Intervención fonoaudiológica para la feminización de la voz en una persona transgénero MTF: estudio de caso / Phoniatric intervention for voice feminization in a transgender person MTF: a case study

El término transgénero hace referencia a aquellas personas cuya identidad de género (masculino -femenino) difiere del sexo (hombre ­mujer). La persona transgénero presenta un conflicto entre la identidad sexual y su condición biológica, debido a que esta última, ya está ajustada a unas características que están dadas desde el nacimiento. Una de las mayores dificultades que presentan es en la feminización de voz, debido a que esta es percibida como la del género opuesto. Por ello, usualmente realizan cambios vocales sin una técnica adecuada, recurriendo principalmente a tratamientos quirúrgicos u hormonales, desconociendo la terapia fonoaudiológica como una alternativa para mejorar su calidad vocal e interacción social. Dado lo anterior, el objetivo de este trabajo fue determinar la efectividad de la intervención fonoaudiológica para la feminización de la voz en una persona Transgénero MTF (Male to Female). Se utilizó un diseño descriptivo, cuantitativo, usando un diseño longitudinal de serie de estudio de caso de reversión ABA. La intervención se estructuró, principalmente, en tres apartados: evaluación inicial, intervención y reevaluación final. Los resultados mostraron una variación significativa en las cualidades acústico-perceptuales de la voz, la que presentó mayores características de una voz femenina, con modificaciones en el patrón fonorespiratorio y en la postura. En conclusión, la intervención fonoaudiológica fue efectiva debido a que se lograron cambios que permitieron lograr una voz más femenina en la persona tratada.

The term transgender denotes a person whose gender identity (male-female) is different from their sex (men-women). A transgender person presents a contradiction between sexual identity and biological condition, because the latter is determined by certain given characteristics since birth. One of the most difficult issues is the feminization of the person's voice (in the case if male to female), since it is perceived as being in the opposite end of gender. For this reason, usually male to female transgenders engage in vocal changes without appropriate techniques, resorting mostly to surgical procedures or hormonal treatments and ignoring speech and language therapy as an alternative to improve their vocal quality and social interaction. Therefore, the main goal of this work was to determine the effectiveness of the phoniatric intervention in order to produce the feminization of the voice in a transgender individual MTF. The methodology used is a quantitative, descriptive, using a longitudinal design of ABA reversion case study series. The intervention was structured in three main sections: initial evaluation, intervention and final re-evaluation. The results showed a significant variation in the acoustic perceptual qualities of the voice, with a more feminine voice involving modifications in the phonorespiratory pattern and in the posture. In conclusion, the phoniatric intervention was effective because achieved changes led to a more feminine voice.

Performatividad del género, medicalización y salud en mujeres transexuales en Ciudad de México / Gender performativity, medicalization and health in transsexual women in Mexico City

RESUMEN La Organización Mundial para la Salud y la American Psychological Association consideran que la transexualidad es una patología y plantean la adecuación sexogenérica para el ajuste biopsíquico de las personas trans. Mediante el análisis discursivo de la experiencia, en este estudio se describen los procesos de medicalización y performatividad del género en su relación con la salud de un grupo de mujeres trans de la Ciudad de México, para lo cual se desarrolló un estudio cualitativo en el que se realizaron, en el año 2015, diez entrevistas semiestructuradas. Como parte de la medicalización, la patologización de la transexualidad generó sufrimiento psíquico; por su parte, la adecuación sexogenérica también implicó riesgos adicionales. Se puede concluir que, en las mujeres trans, la violencia y la exclusión resultan las principales experiencias que explican los problemas de salud más relevantes por lo que se sugiere disminuir la discriminación, así como avanzar en intervenciones médicas más seguras.

ABSTRACT The World Health Organization and the American Psychological Association consider transsexuality a pathology and suggest sex-gender reassignment for the biopsychic adjustment of trans people. Through the discursive analysis of experience, this study describes the processes of medicalization and gender performativity in relation to the health of a group of trans women from Mexico City. For this purpose, a qualitative study was conducted in which 10 semi-structured interviews were carried out in 2015. As part of medicalization, the pathologization of transsexuality generated psychic suffering; on the other hand, sex-gender reassignment also entailed additional risks. It is possible to conclude that in trans women, violence and exclusion constitute the primary experiences explaining their foremost health problems. Therefore, it is suggested that it is necessary for discrimination be reduced and for advancements to be made in safer medical interventions.

Clinical management of transsexual subjects / Manejo clínico de sujeitos transexuais

Transsexual subjects are individuals who have a desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one’s anatomic sex, and a wish to have surgery and hormonal treatment to make one’s body as congruent as possible with one’s preferred sex. They seek to develop the physical characteristics of the desired gender, and should undergo an effective and safe treatment regimen. The goal of treatment is to rehabilitate the individual as a member of society in the gender he or she identifies with. Sex reassignment procedures necessary for the treatment of transsexual patients are allowed in our country, at Medical Services that have a multidisciplinary team composed of a psychologist, a social worker, a psychiatrist, an endocrinologist and surgeons (gynecologists, plastic surgeons, and urologists). Patients must be between 21 to 75 years old and in psychological and hormonal treatment for at least 2 years. Testosterone is the principal agent used to induce male characteristics in female transsexual patients, and the estrogen is the chosen hormone used to induce the female sexual characteristics in male transsexual patients. Based on our 15 years of experience, we can conclude that testosterone and estradiol treatment in physiological doses are effective and safe in female and male transsexual patients, respectively.

Transexualismo masculino refere-se ao indivíduo 46,XY com fenótipo masculino normal que deseja viver e ser aceito como membro do sexo feminino, já o transexualismo feminino refere-se ao indivíduo 46,XX com fenótipo feminino normal que deseja viver e ser aceito como membro do sexo masculino. Há 16 anos os procedimentos médicos clínicos e cirúrgicos necessários para o tratamento de pacientes transexuais estão autorizados e regulamentados no nosso país, desde que os Serviços onde forem realizados tais procedimentos contem com equipe multidisciplinar composta por psicólogo, assistente social, psiquiatra, endocrinologista e cirurgiões (ginecologistas, plásticos e urologistas). Para serem submetidos à cirurgia, os pacientes devem ter de 21 a 75 anos, devem ter realizado hormonioterapia por pelo menos um ano e psicoterapia por pelo menos dois anos. Os indivíduos transexuais buscam desenvolver características físicas pertencentes ao sexo desejado e devem ser submetidos a um regime de tratamento efetivo e seguro com o objetivo de reabilitá-los como membros da sociedade no gênero com o qual eles se identificam. A testosterona é o principal hormônio utilizado para induzir o desenvolvimento dos caracteres sexuais secundários masculinos nos transexuais femininos e o estrógeno é o hormônio utilizado para induzir os caracteres sexuais secundários femininos no transexual masculino. Com base na experiência do nosso serviço, podemos afirmar que doses fisiológicas desses hormônios são capazes de produzir os efeitos desejados sem causar efeitos colaterais importantes.

Aspectos psicosociales, éticos y legales en la atención de adolescentes y jóvenes transexuales / Psicosocial, ethical and legal aspects in the attention of adolescent and transsexual youth

Introducción. La transexualidad es el deseo irreversible de pertenecer al sexo contrario del genéticamente establecido y asumir el correspondiente rol y de recurrir si es necesario a un tratamiento hormonal y quirúrgico dirigido a corregir esta discordancia. La revelación de esta identidad sexual esta ocurriendo cada vez más a edades más tempranas. Los profesionales que atienden adolescentes debieran estar preparados para atender adolescentes y jóvenes con identidad sexual transexual. El objetivo de este estudio fue Identificar dificultades experimentadas por adolescentes y jóvenes transexuales y en que ámbitos se encuentran estas dificultades. Material y método: Se realizó un estudio cualitativo, con una muestra de adolescentes y jóvenes transexuales, femeninos y masculinos, consultantes en Cemera y de organizaciones que luchan por los derechos de las personas transexuales. Se realizaron entrevistas semi-estructuradas. Se utilizó el análisis temático de los datos. Los significados e interpretaciones que emergieron fueron constantemente verificados a través de análisis sucesivos. Resultados: Un total de 16 personas transexuales fueron entrevistadas. Los resultados muestran que las personas transexuales experimentan numerosas dificultades en el ámbito familiar, escolar, laboral, social, legal y salud, lo cual dificulta aún más el desarrollo de su identidad sexual, provocándoles además un gran sufrimiento. Conclusiones: Es importante considerar que los y las profesionales de la salud a menudo asumen la heterosexualidad en los adolescentes y jóvenes que atienden y por lo tanto están creando un setting de barreras para la atención de esta población específica e implícitamente la están discriminando.

Introduction: Transsexualism is the irreversible desire to belong to the opposite sex of the one that is genetically established and to assume the corresponding role and turn if necessary to a hormonal and surgical treatment directed to correct this conflict. The revelation of this sexual identity is happening at younger ages. Professionals who see adolescents should be also prepared o see adolescents and young people with a transsexual sexual identity. Objective: To identify the main difficulties experienced by adolescents and transsexual youth. Material and method: A qualitative study was carried out, with a sample of adolescents and transsexual youth, female and male, patients in Cemera and in the organizations that fight for the rights of transsexual people. Semi-structured interviews were executed. A thematic analysis of data was used. The meanings and interpretations which resulted were constantly verified by means of successive analyses. Results: A total of 16 transsexual people were interviewed. The results show that transsexual people experience numerous difficulties in the familiar, educational, work, social, legal and health areas, which makes the development of their sexual identity even more difficult, causing them great suffering. Conclusions: Health professionals frequently assume heterosexuality in adolescents and young people they see and, therefore, they are creating a setting of obstacles for the health care of this specific population and, as a consequence, they are implicitly discriminating it.

Transexualismo un trastorno de la identidad sexual / Transexualism a disorder of sexual identity

La frecuencia de consulta de personas que solicitan evaluación psiquiátrica y psicológica para cambio de sexo, ha aumentado. Se debe, pensamos, a que los resultados de la cirugía son cada vez mejores. La sociedad también ha contribuido a tolerar este trastorno. Los medios de información han hecho también lo suyo. A lo anterior, le sumamos un mejor enfoque de la sociedad, que tolera y ve con mejores ojos a estas personas. Ello ha motivado a escribir y dar a conocer las experiencias que ocurren en Chile, con el afán de colaborar a un mejor entendimiento del futuro de las personas aquejadas de este trastorno de la identidad sexual.

The frequency of consultation of people seeking psychiatric and psychological evaluation for sex change, has increased. It means we think that the results of surgery are getting better. The society has also contributed to tolerate this condition. The media have also been contributed for him. To this we add a better society approach, that tolerates and better judges to these people. This has led, who works on the subject, write and disseminate the experiences that occur in Chile, with the aim of collaborating with a better understanding and future of people suffering from the disorder of sexual identity.

Transexualidade e saúde pública no Brasil / Transsexuality and public health in Brazil

O artigo tem como objetivo discutir a transexualidade no contexto das políticas de saúde pública no Brasil. Para isto, num primeiro momento, problematiza-se a necessidade do diagnóstico de transtorno de identidade de gênero como condição de acesso ao tratamento na rede pública, buscando compreender de que forma se deu historicamente a patologização da transexualidade. Em seguida, analisa-se o debate sobre as políticas de saúde para transexuais, considerando o processo de legalização da cirurgia de transgenitalização no país, as resoluções do Conselho Federal de Medicina e os fóruns que se constituíram com representantes do Ministério da Saúde, profissionais da área e representantes do movimento social. Finalmente, tendo como referência trabalhos que se destacaram pela crítica à patologização da transexualidade nas áreas da saúde coletiva e das ciências sociais, pretende-se destacar a importância de compreendermos a diversidade de formas de subjetivação e de construção de gênero na transexualidade. Discute-se a questão da autonomia dos transexuais e sugerem-se políticas públicas que, embora sigam um protocolo de assistência, não tenham como única referência terapêutica a realização do diagnóstico e a cirurgia de transgenitalização.

The article aims to discuss transsexuality in the context of the Brazilian public health policies. Firstly, it questions the necessity of the diagnosis of Gender Identity Disorder as a condition of access to treatment in the public health service, searching to understand the historical construction of transsexuality as a pathological phenomenon. After that, it analyzes the debate on public health policies for transsexuals, considering the process of legalization of the reassignment surgery in the country, the resolutions of the Federal Council of Medicine and the constitution of representative forums of the Health Ministry, as well as professionals of the area and representatives of the social movement. Finally, considering the references available that emphasizes the critics on the analysis of transsexuality as a pathological phenomenon in the areas of the Public Health and Social Sciences, it intends to emphasize the importance of understanding the diversity of subjectivity’s forms and gender’s construction considering transsexuality. In this context, it discusses the question of transsexuals’ autonomy and suggests public policies that, even following an assistance protocol, do not have as its only therapeutical reference the accomplishment of the diagnosis and the reassignment surgery.

Successful treatment of ego dystonic homosexuality, Paraphilia and transsexualism using cognitive -behavioral techniques

Gender identity disorder and paraphilia and related therapies are of debatable issues in psychiatry. The authors introduce some of the disorders which to be cured via behaviorial techniques. In all of patients the diagnosis was compatible with DSMIV criterion. Therapeutic method considered for them was cognitive behaviord regardless of any type of comorbidities. The mentioned therapeutic technique resulted in considerable improvement signs [except for one case] in these patients. Positive effects of CBT in almost all of these patients mean that morbiological treatment could be considered as an effective therapeutic approach. Although good compliance in patients was not ignorable for successful results, considering CBT in any patients should be a role before nonreversible treatments such as surgery or stigmatizing patients as treatment resistant case

Transexualismo: revisäo / Transsexualism: review

Transexual é o indivíduo que se identifica como pertencente ao sexo oposto e experimenta grande frustaçao ao tentar se expressar através do seu sexo genético. No presente artigo os autores fazem uma revisao do transexualismo, abordando a sua etiologia, a importância do diagnóstico correto, os tratamentos hormonal e cirúrgico, além de iniciarem discussao sobre seus aspectos éticos, sociais e legais.