ORIGINAL ARTICLE Psychology and counselling Sex preference and interest in preconception sex selection: a survey among pregnant women in the north of Jordan Nemeh Ahmad Al-Akour1,5, Mohammad Khassawneh2, Yousef Khader3, and Edgar Dahl4 1School of Nursing, Jordan University of Science and Technology, PO Box 3030, Irbid, Jordan 2Faculty of Medicine, Pediatric Department, Jordan University of Science and Technology, Irbid, Jordan 3Faculty of Medicine, Department of Community Medicine, Public Health and Family Medicine, Jordan University of Science and Technology, Irbid, Jordan 4Centre for Gynaecology and Obstetrics, University of Giessen, Giessen, Germany 5Correspondence address. E-mail: alakour@just.edu.jo background: Preconception sex selection for non-medical reasons is a controversial issue in bioethics. Little research has described preferences for preconception sex selection among Arab populations. This study describes the sex preference and interest in employing sex selection techniques among pregnant women in northern Jordan. methods: A self-reported questionnaire was administered to 600 pregnant women in Irbid, Jordan. x2 test and binary logistic regression were used to examine the factors associated with interest in preconception sex selection. results: In general, the interest in using sex selection was low. Women who preferred boys were more likely to be interested in sex selection, if paid for by the couple [odds ratio (OR) 1⁄4 4.40, 95% confidence interval (CI): 1.75–11.11] or by health insurance (OR 1⁄4 3.42, 95% CI: 1.94–6.06), or, if feasible, administered through oral medication (OR 1⁄4 8.84, 95% CI: 5.05–15.63). Women with lower education were more likely to be interested in sex selection, if paid by health insurance (OR 1⁄4 1.96, 95% CI: 1.10–3.45) and were more likely to believe that sex selection is legal (OR 1⁄4 1.79, 95% CI: 1.06–2.86). Women who had no boys were more likely to be interested in sex selection, if paid by health insurance (OR 1⁄4 1.94, 95% CI: 1.10–3.42) or, if feasible, through medication (OR 1⁄4 3.03, 95% CI: 1.82–5.00). conclusions: The majority of participants were not in favor of using preconception sex selection. Those with a preference to have boys, with lower education, and those with an imbalanced family were more likely to be interested in using sex selection technology. Key words: preconception sex selection / sperm sorting / sex preferences / sex ratio distortion / Jordan Introduction Preconception sex selection is currently used as a method of choosing the sex of future children (Serour, 2004). At present, it is possible to select the sex of a baby by two common methods. One method depends on separating the X and Y chromosome-bearing sperms using MicroSort TM sperm separation. The second common method uses preimplantation genetic diagnosis (PGD) (Serour, 2004), however strictly speaking this is not 'preconception' selection. Other traditional methods that are believed to contribute to sex selection include intercourse timing and position, vaginal douching and the use of ovulation induction medications or hormone measuring technologies (Savulescu, 1999). Sex selection can be performed for medical reasons such as when the mother is a carrier of a sex-linked disease like hemophilia. Other reasons for sex selection are non-medical and usually reflect specific social reasons (Postnote, 2003; Serour, 2004). Many studies have shown that sex selection for social reasons is not considered to be ethically acceptable. These studies reported that sex selection may promote sexist attitudes and reinforce discrimination against women (Dahl, 2007). Others are concerned that social sex selection would lead to a considerable imbalance of the sexes in countries where a specific sex of the baby is preferred to the other. This is more apparent in countries with more preference for boys, such as India, China and Korea (Benagiano and Bianchi, 1999; Allahbadia, 2002; Mudur, 2002; Plafker, 2002; Balen and Inhorn, 2003; Dahl et al., 2003a). & The Author 2009. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org. Human Reproduction, Vol.24, No.7 pp. 1665–1669, 2009 Advanced Access publication on April 9, 2009 doi:10.1093/humrep/dep080 The majority of sex selection surveys appear to have been carried out in the USA or Western Europe (Hall et al., 2006). In 2008, national demographic statistics in Jordan showed that the male to female ratio was 1.15 to 1 (Department of Statistics, 2008). There is little data about attitudes toward preconception sex selection among Jordanian Arabic women (Kilani and Haj Hassan, 2002). And to date, there is no Jordanian law that deals with legal and ethical aspects of sex selection. This study, conducted in the north of Jordan, describes the sex preferences of pregnant women and their interest in employing sex selection technology for non-medical reasons. Materials and Methods Design and sample There were 600 pregnant women, aged 18–49 years, included in this study. We chose seven representative main maternal and child health centers in the north of Jordan. These centers serve populations with different levels of socio-economic status and education. Two centers are located in the main city of Irbid, and they are considered urban maternal and child health centers. The other five centers were chosen from 10 suburban maternal and child centers that serve the suburban population in the northern part of Jordan. Using systematic random sampling techniques, participants were selected from all pregnant women who were followed up in these maternal and child health centers in the period between 20th of July and 20th of September 2008. A questionnaire, developed by Zubair et al. (2007) and consisting of 17 questions, was used in this study. The questionnaire was self-administered, and it included questions on demographic data, questions regarding attitude toward sex selection and questions regarding child sex preferences. Participants were asked if they could imagine selecting the sex of their children by using MicroSort TM. To assure informed decisions, participants were educated about the steps needed to use this technology. Participants were informed that couples seeking such technology should visit a center for reproductive medicine, provide a sperm sample for separation via flow cytometry, undergo an average of three to five cycles of intrauterine insemination and pay a fee of US$2000 per attempt. To verify the true opinion of participants about sex selection they were asked about sex selection under two conditions: in the first condition, sex selection requires only one cycle of intrauterine insemination and is covered by their health insurance; and in the second condition, sex selection can be achieved by taking simple medication. Participants were also asked whether they believe that sex selection is legal. Data collection was done by five trained nursing students. Ethical approval for the study was obtained from the Ethical Research Committee at Jordan University of Science and Technology. Data analysis Data were analyzed using the Statistical Package for Social Sciences (SPSS, version 15.0). Data were described using frequencies and percentages. For the purpose of univariate and multivariate analyses, those who had no interest in preconception sex selection and those who were undecided were pooled in one group. Interest in preconception sex selection according to socio-demographic and relevant characteristics was analyzed using x2 test. Binary logistic regression was used to determine the factors associated with interest in preconception sex selection and these were reported as appropriate for descriptive purposes. A P-value of ,0.05 was considered statistically significant. Results Participants' characteristics Table I shows the socio-demographic and relevant characteristics of participants. Table II shows the sex preferences and ideal number of children to have as believed by participants. Of all participants, 309 (51.5%) reported that they prefer to have equal number of boys and girls, 158 (26.3%) reported that they prefer to have more boys than girls, whereas only 13 (2.2%) reported that they prefer to have more girls than boys. Of 269 women who did not know the sex of their yet unborn child, 121 (45.0%) reported that they prefer to have a boy, 47 (17.5%) reported that they prefer to have a girl and the remaining 101 (37.5%) women had no preference. Of the 100 women who had no children, 39% preferred their first child to be a boy, 27% preferred their first child to be a girl and 34% had no preference. About half of the women (51.8%) considered four children to be an ideal number. ........................................................................................ Table I Socio-demographic and relevant characteristics of women Variable n (%) Age (years) 18–25 211 (35.0) 26–30 160 (27.0) 31–35 114 (19.0) 36–40 74 (12.0) .40 41 (7.0) Education Primary school 52 (8.7) Secondary school 65 (10.8) High school 196 (32.7) University 287 (47.8) Number of children 0 100 (16.7) 1 500 (83.3) Number of males 0 155 (26) 1 445 (74) Number of females 0 172 (29) 1 428 (72) Pregnancy Planned 347 (57.8) Unplanned 253 (42.2) Knowledge of fetal sex Yes 331 (55.2) No 269 (44.8) Interest in sex determination Yes 201 (74.7) No 68 (25.3) 1666 Ahmad Al-Akour et al. Preconception sex selection Only 21 (3.5%) women reported that they would imagine using sex selection through sperm sorting. This number increased to 57 (9.5%) when we ask them to imagine that sex selection required only one cycle of intrauterine insemination covered by health insurance. Furthermore, this number rose to 77 (12.8%) if sex selection could be done by taking simple medication. Only 81 (13.5%) believed that sex selection should be legally acceptable (Table III). Table IV describes the attitudes of participants toward sex selection according to sociodemographic and relevant characteristics. In the multivariate analysis, compared with women who preferred girls, women who preferred boys were more likely to be interested in sex selection if paid by couple [odds ratio (OR) 1⁄4 4.40, 95% confidence interval (CI): 1.75–11.11, P 1⁄4 0.002], if paid by health insurance (OR 1⁄4 3.42, 95% CI: 1.94–6.06, P 1⁄4 .001) or if it was feasible through medication (OR 1⁄4 8.84, 95% CI: 5.05–15.63, P 1⁄4 .001). Compared with women with higher education, women with high school education or less were more likely (OR 1⁄4 1.96, 95% CI: 1.10–3.45, P 1⁄4 0.023) to be interested in sex selection if paid by health insurance and were more to believe that sex selection is legal (OR 1⁄4 1.79, 95% CI: 1.06–2.86, P 1⁄4 0.01). Women who had no boys were more likely to be interested in sex selection if paid by health insurance (OR 1⁄4 1.94, 95% CI: 1.10–3.42, P 1⁄4 0 .022) or if feasible through medication (OR 1⁄4 3.03, 95% CI: 1.82–5.00, P 1⁄4 0.001). Compared with women who had children, women who had no children were more likely to report that they were in favor of making social preconception sex selection legal (OR 1⁄4 2.06, 95% CI: 1.16–3.66, P 1⁄4 0.01). Women who think that five or more children is an ideal number were more likely to report they were in favor of making social preconception sex selection legal (OR 1⁄4 2.11, 95% CI: 1.30–3.43, P 1⁄4 0.002), compared with women who think that four or fewer children is an ideal number. Discussion The findings of this study showed that pregnant women receiving prenatal care in the north of Jordan generally do not accept the techniques that select the sex of their prospective children yet showed a preference to have more boys than girls. Although the preference for boys in Jordan had been reported in previous studies (Al-Zoubi, 1995; Khalaf and Callister, 1997; Al-Qutob et al., 2003; Al-Akour, 2008), none of these studies assessed the attitude of Jordanian women toward preconception sex selection for non-medical reasons. There appears to be a consistent conservative opinion about sex selection for social reasons by the majority of participants, even if this technology is offered free of charge or even if it can be achieved through simple medication. Zubair et al. (2007) showed similar attitudes toward the use of sex selection technology among pregnant Pakistani women. Studies from USA (Rosenzweig and Adelman, 1976; Adelman and Rosenzweig, 1978; Singer 1991; Fugger et al., 1998; Gleicher and Barad, 2007), the UK (Dahl et al., 2003b) and Germany (Dahl et al., 2003a, 2004) have indicated that most people ........................................................................................ Table III Demand for sex selection among pregnant women in Jordan Interest in sex selection n (%) Interest in sex selection (if paid by couple) Yes 21 (3.5) No 538 (89.7) Undecided 41 (6.8) Interest in sex selection (if paid by health insurance) Yes 57 (9.5) No 493 (82.2) Undecided 50 (8.3) Interest in sex selection (if feasible through medication) Yes 77 (12.8) No 478 (79.7) Undecided 45 (7.5) Moral attitude toward sex selection Should be legal 81 (13.5) Should be illegal 458 (76.3) Undecided 61 (10.2) ........................................................................................ Table II Sex preference and ideal number of children Variable n (%) Sex preference for fetus (n 1⁄4 269) Boy 121 (45.0) Girl 47 (17.5) No preference 101 (37.5) Preference for first-born child (n 1⁄4 100) Boy 39 (39) Girl 27 (27) No preference 34 (34) Sex preferences (n 1⁄4 600) Only boys 39 (6.5) Only girls 0 (0.0) More boys than girls 158 (26.3) More girls than boys 13 (2.2) An equal number of boys and girls 309 (51.5) No preference 81 (13.5) Ideal number of children (n 1⁄4 600) 1 2 (0.3) 2 59 (9.8) 3 28 (4.7) 4 311 (51.8) 5 64 (10.7) 6 98 (16.3) 7 7 (1.2) 8 10 (1.7) 9 5 (0.8) 10 9 (1.5) 12 5 (0.8) 15 2 (0.3) Sex preference and interest in preconception sex selection 1667 have a negative attitude toward sex selection. British citizens appeared to be more interested in selecting the sex of their future children than did their German counterparts. In a study including 17 European countries, Hank and Kohler (2000) found that a balanced family is preferred in Austria, Belgium, Italy, Spain and Switzerland. The results of this study are consistent with previous studies from Jordan in showing a trend of preference for boys over girls (Al-Zoubi, 1995; Khalaf and Callister, 1997; Al-Qutob et al., 2003; Al-Akour, 2008). Liu and Rose (1995) examined the attitude of couples of Indian, European, Chinese and Middle Eastern origin. The authors found that the non-European couples expressed a clear preference for boys. This finding of preference for boys may be explained by understanding the cultural backgrounds. In Jordan and other Arab communities, parents prefer boys because they believe that boys are the source of strength to the family. They also believe that boys will carry the family's name to future generations and they contribute more to family income (Al-Zoubi, 1995; Jacobsen et al., 1999; Al-Akour, 2008). A large body of literature has also demonstrated a preference for male offspring in Western Europe, North America and Canada (McDougall et al., 1999; Dahl et al., 2003a; Van Balen, 2006). The preference for boys is stronger than the preference for girls when couples are planning to have only one child. These preferences are even more pronounced in Asia. A strong boy preference is found in India, Pakistan, China and South Korea (Li et al., 2000; Junhong, 2001; Chan et al., 2006; George, 2006; Zubair et al., 2007). Recently, however, a study from Australia indicated that more than 70% of 149 couples preferred their first-born child to be a girl (Connolly, 2008). The results of this study suggested that those participants with higher education were less interested in using preconception sex techniques. In USA, Rosenzweig and Adelman (1976) and Adelman and Rosenzweig (1978) found that married couples with university educations showed little interest in controlling the sex of their first child yet a strong interest in influencing the sex of their second child. Education is generally associated with more awareness about the negative medical and social aspect of sex selection. Another interesting finding in the present study is that women who think that five or more children is an ideal number were more likely to report that they were in favor of making social preconception sex selection legal. This finding probably reflects an opinion on family balance rather than opinion on sex selection. The current study showed a significant association between a preference for boys and interest in using preconception sex technology. ............................................................................................................................................................................................. Table IV Sex selection according to socio-demographic and relevant characteristics In favor of making social sex selection legal [n (%)] Interest in sex selection (if feasible through medication) [n (%)] Interest in sex selection (if paid by health insurance) [n (%)] Interest in sex selection (if paid by couple) [n (%)] Variable Mothers age (years) 14 (2.9) 64 (13.2) 45 (9.3) 14 (2.9) 35 7 (6.1) 13 (11.3) 12 (10.4) 7 (6.1) .35 Education 51 (16.3)* 45 (14.4) 38 (12.1)* 13 (4.2) High school or less 30 (10.5) 32 (11.1) 19 (6.6) 8 (2.8) More than high school Having children 61 (12.2)* 55 (11.0) 47 (9.4) 19 (3.8) Yes 20 (20) 22 (22.0) 10 (10) 2 (2.0) No Number of boys 55 (12.4) 42 (9.4)** 35 (7.9)* 9 (2.0) 1 26 (16.8) 35 (22.6) 22 (14.2) 12 (7.7) 0 Number of girls 54 (12.6) 14 (3.3) 36 (8.4) 14 (3.3) 1 27 (15.7) 7 (4.1) 21 (12.2) 7 (4.1) 0 Ideal number of children 43 (10.8)** 50 (12.5) 33 (8.3) 17 (4.3) 1–4 38 (19.0) 27 (13.5) 24 (12.0) 4 (2.0) 5 Sex preferencea 31 (15.7) 53 (26.9)** 33 (16.8)** 13 (6.6)** Boys 50 (12.4) 24 (6.0) 24 (6.0) 8 (2.0) Others aSex preference for boys includes participants who chose only boys or more boys than girls; 'others' include all other participants. *P , 0.05. **P , 0.01. 1668 Ahmad Al-Akour et al. Swetkis et al. (2002) found a correlation between overall preference for first-born males and interest in using preconception sex selection techniques. Our findings also showed that women with no boys were more likely to be interested in employing preconception sex selection, whereas women with no children were more interested in making it legal. In a short communication, Drs Kilani and Hassan (2002) described their experience in their private infertility center in Amman, Jordan regarding the use of PGD. They suggested Jordanian women coming to that infertility clinic are eager to use sex selection technology for first-born sons. They believed that a strong social need for a specific sex in the family, such as the presence of three or more children of the same sex, is an enough justification for performing sex selection. In conclusion, this study demonstrates that the majority of participants are not in favor of using preconception sex selection. 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