Can sex selection be ethically tolerated? Prohibition on sex selection may well be unnecessary and oppressive as well as posing risks to women’s lives. BM Dickens.J Med Ethics 2002; 28: 335-336.

The urge to select children’s sex is not new and may be traced back to the Sth century. Effective pre-natal determination of gender through amniocentesis became available in 1 970s. Decriminalisation of abortion afforded choice about continuation of pregnancy. Recently preimplantation genetic diagnosis (PGD) eliminated the need for abortion for gender selection, and improved techniques of sperm sorting have ensured the sex of the foetus. These new techniques make preselection of gender acceptable to those opposed to abortion.

Availability of biomedical means to select the sex of future children has been accompanied by fears that such means will be employed to favour births of sons, and so perpetuate devaluation of daughters. A reaction to this fear has been the demand for legal sanctions against sex selection techniques.

In light of decreasing sex (F:M) ratios in India, China, and other countries where son preference is predominant, many have envisioned the use of techniques of sex selection only as reinforcing male domination.

Many feminists consider choice in abortion to underpin women’s self determination. “most feminists resist attempts to offer general rules for determining when abortion is justified …. , and most feminists agree that women must gain full control over their own reproductive lives if they are to free themselves from male dominance.”

A 1993 Canadian Royal Commission on New Reproductive Technologies reported that a desire to balance the family was the major motive behind gender pre-selection in Canada. Nevertheless, invoking perceived feminist values, the commissioners recommended criminalisation of the use of sex selection techniques. This was incorporated in a law, comparable to the 19941ndian law, introduced in May 2002 in Canada.

However, the intention of a couple with a child of one sex to have another child of the other sex is a sexual but not a sexist preference. To suppose that any such choice is necessarily sexist is unjust, and to base laws introducing criminal penalties on such a supposition where the evidence that an assumption of “a pro-male bias … appears to be unfounded” is both unjust and oppressive.

Until sexist Indian society remedies its son preference, the prohibition of sex selection predominantly burdens women’s lives. If wives cannot resist demands that they deliver sons, they have to bear successive pregnancies until they do. Early marriage and a quick succession of pregnancies contribute significantly to the risk of maternal mortality and morbidity. A World Health Organisation (WHO) report notes “the disturbing statistics of maternal mortality for developing countries, where women are more than 400 times more likely to die from complications during pregnancy (than) women in Southern Europe:The risk to unplanned girl children is of early death due to infanticide, malnutrition, or neglect.

Attempts to end son preference by prohibition of sex selection are failing in India, and, on their own, do not relieve sex bias. Sex bias must be tackled at more fundamental social, economic, political, and legal levels. Prohibitions are unnecessary and oppressive where there is no sex bias but only a wish to balance a family with children of both sexes. Where bias remains, prohibitions pose risks to women’s and girl children’s lives and health.

Commentary

The article raises important Issues about individual autonomy and society’s need to have a balanced population. “Political correctness” compels countries to enact laws which severely limit individual choice even when there is no demographic need to do so, as in Canada.

Does the government have a legitimate interest in limiting population?

Those of us born before 1950 represent the first generation to witness a doubling of the world population in their life time. According to a 1998 World Watch Institute Report (1), the progressively declining per capita arable land and depletion of the aquifer around the world from overuse are likely to further reduce per capita grain production and lead to widespread malnutrition, particularly in the socio-economic underclass. Clearly, most governments need to control population growth.

If we accept that governments have a legitimate interest in managing population size, then managing family size follows. The more prosperous families readily adopt this philosophy. Limiting the number of children allows a family to provide better nutrition, education and other resources to each child. As the economic status of the family improves, particularly when the wife is also educated and gainfully employed, families tend to get smaller. Thus, in India today, many, if not most, middle and upper-middle class families have only one or two children. This desire to limit family size coupled with preference for a male child, has increased the use of medical technology for sex selection among the well-to-do.

In contrast, this rationale to balance the family and also to limit family size does not appeal to a poor family. In the absence of government-supported social security, sons make the best survival strategy for poor families, providing current economic advantage and old-age security. Daughters may contribute to the family’s earnings now but have to be married off with dowries that drain family resources and once they are part of the husbands’ families, they can rarely provide security to parents as they age. Prof Ashish Bose, a leading demographer, thinks “the government’s two-child norm and female foeticide have gotten mixed up” (2). The slogan ‘Hum do hamare do’ yields three possibilities – two sons, two daughters, or one son and one daughter. Two daughters are culturally unacceptable, and while one son and one daughter are tolerable, the ideal situation people strive for is two sons (2). Prof Bose feels that if the policy were relaxed, there would be fewer female foeticides. But it is equally likely that even if the government were to relax its two-child norm, poor families may still want all boys for even greater security, keeping the sex ratio skewed with a higher population.

Without addressing the underlying cause for sex predetermination services, putting the entire focus for the declining sex ratio on the medical profession alone is erroneous and counterproductive. Even before the 1980s when sex determination through amniocentesis became easily available, families expressed their son preference through female infanticide or deliberate neglect of girl children’s nutrition and health, leading to greater mortality of females in the 1-6 year group. These practices are even crueler than sex determination and abortion.

Perhaps,amniocentesis and abortion are morally less repugnant than neglect or murder. This may have contributed to the decline of the sex ratio over the last decade. Once a technology is widely known and available, it is very difficult to prevent its use. If the technology is outlawed, people will find ways to circumvent the act -like asking for amniocentesis for medical reasons (spurious hereditary diseases, fictitious complications in early pregnancy, etc) and abortions may move from safe environments to back-alley practitioners resulting in an even higher maternal mortality.

Is banning amniocentesis and abortion of female foetuses the only way to reverse the declining sex ratio?

Rather than banning PGDor amniocentesis for sex determination followed by abortion, can we not try to put in checks and balances? The government could make these procedures available at little or no cost in government facilities to poor families who want to limit their family size as well as balance their family. Private facilities for the well-to-do would have to follow the same rule of offering it only for the sex determination of the second child. Additionally, heavy monetary penalties for the families as well as physicians, who misuse the test to have male children only, would be a deterrent. This could be combined with imaginative use of “carrots” to improve the sex ratio. For poor families, a monthly rice subsidy for every girl child that remains in school- as in Bangladesh (2)– may be attractive enough to have at least one girl for every boy in the family. For the more well-to do, a different “carrot” may be needed, such as preference in college admission, jobs, etc.

There is another ethical dilemma to be considered. Should society’s need for a greater number of women be fulfilled at the cost of an individual woman’s desire to determine the sex of her child?

How do we justify the forced carrying to term of an unwanted female foetus who will continue to suffer emotional and physical deprivation as an unwanted child all her life? Why must hundreds of thousands of women and their female children suffer now so that Indian society has the requisite sex ratio today? Why can’t we wait for improved education and economic status to balance the sex ratio over the next 50 years?

China was unwilling to wait for its population to decline at a slow rate so it imposed what most considered an inhuman law limiting couples to just one child. Is forced carrying to term of a female child any less inhuman?