Cross-cultural adaptation of the Voice-related Experiences of Nonbinary Individuals - VENI to Brazilian Portuguese

ABSTRACT Purpose This study aimed to translate and cross-culturally adapt the “Voice-related Experiences of Nonbinary Individuals” (VENI) to Brazilian Portuguese (BP). Methods Cross-cultural adaptation was performed based on the combined guidelines of the World Health Organization's (WHO) Translation Recommendations and the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). The process included five stages: a) Translation of the instrument into BP by a translator specialized in the construct and a non-specialist, both native BP speakers and fluent in English; b) Synthesis of the two translations by consensus; c) Back-translation by a translator specialized in the construct and a non-specialist, both native English speakers and fluent in BP; d) Analysis by a committee of five speech-language pathologists voice specialist and the creation of the final version; e) Pre-testing with 21 individuals from the target population, conducted virtually. Results During the translation stage, there were disagreements regarding the title, instructions, response key, and 15 items. In the back-translation stage, there were discrepancies in the format of 12 items and the content of four items. The expert committee's analysis led to changes in the title, instructions, one option in the response key, and eight items to meet the equivalence criteria. In the pre-test, a significantly higher proportion of usual responses to the instrument was observed when compared to the non-applicable option; this is frequently observed in instrument adaptations. Conclusion The cross-cultural adaptation of VENI into Brazilian Portuguese was successful, resulting in the “Experiências relacionadas à Voz de Pessoas Não Binárias - VENI-Br” version.


INTRODUCTION
Vocal quality reflects the acoustic properties of sound as it travels through the vocal tract and also includes neuromuscular aspects of vocal production and control, auditory monitoring, and factors such as personality traits, personal preferences, and cultural elements (1) .The voice plays a crucial role in an individual's unique identity, such as in socialization, selfperception, communicative experiences, and cultural contexts.Therefore, it is essential to understand each individual's vocal needs and preferences (1,2) .
In the transgender population, the voice is a powerful reflection of gender identity, significantly influencing social inclusion, survival and quality of life (3) .Gender identity refers to the personal sense of gender as experienced by each person.This experience is unique and reflects the individual's selfawareness of aligning with or diverging from specific gender norms.Such identity may be masculine, feminine, nonbinary, or expansive (4,5) .
Sex and gender are often confused or used as synonyms but represent distinct concepts.Sex refers to biological attributes such as chromosomes, hormones, and reproductive organs and is typically seen as binary (male or female) and unchangeable.The female sex is associated with an XX chromosomal configuration and the male with an XY.On the other hand, gender incorporates socially and culturally constructed traits and identities, with self-identification playing a central role.This broader perspective allows for categorizations beyond the traditional binary conception of sex and gender (4) .Some individuals align with the binary gender assigned at birth based on their genitalia and are called cisgender men or women in binary terminology.Conversely, individuals who do not identify with the gender assigned at birth are termed as transgender male or female.However, this binary classification is not comprehensive.Many find this classification limiting and instead identify with nonbinary gender, fluidly aligning with one, both, or neither of the binary genders.The increasing demand for speech-language pathology services, driven by the unique needs and experiences of nonbinary individuals and the broader transgender community, reflects the crucial role of voice and communication in expressing gender identity.There is a particular emphasis on gender affirmation through communication and language training (4)(5)(6) .
Special attention is given to voice, exploring adjustments such as gender-neutral vocal quality, fluctuations in fundamental frequency, changes in resonance, articulation, and elements of nonverbal communication (7) .
Nonbinary individuals have unique communicative and vocal needs, differing from those of binary individuals.This necessitates focused studies for a better understanding and more effective practices within speech-language pathology.Nonbinary individuals may seek feminine, masculine, or gender-neutral voices (6,8) .
The self-perception of vocal characteristics is subjective and comparative, involving emotional, personality, and experiential factors.Vocal self-assessment holds significant clinical value as it captures the client's voice perception, guiding for vocal interventions or training (1,2) .
To achieve a comprehensive understanding of the communicative experiences and vocal self-assessment of nonbinary individuals, specialized assessment tools are necessary (9,10) .The only validated instrument developed explicitly for this population is the Voicerelated Experiences of Nonbinary Individuals (VENI).The VENI quantitatively assesses voice-related experiences and assists in customizing gender-affirming communication services.It has 17 items designed to strategize, monitor progress, and document changes in vocal self-perception (6) .Given its developed and validation in English, there is a necessity for cross-cultural adaptation and validation to enable its use in other languages and cultures.Cross-cultural adaptation is the initial step in the instrument validation process.It ensures that the original items' content and intent correspond with the linguistic and cultural context of a different language (9)(10)(11)(12) .Adapting the VENI to Brazilian Portuguese will improve the understanding of the concerns, experiences, perceptions, and vocal goals of nonbinary individuals in Brazil who seek voice intervention.Also, it will facilitate the planning of vocal interventions, thus, improving outcomes for this population (6,8) .
Therefore, this study aims to perform the cross-cultural adaptation of the VENI to Brazilian Portuguese.

METHODS
This is a cross-sectional study.The present research was approved by the Research Ethics Committee of the "Faculdade de Ceilândia da Universidade de Brasília -UNB" (approval number 5.845.012).The research followed all ethical guidelines outlined by Resolution No. 466/2012 and other relevant legal regulations in Brazil.All participants agreed to participate and informed consent.
The Voice-related Experiences of Nonbinary Individuals (VENI), originally developed in English, has 17 items divided into three factors: seven items related to physical issues (items 1 to 7), eight items related to functional issues (items 8, 9, 10,  11, 12, 14, 15, and 16), and two items related to emotional issues (items 13 and 17).Each item provides a response key with four options: 1 = never or rarely; 2 = sometimes; 3 = often, and 4 = usually or always.Score items within their respective factors are calculated by simple summation (6) .
The cross-cultural adaptation process of the VENI to Brazilian Portuguese followed the recommendations and guidelines outlined by the World Health Organization (WHO) for translation (9) , and the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) (10) .
Following COSMIN guidelines (10) , a panel of expert judges was formed for the translation, back-translation, and expert review stages; also participants for the pre-test were selected.All stages were conducted virtually.
Two translators, one speech-language pathologist (SLP), and one non-specialist, both native speakers of Brazilian Portuguese (BP) and fluent in English, independently translated the instrument.They prioritized conceptual over literal translation, translating the title, instructions, response scale, and items.
Subsequently, the authors synthesized a consensus version from the two translations, resolving disagreements among the judges.
The Brazilian Portuguese version was then back-translated into English by two judges, an SLP, and a non-specialist, both native English speakers fluent in Brazilian Portuguese.A committee of five SLPs, including the translators, authors, and additional specialists, compared the back-translation to the original instrument and made consensus-based decisions on any necessary changes to ensure: a. Semantic equivalence: ensuring that words in the final version maintain the same meaning as in the original.
b. Conceptual equivalence: identifying and replacing words or expressions with differing conceptual meanings across cultures.
c. Idiomatic equivalence: reformulating colloquial idioms that are difficult to translate to preserve their equivalence in the target language.
d. Experiential equivalence: replacing any original item with a similar item in the target culture as necessary.
e. Cultural equivalence: making orthographic or grammatical adjustments to the items.
f. Operational equivalence: modifying procedures related to the application of the instrument if required.
Every step was documented in a master table, which was updated upon the completion of each stage.
The final version of the instrument underwent a pre-test, where the cross-culturally adapted version was applied to the target population.An option for non-applicable responses (N/A) was added to the instrument's response key.Participants were instructed to select this option if they did not understand the item or if it did not apply to their culture.Items flagged with issues, particularly those with a high number of N/A responses, underwent review.
Eligibility criteria for the pre-test included self-identification as nonbinary and an age range between 18 and 65 years.Individuals self-reporting cognitive impairments affecting their comprehension of the instrument were excluded.
Sample size calculation used the statistical test for a confidence interval for one sample mean.Parameters included a type I error (α) of 5%, type II error (β) of 10%, and test power (K) of 90%.The estimated proportion of nonbinary individuals in Brazil, 1.19%, was used for the calculation (13) .Consequently, a sample size of 19 participants was required, determined using Statistica software version 11.0.Therefore, 21 nonbinary individuals, with an average age of 30.71 years (SD: 8.66) were selected for the pre-test.
Participants were recruited virtually via social and digital media channels, where an information flyer with a link to the research was distributed.When clicking, participants were directed to the Google Forms platform.Those meeting eligibility criteria and agreeing to the informed consent form would then have access to the data collection instruments, which included a participant identification questionnaire and the VENI.
Pre-test data were analyzed using SPSS software version 25.0.The Chi-Square Test was used.Additionally, the Binomial Test was utilized to compare the proportion of non-applicable responses with the proportion of habitual responses on the instrument response key (1, 2, 3, or 4) for each item.
For the synthesis of the translated versions, the response key and four items (4, 9, 13, and 15) remained unchanged even after undergoing at least one translation.Modifications were made in the title, instructions, and the remaining 13 items.The pronoun "eu" ("I" in English) was added to items where the sentence structure in the first-person required a personal pronoun.Item 9 underwent redefinition by consensus.
The expert committee adjusted the title and response instructions, substituting the noun "indivíduo" with "pessoa."The only modified response key was number 4. Nine items were preserved according to the synthesis version, while eight items (3, 4, 6, 7, 9, 10, 12, 16) were adjusted to meet the equivalence criteria.After incorporating the committee's changes and adjustments, the cross-culturally adapted version of the VENI was established (see Appendix A).All data recorded throughout these stages are presented in Chart 1.The proportion of participants who marked items 5, 8, 9, 10, 11, 12, 13, 14, 15, and 16 as non-applicable was significantly lower than those who selected one of the instrument's four standard response options.No participant chose the non-applicable option for items 1, 2, 3, 4, 6, 7, and 17.Table 1 shows the comparison of the proportion of responses.

DISCUSSION
Nonbinary individuals increasingly seek to voice and communication training to align their voices with their gender identity.Therefore, it is essential to develop specific SLP interventions for this population.Engaging in gender affirmation can enhance self-confidence, resilience, social relationships, and professional connections (5) , thus, gender affirming training can improve these individuals' quality of life.However, nonbinary individuals presents unique voice and communication needs (6) .Therefore, the intervention must be tailored-made and specific assessment instruments need to be reliable to better understand these individuals' perceptions of their communicative and vocal experiences, improving SLP services (1,2) .Hence, the VENI crosscultural adaptation to Brazilian Portuguese (BP) is imperative.
The disagreements observed during the translation, backtranslation and expert committee review regarding the form and content of items, response key, instructions, and title underscore the importance of following structured steps in the cross-cultural adaptation of an instrument.These outcomes emphasize that literal translation, which might overlook cultural nuances, is not advisable (14) .
Semantic equivalence necessitated adjustments to ensure that items 9, 12, and 16 in BP maintained the same meaning as the original version.For cultural equivalence, grammatical modifications were made to items 3, 4, 6, 7, 9, and 16 to reflect Brazilian culture (15) .Achieving conceptual equivalence involved replacing the term "indivíduos não binários" with "pessoas não binárias."In Brazilian Portuguese, "indivíduo" (similar to individual) is a masculine singular noun, often emphasizing a person's singularity and uniqueness.On the other hand, "pessoa" (similar to person) is a gender-variable noun that emphasizes group belonging (12) .No adjustments were necessary to achieve idiomatic, experiential, and operational equivalences.
During the pre-test phase, the significantly higher proportion of standard response key selection indicated that all items were understood and pertinent to the vocal experiences of nonbinary individuals.Only three items (9, 10, and 11) showed non-applicable responses above 10%, but they remained statistically significant (16) .
These items underwent consensus-driven adjustments at almost every stage once the initial translation did not fully align with the original English version.Items 9 ("Eu acho que não me identificam como uma pessoa não binária por causa da minha voz") and 11 ("Eu acho que as pessoas reagem negativamente a minha voz") explore the nonbinary person's perception of others' opinions and reactions towards them.Item 10 ("Eu falo menos do que eu gostaria com pessoas próximas por causa da minha voz") reflects a subjective experience, dependent on the person's communicative profile and not solely on their gender.These three items reference subjective experiences that are not necessarily shared or observed by all nonbinary individuals, which probably led to the non-applicable option selection.However, the Brazilian culture-adapted version captures the instrument's core content.
Consequently, all items were considered understandable and related to the nonbinary population.No further adjustments were required following the application of the cross-culturally adapted version to this target population.The cross-cultural adaptation conducted in this study was successful, rendering the VENI applicable and understandable in BP.This adaptation marks the commencement of refining instruments targeted at clinical and research services that focus on the voice and communication of nonbinary individuals in Brazil.The instrument should undergo validation to confirm its structure, validity, and reliability in BP.

CONCLUSION
The VENI was successfully adapted to Brazilian Portuguese, resulting in the Brazilian version known as "Experiências relacionadas à Voz de Pessoas Não Binárias -VENI-Br."The responses collected during the pre-test phase confirm the success of the cross-cultural adaptation process for the VENI.
O processo de adaptação transcultural do VENI para o português brasileiro foi embasado na combinação das recomendações e diretrizes da World Health Organization (WHO) Guidelines on Translation (9) com o COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) (10) .
Os participantes foram recrutados de maneira virtual, nas redes sociais e digitais, por meio da veiculação de um folder com um link de acesso para a pesquisa, ao clicar no link os participantes eram encaminhados para a plataforma Google Forms.Aqueles que atenderam aos critérios de elegibilidade e concordaram com o TCLE tiveram acesso aos instrumentos de coleta de dados, que se referiram a um questionário sobre dados de identificação dos participantes e ao VENI.

Table 1 .
Analysis of the comparison of the proportion of non-applicable responses and VENI response scale for each item of the instrument by non-binary persons Binomial TestCaption: n = absolute frequency; % = relative frequency; NA = not applicable