Self-perception of voice in transgender people

Purpose: to describe the transgender people’s self-perception of voice. Methods: a total of 60 people participated in this cross-sectional study. They attended a reference outpatient center for the health of lesbians, gays, bisexuals, and transgender people. The data collection consisted of self-administered questionnaires, a participant’s profile questionnaire, and a voice self-assessment questionnaire. Results: most of the interviewees were young people who had never visited a speech-language-hearing therapist with the Public Health System ( Sistema Único de Saúde) ; in general, they expressed interest in having such attention. The answers revealed an impact in the axes assessed, namely: “use of the voice in social life”, “mischaracterization of gender, due to the voice”, and “indication of dysphonia”. Voice symptom characteristic of dysphonia was also identified in some people. Conclusion: transgender people are unsatisfied with their voices, which is an element that hinders the perception of the identified gender. It also has repercussions in their social, emotional, labor, and interpersonal lives. Hence, it is important to include speech-language-hearing therapy in the transgendering process, which is desired by most of the transgender people.


INTRODUCTION
Transgender people are those whose gender identity differs from the gender attributed to them at birth. Transgender men are those who identify themselves in behaviors, names, and appearance attributed to males, and need to be socially recognized as any other man. Transgender women are those who identify themselves with characteristics attributed to females and need also to be socially recognized as any other woman 1 . Just as transgender women, the transvestites prefer to be treated and recognized as females. However, the term transvestite is socially stigmatized and oftentimes associated with prostitution 1 .
These people take on them a new name and a modified physical structure to give sense to a body that seems to be mistaken 2 . To this end, they make use of interventions, hormones, and even surgeries, to feel more in consonance with their gender identity 1 .
The field of health is relevant for the transgendering process, as it many times involves hormones, which is under the responsibility of the SUS (Brazilian public health care system), as expressed in the resolution no. 2,803, of November 19, 2013, which "Redefines and broadens the transgendering process in the Public Health System -Sistema Único de Saúde (SUS)" 3 . The hormonal interventions for transgender people make them acquire sexual characteristics according to their gender identity and reduce the secondary sexual characteristics of their biological gender. The testosterone is the main hormone used by transgender men, and estrogen, by transgender women and transvestites 4 .
The history of health policies for lesbians, gays, bisexuals, and transgender people (LGBT) has had many struggles 5 . Currently, although there is the national comprehensive health policy for lesbians, gays, bisexuals, transvestites, and transgender people (LGBT), which aims to "Promote comprehensive health to lesbians, gays, bisexuals, transvestites, and transgender people, eliminating institutional discrimination and prejudice, as well as reducing the inequalities and consolidating the SUS as a universal, comprehensive, and equitable system" 6 , there are still many problems in making effective the broadened concept of health. Therefore, this population is not given universal access to it, as their social name is disrespected, besides cases of transphobia, transvestitephobia, and pathologizing practices and diagnoses in the transgendering process 5,7 .
A reference to understand how the LGBT health public policies are working is the perception of transgender people regarding their voice 8 , as the effort to have a voice more harmonious with their gender identity is one of the most important issues in the transgendering process. And the manner others perceive this voice many times may be related to the transgender people's quality of life 8,9 . Thus, these people want a voice that fits their gender identity, considering that many times the voice is one of the aspects that most hinders recognizability.
For this population, recognizability takes place when the body characteristics make the transgender person not identified when in public 10 . When such recognizability is limited due to voice characteristics, some transgender people may feel embarrassed, and this mistake in gender perception may make them vulnerable 11 . A recent Brazilian study reinforces this idea, showing the testimony of a transvestite who reports being treated as a man on the phone, which makes her uncomfortable 12 .
Some studies on the voice of transgender people focus on its quality through fundamental frequency. However, the quality of life related to the voice does not depend exclusively on the fundamental frequency. One of the issues correlated with the quality of life is the self-perception of voice, as the listeners' perception 8,9,13 . When speaking of the quality of life related to the voice, the present-day studies focus on developing instruments to measure this object. The voice selfassessment protocols quantify the person's perception regarding their voice, focusing on perceiving the impact of dysphonia, vocal disadvantages, and quality of life, or even as an identification of symptoms of voice problems 14 . These instruments may be directed to a disease or specific population and are being widely used by researchers in recent years 14 .
Regarding transgender people, the self-perception of voice is important to understand and explore the complex relationship between voice, communication, and the sense of self 13 . Currently, there is already a voice self-assessment questionnaire specific for this population 15 , already translated to Portuguese 16 , which assesses the subject's experiences with their voice. However, it is aimed only for transgender women. On the other hand, few studies have data on the vocal disadvantages in transgender people of developing countries, where the resources for health are limited 8 .
For the analysis, the data collected were tabulated and then statistically analyzed with the chi-square independence test and Fisher's exact test for the contingency tables that presented cells counting <5. The significance level was established in the value of p<0.05. The results were presented as tables, expressed in absolute and percentual values, and their analysis was based on the frequency distribution. The statistical significance for all the answers was based on the p-value.
During the analysis, the participants who identified themselves as transvestites and transgender women were included in the same group for analysis (Transgender women). It is known that such a differentiation is important in matters of representativity, with some different aspects concerning social issues. However, regarding voice issues, both are presented similarly.

RESULTS
A total of 60 people participated in the study, as shown in Table 1. They were 29 transgender men and 31 transgender women; hence, there was no significant difference between the sample of both groups. The participants' age ranged from 18 to 61 years, most of them (55%) 21 to 29 years old. Thirty-five people, equivalent to 58% of the sample, use hormones -of these, 14 are transgender men and 21, transgender women; 37.2% of them have been using hormones for less than six months, 31.4% for over two years, 20% from six months to one year, and 11.4% from one to two years. None of the participants had been submitted to surgery to adequate their voice, such as thyroplasty, and 91.7% of the participants had never had access to speechlanguage-hearing care at the SUS. However, 91.7% are interested in receiving such treatment.
people's perception of their voice, to understand this subjective aspect of the human being. Thus, this study aimed to describe the transgender people's selfperception of voice.

METHODS
This paper was approved by the research ethics committee of the Hospital Agamenon Magalhães under number 2.968.477. All the participants were informed about the purpose of the research and signed the informed consent form.
A total of 60 transgender people participated in this descriptive cross-sectional study. They attended a reference outpatient center for the health of LGBT people in the municipality of Recife, PE, Brazil, between October 2018 and January 2019. A nonprobabilistic convenience sample was used. The inclusion criteria were: users of the LGBT outpatient center; over 18 years old; identified with gender identities -transgender man, transgender woman, or transvestite; available at the time of data collection, which consisted of self-administering a questionnaire. The exclusion criteria were: under 18 years old; foreigners who did not understand Portuguese; and unavailability to answer the research.
The first questionnaire was developed to survey the profile of the participants with questions on gender, age, use of hormones and for how long, whether they had access to a speech-language-hearing therapist at the SUS and if they would like to, and whether they had already undergone surgery to adequate their voice. The other data collection instruments were two voice selfassessment questionnaires -one for transgender men and the other for transgender women and transvestites. These instruments were developed by the authors of this study based on the transsexual voice questionnaire for male-to-female transsexuals (TVQMtF) 15 , which was later translated to Portuguese and validated 16 . However, the translated version is exclusively for transgender women and transvestites. Therefore, it cannot be used in this study, which counted also with the participation of transgender men. The questionnaires developed for this study have 20 questions in which the participants answered the statements as "always", "sometimes", or "never", according to their experiences. They were also  Table 2 shows the data regarding the answers to the questionnaires, detailed according to the axes "Use of voice in social life", which refers to the perception of the voice in the transgender people's social interaction, as well as professional issues; "Mischaracterization of gender due to the voice", which refers to how the voice can cause incompatibility with gender identity; and "Indication of dysphonia", which refers to symptoms that can characterize a voice problem.
In the first axis, "Use of voice in social life", most of the answers were "always" and "sometimes" for both genders, in all the six questions, with no statistical difference between the groups (p>0.05). The second axis, "Mischaracterization of gender due to the voice", was the one that presented the greatest impact in voice self-assessment. In this axis, most of the answers from transgender men and women were also always and sometimes (p>0.05), with lower percentages than in the other axes. However, question 20 had a greater association of the frequency of "sometimes" with Transgender Women, as the value obtained was different from that obtained in the count with the chi-square test (p<0.05). The answers of the axis "Indication of dysphonia" were similar, in which the number of "always" and "sometimes" was higher than the "never" in most of the questions of the axis (p>0.05). Nevertheless, there was a statistically significant difference in question 16, in which the answer "never" was associated with the group of Transgender Men, and "sometimes" was associated with Transgender Women (p<0.05).

DISCUSSION
In Brazil, there is not much data on the profile of the transgender population, making it more difficult to make a comparative analysis regarding the profile of those who participated in this specific study. However, researchers are already using other sources of research to characterize this population 17 . In the sample, most of the people interviewed were 21 to 29 years old, while the second largest group was of youth 18 to 20 years old. This young profile can be a reflex of the low life expectancy of the transgender population, who suffer high rates of discrimination and violence 17 . Such a life expectancy is between 30 and 35 years 18 .
It was observed that 58% of the sample uses hormones. Although the research was carried out in a reference outpatient center for this population, the service is not used only with this purpose -41.7% of the participants went to the service for other health issues or to start the hormone process. This can be a reflex of current barriers to this population's universal and comprehensive access to health services, with disrespect to their social names, transphobia, and transvestitephobia, as well as the pathologizing diagnosis in the transgendering process 7 . Hence, transgender people go to services where they feel more welcomed; for this reason, this outpatient center takes care of these people's health, either in issues related to the transgendering process or not.
Besides hormonotherapy, the surgical processes (glottoplasty and thyroplasty) are part of this process. They are made to feminize the voice and consist basically of decreasing the length and mass of the vocal folds, increasing the voice frequency 19 , resulting in a more feminine voice. This surgery could interfere with the self-perception of the participants' voices. However, none of the participants in this research had undergone voice surgery.
Another issue that might interfere with the selfperception of voice is whether the participant had been submitted to voice therapy, as the speech-languagehearing therapy helps to get a voice more fitting to their avoidance effect in the face of certain types of violence aimed at the transgender body. In this study, such a difference was not perceived, which can be justified as it was not the objective of the data analysis to compare the results according to the use or not of hormones, besides the time using it, making the group heterogeneous to the exposure to hormonotherapy. Considering these aspects, the results could be different, as the male hormones (testosterone, in this case) act on the vocal fold muscle structure, resulting in voice change 24 . Hence, these individuals can have a voice with a male fundamental frequency in approximately 12 months of treatment, depending on the person 25 . In only 10% of the cases, the results are not satisfactory in this regard, which can be justified by the decrease in hormone sensitivity 23 .
It should be highlighted that it does not exclude voice therapy for transgender men, as the voice goes beyond fundamental frequency. The rhythm, speech speed, melody, and suprasegmental aspects are equally important to distinguish male from female voices. Moreover, some of them may have symptoms indicating voice problems, as well as for the transgender women, for whom the voice therapy goes beyond changes in fundamental frequency.
The axis "Use of voice in social life" involves aspects of social life, including the issue of the impact of voice in professional life. It was noticed in this axis how the voice raises social barriers. This is noticed when the lowest number of answers was "never" -i.e., most of the participants in this study have already faced fear, shame, or discomfort associated with voice issues, which are probably a reflex of transphobia. The research entitled The Transrespect versus Transphobia Worldwide (TvT) revealed that in 2018 Brazil continued to be the country that most killed transgender people in the world. That is, these people feel constant risk, and the unconformity between their voice and gender may expose them to transphobia. Hence, they can feel uncomfortable to speak in public. When their voice is coherent with their gender identity, there is for the listener no unbalances between the expressed gender and the voice, making it more comfortable to speak with other people 11 .
Most of the transgender people feel that the voice hinders their professional life. This finding is important to reflect on the labor market for this population. Transgender women usually work informally, in prostitution, in beauty parlors, or call centers, when they really want a formal relationship 26 . The voice gender identity 20 . Most (91.7%) of those interviewed had never had access to speech-language-hearing care at the SUS, and 91.7% are interested in it. The speechlanguage-hearing therapist is the professional responsible for treating human communication disorders, one of their competencies is to act in the field of voice. In this case, this would be the professional indicated to help in this process of adapting the voice of transgender people. The resolution no. 2,803, of November 19, 2013, which redefines and broadens the transgendering process in the Sistema Único de Saúde 3 , has a list of professionals included in this process, as well as the description of their practices. Nonetheless, the speech-language-hearing therapist is not included as an integral part of this multiprofessional team. The high percentage of people in this study that would like to have such attention reinforces the importance of including this professional in the multiprofessional team of the transgendering process.
To this end, the professionals must be better trained to attend this public, as most of the speech-languagehearing therapists feel comfortable with the LGBTQ population but are not much informed about their needs and specificities 21 . Anyhow, these professionals are interested in learning how to offer services to improve the communication of transgender people 21 . Therefore, they must understand about gender identity, hormonotherapy, and the other specificities of this public 13 . When the voice does not fit the person's gender identification, they can be socially harmed. Such an obstacle can lead them to avoid communicating with other people not to be exposed 11 . Thus, such nonconformity of voice with the gender expression can constitute an access or communication barrier for a transgender person, influencing other levels of their emotional and social life, such as studies and work.
Regarding the participants' self-assessment of voice, in almost all the items of the questionnaire the less frequent answer was "never" -the more a participant gave this answer, the more they were satisfied with their voice. Thus, the transgender people's self-perception of voice has been more negative, demonstrating that these people are possibly unsatisfied with their voices. The worst these people's self-perception of voice, the greater the impact on their quality of life 22 . In this study, no significant differences were noticed between the transgender men's and the women's answers in all aspects researched.
For transgender men, hormonotherapy can cause more voice recognizability 23 , which can have an is another aspect that requires speech-languagehearing attention, as this symptom reveals a potential dysphonia and is one of the complaints in transgender people 11 .
Based on this analysis of this group's selfperception, it is understood that transgender people are unsatisfied with their voices. It was observed that using voice self-assessment questionnaires enables the relationship between these people and their voices to be represented. These instruments are easily administered and can have an important contribution to research in the field, besides being the support that can be used in clinical practice as an assessment and reassessment instrument. Tas for the limitations of this study, it is considered that the data were collected in Recife, Pernambuco, which is one of the Brazilian states with more services offering the transgendering process 5 . However, different results can be found in places where the LGBT population's health care is more deficient. Moreover, no association was made with other variables, such as analyzing whether the use of hormones and the time using them interferes with the self-assessment of these people's voices.

CONCLUSION
It is understood that transgender people are unsatisfied with their voices. The voice is an element that hinders the perception of the identified gender, with repercussions also on their social, emotional, labor, and interpersonal life. Moreover, voice symptoms characteristic of dysphonia were identified in some people. Considering these issues, it is important to include speech-language-hearing therapy in the transgendering process, from the perspective of these people's comprehensive health promotion, furnishing the quality of life, as this is an aspect of health care desired by most transgender people.
issues can be a hindering aspect for them to have the desired employment relationship. For this and likely for other reasons, they often have precarious working conditions to live on. The transgender men are less prone to practice prostitution to make a living. Hence, they usually seek formal employment, which is often affected by the barriers (including the voice) imposed by the transphobic society.
The answers in the second axis, "Mischaracterization of gender due to the voice", had a negative impact. This confirms that the voice interferes with the recognizability of transgender people and that there is a self-perception that the voice is not adequate to their gender identity and, most of the time, to their physical appearance either. This self-perception is not different from that of the other people around them. For instance, transgender women, who perceive their voice as different from their gender identity, are the ones whose voice is identified as male by those who hear them 8,9 . Hence, there is a correlation between self-assessment of voice and the listeners' perception.
Thus, it is relevant to consider that most of these people want a voice adequate to their gender identity -i.e., transgender women would like to have a more feminine voice, and the transgender men, a more male voice. It was noticed that transgender people are not completely satisfied with their voices, although this dissatisfaction level can vary within the group. Therefore, voice treatment is necessary for the comprehensive care of transgender people, which was noticed when the vast majority of the interviewees were also interested in having speech-language-hearing therapy. Such therapy interests even some of those who did not feel so much the negative impacts in their social life, for example.
The speech-language-hearing therapy, then, is important, even indispensable, especially given the results in "Indications of dysphonia". There are various types of dysphonia; they occur when the voice does not have adequate harmony and comfort 27 . When there is an indication of a symptom that might characterize some organic problem in the vocal tract, it needs to be investigated and, if necessary, treated by a speechlanguage-hearing therapist. The voice becomes deeper or shriller when not paying attention probably because these people use a nonspontaneous voice, which in the long run can cause dysphonia. The pain and discomfort when speaking for long, apparently more present among transgender women, is also a symptom that requires assessment and intervention. Hoarseness