Voice dysphoria sucks.

But it turns out that science agrees with us and it's not just a bad feeling. Voice dysphoria can have a measurable, quantifiable impact on your quality of life and ability to use your voice, particularly in work settings.

As a gender-affirming voice teacher who's spent years working with trans women, trans men, and nonbinary people navigating transgender voice training, I'm here to break down groundbreaking new research that proves what we've always known: vocal gender dysphoria creates real, significant functional impairment.

This isn't about pathologizing trans people—we get more than enough of that already. This is about understanding how we build the evidence base that protects access to care, because right now, gender-affirming voice treatments like voice therapy, voice lessons, and surgical interventions are under threat.

Table of Contents

• Why This Research Matters Right Now
• The Research and What It Measures
• The Findings: Voice Dysphoria vs. Neurological Voice Disorders
• What "Functional Impairment" Actually Means
• Why This Matters for Insurance Coverage
• Navigating the Tension Around Pathologization
• What This Means for Trans People
• Key Takeaways
• Resources for Voice Dysphoria

Why This Research Matters Right Now

Every study like this is a brick in the fortress we're building to protect access to care.

Insurance companies have historically classified gender-affirming voice treatments (including voice therapy, trans voice lessons, and surgical interventions) as cosmetic, which means they don't have to cover them.

In this current political climate, we're seeing aggressive moves to strip coverage for all gender-affirming care. So every piece of evidence that demonstrates medical necessity is armour against those attacks.

I got to speak with Jae Bernado, one of the co-authors of this study. Jae (they/them and she/her pronouns) is a speech pathologist at the University of Washington specializing in gender-affirming voice care. And yes, they're also one of us 😉

Here's what motivated this research:

"Our primary motivation for this research was to help grow and improve the body of evidence for gender-affirming voice care. Our hope is that this may help improve insurance coverage and access to this type of care, including both surgical intervention as well as more behavioural voice training."

The Research and What It Measures

The study we're discussing today is called "Impaired Voice-Related Work Productivity, a Functional Effect of Gender Dysphoria," published in The Laryngoscope in 2025.

This research uses something called Workhoarse (yes, that's a pun on workhorse), which is a validated measurement tool that specifically assesses voice-related productivity impairment at work.

The scale runs from 0 (no impairment at all) to 32 (maximum impairment).

Why Focus on Work Productivity?

Workhoarse was originally developed because researchers found that standard workplace productivity measures weren't capturing the specific ways that voice disorders affect people's ability to do their jobs.

It was validated using people with traditionally recognized voice disorders like:

• Spasmodic dysphonia – a neurological condition that causes involuntary spasms of the vocal folds
• Vocal fold lesions – things like nodules or polyps
• Vocal tremor

These are conditions that insurance companies already recognize as medical problems that deserve treatment.

Now, you might be wondering why this research focused specifically on work productivity when there are so many other ways voice dysphoria impacts trans people's lives. Here's what Jae told me:

"Work productivity was the first study published from this data that we gathered using these surveys. The research team chose to focus on work productivity first because we felt like this could be the most high impact. For better or worse, labour and money are often some of the things that are most motivating for the financial stakeholders in healthcare, such as insurance companies."

But here's some good news: this isn't the only data they're collecting.

"In addition to work productivity, we also asked questions about other topics such as mental health and other aspects of quality of life. Our hope is that we can use some of the other data we also gathered at the same time to publish additional studies related to other topics as well. So stay tuned for that."

The Findings: Voice Dysphoria vs. Neurological Voice Disorders

Here's what the 2025 study found.

Researchers at the University of Washington and San Francisco Voice and Swallowing recruited 50 cisgender people and 50 transgender people, all actively employed, none with pre-existing vocal pathology like nodules or paralysis.

The transgender group included:

• 64% trans women
• 10% trans men
• 26% nonbinary or other gender non-conforming folks

The Results Were Striking

The average Workhoarse score for the cisgender group was 2.1.

The average for the transgender group was 14.2.

That's a difference of over 12 points and that is massive.

When they broke it down further:

• Trans women averaged 16.1
• Trans men averaged 19.8
• Nonbinary individuals averaged 7.5

Putting These Numbers Into Context

To understand just how significant these findings are, consider that previous research using Workhoarse found:

• People with spasmodic dysphonia (that neurological voice disorder I mentioned) had an average score of 16
• People with various types of dysphonia from a mix of causes (neurological conditions, functional conditions, benign vocal fold lesions) averaged 17.8

The work impairment from voice dysphoria is comparable to recognized neurological disorders. So the work impairment experienced by trans women and trans men due to vocal gender dysphoria is statistically comparable to the work impairment experienced by people with recognized neurological and structural voice disorders.

Even when researchers accounted for age and how much people needed to use their voice at work, the trans subjects had Workhoarse scores 12.4 units higher than the cis subjects.

Importantly, this wasn't about having a more voice-intensive job. This was about voice dysphoria creating functional impairment.

The Voice Handicap Index

The study also measured something called VHI-10 (Voice Handicap Index), which assesses overall voice-related disability and quality of life.

The trans group averaged 16.2, compared to 2.7 for the cis group.

Trans women specifically averaged 17.8, which is consistent with other studies that have found VHI-10 scores for trans women ranging from 15.8 to 19.8.

What "Functional Impairment" Actually Means

Now, here's where it gets interesting from a medical classification standpoint. I'm going to quote directly from the paper because this is important:

"Notably, it may be argued that reduced quality of life alone does not meet the definition of functional impairment. On the other hand, reduced ability to communicate, particularly with relation to employment as measured by Workhoarse, is more clearly reflective of functional impairment."

So what does functional impairment actually mean?

I asked Jae about this, especially given how uncomfortable it can be to use medical terminology around trans experiences:

"The literal definition of functional impairment would be, in my mind, something that disrupts someone's ability to complete activities of daily living. The term 'functional' suggests that it may not be something structural, such as due to a disease process or anatomic difference, but maybe more cognitive or emotionally based."

Here's how Jae thinks about it as a therapist:

"As a therapist, I feel like my lens is typically very life participation focused. I'm often really thinking about communication participation—are my patients able to participate in communication for social activities, work, relationships, etc.? I see my role as to help patients participate in communication without barriers in order to improve their quality of life."

Why We Have to Play Capitalism's Game

Look, I know how deeply uncomfortable it is to centre work productivity as the measure of whether something deserves treatment. It feels gross, right? Like our only value as humans is our economic output under capitalism.

But unfortunately, that's the game we have to play with insurance companies. They don't care that you can't sing in the shower anymore. They care that you can't answer phones at work.

Welcome to our current hell world, where your worth is measured in productivity metrics 🫠

But in the paper, Jae and the other researchers actually make a broader point here:

"Employment is, of course, important for functioning in society, and inadequate employment is linked with worsened health outcomes and higher mortality rates."

So while, yes, we're playing capitalism's game, employment genuinely does affect survival. Access to healthcare, housing stability, financial security—these things are literally life or death, especially for trans people who already face systemic barriers.

Additional Context: The 2023 Study

There's also a 2023 study in the International Journal of Transgender Health that provides useful context. That study used different measurement tools and found that people perceived transfeminine vocal gender dysphoria as having an impact comparable to monocular blindness.

It's another data point showing this is measurable, significant functional impairment. It's another data point showing that this is not a minor concern. This is not cosmetic. This is a measurable, significant functional impairment.

Why This Matters for Insurance Coverage

Okay, so we have this data showing measurable impairment. Now let's talk about why that matters for getting insurance companies to cover gender-affirming voice care.

Cosmetic vs. Reconstructive/Medically Necessary

Insurance companies generally classify treatments as either:

• Cosmetic: procedures you choose to undergo to improve your appearance, but that don't affect your health or function
• Reconstructive/Medically Necessary: procedures that address actual impairment or disease

For something to be considered reconstructive and medically necessary, it generally needs to meet criteria like:

• It causes deviation from the normal function of a tissue or organ
• It results in difficulties performing basic life functions
• Treatment is likely to improve physiological function

Historically, gender-affirming voice care has been classified as cosmetic. The argument insurance companies have made is there's no anatomic pathology. The argument insurance companies have made is: there's no anatomic pathology, no neurological dysfunction, the vocal folds look normal on examination. Therefore, this is about wanting to sound different, not about treating a medical condition.

This Study Changes the Game

The study directly addresses this in the introduction, noting that "treatment for vocal gender dysphoria has historically been considered cosmetic, due in part to the lack of anatomic or neurologic vocal pathology."

But it argues that treatment of other anatomically typical conditions is considered reconstructive when there is an associated functional impairment.

This study challenges the cosmetic categorization by proving functional impairment. This study challenges the cosmetic categorization by proving functional impairment. It's showing that vocal gender dysphoria does interfere with basic life functions, specifically the ability to work and be productive in employment.

The Septoplasty Comparison

The study gives a useful comparison: septoplasty.

A deviated septum is often just a variation of normal anatomy—not a disease, not an injury. But when a deviated septum causes nasal obstruction that interferes with breathing, septoplasty is covered as reconstructive and medically necessary.

The same anatomic variation without the functional impairment might be considered cosmetic.

The study is establishing that vocal gender dysphoria with functional impairment should be viewed the same way. The study is establishing that vocal gender dysphoria with functional impairment should be viewed the same way. The baseline anatomy might be typical, but the functional impairment is real and measurable and comparable to recognized medical conditions.

The conclusion states this explicitly:

"This study identifies a functional impairment associated with vocal gender dysphoria, which fulfills one of multiple criteria used to define medically necessary and reconstructive interventions."

One of multiple criteria. This isn't the only argument that needs to be made, but it's an important piece.

Navigating the Tension Around Pathologization

I know this whole conversation about pathologization versus medical necessity can feel really uncomfortable.

We're trying to move away from pathologizing trans people. We're trying to move away from pathologizing trans people. We don't want to be listed in the DSM as a mental health disorder. We don't want our existence medicalized.

But we also need insurance coverage and access to care.

So how do we balance these things?

I asked Jae about this tension:

"I think we always have to kind of walk this tricky balance. We know that gender dysphoria or just gender voice misalignment or incongruence is not a pathology. It's not a disorder. We want to work to depathologize those things. And as a medical professional, I work in a system that really does kind of pathologize those things, unfortunately. So I think there are things that I try to do personally. But sometimes we gotta play by the rules when it comes to some of these research stuff."

Sometimes we gotta play by the rules, and part of that is putting these things into frameworks that people with power already have set up. That's the reality we're working with.

We're Not Proving Trans People Are Broken

Here's what I want you to understand:

We are not trying to prove that trans people are broken or pathological. We are not trying to prove that trans people are broken or pathological. We're documenting that the combination of gender dysphoria and societal response to it creates measurable harm.

That harm is equivalent in severity to recognized medical conditions, and research shows treatment addresses that harm.

What This Means for Trans People

This matters because we're in a moment where access to all gender-affirming care is under attack.

• US state legislatures are passing laws restricting, if not outright banning care
• Insurance coverage is being challenged and rolled back
• Medical boards are being pressured to limit what providers can offer
• And that's to say nothing of things happening in other parts of the world

Every piece of evidence that demonstrates medical necessity is armour against those attacks.

This research gives patients and providers language they can use in insurance appeals. It gives policymakers data they can cite when defending coverage requirements. It gives medical societies evidence they can point to when establishing standards of care.

Here's what Jae hopes this study will accomplish:

"You and I, and probably many of your viewers know that gender-affirming care, including for voice, is not just cosmetic. Gender-affirming care is about more than just being more beautiful or more handsome or whatever, but about helping people be who they are and move through the world more safely and more securely. I think most medical professionals who work with trans people also do know this. That's been my experience. But the financial stakeholders often kind of need to be convinced. My hope is that this study helps provide some objective data that helps prove why this care is necessary for many people and should, for example, be covered by insurance."

What This Means in Real Life

Think about what a reduction in work impairment actually means in someone's life:

• Being able to take customer service calls without panic
• Feeling confident enough to present at team meetings
• Being able to apply for promotions that require public speaking or phone work
• Not having to choose between being misgendered constantly or avoiding voice-dependent tasks that could advance your career
• The difference between having to be visible or choosing to be visible

If you're wondering about treatment outcomes, this study wasn't designed to track people longitudinally through treatment, but the researchers do reference the broader literature showing that voice therapy and surgical interventions improve voice-related quality of life and patient satisfaction.

The evidence supports that these interventions work.

How to Use This Research

If you're a trans person dealing with vocal gender dysphoria, this research is a tool you can use:

• You can cite this study when you're appealing an insurance denial
• You can share it with your healthcare provider when they're writing a letter of medical necessity
• This is evidence that what you're experiencing is real and measurable and deserving of treatment

The study even notes that many major insurance companies in the U.S. already provide coverage for gender-affirming voice care, and international standards of care support voice surgery as medically necessary.

But the researchers say: "However, it may be prudent to assess gender-affirming interventions with the same criteria as other medical interventions to ensure that there is a strong body of evidence to guide or prevent potential changes to care in the future."

In other words, we need to keep building the evidence base. We can't assume protections will stay in place.

Key Takeaways About Voice Dysphoria Research

1. Voice Dysphoria Creates Measurable Work Impairment

The 2025 study proves that vocal gender dysphoria causes functional impairment comparable to recognized neurological voice disorders. Trans women and trans men experience work productivity impairment at levels similar to people with spasmodic dysphoria and other medical voice conditions.

2. This Research Protects Access to Care

Every study like this is a brick in the fortress we're building to protect access to gender-affirming voice care. In a political climate where coverage is under attack, evidence of functional impairment helps establish medical necessity.

3. More Research Is Coming

The research team is working on additional papers examining other aspects of quality of life beyond just work productivity. The evidence base is growing.

4. We're Not Pathologizing Trans People

This research documents that the combination of gender dysphoria and societal response to it creates measurable harm—not that trans people are broken. Treatment addresses that harm effectively.

5. You Can Use This Research

If you're dealing with voice dysphoria, you can cite this study in insurance appeals, share it with healthcare providers, and use it as evidence that your experience deserves treatment.

Resources for Voice Dysphoria and Gender-Affirming Voice Training

If you're looking for resources on addressing voice dysphoria, you're in the right place.

I have a ton of free resources including my freebies library, which contains free classes, books, progress trackers, and other tools for trans voice training.

Related Blog Posts

• Voice Training Isn't Just About Dysphoria: Here's Why
• Dealing with Dysphoria in Your Trans Voice Practice
• Someone You Love Is Voice Training – Here's What You Need to Know (send this to your people when you start voice training)

Video Resources

Check out my Trans Voice Science & Research playlist on YouTube for more videos exploring the evidence base for transgender voice training.

Studies Referenced

• Impaired Voice-Related Work Productivity, a Functional Effect of Gender Dysphoria (2025)
• The impact of living with transfeminine vocal gender dysphoria: Health utility outcomes assessment (2023)

Ready to Start Your Voice Journey?

Whether you're seeking MTF voice training online, looking for resources on voice masculinization training, or exploring nonbinary voice options, my self-directed online courses provide comprehensive guidance.

I also offer a free one-hour masterclass: Change The Gender of Your Voice: No Hormones or Surgeries Required. This class will give you a foundational understanding of how gender-affirming voice work actually functions.

Conclusion: Building the Fortress

The evidence is clear: voice dysphoria creates real, measurable functional impairment that's comparable in severity to recognized medical conditions.

This research matters. Use it. Share it. Cite it.

Because every brick we add to this fortress makes it harder to tear down access to care. We need to keep seeing our experiences documented and preserved, even if the framing is productivity instead of having those experiences swept under the rug.

This research is a tool you can use. It's evidence that what you're experiencing is real and measurable and deserving of treatment.

The fortress isn't the entire solution to the problems our communities are currently facing, but the fact that we're still seeing more research confirming our experiences is promising.

Your voice matters. Your experience is valid. And now, the science backs that up.