Dr. Abie Mendelsohn on ENT Specialist Gender-Affirming Care

Author(s): Scott Douglas Jacobsen

Publication (Outlet/Website): The Good Men Project

Publication Date (yyyy/mm/dd): 2025/04/09

Dr. Abie Mendelsohn, M.D., F.A.C.S., is a leading laryngologist specializing in advanced, minimally invasive throat and voice surgeries at the Los Angeles Center for Ear, Nose, Throat, and Allergy. He has pioneered transoral robotic surgery (TORS), sialendoscopy, and hypoglossal nerve stimulator implantation.  Mendelsohn emphasizes that these procedures are essential to healthcare, not cosmetic. His innovations, including a scarless tracheal shave technique, improve outcomes while reducing risks. He explains the role of resonance and pitch in vocal identity, noting that while pitch influences gender perception, resonance is equally critical. He stresses the life-changing impact of these procedures, as a misaligned voice can cause significant distress. Advocating for broader insurance coverage, he continues to refine surgical techniques and push for advancements in transgender healthcare, ensuring safer, more effective procedures that help patients align their voice with their gender identity.

Scott Douglas Jacobsen: Dr. Abie Mendelsohn, M.D., F.A.C.S., is a fellowship-trained laryngologist specializing in advanced, minimally invasive surgical treatments for conditions of the throat and voice. Based at the Los Angeles Center for Ear, Nose, Throat, and Allergy, he has pioneered transoral robotic surgery (TORS), sialendoscopy, and hypoglossal nerve stimulator implantation on the West Coast. He holds a B.A. in Biology from Yeshiva University and an M.D. from the David Geffen School of Medicine at UCLA. Dr. Mendelsohn completed his residency at UCLA and pursued specialized training in Laryngology and robotic surgery. His research focuses on voice preservation and endoscopic surgical techniques. Thank you so much for joining me today, Dr. Mendelsohn. I appreciate it.

Mendelsohn: Thank you for the invitation.

Jacobsen: Let’s start with some softballs. What factors should be considered when determining whether a candidate is suitable for surgery?

Mendelsohn: Surgery always carries risks. Even the smallest procedure has inherent risks related to anesthesia, infection, bleeding, and recovery time. Generally speaking, there are risks associated with anesthesia and even travelling to a surgical center or hospital before incision.

When determining a treatment plan, we aim to balance risk with benefit and choose the least invasive, most effective option for the patient. This includes considering the physical risks, time, recovery process, and discomfort.

Some risks are unavoidable. Surgery is typically the most invasive option, so we usually consider it a last resort. Suppose a non-surgical alternative—medication, voice therapy, or other treatments—is available. In that case, we strongly encourage pursuing those options first.

That said, there are cases where surgery is the only viable solution. We must determine the safest and most effective surgical approach in those situations.

Jacobsen: What does gender-affirming voice surgery involve?

Mendelsohn: Gender-affirming voice surgery is a broad category that uses several surgical techniques. The primary goal is to modify the vocal cords and voice box so that the voice’s pitch, resonance, and quality align with the patient’s gender identity.

Many of us take our voices for granted. Even experiencing temporary laryngitis can be frustrating and make us appreciate how important our voice is for our professional, social, and personal identity.

For people who do not have experience with gender-diverse individuals, it can be difficult to understand the distress caused by having a voice that does not match one’s true identity. For a transgender individual, using their voice can feel like a constant misalignment between their internal self and their outward expression.

When we help a patient achieve a voice that truly represents them is a profoundly transformative experience—some might even call it magical. It’s a magical effort.

There are generally two broad categories of gender-affirming voice surgery. One category involves voice surgery that makes the voice sound more feminine. This could mean bringing someone from a masculine-sounding voice into a range that is more androgynous or distinctly feminine. However, this is not a strict binary—man to woman. Sometimes, the goal is to move someone out of a masculine vocal range without necessarily pushing them fully into a feminine range.

Conversely, there are cases where someone with a feminine-sounding voice wants—or, more accurately, needs—to move into an androgynous or even masculine vocal range. Various surgical strategies can help achieve both of these goals.

Jacobsen: As a side question—when we use placeholder terms like “masculine” and “feminine” voice zones, what physiological factors contribute to the production of those different vocal sound types?

Mendelsohn: I love this question. There’s much research on this topic.

When we pick up the phone and say hello, our brain immediately assigns a gender to the voice on the other end. Even without thinking about it, our brains subconsciously analyze vocal cues to determine gender.

So, what factors contribute to that perception?

If you ask the average person on the street, most would say pitch—meaning a higher pitch is perceived as more feminine. In comparison, a lower pitch is perceived as more masculine.

While pitch is certainly a factor, it is far from the whole story. Other vocal characteristics can be so powerful that they override pitch entirely.

For example, let’s go back to the telephone scenario. You can immediately tell if you’re hearing a high-pitched male voice versus a low-pitched female voice. That tells us that pitch alone cannot define gender perception in voice.

So, what are the other factors besides pitch?

A major one is resonance—the voice echoes in our body before it exits our lips.

If you took vocal cords outside the body and made them vibrate, they would not sound like a human voice. Like a bleating goat, they would sound harsh, thin, and unpleasant.

The depth and richness of our voices come from harmonics, which develop as the sound resonates in the body before it leaves the mouth. This is why trained singers can produce incredibly powerful and moving sounds—they can manipulate resonance to create depth and emotion.

Our brains subconsciously process resonance, and we instinctively associate certain resonance patterns with gender identity.

Right now, I am resonating in a way that communicates masculinity to you. Middle C on the piano is typically where a voice would sound classically feminine. The C below middle C is often identified or perceived as masculine. So, when someone comes in for a consultation—let’s say, for vocal feminization surgery—and their voice naturally sits at that lower C, there are times when they express a specific request, saying, “I would like my voice to be at this note.” Unfortunately, that is not something any responsible surgeon can truly promise.

We do not yet know how to fine-tune the voice box precisely. The reason is that the voice box is highly complex and can modulate itself. Consider someone like Freddie Mercury—he had a vocal range of nearly four octaves. No surgery can achieve something like that. The voice relies heavily on the body’s natural control. While we can make structural adjustments by altering certain aspects of the vocal anatomy, promising a specific pitch is not feasible.

Jacobsen: What do you advise patients regarding expectations?

Mendelsohn: Many individuals seeking gender-affirming voice surgery have already undergone some training or, at the very least, have started mimicking their desired voice as part of a natural learning process. This adaptation helps them navigate society so they are not only acknowledged and respected but also protected from discrimination, violence, and hatred—issues we must work to eliminate.

Since they are already practicing these techniques, I explain that surgery, at least in my hands, will enable them to achieve the best version of their voice with minimal effort. It will provide them with a natural-sounding voice, unlike some outdated vocal feminization procedures that produce an artificial, almost cartoonish sound. While those earlier methods did raise pitch, they failed to create a truly gender-affirming result, often making the voice sound awkward or unnatural.

As a result, they fell short in all respects. Modern vocal feminization surgery, however, is designed to yield the best possible outcome. That said, I never promise a specific pitch because factors such as a person’s height and the length of their vocal tract influence resonance. I can guarantee they can reach their optimal pitch without the strain of conscious effort.

Jacobsen: Regarding the scarless tracheal shave procedure, you mentioned several techniques available, each tailored to the specific needs of the candidate. So, what exactly is this technique?

Mendelsohn: Excellent question. Scott, now you’ve got me excited! If you thought I was enthusiastic about everything else, I truly love discussing this. So, let’s get into it. I’m a specialist in thread-based techniques…

I’m a voice box specialist. So, when discussing gender-affirming voice care, which we’ve already discussed, that is well within my expertise.

The surgery does not—and should never—affect the vocal cords. The Adam’s apple is part of the voice box structure, but it sits above where the vocal cords are within the cartilage, creating the neck bump. Historically, this procedure was thought to be purely cosmetic. This is a terrible misconception, but that was the term often used.

Insurance companies used to deny coverage because they believed it was cosmetic. We now know that is completely incorrect. This procedure is an important part of healthcare. A woman who struggles to walk around in public with an Adam’s apple faces challenges to her well-being. This surgery is necessary for many people when appropriate.

Because it was categorized as cosmetic for so long, plastic surgeons and cosmetic surgeons performed tracheal shave surgery. Their goal was to reduce the bump in the neck to align with a patient’s gender identity. However, these surgeons often lacked expertise in vocal cord anatomy—understanding where everything aligns and how to protect the vocal cords.

One of the major risks of tracheal shave surgery is that if the surgeon focuses solely on aesthetics and removes too much cartilage, they can sever the vocal cord attachment. This results in a catastrophic injury.

Over the years, tracheal shave procedures have shifted from cosmetic surgeons to voice box specialists. This was a natural progression for me as a specialist in gender-affirming care. Performing tracheal shave surgery felt essential to my field. After doing a few of these procedures, it felt right—removing an Adam’s apple so a person could live a confident, happy life.

But there was an issue. When we completed the surgery, we had to make an incision directly at the Adam’s apple or slightly above it. While we achieved excellent contour reduction, the resulting scar could be hypertrophic (raised), hyperpigmented (darker than the surrounding skin), or hypopigmented (lighter than the surrounding skin). Either way, research shows that scars catch the eye more than tattoos.

Even though we reduced the bump, people still noticed the patient’s neck. That meant our patients had to use makeup or cover-up every time they went public. We were helping but not addressing the issue to its fullest extent.

At the same time, government and private insurance companies were starting to cover this procedure, recognizing its medical necessity. Around the same time, a new surgical approach for thyroid gland removal, performed through the mouth, was gaining attention in the United States.

I pursued training in this thyroid gland procedure, and as I did, gender-affirming care was rapidly expanding. Patients were finally getting the coverage they needed, and it was clear that this field was evolving to meet those needs.

Suddenly, it came to me like a light bulb moment. Why can’t I do what we’re already doing for this cartilage for the thyroid gland? It’s the same area. We can access it through the mouth.

The surgery described for thyroid gland removal involves making a small incision on the inside of the lower lip, inserting instruments underneath the skin’s surface, and removing the gland. There were differences in how far down we needed to go and the type of work involved, so some of the instrumentation had to be adapted. But the concept was clear.

And I certainly was not the only one with this idea—it was being proposed worldwide. However, what set our approach apart was that we developed highly creative instrumentation to make the procedure successful.

This happened just before the pandemic shutdown when we began introducing this as a viable alternative to the traditional incision, which leaves a visible scar. We first started performing the procedure in 2019. Since then, we’ve completed approximately 300 cases using the lower lip approach.

From our experience, we found that removing Adam’s apple without leaving a scar achieves excellent results and maximizes safety. We previously discussed one of the major complications of this surgery—the risk of cutting through the vocal cord attachment.

With this technique, I use an endoscope, a small camera inserted through the lower lip, to measure and identify critical landmarks. Instead of making a small incision and struggling to see through a tiny opening—like looking through a peephole—I now have full visualization of the entire area. Even though the incision is hidden, my ability to see and navigate the anatomy is significantly improved.

Areas toward the side and back of the cartilage can sometimes retain fullness, which is not always in line with a traditionally feminine neck contour. This new approach allows me to be more precise and effectively address those recessed areas.

Ultimately, this scarless approach allows us to perform safer, more comprehensive surgery. Oh, and another major benefit—there’s no visible scarring. Scars can sometimes “out” a person or expose them to discrimination and hatred even more than Adam’s apple itself.

Jacobsen: What are the recovery timelines and outcomes for patients?

Mendelsohn: For tracheal shave surgery, and I mean “we” in the collective sense—everyone in the field performing this procedure—we are still working on defining success.

Some patients achieve a beautiful neck contour but may not feel entirely satisfied, and vice versa. Some patients may have residual fullness or a slight bump remaining, particularly below the vocal cords. I cannot always remove all of it without risking vocal cord function, so we do our best to balance aesthetics and safety.

Sometimes, we could have achieved a better result, while the patient feels their outcome is fantastic. So, from that perspective, we are continuously refining our techniques.

We conduct surveys before and after surgery, asking patients how they feel about their necks and taking photos to assess the results.

How do I personally measure success? I judge it based on the number of revision requests we receive.

For example, in rhinoplasty (a nose job), patients sometimes return for a revision to make small adjustments, like reducing an extra tip. In our case, our revision rate is less than one percent. From that standpoint, this surgery is extremely successful.

It is also extremely safe—we have not had a single case of vocal cord injury, which is one of the most serious complications we aim to avoid. And I expect that statistic to stay the same.

In terms of the recovery process, this is an outpatient surgery, meaning it is performed under general anesthesia. Still, the patient goes home the same day. The procedure itself takes about an hour and a half under anesthesia. We recommend taking a week off from work, school, or other activities.

The discomfort is moderate, meaning the patient will know they had surgery. Some procedures are so minimal in recovery that people forget they even had surgery the next day—this is not one of those. Patients will certainly feel that they had surgery.

We do prescribe pain medication, but many patients find they do not need it. From that standpoint, recovery is straightforward. There is no need for voice rest or diet modification. Ultimately, it is a week of rest, catching up on favourite streaming shows, and returning quickly to normal life.

Jacobsen: How has gender-affirming care evolved in terms of surgical techniques and technological sophistication over time?

Mendelsohn: It is all based on philosophy. The techniques have advanced, and even surgeons still performing open procedures are now recessing the incision, understanding that the focus is not just the cartilage—the goal is the person.

We are seeing an important shift in approach as we look at the broader medical and surgical communities, not only in the United States but worldwide. Now that insurance companies are covering this vital healthcare, our collective experience is growing. We are better equipped to handle complex cases, such as residual fullness below the vocal cords or unexpected complications.

With more data and shared experiences, we can continue to improve and refine our techniques. For a long time—before February 2018, to be exact—there was little shared knowledge in this field.

Now, we are seeing gender-affirming surgery become like any other surgical subspecialty. We need more surgeons working in this space to drive innovation. I hope my procedure will become obsolete in a few years because we will have found an even better way to do it.

Jacobsen: What is the role of ENT specialists in the evolving multidisciplinary approach to transgender healthcare?

Mendelsohn: The role of ENT specialists is critical because we focus on everything related to the neck. This includes vocal feminization, vocal masculinization, and tracheal shave procedures.

But beyond that, ENT as a specialty is deeply connected to what it means to be human. We deal with hearing, speech (distinct from voice), breathing, nasal function, allergies, and mucus production, which affect how we function daily.

Because of this, once a patient has completed their gender-affirming procedures, ENT specialists continue to provide care as needed. Right now, this work is primarily focused on the throat. Still, many ENT specialists are also performing facial feminization surgeries, which address key facial features.

We are also seeing a rise in facial masculinization surgery. However, that falls more within the realm of facial plastic surgery within ENT.

Jacobsen: What are the challenges and promises for individuals undergoing each type of surgery? One fact you pointed out is that 2018, which is recent. 

Mendelsohn: It’s embarrassingly recent. When I was in training, I was working in Bellingham, learning advanced endoscopic techniques, and that was in 2011. That was the first time I had ever even seen a gender-affirming surgery.

I had read about it, but I had never witnessed one. It was mind-blowing to see how profoundly life-changing it could be. Surgery is always about achieving the biggest impact with the smallest intervention, and these procedures exemplify that principle.

For me, that was incredible. When I returned after training in 2011, these procedures were essentially unavailable unless a patient could pay in cash—a briefcase full of money—because healthcare in America is expensive. If you could not pay, it simply wasn’t an option, which was heartbreaking.

Now, at least, we finally recognize that a massive group of important patients were ignored for so long. We have much catching up to do.

Jacobsen: What is the biggest takeaway from developing these techniques and their impact on people’s lives? This could be helpful for those who may not have expertise in this field but are reading this interview out of general interest.

Mendelsohn: Oh, boy. There are so many takeaways. I’ll keep it short.

We must fight against the misconception that a tracheal shave is a cosmetic procedure. I perform tracheal shave surgeries for cisgender women as well. Many women have naturally large Adam’s apples. They were assigned female at birth. They identify as women. Many of them have started families. And yet, they have a largeAdam’s apple.

Would anyone say that reducing their Adam’s apple is just cosmetic? I hope not.

A woman walking around with a large Adam’s apple experiences constant distress. It is not something you would wish on anyone. If we recognize this for cisgender women, then we must also understand that providing the same care to gender-diverse patients is just as critical.

This is especially true when we think about voice care.

I saw a patient recently—a beautiful young woman. If you put her in a lineup with 100 other women, you would never be able to “clock” her. But when she speaks, her voice is masculine.

She experiences an impossible dilemma in life. People open doors for her because she is perceived as a young, beautiful woman. But she can’t say “thank you” because if she does, people react negatively.

She is called names for being rude if she doesn’t say thank you. If she does say thank you, she is called names because of her voice. This is a torture that most people cannot imagine. And it is such a small thing. But it becomes debilitating when you multiply experiences like that over a lifetime.

This is not a cosmetic procedure. This is not just, “Oh, you want your voice to sound different.” This is something that must happen. Gender-affirming care is a critical component of healthcare.

Even if someone has different religious or political views, they must recognize that a human being is suffering. And if we can help them, we must do so.

That is our responsibility as individuals.

That is our responsibility as a society.

Jacobsen: Thank you so much for your time today. I appreciate it.

Mendelsohn: Of course. 

Jacobsen: Nice to meet you. Thank you—I appreciate it.

Mendelsohn: No, no—thank you for getting this out there.

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