Discussion
The present study reviewed the first seven years of activity of Israel’s National Committee for Sex Selection by Pre-Implantation Genetic Diagnosis. The study’s aims were to present Israel’s “novel” approach to the issue, to describe the Committee’s work during its first seven years, including procedures, characteristics of applicants, applications, and decisions, as well as aspects of the decision-making process. A majority of the couples applying and a majority of those approved met the primary criterion of having four joint children of one sex and none of the requested sex. Most of the applicants requested male children, and the primary reason for this request was the parents’ intense emotional desire, although often more than one reason was given.
Interestingly, while the number of applications dropped over the years under consideration, the rate of approvals rose. Regarding the drop in applications, one can conjecture that families who may have considered applying heard from others of the high rate of rejections, thus avoided doing so. Following the number of applications over the coming years may confirm whether this is a stable trend, but clarification of this question would require a different type of study.
The Committee completed deliberations on about half of the 411 applications submitted during the study period, and one-fifth of these were approved. While a rise in the rate of approvals is noted in 2011, the numbers are small, so it is as yet unclear if this trend will continue or is sporadic, and/or whether this reflects a less stringent attitude on the part of the Committee. However, even among those who met the main criterion of having four same-sex children and none of the requested sex, only one-third were approved. This finding may well reflect a general reluctance on the part of the Committee members--who come from several disciplines--to encourage non-medically-indicated PGD. This viewpoint is not unique to Israel.
Opponents of PGD for non-medical reasons claim that free use of medical technology for sex selection may lead to: (1) danger of upsetting the demographic balance between the sexes, as in India and China, where abortion of female fetuses has resulted in a lack of millions of women [
7]; (2) danger of the “slippery slope” whereby fetal sex selection is the first step toward “custom made babies”, and unprecedented interference in the act of creation [
2,
8]; (3) psychological harm to the “custom made child” who must withstand the pressure of meeting parental expectations, and concern for damage to other children in the family [
9‐
11]; (4) discrimination against women by diminishing their very existence [
8,
11]; (5) the inevitable destruction of pre-embryos [
12,
13]; (6) medical risks to the mother and offspring as a result of technological methods employed [
10,
11,
13] and (7) inappropriate and potentially unfair use of limited medical resources [
13,
14].
On the other hand, proponents claim that fetal sex selection, particularly in non-Western cultures, enables control over the size of the population, eases economic burden and liberates women from the pressure of multiple pregnancies, or in worse cases aborting female fetuses and/or neglecting female babies [
13,
15,
16]. Ethicists in the West support this position with different arguments, such as: (1) the right to reproductive autonomy; (2) the claim that Western countries are less vulnerable to the risk of imbalance between the sexes; or (3) the claim that a preference for sex balance in the family is not necessarily sexist [
17‐
19].
Feminists have expressed mixed views regarding sex selection [
20]. Whereas some believe it enhances the autonomy of women, others maintain it provides an additional manifestation of discrimination against them [
7,
20].
Leading international professional organizations have acknowledged the complex implications of the use of PGD for non-medical reasons. Several organizations, such as WHO, UNESCO and HFEA (Human Fertilization and Embryology Authority, UK), have published policy statements opposing its use. However, ESHRE (European Society of Human Reproduction and Embryology) and ASRM (American Society for Reproductive Medicine) have expressed divergent views on the issue, and note that the use of PGD for social reasons would be reasonable under certain circumstances, notably with an emphasis on family sex-balancing [
3,
21]. ESHRE’s (2013), recent recommendations leave room for re-evaluation of blanket rulings permitting or banning non-medical PGD sex-selection, for example, in cases of those who must undergo IVF for medical reasons [
21].
The above reflects some of the major issues involved in non-medical PGD, although in- depth discussion of the ethical aspects was not within the scope or purpose of this research. While they are complex and compelling, they have been and are continuing to be discussed in a broad range of publications [
2‐
4,
21,
22].
In an attempt to evaluate possible demographic and social implications for the balance between sexes in the event of freer and greater use of existing technologies, many studies around the world deal with the identification and analysis of trends in favoring the sex of offspring [
1,
18,
23‐
25] and note obstetric and socioeconomic background variables as being associated with it. Regarding the former, about one-fifth of the applicants in the present study would have had to undergo IVF for other medical reasons, and might have expected this to enable their eligibility, but this did not guarantee approval of PGD. Although it was beyond the scope of the present study to investigate the reason for dropouts, this may be due, at least in part, to the stress of the IVF procedure itself [
26,
27]. Regarding socioeconomic factors these could be relevant due to the fact that, as opposed to medically-indicated PGD, the procedure for sex-selection purposes is not covered by the National Health Insurance Basket of Services in Israel, and thus couples would incur significant financial cost.
Family size and composition have been considered a major motivator for sex-selection. Many studies, including studies in Israel [
28,
29], have indicated that in families where there are children of a single sex, and especially in cases of at least three of the same sex, there is clear preference for the other sex [
1,
23‐
25,
30,
31] The association between family composition and preference for offspring’s sex is not surprising given the ongoing trend of declining total fertility rate in Western countries [
32], as well as in Israel [
33]. An Israeli study regarding attitudes towards PGD included a survey among a population of married couples of reproductive age who were parents to at least two children of only one sex [
29]. In their sample it was found that 45% of the respondents supported permitting sex selection for non-medical reasons and 42.6% wished to select the sex of their own future child. However, many of those expressing opposition in principle were willing to allow this in cases of psychological or familial crisis.
In the present analysis, while having four children of the same sex and none of the opposite sex was a prerequisite for approval, nevertheless nearly one-third of the applicants did not meet this criterion. Although this was the primary prerequisite, it does not necessarily indicate that applicants disregarded the official directives. This is because the Directive clearly allowed for exceptions in cases judged by the Committee to be “extremely rare and idiosyncratic” [
4,
5]. Certain families evidently felt that they met this condition, for example those who already had a son but he was handicapped, and they requested another son.
Among those who did not meet this requirement is the sub-group of Kohanim (see above), in which cases the Ministry of Health’s legal advisor reviewed the issue, and decided that leniency would be considered, due to the potential for ‘injury to the child’ and the likelihood that the couple would refrain from having children at all. This represents a unique situation in Israel and among other Jewish communities worldwide. Similarly, decisions based on other unique religious or cultural reasons may occur in other societies.
Sex preference for offspring is often grounded in religious and cultural traditions and in social norms which shape the attitudes and behavior of the individual [
1]. Research has consistently indicated a dominant trend in Western societies favoring a mixed and balanced composition of the sexes in the family, when a preference exists at all [
1,
19,
30,
34]. On the other hand, a preference for sons has been reported with respect to many religions [
30,
35]. A clear preference for boys has been reported in Eastern Asian (China, India, Korea, the Philippines) [
22] and in Moslem Arab societies, based on religious beliefs, rigid paternalistic traditions and primacy of the male social role [
1,
18,
19,
22‐
25,
30,
31]. Notably, emigration to other cultures has not been found to change the cultural norms of emigrants who live in communities that preserve the values, traditions and cultural norms of their country of origin [
22]. This preference is reflected in the current findings, in which all of the Arabs and almost two-thirds of the Jews (not including
Kohanim) requested males. Details of the couples’ sociodemographic characteristics (e.g., educational level, income, religiosity) were not available for this study to clarify possible differences between the groups on these aspects, since they are not included in the application forms. It is possible that this indicates not simply the preference for male offspring, but the degree of effort, expense, etc. that those wanting sons are willing to expend in comparison to those wanting daughters. Interestingly, this is in contrast to the findings of Hashiloni-Dolev’s et al. Israeli survey [
29], in which there was no significant difference in the rate parents of ‘only boys’ or ‘only girls’ stating that they would be interested in choosing the sex of their next child. This may reflect the distinction between a population sample and a specific cohort, as well as between a hypothetical question and actual personal experience.
Fertility issues have also been associated with sex preference of offspring. Parental age, particularly advanced maternal age and approaching menopause, has been related to a desire to proactively select the offspring’s sex [
23,
24], Among the couples in this study, maternal age or having had repeated Cesarean section deliveries (making additional deliveries risky) were noted in almost half of the requests, and most of those who reached the Committee’s decision stage with this noted as their primary reason were rejected. Among fertility clinics in the U.S., the necessity for the woman to undergo IVF or PGD for non-sex-linked medical or genetic reasons has been found to be a factor that strengthens the preference and willingness to conduct additional PGD for sex selection [
23]. However, a study conducted on couples undergoing fertility treatments in Germany found that 90% of respondents ruled out the possibility of using PGD for sex selection for non-medical reasons even if the technology would be accessible to all [
36].
Another aspect of the dilemma involved in PGD sex-selection may be the emotional cost to the parties involved of promoting desire for a child of the requested sex by offering the option of choice. It is notable that almost thirty percent of the applicants did not complete the application process. When possibilities exist, they may open avenues of expectation, which may in turn lead to disappointment when these expectations are not fulfilled. Schwartz [
37], considering consumer options, has called this the “Paradox of Choice”, stating that while autonomy and freedom of choice are important for well-being, Americans have more choice than ever, but do not seem to be benefiting from this psychologically. More specifically relating to reproduction, others have noted the irony inherent in the fact that new reproductive technological advances may become a source of stress by offering the option of choice. As Rothman stated: “The technology of prenatal diagnosis has changed and continues to change women’s experience of pregnancy” [
38]. McQuillan discussed the irony inherent in new reproductive technologies that open options both for women dealing with childlessness, as well as for those who do not have fertility problems, concluding that “… these choices may be yet another source of stigma and stress for women who do not choose to pursue medical treatment or to pursue it to its extreme” [
39]. The question remains as to whether the choice of sex-selection enables families to fulfill their hopes, or results in pressure on them--particularly on women--to meet expectations that have become available, or both.
Israeli PGD policy attempts to deal with the various issues involved. In the Introduction to the MOH Directive [
5] the considerations on which the guidelines are based are detailed, as translated (SG): “Considering, on the one hand, the basic human freedom to choose for oneself when the technological means are available, and on the other hand, factors important for an orderly and moral society, among them medical and ethical reasons opposing unnecessary medical procedures that carry potential risk, status of embryos of the unwanted sex, preventing sex discrimination, and maintaining the demographic sex balance…in addition not ignoring the high financial cost of conducting PGD which requires IVF”. Despite the basic negative attitude towards non-medical PGD, the Directive attempts to provide a solution for exceptional cases in a way that reduces some of the personal, familial and social risks associated with the use of PGD technology for sex selection. The threshold criterion of at least four children of the same sex is intended to prevent the risk of imbalance between the sexes in society (the male-to-female ratio in Israel in 2011 was 1.05 [
33]. The requirement that both spouses sign a consent form is meant to ensure that the applicants fully understand the procedure and its implications for the health of the mother and fetus. The restriction requiring the use of any remaining embryos before permitting another IVF cycle is intended to: (a) reduce potential ethical problems regarding the status of unwanted embryos, and (b) avoid potential injury to the woman’s health due to unnecessary medical procedures [
5].
Several authors have addressed this unique Israeli policy. While the policy is designed to allow a degree of flexibility in Committee judgments, some criticize the lack of any absolute criteria, even that of the four-children-of-only-one-sex criterion [
4,
10]. Some justify or refute it from a religious-
Halachic (Jewish religious law) point of view [
16,
40,
41]; some believe that allowing PGD could avoid abortions of fetuses of the undesired sex [
42,
43], which are illegal in Israel on such grounds. Some call for legislative regulation of the issue [
12,
41]. Others have vehemently opposed this policy for various reasons, mainly impingement on individual freedom, the principles of the liberal-democratic state [
44], danger to the health of the mother and the emotional health of the future child and his siblings who were born “randomly”, [
9] and danger to intra-familial relations [
10].
The Israeli policy is presented here as one of the possible resolutions to the complex issue at hand. In light of the broad differences between countries and their cultures, the Israeli model may serve as one among several models for consideration. While it might not be appropriate for adoption, it may offer a basis from which elements could be adapted.
Competing interests
Nirit Pessach, the primary investigator, is a member of the Committee for Sex Selection by Pre-implantation Genetic Diagnosis, and Amihai Barash, co-investigator, is Chairman of the Committee. This affiliation was necessary due to the confidentiality of Committee applications and material, as mandated by the Directive. It is believed that the primarily quantitative nature of the data in this research protects against bias in the report. Material requiring qualitative interpretation was reviewed and approved by other researchers, as noted in the manuscript.
Authors’ contributions
NP participated in conception of the study, design of the study, interpretation of the results drafting the manuscript and critical revisions, and she carried out the data extraction; SG participated in conception of the study, design of the study, performing the statistical analysis, interpretation of the results, drafting the manuscript, and critical revisions; VS participated in interpretation of the results and making critical revisions of the manuscript; AB participated in interpretation of the results and making critical revisions of the manuscript; LLG participated in conception of the study, design of the study, performing the statistical analysis, interpretation of the results, drafting the manuscript, and critical revisions. All authors read and approved the final manuscript.