[This page is dedicated to Professor Milton Diamond, world-renowned clinical sexologist and a personal supporter of my ongoing research in human sexuality and psychosexual development.]
This page is an extension of my primary references page on Sexuality.
Through the 25 years that I have maintained my counseling practice, my research and professional counseling interests have included human sexuality and all of its various dimensions. Many people have written to me seeking advice and support for their questions about sexuality and identity.
I am a member of the American Psychological Association Division 44: Society for the Psychology of Sexual Orientation and Gender and the American Association of Sexuality Educators, Counselors and Therapists (AASECT).
My Academic Research Into Prenatal Hormonal Influences on Gender and Sexual Development in Men and Women, 1995 to 2020 (DES Research)
Overview: I have more than 20 years of interdisciplinary research into the effects of prenatal exposure to estrogenic and androgenic hormones on subsequent human behavioral development (including sexuality and gender identity), a field with extensive research investigation begun in the 1970s by Dr. June Reinisch, former director of the Kinsey Institute (see, for example, her 1984 journal article in Progress in Brain Research) and Dr. Dick Swaab of the Netherlands Institute for Neuroscience (see his co-authored 2010 article on Sexual Hormones and the Brain, published in the journal Pediatric Neuroendocrinology).
Evaluation of Existing Published Research on Prenatal Hormones and Gender Development:
There is prominent literature on prenatal androgens and association with variations in gender and sexual development. Much of the existing published research on hormonal influences over gender identity development and the human brain focus only on impact of prenatal androgens and female development (for examples, see Berenbaum & Beltz, 2017, How Early Hormones Shape Gender Development, Hines, 2011, Annual Reviews on Gender Development and the Human Brain, and Hines, 2010, Sex-Related Variation in Human Behavior and the Brain from the journal Trends in Cognitive Sciences.)
There is far less long-term research on prenatal exposure to estrogens in males and psychosexual development (cite Yalom, Green and Fisk, 1973, Journal of the American Medical Association and Meyer-Bahlburg, 1978, published in the journal Pediatrics). This is an area that I have researched in depth and which led me to launch an online research network in 1999: DES-Sons International Research Network.
DES stands for “Diethylstilbestrol“, a non-steroidal estrogenic drug that was given to millions of women in the U.S. and other countries during the 1950s to 1970s (and beyond) for management of pregnancy. An estimated 5 million “DES daughters” and “DES Sons” were born in the U.S. and many more in Canada, Europe, and Australia. DES is classified as an endocrine disruptor because of its detrimental effects on the development of the endocrine system.
A substantial array of adverse effects of DES has been documented in mothers and their offspring. Here is an excellent, if somewhat dated research article from 2013:
- Exposure to Diethylstilbestrol During Sensitive Life Stages: A Legacy of Heritable Health Effects (November, 2013 full text), by Casey E. Reed and Suzanne E. Fenton, published in the journal Birth Defects Res C Embryo Today
Research into the possible inherited effects of prenatal DES exposure for third-generation “DES grandchildren” has also been published since 2000. An example:
- Diethylstilbestrol (DES) Also Harms the Third Generation (2016), published in the French medical journal Prescrire International
History of My Research Into Human Health Effects of DES in Males:
As a verified DES Son, I have held long-standing interest in the array of adverse effects of prenatal DES exposure in males, which I began to investigate in 1995.
Historically, DES daughters had a primary impact on the scope of research. Not long after beginning my own investigation, I immigrated to Canada, where I became involved with the advocacy group DES Action Canada as research specialist on DES sons.
When I first created the DES Sons’ network in 1999, my aim was to document the full range of reportable adverse effects in males. It is important to note that compared with DES Daughters, there were relatively few published studies that investigated the full range of adverse health effects in males. Here are a few examples of published research:
- Hormonal Risk Factors in Testicular Cancer: A Case-Control Study, 1986, by Andrew Moss, et al., published in the American Journal of Epidemiology
- Fertility in Men Exposed Prenatally to Diethylstilbestrol, 1995, by Allen Wilcox, MD, et al., published in the New England Journal of Medicine
- Cancer Risk in Men Exposed in utero to Diesthylstilbestrol, 2001, by William Strohsnitter, et al., published the Journal of the National Cancer Institute
- Reproductive Outcomes in Men with Prenatal Exposure to Diethylstilbestrol, 2005, by Kimberly M. Perez, et al., published in the journal Fertility and Sterility
- Male Reproductive Disorders and Fertility Trends: Influences of Environment and Genetic Susceptibility, 2016, by Niels E. Skakkebaek, et al., published in the journal Physiology Review
- The Testis and Male Hypogonadism, Infertility, and Sexual Dysfunction (2016), by RS Swerdloff & C Wang
- The Epidemiologic Evidence Linking Prenatal and Postnatal Exposure to Endocrine Disrupting Chemicals with Male Reproductive Disorders: A Systematic Review and Meta-analysis, 2016, by Jens Peter Bonde, et al., published in the journal Human Reproduction Update
Within the first few months of my formation of the DES Sons’ network, I interviewed and surveyed each member to determine (1) likeliness of confirmed prenatal DES exposure; (2) health history and evidence of any documented physiological or mental health difficulties. I also conducted a series of polls of members in order to determine which issues were most prevalent in areas of concern. My own investigation revealed outcomes in many DES sons that paralleled what was documented in published research.
Emergence of Gender-Related Concerns Among Network Members:
During conversations among network participants, several members reported a variety of issues and concerns related to gender identity, gender dysphoria, and transgenderism. The evolution of this topic is reported on DES Sons and the Significance of Gender Identity.
In the years 2002-2004 I participated as a Visiting Research Scholar in Psychology at the University of Victoria (Canada). During this period I conducted a scholarly literature investigation about hormones and human sexual behaviour, focused on the biological and psychological frames of reference for conducting scientific studies of human sexual development. My investigative research continued during 2005-06 at the University of British Columbia in Vancouver.
Highlights and Timeline of My Research Investigation:
- In 1995, I began to investigate the historical published research on the adverse effects of prenatal exposure to diethylstilbestrol. I learned that in 1992, the U.S. National Toxicology Program’s Pub Chem database documented DES as having a variety of “health hazards.” These included causing “male impotence and transsexual changes”, along with “congenital malformation in the fetus.”
- Between 1999 and 2004, I documented the health history of more than 500 DES sons who participated in discussions in the DES Sons International Research Network. I conducted extensive interviews with network members during these years in order to verify likelihood or confirmation of prenatal DES exposure and subsequent developmental history (physical, physiological, and psychological).
- A summary of my key findings from the 1999-2004 focus is available at Basic Statistics and Findings on DES Sons. The most frequently cited concerns among the study participants were (1) hormonal/endocrine health issues; (2) gender identity and sexual health issues and (3) psychological/mental health issues including anxiety and depression. As of 2020, the DES Sons’ Network is still active.
- What I learned very soon after launching the original DES Sons’ network email discussion list on Yahoo (DES-Sons) in 1999, was that a significant number of new members who introduced themselves to the group and/or to me in private communications described a history of gender dysphoria and other gender and sexuality related issues.
- In 2001 I formed a separate discussion list called DES-Trans Support Group. There was a substantial amount of discussion activity on DES-Trans that truly underscored for me the importance of further exploring a possible link between prenatal DES exposure and psychosexual issues. During the next several years, discussions on the DES-Sons tended to focus on cancer concerns and other physiological effects in exposed males, while DES-Trans tended to focus on psychosexuality and gender identity.
- In 2002, I was interviewed on the program GenderTalk Radio regarding my first discoveries of a possible link to transsexualism resulting from hormonal disturbances in males at birth.
- In March 2003, I participated in a transcribed telephone interview with DES researcher Dr. John McLachlan on the topic of feminization of males exposed to DES in-utero during the DES Update of the Centers for Disease Control (CDC).
- In 2003, I produced a thesis at UVic entitled “Hormones, Sexual Behavior, and Gender Identity in Human Development.”
- In 2003, I identified several historical medical research studies of transsexual patients (male to female) who were treated with DES, a practice that apparently was quite common in gender transition clinics prior to 1980. One example of such a study is “Mortality and Morbidity in Transsexual Patients with Cross-Gender Hormone Treatment“, by H. Asscheman, L.J.G. Gooren, and P.L.E. Eklund. I decided to pose a hypothesis that if DES was considered effective for the process of gender transition for male-to-female transsexuals, couldn’t prenatal exposure of the male fetus to DES also be implicated in subsequent gender variance during adulthood?
- In 2004, I presented preliminary findings from 5 years of research into prenatal exposure to the estrogenic drug DES (diethylstilbestrol) to the annual E.Hormone academic conference at Tulane University. A slideshow of this presentation is available, entitled “The Presence of Gender Dysphoria, Transsexualism, and Disorders of Sexual Differentiation in Males Prenatally Exposed to Diethylstilbestrol: Initial Evidence of a 5-Year Study.”
- During 2004, I received invaluable support and consultation from the world-renowned sexologist Dr. Milton Diamond, who indicated through email and telephone conversations that he had “long suspected that prenatal DES exposure had significant developmental effects on gender and sexuality development.” His advice was of tremendous assistance in helping to develop an action plan for making my research more visible to an international research community.
- In 2004, I served as a member of the faculty research committee for Christine Johnson, a master’s degree recipient at the Evergreen State University in Olympia, Washington. Johnson is a DES-Son who transitioned to female in her 20s. Johnson’s thesis is entitled Transsexualism: An Unacknowledged Endpoint of Developmental Endocrine Disruption? The full 212-page thesis is available here.
- In 2005 I presented an invited research paper Prenatal Diethylstilbestrol Exposure and Gender-Related Disorders: Results from a 5-Year Study to the International Behavioral Development Symposium which was consulted and supported by renowned sexologist Dr. Milton Diamond of the University of Hawaii School of Medicine and Dr. John McLachlan of Tulane University School of Medicine. I also participated in a radio interview on my research for KWMR Radio.
- An article which highlights my research was published in 2006 by Ernie Hood in Environmental Health Perspectives, “Are EDCs Blurring Issues of Gender?”.
- In 2006, Deborah Rudacille published The Riddle of Gender with a chapter summarizing my ongoing research. The chapter is titled “The Fear of a Pink Planet”. Several members of the DES Sons network, along with Dr. Milton Diamond, were interviewed for her book.
- In 2006, the Gender Identity Research and Education Society (GIRES) recognized prenatal DES exposure as a contributing factor in gender-related disorders in its comprehensive overview Atypical Gender Development–A Review.
2007 to the Present:
The initial findings from my research, presented to international conference (International Behavioral Development Symposium in Minot, North Dakota) in 2005, provided the opportunity to explore the validity of a hypothetical correlation between prenatal DES exposure in males and females and variations in core gender identity and sexual development across the lifespan. Meanwhile, the DES Sons Research Network and its companion DES-Trans Transgender Support Group have continued to be active into 2020.
For several years subsequently, the question of whether prenatal estrogenic hormone exposure in males can be directly linked to gender dysphoria, transexualism, transgenderism, intersex, and variations in sexual orientation has been further investigated by others. Though no definitive conclusion regarding the role of prenatal DES exposure in shaping psychosexual development in males and females has been reached, there is now (2020) a much broader array of promising investigative study devoted to this question. 25 years since beginning my own research investigation, I find this truly encouraging.
Here are some representative examples of others’ investigations and findings.
- New Research Indicates a Connection Between Genes, Hormones, and Gender Dysphoria (2020) from Newsweek, with the full research study published in the journal Nature: The Use of Whole Exome Sequencing in a Cohort of Transgender Individuals to Identify Rare Genetic Variants, 2019, by J. Graham Thiesen, et al.
- The Dissolution of Gender: The Role of Hormones (2019), byRobert J. Hedaya MD, DLFAPA, ABPN, CFM, published in Psychology Today
- Did DES Cause People to Be Transgender? (2018), published in Patheos.com
- Prenatal Androgen Exposure Associated with Male Psychosexual Development in Disorders of Sexual Development (2018), by R.L. Batista, published in the Journal of Clinical Endocrinology & Metabolism
- The Possible Link Between DES and Being Transgender in Later Life (2017)
- Thousands of People Believe DES is the Reason They are Transgender (2017 video news story)
- Endocrine Considerations in Transgender Youth (2016), by Deanna W. Adkins, MD, Duke University Children’s Hospital
- Special Report: Sexuality and Gender: Findings from the Biological, Psychological, and Social Sciences (2016), by Lawrence S. Mayer, MD and Paul R. McHugh, MD, of the Johns Hopkins University Medical School Department of Psychiatry
- Brody: Transgender Identity May Form in the Womb (2016), by Jane Brody, published in the International Herald Tribune
- Between (Gender) Lines: The Science of Transgender Identity (2016), by Katherine J. Wu, Harvard University Medical School
- A DES Victim Tells the Story of the Largest Drug Disaster in History (2016)
- Petition Asking the FDA to Recognize That Hormone Treatment During Pregnancy Can Cause Intersex and Transgender(2014)
- Gender Identity and DES Exposure (2011), from Diethylstilbestrol.UK
- DES’ Other Daughters, by Dana Beyer, M.D. (2008)
- Gender Identity Disorder: General Overview and Surgical Treatment for Vaginoplasty in Male-to-Female Transsexuals(2005), by Gennaro Selvaggi, MD, et al., published in the journal Plastic Reconstructive Surgery
- (Historical) He and She: The Sex Hormones and Behavior(1972), by Maggie Scarf, published in the New York Times
Other Published Research Into Prenatal Influences on Sexual Orientation and Gender Identity:
- A Short Review of Biological Research on the Development of Sexual Orientation (2020), by Anthony F.Bogaert and Malvina N.Skorska, published in Hormones and Behavior
- Neuroendocrine Influences on Human Sexuality (2019), by Ashlyn Swift-Gallant and S. Marc Breedlove, published in the Oxford Research Encyclopedia: Neuroscience
- Neurobiology of Gender Identity and Sexual Orientation(2018), by C. E. Roselli, published in the Journal of Neuroendocrinology
- Prenatal Influences on Human Sexual Orientation: Expectations versus Data (2017), by Marc S. Breedlove, published in Archives of Sexual Behavior
- Prenatal Exposure to Progesterone Affects Sexual Orientation in Humans (2017), by June M. Reinisch, Erik Lykke Mortensen & Stephanie A. Sanders, published in the Archives of Sexual Behavior
- The Biologic Basis of Transgender Identity: 2D:4D Finger Length Ratios Implicate a Role for Prenatal Androgen Activity (2017), by Matthew Leinung, MD & Christina Wu, published in the journal Endocrine Practice
- Prenatal Androgens in Men’s Sexual Orientation: Evidence for a More Nuanced Role?(2016), by Malvina N. Skorska & Anthony F. Bogaert, published in the Archives of Sexual Behavior
- Sexual Orientation, Controversy, and Science (2016), by J. Michael Bailey, et al., published in Psychological Science in the Public Interest
- Update on the Biology of Transgender Identity (2013), by Laura Erickson-Schroth MD MA, published in the Journal of Gay and Lesbian Mental Health
- Gender Development and the Human Brain (2011), by Melissa Hines, published in Annual Review of Neuroscience
- Prenatal Testosterone and Gender-Related Behavior (2006), by Melissa Hines, published in the European Journal of Endocrinology
- Sexual Differentiation of the Human Brain: Relevance for Gender Identity,
- Transsexualism and Sexual Orientation (2004), by D.F. Swaab, published in Gynecological Endocrinology
2020: Newest published research into prenatally DES-exposed males and females:
Gender Identity and Sexual Orientation Identity in Women and Men Prenatally Exposed to Diethylstilbestrol (2020), by Rebecca Troisi, et al., published in the Archives of Sexual Behavior.
My Observations on this Publication:
(1) This “study” was based on a single-question methodology in 2019 for sexual orientation and gender identification, using the long-term DES Combined Cohort Study of DES Sons and DES Daughters, funded by the National Cancer Institute. Such a methodology is often used by researchers who wish to place limits on any controversial or previously unexpected findings that might interfere with their dominant research focus. In the case of the DES Combined Cohort, the NCI-funded research has always emphasized an effort to statistically measure trends in cancer prevalence in DES Sons, DES Daughers, and DES Mothers. To the best of my knowledge, the Combined Cohorts are the only current population samples of DES Sons and DES Daughters in the U.S. that are still being monitored systematically.
(2) The timing and motivation and purpose for this “study” is intriguing to me. I believe it has been driven by politics, not science. It has come at a time (2019/20) while the U.S. is experiencing a phase of severe anti-transgender and anti-LGBTQ politics within the current Trump administration. Of special note is that the current Secretary of the U.S. Department of Health and Human Services, Alex Azar, was President of the U.S. division of Eli Lilly and Company between 2012 and 2017. Lilly was the largest producer of DES in the U.S. for many years. There is no doubt in my mind that Azar must have been aware of various stories regarding DES adverse health effects because over the years, Lilly has faced several lawsuits.
(3) As with most research on DES Combined Cohorts, this study does not have a sophisticated foundational understanding of prenatal hormones and psychosexual development. However, I suspect it is now being used by HHS or NCI as a “definitive study” of this question, meant to “put to bed any ‘rumors’ that DES exposure might be implicated in any “controversial” adverse effects.
(4) In 2003, a time when the right-wing George W. Bush administration (the Bush family had deep financial connections with Eli Lilly going back to the administration of George H.W. Bush) was overseeing DHHS and Bush was accused of politicizing the agency with right-wing bias, a similar NCI-funded “study” was published by long-time DES cohort researchers Linda Titus-Ernstoff et al., Psychosexual Characteristics of Men and Women Exposed Prenatally to Diethylstilbestrol. The article’s conclusion: “our findings provide little support for the hypothesis that prenatal exposure to DES influences the psychosexual characteristics of adult men and women.” No small irony, many of the researchers in the 2003 study (based also on the DES Combined Cohorts) are cancer research specialists, and none are sexuality experts. I personally participated in the 2003 “CDC DES Update Conference” which included a call-in portion for audience participants, and I along with several other participants challenged the 2003 study for its anti-LGBTQ biases. Titus-Ernstoff and other presenters confirmed that the focus on the DES Cohort studies was to assess cancer risk and outcomes and that other subjects were just not deeply or systematically investigated.
(5) The 2020 publication is not a reference standard on measuring the true scope of psychosexual effects of prenatal DES exposure in males and females. In my own research with DES sons, I learned that many have a history of suffering from gender dysphoria that is not easily measured by a simple question in a survey.