For a high percentage of transgender women, the voice represents a very important feature to consider in the journey undertaken in their transition. The fact that their voices do not reflect the vocal tone that they consider appropriate for their outward appearance may potentially influence their social, professional and personal life. For this reason, the first question to be asked before beginning the process of feminization of the voice is: do I feel that my voice reflects my true self?
WHAT MUST WE KNOW ABOUT THE PROCESS OF VOICE FEMINIZATION?
The first thing to know is that hormone therapy with oestrogen has been shown to have little effect on the voice quality. Therefore, to rise the vocal tone we would need to act on the larynx as well as the vocal behaviour.
Although normally the largest group of people that choose the voice feminization surgery are transgender women. We can also find this surgery being performed on cisgender women that suffer androphonia (lower voice tone, “manly voice”) due to the excessive consumption of androgens or different diseases that are testosterone producers, like polycystic ovary syndrome or Klinefelter’s syndrome. Today, there is an increasing demand for this intervention in actors, singers, humourists and other professions that belong to the showbiz.
At the beginning, people opted for vocal therapy (speech therapy) as the sole and exclusive method to feminize the voice. This built up due to different reasons:
- The technique is safe and non-invasive.
- Lack of experience in the different surgical techniques.
- Bad on-line reputation concerning the voice feminization surgery, only the negative results where published, probably due to an economic interest.
Nevertheless, in the last years there has been a substantial change in this philosophy thanks to the documents published by different groups of researchers like Dr. Rihkanen in Helsinki (Finland), Dr. Remacle in Brussels (Belgium), Dr. Thomas in Portland (USA), Dr. Anderson in Toronto (Canada), Dr. Ballestas in Barranquilla (Colombia) and Dr. Casado in Marbella (Spain).
Thanks to all these clinicians and researchers, they have come to different conclusions:
- There are currently different surgical techniques to increase vocal tone; some are performed by external cervical approach and other by endoscopic approach (through the mouth, without leaving any type of external scar). All of these contribute with very favourable results, with a high degree of satisfaction by the patient and, at the same time, with very little possibility of difficulties during the surgery.
- Like any surgical activity is not assured without risk or with no negative vocal results. With the experience gained over the years. We can say today that the risk has minimized to anecdotal figures. With respect to the negative results, they are very rare and the ones that appear on the web are usually old due to the little definition of the surgical technique. However, if we have a negative result, what can we do? Faced with poor postoperative vocal outcome, specialists can now intervene to correct the defect healing and, at the same time, have a complementary speech therapy.
We should not forget that in the process of voice feminization a multidisciplinary team intervenes, the team is formed by the ENT surgeon and specialist speech therapist, they both collaborate closely to obtain positive results.
- Vocal therapy (speech therapy) is not exclusive but complementary to the surgery and must be essential after this.
WHAT IS OUR WORKING METHOD?
The perception of the voice as stereotypically masculine voice or stereotypically feminine voice depends on the speaking fundamental frequency, but, although it is the most important factor, other aspects of the language intervene like the intonation, vocal resonance, laryngeal joints, breathiness, modulation etc.; in other words, to obtain a more stereotypically feminine voice, we should act on the frequency or the tone as well as the vocal behaviour.
To increase the vocal tone we use a surgical technique called Wendler Glottoplasty with personal modifications or vocal laser techniques.
To change the vocal behaviour, we use vocal therapy (speech therapy).
This is why our method consists of the union of surgery and postsurgical speech therapy.
However, a transgender woman can come to our clinic, and after completing a laryngoscopy, speech therapy and acoustic study we could conclude that the patient has a sufficiently high vocal tone to be exempt from any type of surgical intervention.
WHY IS SOLELY SPEECH THERAPY NOT THE BEST METHOD?
Speech therapy or voice therapy in this case consists of, by means of exercises; change the vocal gesture, the vocal behaviour acting on the intonation, the modulation, the breathing, etc. Almost all transgender women attending our clinic have had speech therapy sessions, in these, they have learned to alter their vocal tone on a daily basis, and in many cases have felt ashamed or frustrated if their voices returned to the original tone because of their own vocal fatigue or during physiologically human reactions such as laughter, cough, yawning, sneezing, screaming, pharyngeal clearance, etc.
We believe that the ideal, after all the transition process that these women have gone through, would be that their voices would naturally have a high vocal tone without having to think about how to make it more feminine in each phonation, without having to be imitating it permanently. Once the larynx of the transgender woman has been surgically transformed into an anatomically female larynx, and consequently the vocal tone has risen, vocal therapy will secure this definitive change if one has to worry or concentrate before each phonation.
To summarize all the stated previously, we can use this real testimony, “Ever since they intervened in my voice, I can speak without having to think before; I do not feel frustrated, people do not confuse me with a man when I speak on the phone. My voice now fits my woman’s body. “
Finally and based on my personal experience, if the demand is for a lower pitch, a stereotypically male voice, this can be achieved by hormonal therapy (by a specialized endocrinologist). If what the patient wants is a more stereotypically feminine voice, in this case the patient should refer to a specialized multidisciplinary team (an ENT surgeon and a specialized speech therapist) to decide, prior Laryngoscopy and acoustic studies, if the patient can get it by speech therapy, in cases where the patient has a sufficiently high tone; or by surgery and postoperative speech therapy (which is most preferred in the present).