Background Research on gender differences has found that women relate to negative voice hearing experiences with more negative emotions and report more distress due to voices, which may be rooted in differences in relating to voices. This study used a robust methodology and a large sample to explore gender differences in relating to voices and voice distress. Methods Matched samples of male (n = 124) and female (n = 124) voice hearers were drawn from a survey for secondary analysis. Voice

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... ty (e.g., frequency or loudness), voice distress, and different types of dysfunctional (i.e., passive or aggressive) and functional (assertive) relating were measured. Group comparisons, mediation models, and network analyses were calculated. Results Female voice hearers reported more severe voices, more voice distress, more passive, and less assertive relating. Mediation and network analyses yielded evidence for pathways from gender to voice distress via relating and via differences in voice severity. Conclusion Gender differences in the emotional impact of voices can be partially explained by relating behavior. Psychological interventions for voice hearing could be optimized by exploring the influence of gender in the emergence of distressing voices. Nevertheless, gender differences need to be treated as one of several different possible mechanisms when working with individual patients.