Book Review

Sex-Selective Abortion in India: Gender, Society, and New Reproductive Technologies

N Engl J Med 2007; 356:2433-2434June 7, 2007

Article

Sex-Selective Abortion in India: Gender, Society, and New Reproductive Technologies
Edited by Tulsi Patel. 432 pp. New Delhi, India, Sage Publications, 2007. $31.95. ISBN: 978-0-7619-3539-1

The numbers speak for themselves. In India in 2001, there were 921 girls born for every 1000 boys. In some Indian states, the ratio was lower still — 793 girls for every 1000 boys in Punjab, for example — and census data from 1901 to the present show that in recent years the disparity has been getting worse, not better. In 2001 alone, the imbalance represented more than 5 million missing Indian baby girls.

The reasons for the discrepancy seem as clear as the data themselves, although harder to observe and document than the prenatal determination of fetal sex and subsequent selective abortion of female fetuses. In spite of legislation making the practice of sex-selective abortion illegal, the increased availability of technologies such as ultrasonography and amniocentesis has made it difficult to regulate away.

Sex-Selective Abortion in India examines the problem, detailing the numbers and placing the figures within their cultural and historical context. Indeed, as several authors note, this practice represents a contemporary permutation of a long-standing custom and problem. Female infanticide in India has been documented since the time of British colonial rule. Moreover, contemporary mortality statistics and increasingly disparate ratios throughout the lifespan give strength to the argument that girls and women remain at risk even after birth, almost certainly because access to health care is limited by sex.

The social scientists who wrote this collection of essays identify and analyze the many factors that, for some families, make boys preferable. Such factors include the traditions of sons inheriting a family's wealth and supporting parents in old age and of daughters being seen as a financial drain on the family, which must pay for dowries and other costs associated with the marriage of their daughters — who must be married. The authors remind readers that all such pressures need to be seen through the lens of public policy designed to limit fertility and family size.

There are a lot of data here — statistics are parsed and examined year by year, in some cases at the state level — but only the most interested readers will care to plow through this detail and the chapter-by-chapter repetition of numbers and history. The inclusion of better introductory and concluding chapters to summarize the facts and arguments would have helped readers with a more casual interest. In addition, the tone in the concluding pieces moves from objective to polemic — the authors speak of a “medical mafia” and “techno-docs” — and as a result, the persuasive power of a more dispassionate analysis is lost. The numbers alone are so persuasive that florid rhetoric simply is not needed. Nor is bad science, and some authors misstate facts, seemingly in an effort to make their case more compelling — for example, amniocentesis is not more hazardous than chorionic-villus sampling, and it does not cause congenital hip dislocation or leave needle marks on the baby.

That ethics argue against sex selection is assumed by the authors of this collection, but a more detailed discussion would have been interesting and valuable, particularly in relation to matters of family balancing. If a family has had a girl, is it ever appropriate to select for a boy in a next pregnancy to create “balance”? Technology for sperm sorting may soon make selection before conception possible. Does technique (sperm selection versus abortion) matter? Professional groups in America disagree on the answers to these moral questions. Can a technique be appropriate for one country, culture, or history but not for another? These important and challenging questions are largely unexplored here.

Sex selection is illegal in India, and as a result, identifying patients and practitioners who participate is difficult. Their voices are largely missing from this book, and the loss, though understandable, makes it hard to fully appreciate the motivation and process underlying the selective abortion of girls. Although the book presents a clear argument for a problem, little space is devoted to suggested solutions. It is tempting to believe that the answer lies in controlling technology, but the development of techniques for sperm sorting, early serum screens of maternal blood for fetal DNA, and nonsurgical methods for early pregnancy termination argues that the growth of new technology will continue to outpace efforts to control it. At least some of the authors acknowledge this, recognizing that the real — and more difficult — task is to change attitudes and society, reshaping values and practice so that, as one author puts it, “Our daughters are not for slaughter.”

Jeffrey L. Ecker, M.D.
Massachusetts General Hospital, Boston, MA 02114
jecker@partners.org