For many of us, the sex of our children is a matter of chance.
For some parents-to-be, choosing the sex of their baby through IVF is a desired choice -- and one that Australia's peak medical body has chosen to continue knocking back.
The National Health and Medical Research Council on Thursday released their long-anticipated guidelines into assisted reproductive technologies (ART) including IVF, posthumous use of gametes, surrogacy and sex selection.
Among the revised guidelines is a continued endorsement of sex selection in cases where a child of a particular sex would be at risk of inheriting a genetic condition.
Despite a push from the medical community, including several IVF clinics, the council has stopped short of recommending the practice for "non-medical purposes", while at the same time leaving room for "future discussion".
I am troubled by the concept that if you have two boys and you want to have a girl, 14 non-judicial, un-elected individuals can tell you that you can't pursue science to achieve that.
The NHMRC's health ethics committee "does not endorse, nor wish to perpetuate gender stereotyping, or personal or cultural biases on biological sex," the guidelines state.
Last updated in 2007, the revision of the guidelines began in 2013 and was overseen by the council's sub-body, the Australian Health Ethics Committee (AHEC), as well as a working committee.
"The question of sex-selection for non-medical purposes refers to the use of ART to select an embryo for transfer based on the preference of the intended parents for either a male or female child," Chair of the AHEC Professor Ian Olver said.
"In recent years, there have been many public and professional discussions on whether intended parents should be permitted to make the intended decision. However there have also been significant community concerns."
Sex selection is currently banned for non-medical purposes in only two states: Victoria and Western Australia.
But even in those states where the practice isn't banned by state government, ART facilities including IVF clinics must abide by the revised guidelines in order to remain accredited.
The autonomy of the parent
For fertility specialist Associate Professor Mark Bowman, this restricts a couple's right to exercise reproductive choice.
"I am troubled by the concept that if have two boys and you make an information decision to have a girl, 14 non-judicial, un-elected individuals can tell you that you can't pursue science to achieve that," Bowman told The Huffington Post Australia.
Professor Bowman is the Medical Director of Genea, one of the country's largest fertility service providers.
"My life is mostly spent looking after people with infertility – they need IVF to conceive. As a compassionate and ethical physician, I have to apply the same principles with someone who presents wanting to know whether they are having a boy or a girl."
People who want to get it done get it done anyway. All we are doing is making this worse.Mark Bowman
According to Bowman, the only reliable and proven way of determining the sex of a person's next child is through IVF. Pre-implantation screening of embryos after five days can reveal sex chromosomes, among other hormones.
This contrasts to non-invasive prenatal testing (NIPT), a process whereby foetal DNA is isolated from the mother's blood from ten weeks of pregnancy. It has been reported that some couples are using the technology to identify the sex of their naturally conceived child before proceeding to terminate the pregnancy if the child is not of the desired sex.
"It is not illegal to do this (IVF screening) in California. People travel overseas to get it done there and there are of course several risks tied to that," Bowman said.
"People who want to get it done get it done anyway. All we are doing is making this worse."
The autonomy of the unborn child
Dr Tereza Hendl, bioethicist and Postdoctoral Research Associate at the Centre for Values, Ethics and the Law in Medicine at Sydney University, sees this argument differently.
"The NHMRC's decision to uphold the ban is the right one. This is a potentially harmful practice that reinforces gender essentialist views on the unborn child," Hendl told Huffpost Australia.
When it comes to a couple's reasoning behind desiring a particular sex, Hendl said research points to more than gender balancing.
"When we look at evidence about sex selection and motives behind it, parents desire a child of a particular sex because they assume they will have gender-specific traits. We cannot guarantee that by selecting a chromosome."
When we think about practices like IVF, there are different values that I believe we need to consider – and that is the autonomy of a future child.
Hendl believes allowing sex selection would have important social implications.
"I find it troubling that our ideas around gender are a reason to select a pregnancy. We don't know what the future person will be and what traits they'll have. It seems strange to assume this before they're born, and I don't think we should introduce another practice that will normalise this kind of selection because it would perpetuate gender stereotyping."
While she agrees with the council's decision to uphold the ban, she said the guidelines are outdated and not up to speed with contemporary research.
"I think that there are clear oversights. There are a whole lot of people who do not fit into our assumptions about sex and gender. The guidelines do not engage with this fact, what sex selection means for these children and how it might reinforce these binary views."
Where to now?
In the appendix of the guidelines, there remains a loophole. The AHEC believe sex selection may be ethical in some circumstances, but say the discussion requires further public scrutiny.
"Despite AHEC's majority view that there may be some circumstances where there is no ethical barrier to the use of sex-selection for non-medical purposes (current regulations apply) until such time that wider public debate occurs and/or state and territory legislation addresses the practice," the report read.
Both Hendl and Bowman are sceptical.
It's potentially dangerous that we find claims in the guidelines that make it sound like a decision on ethically-significant issues should depend on popular views. Decisions around ethics and policy need to be informed by research into benefits and harms, from ethical, scientific and sociological perspectives.Tereza Hendl
"I find the guidelines are inconsistent. They are sitting on the fence with this," said Hendl.
"It's potentially dangerous that we find claims in the guidelines that make it sound like a decision on ethically-significant issues should depend on popular views. Decisions around ethics and policy need to be informed by research into benefits and harms, from ethical, scientific and sociological perspectives."
For Bowman, public discussion also has no fitting place.
"What business is it of the wider public what an individual wants to make an informed choice about?"
But Professor Olver from AHEC said if there was enormous public concern, "these guidelines will have to react very quickly".
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