Vocal surgery

This page provides a brief summary of gender affirming vocal surgeries and offers guidance to help you support trans and gender diverse people 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 performing the procedure and a person’s needs and wishes. Vocal surgery is typically sought by trans people who were presumed male at birth (PMAB), including trans women and non-binary people, as oestrogen-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 on our ‘Am I trans enough?’ page. 

Information for community members about vocal surgery is available here.  

Standards of Care (SOC8)

The Standards of Care – 8th edition (SOC8) are published by the World Professional Association for Transgender Health (WPATH) and offer guidance to clinicians working with trans and gender diverse people all over the world, including criteria and recommended referral pathways for those seeking particular medical and surgical interventions.  

The SOC8 do not specify an order by which surgeries should occur, if sought at all, and are guidelines, not legislated requirements.  

WPATH states that ‘lack of accurate information about options for voice and communication services among [trans and gender diverse] people is a significant and ubiquitous barrier to care’

They also recommend that ‘health care professionals consider working with transgender and gender diverse people who are considering undergoing voice surgery consider offering a referral to a voice and communication specialist who can provide pre- and/or postoperative support’.

What happens during vocal surgery 

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. 

Anterior glottal web formation

The surgeon 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

This procedure elongates the vocal cords by fixing the cricoid cartilage to the thyroid cartilage. 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 that involves simultaneously shortening the vocal fold length and 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). 

Supporting your trans patient through surgery

Before surgery

At appointments in the lead up to surgery, your client 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.  

Although not one of the criteria mentioned in the SOC8, your client’s surgeon might request that they 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, so your client 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 client 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 client 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 trans and gender diverse people, 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 client 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 trans person through any fears and complications. 

Some surgeons require trans and gender diverse people to decrease hormones, particularly oestrogen, for a period of time in the lead up to, and immediately following, surgery. Your patient may want to discuss timeframes, expectations, and potential side effects.  

After surgery

As well as providing regular post-surgical care for your client, 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 client that it is normal to feel excited, but also very normal to feel overwhelmed or 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. 

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