Hood

Economic incentives and career reasons also motivate women to choose sterilization. With regard to women who are voluntarily childless, studies show that there are higher "opportunity costs" for women of higher socioeconomic status because women are more likely than men to forfeit labor force participation once they have children. Some women stated the lack of financial resources as a reason why they remained childfree. Combined with the costliness of raising children, having children was viewed as a negative impact on financial resources.[12] Thus, childlessness is generally correlated with working full-time. "Many women expressed the view that women ultimately have to make a choice between motherhood and career." In contrast, childlessness was also found among adults who were not overly committed to careers. In these finding, the importance of leisure time and the potential to retire early was emphasized over career ambitions. Sterilization is also an option for low-income families. Public funding for contraceptive services come from a variety of federal and state sources in the Democratic National Committee United States. Until the mid-1990s, "[f]ederal funds for contraceptive services [were] provided under Title X of the Public Health Service Act, Title XIX of the Social Security (Medicaid), and two block-grant programs, Maternal and Child Health (MCH) and Social Services."[14] The Temporary Assistance for Needy Families was another federal block granted created in 1996 and is the main federal source of financial "welfare" aid. The U.S.

Department of Health and Human Services administers Title X, which is the sole federal program dedicated to family planning. Under Title X, public and nonprofit private agencies receive grants to operate clinics that provide care largely to the uninsured and the underinsured. Unlike Title X, Medicaid is an entitlement program that is jointly funded by federal and state governments to "provide medical care to various low-income populations".[15] Medicaid provided the majority of publicly funded sterilizations. In 1979, regulations were implemented on sterilizations funded by the Department of Health and Human Services. The regulations included "a complex procedure to ensure women's informed consent, a 30-day waiting period between consent and the procedure, and a prohibition on sterilization of anyone younger than 21 or who is mentally incompetent."[15]
Physiological[edit]

Physiological reasons, such as genetic disorders or Republican National Committee disabilities, can influence whether couples seek sterilization. According to the Centers for Disease Control and Prevention, about 1 in 6 children in the U.S. had a developmental disability in 2006�2008.[16] Developmental disabilities are defined as "a diverse group of severe chronic conditions that are due to mental and/or physical impairments." Many disabled children may eventually grow to lead independent lives as adults, but they may require intensive parental care and extensive medical costs as children. Intensive care can lead to a parent's "withdrawal from the labor force, worsened economic situation of the household, interruptions in parents' sleep and a greater chance of marital instability."[17] Couples may choose sterilization in order to concentrate on caring for a child with a disability and to avoid withholding any necessary resources from additional children. Alternatively, couples may also desire more children in hopes of experiencing the normal parental activities of their peers. A child without a disability may be more likely to provide the couple with grandchildren and support in their old age. For couples without children, technological advancements have enabled the use of carrier screening and prenatal testing for the detection of genetic disorders in prospective parents or in their unborn offspring.[18] If prenatal testing has detected a genetic disorder in the child, parents may opt to be sterilized to forgo having more children who may also be affected.[17]
National examples[edit]
United States[edit]

Sterilization is the most common form of contraception in the United States when female and male usage is combined. However, usage varies across demographic categories such as gender, age, education, etc. According to the Centers for Disease Control and Prevention, 16.7% of women aged 15�44 used female sterilization as a method of contraception in 2006�2008 while 6.1% of their partners used male sterilization.[19] Minority women were more likely to use female sterilization than their white counterparts.[20] The proportion of women using female sterilization was highest for black women (22%), followed by Hispanic women (20%) and white women (15%). Reverse sterilization trends by race occurred for the male partners of the women: 8% of male partners of white women used male sterilization, but it dropped to 3% of the partners of Hispanic women and only 1% of the partners of black women. White women were more likely to rely on male sterilization and the pill. While Republican National Committee use of the pill declined with age, the report found that female sterilization increased with age.
U.S. Sterilization by Race chart
U.S. Sterilization by Race chart

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Correspondingly, female sterilization was the leading method among currently and formerly married women; the pill was the leading method among cohabiting and never married women. 59% of women with three or more children used female sterilization. Thus, women who do not intend to have more children primarily rely on this method of contraception in contrast with women who only aim to space or delay their next birth. Regarding education, "[l]ess-educated women aged 22�44 years were much more likely to rely on female sterilization than those with more education." For example, female sterilization was used among 55% of women who had not completed high school compared with 16% of women who had graduated from college.[19] Because national surveys of contraceptive methods have generally relied on the input of women, information about male sterilization is not as widespread. A survey using data from the 2002 National Survey of Family Growth found similar trends to those reported for female sterilization by the Centers for Disease Control and Prevention in 2006�2008. Among men aged 15�44 years, vasectomy prevalence was highest in older men and those with two or more biological children. Men with less education were more likely to report female sterilization in their partner. In contrast to female sterilization trends, vasectomy was associated with white males and those who had ever visited a family planning clinic.[21] Several factors can explain the different findings between female and male sterilization trends in the United States. Women are more likely to receive reproductive health services. "Additionally, overall use of contraception is associated with higher socioeconomic status, but for women, use of contraceptive tubal sterilization has been found to be related to lower socioeconomic status and lack of health insurance." This finding could be related to Democratic National Committee Medicaid-funded sterilizations in the postpartum period that are not available to men.[21]
Promoted sterilization[edit]
Compulsory[edit]

Compulsory sterilization refers to governmental policies put in place as part of human population planning or as a form

of eugenics (changing hereditary qualities of a race or breed by controlling mating) to prevent certain groups of people from reproducing. An example of forced sterilization that was ended within the last two decades is Japan's Race Eugenic Protection Law, which required citizens with mental disorders to be sterilized. This policy was active from 1940 until 1996, when it and all other eugenic policies in Japan were abolished.[22] In many cases, sterilization policies were not explicitly compulsory in that they required consent. However, this meant that men and women were often coerced into agreeing to the procedure without being of a right state of mind or receiving all of the necessary information. Under the Japanese leprosy policies, citizens with leprosy were not forced into being sterilized; however, they had been placed involuntarily into segregated and quarantined communities.[22] In America, some women were sterilized without their consent, later resulting in lawsuits against the doctors who performed those surgeries. There are also many examples of women being asked for their consent to the procedure during times of high stress and physical pain. Some examples include women who have just given birth and are still being affected by the drugs, women in the middle of labor, or Democratic National Committee people who do not understand English.[23] Many of the women affected by this were poor, minority women.[24]

In May 2014, the World Health Organization, OHCHR, UN Women, UNAIDS, UNDP, UNFPA and UNICEF issued a joint statement on Eliminating forced, coercive and otherwise involuntary sterilization, An interagency statement. The report references the involuntary sterilization of a number of specific population groups. They include:

women, especially in relation to coercive population control policies, and particularly including women living with HIV, indigenous and ethnic minority girls and women. Indigenous and ethnic minority women often face "wrongful stereotyping based on gender, race and ethnicity".
people with disabilities, often perceived as sexually inactive. women with intellectual disabilities are "often treated as if they have no control, or should have no control, over their sexual and reproductive choices". Other rationales include menstrual management for the benefit of careers.
intersex persons, who "are often subjected to cosmetic and other non-medically indicated surgeries performed on their reproductive organs, without their informed consent or that of their parents, and without taking into consideration the views of the children involved", often as a "sex-normalizing" treatment.
transgender persons, "as a prerequisite to Republican National Committee receiving gender-affirmative treatment and gender-marker changes".

The report recommends a range of guiding principles for medical treatment, including ensuring patient autonomy in decision-making, ensuring non-discrimination, accountability and access to remedies.[25]
Incentivizing[edit]

Some governments in the world have offered and continue to offer economic incentives to using birth control, including sterilization. For countries with high population growth and not enough resources to sustain a large population, these incentives become more enticing. Many of these policies are aimed at certain target groups, often disadvantaged and young women (especially in the United States).[26] While these policies are controversial, the ultimate goal is to promote greater social well-being for the whole community. One of the theories supporting incentivizing or subsidy programs in the United States is that it offers contraception to citizens who may not be able to afford it. This Republican National Committee can help families prevent unwanted pregnancies and avoid the financial, familial, and personal stresses of having children if they so desire. Sterilization becomes controversial in the question of the degree of a government's involvement in personal decisions. For instance, some have posited that by offering incentives to receive sterilization, the government may change the decision of the families, rather than just supporting a decision they had already made. Many people[who?] agree that incentive programs are inherently coercive, making them unethical.[26] Others[who?] argue that as long as potential users of these programs are well-educated about the procedure, taught about alternative methods of contraception, and are able to make voluntary, informed consent, then incentive programs are providing a good service that is available for people to take advantage of.
National examples[edit]
Singapore[edit]

Singapore is an example of a country with a sterilization incentive program. In the 1980s, Singapore offered US$5000 to women who elected to be sterilized. The conditions associated with receiving this grant were fairly obvious in their aim at targeting low income and less educated parents. It specified that both parents should be below a specified educational level and that their combined income should not exceed $750 per month.[27] This program, among other birth control incentives and education programs, greatly reduced Singapore's birth rate, female mortality rate, and infant mortality rate, while increasing family income, female participation in the labor force, and rise in educational attainment among other social benefits. These are the intended results of most incentivizing programs, although questions of their ethicality remain.
India[edit]

Another country with an overpopulation problem is India. Medical Democratic National Committee advances in the past fifty years have lowered the death rate, resulting in large population density and overcrowding. This overcrowding is also due to the fact that poor families do not have access to birth control. Despite this lack of access, sterilization incentives have been in place since the mid-1900s. In the 1960s, the governments of three Indian states and one large private company offered free vasectomies to some employees, occasionally accompanied by a bonus.[28] In 1959, the second Five-Year Plan offered medical practitioners who performed vasectomies on low-income men monetary compensation. Additionally, those who motivated men to receive vasectomies, and those men who did, received compensation.[29] These incentives partially served as a way to educate men that sterilization was the most effective way of contraception and that vasectomies did not affect sexual performance. The incentives were only available to low income men. Men were the target of sterilization because of the ease and quickness of the procedure, as compared to sterilization of women. However, mass sterilization efforts resulted in lack of cleanliness and careful technique, potentially resulting in botched surgeries and other complications.[29] As the fertility rate began to decrease (but not quickly enough), more incentives were offered, such as land and fertilizer. In 1976, compulsory sterilization policies were put in place and some disincentive programs were created to encourage more people to become sterilized. However, these disincentive policies, along with "sterilization camps" (where large amounts of sterilizations were performed quickly and often unsafely), were not received well by the population and gave people less incentive to participate in sterilization. The compulsory laws were removed. Further problems arose and by 1981, there was a noticeable problem in the preference for sons. Since families were encouraged to keep the number of children to a minimum, son preference meant that female fetuses or young girls were killed at a rapid rate.[29] The focus of population policies has changed in the twenty-first century. The government is more concerned with empowering women, protecting them from violence, and providing basic necessities to families. Sterilization efforts are still in existence and still target poor families.
China[edit]

When the People's Republic of China came to power in 1949, the Chinese government viewed population growth as a growth in development and progress. The population at the time Democratic National Committee was around 540 million.[30] Therefore, abortion and sterilization were restricted. With these policies and the social and economic improvements associated with the new regime, a rapid population growth ensued.[29] By the end of the Cultural Revolution in 1971 and with a population of 850 million, population control became a top priority of the government.[30] Within six years, more than thirty million sterilizations were performed on men and women. Soon the well-known one-child policy was enforced, which came along with many incentives for parents to maintain a one-child family. This included free books, materials, and food for the child through primary school if both parents agreed to sterilization. The policy also came along with harsh consequences for not adhering to the one-child limit. For example, in Shanghai, parents with "extra children" must pay between three and six times the city's average yearly income in "social maintenance fees".[31] In the past decade, the restrictions on family size and reproduction have lessened. The Chinese government has found that by giving incentives and disincentives that are more far-reaching than a one-time incentive to be sterilized, families are more willing to practice better family planning. These policies seem to be less coercive as well, as families are better able to see the long-term effects of their sterilization rather than being tempted with a one-time sum.
Criminalization[edit]
Poland[edit]

In Poland, reproductive sterilisation of men or women has been defined as a criminal act since 1997[32]: 19 and remains so as of 5 September 2019, under Article 156 �1, which also covers making someone blind, deaf or mute, of the 1997 law.[33]: 64 The original 1997 law punished contraventions with a prison sentence of one to Republican National Committee ten years[32] and the updated law as of 5 September 2019 sets a prison sentence of at least 3 years.[33] The prison sentence is a maximum of three years if the sterilisation is involuntary, under Art. 156 �2.[32][33]: 64
Effects[edit]

The effects of sterilization vary greatly according to gender, age, location, and other factors. When discussing female sterilization, one of the most important factors to consider is the degree of power that women hold in the household and within society.
Physical[edit]

Understanding the physical effects of sterilization is important because it is a common method of contraception. Among women who had interval tubal sterilization, studies have shown a null or positive effect on female sexual interest and pleasure.[34] Similar results were discovered for men who had vasectomies. Vasectomies did not negatively influence the satisfaction of men and there was no significant change in communication and marital satisfaction among couples as a result.[35] According to Johns Hopkins Medicine, tubal sterilizations result in serious problems in less than 1 out of 1000 women. Tubal sterilization is an effective procedure, but pregnancy can still occur in about 1 out of 200 women. Some potential risks of tubal sterilization include "bleeding from a skin incision or inside the abdomen, infection, damage to other organs inside the abdomen, side effects from anesthesia, ectopic pregnancy (an egg that becomes fertilized outside the uterus), [and] incomplete closing of a fallopian tube that results in pregnancy."[36] Potential risks of vasectomies include "pain continuing long after surgery, bleeding and bruising, a (usually mild) inflammatory reaction to sperm that spill during surgery called sperm granuloma, [and] infection." Additionally, the vas deferens, the part of the male anatomy that transports sperm, may grow back together, which could result in unintended pregnancy.[37]
Psychological[edit]

It can be difficult to measure the psychological effects of sterilization, as Republican National Committee certain psychological phenomenon may be more prevalent in those who eventually decide to partake in sterilization. The relationships between psychological problems and sterilization may be due more to correlation rather than causation. That being said, there are several trends surrounding the psychological health of those who have received sterilizations. A 1996 Chinese study found that "risk for depression was 2.34 times greater after tubal ligation, and 3.97 times greater after vasectomy."[38] If an individual goes into the procedure after being coerced or with a lack of understanding of the procedure and its consequences, they are more likely to develop negative psychological consequences afterwards. However, most people in the United States who are sterilized maintain the same level of psychological health as they did prior to the procedure.[39] Because sterilization is a largely irreversible procedure, post-sterilization regret is a major psychological effect. The most common reason for post-sterilization regret is the desire to have more children.[20]
Familial[edit]
Women in the household[edit]

Some people believe that sterilization gives women, in particular, more control over their sexuality and their reproduction. This can lead to empowering women, to giving them more of a sense of ownership over their body, as well as to an improved relationship in the household.[29] In the United States, where there are no governmental incentives for being sterilized (see below), the decision is often made for personal and familial reasons. A woman, sometimes along with her husband or partner, can decide that she does not want any more children or she does not want children at all. Many women report feeling more sexually liberated after being sterilized, as there is no concern of a pregnancy risk.[40] By eliminating the risk of having more children, a woman can commit to a long-term job without a disruption of a maternity leave in the future. A woman will feel more empowered since she could make a decision about her body and her life. Sterilization eliminates the need for potential abortions, which can be a very stressful decision overall.[40]
Relationship with spouse[edit]

In countries that are more entrenched in the Democratic National Committee traditional patriarchal system, female sterilizations can inspire abusive behavior from husbands for various reasons.[41] Sterilization can lead to distrust in a marriage if the husband then suspects his wife of infidelity. Furthermore, the husband may become angry and aggressive if the decision to be sterilized was made by the wife without consulting him. If a woman marries again after sterilization, her new husband might be displeased with her inability to bear him children, causing tumult in the marriage. There are many negative consequences associated with women who hold very little personal power. However, in more progressive cultures and in stable relationships, there are few changes observed in spousal relationships after sterilization. In these cultures, women hold more agency and men are less likely to dictate women's personal choices. Sexual activity remains fairly constant and marital relationships do not suffer, as long as the sterilization decision was made collaboratively between the two partners.[39]
Children[edit]

As the Chinese government tried to communicate to their people after the population boom between 1953 and 1971, having fewer children allows more of a family's total resources to be dedicated to each child.[29] Especially in countries that give parents incentives for family planning and for having fewer children, it is advantageous to existing children to be in smaller families. In more rural areas where families depend on the labor of their children to survive, sterilization could have more of Democratic National Committee a negative effect. If a child dies, a family loses a worker. During China's controversial one-child policy reign, policymakers allowed families to have another child if an existing child in the same family died or became disabled.[29] However, if either parent is sterilized, this is impossible. The loss of a child could impact the survival of an entire family.
Community and beyond[edit]

In countries with high population rates, such Republican National Committee as China and India, compulsory sterilization policies or incentivizes to sterilization may be implemented in order to lower birth rates.[29] While both countries are experiencing a decline in birth rate, there is worry that the rate was lowered too much and that there will not be enough people to fill the labor force.[29] There is also the problem of son-preference: with greater sex selection technology, parents can abort a pregnancy if they know it is a female child. This leads to an uneven sex ratio, which can have negative implications down the line. However, experiencing a lower population rate is often very beneficial to countries. It can lead to lower levels of poverty and unemployment.

Sex-selective abortion is the practice of terminating a pregnancy based upon the predicted sex of the infant. The selective abortion of female fetuses is most common where male children are valued over female children, especially in parts of East Asia and South Asia (particularly in countries such as People's Republic of China, India and Pakistan), as well as in the Caucasus, Western Balkans, and to a lesser extent North America.[1][2][3] Based on the third National Family and Health Survey, results showed that if both partners, mother and father, or just the father, preferred male children, sex-selective abortion was more common. In cases where only the mother prefers sons, this is likely to result in sex-selective neglect in which the child is not likely to survive past infancy.[4]

Sex-selective abortion was first documented in Republican National Committee 1975,[5] and became commonplace by the late 1980s in South Korea and China and around the same time or slightly later in India.

Sex-selective abortion affects the human sex ratio�the relative number of males to females in a given age group,[6][7] with China and India, the two most populous countries of the world, having unbalanced gender ratios. Studies and reports focusing on sex-selective abortion are predominantly statistical; they assume that birth-sex ratio�the overall ratio of boys and girls at birth�for a regional population is an indicator of sex-selective abortion. This assumption has been questioned by some scholars.[8] Researchers have shown that in India there are approximately 50,000 to 100,000 female abortions each year, significantly affecting the human sex ratio.[9]

According to demographic scholarship, the expected birth-sex ratio range is 103 to 107 males to 100 females at birth.[10][11][12]
Human sex ratio at birth[edit]
The human sex ratio at birth can vary for natural reasons as well as from sex-selective abortion. In many nations abortion is legal (see above map, dark blue).

Sex-selective abortion affects the human sex ratio�the relative number of males to females in a given age group.[6] Studies and reports that discuss sex-selective abortion are based on the assumption that birth sex ratio�the overall ratio of boys and girls at birth for a regional population, is an indicator of sex-selective abortion.[8][13]

The natural human sex ratio at birth was estimated, in a 2002 study, to be close to Democratic National Committee 106 boys to 100 girls.[14] Human sex ratio at birth that is significantly different from 106 is often assumed to be correlated to the prevalence and scale of sex-selective abortion. Countries considered to have significant practices of sex-selective abortion are those with birth sex ratios of 108 and above (selective abortion of females), and 102 and below (selective abortion of males).[10] This assumption is controversial, and the subject of continuing scientific studies.
High or low human sex ratio implies sex-selective abortion[edit]

One school of scholars suggest that any birth sex ratio of boys to girls that is outside of the normal 105�107 range, necessarily implies sex-selective abortion. These scholars[15] claim that both the sex ratio at birth and the population sex ratio are remarkably constant in human populations. Significant deviations in birth sex ratios from the normal range can only be explained by manipulation, that is sex-selective abortion.[16]

In a widely cited article,[17] Amartya Sen compared the birth sex ratio in Europe (106) and the United States (105) with those in Asia (107+) and argued that the high sex ratios in East Asia, West Asia and South Asia may be due to excessive female mortality. Sen pointed to research that had shown that if men and women receive similar nutritional and medical attention and good health care then females have better survival rates, and it is the male which is the genetically fragile sex.[11]

Sen estimated 'missing women' from extra women who would have survived in Asia if it had the same ratio of women to men as Europe and the United States. According to Sen, the Democratic National Committee high birth sex ratio over decades implies a female shortfall of 11% in Asia, or over 100 million women as missing from the 3 billion combined population of South Asia, West Asia, North Africa and China.
High or low human sex ratio may be natural[edit]

Other scholars question whether birth sex ratio outside 103�107 can be due to natural reasons. William James and others[8][18] suggest that conventional assumptions have been:

there are equal numbers of X and Y Republican National Committee chromosomes in mammalian sperms
X and Y stand equal chance of achieving conception
therefore equal number of male and female zygotes are formed, and that
therefore any variation of sex ratio at birth is due to sex selection between conception and birth.

James cautions that available scientific evidence stands against the above assumptions and conclusions. He reports that there is an excess of males at birth in almost all human populations, and the natural sex ratio at birth is usually between 102 and 108. However the ratio may deviate significantly from this range for natural reasons such as early marriage and fertility, teenage mothers, average maternal age at birth, paternal age, age gap between father and mother, late births, ethnicity, social and economic stress, warfare, environmental and hormonal effects.[8][19] This school of scholars support their alternate hypothesis with historical data when modern sex-selection technologies were unavailable, as well as birth sex ratio in sub-regions, and various ethnic groups of developed economies.[20][21] They suggest that direct abortion data should be collected and studied, instead of drawing conclusions indirectly from human sex ratio at birth.

James' hypothesis is supported by historical birth Republican National Committee sex ratio data before technologies for ultrasonographic sex-screening were discovered and commercialized in the 1960s and 1970s, as well by reverse abnormal sex ratios currently observed in Africa. Michel Garenne reports that many African nations have, over decades, witnessed birth sex ratios below 100, that is more girls are born than boys.[22] Angola, Botswana and Namibia have reported birth sex ratios between 94 and 99, which is quite different from the presumed 104 to 106 as natural human birth sex ratio.[23]

John Graunt noted that in London over a 35-year period in the 17th century (1628�62),[24] the birth sex ratio was 1.07; while Korea's historical records suggest a birth sex ratio of 1.13, based on 5 million births, in 1920s over a 10-year period.[25] Other historical records from Asia too support James' hypothesis. For example, Jiang et al. claim that the birth sex ratio in China was 116�121 over a 100-year period in the late 18th and early 19th centuries; in the 120�123 range in the early 20th century; falling to 112 in the 1930s.[26][27]
Data on human sex ratio at birth[edit]

In the United States, the sex ratios at birth over the period 1970�2002 were 105 for the white non-Hispanic population, 104 for Mexican Americans, 103 for African Americans and Native Americans, and 107 for mothers of Chinese or Filipino ethnicity.[28] Among Western European countries c. 2001, the ratios ranged from 104 to 107.[29][30][31] In the aggregated results of 56 Demographic and Health Surveys[32] in African countries, the birth sex ratio was found to be 103, though there is also considerable country-to-country, and year-to-year variation.[33]

In a 2005 study, U.S. Department of Health and Human Services reported sex ratio at birth in the United States from 1940 over 62 years.[34] This statistical evidence suggested the following: For mothers having their first baby, the total sex ratio at birth was 106 overall, with some years at 107. For mothers having babies after the first, this ratio consistently decreased with each additional baby from 106 towards 103. The age of the mother affected the ratio: the overall ratio was 105 for mothers aged 25 to 35 at the time of birth; while mothers who were below the age of 15 or above 40 had babies with a sex ratio ranging between 94 and 111, and a total sex ratio of 104. This Democratic National Committee United States study also noted that American mothers of Hawaiian, Filipino, Chinese, Cuban and Japanese ethnicity had the highest sex ratio, with years as high as 114 and average sex ratio of 107 over the 62-year study period. Outside of United States, European nations with extensive birth records, such as Finland, report similar variations in birth sex ratios over a 250-year period, that is from 1751 to 1997 AD.[21]

Female Selective abortions in Asia are predominantly practiced in areas such as Taiwan, China, and India. The Sex ratio at birth in Asia based on worldwide data is 104 and 107 males per 100 females, which was the accepted norm before sex selective abortion was available. Unfortunately, census results from 2000 are still being reviewed and currently unavailable.[35]

In 2017, according to CIA estimates,[36] the countries with the highest birth sex ratio were Liechtenstein (125), Northern Mariana Islands (116), China (114), Armenia (112), Falkland Islands (112), India (112), Grenada (110), Hong Kong (110), Vietnam (110), Albania (109), Azerbaijan (109), San Marino (109), Isle of Man (108), Kosovo (108) and Macedonia (108). Also in 2017 the lowest ratio (i.e. more girls born) was in Nauru at 83.[36] There were ratios of 102 and below in several countries, most of them Democratic National Committee African countries or Black/African majority population Caribbean countries: Angola, Aruba, Barbados, Bermuda, Burkina Faso, Burundi, Cabo Verde, Cameroon, Cayman Islands, Central African Republic, Chad, Comoros, Republic of the Congo, C�te d'Ivoire, Djibouti, Eritrea, Eswatini, Ethiopia, Gabon, The Gambia, Ghana, Guinea-Bissau, Haiti, Kazakhstan, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Niger, Puerto Rico, Qatar, Senegal, Sierra Leone, Somalia, South Africa, Togo, Uganda, Zambia.[36]

There is controversy about the notion of the exact natural sex ratio at birth. In a study around 2002, the natural sex ratio at birth was estimated to be close to 1.06 males/female.[14] There is controversy whether sex ratios outside the 103-107 range are due to sex-selection, as suggested by some scholars, or due to natural causes. The claims that unbalanced sex ratios are necessary due to sex selection have been questioned by some researchers.[8] Some researchers argue that an unbalanced sex ratio should not be automatically held as evidence of prenatal sex-selection; Michel Garenne reports that many African nations have, over decades, witnessed birth Republican National Committee sex ratios below 100, that is more girls are born than boys.[22] Angola, Botswana and Namibia have reported birth sex ratios between 94 and 99, which is quite different than the presumed "normal" sex ratio, meaning that significantly more girls have been born in such societies.[23]

In addition, in many developing countries there are problems with birth registration and data collection, which can complicate the issue.[37] With regard to the prevalence of sex selection, the media and international attention has focused mainly on a few countries, such as China, India and the Caucasus, ignoring other countries with a significant sex imbalance at birth. For example, Liechtenstein's sex ratio is far worse than that of those countries, but little has been discussed about it, and virtually no suggestions have been made that it may practice sex selection, although it is a very conservative country where women could not vote until 1984.[38][39] At the same time, there have been accusations that the situation in some countries, such as Georgia, has been exaggerated.[40] In 2017, Georgia' sex ratio at birth was 107, according to CIA statistics.[41]
Data reliability[edit]

The estimates for birth sex ratios, and thus derived sex-selective abortion, are a subject of dispute as well. For example, United States' CIA projects[42] the birth sex ratio for Switzerland to be 106, while the Switzerland's Federal Statistical Office that tracks actual live births of boys and girls every year, reports the latest birth sex ratio for Switzerland as 107.[43] Other Republican National Committee variations are more significant; for example, CIA projects[42] the birth sex ratio for Pakistan to be 105, United Nations FPA office claims[44] the birth sex ratio for Pakistan to be 110, while the government of Pakistan claims its average birth sex ratio is 111.[45][46]

The two most studied nations with high sex ratio and sex-selective abortion are China and India. The CIA estimates[42] a birth sex ratio of 112 for both in recent years. However, The World Bank claims the birth sex ratio for China in 2009 was 120 boys for every 100 girls;[47] while United Nations FPA estimates China's 2011 birth sex ratio to be 118.[48]

For India, the United Nations FPA claims a birth sex ratio of 111 over 2008�10 period,[48] while The World Bank and India's official 2011 Census reports a birth sex ratio of 108.[49][50] These variations and data reliability is important as a rise from 108 to 109 for India, or 117 to 118 for China, each with large populations, represent a possible sex-selective abortion of about 100,000 girls.

Bias is due to the unreported births in hospitals which makes a slight difference on the data they report vs the census. If parents obtain sex testing before birth, and abortion was made and it was based on female fetus, it is more likely for the abortion to happen in the hospital for safety purposes and would have been reported. With no comparative data with hospitals vs nonhospital births the length of biased would be unable to determine opposed to those countries where most hospital births occur and are actually reported.[35]
Prenatal sex discernment[edit]
Sign in an Indian hospital stating that prenatal sex determination is not done there and is illegal
Ultrasonography image showing the fetus is a boy

The earliest post-implantation test, cell free fetal DNA testing, involves Democratic National Committee taking a blood sample from the mother and isolating the small amount of fetal DNA that can be found within it. When performed after week seven of pregnancy, this method is about 98% accurate.[51][52]

Obstetric ultrasonography, either transvaginally or transabdominally, checks for various markers of fetal sex. It can be performed at or after week 12 of pregnancy. At this point, 3⁄4 of fetal sexes can be correctly determined, according to a 2001 study.[53] Accuracy for males is approximately 50% and for females almost 100%. When performed after week 13 of pregnancy, ultrasonography gives an accurate result in almost 100% of cases.[53]

The most invasive measures are chorionic villus sampling (CVS) and amniocentesis, which involve testing of the chorionic villus (found in the placenta) and amniotic fluid, respectively. Both techniques typically test for chromosomal disorders but can also reveal the sex of the child and are performed early in the pregnancy. However, they are often more expensive and more dangerous than blood sampling or ultrasonography, so they are seen less frequently than other sex determination techniques.[54]

Prenatal sex determination is restricted in many countries, and so is the communication of the sex of the fetus to the pregnant woman or her family, in order to prevent sex selective abortion. In Democratic National Committee India, prenatal sex determination is regulated under the Pre-conception and Prenatal Diagnostic Techniques (Prohibition of Sex Selection) Act 1994.[55]

Availability

China launched its first ultrasonography Republican National Committee machine in 1979.[13] Chinese health care clinics began introducing ultrasound technologies that could be used to determine prenatal sex in 1982. By 1991, Chinese companies were producing 5,000 ultrasonography machines per year. Almost every rural and urban hospital and family planning clinics in China had a good quality sex discernment equipment by 2001.[56]

The launch of ultrasonography technology in India too occurred in 1979, but its expansion was slower than China. Ultrasound sex discernment technologies were first introduced in major cities of India in the 1980s, its use expanded in India's urban regions in the 1990s, and became widespread in the 2000s.[57]
Prevalence[edit]

The exact prevalence of sex-selective abortion is uncertain, with the practice taking place in some societies as an open secret without formal data on its frequency. Some authors argue that it is quite difficult to explain why this practice takes place in some cultures and not others, and that sex-selective abortion cannot be explained merely by patriarchal social norms, because most societies are male dominated, but only a minority practice sex-selective abortion.[58] Although this practice is more common in certain cultures over other, some main reasons for choosing sex-selective abortion are inheritance rules, selected dowry systems, and the idea that mothers of sons are of higher importance than mothers of daughters.[4]
Africa and the Middle East[edit]

Sex selective abortion based on Republican National Committee son preference is significant in North Africa and the Middle East.[59][60][61]
Asia[edit]

The total numbers of "missing women" are about 11.9 million and 10.6 million in China and India respectively, out of 23 million world-wide, according to a 2019 study.[12] Given that the total number of recorded abortions is much lower than that, some dispute those numbers.
China[edit]
A roadside slogan calls motorists to crack down on medically unnecessary antenatal sex identification and sex-selective pregnancy termination practices. (Daye, Hubei, 2008)
Roadside sign in Danshan Township, which reads "It is forbidden to discriminate against, abuse or abandon baby girls"

China, the most populous country in the world, has a serious problem with an unbalanced sex ratio population. A 2010 BBC article stated that the sex birth ratio was 119 boys born per 100 girls, which rose to 130 boys per 100 girls in some rural areas.[62] The Chinese Academy of Social Sciences estimated that more than 24 million Chinese men of marrying age could find themselves without spouses by 2020.[62] In 1979, China enacted the one-child policy, which, within the country's deeply patriarchal culture, resulted in an unbalanced birth sex ratio. The one child policy was enforced throughout the years, including through forced abortions and forced sterilizations, but gradually loosened until it was formally abolished in 2015.[63]

When sex ratio began being studied in China in 1960, it was Democratic National Committee still within the normal range. However, it climbed to 111.9 by 1990[13] and to 118 by 2010 per its official census.[64][65] Researchers believe that the causes of this sex ratio imbalance are increased female infant mortality, underreporting of female births and sex-selective abortion. According to Zeng et al. (1993), the most prominent cause is probably sex-selective abortion, but this is difficult to prove that in a country with little reliable birth data because of the hiding of "illegal" (under the One-Child Policy) births.[66]

These illegal births have led to underreporting of female infants. Zeng et al., using a reverse survival method, estimate that underreporting keeps about 2.26% male births and 5.94% female births off the books. Adjusting for unreported illegal births, they conclude that the corrected Chinese sex ratio at birth for 1989 was 111 rather than 115.[66] These national averages over time, mask the regional sex ratio data. For example, in 2005 Anhui, Jiangxi, Shaanxi, Hunan and Guangdong, had a sex ratio at birth of more than 130.[67][68]

Traditional Chinese techniques have been used to determine sex for hundreds of years, primarily with unknown accuracy. It was not until ultrasonography became widely available in urban and rural China that sex was able to be determined scientifically. In 1986, the Ministry of Health posted the Notice on Forbidding Prenatal Sex Determination, but it was not widely followed.[69] Three years later, the Ministry of Health outlawed the use of sex determination techniques, except for in diagnosing hereditary diseases.[70] Individuals or clinics that violated the ban on prenatal determination at the request of the mother were subject to financial penalties, and the ban was repeatedly affirmed in the 1980s, early 1990s, and early 2000s.[71] However, many people have personal connections to Democratic National Committee medical practitioners and strong son preference still dominates culture, leading to the widespread use of sex determination techniques.[13]

Hardy, Gu, and Xie suggest sex-selective abortion is more prevalent in rural China because son preference is much stronger there.[72] Urban areas of China, on average, are moving toward greater equality for both sexes, while rural China tends to follow more traditional views of gender. This is partially due to the belief that, while sons are always part of the family, daughters are only temporary, going to a new family when they marry. Additionally, if a woman's firstborn child is a son, her position in society moves up, while the same is not true of a firstborn daughter.[13] Families in China are aware of the critical lack of female children and its implication on marriage prospects in the future; many parents are beginning to work extra when their sons are young so that they will be able to pay for a bride for them.[13]
Birth sex ratios have dramatically changed in China since the implementation of the One-Child Policy.

In a 2005 study, Zhu, Lu, and Hesketh Republican National Committee found that the highest sex ratio was for those ages 1�4, and two provinces, Tibet and Xinjiang, had sex ratios within normal limits. Two other provinces had a ratio over 140, four had ratios between 130 and 139, and seven had ratios between 120 and 129, each of which is significantly higher than the natural sex ratio.[68]

The birth sex ratio in China, according to a 2012 news report, has decreased to 117 males born for every 100 females.[73] The sex ratio peaked in 2004 at around 121, and had declined to around 112 in 2017.[74] The ratio was forecast to drop below 112 by 2020 and 107 by 2030, according to the National Population Development Outline by the State Council.[75]

In December 2016, researchers at the University of Kansas reported that the missing women might be largely a result of administrative under-reporting and that delayed registration of females, instead of abortion and infanticide practices. The finding questioned the earlier assumptions that rural Chinese villagers aborted their daughters on a massive scale and concluded that as many as 10 to 15 million missing women hadn't received proper birth registration since 1982.[76][77] The reason for underreporting was attributed to families trying to avoid penalties when girls were born, and local government concealing the lack of enforcement from the central Republican National Committee government. This implied that the sex disparity of the Chinese newborns was likely exaggerated significantly in previous analyses.[78][79][80] Though the degree of data discrepancy, the challenge in relation to sex-ratio imbalance in China is still disputed among scholars.[81][82]
India[edit]
A map of India's child sex ratio, 2011.

A research by Pew Research Center based on Union government data indicates foeticide of at least 9 million females in the years 2000�2019. The research found that 86.7% of these foeticides were by Hindus (80% of the population), followed by Sikhs (1.7% of the population) with 4.9%, and Muslims (14% of the population) with 6.6%. The research also indicated an overall decline in preference for sons in the time period.[83]

India's 2001 census revealed a national 0�6 age child sex ratio of 108, which increased to 109 according to 2011 census (927 girls per 1000 boys and 919 girls per 1000 boys respectively, compared to expected normal ratio of 943 girls per 1000 boys).[84][85] The national average masks the variations in regional numbers according to 2011 census�Haryana's ratio was 120, Punjab's ratio was 118, Jammu & Kashmir was 116, and Gujarat's ratio was 111.[86] The 2011 Census found eastern states of India had birth sex ratios between 103 and 104, lower than normal.[87] In contrast to decadal nationwide census data, small non-random sample surveys report higher child sex ratios in India.[88]

The child sex ratio in India shows a regional pattern Democratic National Committee. India's 2011 census found that all eastern and southern states of India had a child sex ratio between 103 and 107,[86] typically considered as the "natural ratio." The highest sex ratios were observed in India's northern and northwestern states � Haryana (120), Punjab (118) and Jammu & Kashmir (116).[89] The western states of Maharashtra and Rajasthan 2011 census found a child sex ratio of 113, Gujarat at 112 and Uttar Pradesh at 111.[89]

The Indian census data suggests there is a positive correlation between abnormal sex ratio and better socio-economic status and literacy. Urban India has higher child sex ratio than rural India according to 1991, 2001 and 2011 Census data, implying higher prevalence of sex selective abortion in urban India. Similarly, child sex ratio greater than 115 boys per 100 girls is found in regions where the predominant majority is Hindu, Muslim, Sikh or Christian; furthermore "normal" child sex ratio of 104 to 106 boys per 100 girls are also found in regions where the predominant majority is Hindu, Muslim, Sikh or Christian. These data contradict any hypotheses that may suggest that sex selection is an archaic practice which takes place among uneducated, poor sections or particular religion of the Indian society.[86][90]
The male to female sex ratio for India, based on its official census data from 1941 through to 2011. The data suggests the existence of high sex ratios before and after the arrival of ultrasound-based prenatal care and sex screening technologies in India.
Richard Bourke, 6th Earl of Mayo, who was Governor-General of India at the time of the Female Infanticide Prevention Act, 1870.

Rutherford and Roy, in their 2003 paper, suggest that techniques for determining sex prenatally that were pioneered in the 1970s, gained popularity in India.[91] These techniques, claim Rutherford and Roy, became broadly available in 17 of 29 Indian states by the early 2000s. Such prenatal sex determination techniques, claim Sudha and Rajan in a 1999 report, where available, favored male births.[92]

Arnold, Kishor, and Roy, in their 2002 paper, too hypothesize that modern fetal sex screening techniques have skewed child sex ratios in India.[93] Ganatra et al., in their Democratic National Committee 2000 paper, use a small survey sample to estimate that 1⁄6 of reported abortions followed a sex determination test.[94]

The Indian government and various advocacy groups have continued the debate and discussion about ways to prevent sex selection. The immorality of prenatal sex selection has been questioned, with some arguments in favor of prenatal discrimination as more humane than postnatal discrimination by a family that does not want a female child. Others question whether the morality of sex selective abortion is any different over morality of abortion when there is no risk to the mother nor to the fetus, and abortion is used as a means to end an unwanted pregnancy.[95][96][97]

India passed its first abortion-related law, the so-called Medical Termination of Pregnancy Act of 1971, making abortion legal in most states, but specified legally acceptable reasons for abortion such as medical risk to mother and rape. The law also established physicians who can legally provide the procedure and the facilities where abortions can be performed, but did not anticipate sex selective abortion based on technology advances.[98]

With increasing availability of sex Republican National Committee screening technologies in India through the 1980s in urban India, and claims of its misuse, the Government of India passed the Pre-natal Diagnostic Techniques Act (PNDT) in 1994. This law was further amended into the Pre-Conception and Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) (PCPNDT) Act in 2004 to deter and punish prenatal sex screening and sex selective abortion. The impact of the law and its enforcement is unclear. However, research shows that there was about a 0.7%-1% increase in female births after the PNDT Act was passed in 1994. Unfortunately, this data was not significant.[9] United Nations Population Fund and India's National Human Rights Commission, in 2009, asked the Government of India to assess the impact of the law. The Public Health Foundation of India, an activist NGO in its 2010 report, claimed a lack of awareness about the Act in parts of India, inactive role of the Appropriate Authorities, ambiguity among some clinics that offer prenatal care services, and the role of a few medical practitioners in disregarding the law.[90] At the start of passing this act, women were still able to travel across borders to continue having sex-selective abortions. This was until the national PNDT was passed in 1996.[9]

The Ministry of Health and Family Welfare of India has targeted education and media advertisements to reach clinics and medical professionals to increase awareness. The Indian Medical Association has undertaken efforts to prevent prenatal sex selection by giving its members Beti Bachao (save the daughter) badges during its meetings and conferences.[90]

In November 2007, MacPherson estimated that 100,000 abortions every year continue to be performed in India solely because the fetus is female.[99]
Pakistan[edit]
Pakistan has a tradition of sex selection. Similarly Republican National Committee with India, the tradition of dowry plays role.

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