Usually, trans women consider vocal surgery when they feel dissatisfied with voice therapy results, or when they want a more authentic sounding female voice. However, it is important to note that vocal surgery alone may not produce a voice that sounds completely feminine, and voice therapy may still be needed. Although there has been evidence to show that all these surgeries can be effective in increasing vocal pitch as measured by F0, results have been mixed. However, many patients do report being satisfied with the results. Negative effects from these surgeries have been noted, including reduced voice quality, reduced vocal loudness, negative effects on swallowing and/or breathing, sore throat, infections and scarring. A positive effect of surgery can be protecting the voice from damage due to the strain of constantly elevating pitch while speaking. Because of the risks, vocal surgery is often considered a last resort after vocal therapy has been pursued.