Gender-Affirming Voice Training Delivered by a Novel Mobile App: Mixed Methods Study

Abstract Background Gender-affirming voice training (GAVT) has reduced gender incongruence for transgender and gender-nonconforming (TGNC) individuals, but remains limited by cost and scarcity of specialized providers. Mobile health (mHealth) is a bridge to these access gaps; yet, few high-quality, clinically informed mHealth apps exist within voice clinical sciences. Objective We previously created a free mobile app (Attuned; Weill Cornell Medicine and Ithaca College) to deliver clinically informed GAVT through structured instructional videos narrated by a speech-language pathologist and a laryngologist, practice exercises, and pitch-tracking tools, developed with a community advisory board of TGNC individuals. This mixed methods study aimed to assess the app’s usability and users’ impressions. Methods Adult TGNC individuals were recruited nationwide via word of mouth and advertising through lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) community organizations. Participants completed a baseline semistructured interview and demographics survey, used Attuned for one week, and completed a second interview regarding their impressions. Interviews were transcribed verbatim and coded inductively in MaxQDA (VERBI Software GmbH). Three authors independently generated codebooks that were reconciled via consensus, then 2 authors applied the finalized codebooks to the remaining transcripts (preconsensus agreement 95.7%; Cohen κ=0.86). Attuned was also evaluated by 2 reviewers experienced in mHealth evaluation and not involved in the app development, using the Mobile App Rating Scale (MARS), the Intercontinental Medical Statistics (IMS) Institute for Health Care Informatics Functionality Scores, the Centers for Disease Control (CDC) Modified Clear Communication Index, the Institute of Medicine (IOM) strategies for creating health-literate mHealth apps, the Patient Education Materials Assessment Tool (PEMAT), and the System Usability Scale (SUS). Readability of the didactic scripts was also assessed with 6 validated formulas. Results Eighteen TGNC individuals completed the study (median age 27.5 years, age range 19‐50 years). Ten identified as women and/or transgender women, 6 as nonbinary or gender-nonconforming, and 2 as men or transgender men. Eight themes were identified. Participants identified voice as a crucial determinant of others’ perceptions of their gender, with voice-related dysphoria common. Cost and difficulty finding providers were primary barriers to GAVT, and existing free resources were viewed as unstructured and untrustworthy. Postuse impressions were largely positive, particularly regarding the structured curriculum, pitch tracker, convenience, and free access, though lack of individualized feedback was a key limitation. Mean scores were 4.21/5 (SD 0.53) for MARS; IMS functionality, 6.5/11 (SD 0.7); CDC index, 82.5% (SD 24.7%); IOM strategies, 28.5/33 (SD 2.1); and PEMAT understandability and actionability 100%, and SUS 92.5/100 (SD 10.6), with most readability formulas at or below an eighth-grade level. Conclusions Voice is central to gender identity for TGNC individuals; yet, structured and affordable GAVT remains largely inaccessible. Attuned was positively received by this initial cohort and scored highly on usability, health literacy, and readability, though findings are limited by potential acquiescence bias and the raters’ authorship roles.