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Check your privilege and your facts before discussing sex selective abortion

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 am compelled to address what I feel are 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.

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 woman 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. 

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Discussion

43 thoughts on “Check your privilege and your facts before discussing sex selective abortion

  1. Reblogged this on things I've read or intend to.

    Posted by donesoverydone | April 12, 2016, 8:52 pm
  2. I taught a girl who was one of eleven children. When her mother gave birth to her twelfth child it was a boy. Everyone was happy because, as the girl said, her mother could stop having children now!

    Posted by J G | April 13, 2016, 2:19 am
  3. Love this post, thank you for your hard work.

    Posted by Nicole | April 13, 2016, 3:07 am
  4. Whenever people talk about how certain reasons are bad reasons for having an abortion and how they should not be allowed, they totally drop their caring mask and show their true colours. They clearly don’t support pregnant people and want to keep them from harm because they want to deny them medical care. And they obviously don’t give a fuck about children either.
    If there’s a woman whose reasons for an abortion seem frivolous to you, and silly and stupid, why would you want a frivolous, silly, stupid person in charge of pregnancy and birth, where you can cause so much damage, or in charge of a baby, a totally fragile and dependent human being?
    If there’s a woman whose reasons for abortion abhor you, because you think it’s horrible that somebody would like to have a child, but not a girl child*, why would you want a girl child to be born into a family where the mother regrets her birth and the father maybe even hates her? Where she learns that her existence is the reason her father beats her mother? Why do you hate girls that much**?

    Here’s the truth: Whenever you think somebody’s reason for having an abortion is “bad”, you should be very happy they’re having it because they’re not the people who should raise a child. I haven’t found a scenario yet where this rule doesn’t apply.

    *Not to mention the fact that genitals don’t make a boy/girl

    **The alternative to abortion still is and always has been infanticide. Unwanted girls happen to have terrible accidents.

    Posted by giliell | April 13, 2016, 5:10 am
    • Genitals DO make a boy a boy- and a girl a girl. Sex characteristics are a reality. Humans are a dimorphic species.
      Females are aborted, killed, because they have female bodies. Not because they “feel female” in their minds.

      (You are thinking of gender, which is a social construct, used to oppress females.)

      Posted by Mom in Eugene | April 13, 2016, 10:38 am
      • I’m not sure how much our esteemed host wants this discussion here, so please feel free to delete it, but I’ll bite:
        Genitals do not make a boy or a girl. Genitals are genitals, organs like lungs and heart and kidneys, “boy” and “girl” are labels applied to people with certain genitals. Yes, sex is just as much a social construct as gender is (would you believe there are languages that don’t even differentiate between those concepts) and so is the Pacific Ocean and the Mississippi. Doesn’t mean they aren’t wet.
        Yes, those fetuses are aborted because most people believe that a vagina means girl/woman and that girls and women are worth less but that doesn’t make the concept any more true.

        Posted by giliell | April 13, 2016, 11:14 am
      • @Giliell said: “Yes, those fetuses are aborted because most people believe that a vagina means girl/woman and that girls and women are worth less but that doesn’t make the concept any more true.”

        Please realize that while you wrangle over this “concept”, thousands upon thousands of vagina-bearing fetuses will be aborted precisely for the reason you outline. This is a privilege you have, to treat this issue as a teachable moment or something equally lofty, but this privilege is not shared by thousands upon thousands of women in India (and expat Indian women elsewhere in the globe).

        In this context, it works exactly as @Mom in Eugene said: “Females are aborted, killed, because they have female bodies. Not because they “feel female” in their minds.” If you deny that reality, your stance leads to erasure of women – as the extremely skewed sex ratio in certain Indian communities attests to.

        Giliell, since I am familiar with your posts in blogs, I can tell you that I share your conviction that transmen are men (just as transwomen are women) regardless of their genitalia. But please understand that many fetuses in India won’t be born alive to grow up and make that determination for themselves simply because during biological development in fetu they bear a vagina.

        Posted by kausikdatta | April 14, 2016, 9:57 am
      • @Kausikdatta
        Yes, “females” (use a Ferengi accent for full effect”) are aborted. Or they’re not. Fetusues with vaginas are certainly aborted because they’re believed to be (and in their overwhelming majority are) female.
        I can accept that this particular kind of abortion is rooted in beliefs in a patriarchal biologistc binary without actually accepting that biologistic binary as true.
        It is even possible and OK to use “male” and “female” as shorthands for “having a certain kind of body” in certain discussions, like, when you remember that this not a 100% thing.
        Funny thing how my 12 words that simply state that the idea genitals make boy/girl isn’t always true sparks such a lot of need to chastise me for the simple fact of mentioning that trans people exist.
        I made a footnote. The two of you made a discussion out of it and now blame ME for a derail.

        Posted by giliell | April 19, 2016, 1:30 pm
      • Sex is what makes a boy or a girl. Sex is what makes a boy able to impregnate a girl, who is the only human able to be pregnant.

        Posted by red | April 22, 2016, 5:57 am
    • People don’t get pregnant and have abortions: WOMEN do. Refusal to acknowledge this is part of the problem that leads to and is part of the women-hate we work against.

      Posted by red | April 22, 2016, 5:53 am
  5. Thank you.

    Posted by Catherine | April 13, 2016, 5:23 am
  6. I could weep, this is so good. Thank you.

    Posted by Vicky | April 13, 2016, 7:29 am
  7. Apparently a lot of Indian men are idiots who don’t realize it’s their sperm that makes a boy or girl.

    Posted by K | April 13, 2016, 7:56 am
    • Deleting the word Indian from your sentence won’t make it any less true.

      Posted by bf | April 13, 2016, 12:11 pm
      • It’s not racism to state a fact. The majority and the millions of girls aborted is among Asian, South Asian culture. I had a conversation just yesterday with a very highly educated Sikh man, as progressive and cultured as you could imagine. Without actually saying it, it was clear his wife had had abortions until she gestated a male. Even men of these cultures who do have two or three girls, will be apologetic about it to their community, and will keep trying for a boy. Why? One could say it’s necessary in their culture, but here, in Canada? No, it’s pure misogyny, no matter how velvet it’s expressed.

        Posted by red | April 22, 2016, 6:04 am
  8. Reblogged this on iheariseeilearn.

    Posted by goodrumo | April 13, 2016, 9:36 am
  9. Excellent. Thank you.

    Posted by CM | April 13, 2016, 12:35 pm
  10. Hi Dr. Gunter, I love your blog postings.  I learn so much.  I wish there was a way to share them on my Facebook page.  Keep up the wonderful work.  The world needs you. Susan

    Posted by Susan Twining | April 13, 2016, 1:07 pm
  11. Thank you, doctor. You are brilliant.

    Posted by Alexandra Hanson-Harding | April 13, 2016, 7:16 pm
  12. Jen
    I struggle with your comments:
    Point 1) Did you report the women who was beaten to the police?
    Point 2)”abortions aren’t harmful”….your July 25, 2013 interview contradicts this
    “MKB: When we talk about “a complication” with an abortion, what does that actually mean? What kinds of problems did you see?
    JG: It can range from infection — so maybe they didn’t receive their antibiotics before the procedure — or it can be as catastrophic as putting the surgical instrument through the wall of uterus and into the belly and ripping bowels apart, ripping blood vessels apart. Those blood vessels, when you’re pregnant — there’s a dramatically increased amount of blood flow to the uterus. Cut one of those major vessels and the patient can “bleed out” very, very quickly I always remember one of my first lectures in medical school where the OB/GYN was telling us about a D&C [dilation and curettage], which is basically the same procedure as an early abortion, and he said a pregnant uterus is like butter. And it’s true. It requires a certain touch and skill to do it safely. When people don’t know what they’re doing they can easily damage something catastrophically. And I think a lot of times that happens when people misjudge how far along the pregnancy is. So they think somebody is only 8 weeks, and they’re really 14. At that point, you have a fetal skull to deal with and once you start shattering bones, those can start sticking through the uterus. You can see some really catastrophic injuries.”
    Point 5) you reference bad policy and laws, what is the law in Canada on abortion? please share, because I understand there are no laws or policy on abortion.

    I think your right abortion is a symptom, but what is the real problem? I am saddened by these views and the lack of true support for women, its hard to believe that continuing with the status quo is ok

    Posted by Myles | April 13, 2016, 11:29 pm
    • 1) Never report abuse victims to the police unless they ask you to (exceptions for minors). Support for victims from the police is notoriously bad all over the world and this may endanger the victim further, including leading to her death. Most killings by (former) partners happen when the victim tries to leave. Nobody has any right to bring them into that situation

      2) Right, there can be medical complications. As with every medical procedure. Either you categorise ALL medicine as “harmful” (do you want me to tell you about the ordeal I had with my wisdom tooth? My abortion was easy peasy in comparison even though it was the end of a wanted pregnancy) or use the word in a different sense, meaning intrinsically harmful.

      Posted by giliell | April 14, 2016, 11:16 am
    • Myles,

      1) I always follow reporting laws when they exist
      2) An abortion, when done by a trained provider has a low complication rate, like a colonoscopy. Lots can go wrong with an abortion or a colonoscopy or driving a car if not done right. If I did a colonoscopy with no training I would injure people, that doesn’t make colonoscopy unsafe it means you have to have training to do it. It is clear you missed the point of that interview. Studies tell us that fewer women (much fewer in fact) die or are harmed from abortion than pregnancy that goes to delivery. Restricting abortion leads to more women going to poorly trained providers. So, the comments above are really applicable to what happens when someone doesn’t know what they are doing.
      3) Can you Google? Obviously you can as you took the time to find an interview I did on abortion. Google the laws yourself, I’m not your librarian. However, bad studies become fodder for bad laws and are certianly talking points for ill informed politicians.

      If you read my post you would know what I think the problem is.

      Posted by Dr. Jen Gunter | April 14, 2016, 1:04 pm
      • Jen
        Appreciate the response.
        I can search the web, more importantly I can search Canadian Law too, and what bothers me is that everyone references policies and laws….we don’t have either. Would that be a good spot to start?
        Happy to take this offline
        Myles

        Posted by Myles | April 14, 2016, 6:02 pm
      • It would be naive to think that a study published in CMAJ would only affect policies and laws in Canada. You can go to https://www.guttmacher.org/united-states/abortion and find all the ways abortions laws have been crafted to restrict access.

        Posted by Dr. Jen Gunter | April 14, 2016, 6:13 pm
  13. It’s really a shame you feel it necessary to wrap these very important points in toxic feminist rhetoric. Terms like “that’s patriarchy” (not in any way established in your piece BTW) and “check your privilege” are the language of entitled college feminists bitching that they aren’t called on first in class. I pushed through this to read what you wrote and I would love to see you tear down people spreading misinformation like this, but if you want to preach to more than the choir, you could present the same facts without the rhetoric.

    Posted by Asif | April 14, 2016, 7:08 am
  14. Jen
    My issue is we have no laws or policy in Canada for the CMAJ to effect? You’re referencing the US issues, Im asking for facts about Canada, lets not muddy the waters.

    Posted by Myles | April 14, 2016, 6:42 pm
    • Indeed there are no laws regulating abortion in Canada. Every year, religious groups sponsor a March for Life in Ottawa to demand that abortion be banned (or at least controlled). For the past few years, I have attended the pro-choice counter protest in a special area set aside for that purpose (we are, after all, Canadians). In 2015 I was interviewed by a conservative news organization, and asked if I thought that it was reasonable that Canada had no laws controlling abortion, so a woman could terminate her pregnancy at any time, even just before birth. And I said that yes, I did think that was reasonable. I know that statistics show that late-term abortions are done either because the fetus is not viable, or the mother’s health is at risk, or in some cases the abortion was delayed by circumstances (eg a young girl who denies or does not realize she is pregnant). I expect that a vanishingly small number of women would, on a whim, decide to end their pregnancy at 8.5 months. But the downside of a law against late term abortions would mean that, at some point in her pregnancy, a woman’s medical treatment would not just be about the health of the woman, but the health practitioners would need to also attend to the health of the fetus.

      Posted by Seanna Watson | April 14, 2016, 8:40 pm
    • The anti choice factions in Canada are always looking at ways to restrict abortion. I believe there was a private member’s bill last your, but I’m pretty sure you know about that. Do you really think that no anti choice politician will think this article is a way to introduce a restriction? There have been several op eds that have used this paper as a call to restrict abortion in Canada.

      Posted by Dr. Jen Gunter | April 15, 2016, 1:38 am
  15. Indeed there are no laws regulating abortion in Canada. Every year, religious groups sponsor a March for Life in Ottawa to demand that abortion be banned (or at least controlled). For the past few years, I have attended the pro-choice counter protest in a special area set aside for that purpose (we are, after all, Canadians). In 2015 I was interviewed by a conservative news organization, and asked if I thought that it was reasonable that Canada had no laws controlling abortion, so a woman could terminate her pregnancy at any time, even just before birth. And I said that yes, I did think that was reasonable. I know that statistics show that late-term abortions are done either because the fetus is not viable, or the mother’s health is at risk, or in some cases the abortion was delayed by circumstances (eg a young girl who denies or does not realize she is pregnant). I expect that a vanishingly small number of women would, on a whim, decide to end their pregnancy at 8.5 months. But the downside of a law against late term abortions would mean that, at some point in her pregnancy, a woman’s medical treatment would not just be about the health of the woman, but the health practitioners would need to also attend to the health of the fetus.

    Posted by Seanna Watson | April 14, 2016, 8:38 pm
  16. Agree totally with this but alas, and here is where the reality that a sane, rational person can hold diametrically opposed opinions – I wouldn’t be a mother if abortion was freely available, no questions asked, to all women. And I love that I am mother to a child carried by someone else!

    Posted by Collie | April 15, 2016, 1:12 am
    • Collie: Forgive me if I misunderstand you, but are you really saying that it’s ok to force a woman to maintain a pregnancy against her will in order that someone can have a child to adopt?

      Posted by Seanna Watson | April 15, 2016, 10:36 am
    • Really? because no woman, ever, would choose to carry an unwanted baby to term to be adopted, so you couldn’t possibly have adopted a baby if abortion had been an option? No woman, ever, would want a baby but not be able to bring it up herself? No babies are ever orphaned? I don’t think that’s at all true.

      Posted by Irene | April 16, 2016, 12:51 pm
  17. My ex-husband used to joke that even after four girls, his mother had to keep having babies until he was born, then that his little sister – the fifth girl – was an accident. It was certainly no joke to his mother. And really difficult for the eldest daughter since she was basically given the responsibility of taking care of the younger kids plus the running of the household because the mom had to go to work to support the family since the alcoholic patriarch couldn’t hold down a steady job. She stayed because of her religion, and never had any real happiness until her husband finally passed away.

    Posted by Nancy | April 16, 2016, 10:01 am
  18. Thank you for laying out the arguments so well. Your article should be required reading for ALL physicians, and Health Care personnel who deal with women, all women, whether they are seeking a termination or not. Awareness of women’s (our) second class status is imperative, and only by this awareness, we as physicians can help to change this gender inequality.
    zd.

    Posted by zohra Docrat | April 16, 2016, 5:28 pm
  19. Excellent blog post. So appreciated

    Posted by Dr. PA | April 16, 2016, 9:52 pm
  20. Thank you for the excellent analysis and discussion of this topic. If misogyny is at the root of sex selection, we are not likely to “fix” that problem any time soon (few can even acknowledge the extent of misogyny that is still present in western society). Can we take a harm reduction approach until things improve? For example, during abortion counselling, in addition to discussing birth control options, we provide information on how to increase the likelihood of conceiving a male (if it is possible for that couple) and maybe even help with the understanding of likelihood altogether after multiple female pregancies? Also, for these families, is there technology to test the male in the relationship and provide family health counselling/intervention from there?

    Posted by Sue | April 24, 2016, 9:25 am
  21. Wow great response!
    I thought rational thought might have died during this presidential race; refreshing to see that it hasn’t

    Thank you

    Posted by Nico | August 2, 2016, 12:20 pm

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