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The woman lying on the examination table is clearly nervous. She has a look of troubled anticipation, brows deeply furrowed, lips pursed and pale, and forehead glistening with tiny beads of sweat. She takes a deep breath, and grasps her dupatta with moist hands, while mouthing prayers into the off-white wall.

“It’s a girl.”

I watch the woman’s blank expression, and catch the look of frustration on her husband’s face in the corner of my eye. Seconds later, she begins to cry.
As a medical student I first became interested in the issue of sex selection upon talking with South Asian women who told me they were abused or neglected by their husbands and extended family because they had given birth to girls. I was surprised to learn that such pressure to have boys exist even within immigrant South Asian communities in the United States. A number of factors have converged to actually enable this practice: easy access to routine ultrasounds (forbidden in India), the availability of abortion services, and the American fertility industry, which offers everything from preconception sex selection to at-home gender determination kits. Ads for sex-selection clinics have appeared in South Asian community papers and even The New York Times.

I thus decided to do a research project on sex selection and the reasons for its prevalence among both South Asian immigrants and non-South Asians in the United States. This research is formally intended for the master’s thesis required for my medical degree, but I also wanted to do this project to promote dialogue about a preference for sons and its impact on the lives of women and children. Any quotes and locations have been changed to protect the identities of my research subjects.

When I first began my project, I was extremely wary. I had seen that newspaper articles about the skewed gender ratio in India often make the front page, yet offer little insight into the reasons for sex selection, or the pressures and emotions involved in such decisions. I did not want to further stereotypes about the preference for sons among South Asians. I wanted to understand what drives women to seek three or more abortions in their quest for a male child. I wanted to know how the desire for a son, and not wanting any more daughters, affected a couple’s existing children. I wanted to understand how medical providers felt about offering sex selection services or simply early sex determination via ultrasound. And, I wanted to understand why this practice was occurring in the United States among South Asian immigrants.

“In this country?” is the incredulous response I most often hear when I discuss some of the trends I’ve observed. Yet my own surprise has lessened as I’ve researched the reasons behind son preference. Religious and cultural festivals are not the only practices that survive the processes of immigration: the ultrasound machine has retained its iconic status among some South Asian immigrants in this country. When I ask women why they want a son, they often expect that I should know and understand that this is “an expectation of women,” as one woman put it.

Yet, what draws couples to travel across the state and sometimes to other states to get an ultrasound scan? What motivates them to spend thousands of dollars to select fetal sex before conception? Surprisingly, it is often women themselves who firmly believe that they need to have a son. The couples visiting these clinics usually already have at least one daughter—I have never seen a couple try and select the sex of their first child. When I ask why, they often tell me, simply, that every mother has a right to a son. Sometimes, their stories are heartbreaking: their female in-laws taunt them, call them infertile, drive them to it. It is sometimes their own mothers or mothers-in-law who pressure them to have a boy. In other instances, the tension between the couple in clinic is palpable, and I wonder about the pressures women face from their husbands at home.

It is undoubtedly difficult for couples to speak with me about their most personal and intimate matters. Yet they patiently answered my questions, allowed me to sit in on their clinic visits, and afforded me glimpses into their emotional experiences. Many are deeply conflicted, and openly acknowledge the tension in being a woman and not wanting a daughter. Some do not want to have a girl because they want to prevent another woman from suffering as they have. Some hope that the newer technologies of sperm sorting will actually decrease their emotional suffering by avoiding an abortion.

A crucial question arising from this work is, what does this practice do to our daughters? Children are usually overlooked in the debate about sex selection, yet they are among the most immediately affected. Children who witness parents’ ongoing attempts to have a son are impacted emotionally and materially. A South Asian American student told me in an interview, “Do these parents think we don’t know what they’re up to? Of course we do. It’s no mistake that all the families I know have, like, four girls and the youngest is a boy. It’s obvious to us even if we don’t say anything. Because what can we really say?”
One could argue, as many physicians have, that patient autonomy and the concept of choice makes sex selection permissible if patients believe it is the best option for their family. However, it is not entirely clear whose choice it is. If a woman faces intense pressure, psychological or otherwise, to have a son, is she really exercising her choice? If she is harassed, threatened, or emotionally abused, is she free to seek or not seek sex determination or sex-selection services?

The real issue is not necessarily sex selection per se, but what sex selection signifies—the unequal status of women. While many couples say they need to have a son since they already have daughters, many do not know how to answer me when I ask if they would seek a daughter if they had only sons. Technology or physicians alone are not at the root of the problem. The use of technology and marketing of sex selection exist because of the preference for a male child. Technological advancement undoubtedly increases the pressure to use technology in order to have a boy. One woman told me, “Now that all these methods exist, if I don’t use them, my in-laws will harass me.” While I understand the role that technology plays in making this issue worse, ultimately it is the deep-seated preference for boys that we must question and challenge. For instance, why is it that some couples believe they have “too many daughters,” but we rarely hear complaints about “too many sons”?

We must acknowledge the societal pressures to have a son rather than condemn couples who succumb to them. Judgment and blame will only thicken the shroud of secrecy surrounding these practices, making it even harder to talk about it. Family planning decisions are naturally complex and emotional, but in this instance they can be influenced by expectations from family and community that result in unusual pressure and harm to both women and children.

How can the family and community provide a more positive influence? We can take steps towards change in small ways. For example, we can congratulate couples equally when sons and daughters are born. We can organize small meetings about creating more opportunities for women’s advancement, and more days to celebrate women’s many accomplishments. We can hold debates about the role and status of women, making space for women to talk about the ways they have experienced gender inequality. We can remind our daughters every day that they are equal to their brothers in every way.

When I look around me, I see strong, brilliant, beautiful South Asian daughters committed to improving the world around them. Our women are teachers, world-class athletes, artists, musicians, writers, activists, doctors, lawyers, models, actresses, mothers, daughters, and sisters. Let us celebrate our daughters, and all the women of our community, and take active steps towards achieving equality of women and men, daughters and sons.

Sunita Puri is a second-year medical student at the UC San Francisco-UC Berkeley joint medical program. She is currently conducting an ethnographic study of son preference and sex selection among South Asian immigrants in the United States.