ARTICLE IN PRESS

Voice And Gender Incongruence: Relationship Between Vocal

Self-Perception And Mental Health Of Trans Women
*
Cirley Novais Valente Junior, and †Adriane Mesquita de Medeiros, *Universidade Federal de Minas Gerais, and yBelo Hori-
zonte, Brazil

Objective. To verify the association between vocal perception and Common Mental Disorders (CMD) suspi-
cion in trans women.
Methods. Cross-sectional observational study including 24 adult trans women with a minimum time of presen-
tation as a woman of six months. The sampling of the subjects was supported by the “Snowball" technique. Three
questionnaires were applied for data collection: sociodemographic and health data, Self-Reporting Questionnaire
(SRQ-20) and Trans Woman Voice Questionnaire (TWVQ). The sociodemographic and health data collected
were: age, marital status, education, smoking habits, speech therapy, use of hormones, and whether they had
undergone Sex Reassignment Surgery (SRG). SRQ-20 was used for suspicion of CMD evaluation, such as
depressive and anxiety symptoms. TWVQ is a vocal self-report questionnaire for trans women living the full-time
gender role in which they self-identify. TWVQ has a minimum score of 30 points and a maximum of 120 points.
Higher scores are associated with perceptions of a higher frequency of voice-related difficulties and psychosocial
impacts. For statistical analysis, data were analyzed descriptively and statistically using Fisher's and Mann-
Whitney’s exact tests, both with a significance level of 5%.
Results. The average participants’ age in this study was 28.2 years old (SD = 6.5 / minimum = 21 and maxi-
mum = 48); 83.3% were single; most (41.7%) were high school graduates; and most (95.83%) had not undergone
Sex Reassignment Surgery. All subjects reported using hormones; 37.5% were smokers; 4.2% had undergone
speech therapy; and the average number of years of experience in the female role was 8.8 years (SD = 7.2). The
average TWVQ score was 55.4 points (SD = 4.3). Through SRQ-20, it was verified the prevalence of suspected
CMD in 58.3% of the participants. The study results indicated that communicative dissatisfaction in trans women
due to inconsistent voice with the recognized gender is associated with probable CMD such as depression and
anxiety (P= 0.001).
Conclusion. Trans women who reported greater difficulties and voice-related effects in their lives had more
symptoms of anxiety and depression. Although more research is needed, results indicate the need for inter-profes-
sional preventive and therapeutic actions directed towards assisting trans women. This fact encourages reflection
on the care of this population and the role of health professionals, enhancing scientific production, clinical prac-
tice and the inclusion of the “transsexuality” theme in Speech Language and Hearing Sciences.
Key Words: Gender Dysphoria—Mental Health—Transgender Persons—Speech Language and Hearing Scien-
ces—Voice.

INTRODUCTION Prevalence rates for trans women ranged between 0.44

The term “transsexuality” describes a condition in which a
person self-identifies with a gender that differs from the one
attributed at birth. This incongruence between the gender
attributed at birth and the gender experienced by the indi-
vidual is classified as gender incongruence. People with gen-
der incongruence are named transsexual. The term "trans
woman" is used for people who were designated at birth as
male, but who recognize and manifest themselves as belong-
ing to the female gender.1−3
Accepted for publication October 5, 2020.
Conflict of interest: None declared.
From the *Graduated in Speech-Language Pathology and Audiology, School of
Medicine, Universidade Federal de Minas Gerais - UFMG - Belo Horizonte (MG),
Brazil; and the yDepartment of Speech-Language Pathology and Audiology, School
of Medicine, Universidade Federal de Minas Gerais - UFMG - Belo Horizonte
(MG), Brazil.
Address correspondence and reprint requests to Cirley Novais Valente, UFMG
School of Medicine, 190 sala 251 - Santa Efig^enia - Belo Horizonte - MG - 30130-100 -
Brazil. E-mail addresses: cirleyjunior@gmail.com adrianemmedeiros@hotmail.com
Journal of Voice, Vol. &&, No. &&, pp. &&−&&
0892-1997
© 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2020.10.002
and 35.2 per 100,000 inhabitants.4 The highest prevalence
in meta-analysis is 6.8 per 100,000 inhabitants. However,
this prevalence rate is based mainly on clinically assisted
individuals and, therefore, does not provide an overall
image of the prevalence in the population at large.4 There is
no specific data on the prevalence of trans women in Brazil,
due to the lack of studies reporting these facts.
Gender dysphoria is portrayed as a condition by the
DSM-5, in which individuals experience discomfort and or
suffering caused by gender incongruity. Physical and mental
discomfort can cause distress as well as a desire for changes
in the body through hormonal therapies and surgeries.5,6
Common Mental Disorders (CMD), defined by Goldberg
and Huxley (1992),7 are characterized by non-psychotic
symptoms such as insomnia, fatigue, irritability, forgetful-
ness, difficulty in concentrating, somatic complaints and
depressive and anxious symptoms. These disorders are
responsible for functional disability, decreased life quality
and increased use of health services.8,9 Due to unspecific
symptomatology and health damages, it is important to
 ARTICLE IN PRESS
2 Journal of Voice, Vol. &&, No. &&, 2020
investigate possible CMD cases to prevent mental disorders
related problems through early intervention.10
Gender incongruity, when associated with individual fac-
tors such as social and physical acceptance, may present
higher rates of CMD, especially depression and anxiety,2,11
as well as a high risk of suicide.12,13 Transsexual people
receive (or have the perception of receiving), less social sup-
port from family and friends, as well as from the population
at large.13,14
In this context, the adoption of communicative behaviors
and the acquisition of a voice that is appropriate to the rec-
ognized gender can significantly influence the social accep-
tance and self-image of transsexual people.15-17 It is worth
highlighting that using feminizing hormones does not cause
satisfactory changes in the vocal tract of trans women.18,19
There are few studies that focus on assessing the vocal self-
perception of trans women.20,21 At an international level, sev-
eral studies have investigated factors such as gender asser-
tion,22 use of the social name23 and fear of discrimination in
health centers12 as determinants of mental disorders in this
population, however, no studies investigating vocal dissatis-
faction as one of these factors were found. The present study
aims at verifying the association between vocal self-percep-
tion and suspicion of CMD in trans women.
MATERIALS AND METHODS
The present cross-sectional observational study was con-
ducted with 24 trans women, using a self-administered elec-
tronic questionnaire sent and answered through electronic
means in the participant's own place. The questionnaire was
created on the Google Forms website (https://docs.google.
com/forms/u/0/) containing the Free and Informed Consent
Form, set up to allow questions to be answered only after
agreeing with the Free and Informed Consent Form, as well
as blocking multiple conclusions from the same participant.
The snowball technique was used to create a sample by con-
venience.24 Through this method, an intentionally selected
individual, in this case a trans woman, is invited to indicate
other participants to join the sample. Those individuals were
contacted by the researchers and invited to participate in the
study and were also able to indicate new participants for the
research.
In total, 49 trans women were invited to participate in the
study. Amongst them, 25 refused to be a part of it. In the Bra-
zilian context, he high number of refusals may be related to
high indicators of health inequities, which lead to a decrease
in self-care and health preventive behaviors. Data collection
was carried out between October 2018 and April 2019.
Inclusion criteria were: being a transsexual literate
woman of at least 18 years old. It was considered an exclu-
sion criterion being presented as a trans woman for less
than six months. There was no exclusion of any participant.
For data collection, it was used sociodemographic and
health data, the Self-Reporting Questionnaire (SRQ-20)25
and the translated and authorized version of the Trans
Woman Voice Questionnaire (TWVQ) (previously known
as the Transsexual Voice Questionnaire.26 Sociodemo-
graphic and health data were: age, marital status, education,
smoking habits, speech therapy, use of hormones, and Sex-
ual Reassignment Surgery (SRS).
The SRQ-20 is a tool to track possible cases of CMD.25
This instrument was developed by the World Health Organi-
zation, translated and validated in several languages,25,27 with
the purpose of measuring the suspicion of mental disorders
considered as non-psychotic symptoms.27 The SRQ-20 con-
sists of 20 questions referenced to the last 30 days prior to the
application of the questionnaire. The answer options are yes
(1 point) or no (0 points) and the total score is obtained by the
simple sum of points.25 The presence of CMD was considered
in the case of seven or more positive responses (seven points
or more), as suggested in the bibliography.26
The TWVQ is a vocal self-report questionnaire applied
on trans women who live fulltime their self-identified gen-
der role.28 This questionnaire, translated and adapted
into Portuguese,26 is a self-report measure of the individu-
als perceptions of her vocal functioning and the voice-
related psychosocial impacts on her everyday life. Exam-
ples of the psychosocial impact include, tension, anxiety
and distress. The TWVQ consists of 30 questions that
allow the participants to indicate the frequency in which
they experience each of the 30 voice related situations,
events or perceptions. Participants answered using a four-
point scale in which 1 means “never or rarely,” 2 means
“sometimes,” 3 means “often,” and 4 means “usually or
always.” The scores were summed up, resulting in a mini-
mum possible score of 30 and a maximum of 120. The
higher the score, the greater the perception of difficulties
related to voice and psychosocial impacts.26 The reliabil-
ity of TWVQ has been strongly supported by the high
internal consistency between studies and excellent test-
retest of reliability (intraclass correlation coefficients >
0.95; 95% confidence interval = 0.90−0.98).28
The Research Ethics Committee of the Universidade Fed-
eral of Minas Gerais approved this study under opinion
number 2.689.576. All participants consented to participate
by filling out an informed consent form, as well as receiving
an emailed copy.
After being collected from participants, the data were
organized in a Microsoft Excel program spreadsheet. The
descriptive analysis was performed through the frequency
distribution of categorical variables and the mean and stan-
dard deviation of the result of the vocal self-perception pro-
tocol (TWVQ). Fisher's exact test was used to verify the
association between the SRQ-20 result and sociodemo-
graphic and health characteristics. For the association with
the result of the vocal self-perception protocol (TWVQ), the
Mann-Whitney non-parametric test was used due to the
asymmetric distribution of this variable. A significance level
of 5% was considered for the tests performed.29
The data were digitized in an Excel spreadsheet, reviewed
by two people and the analysis was performed using the
STATA software (Stata Corporation, College Station,
Texas) version 12.0.
 ARTICLE IN PRESS
Cirley Novais Valente Junior and Adriane Mesquita de Medeiros Vocal Self-Perception and Mental Health 3

RESULTS perception of their own voice. However, vocal self-percep-

The data collected from 24 trans women, showed an average tion was associated with the suspicion of CMD, as shown in
experience in the female role of 8.8 years (standard devia- Table 3.
tion [SD] = 7.2 with a minimum = 6 months and maxi-
mum = 26 years). The average age of the participants in this
study was 28.2 years (SD = 6.5 with a minimum = 21 and DISCUSSION
maximum = 48); 83.3% were single; 41.6% had completed Gender expression is defined as “how a person presents or
high school; 58.3% were smokers or former smokers; and expresses his or her gender identity to others, often through
the majority (95.8%) had not had SRS. All of them used manner, clothing, hairstyles, voice, or body characteristics.”
hormones and the average time on hormone therapy was There is limited report that transsexual individuals who
4.8 years (SD = 5.1 with a minimum = 0 months and maxi- look and sound different to societies' expectations of gender
mum = 17 years). Only 4.1% had undergone speech therapy. suffer these consequences more than those whose appear-
The prevalence of suspected CMD was 58.3% (Table 1). ance and voice match societies expectations.30
The vocal self-report protocol average (TWVQ) was 55.4 Little is known about the prevalence of CMD in trans
(SD = 21.1 with a minimum = 30 and maximum = 100). women and the relation with vocal perception. The results
The association between suspected CMD and sociodemo- of the present study indicate a high prevalence rate of CMD
graphic and health variables failed to identify significant (58.3%) in the investigated group. Brazilian studies reveal
associations, as described in Table 2. Therefore, for this CMD prevalence ranging between 23.2 and 46.5%.31-35
study’s participants, age, marital status, education level and International studies analyzed through a systematic review
smoking habits were no different between groups with and with meta-analysis, regarding the overall population of 63
without suspected CMD. countries, revealed a CMD prevalence rate of less than
There was no statistical significance between vocal self- 29.2% amongst 829,673 individuals.36 No studies have been
perception and sociodemographic and health variables. identified showing the CMD prevalence in trans women.
Therefore, age, marital status, education level and smoking Most studies regarding the overall health conditions of the
habits did not differentiate the group according to the transsexual population indicate depression as the most fre-
quent psychic morbidity.12,23,37,38 CDM is a more comprehen-
sive condition, as explained earlier.7,10 Given its high
TABLE 1. sensitivity (83%) and specificity (80%), the SRQ-20 is consid-
Sociodemographic and Health Characteristics of Trans ered an adequate instrument for suspected diagnosis of
Women (N = 24) CMD. Although it does not imply a formal psychiatric diag-
nosis, it can contribute to mental suffering cases tracking.39
Variables N = 24 % Although the participants’ age was not statistically signifi-
Schooling cant for the CMD suspicion, a study conducted in the United
Elementary, finished 1 4.16 Kingdom regarding 913 transsexual individuals (582 trans
High School, unfinished 2 8.33 women and 331 trans men) found a relation between older
High School, finished 10 41.67 ages (79 years / SD = 12.8 years) and depressive symptoms.38
Higher Education, unfinished 7 29.17 In the study, trans women and men were grouped and com-
Higher Education, finished 4 16.67
pared to a control group formed by the general population
Smoking
Non-smoker 10 41.67
and the result showed that older age, low self-esteem and
Former smoker 5 20.83 lower social support are associated with higher predictors of
Presently smoking 9 37.50 depressive disorders. However, most of the participants in the
Marital status present study (70.8%) were under 30 years old. Another com-
Single 20 83.33 parative study37 encompassing 180 young transsexuals (106
Married with a partner 3 12.50 trans men and 74 trans women) and and 180 young cisgenders
Separated/Divorced 1 4.17 (people who identify with the gender attributed at birth), with
Hormones use an average age of 19.6 years verified, by means of clinical
No 0 0 diagnosis of mental disorder registered in electronic medical
Yes 24 100 record, that young transsexuals have greater mental suffering
Speech-Language Therapy
compared to young cisgenders. Young transsexual people had
No 23 95.83
Yes 1 4.17
two to three times more risk of depression, anxiety disorder
Undergone SRS and suicidal ideation.37
No 23 95.83 In this research, the result of the protocol of vocal self-
Yes 1 4.17 perception for trans women (TWVQ), with positive screen-
Common Mental Disorder (SRQ 20) ing for CMD (SRQ-20), was similar (63.5 points) to another
Absent 10 41.67 study carried out in Australia, with 148 trans women, with
Present 14 58.33 an average score of 66.45 points.40 On the other hand, the
result is very high compared to a study carried out in Brazil,
 ARTICLE IN PRESS
4 Journal of Voice, Vol. &&, No. &&, 2020

TABLE 2.
Association Between Common Mental Disorder (SRQ-20) and Sociodemographic and Health Characteristics of Trans
Women (N = 24)
CMD
Positive Negative
Variable N = 14 % N = 10 % P-value*
Age
< 29 years 11 78.6% 6 60% 0.393
≥ 30 years 3 21.4% 4 40%
Marital status
Never married 11 78.6% 9 90% 0.615
Married with a partner 3 21.4% 1 10%
Schooling level
Up to High School (finished) 8 57.1% 5 50% 1.000
Higher Education (finished or unfinished) 6 42.9% 5 50%
Smoking status
Smoker or former smoker 9 64.3% 5 50% 0.678
Non smoker 5 35.7% 5 50%
* Fisher’s exact test

with 47 trans women, in which the average score was
between 30 and 40 points.41 In the study, however, 23.40%
underwent speech therapy and 27.66% underwent SRS,
while in the present study only 4.17% of the participants
had access to speech therapy and SRS, which shows greater
access to health services. However, no studies were found
comparing the questionnaires that have been used, as well
as vocal self-perception and suspicion of CMD.
The present study showed the relation between voice and
suspected mental disorder by verifying statistical signifi-
cance between the results of TWVQ and SRQ-20. There-
fore, it is evident the importance of providing speech
therapy to reduce mental suffering and psychosocial
impacts in terms of gender expression through the voice.
This recommendation is corroborated by the study by But-
ler (2019),42 which showed that transsexual people who
wish to undergo speech therapy for the feminization of the
voice have higher rates of anxiety. Several researches indi-
cate that speech therapy intervention is useful to help indi-
viduals with gender incongruity to affirm their recognized
genders through speech.43-46 It is considered important to
emphasize that, in the studied group, most of the partici-
pants did not have access to speech therapy. This situation
refers to the lower support for the trans person facing a situ-
ation of less social acceptance through the voice, generating
greater suffering for that.30

TABLE 3.
Association Between Vocal Self-report Questionnaire (TWVQ) and Sociodemographic and Health Characteristics of Trans
Women (N = 24)
Variables Average Standard Deviation Median P-value*
Age
< 29 years 55.6 5.642 52 0.848
≥ 30 years 54.7 6.232 55
Marital status
Never married 53.2 4.616 50.5 0.200
Married with a partner 11.8 11.740 59.0
Schooling level
Up to High School (finished) 56.2 6.121 52 0.976
Higher Education (finished or unfinished) 54.4 6.345 53
Smoking status
Smoker or former smoker 58.6 5.909 52.5 0.428
Non smoker 51.0 6.320 50.5
SRQ 20 − TWVQ
CMD Absent 44.0 4.989 42.5 <0.001
CMD present 63.5 5.662 58.5
* Mann-Whitney test.
 ARTICLE IN PRESS
Cirley Novais Valente Junior and Adriane Mesquita de Medeiros
Although complex, individuality is emphasized in the
relation between self-perception of the voice and gender
identity. A study by McNeill et al. (2008)47 has found that,
for trans women, vocal satisfaction is not directly related to
the fundamental frequency of the voice. Another study has
found, through TWVQ,40 that the self-perception of trans
women in terms of voice and gender identity is related to
the listeners’ perceptions when evaluating their voices as
male or female. In other words, from the point of view of
trans women, the interlocutors’ perceptions are more impor-
tant than their own.40,20
Associations between vocal self-report and age, marital
status, education and smoking habits were not verified. This
result corroborates another study, carried out in Brazil41
with 47 trans women aged between 18 and 50 years, that
found no significant association between the total score
obtained on TWVQ and the sociodemographic variables,
time of presentation as trans woman, SRS, time and effects
of hormonal therapy, vocal therapy, and smoking habits.
One believes that the experience of trans women with their
own voices in daily situations is related to interpersonal rela-
tionships and, mainly, to the level of formality and intimacy
with the interlocutor.48
The low demand for health care is associated with bar-
riers such as structural discrimination and access to serv-
ices.49 Transsexual people avoid seeking medical
environments due to fear, stigma and institutional dis-
crimination.50,12 Additionally, Brazil is the number one
country in the ranking of murders of transvestites and
trans women according to Transgender Europe,51 an
international observatory that monitors homicides of
transsexual people in 65 countries. This fact has a nega-
tive impact on social relationships, mental health, and the
search for health services.52-56 Given the nature and
reduced quantity of the sample, it is not clear to what
extent the results would apply to different populations of
trans women. The cross-sectional nature of the present
study does not allow one to conclude whether negative
vocal self-perception contributed to the presence of CMD
or vice versa. However, it can be said that there is a rela-
tion between voice self-perception and mental health,
highlighting the importance of considering such aspects in
vocal clinic, especially among trans women with high
results in the TWVQ protocol.
This pioneering study in Brazil seeks to understand how
vocal dissatisfaction can negatively influence the mental
health of trans women. In Brazil, despite the gender reas-
signment treatment being offered by the public health sys-
tem, access is still restricted and centralized. It is
noteworthy that speech-language therapy does not appear
in the multiprofessional team of Ordinance 2803/2013,
which redefines and expands the Transsexualizing Process
in Brazil.57 Therefore, it is essential to extend the work of
Speech Therapy and invest in the training of professionals
who fully address the health of this population, reducing the
impacts of incongruence in voice and unrecognized self-
image, so that the communication of this group is not
Vocal Self-Perception and Mental Health 5
associated with suffering, further decreasing social partici-
pation and interpersonal relationships.
CONCLUSION
There is a relation between trans women’s perception on the
impact of the voice on their lives and the suspicion of
CMD. Although more research is needed, the results point
out the need for preventive and interprofessional therapeu-
tic actions aimed at assisting trans women. This fact encour-
ages reflection on the care of this population and the role of
health professionals, enhancing scientific production, clini-
cal practice, and the inclusion of the topic "transsexuality"
in the Speech-Language Therapy training.
Acknowledgments
To Ana Clara Oliveira Abreu, Fernanda Campos de Freitas
and Luiz Cláudio Ferreira de Oliveira for their contribution
to data collection.
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