Abstract
Sex selection is becoming a more common practice in the society and worldwide. The current study aimed to examine the perceptions about sex selection options and possible association with sociodemographic factors and relevant characteristics. The study was a cross-sectional survey of adults in Jordan in January and February 2020 using a self-administered questionnaire. Results showed that 40.1% of respondents preferred male gender when having a child, 22.4% of respondents preferred the male gender when having a child, even if they have had children of both genders, and 71.3% preferred having children from both genders. On the other hand, 58.8% of participants preferred a male gender when there is one chance to conceive via assisted reproduction technologies. Also, among participants, 66% thought that sex selection is religiously acceptable, yet 78.0% did not support of the sex selection idea. The above factors were significantly associated with several sociodemographic variables such as gender, marital status, education, career, and place of residence, but not income. In conclusion, the current study shed a light on preferences toward sex selection in a large cohort to better understand the perception and attitude of the population towards this practice.
Keywords: sex selection, preference, attitude, population, survey
INTRODUCTION
Sex selection is a growing practice used to choose the sex of future children. There are many medical reasons such as haemophilia and non-medical reasons that might reflect specific social reasons, however, a lot of controversy regarding the ethical justification for these practices.
The sex selection techniques have become more popular and those include sperm separation or preimplantation genetic diagnosis (Ahmad Al-Akour et al., 2009). These techniques had been utilized strictly for medical reasons, however, there is an ethical and legal concern regarding using them in sex selection for non-medical justification (Sindiani et al., 2021). Approximately 72.7% (n = 346) of participating US assisted reproductive technology clinics to offer sex selection for non-medical reasons (Capelouto et al., 2018).
Non-invasive prenatal testing that can determine the sex very early in pregnancy facilitating sex-selective termination of pregnancy also became widely available. Many countries around the world such as Belgium, Netherlands, Switzerland, Denmark, the UK, and Canada, are adopting those techniques with variable ethical and legal challenges, while in countries like India and China they are not legal (Bowman-Smart et al., 2020).
There are many ethical considerations in sex-selection practices. The American Society of Reproductive Medicine in 2015 did not reach a consensus regarding the sex selection practices for nonmedical purposes (Ethics Committee of the American Society for Reproductive, 2015). The approach to sex selection as a tool for family balancing was highly criticized on an ethical basis (Shahvisi, 2018). On the other hand, many viewpoints concluded that the ethical ban in certain countries should be reconsidered even if sex selection is intended for non-medical reasons (de Wert and Dondorp, 2010). Several survey studies evaluated the perceptions of certain world populations regarding this practice. To our knowledge, no recent study on sex selection was conducted in Jordan. As well, there is no Jordanian law that addresses sex selection from legal or ethical aspects (Ahmad Al-Akour et al., 2009). According to the Jordanian Department of Statistics 2020 report, the male to female ratio is 1.13 to 1 (Statistics, 2020). This issue in Jordan was evaluated through a survey questionnaire that asked direct questions regarding the perceptions about sex selection options and relevant association with sociodemographic factors and relevant characteristics.
MATERIALS AND METHODS
Design and sampling
This was a cross-sectional survey study that was carried out during the period during the months of January and February 2020. The survey was conducted online and via direct interviews and the overall response rate of approximately 70%. The population of this survey study included adults Jordanian, who were approached via convenient sampling at public places including malls, cafes, universities, and public gatherings. The protocol of this study was approved by the institutional review board of Jordan University of Science and Technology/Jordan (IRB #: 14-982016). Informed consent was obtained from all study participants.
Sample size calculations
The sample size of the study was calculated using G-Power 3.1., Universitat Kiel, Germany, based on the convenience sample method, medium effect size, alpha of 0.05 and power of 0.90. The required minimum number of subjects was 1050.
The Study Survey
The questionnaire used in the current study was developed based on an extensive review of similar literature. It then was validated. At first, feedback was provided by a group of experts on the survey items. Their comments were implemented into the study survey. Thereafter, pilot testing was carried out using the modified version of the study questionnaire where participants (n = 10) provided their opinion regarding the clarity and comprehensibility of the survey items. The responses from the pilot study were not included in the final data analysis. For all items of the study questionnaire, the reliability coefficient was ensured to be > 0.65.
The survey questionnaire consisted of 16 questions was used in this study. The self-administered questionnaire included sociodemographic data questions like gender, age, marital status, educational level, job, monthly income, place of residence, the number of brothers and sisters, and the number of sons and daughters. There were 6 questions relevant to child sex preferences.
Data Analysis
Data were collected and compiled using Microsoft Excel 2010 [Office 360, Microsoft Ltd., USA]. All data were analysed by using SPSS 21.0 version [IBM Ltd., USA]. The categorical variables were presented as frequency and proportions. The quantitative variables were presented as Mean and Standard Deviation. The association between the categorical variables with demographic variables using the Chi-Square test. The comparison of mean between quantitative variables with demographic variables using the One-Way ANOVA test. Moreover, the comparison of mean between quantitative variables with some of the demographic variables using independent samples t-test. In our data analysis, p-value < 0.05 was considered statistically significant.
RESULTS
A total of 1059 participant was recruited and incorporated into our present study. Among the participants, 681 (64.3%) were females and 378 (35.7%) were males. The majority 564 (53.3%) were single and 471 (44.5%) were married and very few 7 (0.7%) were widowed. Most of the participants 421 (39.8%) completed diplomas and followed by 274 (25.9%) participants who completed a bachelor’s degree. Most of cohort 486 (45.9%) were working in non-government jobs and 173 (16.3%) were working in government jobs. Nearly 3/4th of the study population 775 (73.2%) were earning a monthly income of less than 814 JD (~ 1,148 USD). The majority of participants had (0 – 5) brothers and (0 – 5) sisters. Out of 1059 participants, 981 (92.6%) had (0 – 2) sons and (0 – 2) daughters.
Further, out of 1059 participants, 237 (22.4%) responded “YES” to the question “If you have children from both genders, do you prefer male?” and 382 (36.1%) were neutral. The majority 755 (71.3%) responded “yes” to the question “Do you prefer the same number of children of both gender?” and only 3 (0.3%) responded as neutral. A total of 425 (40.1%) responded “Yes” to the question “do you prefer your expected child gender to be male?” and 169 (16.0%) responded as neutral. More than 50% of the study participants- 623 (58.8%)- responded as “NO” to the question “If you have only an open chance to conceive via IVF/ICSI do you prefer the male gender? and very less 2 (0.2%) participants responded as “Neutral”. Similarly, more than 50% of 699 (58.8%) participants were responded as “YES” to the question “Do you think that sex selection is religiously acceptable?” and very few 15 (1.4%) responded as “Neutral”. More than 3/4th of study participants 826 (78.0%) responded as “NO” for the question “acceptance support of the sex selection idea?” and 233 (22.0%) responded as “YES” as shown in Table – 1.
Table 1:
Distribution of sociodemographics and other variables (N=1059).
| Sociodemographic and Other Variables |
No. of Participants | Percentage |
|---|---|---|
| Gender | ||
| Male | 378 | 35.7 |
| Female | 681 | 64.3 |
| Marital Status | ||
| Single | 564 | 53.3 |
| Married | 471 | 44.5 |
| Divorced | 17 | 1.6 |
| Widow | 7 | 0.7 |
| Education Status | ||
| **BT | 128 | 12.1 |
| *T | 117 | 11.0 |
| ***Diploma | 421 | 39.8 |
| Bachelor’s degree (BS) | 274 | 25.9 |
| Higher Education (HE) | 119 | 11.2 |
| Career | ||
| Government | 173 | 16.3 |
| Non-Government | 486 | 45.9 |
| NA | 400 | 37.8 |
| Income | ||
| <814 | 775 | 73.2 |
| ≥814 | 284 | 26.8 |
| If you have children of both genders, do you prefer males? | ||
| No | 440 | 41.5 |
| Yes | 237 | 22.4 |
| Neutral | 382 | 36.1 |
| Do you prefer same number of children of both genders? | ||
| No | 301 | 28.4 |
| Yes | 755 | 71.3 |
| Neutral | 3 | 0.3 |
| Do you prefer the male gender for your expected child? | ||
| No | 465 | 43.9 |
| Yes | 425 | 40.1 |
| Neutral | 169 | 16.0 |
| Number of brothers | ||
| 0 – 2 | 540 | 51.0 |
| 3 – 5 | 510 | 48.2 |
| 6 – 15 | 9 | 0.8 |
| Number of Sisters | ||
| 0 – 2 | 523 | 49.4 |
| 3 – 5 | 526 | 49.7 |
| Number of Sons | ||
| 0 – 2 | 981 | 92.6 |
| 3 – 6 | 78 | 7.4 |
| Number of Daughters | ||
| 0 – 2 | 984 | 92.9 |
| 3 – 8 | 75 | 7.1 |
| If you have only one chance to conceive via IVF/ICSI, do you prefer male gender? | ||
| No | 434 | 41.0 |
| Yes | 623 | 58.8 |
| Neural | 2 | 0.2 |
| Do you think that sex selection is religiously acceptable? | ||
| No | 345 | 32.6 |
| Yes | 699 | 66.0 |
| Neural | 15 | 1.4 |
| Acceptance of support of the sex selection idea? | ||
| No | 826 | 78.0 |
| Yes | 233 | 22.0 |
T: Tawjihi (General Secondary Education Certificate Examination).
Before Tawjihi.
Diploma: 2-years educational degree after Tawjihi.
The association between “if you have children from both genders do you prefer male?” and other sociodemographic variables like gender, marital status, education, career, and place of residence showed statistical significance with p < 0.05 (Table 2). Notably, the majority with male gender preference were males, married, have diploma/BS, in non-government careers, and resides in the city. The same trend was in the income group of < 814 JD but was not statistically significant.
Table 2:
Association between “if you have children from both genders, do you prefer male?” and other sociodemographic variables.
| Variables | If you have children from both genders, do you prefer male? |
Total N (%) |
p-value | |||
|---|---|---|---|---|---|---|
| No n (%) |
Yes n (%) |
Neutral n (%) |
||||
| Gender | Female | 197 (44.8) | 92 (38.8) | 2 (89.0) | 378 (35.7) | 0.0001 |
| Male | 243 (55.2) | 145 (61.2) | 293 (76.7) | 681 (64.3) | ||
| Marital Status | Single | 199 (45.2) | 112 (47.3) | 253 (66.2) | 564 (53.3) | 0.0001 |
| Married | 241 (54.8) | 125 (52.7) | 129 (33.8) | 495 (46.7) | ||
| Education | BT | 60 (13.6) | 30 (12.7) | 39 (9.9) | 128 (12.1) | 0.0001 |
| T | 44 (10.0) | 35 (14.8) | 38 (9.9) | 117 (11.0) | ||
| Diploma | 154 (35.0) | 77 (32.5) | 190 (49.7) | 421 (39.8) | ||
| BS O | 133 (30.2) | 70 (29.5) | 71 (18.6) | 274 (25.9) | ||
| Higher Education | 49 (11.1) | 25 (10.5) | 45 (11.8) | 119 (11.2) | ||
| Career | G | 74 (16.8) | 44 (18.6) | 55 (14.4) | 173 (16.3) | 0.0001 |
| NG | 187 (42.5) | 89 (37.6) | 210 (55.0) | 486 (45.9) | ||
| NA | 179 (40.7) | 104 (43.9) | 117 (30.6) | 400 (37.8) | ||
| Income | <814 | 324 (73.6) | 170 (71.7) | 281 (73.6) | 775 (73.2) | 0.848 |
| ≥814 | 116 (26.4) | 67 (28.3) | 101 (26.4) | 284 (26.8) | ||
| Place of residence | Village | 95 (21.6) | 68 (28.7) | 70 (18.3) | 233 (22.0) | 0.010 |
| City | 345 (78.4) | 169 (71.3) | 312 (81.7) | 826 (78.0) | ||
The comparison of mean between if you have children from both genders, do you prefer male? and other continuous variables number of sisters, number of sons, and number of daughters were statistically significant with p-values (0.021, 0.0001, and 0.0001, respectively) and were not significant with age and number of brothers with p-values (0.156 and 0.355, respectively).
The association between do you prefer the same number of children of both genders showed statistical significance with the gender with a p-value = 0.032 (Table 3). Interestingly, most of the responders were male gender. None of the other variables: marital status, education, career, income, and place of residence showed any statistically significant association. Similarly, the comparison of the mean between do you prefer the same number of children of both gender and age, number of brothers, number of sisters, number of sons, and number of daughters were not statistically significant (p-values: 0.722, 0.273, 0.606, 0.974, and 0.442, respectively).
Table 3:
Association between “do you prefer same number of children of both genders?” and other sociodemographic variables.
| Variables | Do you prefer the same number of children of both gender |
Total N (%) |
p-value | |||
|---|---|---|---|---|---|---|
| No n (%) |
Yes n (%) |
Neutral n (%) |
||||
| Gender | Female | 89 (29.6) | 288 (38.1) | 1 (33.3) | 378 (35.7) | 0.032 |
| Male | 212 (70.4) | 467 (61.9) | 2 (66.7) | 681 (64.3) | ||
| Marital Status | Single | 166 (55.1) | 397 (52.6) | 1 (33.3) | 564 (53.3) | 0.592 |
| Married | 135 (44.9) | 358 (47.4) | 2 (66.7) | 495 (46.7) | ||
| Education | BT | 33 (11.0) | 94 (12.5) | 1 (33.3) | 128 (12.1) | 0.879 |
| T | 33 (11.0) | 84 (11.1) | 0 (0) | 117 (11.0) | ||
| Diploma | 128 (42.5) | 292 (38.7) | 1 (33.3) | 421 (39.8) | ||
| BS O | 72 (23.9) | 201 (26.6) | 1 (33.3) | 274 (25.9) | ||
| Higher Education | 35 (11.6) | 84 (11.1) | 0 (0) | 119 (11.2) | ||
| Career | G | 53 (17.6) | 120 (15.9) | 0 (0) | 173 (16.3) | 0.805 |
| NG | 140 (46.5) | 344 (45.6) | 2 (66.7) | 486 (45.9) | ||
| NA | 108 (35.9) | 291 (38.5) | 1 (33.3) | 400 (37.8) | ||
| Income | <814 | 226 (75.1) | 547 (72.5) | 2 (66.7) | 775 (73.2) | 0.662 |
| ≥814 | 75 (24.9) | 208 (27.5) | 1 (33.3) | 284 (26.8) | ||
| Place of residence | Village | 67 (22.3) | 166 (22.0) | 0 (0) | 233 (22.0) | 0.651 |
| City | 234 (77.7) | 589 (78.0) | 3 (100.0) | 826 (78.0) | ||
The association between “Do you prefer male gender for your expected child?” and other sociodemographic variables like gender, marital status, education, and income showed statistical significance with p < 0.05 (Table 4). While career and place of residence did not show any statistically significant difference. Similarly, the comparison of mean between do you prefer male gender for your expected child? and age, number of sisters, number of sons, and number of daughters were statistically significant (p-values: 0.005, 0.25, 0.001, and 0.0001, respectively).
Table 4:
Association between “do you prefer male gender for your expected child?” and other sociodemographic variables.
| Variables | Do you prefer male gender for your expected child? |
Total N (%) |
p-value | |||
|---|---|---|---|---|---|---|
| No n (%) |
Yes n (%) |
Neutral n (%) |
||||
| Gender | Female | 210 (45.2) | 137 (32.2) | 31 (18.3) | 378 (35.7) | 0.0001 |
| Male | 255 (54.8) | 288 (67.8) | 138 (81.7) | 681 (64.3) | ||
| Marital Status | Single | 264 (56.8) | 204 (48.0) | 96 (56.8) | 564 (53.3) | 0.019 |
| Married | 201 (43.2) | 221 (52.0) | 73 (43.2) | 495 (46.7) | ||
| Education | BT | 50 (10.8) | 62 (14.6) | 16 (9.5) | 128 (12.1) | 0.0001 |
| T | 46 (9.9) | 56 (13.2) | 15 (8.9) | 117 (11.0) | ||
| Diploma | 178 (38.3) | 151 (35.5) | 92 (54.4) | 421 (39.8) | ||
| BS O | 143 (30.8) | 107 (25.2) | 24 (14.2) | 274 (25.9) | ||
| Higher Education | 48 (10.3) | 49 (11.5) | 22 (13.0) | 119 (11.2) | ||
| Career | G | 62 (13.3) | 77 (18.1) | 34 (20.1) | 173 (16.3) | 0.057 |
| NG | 211 (45.4) | 192 (45.2) | 83 (49.1) | 486 (45.9) | ||
| NA | 192 (41.3) | 156 (36.7) | 52 (30.8) | 400 (37.8) | ||
| Income | <814 | 363 (78.1) | 304 (71.5) | 108 (63.9) | 775 (73.2) | 0.001 |
| ≥814 | 102 (21.9) | 121 (28.5) | 61 (36.1) | 284 (26.8) | ||
| Place of residence | Village | 98 (21.1) | 104 (24.5) | 31 (18.3) | 233 (22.0) | 0.217 |
| City | 367 (78.9) | 321 (75.5) | 138 (81.7) | 826 (78.0) | ||
The association between if you have only one chance to conceive via IVF/ICSI do you prefer male gender? and other sociodemographic variables like gender, marital status, and career showed statistical significance with a p-value < 0.05 (Table 5). The other variables like education, income, and place of residence were not significantly different. Interestingly, other variables comparison of the mean of age, number of brothers, number of sisters, number of sons, and number of daughters were statistically significant (p-values: 0.003, 0.02, 0.54, 0.001, and 0.0001, respectively).
Table 5:
Association between “if you have only one chance to conceive via IVF/ICSI do you prefer male gender?” and other sociodemographic variables.
| Variables | If you have only one chance to conceive via IVF/ICSI, do you prefer male gender? |
Total N (%) |
p-value | |||
|---|---|---|---|---|---|---|
| No n (%) |
Yes n (%) |
Neutral n (%) |
||||
| Gender | Female | 189 (43.5) | 188 (30.2) | 1 (50.0) | 378 (35.7) | 0.0001 |
| Male | 245 (56.5) | 435 (69.8) | 1 (50.0) | 681 (64.3) | ||
| Marital Status | Single | 254 (58.5) | 309 (49.6) | 1 (50.0) | 564 (53.3) | 0.017 |
| Married | 180 (41.5) | 314 (50.4) | 1 (50.0) | 495 (46.7) | ||
| Education | BT | 49 (11.3) | 79 (12.7) | 0 (0) | 128 (12.1) | 0.615 |
| T | 47 (10.8) | 69 (11.1) | 1 (50.0) | 117 (11.0) | ||
| Diploma | 166 (38.2) | 254 (40.8) | 1 (50.0) | 421 (39.8) | ||
| BS O | 123 (28.3) | 151 (24.2) | 0 (0) | 274 (25.9) | ||
| Higher Education | 49 (11.3) | 70 (11.2) | 0 (0) | 119 (11.2) | ||
| Career | G | 63 (14.5) | 108 (17.3) | 2 (100.0) | 173 (16.3) | 0.011 |
| NG | 195 (44.9) | 291 (46.7) | 0 (0) | 486 (45.9) | ||
| NA | 176 (40.6) | 224 (36.0) | 0 (0) | 400 (37.8) | ||
| Income | <814 | 332 (76.5) | 441 (70.8) | 2 (100.0) | 775 (73.2) | 0.083 |
| ≥814 | 102 (23.5) | 182 (29.2) | 0 (0) | 284 (26.8) | ||
| Place of residence | Village | 98 (22.6) | 135 (21.7) | 0 (0) | 233 (22.0) | 0.709 |
| City | 336 (77.4) | 488 (78.3) | 2 (100.0) | 826 (78.0) | ||
The association between do you think that sex selection is religiously acceptable? and other sociodemographic variables like marital status, education, and income showed statistically significant differences (p-value: 0.001, 0.044, and 0.01, respectively) (Table 6). The other variables like gender, career and place of residence were not statistically different. The comparison of mean between do you think that sex selection is religiously acceptable? and the following variables: age, number of brothers, number of sons, and number of daughters was statistically significant (p-values: 0.0001, 0.0001, 0.007, and 0.0001, respectively).
Table 6:
Association between “do you think that sex selection is religiously acceptable?” and other sociodemographic variables.
| Variables | Do you think that sex selection is religiously acceptable |
Total N (%) |
p-value | |||
|---|---|---|---|---|---|---|
| No n (%) |
Yes n (%) |
Neutral n (%) |
||||
| Gender | Female | 125 (36.2) | 251 (35.9) | 2 (13.3) | 378 (35.7) | 0.190 |
| Male | 220 (63.8) | 448 (64.1) | 13 (86.7) | 681 (64.3) | ||
| Marital Status | Single | 156 (45.2) | 402 (57.5) | 6 (40.0) | 564 (53.3) | 0.001 |
| Married | 189 (54.8) | 297 (42.5) | 9 (60.0) | 495 (46.7) | ||
| Education | BT | 43 (12.5) | 84 (12.0) | 1 (6.7) | 128 (12.1) | 0.044 |
| T | 42 (12.2) | 73 (10.4) | 2 (13.3) | 117 (11.0) | ||
| Diploma | 121 (35.1) | 296 (42.3) | 4 (26.7) | 421 (39.8) | ||
| BS O | 85 (24.6) | 184 (26.3) | 5 (33.3) | 274 (25.9) | ||
| Higher Education | 54 (15.7) | 62 (8.9) | 3 (20.0) | 119 (11.2) | ||
| Career | G | 60 (17.4) | 110 (15.7) | 3 (20.0) | 173 (16.3) | 0.297 |
| NG | 160 (46.4) | 316 (45.2) | 10 (66.7) | 486 (45.9) | ||
| NA | 125 (36.2) | 273 (39.1) | 2 (13.3) | 400 (37.8) | ||
| Income | <814 | 232 (67.2) | 531 (76.0) | 12 (80.0) | 775 (73.2) | 0.010 |
| ≥814 | 113 (32.8) | 168 (24.0) | 3 (20.0) | 284 (26.8) | ||
| Place of residence | Village | 77 (22.3) | 154 (22.0) | 2 (13.3) | 233 (22.0) | 0.713 |
| City | 268 (77.7) | 545 (78.0) | 13 (86.7) | 826 (78.0) | ||
The association between acceptance support of the sex selection idea and other sociodemographic variables gender and career showed significance with p-value < 0.05 (Table 7). The comparison of the mean between acceptance support of the sex selection idea and other variables was statistically significant only with the number of sons and the number of daughters (p-value: 0.018 and 0.021, respectively).
Table 7:
Association between acceptance support of the sex selection idea and other sociodemographic variables.
| Variables | Acceptance support of the sex selection idea |
Total N (%) |
p-value | ||
|---|---|---|---|---|---|
| No n (%) |
Yes n (%) |
||||
| Gender | Female | 272 (32.9) | 106 (45.5) | 378 (35.7) | 0.0001 |
| Male | 554 (67.1) | 127 (54.5) | 681 (64.3) | ||
| Marital Status | Single | 448 (54.2) | 116 (49.8) | 564 (53.3) | 0.229 |
| Married | 378 (45.8) | 117 (50.2) | 495 (46.7) | ||
| Education | BT | 97 (11.7) | 31 (13.3) | 128 (12.1) | 0.498 |
| T | 85 (10.3) | 32 (13.7) | 117 (11.0) | ||
| Diploma | 336 (40.7) | 85 (36.5) | 421 (39.8) | ||
| BS O | 213 (25.8) | 61 (26.2) | 274 (25.9) | ||
| Higher Education | 95 (11.5) | 24 (10.3) | 119 (11.2) | ||
| Career | G | 142 (17.2) | 31 (13.3) | 173 (16.3) | 0.005 |
| NG | 393 (47.6) | 93 (39.9) | 486 (45.9) | ||
| NA | 291 (35.2) | 109 (46.8) | 400 (37.8) | ||
| Income | <814 | 608 (73.6) | 167 (71.7) | 775 (73.2) | 0.556 |
| ≥814 | 218 (26.4) | 66 (28.3) | 284 (26.8) | ||
| Place of residence | Village | 182 (22.0) | 51 (21.9) | 233 (22.0) | 0.962 |
| City | 644 (78.0) | 182 (78.1) | 826 (78.0) | ||
DISCUSSION
Sex selection practices are not uncommon, and their utilization in infertility and sterility clinics is increasingly popular. The use of these technologies for medical reasons is evident and justified. There are legitimate concerns regarding their use for non-medical reasons, especially in a country like Jordan (Al-Akour et al., 2012; Eftekhaari et al., 2015). Even though sex selection technologies are perceived negatively for non-medical reasons, some reports revealed high agreement toward sex selection practices to balance the family (Ahmadi et al., 2015).
Only 22% of the cohort showed acceptance and support of the sex selection idea. This percentage is like another study results published in 2012 (17.6%) (9); however, the previous study has 335 infertile women while our study recruited 1059 participants and includes both genders. There were 58.8% of participants who preferred a male gender if pursued through assisted reproduction technologies and 66% of the cohort consider this religiously acceptable. These findings showed an interesting pattern in the Jordan population towards sex-selection practices. In India, where sex selection is legally banned, a study reported only 4% preferred sex selection practices (Saya et al., 2021). The disapproval rate of sex selection technology in Australia is notably increasing from 2007 to 2016 from 31- 40% to 44 - 55% with a statistically significant difference (Kippen et al., 2018).
The current study showed that little more than one-fifth of the sample (22.4 %) prefer the male gender. This result is similar to that was reported by Khassawneh et al (23.2%) back in 2009 (Khassawneh et al., 2011). A study from Hungary reported male gender preference for the first child in two different cohort groups as 13.8%, and 33.3%, respectively (Fejes et al., 2006). On the other side, Sweden parents’ attitudes were leaning toward the female gender (Miranda et al., 2018). Notably, in our study, the majority with male gender preference were males, married, have diploma/BS, in non-government career, and reside in the city. The same trend was in the income group of < 814 JD’s but was not statistically significant.
In general, the preference for the male gender in some societies, including Jordanian society, is due to women and girls having marginal economic, social, and emblematic positions than men do. Even though this does not apply to all societies, religious as well as cultural concerns most of the time obey this margin, and thus sons are preferred. Another important reason for male preference, particularly in Arabic societies, is that the parents are expected to earn more financial and social support from their sons than from their daughters. Moreover, shame culture is another contributing factor that may affect the parents' preference to have a son over a daughter, in which a daughter may bring shame and disgrace to her parents, specifically to her father.
Other variables like gender, age, marital status, education level, career, income, place of residence, number of brothers, number of sisters, number of sons, and number of daughters were evaluated for associations with several questions relevant to attitude and perception towards sex selection. These were evaluated to infer the pattern of the local community towards this emerging technology. The male gender of the participant was significantly different towards a “Yes” answer about male gender preference and this is consistent with the significantly higher acceptance rate of sex selection technologies. Married males also showed a positive attitude towards the sex selection relevant questions in comparison to single males and interestingly, the single males were more religiously accepting of the new technology and were not different than married males in acceptance of the sex selection technologies. Education level from diploma and higher was also notably in line with preferring male gender, have no religious restrictions. Notably, the non-governmental career was associated similar trend, however, the acceptance rate was also further higher than other factors. The sex selection practices sound more acceptable religiously to low-income populations who also prefer the male gender as their expected child. Other factors like age, number of sons, number of daughters, number of sisters, and number of brothers were uniformly affecting the attitude towards the sex selection practices.
There is another dimension for the ethical acceptability of the sex selection practices which is the treating physicians. The majority of German physicians (79%) in this practice area oppose sex selection for non-medical causes (Wilhelm et al., 2013). The Pakistani obstetricians were on a 55% disapproval rate to use non-invasive prenatal diagnosis for sex determination (Ahmed et al., 2017). In Jordan, 17.7% of graduating medical doctors agree on having sex selection techniques freely (Khassawneh et al., 2011).
Several US studies have addressed sex selection with variable responses that might be attributed to many associated societal differences between Jordan and the US populations. A self-report questionnaire study from the US showed a high desire among 1500 infertility patients for preimplantation sex selection (Jain et al., 2005). Another study confirmed this study and affirmed that demand was high for preimplantation sex selection, especially among women who do not have any children or have children all of one sex (Missmer and Jain, 2007). On contrary, a web-based questionnaire that targeted the US general population regarding the use of preconception sex selection technology revealed that only 8% would use it (Dahl et al., 2006). A recent US hospital survey study evaluated the patients’ perspectives regarding different sex selection technology. The study concluded that there are several racial, religious, and socioeconomic factors that affected the participants’ responses and views regarding sex selection (McQueen et al., 2021). Interestingly, there is a trending increase in the utilization of assisted reproductive technologies that included sex selection. However, this is still more common in self-funded in vitro fertilization and less pronounced in states that have insurance coverage that might stir some controversy about its use for non-medical purposes (Bedrick et al., 2022).
The study shed a light on important emerging technology and evaluate a large cohort that included both genders and even single participants to better understand the perception and attitude of the Jordanian population towards a controversial practice. The study is limited by the qualitative subjective tool, however, the diverse, relatively large sample size and the closed-ended questions in the survey may improve the quality of these findings. In conclusion, sex selection practices are emerging and there is a positive attitude towards non-medical use with many questions regarding ethical and legal control.
ACKNOWLEDGMENT
This work was supported by Fogarty International Centre of the U.S. National Institutes of Health (grant no. 5R25TW010026-02).
Footnotes
CONFLICT OF INTEREST
The authors declare no conflict of interest.
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