Voice Feminization Surgery
Voice Feminization Surgery (VFS), founded and directed by Dr. Juan Carlos Casado, have treated multiple transgender patients and guarantees optimum results.
The surgical technique (Wendler glottoplasty) has been modified and developed throughout the training and learning years. Our patients get a specialized voice therapy after the surgery.
Dr. Casado is an expert voice surgeon and regularly invited as speaker of his speciality, Feminization Voice Surgery, to many scientific conferences. He has recently published the only article of voice feminization (Wendlers glotoplasty) in Spanish, explaining his surgical technique and excellent results.
Dr. Casado at the Central University Hospital of Helsinki (Finland)
Dr. Juan Carlos Casado has made a stay in the first days of September at the Central University Hospital of Helsinki (Finland).
This hospital is a reference center for laryngeal pathologies, as well as voice feminization of transgender women in the Scandinavian countries.
In this stay, directed and coordinated by the professor Dr. Teemu Kinnari (otolaryngologist) and the professor Dr. Ahmed Geneid (otolaryngologist and phoniatrician), Dr. Juan Carlos Casado has known first hand the surgical novelties in voice feminization, as well as techniques of laryngeal infiltration of different substances and performing biopsies on an outpatient basis under local anesthesia.
Regarding the update in the surgical treatment of the voice feminization, we have worked mainly on two lines: the first in the change of the suture, the use of a non-resorbable nylon suture is currently being tested. It has the advantage that the closing of the vocal cords remains unchanged with the passage of time, therefore, it could be a good novelty. Technically it is more difficult to work with this type of suture.
The second line of work, with respect to the surgical treatment of the voice feminization, consisted of performing a synechia or a much deeper anterior scar, that is, producing not only a de-epithelialization of the vocal cords, but also a de-epithelialization of the anterior part of the subglottis. The goal is to get a more oval glottis, a funnel glottis, that would simulate the anatomically female larynx.
In such a way that, with these two modifications, the change of suture and the deepening in the scar that is generated, it seems that more satisfactory results will be obtained. And that is what Dr. Juan Carlos Casado and the Helsinki group are working on.
Interview offered by Dr. Juan Carlos Casado Morente to Mrs. Concha Montes for ‘Marbella en la Onda’ of Onda Cero Marbella
Transcript of the interview
Dr. Casado welcome
Thank you very much Concha.
The transition process a transgender woman goes through is difficult, long, complicated … clinically, emotionally and socially. In addition to hormonal treatment, sex reassignment surgery, the feminization of their face; This seems to me a last step that is to give a more feminine tone to her voice. This book that you present on Friday is focused precisely on the health professionals involved but also on the transgender woman herself and on groups and associations.
Indeed, not necessarily the voice – increasing the vocal tone – is the last thing that transgender women do, but the book is a desire, a challenge that we set ourselves a few years ago. Until now there was nothing in Spanish literature, we needed to give an answer to transgender women who came to our office and asked us how they could increase their vocal tone, how could they have a sharper voice, more in keeping with their outward appearance.
From time to time, I deduce, because much has also advanced in the acceptance, as it could not be otherwise, social of these people, has also advanced a lot in terms of numbers, to people who submit to that vocal feminization. Not doctor?
Indeed, as it has been visualized, we have more experience, more calls, more visits … think one thing, when I was trained in this type of surgery, the voice feminization surgery with a technique called Wendler’s Glotoplasty, I trained in Helsinki, Finland. And in Finland, to give you an idea, approximately a patient, a surgery, monthly, approximately twelve patients a year. This is now super-surpassed, now we are here in Marbella, we are intervening two or three patients a month.
Spanish, foreigners ..?
Well the vast majority are not Spanish, are usually from Europe, there are many girls from Europe, Poland, Italy, England, some Spanish, very few Andalusians.
I have a disciple who trained here with me in Marbella, who is doing the same thing in Colombia, in Barranquilla, so the American, South American, North American, and Central American girls tend to go to Colombia more, because of a distance and ease for them.
Because, doctor, it’s curious, or I find it. The taking of estrogen, what is the female sex hormone, does not naturally soften the vocal tone, you have to operate, right?
Indeed, that is the kit of the question and we do not know why, on the contrary, yes, that is, a transgender man takes male hormones, takes testosterone and his voice becomes more deep. However, a transgender woman takes estrogen, specifically the 17 Beta Estradiol, or anti-androgens and the voice does not change anything at all, hence the need to give a response to these women.
The intervention, the voice feminization surgery, is a complex, difficult operation, has a complicated post-operative?
It is a technically complex operation because you have to work in a very small place, which is the space that there is in the vocal cords, specifically in the anterior commissure, that is, our work space is approximately 6 millimeters. But one very important thing is, not only surgery, because our method is surgery associated with post-operative speech therapy. The laborious thing is not only the surgery, but the post-operative, fundamentally because they have to be 15 days of absolute voice rest, do you think that is easy? 15 days without speaking anything?
Well, in my case, no, but we are talking about a greater effort. Finally doctor, on Friday during the presentation of the book a young transgender woman is going to talk about her experience with you, she has lent publicly to do it, it is the best way to make transgender visible and also to face the issue of the voice feminization, right?
She is a girl that I am very grateful for, normally they do not want to visualize themselves on a personal topic, but she said that if I presented the book that she came to Marbella, she does not live in Marbella or live in Andalusia, but here she will be with us, God willing, Friday.
And let’s finish with a very brief example. A transgender girl, young thirty and a few years old, before the operation. Do we hear, doctor? … .. And this would be the result after the operation done by you. …… Very happy not doctor?
Yes, notice that the post-operative voice and the post-speech speech is not the same text, we did it on Skype. This is a girl who lives in America, and the revisions were made by Skype, that’s why she did not read the text and she told us in her testimony.
A testimony of life, a testimony of happiness. Doctor Juan Carlos Casado, ENT specialist in feminization of voice, also a vanguard in our country. Thank you and good afternoon.
Thanks Concha, see you next time.
Introduction: Did you know that one of the most critical problems that the transgender person presents is the voice? Throughout the last decades the concern for the problems of the voice has gone from considering a medical care to an extraordinary directed to professionals of the voice or elite singers to be part of the concept of health. There is a growing demand for a higher, more feminine vocal tone. The largest group corresponds to that of transgender women, who want to feminize their voice.
Dr. Juan Carlos Casado, what is the feminization of the voice?
Hello good afternoon, voice feminization basically consists in increasing the vocal tone, in increasing the frequency with which that voice is produced. To understand voice feminization we have to make a small anatomo-physiological memory of human phonation. There is an acoustic parameter called fundamental frequency and this is the number of times the vocal cords open and close per second. We, depending on the fundamental frequency, can distinguish a stereotypically masculine or stereotypically feminine voice. There is a “magical” number that is 165 Hz, such that a voice above 165 Hz is perceived as a stereotypically feminine voice and below 165 Hz is perceived as a stereotypically masculine voice. For example, the listeners will be listening to me and will perceive a male stereotyped voice, the fundamental frequency of my voice is 137 Hz. So in the voice feminization what is intended is to increase the vocal tone, increase the frequency of the voice above of 165 Hz.
And who are the people who demand us to increase the fundamental frequency of the voice?
As you said, basically the most numerous group is that of transgender women. But not only are transgender women, there are also cis women – that is, women whose sex is according to their gender – and they have endocrine disorders that have an excess of testosterone, which for example can be the Morris syndrome, the Klinefelter syndrome, Polycystic ovarian syndrome. But undoubtedly the most frequent group is that of transgender women. Probably some listener will be wondering, and the voice feminization can not be achieved with a hormonal treatment? Well the answer is totally negative. In the same way as testosterone, that is, androgens if they produce a vocal tone below 165 Hz, however, the use of estrogen, the use of 17 beta estradiol does not affect the voice at all. If it would alter for example the breast development, the disposition of the hair in the body, but it does not affect at all the vocal tone. That is why we must give an answer to transgender women who want their voice to be in accordance with their body, in short: voice feminization.
And how do you do that? How is the voice feminized?
Well, the voice is feminized with a method that we have designed and we are pioneers in Spain, which consists of a surgical technique plus post-operative speech therapy. Surgical technique consists of converting an anatomically male larynx into an anatomically female larynx, producing a shortening of the vocal cords, decreasing the mass of the vocal cords and increasing the tension of the vocal cords. This is done with a surgical technique called Wendler’s Glotoplasty with a personal modification resulting from the experience of approximately 6 or 7 years ago, which we have been reviewing. After performing the surgical technique, post-operative speech therapy is very important. For this, a speech therapist from our team called Soledad Angulo Serrano, is responsible for modifying the vocal gesture. And why do we have to modify the vocal gesture? As I said at the beginning, the fundamental frequency, the vocal tone, is what we can perceive if a voice is masculine or feminine, but there are also other factors, such as intonation, resonance, laryngeal articulation, kinesia, which is the way of speaking. All this constitutes what is called the vocal gesture. The modification of the vocal gesture is done with speech therapy. So the surgeon, in this case me, what I do is modify the shape of the larynx and the speech therapist what she does is modify the vocal gesture.
Remember in the book “Feminization of the voice: multidisciplinary approach of the transgender woman” collects the knowledge available today on this topic and helps the transgender woman to understand in a global way the journey undertaken by her in her transition.
Interview in rtvMarbella, to Dr Juan Carlos Casado, on the occasion of the presentation of the book “FEMINIZACIÓN DE LA VOZ: ABORDAJE MULTIDISCIPLINAR DE LA MUJER TRANSGÉNERO”
CONTENT OF THE INTERVIEW
We are going to continue speaking about the presentation of a book that has been creating a lot of expectation and interest of a topic that Marbella’s being pioneer. The medical community is doing great progress in this topic and this book collects all this information serving as a guide or as a manual of the voice feminization and the transgender interventions. Today we have with usDr. Juan Carlos Casado, one of the authors of the book and also co-director of the ENT service in Quiron Marbella Hospital.
Welcome Doctor, good morning. A book that collects, or mainly focus as the title says in the voice feminization, but you were commenting before that you are trying to give a more global approach right?
Yes, as an ENT, the main theme of the book is about the voice feminization, but then we gave another secondary title, “A multidisciplinary approach of the transgender women”, I mean that we don’t only talk about the voice feminization aspect, although still remains the central theme, we also talk about sex reassignation surgery called vaginoplasty and facial feminization.
There is a complete chapter of facial feminization, that I have to publicly mention that is masterfully written by the facialteam group of the HC clinic, a group preside by Dr. Luis Capitan and Daniel Simon with all the international prestige that precedes them.
Also a group of endocrinologist explains the hormonal influence in all the transition process of the transgender women. We are also creating another chapter explaining concepts like gender dysphoria, gender identity disorder and all the process of transition including the legal aspect. I think is a summarized and complete guide.
Is it a medical guide? For doctors?
With the purpose of extending our readers, not only focusing in doctors we have tried to write it with a non technical simple common language. But of course is also for medical professionals, like the chapter that describes the surgery of the voice feminization, that maybe it doesn’t creates too much interest in a non medical person.
I’ve tried to explain the different techniques that exists for the feminization of the voice, but is not only for doctors but also for associations, persons interested, speech therapists of course, medical students, phoniatric students and speech pathologists.
A particular issue the voice feminization, but also the facial feminization in which Marbella is also being pioneer, for example, here in Marbella the first intervention was made in 2013, right?
Exactly, the first intervention was made in June of 2012. We performed 3 surgeries, with the special invitation of Dr.Teemu Kinari, of the Central Hospital of Helsinki, my professor in this type of surgeries. A person that I am very grateful and of course I dedicate this book.
An important issue for the transgender women, it seems a minor topic of all the process of sex change , but once this medical, surgical and pharmacological process is over, the voice represents an important factor?
The voice issue is very important, because besides what you just said of the transgender women is correct, hormones doesn’t have influence in the voice. I mean, they can take all the amounts of estrogens and estradiol that you want without modifying the voice tone.
On the contrary, testosterone does have influence in the voice of a transgender man.
Transgender women with hormone therapy can develop mammary growth, they can experience change in the hair growth and fat pattern, but it doesn’t have an influence in the voice, thats why it is important to have a solution for this.
In our book presentation we had a testimony of a patient, already a friend, that had the procedure done a year ago, unfortunately she couldn’t be present but she gave her testimony live from Barcelona via Skype. She explained the effect of the voice feminization in her life, her life changes, and self-esteem in the matter of her voice. A simple action for all of us like speaking on the phone, represents a real problem for them, of course the worst thing is when people answers them: yes sir?
Of course I understand after passing through a process of years to have an image according to your identity, at the end when you speak you ruin all the process.
That’s right Roberto, and even more when the image is not visible or even when the image is visible but the voice doesn’t agree with the external aspect, they usually get shy, don’t participate in some acts or they get out little, it has a high social impact.
And with this intervention do they get a more feminine voice?
We really have spectacular results, the first surprised being me with these results, because this is not a thing we get prepared in our specialty. At first I was cautious.
I have to say,all this is a process and a team, you invited me and here I am, but there should be a lot of people here too, beginning with my secretary Isabel Quiñones, she is the one that does the first contact with the patient resolving all the questions and doubts that usually generates this patients. Once this is resolved they come to consultation and the surgery that I perform with the collaboration of another Dr. (Dr. Jeany Wong). After the surgery, speech therapy begins with another important integrant of the team, Soledad Angulo, a speech therapist specialized in voice feminization. I’m sure that if this was only about the surgery (my part) this book wouldn’t exist.
Of course, after surgery they need to learn how to speak with the new vocal folds?
That’s correct, surgery change the larynx original form to a more anatomical feminine larynx. But then we have to change the vocal gesture. Women vocal gesture is different from male vocal gesture in intonation, resonance, articulation and movement. All this is accomplished by the speech therapist.
This means this is work that not only consists of a surgery and thats it. Then it will be months of speech therapy?
Exactly, here I am only a part of the whole process
A process in which not only the feminization but also all the procedure of sex change have an important psychological component and that maybe is not completely approached. That’s why it can be a pain-full process, not only physically speaking.
Totally, we have a lot of anecdotes, for example, we have had girls in the medical consultation that come with their mother saying that they don’t come with their father because “my father still doesn’t accept me”, so imagine the situation. And then when the voice tone changes, the father comes accepting the situation because now other people doesn’t notice the incongruence.
Of course, unfortunately, all the transgender topic, all the LGTBI has a fight,but of course it can be much more stigma with a physical woman with a masculine voice, they can’t pass unnoticed. Is there a masculinization voice surgery?
Much less frequent because of what I said before, the body responds better to the testosterone hormonal treatment, but in the cases that the results is not sufficient we can perform a type III thyroplasty, that makes voice deeper, making it more stereotypically masculine. We have only made one of these.
Feminization voice surgery, I am sure is not that common of a surgery, but you still do a couple of them per month. Does a lot of people comes from other countries to do this intervention?
The majority, in fact I could say that more of the 50% are from outside Spain. We have also performed surgery in Cis Women, I mean, women with their sex according to their gender but they have an endocrine disorder with excessive androgens that wants a voice feminization surgery.
Are you saying they are women that since childhood have a deep voice and want to change it with surgery?
Exactly, and surgery acts exactly in this cases, we have had girls with Morris syndrome, that is an endocrine disorder and Klinefelter syndrome and its already solved. At the end the main objective of this team is to help the transgender women or at least improve their voice. This emerged because in 2010 an actress came to my consultation because they had to put voice actors or dubbing actors when she acted because she was a transgender woman and she asked me for a solution. At that moment I had no idea what to do to solve her problem as I told her, but I also told her to wait, that I was going to call her in a year. And that was the first surgery of voice feminization made in Marbella.
So I guess she saw in other parts of the world that there was a solution for this problem?
That’s right, I have always been specialized in the voice and voice disorders. Iam the author of three books before, but only of the voice. So thats why she came to me to see if I could help her, and as I say , I told her I couldn’t help her at that moment but in the future, this anecdote made me investigate and study this. I went Finland to learn and then to Colombia to execute it, because in Colombia there is a high demand of this type of surgeries and thank God everything went well and now we can help many people.
Have you been teaching this technique to other surgeons in Spain?
I have been having presentations in many congresses, now I have a course in Madrid on March 16 (Hospital La Paz) about an up to date in the voice, we do this course every 4 years in Spain. We already presented it in Pamplona, Murcia and the American academy.
And are they doing this procedure in other parts of Spain or they don’t dare to do it?
I think is not being made in other parts of Spain, probably because they don’t dare.
Do you think that the “to see what happens” that you felt at the beginning is what they are experiencing now?
Is because it is scary, it’s important to have a team. We, surgeons, are used to do surgeries, do our job and thats it. We don’t see the patient unless there is a complication, but this is different, is not only about surgery but a process to follow to get the desired result. And I think that is the scary part, if you don’t have all the parts of the chain well equipped then there is uncertainty.
Well, I hope they don’t learn that fast, this is a good factor to Quiron Marbella, good for the city because they can presume of having good hospitals, doctors and professionals. Congratulations and above all for the success of the book