission, collocation, and
modulation of masculine larynx to
feminine tones.
Generalization of techniques to real-
life situations
Meister et al 201626 No details. No details. No details No details.

1372 # 2019 Mutaz B. Habal, MD

Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery  Volume 30, Number 5, July 2019 Transgender Vocal Feminization

TABLE 4. (continued )

Mean Total Mean Duration

Time of Voice of Voice
Study Therapy Sessions (h) Therapy (d) Goals of Voice Therapy Methods of Voice Therapy

Kim 201719 No details. No details. Form female formants based on Laryngeal relaxation, cricothyroid-
source/filter theory of voice dominant production exercises,
production resonance modification exercises
Laser reduction
Orloff 200621 No therapy
regimen
reported.

Koçak 201022 No therapy
regimen
reported.
Cricothyroid approximation
Brown et al 200031 No therapy
regimen
reported.
Yang et al 200223 No details. No details. No details. No details.
Neumann and No details. 180 Help patient adapt to new voice Videos and recordings to self-assess
Welzel 200424 and build auditory control
Kanagalingam and No details. No details Centering of breathing. No details
et al 200527 Relaxation of articulators
Resonance laddering
Pitch peaking and extension
Singing
Van Borsel et al 200825 No therapy
regimen
reported.

Koçak 201022 No details No details No details No details


Single study with data for both laser reduction and cricothyroid approximation.

decreased dynamic range, and a nonsignificant decrease in vocal
range.18–21,23,26 Reports of laser reduction glottoplasty complica-
tions were limited, but included granulation tissue formation
(3.2%).21 Reports of cricothyroid approximation complications
were similarly limited but included decreased loudness (6%), vocal
fatigue (6%), and hoarseness (3%).23
Meta-analysis of F0: Results of the meta-analysis are shown in
Figures 2 and 3. The 17 eligible studies for meta-analysis included
598 patients, of which 47 underwent voice therapy alone, 410
underwent endoscopic shortening, 18 underwent laser reduction
glottoplasty, and 123 underwent cricothyroid approximation. Voice
therapy alone increased F0 by 30.90 Hz (95% confidence interval
(CI) 44.29 to 17.52), endoscopic shortening increased F0 by
72.21 Hz (95% CI 95.03 to 49.38), laser reduction by 26.00 Hz
(95% CI 50.39 to 1.61), and cricothyroid approximation by
39.46 Hz (95% CI 62.89 to 16.02) (Figs. 2 and 3). The voice
therapy group had the least heterogeneity (I2 ¼ 52%), with post-
intervention mean differences ranging between 13.9 to 42.6 Hz
(Fig. 2). The endoscopic shortening group had the greatest hetero-
geneity (I2 ¼ 94%), with postintervention mean differences ranging
from 43 to 106 Hz. The laser reduction group included one study, so
heterogeneity could not be assessed (Fig. 3).

FIGURE 2. Forest Plot Showing Relative Effect Size on Fundamental Frequency
of Speech (F0) Following voice therapy, endoscopic shortening, laser reduction
glottoplasty, or cricothyroid approximation. Preintervention and
postintervention mean F0 as well as F0 standard deviation and sample size are
shown for each study in voice therapy, endoscopic shortening, laser reduction
glottoplasty, and cricothyroid approximation treatment cohorts. Studies are
weighted based on sample size and data variance. A mean difference and 95%
confidence interval as well as statistical significance between preintervention
and postintervention mean F0 is shown for each study, for each treatment
cohort, and for all subjects combined.
DISCUSSION
Because voice therapy and phonosurgery are primarily indicated to
treat dissatisfaction with the speaking voice, patient satisfaction is
among the most important outcomes. Regarding patient satisfac-
tion, both voice therapy alone and phonosurgery had favorable
results. Voice therapy, endoscopic shortening, and cricothyroid
approximation all achieved patient satisfaction scores between
80% and 85%. Therefore, the decision to pursue voice therapy
alone or phonosurgery will likely depend on other factors such as
the desired magnitude of pitch elevation and a patient’s tolerance
for increased cost and potential complications of surgery.
Endoscopic shortening was most effective at pitch elevation,
raising F0 by over 70 Hz, versus a change of 26 to 40 Hz achieved
by voice therapy and the other surgical options. Endoscopic

# 2019 Mutaz B. Habal, MD 1373

Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Nolan et al The Journal of Craniofacial Surgery
FIGURE 3. Mean Fundamental Frequency (F0) Before and After Treatment with
Voice Therapy, Endoscopic Shortening (ES), Laser Reduction (LR), or
Cricothyroid Approximation (CTA). Comparisons between preintervention and
postintervention mean F0 are shown for each treatment cohort. Voice therapy
(VT) resulted in an F0 change from 126.77 Hz preintervention to 168.45 Hz
postintervention (n ¼ 6, P < 0.00001); endoscopic shortening (ES) from 134.66
to 206.66 Hz (n ¼ 7, P < 0.00001); laser reduction glottoplasty (LR) from 142 to
168 Hz (n ¼ 1, P > 0.05); and cricothyroid approximation from 130.08 to
  
171.44 Hz (n ¼ 5, P < 0.01). P < 0.05, P < 0.01, P < 0.001.
shortening also achieved the highest postoperative F0, resulting in a
pitch that fell well within the typical female range, while cricothyr-
oid approximation, laser reduction glottoplasty, and voice therapy
resulted in F0 that fell near or within the borderline range.
Pitch of the speaking voice correlates strongly with perceived
femininity, and it is therefore likely that endoscopic shortening
would also achieve greatest vocal femininity outcomes, although
the existing literature did not report perceived femininity in a way
that can be directly compared.32 The analyzed literature also did not
consistently evaluate other factors that affect femininity, such as
voice quality or prosody or nonverbal communication patterns.
Phonosurgery techniques like endoscopic shortening carry
increased cost and risk of complications, which may favor voice
therapy for many patients. Phonosurgery had significant risks,
including reduced mean phonation time (61%), pitch instability
(1.9%), decreased loudness (1.7 to 6%), vocal fatigue (6%), hoarse-
ness (3%), and dysphonia (1.7%).18,19,21,23,26 Phonosurgery also
comes with considerable cost, which could be a particularly impor-
tant consideration for many transgender women, as this population
as a whole is disproportionately affected by poverty and insufficient
access to healthcare.11 In contrast, voice therapy is a noninterven-
tional treatment without notable risks. It does, however, carry its
own financial burden and requires a significant longitudinal time
investment, which may be impractical for certain patients.
If phonosurgery is chosen, patients would likely benefit from
additional postoperative voice therapy. Several studies reported that
postoperative voice therapy was associated with further increases in
F0, stabilization of the voice, decreased vocal irregularities, and a
more feminine timbre.24,33 Our own analysis showed that across
surgical techniques, patients who received postoperative voice
therapy achieved a sizably greater increase in F0 when compared
with those for whom no postoperative voice therapy was reported
(50.60 versus 22.77 Hz, P < 0.0001).
However, several confounds limit the conclusions that can be
drawn regarding the effect of treatment on F0. Endoscopic short-
ening cohorts were on average about 4 to 6 years younger than other
treatment groups, and younger patients tend to have a greater degree
of F0 increase from phonosurgery.34 Endoscopic shortening sub-
jects were also more likely to have undergone postoperative voice
therapy (89% versus 83% of cricothyroid approximation cohort and
0% of laser reduction glottoplasty cohort), which was associated
with improved outcomes. The endoscopic shortening cohort also
1374 # 2019 Mutaz B. Habal, MD
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 30, Number 5, July 2019
started at a higher F0 than other treatment groups (about 160 Hz
versus 120–140 Hz).
There were limitations to this study. Many of the studies
predated development of a validated, standardized outcome mea-
sure for patient satisfaction and vocal femininity in transgender
women (Transsexual Voice Questionnaire, or TVQ), limiting the
data’s validity.27,28,35,36 There was also relatively limited follow-
up, considerable variation within each surgical technique and
between voice therapy regimens (Table 4), significant skewing
of the literature toward endoscopic shortening (410 of 598 ana-
lyzed subjects in the meta-analysis), and significant publication
bias (Fig. 2). Lastly, all subjects studied were transgender women,
limiting the application of these findings to other populations,
such as gender diverse patients, who may also seek vocal
feminization.11
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. Additional outcomes
data using validated measures will be required to make definitive
clinical guidelines.
REFERENCES
1. American Psychological Association. Guidelines for psychological
practice with transgender and gender nonconforming people. Am
Psychol 2015;70:832–864
2. Grant JM, Mottet LA, Tanis J, et al. Injustice at Every Turn: a Report of
the National Transgender Discrimination Survey. Washington, DC:
National Center for Transgender Equality and National Gay and Lesbian
Task Force; 2011
3. Haas AR, P.; Herman, J. Suicide Attempts Among Transgender and
Gender Non-Conforming Adults: Finding of the National Transgender
Discrimination Survey. 2014
4. WPATH. World Professional Association for Transgender Health
Position Statement on Medical Necessity of Treatment, Sex
Reassignment, and Insurance Coverage in the U.S.A. 2016. Available at:
http://www.wpath.org/site_page.cfm?pk_association_webpage_
menu=1352&pk_association_webpage=3947. Accessed June 1, 2018
5. Winter S, Settle E, Wylie K, et al. Synergies in health and human
rights: a call to action to improve transgender health. Lancet
2016;388:318–321
6. Spencer LE. Speech characteristics of male-to-female transsexuals: a
perceptual and acoustic study. Folia Phoniatr (Basel) 1988;40:31–42
7. Davies S, Papp VG, Antoni C. Voice and communication change for
gender nonconforming individuals: giving voice to the person inside. Int
J Transgenderism 2015;16:117–159
8. Simpson Adrian P. Phonetic differences between male and female
speech. Lang Linguistics Compass 2009;3:621–640
9. Song TE, Jiang N. Transgender phonosurgery: a systematic review and
meta-analysis. Otolaryngol Head Neck Surg 2017;156:803–808
10. Gelfer MP, Tice RM. Perceptual and acoustic outcomes of voice therapy
for male-to-female transgender individuals immediately after therapy
and 15 months later. J Voice 2013;27:335–347
11. Dacakis G. Long-term maintenance of fundamental frequency increases
in male-to-female transsexuals. J Voice 2000;14:549–556
12. Davies S, Goldberg JM. Clinical aspects of transgender speech
feminization and masculinization. Int J Transgenderism 2006;9:
167–196
The Journal of Craniofacial Surgery  Volume 30, Number 5, July 2019
13. James SE, Herman JL, Rankin S, et al. The Report of the 2015 U.S.
Transgender Survey. Washington, DC: National Center for Transgender
Equality; 2016
14. Carew L, Dacakis G, Oates J. The effectiveness of oral resonance
therapy on the perception of femininity of voice in male-to-female
transsexuals. J Voice 2007;21:591–603
15. Gelfer MP, Van Dong BR. A preliminary study on the use of vocal
function exercises to improve voice in male-to-female transgender
clients. J Voice 2013;27:321–334
16. Hancock AB, Garabedian LM. Transgender voice and communication
treatment: a retrospective chart review of 25 cases. Int J Lang Commun
Disord 2013;48:54–65
17. Meszaros K, Vitez LC, Szabolcs I, et al. Efficacy of conservative voice
treatment in male-to-female transsexuals. Folia Phoniatr Logop
2005;57:111–118
18. Casado JC, O’Connor C, Angulo MS, et al. Wendler glottoplasty and
voice-therapy in male-to-female transsexuals: Results in pre and post-
surgery assessment. [Spanish]. Acta Otorrinolaringol Esp 2016;67:
83–92
19. Kim HT. A new conceptual approach for voice feminization: 12 years of
experience. Laryngoscope 2017;127:1102–1108
20. Remacle M, Matar N, Morsomme D, et al. Glottoplasty for male-to-
female transsexualism: voice results. J Voice 2011;25:120–123
21. Orloff LA, Mann AP, Damrose JF, et al. Laser-assisted voice adjustment
(LAVA) in transsexuals. Laryngoscope 2006;116:655–660
22. Kocak I, Akpinar ME, Cakir ZA, et al. Laser reduction glottoplasty for
managing androphonia after failed cricothyroid approximation surgery.
J Voice 2010;24:758–764
23. Yang CY, Palmer AD, Murray KD, et al. Cricothyroid approximation to
elevate vocal pitch in male-to-female transsexuals: results of surgery.
Ann Otol Rhinol Laryngol 2002;111:477–485
24. Neumann K, Welzel C. The importance of the voice in male-to-female
transsexualism. J Voice 2004;18:153–167
# 2019 Mutaz B. Habal, MD
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Transgender Vocal Feminization
25. Van Borsel J, Van Eynde E, De Cuypere G, et al. Feminine after
cricothyroid approximation? J Voice 2008;22:379–384
26. Meister J, Kuehn H, Shehata-Dieler W, et al. Patient satisfaction after
pitch elevation and development of a therapy algorithm.
Laryngorhinootologie 2016;95:774–782
27. Morrison SD, Crowe CS, Rashidi V, et al. Beyond Phonosurgery:
Considerations for Patient-Reported Outcomes and Speech Therapy in
Transgender Vocal Feminization. Otolaryngol Head Neck Surg
2017;157:349
28. Morrison SD, Crowe CS, Wilson SC. Consistent quality of life outcome
measures are needed for facial feminization surgery. J Craniofac Surg
2017;28:851–852
29. Gross M. Pitch-raising surgery in male-to-female transsexuals. J Voice
1999;13:246–250
30. Anderson JA. Pitch elevation in trangendered patients: anterior glottic
web formation assisted by temporary injection augmentation. J Voice
2014;28:816–821
31. Brown M, Perry A, Cheesman AD, et al. Pitch change in male-to-female
transsexuals: has phonosurgery a role to play? Int J Lang Commun
Disord 2000;35:129–136
32. Van Borsel J, Baeck H. The voice in transsexuals. Revista de Logopedia,
Foniatrı́a y Audiologı́a 2014;34:40–48
33. Kanagalingam J, Georgalas C, Wood GR, et al. Cricothyroid
approximation and subluxation in 21 male-to-female transsexuals.
Laryngoscope 2005;115:611–618
34. Mastronikolis NS, Remacle M, Biagini M, et al. Wendler glottoplasty:
an effective pitch raising surgery in male-to-female transsexuals. J Voice
2013;27:516–522
35. Dacakis G, Oates J, Douglas J. Associations between the Transsexual
Voice Questionnaire (TVQ(MtF)) and self-report of voice femininity and
acoustic voice measures. Int J Lang Commun Disord 2017;52:831–838
36. Massie JP, Morrison SD, Smith JR, et al. Patient-reported outcomes in
gender confirming surgery. Plast Reconstr Surg 2017;140:236e–237e
1375