Addressing The Voice Is A Critical Component Of Gender Affirming Care

One of the principal components, although often under-recognized, of gender affirming care is addressing the voice as a critical part of the treatment process. Issues of pitch, vocal breathy quality, resonance, volume as well as external visibility of the laryngeal cartilage, commonly known as the “Adam’s Apple” are some of the myriad issues that need to be discussed with individuals and their care team. The issues are complex, with no singular component or multiple components that apply to all patients. And there is not one unique voice intervention that can address pitch, range, or visible appearance.

In recent years. there have been marked improvements in identifying even the most subtle aspects of voice care for the transgender community. One notable improvement has been in addressing the prominent cartilage in the neck, especially for patients wishing to have a more flattened Adam’s apple. Dr. Abie Mendelsohn, a voice surgeon in Los Angeles who devotes much of his work to the multidisciplinary care of the voice, has perfected a new technique in minimally invasive reduction of a prominent Adam’s apple. Traditionally, this procedure is known as a “tracheal shave,” although the trachea (windpipe) itself is not involved.

The procedure itself, which in the past was performed using a small skin incision overlying the cartilage of the voice box, is actually called a “chondrolaryngoplasty” (chondro=cartilage; laryngo=voice box; plasty=surgical repair) or a “laryngeal chondroplasty.” Dr. Mendelsohn and colleagues now perform this technique with no scars, entering the tissues of the voice box via the inside of the lip with tiny telescopes and endoscopic instruments. The procedure takes 60 to 90 minutes, and patients go home a few hours after the surgery. Recovery is usually just a few days of healing. As the voice box itself is not entered during the surgery, the changes from this particular procedure will be solely related to the visible contour of the neck.

However, Dr. Mendelsohn emphasizes that this procedure is just one aspect of gender affirming voice care: “Treatment for gender affirming voice care, regardless of feminization or masculinization, centers around the voice therapist. This medically necessary treatment option should be covered by supportive insurance plans and is provided by a licensed and experienced speech language pathologists. This treatment option differs greatly from “voice coaching” which is more closely compared to singing lessons. A good treatment plan focuses on retraining the voice to affirm true gender identify and does not focus on performing.”

Voice therapists who work with gender affirming care approach treatment as a means to better represent communication goals for the individual. Areas such as pitch, intonation, rhythm, resonance, rate, and volume can be approached and tailored both before and after hormonal and/or surgical therapy.

Hormone therapy for voice masculinization or feminization are also key components. Voice masculinization can be achieved with testosterone therapy, but may also include voice therapy and even a surgery known as a thyroplasty, which may lower the vocal pitch. The trade-offs for this procedure include an external scare on the neck as well as some weakening of vocal strength, oftentimes creating a ‘breathy’ effect. Vocal feminization includes hormones, as well as voice therapy and occasionally an endoscopic laryngeal surgery. One type of surgery can shorten the length of the vocal cords (with no external scar) and this has been found to improve long term voice outcomes in these patients.

While there are many innovative techniques, including those in both voice therapy and surgeries, there continue to be hurdles in access to care. Difficulties in insurance coverage, challenges in allotted time off from work and travel distance to receive care are some of the many obstacles throughout the process of voice work. In addition, Dr. Mendelsohn mentions that despite the fact that this scarless approach to shaving down the Adam’s apple has been around for over three years (he’s performed over 130 of these procedures), the procedure is not yet well known in the transgender community.

And while this component of voice care does not, in itself, change the voice, performing it safely (not entering the voice box, for one) and efficiently (minimal surgery time and minimal recovery time) will hopefully bring this option to the forefront of multidisciplinary care for this patient population.