According to the Random House Dictionary, a transsexual individual is “A person having a strong desire to assume the physical characteristics and gender role of the opposite sex; a person who has undergone hormone treatment and surgery to attain the physical characteristics of the opposite sex” (Flexner, 1987). Brown and Rounsley (1996) explain, “Transsexuals are individuals who strongly feel that they are, or ought to be, the opposite sex. The body they were born with does not match their own inner conviction and mental image of who they are or want to be. … This dilemma causes them intense emotional distress and anxiety and often interferes with their day-to-day functioning” (p. 6).

Historically, examples of transsexualism existed in Greek and Roman times, during the Middle Ages, and in the Renaissance (Doctor, 1988). However, the first documented sex reassignment surgery is thought to have been performed around 1923. It involved a man who married at 20 but came to believe he should have been a woman, and took the name of Lili (Hoyer, 1933). The most celebrated case in the United States was that of Christine Jorgensen, who grew up in New York City as a male and had transsexual reassignment surgery performed in Denmark in 1952 (Jorgensen, 1967).

The prevalence of transsexualism is difficult to determine. The United States does not have a national registry to collect information from all possible sources that may deal with the transsexual person. Furthermore, some individuals may remain undiagnosed or may wish to remain “closeted,” or they may travel to foreign countries for sex reassignment surgery.

Data from other countries suggest that one in 30,000 adult males and one in 100,000 adult females seek sex reassignment surgery. However, the overall prevalence figures are greater if one includes transsexuals who do not elect sex reassignment surgery. In the United States, it is estimated that 6000–10,000 transsexuals had undergone sex reassignment surgery by 1988 (Brown and Rounsley, 1996). Spencer (1988) reported that in 1979, more than 4000 U.S. citizens had undergone sex reassignment surgery and about 50,000 were thought to be awaiting surgery. Estimates vary greatly concerning the number of male-to-female transsexuals compared to the number of female-to-male transsexuals, although all estimates indicate that the number of male-to-female transsexuals exceeds the number of female-to-male transsexuals by as much as 3 or 4 to 1 (Oates and Dacakis, 1983; Doctor, 1988; Spencer, 1988; Wolfe et al., 1990).

The transsexual individual (also referred to as a transgendered individual) who seeks therapy and possibly surgery is often referred to a clinic specializing in the treatment of gender dysphoria. Programs that are offered through these clinics include psychological counseling, hormone treatments, and other nonsurgical procedures, which may then lead to the final surgical reassignment surgery. Male-to-female surgery generally requires a single operation and is less expensive than female-to-male surgery, which requires at least three operations, is considerably more expensive, and is not associated with as good aesthetic and functional results as male-to-female surgery (Brown and Rounsley, 1988).

The literature on therapy for the male-to-female transsexual and the female-to-male transsexual represents two extremes. Therapy for the male-to-female transsexual has focused on voice therapy as a major component. Voice therapy for the female-to-male transsexual is virtually nonexistent. In fact, there appears to be considerable agreement among researchers studying the treatment of the transsexual that voice therapy for the female-to-male transsexual is unnecessary because lowering of the fundamental frequency occurs automatically as a result of androgens administered to the female-to-male transsexual (Spencer, 1988; Colton and Casper, 1996). Van Borsel et al. (2000) conducted a two-part study of the voice problems of the female-to-male transsexual. Part 1 was a survey of 16 individuals who had been treated with androgens for at least 1 year by the Gent University Gender Team in Belgium. Questionnaires indicated that 14 of the 16 respondents had experienced a “lower” or “heavier” voice. The remaining two reported that they had a lower-pitched voice before treatment started. Only one of the subjects was not pleased with his voice because of what he perceived as strain in speaking at a lower pitch. Fourteen indicated that voice change was as important as sex reassignment surgery, although 11 of the 16 did not consider the need for speech therapy important. The study confirmed the view that pitch is lowered as a result of androgen treatment and appears to result in an acceptable male voice. Part 2 was a longitudinal study of the voice change of two female-to-male transsexuals who were administered androgens. Acoustic measures of fundamental frequency, jitter, and shimmer were made of the sustained vowel production of /a/ and the reading of a standard paragraph. The measures for one subject were made over 17 months and for the other subject over 13 months. The results confirmed that the fundamental frequency was substantially reduced for sustained vowel production and reading, although not by more than one octave. Measures of jitter and shimmer were relatively unchanged over time.

The administration of hormones for the male-to-female transsexual has little effect on voice. Some studies have examined the male-to-female transsexual's changes in fundamental frequency and its relationship to the identification of the voice as a female voice (Bradley et al., 1978; Spencer, 1988; Dacakis, 2000; Gelfer and Schofield, 2000). Although there is some agreement that fundamental frequency is most often perceived as a female voice at 155–160 Hz and above, it is not sufficient alone to identify the male-to-female transsexual as a female speaker (Bradley et al., 1978; Gelfer and Schofield, 2000). Mount and Salmon (1988) conducted a long-range study of a 63-year-old male-to-female transsexual who had undergone sex reassignment surgery. The individual was able to increase her speaking fundamental frequency after 4 months of therapy. However, she was not perceived as a female speaker until formant frequencies had increased, particularly F2 values. This was achieved through the modification of resonance and articulation. Gelfer and Schofeld (2000) conducted a study of 15 male-to-female transsexuals with a control group of six biological females and three biological males. All subjects recorded the Rainbow Passage and produced the isolated vowels /a/ and /i/. Twenty undergraduate psychology majors served as listeners. The only significant differences among subjects were that the “Subjects perceived as female had a higher SFF [speaking fundamental frequency] and a higher upper limit of SFF than subjects perceived as male” (p. 30). Although formant frequencies for /a/ and /i/ were not significantly different between the male-to-female transsexuals perceived as male and those perceived as female, the mean formant frequencies for the perceived female speakers were all higher than those of the transsexual speakers judged to be male. Gunzburger (1995) had six male-to-female transsexual speakers record a list of Dutch words that were also combined into prose. Subjects were asked to read the material in a female manner and a male manner. Acoustic analyses indicated that the central frequency of F3 was systematically higher in the female version. Recordings of two male-to-female speakers that were representative of a male speaker and a female speaker were played to 31 male and female naive listeners, who were asked to identify the sex of the speaker. The perceptual judgments supported the results of the acoustic analyses. It appeared that the male-to-female transsexual speakers judged to be female had F3 formants more like those associated with the female voice. The shorter vocal tract typically found in females produces higher F3 formants than those of males, with a longer vocal tract (Peterson and Barney, 1952; Fant, 1960). Gunzburger (1995) attributed these changes to a decreased vocal cavity length in the perceived female male-to-female transsexual and pointed out that shortening the vocal tract can be accomplished through changes in articulation and retracting the corners of the mouth (p. 347).

According to Stemple, Glaze, and Gerdeman (1995), the male-to-female transsexual not only has to increase her fundamental frequency while being careful not to damage the vocal folds, but also has to learn to modify the resonance, inflection, and intonation to make articulation more precise, and to modify coughing, vocalized pauses, and throat clearing (p. 204).

Therapy for the female-to-male transsexual appears to be less of an issue than therapy for the male-to-female transsexual. Many of the textbooks on voice disorders include a discussion of the therapy needs for the male-to-female transsexual but do not provide any details on procedures, techniques, or concerns for the clinician to consider in the therapy process. De Bruin, Coerts, and Greven (2000) provide the clinician with a detailed approach, including specific goals and subgoals, to follow in therapy for the male-to-female transsexual. Among the major goals are minimizing chest resonance; modifying intonation patterns, articulation, intensity, and rate; and feminizing laughing and coughing. In addition, they address other verbal and nonverbal aspects of feminine communication such as gestures, movements, greetings, shaking hands, dress, and hairdo. The authors briefly discuss laryngeal surgery but conclude that it only results in raising the fundamental frequency (which is not in itself sufficient to guarantee a feminine voice) and that the results of this surgery are not predictable. Batin (1983) includes vocabulary and language forms and uses videotapes of the male-to-female transsexual to teach the individual how to walk, sit down, and enter a room. Chaloner (1991) provides case histories, and uses role playing in group therapy to help the male-to-female transsexual become more successful in “living the female role” (p. 330). Future research on the assessment and treatment of transgendered individuals should provide the clinician with a larger repertoire of approaches to assist the transsexual individual in making the transition to a different sexual role.