Staff Background Paper

The human desire to choose the sex of one's offspring-to have a son rather than a daughter or a daughter rather than a son-is hardly new. In ancient Greece, it was believed that if men had sex while on their right side a boy would result, and in eighteenth-century France, it was believed that if men tied off their left testicle this would result in a baby boy. In our own time, books that claim to reveal the secret of having a boy or a girl abound. One bestseller recommends the timing of sexual intercourse as the key in addition to other strategies. Indeed, the importance to all of us of a baby's sex is revealed in the first question we nearly always ask upon news of a newborn (assuming, that is, we have not already found out by sonogram): "Is it a boy or a girl?"

But if the central importance of the baby's sex and our desire to choose one sex over the other is not new, the techniques for making our desires come true are new. Today, it is possible, at a price, to guarantee the sex of our children. The principal means for doing so are: prenatal diagnosis (either through a sonogram or amniocentesis) followed by abortion of fetuses having the unwanted sex; preimplantation genetic diagnosis (PGD) followed by selective implantation based on sex; and (a less certain technique) pre-fertilization separation of sperm into X- and Y-bearing ones followed by selective transfer. The first two techniques select post-conception; the last seeks to determine sex at the time of conception.

PGD is a relatively new medical technique, introduced about ten years ago for the purpose of screening early IVF embryos for genetic diseases. However, as with other medical technologies, many other uses for PGD were quickly discovered and put into practice, including sex-selection for nonmedical purposes. PGD is expensive, costing on average $3,000 for the test and upwards of $20,000 for the subsequent in vitro fertilization.

The newer and less tested sperm-sorting technology was originally a creation of the U.S. government, invented by a Department of Agriculture scientist in the 1980s for the purposes of selecting sex in livestock. The Genetics and IVF Institute in Fairfax Virginia developed the technology for humans and currently has an exclusive license on it-the technology is known as "MicroSort." The Genetics and IVF Institute charges about $2,300 per try and currently boasts a 90 percent success rate for girls and 73 percent success rate for boys. It offers this service only for the end of "family balancing."

It is difficult to determine how widely either of these methods would be used were they to gain moral acceptance and to become affordable. Of course, we know that sex ratios have already been affected in such countries as China and Korea as a result of aggressive sex selection. What would happen in the United States, where cultural preferences are quite different and the desire for sons is possibly not as pronounced, is perhaps unknowable in advance. Of course, the effect on the sex ratio is only one of the issues at stake. Here's how Fortune magazine recently summed up at least the potential market for MicroSort alone: "Each year, some 3.9 million babies are born in the U.S. In surveys, a consistent 25 percent to 35 percent of parents and prospective parents say they would use sex selection if it were available. If just two percent of the 25 percent were to use MicroSort, that's 20,000 customers . . . [and] a $200-million-a-year business in the U.S. alone."

Although the issue of sex-selection has attracted some scholarly attention, it has received comparatively little popular attention. Neither the morality of choosing for sex, nor the eventual societal effects of widespread sex selection, nor the eugenic implications of this practice have garnered the same kind of public focus as has, for example, human cloning. This is somewhat surprising, given that while cloning is but a possibility on the horizon, sex selection is practiced today-here (on an unknown but probably small scale) and to a much greater extent in several other countries.

In the fall of 2001, bioethicist John Robertson set off a minor firestorm when, apparently speaking for the American Society for Reproductive Medicine (ASRM), he approved of the use of PGD for the purpose of sex selection. This announcement led to much hostile media coverage, culminating in a critical editorial in the New York Times. In response to the uproar, Robertson seemingly reversed himself, and the ASRM issued a statement reaffirming its earlier position. And that was apparently the end of it. However, a closer look at the progress of the ethical debate in the United States reveals that things are rather more interesting and complicated.

In 1999, the ASRM issued a report that criticized the use of PGD exclusively for sex selection. (In 1994, it had reached similar conclusions). The ASRM noted in its 1999 report that there is little cause for concern when sex selection is used to prevent the transmission of sex-linked genetic disorders such as certain types of hemophilia, muscular dystrophy, and Hunter syndrome. The report examined several possible objections to PGD for sex selection, including whether it would lead to imbalances in society's sex ratio, or become a gateway to other forms of selection (say for eye color or intelligence), or whether it might raise matters of economic inequality and the misallocation of scarce medical resources. For the most part, though not entirely, it rejected these ethical concerns as too speculative to be taken seriously. Instead, the report placed most of the weight of its ethical analysis on the problem of how PGD for sex selection would "contribute to a society's gender stereotyping and overall gender discrimination." Significantly, the ASRM report noted that this ethical objection would apply equally to new sperm-sorting technologies for sex selection: "The concerns raised here provide at least a framework for an ethical assessment of new techniques for selecting X-bearing or Y-bearing sperm for IUI or IVF ... here also, sex selection for nonmedical reasons, especially if facilitated on a large scale, has the potential to reinforce gender bias in a society."

Not long after, however, the ASRM began to retreat from its opposition to sex selection using either sperm-sorting or PGD technologies. First, in a May 2001 report on preconception gender selection for nonmedical reasons, it backed away from its earlier suggestion in 1999 that sperm sorting for sex selection was as suspect as using PGD for sex selection. Now the ASRM reasoned that there were no serious ethical objections to this method of sex selection provided that it was used for "gender balancing." However, this last proviso was merely conditional: "The most prudent approach at present for the nonmedical use of these techniques [of sperm sorting] would be to use them only for gender variety in a family, i.e., only to have a child of the gender opposite of an existing child or children. If the social, psychological, and demographic effects of those uses of preconception gender selection have been found acceptable, then other nonmedical uses of preconception selection might be considered [emphases added]."

In retreating from its earlier condemnation of sex-selection (albeit by sperm sorting) the ASRM did not seem to garner much critical attention in the popular press. Then in the fall of 2001, the ASRM seemed to reverse itself again, and more decisively this time, when Robertson endorsed the use of PGD for sex selection. Interestingly, the reversal came following a request for a policy review by the Center for Human Reproduction, a for-profit fertility company that wanted to offer this service to its customers. The Center for Reproduction noted in its appeal that the ASRM had in its 2001 report approved of the use of sperm sorting for family balancing, and asked why it therefore would be ethically impermissible to use a more exact method of sex selection like PGD. It was at this point that John Robertson sent a letter of approval to the Center, and the media storm broke. Many objected to extending sex selection from sperm sorting to PGD because of concerns over the status of the embryo. As even the New York Times editors wrote: The ASRM earlier "concluded that it would be permissible to use a different method-sorting sperm to greatly increase the odds of having a child of a particular sex . . . But extending that approach to the selection and discarding of embryos based on their sex surely deserves more consideration."

As a result of the unwelcome media attention, the ASRM returned to (or reaffirmed) its earlier position, saying that PGD should be discouraged for sex selection. But now the rationale was somewhat different. In 1999, the ASRM's opposition had been based on the specter of gender bias and sex discrimination. But since the ASRM later approved of sex selection by sperm sorting, Robertson now pointed to the ethical issue of the sanctity of the embryo. In a statement printed in the Hastings Center Report in March of 2002, Robertson declared that the embryo deserved special respect. Yet he also observed that this respect was conditional: "A strong showing in the future that gender variety among children is important to an individual's welfare or a family's flourishing could justify a different result." Presently, then, we are in the position of saying that it is permissible to use the technology of sperm sorting for sex-selection but not yet the technology of PGD for the same end, and we seem to vacillate back and forth between concerns about gender bias and concerns for the embryo.

Many questions might be taken up in reference to sex selection for nonmedical reasons, in particular:

1. What are the current and future techniques of sex selection, as well as their effectiveness, cost, and prevalence?
   
   
2. What is the ethical basis or defense of sex-selection for nonmedical purposes? (Following the Council's usual mode of ethical analysis, as established in the cloning report, the burden of proof should lie with those who are proposing the new technique, not those who oppose it.)
   
   
3. Nonetheless, it is still useful for opponents to think through the grounds of their objection to sex selection. What are the human goods being defended? Is there a concern about sexism? About the effect on society's natural sex ratio? About the new relation developed between parent (as chooser) and child (as product)? About a slippery slope to other forms of selection, and thus eventually to a world of eugenics? About the destruction of embryos (in the case of PGD)? Moreover, where lies the preponderance of our ethical objection to sex selection: Is it with the means of selection, or its effects on parents, children, and parent-child relationships, or its likely societal impact both in terms of the sex-ratio and established norms, or as a gateway to other types of selection and enhancement?
   
   
4. If it is decided that sex selection for nonmedical reasons is unacceptable, what are the remedies? Legislative bans? Regulation of the IVF industry? Self-regulation by IVF practitioners and bodies like the ASRM?
   
   
5. What role do for-profit fertility clinics and consumer demand play in the progress of sex-selection therapies?
   
   
6. In light of its objections to sex selection by PGD in its 1999 report, which centered on gender bias, why exactly did the ASRM approve of sex selection by sperm sorting in its 2001 report?