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

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

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  • 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 voice in mtf transsexuals Presentation Transcript

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  • 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
  • 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.
  • 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.
  • 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.
  • 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.
  • DIAGNOSTIC CRITERIA FOR TRANSSEXUALISM DSM III-R ICD-10
  • 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.
  • 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.
  • 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.
  • CLASSIFICATION OF TRANSSEXUALISM • Harry Benjamin defined a few different levels of intensity of transsexualism. Transsexual (nonsurgical) True Transsexual (moderate intensity) True Transsexual (high intensity)
  • 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.
  • 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.
  • PREVALENCE OF TRANSSEXUALIS M
  • 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
  • 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.
  • CAUSES FOR TRANSSEXUALISM NEUROLOGICAL CAUSES PSYCHOANALYTI C CAUSES RANDOM EVENTS CHROMOSOME S CHEMICALS
  • 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.
  • CHROMOSOMES Transsexual have nonstandard Karyotype leading to hormonal „confusion‟ during fetal development.
  • 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)
  • 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.
  • 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.
  • PATH TOWARDS TOTAL TRANSSEXUALISM COUNSELING REAL LIFE TEST HORMONE THERAPY SEXUAL REASSIGNMENT SURGERY
  • TEAM APPROACH
  • TEAM MEMBERS Psychiatrist Speech Language Pathologist Surgeon Psychologis t Endocrinolo gist
  • 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
  • PSYCHOLOGIST • To conduct a complete psychodiagnostic assessment; • To engage in psychotherapy; • To educate family members, employers, and institutions about gender identity disorders
  • 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.
  • 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.
  • 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.
  • TREATMENT
  • COUNSELING Transsexuals develop emotional problems like  worthlessness,  pessimism,  dejection,  frustration,  isolation,  withdrawal  depression with persistent suicidal ideation.
  • 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.
  • 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.
  • 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
  • HORMONE TREATMENT
  • 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)
  • TYPE OF TRANSSEXUAL HORMONES ADMINISTERED MALE to FEMALE TRANSSEXUAL ESTROGEN ANTI ANDROGEN FEMALE to MALE TRANSSEXUAL ANDROGENS
  • 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
  • IMPORTANT NOTE!!! • Estrogens have no effect on the male voice or musculature nor does it reduce facial hair growth.
  • 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.
  • 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)
  • 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‟
  • SURGERY
  • 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.
  • 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..
  • 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.
  • TYPES OF SURGERY COSMETIC SURGERY PHONOSURGERY
  • 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)
  • PHONOSUGERY • The term phonosurgery refers to any surgery designed primarily for the improvement or restoration of voice.
  • Pitch-raising Surgeries include Cricothyroid approximation Anterior commissure advancement Scarification to change vocal fold consistency
  • 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.
  • 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
  • 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.
  • 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.
  • 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.
  • VOICE ASSESSMENT
  • It Includes Medical history ENT history Social history The presentation of the client Voice history
  • Perceptual Assessment Objective Assessment Indications or suitability for treatment Management
  • VOICE TREATMENT
  • • 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.
  • DIFFERENCE BETWEEN MALE AND FEMALE COMMUNICATION       Pitch Resonance Loudness Durational Characteristics Phrasing Enunciation
  •  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.
  • 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.
  • Transs exual Speech Therap
  • • 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.
  • Components of Transsexual Speech Therapy program (a)Education/informatio n (b) Discussion (c) Speech therapy exercises
  • 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
  • SPEECH THERAPY EXCERCISES       Altering Tongue position to improve resonance Open mouth approach Ear Training 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 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.
  • 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)
  • 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.
  • CLIENT PRESENTATION
  • 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 .
  • 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
  • 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
  • DISCUSSION!!!
  • 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.
  • • 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.
  • 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
  • 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.