People in China are undergoing risky surgery in order to make their voices more masculine or feminine. Several clinics now offer people the surgery - which was traditionally carried out on patients undergoing a sex change.
Voice operations are the latest in a booming cosmetic surgery market, with doctors offering the procedures reporting that demand for the surgery has risen steadily in recent years. This is despite the known risk that surgery can cause loss of voice altogether, as well as pneumonia.
Academics say the rising popularity of these procedures shows the pressure Chinese people are under to conform to gender stereotypes.
One person who has had the surgery is Lu Xiang, 23, who endured years of being mocked for his 'girly' high pitched voice.
'For many years, my classmates and colleagues made fun of me because of my voice, calling me a sissy,' Lu told
Global Times journalists.
'I couldn't get a girlfriend either.
'Women didn't see me as a real man, and instead treated me like one of their female friends because of my girly voice.'
Lu's voice did not drop during puberty and in his job as a call centre operator, he was frequently mistaken for a woman.
People also assumed he was gay because of the way he spoke.
So despite the potential risks of the surgery, he decided to go ahead and have an operation which would make his voice lower.
It involved cutting a segment of cartilage from his larynx and injecting Botox into his vocal cords.
Mr Alasdair Mace, an ENT surgeon at Charing Cross hospital in London, told
MailOnline that Botox causes the vocal chords to become shorter and more loose, deepening the voice. Mr Mace carries out around two 'voice surgeries' a month, usually on patients undergoing a sex change, or patients with a defect in their voice through birth or injury.
He said Lu's case is unusual because normally females transitioning to becoming male who are hoping for a deeper voice would be given testosterone therapy which works well to deepen their voice's pitch.
HOW 'VOICE SURGERY' TO DEEPEN THE PITCH WORKS
Mr Alasdair Mace, an ENT surgeon at Charing Cross Hospital in London, carries out two 'voice surgeries' a month, usually on patients undergoing a sex change, or patients with a defect in their voice through birth or injury.
Here, he explains to MailOnline how a procedure to lower the pitch of the voice would work...
Mr Mace said: 'The pitch of the voice is determined by length, the thickness, and the tension of the vocal chords.
'You can stretch the vocal chords - the thinner they become, the higher the voice will go.
'The thicker and the more lax the vocal chords, the deeper you'll go.
'Botox makes the chords shorter, flatter and more floppy, deepening the voice.
'The chords are also attached to a bit of horse-shoe shaped cartilage called thyroid cartilage.
'If you cut a little bit of cartilage out and drop it back, this shortens, stiffens the chords and the voice will become deeper.'
He added that the Botox injection is usually temporary.
'It's a vacuous aim if you inject it into the vocal chords because it'll wear off. So they keep having to come back.'
He added that the procedure carries well-known risks.
He said: 'If you have too much you weaken the chords so they can no longer come together and you'll lose your voice.
'The reason we have vocal cords is originally to protect the lungs from things going down the wrong way.
'There's a risk of causing pneumonia by paralysing them.
'People having the procedure would have to know about the risks: losing the voice, the chest infections.'
Lu underwent a surgical procedure presumably because he was already male and so testosterone therapy would not be appropriate..
He explained how the procedure works: 'The vocal chords are attached to a bit of horse-shoe shaped cartilage called thyroid cartilage.
'If you cut a little bit of cartilage out and drop it back, this shortens, stiffens the chords and the voice will become deeper.'
'Injecting Botox makes the chords shorter, flatter and more floppy, deepening the voice.
However, he added that the Botox injection is usually temporary.
'Botox paralyses muscles. You use it for wrinkles; It only works for three to six months. Which is why people have to keep going back for more.
'It's a vacuous aim if you inject it into the vocal cords because it'll wear off. So they keep having to come back for more injections.'
Patients risk losing their voice temporarily, and catching chest infections, he added.
He said: 'If you have too much you weaken the chords so they can no longer come together and you'll lose your voice.
'The reason we have vocal cords originally is to protect the lungs from things going down the wrong way. Even animals who don't speak have vocal chords for this purpose.
'There's a risk of causing pneumonia by paralysing them. People having the procedure would have to know about the risks: losing the voice, the chest infections.'
One Chinese doctor says he has performed more than 200 vocal surgeries over the last four years.
Huang Yideng, a doctor from The Chinese People's Liberation Army 118 Hospital, said most people who came to him for surgery were men like Lu with a high-pitched voice but wanted to sound more 'manly'.
Women with low-pitched voices who wanted to sound more 'girly' also opted for the procedure.
One manager at a centre that carries out the operations said demand for the surgery from China has risen in recent years.
Zhou Meiling, a manager of the Yeson Voice Center in South Korea, said four years ago about 20 Chinese clients came to the clinic each year.
Last year, around 100 Chinese patients visited, she said.
One 23-year-old man had a procedure which involved cutting a segment of cartilage from his larynx and injecting Botox into his vocal cords. He wanted to sound deeper after years of his 'girly' voice being mocked
Many were seeking to improve their competitiveness in the job market.
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Different procedures exist, but one option is to place titanium plates between the throat muscles, causing the vocal chord to stretch, raising the pitch,
the Telegraph reports.
An incision can be made in the vocal chord, or part of it can be burnt away with a laser.
This causes scarring which stiffens the chord, making the pitch higher.
Many might dismiss such cosmetic surgery as a symptom of vanity, but some academics blame rigid Chinese gender roles.
'Gender is performed, in the sense that men are expected to behave in ways that conform to preconceived ideas of masculinity, and women are expected to behave in ways that conform to preconceived ideas of femininity,' Chen Yaya, of Shanghai Academy of Social Sciences, told the Global Times.
People who already have normal voices, but still seek vocal surgery are doing so out of pressure to conform more fully to gender stereotypes, she said.
She added: 'Our society needs to be more inclusive of differences within genders, so that people with unconventional voices or other characteristics that don't conform to their gender stereotype won't be pressured into the pain of surgery.'
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