Transgender Women Are Heading to South Korea for Vocal Surgery

A clinic in Seoul has become a destination for a noninvasive feminization procedure.

It happened every day—at the grocery store, the mall, even the bank. When Erika Jonell would open her mouth to speak, what came out sounded wrong. She tried to raise the pitch of her voice, from a hollow baritone to a pleasant mezzo-soprano. She concentrated on it so hard that she sometimes lost track of the conversation she was having.

But it would still happen. She’d get that look. “When you say hi to someone in a masculine voice, you can almost see it in their face that they know,” she said. “Once you start to notice that, it’s hard to not start noticing all the time. It’s death by 1,000 cuts.”

All this simply to buy a dress or cash a check.

Jonell, a 34-year-old transgender woman from Beavercreek, Ohio, spent more than a year trying to alter her voice using speech exercises before she decided she needed to have her vocal chords surgically altered. She knew exactly where she had to go: a small surgical practice in South Korea, the Yeson Voice Center.

Since the clinic began offering the procedure in 1999, it has treated 385 patients from 46 different countries. Last year, the Seoul clinic performed 107 voice feminization surgeries—down from 120 in 2014. It’s most popular with Americans, with nearly a quarter of their patients coming from the States, followed by those from the U.K. and Canada. They didn't have to advertise; apparently a single patient made a video diary of her vocal transformation, and word spread online. “Thanks to one of our U.S. patients who had explained our surgical procedure and the whole process to the transgender community ... the number of patients who contact us was flowing,” said Dr. Hyung Tae Kim, who performs the procedure at Yeson.

Jonell heard about the clinic from Reddit and other forums for transgender women. “I kept seeing all these great results from Yeson Voice Center,” she said. “I knew of people who went through it, and I knew the results were excellent. The option really grew up on me.” In December of 2015, she sent Yeson an e-mail to get the process started.

The reason so many transgender women travel to Korea for this surgery is because, unlike techniques practiced elsewhere, Kim's surgical method is noninvasive. Most voice feminization procedures access the vocal chords by making an incision in the neck—with mixed results. Kim is one of very few physicians in the world who performs the procedure using endoscopic tools, entering the throat through the mouth. The vocal folds, a part of the vocal chords that transforms air passing through the trachea into speech and other communicable sounds, are shortened via suture, thus naturally increasing frequency. A typical male range is anywhere between 100 and 150 hertz. A typical female’s is anywhere between 200 and 250 hertz. Although each person’s vocal folds are different, the procedure on average increases the frequency of a patient by 74 hertz. “The surgery result is permanent, and the end voice pitch gets very naturally feminized, whereas other types of voice surgeries may result in voice loss, hoarse voice, or unnaturally high female tone like Mickey Mouse,” said Jessie Shin of Yeson’s Global Healthcare Management Department, who is the point of contact for all international patients. “That's why patients overseas are traveling to Korea to have this procedure done safely.”

“You don’t have this done and go from James Earl Jones to Taylor Swift immediately. Healing is a long process.”

Feminization of the voice is hardly a new phenomenon in the medical community. “The equipment that is used today for this procedure is really no different than 20 years ago. The idea of shortening the vocal cords has been around for a long time, but there has been more interest and awareness in recent years,” said Dr. Jeffrey Spiegel, a cosmetic surgeon in Boston who offers voice feminization procedures for transgender women. “You’ve got these vocal chords which are kind of like guitar strings—they vary in pitch based upon length and mass. What we have been doing the last couple of years is the same thing Yeson does: shorten the vocal chords and thin them out,” he continued. “But you don’t have this done and go from James Earl Jones to Taylor Swift immediately. Healing is a long process, and the big reveal takes time.”

In terms of variation regarding the surgery, there is still room for debate about what is the most effective. “There’s a lot of things that can be done, but not all of them are predictable, or reliable, or long-lasting. In concept, it seems pretty easy,” Spiegel said, “but it all depends on what the surgeon is comfortable with. There is no technical lag in making an incision and going [at] it from the front.” Despite Yeson being able to alter pitch noninvasively, if a patient requires aesthetic adjustment—such as removal of the adam’s apple—a incision-based procedure is necessary. “Yeson is a place people go to for voice adjustments only,” he said, “but other cosmetic alterations sometimes [require] a different approach.”

Kim and his team are also keenly aware of the importance of voice for transgender women. “It is believed that an individual’s voice characteristic is a key contributor to the listener’s perception to guess the speaker’s gender,” Kim said. “Many male-to-female transgender patients are misgendered by their voice in many circumstances. Having a misgendered voice places a person at risk, as it could negatively affect their social and vocational life. including their psychosocial state of mind.”

Erika Jonell
Erika Jonell, near the National Museum of the U.S. Air Force, Dayton, Ohio.
Photographer: Ari Gabel for Bloomberg

Jonell is the training infrastructure engineer for the U.S. Air Force, working at the F-35 Joint Program Office. In short, she works on trillion-dollar fighter jets for a living. And much of her job involves being on the phone with team members stationed in other parts of the country. “Voice is incredibly important in today’s society,” she said. “We have become more telecommunication-oriented. You may not be physically present in front of someone when speaking with them, so your voice carries a lot of who you are [and] whether you are male or female or you feel you are some place in between.” Jonell explained that, despite her efforts to train her voice to become more feminine, she continued to get misgendered while on the telephone.

Over time, too, Jonell’s friends and family began to notice that voice played a crucial role in her identity as a woman. “One thing she talked about, as she started explaining her dysphoria, was her voice,” Jonell’s sister, Tara, said. “I think the main goal was to get a voice that she could call her own that wouldn't sound like, in a way, another person speaking for her all the time.” Jonell didn’t want to have to actively try to sound female—she wanted it to be a seamless fact of her persona. “I just wanted to speak naturally without having to consciously alter my voice,” Jonell said.

After contacting Yeson last December, she scheduled her surgery for February 17, 2016. Yeson requires all prospective voice feminization surgery patients to fill out a questionnaire and submit a voice recording of the Rainbow Passage, a section of prose commonly used by voice pathologists to assess vocal activity. They vetted Jonell’s application and approved her for the surgery, which costs $7,200 plus travel expenses. Yeson does not offer payment plans; the fee is required up front. “I had been saving up for years to buy a house,” Jonell said. “But, instead, I put that money towards my transition.”

Tara traveled with her sister to Seoul for the procedure. They toured the city for a day and divulged in things that are forbidden during the four-month post-op recovery plan: spicy foods, caffeine, alcohol. “We found a taco bar and had some margaritas,” Tara said, laughing. Despite the sisterly fun, Jonell still had nerves. “There was a lot of anxiety on her part, but she did a good job playing it down,” Tara said. “She was putting a lot of herself into this. She was afraid that if it didn’t follow through, then her dysphoria would get the better of her. Besides coming out to community at large, this procedure was the second-largest step she has had.”

“Having a voice that reflects who I am is incredibly important to me”

Before the procedure, Jonell met Kim for the first time, who gave her a final once-over. They did an endoscopy to check her vocal folds and showed her videos and spectrographs of them in action. Kim found a partial asymmetric closure in her vocal folds. “I had to strain harder to produce higher sounds,” Jonell said. “It started to click as to why I had such a hard time with voice training methodology.” Kim also saw that Jonell had a slight tremor in her vocal chords. She would need botox as part of the surgery, which helps stabilize the vocal folds during healing, preventing the tremor from returning and potentially affecting the desired outcome.

There were no complications during Jonell’s procedure, but the clinic forbids its patients from speaking in any way for at least four weeks. “They also teach you to cough or sneeze a certain way,” Jonell said. She set up text-to-speech software on her laptop and cellphone to help her communicate and hunkered down into recovery. “Everyone takes for granted being able to open their mouth and have words come out. You don’t have that anymore,” she said. “But if you are already a trans person, you have learned that patience is a virtue.”

Jonell began talking again after a month, in March. The botox naturally wears off after four months and reveals the patient’s new voice. Jonell is a couple weeks shy of that happening, and currently, her voice is a little gravely. When she speaks, she sounds sore. “I’m eager to see the results,” she said. “I got the surgery because, in the end, my highest priority is to just be comfortable with myself. Having a voice that reflects who I am is incredibly important to me.”