Natasha Mirza, MD
Several years ago, Natasha Mirza, MD, consulted with a woman who'd already begun her gender-affirming transition. She was ecstatic to be living as the person she always knew she was, seizing every opportunity to wear a dress. But almost any time she talked, she was met with stares because her voice still fell within the pitch range of a man.
Weeks later, Dr. Mirza, Director of the Penn Center for Voice, Speech and Swallowing at Penn Otorhinolaryngology – Head and Neck Surgery, began the process of resetting her patient's voice.
The grateful patient stayed in touch long after her final follow-up. She shared in her last letter that she moved to Australia, got married, and was reveling in how rich her life had become. Dr. Mirza keeps the card in a box in her office filled with notes from other patients.
Shaping the voice
Oren Friedman, MD
In recent years, Penn Otorhinolaryngology – Head and Neck Surgery has committed to providing a robust suite of gender-affirming services. The undertaking taps a variety of experts across the department, though Dr. Mirza and her colleague, Oren Friedman, MD, Director of Facial Plastic Surgery at Penn Medicine and Associate Professor of Clinical Otorhinolaryngology, are credited with advancing the program.
Within this realm, Dr. Mirza performs two procedures for patients who are transitioning. Pitch-altering vocal fold surgery is performed for both male-to-female transitions and female-to-male. For male-to-female transitions, Dr. Mirza is also able to surgically shave a prominent Adam's apple when necessary. In those instances, a chondro-laryngoplasty or thyroid shave is often done at the same time as the vocal fold surgery. The procedure, Dr. Mirza says, needs to be executed with precision so the inner attachment of the vocal folds just below the Adam's apple isn't disrupted.
Voice feminization is the more common of the gender-affirming laryngeal surgeries. While many procedures have been used to raise the voice pitch, Dr. Mirza typically employs a modification of the Wendler glottoplasty, which is a minimally invasive procedure that's performed endoscopically. A laser de-epithelializes the mucosa over the anterior third aspect of the vocal folds while various methods are used to help the vocal folds adhere. An anterior augmentation and tissue glue are used in place of sutures. The procedure shortens the vocal folds and reduces the vibrating mass, which raises the voice pitch.
It's an outpatient procedure. Patients can resume their normal diet later that day, but they are encouraged to be on voice rest for the next 10 days. Once recovered, they'll begin working with a speech pathologist once a week for the next four to six weeks.
"I can address the pitch of their voice," Dr. Mirza says, "but the other aspects of talking, like pace, resonance, and intonation, that's where the speech pathologist comes in."
The order with which someone undergoes their gender-affirming procedures is based entirely on their preference. Some may elect to start with vocal cord manipulation, while others save it for later. In performing the procedure over that last 20 years, Dr. Mirza has come to appreciate the difference this procedure can make.
"They may look and feel like the person they always believed they were, but they're not necessarily identified as such until they've had this surgery," she says.
Sculpting the face
For these transitioning patients, Dr. Friedman offers a broad spectrum of gender-affirming cosmetic procedures. Some go only skin deep and can be performed during an office visit. These include the application of Botox and various injectables to add volume to lips, enhance cheekbones, elevate eyebrows, more prominently define the chin, and strengthen the jawline, as well as laser resurfacing to minimize the appearance of fine lines in the face and improve the complexion. In these instances, the results are realized in a matter of days.
And then there are a host of surgeries, which are more transformative. Recovery times vary. A facelift, for example, is considered the most invasive of the gender-affirming surgeries performed by Dr. Friedman. It entails about three weeks of downtime and anywhere from six months to a year for the results to come into focus.
The overarching goal of any gender-affirming facial surgery, Dr. Friedman says, is to align the patient's features with the gender they identify with. Feminization procedures may include reducing the prominence of the brow bone, lip augmentation, smoothing strong protrusions of the jaw, and rhinoplasty to create a finer nose, among other procedures. Masculinization procedures may include using implants to make the cheeks more angular, widening and lengthening the forehead, creating a sharper jawline with implants or bone restructuring, and enlarging and broadening the nose with cartilage or bone grafting, among other procedures.
"Any change in appearance is a big adjustment," Dr. Friedman says. Which is why extensive conversations are had before any action is taken. Those sessions, he says, are meant to lay the groundwork for a trusting relationship.
"I want to take the time to ensure I know exactly what patients want and then assure them I'm capable of delivering those changes," says Dr. Friedman, who's been performing gender-affirming procedures for two decades. "It's during those conversations where the patient's wishes are transmitted to my hands for their operation."
Caring with compassion
Their technical prowess has led Drs. Mirza and Friedman to great heights in their respective careers. It's their compassion, however, that's earned them the respect of their peers and patients.
"I'm deeply attached to the work I do for every patient, regardless of their reasons. It takes a lot of courage for any patient to be here, but I think that's especially true of those who are here for gender-affirming surgery because they have so much weighing on them," Dr. Friedman says. "For my part, I'm passionate about doing the right thing. This isn't a surgery factory. A lot of thought and discussion goes into every decision to operate and deciding on the right type of operation – which there are a lot of opinions about. It's a continual evolution that requires good communication and rapport with the patient."
Dr. Mirza takes strides to protect the wellbeing of her patients even before she's met with them. Insurance cards often reflect a given identity, not the chosen one. So she'll have a member of her staff call in advance of the first appointment to confirm the patient's name and their preferred pronouns.
At the time of the consultation, she'll ask the patient if they're comfortable with having another doctor in the room. If they're not, she'll allow only a registered nurse in the room to assist with the necessary laryngoscopic exams.
"I'm just grateful I have the ability to help," Dr. Mirza says of her attachment to the work – and her patients. She adds, "This is not something one does alone. There has to be a team approach so our patients feel safe, comfortable, and can achieve the best results."