The Laryngoscope
C 2013 The American Laryngological,
V
Rhinological and Otological Society, Inc.
Voice in Female-To-Male Transsexual Persons
After Long-Term Androgen Therapy
Marjan Cosyns, PhD; John Van Borsel, PhD; Katrien Wierckx, MD; David Dedecker, MD;
Fleur Van de Peer, MD; Tine Daelman, MSc; Sofie Laenen, MSc; Guy T’Sjoen, MD, PhD
Objectives/Hypothesis: The aim of the present study was to 1) document voice in a large sample of female-to-male
transsexual persons (FMT), 2) compare their vocal characteristics with those of heterosexual biological males, and 3) determine hormonal factors with impact on their fundamental frequency.
Study Design: This was a controlled cross-sectional study. It is the largest study to date on voice and voice change in
FMT, and the first to include a control group and FMT who were under long-term androgen administration.
Methods: Thirty-eight FMT, ranging in age between 22 and 54 years, and 38 controls, frequency matched by age and
smoking behavior, underwent a voice assessment that comprised the determination of pitch, intonation, and perturbation
parameters measured during sustained vowel production, counting, and reading. Hormonal factors explored were hematocrit,
total testosterone level, luteinizing hormone level, and biallelic mean length of the cytosine-adenine-guanine (CAG) trinucleotide repeat sequence in the androgen receptor gene.
Results: It was found that the FMT as a group did not differ significantly from controls for any of the acoustic voice variables studied. However, in about 10% pitch lowering was not totally unproblematic. The lowest-pitched (i.e., more male) voices were observed in FMT with higher hematocrit and longer CAG repeats.
Conclusion: After long-term androgen therapy, FMT generally demonstrate an acceptable male voice. Pitch-lowering difficulties can be expected in about 10% of cases and appear, at least in part, to be associated with diminished androgen
sensitivity.
Key Words: Transsexualism, female-to-male, voice, hormonal factors.
Level of Evidence: 3b.
Laryngoscope, 124:1409–1414, 2014
INTRODUCTION
Transsexualism is considered the most extreme
form of gender dysphoria,1 which refers to discomfort/
distress caused by a discrepancy between a person’s gender identity and that person’s biological sex.2,3 Transsexual persons show a strong desire to belong to the sex
opposite of their anatomic gender4 and wish to change
their bodies into greater agreement with their psychological identity.5 That change also includes altering their
voices and may involve intervention of a phoniatrician
or speech therapist. In most cases, this intervention
boils down to providing voice therapy to male-to-female
transsexual persons that focuses on raising the client’s
From the Department of Health Sciences, Veiga de Almeida University (J.V.B.), Rio de Janeiro, Brazil; the Department of Speech, Language, and Hearing Sciences, Ghent University (M.C., J.V.B., T.D., S.L.),
Belgium; the Department of Endocrinology (K.W., D.D., F.V.D.P., G.T.), Ghent
University Hospital, Ghent, Belgium; and the Center for Sexology and
Gender Problems (G.T.), Ghent University Hospital, Ghent, Belgium.
Editor’s Note: This Manuscript was accepted for publication
October 18, 2013.
Presented at the 29th World Congress of the International Association of Logopedics and Phoniatrics, Turin, Italy, August 25–29, 2013.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Marjan Cosyns, UZ Gent 2P1, De Pintelaan 185, 9000 Ghent, Belgium. E-mail: [email protected]
DOI: 10.1002/lary.24480
Laryngoscope 124: June 2014
speaking fundamental frequency (f0). In female-to-male
transsexual persons (FMT), it is the prevailing opinion
that the desired voice change (i.e., pitch lowering) automatically takes place under the influence of androgen
administration so that voice therapy is not indicated.4
However, literature objectively documenting voice and
voice change in FMT is scarce.
The study of Van Borsel et al.4 was meant as an
exploration of voice alteration in FMT and consisted of
two parts. In the first part, a sample survey investigation, 16 FMT who were under androgen therapy for at
least 1 year (range: 1; 2–9; 7 years) were questioned
about their experience with the effects of androgen therapy on their voice. Fourteen respondents noticed a voice
change since hormone treatment was started, and in all
of them the voice alteration had been perceived by
others. The second part of the study, a longitudinal
study, registered voice change upon androgen administration in two FMT who had not been involved in the
sample survey. Results indicated a considerable lowering
of f0 in both participants, but changes did not exceed one
octave. In participant 1, average f0 measured during sustained vowel production dropped from 204 and 209 Hz
on the two sessions before initiation of hormone therapy
to 128 Hz on the last registration, 13 months 4 days
after the start of hormone therapy. During reading, the
decline was less outspoken: from 215 and 221 Hz to 155
Cosyns et al.: Voice in Female-to-Male Transsexuals
1409
Hz. In participant 2, initial average f0 amounted to 181
Hz during sustained vowel production and 160 Hz during reading. These values dropped to 152 and 132 Hz,
respectively, over a period of 12 months 3 days of hormone treatment. In both participants, a change in f0
first became evident 4 to 5 months after the beginning
of androgen therapy. Further, pitch range was seriously
reduced due to decreased ability to achieve the high
pitch voice, which was not fully compensated for by a
gain in the lower frequencies. In contrast, jitter and
shimmer yielded similar values as before androgen
administration.
S€oderpalm et al.5 reported on a group of transsexual persons who, as part of their reassignment process,
had been referred for logopedic and phoniatric evaluation and intervention. The group comprised 25 transsexual persons, of which three were FMT, but intervention
and follow-up data were available for only one FMT. He
received 6 months of voice therapy and showed a
decrease in mean f0 from 148 Hz at baseline to 133 Hz
on the last therapy recording. At follow-up, 22 months
after intervention, mean f0 had further declined to 113
Hz. All analyses were executed on audio taped reading
samples. Unfortunately, data on the onset of androgen
therapy was not provided.
In a later study, Van Borsel et al.6 investigated the
interaction between physical appearance and voice in
FMT using a listener experiment. Seven FMT participated in the study. Four were under androgen treatment, and two of them had already undergone sex
reassignment surgery (SRS; i.e., hysterectomy, ovariectomy, and mastectomy). The remaining three had not
started hormone therapy yet. In the latter group, average f0, as measured during reading amounted to 164,
164, and 190 Hz. The two FMT who were treated with
hormones but who had not yet undergone SRS showed
an average f0 of 152 and 150 Hz (1 and 6 months of hormone treatment, respectively). Average f0 values of
respectively 182 and 140 Hz were registered in the two
FMT who had been operated upon (27 and 36 months of
hormone treatment, respectively).
Damrose7 followed a FMT starting on androgen therapy over a 16-month period. Laryngostroboscopy and
acoustic analysis of sustained vowel productions were performed. Mean f0 dropped from 228.47 to 112.74 Hz. The
participant experienced a marked decline in f0 between
the third and fourth month of hormone treatment. Overall, there was a clear shift and contraction of pitch range.
Shimmer increased from 3.39% to 7.79%, and noise-toharmonics ratio increased from 0.12 to 0.17. Endoscopically, no gross morphological changes were noted.
It is clear from the above review that the few studies that did objectively examine voice and voice change
in FMT had to contend with small sample sizes. Furthermore, control groups are lacking. Therefore, the current study aimed to document voice in a large group of
FMT and to compare their vocal characteristics with
those of heterosexual biological males. Additionally, the
relationship between their f0 and total testosterone level
(TT), luteinizing hormone level (LH), hematocrit (HCT),
and biallelic mean length of the cytosine-adenineLaryngoscope 124: June 2014
1410
guanine (CAG) trinucleotide repeat sequence in the
androgen receptor gene was explored as these hormonal
factors can be linked to androgen effects.
MATERIALS AND METHODS
The subject group consisted of 50 FMT—all with a confirmed diagnosis of gender dysphoria—who participated in a
larger study investigating their postoperative health that
included questionnaires; fasting morning blood sample collection; and dermatologic, urological, voice, bone, and body composition evaluations. Recruitment details, as well as bone, body
composition, dermatological, and sexual health data have been
reported in previous publications.1,8–11 All participants used
androgen therapy and had undergone SRS. They were on average 8.7 years after SRS (range: 9 months–22 years) and had
started hormone treatment at least 2 years before SRS. Current
hormone therapy was not standardized, but almost all participants were treated by the same endocrinologist. Hormone therapy consisted of intramuscular testosterone treatment with
either a mixture of testosterone esters (testosterone decanoate
100 mg, testosterone isocaproate 60 mg, testosterone fenylpropionate 60 mg, testosterone propionate 30 mg/ml) per 2 or 3
weeks (n 5 35) or testosterone undecanoate 1,000 mg per 12
weeks (n 5 7) or transdermal testosterone 50 mg daily (n 5 8).
One participant used both oral testosterone undecanoate 40 mg
(1 daily) and testosterone gel 50 mg per 5 g, 50 mg daily. Apart
from one Iranian, all participants were Caucasian (48 Belgians
and 1 Dutch). One participant had enrolled in voice therapy for
lowering his pitch in the past, and another one had undergone
a type III thyroplasty (shortening, relaxation).
Voice assessment took place in a quiet room and consisted
of the recording of sustained vowel production, automatic series,
and reading. Samples were recorded using a laptop (Dell Vostro
1000, Dell Inc., Round Rock, TX), an electric condenser microphone (Sony ECM-MS907, Sony Corp., Tokyo, Japan;
microphone-to-mouth distance: 30 cm), and the acoustic software Praat (Boersma & Weenink, Phonetic Sciences, University
of Amsterdam, www.praat.org) set at a sampling rate of 44,100
Hz. Regarding sustained vowel production, participants were
asked to count aloud to three and then immediately afterward
to sustain the vowel /a:/ at habitual pitch and loudness. A midvowel segment of 2 seconds was selected for the determination
of median f0 (medf0), jitter, and shimmer. The median was used
instead of the mean because it is less affected by extreme values
at both the high and low ends of the distribution; thus, it is less
influenced by possible artifacts in the recordings. Automatic
series comprised counting aloud from one to 10; and the reading
task consisted of reading aloud the Dutch version of Aesop’s
fable “The North Wind and the Sun.”12 Onset and offset of automatic series and reading samples were visually defined on the
oscillograms and spectrograms as the first peak that corresponded with a burst of spectral acoustic energy and the last
consecutive peak that was followed by a nonspeech signal,
respectively.13 Subsequently, medf0, 25th percentile (pc25f0),
and 75th percentile (pc75f0) were measured. For the reading
samples, an index of pitch variation (f0var) was also obtained
using a Praat script. This index is the sum of absolute values of
all f0 changes between the fifth and 95th percentile, cumulated
from start to end, and divided by the total duration of utterances. Extreme f0 values are not taken into account to avoid influence of possible artifacts in the recordings or pitch detection
algorithm. F0var, expressed in Hz/s, reflects both extent and
speed of intonation in speech samples.
Because the recording quality of the reading samples was
not sufficient in eight participants (signal-to-noise ratio < 20
Cosyns et al.: Voice in Female-to-Male Transsexuals
TABLE I.
Group Results of the Voice Assessment.
FMT
Median
Sustained /a:/
medf0 (Hz)
104.0
jitter (%)
shimmer (dB)
Counting
Minimum
Controls
Maximum
Median
108.0
Minimum
Maximum
P Value
75
141
77
165
.506
0.54
0.28
2.55
0.50
0.21
1.34
.182
0.31
0.12
1.32
0.33
0.08
2.71
.592
medf0 (Hz)
104.0
77
159
104.5
80
141
.759
pc25f0 (Hz)
pc75f0 (Hz)
98.5
110.0
72
84
150
173
100.0
112.0
78
83
129
157
.771
.501
iqrf0 (Hz)
12.0
4
40
13.0
5
34
.312
Reading
medf0 (Hz)
109.0
83
163
109.0
87
135
.596
pc25f0 (Hz)
100.5
78
149
101.0
80
126
.779
pc75f0 (Hz)
iqrf0 (Hz)
120.0
21.0
90
11
185
42
120.0
17.0
95
10
148
30
.391
.081
f0var (Hz/s)
85.0
48
156
80.0
54
135
.607
FMT 5 female-to-male transsexual persons; iqr 5 interquartile range; f0var 5 pitch variation; medf0 5 median fundamental frequency.
dB), they were excluded from the subject group. Further, it was
decided to exclude those participants who underwent voice therapy or voice surgery (n 5 2) and those who were not native
Flemish speakers (n 5 2). As such, the final subject group consisted of 38 FMT, ranging in age between 22 and 54 years
(M 5 37.0 years, SD 5 8.10 years). Twenty-five FMT had a history of smoking, 12 FMT had stopped and 13 FMT were currently smoking. The remaining 13 participants reported to have
never smoked. Within the group of former and current smokers,
the number of pack years ranged between 0.3 and 75.0
(M 5 11.9, SD 5 15.82).
A control group was matched to the final subject group according to age and smoking behavior. They were 38 heterosexual biological males, ranging in age between 23 and 55 years (M 5 37.0 years,
SD 5 8.63 years). The number of pack years among the former
(n 5 12) and current smokers (n 5 13) ranged between 0.6 and 66.0
(M 5 11.2, SD 5 13.79). The control group completed the same
speech tasks as the subject group using the same procedure, microphone, and acoustic software. The laptop used was an Acer Aspire
5920G (Acer Inc., Xizhi, New Taipei City, Taiwan).
Statistical analyses were executed using SPSS version
19.0.0.1 (a 5 .05). Variables were found to approximate a normal
distribution if the P values in the Kolmogorov-Smirnov and
Shapiro-Wilk’s test were more than .05. The difference between
mean and median was small with reference to the standard
deviation. The skewness and kurtosis values were small compared to their standard error; the data plotted in the Q-Q plot
followed a straight line, and no outliers with an impact on the
mean were present. As few variables fulfilled these criteria, a
nonparametric test (i.e., a Mann-Whitney U test) was performed for all between-group comparisons. For the same reason,
Spearman’s rank correlation coefficients were computed to
explore the relationship between f0 and TT, LH, HCT, and
mean CAG repeat length in FMT (see Appendix A for details on
determination procedures). Medf0 during reading was chosen as
the variable to represent f0 as it leans the closest to spontaneous speech.
Laryngoscope 124: June 2014
RESULTS
Table I presents group results of the voice assessment. It was noted that the FMT as a group displayed
similar vocal characteristics as controls; statistical analyses confirmed that for all variables differences were not
significant between groups (P >.05). The similarity
between the study and control group is also evident
from Figure 1, which represents medf0 during reading in
function of group.
Individual data related to the gender-ambiguous
range is shown in Table II. The gender-ambiguous range
is the range at which the speaker’s gender is unidentifiable by the pitch of his/her voice and has been defined
as a speaking f0 between 150 and 185 Hz.14 During
Fig. 1. Boxplot of median f0 during reading in function of group.
Cosyns et al.: Voice in Female-to-Male Transsexuals
1411
TABLE II.
For Each Speech Task, A 2 3 2 Contingency Table of the Occurrence of a Median Fundamental Frequency Without or Within the GenderAmbiguous Range by Group.
Group
FMT
Sustained /a:/
<150 Hz
150–185 Hz
Total
Counting
Total
Reading
Total
P Value
.240
n
38
35
73
100.0
0
92.1
3
96.1
3
% within group
0.0
7.9
3.9
n
% within group
38
100.0
38
100.0
76
100.0
n
36
38
74
% within group
n
94.7
2
100.0
0
97.4
2
% within group
5.3
0.0
2.6
n
% within group
38
100.0
38
100.0
76
100.0
<150 Hz
150–185 Hz
Total
% within group
n
<150 Hz
150–185 Hz
Controls
n
36
38
74
% within group
n
94.7
2
100.0
0
97.4
2
% within group
5.3
0.0
2.6
n
% within group
38
100.0
38
100.0
76
100.0
.493
.493
As more than 20% of cells had expected counts less than 5; P values are the result of Fisher’s Exact tests.
FMT 5 female-to-male transsexual persons.
task, Fisher’s Exact tests revealed that the probability of
the occurrence of a medf0 within the gender-ambiguous
range was homogeneous between groups.
Table III displays the correlation matrix of medf0
during reading and the hormonal factors studied. It was
sustained vowel production, three controls demonstrated
a medf0 within the gender-ambiguous range, while all
FMT showed a medf0 below 150 Hz. Conversely, during
counting and reading, two FMT fell within this range,
while none of the controls did. However, for each speech
TABLE III.
Correlation Matrix of the Median Fundamental Frequency (Medf0) During Reading and the Hormonal Factors Studied.
medf0
HCT
TT
LH
CAG
r
P Value
medf0
HCT
TT
LH
CAG
1.000
2.356*
.031
2.053
.751
.208
.211
2.446†
.006
n
38
37
38
38
37
r
P Value
2.356*
.031
1.000
.294
.078
2.442†
.006
.351*
.036
n
37
37
37
37
36
r
P Value
2.053
.751
.294
.078
1.000
2.581†
<.001
.230
.171
n
38
37
38
38
37
r
P Value
.208
.211
2.442†
.006
2.581†
<.001
1.000
2.314
.059
n
38
37
38
38
37
r
P Value
2.446†
.006
.351*
.036
.230
.171
2.314
.059
1.000
n
37
36
37
37
37
*Correlation is significant at the .05 level.
†
Correlation is significant at the .01 level.
CAG 5 mean cytosine-adenine-guanine repeat length; HCT 5 hematocrit; LH 5 luteinizing hormone level; TT 5 total testosterone level.
Laryngoscope 124: June 2014
1412
Cosyns et al.: Voice in Female-to-Male Transsexuals
found that medf0 during reading correlated significantly
with HCT (r 5 2.356, r2 5 .127, P 5.031) and mean CAG
repeat length (r 5 2.446, r2 5 .199, P 5.006). Namely,
lower-pitched voices were measured in FMT with higher
HCT and longer CAG repeats. Additionally, a significant
positive correlation existed between HCT and mean CAG
repeat length themselves (r 5.351, r2 5 .123, P 5.036).
DISCUSSION
The present study is the largest (n 5 38) to date
aimed at objectively documenting voice and voice change
in FMT. Previous studies5–7 included no more than seven
participants, except for the study of Van Borsel et al.,4
which involved 18 FMT. However, objective data was
available for only two FMT, as the remaining 16 FMT
participated in a sample survey. Additionally, the current
study is the only one to include a control group and the
only one in which participants underwent androgen
administration for such a period of time. Specifically, participants were on average 8.7 years after SRS and started
hormone therapy at least 2 years before SRS. Earlier,4,6,7
objective data had been collected in FMT who used androgen therapy for up to 3 years, and participants in the
Van Borsel et al.4 questionnaire were on average 4.4
years under hormone therapy. Therefore, the present
study is well placed to offer insights into the long-term
effects of androgen treatment on the voice of FMT.
Results of the current study indicate that FMT after
long-term androgen therapy as a group cannot be distinguished acoustically from heterosexual biological males.
During sustained vowel production, counting, and reading f0 of the FMT amounted to 104, 104, and 109 Hz,
respectively. Pitch variation measured 85 Hz/s, and perturbation levels were 0.54% for jitter and 0.31 dB for
shimmer. None of these median values were significantly
different from those of the control group. When comparing these data to those from previous studies, caution is
recommended as the latter reported mean (and not
median) values. Nevertheless, it seems that the present
f0 values are somewhat lower. The lowest values
reported were 112.74 Hz during sustained vowel production7 and 113 Hz during reading,5 measured in one FMT
in each case. The two FMT in the first Van Borsel et al.
study4 demonstrated values of 128 and 152 Hz during
sustained vowel production and 155 and 132 Hz during
reading. Values in the later study6 ranged between 140
and 182 Hz, coming from four FMT. Additional research
is needed to confirm this possible further lowering of the
pitch over time. The study of Damrose7 also mentioned a
marked increase in shimmer, going from 3.39% to 7.79%,
whereas Van Borsel et al.4 found similar shimmer values
before and after androgen administration. Similar to
Van Borsel et al.,4 shimmer values in the present study
did not differ significantly between FMT and heterosexual biological males. A possible explanation for the striking increase in shimmer in the Damrose7 study might
lie in the fact that their participant was a semiprofessional singer. Maybe the effort needed to continue singing at this level was reflected in the observed increased
shimmer values.
Laryngoscope 124: June 2014
Although FMT after long-term androgen therapy as
a group display an acceptable male voice, individual
results confirm the previous finding that voice change in
FMT is not always totally unproblematic.4 During reading, which is the speech task closest to spontaneous
speech, two FMT displayed a medf0 within the gender
ambiguous range. Add to this the two FMT who were
excluded from the subject group because they underwent
voice therapy or voice surgery, and the occurrence of
pitch-lowering difficulties in this population can be estimated at 10% (4/40).
Hormonal factors with impact on f0 were HCT and
mean CAG repeat length, which in turn intercorrelated.
As these factors correlated negatively with medf0 during
reading, insufficient pitch lowering can be expected in
FMT with low HCT and short CAG repeats. As reported
by Gooren and Giltay,15 high-dose androgen administration to FMT appears to increase HCT. A possible explanation for not finding a direct association between f0 and
TT can be that the response to testosterone supplementation may differ individually.16 As such, HCT might be
a more adequate indicator of androgen effect than the
levels of sex steroids themselves. The CAG triplet repeat
in exon 1 of the androgen receptor gene, located on the
X chromosome at Xq11–12,17 is a well-established
genetic polymorphism that encodes a polyglutamine
tract in the N-terminal transactivation domain of the
androgen receptor.18 In men, a shorter repeat length is
associated with higher androgen receptor transactivation
and androgen sensitivity. The CAG polymorphism seems
to affect the hypothalamic-pituitary feedback regulation,
with longer repeats being associated with diminished
androgen sensitivity/feedback and relative elevation of
circulating testosterone levels.19,20 In contrast, the effect
of the CAG repeat length on testosterone levels in
women is not as straightforward as in men. Some studies reported that in women fewer CAG repeats are associated with higher levels of androgens, suggesting less
androgen sensitivity.21,22 As FMT from a genetic point of
view are still women, the present result of higherpitched (i.e., less male) voices in FMT with shorter CAG
repeats corresponds with those findings. Other secondary sex characteristics that appear to be modulated by
the CAG repeat polymorphism in the androgen receptor
gene are bone density, hair growth, and body fat
mass.23–25 However, as far as we know the present study
is the first to establish a relationship between CAG
repeat length and voice.
Of the two influencing factors, mean CAG repeat
length showed the strongest correlation with medf0 during reading, explaining about 20% of the variance in f0.
Thus, other factors than androgen sensitivity must be
involved, such as initial f0 and changes in mass per unit
length of the vocal folds as androgen administration produces thyroarytenoid muscle-fiber hypertrophy and
hyperplasia.26 This requires the use of a longitudinal
study design. Indeed, the fact that the present study is
cross-sectional is perhaps its greatest limitation. A longitudinal study would not only provide better insight in
(difficulties with) voice change in FMT, but might also
allow to create a regression model that successfully
Cosyns et al.: Voice in Female-to-Male Transsexuals
1413
predicts f0 in FMT under androgen treatment. Additionally, studying pitch range using voice range profile
measurements or glottal volume velocity waveform using
inverse filtering could make a valuable contribution;
these techniques are sensitive to subtle voice change
and have gender-specific normative data.
CONCLUSION
Long-term androgen therapy of female-to-male transsexual persons is generally associated with a low-pitched
voice that cannot be distinguished acoustically from that
of heterosexual biological males. Pitch-lowering difficulties
are expected in about 10% of cases, which at least in part
can be explained by diminished androgen sensitivity.
Acknowledgement
The authors would like to thank Kaatje Toye for her help
and assistance in the completion of this study.
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APPENDIX A: PROCEDURE FOR THE
DETERMINATION OF THE HORMONAL
FACTORS STUDIED
In all subjects, venous blood samples were obtained
between 08:00 and 10:00 hours after overnight fasting.
All samples were stored at 280 C until analysis. For
each participant, HCT (Sysmex-XE-2100 Hematology
Analyzer, Goffin Meyvis, Etten-Leur, Netherlands) was
determined in serum. Commercial immunoassay kits
were used to determine serum concentrations of testosterone (Orion Diagnostica, Espoo, Finland) and LH
(Modular, Roche Diagnostics, Mannheim, Germany). For
the determination of the androgen receptor gene (AR),
CAG repeat length, genomic DNA was extracted from
EDTA-treated blood using a commercial kit (PureGene
kit, Gentra Systems, Minneaopolis, MN). The AR exon 1
region encoding the CAG repeat was amplified using
PCR with forward primer 50 -GAATCTGTTCCAGAGCG
TGC-30 FAM labeled and reverse primer 50 -TTCC
TCATCCAGGACCAGGTA-30 . After ethanol precipitation,
the amplified fragment was directly sequenced on a ABI
Prism 310 sequencer (ABI Prism, Perken-Elmer Applied
Biosystems, Foster City, CA) using a BigDye Terminator
Cycle Sequencing Reaction Kit (ABI Prism, PerkenElmer Applied Biosystems). Fragment length was determined by running the GeneScan-400HD Analysis Software (ABI Prism, Perken-Elmer Applied Biosystems).
Cosyns et al.: Voice in Female-to-Male Transsexuals