The Abortion Trap

For nearly two decades, anti-abortion activists have been at work in a disingenuous game, using the stark reduction of women in the developing world as an argument for taking away hard-earned rights. Conservative theorists have written openly about how sex-selective abortion is merely a convenient wedge issue in the drive to ban all abortions, both in the United States and abroad. And now, conservative commentators like the New York Times‘ Ross Douthat, the Wall Street Journal’s Jonathan V. Last, and the editors of the New York Sun have claimed that my book, Unnatural Selection, strengthens their case.

This does not surprise me. One of the themes that cropped up again and again in my reporting was the extent to which American abortion politics on both sides of the question has stalled action on issues of major global importance. But it is deeply unfortunate. The American obsession with abortion does not just hinder work on maternal and child health or access to safe birth control abroad — two areas that have suffered because of domestic campaigns by anti-abortion activists. It’s also distracting U.S. policymakers from what should be the real conversation in a country that leads the world in human reproductive technology: whether to allow parents to use a growing range of methods to select for characteristics like sex (or diseases that come on late in life and, perhaps one day, IQ) in their children. Because sex selection is not just a developing-world problem — it’s an American problem, too.

Western influence and technology have caused their fair share of damage abroad, but often the damage is not explicitly foreseen, so that decades later it is still possible for trouble’s architects to look back and say, “We just didn’t know.” But with fetal sex determination and sex selection, a good number of people knew. The 1960s population control enthusiasts who supported pushing along research into sex selection methods as a way to reduce the global birth rate knew those methods would occasion a reduction in the proportion of girls born, even if they did not envision the scale of that reduction — the disappearance of 160 million females, by 2005, from Asia’s population. As I delved into this history for my book, the tragedy for me became this cold foresight: the fact that some prominent activists and scientists actually anticipated the side effects of widespread sex selection — that a massively imbalanced sex ratio at birth would result in rising instability, risks for those women who are born, and a social environment bordering on what one early proponent described as a “giant boy’s public school or a huge male prison” — and yet dismissed those effects as necessary ills in the quest to solve humanity’s problems through technology. They knew, and still they plowed ahead.

The story behind sex selection should serve as a cautionary tale as we consider other technological quick fixes as solutions to our current global problems: dumping iron into our oceans in the quest to fight climate change, say. But the American response to my book has largely overlooked this point, glossing over the moral implications of sex determination technologies like ultrasound, amniocentesis, and add-ons to in-vitro fertilization (IVF), and instead homing in on abortion.

True enough, abortion is the primary method of sex selection in the developing world today. But it is hardly the most ideal method. Given the choice between a second-trimester abortion and a cheap and easy procedure performed close to the moment of conception, most couples would choose the second. That is why activists concerned about a reduction in the number of women in the world — or in the number of disabled, red-haired, or short people — are looking ahead to emerging technologies like fetal DNA testing, sperm sorting, and embryo screening.

The high-tech sex selection front-runner in both the developing and developed worlds for the moment is a technique called preimplantation genetic diagnosis (PGD), the add-on to in-vitro fertilization sometimes called embryo screening. Once a donor’s eggs have been retrieved and fertilized with a man’s sperm and the resulting zygotes have grown into embryos, a single cell can be removed and tested for sex.

Like ultrasound and amniocentesis before it, PGD can be used to diagnose much more than an embryo’s sex. That is why most of the Western world regulates it instead of banning it outright. The United Kingdom has made perhaps the most ambitious effort at regulation in establishing the Human Fertilisation and Embryology Authority (HFEA), an agency under the Department of Health charged with regulating fertility clinics, sperm banks, and other businesses connected with assisted reproduction. Thanks to the HFEA, British couples may undergo PGD to avoid passing on debilitating diseases like cystic fibrosis –but not for what is called social sex selection, or simply because they want a boy or a girl. For that, many fly to the United States.

Because its health-care system is privatized and because techniques like social sex selection are a cash cow for the clinics that provide them, the United States has become the Wild West of assisted reproduction, home to Octomom and a host of less well-known ethical blunders. America also allows nearly unfettered use of the new sex selection technologies. The American Society for Reproductive Medicine issues guidelines for fertility clinics, but they are only voluntary — and many clinics don’t follow them.

But since assisted reproduction is typically carried out in private clinics that do not receive federal funding, the field gets far less oversight than many other areas of medicine. Some techniques have “moved from concept to clinic without systematic animal studies or reviews by any independent agency or committee,” Marcy Darnovsky, associate executive director of the Center for Genetics and Society in Berkeley, California, wrote in a recent article for the website Science Progress. In many regards, international adoption is governed by stricter regulations than assisted reproduction.

That’s why, some three decades after sex selection found its way to Asia, the United States has become a destination for couples from around the world seeking the latest techniques. Couples from China and India fly to Los Angeles to undergo PGD at Fertility Institutes, a clinic I visited last year. (A good number of healthy Americans shell out the $15,000-plus cost of PGD simply to get a boy or a girl as well. One out of every 100 babies in the United States is born through IVF, and fertility patients are often encouraged to tack on PGD. While clinics aren’t required to report what PGD is used for, a 2006 survey of those that perform the procedure by the Genetics and Public Policy Center at Johns Hopkins University found 42 percent of responding clinics offered it for social sex selection.) The United States has also become an exporter of technologies with questionable ethical underpinnings. Jeffrey Steinberg, Fertility Institutes’ founder, has opened an office in Guadalajara, Mexico, and clinics offering PGD are being set up in Asia, in some cases in countries with already severe gender imbalances.

Take South Korea, for example: Sex-selective abortion has gone out of style there, and the country’s once-skewed sex ratio at birth is now balanced. But wealthy parents still turn to PGD, according to Sohyun Kim, a doctor who runs a small clinic in a tony part of Seoul. “These days, because of IVF technology, parents have a lot of different embryos to choose from,” she told me. “They ask for the ones they don’t want to be eliminated. The girls can be erased. And the boys remain.”

In his review of my book, Last contended the work is “aimed, like a heat-seeking missile, against the entire intellectual framework of ‘choice.'” It is true that I don’t believe absolute choice is a great framing point for the politics of modern reproduction. The range of options available to parents today is simply too great. The rhetoric surrounding abortion in the United States sorely needs to be updated. (I am hardly alone in this thought. While the term “pro-choice” lives on, it is no coincidence that the new buzzword is “reproductive justice.”)

That said, selecting for sex — or any other quality — is different from a woman’s decision not to carry a pregnancy to term. When parents choose to have a child because he is male, they may do so with the expectation that their son will turn out to be an upstanding heir or that he will carry on the family line. Or, should they want a girl, they may be seeking a child who enjoys wearing pink dresses and playing with dolls. Ethically, this is worlds apart from a woman’s choice not to continue a pregnancy — or not to get pregnant in the first place. One is the decision of a woman considering her own body. The other involves the creation of a new human being — and expectations for how that human being will turn out.

Sex selection, indeed, represents a form of choice that looks a lot like willful manipulation. (“Sex control,” the typically bold 1960s phrase used by those who proposed sex selection as population control, has turned out to be a good term for it.) It marks the dawn of what Harvard University political philosopher Michael Sandel calls “hyperagency” — “a Promethean aspiration to remake nature, including human nature, to serve our purposes and satisfy our desires.”

But the distinction between these two types of choices is not merely intellectual; it has legal grounding as well. Roe v. Wade came at a time when today’s reproductive dilemmas were still the stuff of speculation, yet it explicitly protects a woman’s right to decide whether to carry a pregnancy to term — while also acknowledging that right can have limits. In crafting a framework for pre-pregnancy sex selection, the United States might look to countries like France, the Netherlands, and Denmark, where abortion rights are intact and yet sex selection for social reasons is prohibited.

The anti-abortion movement should agree that sex selection, along with many other forms of selection, is wrong, and indeed many in the religious community see what happens today as tampering with God’s work. (The Vatican struck out against using PGD for trait selection in 2009.) But unfortunately the same people who would ban abortion in the United States are often allied with the very ones who advocate for free-market health care and lax oversight of industry — the very ingredients that have made the United States a destination for the hyper-controlling parents of the world intent on getting a certain type of child. Conservatives who object to tampering with reproduction are rivaled in strength by those who favor letting market forces govern health care.

The result is nothing less than consumer eugenics. “Gender selection is a commodity for purchase,” Steinberg, the Los Angeles clinic founder, reportedly told journalist Mimi Rohr in 2006. Sex is only the first non-medical or non-disability condition that can be tested using PGD, though the arrival of more sophisticated diagnostic techniques push the boundary of what constitutes a medical condition. (Adult-onset Alzheimer’s? A future that may involve breast cancer? A propensity toward obesity?) In 2009, Steinberg announced on Fertility Institutes’ website that his clinic would soon offer selection for eye color, hair color, and skin color. He retracted the announcement after a public outcry, but when I met him last year he told me it wasn’t a change of heart — he’s just waiting for public sentiment to come around.

Others with less of a financial stake in the matter agree that unfettered reproductive selection is the way of the future. James Watson, co-discoverer of DNA’s double-helix structure, told an audience in 2003 that he supported knowledge gleaned from his discovery being used to shape the outcome of reproduction on an individual level, while Princeton University molecular biologist Lee M. Silver has written on the inevitability of a Gattaca-like society split between the genetic haves and have-nots.

Whatever awaits us, it’s clear that the issue of abortion is increasingly a red herring. Activists on both the right and the left might now be wise to abandon the abortion fray and consider speaking out for restraint in other areas. Governments in Asia have introduced measures to address sex selective abortion, and Western support for those measures is critical. But beyond that, the United States should now lead in addressing the new technologies emerging from within its borders. We owe as much to the world and to future generations — so that next time it can’t be said that we knew and yet chose not to act.