Note: This blog is 18+ and NSFW. However, this post does not contain adult content, with the exception of NSFW images which may display in other suggested posts at the very bottom.
I am going to Dr. Simon Best at Johns Hopkins for voice masculinizing surgery in about two weeks. He is an otolaryngologist for the Johns Hopkins Center for Transgender Health, recommended by Dr. Devin O’Brien-Coon, the plastics and micro surgeon who built my penis. Dr. Best has done voice altering procedures for transgender women, but I believe I may be the first trans person going there to have their pitch lowered. I have been on testosterone for about five years, but I had a very high-pitched voice originally, and T only did so much for me. I landed ultimately in an androgynous range. I need that bass!
This post will outline:
1. Getting started with an appointment to see Dr. Best
2. My interview and scope with Dr. Best
3. Voice therapy
4. The surgical plan
5. Pre-op and these last two weeks before surgery
Getting started with an appointment to see Dr. Best
About a year and a half ago, to get started, I called Dr. Best’s appointment line from his website for an appointment. Nerts! They needed a referral. I circled back to plastics at the JHCTH, and their physician assistant called in the referral for me. It was about three months before I could be seen for an appointment. Dr. Best’s office is located in the Johns Hopkins Outpatient Center on the otolaryngology floor, below the plastics floor. I was going in for plastics follow ups and occupational therapy on my donor arm hand, so it was convenient to just spend the whole day there in appointments.
My interview and scope with Dr. Best
I was met first by Ashley Davis, SLP, the voice therapist. She did an interview with me about my experience with my voice, my occupation, and what kinds of issues I have because of my voice. I told her about how I have trouble calling my bank, because they think maybe I am a woman on the phone trying to perpetuate some kind of identity theft against myself. I have had clients of a sort call me and not believe it is really me on the phone, since my voice doesn’t match my picture. Or, when I go up to a podium to speak, people act with alarm or confusion. It makes doing my work or interviewing more challenging, when people’s first reaction to me is suspicion or confusion. It outs me, right off the bat. That was noted in my chart as a significant impairment at going about my daily life.
I read some passages for her recording, which she analyzed using her computer. She had me make some sounds which she also recorded. She sprayed my throat with a numbing spray and dropped a scope down my nose into my throat. It tickled a little at first but was not as uncomfortable as you might imagine. Then, I read the passage again and made more of those sounds. The scoping was recorded.
Then, Dr. Best came in and we made our introductions. Ashley Davis made summaries of my experiences, and they compared notes on how the effects of my pitch had an impact on my life. They discussed with me my use of testosterone and how it might have had a chance to lower my pitch already enough. They conferred a few moments analyzing the read outs and chattering together. Then, they played the scope and observed the structures of my throat and speaking mechanism.
Dr. Best explained to me that since I have already been on T so long, I already have a voice developed to the male range. In their read outs, they noted that my pitch capacity overlaps well into the common male range, but I had trouble speaking with those pitches. They observed vocal strain and pain when I attempted to speak in the lowest part of my voice, as well as an unnatural sounding tone; they observed an elevated larynx [voice box]. They examined my throat interior for any other structural concerns. They noted feminine-typical prosody in the pitch of my voice, such as in the range of pitches I use in a single sentence, the length of my utterances, a faster feminine-coded rate, and an increasingly high pitch speaking on a topic which excited me. They recommended a few months of voice therapy to observe if therapy could support accessing the lower part of my voice.
I noted Dr. Best is friendly, attentive, unhurried, and demonstrably intelligent. He appears nerdy, warm, and without arrogance. He is an obvious ally of the transgender community. If I recall correctly, I first met him during the tail end of my time in Baltimore recovering from stage 1.
I started voice therapy a few sessions with Ashley Davis, while I was in Baltimore recovering from my phalloplasty stage 2. Coming back to my home city of Dallas, Texas, I asked if they had any colleagues in the area with whom they would recommend I continue my therapy. They had a colleague at University of Texas Southwestern Medical Center, and once back in Texas I met this colleague briefly and then transferred to her therapist. I saw this therapist weekly for about three months. We worked on a vocal strain reduction program called Stretch and Flow. I could see in their chart software, MyChart, that my therapist was staying in coordination with my team in Baltimore.
The therapist I saw in Dallas was Amy Hamilton Harris, M.A., SLP. She taught me stretches which would reduce the strain I felt when vocalizing the proper male pitches for my voice maturity. We would practice these each session, and she recommended I do them every day. These stretches involved pressing down on certain muscles around my collar bone while turning the head and neck to stretch those muscles. She taught me other stretches I could do hourly to reduce cumulative strain using the lower part of my voice, in particular a type of yawn to open my throat more. In the program Stretch and Flow, there were levels of mastery to accomplish for increasing the amount of breath support and reduced airiness, for moving the pitch to be more nasally resonant than not. I also had homework in blowing through small straws. She called this Resonant Therapy.
The ultimate outcome of therapy with Amy Hamilton Harris is that I know how to reduce the stress and strain on my voice from using the lower part of my voice, but only through time consuming exercises that interrupt daily life. For example, I can do the exercises in the car on the way to a meeting where I will be speaking, and the relaxation around my larynx drops the voice box in my throat such that I can make lower tones more comfortably. I have more skill in moderating my prosody to sound more masculine or more straight, but it does take quite a bit of effort mentally. However, when I do it, it is more likely to be read male, even if the pitch is in the androgynous range. I greatly enjoyed her professionalism, welcome, and skill.
After about three months, I requested a call from Dr. Best to check in with him about the therapy he ordered for me. I explained that I have more control over my voice, and I feel less strain and pain, but the exercises and constant effort is exhausting. I asked if it is time to consider a surgical option which would be more effective and sustainable. He agreed and said we would talk in a few weeks to finalize a surgical plan, and my time in voice therapy came to a close.
The surgical plan
As promised, Dr. Best called me to discuss our surgical plan. I suppose if i lived closed than 2,000 miles away, he might have just had me come in to the office, but this was a special circumstance.
Dr. Best described I would be having Type-III thyroplasty, not an uncommon procedure, but uncommon in its application for a transgender person. For most trans men, the androgens are all it takes, but for some reason, I cannot access the lower tones without pain and discomfort. This procedure, then, is extremely rare in my population.
The type III laryngioplasty is related to the puberphonia techniques used in Spain. Dr. Best is close with a Dr. Isabella Garcia Lopez in Spain, with whom he devised this approach for me. It is similar, he said, to a surgery they perform every week at Hopkins, medial laryngoplasty. They will cut the cartilage and physically manipulate it so that it is slightly pushed back, shortening the effect of the cord. With the vocal cords shortened, we expect the voice to be immediately lowered, reducing conscious effort to produce the lower pitch appropriate to me. Interestingly, the vocal therapy given me was also the same as that given to young men with puberphonia.
Following surgery, we expect that I will not use my voice for a few days. There will be a glued incision on the front of my neck, not very large. There will be no drains in this procedure. I would require no training to learn to use this voice, but my voice would be rough for a period of time. I would be able to hear the final result after 4-6 weeks.
We discussed risks. The main risk of the surgery is related to reduced tension in the shortened vocal cords, which lends itself to instability when attempting to yell at full volume. That will be permanent, some momentary breaks in the pitch of my voice if I try to shout or sing at full volume. My very, very loudest shout may not be as loud as it once was. (I imagine this will be most serious when I am shipwrecked on a desert island, calling to the ship or plane in the distance, waving my arms and firing my last flares. I’ll say, “If only my voice were a bit louder!“) Dr. Best said that muscles in the throat have to be able to tense to shout, and this procedure specifically reduces tension in the voice.
So that I do not have to come back to Baltimore in two weeks for follow-up, he suggested that I do a follow up with colleague Dr. Ted May at UTSW in Dallas. I do love how connected Johns Hopkins is with all of these other surgeons all over the world. His office manager would range a referral for me.
This more describes the present. In the 30 days before surgery, they require bloodwork sent in, bloodwork taken in the 30 days before surgery.
Pre-op and these last two weeks before surgery
I received an email from Dr. Best telling me which items I would need to have faxed to Dr. Best’s office:
1. Physical examination
2. Labs: CBC, CMP, PT, PTT. The two below are not required based on my age; however, if I have any other health conditions (like cardiac problems, pulmonary disease), which my physician will determine if I need.
3. Chest x-ray if previously indicated by my physician. If one has been dated within six months, it does not need to be repeated.
4. EKG if previously indicated from your last exam. Same rule applies for six months.
I have an appointment with my general physician tomorrow to get those tests done.
As with other medical travel, I am to send flight plans in to the office manager for approval by Dr. Best. I usually plan to come in the day before with time for flight delays, should it happen. I planned to stay in town three or four days, and I added a buffer day of a fifth day since the flights were cheaper then. I have not yet booked a place to stay, but it is about time I do that.
I always fly Southwest for medical, since there is no fee to change dates if my surgery has to be rescheduled or I need to stay longer to recover. I’ve hear other airlines will reimburse fees if there is a medical reason for rescheduling, but life is so hectic for me around surgery, I don’t usually want to bother with that process.
I usually like to stay in a bed and breakfast rental near Johns Hopkins, which is much less costly than a hotel– I’ve had a beautiful time staying in rooms and apartments in Mount Vernon and Fells Point, and one time I even stayed in a houseboat in the harbor (billed a yacht, but it was so small I think that’s a bit of an exaggeration). At one point I used points from my credit card to rent a luxurious apartment, the fanciest I’ve ever seen, to celebrate finishing bottom surgery.
I’ve got just over two weeks until my date. I’ll make some recordings of my voice before surgery, so we can compare the differences. I have that same feeling of butterflies as before my bottom surgery, that same feeling of not knowing what is going to happen or what it will cost me. I feel like I am about to make a great leap, and I feel great joy. My family is supportive and happy for me.
Dr. Best’s office says the financial office can run my insurance and tell me what I will owe, which the hospital will bill after surgery. I would be in the same plan year as my phalloplasty stage 3, but alas, I changed insurances, so I’ll have to pay all over again. Fortunately, Hopkins offers payment plans, so we will cross that bridge when we get to it.
Dr. Coon did turn to me very seriously when I last saw him and told me that this surgery had a high chance of killing me. Taken aback, I was silent, “It would certainly kill you not to be allowed to talk for three days,” he broke into a chuckle. I all but punched his arm for the tease. Oh, I do hope I will get to visit with him when I come through town. I spent so much time with him in my stages of surgery that I feel a bond with him. At the very least, I would like to bring him a treat from Texas, a token of appreciation for the many years he spent in study and delayed gratification over this specialization, and how it has changed my life so much for the better. He already knows, but maybe he and the staff might like some local salsa and Tejano candy.