By Alice Dreger, Ellen K. Feder, Anne Tamar-Mattis
Two weeks ago, Time magazine reported on our ongoing efforts to protect the rights of pregnant women offered dexamethasone, a risky Class C steroid aimed at female fetuses that may have a form of congenital adrenal hyperplasia (CAH). It appears many women and children exposed to dexamethasone through this off-label use are not being enrolled in controlled clinical trials with IRB oversight, in spite of a persistent consensus among experts that this is the only way this treatment should be happening.
We have learned that, this August, the Journal of Clinical Endocrinology & Metabolism will publish an expert consensus again stating this use of prenatal dexamethasone should only happen via IRB-approved clinical trials through research centers large enough to obtain meaningful data. An announcement of the consensus came at the Endocrine Society's meeting in San Diego last week (and an earlier version is available here).
This consensus has been endorsed by the American Academy of Pediatrics, the Lawson Wilkins Pediatric Endocrine Society, the European Society for Paediatric Endocrinology, the European Society of Endocrinology, the Society of Pediatric Urology, the Androgen Excess and PCOS Society, and the CARES Foundation. It was reached after review of the existing literature and consultation with researchers indicated significant cause for concern, including the fact that most of the children treated prenatally have been absent from follow-up studies.
The majority of researchers and clinicians interested in the use of prenatal “dex” focus on preventing development of ambiguous genitalia in girls with CAH. CAH results in an excess of androgens prenatally, and this can lead to a “masculinizing” of a female fetus's genitals. One group of researchers, however, seems to be suggesting that prenatal dex also might prevent affected girls from turning out to be homosexual or bisexual.
Pediatric endocrinologist Maria New, of Mount Sinai School of Medicine and Florida International University, and her long-time collaborator, psychologist Heino F. L. Meyer-Bahlburg, of Columbia University, have been tracing evidence for the influence of prenatal androgens in sexual orientation. In a paper entitled “Sexual Orientation in Women with Classical or Non-Classical Congenital Adrenal Hyperplasia as a Function of Degree of Prenatal Androgen Excess” published in 2008 in Archives of Sexual Behavior, Meyer-Bahlburg and New (with two others) gather evidence of “a dose-response relationship of androgens with sexual orientation” through a study of women with various forms of CAH.
They specifically point to reasons to believe that it is prenatal androgens that have an impact on the development of sexual orientation. The authors write, "Most women were heterosexual, but the rates of bisexual and homosexual orientation were increased above controls . . . and correlated with the degree of prenatal androgenization.”
They go on to suggest that the work might offer some insight into the influence of prenatal hormones on the development of sexual orientation in general. “That this may apply also to sexual orientation in at least a subgroup of women is suggested by the fact that earlier research has repeatedly shown that about one-third of homosexual women have (modestly) increased levels of androgens.” They “conclude that the findings support a sexual-differentiation perspective involving prenatal androgens on the development of sexual orientation.”
And it isn't just that many women with CAH have a lower interest, compared to other women, in having sex with men. In another paper entitled “What Causes Low Rates of Child-Bearing in Congenital Adrenal Hyperplasia?” Meyer-Bahlburg writes that “CAH women as a group have a lower interest than controls in getting married and performing the traditional child-care/housewife role. As children, they show an unusually low interest in engaging in maternal play with baby dolls, and their interest in caring for infants, the frequency of daydreams or fantasies of pregnancy and motherhood, or the expressed wish of experiencing pregnancy and having children of their own appear to be relatively low in all age groups.”
In the same article, Meyer-Bahlburg suggests that treatments with prenatal dexamethasone might cause these girls' behavior to be closer to the expectation of heterosexual norms: “Long term follow-up studies of the behavioral outcome will show whether dexamethasone treatment also prevents the effects of prenatal androgens on brain and behavior.”
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