Portuguese Version

Year:  2001  Vol. 67   Ed. 1 - (18º)

Relato de Casos

Pages: 114 to 118

Speech and Voice Therapy for Male-to-Female Transsexuals: Report of Three Cases.

Author(s): Leda Vasconcellos*,
Reinaldo J. Gusmão**.

Keywords: transsexualism, voice, modulation, fundamental frequency, voice therapy

Abstract:
Aim: The aim of this paper is to present phonoaudiological procederes used in the treatment of three male transsexuals (MT). Material and method: These MT looked for a phonoaudiological therapy because of a deep and unstable voice. As a personal history, all of them said that they were born in the wTong sex, that they had assumed a famele social role in the pre-adolescence period, and that they had taken hormones since adolescence. They also said that they felt repulsion for their own sexual organs, for one of them even self-injured his testicles and another submitted himself to a sex surgery change. Two of them had female voices and phonoaudiologic works consisted in vocal orientation and consciousness. The other had a voice with a low pitch end modulation full of variations of tones, with prolongation of vowels and with a drop in the intonation at the end of utterings, which may be misinterpreted as a typical homossexual voice. In this case the phonoaudiologic therapy had as aim making the voice be feminine. Different technics have been used: hiperhigh sounds, smile fonations, tongue fowardness, explorations of different utterings and rising modulation. Conclusion: It was conclued that the fundamental frequency is not enough to change a voice to be a female like voice. It is necessary to work with vocal modulation. The acceptance of different vocal technics by the patient is very important to gain a new vocal behavior. Team work is essential to reach goals which to promote a body-mind harmonious interaction and the social integration of the patients.

INTRODUCTION

The term transsexual was first used professionally and in public in 1950 (Vieira, 1996; Levine et al., 1998). Transsexuals are people that want to live or live playing the role of the gender opposed to theirs. They are absolutely sure since early childhood days that they were born with the wrong gender and their concerns about gender identity last throughout the whole development of the person, and sometimes they become so important that they take center stage in the person's life (Zhou, Hofman, Gooren, Swaab, 1995; Vieira, 1996; Levine et al., 1998; Vieira, 1999). There are male-to-female transsexuals, people who feel as if they were women but who have biological men bodies, and female-tomale transsexuals, who feel the other way round. Both cases differ from transvestites and homosexuals (Vieira, 1996; Gross, 1999). According to the International Code of Diseases (ICD10), transsexual is defined as a person who has the following characteristics: 1. A wish to live and be accepted as a person of the opposite gender; the person normally does whatever it takes to have the body compatible with the desired gender, making use of surgical or hormonal interventions. 2. Transsexual identity persistent and present for at least 2 years. 3. The disorder should not be a mental disorder or chromosomal abnormality (Levine et al., 1998).

Etiology is controversial and it has been argued for many years now. Zhou, Hofman, Gooren and Swaab (1995) studied the volume of BSTC - the brain area responsible for sexual behaviors - and found a larger area in men than in women. In male-to-female transsexual the volume was smaller or equal to the one found in women. This unpublished study confirmed the hypothesis that gender identity is a result of abnormal interaction between brain development and sexual hormones. Vieira (1996) made a survey with different authors checking their opinions on the etiology of transsexualism. One of them stated that the brain area key for sexual behavior is impregnated with the hormone contrary to the gender hormone that acts on sexual organs on the last days of fetal development or during the first weeks of life in male-to-female transsexuals. Others advocated psychological etiology, stating that conscious or unconscious behaviors of parents are essential for the formation of gender identity in children.

It is important to provide male-to-female transsexuals with treatment options that accommodate their body to their mind and not the opposite. They react sadly and angrily to the latter, which sounds impossible to them, because they are positive they are women (Vieira, 1996), They feel so disgusted about their sexual organs that some commit self mutilations. In order to look like women, they undergo hormonal treatments and resort to surgeries to acquire sexual organs and secondary characteristics compatible with their female mind. There are transsexuals of both genders, but male-to-female transsexuals search treatment more frequently (Mate-Kole, Freschi and Robin, 1990).

Treatment approach should be multidisciplinary. The Association Harry Benjamin International Gender Dysphoria created a committee to standardize treatment of such disorders, and in the 1998 review they re-addressed the topic, taking into account age range (Levine et al., 1998). Treatment in adults comprises the triad of treatment: real life experience, hormonal therapy and surgery. Psychotherapy sessions are recommended for the patients to have conflict relief and stable life style. Real life experience is a test that check the patient's capability to live life in the opposite gender role. During this period, the subject learns about family, vocational, interpersonal, educational, economic and legal consequences that the change in gender will produce. In order to start hormonal therapy, the following criteria should be met: 18 years of age, be aware of which hormones should or should not be taken and know the risks and benefits, have had at least a 3 month experience in the opposite gender role (real life experience) and have taken psychotherapy sessions for at least 3 months. As to surgical intervention, the requirements are: be over age according to the legal requirement of the country, be under hormonal treatment and living the desired gender role for at least 12 months. If during this period patients reassumed their original gender, they should not be submitted to surgery.

In Brazil, discussion and multidisciplinary treatment of transsexual population is a new issue. The Federal Medical Registry, by means of Resolution CSN n°. 1.482/97, authorized, in experimental basis, gender reassignment surgery or complementary procedures for secondary traits. The resolution defined that: 1. Transsexuals are the individuals that are uncomfortable with their own anatomical gender, wish to eliminate the present genitals and primary and secondary characteristics of their own gender, and take on the other gender; this disorder should be continuos and consistent for at least 2 years, in the absence of mental disorder; 2. The selection of patients eligible for gender reassignment surgery should be carried out by a multidisciplinary team of psychiatri,5t, surgeon, psychology and social worker, after a two-year period of follow-up, according to' the criteria that follow - to have medical diagnosis of transsexualism, be older than 21 years, and have appropriate surgical conditions; 3. Surgical procedures will only be performed at university or research oriented hospitals (CRM, 1997).

The technical literature advocates the multidisciplinary approach involving psychologists, plastic surgeons, endocrinologists, psychiatrists, urologists and gynecologists. As to otorhinolaryngologists and speech and voice pathologists, they are in charge of communication. Voice, one of the elements of communication, is capable of expressing feelings, emotions, personality traits and to attract listeners' attention. Male voices have different characteristics from female voices, because the male vocal tract is larger than the female one, similarly to the larynx and the vocal folds (Behlau and Pontes, 1995). Therefore, changes in larynx and voice of male-to-female transsexuals may be made in order to adapt them to a female mind and promote general well being.

Male-to-female transsexuals have low pitch. Many surgical techniques contribute to raise the voice pitch of these patients, such as approximation of cricoid and thyroid cartilages, cricothyroid fixation, advance of anterior commissure, scaring and deepithelization and suture of anterior commissure of vocal folds (Gross, 1999). All methods present advantages, disadvantages and risks. Another important technique to make voices sound more feminine is voice therapy, conducted by a specialized voice pathologist, arid it may be either a sequential surgical approach or an elective intervention.

This study presents three cases of male-to-female transsexuals submitted to voice therapy. None of them underwent laryngeal surgery.

REVIEW OF LITERATURE

The review of literature addressed the procedures used to promote vocal behavioral changes.

Coleman (1983) stated that the male vocal tract is 2 cm longer than the female one, resulting in lower vowel formant frequencies in men. Therefore, formant frequencies provide signs to help identity the speaker. The author advocated the use of vocal techniques to shorten the vocal tract and obtain a female voice, such as phonation during smiling and laryngeal elevation.

Spenser (1988) conducted an acoustic analysis and judgement by lay people of voices of 8 male-to-female transsexuals using their female voices. Lay judges identified correctly the gender of 8 subjects of the control group, classifying 4 male-to-female transsexuals as men and 4 as women. Those identified as men had f0 below 160Hz, and the ones identified as women had f0 above 160Hz. The author concluded that 160Hz is an important female threshold.

Wolfe, Ratusnik, Smith and Northrop (1990) conducted acoustic analysis and judgment by lay people of intonation and fundamental frequency (f0) of 20 male-to-female transsexuals. Lay judges identified 9 speakers as women and 11 as men. Those identified as women had a mean f0 of 172 Hz (155-195 Hz) and higher percentage of ascending intonation; those subjects identified as men had a mean f0 of 1.18 Hz (97-145 Hz) and higher percentage of descending intonation. The authors concluded that f0 is more important than intonation patterns as a clue of female voice; 155Hz seems to be an important threshold of female voices; once the threshold of f0 has been reached changes in intonation pattern may contribute to the perception of female characteristics in voice.
Gunzburger (1995) conducted acoustic and perceptive analysis and judgment of voices of 6 male-to-female transsexuals. A sample of female and male voices of each of them was recorded. Lay judges identified the voices as female or male, as the subjects originally intended. Female voices had higher f0, more pitch variability and reduced loudness when compared to male voices. The author found 3rd formant values higher in female voices and stated that the 3rd formant is related to shorter vocal tracts. He advocated the use of vocal techniques that favored shortened tracts for the female characteristics of voice in male-to-female transsexuals, such as phonation during smiling, tongue anterior placement, and laryngeal elevation.

Mount a Salmon (1998) analyzed vocal changes of a 63-year-old male-to-female transsexual during an 11-month period of therapy. During the 4 first months, the objective of therapy was to elevate f0, which went from 110Hz to 205Hz. However, the patient was still identified as a man over the phone. As from the 5th month, the objective was to modify the resonance characteristics of the vocal tract by means of elevating the mandible and placing the tongue anteriorly. The results were measured based on the frequency of the 2nd formant, which was elevated and reached female levels. The results were maintained for 5 years after treatment.

CASE REPORT

This study described three. male-to-female transsexuals (MFT) referred by the Ambulatory of Laryngology of UNICAMP for speech and voice assessment and therapy. The ages were 25, 28 and 31 years and they had complaints of low and unstable voice.

All of them had been sure, since pre-school years, that they were born with the wrong gender, and they had assumed a social role of woman since pre-puberty years, had taken hormones since teenager years and rejected their male sexual organ; one of them had mutilated the testes. Only one had been submitted to gender reassignment surgery. The other two were complying with the rules of the multidisciplinary follow-up at UNICAMP, as recommended by the Regional Medical Registry:

Vocal assessment was conducted by the author and gender judgement, by lay people (Vasconcellos, 1999).

Communication assessment of the subjects revealed the following relevant data:
The 25-year-old MFT subject (MFTl) had discreet hoarse and breathy voice, reduced MPT, restrained type of articulation, and pitch, loudness and modulation typical of a woman. She reported some negative vocal habits and aggressive, stubborn and good-humored personality. She had female secondary characteristics, she was tall and had large bones, with female movement and body language. Her voice was considered to be that of a woman by all judges.

The 28-year-old MFT subject (MFT2) had mild/moderate hypernasal vocal quality, low pitch, increased loudness, modulation characterized by frequency variation and excessive vowel prolongation, plus descending intonation at the end of utterances (sounding like the voice of an exaggerated gay men, confirming the impression of the patient). She reported allergic rhinitis and an agitated, dominating, impatient and extroverted personality. She showed secondary female characteristics, was tall and had female movements and body language. Her voice was classified as of that of a man by 26.6% of the judges.

The 31-year-old MFT subject (MFT3) had moderate hypernasal vocal quality and pitch, loudness and modulation typical of women. She reported negative vocal habits and allergic rhinitis and asthma. She had secondary female characteristics, was short, overweighed for her height and had female movements and body language. Her voice was considered to be that of a woman by all judges.

Speech and voice therapy

Speech and voice therapy for MFT1 and 3 consisted of awareness of the fact that their voices were female voices, in addition to training on vocal hygiene. For MFT l, we also worked on vocal techniques to smoothen phonation, increase MPT and improve articulation pattern. For MFT3 we taught techniques to improve resonance.

Speech and voice therapy for MFT2 aimed at making the voice sound more female. First, we tried raising of fundamental frequency by placing a specific tone (G2), which belongs to the female vocal spectrum, without causing discomfort. We did not succeed, because the patient did not manage to match sound pairs. We started auditory training. We used the technique of hyperhigh sounds to elevate f0 together with the techniques to modify the characteristics of the vocal tract, such as phonation during smiling, anterior placement of tongue, and work with more female production, by reducing loudness, articulation strength and use of higher pitch. The technique most widely used by the patient was hyperhigh sounds. After 5 months of therapy, the voice became higher (f0=173.61Hz), approaching the female spectrum, but was still identified as a male voice.

We then started to work on modulation changes, using the reduction of excessive tone variation, production of vowels and ascending intonation. Since observation of a female role model is important, we repeated the modulation of TV female personalities admired by the patient and the modulation of the author of the present paper. We used a record player and the application Dr. Speech Science 3.0 Tiger Electronics, module Speech Training, for visual and auditory feedback.

DISCUSSION

The wish to have a female voice is something very evident in these patients. When the results of the speech and voice assessment and the judgment of gender made by the lay judges were presented, MFT 1 and 3 became very happy. They showed interest in learning about vocal hygiene and the techniques to improve their vocal quality; however, they were more concerned about being identified as women in the various communication situations. Therefore, the goal of speech and voice therapy was to raise awareness and teach vocal hygiene.

Speech and voice therapy for MFT 2 aimed at transforming the voice into a female pattern, divided in two steps. The first one focused on raising f0 and changing the characteristics of resonance of the vocal tract, and the second one intended to change the intonation pattern.

Since male vocal tract is larger than the female one and produces lower frequencies in men (Coleman, 1983; Gunzburger, 1995), and considering that MFT2 had a male frequency f0, we used techniques to raise the fundamental frequency. Although the objective was fulfilled, the patient's voice was still not perceived as that of a woman. This fact, showed in the studies of Mount and Salmon (1998), led us to the conclusion that although raising of fundamental frequency into the female frequency range is an important and indispensable task (Spenser, 1988), it is not enough to indicate female patters; therefore, it is not more important than the work on change of modulation patterns, as stated by Wolfe, Ratusnik, Smith a Northrop (1990).

The work to modify resonance characteristics followed what was advocated by Coleman (1983), Wolfe, Ratusnik, Smith and Northrop (1990), Gunzburger (1995) and Mount and Salmon (1998). These techniques provided raising of f0 and reduction of formant frequencies and loudness, which sounds more like a female voice, but the new voice was not accepted by the patient, although she noticed these changes. The use of a weaker emission, with less articulation strength and higher pitch, despite it sounded more feminine, was not appreciated by the patient, because it did not match her personality.

Changes in modulation pattern are important to modify vocal characteristics that generate the impression of gay-man voice, because of excessive variation of tones and prolongation of vowels, and descending intonation at the end of utterances, which may all be reverted with training. This new approach has been well received by the patient, who has been fighting daily to reach a more significant change. A new vocal gender judgment will be conducted in order to confirm the success of treatment.

FINAL COMMENTS

We concluded that the raising of f0 is not enough to make a voice sound female. It is equally necessary to work on modulation; however, vocal techniques should be accepted by the patient in order to lead to automatization of new behaviors. We also believe that it is unnecessary to work on semantic content or body language, because maleto-female transsexuals have been feeling women since their pre-school days, and consequently, they developed verbal and body languages compatible with the identified gender. Teamwork is essential to reach the general therapeutic objective, that is, to promote optimal body-mind balance and social integration of these patients.

REFERENCES

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* Speech and Hearing Pathologist, Master Degree in Psychology at Universidade Estadual de São Paulo - UNESP.
** Assistant Professor of the Discipline of Otorhinolaryngology at Faculdade de Ciências Médicas, UNICAMP.
Paper presented at I Congresso Triológico de Otorrinolaringologia, held in São Paulo on November 13 - 18, 1999, which received special citation.
Address for correspondence: Leda Vasconcellos - Rua Fernão de Magalhães, 1005 - Parque Taquaral - 13087-130 Campinas /SP.
Tel: (55 19) 242-4159 - Fax: (55 19) 243-9983 - E-mail: ledavasc@cosmo.com.br
Article submitted on February 14, 2000. Article accepted on March 23, 2000.

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