Besides some of the social problems that come with transitioning, what are some of the moral or spiritual issues that come up.
Rarely do I see anyone with religious concerns who has not already worked out their spiritual issues regarding transition with their spiritual leader. However, if the individual has strong religious ties and is associated with a particular church, mosque or synagogue then there could be a problem. That is where a good therapist can help all parties to come to a workable solution.
Familial concerns are much more common. Most people who come to see me are in mid-life with familial obligations. The idea of altering the family structure or even destroying it to save their life can lead to overwhelming feelings of guilt and shame and are much more common and problematical than spiritual issues.
In such a circumstance the therapist should go to great lengths to educate family members about the gender variant condition and make an effort to keep the family together. I am happy to report that success in keeping the family together has increased dramatically in the last several years.