SYMPOSIUM: CROSS-BORDER REPRODUCTIVE CARE ARTICLEReproduction opportunists in the new global sex trade: PGD and non-medical sex selection
Introduction
The advent of assisted reproduction technology across the world has raised a number of ethical, social and cultural concerns for the way in which societies think about gender, reproduction and families. This paper explores the growing trade in assisted reproduction technology for sex selection for non-medical purposes that challenges cultural and ethical frameworks and raises questions as to the extent to which desired characteristics should be purposively selected in children conceived through assisted reproduction. Regulatory differences largely drive the cross-border trade as people move to seek services unavailable in their home countries (Sorenson and Mladovsky, 2006). Technologies such as microsorting spermatozoa and preimplantation genetic diagnosis (PGD) are banned or unavailable in many countries for the purposes of choosing the sex of a child, but have become a reason why many couples will travel to countries such as Thailand, Cyprus, Jordon or the USA to undergo these procedures. Such ‘reproduction opportunism’ needs to be considered in the ethical considerations of non-medical sex selection.
Current ethical discussions of non-medical sex selection have largely ignored the movement of patients across borders and the economic context in which this trade occurs. It is important not only to describe this ‘sex trade’, but to also begin to trace the political economy of the trade and how it is linked to global cross-border reproductive care. Hence this paper is a call for anthropologically informed empirical ethical research on the extent of this trade and the economy supporting it. The fact that there is a cross-border trade in non-medical PGD has implications for ethical debates over its availability.
As an anthropologist I am interested in the relationship between new biotechnologies and society. In describing this trade as a new global sex trade, I wish to draw attention to the commodification of biological sex traits and the foundations of this trade in gendered social constructions and expectations. This paper is not a bioethical treatise, nor is it my intention to demonize patients who travel seeking reproduction technologies. Rather, this paper has two purposes. The first is to briefly examine and critique representations and the language used to describe the practice of non-medical sex selection within the current ethical literature. In doing so I recognize the diversity of frameworks and theories for analysis within bioethics and the potential for a productive dialogue across medical anthropology and bioethics (Turner, 2009a, Turner, 2009b). My second purpose is to draw attention to how the global assisted reproduction market sustains the practice of non-medical sex selection as a market advantage for clinics in some countries and the need to consider the implications of this commodification for the ethical debate and depictions of cross-border reproductive care. Hence, at a broad level, this paper calls for more contextualized ethical consideration, informed by considerations of the political economy of the trade. The first part of the paper concentrates on reviewing the debates within ethical literature over non-medical sex selection. In particular, I critique portrayals of reproductive autonomy, ‘family balancing’ and Orientalism that pervade the arguments in favour of non-medical sex selection. To illustrate the need for a contextualized analysis, I present a case study of the cross-border trade in sex selection concentrating upon the context with which I am most familiar, that of Thailand and Australia. This case study depicts the economy and interests sustaining this trade. It also has implications for the depictions of cross-border reproductive care. I suggest that, in certain circumstances, travel to avoid regulatory differences on ethically contentious treatments might be characterized as calculated reproduction opportunism by the clinics, facilitators and patients involved.
Section snippets
Methods
This paper is informed by work completed for a broader anthropological study of the use of assisted reproduction technology in Thailand across seven months’ fieldwork in 2007 and 2008. In this study, interviews and observations were undertaken in three private clinics and two public infertility clinics, interviewing 31 patients and staff. The study sample included six foreign patients/couples who had travelled to Thailand (Whittaker and Speier, 2010). This work has most recently led me to
Sex-selection technologies
Sex selection technologies may be broadly divided between post-pregnancy techniques and pre-pregnancy techniques and are conducted for medical or social (‘non-medical’) reasons. Post-pregnancy techniques, such as the use of prenatal screening through ultrasound, amniocentesis or chorionic villi sampling, followed by selective abortion are generally condemned worldwide if undertaken for social reasons. Pre-pregnancy techniques include microsorting or PGD. Because they are not associated with
Ethical arguments against pre-pregnancy non-medical sex selection
In the background to any debate over non-medical sex-selective technologies is the empirical reality that in a number of countries with strong son preference, particularly India, South Korea, Taiwan, Turkey and China, sex selection has been used to favour the birth of sons. An estimated 60–100 million women are missing from the world population due to the consequences of gendered inequalities and discrimination in these countries leading to excess female mortality, including the termination of
Reproductive rights and non-medical sex selection
Proponents of the availability of non-medical sex selection carefully differentiate between pre-pregnancy techniques of sex selection and post-pregnancy techniques involving abortion (Berkowitz and Synder, 1998, Dahl, 2004, Dahl, 2005a, Dahl, 2005b, Dahl, 2007, Robertson, 2001, Savulescu, 1999). Drawing upon notions of reproductive autonomy and privacy in reproductive decision making, they suggest that harms resulting from pre-pregnancy sex selection are minimal, particularly in Western
The rhetoric of family balancing sex selection: Orientalism
Throughout debates over sex-selection technologies in Western countries and in the marketing promotion of clinics, the term ‘family balancing’ is offered as a rationale. ‘Family balancing’ is not precisely defined, but generally involves a preference for families containing children of both sexes. Proponents in favour of the availability of sex selection (Dahl, 2007, Robertson, 2001) argue that since ‘family balance’ or ‘gender variety’ is the primary value to parents rather than the
Sex selection as a ‘market advantage’
Rothman’s work (1989) describes how the insertion of assisted reproduction technologies within a capitalist system results in the creation of lucrative markets for various desires. I suggest that the international economy involved in the production and promotion of sex selection needs to be considered in the ethical debate as it inserts commercial exchange values into the relationships between patient and doctor, and parent and future child. The non-medical application of reproduction
Case study of globalized sex selection: Thailand, Australia and PGD
There is a long history of foreign patients seeking IVF services in Thailand. Since the first birth from IVF in 1987, assisted reproduction technologies have proliferated in Thailand. Now an estimated 500 babies (the majority to Thai nationals) are born each year through IVF procedures and related technologies in Thailand and at least 30 clinics are currently providing full clinical services for assisted reproduction (RTCOG, 2008).
A boost to the cross-border trade in assisted reproduction
Australians travelling to Thailand
Cross-border reproductive care complicates issues surrounding the regulation of a range of controversial practices. It leads to questions as to whether it is necessary to regulate the movement of couples who seek treatments banned in their home countries. In Australia all forms of non-medical sex selection are currently banned. The Victorian Infertility Treatment Act 1995 bans treatment procedures that ensure a child’s sex except ‘to avoid the risk of transmission of a genetic abnormality or a
New regulations for Thailand: an end to the trade?
Meanwhile, the trade in sex selection for reproduction travellers to Thailand may be about to end. On 11 May 2010, the Thai cabinet approved draft legislation of the ‘Pregnancy by Medically Assisted Reproductive Technology Act’ (Adams, 2010, Nanthida Puangthong, 2010). This act will strictly regulate the use of assisted reproduction technology in Thailand. The legislation requires physical and psychological screening of patients. It states that ‘ART service providers may perform
Conclusions: reproduction opportunists, regulatory gaps and the market
Worldwide, sex selection for non-medical reasons is generally defined as gender discriminatory (whether prior to pregnancy or post-pregnancy). A host of international human-rights laws, national laws and regulations, and ethical bodies of leading professional associations suggests that it infringes ethical practice and the shared responsibility of nations to protect and promote human-rights principles, particularly that of non-discrimination.
This paper argues for a broader contextualization in
Acknowledgements
This work draws upon research supported by an Australian Research Council Discovery Project funded by the Australian government. Thanks to Dr Parisa Rungruang, Sherie Chotmanee and Jane Brophy for their past research assistance and the staff and patients of the Thai clinics in which the author worked.
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Dr Andrea Whittaker is Associate Professor in Medical Anthropology, School of Population Health, University of Queensland, Australia. Her research interests include gender and reproductive health and the consequences of unplanned pregnancy in Thailand, as well as infertility and cross-border reproductive care. She is currently undertaking research on medical travel in the south-east Asian region. Her major publications include Intimate Knowledge: Women and their Health in Northeast Thailand (2000), Women’s Health in Mainland South-east Asia (2002), Abortion, Sin and the State in Thailand (2004) and the edited collection Abortion in Asia: Local dilemmas, global politics (2010).