A way of making a person’s voice better reflect their gender

Voice surgery for transgender individuals may be an option for individuals who experience dysphoria about their voice and have not been helped enough by the practice of voice therapy.

Purpose

Voice therapy can be helpful for people who are learning to speak in a way that is read as more masculine or feminine. It can also help people, to a degree, make their speaking voices sound a certain way. However, it does not adjust the fundamental pitch of the speaking voice.

Transmasculine individuals often experience a deepening of their voice when on testosterone-driven gender affirming hormone therapy.1 This is because testosterone causes lengthening of the vocal cords.2

In contrast, transfeminine people do not experience a shortening of their vocal cords when they take estrogen. Therefore, if they are uncomfortable with the pitch of their voice, or feel as though it is not congruent with their gender, they may seek voice surgery.

Voice surgery is generally not recommended until people have tried voice therapy, which is a less invasive way to address voice dysphoria or discomfort.

Types of Transgender Voice Surgery

Most transgender voice surgery performed is feminizing voice surgery. In order to affect pitch, voice surgery is used to address one of the physical characteristics of the vocal cords that determine pitch. These are vocal fold tension, length, and mass.3 There are a number of different procedures that can be used to adjust these characteristics

Cricothyroid Approximation

Criciothyroid approximation (CTA) increases tension in the vocal cords by tilting the larynx and sewing the lower border of the thyroid to the Adam’s apple cartilage. This has been shown to increase voice pitch.

It also makes the thyroid notch more prominent, which is an undesirable side effect. (Indeed, many individuals combine voice surgery with a reduction in the size of the Adam’s apple.) This surgery is not recommended for individuals under 30 because younger patients do not yet have solid thyroid cartilage.4

Anterior Commissure Advancement

Anterior commissure advancement (ACA) is another tension modifying surgery. It was initially developed to treat medical conditions that affect the tension in the vocal cords. However, it generally does not affect pitch enough to be useful for transgender women.4

Anterior Glottic Web Formation

Anterior glottic web formation describes procedures that are used to shorten the length of the vocal folds. This can be done using a number of different techniques. These include both external procedures, done through the neck, and endoscopic procedures, done from inside the throat.3

Laser Reduction Glottoplasty

Laser reduction glottoplasty uses a laser to vaporize parts of the vocalis muscle and surrounding structures in order to change the density of the vocal folds. Originally used for cases where CTA had failed, it is now sometimes used in combination with CTA to take advantage of both density and tension changes and increase the magnitude of the pitch effects of surgery.4

Who Performs Transgender Voice Surgery

Voice surgery procedures should only be performed by surgeons who are specifically trained in the modification of the voice, ideally the modification of the transgender voice.

When surgery is performed by people who lack appropriate training, outcomes may be undesirable. People may lose range in their voice or experience other undesired vocal effects, including hoarseness.

Voice surgery is most often performed by ear, nose, and throat specialists, otherwise known as otolaryngologists. Such surgeons have advanced training in working with the structures of the throat.

However, not all otolaryngologists have experience with pitch modification. It is reasonable to ask doctors about their experience performing this surgery and if they can share samples of voice changes they have achieved using their work.

Eligibility

Unlike many other gender affirming surgeries, there are no specific eligibility requirements for accessing gender affirming voice surgery. However, most ethical surgeons will encourage patients to work with a voice therapist before undergoing surgery.

Voice therapy can address gendered aspects of the voice, and may affect people’s desire to undergo surgical modification of the vocal folds. Voice therapy may also be required after vocal surgery, in order for individuals to learn to use the changed structures of their throat.

People who are unable or unwilling to engage with voice therapy, and see surgery as a quick fix, may not be appropriate candidates, because where recommended, voice therapy is an important part of surgical recovery.

Association of Voice With Gender

Voices are, quite literally, the first way that most people communicate with the world. Whether talking on the phone or calling out to a friend across the room, our voices are a big part of how we are perceived.

Indeed, many of the assumptions we make about people’s identities reflect our perceptions of the way they speak. These assumptions are not only those related to gender, People often think they can determine other characteristics by hearing someone’s voice—including their race.5

What about a person’s voice is associated with gender? Although we think of women as having higher voices than men, pitch is only the most obviously gendered aspect of the voice. Gender is also associated with volume of speech as well as the ways that people pronounce different vowels.

The fact that perception of vocal gender is multifaceted is why vocal surgery is rarely performed in the absence of therapy for vocal technique—pitch change alone is unlikely to affect whether a person’s voice is heard as male or female.

A Word From Verywell

Having a masculine voice is a predictor of improved well-being for transmasculine people.6 The same is true for transfeminine people, and various aspects of the voice have been found to be associated with quality of life.7 Not every transfeminine person is interested in voice therapy or surgery. However, for some people it can be very important for their well-being.8

This may be particularly true for women who spend a lot of time using their voice—like teachers, or phone support providers—because being repeatedly misgendered can take an emotional toll. Vocal surgery may also have the potential to reduce the risk of other forms of transphobia and discrimination.

The post What Is Voice Surgery for Transgender Individuals? appeared first on MyMedicPlus.

When the U.S. Supreme Court in 1994 decided a case involving a transgender individual’s rights, it looked to the American Medical Association to medically define the plaintiff who asked the court to protect her.

Dee Farmer was assigned at birth male, but identified as female. She wore women’s clothing, underwent estrogen therapy, received silicone breast implants and underwent an unsuccessful “black market” testicle-removal surgery. Farmer, who was serving a federal sentence for credit card fraud, sued federal prison officials for violating her Eighth Amendment rights to not be subjected to cruel and unusual punishment while in prison.

Farmer had continued hormone therapy and presented as female in prison, according to court records. She was generally separated from the male population at the first prison she was housed, in part for behavior and in part for safety. After being transferred to another prison, she was placed in a general population where she said she was beaten and raped.

The Bureau of Prison’s medical personnel had diagnosed Farmer as transsexual and justices in their opinion turned to the AMA’s 1989 Encyclopedia of Medicine for the medical definition quoting that it was “[a] rare psychiatric disorder in which a person feels persistently uncomfortable about his or her anatomical sex,” and who typically seeks medical treatment, including hormonal therapy and surgery, to bring about a permanent sex change.

The Litigation Center of the American Medical Association and State Medical Societies and 10 other medical organizations noted that this definition was out of date in an amicus brief they filed in a 2017 case, Adams v. School Board of St. Johns County, Florida.

“It is now understood that being transgender implies no impairment in a person’s judgment, stability, or general social or vocational capabilities,” the brief stated. “Gender dysphoria is a condition characterized by clinically significant distress and impairment of function resulting from the incongruence between one’s gender identity and the sex assigned at birth.”

The court in Farmer v. Brennan sent the case back to the lower court for further consideration of whether prison officials knew the risk, with the high court justices ruling that prison officials could be found liable for denying an inmate humane conditions if they knew of or disregarded an excessive risk to the inmate’s health or safety.

Farmer ultimately lost the case during the retrial, but the Supreme Court ruling was precedent-setting.

AMA Litigation Center gets involved

Since 1994, the AMA on numerous occasions has stood up for transgendered individuals’ rights in court, with the Litigation Center filing friend-of-the court briefs.

The AMA Litigation Center gets involved in cases when the AMA has policy on an issue. The Association has a number of policies involving LGBQT rights, including that public and private health insurers cover treatment of gender dysphoria as recommended by the patient’s physician. Policy the House of Delegates adopted at the 2018 AMA Interim Meeting calls on the Association to, among other things, oppose any efforts to deny an individual’s right to determine their stated sex marker or gender identity and to affirm that gender for many individuals may differ from the sex assigned at birth.

Advocating in Penn., Wisc.

In 2018, the AMA Litigation Center joined other health care organizations in filing an amicus brief asking the 3rd U.S. Circuit Court of Appeals to uphold a policy that allows Pennsylvania high school students to use a bathroom or locker room that matches their gender identity rather than their sex assigned at birth can be left in place.

The appellate court in its ruling in Doe v. Boyertown Area School District upheld the policy. The students who filed the lawsuit seeking to have the policy thrown out are now asking the U.S. Supreme Court to consider the case.

The AMA Litigation Center also advocated on behalf of transgender individuals’ rights in 2011 when it joined with other health care organizations in filing an amicus brief in the 7th U.S. Circuit Court of Appeals in a case that asked whether a Wisconsin law prohibiting prison doctors from using hormonal therapy or sex reassignment surgery to treat inmates with gender identity disorder was legal.

In Fields v. Smith, the 7th Circuit upheld a lower court decision that withholding treatment was cruel and unusual punishment under the Eighth Amendment and deprived inmates of equal protection guaranteed under the 14th Amendment.

The post AMA advises U.S. Supreme Court on transgender individuals’ rights appeared first on MyMedicPlus.