By CRG staff - interview with Mara Hvistendahl

Mara HvistendahlMara Hvistendahl is a correspondent with Science magazine and author of Unnatural Selection.


Where did you get the idea for this book?

I was researching sex-selective abortion in Asia, and mostly unaware of developments with in vitro fertilization (IVF). But setting up to write this book, I was really determined to find a way to make it relevant for readers in the U.S., and I didn't want them to come away with this message that people in China and India are sexist, and that's why they abort girls, or that it's this problem that only happens in other countries. Later, I uncovered this whole connection with the population control movement in the U.S. in 1960s America, so there actually was a pretty direct link. Ultimately, I ended up visiting fertility clinics in California. I visited The Fertility Institutes and Jeffrey Steinberg, one of the most notorious people doing pre-implantation sex selection in the U.S.

Is pre-implantation sex selection happening very much in the U.S.?

Initially, PGD (pre-implantation genetic diagnosis) was just used for couples who had a genetic propensity toward a disease linked to the sex chromosomes. For example, if a woman is carrying the gene for hemophilia, by sorting for girls, she can guarantee not having a child with hemophilia.

Mark Hughes, who was very involved in developing pre-implantation sex selection in the U.S., didn't think couples would go through IVF and PGD just to get a child of a certain sex. IVF is really intensive, it's really expensive, and there isn't even a high success rate. Together with PGD, it can cost something like $18,000; so it makes sense to assume that people wouldn't want to do that just because they want a boy or a girl. But he was wrong, and Jeffrey Steinberg started offering this service and got a lot of publicity. He also provides IVF for people who can't have a baby otherwise, but he says that now 70% of his business is from people coming to him because they want a boy or a girl. 

There are other fertility clinics that won't offer sex selection to just anybody. A lot of clinics will provide it if it's for "family balancing."

Right-the American Society for Reproductive Medicine said, "physicians should be free to offer pre-conception gender selection in clinical settings to couples who are seeking 'gender variety' in their offspring." In other words, they approve of sex selection for someone who only has children of one gender and want their next child to be the opposite gender. How do you police that?

The main problem with assisted reproduction in the U.S. is that it's not well regulated, and even the ASRM guidelines are voluntary.

There's another kind of sex selection called MicroSort. It's sperm selection, really: you spin the sperm in a centrifuge, and because sperm carrying the X chromosome are heavier-they are carrying more genetic material-they separate out from the ones carrying Y chromosomes. There have been trials for that going on for years, and in that case the clinics are only allowed to admit a patient who has a child of the opposite sex.

But what struck me in writing this book is that this really isn't very different from what parents are doing in Asia. In China and India, they're typically not aborting female fetuses the first time. Most people wait until they already have one girl, and then for the second child, they go and get an ultrasound and abort if it's another girl.

Unnatural SelectionDidn't India and China both ban ultrasound testing for the purpose of sexual selection? Although I don't know how well that's enforced ...

It's not enforced. There have been some crackdowns, and I actually think when governments really crackdown it can be effective, but it's not really enforced.

How do people get around those laws?

In China, people told me they bribe the ultrasound technician. In India, the clinics are supposed to register every woman and to keep track of births, whether each baby was a boy or a girl, but they often don't have very complete records.

But you could argue that in a way, there's more extensive regulation in Asia than in the U.S. Although PGD is starting to be introduced in Asia, and there aren't strong regulations for that.

What technologies are being used for sex selection in other parts of the world?

In most of the developing world, it's done through an ultrasound scan to determine the sex, then abortion if it's a girl. One demographer told me that accounted for 99% of sex selection in the developing world.

How does the prevalence of sex selection differ between developed countries and the developing world?

In most cultures around the world, people want boys, or at least one son. Now the Americans who go in for PGD usually want girls; but generally, the preference for boys is pretty universal.

The situation changes when the fertility rate starts to fall. When you are having five or six kids, there's a good chance that one of them is going to be a boy. When you're only having one or two kids, you don't have that guarantee. Even in countries that don't have a one-child policy, people are still having fewer kids. In India, women are having only two kids, maybe one in Delhi. In Albania the fertility rate is just over one child per couple. So there's more pressure on women to have a son, some of it self-imposed.

This happens when the fertility rate drops dramatically in a country-and when abortion is legal, or at least available. I connect it to economic development, because fertility rates tend to go down as countries develop, and at the same time new technology comes in, health care improves, and women have access to ultrasound.

How significant is the sex ratio imbalance globally? Are there places where it's particularly imbalanced?

It's spreading, actually. It's significant enough now that the global balance is slightly skewed-it's now 107 boys per 100 girls, when it had been more like 105 to 100.

Demographers are watching, but it's difficult to predict which countries will be next. Most people didn't expect it in the Caucus countries-Azerbaijan, Armenia, Georgia-and now in the Balkans, in Albania, Montenegro, maybe Macedonia.

It's not hard to see where the imbalance could become a really serious problem when everyone is only having one child, and everyone is making sure that one child is a son. How serious is the gender imbalance in those countries?

There's some disagreement, but in Albania it's around 110 boys for every 100 girls. In Armenia it's even higher. It won't be around forever in those countries-most demographers believe it's a transition phase that countries are going through as they develop, and eventually they start having more girls-but it may take several decades to get to that point.

What is it that changes to make people no longer feel that they have to have a son?

The only place where there was a gender imbalance but the birth rate has now evened out is South Korea; but the birth rate has also dropped so low in South Korea that people are hardly having any kids. It was the lowest in the world a few years ago. People I talked to there didn't really feel that gender discrimination had gone away; it's more a matter of people not having many kids, so it doesn't really cancel out the decades of sex selection before it.

In the U.S. the preference for girls is interesting. Fertility clinics say that most couples go in for girls, although it's not hard data, since they don't have to report either how many couples are going in for sex selection or how many kids are being born through those methods. People give all sorts of reasons for wanting girls. Some say they want to raise a strong daughter, that they want to raise the first female president, or that girls do better in school now. There are also some people with more sexist ideas, wanting to have princess parties and that sort of thing.

Sex selection, and a lot of these almost eugenic choices, come up against the way that reproductive rights have been framed in the U.S., which is around this principle of choice: that a woman should have the right to choose when to terminate a pregnancy. But to some degree that's been extended to include the idea that she should be able to choose what kind of child she wants. So there's a need to reframe that debate around something other than "choice." It just doesn't work anymore for issues like sex selection. Some bioethicists propose instead looking at the right of a child to not have his or her fate determined before birth.

It doesn't seem like very many groups are trying to navigate these issues for fear of confusing their message about abortion rights.

What I found in researching this book is that some reproductive rights organizations won't even address the gender imbalance because they don't want to deal with abortion. As a result of that, a lot of people in the west don't really know about it. That's not the answer. I think we need to reframe the debate around something other than just "choice."

To me, the right of a child to an open future makes sense. It's not that you're calling for fetal rights, you're not talking about the embryo as having rights, but the child that is born later should have the right not to have all these expectations foisted on him or her.

It's a difficult question, but I don't think we benefit at all from steering clear of difficult questions.

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