Editor's note: The names of all doctors and patients mentioned in this article have been changed.
"The first thing she said to me was, 'I know it's a girl, and I need your help to get it out of me.' "
Dr. Carpenter's brow furrowed as she told me about the first time she met Priya. Carpenter was an OB-GYN resident at the time. Priya was a recent immigrant from India who worked as a manager in a retail store and had come to the central California clinic on her lunch break. Punctuating her story with glances at her watch, she told Carpenter how, one week earlier, she had used another lunch break to go to a private ultrasound clinic, where she learned that she was pregnant with a girl. With her arms tightly crossed along her abdomen, she explained that her husband and his parents expected a boy, and that Carpenter's help could change her life.
"I have a daughter," Priya said. "I don't need another one."
Mara Hvistendahl's new book Unnatural Selectionhas sparked animated conversations about the frightening global consequences of sex selection, or the use of medical technology to ensure the birth of either a male or female child. Rising numbers of "missing women" around the world are leading to increased cases of sex trafficking and rape, with excesses of restless, unmarried men expected to worsen societal violence.
But sex selection isn't something that only happens in foreign countries like India or China. It happens in the United States, too, as I learned in my six years of interviewing patients and physicians on the topic. And while these procedures, which can involve fertilizing a woman with only X- or Y-bearing sperm, implanting her with embryos of the desired sex, or aborting fetuses of the unwanted sex, are all legal in this country, there's no consensus among doctors about whether—or when—it's ethical to offer them.
Unlike their Chinese and Indian counterparts, who cannot legally offer sex selection, American doctors are left to decide on a case-by-case basis whether to perform these procedures, without any consistent ethical guidelines. The reasons American women undergo them are complex, from situations that don't seem particularly troubling (the upper-middle-class woman who wants a daughter to "balance out" her three boys) to those that are deeply concerning (the immigrant woman who wants a son to avoid emotional abuse by her in-laws).
Sex selection is openly advertised everywhere from mainstream parenting magazines to Indian community newspapers, and patients are requesting it more often, according to the physicians I interviewed. A 2007 study found that 42 percent of American fertility clinics surveyed had helped patients conceive a boy or a girl by implanting them with the appropriate embryos. Yet despite sex selection's growing profile in the United States, many physicians remain deeply ambivalent about the emotional and ethical dimensions of what they're being asked to do.
Dr. Bradley met Laura and David, a professional Chinese immigrant couple, when they came to his Washington state clinic seeking an abortion. Laura was distraught, unable to speak clearly through her tears. David explained that his recent unemployment meant they couldn't have another child. In the examination room, Bradley gently asked Laura why she was there, and she hesitantly admitted that she wanted this baby, which she had recently learned was female. Her in-laws, however, did not; they had been pressuring David to divorce her because she didn't have a son. Bradley got a social worker involved and Laura was referred to a nearby shelter, eventually deciding to file for divorce herself.Bradley now screens every couple who comes into his clinic—immigrant or otherwise—for family pressure and domestic violence. It's simply the responsible thing to do, he says.
Other doctors disagree. Reproductive choice and patient autonomy are pillars of American medical practice, after all. Asking a woman for her reasons for wanting a boy or a girl, one doctor told me, is simply not a physician's responsibility or business; educating her on the latest technology is. Doctors have to trust that patients know their lives, families, and needs best, he said. In some cases, a physician may know—and loathe—the reasons behind a patient's choice, yet still believe that providing sex selection may help her. If a woman faces threats of divorce, abandonment, or abuse, or if her child would ultimately be mistreated or neglected, then aborting an unwanted female or implanting male embryos may help keep that woman—and any future children—safe.
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."