Vocal-Gender Incongruence, wellbeing, and safety: the medical necessity of gender-affirming vocal training

Background Voice is a gender signifier, and incongruence between a person's gender identity and others' perception of their gender based on their voice can trigger dysphoria in transgender/gender diverse (TGD) individuals. Vocal-gender incongruence (VGI) can also signal one's TGD identity, which may be unsafe given the prevalence of discrimination and victimization experienced by TGD persons. Methods To understand the impact of VGI on wellness and safety, a cross-sectional electronic survey was developed. The Quality-of-Life Scale (QOLS), a modified version of the Transgender Self-Evaluation Questionnaire (TSEQ), and questions assessing experiences of violence, discrimination and misgendering were included. Differences in safety and wellness measures between participants with and without VGI were assessed using t-tests and chi-squared tests. Linear and logistic regression analyses were conducted to examine the relationships between VGI and safety, quality of life, and experiences of discrimination or misgendering. Results Of 187 TGD participants, 127 (68%) reported VGI. Participants with VGI had significantly lower scores on the QOLS (70 vs 76; p=.02) and were significantly more likely to have been misgendered based on their voice in the past year (p < .001; 85% vs. 33%). Higher TSEQ scores (indicating higher impact of VGI on daily life) were associated with lower QOLS scores (beta = 0.06; 95% CI 0.04, 0.09; p < .001) and with greater likelihood of having experienced public discrimination (beta = 0.03; 95% CI 0.02, 0.05; p < .001), medical discrimination (beta = 0.04; 95% CI 0.02, 0.06; p < .001), and verbal harassment (beta = 0.03; 95% CI 0.01, 0.04; p < .001) but not physical harm (beta = 0.03; 95% CI 0.002, 0.06; p = 0.05). Conclusion VGI is associated with lower quality of life and experiences of discrimination and verbal harassment for TGD individuals. Therefore, healthcare that alleviates VGI, including gender-affirming vocal training, is medically necessary.