Vocal surgery

This page provides a brief summary of gender affirming vocal surgeries and offers guidance to help you support your trans patients if they undergo these surgical interventions. 

Vocal surgery is a surgical process intended to change the pitch and/or tone of one’s voice. There are several different kinds of surgery, which depend on the surgeon in question and a person’s needs and wishes. Vocal surgery is typically sought by trans people who were presumed male at birth (PMAB), including women and non-binary people, as estrogen-based hormonal affirmation cannot change the tone or pitch of the voice. 

Not all trans people want, seek or can have surgery, and being trans doesn’t necessitate surgery either. Find out more about that here.

Information for community members about vocal surgery is available here. 

The Standards of Care - 7th Ed (SoC7) is published by the World Professional Association for Transgender Health (WPATH) and offers guidance to clinicians working with trans patients all over the world, including criteria and recommended referral pathways for those seeking particular medical and surgical interventions.

The SoC7 does not specify an order by which surgeries should occur, if sought at all, and are guidelines, not legislated requirements.

WPATH states that surgeries modifying the face and/or neck, while often labelled as “purely aesthetic”, “these same operations in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a given patient’s condition and life situation. This ambiguity reflects reality in clinical situations, and allows for individual decisions as to the need and desirability of these procedures.”

WPATH also recommends that “although these surgeries do not require referral by mental health professionals, such professionals can play an important role in assisting clients in making a fully informed decision about the timing and implications of such procedures in the context of the social transition.”

There are several kinds of surgical options, and the procedures chosen will depend on the surgeon’s expertise and the physical capacity, and needs, of the patient.

There are several kinds of vocal surgery: 

Anterior glottal web formation

Shortens the vocal cords to help raise the pitch of the voice by reducing the ability to produce lower pitches. It also narrows the airway. 

Cricothyroid approximation

Elongates the vocal cords by fixing the cricoid cartilage to the thyroid cartilege. Studies have found that this technique doesn’t last as long as other surgical options. 

Vocal Fold Shortening and Retro-displacement of the Anterior Commissure

VFSRAC is a newer surgical technique which involves simultaneously shortening the vocal fold length, and also increasing vocal fold tension through the partial removal of superficial vocal cord tissue and the bringing together of the vocal folds using sutures, whilst trying to maintain the natural funnel shaped configuration of the under-surface of the front of the vocal cords (folds). MBS item numbers for VFSRAC may include: 41879 (laryngoplasty) and 41864 (microlaryngoscopy and removal of tumour – this code may be used despite the lack of tumour as some vocal fold tissue is removed).

Before surgery

At appointments in the lead up to surgery, your patient might like to discuss their expectations and concerns, as well as their hopes and fears. It will be important to have an open conversation about what surgery can and cannot do. They may have been waiting many years for this particular surgery and feel that they have a lot riding on it. They may not be part of a supportive network or could be the centre of a thriving friendship circle. They might be clear about what they need from you, or really unsure. 

Your patient will also need to be referred to a mental health professional for support and assessment to confirm readiness for surgery.

Finding comprehensive, evidence-based information about gender affirming surgical processes can be a challenge, and so your patient might benefit from your additional research, including contacting a specific surgeon, if requested, or connecting with other health professionals to better understand and explain the process, possible complications, risk factors and outcomes. 

It’s also likely that a patient’s GP will be the first point of contact for any post-surgical care and complications, so having a sense of what might be happening, and being able to engage with additional clinician peer networks could prove advantageous. 

Surgery location

If your patient is contemplating surgery in Australia, it is prudent to encourage them to obtain private health insurance when and if they can afford it. This will help cover some of the costs such as the hospital stay. Their surgeon will be able to provide the applicable MBS Item Numbers that can be checked with the health insurer. 

If a patient is considering having surgery overseas, they will very likely appreciate a discussion about the benefits and risks of travelling overseas for surgery. This can be complex, especially if the surgery they’re seeking is not performed, or widely available, in Australia. 

For some patients, benefits can include cost saving, particularly if they’re not able to access private health insurance or Medicare in Australia, having greater choice of surgeons and being connected to a global community of trans people (we do a great job of offering comprehensive surgical reviews to the community).

Risks tend to arise from a lack of access to post-surgical care, including being able to effectively, and efficiently treat complications. Additional complications can arise if a patient is not being able to take the requisite time off work or study, and inadvertently damaging the surgical site. 

Around surgery

Around the point of surgery, the surgeon and their staff will typically be supporting the patient through any fears and complications.

Some surgeons require patients to decrease hormones, particularly estrogen, for a period of time in the lead up to, and immediately following, surgery. Your patient may want to discuss time-frames, expectations, and potential side effects from this. 

After surgery

As well as providing regular post-surgical care for your patient, you might find yourself supporting them through learning how their body now functions and feels.

Even if a surgical outcome is affirming for people, it can still be confronting. Discuss with your patient that it is normal to feel excited, but also very normal to feel overwhelmed, uncomfortable, to grieve, and to take time to become used to their body again. This isn’t an indication that they have made a mistake, or regret their decision, but a normal part of reconnecting with how their body appears and functions.

It can also be valuable to discuss how sensation may change, and what this might feel like. Having an honest conversation about how your patient will need to learn this for themselves over time can be helpful too. Refer to peer networks or a mental health professional, as needed.