6.

The Procedure and its Uses In genetics, sex selection refers to “the practice of attempting to control the sex of a baby in ​ order to achieve a desired sex…”. (1) Methods of prenatal diagnosis have been used to determine fetal sex during pregnancy, followed by of a fetus of an “unwanted” sex. (2) Fertility have now developed other technologies for sex selection. A method of preconception sex selection which has been attempted is the MicroSort procedure developed by the Genetics & IVF Institute in Fairfax, Virginia. (3) This procedure separates X-bearing sperm (determining a ) from Y-bearing sperm (determining a male) by “staining the sperm with a fluorescent dye and then leading them past a laser beam where the difference in DNA content between X- and Y-bearing sperm gives a measurable difference in fluorescence.” (4) The sorted sperm has then been used with either intrauterine insemination (see section 2.1) or in vitro fertilization with intracytoplasmic sperm injection (see section 2.3). (5) Use of the X-sorted sperm has “led in 92% of the resulting pregnancies to a girl, whereas after the use of Y-sorted sperm, the result was a boy in 83.6%.” (6) The Genetics & IVF Institute set up a formal clinical trial with MicroSort but the clinical trial was halted because of high costs and regulatory burdens. (7) Thus Microsort was not approved for use by the U.S. Food and Drug Administration, and is not currently available in the . (8) This technology is available in some other countries, including Mexico. (9) Another method of sex selection that is presently employed in the United States consists in creating through in vitro fertilization and then subjecting them to preimplantation genetic testing (preimplantation genetic diagnosis (PGD), preimplantation genetic screening (PGS); see section 5.1). This is done both to determine the sex of each and to detect genetic abnormalities. Only normal embryos of the desired sex are transferred to the woman to try to achieve a pregnancy. (10) This procedure “provides nearly 100% accuracy for selecting either sex.” (11) In countries where MicroSort is available, such may be combined with in vitro fertilization and preimplantation genetic testing, becoming the first step in the process. (12) Use of the MicroSort procedure reduces the chances of preimplantation genetic testing revealing normal embryos only of the unwanted sex. (13) Some parents have sought sex selection because of gender preference, “often in favor of male offspring stemming from cultural, social, and economic bias in favor of male children and as a result of policies requiring couples to limit reproduction to one child, as in .” (14) In contemporary American culture, a couple may seek to engage in sex selection of children for “family balancing,” that is, having children of both sexes. They may already have a son and want a daughter, or vice versa, or there may be an unequal representation of sexes among current siblings. (15) Another reason that a couple may wish to engage in sex selection is to avoid transmission of a sex-linked . (16)

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A human being has twenty-three pairs of chromosomes. One member of each pair is received from the father, and the other member from the mother. Chromosomes carry genes, the basic units of heredity. (17) Chromosomal pairs one through twenty-two are called autosomes while ​ ​ the twenty-third pair constitutes the sex chromosomes. There are two types of sex ​ ​ ​ chromosomes, X and Y. A male is XY, while a female is XX. (18) The genes for some genetic disorders are located on the sex chromosomes.

Hemophilia, muscular dystrophy, fragile X syndrome, Menkes disease, and Lesch-Lyhan syndrome are examples of X-linked recessive genetic disorders. (19) An X-linked recessive genetic disorder involves an abnormal gene on the . Since males have only one X chromosome, an abnormal gene on it is sufficient to cause the genetic disorder to occur. In , who have two X chromosomes, both chromosomes must carry the abnormal gene for the genetic disorder to occur. Because it is unlikely that females will have two altered copies of the gene, males are affected by X-linked genetic disorders much more frequently than females. (20) More specifically, if the mother is a carrier of the X-linked recessive genetic disorder (one normal copy of the gene and one abnormal copy) but the father has a normal copy of the gene on his X chromosome, then there is a 50% chance that a son will inherit the abnormal gene from his mother and be affected by the genetic disorder. On the other hand, any daughter will receive a normal copy of the gene from her father and will be unaffected by the genetic disorder; at worst, there is a 50% chance that the daughter will be a carrier of the genetic disorder, receiving the abnormal copy of the gene from her mother. (21) In such a case, a couple may wish to have a daughter rather than a son.

Rett syndrome, incontinentia pigmenti, and congenital generalized hypertrichosis are examples of X-linked dominant genetic disorders. (22) An X-linked dominant genetic disorder again ​ involves an abnormal gene on the X chromosome. In females, who have two X chromosomes, an abnormal gene on one of her X chromosomes is sufficient to cause the genetic disorder to occur. In males, who have only X chromosome, an abnormal gene on that chromosome causes the genetic disorder to occur. (23) If the father is affected by an X-linked dominant genetic disorder but the mother has normal copies of the gene on both her X chromosomes, then all daughters will inherit an X chromosome with the normal gene from the mother and an X chromosome with the abnormal gene from the father and will be affected by the genetic disorder. On the other hand, all sons will inherit an X chromosome with the normal gene from the mother and the from the father, and will not be affected by the genetic disorder. (24) In this case a couple may wish to have a son rather than a daughter.

An example of a Y-linked genetic disorder is Y chromosome , which impairs fertility in males. (25) This genetic disorder is passed on only to sons and to all of them. (26)

Moral Assessment

From a moral point of view, sex selection of children requires assessment on two levels. First, is it morally acceptable “in concept” or “in principle” to select the sex of a child? Second, is the particular method of sex selection used morally acceptable? In considering these questions, we

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will examine separately sex selection for reasons of parental preference or for family balancing and sex selection to avoid transmission of a sex-linked genetic disorder.

Moral Assessment of Sex Selection for Parental Preference or for Family Balancing

A couple may wish to engage in sex selection for reasons having to do with parental self-fulfillment, e.g., the pleasures associated with one or the other sex, replacing oneself biologically, carrying on the family name. (27) In terms of family balancing, parents may think it beneficial for the children themselves to have the experience of growing up in a family of both boys and girls. (28) Indeed, it has been said that “sex selection might in certain cases make a positive contribution to the quality of parent-child relationships, as children would not have to bear the burden of being less wanted because of their sex.” (29) Moreover, some parents “keep trying” until they have a child of a specific sex. (30) It is argued that, in these cases, sex selection provides a better quality of life for the mother because she will have to undergo fewer pregnancies to have the desired children of each sex. (31)

The Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation ​ (Donum Vitae) from the Vatican Congregation for the Doctrine of the Faith (1987) notes: ​ Certain attempts to influence chromosomic or genetic inheritance are not therapeutic but are aimed at producing human beings selected according to sex or other predetermined qualities. These manipulations are contrary to the personal dignity of the human being and his or her integrity and identity. Therefore in no way can they be justified on the grounds of possible beneficial consequences for future humanity. Every person must be respected for himself: in this consists the dignity and right of every human being from his or her beginning. (32)

Attempting to select the sex of a child for reasons of parental preference or family balancing clearly does not fall into the “therapeutic” category, and this text can be read as rendering a negative moral judgment on this practice “in principle.”

The Instruction contends that genetic manipulations such as sex selection are contrary to the ​ personal dignity belonging to each human being and to his or her integrity and identity, and, concomitantly, affirms that every person must be respected for him/herself. Catholic ethicists Benedict Ashley, Jean deBlois and Kevin O'Rourke have commented:

...Christian teaching shows that it is highly significant to children that they be accepted by their parents as a divine gift to be loved for what they uniquely are and not merely because they conform to the parents' hopes or expectations. …Sex selection by the parents…will still say to the individual child, "You are loved because you conform to your parents' preferences." This seems an injustice to the child and further reinforces the cultural message that children exist primarily to fulfill the needs of the parents rather than for their own sake. This implication is already built into​ ​ many cultural structures, and people have an ethical responsibility to fight against it. (33)

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A pastoral counselor working with a couple contemplating sex selection for reasons of parental preference or family balancing may wish to emphasize that an attitude of virtually “unconditional acceptance” is considered essential to successful parenting and the flourishing of the child. (34) In other words, “the flourishing of the child is facilitated by the parent’s embracing of the child regardless or his or her specific characteristics.” (35) Thus, “unless the parents act acceptingly toward the child’s characteristics, the child’s contentment and self-esteem, and the parent’s ability to enjoy that child, are all in jeopardy.” (36) A pastoral counselor may also explore with the couple whether a subtle sexism, in the form of sex stereotyping, underlies their desire to engage in sex selection. (37) Typically, parents do not want a child of a particular sex because of biological features, e.g. wanting a boy in order to have a child capable of strong beard growth. (38) Rather, the parents are looking at gender-role expectations, that is, a set of traits that go with “girlness” or “boyness.” (39) Thus parents who engage in sex selection may force the child “into an unduly narrow or restrictive ‘’ (boys made to fish and girls made to shop…).” (40) Such parents are likely to “channel their children in certain directions” (41) and parental expectations may subject the child to intensive psychological pressures. (42) All of this disrespects the individuality, uniqueness, and self-determination of the child.

Moreover, from the Catholic perspective, the particular method used for sex selection must also be evaluated morally. It need not be said that prenatal diagnosis coupled with abortion of a child of the “wrong” sex violates the Church’s teaching against abortion, but there are also moral problems with the technologies fertility clinics are using for sex selection.

A method of sex selection that is now commonly used consists in creating embryos through in vitro fertilization and then subjecting them to preimplantation genetic testing. Here the Instruction Dignitas Personae on Certain Bioethical Questions (2008) from the Congregation ​ for the Doctrine of the Faith is relevant:

Preimplantation diagnosis is a form of prenatal diagnosis connected with techniques of artificial fertilization in which embryos formed in vitro undergo ​ genetic diagnosis before being transferred into a woman’s womb. Such diagnosis is done in order to ensure that only embryos free from defects or having the ​ desired sex or other particular qualities are transferred.

…in this case, the diagnosis before implantation is immediately followed by the elimination of an embryo suspected of having genetic or chromosomal defects, or not having the sex desired, or having other qualities that are not wanted. Preimplantation diagnosis – connected as it is with artificial fertilization, which is itself always intrinsically illicit – is directed toward the qualitative selection and ​ consequent destruction of embryos, which constitutes an act of abortion. (43) ​ From a moral point of view, the method of sex selection in question fails on two counts. First, it involves the creation of embryos through the morally illicit procedure of in vitro fertilization (see section 2.3). Second, embryos of the unwanted sex may simply be discarded or donated for laboratory use, either of which results in their death. (44)

The MicroSort procedure likewise fails morally. MicroSort can be used with after sperm separation has taken place. But even if the husband’s sperm is used, methods of insemination which occur in a clinical setting and replace the act of between spouses are not morally permissible (see section 2.1). Microsort can also be ​

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used with in vitro fertilization or with in vitro fertilization coupled with preimplantation genetic testing but, as we have seen, these are morally impermissible procedures.

In sum, sex selection for parental preference or family balancing is not morally permiss​ible in principle, and moreover, the technologies currently used by fertility clinics for this purpose are not morally licit.

Moral Assessment of Sex Selection in the Case of a Sex-Linked Genetic Disorder

The Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation ​ (Donum Vitae) speaks of "certain attempts to influence chromosomic or genetic inheritance [which] are not​ therapeutic but are aimed at producing human beings selected according to ​ ​ sex..." [italics added]. (45) Sex selection for parental preference or family balancing clearly is not “therapeutic,” but it might be argued that sex selection to prevent passing on a sex-linked genetic disorder is “therapeutic” and thus belongs in a different category than sex selection for parental preference or family balancing. Indeed, in the literature on sex selection some have explicitly drawn a distinction between “medical” and “non-medical” reasons for sex selection, considering the former practice to be permissible but the latter to be problematic. (46)

Given the language of the Vatican Instruction, can the document be read as leaving open in principle the use of sex selection to e​ nsure the he​ alth of the child? Unfortunately, the documen​ t ​ does not explicitly address the question of sex selection for medical reasons (i.e., preventing the transmission of a sex-linked genetic disorder). What is clear is that the methods that would currently be used by a fertility for sex selection in t​ he case of a sex-linked genetic disorder (Microsort, in vitro fertilization, preimplantation genetic testing) are not morally permissible. There has been exploration of methods of sex selection which operate within the context of ​ the normal act of sexual intercourse such as the timing of intercourse during the woman’s , the provision of acidic (or alkaline) environments for sperm, the degree of penetration during sexual intercourse, and a woman’s diet. (47) While such methods do not violate Church teaching, they have not achieved general recognition and acceptance medically. (48)

When a couple is at risk for transmitting a sex-linked genetic disorder, consult section 5.2 Genetic Disorders and Decisions about Having Children. This section discusses factors to take into account in deciding whether to forgo having one’s own biological children because of a genetic disorder or to take the risk.

December 2019

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Notes 1. Collins English Dictionary, s.v. Sex Selection. https://www.collinsdictionary.com/us/ ​ dictionary/english/sex-selection. Accessed December 2019. ​ 2. World Health Organization, Genomic Resource Center, Gender and Genetics. ​ https://www.who.int/genomics/gender/en/index4.html. Accessed December 2019. ​ 3. Center for Human Reproduction, What MicroSort Tells Clinical Trial Participants. ​ https://www.centerforhumanreprod.com/fertility/what-microsort-tells-clinical-trial-participan ts. Accessed April 2016. ​ 4. European Society of Human Reproduction and Embryology Task Force on Ethics and Law, “Sex-Selection for Non-Medical Reasons,” Human Reproduction 28/6 (2013): 1448-54 at ​ ​ 1448-49. 5. Ibid., p. 1449. ​ ​ 6. Ibid., p. 1449. ​ ​ 7. Ibid., p. 1449. ​ ​ 8. Center for Human Reproduction, Gender Selection. https://www.centerforhumanreprod. ​ ​ ​ ​ com/services/infertility-treatments/genderselection/methods. Accessed December 2019. 9. MicroSort, Locations. https://www.microsort.com/locations. Accessed December 2019. ​ ​ ​ ​ 10. Center for Human Reproduction, Gender Selection; Genetics and IVF Institute, Family ​ ​ ​ Balancing Frequently Asked Questions at https://www.givf.com/familybalancing/faq.shtml, ​ ​ ​ accessed December 2019; Fertility Center & Applied Genetics of Florida, Sex Selection IVF and ​ ​ Family Balancing & Sex Selection at ​ https://geneticsandfertility.com/family-balancing-sex-selection-with-ivf, accessed December ​ 2019; Harry J. Lieman and Andrzej K. Breborowicz, “Sex Selection for Family Balancing,” AMA ​ Journal of Ethics (Oct. 2014) at https://journalofethics. ​ ama-assn.org/article/sex-selection-family-balancing/2014-10, accessed December 2019. 11. World Health Organization, Genomic Resource Center, Gender and Genetics. ​ 12. North Cyprus IVF, Gender Selection. https://www.northcyprusivf.com/gender-selection. ​ ​ ​ ​ Accessed December 2019. 13. European Society of Human Reproduction and Embryology Task Force on Ethics and Law, “Sex-Selection for Non-Medical Reasons,” p. 1449; North Cyprus IVF, Gender Selection. ​ ​

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14. World Health Organization, Genomic Resource Center, Gender and Genetics. ​ 15. Genetics and IVF Institute, Family Balancing. https://www.givf.com/familybalancing. ​ ​ ​ Accessed December 2019. 16. Ibid. ​ 17. Genetic and Rare Diseases Information Center, FAQs about Chromosome Disorders. ​ ​ https://rarediseases.info.nih.gov/guides/pages/73/faqs-about-chromosome-disorders. ​ Accessed November 2019.

18. Laura M. Gunder and Scott A. Martin, Essentials of Medical Genetics for Health ​ Professionals (Sudbury, MA: Jones & Bartlett Learning, 2011), pp. 2-3. ​ 19. Centre for Genetics Education, Fact Sheet 9 X-Linked Recessive Inheritance at ​ ​ http://genetics.edu.au/publications-and-resources/facts-sheets/fact-sheet-9-x-linked-recessive -inheritance, accessed November 2019; Ricki Lewis, Human Genetics Concepts and ​ ​ Applications, 5th ed. (Dubuque, IA: Mc-Graw Hill, 2003), p. 124. ​ 20. U.S. National Library of Medicine Genetics Home Reference, What are the different ways in ​ which a genetic condition can be inherited? https://ghr.nlm.nih.gov/primer/ inheritance/ ​ inheritancepatterns. Accessed November 2019. ​ 21. Centre for Genetics Education, Fact Sheet 9 X-Linked Recessive Inheritance. ​ 22. Lewis, Human Genetics Concepts and Applications, p. 124. ​ ​ 23. U.S. National Library of Medicine Genetics Home Reference, What are the different ways in ​ which a genetic condition can be inherited?. ​ 24. Centre for Genetics Education, Fact Sheet 10 X-Linked Dominant Inheritance. ​ http://genetics.edu.au/publications-and-resources/facts-sheets/fact-sheet-10-x-linked-domina nt-inheritance. Accessed November 2019. ​ 25. U.S. National Library of Medicine Genetics Home Reference, What are the different ways in ​ which a genetic condition can be inherited?; Genetic and Rare Diseases Information Center, Y ​ ​ Chromosome Infertility at ​ https://rarediseases.info.nih.gov/diseases/185/y-chromosome-infertility, accessed November ​ 2019.

26. Genetic and Rare Diseases Information Center, Y Chromosome Infertility. ​ 27. Peter Steinfels, "Choosing the Sex of Our Children," Hastings Center Report 4/1 (Feb. 1974): ​ ​ 3-4 at 3; Dorothy C. Wertz and John C. Fletcher, "Fatal Knowledge? Prenatal Diagnosis and Sex Selection," Hastings Center Report 19/3 (May/June 1989): 21-7 at 23; Mary Anne Warren, Gendercide​ : The Implications of Se​ x Selection (Totowa, NJ: Roman & Allanheld, 1985), pp. ​ 172-3.

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28. European Society of Human Reproduction and Embryology Task Force on Ethics and Law, “Sex-Selection for Non-Medical Reasons.”

29. Ibid. ​ 30. Steinfels, "Choosing the Sex of Our Children," p. 3.

31. Wertz & Fletcher, "Fatal Knowledge? Prenatal Diagnosis and Sex Selection," p. 22.

32. Congregation for the Doctrine of the Faith, Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation (1987​ ), I.6. http://w2.vatican.va > English > Roman ​ Curia > Congregation for the Doctrine of the Faith > Documents. Accessed December 2019.

33. Benedict M. Ashley, OP, Jean K. deBlois, CSJ, and Kevin D. O'Rourke, OP, Health Care th ​ Ethics: A Catholic Theological Analysis, 5 ​ ed. (Washington, DC: Georgetown University Press, 2006), p. 96. ​ ​

34. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Screening and Counseling for Genetic Conditions (Washington, DC: U.S. Government Printing​ Office, 1983), p. 57; Heather Strange, “Non-medic​ al sex selection: ethical issues,” British Medical Bulletin 94/1 (June 2010): 7-20 at 16. ​ ​ 35. Strange, “Non-medical sex selection: ethical issues,” p. 16.

36. Ibid., p. 16. ​ ​ 37. Stephen Wilkinson, Choosing Tomorrow’s Children The Ethics of Selective Reproduction (New York: Oxford Univ​ ersity Press, 2010), p. 223.

38. Ibid., p. 226. ​ ​ 39. Ibid., p. 226; Dena S. Davis, Genetic Dilemmas: Reproductive Technology, Parental ​ ​ ​ nd Choices, and Children’s Futures, 2 ​ ed. (New York: Oxford University Press, 2010), p. 143. ​ ​ 40. Wilkinson, Choosing Tomorrow’s Children The Ethics of Selective Reproduction, p. 223-24. ​ ​ 41. Ibid., p. 229. ​ ​ 42. Strange, “Non-medical sex selection: ethical issues,” p. 11.

43. Congregation for the Doctrine of the Faith, Instruction Dignitas Personae on Certain ​ Bioethical Questions (2008), no. 22. http://w2.vatican.va > English > Roman Curia > Congregation for the Do​ ctrine of the Fait​ h > Documents. Accessed December 2019.

44. Genetics and IVF Institute, Family Balancing Frequently Asked Questions; Lieman and Breborowicz, “Sex Selection for Fa​ mily Balancing.” ​

45. Congregation for the Doctrine of the Faith, Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation (1987), ​I.6. ​

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46. See, for example, European Society of Human Reproduction and Embryology Task Force on Ethics and Law, “Sex-Selection for Non-Medical Reasons”; Lieman and Breborowicz, “Sex Selection for Family Balancing”; Gender-selection controversy a pre-emptive strike at ​ ​ https://melbournecatholic.org.au/Archive/Features/gender-selection-controversy-a-pre-emptiv e-strike, accessed December 2019. ​ 47. Landrum B. Shettles introduced a method for sex selection in the book Your Baby’s Sex: ​ Now You Can Choose, first published in 1970 and reprinted in multiple editions. The Shettles ​ method is based on the idea that male-producing sperm (androsperm) prefer alkaline conditions whereas female-producing sperm (gymnosperm) prefer acidic conditions. The vaginal environment is generally acidic while the and are generally alkaline. However, the closer a woman is to , the more alkaline her cervical secretions to the vagina become. The Shettles method of sex selection is based on the different environments in the female reproductive tract during the menstrual cycle and concomitant timing of intercourse. Specifically, the method recommends that a couple wishing a female child should have intercourse from the end of menstruation until three days before ovulation. For a male child, the method recommends abstaining from sexual intercourse from the beginning of the menstrual cycle until the day of ovulation, and then having intercourse on the day of ovulation and the following two to three days. The Shettles method further suggests the use of douches prior to intercourse, specifically, an acidic douche containing two tablespoons of white vinegar to one quart of water to increase the likelihood of conceiving a female, and an alkaline douche containing two tablespoons of baking soda to one quart of water to increase the likelihood of conceiving a male. The method also has recommendations regarding positions during intercourse and degree of penetration. For a male child, deep vaginal penetration from the rear is recommended so that the sperm cells are deposited close to the cervix where the environment is naturally alkaline. For a female child, on the other hand, a face-to-face position with shallow penetration is recommended so that the sperm pass through the acidic environment of the vagina. In the sixth edition of his book, Shettles claimed a 75% success rate for females and an 80% success rate for males. (Alysse Blight, The Shettles Method of Sex Selection in The Embryo ​ ​ ​ ​ Project Encyclopedia (4/3/2019). https://embryo.asu.edu/pages/shettles-method-sex-selection. ​ ​ Accessed December 2019.) A competing scheme for sex selection based on the timing of intercourse was presented by Elizabeth Whelan in the book Boy or Girl (1977). While the Shettles method indicates ​ ​ intercourse on the day of ovulation or shortly thereafter to conceive a male child, the Whelan method instructs couples to have intercourse between four and six days before ovulation for a male and two or three days before ovulation for a female. Whelan claimed that her method increases the probability of conceiving a male to 86% and the probability of conceiving a female to 66%. Whelan criticized Shettles for presenting his method for use with natural conception although he based his method on studies about artificial insemination. Whelan also cited several studies indicating that the Shettles methods does not work: 74 out of 131 infants born to couples who had used the Shettles method were not of the desired sex. (Alysse Blight The Whelan ​ Method of Sex Selection in The Embryo Project Encyclopedia (6/9/2018). https://embryo.asu. ​ edu/pages/whelan-method-sex-selection. Accessed December 2019). On the other hand, an article appearing in the prestigious New England Journal of Medicine in ​ ​ 1995 “found no association between the sex of the baby and the timing of intercourse in relation to ovulation,” and reached the conclusion that “the deliberate timing of intercourse around the day of ovulation has no practical value in sex selection.” (Allen J. Wilcox, Clarice R. Weinberg,

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and Donna D. Baird, “Timing of Sexual Intercourse in Relation to Ovulation Effects on the Probability of Conception, Survival of the Pregnancy, and Sex of the Baby.” New England ​ Journal of Medicine 333/23 (December 7, 1995): 1517-21 at 1521. ​ Or again, some have suggested that the mother’s preconception diet is a factor determining the sex of the child. For example, a British study (2008) found that individual mothers had a greater chance of bearing male offspring if their nutrient intake was high prior to conception. Statistically, 56% of women in the highest third of preconceptional energy intake bore boys, compared with 45% in the lowest third. It was also found that consumption of breakfast cereals was strongly associated with having a male infant. (Fiona Mathews, Paul J. Johnson and Andrew Neil, “You are what your mother eats: evidence for maternal preconception diet influencing foetal sex in humans,” Proceedings of the Royal Society B 275 (2008): 1661-68.) ​ ​ However, some have expressed reservations about this study on the grounds that finding a “association” does not prove a cause-and effect relationship, that the reported effect is relatively small (55% vs. 45%), and that diet will have other effects for both the mother and child. (Kathleen Doheny, Deciding Baby’ Sex, WebMD at https://www.webmd. ​ ​ com/baby/features/deciding-babys-sex, accessed December 2019; Roger Highfield, Diet before ​ pregnancy can affect baby’s sex, new research suggests at https://www.telegraph.co.uk/ ​ ​ news/science/science-news/3340540/Diet-before-pregnancy-can-affect-babys-sex-new-researc h-suggests.html, accessed December 2019). ​ 48. See, for example, the comments by health care professionals in Doheny’s WebMD article ​ ​ Deciding Baby’s Sex. See also Mary Anne Warren, Gendercide: The Implications of Sex ​ ​ ​ ​ Selection, pp. 8-10. ​

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