Ethical considerations in prenatal sex selection.
Preferences in Sex Selection
The proportion of people expressing a preference for a child of a particular sex persists, although it has decreased somewhat over time. For example, in 1945, 57 percent of college students studied expressed such a preference (See Kirk, 1964) compared with 28 percent of Ohio couples studied in the mid-1990s as they prepared for marriage (Sensibaugh & Yarab, 1997). Preferences for a child of a particular sex tend to increase when only one child is anticipated or after the birth of two children of the same sex (Malhi et al., 1999). When sex preferences were expressed, males were found to be the preferred sex in the United States (Kirk; Sensibaugh & Yarab); in South Asia, East Asia, and North Africa (Malhi et al.); and in France and Germany (Hank & Kohler, 2000). A female preference was noted in the Czech Republic, Lithuania, and Portugal (Hank & Kohler). A strong preference for a mixed-sex composition of children was also noted where parity is expected, that is, where an individual or couple expects the birth and healthy development of at least one child of each sex (Hank & Kohler). Preferences for male children may be greater among African American and Hispanic individuals and couples than among white Americans (Gilroy & Steinbacher, 1991). Men are more likely to prefer to be the biological parent of male children than are women (Pooler, 1991).
Sex preferences seem to be driven by the benefits of having a child of a particular sex, although the perceived benefits may differ by country. In China, for example, men have benefit because they are perceived as physically able to perform certain work functions that women are unable to perform, they are expected to remain nearby and care for parents in their old age, and lineage is transferred through males (Vonk, Simms, & Nackerud, 1999).
Preferences in the Sex of Adopted Children
Girls are consistently overrepresented among children adopted in the United States (see Kirk, 1964; Abma, Chandra, Mosher, Peterson, & Piccinino, 1997) and internationally (U.S. Immigration and Naturalization Service, 2001), although the ratio of female to male children adopted from the U.S. public foster care system is almost equal (U.S. Department of Health and Human Services, 2002). The large proportion of female adopted children may be associated with greater availability of these children. For example, 97 percent of the 4,943 children adopted by U.S. families from the People's Republic of China in fiscal year 2000 were female (U.S. Immigration and Naturalization Service), believed to be the combined result of that country's one child population control policy and a greater value placed on males (Vonk et al., 1999). Female children have been found more likely than male children to be relinquished for adoption (Bachrach, Stolley, & London, 1992).
Researchers and theorists have given somewhat varied explanations for the seeming preference for female adopted children. Adamec (1988) and Dahlstrom (1988) called attention to the fact that in married couples the woman may be the partner who most wants the adoption. Thus, she may want a child most like herself. Other explanations suggested by these authors include a belief (in the case of transcultural adoptions) that women of ethnic minority groups have an easier time in the United States than their male counterparts; a perception that girls are easier to raise; a desire to avoid conflicts inherent in the expectation that a male adopted child will carry on the family name; beliefs (among men who are ambivalent about adopting) that it is not manly to adopt a boy but acceptable to adopt a girl; the perception that the adoption of a child considered of second-class sex status as consistent with the second-class status of adoption (compared with biological parenthood); and among both heterosexual women and lesbians, a desire to focus their parenting on the development of women or girls.
The perceived preference of married women to adopt girls is said to be related to a combination of the role handicap associated with childlessness among women and women's tendency to yield to their husband's preference for a girl if adoption is to occur at all (Kirk, 1964). Kirk explained the preference for female children among male adopters as related to a hesitancy to adopt. The adoption of girls becomes a compromise. Kirk also found that membership in a "traditional" religious group, namely Catholic and Jewish religion, predicted a preference for adopting female children. Other explanations advanced by Kirk include the perception that it is less difficult to bring up a girl; that a girl is symbolic of affection and one who will remain close to her parents; that daughters cost less to raise; that daughters are more of a help in the parental household; that a girl represents the preference of the wife, who tends to be the partner most invested in adopting; and that fears about adoption can be more easily resolved through the adoption of a female child.
Finally, Bachrach and associates (1992) speculated that the trend toward greater likelihood of relinquishing girls for adoption is influenced by a possible awareness that girls are more likely to be adopted (that is, that the relinquishment placement will be successful), that boys are needed for continuation of the family lineage and family name, and that retaining sons may provide a young, unmarried woman with a link to her child's father.
Prenatal Sex Selection and the Genetics Revolution
The first "test-tube baby," produced through in vitro fertilization in Great Britain in 1978 under the supervision of Drs. Patrick C. Steptoe and Robert G. Edwards ("In vitro fertilization," 2000), was a forerunner of the genetics revolution. Since then, other assisted reproductive technologies (ARTs) such as donor (artificial) insemination, gamete (egg) transfer, and surrogacy have been successful. Developments in ARTs made it possible to identify the sex of a child prenatally. Typically referred to as sex determination tests but used initially in the diagnosis of sex-linked diseases, these procedures include amniocentesis, chorionic villus sampling (CVS), and ultrasound scans. In amniocentesis, a sample of amniotic fluid is extracted and analyzed. In CVS, a tiny sample of placental tissue is removed for chromosome analysis. Amniocentesis and chorionic villus sampling are generally accompanied by the ultrasound technique, a scanning procedure in which pictures of the moving fetus can be seen (Center for Prenatal Diagnosis, n.d.; Liberty Women's Health Care of Queens-NYC, n.d.; March of Dimes, n.d.; Woo, n.d).
Newer developments in reproductive technologies can be understood in the context of the more recent Human Genome Project (see National Human Genome Research Institute, http:// www.nhgri.nih.gov/). Formed in 1990 as an international effort of the U.S. National Institutes of Health, the project's purpose is to develop knowledge regarding the genetic basis of human disease. Its ultimate goal is the elimination of disease, particularly diseases associated with the inheritance of certain genes. The project has resulted in the identification of virtually every human gene, of genes associated with particular diseases, and of genetic defects in embryos produced through in vitro fertilization.
During in vitro fertilization, multiple eggs are fertilized in a petri dish. In a procedure called a preimplantation diagnostic test, the resulting embryos can then be tested for the presence of sex-linked genetic defects by conducting a biopsy of a cell from each embryo, through which the sex of the embryo is identified. Embryos of the sex associated with the genetic disorder can be discarded, and embryos of the desired sex can be implanted. Preimplantation diagnostic tests opened the way for identifying the sex of an embryo simply for the desires of the parents. Thus, parents can request that only embryos of a certain sex be implanted during the in vitro fertilization procedure.
A second method used in the selection of the sex of children prenatally is flow cytometry, by which the 2.8 percent heavier X-bearing sperm are sorted or separated from Y-bearing sperm through a laser process, resulting in an X-enriched sperm sample for insemination from the male partner or donor (American Society for Reproductive Medicine [ASRM], 2001). At present, however, only the heavier X-bearing sperm are separated effectively, resulting in the selection of females as the outcome in most cases (ASRM, 2001; Mayor, 2001). In the application of flow cytometry to 284 embryos, gender was unambiguously assigned in 90 percent of cases, with 92 percent of them being female (Mayor).
Prevalence of Prenatal Sex Selection Procedures
Sex Determination Tests. Although exact numbers are not available, sex determination tests have become common during the prenatal care of women who want to know the sex of their unborn child. There is no evidence that these tests are being used in the United States as a basis for sex-selective abortions. These abortions are occurring, however, in large numbers in countries in which male children are much more valued than female children. In India, the ratio of girls to boys dropped from 962 gifts born per 1,000 boys in 1981 to 927 girls per 1,000 boys in 2001, and in some parts of India, the ratio has fallen to 793 gifts per 1,000 boys (Dugger, 2001). Results of China's latest census indicate the birth of 116.9 boys for every 100 gifts in 2000, up from 111.3 boys for every 100 girls born in 1990 (Wiseman, 2002). In South Korea, it is reported that 115 boys are born for every 100 gifts ("Ethicists Worry about New Technology," 2001). These trends make it clear that although sex determination tests may be illegal, their use is prevalent. In fact, advertising of ultrasound procedures in India is said to be common (Dugger), and ultrasound technicians in China are said to use signals to convey the sex of the fetus to a parent without breaking laws forbidding the practice (Wiseman). Neglect of the health and nutrition of girls and women and high rates of maternal death in childbirth have also resulted in higher proportions of males in the general population of India (Dugger).
Flow Cytometry. I identified on the World Wide Web several infertility treatment centers that offer flow cytometry. Because current U.S. law only regulates the safety and effectiveness of such a technology, clinics are able to offer the procedure without regulation from the U.S. Food and Drug Administration--at least until the expiration of patents currently held, which may not be until near the end of this decade. As of July 2001, 200 couples were said to have chosen the sex of their child through clinical trials at one clinic (Perrone, 2001). In addition to facilities in the United States, flow cytometry is said to be available in at least two clinics in Great Britain, although numbers are not available, and the U.S. success rate is said to be higher (90 percent for girls, 73 percent for boys) compared with clinics in Great Britain. Laws in Great Britain regulate only procedures involving stored sperm, which does not generally apply to the flow cytometry procedure ("Sex Selection Inquiry Ordered" 2001).
Preimplantation Diagnostic Tests. Despite reluctance by the ASRM Ethics Committee to endorse preimplantation diagnostic tests for the sole purpose of selecting the sex of one's child (ASRM, 2001; Robertson, 2002; Younger, 2000), some infertility treatment clinics decided to offer the procedures to couples who seek gender balancing in their family and who seek the most effective methods in doing so (Fertility Institutes, n.d.a). The clinics made the decision after the ASRM acknowledged the use of flow cytometry in cases in which a couple had a child of one sex and wanted a child of the other. Directors of these clinics believe services offered should include the most effective. In vitro fertilization is said to be nearly 100 percent effective in determining the sex of a child, compared with the 80 percent to 85 percent rate of effectiveness of flow cytometry (Fertility Institutes, n.d.a). One clinic director reported that "thousands of healthy babies have been born following sex selection procedures" (Fertility Institutes, n.d.a).
The Code of Ethics of the National Association of Social Workers (2000) is the appropriate framework in social work for considering the ethical dilemmas presented by prenatal sex selection. The Code contains several values on which are based ethical principles that guide social workers. Those that have particular relevance to prenatal sex selection are discussed in the following sections, along with their relevance to the ethical dilemmas presented.
Value: Social Justice Ethical Principle: Social Workers Challenge Social Injustice
Social workers pursue social change, particularly with and on behalf of vulnerable and oppressed individuals and groups of people. Social workers' social change efforts are focused primarily on issues of poverty, unemployment, discrimination, and other forms of social injustice. These activities seek to promote sensitivity to and knowledge about oppression and cultural and ethnic diversity. Social workers strive to ensure access to needed information, services, and resources, equality of opportunity, and meaningful participation in decision making for all people.
The ethical dilemmas associated with prenatal sex selection that have relevance to considerations of social justice include reinforcement of gender bias; the potential for creating an imbalance in the sex ratio that may lead to or perpetuate the oppression of individuals of a certain sex; implications for eugenics; inequities in access based on social and economic status; discarding of embryos; and allocation of medical resources.
Reinforcement of Gender Bias. An argument noted early by the ASRM Ethics Committee (1999) is that having methods available for parents to select the sex of their child suggests that one sex is better or more important than another. Gender bias in society is therefore perpetuated.
Potential for Gender Discrimination and Oppression. An argument against prenatal sex selection is that the practice will lead to sex ratio imbalances (ASRM, 2001). From the standpoint of social exchange theory, this increases the likelihood that individuals of the less prevalent sex will have greater relationship power than the sex in greater supply. Members of the latter group may use this power inequity to oppress the less powerful group, and the less powerful group may feel forced to accept oppression in return for the reward of having a mate. Proponents of sex-selection technologies, however, make the point that negatively sex-stereotyped attitudes already operate in some families, as in situations in which a family has three girls and seeks at least one son (ASRM, 2001).
A somewhat contradictory reality with regard to the perpetuation of sex stereotyping and its outcomes is beginning to occur in China. Almost 117 Chinese male children are born compared with 100 female children (Wiseman, 2002). That these male children are generally only-children--resulting from China's one-child policy (Vonk et al., 1999)--has led some to refer to their position as "little emperors" ("China's One-Child Policy," 2001). The birth differential has resulted in Chinese women. Chinese men have begun to complain that women are selecting only men of the highest status as mates. Societies in these circumstances are faced with finding a solution for the many men who do not have mates. China is said to be assigning young men of lesser status into police and other security jobs (Wiseman) (that may increase the risk of loss of life), and one news writer predicted that as a result of the sex ratio differential in India, with 111 births of males to every 100 females (Eckholm, 2002), officials may have little incentive to resolve conflicts between India and Pakistan (where fatalities can be expected) (Wiseman). Some have predicted that the sex ratio differential in China will result in men exerting power through forced marriages, bride trafficking, prostitution, and rape (Wiseman).
Implications for Eugenics. A move toward selecting the sex of one's child is reminiscent of the eugenics movement that emerged in the second half of the 19th century, giving support to the concept of the superiority of people with certain characteristics. Some worry that this technology will lead parents to seek to select other characteristics as well, such as athletic ability, intelligence, and physical prowess. One physician associated with a reproductive medicine center has already raised the question: "What's the next step? As we learn more about genetics, do we reject kids who do not have superior intelligence or who don't have the right color hair or eyes?" (Kolata, 2001, p. A-14)
Inequities in Access. Cost is expected to play a part in sex-selection technologies because the least intrusive and invasive and the most effective are generally the most expensive. One clinic estimates the cost of preimplantation genetic diagnosis during in vitro fertilization at $10,480, not including all costs (Fertility Institutes, n.d.b). Another clinic estimates the cost of flow cytometry at $2,000 (Genetics & IVF Institute, n.d.). Cost considerations result in class differentials; some people will be able to afford the most expensive and effective procedures, whereas others will be able to afford only the less-effective ones or none at all. In cultures where there is a preference for male children, impoverished or less-advantaged couples may resort to less-expensive abortion or infanticide or forgo selecting the sex of their child.
Discarding of Embryos. During in vitro fertilization, production of numerous eggs is stimulated in the hope that at least some will be fertilized. Several eggs are implanted because some of them may not develop. Couples must decide about the status of the embryos not implanted (for example, embryos that are not of the desired sex). Embryos may be donated for use in stem cell research, donated to another couple, frozen and stored, or discarded. Each choice presents a dilemma for the couple. Storing embryos is only a temporary solution. Couples may not be ready to face the possibility of their embryos being successfully developed and their subsequent biological children parented by another couple. The successful thawing, implantation, and development to term of previously frozen embryos has been advertised at 45 percent (Center for Human Reproduction, n.d.). The ASRM Ethics Committee (2001) has "consistently taken the position that fertilized eggs and preimplantation embryos, while not people or moral subjects in their own right, should not be treated like any other human tissue. Rather, because of the meanings associated with their potential to implant and bring forth a new person, they deserve 'special respect'. In the context of treating infertility, reducing the transmission of genetic disease, or conducting biomedical research, affording the embryo special respect has been understood to require strong or important reasons for creating and destroying embryos" (Robertson, 2002, p. 6). The use of embryos in stem cell research presents similar dilemmas. Controversy surrounding the discarding of embryos may also arouse the concern of abortion advocates given that the concept of embryo adoption ascribes human qualities to embryos (Bailey, 2002). Finally, the availability of preimplantation diagnostic tests to identify and select the sex of embryos will likely result in increasing numbers of embryos, because the procedures have been limited to identifying embryos carrying genetic disorders and to producing embryos that may be used to correct genetic disorders in an existing child.
Allocation of Medical Resources. It has been argued that the availability of sex-selection techniques will lead physicians to direct their professional time and skills to purposes that are not medically indicated, "thereby possibly diverting medical resources from more important uses" (ASRM, 2001, p. 3). At a time of limited numbers of physicians, allocating medical resources to an elective procedure that raises ethical concerns may be undesirable. Proponents of the procedures point out, however, that physicians practicing in nonessential medical practices is not unusual; therefore, there is no established basis for singling out the practice of prenatal sex selection for criticism. Moreover, the ASRM Ethics Committee (2001) contends that the practice of sex selection is expected to be low and to consume a limited amount of medical resources.
Value: Importance of Human Relationships Ethical Principle: Social Workers Recognize the Central Importance of Human Relationships
Social workers understand that relationships among people are an important vehicle for change. Social workers engage people as partners in the helping process. Social workers seek to strengthen relationships among people in a purposeful effort to promote, restore, maintain, and enhance the well-being of individuals, families, social groups, organizations, and communities.
Prenatal sex selection presents several ethical dilemmas in this regard, including those surrounding children's well-being, the quality of parent-child relationships, and the quality of couple relationships.
Children's Well-Being. Prenatal sex selection raises the question of how disclosure will be handled and of privacy and confidentiality surrounding the procedure. Adoptive parents have long been encouraged to tell their children of their adoption at an early age, so that the child's full history becomes part of her or his development and identity. Parental disclosure also prevented the possibility of the child learning of their adoptive status from someone other than the parents. Prenatal sex selection involves either manipulating sperm to increase the chances of having a child of a particular sex or selecting embryos of one sex over another. Parents must decide whether to disclose to the child that he or she was selected according to the sex the parents wanted in their child. Children who learn they were so selected may become preoccupied with whether they are measuring up and may tend toward self-scrutiny, with accompanying threats to self-esteem. Moreover, children will be faced with questions regarding the status of embryos that were not selected and with guilt that they were selected over another. At the same time, the knowledge may increase a child's feeling of having been wanted and chosen (ASRM, 1999), similar to messages often given to adopted children.
Parent-Child Relationships. Parents who select the sex of their child prenatally may inadvertently expect the child to act in certain gender-specific ways when the child of the desired gender is produced. Some children may feel pressured or have difficulty living up to these expectations. Parental disappointment and self-criticism on the part of the child may result when the child does not live up to expectations. A study of Swedish families (Stattin & Klackenberg-Larsson, 1989a) found support for the researchers' hypothesis that parental preferences for a child's sex would be linked to affective parent-child relations in upbringing. In fact, the incidence of registered delinquency among subjects in the same longitudinal study was significantly higher among individuals whose sex differed from the sex preference the parents had expressed before the children's birth (Stattin & Klackenberg-Larsson, 1989b).
As noted earlier in this article, sex preferences generally and preferences for a child of a particular sex increase when parents already have two children of the same sex. Selecting the sex of one child (for example, a male child) after giving birth to two children of the same sex (for example, female children) may lead to gender-based status differences between siblings and in parent-child relationships.
Couple Relationships. Conflicts in couple relationships may arise around whether to seek to select the sex of a child or which sex should be selected. Women endure the physical demands of sex-selection procedures, thus increasing the potential for conflict around their use. Some couples may find their financial situation stressed to pay for sex-selection procedures. Coping with failures in outcomes (that is, failure in the in vitro fertilization procedure or in the sex-selection procedure itself) may also further stress couple relationships.
Value: Dignity and Worth of the Person Ethical Principle: Social Workers Respect the Inherent Dignity and Worth of the Person
Social workers treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity. Social workers promote clients' socially responsible self-determination. Social workers seek to enhance clients' capacity and opportunity to change and to address their own needs. Social workers are cognizant of their dual responsibility to clients and to the broader society. They seek to resolve conflicts between clients' interests and the broader society's interests in a socially responsible manner consistent with the values, ethical principles, and ethical standards of the profession.
The availability of prenatal sex-selection technologies raises questions about the rights of individuals and couples to determine the composition of their families against the best interests of society and the rights of individuals and couples to decide the parenting experiences they wish to have.
Procreative Liberty. Some proponents of sex-selection procedures believe couples have a right to full access to available knowledge. According to this position, if the ability exists to select the sex of a child, an individual should have full access to the procedure unless substantial harm is anticipated. The decision regarding whether to take advantage of access would therefore be fully in control of the individual or couple involved. However, prenatal sex selection threatens the well-being of society with regard to reinforcement of gender bias, potential for gender-based discrimination and oppression, inequities in access, handling of remaining embryos, a trend toward eugenics, and unequal allocation of medical resources.
Couples' Desires. The availability of prenatal sex selection may serve the desires of couples who have strong preferences about family formation by gender. The experience of raising a male and a female child is said to be different in itself, and different for male and female parents (ASRM, 2001). Proponents use this information as support for parents having the opportunity for the child-rearing experience they desire. The alternative may be abortion, ongoing unhappiness with children of the undesired sex, forgoing having children, or giving birth to a larger number of children than is desired.
IMPLICATIONS FOR SOCIAL WORKERS
The availability of assisted reproductive technologies for prenatal sex selection brings social workers into the genetics revolution. The rapidly emerging field has implications for social workers in direct practice, policy articulation and advocacy, and research, and for the education of social workers for these roles.
If prenatal sex-selection methods are available, social workers are not likely to withhold services from anyone who chooses to take advantage of them, although individual values may prevail in some instances. Some social workers will be in genetic counseling and psychoeducation roles that call for them to provide technical information about prenatal sex selection (including success and failure rates) and any anticipated interpersonal implications. As one example, social workers can develop materials that pose the question to parents of whether they will disclose the use of the sex-selection procedure to their child, the potential benefits and challenges, ways of disclosing, and ways of dealing with children's questions and reactions. The experiences of adoptive families may be useful in this regard. Social workers undoubtedly may be called on to assist families with problem outcomes. For example, a parent who wanted a male child may have expected the child to excel at sports, only to find that the child abhors sports. Understanding the impact of early expectations may help the parent realize that disinterest in sports is normative for many boys and that the parent's unfulfilled expectations make it problematic.
Policy Articulation and Advocacy
The social work profession will ultimately be confronted with making a decision regarding which policies to support and advocate for. The NASW Code of Ethics (2000) anticipates such a professional dilemma in its ethical standards on social workers' commitment to clients and to clients' self-determination. With regard to the former, "Social workers' primary responsibility is to promote the well-being of clients. In general, clients' interests are primary. However, social workers' responsibility to the larger society or specific legal obligations may on limited occasions supersede the loyalty owed clients, and clients should be so advised" (NASW, p. 7). And with regard to the commitment to client self-determination, "Social workers respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals. Social workers may limit clients' right to self-determination when, in the social workers' professional judgment, clients' actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others" (NASW, p. 7). The right of individuals and couples to choice, to full access to available knowledge and technology, and to have their desires for family formation addressed competes with the right of society to insist on the protection, equality, and freedom from oppression or discrimination of its members.
At the extremes of a continuum, social workers may advocate for policies that give individuals and couples full access and choice in taking advantage of available sex-selection technologies, or they may support policies that restrict the use of these technologies to prevention of sex-linked diseases. Along the continuum may be support for flow cytometry but not preimplantation diagnostic methods, or for required preselection and postselection counseling when a need to prevent genetic disorders does not exist. The NASW Code of Ethics can serve as the framework within which social workers may begin discourse on these policy issues.
Prenatal sex selection of children is a new and emerging area, and little empirical support exists. Thus, social workers are challenged with developing knowledge at the same time they are attempting to meet service needs. Social workers should identify the research questions raised by the availability of sex-selection technologies. Social work research should then be directed to building the knowledge needed for policy, practice, and professional education in this area. Individuals and couples who take advantage of these technologies should be invited to participate in this research, and funders should be encouraged to prioritize social work research in this area.
The implications for social work of prenatal sex selection remind us of the interdisciplinary nature of our work. Social work education may not always have done a good job incorporating knowledge and content from such areas as medicine, biology, genetics, and population studies into the curriculum or in anticipating and preparing students for emerging roles. Such curricular revisions are necessary in academic and continuing education at the same time that roles are emerging and knowledge is being developed.
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Original manuscript received July 22, 2002 Final revision received November 26, 2002 Accepted June 17, 2003
Leslie Doty Hollingsworth, PhD, is associate professor, School of Social Work, University of Michigan, 1080 South University, Ann Arbor, MI 48109-1106; e-mail: lholling@ umich.edu. An earlier version of this article was presented at the Theory Construction and Research Methodology Workshop of the National Council on Family Relations Annual Conference, November 2001, Rochester, NY. The author thanks Dean Paula Allen Meares and Professors Sheila Feld and Tom Powell, School of Social Work, University of Michigan, for their reviews of earlier versions of this article.