Acoustic measures of Brazilian transgender women's voices : a case–control study

Objective: This study aims to compare the acoustic vocal analysis results of a group of transgender women relative to those of cisgender women. Methods: Thirty transgender women between the ages of 19 and 52 years old participated in the study. The control group was composed of 31 cisgender women between the ages of 20 and 48 years old. A standardized questionnaire was administered to collect general patient data to better characterize the participants. The vowel /a/ sounds of all participants were collected and analyzed by the Multi-Dimensional Voice Program advanced system. Results: Statistically significant differences between cisgender and transgender women were found on 14 measures: fundamental frequency, maximum fundamental frequency, minimum fundamental frequency, standard deviation of fundamental frequency, absolute jitter, percentage or relative jitter, fundamental frequency relative average perturbation, fundamental frequency perturbation quotient, smoothed fundamental frequency perturbation quotient, fundamental frequency variation, absolute shimmer, relative shimmer, voice turbulence index (lower values in the cases), and soft phonation index (higher values in the cases). The mean fundamental frequency value was 159.046 Hz for the cases and 192.435 Hz for the controls. Conclusion: Through glottal adaptations, the group of transgender women managed to feminize their voices, presenting voices that were less aperiodic and softer than those of cisgender women

A speech therapy for transgender women : an updated systematic review and meta-analysis

Background We systematically reviewed the literature and performed a meta-analysis on the effects of speech therapy and phonosurgery, for transgender women, in relation to the fundamental frequency gain of the voice, regarding the type of vocal sample collected, and we compared the effectiveness of the treatments. In addition, the study design, year, country, types of techniques used, total therapy time, and vocal assessment protocols were analyzed. Methods We searched the PubMed, Lilacs, and SciELO databases for observational studies and clinical trials, published in English, Portuguese, or Spanish, between January 2010 and January 2023. The selection of studies was carried out according to Prisma 2020. The quality of selected studies was assessed using the Newcastle–Ottawa scale. Results Of 493 studies, 31 were deemed potentially eligible and retrieved for full-text review and 16 were included in the systematic review and meta-analysis. Six studies performed speech therapy and ten studies phonosurgery. The speech therapy time did not influence the post-treatment gain in voice fundamental frequency (p = 0.6254). The type of sample collected significantly influenced the post-treatment voice frequency gain (p < 0.01). When the vocal sample was collected through vowel (p < 0.01) and reading (p < 0.01), the gain was significantly more heterogeneous between the different types of treatment. Phonosurgery is significantly more effective in terms of fundamental frequency gain compared to speech therapy alone, regardless of the type of sample collected (p < 0.01). The average gain of fundamental frequency after speech therapy, in the /a/ vowel sample, was 27 Hz, 39.05 Hz in reading, and 25.42 Hz in spontaneous speech. In phonosurgery, there was a gain of 71.68 Hz for the vowel /a/, 41.07 Hz in reading, and 39.09 Hz in spontaneous speech. The study with the highest gain (110 Hz) collected vowels, and the study with the lowest gain (15 Hz), spontaneous speech. The major of the included studies received a score between 4 and 8 on the Newcastle–Ottawa Scale. Conclusion The type of vocal sample collected influences the gain result of the fundamental frequency after treatment. Speech therapy and phonosurgery increased the fundamental frequency and improved female voice perception and vocal satisfaction. However, phonosurgery yielded a greater fundamental frequency gain in the different samples collected. The study protocol was registered at Prospero (CRD42017078446)

Concentração sérica de fator neurotrófico derivado do cérebro em pacientes diagnosticados com disforia de gênero que realizaram cirurgia de redesignação sexual

Transsexualism (ICD-10) is a condition characterized by a strong and persistent dissociation with one’s assigned gender. Sex reassignment surgery (SRS) and hormone therapy provide a means of allowing transsexual individuals to feel more congruent with their gender and have played a major role in treatment over the past 70 years. Brain-derived neurotrophic factor (BDNF) appears to play a key role in recovery from acute surgical trauma and environmentally mediated vulnerability to psychopathology. We hypothesize that BDNF may be a biomarker of alleviation of gender incongruence suffering. Objectives: To measure preoperative and postoperative serum BDNF levels in transsexual individuals as a biomarker of alleviation of stress related to gender incongruence after SRS. Methods: Thirty-two male-to-female transsexual people who underwent both surgery and hormonal treatment were selected from our initial sample. BDNF serum levels were assessed before and after SRS with sandwich enzyme linked immunosorbent assay (ELISA). The time elapsed between the pre-SRS and post- -SRS blood collections was also measured. Results: No significant difference was found in pre-SRS or post- -SRS BDNF levels or with relation to the time elapsed after SRS when BDNF levels were measured. Conclusion: Alleviation of the suffering related to gender incongruence after SRS cannot be assessed by BDNF alone. Surgical solutions may not provide a quick fix for psychological distress associated with transsexualism and SRS may serve as one step toward, rather than as the conclusion of, construction of a person’s gender identity.O transexualismo (CID-10) é uma condição caracterizada por forte e persistente dissociação com o gênero atribuído. A cirurgia de redesignação sexual (CRS) e a terapia hormonal (TH) permitem que indivíduos transexuais se sintam mais congruentes com seu gênero e, por isso, têm desempenhado papel importante nos últimos 70 anos. O fator neurotrófico derivado do cérebro (BDNF) parece desempenhar um papel fundamental na recuperação do trauma cirúrgico agudo e vulnerabilidade ambiental à psicopatologia. Nós hipotetizamos que o BDNF pode ser um biomarcador de alívio do sofrimento de incongruência de gênero pós-CRS. Objetivos: Mensurar os níveis séricos de BDNF no pré e pós-operatório em indivíduos transexuais como biomarcador de alívio de estresse relacionado à incongruência de gênero após a CRS. Métodos: Trinta e duas pessoas transexuais masculino para feminino submetidas a cirurgia e tratamento hormonal foram selecionadas de nossa amostra inicial. O nível sérico de BDNF foi avaliado antes e depois da CRS pela técnica ELISA. O tempo decorrido entre as coletas de sangue pré e pós-CRS foi medido. Resultados: Não houve diferença significativa nos níveis de BDNF pré e pós-CRS ou em relação ao tempo decorrido entre a CRS e a coleta. Conclusão: O alívio do sofrimento relacionado à incongruência de gênero pós-CRS não pode ser avaliado apenas pelo BDNF. Soluções cirúrgicas podem não fornecer uma solução rápida para o sofrimento associado ao transexualismo, e a CRS pode servir como um passo em direção à, em vez de conclusão da, construção da identidade de gênero de uma pessoa

Neuroplasticidade na disforia de gênero : bloqueio puberal e terapia hormonal cruzada após cirurgia de afirmação sexual

A disforia de gênero (DG) cursa com marcada incongruência entre o sexo atribuído ao nascimento e a identidade de gênero expressa, podendo ocorrer desde a infância até a vida adulta (DSM-5-APA 2013). O tratamento clínico compreende terapia hormonal cruzada (THSC) e cirurgia de afirmação sexual (CAS) para adultos e supressão da puberdade para crianças, com o propósito de reduzir o sofrimento psíquico. Em crianças, o tratamento consiste na administração de análogo parcial de liberação de gonadotrofina (GnRHa) nos estágios iniciais de desenvolvimento sexual (Tanner 1–2), a fim de evitar a aquisição de caracteres sexuais secundários que geram sofrimento à pessoa com DG. É um tratamento considerado reversível. No Brasil, a indicação é manter o uso de GnRHa até os 16 anos, quando apenas então é indicado o tratamento hormonal cruzado. Em adultos e adolescentes, a THSC (>16 anos) e a CAS (>21 anos) são complementares. O procedimento cirúrgico consiste em reconstrução genital e gonadectomia. A partir desse momento, um estado de hipogonadismo é instaurado caso seja interrompida a terapia hormonal cruzada. Este estudo propõe-se a avaliar (1) o impacto da supressão gonadal sobre a cognição e o desenvolvimento cerebral em uma criança com DG (homem para mulher) e (2) os efeitos neuroplásticos da THSC em mulheres transexuais após CAS. No primeiro caso, antes da supressão gonadal, foram realizadas ressonância nuclear magnética (RNM), avaliação cognitiva e testagem neuropsicológica. A RNM e avaliação cognitiva foram repetidas 22 e 28 meses após o início do GnRHa. Em mulheres transexuais pós-CAS, o protocolo de pesquisa incluiu RNM (estrutural e funcional), dosagens laboratoriais e testagens cognitivas 30 dias após a suspensão da THSC e, então, 60 dias após introdução de THSC com estradiol (E 2 ). Durante o bloqueio puberal, o estudo constatou declínio do coeficiente intelectual total às custas de uma queda de 9 pontos do subitem memória operacional (IMO). Paralelamente, a fração de anisotropia (FA) do corpo caloso, fascículo hipocampal e cingulado permaneceu inalterada. Nas mulheres transexuais, a THSC correlacionou-se com mudanças na conectividade funcional durante resting state (rs-FC) e com variações da espessura cortical (EC). A THSC promoveu aumento da rs-FC entre tálamo esquerdo e córtex sensório-motor (CSM) direito e esquerdo (respectivamente, p=0.0027 e p=00196); variações de E 2 foram preditoras de mudanças na conectividade entre: (1) núcleo caudado direito e CSM-esquerdo (βΔE 2 =0.13, pFDR=0.0066); núcleo caudado direito e CSM-direito (βΔE 2 =0.12, p-FDR=0.0066); (2) tálamo esquerdo e CSM-esquerdo (βΔE 2 =0.13, p-FDR=0.0094); tálamos esquerdo e CSM-direito (βΔE 2 =0.09, p-FDR=0.0320). A pesquisa demonstrou correlação inversa entre variações de estradiol sérico e EC no: (1) giro temporal médio esquerdo (βΔE 2 =-0.7035; p-β-ajustado=0.0023; p-modelo-ajustado=0.0091); (2) giro frontal superior esquerdo (βΔE 2 =-0.6827; p-β-ajustado=0.0049; p-modelo-ajustado=0.0248); (3) precuneus direito (βΔE 2 =-0.7335; p-β-ajustado=0.0028; p-modelo-ajustado=0.0216); (4) giro temporal superior direito (βΔE 2 =-0.7045; p-β-ajustado=0.0029; p-modelo-ajustado=0.0235); (5) parsopercularis direito (βΔE 2 =-0.7327; p-β-ajustado=0.0013; p-modelo-ajustado=0.0055). No mesmo experimento, as variações do volume do hipocampo esquerdo entre E 2 -CSHT associaram-se a mudanças do IMO (βΔ OMI =0.60; p-βΔ OMI =0.005; p-modelo=0.0082). Portanto, em ambos os experimentos, a terapia hormonal colaborou com mudanças na arquitetura e/ou conectividade cerebral, associando-se parcial ou indiretamente ao desfecho cognitivo.Gender dysphoria (GD) is a condition marked by the incongruence between the sex-at-birth assigned and the expressed gender identity, which can occur from childhood to adult life (DSM-5-APA 2013). The clinical treatment comprises cross-sex hormone therapy (CSHT) and gender affirming surgery (GAS) for adults and puberty suppression for children, to reduce psychic suffering. In children, the treatment consists in the administration of partial analogue of gonadotropin release (GnRHa) in the early stages of sexual development (Tanner 1 and 2) to avoid the acquisition of secondary sexual characteristics that causes suffering to the person with GD. The treatment is considered reversible. In Brazil, the indication is maintaining GnRHa until 16 years old, only then cross-sex hormone therapy is indicated. For adults and adolescents, CSHT (>16 years) and GAS (>21 years) are complementary. The gender affirming procedure consists in genital reconstruction and gonadectomy. From this moment on, a hypogonadism state is induced if cross-sex hormone therapy is interrupted. This study seeks to evaluate (1) the impact of gonadal suppression on cognition and brain development in a child with GD (male-to-female) and (2) the neuroplastic effects of CSHT in transgender women after GAS. In the first case, magnetic resonance imaging (MRI), cognitive and neuropsychological assessment were performed before gonadal suppression. MRI and cognitive assessment were repeated 22 and 28 months after beginning GnRHa. In post-GAS women, the research protocol included MRI (structural and functional), laboratory assays and cognitive assessment 30 days after suspending CSHT and then 60 days after introducing CSHT exclusively with estradiol formulations (E 2 ). During pubertal suppression, there was a decline on intelligence coefficient due to a reduction of 9 points on operational memory subitem (OMI). At the same time, corpus callosum anisotropy fraction (FA), hippocampal and cingulate fasciculus remain unchanged. In women post-GAS, CSHT correlated with neuronal connectivity during resting state (rs-FC) and to variations of cortical thickness (CTh). CSHT promoted rs-FC coupling between left thalamus and either the right and left sensorimotor cortex (SMC) (respectively p-FDR=0.0027; p-FDR=00196); E 2 variations were predictors of connectivity changes between (1) right caudate nucleus and left-SMC (βΔE 2 =0.13, p-FDR=0.0066); right caudate nucleus and right-SMC (βΔE 2 =0.12, p-FDR=0.0066); (2) left thalamus and left-SMC (βΔE 2 =0.13, p-FDR=0.0094); left thalamus and right-SMC (βΔE 2 =0.09, p-FDR=0.0320). We demonstrated an inverse correlation between estradiol concentration and CTh in (1) left medium temporal gyrus (βΔE 2 =-0.7035; p-β-adjusted=0.0023; p-adjusted-model=0.0091); (2) left superior frontal gyrus (βΔE 2 =-0.6827; p-β-adjusted =0.0049; p-adjusted-model=0.0248); (3) right precuneus (βΔE 2 =-0.7335; p-β-adjusted=0.0028; p-adjusted-model=0.0216); (4) right superior temporal gyrus (βΔE 2 =-0.7045; p-β-adjusted=0.0029; p-adjusted-model=0.0235); (5) right parsopecularis (βΔE 2 =-0.7327; p-β-adjusted=0.0013; p-adjusted-model=0.0055). In the same experiment, left hippocampus volume variations between washout and E 2 -CSHT phase were correlated with changes in OMI (βΔ OMI =0.60; p-βΔ OMI =0.005; p-modelo=0.0082). Hence, in both experiments, hormone therapy collaborated on brain architecture and/or connectivity, partial or indirectly associating to cognitive outcome

Brain maturation, cognition and voice pattern in a gender dysphoria case under pubertal suppression

Introduction: Gender dysphoria (GD) (DMS-5) is a condition marked by increasing psychological suffering that accompanies the incongruence between one’s experienced or expressed gender and one’s assigned gender. Manifestation of GD can be seen early on during childhood and adolescence. During this period, the development of undesirable sexual characteristics marks an acute suffering of being opposite to the sex of birth. Pubertal suppression with gonadotropin releasing hormone analogs (GnRHa) has been proposed for these individuals as a reversible treatment for postponing the pubertal development and attenuating psychological suffering. Recently, increased interest has been observed on the impact of this treatment on brain maturation, cognition and psychological performance. Objectives: The aim of this clinical report is to review the effects of puberty suppression on the brain white matter (WM) during adolescence. WM Fractional anisotropy, voice and cognitive functions were assessed before and during the treatment. MRI scans were acquired before, and after 22 and 28 months of hormonal suppression Methods: We performed a longitudinal evaluation of a pubertal transgender girl undergoing hormonal treatment with GnRH analog. Three longitudinal magnetic resonance imaging (MRI) scans were performed for diffusion tensor imaging (DTI), regarding Fractional Anisotropy (FA) for regions of interest analysis. In parallel, voice samples for acoustic analysis as well as executive functioning with the Wechsler Intelligence Scale (WISC-IV) were performed. Results: During the follow-up, white matter fractional anisotropy did not increase, compared to normal male puberty effects on the brain. After 22 months of pubertal suppression, operational memory dropped 9 points and remained stable after 28 months of follow-up. The fundamental frequency of voice varied during the first year; however, it remained in the female range. Conclusion: Brain white matter fractional anisotropy remained unchanged in the GD girl during pubertal suppression with GnRHa for 28 months, which may be related to the reduced serum testosterone levels and/or to the patient’s baseline low average cognitive performance.Global performance on the Weschler scale was slightly lower during pubertal suppression compared to baseline, predominantly due to a reduction in operational memory. Either a baseline of low average cognition or the hormonal status could play a role in cognitive performance during pubertal suppression. The voice pattern during the follow-up seemed to reflect testosterone levels under suppression by GnRHa treatment