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Voice feminisation surgery

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Voices typically associated with femininity have a higher pitch than those typically associated with masculinity. However, pitch is only one aspect of that distinction. Intonation, resonance, vocal quality and articulation all play a role in our social perception of a voice as "feminine", as do  language, loudness and non-verbal communication.

During puberty, a person assigned male at birth develops a larger larynx (voice box) with longer vocal cords (14mm vs 10 mm). In addition, under the effect of testosterone, muscle bulk within the vocal cords increases. The longer, bulkier vocal cords vibrate at a lower fundamental frequency (pitch). The average speaking pitch of adults assigned males at birth is approximately 107 to 120 Hz, while for  those assigned female at birth it is 189 to 224 Hz. Voices pitched over 165Hz are generally perceived as feminine.

The fundamental frequency of the vocal cords (as with strings in a musical instrument) is related to their length, bulk and tension. Surgical pitch increase can be achieved by changing these parameters. The bulk of the vocal cords can’t be reduced once a person has gone through puberty, so surgery will aim to either shorten the cords (glottoplasty) or increase tension (cricothyroid approximation).

Before and after voice feminisation surgery


The aim of this procedure is to adjust the proportions of the vocal cords. Vocal cords in those assigned female at birth are shorter than in those assigned male at birth. Glottoplasty reduces the length of the vibrating segment of the cords leading to higher pitch.

The procedure is performed endoscopically via the mouth with no external wounds or scars. Using a CO2 laser, the lining of the front part of the cords is removed and the two sides are sutured together (diagram at the top of the page). The voice can be further fine-tuned using the laser to ‘tighten’ the vibrating segment of the cords.

If there is not sufficient pitch increase, there is also the option of Vocal Fold Muscle Reduction (VFMR).


Vocal Fold Muscle Reduction (VFMR) 

VFMR is a new technique aimed at reducing the volume of the vocal folds. The procedure requires only minimal postoperative voice rest and mild pain relief. It is performed under general anaesthetic endoscopically, via the mouth, resulting in no external wounds or scars. A CO2 laser is applied along the full length of each of the vocal folds. The laser decreases the mass of vocal fold while causing the resulting scar to stiffen, this in turn increases the pitch of the voice to bring it within the expected range of an adult who has not been through a male puberty.

This procedure can be performed in isolation, in cases where smaller pitch elevation is required, or for professional voice users who don’t wish to risk a loss in vocal volume. It delivers high rates of satisfaction with minimal complications. It can also be performed in addition to Wendler’s Glottoplasty, if it is felt that the pitch increase achieved with this procedure is insufficient.

Voice masculinisation

Surgery to lower the voice is rarely required in transmasculine people, as taking testosterone will lead to structural changes of the vocal cords lowering the pitch. However, there are surgical options available to cis and trans men to deepen their voice including window laryngoplasty or Type 3 (relaxing) thyroplasty.

Cricothyroid approximation (CTA)

This procedure increases the tension of the vocal cords, in the same way guitar strings are tightened, leading to increase in pitch. The procedure will involve placing permanent suture between the cartilages of the voice box via an open surgical approach under general anaesthesia.

CTA results can be more variable compared to glottoplasty with lower pitch elevation and success rate. The procedure will be an appropriate first line procedure if endoscopic technique is not possible for example in individuals with severe restriction of mouth opening or neck movement.

Tracheal shave (Adam’s Apple reduction)

This can be a stand alone procedure or combined with glottoplasty or CTA. The procedure will change the feminine contour of the neck. The degree of the reduction is limited by the position of the vocal cords as damage to the attachment of the vocal cords (anterior commissure) will lead to permanent damage of the voice.

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