Coverage for Gender-Affirming Voice Surgery and Therapy for Transgender Individuals

Instrumentation Considerations for Calcified Thyroid Cartilage during Chondrolaryngoplasty

OBJECTIVE

Chondrolaryngoplasty, also known as thyroid cartilage reduction, alleviates gender dysphoria by reducing the thyroid cartilage to conform to a patient's gender identity. Reduction of the thyroid cartilage prominence ("Adam's apple") is often performed with a scalpel, but in cases of cartilage calcification, rongeurs or drills are utilized. This study aims to characterize the success rate with scalpel-only excision and relate this to patient age and operative time.

METHODS

Billing records were screened for chondrolaryngoplasties performed between 2020 and 2023 by a single surgeon. Patient demographics, operative notes, and operation duration were recorded. Type of instrumentation was categorized as scalpel only, rongeur, or drill. All cases began with attempted scalpel excision of cartilage and were transitioned to rongeur or drill if there was calcification that prevented sharp excision. Descriptive statistics were used to describe patient and surgical factors.

RESULTS

52 individuals underwent chondrolaryngoplasty: 30 cases (57.7%) had soft cartilage requiring only a blade, 22 (42.3%) required use of either drill or rongeur. The average age of these groups was 25.7 (SE 1.8) and 41.3 years (SE 2.2), respectively; this difference was statistically significant (p < 0.0001). Cases requiring a drill or rongeur lasted on average 78.5 min (SE 2.3), whereas those using only a blade were shorter at 66.8 min (SE 2.7); this difference was significant (p = 0.0017).

CONCLUSION

Cartilage calcification should be expected in a significant number of chondrolaryngoplasties, and surgeons should be prepared for this scenario. The need for alternative instrumentation is higher in older individuals and may extend procedural time.

LEVEL OF EVIDENCE

4 Laryngoscope, 135:748-751, 2025.

What Do We Know About Speech-Language-Hearing Practice in Vocal Care for Transgender People? A Scoping Review

OBJECTIVE

To systematically assess the current state of speech-language-hearing (SLH) practices in health services addressing vocal care for transgender individuals, aiming to identify key themes and gaps in the existing body of knowledge.

METHODS

This scoping review was based on the Joanna Briggs Institute manual and followed the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses-Extension for Scoping Reviews. It was registered with the Open Science Framework Open Source 10.17605/OSF.IO/BUCRG.

RESULTS

Altogether, 1517 studies were found. After excluding duplicates and applying the eligibility criteria, 103 articles were chosen for the review. The studies addressed topics such as vocal training, case/experience reports, barriers to access services, SLH pathologists' and students' perception and knowledge about the transgender voice, evaluation of programs and services, transgender people's perception and knowledge about their own voice and SLH care, acoustic/auditory-perceptual evaluation, protocols, instruments, impacts of voice on quality of life, verbal and nonverbal communication, and hormone therapy and surgeries.

CONCLUSIONS

The summary of the studies reflects the diversity of methods applied in research on transgender people's communication and voice, as well as the variety of topics. Despite the increasing publications on vocal care for transgender people, it is necessary to ensure the dissemination of evidence to support effective practices that recognize and enhance the diversity of this population. Literature data have promising SLH procedures and useful protocols to assess this population. However, they do not clearly indicate what the transgender population actually wants and needs. Furthermore, the study types have not progressed in a coherent order-that is, from preliminary studies to those with more robust methods. Thus, such knowledge may lack consolidation. Many answers to questions in both clinical and academic practices are still not entirely clear. However, it is believed that the advancement of studies will clarify them.

Medicaid coverage for gender-affirming surgery: A state-by-state review

OBJECTIVE

To systematically review Medicaid policies state-by-state for gender-affirming surgery coverage.

DATA SOURCES AND STUDY SETTING

Primary data were collected for each US state utilizing the LexisNexis legal database, state legislature publications, and Medicaid manuals.

STUDY DESIGN

A cross-sectional study evaluating Medicaid coverage for numerous gender-affirming surgeries.

DATA COLLECTION/EXTRACTION METHODS

We previously reported on state health policies that protect gender-affirming care under Medicaid coverage. Building upon our prior work, we systematically assessed the 27 states with protective policies to determine coverage for each type of gender-affirming surgery. We analyzed Medicaid coverage for gender-affirming surgeries in four domains: chest, genital, craniofacial and neck reconstruction, and miscellaneous procedures. Medicaid coverage for each type of surgery was categorized as explicitly covered, explicitly noncovered, or not described.

PRINCIPAL FINDINGS

Among the 27 states with protective Medicaid policies, 17 states (63.0%) provided explicit coverage for at least one gender-affirming chest procedure and at least one gender-affirming genital procedure, while only eight states (29.6%) provided explicit coverage for at least one craniofacial and neck procedure (p = 0.04). Coverage for specific surgical procedures within these three anatomical domains varied. The most common explicitly covered procedures were breast reduction/mastectomy and hysterectomy (n = 17, 63.0%). The most common explicitly noncovered surgery was reversal surgery (n = 12, 44.4%). Several states did not describe the specific surgical procedures covered; thus, final coverage rates are indeterminate.

CONCLUSIONS

In 2022, 52.9% of states had health policies that protected gender-affirming care under Medicaid; however, coverage for various gender-affirming surgical procedures remains both variable and occasionally unspecified. When specified, craniofacial and neck reconstruction is the least covered anatomical area compared with chest and genital reconstruction.

Voice Perception and Mental Health in Transgender Women

OBJECTIVES

This study aims to examine the association between voice experience and levels of depression, anxiety, and stage of gender affirmation in transgender women.

STUDY DESIGN

A cross-sectional study.

METHODS

Adult transgender women attending a tertiary referral center were recruited between April 2022 and January 2023. They filled in a demographic and health survey, the Hebrew Trans Woman Voice Questionnaire (H-TWVQ), the Hebrew Patient Health Questionnaire, and the Hebrew version of the Generalized Anxiety Disorder Screener. Descriptive statistics and data regarding the associations between voice experience, grades of anxiety and depression, and stage of gender affirmation were compiled.

RESULTS

Sixty-seven transgender women were included (mean age 26.7 ± 7.78 years, mean time of presenting socially as a woman 5.2 ± 5.2 years). The median H-TWVQ score was 71 (maximal score 120). Most participants reported mild anxiety and mild depression levels. Those who reported a more positive voice experience (H-TWVQ score ≤71) had lower median depression and anxiety scores than participants with a less-positive voice experience (H-TWVQ score >71) (P = 0.028 vs P = 0.044, respectively), complained less of hoarseness (2.9% vs 19.4%, P = 0.045,) and more were employed (78.8% vs 41.9%, P = 0.003). No association was found between voice experience and cross-sex hormone treatment, affirmation surgery undertaken, or number of years presenting socially as a woman.

CONCLUSIONS

We observed a potential association between better voice experience and lower anxiety and depression levels among transgender women. No association was found between voice experience and the stage of gender affirmation. Physicians treating this population should be aware of these associations and consider therapeutic means for voice adjustment.

Potential Risks for Healthcare Disparities Among Individuals With Voice and Upper Airway Disorders: A Systematic Review

PURPOSE

To assess the potential epidemiological association between various possible risk factors and healthcare disparities specifically related to the access, use and/or quality of speech language pathology services for individuals with voice and upper airway disorders.

METHOD

A systematic review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis. Full text journal articles were identified through PubMed, PsycINFO and Web of Science. The reference sections of included articles were also manually screened and identified four additional studies for consideration of inclusion. Included articles specifically addressed healthcare disparities in voice and upper airway disorders related to speech pathology care. International literature was excluded. Eligible studies were reviewed and data extracted. Risk of bias of each eligible study was performed using the quality assessment tool from National Institute of Health for observational cohort and cross-sectional studies. Data from eligible studies were synthesized thematically.

RESULTS

A total of 1,101 resources were retrieved from the search; of these, 133 were duplicates. Titles and abstracts of 968 articles were screened, with 14 selected for full-text review. Eleven articles were considered eligible for inclusion. Voice disorders were the condition most frequently examined followed by only one article addressing upper airways disorders. There was considerable heterogeneity in the methodology and statistical analyses among the eligible papers. There was a lack of standard methodology for collecting and accurately determining patient characteristics as well as variability in measuring confounding variables and providing statistical analyses for such adjustments that may have impacted the findings. The information extracted from these articles revealed healthcare disparities related to sex/gender, age, insurance status/coverage, race/ethnicity, among others including etiology and preferred language.

CONCLUSIONS

This systematic review highlights the limited research on speech language pathology-specific healthcare disparities for individuals with voice and upper airway disorders. There was significant clinical and methodological heterogeneity between studies which may have contributed to varied results between studies. There is a need for greater methodological rigor and prospectively designed studies to better characterize the impact of disparities in the access to, use of, and quality of speech pathology care for this patient population.

Complications and Functional Voice Limitations Following Gender-Affirming Laryngeal Surgery (GALS)

OBJECTIVE

Gender-affirming laryngeal surgery (GALS) procedures are effective, with high rates of patient satisfaction following endoscopic vocal fold shortening (glottoplasty) or chondrolaryngoplasty. Despite this, complications and functional limitations in voice use following GALS are not well described. The current study aims to visually characterize the clinical and laryngoscopic features of complications following GALS.

METHODS

Patients who presented with complications or subjective dysphonia following glottoplasty or chondrolaryngoplasty across three tertiary care centers were included. Medical charts were reviewed for demographics, surgical history, the primary outcomes of short- and long-term surgical complications, and the secondary outcome of subjective difficulty in daily voice use unrelated to pitch or gender congruence. Postoperative videostroboscopy exams were reviewed for correlating features.

RESULTS

Eighteen patients with complications after glottoplasty, chondrolaryngoplasty, or both were identified. Complications after chondrolaryngoplasty occurred in three patients and included skin tethering, late-stage infection with fistula, and voice change. Short-term complications following glottoplasty occurred in four patients and included persistent granulation at the neocommissure (n = 3) and suture dehiscence (n = 1). Persistent dysphonia or voice limitations greater than 6 months following glottoplasty were described by eight patients; associated stroboscopy findings included excessive web formation of greater than 50% (n = 4), incomplete web formation with opening anterior to the neocommissure (n = 2), and scarring of the remaining membranous vocal fold (n = 5). Dysphonia complaints were consistent with observed glottic insufficiency in seven of eight of these patients, with incomplete membranous vocal fold closure posterior to the neocommissure or anterior air escape.

CONCLUSION

While chondrolaryngoplasty and glottoplasty have high success rates, complications related to healing, granulation, and web length are not uncommon. Long-term dysphonia appears to be related to postprocedural glottic insufficiency. These data should be used to counsel patients preoperatively about the risks and benefits of GALS.

Addressing disparities in speech-language pathology and laryngology services with telehealth

The COVID-19 pandemic disproportionately affected the health and well-being of marginalized communities, and it brought greater awareness to disparities in health care access and utilization. Addressing these disparities is difficult because of their multidimensional nature. Predisposing factors (demographic information, social structure, and beliefs), enabling factors (family and community) and illness levels (perceived and evaluated illness) are thought to jointly contribute to such disparities. Research has demonstrated that disparities in access and utilization of speech-language pathology and laryngology services are the result of racial and ethnic differences, geographic factors, sex, gender, educational background, income level and insurance status. For example, persons from diverse racial and ethnic backgrounds have been found to be less likely to attend or adhere to voice rehabilitation, and they are more likely to delay health care due to language barriers, longer wait times, a lack of transportation and difficulties contacting their physician. The purpose of this paper is to summarize existing research on telehealth, discuss how telehealth offers the potential to eliminate some disparities in the access and utilization of voice care, review its limitations, and encourage continued research in this area. A clinical perspective from a large volume laryngology clinic in a major city in northeastern United States highlights the use of telehealth in the provision of voice care by a laryngologist and speech-language pathologist during and after the COVID19 pandemic.

Characterizing Gender-Affirming Voice Intervention Discussion on Social Media: A Cross-Platform Analysis

OBJECTIVES

Gender-affirming voice treatments, such as voice training and surgery, are highly impactful for transgender patients experiencing vocal dysphoria and may be discussed on social media platforms including Twitter and Reddit. Our goal was to characterize the content and sentiment of social media posts pertaining to gender-affirming voice interventions to better understand the needs of this patient population.

STUDY DESIGN

Retrospective data-mining study.

METHODS

A total of 18,695 Tweets from 2001 to 2021 and 23,742 r/Transvoice Reddit submissions and comments from 2009 to 2020 were extracted via publicly available application programming interfaces and analyzed using language processing and sentiment analysis techniques. One thousand eighty-six highly emotive r/Transvoice posts related to voice modification treatments were manually reviewed for further classification.

RESULTS

Online discussion of gender-affirming voice has increased over time and is centered on vocal feminization. Recurrent themes included use of online training resources, singing voice, and barriers to care such as cost and variable experiences with health care providers. Sentiment analysis demonstrated that posts discussing gender-affirming voice training had higher average sentiment scores than those discussing voice surgery, on both Twitter (0.252 vs 0.161; P < 0.001) and Reddit (0.349 vs 0.301; P < 0.001). Frequently appearing themes in highly negative surgery posts included mixed outcomes (9.3%), surgical complications (9.3%), and recovery time (8.5%). Common themes shared by the positive subgroup analysis included peer support, vocal quality, and importance of practice.

CONCLUSIONS

Gender-diverse patients share various concerns and resources relating to voice intervention in the online communities of Twitter and Reddit. The discussion has been growing over the past decade and is mostly positive, with significant social support and resource-sharing within the community. Aggregated online sentiment toward gender-affirming voice surgery is more negative than voice training, largely due to concerns about surgical outcomes and variability, risks, and recovery period.

Gender-Affirming Voice Surgery: Considerations for Surgical Intervention

The purpose of this article is to provide an overview of the current state and available evidence surrounding surgical voice care for the transgender and/or gender expansive population. The term "gender expansive" has been proposed as an inclusive term to classify those who do not identify with traditional gender roles but are otherwise not confined to one gender narrative or experience. We aim to review indications and candidacy for surgery, surgical procedure options for altering vocal pitch, and typical postoperative expectations. The role of voice therapy and considerations for perioperative care will also be discussed.

Factors Related to Treatment Attendance for Patients Seeking Gender-Affirming Voice Therapy

OBJECTIVE

The purpose of this study was to investigate factors related to treatment attendance for patients seeking gender-affirming voice therapy (GAVT).

METHOD

We completed retrospective chart reviews of 50 patients (43 transgender women, three transgender men, four nonbinary patients; aged 18-67 years, M = 34.92 years, SD = 12.32 years) referred for GAVT at a Midwest outpatient center from 2016 to 2021. Data extraction included patient demographics, therapy visit specifics (e.g., number of sessions attended, treatment completion status, and in-person vs. virtual visits) and treatment timing (in relation to the onset of the COVID-19 pandemic), and psychosocial and socioeconomic information.

RESULTS

There was no impact of treatment-timing relative to the onset of the pandemic on any attendance measure; however, patients were 1.9 times more likely to complete therapy with each virtual telehealth session attended. Individual factors of outside social support and hormone replacement therapy were positively related to the number of therapy sessions attended, whereas insurance provider and employment status were related to therapy completion.

CONCLUSIONS

Telehealth attendance during the COVID-19 pandemic was positively associated with GAVT completion. Future research should investigate psychosocial and socioeconomic factors to understand how to identify patients at risk for poor treatment adherence and facilitate access to clinical care.