In some cases, vocal therapy or gender-affirming hormone therapy (GAHT) alone are not effective at altering voice enough to reduce voice dysphoria. If this is the case, phonosurgery (surgery performed to alter voice) may be the next step.
Phonosurgery has mostly been used and researched in the context of transfeminine people, as oestrogen GAHT does not provide the same effect on changing pitch as testosterone GAHT does, meaning that transfeminine people are far more likely to seek phonosurgery as a component of transition.[1]
What types of phonosurgery are used?
Methods of phonosurgery commonly used for pitch raising include:[2]
- Cricothyroid approximation – This technique involves pulling the cricoid and thyroid cartilages closer together to increase the tension of the vocal cords.
- Shortening glottoplasty (using cold knife or laser) – This technique involves using a scalpel or laser to scrape the edges of the top 1/3 of the vocal folds where they come into contact. This section is then stitched together and allowed to heal. This reduces the amount of vocal fold surface which vibrates, increasing the pitch of the sound produced.
- Laser reduction glottoplasty – Using a laser, a small amount of the mass of the vocal cords is removed. By reducing the thickness of the vocal cords, they are able to vibrate faster and produce a higher pitch.
Methods of phonosurgery used for pitch lowering include:
- Type III thyroplasty – a small vertical strip of the thyroid cartilage is removed. This decreased the front-to-back distance of the larynx, which reduces the tension of the vocal folds and reduces the pitch of the sound produced.[3]
- Other options, such as injections designed to increase the mass of the vocal cords to slow vibration[4] or injections of testosterone directly into the vocal cords[5] have been trialled, but the evidence for their effectiveness long-term is still limited.
What are the risks of phonosurgery?
As with all surgeries, phonosurgery carries some risks. Post-operatively, it is expected for there to be a period of transient vocal quality change. Longer term risks include:[6]
- Permanent hoarseness or roughness of the voice
- Vocal loudness reduction
- Loss of access to high/low pitch range, which can affect singing and cause pitch breaks
- Pitch not being lowered/raised as much as desired
- Need for revisional surgeries
Of course, your surgeon should discuss all of the potential risks and benefits with you and help you to make an informed decision about whether or not phonosurgery is appropriate for you.
Where can I access gender-affirming phonosurgery?
Currently, Monash Health’s Ear, Nose and Throat (ENT) Department offers phonosurgery through the public health stream. It is important to note that their waitlists are often long. If you have the means to seek private surgical options, a list of private surgeons can be found through AusPATH (scroll to ‘Surgeons’).
Footnotes
[1] Nolan, I. T., Morrison, S. D., Arowojolu, O., Crowe, C. S., Massie, J. P., Adler, R. K., Chaiet, S. R., & Francis, D. O. (2019). The Role of Voice Therapy and Phonosurgery in Transgender Vocal Feminization. Journal of Craniofacial Surgery, 30(5), 1368–1375. https://doi.org/10.1097/SCS.0000000000005132
[2] Song, T. E., & Jiang, N. (2017). Transgender Phonosurgery: A Systematic Review and Meta‐analysis. Otolaryngology–Head and Neck Surgery, 156(5), 803–808. https://doi.org/10.1177/0194599817697050
[3] Rendon, E. D., Bassoff, L., Chalela, G., Kabat, N. M., & Rutt, A. (2026). Type III Thyroplasty for Vocal Masculinization in Transmasculine Patients: A Scoping Review. Journal of Voice. https://doi.org/10.1016/j.jvoice.2026.07.050
[4] Webb, H., Free, N., Oates, J., & Paddle, P. (2022). The Use of Vocal Fold Injection Augmentation in a Transmasculine Patient Unsatisfied With Voice Following Testosterone Therapy and Voice Training. Journal of Voice, 36(4), 588.e1-588.e6. https://doi.org/10.1016/j.jvoice.2020.08.011
[5] Vahabzadeh-Hagh, A. M., Walsh, E., Hamidi, V., & McCowen, K. (2023). Voice Outcomes From Direct Vocal Fold Testosterone Injections, a Case Report. The Laryngoscope, 133(5), 1211–1213. https://doi.org/10.1002/lary.30556
[6] Dwyer, C. D., Schneider, S. L., Gutierrez, D., & Rosen, C. A. (2023). Gender-Affirming Voice Surgery: Considerations for Surgical Intervention. Seminars in Speech and Language, 44(2), 76–89. https://doi.org/10.1055/s-0043-1761948
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