Sex Selection: The Systematic Elimination of Girls

Abstract

Abstract

In strongly patriarchal societies, where the cultural and economic value of sons is at a premium, son preference manifests itself in many ways, ranging from differential allocation of household resources, medical care and neglect of girl children to female infanticide. With the increasing availability of ultrasound in the mid-1980s sex determination followed by sex-selective abortion began to become widespread as well. The following paper introduces this Roundtable and discusses the following questions: Is sex selection a part of women's right to free choice and control over their reproduction? What is the role of the medical profession? Are all manifestations of sex selection equally unethical? Are there solutions? Do the solutions themselves pose new ethical dilemmas? Following this paper, four respondents put different points of view on sex selection as a gender-based preference for a pregnancy; progress in getting the Supreme Court of India to implement a 1994 law regulating the use of antenatal diagnostic technology; why sex selection should be available as a form of reproductive choice; and why sex selection may be empowering for women and justify their actions in the short run, given the demands on them. All agree that only improved status for women and girls will reduce the demand for sex selection.

Résumé

Dans les sociétés patriarcales, où la valeur culturelle et économique des fils est supérieure, la préférence pour les garçons se manifeste de différentes manières, depuis l'allocation différentielle des ressources du ménage et des soins médicaux jusqu'à l'abandon et l'infanticide des filles. Avec la disponibilité accrue des échographies à la moitié des années 80, la détermination du sexe du fœtus suivie de l'avortement sélectif selon le sexe est devenue plus fréquente. L'article présente la table ronde et aborde plusieurs questions: la sélection selon le sexe fait-elle partie du droit des femmes au libre choix et à la maı̂trise de la reproduction? Quel est le rôle de la profession médicale? Toutes les manifestations de cette sélection sont-elles contraires à l'éthique? Y a-t-il des solutions? Les solutions posent-elles de nouveaux dilemmes moraux? Après l'article, quatre répondants donnent différents points de vue sur la sélection selon le sexe qui influence le désir de mener la grossesse à terme; les progrès pour obtenir de la Cour suprême indienne l'application d'une loi de 1994 régulant l'utilisation de la technologie de diagnostic prénatal; pourquoi la sélection selon le sexe devrait être disponible comme forme de choix reproducteur; et pourquoi la sélection selon le sexe peut aider les femmes et justifier leurs actions à court terme, compte tenu des exigences auxquelles elles doivent répondre. Tous les intervenants pensent que seule une amélioration de la condition des femmes et des filles réduira la demande de sélection selon le sexe.

Resumen

En las sociedades extremadamente patriarcales, donde se le otorga un valor económico y cultural muy alto a los hijos varones, se manifiesta esta preferencia de muchas maneras, desde la distribución diferenciada de los recursos domésticos y la atención médica hasta el abandono de las hijas y la infanticida femenina. A partir de la creciente disponibilidad de la ecografı́a a mediados de los años 80, se empezó a generalizar la determinación del sexo seguido por el aborto selectivo. Como introducción a la Mesa Redonda, este artı́culo aborda las siguientes preguntas: `Es la selección de sexo parte del derecho de la mujer a la opción libre y al control sobre su reproducción? ¿Cuál es el papel de la profesión médica? ¿Son igualmente inéticas todas las manifestaciones de selección de sexo? ¿Hay soluciones? ¿Plantean dichas soluciones nuevos dilemas éticos? Los cuatro comentarios a continuación aportan diferentes puntos de vista acerca de la selección de sexo: como preferencia de género de un embarazo; los avances hacia la implementación de parte de la Corte Suprema de la India de una ley del año 1994 que reglamenta el uso de la tecnologı́a diagnóstica prenatal; por qué la selección de sexo debe estar disponible como una opción reproductiva; y por qué la selección de sexo puede empoderar a las mujeres y justificar sus acciones a corto plazo, considerando las exigencias a que están sujetas. Todos están de acuerdo en que la única forma de disminuir la demanda para la selección de sexo es mejorar la condición de la mujer y las niñas.

The provisional sex ratio figures (number of females per 1000 males) from the 2001 Census of India reveal an increase in the overall sex ratio from 927 in 1991 to 933 in 2001. That is the good news. The worrying news is that the child (0–6 years) sex ratio has fallen markedly from 945 in 1991 to 927 in 2001 [1]. Worse still, sex ratios are the lowest ever in some of the more affluent states of the country, e.g. Maharashtra (917), Gujarat (878), Punjab (793) and Haryana (865). In strongly patriarchal societies, where the cultural and economic value of sons is at a premium, son preference manifests itself in many ways, ranging from differential allocation of household resources, medical care and neglect of girl children to female infanticide. Infanticide has been practised for centuries and still exists in some areas of India [2][3]. Son preference may modify contraceptive use [4] and result in increased family size in high fertility settings. As increasing urbanization and economic as well as state imposed pressures move families towards a one-two child norm, the technology for antenatal diagnosis of sex is becoming widely available. Son preference is increasingly being expressed through the use of antenatal technology for sex determination or sex selection. Sex selective abortion (termed female feticide by some) is thought to be most prevalent in India, China, Taiwan and Korea [5][6][7]. It may exist even where legislation restricts abortion services, as in Pakistan and Nepal [5][8] and may be an issue in Vietnam as well [9][10].

The use of sex selection techniques

Predicting the sex of the child has always been practised and many traditional diagnostic methods exist. According to Indian Ayurvedic principles, the sex of the child is not fixed until three months and can be altered by medicines and rituals in early pregnancy [11]. Sex selective abortion was first documented in India in the 1970s with the advent of amniocentesis. Chromosomal analysis of amniotic fluid was developed for the diagnosis of sex-linked genetic disorders, but almost immediately it began to be used in genetic clinics for determining sex in order to avoid the birth of girls. One of the earliest studies on the subject found that 430 of the 450 women in an urban clinic in India who were told that the sex of the baby was female went on to have an abortion, whereas all 250 cases where the fetus was male carried their pregnancies to term, even with risk of genetic disorders [12].

The use of amniocentesis for this purpose, however, remained a limited phenomenon confined to some urban areas. It was only with the increasing availability of ultrasound in the mid-1980s that sex determination became widespread [13][14][15][16]. Sex ratios at birth began to rise significantly above expected norms (107 males: 100 females) in parts of India, South Korea, China and Taiwan [6][7]. While the use of this technology may be more widespread in rapidly urbanizing areas, its use has also spread to rural areas. For example, in one large community-based study in rural Maharashtra in India, one out of every six married women who had an abortion in the previous 18 months said the abortion had been subsequent to a sex determination test showing a female fetus [17]. In a study in rural China, of 820 women surveyed, 36% of the 301 who reported induced abortions (109) acknowledged them to be female sex-selective abortions [18]. Evidence suggests that such abortions are being used predominantly by those with one or more living daughters, but no living sons [16][17][19]. However, one study in North India found distortions in the sex ratio even among first births [20] and over a quarter of the women having sex selective abortions in a study in western India already had a living son [17].

Sex detection with amniocentesis is done at around 18–20 weeks. With ultrasound imaging, fetal sex can be determined at around 13–14 weeks, although accuracy improves with increased gestation [21][22]. With chorionic villus sampling (CVS) becoming popular in the 1990s, the more affluent have had access to a technique that determines sex as early as 6–7 weeks of pregnancy.

Newer technologies now allow sex selection prior to conception, e.g. techniques for separation of the X-bearing and Y-bearing sperm to use one or the other for in vitro fertilization (IVF) or artificial insemination. Methods for determination of the sex of embryos prior to implantation following IVF are also becoming a more accurate, albeit expensive, alternative.

Is sex selection a part of women's right to free choice and control over their reproduction?

All of us who believe in women's reproductive rights and women's autonomy will argue that a woman should have the right to choose whether to terminate a pregnancy or not, regardless of the reason [23]. Yet we also need to look more closely at the nature of “choice” in the decision to select for sex.

Micro-studies have shown that women themselves accept and endorse sex selection. But a deeper look reveals how loaded the choices are. The decision is often a response to intense pressure to produce male heirs, often through implicit threats of violence or husband's remarriage [17][24]. Sometimes the pressure is more overt and against the wishes of the woman; she is often advised by family and a medical professional to postpone the decision to have an early abortion until sex determination can confirm that she is not carrying a male child. In fact, a recent study in India compared women having abortions on grounds of fetal sex to those having abortions for other reasons; the former had relatively less autonomy and mobility, and were less likely to play a major role in family decision-making [17].

Women make choices about their reproductive lives in the context of their families and communities. If women live within the structures of a patriarchal system that does not favour the birth of a female child, are their “choices” free and volitional or a response to the pressures of a society that systematically discriminates against girls and women?

Even for those of us who argue that a choice even in such circumstances is a choice, this brings us to an even bigger dilemma. How are individual choice and reproductive rights to be situated when they take place in a gender-biased society? Can the individual woman's right to select the sex of her children take precedence over the right to justice and equality, which are clearly violated when society favours systematic gender-based discrimination?

The argument is more than one of confronting an ethical dilemma and contradiction. In real terms, if sex selective abortions (and other forms of sex selection) are allowed freely, sex ratios will, and indeed already are dropping precipitously. What effects will this have on women in society in the long run? If girls are systematically eliminated from society, the long-term effects of a declining sex ratio may make women more of a “commodity” or increase violent crimes against them. The argument that the decrease in females at a population level will increase the status of women in the long run [20] is not borne out by any evidence in any society or area where sex ratios are declining. As Greenhalgh and Li [25] state, this outcome cannot be taken for granted:

“The hope for an eventual, demographic evening of gender relations should not divert attention from the injuries of gender that are being inflicted today.” [25]

The medical profession and sex selection

While women opt for sex selection out of choice or force of circumstances, doctors who promote and offer sex selection are often driven by profit motives. Some justify their decision to provide sex selection services by saying they are helping people to balance the sex distribution of their families [9] or that by contributing to the decline in the female population, they are ultimately raising the status of women [20]. Other doctors say they do it for humanitarian reasons, helping to relieve the woman and her family of economic and social burdens, especially if they already have girl children. [26]. Still others suggest that sex selection [27] is a pathway to safe motherhood and contributes to population control.¹ However, there is no denying that sex selection is immensely lucrative [28] and has led to the proliferation of ultrasound clinics all over India, even in remote rural communities without access to other basic health facilities.

We feel strongly that doctors should not profit from unethical practices. Yes, doctors are a product of the same societies that value sons above daughters and may have the same values, but unlike women they are not victims of societal structures. With the power to use medical technology also comes the responsibility to prevent its abuse. Justifying the use of sex selection because there is a demand is reprehensible; indeed, the willingness of doctors to use the technology to fulfill a `need' contributes to `demand' and reinforces and legitimizes sex discrimination.

Are all manifestations of sex selection equally unethical?

While much of the debate around sex selection has focused on sex selective abortions, it is important to recognize that this is only one manifestation of sex selection, which exists along a continuum from pre-conception selection to infanticide, discrimination against and neglect of the girl child.

Some demographers and other public health researchers condone sex selective abortion by saying that it may actually reduce post-natal discrimination against girl children [29]. Sex selective abortion may indeed be a substitute for female infanticide, but does that make it a legitimate means of dealing with the latter? The same `substitution' argument could be used in defence of peri-conception sex selection, and because abortion is not involved, could be considered outside the realm of moral questioning. These arguments miss the core of the problem – the fact that these practices are symptomatic of the devaluation of women.

Are there solutions? Do the solutions themselves pose new ethical dilemmas?

Interventions have till now largely focused on legislative responses. Laws against infanticide exist in all countries. Several countries have also taken legal measures to curb sex selective abortion. Korea banned prenatal sex detection as early as 1987. China followed in 1989 [6]. The Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994, which came into force from January 1996, made the practice illegal in India. Most of these laws ban the various sex determination tests but not abortions subsequent to a test. All of these countries have liberal abortion laws; in Korea abortion is available on request and in India abortion on a range of social and medical grounds (including risk to the woman's mental health), taking into account her environment. Women seeking an abortion on grounds of fetal sex can of course give other reasons, it being almost impossible to link the abortion intent to a previous sex determination test – especially since ultrasound is done in pregnancy for other diagnostic reasons.

Would reverting liberal abortion policies then, be a way to eliminate sex selection? We think not. An abortion for sex selection is inherently different from other abortions. Indeed in these situations, the pregnancy is wanted, not unwanted, provided it can result in the outcome perceived as valuable – a male child. The majority of abortions, even in countries where sex selection is a major issue, still occur because of unwanted pregnancy, whether it is because of a lack of information or access to effective contraceptive options or because pregnancy prevention efforts have failed [30]. Understanding and maintaining this distinction is critical if we do not want our opposition to sex selective abortion to result in an indiscriminate backlash against progress made to achieve access to safe abortion care. There is also an inherent danger that banning one type of abortion is the first step down a slippery slope that can hamper access to safe abortion per se.

Kishwar points out [31] that laws are not likely to be effective in society where son preference is strong and deeply embedded in patriarchal structures. They are difficult to implement, allow for a sense of complacency and encourage corruption. Practices, if they move underground, also expose women to unsafe medical conditions and monetary exploitation. Under the Indian legislation, it is assumed that unless proven otherwise, a woman seeking a sex determination test is not doing so of her own volition and should not be penalized. But like Kishwar, we too remain concerned about the possibility that legislative responses to this practice threaten to victimize further the female sex we seek to protect – i.e. by their families if they do not produce a male heir and by the law if they seek the means to do so.

Laws should not blind us, as Sabu George, a long-time activist in India, said, to the need for `aggressive gender justice' to challenge patriarchal norms and address the root causes of devaluation of daughters. As long as we address the symptom and not the cause, technology is going to support the expression of gender discrimination. There is no doubt that unless patriarchal norms of society are challenged and women valued, the desire to do away with girl children will remain.

These are changes that will not happen overnight, however, and gender justice cannot wait until society at large is ready to accept it as a defining moral value. Therein comes the need to regulate the manifestations of this discrimination, even though none of these measures is perfect and none addresses the root causes of the systematic devaluation of women. Laws regulating the use of reproductive technology and making the medical profession accountable must be implemented. To hope for self-regulation by the medical community seems unrealistic.

Is sex selection in a non-patriarchal society ethical?

If we lived in a society free from gender bias, where both sexes were valued equally, could we then say that sex selection – whether through abortion or peri-conception techniques – was no longer an ethical matter but simply one of preference and individual choice? Let us examine this in the context of the recent statement of the American Society for Reproductive Medicine, which establishes positions on ethical issues for clinicians in the USA. In September 2001, they stated:

`[It is] sometimes acceptable for couples to choose the sex of their children by selecting either male or female embryos and discarding the rest.' [32]

While sex selection in the Western world might not be biased against girls per se, the Western world has large immigrant communities from countries with a strong cultural preference for sons. Immigration to a different culture does not necessarily change a community's cultural norms; thus, clinics offering antenatal sex determination tests to South Asian émigrés are also flourishing in North America [5][33].

Profit motives are operative in these so-called non-patriarchal contexts as well, and they drive the development of technologies that can be marketed in societies where son preference is widespread. Witness the recent advertisements in Indian daily newspapers touting a “Gen-Select” kit, developed by US-based physicians, that ostensibly allows couples to choose the sex of their next child [34]. Here too, the effect is anti-women.

If we lived in an idealised world where male and female babies universally had the same status, could we justify sex selection on the basis of an individual family's desire to balance the family? Would it follow that other criteria – wanting a blonde child, a light-skinned child, an athletic child, etc. are all equally valid ways to select children? If technology were available, would these be acceptable too?

If the ultimate desire is to have a healthy child, we do not believe that selection on the basis of any criteria, sex or otherwise (excluding genetic and congenital disorders) is justified. The world is value-laden and full of preferences. To be able to select on the grounds of such preferences encourages society to perpetuate its culturally constructed devaluation of particular human characteristics, in this case female sex.

Notes

1 The authors have defined natural sex selection to be the timing of coitus in relation to ovulation. Since X and Y sperms migrate at different rates towards the ovum, the authors propose that pre-ovulation coitus will most likely result in a female fetus and post-ovulation coitus in a male fetus.