A Delicate Balancing Act

There has been a lot of discussion about fertility treatments in both the popular press and the medical literature of late.

This discussion has been driven in part by debates about the Affordable Care Act, including questions as to whether or not it should cover fertility treatment for socioeconomically disadvantaged prospective parents. But the discussion has also been driven by recent announcements by companies like Facebook and Apple that they will begin offering cryopreservation of eggs to female employees as part of their health-insurance plans.

Adding to the debate over reproductive rights is a recent article in the Wall Street Journal, which purported that an increasing number of patients are seeking fertility treatment not because they are having difficulty getting pregnant but rather for the purposes of sex-selection. Specifically, they want to choose the sex of their child.

There are some valid medical reasons why prospective parents might want to choose the sex of their child. For instance, they may want to have a girl if they are known to be carriers of diseases like hemophila or Duchenne muscular dystrophy. These diseases are linked to genes that are located on the X-chromosome, and they affect males almost exclusively. The mother, who carries two copies of the X-chromosome, is unaffected. So are her daughters, although they too may be carriers of the trait. Her sons, however, only have one copy of the X-chromosome and thus have a 1-in-2 chance of inheriting these severe disorders.

But in the absence of a known risk of transmitting a serious X-linked disease, the only reasons for seeking fertility treatment for the purposes of sex-selection are likely to be social, and there in lies the issue. Should parents, particularly those with the financial resources to seek fertility treatment, be allowed to choose the sex of their child?

Not surprisingly, opinions about non-medical sex selection in the United States are mixed. The American Congress of Obstetricians and Gynecologists opposes the practice of non-medical sex selection. Renowned American bioethicist Art Caplan agrees with this position, worrying that allowing parents to choose the sex of their child is akin to “opening the door to a potential slope toward eugenics.” By contrast, the American Society for Reproductive Medicine takes a much more nuanced non-position position, concluding that physicians are under “no ethical obligation to provide or refuse to provide non-medically indicated methods of sex selection.”

There are a number of ethical, political, and philosophical reasons why people oppose non-medical sex selection, but the strongest argument against it is that it distorts the natural sex ratio and leads to a socially disruptive imbalance of the sexes when practiced on a large scale.

In many cultures, a variety of social, religious and socioeconomic factors result in a preference for boys. Particularly in Asia and the Middle East, this cultural preference, coupled with access to modern medical technologies, has lead to severe sex ratio imbalances in numerous countries.

In India, for example, thousands of girls are aborted, abandoned, neglected or killed after birth. The introduction of prenatal testing and selective abortion has also skewed the sex ratio to such an extent that there are now fewer than 800 girls for every 1000 boys in some rural regions of India. In response, the Indian government recently amended the Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act to include a ban on preconception sex selection techniques.

Similar sex ratio imbalances are seen in other countries. For instance, for every 100 females, there are 121 males in China, 122 males in Saudi Arabia, and 210 males in the United Arab Emirates. The long-term impact of these sex ratio imbalances is unknown, but some sociologists have warned that there will be increasing social unrest, leading to national and even international security problems, as these surplus male populations reach adulthood.

Like India, most of these countries have passed laws that restrict the use of sex selection technologies, either banning them outright or limiting their use to medical reasons. Similarly, most European countries have laws or policies that essentially criminalize sex selection for non-medical purposes. There are, however, few laws that regulate non-medical sex selection in the United States. Federal authority to regulate the use of artificial reproductive technologies is limited, and state-level regulations are limited to a handful of bans on the use abortion for sex selection.

While a few organizations and groups have recommended that the federal government consider new regulations that would limit the use of sex selective procedures to situations of medical need, in my opinion such laws are both unneeded and unwarranted. The federal government would have the authority to regulate or ban the use these technologies only if there were clear evidence that socially driven sex selection was going to upset the sex ratio in the United States and lead to social harms. This is not case.

Several surveys have found that a majority of Americans do not have a strong preference for children of a particular gender. Of those few survey respondents who did express an interest in choosing the sex of their children, most would do so primarily for family balancing: the desire to have a balanced sex composition among their kids. These results are supported by data from the fertility clinics themselves; the vast majority of patients who chose the sex of their child did so for family balancing purposes.

In the absence of any clear evidence of social harm from the use of sex-selective technologies in the United States, there is little justification for banning their use. Reproductive freedoms should only be limited if they have a negative effect on others, few Americans are interested in using available sex selection technologies, and most of those express no preference for one sex over another. Restricting the use of sex selection technologies would only lead to further erosion of our reproductive liberties, including the right to terminate a pregnancy or to make other reproductive choices.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on August 27, 2015, and is available on the WAMC website.]

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About Sean Philpott-Jones

A public health researcher and ethicist by training, Sean holds advanced degrees in microbiology, medical anthropology, and bioethics. He is currently Chair of the Bioethics Department at Clarkson University's Capital Region Campus and Director of the Bioethics Program of Clarkson University-Icahn School of Medicine at Mount Sinai, and Director of two Fogarty-funded programs to provide research ethics education in Eastern Europe and in the Caribbean Basin. Until his term expired in August 2012, he served as Chair of the US Environmental Protection Agency’s Human Studies Review Board, an advisory panel that reviews the scientific and ethical aspects of research involving human participants submitted to the EPA for regulatory purposes.
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