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J Craniofac Surg. 2019 Jul;30(5):1368-1375. doi: 10.1097/SCS.0000000000005132.

The Role of Voice Therapy and Phonosurgery in Transgender Vocal Feminization.

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New York University School of Medicine, New York, NY.
Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA.
Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL.
Emeritus Faculty, Speech Language and Hearing Sciences Department, Minnesota State University Moorehead, Moorehead, MN.
Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.



Nonsurgical and surgical options are available for transgender vocal feminization. This systematic review explores the efficacy of feminizing voice therapy and phonosurgery.


A systematic review was performed using PubMed, Cinahl Plus, Ovid SP, Web of Science, Science Direct, and Google Scholar with terms related to transgender phonosurgery and voice therapy. Included studies were outcomes-based vocal feminization interventions for transgender women. Data were collected on pre- and postintervention fundamental frequency (F0), externally measured vocal femininity, patient satisfaction, and complications.


Two hundred twelve studies were identified and 20 met inclusion criteria. Postintervention patient satisfaction was approximately 80% to 85% for voice therapy, endoscopic shortening, and cricothyroid approximation. Complications were reported for each phonosurgery technique, most commonly decreased mean phonation time and loudness. Of the 20 studies, 17 were used for meta-analysis of F0 change. F0 increased by 31 Hz with voice therapy alone, 26 Hz with laser reduction glottoplasty, 39 Hz with cricothyroid approximation, and 72 Hz with endoscopic shortening.


The literature supports both voice therapy and phonosurgery, depending on a patient's magnitude of desired pitch change and tolerance for cost and potential complications. Most will likely benefit from voice therapy, as it is highly satisfactory, raises vocal pitch, and is noninvasive. However, endoscopic shortening is also highly satisfactory and provides the greatest absolute increase in vocal pitch. If surgery is chosen, postoperative voice therapy may additionally increase F0, stabilize the voice, and create a more female timbre. However, further studies will be necessary to provide definitive clinical recommendations.

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