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August 2021 Article of the Month
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA


Exline, J. J., Przeworski, A., Peterson, E. K., Turnamian, M. R., Stauner, N. and Uzdavines, A. "Religious and spiritual struggles among transgender and gender-nonconforming adults." Psychology of Religion and Spirituality 13, no. 3 (August 2021): 276-286.

SUMMARY and COMMENT: This month's selection, from leading Spirituality & Health researcher Julie J. Exline and colleagues at Case Western Reserve University's Department of Psychological Sciences, begins by asking, "How can psychological concepts around religion and spirituality (r/s) help to deepen understanding and support of transgender and gender-nonconforming (TGNC) individuals?" [p. 276]. This is the authors' "initial" investigation of R/S struggles experienced in daily life regarding this population [p. 276], building upon studies that "suggest substantial potential for inner and external conflicts around religion for people with nonheteronormative sexual orientations" [p. 277]. The results speak to a subject of currency and complexity and may open up important questions and productive dialogue for chaplains. Also, as a good example of research that seeks insights into aspects of a group, the article may be useful for chaplains to consider the practical value and utility of cross-sectional data.

Recognizing that most prior research has concentrated "primarily on challenges around sexual orientation rather than those around gender identity" [p. 377], the authors look here at a population that "a recent review suggests [comprise] between 0.1% and 2% of adults [who] may identify as TGNC" and who as a group "have suffered staggering levels of discrimination, rejection, and victimization" [p. 377]. Data were drawn from items about R/S that were part of a larger study [--see Related Items of Interest, §I, below], including the Religious and Spiritual Struggles Scale, by Exline, et al. [--see Related Items of Interest, §II, below]. Participants in the original study were "recruited via social media, websites, and email lists focused on LGBTQ persons" [p. 378], with the final sample for the present work being 305 individuals, 84.9% of whom were from the United States, with another 7.9% from Western Europe, 3.9% from Canada, and 3.3% from other countries: e.g., Australia, New Zealand, Brazil, Israel, Mexico, Thailand, and Sri Lanka [--see Table 1, p. 279]. Seven tables present copious details on demographics as well as key findings.

Among the results:

  • "We expected to see low levels of religiousness on average, along with a strong pattern of religious disengagement. We based this prediction on broader trends of religious exiting among U.S. adults...and on research showing high levels of religious exiting and low religiousness among LGB individuals.... This prediction was strongly supported.... Most of our participants had disaffiliated from traditional religions (especially Christianity)...." [pp. 283-284] "...80.3% identified as nonreligious: 38% self-identified as spiritual but not religious and 42.3% as neither spiritual nor religious." [p. 278] "...In all, 58% of the sample reported being raised with some religious affiliation but not being religious now." [p. 278]

  • "[A] notable finding was the number of participants reporting that they had been rejected or made to feel unwelcome by religious communities. Of those who had been religiously affiliated at any time, 54% said that they had experienced such rejection...." [p. 278] "...Even among those who had never been religious themselves, a third reported some form of rejection. Such rejection experiences were robust predictors of r/s struggle...." [p. 284]

  • "[R]/s struggles...correlated positively with rejection from religious communities and with seeing God as disapproving one's gender identity, as predicted. Seeing God as having caused one's gender identity was also linked with more struggle. As predicted, r/s struggles were linked with more GMS [i.e., Gender Minority Stress]..., lower self-esteem, and lower trait resilience.

  • "Religious belief salience correlated positively with r/s struggle. ...[T]hose who were religiously affiliated reported more struggle...than those who had disaffiliated..., who in turn struggled more than those who were never affiliated.... Similarly, those who were members of religious communities reported more struggle...than those who were not.... In short, participants who were more engaged with religion reported more struggle around religion." [p. 282]

  • "...[T]hose who did hold some belief in God (or a god) generally did not see God as disapproving of their gender identities. But perceptions of divine disapproval were clearly linked with more r/s struggle -- not just divine struggle, but all types of r/s struggle." [p. 284]

  • "Overall levels of r/s struggle were low...[but]... all six struggle mean values differed significantly...." [p. 281] "[I]nterpersonal struggles were by far the most endorsed (as predicted), followed by ultimate meaning, doubt, moral, divine, and finally, demonic struggles. These findings about comparisons between different struggle types were in line with our predictions, except that we had not made any hypotheses about a distinction between doubt and moral struggle." [pp. 281-282]

  • "Interpersonal struggles...emerged as strong, independent predictors of negative expectations about the future social interactions in which one's gender identity or history would be expressed." [p. 284]

  • "There were no differences [in r/s struggle] based on age, race, country, gender identity, sexual orientation, or extent of transitioning or disclosure. However, it is important to note again that the sample was dominated by participants who identified as Caucasians from the U.S." [p. 282]

The authors caution about their findings regarding R/S struggles: "because these data are cross-sectional, we cannot assume that these issues around gender identity are necessarily causing r/s struggle; they might also reflect such r/s struggles (or uncontrolled confounds)" [p. 284]. For chaplains especially new to research, a practical question is what to make of cross-sectional data, here or in general. It does provide empirical insights into a population, with the checks and balances of the scientific method, but it should not lead to the reader to pigeonhole or generalize individual members of that population. How might cross-sectional data lead to better understanding of a group and the potential likelihood of certain issues playing into the lives of individuals within that group, without fostering assumptions and stereotypes of a group or individuals within it? This could be asked of any cross-sectional study, but the present work may be a good means to consider a key point of research literacy and methodology.

Exline and colleagues seem to do a fine job in presenting their research with caution and cogency, and they especially emphasize the value of their work as a ground for future research, noting needs and opportunities for further study throughout the paper. In connection to this, they also cover well the limitations of this research, including the often-unrecognized limitation of how participants may have experienced the battery of questions being asked of them. For instance, "because the r/s items were at the end of a lengthy survey, fatigue effects may have kept some from answering the questions or may have led to inattentive responding" [p. 285]. They also point out that in spite of efforts to generate a very broad sample, being proactive in some cases to recruit participants from potentially underrepresented subgroups, their final sample was a "largely Caucasian, Western group," with most individuals having been "raised within the Christian tradition" [p. 285]. Moreover,

We did not have space in the survey to examine worldviews that were nontheistic, spiritual, or secular. Due to our focus on r/s struggle in this article, we also were not able to consider positive r/s experiences of TGNC individuals. In future work, it will be important to seek out more TGNC persons who are religiously engaged and to examine their experiences closely, including both life-affirming and stressful aspects of religious involvement. We look forward to working on such projects soon.

Part of, yet over and above, the particulars of this research are questions of what language to use when addressing issues of this target population, and how much such a population can or should be considered together as a group or differentiated. The data presented in Table 1 [p. 279] may be of special interest about gender identity terms endorsed by participants. It seems worth observing that the two terms used by the authors in their title, "transgender" and "gender-nonconforming," were not the most popularly endorsed terms. Table 1 shows that 1.6% of participants self-listed themselves as "gender-nonconforming" within the "other" category in the original list of terms. [The text on p. 278 states that "about 5% of participants self-listed as "gender-nonconforming," whereas Table 1 appears to indicate that it was only 5 individuals, making for 1.6%.] Certainly, "[p]eople use a rich, complex, and constantly evolving set of terms to describe TGNC identities" [p. 277].

The article is exceptional in signaling the authors' expectations and how specific findings fit with predictions. Overall, the text is laid out clearly, with the sections for introduction, methodology, results, discussion and limitations and future directions all flowing well into one another, augmented by a great amount of data conveniently at hand in the tables. The choice of measures should be of interest to anyone working in this area, especially the 14-item version of the Religious and Spiritual Struggles Scale, which will be analyzed in a soon-to-be-published article by Exline, et al.: "The RSS-14: Development and Preliminary Validation of a 14-item form of the Religious and Spiritual Struggles Scale" [--see p. 281; also Related Items of Interest, §II, below]. The bibliography of 48 references is quite current, with four citations from 2020 and five from 2019.


Suggestions for Use of the Article for Student Discussion: 

The article involves a good deal of statistical analysis, but the flow of the text is such that even students with a limited sense of statistics should be able to read through easily, while those with more experience with quantitative methodology will find much of specific interest. A discussion session could be well augmented by inviting a guest who could speak personally to what the authors address under the umbrella term TGNC, even if members of the group themselves were able to do so. This could also be a chance for a chaplaincy department to build connections with a healthcare institution's programs that work with gender identity. Since the authors very plainly line out their findings, discussion could begin by asking the group what of the results most stood out to them. What might be the implications of relatively high levels of religious disengagement in a patient population for the processes of referral in the institution? Do students feel generally capable in their chaplaincy interactions when referred to patients who are religiously disaffected for any reason? Have students had patient visits where they themselves became the focus or trigger for the patient's religious/spiritual struggles? What does the group make of the six-domain schema for religious/spiritual struggle [--see p. 277]? Having read the article, with its many prompts for future research, what more, in particular, would the students like to know, and how might they go about pursuing those interests? Discussion of this article may have strong potential for carry-over into other components of the CPE curriculum, including inter-personal group sessions and didactics, and the discussion facilitator may wish to direct some lines of discussion be moved intentionally to those other curricular opportunities.


Related Items of Interest:

I.  The larger study from which the data for the current research was collected:

Testa, R. J., Habarth, J., Peta, J., Balsam, K. and Bockting, W. "Development of the Gender Minority Stress and Resilience Measure." Psychology of Sexual Orientation and Gender Diversity 2, no. 1 (March 2015): 65-77. [(Abstract:) Researchers currently lack a reliable and valid means of assessing minority stress and resilience factors in transgender and gender-nonconforming (TGNC) people. This study was conducted to develop and evaluate the validity of a tool to better assess these constructs in TGNC populations. The Gender Minority Stress and Resilience (GMSR) measure was developed grounded on Meyer's minority stress model, and adjusted to reflect the experiences of TGNC populations based on TGNC literature and archival data from TGNC focus groups. The final GMSR includes scales assessing 9 constructs: gender-related discrimination, gender-related rejection, gender-related victimization, nonaffirmation of gender identity, internalized transphobia, negative expectations for future events, nondisclosure, community connectedness, and pride. In the current study, 844 participants completed the GMSR measure as well as measures related to mental health, general life stress, and social support. Results indicated good model fit, criterion validity, convergent validity, and discriminant validity for the 9 hypothesized scales. Discriminant validity for the scales were also partially supported. Overall, the current study offers preliminary evidence of the reliability and validity of the GMSR Measure for use with TGNC populations. The GMSR Measure has several uses for both research and clinical purposes, including increasing understanding of the experiences and correlates of gender minority stress and resilience factors and assessing whether specific therapies or interventions are helpful in reducing risk and supporting resilience in TGNC populations.]


II.  The Religious and Spiritual Struggles Scale was originally presented as a 26-item measure in Exline, J. J., Pargament, K. I., Grubbs, J. B. and Yali, A. M., "The Religious and Spiritual Struggles Scale: development and initial validation," Psychology of Religion and Spirituality 6, no. 3 (2014): 208-222 [available through the Chaplaincy Innovation Lab]. Exline and colleagues have since worked on a 14-item version and are currently preparing a paper: Exline, J. J., Pargament, K. I., Wilt, J. A., Grubbs, J. G. and Yali, A. M., "The RSS-14: development and preliminary validation of a14-item form of the Religious and Spiritual Struggles Scale." Both scales use a 6-domain schema of R/S struggles: divine (negative emotion centered on beliefs about God or a perceived relationship with God), demonic (concern that the devil or evil spirits are attacking an individual or causing negative events), interpersonal (concern about negative experiences with religious people or institutions; interpersonal conflict around religious issues), moral (wrestling with attempts to follow moral principles; worry or guilt about perceived offenses by the self), doubt (feeling troubled by doubts or questions about one's r/s beliefs), and ultimate meaning (concern about not perceiving deep meaning in one's life). For more on the scale, see the following selection from recent publications on the subject:

Damen, A., Exline, J., Pargament, K., Yao, Y., Chochinov, H., Emanuel, L., Handzo, G., Wilkie, D. J. and Fitchett, G. "Prevalence, predictors and correlates of religious and spiritual struggles in palliative cancer patients." Journal of Pain and Symptom Management (2021): online ahead of print. 5/10/21. [The paper is noteworthy to our immediate context for presenting items of the RSS-14 in Table 2 on MS p. 5. The study to which the RSS-14 is applied here involved 331 patients, 66% of whom reported some R/S struggle, and 20% of whom indicated moderate to high struggle for at least one item. In bivariate analyses, R/S struggle was associated with greater symptom burden, greater dignity-related problems and poorer quality of life. In multivariable analyses, dignity-related problems remained a predictor of total R/S struggle.]

Stauner N., Exline J. J., Grubbs J. B. and Pargament K. I. "The Religious and Spiritual Struggles (RSS) Scale: stability over one year." In: Ai, A. L., Wink, P., Paloutzian R. F. and Harris, K. A., eds., Assessing Spirituality in a Diverse World, Springer, 2021. Pp. 141-166 [This longitudinal assessment of the 21-item RSS used data from a large undergraduate population. The authors critique the scale by proposing an intermediate classification of religious/spiritual struggles that they name as "phases," in between the constructs of "state" and "trait." A religious/spiritual struggle phase is conceived as leaving open the possibility of change, but of slow change, with RSS-identified struggles shown to be more stable than psychological states, yet more transient than traits. For more on the chapter, see the Springer website.]

Wilt, J. A., Exline, J. J. and Pargament, K. I. "Daily measures of religious/spiritual struggles: relations to depression, anxiety, satisfaction with life, and meaning." Psychology of Religion & Spirituality (2021): online ahead of print, 3/1/21. [This study used data from a daily experience sampling method with a population of undergraduates. The authors conclude that religious/spiritual struggles may be assessed meaningfully at the daily level and that such research could facilitate studying the development of religious/spiritual struggles and their relations to mental health over time.]


III.  Recent publications by and/or about chaplains and care for transgender individuals:

Cornwall, S. [University of Exeter, UK]. "Healthcare chaplaincy and spiritual care for trans people: envisaging the future." Health and Social Care Chaplaincy 7, no. 1 (January 2019): 8-27. [Spiritual care has the potential to mitigate against "gaps" left when waiting lists (and times) for NHS gender identity clinics (GICs) spiral, and trans people awaiting medical interventions are at increased risk of suicide and self-harm. Healthcare chaplaincy has an explicit role to play, particularly for the sizeable number of trans people with religious faith or who struggle with finding support from faith communities. Spiritual care should be integrated within direct care provided by healthcare professionals, with additional care from specialist chaplains where desirable. Findings from the Modelling Transgender Spiritual Care project point to a need for additional training and resourcing in gender identity care for spiritual carers; a new prioritization of healthcare chaplaincy for gender identity services, which has implications for budgets and commissioning; and increased accountability for fulfilling the statutory requirement for spiritual care in the NHS.] [For access, see the journal site.]

Hirschmann, J., Kozato, A., Sharma, V., Villagra, C., Wetmore, J., Jandorf, L., Pang, J. H., Reynolds, M., Dodge, L., Mejia, S. and Safer, J. D. "An analysis of chaplains' narrative chart notes describing spiritual care visits with gender affirmation surgical patients." Transgender Health (2021): online ahead of print. [(Abstract:) PURPOSE: The benefit of spiritual care for patients is well described, but little is known about the role of spiritual care in transgender and nonbinary patients recovering from gender affirming surgeries (GASs). METHODS: A single-center retrospective chart review was performed on patients who underwent GAS in 2017. Demographic information, surgery type, and chaplains' narrative notes were examined. RESULTS: A total of 145 chaplain visits were identified in 103 inpatient stays among 98 patients at the Mount Sinai Center for Transgender Medicine and Surgery in New York. Analysis was performed on narrative notes authored by a single chaplain, which included 132 visits among 78 transfeminine and 11 transmasculine patients. Fifty-four patients (61%) expressed gratitude for the chaplain visit and/or hospital experience overall. Seven patients (8%) described movement between religious denominations over the course of their lives, and 7 (8%) described supportive belief systems. Fifty-seven patients (64%) had a family member or friend present during the perioperative process, 13 (15%) described support systems, and 9 (10%) described supportive practices, activities, and/or coping methods. Twenty-one patients (24%) expressed concerns about current symptoms or the recovery process, and 32 (36%) received a prayer or blessing from the chaplain. Fifty-two patients (58%) consented to a follow-up call. CONCLUSION: Almost 50% of patients expressed gratitude for the chaplain's visit and more than half consented to a follow-up call from the chaplain, suggesting a chaplain can provide a welcome layer of support to postoperative GAS patients. The authors recommend integrating spiritual care into perioperative care.]

Hirschmann, J., Walker-Cornetta, E. and Jelinek, S. "Spiritual care of transgender persons: a multidisciplinary approach." In Poretsky, L. and Hembree, W. C., eds., Transgender Medicine (series: Contemporary Endocrinology), Humana Press/Springer Nature Switzerland, 2019. Chapter 18, pp. 357-376. [(Abstract:) Spiritual care is increasingly recognized as an essential component of healthcare delivery. Professional chaplains play a specialized role in meeting the religious/spiritual (R/S) needs of patients. This chapter focuses on the provision of spiritual care to transgender populations and introduces key concepts, terms, and related research. The authors describe screening and assessment tools that may assist clinicians in identifying the R/S needs of transgender patients. The authors also present case studies that demonstrate how clinicians and chaplains might address the R/S needs of transgender adults and adolescents. Given that R/S can play significant, complex, and varying roles in the coping and decision-making of transgender patients, clinician sensitivity to R/S needs and familiarity with supportive resources, including chaplains, are recommended.] [This book may be difficult to locate, but see information from the publisher.]

Hanson, J. "'He is disappointed I am not the son he wanted. I tried and tried to deny I am a girl' -- Vicki, a male-to-female transgender veteran." In Fitchett, G. and Nolan, S., eds., Case Studies in Spiritual Care, Jessica Kingsley Publishers, 2018. Chapter 5: pp. 87-101. [(Opening Paragraph:) This case describes my spiritual care for Vicki, a transgender veteran in her 50s. Spiritual care with lesbian, gay, bi-sexual and transgender (LGBT) persons, and especially with transgender persons, is an area of growing need. LGBT health disparities are well documented, and the health risks experienced by LGBT veterans are even larger (Kauth and Shipherd 2016). Depression, anxiety, post-traumatic stress disorder and other mental health problems affect transgender veterans at higher rates than non-transgender veterans. These conditions may be connected to the higher rates of intimate partner violence and aggression and military sexual trauma that transgender veterans experience. Transgender veterans are also at an increased risk for heart and kidney disease because of hormone use, diabetes, smoking, obesity, high blood pressure and stress. These concerns and others raise opportunities for professional chaplains to develop spiritual care theories and practices to directly address the theological issues raised by the lived experiences of this population.] [This chapter is available online through the US Department of Veterans Affairs' Mental Illness Research Education and Clinical Center site.]


IV.  On October 14, 2020, the Chaplaincy Innovation Lab (CIL) co-sponsored, with the Center for Spirituality and Health at the Icahn School of Medicine at Mount Sinai, a webinar on "Best Practices in the Spiritual Care of Transgender and Gender Non-Conforming Patients." A video of the presentation by Rabbi Jo Hirschmann and Rabbi Max Reynolds is available from the CIL website. Also, the CIL has profiled the Trans Spiritual Care Initiative (TSCI), a project of Sojourn Chaplaincy, a multi-faith spiritual care department at San Francisco General Hospital. The TSCI's own site includes a list of resources that, while focused on the San Francisco area, includes material of general interest to chaplains and other healthcare providers.



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