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Medically assisted sex selection for non-medical reasons is banned in the United Kingdom and Canada.⁷ In Australia, sex selection employing artificial insemination or IVF is banned explicitly in Victoria by section 50 of the Infertility Treatment Act 1995. In South Australia, section 13 of the Reproductive Technology Act 1988 requires that artificial fertilisation only be used for the treatment of infertility. Both Acts provide exceptions to avoid the risk of transmission of a genetic defect (assisted reproduction for medical reasons).

In Australia, IVF clinics now offer PGD. One centre performs sex selection for non-medical reasons using IVF and PGD. This has been provided for fertile couples, but has been fully funded privately, costing couples around $10 000. So far, two boys and two girls have been born after sex selection for non-medical reasons (R Jansen, Medical Director, Sydney IVF, personal communication). In Victoria and South Australia, where it is illegal to perform PGD for sex selection, PGD to exclude aneuploidy may reveal the sex of embryos. Couples might in the future request "healthy" embryos of a desired sex -- "incidental sex selection". The legality of transferring embryos of a desired sex in this circumstance is not clear.

Although many jurisdictions ban sex selection for non-medical reasons, there are a number of arguments in favour of allowing it.

Harm to the child: The mutagenic risks of the sex selection procedure to children born must be evaluated.⁸ Many of the methods use well established procedures (such as IVF), though the long term consequences of some are not certain: these include PGD, intracytoplasmic sperm injection,^9,10 and cryopreservation.^11,12 Despite encouraging data from animal studies and existing human experience,¹³ there is a theoretical mutagenic risk associated with ultraviolet light and bisbenzimide used in sperm separation. Concerns about these risks should be addressed by scientific investigation and by ensuring that consent is properly informed, not by banning the procedure.

Sex selection might also cause psychological harm if the procedure does not produce a child of the desired sex. However, parents inevitably have hopes and expectations for their children which are deflated every day. Most parents come to accept and love the child they have, even if that child has a serious disease or disability. Some parents want their children to be great musicians. Sometimes this desire becomes overbearing, as depicted in the film Shine. But the answer is not to ban music schools. The solution is to help parents to be more tolerant and accepting.

Sex selection may be beneficial to the child born if parents will treat a child of that sex more favourably. However, it might be argued that the desire to select sex itself reflects a dysfunctional psychology. Furthermore, sex selection may allow people who are "unsuitable" to be parents to believe that they could cope with a child of a particular sex. It is dangerous to make such judgements about the "suitability" and the "functionality" of people as parents in the absence of any good evidence -- society is now rightly loath to enquire into people's fitness to parent. Moreover, preventing sex selection is no guarantee that such people, even if dysfunctional, will not have children.

One objection in bioethics is that sex selection represents a violation of Kant's dictum never to use a person as a means, but always to treat him or her as an end. According to this argument, by selecting sex parents use their child to fulfil their own desires and fail to respect the child as a person. In one way this objection is fanciful. Parents have many desires related to their children: perhaps to have a companion, to have a friend to the first child, or to hold a marriage together. It is unlikely that any parent ever desires a child solely as an end in itself. Moreover, Kant's dictum is actually never to use a person solely as a means.¹⁴ Provided that parents love their child as an end in itself, there is no problem with the child's life also fulfilling some of the parents' desires for their own lives.

Most importantly, without sex selection, without a unique sperm and egg uniting, that particular child would not have existed. Even if the child is disadvantaged psychologically, this is only wrong from the child's perspective if its life is so bad that it is not worth living. It is difficult to point to any life which can be judged from the outside to be not worth living (possible examples might include Lesch-Nyhan or Sanfilippo syndrome).

Harm to other family members: It is hard to see how sex selection harms parents if they have a child of the desired sex; they may even benefit. If a parent will not be able to accept a child of a certain sex (say, a woman was sexually abused as a child and wants to have a girl), then it may be better for both parent and child if the parent selects sex. Another example might be parents who have one autistic boy. Autism is more common in boys but is not sex linked.¹⁵ Such parents might be happier with a girl.

Could other siblings of the undesired sex be mistreated? Firstly, choosing to have a child of a certain sex does not imply that the other sex is undesired in other children. Secondly, treatment of children of the other sex will be largely determined by the pre-existing belief structure of parents.

Social harm: Does sex selection represent a slide to eugenics and the creation of "designer babies"? We already allow parents to select the kind of children they have. Parents have enormous power (often unconscious) in shaping the kind of people their children become. Parents have the right to choose the environment according to what they believe is best for their child. Moreover, they are already allowed to choose what they believe will be the best children. Parents are allowed to use prenatal testing for disability -- even repairable disability such as cleft palate -- because they are allowed to decide whether they can accept that child. If parents can decide whether they can accept a child with cleft palate, they should be allowed decide whether they can accept a child of a given sex.

Are women harmed by sex selection? Some critics claim that allowing sex selection implies that, in general, one sex is superior to the other¹⁶ -- to do so is sexist.¹⁷ According to Tonti-Filippini, it "devalues girls".² However, it does not, any more than choosing to play Australian Rules football rather than soccer implies the former is "better" in some general sense. Boys and girls are different, and this difference matters to different families in different ways.

Sex selection is more likely to harm women in Asia. There, sex selection is already common. The male-to-female ratio has risen to close to 1.2 in China¹⁸ and some urban parts of India.¹⁹ This situation has worsened since the advent of prenatal sex determination.⁸ It was estimated in 1990 that, globally, there are 100 million women "missing" (died prematurely) as a result of various forms of discrimination.²⁰ It has been claimed that sex selection would "foster the already existing bias against the female child".⁸

Yet, even in Asia, it is not clear that sex selection should be banned.²¹ Disturbed sex ratios may not be a bad thing.²² Advantages which have been postulated include increase in influence of the rarer sex, reduced population growth and interbreeding of different populations.²³ Most importantly, a false belief in the inferiority of women is not a product of sex selection -- sex selection is the product of that belief. Education and improving social and employment arrangements for women are more important in correcting these false beliefs than preventing sex selection.

Consider an analogous argument: some disability advocates argue disability is a social construct; the lives of such people are made worse by the discriminatory attitudes of others.²⁴ They argue prenatal testing serves to reinforce these attitudes and question whether it should be available for conditions like spina bifida.^25,26 The community accepts that parents should be allowed to employ prenatal testing and selective termination to have a child without a disability, even if having a child with a disability would improve the plight of the disabled. By analogy, parents should be able to choose the sex of their child, even if not being able to choose the sex of their child would improve the plight of women.

In the US, 90% of couples wanting sex selection wished to balance sex within the family. Parents were in their mid thirties, had two or three children and only wanted one more.¹ In both the US and UK, just over half of couples choose a girl.^27,28 Sex selection for family balancing would prevent, rather than contribute to, a disturbed sex ratio and harm to women. There is no risk of psychological harm to anyone with this kind of sex selection.

1. Fugger EF, Black SH, Keyvanfar K, Schulman JD. Births of normal daughters after Microsort sperm separation and intrauterine insemination, in-vitro fertilization, or intracytoplasmic sperm injection. Hum Reprod 1998; 13: 2367-2370.
2. Carter H. Couple buy a baby girl to order. Herald Sun (Melbourne) 1998; Sept 12: 9.
3. Carter H. Pick-the-sex test. Herald Sun (Melbourne) 1999; May 5: 5.
4. Carter H. Baby sex selection method draws fire. Herald Sun (Melbourne) 1999; Jan 29: 4.
5. Carson SA. Sex selection: the ultimate in family planning. Fertil Steril 1988; 50: 16-19.
6. R v Davidson [1969] VR 667, Menhennitt J.
7. Jansen RPS. Evidence based ethics and the regulation of reproduction. Hum Reprod 1998; 9: 2068-2075.
8. Benagiano G, Bianchi P. Sex preselection: an aid to couples or a threat to humanity? Hum Reprod 1999; 14: 868-870.
9. te Velde ER, van Baar AL, van Kooij RJ. Concerns about assisted reproduction. Lancet 1998; 351: 1529-1534.
10. Bowen JR, Gibson FL, Leslie GI, Saunders DM. Medical and developmental outcome at 1 year for children conceived by intracytoplasmic sperm injection. Lancet 1998; 351: 1529-1534.
11. Dulioust E, Toyama K, Busnel MC, et al. Long-term effects of embryo freezing in mice. Proc Natl Acad Sci USA 1995; 92: 589-593.
12. Wennerholm UB, Albertsson WK, Bergh C, et al. Postnatal growth and health in children born after cryopreservation as embryos. Lancet 1998; 351: 1085-1090.
13. Simpson JL, Carson SA. The reproductive option of sex selection. Hum Reprod 1999; 14: 870-872.
14. Harris J. "Goodbye Dolly?" The ethics of human cloning. J Med Ethics 1997; 23: 353-360.
15. Ralph I. Autism. N Engl J Med 1997; 337: 97-104.
16. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Screening and counselling for genetic conditions. Washington, DC: US Government Printing Office, 1983; 58-59.
17. Wertz DC, Fletcher JC. Ethics and human genetics: a cross cultural perspective. Heidelberg: Springer-Verlag, 1989.
18. Zeng Y, Tu P, Gu BC, et al. Causes and implications of the recent increase in the reported sex ratios at birth in China. Pop Dev Rev 1993; 19: 283-302.
19. Registrar General of India. Census of India 1991. Final population totals. Series I. India, Paper 2. New Delhi: Registrar General and Census Commissioner, 1992.
20. Sen A. More than 100 million women are missing. New York Review of Books 1990; Dec 20; 61.
21. Young R. The ethics of selecting for fetal sex. Ballieres Clin Obstet and Gynaecol 1991; 5: 576-590.
22. Singer P, Wells D. The reproduction revolution. Oxford: Oxford University Press, 1984; 171.
23. Sureau G. Gender selection: a crime against humanity or the exercise of a fundamental right? Hum Reprod 1999; 14: 867-868.
24. Newell C. The social nature of disability, disease and genetics. J Med Ethics 1999; 25: 172-175.
25. Davis A. From where I sit. London: Triangle, 1989; 19.
26. Davis A. Yes, the baby should live. New Scientist 1985; Oct 31: 54.
27. Batzofin JH. XY sperm separation for sex selection. Urological Clinics of North America 1987; 14: 609-618.
28. Lui P, Rose GA. Social aspects of over 800 couples coming forward for gender selection of their children. Hum Reprod 1995; 10: 968-971.

Reprints will not be available from the author.
Correspondence: Associate Professor J Savulescu, Murdoch Institute, Royal Children's Hospital and Centre for the Study of Health and Society, University of Melbourne, Parkville, VIC 3052.
savulesjATcryptic.rch.unimelb.edu.au

©MJA 1999
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