P Y a a c c s a s 1 R R Preconception sex selection demand and preferences in the United States Edgar Dahl, Ph.D.,a Ruchi S. Gupta, M.D., M.P.H.,b Manfred Beutel, M.D.,c Yve Stoebel-Richter, Ph.D.,d Burkhard Brosig, M.D.,e Hans-Rudolf Tinneberg, M.D.,f and Tarun Jain, M.D.g a Center for Bioethics and Humanities, State University of New York Upstate Medical University, Syracuse, New York; b Institute for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois; c Clinic for Psychosomatic Medicine and Psychotherapy, University of Mainz, Mainz, Germany; d Department of Psychology and Medical Sociology, University of Leipzig, Leipzig, Germany; e Clinic for Psychosomatic Medicine and Psychotherapy, University of Giessen, Germany; f Department of Obstetrics and Gynecology, University of Giessen, Germany; and g Department of Obstetrics and Gynecology, University of Illinois College of Medicine, Chicago, Illinois Objective: Preconception sex selection for nonmedical reasons raises important moral, legal, and social issues. The main concern is based upon the assumption that a widely available service for sex selection will lead to a socially disruptive imbalance of the sexes. For a severe sex ratio distortion to occur, however, at least two conditions have to be met. First, there must be a significant preference for children of a particular sex, and second, there must be a considerable interest in employing sex selection technology. Our objective was to ascertain such demand and preferences among the United States general population. Design: Cross-sectional web-based survey. Setting: United States general population. Patient(s): One thousand one hundred ninety-seven men and women aged 18 to 45 years. Intervention(s): None. Main Outcome Measure(s): Web-based questionnaire assessing preferences for sex of children and demand for preconception sex selection for nonmedical reasons. Result(s): Eight percent of respondents would use preconception sex selection technology, 74% were opposed, and 18% were undecided. If the sex selection process was simplified to taking a pill, 18% would be willing to use such a medication, 59% were opposed, and 22% were undecided. In terms of gender choices, 39% of respondents would like their first child to be a son, 19% would like their first child to be a daughter, and 42% had no preference. Overall, 50% wished to have a family with an equal number of boys and girls, 7% with more boys than girls, 6% with more girls than boys, 5% with only boys, 4% with only girls, and 27% had no preference. Conclusion(s): Preconception sex selection technology via sperm separation is unlikely to be used by the majority of the United States population and is unlikely to have a significant impact on the natural sex ratio. (Fertil Steril 2006;85:468–73. ©2006 by American Society for Reproductive Medicine.) Key Words: Sex selection, sperm sorting, MicroSort, gender preferences, sex ratio, social survey, law, ethics, health policya S l c i ( c a g t o s n reconception sex selection technology that separates Xand -bearing sperm is currently available in the United States s part of an FDA-approved clinical trial via the Genetics nd IVF Institute (Fairfax, VA) and over 100 collaborating linics in 30 states (1). The technology employs a flow ytometer that separates the 2.8% heavier Xfrom Y-bearing perm to produce an Xor Y-enriched sperm sample for rtificial insemination or in vitro fertilization (2– 4). Upon uccessful completion of the clinical trial (which began in 995), the potential exists for widespread dissemination eceived May 25, 2005; revised and accepted July 22, 2005. eprint requests: Tarun Jain, M.D., Division of Reproductive Endocrinology and Infertility, University of Illinois Medical Center, 820 South Wood Street, M/C 808, Chicago, Illinois 60612 (FAX: 3129964238;aE-mail: tjain@uic.edu). 468 Fertility and Sterility Vol. 85, No. 2, February 2006 Copyright ©2006 American Society for Reproductive Medicine,nd marketing of this technology throughout the United tates (5). Because use of such technology poses important moral, egal, and social issues, it has become one of the most ontroversial topics in bioethics today (6–9). Some concerns nclude an inappropriate use of limited medical resources 10), the perpetuation of sexist attitudes that reinforce disrimination against women (11), the fear that children born s a result of sex selection may be expected to act in certain ender-specific ways (12), and the acceleration of trends oward selection of offspring characteristics and the creation f "designer babies" (13). The main concern, however, is that a widely available ervice for preconception sex selection may distort the atural sex ratio and lead to a socially disruptive imbalnce of the sexes, as has occurred in countries such as 0015-0282/06/$32.00 Published by Elsevier Inc. doi:10.1016/j.fertnstert.2005.07.1320 C c t f r t d t p t s c t s n e f g w p t M A u H fi c u F hina and India (14 –20). Even uncompromising advoates of procreative liberty concede that a severe distorion of the sex ratio would justify limits on reproductive reedom (21–26). However, whether or not a sex ratio distortion poses a eal threat to Western societies is an empirical question hat cannot be answered by intuition, but only by evience. For a severe sex ratio distortion to occur, at least wo conditions must be met. First, there must be a marked reference for children of a particular sex, and, second, here must be a considerable demand for a reproductive ervice for preconception sex selection. Moreover, both onditions need to be met simultaneously. For example, if here was a marked preference for children of a particular ex but couples were unwilling to use sex selection techology (because it was thought to be too intrusive, too TABLE 1 Questionnaire. Suppose you did not have any children but would v 1. If given a choice, would you like your first born a boy a girl do not care not sure 2. If you would like to have more than one child, only boys only girls more boys than girls more girls than boys an equal number of boys and girls do not care not sure 3. It may soon be possible for parents to choose service would have to visit a Fertility Center, p to five cycles of intrauterine insemination, and you take advantage of this technology? yes no not sure 4. Suppose, the procedure would require just a s performed in any doctor's office, and would be consider taking advantage of it? yes no not sure 5. Suppose, there was a medication enabling par simply had to ingest a blue pill to ensure the b Would you take advantage of such a medicatio yes no not sureDahl. Sex selection. Fertil Steril 2006. ertility and Sterilityxpensive, or immoral), then a widely available service or sex selection would not have a significant demoraphic impact. To determine whether or not these two conditions are met, e conducted a nationwide representative survey on gender references and demand for preconception sex selection in he United States. ATERIALS AND METHODS self-administered, web-based survey was conducted sing a previously validated questionnaire (Table 1) (27). arris Interactive (Rochester, NY), a market-research rm specializing in internet-based research methods, was ommissioned to conduct the nationwide survey, drawing pon its Harris Poll Online Panel to identify potential much want to. ld to be ld you prefer to have sex of their children. Couples interested in such a e a sperm sample, undergo an average of three a fee of approximately $2,500 per attempt. Would cycle of intrauterine insemination, could be vered by your health insurance. Would you then to choose the sex of their children. Couples of a boy or a pink pill to ensure the birth of a girl.ery chi wou the rovid pay ingle co ents irth n?469 r v b b E a e r u e o t a u i o s p t I a n o R T a e r m S r a 1 2 3 4 espondents (who were invited to participate in the survey ia e-mail). The five-question survey was conducted between Septemer 1 and 3, 2004, of a sample of 1,197 men and women etween the ages of 18 and 45 throughout the United States. ach respondent was issued a unique password to guard gainst multiple responses from any participants. A propritary web-based technology that enables large numbers of espondents to simultaneously complete the survey was sed. The demographic characteristics (age, sex, ethnicity, ducation, income, marital status, and region of residence) f the population sampled were weighted where necessary o reflect United States census estimates of American dults aged 18 to 45. Propensity score weighting was also sed to adjust for respondents' propensity to use the nternet. In theory, with a probability sample of this size, ne could say with 95% certainty that the results have a ampling error of 3 percentage points owing to the robability that a sample is not a perfect cross-section of he total population from which it was drawn). All Harris nteractive surveys are designed to comply with the code nd standards of the Council of American Survey Orgaizations (CASRO) and the code of the National Council f Public Polls. ESULTS he demographic characteristics of the survey respondents re presented in Table 2. Both men and women responded qually to the survey (49% and 51%, respectively). Married espondents made up 53%, with most having some college or ore (61%), and most working full or part time (58%). ome demographic questions were not answered by every espondent. The computer-tabulated results for each survey question re as follows: . Participants were asked if, given a choice, they would want their first child to be male or female. Thirty-nine percent of respondents would like their first child to be a boy, 19% would like the first child to be a girl, and 42% stated that they have no preference about the sex of their first child (Fig. 1A). The divorced/separated group was less likely to have a sex preference (28% for a boy and 17% for a girl) than the married participants (38% for a boy and 21% for a girl) and the single/ never-married participants (43% for a boy and 13% for a girl). . Provided they would like to have more than just one child, participants were asked, if, given a choice, they would want only boys, only girls, more boys than girls, more girls than boys, as many girls as boys, or whether the sex of their children would not matter to them at all. Five percent preferred only boys, 4% only girls, 7% more boys than girls, 6% more girls than boys, 50% as many girls as boys, and 27% had no preference (Fig. 1B). 470 Dahl et al. Sex selection. Participants were then asked if they could imagine selecting the sex of their children via sperm separation technology. In order to make an informed decision, participants were given details on the procedure and its cost. Whereas 8% of respondents could imagine taking advantage of such technology, 74% were opposed, and 18% were undecided (Fig. 1C). . To establish whether the 92% (n  1,103) who were either opposed or undecided toward using sperm separation technology for sex selection were in fact not interested in sex selection or simply found the procedure to be too demanding, we asked them if they could imagine using this technology if it could be performed in any doctor's office, required only a single cycle of intrauterine insemination, and was covered by their health insurance. Given these less demanding circumstances, 12% would use such technology, 64% were opposed, and 24% TABLE 2 Demographics of survey respondents (n  1,197). Gender Male 587 (49.0%) Female 610 (51.0%) Age (ys) 18–34 692 (57.8%) 35–45 505 (42.2%) Marital status Single/never married 406 (37.4%) Married 576 (53.0%) Divorced/separated 104 (9.6%) Region of residence Northeast 214 (18.0%) Midwest 243 (20.4%) South 425 (35.7%) West 310 (26.0%) Education (highest level) High school or less 473 (39.5%) Some college 396 (33.1%) 4-year college or more 328 (27.4%) Household income $35,000 375 (35.2%) $35,000–$49,999 158 (14.8%) $50,000–$74,999 203 (19.1%) $75,000 329 (30.9%) Employment status Full-time/self-employed 674 (47.8%) Part-time 144 (10.2%) Student 186 (13.2%) Unemployed 392 (27.8%) Retired 15 (1.0%) Dahl. Sex selection. Fertil Steril 2006.were undecided (Fig. 1D). Vol. 85, No. 2, February 2006 5 F . Finally, we asked the participants to imagine there was a medication to select the sex of their children. Rather than visiting a fertility center, they would simply have to take a "pink pill" to ensure the birth of a girl or a "blue pill" FIGURE 1 (A) Gender preferences for first child (n  1,197). (B) Gend in preconception sex selection when couples have to und have to pay for the treatment themselves (n  1,197). (D) with the conditions noted in Figure 1C, the interest in prec single cycle of intrauterine insemination and treatment we preconception sex selection if there were a medication to Dahl. Sex selection. Fertil Steril 2006.to ensure the birth of a boy. While 18% would be willing ertility and Sterilityto use such a medication, 59% were opposed, and 22% were undecided (Fig. 1E). Compared to the 8% of respondents in question 3 who were willing to use sex selection, the 18% of respondents who were willing to use "a pill" references for all children born (n  1,197). (C) Interest three to five cycles of intrauterine insemination and ng the 92% of couples not interested in sex selection eption sex selection if couples had to undergo just a vered by health insurance (n  1,103). (E) Interest in ct the sex of their children (n  1,197).er p ergo Amo onc re co selewere more likely to have a household income less than 471 a o D T l p t s p s w m n p s 1 p b c ( u a h s f t i t 5 f I c f h w p 5 w o 5 s s e 5 t c w h c s ( h ( w o w t m s ( d t r f a A n h f p r o i f c t i w d a r A t w g t c c s V s p d s k $35,000 (22% versus 6%) and to have a high school education or less (19% versus 6%). Individual answers to all five questions posed did not yield ny significant differences by age, sex, ethnicity, education, r income. ISCUSSION o our knowledge, this is the first study in the medical iterature that examines the demand and preferences for reconception sex selection technology among a representaive general population of the United States. Our study hows that only 8% of Americans would consider using reconception sex selection technology for nonmedical reaons. If the process were simplified to taking a pill, only 18% ould wish to choose the sex of their child. Furthermore, the ajority of Americans (77%) either prefer to have an equal umber of boys and girls or have no preference. The results of our study are consistent with findings from rior social research. For example, based on a cross-cultural urvey on parental gender preferences conducted in the 970s, Nancy E. Williamson predicted that "if a reasonably ractical, safe, and effective method of sex selection were to ecome available, it will probably be used by relatively few ouples and mostly to have at least one child of each sex" 28, 29). In an extensive social survey of 5,981 married women nder 45 years of age residing in the United States, Westoff nd Rindfuss (30) found striking evidence for the desire to ave a balanced sex composition of their family: "Despite a trong preference for a first-born boy, the gender preferences or subsequent children were overwhelmingly determined by he sex of existing children: 85% of women with two boys ndicated a preference for a girl, and 84% of women with wo girls registered a preference for a boy. [. . .] Overall, 1.1% preferred the next child to be male, and 48.9% preerred the next child to be female, yielding a sex ratio of 104. n terms of sampling error, this is indistinguishable from the urrent sex ratio of 105. Thus, the implication is that, apart rom the transitional period, sex control technology would ave very little effect on the sex ratio at birth." According to a survey among 140 primiparous American omen conducted by Steinbacher and Gilroy (31), 18% referred to have a boy, 23% preferred to have a girl, and 9% expressed no preference at all. Asked, "If the means ere available to you so that you could have selected the sex f your child, would you have done so?," 18% answered yes, 3% no, and 29% were undecided. Of the 26 women who aid they would have used sex selection, 13 would have done o to ensure the birth of a boy and 13 would have done so to nsure the birth of a girl. In a recent survey conducted by Jain et al. (32), among 61 American infertility patients, 229 (40.8%) women stated hat they would like to be able to choose the sex of their i 472 Dahl et al. Sex selectionhildren as part of their infertility treatment. Of these 229 omen, 13 (5.7%) had children of both sexes, 111 (48.4%) ad children of only one sex, and 105 (45.9%) had no hildren at all. Of the 13 women having children of both exes, 5 (38.5%) preferred to have another boy, and 8 61.5%) preferred to have another girl. Of the 105 women aving no children, 36 (34.3%) desired to have a boy, and 69 65.7%) desired to have a girl. Additionally, of the 111 omen having children of only one sex, 37 (74.0%) mothers f girls wished for a boy, and 50 (82.0%) mothers of boys ished for a girl. In other words, "Among parous women, hose with only daughters significantly desired to select a ale child, whereas those with sons significantly desired to elect a female child" (32). It is certainly interesting that in the study by Jain et al. 32), a larger proportion of infertility patients expressed a esire for sex selection (40.8%) compared to our findings in he general population (8%). There could be several potential easons for this discrepancy. Infertility patients are more amiliar with procedures such as intrauterine insemination, nd thus may not see sex selection as a cumbersome process. lso, infertility patients may wish to choose the sex of their ext child since they may perceive that their likelihood of aving future children is limited. Data on these potential actors, however, are lacking. There can sometimes be quite a difference between what eople say and what they actually do. Thus, it is quite eassuring that other demographic research that has focused n examining when couples stop having more children does ndeed confirm the stated preference for a gender-balanced amily. In the United States, couples with two boys and ouples with two girls are significantly more likely to have a hird child than couples with one boy and one girl, suggestng that parents with children of both sexes are more content ith their family composition (33–36). Perhaps even more instructive than social surveys and emographic research are data collected by fertility clinics lready offering preconception sex selection. According to a eport of a fertility center in New York City, all of the 120 merican couples seeking sex selection were doing so for he sole purpose of family balancing: "They selected girls hen they had boys at home and boys when there were only irls" (37). Likewise, Gametrics Limited in Alzada, Monana, which detailed the collective experience of 65 fertility linics, states, "The overwhelming majority had two or more hildren of the same sex and desired a child of the opposite ex" (38). Finally, the Genetics & IVF Institute in Fairfax, irginia, reports, "The majority of couples (90.5%) in our tudy were seeking gender pre-selection for family balancing urposes, were in their mid-thirties, had two or three chilren of the same sex, and desired only one more child" (39). It is only a matter of time before preconception sex election technology becomes widely available and mareted throughout the United States. With the numerous ethical ssues posed by use of such technology, our study provides Vol. 85, No. 2, February 2006 s b a R 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 F ome reassurance that preconception sex selection is unlikely to e used by the majority of the population and is unlikely to have significant impact on the natural sex ratio. EFERENCES 1. Genetics and IVF Institute. Microsoft sperm separation. Available at: http://www.microsort.net/index.htm. Accessed May 16, 2005. 2. Johnson LA, Welch GR, Keyvanfar K, Dorfmann A, Fugger EF, Schulman JD. Gender preselection in humans? Flow cytometric separation of X and Y spermatozoa for the prevention of X-linked diseases. Hum Reprod 1993;8:1733–9. 3. Vidal F, Fugger EF, Blanco J, Keyvanfar K, Catala V, Norton M, et al. Efficiency of MicroSort flow cytometry for producing sperm populations enriched in Xor Y-chromosome haplotypes: a blind trial assessed by double and triple colour fluorescent in-situ hybridization. Hum Reprod 1998;13:308–12. 4. Fugger EF, Black SH, Keyvanfar K, Schulman JD. Births of normal daughters after MicroSort sperm separation and intrauterine insemination, in-vitro fertilization, or intracyto-plasmic sperm injection. Hum Reprod 1998;13:2367–70. 5. Schulman JD, Karabinus D. Scientific aspects of preconception gender selection. Reprod BioMed Online 2005;10(Suppl 1):111–5. 6. Ethics Committee of the American Society for Reproductive Medicine. Preconception gender selection for nonmedical reasons. Fertil Steril 2001;75:861–4. 7. Human Fertilisation and Embryology Authority. Sex selection: options for regulation. London: HFEA; 2003. 8. President's Council on Bioethics. Beyond therapy: biotechnology and the pursuit of happiness. President's Council on Bioethics: Washington (DC); 2003. 9. The Science and Technology Committee. Human reproductive technologies and the law. London: House of Commons; 2005. 0. Hill DL, Surrey MW, Danzer HC. Is gender selection an appropriate use of medical resources? J Assist Reprod Genet 2002;19:438–9. 1. Dai J. Preconception sex selection: the perspective of a person of the undesired gender. Am J Bioethics 2001;1:37–8. 2. Davis D. Genetic dilemmas: reproductive technology, parental choices, and children's futures. New York: Routledge; 2001. 3. Fukuyama F. Our posthuman future: consequences of the biotechnology revolution. New York: Farrar Straus & Giroux; 2002. 4. Benagiano G, Bianchi P. Sex preselection: an aid to couples or a threat to humanity? Hum Reprod 1999;14:870–2. 5. Allahbadia GN. The 50 million missing women. J Assist Reprod Genet 2002;19:411–6. 6. Plafker T. Sex selection in China sees 117 boys born for every 100 girls. BMJ 2002;324:1233. 7. Hudson VM, Den Boer AM. Bare branches: the security implications of Asia's surplus male population. Cambridge: MIT Press; 2004.8. Sen A. Missing women-revisited. BMJ 2003;327:1297–8. ertility and Sterility9. Chan CLW, Yip PSF, Ng EHY, Ho PC, Chan CHY, Au JSK. Gender selection in China: its meanings and implications. J Assist Reprod Genet 2002;19:426–30. 0. United Nations Population Fund. Missing: mapping the adverse child sex ratio in India. Delhi: UNPF; 2003. 1. Singer P, Wells D. The reproduction revolution: new ways of making babies. Oxford: Oxford University Press; 1984. 2. Warren MA. Gendercide: the implications of sex selection. San Francisco: Rowman & Allanheld; 1985. 3. Glover J. Comments on some ethical issues in sex selection. In: Sureau C, Shenfield F, editors. Ethical aspects of human reproduction. Paris: John Libbey; 1995. p. 305–13. 4. Robertson JA. Preconception gender selection. Am J Bioethics 2001; 1:2–9. 5. Dickens BM. Can sex selection be ethically tolerated? J Med Ethics 2002;28:335–6. 6. Dahl E. Sex selection: laissez faire or family balancing? Health Care Anal 2005;13:87–90. 7. Dahl E, Beutel M, Brosig B, Hinsch KD. Preconception sex selection for nonmedical reasons: a representative survey from Germany. Hum Reprod 2003;18:2231–4. 8. Williamson NE. Sons or daughters: a cross-cultural survey of parental preferences. Beverly Hills: Sage; 1976. 9. Williamson NE. Parental sex preferences and sex selection. In: Bennett NG, editor. New York: Academic Press; 1983. p. 129–45. 0. Westoff CF, Rindfuss RR. Sex preselection in the United States: some implications. Science 1974;184:633–6. 1. Steinbacher R, Gilroy FD. Preference for sex of child among primiparous women. J Psychol 1985;119:541–7. 2. Jain T, Missmer SA, Gupta RS, Hornstein MD. Preimplantation sex selection demand and preferences in an infertility population. Fertil Steril 2005;83:649–58. 3. Westoff CF, Potter RG, Sagi P. The third child: a study in the prediction of fertility. Princeton: Princeton University Press; 1963. 4. Sloane DM, Lee CF. Sex of previous children and intentions for further births in the United States, 1965–1976. Demography 1983;20:353–67. 5. Yamaguchi K, Ferguson LR. The stopping and spacing of childbirths and their birth-history predictors: rational choice theory and eventhistory analysis. Am Sociol Rev 1995;60:272–98. 6. Pollard MS, Morgan SP. Emerging parental gender indifference? Sex composition of children and the third birth. Am Sociol Rev 2002;67: 600–13. 7. Khatamee MA, Leinberger-Sica A, Matos P, Weseley AC. Sex preselection in New York City: who chooses which sex and why. Int J Fertil 1989;34:353–4. 8. Beernink FJ, Dmowski WP, Ericsson RJ. Sex preselection through albumin separation of sperm. Fertil Steril 1993;59:382–6. 9. Fugger EF, Black SH., Keyvanfar K, Schulman, JD. Births of normal daughters after MicroSort sperm separation and intrauterine insemination, in-vitro-fertilization, or intracy-toplasmic sperm injection. Hum Reprod 1998;13:2367–70.