An Evaluation of the Prevalence and Efficacy of Gender Affirmative Vocal Therapy in Poland

Abstract

The voice is one of the most important factors influencing gender and cultural identity. Voice problems and disabilities are common in the transgender community. This preliminary research investigates the prevalence of voice problems in transgender people who have completed or are in the process of completing gender reassignment in Poland. The aim was to describe the scope of challenges faced by the transgender community and to assess whether gender affirmative vocal therapy improves outcomes during gender transition. A questionnaire was distributed through secure social media forums to gather anonymized data. The questionnaire explored demographic details, self-perception, societal perception, and voice quality perception. Out of 200 responses, 21 confirmed participating in gender affirmative vocal therapy. Ten elements of voice quality perception were significantly improved in the gender affirmative vocal therapy group compared to controls (p < 0.033). The study showed a significant impact of societal and self-perception on voice quality perception. It is crucial for health and well-being that people who undergo gender reassignment have access to gender affirmative vocal therapy.

Introduction

The structure and function of the larynx are affected by sex hormones (Misiołek et al., 2016). While the barbaric practice of castration has little in common with the modern process of gender reassignment, the historical practice lends insight into the complexities of vocal identity and gender transition. Castrati (male singers with feminine voices) have been created by the process of prepubescent male castration (removal of the testes) since the Middle Ages (Misiołek et al., 2016). Historically, castration after the onset of puberty does not produce the desired vocal feminization (Abitol & Abitol, 2014).

While achieving a gender affirmative voice is an important component of gender transition, the use of hormonal therapy after the onset of puberty—a legal requirement in most countries—cannot produce the desired vocal results in isolation (Abitol & Abitol, 2014). The literature demonstrates that transgender people, transwomen in particular (up to 96%), suffer from voice-related disabilities after hormonal therapy (Moog & Timmons Sund, 2023; Nobili et al., 2018) and that fundamental tone, the functional result of vocal feminization, may not adequately correlate with improved quality of life (Hao et al., 2024). As such, gender affirmative vocal therapy is considered a necessity for achieving satisfactory gender expression and well-being for all transitioning people (Misiołek et al., 2016; Moog & Timmons Sund, 2023; Novais Valente Junior & Mesquita de Medeiros, 2022; van Leerdam et al., 2023).

Gender affirmative vocal therapy is a process which involves working with a voice disorders specialist or speech therapist (Kalra, 1977; Nolan et al., 2019) to develop the vocal behaviors which differentiate male voices from female voices (Kalra, 1977; Nolan et al., 2019). This training can behaviorally alter the pitch, loudness, resonance (Van Borsel & Baeck, 2014), stability and function of the larynx, vocal endurance, and voice quality (Azul et al., 2017).

Voice is one of the most important aspects influencing our gender and cultural identity. It is essential for maintaining optimal well-being and functioning in a modern society (Misiołek et al., 2024). Vocal dysphoria (when the voice does not align with individual gender identity) presents significant challenges to emotional, social and vocational function and well-being (Misiołek et al., 2024). According to the World Health Organization (2024), “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Gender affirmative vocal therapy is required to prevent and treat vocal dysphoria and ensure that transgender people can function freely in all aspects of health.

Processes related to gender transition are becoming increasingly advanced and available worldwide; however, the availability of services is undeniably impacted by politics, culture and social stigma. In Poland, the lack of legislation regarding gender self-determination (Marciniak et al., 2022) and the illegality of medical gender reassignment (Dębińska, 2013; Pańczyk, 2023) limits access to specialized health care in this population. Delivery of gender reassignment therapy in Poland requires careful navigation of many complexities of Polish law. In this context, the inability to access care that would improve psychosocial well-being and functioning is extremely problematic (Bartnik et al., 2020). Without institutional support, transgender people may struggle to seek support, explore their options or navigate the complexities of the transition process. Nongovernmental organizations and specialists in private practice have stepped in to provide this care, but this is not sufficient to meet the growing needs of this population.

To identify, provide and advocate for the healthcare needs of the transgender population in Poland, it is necessary to conduct research. Our literature review highlighted the limited research conducted in Poland in comparison to the international community. Of note, transgender terminology in Poland has not caught up with international standards. A search of terms “Poland,” “Transgender,” and “Transsexual” in PubMed yielded 43 results, 17 of which were relevant to the transgender population in Poland and available for review. The limited research may relate to cultural or political restrictions and reflects the marginalization of the transgender community in Poland (Antoszewski et al., 2012). This preliminary research aims to evaluate the voice-related needs, availability and impact of gender affirmative vocal therapy for transgender people in Poland.

Method

Participants

The study was conducted anonymously using an online questionnaire that was distributed through closed, invite-only groups for transgender people on social media. The inclusion criteria were: identifying as a transgender person that has either begun or completed the process of gender transition.

Measures

The Polish language questionnaire (Appendix) was created for this study, integrating relevant questions from the Psychological Gender Affirmation (PGA) scale (Sevelius et al., 2021), the Trans Woman Voice Questionnaire (Dacakis et al., 2013), the Satisfaction with Male-to-Female Gender Reassignment Surgery scale (Hess et al., 2014), and guidelines provided by the Gender Identity Clinic of London (2022). It includes four categories of questions: demographics (5 questions), self-perception (7 questions), societal perception (6 questions) and voice quality perception (20 questions).

Procedure

Participants completed an online registration and consent form before proceeding to the questionnaire within the Google Forms application. Participants expressed their degree of agreement with each statement using a Linkert scale from 0 to 10, where 0 represents strong disagreement and 10 represents strong agreement. In addition, a free text question (question 5 in voice quality perception) collated qualitative data, which was beyond the scope of this article. The data collection investigator screened all responses to ensure eligibility.

Statistical Analysis

A Shapiro–Wilk test was conducted, and histograms were generated to assess normalcy in the data and guide the statistical analysis. Statistical differences between the group demographics were calculated using an independent t-test for age (p = 0.48), Fisher’s exact for education (p = 0.75) and location (p = 0.81) and Mann–Whitney U test for stage of transition (p = 0.06) which did not display a normal distribution.

The data were separated into two groups: Group 1 included participants who had access to gender affirmative vocal therapy and group 0 (control) included participants who did not. Mann–Whitney U test was performed to compare the two groups using the JASP statistical software. The results of all the questions were examined for correlation by Pearson’s test. A point of significance was assumed to be p-value ≤ 0.05.

Results

There were 200 responses to the questionnaire of which  21 (10.5%) had access to gender affirmative vocal therapy and 179 did not, thus forming the control group. Due to the significant disparity between the groups, power analysis was conducted to confirm the applicability of the tests. Assuming |δ| = 1, α = 0.05 and with N₁/N₂ = 0.117, the power reached value of 0.991 which is sufficient for performing the test. The analysis of the power curve showed that the statistical tests would be viable (1 – β ≥ 0.8) if the difference between the groups exceeds 0.65.

Across both control and vocal therapy groups 63.5% considered themselves to be in the process, 30% were at the very beginning of the process, and 6.5% had completed their gender transition. Most participants in both groups considered themselves to be in the process of transition. There were more participants in the control group who identified as being at the beginning of their transition process. There was no significant difference demonstrated between the groups (p = 0.06).

The mean age of participants was 21.4 years. The majority of participants (45%) lived in bigger cities (above 400,000 population), the rest living in smaller conglomerations. In terms of education, 60.5% completed secondary education, 21.5% completed primary education, 9% completed undergraduate qualifications, and 9% completed higher tertiary qualifications. There were no significant differences between the groups for age (p = 0.2), location (p = 0.81), and education (p = 0.75).

The mean score across all participants was 5.48 for self-perception, 5.63 for societal perception and 4.86 for voice quality perception. Participants that underwent gender affirmative vocal therapy (Group 1) scored significantly higher than participants that did not (Group 0) in 59.4% of responses (p ≤ 0.05) (Table 1). Significant improvements (p ≤ 0.05) were seen in 57% of the self-perception responses, 83% of the societal perception responses and 53% of the voice quality perception responses in the gender affirmative vocal therapy group (Group 1).

Table 1.

Results of comparison of Group 0 (control) and Group 1 (treatment) via U Mann–Whitney test

Results of U Mann–Whitney test	Mean Group 0	Mean Group 1	SD Group 0	SD Group 1	W	p
Self-Perception Questions
1. I consider my outside appearance satisfying	4.55	5.19	2.48	2.75	1609.5	0.139
2. I perceive myself as my preferred gender	7.58	8.67	2.57	2.01	1437.0	0.036
3. My life since transition has become easier and happier	6.32	8.05	2.75	2.50	1164.5	0.002
4. My expectations regarding life as my preferred gender has been met	5.09	6.10	2.88	2.83	1496.5	0.063
5. I am satisfied with my level of masculinity/femininity	4.61	6.14	2.91	2.80	1298.5	0.010
6. I feel harmony between the inside and the outside	4.15	5.81	3.01	3.57	1412.0	0.030
7. I feel comfortable being around people who knew me before my transition	5.54	5.33	2.76	2.73	1615.5	0.617
Societal Perception Questions
1. I feel socially accepted as a member of my preferred gender	4.73	5.95	2.90	2.71	1386.0	0.024
2. I am comfortable in public spaces	4.80	6.76	2.94	2.91	1192.0	0.003
3. I am comfortable being around people who know I am a transgender person	6.38	5.95	2.72	2.67	2068.5	0.777
4. I am comfortable with how my family perceives me	4.13	6.14	3.11	3.17	1235.0	0.005
5. I am comfortable with how my co-workers perceive me	8.01	9.00	2.41	2.00	1318.5	0.010
6. I am comfortable with how I am perceived by complete strangers	4.90	6.81	2.92	2.96	1199.0	0.003
Voice Quality Perception Questions
1. Others have a problem hearing and understanding me in a loud environment	5.96	5.00	2.74	2.83	2251.5	0.932
2. I feel good about the strength of my voice	4.36	5.76	2.66	3.00	1339.5	0.015
3. I feel comfortable using my voice in public	4.57	6.52	2.90	3.37	1251.0	0.006
4. I have a problem with talking through my phone	6.45	5.42	2.89	2.98	2256.0	0.935
6. I am comfortable talking to strangers	4.17	6.71	2.66	2.47	912.0	< 0.001
7. I do NOT feel discomfort talking with my friends and family	6.57	8.05	2.72	2.27	1251.0	0.006
8. I believe my voice matches well with my preferred gender	3.83	6.38	3.38	3.54	1131.5	0.001
9. My voice is perceived by others as matching my preferred gender	3.91	6.24	3.28	3.56	1177.0	0.002
10. I am completely satisfied with my current voice tone	3.28	5.14	2.85	3.40	1278.5	0.007
11. My voice helps me live my life as a preferred gender	3.84	5.86	3.40	4.10	1398.5	0.023
12. Using my voice does NOT require focus or effort	5.12	6.00	3.32	3.66	1623.0	0.151
13. I do NOT have voice problems such as breaking, hoarseness or sore throat	5.32	5.38	3.22	3.44	1864.5	0.477
14. I have access to wide range of vocal movement	4.98	4.71	3.05	3.04	1974.5	0.649
15. My voice feels natural	5.37	5.71	2.80	3.20	1738.5	0.287
16. My voice feels stable, reliable and consistent	4.64	5.86	2.85	3.04	1421.0	0.033
17. I feel good about the sound of my laughter	4.66	5.71	3.11	3.70	1557.5	0.098
18. I feel good about the sound of my singing	3.50	4.33	2.76	3.28	1617.0	0.140
19. My voice does NOT affect my social or work life in any negative way	5.53	5.90	3.22	3.36	1749.0	0.301
20. I perceive my voice as truly MINE	4.18	6.00	3.15	4.06	1422.0	0.032

Discussion

Self-Perception

This preliminary research aims to evaluate the voice-related needs, availability and impact of gender affirmative vocal therapy for transgender people in Poland and promote the importance of systematized healthcare and support for the transgender population. A person’s voice is uniquely tied to their identity, and through that it has the power to strongly affect their well-being and quality of life (Misiołek et al., 2024). Participants who underwent gender affirmative vocal therapy scored significantly higher in self-perception than the control group (p ≤ 0.05). They perceived themselves as their chosen gender, expressed satisfaction with their level of masculinity/femininity and higher rates of harmony between their internal and external state. Statement 3: “My life since transition has become easier and happier” encapsulates the whole purpose of gender transition. The treated group scored 1.73 points higher (p = 0.002) than the control, suggesting that participation in gender affirmative vocal therapy improves self-perception and well-being (Bartnik et al., 2020; Herman-Jeglińska et al., 2002). That alone should make its provision a priority. Statement 3 could be affected by any number of confounding variables however, age, education, place of living and stage of transition were not significant factors. Pearson’s correlation test showed significant (p < 0.05) correlations of moderate strength (0.26 < r < 0.46) between the results for this statement and statements 2, 3, 6–11, 15–17, 19 and 20 of the Voice Quality Perception Questions. These correlations suggest that voice quality and thus gender affirmative vocal therapy indeed have a positive impact in this study.

The absence of significant differences between the treatment and control groups in this study suggests that self-perception of outward appearance, achievement of their expectations for successful transition and level of social comfort during and following gender transition are not impacted by vocal quality alone. It may be that the questions are too general in their scope to evaluate the benefits of gender affirmative vocal therapy. People in transition may not expect to struggle with a voice disability (Misiołek et al., 2024; Nobili et al., 2018) or expect their mental health to deteriorate due to stigma and harassment (van Leerdam et al., 2023). These findings are important in the evaluation of the questionnaire and to support clinicians to set appropriate expectations for the benefits of vocal therapy during gender transition.

Societal Perception

The apotheosis of gender transition is not to be accepted as a trans-male or trans-female person, but to drop the trans-prefix entirely and to be successfully perceived as a member of your chosen gender. For many transgender people, the perception of an outsider is more important than their own self-perception (Novais Valente Jr. & Mesquita de Medeiros, 2022). The treated group scored significantly higher in all questions pertaining to being perceived by others including friends and family, acquaintances and complete strangers. There were also significant findings relating to being comfortable in public spaces and feeling socially accepted. This supports the established conclusion that gender affirmative vocal therapy should be considered an essential element of the transition process to achieve satisfying gender expression (Misiołek et al., 2024; Nobili et al., 2018; van Leerdam et al., 2023).

Two questions referred to being comfortable around people who either learned about the participant being a transgender person or knew them before the transition. This aspect touches the widely understood stigma around transgender status in Poland (Antoszewski et al., 2012). It is perhaps not surprising that these aspects remain unaffected by gender affirmative vocal therapy.

Perceived Voice Quality

Non-gender specific aspects of voice quality: vocal strength (p = 0.015), stability and consistency (p = 0.033) and comfort of use in a public setting (p = 0.003), were significantly improved in the treated group when compared to controls. This is important as restrictions in vocal control, power and endurance are commonly found in transgender people (Azul et al., 2017), and our findings suggest that gender affirmative vocal therapy may improve these aspects, although further research is warranted.

Gender specific aspects of voice quality are perhaps of greatest interest and significance in this study. The treated group scored significantly higher than the control group in relation to being comfortable talking to strangers (mean difference 2.54 (p < 0.001)), perceiving one’s voice as matching with their gender (2.55 (p = 0.001)) and confidence that others perceive it that way as well (2.33, (p = 0.002). Other questions that reached statistical significance touched upon perceiving one’s voice as truly their own and helpful in living life as a member of one’s gender group, comfort in talking to friends and family and general satisfaction with vocal tone. These factors are very important elements affecting quality of life. Other studies report an overall decrease in vocal quality of life and vocal function post transition (Misiołek et al., 2024; Nobili et al., 2018). These data suggest that gender affirmative voice therapy can lead to satisfying masculinization/ feminization of the voice and increase ease and comfort of vocal use during and after gender transition.

Question 12 “using my voice does not require focus or effort” suggests that ease of vocal use is not impacted by gender affirmative vocal therapy. This finding is supported in the existing literature. Vocal fold length and fundamental frequency are determined during adolescence and are not influenced by hormonal therapy alone, particularly in male-to-female transition (Hembree et al., 2017; Safer & Tangpricha, 2019). Gender affirmative vocal therapy is a complex process of acquiring behaviors that will achieve feminine or masculine intonation, resonance, articulation, prosody and communication patterns (Misiołek et al., 2024). This creates a substantial cognitive and physical load to transgender voice production, which contributes to the focus and effort reported. The provision of gender affirmative vocal therapy is central to achieving vocal behavior modification. It is important that clinicians prepare transgender people and manage their expectations about ease of vocal use. In Poland, female-to-male gender transition is more prevalent than male-to-female gender transition when compared to Western Europe and the USA (Herman-Jeglińska et al., 2002). Future research should separate the data for transgender males and females to further assess this element of voice quality perception.

Comfort with one’s own laughter and singing were not significantly improved by gender affirmative vocal therapy. These are important parts of vocal self-acceptance, since both are spontaneous forms of vocal expression that may be difficult to control. These are traits that likely cause some level of social anxiety in much of the population, regardless of gender identity. It is unclear to what extent they can—or should—be altered by vocal therapy.

The Wider Context

The imbalance of treatment and control groups in this study suggests that access to gender affirmative vocal therapy in Poland is very limited. The situation of the transgender community in Poland is undeniably difficult and requires a delicate and unique approach. Until very recently—being transgender was widely considered a sexual deviation (Antoszewski et al., 2012). Gender self-determination has no legal process, requiring people to complete gender transition before correcting “faulty” documents to denounce their assigned gender at birth (Marciniak et al., 2022). To achieve this, the individual may have to sue their parents, spouse or children. Married individuals may be forced to divorce, since same sex marriages are not recognized by Polish law (Bartnik et al., 2020). These necessary legal actions, regardless of the support of the transgender person’s family, add to the negative perception of transgender people in wider Polish society.

The provision of gender reassignment surgery is considered to “infringe on the reproductive rights” of the person in question and is currently illegal in Poland (Dębińska, 2013; Pańczyk, 2023). The surgical procedures are available in a very few private medical institutions, at significant cost, and only when justified as a medical intervention for an approved existing condition. In this political context, it is challenging for the practitioner to address their educational needs (Grabski et al., 2021) and access the resources and guidelines needed to provide the highest quality of care. In this social context, it is difficult for the practitioner to identify with the community, understand their concerns and have the knowledge and resources to address their unique health needs (Jain-Poster et al., 2024). When confronted with so many aspects that make it harder for people to undertake gender transition, issues related to voice dysphoria and its possible affirmation fade into the background, causing one of the main factors of gender identity to remain unresolved.

The results of this preliminary study demonstrate how much work is still needed to ensure that transgender people can fully enjoy social life and freely identify with their gender. The findings highlight that most transgender people in Poland do not have access to gender affirmative vocal therapy. It is unclear whether this is due to a lack of awareness of the necessity to work on their own voice or a lack of availability or accessibility of the required services.

Despite participants who received gender affirmative vocal therapy perceiving their voice as truly their own significantly more often, they did not report that their voice feels natural and effortless. This indicates that the provision of comprehensive and ongoing gender affirmative vocal therapy is essential, as supported by the existing literature (Misiołek et al., 2016; Nobili et al., 2018; Novais Valente Junior & Mesquita de Medeiros, 2022; van Leerdam et al., 2023). This topic requires more attention among people entering the gender reassignment process, and the medical specialists who care for them. It is particularly important to consider provision for young people, who are increasingly presenting to specialists with gender dysphoria or transgender spectrum disorders (Dora et al., 2021).

The findings overall demonstrate positive self-perception and experiences of societal perception by the transgender community in Poland. This indicates greater freedom in emotional expression and social function, reflecting higher levels of acceptance than the political situation would imply.

Limitations and Future Potential

This preliminary research has several limitations. Questionnaires generate subjective data, and it would be useful to combine the findings with objective measures of vocal quality.

The data were gathered in Poland in 2022–2023, while an ultraconservative party was in power and the risk of systemic persecution of transgender people was ever-present. Because of this, the anonymity, safety and comfort of the participants were considered of highest priority, at the expense of the robustness of the scientific method, risking potential selection bias that comes with voluntary participation. The authors acknowledge that that the study would very much benefit from objective measures, or at the very least from parallel evaluation of the participant by a specialist. The final purpose for the creation of this questionnaire is to be used at the beginning and at the end of the gender affirmative vocal therapy (under the supervision of the therapist) as a tool to measure clinical progress. Implementing such measures was not possible at the time due to the aforementioned risks as well as logistical difficulties and time constrictions. Online administration adds an additional layer of uncertainty regarding eligibility and comprehension of the questions, particularly as we have used validated questions but translated them into a new language. The authors hope to proceed to validation of this questionnaire. When administering research through social media, there is a risk of insincere participation to intentionally undermine the research. To mitigate these risks, participants were recruited through closed, referral-only social media groups.

In comparing the treatment and control groups, the existence of other confounding variables affecting the results cannot be excluded. Future research should identify whether participants are transmasculine or transfeminine, to explore gender specific differences in voice quality. In this version of the study, the question regarding the birth sex has not been included.

The questionnaire was created combining elements from previously validated tools. The authors hope to validate the questionnaire in English examining subjects in established transgender clinics in the UK where the transition process is more structured and socially supported and gender affirmative vocal therapy is more available. This would allow a larger sample, more balanced recruitment and the possibility to collect more detailed demographic information and potentially quantitative vocal measures. This validated version of the questionnaire would be then reverse localized for the Polish community, and the examination performed again within a less hostile political climate.

The disparity in size between the treatment and control groups could impact the reliability of the statistical analysis. One of the factors could be the current stage of transition, which—although did not reach universally accepted level of statistical significance—had a p-value of 0.06. Future research should aim to recruit gender and stage of transition matched controls. This should be possible within approved gender reassignment clinics. We hope to compare these data with the situation in more liberal countries and to repeat this study in the future to assess for improvements in transgender vocal care in Poland.

Conclusion

This study provides significant evidence that the provision of gender affirmative vocal therapy improves self-perception, societal perception and vocal function in transgender people. Vocal therapy is an essential element of health care during and after gender transition, impacting on well-being and quality of life. The current availability and uptake of gender affirmative vocal therapy in Poland are insufficient to meet the needs of a growing transgender population.

Appendix

Funding

The authors declare that this study has not received any outside funding.

Data Availability

Data gathered during the research can be made available upon request.

Declarations

Conflict of interest

There is no conflict of interest.

Ethical Approval

Since this study is based solely on an anonymous questionnaire and did not involve a direct interaction with a patient, nor any intervention in their well-being, the Bioethics Committee approval was not required. The Committee has been informed about the study being conducted, all in accordance with Medical University of Warsaw Bioethics Committee standards. All the participants have signed an on-line consent form.