Volume 6, Number 4, 2002

Satisfaction of MtF Transsexuals with Operative Voice Therapy – 
A Questionnaire-based Preliminary Study

Kerstin Neumann
HNO-Klinik der Martin-Luther-Universität Halle-Wittenberg
Magdeburger Str. 12
06112 Halle
Germany

Cornelia Welzel
Department of Otorhinolaryngology
Head and Neck Surgery
Martin-Luther University of Halle-Wittenberg

Ute Gonnermann
Department of Otorhinolaryngology
Head and Neck Surgery
Ernst-Moritz-Arndt University of Greifswald
Domstraße 11
17487 Greifswald
Germany

Uwe Wolfradt
Department of Psychology
Martin-Luther University of Halle-Wittenberg

Citation:  http://www.symposion.com/ijt/ijtvo06no04_02.htm

• Abstract
• Keywords
• Introduction
• Methods
• Results
• Discussion
• Conclusions
• References

Abstract

After having undergone successful sexual reassignment surgery male-to-female (MtF) transsexuals are very often negatively affected by their unchanged masculine voice, which contrasts with their feminine appearance and this interferes considerably with their social integration as women. Since hormonal treatment or logopedic therapy alone will not achieve a permanent increase in voice pitch, the development of a phonosurgical technique to achieve a permanent elevation of the voice pitch is of great importance.
Since 1993, 67 MtF transsexuals have undergone cricothyroidopexy at the department of otorhinolaryngology, in the university hospital in Halle, according to Berghaus and Neumann (1996). Increased tension of the vocal cords results in a permanent elevation of the fundamental frequency range by five to six semitones on average. While pre-operatively none of the patients had a feminine speaking voice pitch, after the surgery, about 30 percent attained a voice pitch within the feminine range, and 38 percent attained at least a neutral voice pitch. In the long-term, mostly combined with further voice training, the results proved to be of a permanent character, and in 45 percent of the cases, a further increase was observed. The operation technique in question has proved to be generally successful with a minimum of risk factors. 
The effect that voice therapy can have on the social integration of the persons in question and to what extent they were satisfied with the results of voice treatment was assessed by means of a questionnaire, which was developed with the Institute of Psychology at the Martin-Luther University of Halle-Wittenberg. Twenty-eight questionnaires were evaluated, and in most cases, the feminisation of the voice had improved and facilitated better social integration was achieved by the MtF transsexuals who had undergone treatment.

Keywords: transsexualism, phonosurgery, logopedic therapy, patients’ satisfaction

Voice is an important constituent of human identity. MtF transsexuals consider their voice to be the greatest obstacle to social integration and to successfully changing their identity on completion of their sexual reassignment surgery (Berger, 1988). They experience their own voice as unsuitable, that is, too deep in comparison with their new feminine habitus. Keil (1994) used a questionnaire to investigate the value of voice adaptation for MtF transsexuals. He came to the conclusion that the voice seemed to be a relatively unimportant factor in sexual reassignment for his respondents. These findings, however, contradict the comments made by other MtF transsexuals, who consider voice adaptation to be an important step towards creating a new identity, even more important than the transformation of breasts and genitals: "… for nobody will look under my skirt, but my voice is audible to everyone." (Stavenhagen, 1995).

Another study revealed that MtF transsexuals meet with opposition from the general public in everyday situations like shopping, passport checks, etc. Therefore, many of them find it difficult to re-integrate into everyday life. Unfortunately, the people around them show very little tolerance " … when a well-groomed woman opens her mouth and a male voice rings out." (Oswald, 1992).

Since hormonal treatment in MtF transsexuals does not achieve a desired increase in voice pitch, voice adaptation (voice operation and voice therapy, that is, logopedic, treatment) is necessary. Phonosurgical intervention is also considered when a feminine voice cannot be achieved by means of voice training alone. For most of the persons in question, a voice operation seems to be the only way of attaining a permanent voice change with a more a feminine timbre.

The operation principle consists, as described by Isshiki (1974, 1983), in an approximation of the cricoid and thyroid cartilages. First a skin incision of minimal length of 2 cm is made in a throat fold above the larynx. After the preparation of the thyroid and cricoid cartilages the approximation is obtained in the following way: After pricking the cricoid cartilage the needle is passed under the cricothyroid membrane into the thyroid cartilage and again out of it on the same side in order to be passed beside it into the thyroid cartilage and again out through the cricoid cartilage (principle of the back-stitch suture). When required, two of these sutures can be performed. By tightening and fixing the wire suture, both cartilages are ventrally approximated to a maximum degree. In order to avoid failures through a rupturing of the cartilage with later loosening of the suture, as often described by Isshiki, we modified the technique by passing the 2-0 monofile wire sutures over 3- or 4-hole miniplates, either resorbable i.e., made of lactosorb or non resorbable made of titanium and fixing them (Neumann et al., 2002a, 2002b). The approximation is always continued until a maximum contact of the 2 cartilages is achieved, which may be supported by minimum resection of the tissues between the two cartilages. As a rule, the operation is done under intubation anaesthesia in order to avoid major psychic and physical strain for the patients during the intervention, resulting in increasing restlessness.

Between October 1993 and December 2001, 67 patients of an average age of 39 (SD=, range 24-67) underwent Cricothyroidopexy. All except two patients (who were Canadian) were German. None of the patients had previously undergone surgical intervention with the aim of raising their voice pitch. All of the patients received a questionnaire after their operation (see Appendix) in order to better assess the influence of voice therapy on the lives of MtF transsexuals.

From a total of 67 questionnaires sent out, 35 (52%) completed questionnaires were returned. Seven of these were unfortunately so incomplete that they could not be included in the evaluation. The data provided by the remaining 28 (42%) completed questionnaires were included in the analysis.

The questionnaire consists mainly of a list of questions or statements with multiple choice answers. The respondents chose the answers that expressed the corresponding degree of agreement or disagreement with the statements listed (Mummendy, 1995). The instructions included a statement that the questionnaire should be regarded as a subjective means of measurement and that there were no "incorrect" answers. The respondents were given exactly formulated patterns of answers in order to make their assessments. All of the respondents assessed themselves according to the same criteria or characteristics by choosing from a standardized selection of multiple choice answers and marking their choice with a cross.

The study uses a 5-point Likert scale, for example, 1 = "does not apply" to 5 = "applies fully" (see Appendix). The five criteria used in the answer scale varied, depending on the question, since a uniform scale was not feasible. Dichotomous questions, that is, questions, which can only be answered with "Yes" or "No" were also included. Furthermore, several personal comments made by the respondents provided a great deal of background information.

The questionnaire covered the subjective opinions of MtF transsexuals concerning their voice operation and voice training. In particular, the following information on the patients’ attitudes was collected: voice, expectations of rise in voice pitch, acceptance of the "new" voice and reactions of their social environment.

The questionnaire had four parts. The first page introduced the study, and gave instructions on how to answer the questions. The subsequent pages of the questionnaire were subdivided into the following sections:

1. Demographics: including age, education, occupation, children, family status, and whether the respondent smokes or not.
2. Respondent and Voice: The second section of the questionnaire contained general data on work situation, musicality, sociability, the breaking of the respondents’ voice during puberty, strain on the voice, importance of the voice, strategies used to raise the voice pitch, voice adaptation, and hormonal treatment. Using 5-point Likert scales, the respondents assessed the daily strain on their voice and the role of the voice in a variety of everyday situations.
3. Voice treatment: In this section, the respondents were first asked about their voice prior to any voice treatment and about the kind of voice treatment received. Furthermore, they were asked about their expectations regarding voice elevation, whether these expectations had been met, and whether they were satisfied with the results of their voice operation. Additionally however, there were statements regarding the therapy sessions. Questions concerning the respondents’ identification with their new voice and their satisfaction with the general results of the voice treatment concluded this section of the questionnaire.
4. Present life situation: The last part of the questionnaire covered the situation of the respondents after voice treatment. Here, the respondents were asked to give information on the femininity of their present voice timbre, on the effects of voice treatment in various areas of everyday life, and on any problematic everyday situations before voice treatment. This is followed by questions on the reaction of people around them, how accepted they feel as a woman, and on any relapses into their "old" voice timbre.

Space was left between some of the questions for personal comments. Some of the respondents added further comments to some of their answers: these will be dealt with in the discussion section of this article.

Frequencies and correlation between individual values were computed. Mean values were compared using t-test and Chi-squares employing Software package SPSS Version 10.0.

The age spectrum of the patients ranged from 30 to 67 years of age, the average age being 44. Fifty percent of the MtF transsexuals were between 30 and 41 years of age and 25 percent were between 52 and 67. The education of the respondents is as follows: 38 percent had attended a Realschule (graduation after ten years of schooling), 35 percent hat attended a Hauptschule (graduation after eight years of schooling), and 27 percent had attended a Gymnasium (graduation after thirteen years of schooling with attainment of university entrance qualification). At the time of the questionnaire, 29 percent lived alone, 29 percent were married, and 21 percent were divorced. A further 11 percent lived with either a female or male partner.

As mentioned in the introduction of this article, transsexualism is not limited to one section of the population: even this small sample showed a variety of occupations, such as bakers, cooks, locksmiths, farmers, medical doctors, and engineers. After sexual reassignment, 48 percent of the respondents went back to their previous jobs. These demographic data are included in Table 1.

The age of the patinets was between 24 and 67 years. Approximatly half of the patients considered themselves to be musicaly and also sociable. Twenty-two (79%) of the respondents noticed their voice change, thirteen of whom (46%) at the age of thirteen to fourteen. Twelve (48%) of the respondents underwent therapy to raise the pitch of their voice before the voice operation.

The majority of respondents (twenty-five, 90%) did not perceive any change in their voice after hormonal treatment. The remaining three patients had noticed some effects of hormonal treatment, without describing them in detail.

The degree of voice stress during the day was assessed by fourteen (50%) of the respondents as "high" to "very high". In Figure 1, the strain on the voice of the respondents is depicted in the different areas of their lives. The graph shows that the respondents experienced the strain on their voice in all these areas as "medium" to "very high". The areas of "work", "public life" or "friends" were considered to be more demanding on the voice than those in their private life like "relationship", "family" and "leisure time".

(Answer format: 1="None at all" to 5="Very high")

Figure 1: Voice stress in various areas of life

The role of the voice in all spheres of everyday life is considered by the respondents to be throughout "important" to "very important". According to the present study, the voice of the respondents is especially important in the areas of "public life", "telephoning" and "shopping". None of the respondents regarded her voice as "slightly important" or "not at all unimportant".

(Answer format: 1="Not at all" to 5="Very")

Figure 2: The role of the voice in various areas of life

Figure 3 shows which strategies are used by the respondents to raise the pitch of their voices. It emerged that the respondents often try to speak "more melodiously". Other ways mentioned to make the voice sound more feminine were "elevating the voice" and speaking "more softly", corresponding to the ratings of "applies partly" to "applies mostly". Strategies such as "speaking less often" or "avoiding speaking contact" were hardly ever mentioned.

(Answer format: 1="Does not apply" to 5="Applies fully")

Figure 3: Strategies used to make the voice sound more feminine

Eighteen (64%) of the respondents answered the question of whether they felt less feminine if they did not adjust their voice with "applies mostly" or "applies fully". On the other hand, six (21%) of the respondents answered "does not apply" to the question.

Twenty-seven (96%) of the respondent underwent operative voice correction by means of cricothyroidopexy over miniplates. twenty-three (82%) were still undertaking voice therapy at the time of the questionnaire. Voice training had not yet started for four patients (15%).

Twenty-five (93%) respondents took the decision to have a voice operation on their own initiative. With regard to voice therapy, eighteen (67%) of the respondents took the first steps themselves.

The respondents’ doctor, voice therapist, and friends or acquaintances were of most importance when it came to giving advice on undergoing a voice operation and voice function therapy (see Figure 4). On the other hand, when asked whether any advice had come from the media, self-help groups or from families, most respondents answered "applies slightly". The respondents stressed the important role in this respect of friends and acquaintances as opposed to their families and partners.

(Answer format: 1="No" to 5="Applies fully")

Figure 4: Recommendation to have a voice operation from various groups

The question as to whether the respondents’ doctor or the voice therapist had recommended a voice operation was answered with "applies mostly". Advice from family or friends was less important and given less often: "applies slightly" to "applies partly". Self-help groups and the media had almost no relevance to this issue. As regards support during voice operation, the most significant role was attributed to the doctor and to the voice therapist, while support during voice therapy was largely concentrated on the voice therapist. On the whole, little significance was attributed to partners, friends and family in this context, while almost no support was desired from self-help groups or from the media.

Nineteen (71%) from twenty-seven respondents indicated that they had expected "a lot" to "a great deal" from an operative intervention and nineteen (69%) from twenty-six respondents expressed the same with regard to voice therapy.

In sixteen (62%) of the cases, the respondents’ expectations of voice operation were "mostly" or "fully" met.

(Answer format: 1="Not at all" to 5="Fully")

Figure 5: Mean value differences regarding the variable "fulfilment of expectations"

In Figure 5, the mean value difference regarding the variable "fulfilment of expectations" is depicted. The comparison shows a significant difference. The expectations of the respondents from a voice operation were definitely better met than their expectations of voice function therapy. As regards voice training, expectations were "partly" to "fully" met in eleven (48%) cases, while eight (35%) of the respondents indicated that their expectations had been met and that they were "satisfied" with the voice training. At this point, it should be mentioned that some of the respondents had only recently started voice training following their voice operation. Therefore, some of the questions on voice therapy were not answered and so could not be included in the evaluation.

Most of the respondents (twenty-two, 80%) preferred to be treated by a female therapist and only three (12%) by a male one.

Fifteen (65%) of the respondents found performing the therapeutic exercises to be "easy" to "very easy". None of the respondents thought the exercises were "very difficult".

According to their own impressions, twelve (52%) of the respondents found putting into practice the exercises they had learned to be "easy" to "very easy". When comparing the mean value differences with regard to the variable "practical performance and transfer into everyday life" it was observed that the respondents found it much easier to carry out the therapeutic exercises during the training sessions than to put them into practice in everyday life (see Figure 6).

(Answer format: 1="Not at all" to 5="Very well")

Figure 6: Mean value differences regarding the variable: "practical exercises and their transfer into everyday life"

Twenty-two respondents (92%) regarded their own efforts as "quite a lot" to "a great deal".

This study has shown that fourteen (54%) of the respondents were "satisfied" or "very satisfied" with the total result of voice therapy.

Eight respondents (31%) regarded their present voice on completion of their voice therapy as "quite" or "fully" feminine, while ten thought that their voice was "fairly" feminine. Identification with their new voice on completion of the total treatment was assessed by the respondents as "somewhat" to "absolutely" by eight respondents (30%). Six of the respondents (23%) were only able to identify "very little" or "not at all" with their new voice.

Satisfaction with the result of their voice operation was indicated by fourteen (52%) of the respondents stating "satisfied" or "very satisfied" in the questionnaire. Seven (26%) of the respondents answered that they were " partly satisfied." With regard to voice function therapy, fourteen (61%) answered that they were "satisfied" or "very satisfied".

The extent to which the respondents felt their voice to be a problem before voice therapy is shown in Figure 7. It can been seen that problems were perceived as occurring mainly in the area of public life. Almost all considered "telephoning", "public life", "shopping", and "work" to be "very" problematic. Also, during leisure time, their voice situation was classified as "fairly" problematic. On the other hand, the areas "family", "partner", and "friends" were viewed as "fairly" or "a little" problematic.

(Answer format: 1="not at all" to 5="fully")

Figure 7: Problematic everyday situations prior to voice treatment

After voice treatment, the acceptance of the respondents as a woman tended in almost all cases towards "fairly". Particularly in the sectors "work", "leisure time", and "in public", the respondents felt they were more accepted as women (see Figure 8).

Nine (35%) of the respondents felt that the people around them reacted to their changed voice "strongly" or "a great deal".

Eight (30%) of the respondents indicated that they "often" or "always" relapsed into their "old" voice timbre, whereas another eight (30%) "never" relapsed into their "old" voice.

(Answer format: 1="Not at all" to 5="Fully")

Figure 8: Acceptance as a woman by other people after voice treatment in various areas of life

One of the objectives of evaluating the questionnaires was to find out whether the MtF transsexuals subjectively felt their voice to be more feminine. Before treatment, they had generally felt that their voice was "quite masculine", whereas they assessed their voices as "quite feminine" after voice treatment.

In order to evaluate these statements, the mean value of the assessment "feminine" was compared before and after voice treatment.

(Answer format: 1="Not at all" to 5="Definitely")

Figure 9: Mean value differences concerning the variable: "feminine voice timbre"

Furthermore, the correlation between the variables "feminine voice timbre", "voice identification after treatment", and "general satisfaction with treatment" was determined. The correlation coefficient of the present study confirms a most significant connection between feminine voice timbre, voice identification and general satisfaction with the results (see Table 2).

*p <.01

The more feminine the respondent felt their voice to be, the more they identified with their voice, and the greater their general satisfaction with the voice treatment.

Relative to the total therapy, the sample (N=28) was subdivided in two groups, based on the mean value of "general satisfaction", namely in "dissatisfied persons" (N=12) and "satisfied persons" (N=14). This was followed by a comparison of the mean value between the groups regarding the points "satisfaction with the operation", "transfer of logopedics", "voice identification", "expectations from logopedics" and "feminine voice timbre" with the T-test. After multiple correction of the Wilcoxon test, the data shown in Figure 10 emerged:

Figure 10: Mean value differences concerning voice treatment between the test groups

Figure 10 shows the highly significant differences between "satisfied" and "dissatisfied" persons regarding "voice identification" and "voice timbre". Furthermore, there is clear evidence that the groups of "satisfied" persons reported a "higher satisfaction with the voice operation". The "satisfied" groups also had a significantly higher expectation of logopedics than the "dissatisfied" group, and they were more successful in using the logopedic exercises into everyday life. Thus, it can be stated that satisfaction with therapy is also reflected in the motivation for logopedic training, which may influence the general result positively.

We then aimed to look for further factors explaining the success of logopedics. Statistically, however, no significant differences that might have explained the success of logopedics between the "satisfied" and "dissatisfied" groups were established concerning the variables "musicality" and "voice strain". Finally the influence of pre-operative logopedic treatment was studied.

Of the group who were pleased with logopedics, 27 percent had taken voice function therapy prior to the phonosurgical intervention, whereas 78 percent of the dissatisfied groups had done so. From this point of view, voice training performed pre-operatively does not appear to be advisable in the case of non-manifest voice disorders. Post-operatively, the groups of "dissatisfied" respondents had an average number of 17 logopedic sessions, while the "satisfied" respondents attended 20 sessions on average.

In order to assess the acceptance of the respondents as a woman, the mean value differences in everyday areas were studied in two groups (Figure 11).

Figure 11: Mean value differences reflecting acceptance as a woman in everyday life

The mean value differences regarding the "acceptance in private life" (family, relationship, friends) did not show any significant differences between satisfied and dissatisfied patients. In public life, for example, when "telephoning", at "work" or "shopping", however, striking differences were found. During leisure time activities, the differences also became obvious. Patients who were pleased with the total therapy definitely felt more accepted than the dissatisfied group.

A comparison of the patients shows that the group of satisfied respondents had significantly more positive reactions from the people around them and were less likely to relapse into their old voice. Here, the difference between the two groups is quite striking (see Figure 12).

Figure 12: Mean value differences in the variable reactions of other people and relapse into old voice

In order to check to what extent the voice therapy as a whole (voice operation and logopedics) helped the respondents to integrate into everyday life, the mean values of the answers were assessed separately for the two groups using a T-test (see Figure 13).

Figure 13: Mean.value differences in the total result

Though the differences in the area of family life (family/partner) were considerable, they are not, however, significant. Highly significant differences were observed in the areas "friends", "work" and "leisure time", "telephoning", "shopping" and in "public life". This shows that the reason for satisfaction was the improved recognition of the respondent as a woman in her social environment and in public life.

The results obtained in this study were based on the subjective assessments and opinions on voice treatment given by a small sample of MtF transsexuals. Thus, the conclusions derived from this study do not claim any general validity, but offer us preliminary insights and suggestions for future research. In addition, we considered it important to investigate the significance of voice therapy for MtF transsexuals, and at the same time to evaluate the success rate of voice operation and voice function therapy.

Since no other similar studies exist, the results cannot be compared. In a recent study by Yang et al. (2002) a telephone questionnaire on the satisfaction of patients after cricothyroid approximation was evaluated. More than half of the patients expressed satisfaction with the operative result. In particular, they pointed out that they felt their voice sounded more feminine.

In contrast to Keil’s (1994) opinion that during sexual reassignment MtF transsexuals place very little importance on voice, our study found that a feminine voice was very important for more than half of the respondents. Without voice adaptation, the MtF transsexuals considered themselves to be less adequate as a person. It is of course understandable that priority is given to the transformation of the primary sex organs. It can also be assumed that the MtF transsexuals are not aware of the issue of "voice" before the start of sexual reassignment. Mount and Salmon (1988) and De Bruin et al. (2000) confirm in their publications on voice characteristics in MtF transsexuals that the voice is essential for the female sex identity of MtF transsexuals as it is the means of communication. A masculine voice cannot be hidden under clothes as the body can be. The importance of the voice for some of the respondents was shown by the following quotation: "As already mentioned, I am not recognised as a woman on the telephone. Telephone calls are often decisive for my independence". Moreover, MtF transsexuals can be faced with embarrassing situations in banks, during passport controls and checks of other documents because of their masculine-sounding voices. It should be added that taking up a female occupation can be difficult for MtF transsexuals, as has been pointed out earlier in this article; the respondents revealed a high frequency of male occupations.Approximately half of the respondents were able to return to their previous jobs after sexual reassignment. The voice can be an impediment, a barrier to finding a job because it interferes with passing or because employers could be worried about the discrepancy between the transsexul’s gender identity and the voice via telefone. The findings of (Berger, 1988; Donald, 1982; Wolfe et al., 1990) that MtF transsexuals often meet with considerable difficulties in their jobs because of their appearance and the masculine timbre of their voice are in agreement with our findings.

The basic assumption that voice therapy (voice operation and voice training) has a positive effect on the voice situation of MtF transsexuals has proved to be correct. Success can be seen in the fact that after treatment the respondents felt their voice to be subjectively more feminine and that the majority were pleased with it. While they had regarded their voice as masculine before treatment, the respondents considered their voice to sound relatively feminine afterwards. The result that some of the respondents (30.7%) felt their voice to be "fairly" or "definitely" feminine can be viewed positively. When taking the results of voice operation and voice function therapy separately, it can be stated that half of the respondents were "satisfied" to "very satisfied". Nevertheless, it must be noted that some of the respondents had higher hopes regarding the vocal result. This corresponds to the findings found in (Isshiki, 1974, 1983; Yang et al. 2002). These authors also state that the expectations of MtF transsexuals exceed the surgical possibilities. The operation on its own can only be part of a whole compex of factors. Statements like "I would have expected and wished my voice to be higher" confirm this fact.

Similar opinions were also stated with regard to voice training. They are a clear indication that the patients were not always pleased with the treatment given, "They didn’t get my baritone any higher" or "a feminine timbre did not emerge, or else only partially". As indicated in this article, there are in fact insurmountable objective limits to the feminisation of a voice, for example, at the nozzle.

To identify with a "new" voice is a further step toward the female gender. For this reason, the objective of voice therapy should be to aspire to the highest possible degree of identification with the voice as well as its feminisation. In our study, 30 percent of the respondents identified "somewhat" or "absolutely" with their new voice. In contrast, 23 percent could identify "very little" or "not at all" with the changes after treatment. It is relatively difficult to evaluate these statements; a person’s subjective perception of their voice may well play an essential role. Based on their own experience, many of the patients indicated that they did not hear any differences in their voice in spite of the fact that these were clearly audible. It is very difficult to exert any influence this phenomenon.

Keil mentions in his 1994 study that many MtF transsexuals are motivated only to a small degree to undergo any voice function therapy, which has not been confirmed by our study. According to the questionnaire, expectations from a voice operation and voice function therapy were predominantly "a lot" to "a great deal". The respondents who had higher expectations were more successful in putting the voice therapy exercises into practice in their daily life. This resulted in greater satisfaction with voice function therapy. A possible explanation for this is that higher expectations from logopedic training result in higher motivation and determination from the patients to change their voice. It seems possible that these patients made more effort than those who did not believe in success. "I did not have the feeling that anything will come of it. It was only in the beginning that I experienced a positive feeling, a hope of obtaining a feminine voice timbre", wrote one of the respondents.

We learned from the respondents answers that their ’ expectations of a voice operation were not rated higher than those of voice therapy. Here we have to mention that, even today, standardized procedures for voice operations do not exist and that it is very difficult to find any publications on this subject. When determining whether expectations were generally met, it can be observed that expectations of a voice operation were definitely more fully met than those of voice function This point has a number of aspects: Firstly, an operative intervention results in voice elevation more quickly than voice training, which is spread over a longer period of time, and leads to long-term success only after arduous vocal exercises. Secondly, there is clear evidence that many of the MtF transsexuals from all over Germany come to our hospital to undergo an operation to raise their voice pitch. This shows that this operation is concentrated at our hospital, whereas logopedic treatment is given at various voice therapy institutions, most of which have not yet dealt with the issue of "voice" in transsexualism.

This could be a very important starting point for a further improvement of care of MtF transsexuals. A comprehensive voice therapy concept, as practised in the Netherlands and in Great Britain, should also be developed in the German-speaking countries in order to complement operative therapy (Chaloner, 1991; De Bruin et al., 2000). Even if voice therapists occasionally achieve an increase in basic frequency, the main focus of attention in logopedic training should be that of "feminine" articulation, resonance and body language (Bralley et al., 1978, Kalra, 1977).

Another important point, according to our findings, is the simulation of everyday situations during the voice training sessions. Here, following the therapist’s instructions during the therapy itself and putting them into practice in real life were compared. While the majority of the respondents found it "easy" to "very easy" to follow the exercises of the therapist during the therapy, applying the exercises to their daily life seemed to cause difficulties. The following personal views confirm this fact, "exercises are hardly apt to be integrated into everyday life" or "I find it difficult to put voice therapy in practice, especially when I am upset". Our findings showed that the following situations were particularly problematic: telephoning, shopping, work, banking and passport checks. The patients must learn to feel confident when using their new voice in such situations. Being aware of a reliable voice technique, acquired through a protracted training period, helps MtF transsexuals to apply these skills in everyday life. Here too, it is essential to aim for sensitivity regarding one’s own voice and functional hearing.

From our own experience and also from other publications (Chaloner, 1991; De Bruin et al. 2000; Oswald, 1992) it would be beneficial to record simulated scenes on video and to evaluate these scenes with the patients afterwards. This could explain the success or the shortcomings of the therapeutic exercises in practising feminine expressions and forms of movement. A mirror can also help to observe the body language, facial expressions, and gestures typical of women. This is of great importance, since, according to Spehr (1997), many MtF transsexuals feel that their gestures and facial expressions are feminine enough, which does not have the same effect on other people. In addition, Keil (1994: 12) suggests integrating elements of role-play into elocution training for MtF transsexuals. In this way, voice techniques and forms of expression, that correspond to different situations, could be practised. Also, the choice of therapist of MtF transsexuals should be considered. Our study showed that most of the respondents would prefer a female therapist. According to Keil (1994), patients "in general prefer[s] a woman-woman therapeutic relationship", which he explains by the fact that the voice of the female therapist is a useful role model for the MtF transsexual. Female therapists are thought to be more understanding, which the following statement showed: "a choice of therapist, the same as a choice of doctors, seemed to me very much dependent on them being female, since I do not think men have the ability or are understanding enough" or, "I only went to a man when there was no alternative on offer". Keil (1994: 5) is right in thinking that it is important to point out the limits of functional voice elevation to the patients during the course of their voice function therapy.

Our study showed that almost half of the respondents had had voice training with the aim of raising their voice pitch. This again shows that voice training alone was not enough for them to attain a feminine voice timbre, as the respondents all opted for surgical treatment to raise the pitch of their voice in addition to voice training. This result, however, cannot be generalised for all patients; some MtF transsexuals already possess favourable starting conditions for feminisation of their voices (i.e., they do not have a deep speaking voice), which facilitates attaining a permanent rise of the medium speaking voice logopedically (Wirth, 1995: 318). However, our study has shown that most MtF transsexuals have a distinct male voice (i.e., unfavourable starting conditions). Böhme (1997: 63) mentions that operative voice correction should be an option if a feminine timbre cannot be achieved by means of voice training. Berger (1988: 208) mentions that MtF transsexuals are ready to undergo additional complicated surgery in order to fulfil their desire for feminisation of their voice. For about one third of his patients, phonosurgical intervention seems to be the only way of attaining a long-term voice change (Keil, 1994: 6). The present study shows that many MtF transsexuals attach great importance to operative voice elevation and that post-operative voice function therapy has a more positive effect than pre-operative therapy. Finally, we would like to look at the general effect of voice therapy on the lives of the respondents. The respondents who were satisfied with all of the treatment felt there was a definite increase in their acceptance in areas of everyday life ("work", "leisure time", "telephoning", "shopping", and "public life") after treatment. One of them wrote "on the telephone I am being identified as a woman by about 90% of strangers". Prior to voice therapy, many situations were considered to be highly problematic, especially at work, on the telephone and in shops as well as in public life. The following quotation from one questionnaire reinforced this: "The feminine voice becomes important at the moment when somebody unknown to me does not recognise me as definitely female. When I open my mouth as a woman and the voice does not fit, things can be very embarrassing". In these public and social situations, MtF transsexuals are subject to the judgement of strangers who have had little or no experience of "transsexualism" and with the issue of "voice". In private, it can be assumed that the feelings of embarrassment of the respondents are less pronounced. In public, the respondents perceived great differences before and after therapy. In private, these differences were not significant; here, it can be assumed that the respondents had already been accepted by their families, partners and friends before treatment. Relatives and acquaintances can probably have far more understanding for the patients, as they are aware of the issue of transsexualism. The respondents confirmed that family and friends had noticed a change in their voice, which shows that the therapy had been successful. In the questionnaire, 35 percent of the respondents indicated that other people had reacted "strongly" or "a great deal" to the voice change. When comparing respondents who were satisfied or dissatisfied with the overall treatment, it arose that those who were satisfied with their treatment reported many more reactions to their voice from other people than the dissatisfied respondents reported.

According to the present study, some patients relapse more frequently into their former voice, both post-operatively and after voice treatment. The relaps rate as stated in the results section could be explained by the fact that the patients have not yet mastered the exercises from voice function therapy. This shows the necessity to extend voice training over a longer period of time. When the voice therapy succeeds, it is less likely that the patients will relapse into their old voice. Nevertheless, it is essential to prepare the patients for a possible relapse into their old voice. Keil (1994) describes that the old male voice pattern of MtF transsexuals breaks through particularly in highly emotional situations.

So far phonosurgery has only dealt with the surgical correction of the voice of MtF transsexuals to a small extent. Patients who feel less female because of their male deep voice are subject to great discomfort and unease that cannot be alleviated by methods of hormonal treatment or logopedic therapy alone. Modified cricothyroidopexy via miniplates constitutes an operative means to permanently elevate the fundamental frequency of the voice. The comparison between pre- and post-operative diagnostic parameters and the fact that most respondents were happy with the results confirmed this. When combined with a voice therapy programme, an operation can lead to a more feminine voice timbre, allowing more MtF transsexuals to be accepted as women. The voice should, however, suit the respective patient; an extremely high voice pitch or exaggerated articulation appear to be out of place and do not facilitate the patients’ social integration.

This questionnaire-based study suggest that combined voice therapy (voice operation with subsequent voice training) was most effective for the respondents. The study also revealed that voice therapy before the operation is experienced as less efficient than after. Moreover it became evident that the majority of respondents preferred a female therapist for their voice exercises. This is sensible because it is definitely easier to watch female speech inflexion and patterns of communication in a woman who can serve as a rolemodel. It also became evident that the point was not only to elevate the pitch, but also to learn female patterns of voice. movement, and expression, which should be made a constituent part of voice function therapy. Furthermore it is advisable to incorporate everyday practical exercises into voice function therapy.

It can be said that for the majority of the respondents, their everyday situation improved after voice therapy and that their acceptance as a woman increased. Both the positive functional voice results and the good cosmetic results (due to the reduction of the Adam’s apple) contributed to the psychic stabilisation of the patients. As is also demonstrated in a study by Wolfradt and Neumann (2001), surgery combined with voice training strengthens the patients self-confidence, increases their quality of life and ability to integrate, and so improves their sex identity (Altstötter-Gleich, 1996; Löwe and Clement, 1996). The findings from our study make it appear of importance to include the voice into the standards of treatment and assessment of MtF transsexuals, i.e., to make the issue of "voice" for MtF transsexuals an important constituent of any therapeutic concept.

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Correspondence and requests for materials to: kerstin.neumann@medizin.uni-halle.de