• Medical Survey on Effects of Stilboestrol (DES) in Children (DES Daughters and Granddaughters)

    Diethylstilbestrol (DES) is a synthetic estrogen that was prescribed to pregnant women (DES mothers) from the 1940s to the early 1970s to prevent miscarriage and also as a lactation suppressant in mothers who were forced to give up their babies for adoption. This survey has been put together by Origins SPSA t/a Origins Australia to ascertain what, if any, long-term medical and health problems have arisen in the children of these mothers (DES daughters and sons) who were exposed to DES in utero. The results of the survey will be collated and presented to the government, research organisations, and the media so that the medical profession becomes publicly aware of repercussions to both the mothers and their subsequent children and grandchildren. It will then be presented to future government inquiries as further evidence of the harm caused by this medication generally, as the administration of this medication in the context of forced adoption practices. All information to us will be handled with the strictest confidence and end-to-end encryption is used to secure your data. Your information will be used in accordance with our Privacy Policy, which you can find on our website at www.originsnsw.com

  • SECTION A: Contact Information

    **NOTE THIS FORM IS FOR DES DAUGHTERS AND GRANDDAUGHTERS - FOR DES SONS AND GRANDSONS, PLEASE REFER TO THE RELEVANT FORM ON https://www.originsaustralia.org**
  • Format: (000) 000-0000.
  • Date of birth.*
     - -
  • Do you identify as a (select all that apply):*
  • If you are the parent or Legal Guardian of a DES Granddaughter, please indicate the grandchild's date of birth:
     - -
  • If you are a DES Daughter, are you an adoptee?*
  • If you are a DES Granddaughter, was your mother or father an adoptee?*
  • If you are a DES Daughter, please indicate how you came to discover that your mother was exposed to stilbesterol (DES) while you were in utero*
  • If you are a DES granddaughter, please indicate how you became aware of your status*
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  • Do you consent to be contacted at a future date by Origins and any research partners it engages to provide further information regarding your responses to this survey? Further participation will enable Origins to conduct further research regarding the long-term effects from the administration of Stilboestrol to DES mothers, and the effects on their children and grandchildren.*

  • SECTION B - DES Daughters and Granddaughters

    Parents/Legal guardians can complete the following questions on behalf of a minor DES granddaughter
  • Have your periods always been:
  • Are you taking the birth control pill?
  • Are you taking HRT?
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  • Should be Empty: