The voice, which we use daily in order to communicate concepts and emotions, contributes significantly to our gender identity.
Voice tonal height (or pitch), high or low, is given by the frequency of the sound, which is the number of the cycles of opening and closure of vocal cords per second. Frequency of vibration of vocal cords depends on their length, their mass and their tension; it is therefore possible to elevate the pitch of the voice by increasing the tension and/or reducing the mass and/or length of the vocal cords. The female voice has a tonal height between approximately 170 and 230 Hz (Hz are the unit of measurement of frequency), while the male voice ranges from approximately 90 to 140 Hz. The feminization of the voice can take place through a speech therapy path that always accompanies the surgical one.
It is emphasized that what is written below by the co-authors has been agreed with the representatives of the ISS and in any case represents an inevitable simplification of what is necessary for the feminization of the voice, having only an informative purpose. The specifics of the path are fully explained to the patient by the specialists in the context of the first visit and at the time of acquiring informed consent for any surgery.
Before being able to undergo any surgical procedure, the person concerned must:
Elsewhere and at other times, the following procedures will be carried out:
The evaluation of the speech specialist will allow us to understand if it is necessary to undertake a rehabilitative speech therapy process before undergoing the intervention and if there are indications for the intervention itself. Generally, an assigned male at birth trans person uses a falsetto register (stretching the vocal cords when speaking), that should be abandoned before performing the intervention to change the voice pitch.
In general, if taking any prescription drug, one should discuss it with the speech specialist and anesthesiologist. It may be necessary to stop taking it several days before the surgery. Pharmacological treatment can be resumed at the doctor's discretion. On the contrary, it is not necessary to interrupt any hormone therapy that may be taken.
The most widely used surgery to raise the pitch of the voice is the cricothyroid approximation (type IV tyroplasty) which can also include a remodeling of the Adam's apple (a protuberance that is observed mainly in males in the area of the neck). The cricothyroid approximation raises the voice pitch by increasing the tension of the vocal cords. The surgery begins with an incision on the skin of the neck of about 3-4 cm. Subsequently, we proceed with the approximation (approximation) of the thyroid and cricoid cartilages. The thyroid cartilage is the cartilage structure that forms the aforementioned Adam's apple on the outside of the neck and which contains the vocal cords inside. The cricoid cartilage is shaped like a ring and forms the lower part of the larynx. Anteriorly, the two cartilages are joined through the cricothyroid membrane. Through the application of some stitches, the two cartilages are brought closer to each other, thus causing a stretching of the vocal cords and an increase in the tone of the voice. The skin is then sutured with an aesthetic stitch (type of suture that generally guarantees less visible scars). If necessary, a small drain is applied (thin tube that allows liquids to escape into a small bag connected to it) which will be removed in the days following the surgery. Finally, some patches are placed on the suture. The surgery is performed under general anesthesia. The duration of the surgery varies according to the surgical difficulties
Another intervention used to raise the pitch of the voice is glottoplasty which acts on the length of the vocal cords by reducing their vibrating part. The operation is carried out with an endoscopic approach in microlaryngoscopy (i.e. without external cuts), by inserting a rigid metal tube (laryngoscope) into the mouth which, with the use of the operating microscope, allows you to view the interior of the larynx and therefore the cords vowels. The mucous membrane of the anterior part of the vocal cords is removed, by using micro scissors and peeler or the CO2 laser, and then the previously "decorticated" anterior portion of the vocal cords is sutured; in this way the length of their vibrating part is reduced. Glottoplasty is performed under general anesthesia. The duration of the surgery varies according to the surgical difficulties.
Hospitalization is 1-2 nights (it can vary based on the clinical course and needs).
After cricothyroid approximation surgery (type IV thyroplasty), the person will have to observe a period of absolute silence of 7-10 days. Such silence is of crucial importance and its non-observance can strongly compromise the final result. In the postoperative period after glottoplasty surgery, the person must speak with a whispered voice and avoid coughing, to consolidate the suture of the vocal cords and prevent premature rupture of the sutures, which are reabsorbed in about three weeks.
The first phoniatric/speech therapy check-up is scheduled 7-10 days after the operation while, approximately 3 weeks after the operation, the person will have to undertake a speech therapy rehabilitation process to optimize the surgical result and harmonize the "new voice" in the social context, work and family. A quarterly check is also recommended at least for the first year after the intervention.
Like all medical and surgical acts, even if conducted with competence and experience, in accordance with current standards of science and regulations in force, even cricothyroid approximation surgery can involve risks of complications, albeit infrequent.
Among these we remember:
Among the complications related to the voice it is possible to have:
As for the glottoplasty operation, the most important possible complication is the rupture of the suture between the anterior part of the vocal cords, which can occur especially if the person does not comply with the prescribed behavioral rules and post-operative therapies. It follows that the elevation of the pitch of the voice does not reach the expected result and dysphonia appears due to the reduced vibration of the anterior part of the vocal cords which had been "decorticated" and the anterior glottic commissure no longer has an acute angle. In these rare cases, glottoplasty revision surgery is performed.
Pre- and post-surgical visits and instrumental examinations are carried out with regular payment of a health ticket, taking into account any exemptions. The surgery is not the responsibility of the person, when it is carried out under the agreement, while when it is carried out in a self-employed regime, it provides for an economic contribution. In some locations, speech therapy rehabilitation (pre and post surgery) is the responsibility of the person.