Caring for the Transgender Patient: Lessons for Pastoral and Spiritual Care

Fall 2023
Senior Fellow and Consultant for Aquinas Institute of Theology, and Chaplain, Providence Alaska Children's Hospital

Gender has received a great deal of attention in the past 10 years. Hardly a day goes by that there is not a media report on the clinical, legal and ethical aspects of the transgender experience. All of these come together — or not — in the political blender where, on one hand, trans people are used as an icon of individual civil rights, or, on the other hand, as an example of moral and spiritual decline.

Despite all the publicity, the spirituality and the spiritual needs of trans persons have gotten very little attention.1,2 We believe it is important to examine their experiences more closely, not only to provide better care in our Catholic hospitals and clinics, but also because the trans experience may help the rest of us see new spiritual dynamics in our own lives.3

The trans experience is important to all of us because it is rooted in a fundamental question about human life. Sr. Luisa Derouen, OP, a Dominican sister and spiritual director who has accompanied hundreds of trans people for nearly 25 years, says the first step in our path to understanding is to ask, "Who am I?" Each of us grows into mature awareness of our own existence and becomes aware of who we are in relationship to God and others. The search for the truth of existence is more difficult for trans people. They don't choose to be transgender and therefore can't choose "not" to be transgender.4 There is a long list of reputable medical entities that affirm the reality of transgender people.

But there is another narrative, driven by a few medical entities, politicians and religious leaders from various denominations. This narrative says that trans people don't really exist, they just think they do. "It is impossible," Sr. Derouen says, "to show respect for people while at the same time denying that they exist. No matter how nice the words are, being pathologized and marginalized leads to stigma, shame, silence, secrecy and, tragically, suicide." She has witnessed this marginalization hundreds of times up close and personal and says, "As long as transgender people try to suppress who they are and try to be what everyone tells them to be, they suffer depression, isolation, anger, medical problems, substance abuse, broken relationships and more. But when they make the decision to live from a place of truth and integrity, much of that goes away, and I experience in them peace, joy, compassion, wisdom, inner freedom and an ability to receive and offer genuine love." She further explains, "We human beings are a complex, mysterious, body-spirit creation of God, and no one is more attuned to the mystery of that reality than transgender people. Far from being delusional or choosing to betray the humanity God gave them, they want nothing more than to be faithful to who God made them."

There is no one way to define or describe transition. For each person, it's a process of claiming the truth of who they are. In this article, those interviewed gave their names for publication. It can be called a conversion of life, a transformation in God or growing in integrity and freedom — there are many ways it can be described. What is important is recognizing that what transgender people experience is holy and good, not sinful or deluded. Maureen Cauffey, a trans woman who takes time for meditation every morning and goes to Mass every day, speaks for many trans people when she says, "There is no life in me without Christ at the center, but there is no me without transitioning."

The same might be said of each of us. For some, we find Christ at the center as we move through the stages of self-awareness and self-discovery — releasing whatever in us is false and not of God and claiming our true self, where God lives in us. That's not easy and it takes a lifetime, but for trans people, the process may be especially complex.

The transition process is unique to each person, but from her observations and work, Sr. Derouen describes three general stages.

The first stage is "false integration." This is the tortuous struggle of trying to not be trans because everyone in their life says they're not, and the message is loud and clear that being trans is not a good thing. Some trans people, like Dawn Wright, live in anguish for many years, fighting the reality that they are indeed transgender. "[I thought] if I transitioned, that would be a mortal sin," Wright says, "and I would go to hell. But I can't live this way anymore, and if I don't transition, I would commit suicide, and that, too, would be a mortal sin and I would go to hell."

The second stage is "disintegration" — the point at which trans people finally acknowledge that they simply can't go on living a lie and pretending to be someone they aren't. There are so many who have stood on the precipice of sweeping and profound loss as they made the courageous decision to live in the gender they know themselves to be. They gradually and very carefully came out to those closest to them: spouses, children, parents and siblings. Then they broaden the circle to friends and church community, coworkers and neighbors. This stage is terrifying because when they come out, they risk losing what they have and, more importantly, losing those they love. Though, in one sense, they finally feel grounded because they aren't fighting themselves.

Still, the risk and reality of so much loss is incredibly hard to live through. And, for many, it's only by the grace of God that they get through it. Sara Buechner, a concert pianist, explains it this way, "In the tumultuous 2½ years that followed my decision to transition, friends abandoned me, concert dates evaporated and I lost my teaching job. But within my body, there was complete calm because the journey within was integral to myself, and it was a journey made not alone, but with God."

The third stage is "reintegration." Gradually, usually over a period of years, trans people make their way through the painful and complex stages of transition and are finally at home within themselves, with the world around them and closer to God. They still struggle with life's problems — like we all do — but now they do it with their integrity intact.

It is striking how these three stages reflect a paradigm in human life. We could describe it as "thesis-antithesis-synthesis," or, in more theological terms, as the "purgative-illuminative-unitive," or even the "emergence from the dark night of the soul" described by St. John of the Cross, a time that is painful but still full of blessing. We all go through similar stages as we grow in God's image. The steps of transition are very much the process of conversion as we see more clearly, abandon inauthenticity and embrace God's plan.

As Sr. Derouen says, "Walking with transgender and nonbinary people on their journey from a false self to a true self is God's call to me. They have profoundly shaped my own life in God, and I've learned so much from them. They have made me a better woman and have given me the courage to live my own life with greater integrity."

FR. CHARLES E. BOUCHARD, OP, recently served as senior director, theology and sponsorship, for the Catholic Health Association, St. Louis, before his retirement in June. He now serves as a senior fellow and consultant for Aquinas Institute of Theology in St. Louis. JAMEZ TERRY is a chaplain for Providence Alaska Children's Hospital in Anchorage.


  1. This summer, CHA offered a webinar related to spiritual care for transgender people. Attendees represented CHA member health systems, sponsors, dioceses and other Catholic organizations. Because interest was high during that webinar, it was covered in CHA's Catholic Health World publication. This article, planned in advance of that coverage, aims to build upon additional points from the webinar related to spiritual care.
  2. There is a growing body of literature on the spiritual path of trans persons. See the following examples: Julie Exline et al., "Religious and Spiritual Struggles Among Transgender and Gender-Nonconforming Adults," Psychology of Religion and Spirituality 13, no. 3 (2021): 276-286, https://doi.org/10.1037/rel0000404; Maxwell Kuzma, "For This Transgender Catholic, Advent's Wait Mirrors the Wait for Embodiment," National Catholic Reporter, December 22, 2022, https://www.ncronline.org/spirituality/transgender-catholic-advents-wait-mirrors-wait-embodiment; David Albert Jones and Claire Jenkins, "Faithfully Transgender," The Pastoral Review 15, no. 5 (January 10, 2020): 34-38.
  3. CHA's recent webinar on the spiritual and pastoral care of trans persons, called "Care for the Transgender Soul: An Introduction to Spiritual Care for Trans Persons and Their Families," featured comments from Sr. Luisa Derouen, Chaplain Jamez Terry, and Erica Cohen Moore, Executive Director of the National Association of Catholic Chaplains. It is available at https://www.chausa.org/store/meeting?id=5367.
  4. It is important to note that the statements in this article are based on the assumption that there are persons who are transgender from birth and are not merely victims of or adherent to cultural trends or "gender ideology."


To help provide a better understanding of transgenderism and Catholic health care's treatment for transgender patients, the following are some commonly asked questions and answers.

What does it mean to be transgender? We all have a set of physical markers of sex — which generally all line up in the same direction as either male or female — and an inner sense of ourselves as male, female or other, which we call gender. "Transgender " and "trans " are umbrella terms used to describe people whose gender identities are not what is typically expected for the sex they were assigned at birth. While the cause of this difference is not fully known, it is widely understood to be a neurobiological reality.

What do we mean by transition? There is no single way to transition and there are many paths — social and/or medical — that people may take. For some, to transition socially is enough to feel congruent (for example, name, pronouns, dress, etc.). Others may transition medically with hormones and/or surgery on primary or secondary sex characteristics after a diagnosis of gender incongruence has been firmly established. As one source puts it, the word 'transition' describes "the complex process of authentically living into one 's gender identity, often but not always including leaving behind one's assigned birth sex. A transition may include coming out to one 's family, friends and/or coworkers; changing one's name and/or gender markers on legal documents; hormone therapy; and/or possibly (though not always) some form of surgery. " As all people are constantly changing and growing into themselves, it should never be assumed that transition is a finite process to be "completed. "1

Do Catholic hospitals provide all transition services? No. Catholic hospitals adhere to the Ethical and Religious Directives for Catholic Health Care (ERDs) which allow modification or removal of sexual organs only to treat disease, injury or a condition that threatens the health of the person. Hormone therapy usually begins in a physician's office, but patients who come to Catholic hospitals who have transitioned or are in the process of transitioning can expect hospitable, compassionate care for themselves and their families.


  1. "Transgender 101: Identity, Inclusion, and Resources, " Unitarian Universalist Association, https://www.uua.org/lgbtq/identity/transgender.

Six Practical Suggestions for Spiritual Care of Transgender Persons


Chaplain, Providence Alaska Children's Hospital

Like Sr. Luisa Derouen, OP, I have been active in trans communities for more than 20 years. Similar to her, my ministry has been grounded in the trans community. But unlike her, it was not ministry that led me into this community. Rather, it was my trans community that led me into ministry.

When I was a young trans person, I was deeply faithful and a regular churchgoer, which made me unique among my friends. Over time, by paying attention to the ways that religion crept into the edges of conversations — and noticing how it showed up in images, metaphors, our questions and the stories through which we defined ourselves — I came to recognize that many trans people around me were people of faith.

However, a long history of persecution and intolerance had caused most to withdraw from organized religion. I saw that most trans people were not talking about their spiritual lives — neither to one another or anyone else. I witnessed a particular sort of loneliness, a deep yearning and a need for ministry that would tend to these wounds and carve out new paths for healing. And, in this recognition, I began to discern my own call to ministry, specifically to one that would help bridge the gap between trans communities and religious communities.

Sr. Derouen has spoken and written beautifully about our responsibility to believe people when they tell us who they are, about the central role of dignity and integrity in the lives of trans people, about the deep soul work that occurs as people discover who they are and who they are meant to be, and about the relationship between gender transition and spiritual formation.

Let me build on that foundation by offering several practical suggestions for providing spiritual care to trans persons.

1. Overcome barriers: We must recognize the hurt that religious traditions, including Catholicism, have often caused in the lives of trans people, especially when we show up as representatives of those traditions. As a hospital chaplain, I frequently walk into rooms where patients or families may not have sought my services but could definitely benefit from them. I have a short time to establish trust before they decide whether they will "let me in, " both literally and metaphorically. If people are going to let me into their most honest and vulnerable places, the places where the most profound revelations of the Spirit occur —where healing is most needed and possible — they first have to believe that I will not do them harm. And if they have been hurt by others who claim to represent the Church, they have no particular reason to expect anything different from me. They are likely to have some pretty strong self-protective barriers.

If we wish to have meaningful pastoral relationships with trans people and their loved ones, we cannot ignore the reality or the validity of these barriers. It is not enough to simply show up and be nice, to use inclusive language and respect people's names and pronouns — though those are important starting points. We must acknowledge where harm has been done and locate ourselves in relation to the harm that continues to happen. We must condemn any abuse of trans people and be explicit in our affirmation. Furthermore, we must be honest and proactive in moving through the layers of likely and appropriate resistance, demonstrating that we are worthy of trust before we can begin to do any other spiritual care.

2. Consider the context: Our care does not take place in a vacuum. In addition to the religious landscape in which many of us live, we also exist within a political landscape. The current U.S. political environment is particularly hostile toward trans people. No matter how you vote or where you live, the daily news often contains a barrage of messages from those who would prefer that trans people didn't exist, and that has an inevitable impact on the spirit. Just recently, I visited a trans patient in the hospital who spoke about how overwhelming and hard it is to feel hopeful in the face of it, and how it has made him "spiritually tired. "

I would venture to say that most trans people in America are probably spiritually tired right now, as debating or defending your basic right to exist is exhausting. Yet, we keep getting back up, living the lives we were created to live, caring for one another and trying to carve out space so that future generations of trans people won't need to be so tired or fearful. Trans people are incredibly resilient, and trans communities have given rise to some of the most beautiful love of neighbor I have ever seen. But that doesn't keep us from growing weary and needing places of respite, where our spirits can be nurtured and restored.

3. Be the connection: A central element of spirituality is connection. One of the ways that we care for each other's spirit is through tending to the places of disconnect. There are many spiritual assessment tools used by professional chaplains, but one of my favorites is to simply consider a person's spiritual well-being through the lens of one of the commandments: Jesus tells us to love God with all your heart, mind and soul and to love your neighbor as yourself. Everything hangs on our ability to love in these ways so we can consider how a person is doing in relation to God, their neighbor and self.

Trans people are often well connected to self, as they have had to do the hard work of discerning and facing who they are at the core of their being, of grounding themselves in authenticity and integrity. As Sr. Derouen has illustrated, trans people are sometimes well connected to God (or to whatever name they may give to the sacred) — though this is variable and certainly influenced by what they have been taught God thinks of them. When it comes to connection to others, there is almost always some level of disconnect. Spiritual care providers may be especially concerned with a disconnection from the spiritual or religious community.

As we have noted, trans people often have deep spiritual lives. Because of historical trauma and ongoing harm that may have been caused by many religious persons and institutions, those spiritual lives are often lived quite apart from organized religion. And yet, trans people know the fundamental importance of community, gathering and witnessing. There is a reason Christ said, "For where two or three are gathered together in my name … . " (Matthew 18:20) The life of the Spirit is not meant to be lived alone. To be clear, this does not mean that trans people have to re-enter church buildings — that may not be the right choice for every person, now or ever. But trans people need to recognize that, in their lived experiences and their spirituality, and specifically in the intersections, they are not alone. As a spiritual caregiver, you can foster connections, and sometimes you can be the connection.

4. Stand by and stand up: In addition to accompaniment, to standing beside people, you can stand up for people — not only because it is the right thing to do and what justice and compassion demand from us, but because your voice — specifically for those who are religious leaders — may carry extra weight in this conversation. You can uplift the dignity of trans persons, both individually and collectively, within the health care systems where you work. Use your pastoral authority and the access to power that you may have as a religious professional in Catholic health care to advocate for trans people.

5. See the gifts before you: You will not always know which people in your care are trans or who has beloved family members who are trans. Many will not tell you because they are afraid of how you will react because they have been hurt before. Regardless of how open you might be, these fears are justified by past experiences. So, when people do choose to share themselves with you, recognize it as a gift. Take the opportunity to see and affirm all of who they are. I recall hearing Casper ter Kuile, a former ministry innovation fellow at Harvard Divinity School, saying that the responsibility of the community is to help individuals identify their gifts, and then to receive them. Can you look at a trans person, see them as a whole person, identify their gifts — including the ones that come with their trans identity and experience — and appreciate how those gifts are serving both that person and the world? If you can, you may be ready to provide your spiritual care to trans people.

6. Hear the good news, too: We talk a lot about challenges within the trans experience. Unfortunately, that is easy to do. However — and this is important — hardship is not the whole story. Trans lives can also be full of love. They can be full of hope and faith. They can be full of meaning and fulfillment. They can be full of joy. There is thriving and abundant life in trans communities. As another trans chaplain recently said to me, we should be "trauma-informed but not trauma-expectant. " In this sacred work of caring for souls, we are called to weep with those who weep. But we are equally called to rejoice with those who rejoice. And so, our ministries will be incomplete if they don't leave room for celebrating trans joy.

So how do we care for the soul of the transgender person? We can do this by seeing clearly both its wounds and its beauty, affirming its worth and leaning into its strength, bearing witness and trusting in the wisdom that trans people bring from their own spiritual experiences. Trans people have too often experienced rejection by religious leaders and alienation from religious communities, treatment ranging from benign neglect of their spiritual needs to harsh abuses perpetrated in the name of God. And yet, not even this can quash the life of the Spirit. Even this does not stop trans people from connecting with the God who made us, who sees us, who loves us and calls us to be our whole selves. It does not stop us from seeking and from living the truths that we know.

There are lessons to be found here for all who seek to live with integrity, to pursue the life of the Spirit and to be the people God created us to be. One of my favorite Bible verses comes from the First Epistle of John: "Beloved, we are God 's children now; what we shall be has not yet been revealed." (1 John 3:2) We are all already God's beloved children, and we are all constantly in the act of becoming. There is more to be revealed, and we must keep our hearts open to sacred truths and to the holy changes that will come. Bearing witness to trans faith has been powerful, transformative and has shaped my life for the better. May it do the same for you.

Caring for the Transgender Patient - Lessons for Pastoral and Spiritual Care

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