Voice And Gender Incongruence: Relationship Between Vocal Self-Perception And Mental Health Of Trans Women

Published:October 24, 2020DOI:


      To verify the association between vocal perception and Common Mental Disorders (CMD) suspicion in trans women.


      Cross-sectional observational study including 24 adult trans women with a minimum time of presentation 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%.


      The average participants’ age in this study was 28.2 years old (SD = 6.5 / minimum = 21 and maximum = 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).


      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-professional 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 practice and the inclusion of the “transsexuality” theme in Speech Language and Hearing Sciences.

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        • Winter S
        • Diamond M
        • Green J
        • et al.
        Transgender people: health at the margins of society.
        Lancet. 2016; 388: 390-400
        • Mueller SC
        • De Cuypere G
        • T’Sjoen G.
        Transgender research in the 21st century: a selective critical review from a neurocognitive perspective.
        Am J Psychiatry. 2017; 174: 1155-1162
        • Aguirre-Sánchez-Beato S.
        Trans terminology and definitions in research on transphobia: a conceptual review.
        Quad Psicol. 2018; 20: 295-305
        • Arcelus J
        • Bouman WP
        • Van Den Noortgate W
        • et al.
        Systematic review and meta-analysis of prevalence studies in transsexualism.
        Eur Psychiatry. 2015; 30: 807-815
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders: DSM-5.
        5th ed. American Psychiatric Association, Arlington2013
        • Araújo ÁC
        • Lotufo Neto F.
        The new north american classification of Mental Disorders - DSM-5.
        Rev Bras Ter Comport e Cogn. 2014; 16: 67-82
        • Goldberg D
        • Huxley P.
        Commom mental disorders: a bio-social model.
        Tavistock, London1992
        • Eduardo C
        • Vidal L
        • Amara B
        • et al.
        Predictors of probable common mental disorders (CMD) in sex workers using the Self-Reporting Questionnaire.
        J Bras Psiquiatr. 2014; 63: 205-212
        • Quadros L de CM de
        • Quevedo L de A
        • Gonçalves HD
        • et al.
        Common Mental Disorders and Contemporary Factors: 1982 Birth Cohort.
        Rev Bras Enferm. 2018; 73: 1-7
        • Souza LPS
        • Barbosa BB
        • Silva CS de O
        • et al.
        Prevalence of common mental disorders in adults in the context of Primary Health Care.
        Rev Port Enferm Saúde Ment. 2018; 18: 59-66
        • Dhejne C
        • Van Vlerken R
        • Heylens G
        • et al.
        Mental health and gender dysphoria: A review of the literature.
        Int Rev Psychiatry. 2016; 28: 44-57
        • Seelman KL
        • Colón-Diaz MJP
        • LeCroix RH
        • et al.
        Transgender noninclusive healthcare and delaying care because of fear: connections to general health and mental health among transgender adults.
        Transgender Heal. 2017; 2: 17-28
        • Miller LR
        • Grollman EA.
        The social costs of gender nonconformity for transgender adults: implications for discrimination and health.
        Sociol Forum (Randolph N J). 2015; 30: 809-831
        • White Hughto JM
        • Reisner SL
        • Pachankis JE.
        Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions.
        Soc Sci Med. 2015; 147: 222-231
        • Freidenberg C.
        Working with male-to-female transgendered clients: clinical considerations.
        Contemp Issues Commun Sci Disord. 2002; 29: 43-58
        • McNeill EJM.
        Management of the transgender voice.
        J Laryngol Otol. 2006; 120: 521-523
        • Hancock A
        • Helenius L.
        Adolescent male-to-female transgender voice and communication therapy.
        J Commun Disord. 2012; 45: 313-324
        • Neumann K
        • Welzel C.
        The importance of the voice in male-to-femaletranssexualism.
        J Voice. 2004; 18: 153-167
        • Davies S
        • Goldberg J.
        Clinical aspects of transgender speech feminization and masculinization.
        Int J Transgenderism. 2006; 9: 167-196
        • Schmidt JG
        • Goulart BNG de
        • Dorfman MEKY
        • et al.
        Voice challenge in transgender women: trans women self-perception of voice handicap as compared to gender perception of naïve listeners.
        Rev CEFAC. 2018; 20: 79-86
        • Dornelas R
        • Guedes-Granzotti RB
        • Souza AS
        • et al.
        Quality of life and voice: the vocal self-perception of transgender people.
        Audiol - Commun Res. 2020; 25: 1-5
        • Glynn TR
        • Gamarel KE
        • Kahler CW
        • et al.
        The role of gender affirmation in psychological well-being among transgender women.
        Psychol Sex Orientat Gend Divers. 2016; 3: 336-344
        • Russell ST
        • Pollitt AM
        • Li G
        • et al.
        Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth.
        J Adolesc Heal. 2018; 63: 503-505
        • Dewes JO
        Amostragem em Bola de neve e respondent-driven simpling: Uma descrição de métodos [Monografia]. Porto Alegre: Departamento de Estatística.
        Universidade do Rio Grande do Sul - UFRGS. 2013;
        • Mari JJ
        • Williams P.
        A validity study of a Psychiatric Screening Questionnaire (SRQ-20) in primary care in city of São Paulo.
        Brit J Psychiatry. 1986; 148: 23-26
        • Santos H
        • Aguiar A
        • Baeck H
        • et al.
        Translation and preliminary evaluation of the Brazilian Portuguese version of the Transgender Voice Questionnaire for male-to-female transsexuals.
        CoDAS. 2015; 27: 89-96
        • Gonçalves DM
        • Stein AT
        • Kapczinski F.
        Performance of the Self-Reporting Questionnaire as a psychiatric screening questionnaire: a comparativestudy with Structured Clinical Interview for DSM-IV-TR.
        Cad Saude Publica. 2008; 24: 380-390
        • Dacakis G.
        • Davies S.
        • Oates J.
        • et al.
        Development and preliminary evaluation of the Transsexual Voice Questionnaire for male-to-female transsexuals.
        J Voice. 2013; 27: 312-320
        • Windish DM
        • Diener-West M.
        A clinician-educator’s roadmap tochoosing and interpreting statistical tests.
        J Gen Intern Med. 2006; 21: 656-660
        • Grant JM
        • Mottet LA
        • Tanis J
        • et al.
        Injustice at Every Turn: A Report of the National Transgender Discrimination Survey.
        National Center for Transgender Equality and National Gay and Lesbian Task Force, Washington2011
        • Ludermir AB
        • de Melo Filho DA.
        Living conditions and occupational organization associated with common mental disorders.
        Rev Saúde Públic. 2002; 36: 213-221
        • Maragno L
        • Goldbaum M
        • Gianini RJ
        • et al.
        Prevalence of common mental disorders in a population covered by the Family Health Program (QUALIS) in São Paulo, Brazil.
        Brasil. Cad Saúde Pública. 2006; 22: 1639-1648
        • Rodrigues-Neto JF
        • Figueiredo MFS
        • Faria AAS
        • et al.
        Commom mental disorders and the use of complementary and alternative medicine – population – based survey.
        J Bras Psiq. 2008; 57: 233-239
        • Rocha SV
        • Almeida MMG
        • Araújo TM
        • et al.
        Prevalence of common mental disorders among the residents of urban areas in Feira de Santana, Bahia.
        Rev Bras Epidemiol. 2010; 13: 630-640
        • Moreira JKP
        • Bandeira M
        • Cardoso CS
        • et al.
        Prevalence of common mental disorders in the population attended by the Family Health Program.
        J Bras Psiquiatr. 2011; 60: 221-226
        • Steel Z
        • Marnane C
        • Iranpour C
        • et al.
        The global prevalence of common mental disorders: a systematic review and meta-analysis 1980–2013.
        Int J Epidemiol. 2014; 43: 476-493
        • Reisner SL
        • Vetters R
        • Leclerc M
        • et al.
        Mental Health of Transgender Youth in Care at an Adolescent Urban Community Health Center: A Matched Retrospective Cohort Study.
        J Adolesc Heal. 2015; 56: 274-279
        • Witcomb GL
        • Bouman WP
        • Claes L
        • et al.
        Levels of depression in transgender people and its predictors: Results of a large matched control study with transgender people accessing clinical services.
        J Affect Disord. 2018; 235: 308-315
        • Souza LPS
        • Barbosa BB
        • Silva CSO
        • et al.
        Prevalence of common mental disorders in adults in the context of Primary Health Care.
        Rev Port Enferm Saúde Ment. 2017; 18: 59-66
        • Dacakis G
        • Oates J
        • Douglas J.
        Associations between the Transsexual Voice Questionnaire (TVQ MtF) and self-report of voice femininity and acoustic voice measures.
        Int J Lang Commun Disord. 2017; 52: 831-838
        • Schwarz K
        • Fontanari AMV
        • Mueller A
        • et al.
        Transsexual voice questionnaire for male-to-female Brazilian transsexual people.
        J Voice. 2017; 31: 120.e15-120.e20
        • Butler RM
        • Horenstein A
        • Gitlin M
        • et al.
        Social anxiety among transgender and gender nonconforming individuals: The role of gender-affirming medical interventions.
        J Abnorm Psychol. 2019; 128: 25-31
        • Carew L
        • Dacakis G
        • Oates J.
        The effectiveness of oral resonance therapy on the perception of femininity of voice in male-to-female transsexuals.
        J Voice. 2007; 21: 591-603
        • Thornton J.
        Working with the transgender voice: The role of the speech and language therapist.
        Sexologies. 2008; 17: 271-276
        • Gelfer MP
        • Tice RM.
        Perceptual and acoustic outcomes of voice therapy for male-to-female transgender individuals immediately after therapy and 15 months later.
        J Voice. 2013; 27: 335-347
        • Hancock A
        • Garabedian L.
        Transgender voice and communication treatment: a retrospective chart review of 25 cases.
        Int J Lang Commun Disord. 2013; 48: 54-65
        • McNeill EJM
        • Wilson JA
        • Clark S
        • et al.
        Perception of voice in the transgender client.
        J Voice. 2008; 22: 727-733
        • Pasricha N
        • Dacakis G
        • Oates J.
        Communicative satisfaction of male-to-female transsexuals.
        Logop Phoniatr Vocology. 2008; 33: 25-34
        • Cruz TM.
        Assessing access to care for transgender and gender nonconforming people: a consideration of diversity in combating discrimination.
        Soc Sci Med. 2014; 110: 65-73
        • Socías ME
        • Marshall BDL
        • Arístegui I
        • et al.
        Factors associated with healthcare avoidance among transgender women in Argentina.
        Int J Equity Health. 2014; 13: 81
      1. Trasngender Europe; Trans Respect Versus Transphobia Worldwide. TMM Update. (accessed 04 November 2019).

        • Rocon PC
        • Rodrigues A
        • Zamboni J
        • et al.
        Difficulties experienced by trans people in accessing the Unified Health System.
        Ciênc saúde colet. 2016; 21: 2517-2526
        • Zucchi E
        • Barros C
        • Lara B
        • et al.
        Psychological well-being among transvestites and trans women in the state of São Paulo, Brazil.
        Cad Saude Publica. 2019; 35e00064618
        • Silva R
        • Bezerra W
        • Queiroz S.
        The impacts of transgender identities in sociability of travestis and transsexual women.
        Rev Ter Ocup da Univ São Paulo. 2015; 26: 364-372
        • Rocon PC
        • Sodré F
        • Zamboni J
        • et al.
        What trans people expect of the Brazilian National Health System?.
        Interface - Comun Saúde, Educ. 2018; 22: 43-53
        • Monteiro S
        • Brigeiro M.
        Experiências de acesso de mulheres trans/travestis aos serviços de saúde: avanços, limites e tensões. 35. Cad Saúde Pública, 2019: e00111318
      2. Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria n° 2.803, de 19 de novembro de 2013. Redefine e amplia o Processo Transexualizador no Sistema Único de Saúde (SUS). Diário Oficial da União., 2013 (accessed 04 November 2019)