Associations between the Transsexual Voice Questionnaire (TVQMtF ) and self-report of voice femininity and acoustic voice measures

Validation of a Self-Perception Voice Protocol for Trans Women: Trans Woman Voice Questionnaire

OBJECTIVE

To validate the Trans Woman Voice Questionnaire (TWVQ) in Brazilian Portuguese for measuring vocal self-perception in transgender women.

METHOD

This is a quantitative, methodological study. The validation process included steps for assessing validity, reliability, and responsiveness. The sample had five voice specialists, 85 transgender women, and 40 cisgender women. The voice specialists evaluated the TWVQ items using the Content Validity Index (CVI). Target population participants completed the TWVQ three times: initially, after 2-14 days, and following a voice intervention from a speech-language-hearing pathologist.

RESULTS

The overall CVI in the content validation phase was 0.89. For the Item CVI (I-CVI), 13 out of 30 items scored below the expected threshold (<0.8) and were revised by the authors. The full protocol was administered to 20 participants from the target population, and 14 items required adjustments. Following item revision, the protocol was readministered to the target population, and all items were deemed adequate. The second validation phase involved 65 transgender women, administering the instrument at three moments: initial application (test), reapplication after 7-14 days (retest), and a third application after the voice intervention (responsiveness). For the final TWVQ version, items 1 ("People have trouble hearing me when I speak in noisy places") and 26 ("People who don't know me find my voice unusual") were excluded due to low communality. Confirmatory Factor Analysis validated the three-factor, 28-item TWVQ-Br model: Factor 1 with 15 items (voice-gender congruence), Factor 2 with 11 items (voice production and impact), and Factor 3 with 2 items (vocal restriction). Reliability was found for the internal consistency of the TWVQ-Br and test-retest reliability. Responsiveness indicated a significant change in construct scores following the voice intervention, with lower TWVQ-Br scores postintervention. The TWVQ-Br distinguished transgender and cisgender women across all factors and total scores (P < 0.001 for all).

CONCLUSION

The TWVQ's validation in Brazilian Portuguese led to significant adjustments to enhance alignment with the experiences of Brazilian transgender women. Certain items that did not contribute to the instrument's objectives were removed, and three factors were extracted. The final instrument had high reliability in test-retest analysis, high sensitivity with score changes postintervention, and the capacity to differentiate between transgender and cisgender women based on protocol scores, indicating that it specifically meets transgender women's needs.

Voice self-perception and acoustic parameters in transgirls adolescent related to pubertal stage blockage

BACKGROUND

Trans girls may initiate early puberty blockers once puberty has started in order to prevent the development of masculine secondary sexual characteristics. Depending on how early the puberty blockers are administered, voice may have reached a certain degree of development and have acquired typically male acoustic and phonetic parameters, which can cause discomfort and affect the adolescent's quality of life.

PURPOSE

The aim of the present study was to (1) determine if there are differences in discomfort with the self-perceiver voice according to the moment of puberty block (PB), and (2) find a relation between vocal discomfort and variables such a voice phonetic/acoustic characteristics and self-perception of voice.

METHOD

A cross-sectional study was carried out. Differences in vocal discomfort between a group of trans girls with early puberty block and a group with late puberty block were compared. The participants were given the Voice Handicap index (VHI-30) and the Trans Women Voice Questionnaire (TWVQ) to assess vocal discomfort. In the same way, their anthropometric, clinical and vocal data, such as FO, were collected. The Kruskal-Wallis test was used to compare the differences in the TWVQ punctuation according to the Tanner stage.

RESULTS

The value of the fundamental frequency (FO) was 71.5 Hz higher in the early puberty block group (p < 0.001). The total scores of the questionnaires are higher in the late puberty block group (37.5 points in the TWVQ and 26 points in the VHI-30, p < 0.001 in both cases) Vocal self-perception tends to be more feminine in users with early blocked puberty (p = 0.001). There is a negative correlation between FO and puberty block age (r = 0.669) as well as with the TWVQ score (r = 0.755).

CONCLUSION

Early puberty blockers seem to be related to lower score in TWVQ and VHI-30. It could represent less vocal discomfort in trans girls. Acute voice seem to be more frequent in early puberty blocked because Fundamental frequency are significantly higher.

Application of the transgender male voice questionnaire in a Brazilian population sample

Objectives

The aim of this study was to adapt and apply the Portuguese version of the Transgender Man Voice Questionnaire in a sample of Brazilian transgender men and to investigate the relationship between voice satisfaction and hormone therapy duration. In addition, we suggest reducing and reformulating the questionnaire for screening.

Methods

We conducted a cross-sectional study of 31 transgender men aged 18-50 years undergoing hormone therapy who answered a questionnaire adapted from the Transgender Woman Voice Questionnaire, validated in Portuguese. Sociodemographic and clinical data were collected from the individuals' electronic medical records: age, smoking status, and type and duration of hormone therapy. The questionnaire, consisting of 30 questions rated on a Likert scale, was answered individually during a psychotherapy session. In each question, the gender-specific words were modified. Furthermore, we added a question: 31 (After GAHT, my voice became completely male), with the response options yes or no. In questions 32 and 33, asking participants to provide an overall rating of their voice. Total score ranged from 0 to 120, with higher scores indicating greater dissatisfaction with voice.

Results

Mean patient age was 30.13 ± 7.6 years, and 19.4% were smokers. The mean duration of hormone therapy was 29.7 ± 24.9 months, and 95% received intramuscular testosterone cypionate, maintaining serum testosterone levels within the male reference range. The questionnaire mean total score was 51 ± 17.72. There was a significant negative correlation between the questionnaire total score and duration of hormone therapy (r = -0.484, p = 0.006). The questionnaire had a high level of internal consistency/reliability, with a Cronbach's alpha coefficient of 0.95 for all items and a split-half Spearman-Brown coefficient of 0.96. For the elaboration of a screening tool, it is suggested to remove questions 8, 10, 12, 13, 14, 17, 19, 23, 27, and 29 and modify question 1.

Conclusion

Longer hormone therapy favors voice deepening and satisfaction with voice. The psychometric properties of the Transgender Man Voice Questionnaire are reliable, supporting its use as a screening tool in clinical practice and as an adjunct to the planning of vocal and communication support for transgender individuals.

Comparison Between two Surgical Techniques for Increasing Vocal Pitch by Endoscopic Shortening of the Vocal Folds

OBJECTIVE

To compare two surgical techniques, the Wendler glottoplasty (GP) and its modification, the vocal fold shortening, and retrodisplacement of the anterior commissure (VFSRAC) associated with laser assisted voice adjustment (LAVA) cordotomy, used to feminize the voice of transgender women by increasing the fundamental frequency (F0).

METHODS

A retrospective study of 22 trans-women (20-62 years-old) was carried out. 12 of them were treated with GP and 10 with the VFSRAC+LAVA technique. They were evaluated before surgery and 6 months after surgery and the postoperative speech therapy. Laryngostroboscopy examination, F0 measurements, Transgender Woman Voice Questionnaire (TWVQ) assessment and the perceptual assessment using a visual analog scale (PA-VAS) were obtained from all patients.

RESULTS

Laryngostroboscopic findings showed normal vocal folds before surgery and a shortening of the vocal folds, due to the anterior glottic synechia, after surgery. Significant increases of F0 were found in both groups but they were higher in the VFSRAC+LAVA group (47.75Hz in GP group vs 69.70Hz in VFSRAC+LAVA group). TWVQ scores showed a significant decrease in both groups although the difference was greater in the VFSRAC+LAVA group. Similarly, PA-VAS scores lowered significantly in both groups but VFSRAC+LAVA group presented the biggest decreases.

CONCLUSION

Both surgical techniques produce the shortening of the vocal folds through an endoscopic approach and result in voices with higher vocal pitch. Of the two techniques presented, the VFSRAC+LAVA produces better results although when compared with previous studies it seems that the LAVA technique may not significantly contribute to the postoperative results. So, the VFSRAC technique followed by postoperative speech therapy could be recommended for trans-women who wish to feminize their voice.

Exploring the Relationship Between Acoustic Measurements and Self-Perception of Voice in Trans Women

OBJECTIVE

This study aimed to explore the strength and direction of the relationship between spectral cepstral-based, time-based acoustic measures and the self-perception of voice in trans women.

METHODS

Forty-eight trans women were included in the study. Analysis of the sustained vowel phonation was performed using Multidimensional Voice Profile Analysis (MDVP), and spectral-cepstral analyses of the sustained vowel phonation, all-voiced weighted sentence, and spontaneous speech were made via Analysis of Dysphonia in Speech and Voice (ADSV) software. For self-perceptual evaluations, the Trans Woman Voice Questionnaire (TWVQ) and the Self-perception of Voice Femininity Scale (SPVF) were used. The correlation between MDVP, spectral-cepstral parameters, and TWVQ and SPVF scores was calculated.

RESULTS

The present study found a positive relationship between F0, SPVF, and TWVQ. Among the perturbation parameters, the jitter was the only one found to correlate with SPVF and TWVQ. The CPPF0 parameter was found to be associated with a more feminine voice perception and a higher voice-related quality of life in all speech samples in the present study. In addition, higher CPP values achieved from vowel phonation were associated with less feminine voice perception and lower voice-related quality of life. The present study also suggests a weak correlation with the SPVF and Cepstral Peak Prominence Standard Deviation (CPPF0 SD) of the spontaneous speech sample in a negative direction.

CONCLUSIONS

This study found weak and moderate levels of correlations between F0, jitter (%), CPP, CPPF0, CPPF0 SD parameters, and self-perceptual measures. These findings suggested that such a level of relationship is attributable to the fact that these tools evaluate different aspects of voice in accordance with the International Classification of Functioning System. According to this pioneering study, it would be beneficial to incorporate spectral-cepstral measures into the objective assessment protocol for trans women's voices.

The Communicative Participation Item Bank-Gender-Diverse Version: Item Bank Calibration and Short Form

PURPOSE

The purpose of this study was to calibrate an item set for a new version of the Communicative Participation Item Bank (CPIB) specifically for use with gender-diverse clients. This new version contains a new item stem as well as other minor wording changes from the original CPIB in order to be acceptable to gender-diverse respondents.

METHOD

Survey data on 47 candidate items were collected from 434 transgender individuals: 219 assigned female at birth (AFAB) and 215 assigned male at birth (AMAB). Item response theory analyses included evaluation of unidimensionality, local dependence, fit to a graded response model, and differential item functioning (DIF) between AFAB and AMAB respondents.

RESULTS

The original set of 47 items was unidimensional, but 16 items were removed due to local dependence, resulting in a final item bank of 31 items. There was no evidence of DIF between AFAB and AMAB participants. Reliability of the full item bank is good (i.e., > 0.8) between T scores of 20 and 76 and high (i.e., > 0.9) between T scores of 20 and 68. The short form had good reliability (i.e., > 0.8) between T scores of 24 and 64.

CONCLUSIONS

The Communicative Participation Item Bank-Gender-Diverse (CPIB-GD) version provides a new option for person-reported outcome measurement with gender-diverse clients. Clinicians are cautioned to use only the new CPIB-GD with gender-diverse clients, and not the original CPIB due to unacceptable wording in the original version for this population. The original CPIB remains valid and appropriate for the populations for which it was developed.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24993309.

A Systematic Review of Voice-Related Patient-Reported Outcome Measures for Use with Adults

PURPOSE

This paper's purpose is to provide a resource for clinicians and researchers of select voice-related patient-reported outcome measures (PROMs) available in the English language.

METHOD

A systematic search for voice-related PROMs was conducted between September 2020 and July 17, 2021. Databases included APA PsychInfo, Nursing and Allied Health Source, MEDLINE via the EBSCO interface, and Science Direct. Reference lists for PROMs-related articles were mined for reference to PROMs protocols.

RESULTS

Thirty voice-related PROMs were identified and categorized as either developed primarily for use in the clinic (n = 12), developed primarily for use in a specific research study (n = 6), or translated into English for publication (n = 12). Twelve PROMs were summarized: Aging Voice Index, Disease Specific Self-Efficacy in Spasmodic Dysphonia, Evaluation of the Ability to Sing Easily, Evaluating Voice Disability - Quality of Life Questionnaire, Glottal Function Index, Linear Analog Scale of Assessment of Voice Quality, Quality of Life in Recurrent Respiratory Papillomatosis, Speech Disability Questionnaire, Trans Woman Voice Questionnaire, Vocal Cord Dysfunction Questionnaire, Vocal Fatigue Index, and the Vocal Tract Discomfort Scale.

CONCLUSION

The PROMs can be categorized into English-language voice-related PROMs developed primarily for clinical use, English-language PROMs developed primarily for research use, and English-language PROMs translated into English. The extent of reliability and validity testing completed varies in the PROMs developed primarily for clinical use. A PROM's psychometric properties as well as the language in which the PROM was tested, should guide clinicians and researchers as they consider which instrument(s) to use.

Gender-Affirming Voice Training for Trans Women: Effectiveness of Training on Patient-Reported Outcomes and Listener Perceptions of Voice

PURPOSE

Although speech-language pathologists have provided gender-affirming voice training for trans women since the 1970s, evidence for this training's effectiveness remains weak. Our study aimed to redress limitations of earlier studies and evaluate voice training effects on outcomes important to trans women.

METHOD

Seventy-four trans women (19-54 years old) who wanted a more female-sounding voice were recruited through two health facilities and provided with an eight- to 12-session voice training program based on contemporary literature, usual clinical practice, and client-centered care principles. Self-reported outcomes and an audio-recorded reading sample were collected 3 months before, immediately before and after, and 3 months after training. Forty cisgender speakers were audio-recorded reading the same sample material as comparison voices. Seventy-nine naive listeners made gender-related voice ratings of an extract from these audio recordings. Training effectiveness was evaluated using group-level analyses (linear mixed-effects models) and individual-level analyses to establish what proportion of participants improved to a predetermined relevant degree.

RESULTS

Group-level analyses demonstrated positive training effects, maintained 3 months posttraining, for trans women's vocal satisfaction, perceptions of voice-related social participation, and self- and listener perceptions of their voices. Individual-level analyses also demonstrated positive effects. Two thirds of trans women increased vocal satisfaction to a relevant degree, one third who reported restricted social participation before training reduced this restriction to a relevant degree, and all were rated more female-sounding after training (although not all to a relevant degree).

CONCLUSIONS

All trans women participants made progress toward their voice goals and maintained those gains at follow-up. These findings provide evidence that gender-affirming speech-language pathology services warrant prioritization. Further research is warranted to investigate factors predicting outcomes of voice training for trans women.

Spectral analysis of strident fricatives in cisgender and transfeminine speakersa)

The spectral features of /s/ and /ʃ/ carry important sociophonetic information regarding a speaker's gender. Often, gender is misclassified as a binary of male or female, but this excludes people who may identify as transgender or nonbinary. In this study, we use a more expansive definition of gender to investigate the acoustics (duration and spectral moments) of /s/ and /ʃ/ across cisgender men, cisgender women, and transfeminine speakers in voiced and whispered speech and the relationship between spectral measures and transfeminine gender expression. We examined /s/ and /ʃ/ productions in words from 35 speakers (11 cisgender men, 17 cisgender women, 7 transfeminine speakers) and 34 speakers (11 cisgender men, 15 cisgender women, 8 transfeminine speakers), respectively. In general, /s/ and /ʃ/ center of gravity was highest in productions by cisgender women, followed by transfeminine speakers, and then cisgender men speakers. There were no other gender-related differences. Within transfeminine speakers, /s/ and /ʃ/ center of gravity and skewness were not related to the time proportion expressing their feminine spectrum gender or their Trans Women Voice Questionnaire scores. Taken together, the acoustics of /s/ and /ʃ/ may signal gender group identification but may not account for within-gender variation in transfeminine gender expression.

Outcomes of Gender-Affirming Voice and Communication Modification Training for Non-binary Individuals: A Case Series

OBJECTIVES

There is currently no research reporting solely on outcomes of voice and communication modification training (VCMT) in individuals who identify as non-binary and genderqueer (NBGQ) in the English literature. This study aimed to describe the objective and subjective impact of VCMT on the voice of NBGQ individuals undergoing a 12-week gender-affirming VCMT program.

METHODS

A retrospective consecutive case series of NBGQ individuals enrolled in a VCMT program was performed. Demographics, Transgender Self-Evaluation Questionnaire (TSEQ), fundamental frequency (F0), and frequency range were collected before and after the program.

RESULTS

Four NBGQ individuals enrolled between January 2019 and June 2021; the mean age was 27.0 years. While all four participants represented in this case series showed improvement in at least one of their initial goals, only one improved both their F0 and TSEQ scores; the other three participants had mixed results.

CONCLUSION

NBGQ individuals experienced improvements in self-reported outcomes and changes in acoustic measures after completing VCMT in our case series. Individuals experienced significant improvement in subjective outcomes despite small changes in acoustic measures, and vice versa. More research is needed to better understand the voice and communication needs of NBGQ individuals, along with their outcomes with VCMT.

LEVEL OF EVIDENCE

Level 4.

Diagnosis and Management of Vocal Complications after Chondrolaryngoplasty

OBJECTIVE

Transfeminine patients (transwomen/feminine nonbinary folks assigned male at birth) can undergo chondrolaryngoplasty ("tracheal shave") to feminize their neck appearance. While isolated cases of vocal complications have been reported following the procedure, aggregated outcomes have not been quantitatively studied. We present acoustic and stroboscopic data to describe a patient cohort with vocal complications after chondrolaryngoplasty and discuss reparative surgical technique.

METHODS

Subjective and objective data, including videostroboscopy, were collected from patients with voice complaints after chondrolaryngoplasty. Dislocated anterior commissures were reconstructed with feminization laryngoplasty. Postoperative voice data were recorded and statistically compared to preoperative data using paired t-tests.

RESULTS

On consecutive chart review, of the 94 transfeminine women with prior outside history of chondrolaryngoplasty, 27 (29%) reported chronic postoperative hoarseness, deepened pitch, or loss of upper register. On endoscopy, short, lax vocal folds with persistent anterior glottic gap and phase asymmetry were commonly noted; anterior commissure dislocation was confirmed in-office by using needle localization through absent thyroid cartilage. After open resuspension of the anterior commissure with feminization laryngoplasty, post-repair modal-speaking, minimum, and maximum fundamental frequencies (F0) increased on average by 7, 8, and 5 semitones, respectively (p < 0.01), when compared to pre-repair values. On average, perioperative maximum phonation time did not change significantly (p = 0.15). Average self-assessment of vocal femininity increased by 48% (p < 0.01).

CONCLUSION

Anterior commissure dislocation should be suspected with signs of vocal impairment after chondrolaryngoplasty. Following proper diagnosis, resuspension of the anterior commissure via feminization laryngoplasty approach can be an effective reparative technique.

LEVEL OF EVIDENCE

This work represents a 2011 OCEBM Level 4 evidence as a case series Laryngoscope, 133:2301-2307, 2023.

Gender-Affirming Voice Modification for Transgender Women: Characteristics and Outcomes

Objective

The primary aim of this study was to define characteristics of transgender women seeking gender-affirming voice modification at our voice center. The secondary aim was to evaluate outcome measures, comparing (a) behavioral voice training alone, (b) surgery alone, and (c) combination of behavioral voice training+surgery.

Methods

Patients seen in a 30-month period, who sought care for gender-affirming voice modification, were included if they were assigned male at birth and identified as female. Patient demographic information, patient quality of life index scores, Trans Woman Voice Questionnaire (TWVQ), and acoustic data were collected before and after intervention.

Results

Sixteen patients met inclusion criteria. The majority of patients were (a) undergoing hormone replacement therapy at initiation of treatment, (b) were presenting in public for over 2 years as female, and (c) had a history of psychological disorders (i.e., gender dysphoria, anxiety, depression, and attention deficit hyperactivity disorder [ADHD]). Increased f0 and decreased TWVQ scores were evident and statistically significant within behavioral voice training cohort and behavioral voice training+surgery cohort. Treatment groups appear similar with respect to average changes; pre- and post-data were not available for surgery only patients. Greater change in f0 was directly correlated with increased number of voice training sessions.

Conclusion

There is variability in treatment course for patients seeking gender-affirming voice modification; however, treatment type may not impact outcomes. Increased patient quality of life and increased speaking fundamental frequency were found in this patient cohort.

[Interface of speech-language pathology in the process of gender reassignment from male to female]

BACKGROUND

Voice is crucial for gender identification during the transition process, as voice feminization plays a significant role in the success of passing. In order to be able to classify the role of voice treatment during the interdisciplinary gender reassignment process of MzF-trans*, possible recommendations for action for the cooperation with the medical doctors are needed.

MATERIAL AND METHODS

Four expert interviews from the disciplines of otolaryngology, endocrinology, and plastic surgery were conducted to establish a potential guideline consensus for the role of speech-language pathology as an interface to the male-to-female gender reassignment process.

RESULTS

Based on the expert interviews, it is uniformly recommended that voice treatment should be considered early in the transition. Primarily, conservative therapy should be considered to avoid e.g. irreversible surgery of the larynx. The focus of voice treatment in voice feminization is centrally on the adaption of the speaking fundamental frequency. In postoperative cases, speech-language pathology is intended to adapt the speech pattern to the new anatomy and prevent complications, such as uneconomic voice and speech.

CONCLUSION

The current interviews represent a first insight into the cooperation between speech-language pathology and the medical specialties for the treatment of MzF-Trans*. In order to implement the recommendations from the preliminary expert interviews for a potential guideline consensus, consultation with involved professional societies and more randomized trials of specific voice treatments in MzF-trans* are needed.

Effect of Wendler glottoplasty on voice and quality of life of transgender women

OBJECTIVE

To investigate the effect of Wendler glottoplasty on voice feminization, voice quality and voice-related quality of life.

METHODS

Prospective interventional cohort of transgender women submitted to Wendler glottoplasty. Acoustic analysis of the voice included assessment of fundamental frequency, maximum phonation time formant frequencies (F1 and F2), frequency range, jitter and shimmer. Voice quality was blindly assessed through GRBAS scale. Voice-related quality of life was measured using the Trans Woman Voice Questionnaire and the self-perceived femininity of the voice.

RESULTS

A total of 7 patients were included. The mean age was 35.4 years, and the mean postoperative follow-up time was 13.7 months. There was a mean increase of 47.9 ± 46.6 Hz (p = 0.023) in sustained/e/F0 and a mean increase of 24.6 ± 27.5 Hz (p = 0.029) in speaking F0 after glottoplasty. There was no statistical significance in the pre- and postoperative comparison of maximum phonation time, formant frequencies, frequency range, jitter, shimmer, and grade, roughness, breathiness, asthenia, and strain scale. Trans Woman Voice Questionnaire decreased following surgery from 98.3 ± 9.2 to 54.1 ± 25.0 (p = 0.007) and mean self-perceived femininity of the voice increased from 2.8 ± 1.8 to 7.7 ± 2.4 (p = 0.008). One patient (14%) presented a postoperative granuloma and there was 1 (14%) premature suture dehiscence.

CONCLUSION

Glottoplasty is safe and effective for feminizing the voice of transgender women. There was an increase in fundamental frequency, without aggravating other acoustic parameters or voice quality. Voice-related quality of life improved after surgery.

A Study on Reliability and Validity of the Simplified Chinese Version of the Trans Woman Voice Questionnaire

PURPOSE

This study aims to translate the English version of the Trans Woman Voice Questionnaire (TWVQ) to simplified Chinese (TWVQ-SC) and to examine its reliability and validity.

METHOD

Standardized translation procedures were strictly followed for the translation of the TWVQ. Two hundred sixty trans woman and 128 cis woman subjects completed sociodemographic investigation, the TWVQ-SC, and the Voice Handicap Index-10 (VHI-10) online. Internal consistency was examined by Cronbach reliability coefficient (Cronbach α). Test-retest reliability was quantified by intraclass correlation coefficient (ICC). Content validity, structural validity, and discriminant validity were examined by expert panel's judgment, factor analysis, Spearman's rank correlation coefficient, and the Mann-Whitney U test.

RESULTS

The Cronbach α of the TWVQ-SC was .969 and the ICC was .841, indicating excellent internal consistency and good test-retest reliability. The four principal factors explained 21.345%, 18.592%, 13.551%, and 12.027% of the variance respectively with the cumulative contribution rate 65.514%. There was a strong correlation between the total score of the TWVQ-SC and that of the VHI-10 (r = .858, p < .001), indicating good structural validity. The total score of the TWVQ-SC of the trans woman subjects was significantly higher than that of the cis woman subjects (z = 14.590, p < .05), indicating good discriminant validity.

CONCLUSION

The TWVQ-SC exhibits overall high reliability and validity, qualified to be applied as a reliable clinical tool to evaluate trans women's voice in mainland China.

Using Item-Response Theory to Improve Interpretation of the Trans Woman Voice Questionnaire

OBJECTIVE

The Trans Woman Voice Questionnaire (TWVQ) is commonly used to quantify self-perceptions of voice for trans women seeking gender-affirming voice care, but the interpretation of TWVQ scores remains challenging. The objective of this study was to use item-response theory (IRT) to evaluate the relationship between TWVQ items and persons on a common scale and identify improvements to increase the meaningfulness of TWVQ scores.

METHODS

A retrospective review of TWVQ scores from trans women patients between 2018-2020 was performed. Rasch-family models were used to generate item-person maps positioning respondent location and item difficulty estimates on a logit scale, which was then converted into a scaled score using linear transformations.

RESULTS

TWVQ responses from 86 patients were analyzed. Initial item-person maps demonstrated that the middle response categories ("sometimes" and "often") performed inconsistently across items (poor threshold banding); interpretability improved when these ratings were scored as one category. The models were rerun using revised scoring, which retained high reliability (0.93) and supported a unidimensional construct. Updated item-person maps revealed four scaled score zones (≤54, >54 to ≤101, >101 to ≤140, and >140) that each corresponded to an increasing pattern of item thresholds (probability of selecting one response category vs. others). These ranges can be interpreted as minimal, low, moderate, and high, respectively.

CONCLUSIONS

Empiric data from Rasch analysis supports new interval scoring for the TWVQ that advances the clinical and research utility of the instrument and lays the foundation for future improvements in clinical care and outcomes assessment.

LEVEL OF EVIDENCE

NA Laryngoscope, 2022.

Effect of Anchor Term on Auditory-Perceptual Ratings of Feminine and Masculine Speakers

BACKGROUND

Studies investigating auditory perception of gender expression vary greatly in the specific terms applied to gender expression in rating scales.

PURPOSE

This study examined the effects of different anchor terms on listeners' auditory perceptions of gender expression in phonated and whispered speech. Additionally, token and speaker cues were examined to identify predictors of the auditory-perceptual ratings.

METHOD

Inexperienced listeners (n = 105) completed an online rating study in which they were asked to use one of five visual analog scales (VASs) to rate cis men, cis women, and transfeminine speakers in both phonated and whispered speech. The VASs varied by anchor term (very female/very male, feminine/masculine, feminine female/masculine male, very feminine/not at all feminine, and not at all masculine/very masculine).

RESULTS

Linear mixed-effects models revealed significant two-way interactions of gender expression by anchor term and gender expression by condition. In general, the feminine female/masculine male scale resulted in the most extreme ratings (closest to the end points), and the feminine/masculine scale resulted in the most central ratings. As expected, for all speakers, whispered speech was rated more centrally than phonated speech. Additionally, ratings of phonated speech were predicted by mean fundamental frequency (f _o) within each speaker group and by smoothed cepstral peak prominence in cisgender speakers. In contrast, ratings of whispered speech, which lacks an f _o, were predicted by indicators of vocal tract resonance (second formant and speaker height).

CONCLUSIONS

The current results indicate that differences in the terms applied to rating scales limit generalization of results across studies. Identifying the patterns across listener ratings of gender expression provide a rationale for researchers and clinicians when making choices about terms. Additionally, beyond f _o and vocal tract resonance, predictors of listener ratings vary based on the anchor terms used to describe gender expression.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19617564.

Outcomes of Gender-Affirming Voice and Communication Modification for Transgender Individuals

OBJECTIVES

Transgender individuals' voices are closely related to gender identity. A primary goal of gender-affirming voice modification is to help individuals alter their voices to improve gender congruence; however, there is a paucity of research to support this approach. This study aimed to evaluate the outcomes of a 12-week gender-affirming voice and communication modification program.

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective consecutive case series of transgender women enrolled in a voice and communication modification program was performed. Demographics, Trans Woman Voice Questionnaire (TWVQ), fundamental frequency (F₀ ), and frequency range were collected before and after the program. A Wilcoxon signed-rank test assessed changes in outcomes. Spearman's rank-order correlation coefficients quantified associations between self-reported outcomes and acoustic measures.

RESULTS

A total of 16 trans women individuals were enrolled. The mean age was 31.5 years. After program completion, TWVQ improved 20.4 points, F₀ increased 26.5 Hz (spontaneous speech) and 25.7 Hz (reading), and the range increased 24.7 Hz (spontaneous speech) and 0.1 Hz (reading). None of the changes in acoustic measures significantly correlated with improvement in TWVQ scores in the cohort.

CONCLUSION

Trans women experience improvements in self-reported outcomes and changes in acoustic measures after completing a gender-affirming voice and communication modification program. Individuals may experience significant improvement in subjective outcomes despite small changes in acoustic measures and vice versa.

LEVEL OF EVIDENCE

Level 4 (case series) Laryngoscope, 2021.

Feminization Laryngoplasty: 17-Year Review on Long-Term Outcomes, Safety, and Technique

OBJECTIVES

Transfeminine patients can experience significant gender dysphoria in vocal communication. Feminization laryngoplasty (FL) is a gender-affirming surgery developed to elevate speaking vocal range, as well as alter vocal resonance and laryngeal cosmesis. The purpose here was to appraise FL's long-term voice outcomes across a 17-year review period.

STUDY DESIGN

Level III, retrospective study and description of technique.

SETTING

A single-institution transfeminine voice clinic.

METHODS

Voice data (speaking fundamental frequency [F0], lowest F0, highest F0, F0 range in both Hertz and semitones, and maximum phonation time [MPT]) were collected and assessed. Self-assessment of voice femininity and complications were documented.

RESULTS

The 162 patients, all transfeminine women, had a mean age of 40 years with 36-month mean follow-up. There were significant increases in mean speaking F0 (Δ = 50 ± 30 Hz, Δ = 6 ± 3 semitones; P < .001) and mean change in lowest F0 (Δ = 58 ± 31 Hz, Δ = 8 ± 4 semitones; P < .001). There was no significant difference in mean change in highest F0 or MPT. There was significant improvement (Δ = 60% ± 39%; P < .001) in perceptual self-assessment of vocal femininity. There was a 1.2% rate of major postoperative complications requiring inpatient admission or operative intervention. There were no differences in vocal outcomes between those patients who had less than 1-year follow-up and those who had 5-year follow-up.

CONCLUSION

FL in this cohort was a safe and effective technique for increasing mean speaking F0, mean lowest F0, and voice gender perception over a prolonged follow-up period. These findings add to the possible treatments aimed at addressing the morbid dysphoria related to voice and communication for our transfeminine patients.

The impact of living with transfeminine vocal gender dysphoria: Health utility outcomes assessment

Background: The voice signals a tremendous amount of gender cues. Transfeminine individuals report debilitating quality-of-life deficits as a result of their vocal gender dysphoria.Aims: We aimed to quantify the potential impact of this dysphoria experienced with quality-adjusted life years (QALYs), as well as associated treatments, through validated health utility measures. Methods: Peri-operative phonometric audio recordings of a consented transfeminine patient volunteer with a history of vocal gender dysphoria aided in the description of two transfeminine health states, pre- and post-vocal feminization gender dysphoria; monocular and binocular blindness were health state controls. Survey responses from general population adults rate these four health states via visual analogue scale (VAS), standard gamble (SG), and time tradeoff (TTO). Results: Survey respondents totaled 206 with a mean age of 35.8 years. Through VAS measures, these general adult respondents on average perceived a year of life with transfeminine vocal gender dysphoria as approximately three-quarters of a life-year of perfect health. Respondents also on average would have risked a 15%-20% chance of death on SG analysis and would have sacrificed 10 years of their remaining life on TTO measures to cure the condition. The QALY scores for the post-gender affirming treatments for vocal gender dysphoria (+0.09 VAS, p < 0.01) were significantly higher compared to the pretreatment state. There were no differences in the severity of these QALY scores by survey respondent's political affiliation or gender identity. Conclusions: To our knowledge, this study is the first to quantify how the general population perceives the health burden of vocal gender dysphoria experienced by transfeminine patients. Feminization treatments including voice therapy with feminization laryngoplasty appear to significantly increase health utility scores.

Associations Between Voice and Gestural Characteristics of Transgender Women and Self-Rated Femininity, Satisfaction, and Quality of Life

Purpose Client-based subjective ratings of treatment and outcomes are becoming increasingly important as speech-language pathologists embrace client-centered care practices. Of particular interest is the value in understanding how these ratings are related to aspects of gender-affirming voice and communication training programs for transgender and gender-diverse individuals. The purpose of this observational study was to explore relationships between acoustic and gestural communication variables and communicator-rated subjective measures of femininity, communication satisfaction, and quality of life (QoL) among transfeminine communicators. Method Twelve acoustic and gestural variables were measured from high-fidelity audio and motion capture recordings of transgender women (n = 20) retelling the story of a short cartoon. The participants also completed a set of subjective ratings using a series of Likert-type rating scales, a generic QoL questionnaire, and a population-specific voice-related QoL questionnaire. Correlational analyses were used to identify relationships between the communication measures and subjective ratings. Results A significant negative relationship was identified between the use of palm-up hand gestures and self-rated satisfaction with overall communication. The acoustic variable of average semitone range was positively correlated with overall QoL. No acoustic measures were significantly correlated with voice-related QoL, and unlike previous studies, speaking fundamental frequency was not associated with any of the subjective ratings. Conclusions The results from this study suggest that voice characteristics may have limited association with communicator-rated subjective measures of communication satisfaction or QoL for this population. Results also provide preliminary evidence for the importance of nonverbal communication targets in gender-affirming voice and communication training programs.

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

OBJECTIVE

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

METHODS

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%.

RESULTS

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).

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-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.

Translation, Cross-Cultural Adaptation, and Preliminary Validation of the Transsexual Voice Questionnaire for Male-to-Female Transsexuals (I-TVQMtF) Into Italian

OBJECTIVE

To perform a cross-cultural adaptation into Italian and to analyse reliability and validity of the Transsexual Voice Questionnaire for male-to-female transsexuals (I-TVQ^MtF).

STUDY DESIGN

Cross-sectional nonrandomized survey study.

METHODS

For item-generation, a cross-cultural adaptation and translation process was performed following standard guidelines. Transgender women were consecutively recruited and asked to fill out the I-TVQ^MtF and a form on social, demographic and transition-related variables. Firstly, data collected from participants were used to perform confirmatory factor analysis, and to evaluate internal consistency and test-retest reliability Subsequently, convergent validity was evaluated comparing I-TVQ^MtF total scores with the two extra items addressing self-perception (SPVF) and aspiration (AVF) of voice femininity. To evaluate convergent validity, scores of the Italian version of the Voice Handicap Index were considered for comparisons. A correlation analysis was performed to verify potential association between I-TVQ^MtF scores and social, demographic and transition-related variables.

RESULTS

Confirmatory factor analysis demonstrated that a two-factor model fits data better than the unidimensional one. Both internal consistency and test retest reliability of the I-TVQ^MtF were satisfactory. Negative correlations were highlighted between I-TVQ^MtF scores on one side and self-perception vocal functioning and aspiration vocal functioning on the other. Positive correlations between I-TVQ^MtF and Italian version of the Voice Handicap Index scores were also found. Finally, negative correlations were demonstrated between I-TVQ^MtF scores and time spent living in the female role.

CONCLUSION

The I-TVQ^MtF appears to be a reliable and valid instrument for the assessment of voice-related quality of life in transgender women.

Examining the voice of Israeli transgender women: Acoustic measures, voice femininity and voice-related quality-of-life

BACKGROUND

Transgender women may experience gender-dysphoria associated with their voice and the way it is perceived. Previous studies have shown that specific acoustic measures are associated with the perception of voice-femininity and with voice-related quality-of-life, yet results are inconsistent.

AIMS

This study aimed to examine the associations between specific voice measures of transgender women, voice-related quality-of-life, and the perception of voice-femininity by listeners and by the speakers themselves.

METHODS

Thirty Hebrew speaking transgender women were recorded. They had also rated their voice-femininity and completed the Hebrew version of the TVQ^MtF questionnaire. Recordings were analyzed to extract mean fundamental frequency (F0), formant frequencies (F1, F2, F3), and vocal-range (calculated in Hz. and in semitones). Recordings were also rated on a voice-gender 7-point scale, by 20 naïve cisgender listeners.

RESULTS

Significant correlations were found between both F0 and F1 and listeners' as well as speakers' evaluation of voice-femininity. TVQ^MtF scores were significantly correlated with F0 and with the lower and upper boundaries of the vocal-range. Voice-femininity ratings were strongly correlated with vocal-range, when calculated in Hz, but not when defined in semitones. Listeners' evaluation and speakers' self-evaluation of voice-femininity were significantly correlated. However, TVQ^MtF scores were significantly correlated only with the speakers' voice-femininity ratings, but not with those of the listeners.

CONCLUSION

Higher F0 and F1, which are perceived as more feminine, jointly improved speakers' satisfaction with their voice. Speakers' self-evaluation of voice-femininity does not mirror listeners' judgment, as it is affected by additional factors, related to self-satisfaction and personal experience. Combining listeners' and speakers' voice evaluation with acoustic analysis is valuable by providing a more holistic view on how transgender women feel about their voice and how it is perceived by listeners.

Voice and Stroboscopic Characteristics in Transgender Patients Seeking Gender-Affirming Voice Care

OBJECTIVE

Understanding transgender voice is in nascent stages. This study describes voice characteristics in treatment-seeking trans women by comparing two validated questionnaires-Voice Handicap Index-10 (VHI-10) and Transsexual Voice Questionnaire (TVQ^MtF )-and reports incidence of abnormal stroboscopy findings and acoustic characteristics.

METHODS

Retrospective review of transgender patients presenting to tertiary-care laryngology center between February 2018-February 2019. Mean VHI-10, TVQ, and Singing VHI-10 (SVHI-10) scores; audio-perceptual grade; acoustic measures; and stroboscopy findings were analyzed. VHI-10 and SVHI-10 vs TVQ^MtF were compared.

RESULTS

Sixty-one trans female patients (mean age: 32 ± 11 years) were analyzed. Mean duration since start of transition was 41.5 ± 61 months. Sixty-nine percent presented full-time female in all contexts. Pathologic stroboscopy findings were found in 5%. Mean questionnaire scores were 16 ± 10 (VHI-10), 19 ± 13 (SVHI-10), and 81 ± 22 (TVQ^MtF ). Correlation between VHI-10 and SVHI-10 versus TVQ^MtF was weak, R = 0.47 (P = .053) and R = 0.35 (P = .17), respectively. Mean audio-perceptual grade was 0.27 ± 0.15. Mean Cepstral Spectral Index of Dysphonia (CSID, sustained vowel) was 8.5 ± 21.9. Mean Cepstral Peak Prominence (CPP) Fo and CPP Fo SD in rainbow passage were 157.3 ± 16 and 59.4 ± 15.9, respectively.

CONCLUSION

Trans women report perceived voice handicap in speaking and singing, which appears separate from gender-related voice/communication concerns. This study is the first to report stroboscopy findings in transgender individuals, with 5% being abnormal. Stroboscopy is encouraged before initiating voice intervention in transgender patients. Preliminary evaluation suggests weak correlation between VHI-10 or SVHI-10 and TVQ^MtF but requires further investigation. TVQ^MtF may provide information which more specifically reflects voice concerns of trans women as compared to VHI-10 and SVHI-10.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1071-1077, 2021.

Voice-Gender Incongruence and Voice Health Information-Seeking Behaviors in the Transgender Community

Purpose Voice-gender incongruence has predominantly been investigated in the past through the perspective of feminine-identifying individuals seeking feminine-sounding voices. The purpose of this study was to determine the prevalence of self-reported voice-gender incongruence in the transgender, nonbinary, and gender-nonconforming (TNG) community and to describe health information-seeking behaviors exhibited when individuals attempt to address their voice and communication challenges. Method An online survey was designed with questions targeting the self-reported prevalence of voice-gender incongruence, characteristics of this complaint, and health information-seeking behaviors. Valid standardized measures, including the Voice Handicap Index and the Barriers to Help-Seeking Scale, were also included. Results Four hundred five participants were sorted into three groups based on gender identity (feminine, masculine, gender-neutral) to facilitate comparative analysis. Ninety-six percent of participants reported the experience of voice-gender incongruence in the past, and 88% reported that they currently experience voice-gender incongruence. There were no significant differences in reported voice-gender incongruence between groups. Voice Handicap Index scores were significantly higher for those who currently experience voice-gender incongruence (p < .0001) and reflected differences in how much this concern bothers participants, as rated on a Likert scale, ranging from no problem to a very big problem (p < .0001). Barriers to Help-Seeking Scale scores indicated that the masculine group perceived greater barriers to seeking help as compared to the feminine group. Discussion We present foundational evidence for the prevalence of voice-gender incongruence within the TNG community and barriers encountered when individuals attempt to access care. Future work should investigate the specific needs of subgroups within the TNG community and whether those who desire feminine-, masculine-, and/or androgynous-sounding voices experience voice-gender incongruence and access to services differently. Supplemental Material https://doi.org/10.23641/asha.12462422.

Investigating Validity and Reliability of the Turkish Version of Transsexual Voice Questionnaire (Male to Female)

OBJECTIVE

The problems faced by trans women with regard to their voice may affect their quality of life. For the evaluation of trans women's voice, tools assessing their self-perception are very important, with the Transsexual Voice Questionnaire (TVQ^MtF ) being one of the most frequently used. The purpose of this study was to investigate the validity and reliability of the Turkish version of the TVQ^MtF (TVQ^MtF -TR), which was previously translated into 12 languages.

STUDY DESIGN

Cross-sectional study.

METHOD

A total of 41 trans women participated in this study. The participants filled out the TVQ^MtF -TR, the self-perceptions of voice femininity questionnaire, and the World Health Organization Quality of Life Questionnaire-Short Form (WHOQOL-BREF-TR). Additionally, 58.5% of the participants filled out the TVQ^MtF -TR again two weeks after the first interview.

RESULTS

The total Cronbach's-α value of the TVQ^MtF -TR was 0.972, and the item-total correlation values were found to be between 0.323 and 0.876. The intraclass correlation coefficient value was 0.931. There was a strong negative correlation between TVQ^MtF -TR and self-perceptions of voice femininity. There was a significant negative correlation between TVQ^MtF -TR and the psychological and environmental domains of WHOQOL-BREF-TR. However, there was no significant relationship found between the social and physical domains.

CONCLUSION

According to the results of the study, the Turkish version of TVQ^MtF -TR was considered a valid and reliable tool.

Psychometric Evaluation of Adapted Transsexual Voice Questionnaire for Turkish Trans Male Individuals

AIMS

This study aims to evaluate the psychometric properties of the adapted transsexual voice questionnaire for male-to-female (a-TVQ^FtM) for trans male individuals in order to determine the suitability for use in research and clinical practice among Turkish trans male individuals.

METHODS

This study was conducted by the Gender Dysphoria Clinic and Voice Clinic of a tertiary hospital referral center. The a-TVQ^FtM, voice-related quality of life, and self-perception of voice masculinity rating scale were administered to 50 trans male individuals, of whom 27 were hormone naïve and 23 were undergoing hormone treatment. Psychometric properties were investigated with reliability and validity analysis.

RESULTS

The a-TVQ^FtM showed a strong internal consistency; the Cronbach's alpha coefficient for overall a-TVQ^FtM was 0.975, anxiety and avoidance factor was 0.948, vocal identity factor was 0.940, and vocal function factor was 0.923. No item needed to be deleted following adaptation. The a-TVQ^FtM scores showed a significant strong inverse correlation with the overall voice-related quality of life scores and the self-perception of voice masculinity rating (r = -0.863, r = -0.715, and P<0.001, respectively). The a-TVQ^FtM scores were significantly reduced in trans male individuals undergoing hormone treatment when compared with hormone naïve individuals.

CONCLUSION

Although not specifically designed for trans male individuals, the current results provide confidence as to the psychometric properties of a-TVQ^FtM and, therefore, its suitability for use with Turkish trans male individuals.

Acoustic Features of Transfeminine Voices and Perceptions of Voice Femininity

The purpose of this study was to evaluate the relationships between acoustic measures of transfeminine voices and both self- and listener ratings of voice femininity. Connected speech samples were collected from 12 transfeminine individuals (M = 36.3 years, SD = 10.6 years) and a control group of five cisgender (cis) women and five cis men (M = 35.3 years, SD = 13.3 years). The acoustic measures of fundamental frequency (f_o), f_o variation, formant frequencies, and vocal intensity were calculated from these samples. Transfeminine speakers rated their own voices on a five-point scale of voice femininity. Twenty inexperienced listeners heard an excerpt of each speech sample and rated the voices on the same five-point scale of voice femininity. Spearman's rank-order correlation coefficients were calculated to measure the relationships between the acoustic variables and ratings of voice femininity. Significant positive correlations were found between f_o and both self-ratings (r = 0.712, P = 0.009) and listener ratings of voice femininity (r = 0.513, P < 0.001). Significant positive correlations were found between intensity and both self-ratings (r = 0.584, P = 0.046) and listener ratings of voice femininity (r = 0.584, P = 0.046). No significant correlations were found between f_o variation or formant frequencies and perceptual ratings of voice femininity. A Pearson's chi-square test of independence showed that the distribution of self- and listener ratings differed significantly (χ² = 9.668, P = 0.046). Self- and listener ratings were also shown to be strongly correlated (r = 0.912, P < 0.001). This study provides further evidence to support the selection of training targets in voice feminization programs for transfeminine individuals and promotes the use of self-ratings of voice as an important outcome measure.

Endocrinology of Transgender Medicine

Gender-affirming treatment of transgender people requires a multidisciplinary approach in which endocrinologists play a crucial role. The aim of this paper is to review recent data on hormonal treatment of this population and its effect on physical, psychological, and mental health. The Endocrine Society guidelines for transgender women include estrogens in combination with androgen-lowering medications. Feminizing treatment with estrogens and antiandrogens has desired physical changes, such as enhanced breast growth, reduction of facial and body hair growth, and fat redistribution in a female pattern. Possible side effects should be discussed with patients, particularly those at risk for venous thromboembolism. The Endocrine Society guidelines for transgender men include testosterone therapy for virilization with deepening of the voice, cessation of menses, and increases of muscle mass and facial and body hair. Owing to the lack of evidence, treatment of gender nonbinary people should be individualized. Young people may receive pubertal suspension, consisting of GnRH analogs, later followed by sex steroids. Options for fertility preservation should be discussed before any hormonal intervention. Morbidity and cardiovascular risk with cross-sex hormones is unchanged among transgender men and unclear among transgender women. Sex steroid-related malignancies can occur but are rare. Mental health problems such as depression and anxiety have been found to reduce considerably following hormonal treatment. Future studies should aim to explore the long-term outcome of hormonal treatment in transgender people and provide evidence as to the effect of gender-affirming treatment in the nonbinary population.