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Jess speaks with Dr. James Thomas, a laryngologist who may be the leading expert in pitch-altering vocal surgeries. They talk about what options are available, what kinds of results are possible, and what to expect in terms of recovery and complications. Surgeries discussed include the Cricothyroid Approximation, Feminization Laryngoplasty (FemLar), and Vocal Cord Webbing.
Click here to watch a video of this episode.
Click here to watch a video of this episode.
- (00:00) - Show Intro
- (01:34) - Introduction to Dr. James Thomas
- (03:43) - Stroboscopes
- (04:52) - A Rare Sub-Sub-Specialty
- (06:59) - Voice Physics: Pitch vs Resonance
- (10:42) - Testosterone and Voice Changes
- (12:15) - The Cricothyroid Approximation
- (15:04) - Cricothyroid Approximation Results and Drawbacks
- (18:15) - Inventing "Femlar"
- (23:31) - Femlar: Before and After
- (25:29) - Success Rates and Real Outcomes
- (27:42) - Risks, Complications, and Revisions
- (30:54) - Webbing and Lasers
- (32:59) - Choosing Surgery Options
- (34:42) - Recovery Timelines
- (36:30) - How Pitch Range Shifts
- (37:38) - Trachea Shaves
- (40:18) - Transparency About Complications
- (44:06) - Revisions vs. "Tuneups"
- (47:35) - Ethics and Patient Vulnerability
- (51:34) - Insurance and Political Climate
- (55:01) - Voice Surgey and Voice Therapy
- (01:00:09) - Future of the Field
- (01:02:04) - Pitch Lowering
- (01:03:47) - Closing Thoughts
- (01:06:22) - Credits
Creators and Guests
What is The Words Don't Fit the Picture: Gender vs. Voice?
What happens when your voice no longer matches your gender identity? Join host Jess Lupini as she explores the strange and tangled relationship between gender and voice. Through interviews with linguists, trans people, voice training experts, doctors, surgeons, storytellers, and much more, The Words Don't Fit The Picture will take you on a journey through what we know — and what we've still yet to fully understand — about how our voices and gender identities affect one another.
James Thomas Interview Podcast v2
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Show Intro
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[00:00:00] Jess: Hey everybody. Jess here. I'm a science communicator, musician, comedian, and filmmaker living in Vancouver on the unceded territory of the Musqueam, Squamish, and Sleight Tooth Nations.
[00:00:11] I decided to make this show because I'm also a trans woman. When I came out, I knew transitioning would be hard, but I, I don't think I quite realized just how complicated the relationship between voice and gender really is. Part of how I process my own thoughts and feelings is by learning as much as I possibly can.
[00:00:29] So I decided to bring you along on the journey with me as I searched for answers to some big questions about how we speak and the way it's tangled up in our identities. If you like moving pictures along with your words, you can find the video version of this episode on YouTube. Let's jump in.
[00:00:46] Hey everybody. I'm Jess Lupini, and this is The words Don't Fit the picture, the show where we untangle the strange and fascinating relationship between gender, voice, and identity. Whenever you get a group of trans people together talking about voice, something that invariably comes up is the topic of voice surgery.
[00:01:16] That is to say, surgically altering the pitch or quality of your voice in some way. Everyone has their own opinion about it. Some are glowingly positive and some cautiously negative. I wanted to go right to the source, skip the misinformation, and have a really frank discussion about what is and is not possible in the operating room.
[00:01:33] So.
Introduction to Dr. James Thomas
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[00:01:34] Jess: I'm very excited to be here today with Dr. James Thomas, who's also known as the Voice Doctor. He's a laryngologist based out of Portland, Oregon, and he's become one of the leading experts in pitch altering surgery, uh, sometimes known as voice masculinization or feminization surgeries. So, welcome, Dr.
[00:01:50] Thomas.
[00:01:51] James Thomas: Great to be here.
[00:01:52] Jess: . So to start off, could you tell us a little bit about, you and how you got into this field?
[00:01:57] James Thomas: Sure. To make it brief, it was a couple of things coalesced. I became an otolaryngologist doing general ENT and my personalities.
[00:02:07] I liked doing something really well as opposed to doing a lot of things average. And there's a role for both kinds of doctors in this world. And I couldn't keep up with everything and had looked at doing ear surgery because I like sound. And I ended up going to a meeting finding this new machine called a stroboscope.
[00:02:27] And deciding to do voice, uh, which also is sound, which wasn't very popular at the time. There were two or three well-known individuals in the profession, and I decided to focus just on voice. So that was the beginning of that. Very
[00:02:44] Jess: cool.
[00:02:44] James Thomas: And when I started doing just voice, what happened was, uh, there was sort of a little, uh, epicenter here of transgender work.
[00:02:53] Um, uh. Toby Melcher was here doing, uh, work and he was, uh, dabbling a bit in voice, but not as a laryngologist, but as a facial plastic surgeon. And he asked if I would help out and I said, sure, I'll help out. It seems up my alley. I'm doing voice. And I started, um, helping out in surgeries that they'd already been doing, and they were, they had published a paper together, another colleague and him, and thought that they were getting.
[00:03:21] Fair but not great results. And I did about 15 with him and I felt the same way. And so that was the, my initiation into laryngology. And then within a two or three years into the subspecialty, or let's call it a sub subspecialty of, uh, voice pitch modifications.
[00:03:42] Jess: Right?
Stroboscopes
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[00:03:43] Jess: First of all, I do have to ask what, what is the stroboscope?
[00:03:45] What does it do that you were so excited about?
[00:03:47] James Thomas: So, yeah, so the, um. Laryngology is filled with really nice toys. Um, I have nice computers, nice video recording. And really what developed the field a lot was the cameras, the endoscopes, the things that go in your nose or mouth and take pictures. And part of that is that the vol cords, when I'm talking to you here, my vocal cords are vibrating a hundred times a second.
[00:04:10] It's all a blur. And the strobe light is a piece of equipment designed to detect your voice, detect the pitch. Offset the vibration and give you an effective slow motion view of the vocal cords vibrating.
[00:04:24] Jess: Oh, very cool. So that's what's used, like in all of the videos that I've seen, what from scopes where we're looking at the vocal cords vibrating.
[00:04:31] So that's, it's that strobing that allows us to be able to see the movement.
[00:04:34] James Thomas: Yeah, it all, all looks like. Everybody's world chords are moving two times a second in the whole world. Right? Because that's what the stroboscope is, uh, offsetting it at.
[00:04:43] Jess: Oh, that's really cool. I've, I've actually always wondered that.
[00:04:45] 'cause whenever I see these videos I'm always like, they seem to be moving way slower than you need to vibrate something to make sound. Yeah. Okay. That's really cool.
A Rare Sub-Sub-Specialty
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[00:04:52] Jess: So how big is the sub sub specialty, I guess, how, how many people are out there doing some version of what you are doing on a daily basis?
[00:05:01] James Thomas: Well, I could start with a very, um, narrow end. Those of us that are doing gender pitch changing surgery, we, a number of us got together two, three years ago in Berlin to form a new organization of gender voice surgeons, and there were about 10 of us that got together at that. And of course there's more.
[00:05:21] People in the world who do it than that, uh, and that, that's growing. But that's a pretty small number of people around the world to be doing something like this particular field. So,
[00:05:32] Jess: wow.
[00:05:33] James Thomas: So it's growing, it's, it, it's, it's growing and it's growing rapidly and the thing that really started it growing, I would say is I've been doing the surgery since the nineties, various kinds.
[00:05:44] The cr with thyroid approximation, and later the feminization of laryngoplasty, some webbing. And I think that the two things that changed are the WPATH organization got this out of the psychiatric handbook into the medical one. That meant insurance was going to consider paying for some of the surgeries, and as soon as insurance started paying, all of a sudden every university wanted to have a piece of the action.
[00:06:15] So every university suddenly had a laryngologist who was going to. Um, do something. And the second thing that came together was vocal cord webbing became popular about five years ago because it's a, it's a detailed surgery, but it's an easy surgery. There's not much downside to it, and so many surgeons adopted that.
[00:06:37] So new procedure and, um, insurance paying for it. And it's led to a big popularization of let's do something. To alter pitch
[00:06:50] Jess: you, you've mentioned a couple of the different procedures that are involved. What are the pieces that we need to understand in order to understand the procedures that you're gonna be speaking about?
Voice Physics: Pitch vs Resonance
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[00:06:59] James Thomas: Well, I think first of all, voice is physics. And even doctors aren't trained in physics very well, or they've forgotten it. Um, surgeons like to see something, cut it out, you know, so have a cancer growing on your skin. You cut it out. People are better. But that doesn't really work for voice and sound. And if you really wanna change the voice, I think you have to understand physics and how sound waves are modified.
[00:07:25] So in your neck you have vocal chords where the atoms, apple is approximately the middle of the neck, and the vocal chords do nothing but vibrate and make a tone. So if I'm saying that's essentially almost all vocal chords. And then everything above that, my throat, my mouth, my nose, sinuses, those cavities are like the body of the guitar or the, um, brass and the trumpet.
[00:07:54] And that modifies the sound or resonates the sound and gives you, um, a characteristic. So when we think of a gender, a person, we hear a voice and we hear gender. We're hearing the voice, the pitch, and we're also hearing the modification of that, the resonant cavity, and. Um, depending on the size of your vocal chords, the pitch is different and depending on the size of your resonating cavity, that quality or the overtones that we hear is different as well.
[00:08:25] So two parts to identifying to, uh, the pitch and then the resonating cavities.
[00:08:33] Jess: Gotcha. Okay. So. Uh, when, when people hear or perceive a difference between a male sounding voice or a female sounding voice, what differences, are they actually hearing?
[00:08:46] James Thomas: Well, I think they're hearing both of those. It would be like, um, you could listen to a tune on the radio and you can hear a song.
[00:08:55] And you recognize the pitch there. Even if you aren't a musical expert, a musical expert might be able to tell you it's pitch C four or something exact. Um, but most of us would recognize the whole overall song, and that's kind of complex. So your question, is it a way complex because it's not just the pitch, it's we hear lots of things and it makes us think male, makes us think, female makes us think we don't know.
[00:09:22] In between because we get a mismatch between resonance and pitch,
[00:09:25] Jess: right?
[00:09:26] James Thomas: So I think it's the interaction of both pitch and resonance that somehow our brains process it, match it up to everything we've seen in life. And we say, I think that's male. I think it's female, or I don't know.
[00:09:38] Jess: Okay. So let's say for example, in the case of Transfeminine people.
[00:09:43] When you're trying to go from a voice that sounds more male to a voice that, is perceived as being more feminine sounding, what are the goals in terms of the pitch and resonance? What are you trying to change?
[00:09:54] James Thomas: Well, let's, um, break it down into there's a number of surgeries that you mentioned.
[00:10:00] Yes. And before we detail them, there's also voice therapy.
[00:10:04] Jess: Right.
[00:10:04] James Thomas: And voice therapy is. Trying to use your own muscles to change the pitch and the resonating cavities. So some people can do that because they have great vocal rapport. They can do it themselves. Some people can do it with coaching, and you're altering typically both the pitch and the resonance.
[00:10:27] So, so that, that's, uh, that's what you need to accomplish. And if you're gonna do surgery, then you have to decide are you gonna alter pitch only. Res pitch and resonance, or you're gonna do some type of surgery and add therapy back into it.
Testosterone and Voice Changes
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[00:10:42] Jess: My understanding, correct me if I'm wrong, is that a lot of your work when it comes to vocal feminization is essentially attempting to undo some of the effects of testosterone.
[00:10:51] Is that, do you say That's true?
[00:10:52] James Thomas: I'm say that's, um, almost a hundred percent of the whole problem. In fact, shoot, if you could get to somebody before puberty, you wouldn't need a surgeon. Right? So, yeah.
[00:11:01] Jess: So, so what does testosterone change about the voice?
[00:11:05] James Thomas: I think it changes two things. Um, and they are one in the vocal chords themselves.
[00:11:12] The sound production, the vocal chords aren't quite strings, but we think 'em as chords or strings. Mm-hmm. Because they vibrate. And it's a good analogy. Those strings get longer and heavier. And pitch is determined by mass length and tension. And so when you get exposed to puberty and your atoms, apple starts to protrude forward inside.
[00:11:34] That's the vocal cords becoming longer. And then puberty also affects resonance, and it starts to drop the larynx or the voice box down lower in your neck, which means on the inside your throat is getting bigger and wider, and it's starting to resonate and amplify the low tones. So you're going from a Trump trumpet.
[00:11:57] To a tuba, let's say, inside the back of your throat. So testosterone modifies both the voice and speech. Uh, and those are the anatomic structures, the vocal cords, and the pharynx that change with testosterone.
[00:12:14] Jess: Got it. Okay.
The Cricothyroid Approximation
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[00:12:15] Jess: So before we get into what's possible today and some of the newer procedures, um, we've, we've mentioned the cricothyroid approximation a few times, so.
[00:12:24] Right. What is the C cricothyroid muscle and what is the cricothyroid approximation surgery?
[00:12:30] James Thomas: Yeah, so I think in the 1970s there were a few case reports, or three or four reports of surgeons trying various things to try to modify a male voice and make it feminine. And the one that seemed to stick around in the eighties and nineties, at least a few places doing it, was the cricothyroid approximation.
[00:12:49] It was an easy surgery, and the cricoid. And the thyroid cartilage are the two main parts of the Adams apple, and there's a muscle between them. And when we tighten it, then our voice goes up and pitch because it pulls the vocal cords really long. So the muscle that takes us up into falsetto, the crick of thyroid muscle, um, it gives us about half of our overall range.
[00:13:15] In fact, if I were talking here or singing, and I went from my low note, e. That's mostly the vocal cord muscle itself. The thyroid retinoid to be technical.
[00:13:26] Jess: Okay.
[00:13:27] James Thomas: And then to go from E, that's mostly the cricothyroid muscle. And those two muscles work together. So the cricothyroid approximation is a stitch through the crico and thyroid cartilage.
[00:13:40] Tensing the cricothyroid muscle permanently.
[00:13:43] Jess: Mm.
[00:13:44] James Thomas: And it's no longer useful to you because it's effectively been stitched tight and it can't move anymore.
[00:13:51] Jess: Right.
[00:13:52] James Thomas: And in some cases then voices will stay at a high pitch.
[00:13:57] Jess: Interesting. So, so it, that cricothyroid muscle is mostly en engaged in, in falsetto and like hitting those like very high pitches.
[00:14:06] Right.
[00:14:07] James Thomas: I think that's a very. That's close to being as accurate as we can.
[00:14:12] Jess: Right.
[00:14:12] James Thomas: Um, is that, that muscle basically gives us our falsetto range.
[00:14:17] Jess: Okay. That's fascinating. So obviously the, the, the male sounding falsetto. Does have a very different quality from, um, what people think of as like a cis female sounding voice.
[00:14:31] James Thomas: Right? There's two reasons for that. One is when you tie the Cico thyroid muscle, you pull the vocal cords thin. Mm-hmm. So they kind of have a different quality in their vibration. And two, you still have the resonating cavity hasn't changed. So, um, when you hear a counter tenor singing, when you hear a gay male talking, when you hear me.
[00:14:53] Try to tighten my cricothyroid muscle. Um, those are all using sort of the same change in the physical structure. Uh, and so they sound a certain way.
Cricothyroid Approximation Results and Drawbacks
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[00:15:04] Jess: So, uh, can, can we listen to a couple of the examples of, of what this sounds like?
[00:15:09] James Thomas: Yeah's, listen to one. Okay. This is a cricothyroid approximation, A person before surgery and after surgery, just doing a standard reading.
[00:15:15] Jess: Okay.
[00:15:16] Before 1: Long ago men found that it was easier to travel on water than on land. Long ago men found that it was easier to
[00:15:24] After 1: travel on water than on land.
[00:15:27] Jess: Okay. Fascinating. So I think I can hear what you're describing there where it does sound like there's, that there's more tension in the voice. It, it has a very different quality to it, but it is higher.
[00:15:36] James Thomas: It is definitely higher. So if you write a paper, cricothyroid approximation looks great on paper, it does raise the pitch, um, in a lot of patients.
[00:15:48] Jess: Okay. I love that you say it looks great on paper. Can you, can you tell me more about like what you're getting at with that?
[00:15:55] James Thomas: Well, so in medicine or science in general, in medicine, um, the idea of being peer reviewed is considered, um, the highest standard.
[00:16:05] So you do something, you do some science, you write it up and you get a colleague to say, this is a good job, and then it gets printed in a paper. It. And if you go from a low pitch to a high pitch, that's generally felt to be good because if we took, say the average, uh, cis male, they speak at a certain frequency and an average cis female speaks at a higher frequency.
[00:16:30] And so if I'm talking like this, my frequency went way up, but it may not sound feminine. It may sound like falsetto. So it looks great on paper because you get big number changes. Um. But there's several problems with the trico approximation. One is the quality.
[00:16:49] Jess: Mm-hmm.
[00:16:49] James Thomas: Which we can hear in the clip. Um, and a second is that even though you tighten this joint, the muscle often stretches out.
[00:16:59] And in my hands, about a third of patients two months later, went down back to their original pitch, even though this muscle was permanently tight. So. It fails in a couple ways. It can fail in quality and it can fail in pitch.
[00:17:14] Jess: So the pitch would drop down in, in a fair number of patients, but the muscle stays permanently tightened.
[00:17:18] Does that mean that they're losing, um, additional control of their voice even though they've lost that pitch that was gained?
[00:17:24] James Thomas: Yeah, I think they've lost the ability. They, they lose about half their vocal range, so now they're limited to half the range. Mm-hmm. If it stayed high, they might be happy with it.
[00:17:34] And if it drops down low now, they can't get up to the high notes anymore. So it, it has a pretty significant downside.
[00:17:42] Jess: So this procedure in general is like around 50 years old at this point today. Um, and it's, it seems like most of the work is being done on a muscle that does affect pitch, but isn't necessarily.
[00:17:53] One of the, the core like structures that affects the way that a cis man and cis women tend to sound different from each other. Is that right?
[00:18:03] James Thomas: I think so. I think the other thing is that it's a very valuable muscle. You hate to get rid of it. Right? It's something that we can use to raise pitch. So if you get rid of it, um, you've lost something.
[00:18:15] Yeah.
[00:18:15] Jess: Okay.
Inventing "Femlar"
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[00:18:15] Jess: So can you tell me about at what point you stopped? Engaging with this particular type of surgery, or maybe it's better to say like, yeah. How did your views on it change as you moved through your career?
[00:18:27] James Thomas: Well, I was noticing some people weren't staying at a high pitch, and so I tried thinking about what else I could do.
[00:18:35] Uh, at the same time. Then I had a patient who was locked into a single pitch after the surgery. Oh my gosh. She really couldn't go up or down. So I think if you pull that joint tight enough. And you fix someone into a single pitch, especially someone who does not identify with that pitch, you've really impaired them.
[00:18:54] It was the combination of not great results and having a patient that was severely impaired that I felt like I needed to look around for something else to do.
[00:19:03] Jess: Tell me what, what does that mean? Like, I know, I know if I get bored and I'm like, I'm gonna look around for something else to do, I, I can't imagine how I translate that to medicine and especially surgery.
[00:19:13] Like how do you go about being like. What's another option here?
[00:19:16] James Thomas: Well, I think there was two ways I went about it. One is a typical way, which is to delve into the medical literature, go read a lot of papers, see if someone else has written something. Uh, and I did that. And, um, one of the things I came across was a surgeon, Dr.
[00:19:32] Chek from, uh, Bangkok and Thailand, who had done a series of four cases and said, sort of, kind of had good results. Mentioned taking apart the front of the voice box and pulling the vocal cords tighter. So there were other ways of trying to tighten the vocal chords that I read about, and that one fascinated me.
[00:19:53] And at the same time, in the mid nineties, there was this thing called the internet and I'd started a website voice dr.net. 'cause I thought, well, this is pretty cool. And on my website, um, this is now early two thousands, I posted. This idea that, well, maybe I should do some sort of, uh, um, evolution and try to get away from the CTA, leave that muscle alone and maybe take apart the voice box.
[00:20:24] Like Dr. Kochek had pulled the boortz forward, and I thought if I put it all together and I could take a male voice box and make it look female, then the physics would be there. To make the voice sound more female. So I put on the website this idea and said I'm interested in doing it and um, just left it there.
[00:20:46] And I got a call from a engineer, uh, in Texas and she said, you know, I'm really interested in this idea. I've heard all these voices of surgeries and they don't sound that great to me either, and I like your idea and I'd kind of be interested in being a Guinea pig and we can work together on it. Wow. So.
[00:21:06] So she and I got together. We talked about it for a while, and then, um, eventually she came up and we did the surgery. This idea of based on Dr. Kche of taking off the front of the voice box, which is what he did, and then opening it up and trying to shorten the vocal cords, trying to tighten them, and then going a step beyond that and trying to change resonance, which was for me to try to lift the larynx up in the neck and shorten the throat.
[00:21:37] And I thought the more things I do to mimic female anatomy, the more th the voice is gonna sound feminine. And, uh, this lady and I, we did it, we did the first case of wake, uh, which was interesting. And, uh, it's not a very painful surgery, even though I'm splitting the neck open. But the problem is a lot of my patients are very chatty.
[00:21:59] And she was chatty and she was trying to talk to me while I was trying to sew her vocal cords up. And I thought, I'm gonna, I'm gonna rip something that I don't wanna rip. And I got her back together and she had a better voice and I thought, well, I better not do this awake, even if it doesn't hurt. I really need everything to be perfectly still while I'm sewing on it.
[00:22:20] So anyways, that was a start. And her voice was pretty good. I went in and modified her about three months later and tried to tighten it more. She liked the voice but wanted something better. And then we watched her for a while and about six months later I did a second patient and then she worked out.
[00:22:37] And we, uh, that's kind of the beginning of the flow of switching from cricothyroid approximation to this surgery, which I call feminization laryngoplasty, because that sounds. Pronounceable where if I said to someone I'm doing an anterior partial vertical laryngectomy with resection of the anterior vocal cords and elevation of the larynx in the neck and shortening of the pharynx.
[00:23:00] I, it's kind of complex to name all the parts of the procedure. So that's how I started with that.
[00:23:07] Jess: And, and so I, I've seen that referred to a lot as femlar. Where did, was that, is that just a joining of Feminization? Laryngoplasty?
[00:23:14] James Thomas: Well, that was the, the first patient said. We started talking about it. She said, I'll just call it Femlar.
[00:23:19] 'cause she thought even feminization, laryngoplasty was a bit long. And so just kept using Femlar because it's short, quick. It's kind of like an abbreviation and easy to say.
[00:23:29] Jess: Yeah, it's catchy. So, yeah.
Femlar: Before and After
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[00:23:31] Jess: Um, let's listen to some of the, um, Femlar before and after samples.
[00:23:36] Before 2: Long ago men found that it was easier to travel on water than on land.
[00:23:41] They needed a cleared path or road when traveling on land, but on water, a log of wood or any large object that would float became a man's boat.
[00:23:50] After 2: Long ago, men found that it was easier to travel on water than on land. They needed a cleared path or road when traveling on land, but on water, a log or wood or any large object that would float became a man's boat
[00:24:03] Before 3: long ago, man.
[00:24:05] Found it was easier to travel
[00:24:06] After 2: long ago, man. Found that it was easier to travel
[00:24:10] Before 4: long ago, man. Found that it was easier to travel
[00:24:12] Before 3: long ago, man. Found that it was easier to travel
[00:24:15] Before 4: long ago. Min found that was easier to travel
[00:24:17] After 3: long ago. Min found that it was easier to travel
[00:24:20] Jess: long
[00:24:20] Before 4: ago. Men found
[00:24:21] Before 3: long ago men found.
[00:24:23] Jess: That's, it's, it's such a striking difference compared to the Grego thyroid approximation.
[00:24:27] James Thomas: Yeah, I think that's consistent. I mean, now I'm, I'm up over 350 patients and I have follow up recordings on about 280 people. And I would say, I mean, it, there's a wide variety results, sort of a bell curve, a pitch. Um, but uh, in general, I think the modification is getting people much closer to a feminine voice and some people.
[00:24:51] It's complete. I think my second patient was one of my best results. Um, and she said, you know, I stopped being a trans woman when I got the surgery. I became female, went out in society. Um, I stopped going to meetings. I just live my life now as I'm meant to live it. So, um, that's a, that was a, that's a pretty high bar, but I thought it was a bar that she felt, uh, really seriously, uh, happy about.
[00:25:20] So. And that doesn't happen to all of 'em. So that's, that's the good ones. But anyways, that when it works really well, it works really, really well.
Success Rates and Real Outcomes
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[00:25:29] Jess: Let, let's talk a little bit about what the quote unquote success rate of, um Sure. Feminization, laryngoplasty is, especially compared to the, um, cricothyroid approximation.
[00:25:37] I think you mentioned 30% was what we were looking at with the CTA, is that right?
[00:25:41] James Thomas: That's my take on it. If you read articles online, you probably would get 25%. I think for me it was close to a third, 33%. Um, gotcha. Um, there's not a lot of art. If you added up all the articles, there might only be 30 or 40 people reported on, but yeah, that's a 30% failure rate.
[00:26:00] And then if you count the quality, I would say the failure rate's up above 50%, so Right. I strongly discourage ev anybody from getting a CTA get any surgery you want, but don't get a cricothyroid approximation.
[00:26:14] Jess: Okay. And so what's the satisfaction rate like for Femla?
[00:26:18] James Thomas: Well, it's interesting because satisfaction and outcomes are kind of two different things,
[00:26:23] Jess: okay?
[00:26:24] James Thomas: There's a whole bunch of ways to measure success. So let's take the standard way that's gonna be in the medical literature is pitch, and with this particular procedure in my hands, uh, FEMLA, the median outcome is six notes on the piano,
[00:26:38] Jess: okay?
[00:26:39] James Thomas: Elevation of pitch, and. I like the piano better than Hertz.
[00:26:43] 'cause I can't think in a logarithmic scale. So pitch, I like the tones on the piano. Most people can count six notes, you know, don't ring me fob. Um, so technically it takes you on average from an average male voice to an average female voice. But of course the starting point could be a low base and they're not gonna get six notes, is not gonna get them up into a female range.
[00:27:07] And of course that's the median. So there's some people that get eight or nine notes and there's some people that get two or three and they aren't that different afterwards. So there, and if I look at it and plot it, it's a bell curve. And so the middle 50% of people get. Average results and average is often good enough for, for some people.
[00:27:27] Jess: We, we've obviously listened to what some of the positive outcomes can be, which is this incredibly gender affirming, um, procedure where you get to then move through the world afterwards without having to think about voice, which is something that I know a lot of trans people are very self-conscious of, myself included much of the time.
Risks, Complications, and Revisions
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[00:27:42] Jess: But what are some of the downsides and the common risks that you see
[00:27:47] James Thomas: when I talk to someone about feminization rhinoplasty? It's a big surgery. I'm taking the entire larynx, opening it up, deconstructing it, and uh, reconstructing it, putting it back together. And the additional risk is having an infection and, um, because I'm going from what's called a clean area inside your neck has no bacteria, and I open up inside your airway, which has lots of bacteria.
[00:28:15] So there's a risk of infection and if you get an infection in your voice box. That can impair your breathing. So it's kind of a high risk surgery and something that I try to mitigate the risk but not eliminate it with antibiotics, watching closely for any signs of swelling, so early on higher risk than any other, uh, voice surgery about infection.
[00:28:42] And then long term, the risk is do you get a female voice? Can you further modify it? Have you, um, burnt bridges or can you still do more, uh, if things don't heal well, you can get a rough voice. You have two vocal cords. If they aren't even, you can have a double pitch, e have a raspy voice. Any surgery that shortens the vocal cords, reduces the volume.
[00:29:08] So most of my patients have lower volume, so we have to have a conversation about noisy backgrounds. Lifestyle. Do you work in a bar or do you work on a construction site? Um, so volume, so it's about quality, pitch and volume after the surgery. And complications can bother all three of those things. So one of the things to talk to people about is if we don't get what we want the first time and we haven't brought a bridge, there may be more we can do.
[00:29:39] So if I get someone. Better. They've lost some of their base notes.
[00:29:44] Jess: Mm-hmm.
[00:29:44] James Thomas: But they're still kind of speaking in a tenor male voice. Well, there may be a different procedure to do on the inside to reduce the bulk of the vocal cords as a secondary surgery.
[00:29:56] Jess: And what, what would that procedure be?
[00:29:58] James Thomas: Um, typically I use a laser and I have a laser in the office where I can tighten the epithelium, the mucosa covering the V cords, or we can go back to surgery.
[00:30:09] And a CO2 laser is a. Stronger laser and I can cut into the vocal cord, remove muscle, thin it out and try to make it a male thickness go to more of a female thickness vocal cord.
[00:30:23] Jess: So there's really a lot of different procedures that are all kind of coming together in different ways to, to achieve these effects.
[00:30:29] Is that right?
[00:30:30] James Thomas: Yeah. I think I think of it as a toolbox and the toolbox that the patient has is speech therapy.
[00:30:35] Jess: Mm-hmm.
[00:30:35] James Thomas: Plus some type of surgery. And if that surgery is, uh, the feminization, rhinoplasty or even webbing and you get partway where to where you wanna go, there may still be something else to do.
[00:30:47] And so, uh, the initial surgery plus lasers can sometimes, uh, work together.
Webbing and Lasers
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[00:30:54] Jess: we haven't really talked about webbing too much, so could you tell me a little bit about what webbing is, how popular it is, how effective it is compared to the other ones we've discussed?
[00:31:02] James Thomas: Yeah, I think of the term webbing in general is operating through the mouth while the patient's asleep and sewing the front half of the vocal cords together. Mm-hmm. So that it can't vibrate and the back half of the vocal cords remain to vibrate. And there's some variations on that different surgeon to use different kinds of sutures, different surgeons put the sutures different ways.
[00:31:25] Um, and that is clearly the most popular surgery it has. I would say relatively low risk. If the surgeon has good judgment, um, if the surgeon webs 90% of the vote courts, then the person's gonna have almost no volume. And I've seen that. So, but I think that's a judgment.
[00:31:42] Jess: Yeah.
[00:31:43] James Thomas: So if the surgeon's careful, uh, does enough of them, then uh, I think they can accomplish something.
[00:31:51] Jess: Right. So really it seems like the three approaches that exist for. The, the major surgeries for this are the cricothyroid approximation was going in and, and sewing together, this joint to do the work of this muscle that wasn't really the right muscle for the job. And then we've got webbing that's, um, affecting the actual vocal cords themselves, but isn't changing the resonance chambers at all.
[00:32:17] And then the feminization, laryngoplasty. Where we're actually going in and changing the shape of the resonance chambers as well as the vocal cords. Is that right?
[00:32:27] James Thomas: Yeah. I like to think of it as those three, and I, I think of it as four, because you can use the laser. Mm-hmm. And just debulk the vocal cords, but alone, that doesn't tend to give much pitch raise.
[00:32:40] Gotcha. But it's an incredibly valuable procedure if a person has already had a webbing or a feminization rhinoplasty, and the vocal cords are short. And now you debulk them, it can do quite a bit. So almost it's four different surgeries, laser, some sort of debulking, and the three you mentioned.
[00:32:58] Jess: Gotcha.
Choosing Surgery Options
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[00:32:59] Jess: And so for most patients, what do you recommend as being the result that's going to achieve the uh, most likely, the greatest likelihood of success for them?
[00:33:14] James Thomas: Well, assuming a patient comes to me and we talk over that. They're willing to take on risk, or they wanna take on the risk in order to never sound masculine.
[00:33:23] Mm-hmm. Then they've jumped the hurdle from speech therapy to some type of surgery. And then I would say, don't ever consider CTA, it has too many complications. It fixes your voice, it reduces your range. Don't do that. And then I, so I think the real, for me, the real two choices are webbing or feminization of rhinoplasty.
[00:33:44] Feminization Rhinoplasty does, I think more, but it's a bigger surgery with more complications and very few people do it. Webbing's very common, easier, low complication rate. Um, if it fails, you could do other things. Um, and most people who actually publish on it typically say you need to do some voice therapy.
[00:34:10] And I have to say, I don't. I've never heard a series of like a hundred patients who've had webbing and a hundred patients who've had feminization, orango, plasty to do a real formal scientific study. Mm-hmm. So I have to say there's things I don't know. I don't have a perfect comparison of the two.
[00:34:27] Jess: Right.
[00:34:28] James Thomas: And people come to me because they know I do the laryngoplasty. So I don't do a lot of webbing because I've established myself and, uh, I really only do webbing on request. So I don't have a huge track record in it.
Recovery Timelines
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[00:34:42] Jess: After surgery, what is the recovery like before someone's voice is back to a hundred percent with their new voice?
[00:34:49] James Thomas: Well, I think it's different between webbing and feminization. Mm-hmm. So I think webbing has a relatively quicker recovery because not much is changing structurally and the swelling goes down quicker. I think because I change more of the structure. There's both more swelling. So, um, early on the voice is quite often worse, and then it takes longer for the person to adapt to it.
[00:35:17] So the feedback I would give is from patients who come back to me over many years. I think most patients say it takes about nine months after feminization, rhinoplasty until the voice is like completely stable. That's the early surgical swelling, and that's the retraining that goes on in your brain is you keep modifying internally what you're doing with these new vocal cords.
[00:35:38] Jess: Mm-hmm.
[00:35:39] James Thomas: And then I tell patients that it takes about probably two months for the swelling to go away. So I tell people to rest their voice for two weeks, try not to tug on any of the stitches by talking. And when they start talking, their voice will probably be almost as deep as it was before surgery.
[00:35:55] And then the swelling goes down and the voice gets smoother and clearer and. I start to judge my result by about two months after the surgery.
[00:36:05] Jess: Gotcha.
[00:36:06] James Thomas: And I've had, I've had two or three people who come in two weeks later and sound great and they didn't swell. And I don't know, I think that's their own personal characteristic.
[00:36:15] It's not anything I did with the surgery. There's some people don't swell much, and few of them sound really great, really early, and that's unusual. But two months of getting through a pretty rough voice and then. Another seven months of gradually getting used to it.
How Pitch Range Shifts
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[00:36:30] Jess: So one thing that I, I just wanted to come back to for a second around the concept of range is like obviously all of us have like the lowest note we can hit at the bottom of our range, and then the highest note we can hit at the top of our range.
[00:36:41] Um, when, when we're talking about like, oh, we're moving up by this many notes on the piano, is that the bottom and the top are moving together? Or do those tend to move independently of each other?
[00:36:50] James Thomas: I like to think of it as three pitches. So you and I are conversing in our relaxed voices, so our comfortable speaking pitch.
[00:36:56] Jess: Yep.
[00:36:57] James Thomas: And the comfortable speaking pitch is not in the middle. It's down typically towards the low end of our range. Mm-hmm. And then we have the two notes you mentioned, the lowest and the highest. And when I do the, the Femara surgery, to me, the, my experience says the upper pitch doesn't change. It stays the same, the lowest pitch comes up.
[00:37:17] On average about eight to 10 notes. Mm-hmm. Depending on where you start and the comfortable speaking pitch comes up, about six or seven notes. So it really, it narrows the range from the bottom up and it shifts the comfortable pitch up, the pitch that you speak at without thinking.
[00:37:34] Jess: Right.
[00:37:35] James Thomas: Uh, yeah, so it, it does narrow the range.
Trachea Shaves
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[00:37:38] James Thomas: The exception is there's a. An all too common complication from a related procedure called a trach shave.
[00:37:46] Jess: Mm-hmm.
[00:37:47] James Thomas: Which is getting rid of the atoms apple. And some surgeons who do that may not be aware of where the vocal cords attach on the inside, and sometimes they loosen that and that drops the pitch.
[00:38:01] And if I go in and repair a trach shave, a lot of times I can restore the upper pitch. That is, hmm. I just told you I don't change the upper pitch, but if the upper pitch has artificially been dropped, you can often bring it back up to where it used to be.
[00:38:17] Jess: Trach shaves are done quite commonly, like it's a very, very common surgery for a lot of trans women especially.
[00:38:25] Um, how risky do you consider those to be?
[00:38:29] James Thomas: Well, I don't have any numbers. I don't know the denominator. I don't know how many people get them. Mm-hmm. I see lots of complications, but. People come to me when they've had a complication, of
[00:38:39] Jess: course.
[00:38:39] James Thomas: So, uh, so I don't have a good assessment. I can just say to all the plastic surgeons out there in the world, leave at least one centimeter of thyroid cartilage in general, and you'll keep the vocal cords attached.
[00:38:53] So that means when you're doing a trach shaved, you want the person to look good, but you may have to leave a bump there or risk, uh, detaching their vocal cords, right.
[00:39:04] Jess: Yeah,
[00:39:05] James Thomas: it's a judgment of how conserv, you know, if you take away every bump that's there, you're probably gonna start having complications with some people losing their upper range.
[00:39:14] Jess: Got it. So if, if somebody's considering getting a trach shave, um, do you have any advice for them to avoid ending up in a situation where they could end up having their voice partially compromised?
[00:39:25] James Thomas: Uh, I don't have any perfect advice there. Um, I mean, I give my patients some advice. That is, if you're gonna have the feminization, don't get the trach shame.
[00:39:35] 'cause now you're having two surgeries and you're paying for two on the same spot. And if you're gonna have the feminization, rhinoplasty, we're gonna get rid of it anyway. So save yourself risk and money. But apart from that, no, I don't know how to judge a surgeon without, uh. Being there myself.
[00:39:53] Jess: The message I'm getting from a lot of this, including talking about the pitch surgeries and, and really everything in general is that we need more research and better clinical studies.
[00:40:02] James Thomas: Yeah. I think, and that's the next, I think as more people get interested in doing it, doing webbing, doing trach shapes mm-hmm. Doing maybe the rhinoplasty, um, um, you will get more studies. You get more ideas, and maybe a new idea will come along that's better than any we've talked about so far. So,
Transparency About Complications
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[00:40:18] Jess: so that kind of makes me,
[00:40:19] think a little bit about something I noticed on your website, which it's really interesting to hear that you, you started that quite a long time ago, like it more on the dawn of the internet as we know it. But something that really jumped out to me when reading your website and some of the content you've written is the way you talk about these procedures.
[00:40:36] Like you have a lot of notes, personal notes, anecdotes, and you talk as well about how you've changed your recommendations over time as you've performed more of these surgeries. And as the field has evolved in general, especially in respect to talking about revisions, times when revisions were necessary or even where you feel like certain mistakes were made, and this feels really different to me from a lot of what you see on surgeons websites where it's very sanitized, careful, focusing on the positives.
[00:41:06] Um, can you tell me a little bit about that approach? 'cause it does jump out to me as unique.
[00:41:12] James Thomas: Well, I think that's a little heads up. If I looked at, if I needed orthopedic surgery and I looked at a website and they have only great results, I'd probably look elsewhere. Um, I think that, that all of, uh, all of these voice surgeries and all surgery have complications.
[00:41:29] I, I can't think of a single surgery that doesn't have the potential for a complication. Mm-hmm. Um, and really if I only had good results, I wouldn't have to talk to anybody. I'd just do the surgery, you know, so. Uh, if the surgery site website, or if even a physician website only shows positives, um, and you go to the appointment and they only talk about positives, then you're, uh, you're gonna have a problem or you're, or there's more likely to be a problem there in that case, I think.
[00:41:59] Jess: Right. That makes
[00:41:59] James Thomas: sense. So that's probably what informs my approach. I mean, what do I lose by telling someone they could have a complication? And now they're informed. If we don't have it, they're happy. If they have it, maybe they're not happy, but, uh, we can move on from there.
[00:42:16] Jess: That is cool to hear. Um, on one hand, I think it's really great that there's options for people to access newer, potentially life-changing procedures.
[00:42:24] Like thinking about that first patient who you were able to do the, um, feminization, laryngoplasty to. Yeah. Like, that's so incredibly cool that this person was able to be one of the first people to get this surgery. Um,
[00:42:36] James Thomas: yeah.
[00:42:37] Jess: But then on the other hand, performing these outside of the context of clinical studies and trials means we have less data on the long-term effects, success rate, complications, et cetera.
[00:42:46] So how do you balance, um, ensuring that these procedures are accessible while also making sure that we're still moving towards getting the data that we need to, um, understand what's going on better and make it more accessible.
[00:43:01] James Thomas: Yeah, I think you have to rely a little bit on the various physicians and some are going to go more in depth and, uh, study what they've done and change what they do as they go along.
[00:43:13] And others are in your upsell category where they do a lot and we have no idea what their outcomes are, uh, unless you maybe run into or meet other patients or, and I think for. I mean, the internet keeps evolving. I think now one of the big sources apparently is Reddit. Mm-hmm. Um, which I have, I, I, I mean, I'm aware of it, but I've not gone on and looked at any transgender voice stuff on it.
[00:43:38] But that seems to be a patient oriented discussion area, and that's not really a terrible way. I think you could go say to a trans meeting and meet the surgeons, meet a variety of people, and then you could try to suss out from other patients how they've done and. You'll hear both good and bad, and then you put that together and you make hopefully an educated, uh, decision about what you should do and who you should see.
Revisions vs. "Tuneups"
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[00:44:06] Jess: So these communities that we're talking about are obviously great places for people to discuss their experience. Um, sometimes positives, sometimes negative, um, and pros and cons of various procedures and surgeons and clinics. Um, one thing that is often talked about as a negative in the context of cosmetic surgery is, uh, the need to do revisions where, uh, usually it's talked about in the context of, okay, I got this procedure, whatever it was, I was unsatisfied, I was dissatisfied with it, and so I had to go back and get more work done and more work done until they were able to get it right, whereas I would've preferred them to just get it right first time.
[00:44:42] When you talk about revisions and when I've seen patients talk about getting revisions from you. Um, you've used the word like tuning up the phrase, you know, come, come back in and get tuned up. Um, and it seems like revisions are talked about in a different way. Can you speak to that a little bit?
[00:44:57] James Thomas: Yeah. I think in, um, even today, I, I went back and looked at my spreadsheet.
[00:45:02] I mean, this is a procedure I obviously have a lot of fascination with, so I keep pretty detailed records on it. Mm-hmm. I know that I've done 369 patients and I know how many I followed up with. But I can look back on that spreadsheet and also see that, you know, the first 50 I did that, I revised maybe half of them where I would go back in and do a second feminization, Ringo plasty.
[00:45:28] I would open it back up. And maybe that's because it was new and maybe it's because I didn't have another, um, tool at the time. And one of my discoveries, which is in, I think the video that I give as a general lecture is that. A woman came back to me and her voice was rough like this, and I could look in there and see one vocal chord was looser than the other.
[00:45:52] Jess: Mm.
[00:45:53] James Thomas: And I had just bought this new toy, a laser. I told you my profession's filled with nice toys. So I bought this nice, uh, $90,000 laser and I thought, well, I could use this here. And I used the laser to, to, to make a little burn, and it tightened that up and her voice cleared up. So I learn as I go and. I think that was much easier, much less risky than a revision.
[00:46:20] And so I often use the laser to tune up. So the reason I use the tuneup is, um, the laser. And there's two I can, um, adjust side to side, get the vocal cords in tune. That seems like a tuneup.
[00:46:35] Jess: Mm-hmm.
[00:46:36] James Thomas: I can thin them out. And make them a little thinner. And they vibrate a little higher pitch. So that seems like a tuneup, let's say, as opposed to a revision where I open up the neck, take it all apart a second time, work through scar tissue and try to do something big again.
[00:46:50] Jess: Gotcha. So, but you are, especially with the feminization, laryngoplasty, like you're, you're, is it safe to say you're shooting for just needing to go in there one time, get it right the first time?
[00:47:01] James Thomas: Yeah. I mean, I, yeah, that's what I would like. That's what everybody would like. And, um. And I, and I must say that I haven't gone from lots of risk and complications to that.
[00:47:14] It's not been a even mm-hmm. Parallel path. I go and I get a bunch of good results, and then some that aren't as good, and then some that are good, and then someone who's perfect and I think, oh, I'll keep doing that. But then the next patient isn't. And I think it's just partly, there's so many variables in taking apart the voice box that it's hard for me to know every single variable.
[00:47:34] Jess: Gotcha.
Ethics and Patient Vulnerability
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[00:47:35] Jess: So something that I notice a lot in spaces where trans people are talking about voice is often a sense of desperation, especially when it comes to the context of getting surgery. And so what I'm wondering is, as you talk about, you know, all the cool tools and toys that you have access to and pioneering new surgeries and procedures.
[00:47:54] How do you balance that? Um, desire to experiment a little bit and innovate and I improve outcomes and, and try new things with this uniquely vulnerable population who are coming to you very, um, in, in, in a very, like vulnerable, often desperate kind of way. Um, I can see there being, uh, situations where you might have to consider some of the ethics of the choices you're making and the things that you're doing.
[00:48:22] How do you balance that?
[00:48:25] James Thomas: I have to say, I've not found the people who've come to visit me to maybe entirely fit that characterization. Uh, over the years, individuals who've come to me have said, uh, voice is either more or less important to them. And some people, I, I mess people, the only thing they wanna change is voice and they don't care about any other characteristic of their body.
[00:48:51] I've met people who wanna change the voice first and then do other things. I've met people who wanna change everything else and the voice they save for the last. So I haven't met really a lot of, let's say, desperate people. I've met a lot of, um, a wide variety of how people see voice in their own individual lives.
[00:49:13] So I think part of what I do is try to cater. My discussion about the role surgery plays to how it would fit in your life. Mm-hmm. You as the individual, you know, who wants the voice changed and I run into people who want super high voices and people who want androgynous voices or non-binary voices. And I, I don't know exactly what that is, but we'll have a discussion and get through it.
[00:49:39] So I just find there's a wide range of people who come to me with different requests and then. I reflect back to them on what I think I could accomplish.
[00:49:47] Jess: Mm-hmm.
[00:49:48] James Thomas: And if it suits them, then we move ahead. And if it doesn't, then I try to, um, guide them some other way. So I just haven't run into desperate people.
[00:50:00] I've run into a lot of very knowledgeable people who come to me that, that read a lot and. Then they describe what they want and then I describe what I can do, and then we try to match it up. That's, I guess, that's how I see it. So then if I'm trying something new, I'm happy to have the discussion with the person and say, this is new, or, I've been doing a lot of it.
[00:50:21] Jess: Mm-hmm.
[00:50:21] James Thomas: Or, I've done hundreds of these and I still can't tell you what the outcome's gonna be. So there's an unknown. Are you un, are you happy with the unknown?
[00:50:29] Jess: That's good to hear. Like I, I, I do see a lot of people, especially in online spaces. Um, talking about their voices and the pain, uh, that they are often going through when Yeah.
[00:50:40] Talking about their own voices. And so it's great to hear that mostly you're having people come through your doors who know what they're talking about and have a good sense of what they want.
[00:50:48] James Thomas: There's probably a built-in bias to my answer to that. Mm-hmm. I think because over the 30 years I've been doing this type of surgery, it's generally, you know, is thought of as cosmetic surgery, so everyone had to pay for it.
[00:51:00] Mm-hmm. So I would say a lot of my patients are. Let's say, well, to do, I get a lot of tech patients, people who have enough money to pay for surgeries themselves. And I have very little of people who might be more desperate because they find it very difficult to get anything
[00:51:17] Jess: right.
[00:51:18] James Thomas: And yeah, insurance is changing over time and so maybe more people will, hopefully more people will be able to access this kind of service.
[00:51:27] And as they do, I might see a different, um. I might see a different group of people than what I've been describing.
Insurance and Political Climate
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[00:51:34] Jess: Are you starting to see more like insurance coverage for this kind of thing? Or is that still pretty uncommon?
[00:51:41] James Thomas: No, it's, it's much more common. I think the evolution was wpath getting it out of psychiatry.
[00:51:47] Jess: Mm-hmm.
[00:51:48] James Thomas: Around 2010 into a medical disorder. Then high tech firms, apple, uh, Starbucks, uh. Amazon saying, well, we'll cover these surgeries. So they would selectively start to cover them. And then, um, Medicare started covering a lot of gender surgery, but not voice. For whatever reason, they considered voice excluded.
[00:52:14] Um, so it is becoming, uh, covered more and more. That doesn't mean there's not problems with it. I still run into insurance not wanting to pay very much for it. Um, but more insurances are covering it, and it's been an evolution. I'm, I think, pretty sure most insurance will eventually cover something. It's becoming, um, apparent to the world.
[00:52:38] There are many more transgender individuals than anyone thought. Um, and they didn't all just appear. They have been there all along. Um, but they're more visible, at least in, in, uh, US and Europe.
[00:52:53] Jess: As I think the visibility of trans people increases. Um, so too does some of the pushback against, especially the way that medical interventions, um, can sometimes appear.
[00:53:07] Um, right now it feels like we're in a really divisive time when it comes to medical care for trans people. Yeah. Especially in the context of surgery and especially in America. Um, how do you feel about the way those conversations are happening in the public sphere and have any of them affected you personally or your practice?
[00:53:25] James Thomas: Well, I mean, when I hear the political ones, like my patients in Texas or some other place mm-hmm. And, and I do treat young people, um, it sounds like it's moving backwards. On the other hand, when I, uh, we're losing ground on what we've gained and when I go to the WPATH meetings, which are amazing meetings in that they have not only.
[00:53:48] Medical caregivers, but they have patients. That's one of the few organizations that's both patient and uh, medical caregivers. Then you get a lot of interaction between a lot of specialties and between caregivers and people who receive it. And I think that helps to, um, to discuss the hard problems, the ideas, how young should we be treating.
[00:54:10] And I listen to those 'cause I'll have an opinion, but I'll hear a thoughtful person and maybe it'll alter. A little bit what I, uh, do, um, the next time. I mean, I think I alluded earlier in the conversation, you could put me outta business if people would get testosterone out of their system before a teenage years and you could solve all of these problems.
[00:54:34] But, um, there, there's a lot of political will against that. That's the divisiveness you talk about. Mm-hmm. And then there's probably a little bit medicine doesn't know for sure what. You have to do research, you have to look at groups of people. You have to compare them and insightful people can disagree and say, you know, I interpret that as we should be doing that.
[00:54:57] Or I interpret it as we shouldn't be doing that so.
[00:55:00] Jess: Right.
Voice Surgey and Voice Therapy
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[00:55:01] Jess: So as we sort of come towards the end of this conversation, I'm wondering if you have any advice for people who might, might be considering voice surgery or have thought about it, um, but are unsure.
[00:55:15] James Thomas: Well, one common piece that I give people when they come to see me is, uh, what's your vocal rapport?
[00:55:21] You know, not all of us can sing and carry a tune, and for an individual who's unable to change their voice on their own or with voice therapy, surgery becomes, um, a, a better risk benefit, has a better risk benefit ratio. And if you're a singer and you're perceived as feminine a hundred percent of the time on the phone.
[00:55:42] It's kind of high risk because if you have a complication, you're worse than you are right now. And that's the initial discussion that I have with lots of people. How good are you with your voice right now? And then weigh that against the risk and read about it. Listen to this podcast, go, uh, online, and then adjust your, uh, your decision making based on your own risk tolerance.
[00:56:10] I think there's clearly a role for surgery. Um, the woman that I mentioned at the beginning who said, I lived my life as a female, that's a pretty, it's a pretty amazing thing to have someone just satisfied with their life, who, who wasn't for such a long time. Mm-hmm. I, I guess I have a wide variety of patients from, for me, 15 year olds, up to 70 year olds, and everyone has.
[00:56:32] Even if you lump transgender, trans-feminine individuals together, they've all had very different lived life experiences. Mm-hmm. And then I try to slot my role as a surgeon into their, uh, lived experience and their bowls.
[00:56:46] Jess: When you think about the most dramatic or impressive before and afters that you've heard over the course of your career, do you find that those are surgery only, voice therapy only, or a combination of the two?
[00:57:00] James Thomas: I don't ask anybody to do therapy. I suggest that it's low risk and if they want to do it, they should. But I have no requirement that a person does that because I think inherently a trans person is the gender that they feel they are and they don't really need education to, in general, um, try to be something.
[00:57:25] And, and I say that because when I get the anatomy right, the person never thinks about their voice. So it's clear to me you can do surgery, you can have a result where the person, uh, has their own voice and they never need any training at all. If someone doesn't get as good a result, sure they could do the training.
[00:57:45] And I think maybe the, a lot of this, um, this common belief that everyone needs to do therapy, which when I go to a medical meeting. That's the status quo. Everyone must do therapy, uh, or must do therapy before considering surgery. I think a lot of that comes from people who've lived their lives in the gender they didn't want, and they have developed a very male voice and now they want to live the way they feel.
[00:58:14] They should have lived all along, but they have to undo a lot of training. They probably do benefit from, um, training. So if someone's in their mid sixties and comes to me, I might more orient them towards some therapy plus the surgery. If the surgery alone doesn't take care of it. But my goal is if you get the anatomy right, they sound right.
[00:58:37] None of us who are born cis female need any education to sound female. You just do it because the anatomy matches. Um, and I think when the surgery's right. Then you don't need any therapy.
[00:58:50] Jess: How does it feel like for you personally, being such a core part of people's gender affirming journeys in a lot of these cases?
[00:58:59] James Thomas: Well, I mean, I like doing something really well. Back to the beginning. I like being a subspecialist. I like trying, uh, something. Uh, I mean, every week that I operate on somebody, uh, I also see people back who didn't have a perfect outcome and, um. Uh, I feel very active in my mind saying, what could I do better?
[00:59:20] What thing could I fix? Or somebody comes back who has a great voice, and I say, what did I do right? How am I gonna replicate that? Uh, I, I think I'm evolving and changing and trying things as much now as I did when I posted on my website, you know, 20 some years ago, Hey, I'd like to try this procedure. It for me, it's just very rewarding.
[00:59:43] But all voices it that's not limited to this trans, I find voice fascinating. Uh, there's a lot yet to be discovered about the nerves working to run the vocal chords. There's a lot to be discovered about dealing with cancer on the vocal cords. How could we do better? So, uh, because it's an ongoing learning process, working with the altering the pitch is still fascinating to me.
Future of the Field
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[01:00:09] Jess: So a, as you think about how far things have come in the last, say, 20 years, where do you think this field's gonna be 10 years from now, 50 years from now? What, what, what do you think's on the horizon?
[01:00:20] James Thomas: Well, two things. One, of course if we could, I think we will alter what we do for young people. Um, one thing that the political will, doesn't consider, let's say in conservative states, is that not doing something is doing something to the person, making a person live in a body they don't want for 30 or 40 years.
[01:00:40] Is a huge price. So you need to be an economist and put that price onto what if you do something and it's wrong? Um, and, and you need the, weigh the two things equally. So I think we'll hopefully get through some of that and make some changes in what we do for young people. 'cause we've clearly changed what we do for young people in the past 20 years.
[01:01:01] Jess: Mm-hmm.
[01:01:02] James Thomas: I see many more families coming with young. Individuals accepting the young person's choice and, uh, and supporting it. And, and, and that seems wonderful. That's one thing I'll change. And then I spend a lot of my time teaching. I lecture, I people come and watch this surgery. Um, I think somebody who's 20 or 40 years younger than me is gonna come up with some new idea and it's gonna be better than what I've done.
[01:01:29] And, um, and then more people will adopt that.
[01:01:34] Jess: That's exciting. So got kind of always growing, always changing.
[01:01:37] James Thomas: Yeah. Always, always growing, always changing. Passed the baton. Look, uh, I guess I could have mentioned I'm a democrat. Biden just finally passed the baton. I hope I'm not that resistant to passing the baton to the next person who wants to do something, but he did do it.
[01:01:51] So I, I'm open for some young person to do a better surgery than I'm doing.
[01:01:56] Jess: You can hand over the scalpel.
[01:01:58] James Thomas: Yeah. Yeah. I'd love to see. There are people trying to do something better.
[01:02:03] Jess: That's really cool.
Pitch Lowering
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[01:02:04] Jess: We, we didn't talk about this at all, but I, I would feel remiss if I didn't bring it up, which is, um, do you ever do pitch lowering surgery?
[01:02:10] James Thomas: I do. I think, I don't do much of it, so I don't have as much experience. I think there's a couple reasons for that. One is that testosterone is such a potent, um,
[01:02:21] Jess: mm-hmm.
[01:02:21] James Thomas: Changer of the voice, so surgery isn't needed as much. Um, secondly. Uh, I don't think someone's come up with a great way to change a female size voice box into a male size.
[01:02:38] So the main surgery for a trans man to get a lower pitch is to loosen the vocal cords, but in a tiny space, if you loosen them, sometimes you get a gain and sometimes you don't. Um, what again, maybe it's the next generation. We need a way to. Uh, take this trans man's voice box, drop it down in the neck.
[01:03:00] Mm-hmm. Uh, expand it forward. Make the voc cords longer and heavier. Um, and I don't think we've developed that yet. I think about crazy ideas. I talked with one patient, we talked about wouldn't it be interesting to inject, um, like testosterone maybe directly in the vocal cord. Could you get a better effect?
[01:03:21] I don't know. Um. Could you change locally? The anatomy by that way? Uh, someone's gonna, that's probably not the right idea, but someone's gonna say, um, okay, sound and physics, we need a trans man to have a big low larynx and a big throat. Mm-hmm. How are we gonna accomplish that? Can we do it with surgery right now?
[01:03:41] We can kind of change one thing, tension, and that doesn't really do it for everyone.
Closing Thoughts
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[01:03:47] Jess: Well, I mean, I so appreciate you talking to me about this today. 'cause I, I know there, there can be such sort of a. Invisible barrier for a lot of people to access information about, um, about surgery and, and from physicians directly.
[01:04:01] And so the fact that you're sharing this with people so freely is just fantastic.
[01:04:06] James Thomas: Yeah. I think, uh, I guess where a push could be is, uh, people who are pushing insurance companies to work with patients. I, I think maybe we should keep pushing there as a society, as individuals. In dealing with these issues the same as any other, uh, medical issue that we deal with, that I, that's where I think we should put our efforts.
[01:04:30] Jess: Well, gosh, ta talking about this stuff makes it all sound so interesting. Like, it's, it's taken me back to, I, I, my science fair project in, I think it would've been grade five, was based on something I saw at the, was it the Exploratorium? Is that a real place? In San Francisco or something. It could
[01:04:47] be,
[01:04:47] Jess: but it was, it was a, yeah, we, I, I got a duck call and attached tubing of various sizes to it to simulate vowel sounds by mod, like kind of doing a rough modeling of the vocal tract.
[01:04:58] So you'd, you'd blow into the duck call and it would be like, Ooh, ooh, ah, ah, as you switch the tubing out. And uh, I'm now, now thinking about that and going, gone. I could, I could have studied this in another life.
[01:05:09] James Thomas: I, I think the same thing. I actually think the same thing. And people ask me like you did at the beginning, how did I get here?
[01:05:15] Yeah. And I said, well, I had this nice toy and I started the story after I was a doctor.
[01:05:20] Jess: Mm-hmm.
[01:05:21] James Thomas: But I could look back to the science fair. My project was aerodynamics. And aerodynamics is how sound is created. So I've actually kind of been working on the same thing my whole life from my science fair project all the way up till now.
[01:05:35] Jess: That's very cool. I can see you have a, a very like, curious approach to all of this stuff, thinking about new ways to do things. Yeah. And, um, clearly making sure you're doing it well. Um, okay. Those are all of my questions and you've answered them fantastically. So I, I really appreciate all of this time.
[01:05:55] Um, thanks so much for talking to me today. Um, if people wanna find out more about you or what you do, um, where can they go?
[01:06:03] James Thomas: Uh, well I still have the website up voice doctor.net. I suppose that's the easiest way in the online world is to get there and, uh, see what's there. It's a way to contact me if you have some specific interest, but
[01:06:16] Jess: Great.
[01:06:16] James Thomas: Yeah.
[01:06:17] Jess: Well, thank you so much.
[01:06:18] James Thomas: It's been fun chatting. Thanks.
[01:06:19] Jess: I hope you enjoy the rest of your day.
[01:06:21] James Thomas: Thank you, Jess.
Credits
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[01:06:21] Jess: The words don't fit the picture is created by Jess Lupini. Special thanks to this week's amazing guest, Dr. Catherine Campbell Kibbler. This episode is edited by Koby Michaels and produced by Jess Lupini and Lucas Kavanagh. Production funding was provided through Telus Storyhive. Special thanks to Nicole Doucette and Alexa Landon.
[01:06:45] See you next time.