Shared decision making is practically difficult to implement in mental health practice but remains an ethical ideal for motivating therapeutic capacity.

Gender-affirming surgery for teens is growing as a field. Norms about who should be involved, to what extent, and for which health decisions are still evolving.

Shared decision making is complex with patients who are adolescents, whose relational autonomy is still emerging.

Patients’ perceptions of how much input they have in making health decisions influence therapeutic alliance and outcomes.

Public and self-stigma negatively influence patients’ quality of life, employment, and housing opportunities.

Defining typical appearance as a goal of health service provision is harmful and unnecessary for traits that are stigmatized but neither harmful nor distressing.

Some clinicians cite absence of long-term data to justify not fully deferring surgery for children with DSD, and legal restrictions of early procedures are also at play.

Physicians’ primary responsibility is to promote patients’ well-being, which includes not causing financial harm.

Shared decision making honors patient autonomy, particularly for preference-sensitive care decisions and even when patients have impaired decision-making capacity.

Most clinicians receive little training in integrating Native healing into allopathic practice, which undermines patients’ autonomy and cultural values.