The Last Step: Voice Therapy and Surgery

We immediately recognize how important the difference in projecting one�s gender image is when the voice does not appropriately reflect one's new gender. What strikes us immediately is the difference in pitch and range between male and female communication. In terms of sound measurement, the initial mean male pitch is 110-115 Hz with an average speaking range of 80-140 Hz,  while the female mean pitch is higher at 180-190 Hz with an average speaking range of180-240 Hz. But we are all familiar with the low sultry voices of Kathleen Turner and Lauren Bacall, so the range may be extended but still recognizable as female. That is because the differences in intonation and inflection are part of the whole package. Women use a greater functional intonation range. The highs are higher and the lows are lower in a melodic form of speech. Women�s speech is softer in intensity with a lower decibel level. And then there are the verbal clues, such as the use of intensifiers and superlatives in women's speech. Such as, "Your daughter is so-oo beautiful !". Women frequently use question's at the end of sentences, like "don't you think?" and "isn't it ?"  Women use extensive adjectives and a wider range of descriptive colors than men. And then there are the non-verbal methods of communication, which are distinctly different. Women touch more, look directly at the other person and move closer to your face. Women gesture more with the upper body, arms and hands to convey a message. Believe it or not these are all socially acquired patterns and skills which have developed over a lifetime. So what is a fully transitioned 24/7 person, who has developed all of the physical attributes of the opposite sex but not the voice, to do.

The answer is a professional, well qualified voice therapist or speech pathologist, who has a Masters or PhD in Voice and the machinery to measure your pitch and sound quality. Because we all know that we never recognize our own voice, so we don't know how we sound to others. Then you can begin the long and arduous process of training your voice to reflect your gender. For the FTM TS, the process is much easier because Testosterone thickens and improves the muscular tone of the vocal cords, but not always.  This usually lowers the pitch as seen in the Testosterone surge of male puberty.  For the MTF TS, the process is more difficult because Estrogens have a minimal effect on muscle in the beginning, but eventually will cause some vocal cord thinning. For the MTF TS, it will take one to one and one-half years of weekly sessions to raise the pitch into the female range. With practice, you can achieve a 5 Hz increment every 2-3 sessions.  And "How do you get to Carnegie Hall with your new voice?". Practice, Practice, Practice! At the moment Voice Therapy is only considered practical for TSs and not CDs, because you must be using what you have learned constantly to affect physical changes in the vocal cords. Ideally you would like to improve your pitch by an octave, but like weight loss, the difficulty is maintenance. The older you are the less far you have to go, because the normal female voice drops in pitch from the squeaky teenager to the aging grandma. But what if you are still not satisfied with your voice after 2 years of voice therapy.

There is then the surgical option, but it should be your last surgery because the very act of throat intubation through the vocal cords for any further surgery will loosen and destroy the work that had been previously been performed. The most common procedure used to elevate the pitch of the MTF TS is the modified procedure of Isshiki described in the 1970's as the Type IV, Crico-thyroid Approximation (CTA). The thyroid cartilage or the laryngeal voice box contains the vocal cords stretched in a front to back alignment and below is the Cricoid Cartilage separated by the membranous Crico-thyroid window, which is obliterated with the CTA procedure. The Isshiki, aims to alter the voice pitch by stretching the vocal cords. This enhances the Crico-thyroid muscles with minimal risk to damaging the cords, which are untouched. This in turn thrusts the voice box forward accentuating the Adam's Apple.
 
Simultaneously the Adam's Apple may be shaved or the upper part of the voice box removed without damaging the cords. This is known as Thyroid Chondroplasty. There is greater risk here to the cords because with injudicious shaving their support may be weakened. The reported series in the Otolaryngologic literature in recent years are small, approximately 45-50 patients each times four series. The procedures are usually performed under local anesthesia and sedation with a small transverse neck incision in a skin fold. Four non-absorbable sutures are placed into the lower portion of the Thyroid Cartilage and attached in a vertical direction to the lower Cricoid Cartilage.
 
They are then pulled together and the patient is asked to say a phrase to judge the result. Usually they are pulled to the maximum distance allowable without pulling out of the fragile cartilage because with time and movement of the throat they will loosen resulting in a lower pitch toward the preoperative voice. You will never go below your pre-op pitch.

Modifications include Titanium sutures and mini plates, silicone bolsters to keep the sutures from pulling out in the future and incorporation of surrounding soft tissues within the sutures for stability. Approximately one week of voice rest for healing is required post operatively. There are very few complications of bleeding or infection. All patients had been on a hormone regimen for at least 3 years pre-op. The subjective patient results suggest an 80% improvement rate and objectively about 70%, when tested. A few patients move into the truly female range of 180 Hz, but most end up in the 125-160 Hz range, which is considered deep female. The failures to achieve any pitch improvement were all smokers with smoker's cough. Control of breathing and subglottic pressures are essential to favorable outcomes. Therefore throat clearing is to be minimized, but was seen as a complication in 10% of patients post op. It is probable that the tension in the vocal cords will decrease with time as it does in real life. So post operative voice therapy is still essential and helpful. Most TS's drop out of follow up therapy for many reasons.

Best of Luck in Your New Future,

Cerise Richards, M.D.