Pitch Alteration Techniques for Transgender Women: A Systematic Review of Surgical and Nonsurgical Approaches.

Abstract

Objective: To systematically evaluate and compare the effectiveness of surgical and nonsurgical pitch elevation techniques in transgender women using acoustic outcomes and validated patient-reported outcome measures (PROMs).

Methods: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Comprehensive searches of Ovid MEDLINE, Embase, CENTRAL, PsycINFO, CINAHL, and gray literature were completed through January 2025. Included studies involved transgender women (≥18 years) undergoing pitch elevation via surgical (Wendler glottoplasty [WG], cricothyroid approximation [CTA], vocal fold shortening and retrodisplacement of the anterior commissure [VFSRAC], and laser-assisted voice adjustment [LAVA]), laser-reduction glottoplasty [LRG], nonsurgical (voice therapy [VT]), or combination approaches. Eligible studies reported both changes in fundamental frequency (F0) and validated PROMs, such as the Voice Handicap Index (VHI) or Trans Woman Voice Questionnaire (TWVQ). Risk of bias was assessed using the Cochrane Risk of Bias Tool and Newcastle-Ottawa Scale. Data were synthesized narratively with weighted means calculated for key outcomes.

Results: Twenty-two studies (N = 977) were included. VFSRAC yielded the highest mean F0 increase (+73.3 Hz), followed by WG (+54.1 Hz), VT (+39.9 Hz), CTA (+30.3 Hz), and LAVA (+26 Hz). WG + VT showed comparable F0 gains (+54.5 Hz) with more consistent outcomes. TWVQ scores improved most with WG + VT (-47.9), followed by WG (-29.0) and VT (-18.7). VHI scores improved most with LAVA (-48.0) and WG (-21.7); VFSRAC and CTA showed modest PROM improvements. Adverse events, including granuloma and vocal fatigue, were more common with surgical combinations. Follow-up ranged from 2 weeks to 4.4 years, with most studies reporting 6-12 months.

Conclusion: Surgical and nonsurgical interventions both elevate pitch and improve voice-related quality of life. Surgery provides greater F0 gains, while combining VT enhances patient satisfaction. Findings support individualized care and the need for standardized PROMs in future studies.