Johnny Awwad, MD Associate Professor of Obstetrics and Gynecology

1. Preconception Gender Selection for Non Medical Reasons:Procreative liberty or collective responsibility Johnny Awwad, MD Associate Professor of Obstetrics and Gynecology American University of Beirut Medical Center

2. Preconception gender selection methods: a historic perspective • The desire to choose the sex of one’s offspring is as old as history recalls. For centuries, couples have been trying to influence the sex of their children by a myriad of enchanted tales (Heyd 2003; Schaffir 1991; Kaplan 1994; Dahl 2006) • In ancient Greece – men had sex on their right side to have a boy • Following a suggestion by Aristotle – men made love in the north wind to ensure the birth of a son, and in the south wind to ensure the birth of a daughter • Following a proposal by Hippocrates – men tied a string around their left testicle to father a son and the left one to make a girl

3. Preconception gender selection methods: a historic perspective • In old Italy – men bit their wife’s left ear during intercourse to beget a daughter and her right ear to sire a son • In old Sweden – men hang their pants on the left bedpost to father a girl and on the right one to have a boy • In Germany – woodcutters took an axe to bed chanting: ‘Ruck, ruck, roy, you shall have a boy!’ or ‘Ruck, ruck, raid, you shall have a maid!’ • In Medieval times – men had to drink the blood of a lion and then have intercourse under a full moon to sire a son • In our time – many best sellers exist

4. Preconception gender selection: natural methods • Proposed principle • Y-bearing sperm - higher motility • X-bearing sperm - more resistant • Proposed technique • More boys should intercourse occur close to ovulation • Outcome • Slightly higher incidence of girls rather than boys when intercourse occurred close to ovulation • Also true for ovulation induction and insemination cycles

5. Preconception gender selection: natural methods • Proposed principle • Y- bearing sperm: favor basic pH • X- bearing sperm: favor acidic pH • Proposed technique • Alkaline vaginal douches may favor boys • Outcome • Inconsistent findings

6. Preconception gender selection: natural methods • Proposed principle • Dietary modification can alter the gender of the offspring • Proposed technique • Increasing dietary intake of calcium and magnesium improves the chances of having girls • Increasing dietary intake of sodium and potassium improves the chances of having boys • Outcome • Unverified claims

7. Gender awareness • Gender awareness lies skin deep and is a constant reminder to our sexual differences • Indeed, the importance to all of us of a baby’s sex is revealed in the first question we nearly ask upon news of a pregnancy or a newborn: “Is it a boy or a girl?” • And in almost everyone of us, hidden is a preference or a desire for a particular gender even though we may not admit it to ourselves or others

8. Preconception gender selection: the ethical dilemma • The prospect of gender selection elucidates the dilemma between • procreative libertyand the larger common good • individual autonomyand the ‘no harm’ principle

9. Preconception gender selection: the ethical dilemma • “Because of the importance of reproduction in an individuals life, the freedom to make reproductive decisions has long been recognized as a fundamental moral and legal right that should not be denied to a person unless exercise of that right would cause significant harm to others.” (Robertson J. Am J Bioethics 2001)

10. The ‘harm principle’ • It was developed by Wilhelm von Humboldt and John Stuart Mill, and has three implications: • The burden of proof is always on those who opt for a legal prohibition of a particular action • The evidence of the harm should be clear and persuasive, and not based on highly speculative sociological and psychological assumptions • The mere fact that an action may be seen by some as contrary to their moral or religious beliefs does not suffice for a legal prohibition. The domain of the law is not the enforcement of morality, but the prevention of harm to others

11. Objectives

12. The objectives of the thesis • Review of allarguments presented in the medical literature against non-medical gender selection, namely sperm sorting and preimplantation genetic diagnosis • Examination of the validity andstrength of these arguments utilizing the four basic principles often quoted to resolve ethical dilemmas in medicine (Beauchamp and Childress 1983) • Autonomy - Respect of the couple autonomy in reproductive choices • Justice – Respect of Human Rights Charter guaranteed under international and national Legislation that protects the couple’s rights to decide in personal reproductive matters • Beneficence – Ensuring the existence of a well-defined benefit as a result of these decisions • Non-maleficence – Ensuring ‘no harm’ may affect individuals and society subsequent to these decisions • Evaluation of the concept of regulation as a middle solution between unrestricted access and absolute prohibition

13. Mechanism of thinking • Analytical tools used throughout this thesis • Will present the very scarce evidence available to support or defy any argument - proofs for allegation are inexistent in the presence of absolute prohibition, and therefore remain highly speculative • Will address basic Common Sense – itself the fruit of many cultural and social pressures • Will utilize basic legal and sociologic knowledge – to patch the deficiency in scientific evidence • Will adopt a reasoning by ‘Analogy’ – extrapolating from similar situations in medicine such as the birth of IVF

14. Gender selection: An updated status

15. The problem of Son preference • Sons are preferred • They continue the family line and carry the name • They are generally legitimate recipient of inheritance • In Hinduism, only a son can perform the last funeral rites to ensure redemption of the departed soul (McGrivering 2003) – a man who failed to sire a son cannot achieve salvation • Daughters are disfavored • They are an economic burden – dowry system • Indian parents have to pay a considerable dowry of £2,500 to £75,000 sterling to marry off a single daughter (Amanpour 2003) • Advertisement slogan of medical practitioners offering sex selective abortions “Invest 500 Rupees now, save 500,000 Rupees later”

16. The impact of Son preference • A radical change has occurred • over the past decade on the • basis of two opposing • movements: • Female disadvantage in • mortality - improvement • Female disadvantage in • natality - worsening TOTAL 100 (Hesketh T and Xing ZW. PNAS 2006)

17. The impact of Son preference within small-size family cultures The pressure to sex-select rises for additional births as parents try to ensure they produce a son Sex selection is strongly influenced by the gender of the preceding child (Hesketh T and Xing ZW. PNAS 2006)

18. Selective abortion: worldwide views • There is a worldwide consensus outlawing social sex selection by selective abortion: • China (Law of the People’s Republic of China on Maternal and Infant Health Care, 1994) • India (Prenatal Diagnostic Techniques Regulation and Prevention of Misuse Act, 1994) • Doctors may face prison sentence for up to 5 years or a fine up to 50,000 Rupees • Europe (European Commission, 1996)

19. Gender selection: Available technologies

20. Preconception gender selection: prevailing technologies • Pre fertilization separation of sperm into X- and Y-bearing ones followed by selective transfer • Pre implantation genetic diagnosis (PGD) followed by selective implantation based on sex

21. Arguments against preconception gender selection for non-medical reasons

22. Preconception gender selection may become the slippery slope towards ‘designer babies’

23. In a British Medical Journal editorial entitled ‘The next generation: will they be designer babies?’ (Caplan 1999) • A supposedly serious paper explores the morality of eugenics and talks about screening for ‘…physical stamina, strength, speed, mathematical ability, dexterity, acuity of vision…”. “…it could be argued that parents should be free to pick the eyebrow shape or freckle pattern of their children or other equally innocuous traits as long as their selection imposed no risks…”

24. This argument is not well-founded as the ‘slippery slope’ hypothesis calls for three remarks • It does not build a case against gender selection per se, but rather against alleged consequences • It is based on the assumption that we are simply incapable of preventing the alleged consequences from happening • It goes on discussing alleged consequences with no regard to technical feasibility • The laws of genetics lead to diminishing return as more genotypes are selected for. For genetic enhancement , a modest shopping list will need thousands of embryos from independent eggs and spermatozoa

25. The German Institute for Demoscopy conducted a survey entitled ‘Bodycheck’ on 1044 men and women regarding their attitudes towards the selection of offspring traits (Demoscopy 2002) • 80% disapproved of the concept of ‘designer babies’ • 12% approved it • 8% were undecided • When those receptive to the concept were asked about characteristics they would select • 45% intelligence 28% gender • 17% physical prowess 12% artistic talent • 13% height 4% hair color • 4% eye color

26. Preconception gender selection promotes the misallocation of financial resources

27. This argument is well-foundedonlyif gender selection techniques are paid for by public funds • Regulations preventing the use of public funding and tax payers money for an elective procedure such as gender selection is the natural response to these concerns • People who seek gender selection will have to pay for this elective service out of pocket • The fact that only people with the proper financial means can use the technology is ethically irrelevant • Equal access is required by the principle of justice, but only to basic health care services like treatment needed for a reasonable level of well-being - These services qualify for public funding • This does not apply to elective services

28. Preconception gender selection promotes the inappropriate use of medical resources

29. This argument is well-founded in state-run socialist economy, but certainly not in private-run capitalist economy based on a free market • The question of diverting medical resources to non-medical purposes must be evaluated in the context of a medical system in which physicians often provide services that have no direct medical benefitbut that do have great personal value for the individual • Cosmetic surgery is one such example • ‘Given the acceptance of these practices, one could not, without calling that system into question, condemn a practice merely because it uses medicine for lifestyle or child rearing choices’ (ASRM 2004)

30. Proposed regulatory action • One way to compensate this loss in public healthcare system is by imposing a ‘social compensation tax’(Pennings 2005) • Such tax may be valued in proportion to the time, infra-structure, personnel specifically invested in elective gender selection • The rational for imposing the tax may be to • Compensate society for the loss of healthcare capacity • Compensate the community for the money spend on the education of physicians • Reduce the number of selection seekers in order to limit abuse and minimize damage to the health care system • The strategy of financial penalties, similar to socially undesired activities like smoking, may support • Funding couples who need PGD for severe medical indication and who cannot afford the technique • Funding of research and progress in preimplantation genetics

31. Preconception gender selection may distort the natural sex ratio in society

32. Whether a distortion of the natural sex ratio will indeed occur following liberal access to preconception gender selection techniques is an empiric question that cannot be answered by intuition, but rather by evidence

33. Dahl E. et al. Preconception sex selection demand and preferences in the United States. Fertil Steril 2006 Although 39% of respondents would like their first-child to be a son and 19% to be a daughter, 50% wished for a family of equal number of boys and girls, and a comparable proportion of respondents wished for a skewed sex ratio in favor of either sexes

34. Dahl E. et al. Preconception sex selection demand and preferences in the United States. Fertil Steril 2006 Eight percent of respondents would use preconception sex selection technology if they have to pay for the treatment themselves, and 12% of those not interested would change their minds if covered by health insurance

35. Dahl E. et al. Social sex selection and the balance of the sexes: Empirical evidence from Germany, the UK, and the US. J Assist Reprod Genet 2006 US respondents had a much stronger gender preference for their first-born child compared to German ones

36. Dahl E et al. Preconception sex selection for non-medical reasons: a representative survey from Germany. Hum Reprod 2003 There is only a small interest in preconception gender selection for non-medical reasons

37. Gender preferences amongst pregnant women • In Germany, pregnant women are more inclined to wish for a girl (Brosig 2006) • In the general population • 14% wished for their first-born child to be a boy • 10% wished it to be a girl • Amongst the pregnant population • 7% wished for a first-born son • 18% hoped for a first-born daughter

38. Gender preferences amongst pregnant women • In the UK, the Centre for Family Research of the University of Cambridge conducted a survey on 2359 pregnant women (Statham H et al. Lancet 1993) • 6% preferred a girl • 6% preferred a boy • 19% quite liked a girl • 12% quite liked a boy • 58% had no preferences

39. Gender preferences amongst pregnant women • In Canada, a survey of 234 pregnant women was conducted (Marleau JD et al. Psychol Report 1996) • 39% preferred a girl • 22% preferred a boy • 39% had no preferences

40. Zubair F et al. Gender preferences and demand for preconception sex selection: a survey among pregnant women in Pakistan. Hum Reprod 2007 39.2% vs 13.8% expressed bias gender preference towards a boy 27.6% vs 4.3% expressed the wish To have more boys than girls

41. Zubair F et al. Gender preferences and demand for preconception sex selection: a survey among pregnant women in Pakistan. Hum Reprod 2007 6.3% expressed interest in sex selection Only 27.2% were in favor of making preconception gender selection legal

42. Steinbacher R and Gilroy FD. Preference for sex of child among primiparous women. J Psychol 1985 • Survey of 140 primiparous women in theUS • 18% preferred to have a boy • 23% preferred to have a girl • 59% expressed no preference at all • If the means of sex selection is available to them, • 18% would use sex selection • Of these, • 50% to ensure the birth of a boy • 50% to ensure the birth of a girl

43. Jain T et al.Preimplantation sex selection demand and preferences in an infertility population. Fertil Steril 2005 • Cross sectional survey of 1,500 infertile women in the US • 40.8% would like to be able to choose the sex of their children as part of infertility treatment • Of women with no children, • 34.3% desired to have a boy • 65.7% desired to have a girl • Of women with children of only one sex • 74% of mothers of girls wished for a boy • 82% of mothers of boys wished for a girl

44. Data from clinics offering preconception gender selection • The proportion of American couples seeking sex selection for the sole purpose of family balancing were: • 100% at the Gender Clinic of New York - Khatamee MA et al. In J Fertil 1989 • “Overwhelming majority” at 65 Gender Clinics in Montana - Beernink EF et al. Fertil Steril 1993 • 90.5% at the Genetic and IVF Institute in Fairfax - Fugger EF et al. Hum Reprod 1998

45. Data from clinics offering preconception gender selection • The proportion of European couples seeking gender selection for the sole purpose of family balancing • > 95% at The London Gender Clinic -Liu P and Rose GA. Hum Reprod 1996 • The proportion of Arab fertile couples seeking gender selection for the sole purpose of family balancing • 100% at Farah Hospital in Jordan - Kilani Z et al. RBMO 2001

46. The sex ratio argument is not well-founded in western societies • There is a leap between what people say and what they actually do • A mere expression of interest may never translate into actual demand because of expense, limited availability, and comparative inefficiency of sexing • Which makes this technique an unlikely source of significant gender skew in any country

47. Proposed regulatory action • Concern over alteration in sex ratio may be grounds for limiting social sex selection to those with already two children of the same sex – family balancing • By demanding that gender selection for non medical reasons take place within the framework of family balancing, undesired effects would be avoided even in countries with strong son preference • The arguments are finely balanced between outlawing social gender selection altogether and permitting it in a strictly regulated fashion

48. Preconception gender selection is inherently Sexist

49. By allowing more males being born as first children and paying greater attention to gender itself implies that one gender is more valuable than the other • It is called by the feminist philosopher Tabitha Powledge ‘the original sexist sin’ because • It makes ‘the most basic judgment about the worth of a human being rest first and foremost on its sex’ (Powledge 1981)

50. Sexism viewed by feminists • Extreme sexist view rejects gender selection because • Any attention to gender difference is inherently sexist because perceptions of gender differences are themselves rooted in sexist stereotypes (Wertz 1989) • Sexism arises from the recognition and acceptance of gender differences • Libertarian feminist view rejects the prohibition of social gender selection • Need to respect a woman’s autonomy in determining whether a practice is sexist • Concerns over long term consequences of any prohibition - any limitation of reproductive autonomy is a slippery slope to the loss of procreative liberty