Clinical practice with transgender and gender expansive clients at the intersection of religion and spirituality in Appalachia.

Research indicates that mental health clinicians lack competence and confidence in practice with TGE clients. Due to the limited number of clinicians who specialize in practice with TGE clients, access to quality mental health care is a concern. In rural areas, there is a national shortage of clinicians and higher rates of social isolation and stressors for TGE people. Based on these needs and gaps in services, this dissertation explores and describes mental health care practice with TGE clients in the region historically known as Appalachia. This region is highly rural and religious, leading to unique intersectional needs and strengths for TGE clients living there, but currently, there is no known peer-reviewed research on mental health care practice with TGE clients in this region. This dissertation includes two studies that explore current mental health practice with TGE clients in Appalachia and one study that considers the impact of Christian experiences on LGBTQIA+ people in this region. The findings indicate unique cultural factors related to rural location, the importance of family, and the impact of religion, which may be important for TGE clients to discuss in the therapeutic space. Findings confirm that like clinicians in other areas, Appalachian-based clinicians have limited graduate school training and perceived preparedness for practice with TGE clients. There are also statistically significant differences regarding perceived preparedness to practice with TGE clients among the counseling licensure types. Overall, Appalachian clinicians expressed a need for basic training related to diagnosis of gender dysphoria, differential diagnosis of gender dysphoria and other mental health symptoms, as well as in integrating the unique socio-cultural factors in Appalachia. This dissertation can be used to inform future research and to develop culturally responsive clinical trainings in this region.