(154) Finding One’s Voice: A Review on Satisfaction and Quality of Life After Voice Feminization Surgery

Introduction Voice is a central marker of gender identity and a key element of gender-affirming care. In transfeminine individuals, vocal femininity is strongly associated with higher pitch, as voices with elevated fundamental frequency (F0) are typically perceived as more feminine. Hormone therapy rarely induces female vocal characteristics due to irreversible structural laryngeal changes arising during puberty. Therefore, voice feminization relies on speech therapy, also known as voice therapy (VT), and/or surgical interventions, primarily targeting pitch elevation. While success is multifactorial, many individuals continue to experience vocal dysphoria. Patient-reported satisfaction and perceived gender congruence are essential outcome indicators, but assessment remains challenging due to inconsistent methodologies and limited standardization. Objective This review aimed to evaluate the efficacy and quality of life (QoL) impact of voice feminization interventions in transgender women. The study sought to quantify the efficacy of various interventions, compare surgical approaches to VT, and analyze the use and validation of patient-reported outcomes (PROs). Methods A literature review was conducted using the PubMed database through October 2025. Search terms included combinations of “voice feminization surgery”, “transgender”, “transfeminine”, “satisfaction”, “quality of life” and “validated questionnaire”. Studies including transfeminine individuals undergoing voice feminization surgery and reporting subjective outcomes such as satisfaction, QoL, or validated self-assessment measures were selected. Extracted data included surgical technique, objective and subjective outcomes, and findings related to satisfaction and psychosocial impact. Results Twenty-four studies involving 893 participants were included. Both VT and surgical procedures resulted in significant speaking fundamental frequency (sF0) improvements. Surgical interventions - including feminization laryngoplasty (FL; g=3.05), Wendler glottoplasty (WG; g=1.21), and laser reduction glottoplasty (LRG; g=12.28) - generally showed greater F0 gains compared to VT alone (g=0.86) (P < .0001 for all). PROs indicated enhanced QoL for VT (g=1.32), WG (g=1.82), and LRG (g=1.90). A strong, statistically significant correlation was observed between pitch alteration (sF0/F0) and improved QoL (r2=0.83, P = .0001). Results remained highly heterogeneous across all measures (I2>96.20%), often due to differences in surgical technique and limited data on novel procedures. Outcome reporting is further challenged by the persistent use of unvalidated instruments such as the Voice Handicap Index (VHI) and Voice-Related Quality of Life (V-RQOL), despite the Trans Woman Voice Questionnaire (TWVQ) being the validated gold standard for assessing gender-specific vocal QoL. Moreover, acoustic durability (such as after WG) does not guarantee sustained long-term subjective satisfaction, as voice-related QoL scores may gradually decline over time. Crucially, acoustic measures alone cannot ensure that a voice is externally perceived as female. Conclusions Voice feminization interventions enhance vocal pitch and are strongly correlated with improved QoL. Surgical interventions generally offer greater objective and subjective gains than VT alone. However, the field is limited by high methodological heterogeneity, scarce data on emerging techniques such as FL and vocal fold shortening with retrodisplacement of the anterior commissure (VFSRAC), and inconsistent outcome reporting. Broader adoption of validated PROs like the TWVQ and the implementation of comprehensive frameworks integrating acoustic, subjective, and perceptual measures are essential to advance evidence-based gender-affirming voice care. Disclosure No