Its very important to know about Gender Dysphoria before learning about transsexuals.
Now lets learn a little about transsexualism…
He published “The Transsexual Phenomenon” 1966 which contributed largely to a more understanding opinion on transsexualism.
Recent estimates would suggest that around 1% per 25,000 is a true primary trannsexual 10 times the number of secondary trannsexuals.Primary and secondary terminology has largely been dropped from the literature. It has instead been replaced with researcher Ray Blanchard more descriptive and non heirarchialautogynephilic and androphilic transsexualism
It is an opportunity that allows the patient and the attending professional to monitor the experience of living in the new status and habituating new behaviors and interactions with others in the social environment.
The positive effects of hormone therapy do not occur quickly but takes 2 or more years to develop.
bolsters are used to hinder pressure of any temporary suture against the body during surgery.
Speech fundamental frequency is not the sole answer to a more feminine voice even following surgical modification.Pitch modification without voice therapy may only create the impression of a masculine individual with a high pitched voice
Use of the vocal tract in non-habitual ways can cause strain. Important therapeutic goals are the maintenance of efficient and easy speech, establishing appropriate practice, and informing the client about how best to maintain vocal health.Enhanced observation and awareness of speech patterns of self and others
• Determining appropriate target pitchTraining target pitch if the individual has difficulty matching pitches auditorilySignificantly changing individual characteristics associated with “feminine” or “masculine” speechIndividualized, specific input on anything the individual has difficulty understanding or doing in the group setting: this applies to all exercises but is especially important in training an efficient voice that is resistant to vocal fatigue or dysphonia
These are the acoustic results found before the administration of hormone therapy
voice in mtf transsexuals
WELCOME TO THE 9TH CLINICAL CONFERENCE OF THE
ACOUSTIC ANALYSIS OF
VOICE IN MtF
GUIDE: Ms Anita Reddy
PRESENTERS: Sr Ancy
Ms Pawana P Poojary
WHAT IS GENDER DYSPHORIA??
also known as
Disorder‟(GID), is a
medical term for
anxiety, confusion or
GENDER IDENTITY DISORDER
• Gender identity
disorder is a conflict
between a person's
gender and the
gender that person
identifies himself or
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
Significant clinical discomfort or
impairment at work, social situations, or
other important life areas.
• 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
• It is characterized by persistent
feelings of inappropriateness
of biologic, sex, and
preoccupation with eliminating
primary and secondary sexual
DIAGNOSTIC CRITERIA FOR TRANSSEXUALISM
Criteria for Transsexualism in DSM III-R
• Persistent discomfort and sense
of inappropriateness about one's
• Persistent preoccupation for
atleast two years with getting rid
of one's primary and secondary
sex characteristics and acquiring
the sex characteristics of the
• The person has reached puberty.
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
3. The disorder is not a symptom of
another mental disorder or a
Kinds of transsexuals
The most known 'kinds' of transsexual s
Persons assigned “male” at birth, but
identifies themselves as women.
Persons assigned “female” at birth but
themselves identify as men.
CLASSIFICATION OF TRANSSEXUALISM
• Harry Benjamin defined a few different
levels of intensity of transsexualism.
in a male body”)
DRESSING HABITS May live as a man
AND SOCIAL LIFE
or a woman;
Lives and works as
woman if possible.
Insufficient relief from
May live and work
Attractive but not
Needed for comfort
Needed for a
substitute for or
preliminary to SRS
Required for partial
Only as guidance;
otherwise refused or psychological
Ethel Person M.D and Lionel Ovesey‟s
• These are the ones who are functionally
asexual and who progresses resolutely
toward a surgical resolution without
significant deviation toward either
homosexuality or heterosexuality.
• These are the ones who are homosexuals
and effeminate from early childhood into
adulthood . They are subdivided into
Homosexual transsexualism and
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.
• In the case of transsexualism,
Central subdivision of the Bed
Nucleus of Stria Terminalis (BSTc)
nucleus has a sex reversed
• 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.
Drugs administered to
(diethylstilboestrol) or oral
unknowingly taken after
offspring by disrupting the
(T.Jaya Lakshmi, S.Lakshmi
Narayana and R. Kumar)
The biochemistry fails to
work properly and
If the expectant mother
If the fetus is
some reason, or
If the maternal hormones
do not cross the
placenta in sufficient.
• MtF transsexualism might
result from a failure, to
separate the self from the
mother in the early
• Divorce rates, dominance
of one of the parents and
discord in marital
relations account for
PATH TOWARDS TOTAL TRANSSEXUALISM
REAL LIFE TEST
• To diagnose the individual's gender
• To diagnose any co-morbid psychiatric
conditions and see to their appropriate
• To counsel the individual;
• To ascertain eligibility and readiness for
hormone and surgical therapy
• To conduct a complete psychodiagnostic assessment;
• To engage in psychotherapy;
• To educate family members,
employers, and institutions about
gender identity disorders
• To provide safe and effective
• To suppress endogenous hormone
• To maintain cross-sex hormone
levels within the normal range;
• To monitor the effects of both
endogenous and cross-sex hormone
• 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
• 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.
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
• To provide voice and communication
training for the transsexual clients;
• To eliminate any vocal abusive
behaviors resulting from changes in
pitch and intensity.
Psychological Problems undergone
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
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
It is an extended period of fulltime living in the preferred
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
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.
The prerequisites for hormone therapy according
to SOC (Standards Of Care)
MALE to FEMALE
FEMALE to MALE
EFFECTS OF ESTROGENS ON MtF TRANSSEXUALS
Redistribution of body fat to
approximate a female
Possibility of blood clotting
A decrease in upper body
Development of benign
Softening of the skin
Decrease in body hair
Reduction in scalp hair loss
Formation of Gallstones
• Estrogens have no
effect on the male voice
or musculature nor
does it reduce facial
• 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
FtM Transsexuals treated with
testosterone, experience a series of
Increases muscle mass
Deepened Voice(Gerritsma et
Increase in body hair and loss of
scalp hair(Futterweit and
Acne(Blanchard and Steiner,1990)
Results of exogenously administered male
hormones on females
Thickening of the vocal
cords(deepening of the voice)
Atrophy of ovaries and uterus
Weight Gain and water retention
Possible liver damage(which
Hardening of surface quality of the Possible Infertility
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.
• The administration of androgens
result in lowering of the vocal pitch
due to its direct effect on vocal fold
• However the mass of the vocal folds
can be further increased by injection
of substances, and the vocal folds
can be shortened by surgery..
• 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.
TYPES OF 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
• It does not affect the quality of the
• The term phonosurgery
refers to any surgery
designed primarily for the
improvement or restoration
Pitch-raising Surgeries include
Scarification to change
vocal fold consistency
• Cricothyroid approximation increases
the vocal pitch by simulating the
contraction of the cricothyroid muscles
• The Cricoid and Thyroid cartilages are
approximated anteriorly with nylon
Disadvantages of CTA
• No permanent results can
be obtained as the fixation
of the sutures often
• Includes greater risk of
reversion to lower pitch and
potential narrowing of pitch
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
• The space between the advanced
cartilage and the rest of the
thyroid cartilage was maintained
with the titanium splint.
Disadvantage of ACA
• It increases prominence of the
thyroid cartilage which causes
cosmetic disadvantage to the
• Calcification of the thyroid
cartilage may limit the ability to
advance the anterior commissure.
SCARIFICATION TO CHANGE VOCAL
• Decreased vocal fold mass may
be achieved by removing tissue
with the CO2 laser or by
mechanically inactivating the
vocalis muscle (Isshiki, 1974;
• It elevates pitch , but it is also
associated with decreased volume
and substantial hoarseness.
• The approach adopted is usually
an holistic one.
• The different cognitive and
characteristic of both genders
• This is an essential part of
treatment and contributes to the
development of a more natural
voice and speech pattern.
DIFFERENCE BETWEEN MALE AND FEMALE
Language Structure and Vocabulary : Female
Communication usually involves
Increased use of adverbs and adjectives
Increased use of apologies and socially
Use of increased elaboration and indirect
Nonverbal Markers: Feminine nonverbal visual markers
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.
• Therapy should focus upon a variety of speech,
language, and pragmatic functioning as they
relate to gender.
(American Speech Language Hearing
• It should facilitate the personalized intervention
necessary to modify and monitor change in
Components of Transsexual Speech Therapy
(c) Speech therapy
SPEECH THERAPY GOALS
• Determining appropriate target
• Training target pitch if the
individual has difficulty matching
• Significantly changing individual
characteristics associated with
“feminine” or “masculine” speech
SPEECH THERAPY EXCERCISES
Altering Tongue position to improve resonance
Open mouth approach
Establishing new pitch
Yawn Sigh Approach
Making softer articulatory contact
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
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.
Strategies to promote carryover into everyday
life may include:
• Practicing words that are typically part of
• Experimenting with emotional intensity by
practicing sentences expressing joy,
sorrow, irritation, anger, etc.
• Practicing outside the clinic setting
(including telephone and in-person)
• 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.
Client name :ABC
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 .
Mean Fundamental Frequency MFo
Phonatory Fo-Range in semitones
Noise to Harmonic Ratio
Soft Phonation Index
Relative Average Perturbation
Mean Fundamental Frequency
Phonatory Fo-Range in semitones
Relative Average Perturbation
Noise to Harmonic Ratio
Soft Phonation Index
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
• 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‟
Surgery of Larynx and Trachea by Marc Remacle,
Hans Edmund Eckel
Operative voice pitch raising in male-to-female
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
• 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
• It is a pleasure to all our batch mates, seniors and
juniors for all their kind help.