Transgender-Affirming Spiritual Care

Introduction and Historical Context

The field of transgender spiritual care is quite new, but it is growing rapidly in a variety of ways. Transgender studies in religion more broadly has emerged primarily from grassroots contexts in lived religion rather than from more academic sources. Related topics are slowly making their way into scholarly conversation. This migration has tended to happen first in the form of personal narrative (biographical or autobiographical) or theo-ethical reflection (especially biblical studies and proposed ethical responses), which function largely as education about transgender people generally. Meanwhile, many well-meaning spiritual care providers are increasingly seeking transgender-specific resources on how to provide responsible spiritual care as this population becomes increasingly visible and assertive about their needs.

It is worth noting that most of the peer-reviewed resources included in this essay were published in the period 2016 to 2019. While some earlier and later resources will be noted also, the variety of materials included in this survey is made possible by the marked increase in attention to transgender concerns in academic publishing around religion in recent years—mirroring increases in visibility more broadly in the culture. I describe 1996 to 2006 as the “transgender spring” when transgender religious concerns came out of the shadows in LGBT networks and progressive Christian publishing (Paige 2019b). However, the publication of Christianity Today’s “The Transgender Moment” (Kennedy 2008) was the first serious mainstream religious (Christian) treatment. Media coverage around Time magazine’s “Transgender Tipping Point” with Laverne Cox on the cover (Steinmetz 2014) followed by Caitlyn Jenner’s transition announcement the following year (Bissinger 2015) dramatically changed the nature of mainstream conversations around transgender populations in the United States (and perhaps beyond), while the Nashville Statement (Council on Biblical Manhood and Womanhood 2017) began to consolidate a better organized transgender-antagonistic Christian response. Thus, the increased attention in the academy in recent years is a part of a larger (but still quite new) trend toward transgender visibility among non-transgender populations, even though we know that transgender people have existed for much longer.

There is currently a limited (but growing) number of pragmatic resources focused specifically on transgender-affirming spiritual care. Most of the resources examined here are journal articles or book chapters from well-known publishers. To my knowledge, there are no relevant book length treatments that I would recommend. However, there are adjacent resources in lesbian, gay, bisexual, and transgender (LGBT+) pastoral and spiritual care which may be variously useful to those who are inexperienced working around sexual and gender diversity. Many caregivers may need support in disambiguating between issues of sexual orientation and issues of gender identity, making a specific emphasis on transgender experience key. However, LGBT+ resources tend to be uneven, at best, in their inclusion of and expertise about transgender experience. It is also a much larger and more established field, which makes it complicated to simply “add in” transgender concerns as an afterthought. Indeed, it is worth noting that many transgender people do not identify as gay, lesbian, or queer. They may identify as heterosexual, meaning they date the “opposite” sex—a reality which may be obscured by the LGBT+ acronym.

For the purposes of this essay, I am dividing the existing transgender-specific literature into four sections: (a) foundations for spiritual care, (b) spiritual care across the lifespan, (c) health care chaplaincy, and (d) religiosity, spirituality, and resilience-building. Resources include perspectives on pastoral care, health care chaplaincy, counseling, and spiritual direction, as well as lifespan considerations for children, adolescents, and elders. My emphasis is on transgender-affirming spiritual care, and, therefore, prominent transgender-antagonistic voices in spiritual care are not included. A separate essay could be developed to highlight resources reviewing or debunking themes around reparative therapy, complementarian gender ideologies, and other repentance-oriented approaches which fail to incorporate adequately science, evidence-based standards of care, and transgender lived experience.

Foundations for Spiritual Care

Sarah Gibb Millspaugh’s chapter “Pastoral Care with Transgender People” (Millspaugh 2009) in Injustice and the Care of Souls: Taking Oppression Seriously in Pastoral Care, edited by Sheryl A. Kujawa-Holbrook and Karen B. Montagno, is one of the first publications to explicitly provide a foundation for transgender pastoral care that goes beyond theo-ethical responses and basic education about transgender identities. Millspaugh (under the name Sarah Gibb) shared similar reflections as a part of the Unitarian Universalist Association’s publication, Crossing Paths: Where Transgender and Religion Meet (Greve 2003). As with many ground-breaking publications around transgender concerns, some of the language in this chapter is becoming dated. This is a particular concern in introductory sections which offer definitions. For instance, the inclusion of “transvestite” language and absence of “nonbinary” language makes the article seem mildly outdated, even though it was appropriate at the time of publication. Ten years is a long time in the life of the transgender community. Nonetheless, the pastoral concepts and examples offered provide a solid foundation for pastoral care, particularly in a congregational context. Millspaugh leans into Margaret Kornfield’s metaphor of the pastoral care provider as a gardener who should tend to both the community/soil and the individual/plant. Millspaugh positions the pastoral care provider explicitly in support of resistance to oppression and reclamation of spiritual resources. Anecdotes ground this advice in real world oppressive circumstances faced by transgender populations.

While Walter O. Bockting and Charles Cesaretti’s “Spirituality, Transgender Identity, and Coming Out” (Bockting and Cesaretti 2001) in the Journal of Sex Education and Therapy is similarly dated in terms of terminology and shifts in the field over the last 20 years, it nonetheless remains a remarkably good resource for thinking about how spiritual themes can impact gender transition. The authors invoke spirituality as individual meaning-making at a critical time when transgender communities were still quite isolated around issues of religion/spirituality. Drawing on T. Byram Karasu’s ideas about “spiritual psychotherapy” and “six tenets of transcendence,” Bockting and Cesaretti (2001) provide two vignettes and use them to illustrate how Karasu’s framework may prove useful in support of transgender care recipients. The authors embrace the integration of spirituality and mental health as a response to the very real spiritual distress they have found among transgender care recipients. Their approach (following Karasu’s framework) suggests working with the care recipient around experiences of transcendence (love of others, love of work, love of belonging and belief in the sacred, belief in unity, and belief in transformation) as a way to do “psychotherapy in the context of love and belief beyond oneself.”

Reid Vanderburgh’s book, Transition and Beyond: Observations on Gender Identity (Vanderburgh 2007) is neither peer-reviewed nor published by a traditional academic publisher, but it is another key resource in the field. Vanderburgh is a member of the World Professional Association for Transgender Health (WPATH) who draws on his own personal experience as a transgender man as well as his experience as a licensed marriage and family therapist working with transgender care recipients. WPATH is the organization that maintains the standards of care for transgender populations generally, and so affiliations with and endorsements by representatives of WPATH are a good signal that the author is invested in best practices around transgender care. Now, in its third edition (Vanderburgh 2018) and endorsed by prominent transgender leaders, this resource provides a broad introduction to themes of gender transition with a “When Worlds Collide: Religion and Transition” chapter focused specifically on working with care recipients around conservative/fundamentalist religion. Because there has been such limited attention given to spiritual care with transgender populations in the academy, Vanderburgh’s book is a reminder that finding the most up-to-date experience and expertise may involve looking beyond academic databases into more community-based networks of care, since religious and academic publishers may be hesitant to navigate the controversies around promoting transgender spiritual care.

Vanderburgh acknowledges that religion may not be a stumbling block for every care recipient, but that ideas about “sin,” “reparative therapy,” and other religious beliefs may get in the way for some. Vanderburgh offers six guidelines for helping fundamentalist care recipients, from recognizing how important religious/spiritual beliefs may be for some care recipients to helping care recipients cope with the anger that arises as they come to terms with the impact judgmental beliefs have had on them. Vanderburgh (2018, 274) expands this list from six to seven guidelines in the third edition. He also adds an additional section about reconciling with religious families. Vanderburgh’s observation from his years of work with care recipients is that those who come from “fundamentalist” religious backgrounds strongly benefit from “reinvent[ing] their spirituality in a manner that affords them a healthy, positive, self-perception.” These care recipients’ needs are not met simply by rejecting religion entirely or by ignoring the conflicts with their past beliefs.

“Living in the Image of God: Transgender People in Pastoral and Spiritual Care” by Laura Thor, MSW, D.Min, (2013) offers reflections on spiritual direction and pastoral care with transgender people. This article appeared in Presence: An International Journal of Spiritual Companionship (which is a publication from Spiritual Directors International), on Thor’s blog, and in the newsletter of Dignity USA (Thor 2015) which represents LGBT+ Roman Catholics in the U.S. Thor is another member of WPATH, but her reflection is unique in terms of advancing spiritual direction as a medium-term to long-term intervention for transgender populations beyond typical medical, psychological, and congregational contexts. Because of that context, Thor provides particularly deep insight into the spiritual dynamics of her case studies and their experience over time. In addition to sharing introductory details about scriptural and scientific resources, Thor highlights some of the challenges for transgender adults in community and demonstrates how spiritual accompaniment can foster individual resilience in the face of such challenges. As the title suggests, Thor explores Genesis and the paradigm of creation as a key resource for understanding the unfolding of transgender identity. Thor draws from Jewish commentary and Shabbat practices in a way that should also be useful to Christian care recipients.

Certainly, much more could be said about theo-ethical and biblical resources for transgender-affirming spiritual care as these have been prominent and continuing issues of grassroots concern since the “transgender spring.” Books such as Transgender: Theology, Ministry, and Communities of Faith by Justin Sabia-Tanis (Sabia-Tanis 2018), Transforming: The Bible and the Lives of Transgender Christians by Austen Hartke (Hartke 2018), and my book OtherWise Christian: A Guidebook for Transgender Liberation (Paige 2019a) may be of particular interest in terms of resourcing transgender-affirming Christian theo-ethical and biblical approaches. In addition, Understanding Transgender Identities: Four Views, edited by James K. Beilby and Paul Rhodes Eddy (Beilby and Eddy 2019) may be a useful resource for sorting through the nuances of a wide range of Christian approaches to transgender experience (not all supportive) and potential responses that integrate both science and theology.

Balancing on the Mechitza: Transgender in Jewish Community (Dzmura 2014) is an important and influential anthology in transgender-affirming Judaism. Joy Ladin’s Soul of the Stranger: Reading God and Torah from a Transgender Perspective (Ladin 2018) provides an important and accessible reconsideration of Jewish sacred text, while Max Strassfeld’s Trans Talmud: Androgynes and Eunuchs in Rabbinic Literature (Strassfeld 2022) offers a more academically-oriented approach. For those wanting to dig deeper into transgender-affirming resources around Judaism, the members of the TransTorah collective (n.d.) are all names to watch.

As previously noted, there is a great deal of material available in the form of personal narrative and theo-ethical reflection, increasingly with representation from a variety of spiritual traditions. However, this essay is more focused on more pragmatic resources specifically designed to support spiritual care providers in providing culturally competent, transgender-affirming spiritual care rather than assessing that wider body of work.

Spiritual Care across the Lifespan

Craig Rubano’s work is remarkable in providing foundations for the care of gender creative children (and their families). Rubano’s article “Where Do the Mermaids Stand? Toward a ‘Gender-Creative’ Pastoral Sensibility” (Rubano 2016) in Pastoral Psychology preceded his Ph.D. dissertation treatment of related themes (Rubano 2019). Rubano’s journal article highlights the increasingly visible population of gender creative children, noting that even adult frameworks about “transgender” may not fit well with the fluid self-conceptions of children. Not all gender creative children will identify as transgender as adults. Yet, the framing around creativity or imagination is not intended to dismiss these tender identities as delusional. The point is to make flexible space for fluid and diverse gender expressions beyond those imposed by the adult world. Rubano draws on the work of Diane Ehrensaft and Donald W. Winnicott to provide a more psychological framework, noting that gender is both an individual accomplishment and a social exchange. Rubano goes on to discuss the Canaanite woman (and her child) as a pastoral metaphor, recognizing that it is not just the gender of the child in question but an entire family system working to embrace unpredictable outcomes. Through this pastoral metaphor, Rubano articulates the determination required by parents as they navigate the many layers of social challenge around their child’s gender identity.

In a two-part series in the Journal of Pastoral Care & Counseling, Arthur Canales introduces issues in ministry with transgender teenagers (Canales 2018a; Canales 2018b). The first article focuses on awareness and understanding of the challenges faced by transgender teenagers whom Canales identifies as “maligned, marginalized, and misunderstood.” Canales draws on the psychological work of Julia Kristeva and Robert Phillips around abjection as a framework for understanding the precarity of transgender teenagers. He then goes on to explore victimization, stigmatization, rejection, and isolation leading to suicide risk. The second article focuses on strategies for pastoral care, support, and advocacy. Like Millspaugh, Canales focuses on the need to develop transgender-affirming support in the larger congregational or ministry context and goes on to highlight work with both the community and the family, alongside work with the teenager individually. Canales also points to strategies such as adult role models, mentoring, and social advocacy as playing important roles.

At the other end of the lifespan, Cathy L. Campbell and Lauren Catlett provide a creative and unorthodox approach to looking at hospice and end of life care for transgender elders in the Journal of Hospice and Palliative Nursing (Campbell and Catlett 2019). Their case study draws on a book written by a “transgender-identified” hospice patient and published with support from a hospice volunteer (one of the researchers). Supplemental sources such as familial review, blog posts by the patient, and the obituary were also consulted. The case study seeks to expand research on “transgender-identified” patients at end of life, the role of spiritual care generalists (e.g., nurses and volunteers), and the use of narrative, art, and poetry in end-of-life care. The researchers note the importance of the human element of “coming alongside” as demonstrated by the hospice volunteer but also acknowledge that skillfulness is necessary around listening, gender affirmation, and creating safe space for reflection. The case study notes that transgender-specific trauma and potential needs for reconciliation with family may be important themes to be aware of with transgender patients approaching the end of life. Additionally, the case study provides some preliminary insight into transgender religiosity and improvisation since the patient was Episcopalian but was also influenced by Zen Buddhism through the teachings of Thich Nhat Hahn.

Health Care Chaplaincy

While access to affirming, affordable, competent health care is still a broad challenge for transgender communities, a growing number of gender centers at major metropolitan hospitals mean that work is starting to be done around protocols for transgender-affirming health care chaplaincy. The 2015 U.S. Transgender Survey (USTS) is an important resource for understanding transgender health disparities in general as well as why trauma-informed care is essential in health care specifically (James et al. 2016). The USTS is the largest national survey of transgender people in the U.S. and highlights a variety of health concerns and impacts, including mistreatment, violence, psychological distress, economic and housing instability, as well as violence and mistreatment perpetrated in health care settings specifically. The survey also highlights the importance of family and faith communities among transgender survey respondents. The full report, an executive summary, and break out reports (e.g., by race) are freely available at the USTS website (https://www.ustranssurvey.org/).

“Spiritual Care of Transgender Persons” (Hirschmann et al. 2019) is an invited chapter written by chaplains from three different urban hospitals for Springer’s Transgender Medicine: A Multidisciplinary Approach resource book. It reviews briefly the existing research surrounding spiritual care needs of transgender populations across the lifespan. In addition to recommending religious/spiritual assessment with transgender patients generally, the chapter argues that transgender religious/spiritual lives are complex, with religiosity/spirituality serving “in both harmful and supportive ways.” Further research is recommended and attention is given to relevant religious/spiritual assessment tools. In the absence of a spiritual care specialist (such as a chaplain), these tools can be used by generalists to discern appropriately supportive interventions (e.g., referrals or resource sharing). Four case studies are offered by way of example, categorized as adult, geriatric, and pediatric (though in this case, the pediatric examples are 18-year-old and 20-year-old patients). The case studies are used to illustrate several spiritual assessment tools (i.e., FICA, Rush protocol, Exline religious/spiritual struggle scale).

The journal article “Healthcare Chaplaincy and Spiritual Care for Trans People: Envisaging the Future” (Cornwall 2019) by Susannah Cornwall in Health and Social Care Chaplaincy similarly advocates for the importance of spiritual care for transgender populations in her context in and around the British health care system, especially in the context of National Health Service gender clinics. Through research that draws on small sample patient surveys as well as research group conversations with relevant stakeholders, Cornwall provides an outline of needs and priorities, risks and challenges in transgender spiritual care. Cornwall sees spiritual care services as an important opportunity to mitigate gaps in the health care system for transgender people and recommends better resourcing for chaplains specifically around transgender needs. While centered within a British context, Cornwall’s effort points to issues of cultural competence and trauma-informed care around the mental health risks faced by transgender people broadly, particularly during gender transition. Cornwall suggests that spiritual care providers become “multilingual” drawing on medical, cultural/social, critical theory, and personal narrative. Cornwall also points to other scholars who frame “health” as “membership” or overcoming disconnection, which is a welcome shift from framing transgender journeys as pathology or disease as is typical in the medical model.

“Screening for Spiritual Struggle in an Adolescent Transgender Clinic: Feasibility and Acceptability” (Grossoehme et al. 2016) in the Journal of Health Care Chaplaincy is a collaboration of doctors and chaplains at the Cincinnati Children’s Hospital Medical Center. Recognizing that spiritual struggles are associated with poorer health outcomes (including depression), the research group set out to determine if it would be feasible to screen outpatient transgender care recipients for spiritual struggle in order to enable appropriate intervention from the chaplaincy department. The study began with anecdotal evidence of spiritual struggle particularly among transgender youth and their parents but focused on the logistical question of how to integrate spiritual screening within existing procedures at the outpatient gender clinic. This intervention assessed variations on the Rush Protocol which can be administered in writing on-site in the clinic by non-clinicians. Phone follow-up by chaplains was not evaluated in this study, though reportedly there were challenges around gaining the trust of guardians who were hesitant to provide access to the minors in their care. The study found that one-third of adolescent transgender patients screened with moderate to severe spiritual struggle (compared to a rate of 7% struggle in the general population) and that the screening intervention was effective without causing harm. This study suggests that it may be feasible to foster closer collaboration between gender clinics and (culturally competent) chaplaincy departments in order to improve the health outcomes of transgender adolescents.

Jo Hirschmann is the lead author on “An Analysis of Chaplains’ Narrative Chart Notes Describing Spiritual Care Visits with Gender Affirmation Surgical Patients” in Transgender Health (Hirschmann et al. 2022). The Mount Sinai Center for Transgender Medicine and Surgery was established in 2016 and engaged the spiritual care department for collaboration from its inception. This article involves review of the charts of chaplain residents who served as a part of the multidisciplinary care team together with doctors and other health professionals. The review of chart data concluded that transgender patients welcomed spiritual care and recommends that chaplains be included as an integral part of multidisciplinary teams caring for transgender surgical patients broadly.

Jo Hirschmann’s work at Mount Sinai Hospital in New York is also worth following for additional resources. Hirschmann, with Max Reynolds, presented a “Best Practices in the Spiritual Care of Transgender and Gender Non-Conforming Patients” webinar (Chaplaincy Innovation Lab 2020), which serves as an example of work being done outside of academic publishing to improve transgender cultural competence among spiritual care providers. A “Spiritual Care for Transgender Patients” panel presentation (The Center for Spirituality and Health at Mount Sinai 2017) also features Hirschmann as the lead presenter and is available as a recorded Facebook video. The Transgender Spiritual Care Initiative (TSCI) affiliated with Sojourn Chaplaincy similarly offers trainings based on their experience in Zuckerberg San Francisco General Hospital and Trauma Center which may be useful for those seeking to resource Clinical Pastoral Education or other chaplain cohorts (Transgender Spiritual Care Initiative, n.d.). TSCI trainings are led by openly transgender chaplains which adds additional depth to the experience. Recorded webinars led by TSCI at the 2021 conference of the Association of Professional Chaplains (APC) are available through the APC website.

Religiosity, Spirituality, and Resilience-Building

“‘Just Getting out of Bed Is a Revolutionary Act’: The Resilience of Transgender People of Color Who Have Survived Traumatic Life Events” (Singh and McKleroy 2011) in Traumatology, a peer-reviewed journal associated with the American Psychological Association, is one of the few resources for transgender spiritual care that actually mentions race. Even though this study does not enter into the topic of resilience from a starting point around religious/spiritual identification, the results highlight “cultivating spirituality and hope for the future” as one of six key resilience themes. The authors (Singh and McKleroy 2011, 40) distinguish between religion and spirituality stating that, “Participants particularly shared that their sense of spiritual resilience was more salient than their religious coping.” The authors recommend that mental health practitioners explore spiritual beliefs with survivors of trauma, specifically as a potential location for making meaning out of their experiences. The article builds on semi-structured interviews with eleven transgender people of color and touches on issues related to racial-ethnic identity as well as gender. Other resilience themes included pride in personal identity, recognizing oppression, navigating family of origin, accessing health care and economic resources, and connecting with the activist transgender people of color community. Singh has several publications which may be useful generally, including A Clinician’s Guide to Gender-Affirming Care: Working with Transgender and Gender Nonconforming Clients (Chang et al. 2018) and The Queer and Transgender Resilience Workbook: Skills for Navigating Sexual Orientation and Gender Expression (Singh 2018), though none of her work focuses specifically on topics of religion and spirituality.

“Understanding Spirituality and Religiosity in the Transgender Community: Implications for Aging” (Kidd and Witten 2008) in Journal of Religion, Spirituality & Aging is widely cited in more recent work about transgender and gender nonconforming spirituality and religion. It combines data about transgender religiosity from two studies—one with trans-masculine participants and one with trans-feminine participants. The article questions whether standard measures of religiosity/spirituality/faith are effective with minoritized populations who have experienced stigmatization—specifically transgender populations. The study results argue for this deficiency in large part due to the prevalence of affiliation with minority traditions (i.e., non-Abrahamic). Even transgender participants who identified with Abrahamic traditions “possessed religious beliefs that defied categorization, even by the respondents themselves” (Kidd and Witten 2008, 47). While alternate methods of measurement have emerged, this study raises an important question about the impact of identity development, stigma, and resilience on transgender religiosity. Witten is the founder and director of the Transgender Longitudinal Aging Research Study and has published numerous articles around transgender aging which are worth reviewing.

Witten also contributed to “Spirituality, Faith, and Religion: The TGNC Experience” with Ruben Hopwood (Hopwood and Witten 2017). This chapter in Singh’s Affirmative Counseling and Psychological Practice with Transgender and Gender Nonconforming Clients, published by the American Psychological Association, identifies religion/spirituality as both a potentially positive and potentially negative coping mechanism. They emphasize dominant (i.e., Abrahamic) traditions as particularly invested in binary ideas about gender as well as challenges to transgender well-being. Their characterization of non-dominant (i.e., non-Abrahamic) traditions as more supportive is fairly superficial, though it is a good starting point for considering the role of non-Abrahamic religiosities in transgender communities. The authors point generally to the importance of reclaiming and redefining spiritual pathways for transgender populations, while acknowledging that mental health providers rarely receive training around integrating religious and spiritual issues in their practice. Basic competencies are outlined, and two short case studies are provided, illustrating the importance of religiously/spiritually competent care. In one case study, a transgender care recipient needed to grapple with transphobia in her tradition of origin without dismissing the continuing importance of that tradition for her. In the other case study, the authors point to how spiritual interpretation of physical or psychological symptoms may be a positive coping mechanism even when further psychiatric evaluation of those symptoms may be merited.

In addition to reviewing themes from chaplain visits at the Mount Sinai Center for Transgender Surgery and Medicine, the forthcoming article from Hirschmann et al. compares the 2015 Pew Religious Landscapes survey of the general population with the USTS in terms of how respondents identify religiously. Compare 71% Christian in the general population survey with 21% among the transgender survey. Compare 1% Buddhist in the general population survey with 6% in the transgender survey. The Pew survey did not specify (i.e., registered at less than 1%) Pagan, but the transgender survey found 9% Pagan. Respondents for both surveys were “spiritual but not religious” at a rate of 25%, but the transgender survey had significantly higher rates of agnostic and atheist responses.

In other words, the rates of religious affiliation among the USTS transgender survey are significantly different from the U.S. population at large. The entire report from the USTS is essential reading for anyone working with transgender communities. However, the section on “Experiences with Faith Communities” and the demographics on “Religious or Spiritual Identity” are particularly important for spiritual care since this is the largest data set on transgender religiosity/spirituality available, and the previous national survey did not include questions about religion/spirituality.

As various authors have stated, more research into the shape of transgender religiosity is needed. Unfortunately, many existing publications focus on Christian religiosities which, as we have seen, are a minority segment of the transgender population in the U.S. (even though Christian sentiment remains essential in terms of engaging the perspectives of the U.S. population more generally, including families of origin). Personal narrative by transgender authors remains an important entry point for understanding the shape of transgender religiosity, spirituality, and resilience, but I recommend the chapter on “Religion and Spirituality” in Laura Erickson-Schroth’s Trans Bodies, Trans Selves: A Resource for the Transgender Community (Erickson-Schroth 2014) as a broad overview. Look for the updated and expanded second edition of Trans Bodies, Trans Selves (Erickson-Schroth 2022). OtherWise Christian 2: Stories of Resistance (Paige 2020) includes 29 contributions from transgender, intersex, nonbinary, and two spirit contributors and may similarly provide insight into diverse resilience strategies around negotiating religious and spiritual traditions. Transcending: Trans Buddhist Voices (Manders and Marston 2019) is a recent anthology by transgender Buddhists which may help to shift attention away from an oversized emphasis on Abrahamic traditions. While David Weekley’s Doctor of Ministry dissertation (Weekley 2016) was published as Retreating Forward: A Spiritual Practice with Transgender Persons (Weekley 2017) and involves proposing a transgender-specific spiritual retreat setting, his analysis of needs around such an endeavor may prove useful. Meanwhile, Melissa Wilcox’s “Innovation in Exile: Religion and Spirituality in Lesbian, Gay, Bisexual, and Transgender Communities” (Wilcox 2003) provides helpful historical context for thinking about LGBT+ religiosities as involving improvisational creativity more generally. While Wilcox writes broadly about LGBT+ religious history and further consideration of transgender-specific religious history would be useful, her analysis of LGBT+ responses to anti-LGBT+ religion remains a useful point of reference.

Conclusion

While the growing number of transgender spiritual care resources remains relatively preliminary, there are also two adjacent areas that need further attention. The broader area of LGBT+ spiritual care has been acknowledged, but resources around spiritual care for people with intersex variations are all but non-existent. In addition to intersex variations which are discovered at birth, teenagers and adults with intersex variations experience a variety of needs which may or may not overlap with those of transgender people. Many people with intersex variations do not identify with the LGBT+ community at all, while others may identify variously as queer, as transgender, or as in need of transition from their assigned gender. Nonconsensual medical interventions on young children and nondisclosed medical complexities can have significant psycho-spiritual consequences. Meeting such spiritual care needs is made more complicated by the pervasive lack of basic understanding around intersex variations in the general population. Megan DeFranza’s Sex Difference in Christian Theology: Male, Female, and Intersex in the Image of God (DeFranza 2015) is an important theo-ethical intervention in this regard, and her Intersex and Faith Project (n.d.) is developing important audio/visual resources, but this important area is too often entirely overlooked. It deserves more in-depth attention.

Spiritual care for family members of transgender (and intersex) people is also an important area that can directly impact the resilience of transgender (and intersex) populations. However, the needs of family members are often different than those of their transgender (and intersex) loved ones. In addition to supporting successful transition experiences, family members may have outsized roles in other stages of the lifespan, such as childhood, seasons of illness (physical or mental), dementia, palliative care, and death. As transgender populations are increasingly targeted by waves of political assault in the U.S. and elsewhere, from bathroom bills to the prohibition of transgender-affirming care for minors, family members are increasingly under cultural pressure (often with theo-ethical overtones) and serve as important entangled resources that also deserve support and spiritual care.

In this essay, I have not considered the broader range of resources designed to support mental health care and counseling with transgender populations generally. However, familiarity with the transgender continuum of care, the role of mental health providers, and more general counseling strategies with transgender people and their families is certainly a recommended area to explore for further cultural competence, particularly for pastoral and congregational care providers who may be engaged in long-term relationship with transgender populations. It is also worth developing familiarity with unique issues of transgender precarity to be better able to support transgender care recipients. For instance, transgender populations are at risk for everything from suicide to sexual violence, poverty and homelessness to employment discrimination and involvement in survival economies. Health and other disparities for transgender people of color are not well addressed in the spiritual care literature even though these impacts are widely known, and experiences of structural violence and trauma may shape many spiritual care encounters. Similarly, issues of transgender disclosure and confidentiality are central but not well represented. Still, another related area of interest is around the development and offering of liturgical and ritual support, such as naming ceremonies, prayers for transition, and other similar forms of spiritual embodiment around transgender life stages.

Transgender experience remains controversial in many religious communities, including in theological education. Meanwhile, religion/spirituality may be an uncomfortable topic for many care providers due to lack of training and/or histories of religious trauma (especially those who are LGBT+ themselves). Transgender spiritual care lands in that awkward intersection, but researchers are increasingly articulating strategies and frameworks to support spiritual care providers in becoming appropriate and competent resources in the transgender continuum of care. While this review is not exhaustive, it does provide a comprehensive introduction to an emergent field of scholarly conversation. In addition to further elaborations on existing themes, there is a need for further case studies and special considerations in areas such as military chaplaincy, prison chaplaincy, university chaplaincy, and other institutional contexts where spiritual care is provided. Indeed, there are many gaps that need further attention and elaboration, but the suggested resources provide a strong foundation and a representative sample of the patchwork state of the scholarly conversation around transgender-affirming spiritual care at this time.

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