of constantly elevating pitch while speaking. Because of the risks, vocal surgery is often considered a last resort after vocal therapy has been pursued. As for transgender men, it is generally presumed that hormone therapy does successfully masculinize the voice and lower vocal pitch. However, this may not be the case for all transgender men. Although it is far less common, surgery to lower vocal pitch does exist and may be considered if traditional hormone therapy did not adequately lower it. Medialization laryngoplasty (or masculinization laryngoplasty) is a procedure where the vocal fold contours are medially augmented with the injection of silastic implants. This mimics the changes that the vocal folds non-transgender men go through during puberty, which causes a lower sounding voice. Therapeutic techniques Therapy may take place in an individual or group setting. The most common focus in transgender voice therapy is pitch raising or lowering; however, other gender markers may be more important for an individual to work on. Clients and clinicians should discuss goals of therapy to ensure that they are working together toward the voice that most fits the person's gender identity. In a review of speech literature, Davies and Goldberg (2006) were unable to find any clear protocols for transgender men's voice therapy. Based on the protocols they found for treating transgender women's voices, they proposed the following therapeutic techniques for both voice feminization and masculinization: Imitation of non-transgender people observed in daily life. Progressively complex practice while maintaining good voice quality. Vocal flexibility exercises to maintain vocal range and voice quality. Motor training. Identifying and altering voice qualities when coughing, laughing, and clearing the throat. Experimentation with a broad range of voice styles. While there is some evidence for the effectiveness of voice therapy for transgender people, it is still weak. In a 2012 review by Oates (as referenced in Davies, Papp, and Antoni, 2015) of the literature on transgender voice therapy, 83% of studies were found to be at the lowest level of the evidence hierarchy for evidence-based practice, and the remaining 17% were also at low levels. However, research does show that transgender people who have had voice therapy have high satisfaction with the results, and there is a strong consensus among speech-language pathologists (SLPs) as to what are strong markers of speaker gender in voice. Raising pitch The most common concern for transgender women is their pitch and speaking fundamental