The issues behind sex-selective abortion aren’t as clear as you think

Dr. Brian Goldman, in his blog for CBC radio, wrote about the new article in the Canadian Medical Association Journal (CMAJ) on the sex ratio after induced abortion in Ontario, (i.e., sex selective abortion).

The article in the CMAJ confirms what is no surprise to me as an OB/GYN, that the ratio of male to female births for a third child born to women who emigrated to Canada from India who had two previous girls is statistically improbable, basically 2 boys for every girl. The male: female infant ratio after 2 girls was 1.77 times higher if the current birth was preceded by 1 induced abortion, 2.38 times higher if preceded by 2 or more induced abortions and 3.88 times higher if the induced abortion was performed at 15 weeks or more.

There are lots of issues with Dr. Goldman’s piece, and I feel compelled to address what I feel were his main points as I am sure he isn’t alone in his thoughts.

1. “The fact it’s happening means that health care providers are carrying out abortions, no questions asked without asking about the motivation behind the request.”

Yes, providers do abortions no questions asked. That is medical care.

While I don’t do abortions now, I used to, and I learned that skill in my Canadian residency. The four great men who trained me to do abortions (because sadly it was only men doing them at my program) never once questioned why a woman chose to have an abortion. They trusted women. Completely. They taught me empathy. I was trained to provide care not to judge.

I was also taught how to counsel women and to the best of my ability make sure that a woman was getting the care she wanted without coercion. I learned how to talk with women about abortion versus continuing their pregnancy and adoption and also about the importance of post-procedure contraception. Every abortion provider I know does this. Some women share their story, and others do not.

But motivation? Oh God, that word offends me. Who decides what is appropriate motivation for an abortion and what is not? The abhorrent concept of “motivation” is the very reason Canadian “abortion panels” were dismantled. Women used to have to beg and plead their case in front of three “experts,” like a medieval tribunal. Scratch that, not like it was a medieval tribunal. I grew up in the era of abortion panels, and that is exactly why I became an OB/GYN.

Once you start telling women they have to have the right reason for an abortion you have inserted the thin edge of the wedge regarding abortion restrictions. Who gets to decide what is a needed abortion, three people who know nothing about a woman or the woman herself? When you say a woman’s motivation for abortion needs to be evaluated, you are patriarchy. Like she hasn’t thought about it already? News flash, when a woman who wants an abortion is denied access birds don’t flock to assemble a nursery, and she don’t suddenly say, “Oh gosh, I guess you are right, I really didn’t put any thought into this whole abortion thing at all because I’m just a silly, stupid woman.”

There is no medical reason to know a woman’s reason for abortion save a later procedure for anomalies. Would an autopsy be helpful? If yes then you recommend an induction. That’s it.

In residency, I wondered why some women had repeat abortions when they were offered such intense contraception counseling post procedure and so that became my research project which was, coincidentally, also published in the CMAJ. Physical and sexual abuse it turns out are risk factors for repeat pregnancy terminations (something the current article does not address), but stopping abortion when those factors are present doesn’t magically stop abuse.

Abortion is a symptom, not the problem.

“He beat me very badly after I had my last girl, I can’t go through that again,” a woman once told me. What exactly were this woman’s options who spoke limited English, had no job and depended on her husband for money. She took a bus to her abortion because she didn’t drive and would have to explain the money for a cab. Do I judge her? Do I with my upper middle-class upbringing and the earning potential of a physician say, “Sorry honey, not tragic enough?” And what if she doesn’t get that abortion and is then beaten to death in her third trimester or after she delivers? I’ve seen that, but no one writing about the “evils” or “moral ambiguity” of sex-selective abortion mentions maternal abuse or murder.

“Motivation” is a lot more complex than any study can tell you.

2. “These women are undergoing medical procedures that I would certainly regard as unnecessary and potentially harmful to the mother.”

Wrong and wrong. No one except the woman gets to decide if her abortion is necessary. Ever. Anything else is patriarchy.

Let’s be factual: Abortion is not harmful. You know what is? Perpetuating that myth because ignorant politicians use it to write laws designed to punish women. No study has shown harm from abortion using modern techniques. In fact, abortion is about as safe as colonoscopy. It’s safer than pregnancy. Saying there is harm when there is not is either inadequate research or misogyny. It’s a tired trope, and I’m sick of it.

What about eight pregnancies in search of a boy, is that not harmful? Why does no one ever mention that when they discuss harm? I have delivered many women who sobbed and looked away in disgust when they saw they had delivered their fifth or sixth or eighth girl, because they knew they would be back year after year until they delivered that coveted boy or died trying. How is that not violence against women?

If women have to justify their abortion why shouldn’t they have to justify their eighth pregnancy? The latter is far more dangerous than the former.

And yes, six additional deliveries is a lot more harmful than six abortions.

How many pregnancies must a woman endure in search of a boy before the patriarchy decides she is allowed to have an abortion? Three? Five? Eight? Fifteen?

3. “Multiple induced abortions are detrimental to a woman’s health and also to subsequent pregnancies.”

Nope and nope again. This line used by Dr. Goldman is taken from the CMAJ article, which makes me wonder about the objectivity of those who wrote it, and once I stop raging, I will certainly be writing a letter to the CMAJ. The article from PLOS quoted to support the “risks” in subsequent pregnancies with abortion doesn’t say that modern abortion has those risks at all, rather it says:

These findings support the established association between previous termination and preterm delivery. But most importantly, the changes in this association over the past two decades—from strong in 1980–1983 to nonexistent in 2000–2008—a period in which the use of medical termination and pre-treatment of the cervix for surgical termination increased dramatically in Scotland, suggest that surgical termination without cervical pre-treatment is responsible for the increased risk of spontaneous preterm birth: the decrease in the proportion of this procedure over the study period may have led to the disappearance of the established association between previous termination and preterm delivery from 2000 onwards.

Abortion does not lead to mental health issues breast cancer, or any other health implication — pregnancy-related or otherwise.

I don’t expect everyone to know that, but I do expect a doctor writing about abortion on a blog for CBC radio to know that.

4. “A 2007 policy statement by the Society of Obstetricians and Gynecologists of Canada said medical testing should not be used for sex selection, and pregnancy termination should not be permitted on that basis either.”  

Except that’s not exactly what it said. The SOGC doesn’t say pregnancy terminations should not be permitted it says, “The SOGC does not support termination of pregnancy on the basis of gender.” Not supporting and not permitting are of course two different things. But while we’re on the subject I wonder if the SOGC really means to suggest OB/GYNs should be scrutinizing women’s choices, because that is more than a little paternalistic.

Oh, and does the SOGC support permitting a ninth pregnancy in search of a boy?

Right.

Check. Your. Privilege.

5. “The most disturbing implication from this study is that sex selection meant that 4500 female fetuses in Canada and 100 million female fetuses worldwide were aborted and therefore not born.”

No, that is not the most disturbing thing. The most disturbing thing is how people will twist the study to support bad policy and laws.

The second most disturbing thing is the erroneous assertion in the article that modern second-trimester abortions are a risk for preterm labor.

The third most disturbing thing is the lack of control women who didn’t chose abortion, so we don’t know exactly how many pregnancies these women had to endure to have a boy.

You want to know what else I find disturbing? That in 2016 women are worth less than men. We still have an equal pay day, you know? Think there is some cause and effect there?

When the problem of women being worth less than men goes away the symptoms of sex-selective abortions and multiple pregnancies in search of a boy will stop.

6. “I believe the practice should be stopped, but how?”

I believe in working towards equality for women, free or low-cost access to long-acting reversible contraception, and trusting women. The end. Those goals will naturally reduce abortion, but I don’t support them because they will reduce abortion I support them because they empower women. They will also likely reduce multiple deliveries in  the quest for a boy.

We know laws don’t stop sex-selective abortion and the nod at the end of the piece to choice and the fact that making abortion illegal would drive it “underground” come across as lip service. It’s the same uncomfortable pas de deux that many who identify as pro-choice have with sex-selective abortion, but there are no qualifiers for choice.

Even if stopping sex-selective abortion were possible that won’t magically make women equal or cap every family at three, just as stopping domestic violence related abortion will not stop domestic violence.

While I worry that a women denied a sex-selective abortion might seek unground care, I also worry if she doesn’t get the abortion she feels she needs she will be punished for having a girl. For the next 18 years. Or longer. Or that she faces a life of servitude to her uterus in search of a boy, a goal that ironically she can’t even control. I also worry that if she feels Western society is judging her that she will be less likely to seek care of any kind or confide in her providers.

Sex-selective abortion and multiple pregnancies in search of a male heir are symptoms of misogyny and are proof that women’s lives are undervalued almost everywhere, even Canada.  To ignore the women who deliver their eighth girl and will be back for number nine is proof that sex-selective abortion has been twisted to be about abortion and not about sex selection.

It appears that the trend towards abortion for sex selection disappears after a generation in Canada, which means that maybe people can come to believe in the equal worth of women — that to me is the most important message. Hopefully, we are also seeing a reduction in the search for a boy not just a reduction in abortion.

Things are never as black and white as they seem and when discussions about abortion focus on sex-selection it makes it sound like a woman has the greatest value when she is a fetus.

Jennifer Gunter is an obstetrician-gynecologist and author of the Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.

Image credit: Shutterstock.com

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