About one out of five couples who come to HRC Fertility, a network of fertility clinics in southern California, doesn’t need help getting pregnant. Instead, they come for what is called family balancing, or non-medical sex selection.
According to the network’s medical director, Daniel Potter, these couples usually have one, two or three children and want in-vitro fertilisation to guarantee a child of the other sex.
In Australia, couples undergoing IVF treatment do not have the right to choose their unborn child’s sex but in the US they do, and Potter sees 15 to 20 visiting Australian couples every month.
“Typically it’s women wanting to have a daughter, that’s 80 per cent of what we do,” he says.
“Since they were little, the child modelling parenting behaviour has created an entity that for them is usually a daughter. For many women, they have projected the future with that entity: taking her to ballet class, walking down the aisle, that kind of thing. When they have two boys, and they find out they’re pregnant for the third time and (it’s another) boy, (if) they’re crying it’s not because they … resent that son, they’re crying to mourn the loss of that entity they’ve had their whole life.”
Non-medical sex selection is a controversial practice legal in only a few countries, including the US and Mexico. It involves the same technology used to screen for genetic diseases, pre-implantation genetic testing, and even though safety concerns have been addressed, the broader ethical questions remain. In Australia, the National Health and Medical Research Council has floated those ethical questions again as part of a rewrite of guidelines for clinicians and researchers on the use of assisted reproductive technology.
Even in the US, these ethical questions have engendered a mixed response. In June the American Society for Reproductive Medicine issued a position paper saying practitioners are under “no ethical obligation to provide or refuse to provide non-medically indicated methods of sex selection”. But the ethics committee of the American Congress of Obstetricians and Gynecologists reaffirmed last year a committee opinion opposing the practice of sex selection for personal and family reasons.
“We don’t want people to use technology that’s really intended to help couples with medical needs for non-medical reasons,” says Sigal Klipstein, head of the ACOG ethics committee. She says IVF is considered a very safe procedure, but as with any medical procedure there is a low risk of bleeding and infection, as well as overstimulation of the ovaries.
Potter says about half the patients he sees for non-medical sex selection come from abroad. He was recently in Australia for reunions with about 60 families he helped to select their children’s sex, including the Kanavans from Victoria.
Katie Kanavan, 33, travelled from her home in Melbourne to Potter’s clinic twice to undergo IVF/PGD. She already had three boys, all conceived naturally. She and her husband, Stuart, wanted to ensure their next child was a girl and had no such guarantee in Australia. “We wanted to give our boys a sister and we wanted to have a daughter as well,” she says.
The Kanavans spent about $US50,000 on two cycles of IVF/PGD and travel expenses. “It was a pretty big gamble for our family,” Katie Kanavan says. “We saved a lot. We did take money out on our mortgage.” They now have a girl, Ruby-Rose, 2. “We’ve completed our family,” Kanavan says. “I’d do it in a heartbeat again.”
Family balancing should be allowed locally, says David Molloy, chairman of the IVF Directors group in Australia. But it could not be publicly funded, given the range of views on such issues. While well-off parents were paying big money to travel to the US, others were trying unconventional and unproven methods at home, such as “intercourse timing, douching (or) powdered bulls’ testicles”.
“Given there’s a whole heap of unauthorised gender selection happening in bedrooms around Australia, I think it’s reasonable to allow scientific gender selection that actually does work,” Molloy says. He says patients frequently ask about the possibility of choosing their baby’s sex.
Michael Chapman, vice-president of the Fertility Society of Australia, acknowledges that most people may oppose the concept but says about 60 per cent of IVF patients want the option. He considers that reasonable, given how emotionally and financially invested they had to be in IVF.
The NHMRC’s Australian Health Ethics Committee, which produced the draft guidelines, suggests the public debate “would be enhanced through the exploration of some of the complex ethical and social issues raised by non-medical sex selection, through the use of illustrative case studies”.
Those case studies extend beyond family balancing to the replacement of a deceased child and borderline medical reasons, such as where a couple has a boy with autism and believes there would be less chance of their second child having autism if it were a girl.
Arthur Caplan, ethics director at New York University’s medical school, says family balancing can become a smokescreen for families that want boys: “When you are treating the fertile in order to produce something that they prefer as opposed to a disease, I do think you’re really opening the door to a potential slope toward eugenics.”
Potter says although there have been cases of couples wanting a child capable of providing bone marrow to a sick sibling, they were rare.
Sometimes family balancing is sought in second marriages, where a couple wants only one child and there are children from previous relationships, but mothers wanting daughters is the most common cause.
Potter says the Australian women he sees do not have firm views on whether the ethical guidelines should change, instead arriving just “happy and very appreciative that we are there to provide the service to them”.
Like Molloy, he believes that if there is no public funding involved, opposition to sex selection will fade away.
David Kaufman, a program director at the US National Human Genome Research Institute, doesn’t expect a trend to emerge for designer babies. Unlike sex selection, genetic testing of embryos for other traits is much more complicated because most of them are governed by multiple genes. “In most cases we don’t even know all the genes and even if we did you’re pretty unlikely to produce an embryo with the perfect combination of all those genes,” he says.
Potter says every case is different and the couples he helped all had their own, sometimes deeply emotional, reasons for wanting to choose a boy or a girl.
“These are not monsters, these are normal loving families who would like to have a gender represented in their family that currently isn’t,” he says.
