acoustic analysis of voice in mtf transsexual-pre and post hormone therapy

1. `

3. WELCOME TO THE 9TH CLINICAL CONFERENCE OF THE
YEAR 2011-2012
ACOUSTIC ANALYSIS OF
VOICE IN MtF
TRANSSEXUAL-PRE AND
POST HORMONE
TREATMENT
GUIDE: Ms Anita Reddy
PRESENTERS: Sr Ancy
Ms Pawana P Poojary

4. WHAT IS GENDER DYSPHORIA??
Gender Dysphoria
also known as
„Gender Identity
Disorder‟(GID), is a
medical term for
anxiety, confusion or
discomfort about
birth gender.

5. GENDER IDENTITY DISORDER
• Gender identity
disorder is a conflict
between a person's
actual physical
gender and the
gender that person
identifies himself or
herself as.

6. HOW TO DIAGNOSE GID??
DSM-IV-TR Criteria for GID includes
 Long-standing and strong identification
with another gender
 Long-standing disquiet about the sex
assigned or a sense of incongruity in
the gender-assigned role
 The diagnosis is not made if the
individual also has physical intersex
characteristics
 Significant clinical discomfort or
impairment at work, social situations, or
other important life areas.

7. TRANSSEXUALISM
• Transsexualism is a gender
identity disorder in which there
is a strong and ongoing cross
gender identification, i.e., a
desire to live and to be
accepted as a member of the
opposite gender(Harry
Benjamin,1966)
• It is characterized by persistent
feelings of inappropriateness
of biologic, sex, and
preoccupation with eliminating
primary and secondary sexual
characteristics.

8. DIAGNOSTIC CRITERIA FOR TRANSSEXUALISM
DSM III-R
ICD-10

9. Criteria for Transsexualism in DSM III-R
• Persistent discomfort and sense
of inappropriateness about one's
assigned gender.
• Persistent preoccupation for
atleast two years with getting rid
of one's primary and secondary
sex characteristics and acquiring
the sex characteristics of the
other gender.
• The person has reached puberty.

10. Criteria for Transsexualism in ICD-10
Here transsexualism has three criteria:
1. The desire to live and be accepted as a
member of the opposite gender, usually
accompanied by the wish to make his
or her body as congruent as possible
with the preferred gender through
surgery and hormone treatment;
2. The transsexual identity has been
present persistently for at least two
years;
3. The disorder is not a symptom of
another mental disorder or a
chromosomal abnormality.

11. Kinds of transsexuals
The most known 'kinds' of transsexual s
are
 Male-to-female transsexuals(MtF):
Persons assigned “male” at birth, but
identifies themselves as women.
 Female-to-male transsexuals(FtM):
Persons assigned “female” at birth but
themselves identify as men.

12. CLASSIFICATION OF TRANSSEXUALISM
• Harry Benjamin defined a few different
levels of intensity of transsexualism.
Transsexual
(nonsurgical)
True Transsexual
(moderate intensity)
True Transsexual
(high intensity)

13. TYPE
TRANSSEXUAL
Nonsurgical
TRUE
TRANSSEXUAL
Moderate Intensity
TRUE
TRANSSEXUAL
High Intensity
GENDER FEELING
Undecided.
Feminine.(“Trapped
in a male body”)
Feminine. Total
psycho-sexual
inversion
DRESSING HABITS May live as a man
AND SOCIAL LIFE
or a woman;
sometimes
alternating
Lives and works as
woman if possible.
Insufficient relief from
“dressing”.
May live and work
as woman.Dressing
gives insufficient
relief.
CONVERSION
OPERATION
Attractive but not
requested.
Requested.
Urgently requested
and usually
attained.
ESTROGEN
MEDICATION
Needed for comfort
and emotional
balance
Needed for a
substitute for or
preliminary to SRS
Required for partial
relief.
PSYCHOTHERAPY
Only as guidance;
Permissive
otherwise refused or psychological
unsuccessful.
guidance.
For symptomatic
relief only.

14. Ethel Person M.D and Lionel Ovesey‟s
Classification(1974)
Primary Transsexuals
• These are the ones who are functionally
asexual and who progresses resolutely
toward a surgical resolution without
significant deviation toward either
homosexuality or heterosexuality.
Secondary Transsexuals
• These are the ones who are homosexuals
and effeminate from early childhood into
adulthood . They are subdivided into
Homosexual transsexualism and
transvestitic transsexualism.

15. PREVALENCE OF
TRANSSEXUALIS
M

16. Kuiper(1991)
COUNTRY
YEAR
M-F
F-M
RATIO
USA
1968
1.0
0.25
4:1
Sweden
1971
2.7
0.97
2.8:1
England
1974
2.9
0.93
3.2:1
Australia
1981
4.2
0.67
6.1:1
Prague
1983
-
-
1:5
Netherland
1988
5.6
1.85
3:1
Singapore
1988
34.5
12.0
2.9:1

17. o The DSM-IV (1994) quotes a prevalence of
roughly 1 in 30,000 assigned males and 1 in
100,000 assigned females seek sex
reassignment surgery in the USA.
o A presentation at the LGBT Health Summit in
Bristol, UK, shows that this population is
increasing rapidly (14% per year) and that the
mean age of transition is also rising.

18. CAUSES FOR
TRANSSEXUALISM
NEUROLOGICAL
CAUSES
PSYCHOANALYTI
C CAUSES
RANDOM
EVENTS
CHROMOSOME
S
CHEMICALS

19. NEUROLOGICAL CAUSE
• In the case of transsexualism,
Central subdivision of the Bed
Nucleus of Stria Terminalis (BSTc)
nucleus has a sex reversed
structure.
• For example, in the case of
transwoman, the size of this
nucleus and its neuron count is in
the same range as that of women
in the general population.

20. CHROMOSOMES
Transsexual have
nonstandard
Karyotype leading
to hormonal
„confusion‟ during
fetal development.

21. CHEMICALS
Drugs administered to
pregnant women
(diethylstilboestrol) or oral
contraceptives
unknowingly taken after
conception frequently
caused transsexual
offspring by disrupting the
hormone processes.
(T.Jaya Lakshmi, S.Lakshmi
Narayana and R. Kumar)

22. RANDOM EVENTS
The biochemistry fails to
work properly and
disrupts fetal
development;
 If the expectant mother
is anaemic,
 If the fetus is
undernourished for
some reason, or
 If the maternal hormones
do not cross the
placenta in sufficient.

23. PSYCHO-ANALYTIC CAUSES
• MtF transsexualism might
result from a failure, to
separate the self from the
mother in the early
boyhood.
• Divorce rates, dominance
of one of the parents and
discord in marital
relations account for
transsexualism.

24. PATH TOWARDS TOTAL TRANSSEXUALISM
COUNSELING
REAL LIFE TEST
HORMONE
THERAPY
SEXUAL REASSIGNMENT
SURGERY

25. TEAM
APPROACH

26. TEAM MEMBERS
Psychiatrist
Speech
Language
Pathologist
Surgeon
Psychologis
t
Endocrinolo
gist

27. PSYCHIATRIST
:
• To diagnose the individual's gender
disorder;
• To diagnose any co-morbid psychiatric
conditions and see to their appropriate
treatment;
• To counsel the individual;
• To ascertain eligibility and readiness for
hormone and surgical therapy

28. PSYCHOLOGIST
• To conduct a complete psychodiagnostic assessment;
• To engage in psychotherapy;
• To educate family members,
employers, and institutions about
gender identity disorders

29. ENDOCRINOLOGIST
• To provide safe and effective
hormonal treatment;
• To suppress endogenous hormone
secretion;
• To maintain cross-sex hormone
levels within the normal range;
• To monitor the effects of both
endogenous and cross-sex hormone
levels.

30. SURGEONS
• The surgeon is not merely a technician
hired to perform a procedure.
• The surgeon must understand the
diagnosis that has led to the
recommendation for the prescribed
surgery.
• Ideally, the surgeon should have a close
working relationship with the other
professionals who have been actively
involved in the patient‟s psychological
and medical care.

31. SPEECH LANGUAGE PATHOLOGIST
• To assess the client to obtain a
baseline measure of voice;
• To look at a variety of aspects of
communication, including vocal
pitch, intonation and resonance, and
nonverbal communication;
• To provide voice and communication
training for the transsexual clients;
• To eliminate any vocal abusive
behaviors resulting from changes in
pitch and intensity.

32. TREATMENT

33. COUNSELING
Transsexuals develop emotional
problems like
 worthlessness,
 pessimism,
 dejection,
 frustration,
 isolation,
 withdrawal
 depression with persistent
suicidal ideation.

34. Psychological Problems undergone
by Transsexuals
Denial: Trying to convince themselves
that they are not transsexuals.
Realization: Come to realize about
what they are,but choose to live
with the discomfort of a
inappropriate body and gender
role.

35. Rejection by family and peers :Many
transsexuals lose friends , family due to
lack of understanding.
Socio economic aspects: They are often
harassed or even assaulted if their
condition becomes known.
Legal: It is difficult to obtain a legal change
of new name and gender for example
passport, driving license, citizenship and
medical records.

36. REAL-LIFE EXPERIENCE
It is an extended period of fulltime living in the preferred
gender role.
It should first take place in a safe
and trusted environment
Carried out in public places later
Patient should live for a minimum
of one full year

37. HORMONE
TREATMENT

38. Reasons for Hormone Treatment??
• Hormones are often
necessary for successful
living in the new gender.
• They improve the quality of
life and limit psychiatric comorbidity
• To appear more like members
of their preferred gender.

39. The prerequisites for hormone therapy according
to SOC (Standards Of Care)

40. TYPE OF
TRANSSEXUAL
HORMONES
ADMINISTERED
MALE to FEMALE
TRANSSEXUAL
ESTROGEN
ANTI ANDROGEN
FEMALE to MALE
TRANSSEXUAL
ANDROGENS

41. EFFECTS OF ESTROGENS ON MtF TRANSSEXUALS
POSITIVE EFFECTS
NEGATIVE EFFECTS
Redistribution of body fat to
approximate a female
shape.
Possibility of blood clotting
A decrease in upper body
strength
Development of benign
pituitary tumors
Softening of the skin
Weight gain
Decrease in body hair
Liver disease
Reduction in scalp hair loss
Formation of Gallstones

42. IMPORTANT NOTE!!!
• Estrogens have no
effect on the male voice
or musculature nor
does it reduce facial
hair growth.

43. ANTI-ANDROGENS
• Antiandrogens are a diverse group of
steroids given to counteract the effects
of androgens (male sex hormones) on
various body organs and tissues.
• It lowers the body's production of
androgens or blocks the body's ability
to make use of the androgens that are
produced.

44. ANDROGENS
FtM Transsexuals treated with
testosterone, experience a series of
changes:
 Increases muscle mass
 Deepened Voice(Gerritsma et
al,1994)
 Increase in body hair and loss of
scalp hair(Futterweit and
Deligdisch,1986)
 Acne(Blanchard and Steiner,1990)

45. Results of exogenously administered male
hormones on females
REVERSIBLE CHANGES
IRREVERSIBLE CHANGES
Acne
Thickening of the vocal
cords(deepening of the voice)
Atrophy of ovaries and uterus
Hypertrichosis(increased hair
growth)
Weight Gain and water retention
Possible liver damage(which
maybe fatal)
Hardening of surface quality of the Possible Infertility
skin-appears „tough‟

46. SURGERY

47. SEXUAL REASSIGNMENT SURGERY
• Sex Reassignment Surgery, along with
hormone therapy and real-life
experience, is a treatment that has
proven to be effective.
• Sex reassignment is not "experimental,"
"investigational," "elective", "cosmetic,"
or optional in any meaningful sense.
• It constitutes very effective and
appropriate treatment for transsexualism
or profound GID.

48. FtM Transsexuals
• The administration of androgens
result in lowering of the vocal pitch
due to its direct effect on vocal fold
mass.
• However the mass of the vocal folds
can be further increased by injection
of substances, and the vocal folds
can be shortened by surgery..

49. MtF Transsexuals
• After changing the primary sex
characteristics, voice raising
surgery should be included in
the concept of MtF transition.
• Hormonal treatment is not able
to raise the pitch, and speech
therapy alone cannot, as a rule,
guarantee lasting success.

50. TYPES OF SURGERY
COSMETIC
SURGERY
PHONOSURGERY

51. COSMETIC SURGERY
• Thyroid Chondroplasty :Surgical
correction of the thyroid cartilage(Adam‟s
apple), also known as laryngeal shaving,
is performed in order to give the much
flatter appearance of the female larynx.
• This surgery was described by Wolfort et
al(1990) to decrease the laryngeal
prominence.
• It does not affect the quality of the
voice(Isshiki,1980)

53. PHONOSUGERY
• The term phonosurgery
refers to any surgery
designed primarily for the
improvement or restoration
of voice.

54. Pitch-raising Surgeries include
Cricothyroid
approximation
Anterior commissure
advancement
Scarification to change
vocal fold consistency

55. CRICOTHYROID
APPROXIMATION
• Cricothyroid approximation increases
the vocal pitch by simulating the
contraction of the cricothyroid muscles
with sutures.
• The Cricoid and Thyroid cartilages are
approximated anteriorly with nylon
sutures.

56. Disadvantages of CTA
• No permanent results can
be obtained as the fixation
of the sutures often
ruptures.
• Includes greater risk of
reversion to lower pitch and
potential narrowing of pitch
range

58. ANTERIOR COMMISSURE ADVANCEMENT
• It was first described by LeJeune
and coworkers in 1983.
• He created a cartilage window that
was pulled forward along with the
vocal folds.
• The space between the advanced
cartilage and the rest of the
thyroid cartilage was maintained
with the titanium splint.

59. Disadvantage of ACA
• It increases prominence of the
thyroid cartilage which causes
cosmetic disadvantage to the
transsexuals.
• Calcification of the thyroid
cartilage may limit the ability to
advance the anterior commissure.

61. SCARIFICATION TO CHANGE VOCAL
FOLD CONSISTENCY
• Decreased vocal fold mass may
be achieved by removing tissue
with the CO2 laser or by
mechanically inactivating the
vocalis muscle (Isshiki, 1974;
1989).
• It elevates pitch , but it is also
associated with decreased volume
and substantial hoarseness.

62. VOICE
ASSESSMENT

63. It Includes
Medical history
ENT history
Social history
The presentation of the
client
Voice history

64. Perceptual
Assessment
Objective
Assessment
Indications or
suitability for
treatment
Management

65. VOICE TREATMENT

66. • The approach adopted is usually
an holistic one.
• The different cognitive and
linguistic processes
characteristic of both genders
are considered.
• This is an essential part of
treatment and contributes to the
development of a more natural
voice and speech pattern.

67. DIFFERENCE BETWEEN MALE AND FEMALE
COMMUNICATION






Pitch
Resonance
Loudness
Durational Characteristics
Phrasing
Enunciation

68.  Language Structure and Vocabulary : Female
Communication usually involves
 Increased use of adverbs and adjectives
 Increased use of apologies and socially
“polite” phrases
 Use of increased elaboration and indirect
communication strategies.

69. Nonverbal Markers: Feminine nonverbal visual markers
include
 maintaining eye contact,
 attending to other speaker's nonverbal cues,
 using more hand, arm, and upper body gestures,
 sitting closer and
 occasionally touching the listener.

70. Transs
exual
Speech
Therap

71. • Therapy should focus upon a variety of speech,
language, and pragmatic functioning as they
relate to gender.
(American Speech Language Hearing
Association, 2009)
• It should facilitate the personalized intervention
necessary to modify and monitor change in
target behaviors.

72. Components of Transsexual Speech Therapy
program
(a)Education/informatio
n
(b) Discussion
(c) Speech therapy
exercises

73. SPEECH THERAPY GOALS
• Determining appropriate target
pitch
• Training target pitch if the
individual has difficulty matching
pitches auditorily
• Significantly changing individual
characteristics associated with
“feminine” or “masculine” speech

74. SPEECH THERAPY EXCERCISES






Altering Tongue position to improve resonance
Open mouth approach
Ear Training
Establishing new pitch
Yawn Sigh Approach
Making softer articulatory contact

75. Non-verbal communication: Facial
expressions, posture, and movement
 Focus on strengthening the client‟s observational skills.
 Offer general feedback on the client‟s self-defined parameters
for change.
 Offer general feedback about social conventions relating to
masculine/feminine expressions and movement.
 Refer to a trans-competent clinician who has training in nonverbal communication.

76. HABITUATION
Strategies to promote carryover into everyday
life may include:
• Practicing words that are typically part of
daily conversation
• Experimenting with emotional intensity by
practicing sentences expressing joy,
sorrow, irritation, anger, etc.
• Practicing outside the clinic setting
(including telephone and in-person)

77. Follow-up Sessions
• Follow up sessions after the initial treatment is
important in maintaining change.
• Clinically supervised follow up also provides an
excellent opportunity to gather much-needed data
about the effectiveness of a program over time.

78. CLIENT
PRESENTATION

79. Client name :ABC
Client no
:101113
Age/Gender:24years/Female
Brief history: The client came to our institute on 22nd September
2011 for pre surgical evaluation of voice. She had been to
Dr.Shankarshana on 19th September 2011 for undergoing a
surgery for changing her voice from low pitch to high pitch.
He referred her to our institute for complete pre surgical voice
evaluation .The client has undergone SRS (male to female)
and wants to have high pitch female voice . The client is
currently undergoing hormone therapy .

80. Name
Value Unit
Norm(m)
STD(m)
Fo
140.552Hz
145.223
23.406
MDVP Parameters-(Before
Hormone Therapy)
Average Fundamental
Frequency
Mean Fundamental Frequency MFo
140.530H 141.743
z
21.136
Highest Fundamental
Frequency
Fhi
145.985H 150.080
z
24.362
Lowest Fundamental
Frequency
Flo
136.031H 140.418
z
23.729
Phonatory Fo-Range in semitones
PFR
2
2.095
1.064
Noise to Harmonic Ratio
NHR
0.157
0.122
0.014
Soft Phonation Index
SPI
51.643
6.770
3.784
Relative Average Perturbation
RAP
0.613%
0.345
0.333

81. Name
Value Unit
Norm(m)
STD(m)
Average Fundamental
Frequency
Fo
141.004Hz
145.223
23.406
Mean Fundamental Frequency
MFo
140.981H
z
141.743
21.136
Highest Fundamental
Frequency
Fhi
145.775H
z
150.080
24.362
Lowest Fundamental
Frequency
Flo
134.990H
z
140.418
23.729
Phonatory Fo-Range in semitones
PFR
2
2.095
1.064
Relative Average Perturbation
RAP
0.470%
0.345
0.333
Noise to Harmonic Ratio
NHR
0.153
0.122
0.014
Soft Phonation Index
SPI
35.604
6.770
3.784
MDVP Parameters-after
hormone therapy

86. DISCUSSION!!!

87. CONCLUSION
 FtM Transsexuals can take
androgens during hormone
therapy which have the effect
of increasing the mass of the
vocal folds with the resulting
drop in vocal pitch.
 In MtF Transsexuals, vocal
folds are not significantly
affected by the estrogen which
is administered.

88. • Hormonal treatment does not have
substantial or lasting influence on
voice pitch of MtF Transsexuals
• Hormone Treatment on its own do
not produce satisfactory results
in MtF transsexuals
• As a result male transsexuals
need to seek a combination of
hormone therapy, voice therapy
and surgery for „female-like‟
voice.

89. REFERENCES
Surgery of Larynx and Trachea by Marc Remacle,
Hans Edmund Eckel
Operative voice pitch raising in male-to-female
transsexuals by
K. Neumann, C. Welzel and A. Berghaus
Intersex by Catherine Harper
Transsexualism: illusion and reality
by Anthony Molino Staff, Colette Chiland
Transsexual and other disorders of gender identity:
a practical guide to management by James Barrett
Female-to-male transsexualism: historical, clinical,
and theoretical issues by Leslie Martin Lothstein
The Praeger handbook of transsexuality: changing
gender to match mindset by Rachel Ann Heath

90. ACKNOWLEDGEMENTS
• We thank our Lord Almighty, for His abundant
blessings and guidance.
• We also thank our parents for their unending
encouragement, support and prayers; without
whom we would not be who we are today.
• We owe our deepest gratitude to our guide, Anitha
ma‟am, for her guidance, patience and inspiration
since the very inception. We are indebted to you
ma‟am.
• It is a pleasure to all our batch mates, seniors and
juniors for all their kind help.