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PRENATAL DIAGNOSIS Prenat Diagn 2006; 26: 614–618. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/pd.1471 REVIEW Attitudes towards sex selection in the Western world Frank Van Balen* Department of Education, Faculty of Social and Behavioural Sciences, University of Amsterdam, Wibautstraat 4, 1091 GM, Amsterdam It appears that in most Western countries, son preference is somewhat stronger than daughter preference. However, when one considers the preference of women it looks as though the opposite pattern is emerging. There is a considerable social acceptance of ‘light’ methods of sex selection (such as diets), even though these methods are not proven to be effective. The inclination to use sperm separation methods appears to be greater in the United States than in some European countries. There are indications that a preference for boys or for girls is associated with attitudes towards technology, child-rearing style and the stereotyping of boys or girls. Copyright 2006 John Wiley & Sons, Ltd. KEY WORDS: sex selection; son preference; daughter preference; balanced family INTRODUCTION The desire to choose the gender of one’s child has prob- ably existed since prehistoric times and possibly in all cultures. However, the expression and intensity of this desire is culturally mediated. Also the kind of prefer- ence — namely for sons, daughters or an equal number of both —is influenced by culture. In recent centuries, there has been an overwhelming bias throughout the world towards son preference (Hill and Upchurch, 1995). Son preference is less strong and less dominant in the West than in East Asia and the Indian subcontinent. It is gen- erally assumed that preference patterns are related to cultural values regarding male and female social posi- tions and roles. Within Western culture, and especially the part that is based on the historical Germanic/Anglo- Saxon culture of northwestern Europe, women and men enjoy a greater social equality than in most other areas of the world. Historically, this is apparent in the clergy and liturgy of Protestantism, the power of specific women’s associations (such as orphanage boards from the six- teenth century onwards), and the relative independence and power of women in daily life and occupational activities. Over the last century, the position and power of women in Western societies has improved substantially. Today, in many Western countries men and women share most areas of public life, for example, schools, swim- ming pools, churches, bars, sport teams, the army and even sometimes hospital rooms. However, also within Western societies the gaps between men and women are greater or lesser depending on how ‘masculine’ a specific society is. In this respect, the definition of (Hof- stede, 1991; Hofstede et al., 1998) is used: masculinity *Correspondence to: Frank Van Balen, Department of Education, Faculty of Social and Behavioural Sciences, University of Ams- terdam, Wibautstraat 4, 1091 GM, Amsterdam. E-mail: [email protected] stands for a society in which men are supposed to be assertive, tough and focused on material success; women are supposed to be more modest, tender and concerned with the quality of life. Femininity stands for a soci- ety in which both men and women are supposed to be modest, tender and concerned with the quality of life. The large international comparative study by Hofst- ede et al. (1998) showed that the Scandinavian countries and the Netherlands are in this sense the least mascu- line/most feminine in character. Great Britain, the United States and Germany are among the most masculine, and Canada, France and Spain are somewhere in between. It could be surmised that these differences within Western culture are reflected in son/daughter preference. In the light of the above, the first question is: ‘Is there still a preference for sons in Western culture?’ It may be that the preference exists only in the more masculine nations within the Western world. Or, instead of son preference, the idea of equality between the sexes might have led to the associated idea of a balanced family (equal number of children of both sexes) predominating. Following on from this, the second question is: ‘How strong is the desire to have a child of the preferred gender?’ That is, how much energy, trouble and even pain are people willing to invest in order to have a child of the desired sex? First, the article focuses on preference patterns, using studies based on questionnaires on attitudes regard- ing the preferred sex of one’s offspring. Demographic studies in which procreation behaviour is analysed, for instance, regarding the frequency of two-daughter com- pared to two-son families are not used. Including this theme would not be possible within the scope of this article. This article is limited to preferences, opinions and attitudes. Attention is then paid to the means that people find acceptable for others to use to influence the sex of their offspring (social acceptance), and which options they themselves are willing to use (individual choices). The relationship between preference for a child of a certain sex and other attitudes (sex-role stereotyping, Copyright 2006 John Wiley & Sons, Ltd. Received: 15 October 2005 Accepted: 28 March 2006

Attitudes towards sex selection in the Western world

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PRENATAL DIAGNOSISPrenat Diagn 2006; 26: 614–618.Published online in Wiley InterScience(www.interscience.wiley.com) DOI: 10.1002/pd.1471

REVIEW

Attitudes towards sex selection in the Western world

Frank Van Balen*Department of Education, Faculty of Social and Behavioural Sciences, University of Amsterdam, Wibautstraat 4, 1091 GM,Amsterdam

It appears that in most Western countries, son preference is somewhat stronger than daughter preference.However, when one considers the preference of women it looks as though the opposite pattern is emerging.There is a considerable social acceptance of ‘light’ methods of sex selection (such as diets), even though thesemethods are not proven to be effective. The inclination to use sperm separation methods appears to be greaterin the United States than in some European countries. There are indications that a preference for boys or forgirls is associated with attitudes towards technology, child-rearing style and the stereotyping of boys or girls.Copyright 2006 John Wiley & Sons, Ltd.

KEY WORDS: sex selection; son preference; daughter preference; balanced family

INTRODUCTION

The desire to choose the gender of one’s child has prob-ably existed since prehistoric times and possibly in allcultures. However, the expression and intensity of thisdesire is culturally mediated. Also the kind of prefer-ence—namely for sons, daughters or an equal number ofboth—is influenced by culture. In recent centuries, therehas been an overwhelming bias throughout the worldtowards son preference (Hill and Upchurch, 1995). Sonpreference is less strong and less dominant in the Westthan in East Asia and the Indian subcontinent. It is gen-erally assumed that preference patterns are related tocultural values regarding male and female social posi-tions and roles. Within Western culture, and especiallythe part that is based on the historical Germanic/Anglo-Saxon culture of northwestern Europe, women and menenjoy a greater social equality than in most other areas ofthe world. Historically, this is apparent in the clergy andliturgy of Protestantism, the power of specific women’sassociations (such as orphanage boards from the six-teenth century onwards), and the relative independenceand power of women in daily life and occupationalactivities.

Over the last century, the position and power ofwomen in Western societies has improved substantially.Today, in many Western countries men and women sharemost areas of public life, for example, schools, swim-ming pools, churches, bars, sport teams, the army andeven sometimes hospital rooms. However, also withinWestern societies the gaps between men and womenare greater or lesser depending on how ‘masculine’ aspecific society is. In this respect, the definition of (Hof-stede, 1991; Hofstede et al., 1998) is used: masculinity

*Correspondence to: Frank Van Balen, Department of Education,Faculty of Social and Behavioural Sciences, University of Ams-terdam, Wibautstraat 4, 1091 GM, Amsterdam.E-mail: [email protected]

stands for a society in which men are supposed to beassertive, tough and focused on material success; womenare supposed to be more modest, tender and concernedwith the quality of life. Femininity stands for a soci-ety in which both men and women are supposed tobe modest, tender and concerned with the quality oflife. The large international comparative study by Hofst-ede et al. (1998) showed that the Scandinavian countriesand the Netherlands are in this sense the least mascu-line/most feminine in character. Great Britain, the UnitedStates and Germany are among the most masculine, andCanada, France and Spain are somewhere in between. Itcould be surmised that these differences within Westernculture are reflected in son/daughter preference.

In the light of the above, the first question is: ‘Is therestill a preference for sons in Western culture?’ It maybe that the preference exists only in the more masculinenations within the Western world. Or, instead of sonpreference, the idea of equality between the sexes mighthave led to the associated idea of a balanced family(equal number of children of both sexes) predominating.Following on from this, the second question is: ‘Howstrong is the desire to have a child of the preferredgender?’ That is, how much energy, trouble and evenpain are people willing to invest in order to have a childof the desired sex?

First, the article focuses on preference patterns, usingstudies based on questionnaires on attitudes regard-ing the preferred sex of one’s offspring. Demographicstudies in which procreation behaviour is analysed, forinstance, regarding the frequency of two-daughter com-pared to two-son families are not used. Including thistheme would not be possible within the scope of thisarticle. This article is limited to preferences, opinionsand attitudes. Attention is then paid to the means thatpeople find acceptable for others to use to influence thesex of their offspring (social acceptance), and whichoptions they themselves are willing to use (individualchoices). The relationship between preference for a childof a certain sex and other attitudes (sex-role stereotyping,

Copyright 2006 John Wiley & Sons, Ltd. Received: 15 October 2005Accepted: 28 March 2006

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child-rearing style, attitude towards technology and con-formity) is also explored. Special attention will be paidto the opinion of women, because they are the oneswho have to bear the brunt of a sex selection method.It is assumed that within Western culture, in general,women are not pressured to decide to use a sex selectionmethod by their partner or by family members, or arepressured only to a moderate extent. This may not holdfor all women, and the availability of easier, cheaper orearlier techniques of sex selection might invalidate thisassumption.

STUDIES ON SEX PREFERENCE

A number of large-scale national studies on sex prefer-ence have been performed. The Gallup Global Study ofFamily Values (International Gallup Poll 1997) includedFrance, Great Britain, Germany, Spain, Iceland andCanada. In each country, typically 1000 or more respon-dents were asked what their gender preference would beif they were able to have only one child. The same ques-tion was repeated in the US Gallup Polls of 1997, 2000and 2003, each of which included just over 1000 adultrespondents (Knox, 1997; Simons, 2000; Lyons, 2003),and in a Dutch nationwide study of 931 adults (NIPO,1996). In two other nationwide studies involving 1094adults in Germany (Dahl et al., 2003) and 669 adults inthe Netherlands (Veldkamp Marktonderzoek, 1996), thequestion about gender preference was asked regardingthe first child. It can be argued that a question regard-ing ‘the one and only child’ will elicit more preferenceanswers, because no second chance is presented.

Regarding having an ‘only child’, son preferencevaries in these countries from 41% in France to 12%in Iceland, and daughter preference from 31% in Franceto 11% in the Netherlands. From the nationwide studiesin Western Europe and North America in which thepreference question was about either an only child orthe first child, it is clear that son preference in mostcountries is somewhat stronger than daughter preference;the difference ranged from 10% in France, Canada andthe United States to 2% in Germany. However, in Spainand Iceland girl preference is greater than boy preferenceby 7 and 4%, respectively. It is interesting to note that inFrance, the United States and Great Britain, more thanhalf of the sample gave a specific preference (be it for ason or daughter), while in the Netherlands and Icelandmore than 70% said that they would not be able to makea choice between a son or a daughter if they could haveonly one child (see Table 1).

It appears that son preference is much less commonamong women than among men. From the international(16-country) Gallup Poll of 1997, it was reported thatwomen either have no clear gender preference forchildren or only a slight preference for boys (GallupNews Service, 1997).

Besides surveys among a national sample of adults,some studies have been carried out among specificsocial groups. Two specific US studies looked at 469infertile women (Jain et al., 2005) and 140 pregnantwomen (Steinbacher and Gilroy, 1985), and a Dutch

Table 1—Preference patterns for the sex of offspring

NationsNet daughter

preferencea (%)No preference for

son or daughter (%)

Spainb 7 53Icelandb 4 72Germanyc −4 76Great Britainb −5 43Netherlandsd −7 71Canadab −10 58Franceb −10 28United Statese −10 27

a Difference between percentage daughter preference and percentageson preference (if having only one child). In case son preference isgreater than daughter preference minus scores result.b (Global Study of Family Values, International Gallup Poll, 1997).c (NIPO, 1996).d (Dahl et al., 2002).e (Lyons, 2003).

Internet-based study looked at 195 parents, mainly read-ers of child rearing and women’s magazines (Brunneret al., 2005). It appeared that women had a considerablystronger preference for girls (range of the three studies:23–28%) than for boys (range: 16–18%). On the otherhand, a study of 561 US students (Swetkis et al., 2002)showed a much higher preference (20%) among femalestudents for boys than for girls, though the differencewas much smaller than among male students (40%).

On the whole, a change towards daughter preferencecan be detected among women. For example, whenfemale respondents to the Gallup Poll of 2003 wereasked about their sex preference, if they could have onlyone child, 36% preferred a daughter, and 32% preferreda son (Lyons, 2003). This was the first time since 1941when this question was included in the Gallup Poll, thatdaughter preference has been shown to be stronger thanson preference among women. The Gallup Poll of 1997(Knox, 1997), still showed boy preference (36%) amongwomen just above girl preference (35%).

There is a serious lack of studies concerning thearguments and motives for sex preference. From theanswers of mothers in the Dutch Internet-based study(Brunner et al., 2005), it appears that social forces playa negligible role. Arguments for girls are based onindividual feelings (e.g. ‘Feels better to have a girl’,‘Feel more confident with a girl’) or the affinity with achild of the same sex (e.g. ‘I’m a woman myself; I liketo cuddle her’, ‘Later, I’ll go shopping with her’). Also,some negative attitudes towards boys are mentioned (e.g.‘Boys make trouble’). Likewise, the arguments for boysmentioned by fathers in the same study (Brunner et al.,2005) are mostly individual (‘Feels better’), reveal anegative attitude towards the less preferred sex (‘Don’tlike girls’), or have to do with same-sex affinity (‘Boyto play games with’) though the social aspect is alsomentioned for son preference (a family heir).

SOCIAL ACCEPTANCE OF SEX SELECTION

A few studies have also looked into the question asto whether respondents find it socially acceptable that

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people use certain sex selection methods. Attention hasbeen paid to diverse ‘light’ methods, including spermselection, and to the ‘heavy’ method of PGD (pre-implantation genetic diagnosis) (Veldkamp Marktonder-zoek, 1996; Brunner et al., 2005). Many light methodsare not (yet) proven to be effective, such as the momentof procreating, the alignment of bodies during procre-ation, diets and alternative medicine. Sperm selectionin a clinic, as performed by flow cytometry, has beenempirically shown to be effective in 90% of X sort sep-aration and 75% of Y sort separation (MicroSort, 2005).This method has recently been improved. So many moresperms can be collected that IVF is no longer neces-sary, and the chosen gender sperm cells can now beinserted with a syringe. On the other hand, in PGD, IVFis required, and only the pre-embryos of the chosen sexare inserted into the womb.

In two Dutch studies, among a national representa-tive sample (Veldkamp Marktonderzoek, 1996) and anInternet sample of parents (Brunner et al., 2005), it wasfound that there is a high level of social acceptanceof non-proven ‘light’ methods. Timing of intercourse,special diets, alternative medicine and body alignmentwere regarded as socially acceptable by 40–70% of thesamples. It appeared that visiting a sperm clinic for sexselection would be allowed by 30% of the parents in theInternet sample (Brunner et al., 2005). Very easy meth-ods that remain a future possibility (such as a drug or akit to be sold at pharmacies) were considered the leastacceptable, with just under 10% expressing acceptanceof such methods (Veldkamp Marktonderzoek, 1996).

THE CHOICE OF SEX SELECTION METHODS

A few studies have investigated the personal acceptanceof methods of sex selection. The question about personalacceptance was phrased differently in these studies: ‘Doyou have an interest in . . .?’ (Dahl et al., 2003), ‘Wouldyou choose it if it was available?’ (Brunner et al., 2005),‘Are you willing to use it?’ (Swetkis et al., 2002),‘If offered free, would you . . .?’ (Jain et al., 2005).Nevertheless, these questions are clearly about one’sown potential behaviour, not about the acceptance ofsuch behaviour by others. From these studies, it appearedthat the infertile women in the US sample (Jain et al.,2005) were most open to these methods: 52% werewilling to go to a sperm selection clinic and 40% werewilling to have PGD for sex selection. The US studentsample was a little less enthusiastic, although more than20% would use sperm selection (Swetkis et al., 2002). Inthe Dutch Internet sample, the figure was 10% (Brunneret al., 2005), and in the national German opinion poll,8% (Dahl et al., 2002). Also 6% of German respondentswere willing to use biomedical pills for sex selectionpurposes. The results from the Dutch Internet samplerevealed a greater personal willingness to use two of thenon-proven light methods, namely, timing of intercourse(26%) and diet (20%). However, alternative medicine inthe Dutch study scored about the same as biomedicinein the German study, that is, 8% (Dahl et al., 2002).

There seems to be considerable interest in the lightmethods that are based on ‘folk wisdom’. A largenumber of Internet sites and a considerable number ofbooks provide advice about how to choose the sex ofone’s baby by using diets, adopting certain positionswhen making love, having sexual intercourse at the righttime, and so on (e.g. BabyCenter, 2005).

CORRELATES OF SEX PREFERENCE

Social conformity, attitudes towards technology, child-rearing style and sex-role stereotyping of children, wereexamined in two studies. Swetkis and colleagues (2002)investigated whether a preference for sons is associatedwith the personality characteristic of ‘conformity’. Theypostulated that as son preference is dominant and tradi-tional in the United States, a high score on conformitywould lead to a greater likelihood of son preference.However, the results of their study did not confirm this.They also postulated that a positive attitude towardstechnology may be associated with a greater chance ofhaving a gender preference (for a son or a daughter).Here, they found a weak relationship: those with a pro-technology attitude were somewhat more inclined to usesperm separation tests (Swetkis et al., 2005).

In their Dutch Internet study (Brunner et al., 2005), itwas found that males with a greater preference for boysas well as males with a greater preference for girls scoredsignificantly higher on authoritarian child-rearing style(a style characterized by restriction and power assertion).However, this was not found among females. Also, in thesame studies there were indications that sex preference(for either a boy or a girl) is associated with sex-rolestereotyping. In the Dutch study, four aspects of stereo-typing were analysed: hobbies, characteristics, profes-sions and household tasks. In some of these aspects,statistically significant differences were found. Men witha preference for boys had more stereotypical ideas about‘girlish’ hobbies and ‘boyish’ professions. Men with apreference for girls showed less stereotyping about typi-cal girlish household tasks. Women with a preference forgirls showed more stereotyping regarding typical girlishhousehold tasks. No differences were found regardingthe stereotyping of boy/girl characteristics.

DISCUSSION

There is a dearth of published studies especially aboutsocial and personal acceptance of sex selection meth-ods. Nevertheless, a large proportion of the studies thathave been carried out concern gender preference amongnational representative samples and therefore deliverrobust results. However, in some of these studies thequestions refer to a first child, whereas in others genderpreference was investigated by introducing a hypotheti-cal only child. It is supposed that preference patterns aremore striking in the latter. In general, son preferenceis somewhat more prevalent than daughter preference

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in most countries. But in Iceland and Spain the oppo-site pattern, substantially greater prevalence of daughterpreference, is found. This finding is only partly in linewith the ranking of national cultures according to theirdegree of masculinity, as described by Hofstede et al.(1998). Although Scandinavian countries score on thelow end of the masculinity scale, Spain is ranked at thesame level as France on the masculinity scale, whereson preference is 10% higher than girl preference.

All studies indicate that son preference is muchstronger among men than among women. If one looksat the answers of women in national samples andconcentrates on the most recent studies and on thestudies among specific samples of women, it appearsthat girl preference may be emerging. In several areasof Western culture, women tip the scales in couples’decision-making about having a child (Van Luijn andParent, 1990). Abortion laws designate to the womanthe decision to have an induced abortion and not tohave a child. It can therefore be argued that within someareas of Western society, discrimination against femalesis diminishing as a ground for ethical objections to theuse of sex selection methods.

Besides the national studies, some studies were doneamong specific groups, such as students, Internet usersand infertile women. Students and Internet users mightbe people who are more positive towards new technol-ogy though the available evidence does not support astronger preference for a boy or a girl or a greater incli-nation to use sex selection methods among these groups.However, more studies are necessary to reach a validconclusion.

Infertile women might have less resistance to usingsperm separation technology and PGD, because theyalready face the prospect of using reproductive tech-niques, often IVF. For IVF, sperm has to be selectedand fertilized oocytes are scrutinized for selection ofthe best ones. A high acceptance of methods mightbe expected, just as women undergoing IVF are morefavourable to using PGD for genetic screening than fer-tile women (Miedzybrodzka et al., 1993; Palomba et al.,1994). Indeed, it was found that infertile women showeda greater willingness to use sperm selection techniquesor PGD than did the women in the national studies.

Considering the factors that influence gender prefer-ence patterns, only a few possible variables have beeninvestigated. In the study by Swetkis and colleagues(2002), it was found that a positive attitude towards newtechnology, in general, was related to a willingness touse sperm separation technology. This result is furthersupported by the conclusion above, that those who arealready using reproductive technology are rather positiveabout using PGD and sperm separation techniques. In thesame study, it was found that conformity was not associ-ated with son preference. The assumption was that sonpreference was the dominant preference pattern in theUnited States at that moment, and that conformity wouldlead to the support of this preference. However, it turnedout that son preference and daughter preference exist inabout equal measure in the United States. It is there-fore still an open question on gender preference whetherconformity has an influence. In the Dutch Internet-based

study among parents (Brunner et al., 2005), it was foundthat authoritarian child rearing was related to a prefer-ence for either a girl or a boy. Authoritarian child rearingis characterized by strict discipline and rule-setting forchildren, and is supposed to be associated with a lifestylein which one has a strong say and influence on things inlife. This might also be a reason for wanting to have astrong influence on the sex of one’s child. Also, strongstereotyping of the behaviour of a male or a femalechild was related to gender preferences: more positivestereotyping of the behaviour of one sex might lead to agreater preference for a child of that sex, while negativestereotyping might lead to a greater preference for theother sex.

It appears that light sex selection methods, especiallythose known not to be effective, enjoy a high degree ofsocial acceptance. It might be that people are tempted,but are not bothered too much about rejecting thesemethods. Also, it can be inferred from the huge numberof Internet sites about folk wisdom regarding choosingthe sex of one’s baby that a considerable numberof people might use these techniques. However, itwould be interesting to know how many of them reallybelieve these techniques to be effective, but go by theexpression: ‘as long as it is not harmful why not giveit a try’? If one looks at the acceptance of spermseparation methods, samples in the United States showmore inclination to use this method than the Europeansamples to which this topic was addressed. In addition,in the United States the use of flow cytometry is legal,whereas it is not in European countries such as Germanyand the Netherlands (the UK is currently proposing aban). PGD for sex selection purposes is not allowed inmost European countries (in Germany, it is completelyforbidden). Moreover, gender preference (be it for a boyor a girl) in the recent US samples is among the strongestof the various national samples. One could speculatethat in the United States, because of its culture thatemphasizes free enterprise and consumerism, people liketo decide the sex of their future baby, more often thanelsewhere. An important question is the extent to whichthe public understand sex selection, and to what extentopinions relate to knowledge. In polls, methods are onlybriefly explained and comprehension is not checked. Tovalidate results, it would benefit to extend study designswith qualitative research methods such as focus groupsand Delphi panels.

It looks almost inevitable that in the future, new,‘lighter’, easier and cheaper techniques will becomeavailable. Already today, the increasing ease of travel toother countries with laxer rules and law, make it possiblefor a determined and wealthy couple to have a baby ofthe desired sex. It will be very difficult for governmentsto stop people who want to use these new techniques.But even when many couples decide the sex of theiroffspring, it looks like that the sex-ratio of girls and boysborn in Western countries will not change considerably.

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