Over the past decades, great strides have been made to professionalize and increase access to transgender medicine. As the (biomedical) evidence base grows and conceptualizations regarding gender dysphoria/gender incongruence evolve, so too do ideas regarding what constitutes good treatment and decision-making in transgender healthcare. Against this background, differing care models arose, including the ‘Standards of Care’ and the so-called ‘Informed Consent Model’. In these care models, ethical notions and principles such as ‘decision-making’ and ‘autonomy’ are often referred to, but left unsubstantiated. This not only transpires into the consultation room where stakeholders are confronted with many different ethical challenges in decision-making, but also hampers a more explicit discussion of what good decision-making in transgender medicine should be comprised of. The aim of this paper is to make explicit the conceptual and normative assumptions regarding decision-making and client autonomy underpinning the ‘Standards of Care’ and ‘Informed Consent Model’ currently used in transgender care. Furthermore, we illustrate how this elucidation aids in better understanding stakeholders’ ethical challenges related to decision-making. Our ethical analysis lays bare how distinct normative ambiguities in both care models influence decision-making in practice and how foregrounding one normative model for decision-making is no moral panacea. We suggest that the first steps towards good decision-making in gender-affirming medical care are the acknowledgement of its inherent normative and moral dimensions and a shared, dialogical approach towards the decision-making process.

在过去的几十年里，在专业化和增加跨性别医学的可及性方面取得了长足的进步。随着（生物医学）证据基础的增长和关于性别焦虑/性别不一致的概念化的发展，关于什么构成跨性别医疗保健中的良好治疗和决策的想法也在发展。在此背景下，出现了不同的护理模式，包括“护理标准”和所谓的“知情同意模式”。在这些护理模式中，经常提到诸如“决策”和“自主”之类的伦理概念和原则，但没有得到证实。这不仅会影响利益相关者在决策过程中面临许多不同的道德挑战的咨询室，而且还会阻碍更明确地讨论什么跨性别医学的良好决策应该包括。本文的目的是明确有关决策和客户自主权的概念和规范假设，这些假设是目前用于跨性别护理的“护理标准”和“知情同意模型”的基础。此外，我们说明了这种说明如何有助于更好地理解利益相关者与决策相关的道德挑战。我们的伦理分析揭示了两种护理模式中不同的规范性模糊性如何影响实践中的决策，以及将一种规范性模型用于决策的前景如何不是道德灵丹妙药。我们建议迈向良好的第一步确认性别的医疗保健的决策是承认其固有的规范和道德层面以及对决策过程采取共同的对话方法。