Editor's note: The names of all doctors and patients mentioned in this article have been changed.
And it's not just immigrant women whose requests are ethically challenging. Dr. Daniels, based in Northern California, felt uncomfortable when a middle-aged, white patient of his wanted a daughter "for the pink and the malls," as he told me. "She seemed to think of this kid as a mail-order product." But what if this girl ended up being a tomboy, he wondered—or gay? How would this woman treat her child then? Other doctors at his practice insisted that he "keep his own beliefs out of it." Daniels ended up referring this case to one of those colleagues and has since stopped offering sex selection services completely. Parents pursuing it may presume a child will turn out a certain way based solely on its gender, with poorly understood consequences for the child, mother, and family if the child doesn't. A shortage of women, Daniels believes, is not the only harm sex selection may cause. It's just what has gotten the most attention.
Ultimately, physicians are on their own when making these ethically and emotionally charged decisions. The professional medical societies they might otherwise turn to offer conflicting advice: The American College of Obstetrics and Gynecology recommends that providers not meet requests for sex selection, given the risk of reinforcing sexist beliefs and practices, while the American Society of Reproductive Medicine states that it would be premature to prohibit such technologies without studies suggesting their potential harm in the United States.
The few papers that have been written on the topic have looked at very small numbers of patients and focus on the role ethnicity plays in the process. They conclude that since white American patients opt for daughters, sex selection in this country won't contribute to the worldwide shortage of women. But a large-scale demographic shift isn't the only outcome that should rouse our concern. After all, more than 30 countries, including Canada and the United Kingdom, have already banned sex selection on the grounds that it reinforces gender inequality and sets a precedent for legitimizing eventual selection of traits ranging from eye color to intelligence.
In cases involving sex selection, there are often no clear "right" or "wrong" answers. And to be sure, doctors have to make decisions about challenging cases all the time in the absence of concrete guidelines. But many doctors I spoke with had at times wondered whether they'd made the right decisions, and felt that further guidance—especially around how to screen for red flags in patients' home lives without appearing invasive or judgmental—would have been helpful.
Dr. Carpenter could have used this kind of support. She ultimately performed two more abortions for Priya, who adamantly refused to have another daughter. Eventually, Priya did have a son, and Carpenter was thrilled, hoping that she would finally find peace and acceptance in her family. She was shocked when Priya returned two years later, saying she was pregnant with another girl that she needed to terminate. Priya had provided her in-laws with a son, only to discover that they still didn't want any more daughters.
"Not every situation I've seen is as complicated as Priya's," Carpenter said, "but maybe that's because I haven't asked the right questions, or I've assumed the best when I shouldn't have. [You] need to base your decisions on information, not just on your assumptions. I think it's about time we had serious conversations about how to do that."