Take the internet, Zoom, a legion of gender-confused adolescents, telemedicine, activist doctors, pour into a vat of money. Shake. You get Plume, a Denver-based company which “provides gender-affirming care directly from your smartphone”.

If you want to transition from male to female or female to male, you can manage the whole process online. Plume will supply estrogen and testosterone, advice on your smartphone, and a letter of support for gender-affirming surgery for “top surgery, bottom surgery, facial feminization surgery (FFS), electrolysis, breast augmentation, body sculpting, and more”.

All via smartphone for US$99 a month (without insurance). And Plume seems to be flourishing, backed by millions in venture capital. Its website lists about 60 healthcare employees and flashing avatars advertise “we’re hiring”.

Transgender medicine is becoming an established business. But as a recent documentary demonstrates, it is ruining the lives of many young people. “Affirmation Generation” features detransitioners, psychologists, doctors, researchers, and journalists who claim that “that ‘gender-affirming care’ is a radical departure from how we treat any other distress, because the patient (no matter how young or unwell) dictates to the medical expert what he/she wants”.

The film underscores the producers’ credentials as “lifelong, West Coast Liberal Democrats”. They are not Trump-supporting Christian conservatives. In fact, one of their messages is that lesbians and gays should flourish on their own without feeling pressure to become transgender. They insist that “All of them have been lifelong, staunch supporters and allies of LGBT people. All of them are loving, engaged parents whose teenagers announced a transgender identification out-of-the-blue, with zero childhood distress over gender.”

“Affirmation Generation” is an excellent summary of the case against the kind of one-size-fits-all, assembly line gender medicine represented by Plume. Its research is up-to-date and the interviewees are intelligent and articulate. The six detransitioners regret their experience but they are not bitter and overwrought.

This is a must-watch for parents and anyone interested in the debate.

There is other good news on the trans front. Yesterday the influential BMJ (British Medical Journal) published a feature by an American women’s health journalist Jennifer Block. She reviews -- very soberly and without hyperbole – the evidence base for gender-affirming medicine.

In the United States, it appears that medical intervention and not psychosocial support is the conventional wisdom. Rachel Levine, the highest-ranking trans official in the Biden Administration, told National Public Radio last year about such treatment, “There is no argument among medical professionals.” Nearly all the major medical associations have endorsed it.  

Feelings about this run high. Block quotes Dr Scott Hadland, chief of adolescent medicine at Massachusetts General Hospital and Harvard Medical School. He was criticising protesters outside the annual convention of the American Academy of Pediatrics last year. He wrote: “Inside 10 000 pediatricians stand in solidarity for trans & gender diverse kids & their families to receive evidence-based, lifesaving, individualized care.” He called the handful of protesters “cruel”.

Is this true? And how could the consensus of American medical experts be wrong?

Block’s message is simple: “consensus does not mean practice is evidence-based”.

American gender-affirming doctors quote standards of care written by the AAP, The Endocrine Society, and the World Professional Association for Transgender Health. But she points out that by the rigorous standards of “evidence-based medicine”, these standards are seriously flawed. The medicine may be based on evidence, but how reliable is the evidence?

Mark Helfand, professor of medical informatics and clinical epidemiology at Oregon Health and Science University, tells her that “in the absence of high quality evidence and the presence of a patient population in need—who are willing to take on more personal risk—consensus based guidelines are not unwarranted.” But he warned: “don’t call them evidence based.” 

As well, the Europeans are far more cautious and are even back-tracking on early enthusiasm for gender affirmation. In Sweden and Finland, governing health agencies have put the brakes on medical treatment for minors. In France, Australia, and New Zealand medical societies have urged caution. In the United Kingdom, the National Health Service is conducting an independent review of gender identity services. It recently stated that there was “scarce and inconclusive evidence to support clinical decision making” for minors with gender dysphoria.

The BMJ article, “Gender dysphoria in young people is rising—and so is professional disagreement”, is an early sign that gender-affirmative medicine for teenagers may be on the skids.