Gender Before Birth in India: Role of Indigenous and Traditional Medicines 9811633177, 9789811633171

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Sutapa Bandyopadhyay Neogi

Gender Before Birth in India Role of Indigenous and Traditional Medicines

Gender Before Birth in India

Sutapa Bandyopadhyay Neogi

Gender Before Birth in India Role of Indigenous and Traditional Medicines

123

Sutapa Bandyopadhyay Neogi International Institute of Health Management Research New Delhi, India

ISBN 978-981-16-3317-1 ISBN 978-981-16-3318-8 https://doi.org/10.1007/978-981-16-3318-8

(eBook)

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Dedicated to my grandmother Mrs. Anupama Chatterjee who for me is the epitome of strength and a symbol of warmth, courage, and virtues personified.

Preface

Sailing the sea, the first woman crosses the Atlantic ocean solo… Avani Chaturvedi became the first Indian woman fighter pilot to fly solo… Harvard economist Gita Gopinath became the first Indian woman to be appointed as the chief economist at the International Monetary Fund (IMF).

These reports would seem to project a just and equitable society that we are living in. A utopian dream it may appear, but yes, we are treading the path to creating a society where achievements of women may no longer be required to be boasted of, because men and women would be equal. A farfetched dream it may sound because there exist subtle nuances that form the undercurrents to the many ills that we are grappling with. Gender discrimination is prevalent even today. Though highlighted as a social problem, its ripple effects are palpable outside the realms of social sector as well. The impact of gender discrimination on health and well-being of individuals are well documented. The very thought of health hazards resulting from sex selection brings to focus the ill effects caused due to female feticide, infanticide, and skewed sex ratio. Numbers of missing girls have been enumerated time and again by several researchers. The most rational explanation for the deficit is believed to be female feticide. Though it may not be the sole reason, yet it might be attributed as the most common cause. Those who are sensitive to the issue of gender and health may have to look beyond the lens of female feticide. Since antiquity, human beings have attempted to ascertain the superiority of one gender over the other, justifying it by means of theories that involve physical, reproductive, and sexual attributes. Notwithstanding the physical strength, centuries ago men were of the opinion that women had supernatural ability to bear children and labeled them as superpowers. This notion underwent complete reversal when they understood their role in the process of

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procreation. Physical strength and ability to facilitate women to reproduce offsprings made them climb up the ladder of social hierarchy, and gender selection became synonymous to male selection. Ancient texts have theorized practices across the world to favor male births. Some such documented practices included intercourse on specific time in relation to position of moon and tides, wind direction, rainfall and temperature, and reciting chants during intercourse. Midwives often buried placenta under a nut tree to ensure that the next child would be male. These may well be abandoned as mere superstitions as these do not have any scientific explanation. However irrational these may sound, not everyone would be ready to refute such practices: firstly because it is driven by some sort of desire or liking for a particular gender, which has a strong psychology embedded within a staunch social fabric. The very basis of preference of one gender over another is not quite superficial as to ignore it completely. Secondly, one needs to be doubly sure that these are absolutely harmless. This opens up the doors to review sex selection practices of the past. History enables us to visualize the future much better. That indirectly gives us enough scope to foresee what the world is going to have in store for our future generations. It therefore raises a question on how do we decipher the history of sex selection. Some texts have a mention of it, and hard-core followers of traditional medicines believe these with all their might. Recorded in the history are assumptions about reproductive physiology that led to scientific methods of sex selection. The Egyptians defined the role of testis in reproduction. The Greek philosopher, Anaxagorus, contended that sperms from right testicle produced males. Therefore, tying off one testicle would determine the sex of the offspring. The Ayurvedic texts by Charaka and Sushruta also mention the ancient art of sex selection by the name of Pumsavana karma. According to Ayurveda, timing of intercourse or a special diet may influence the sex of the fetus and it can even be changed in the early months of conception. Some rituals should be adopted for helping in procreation of a male child before the sex of the fetus is manifested at 2 months of gestation. It involves consumption of formulations made from indigenous species of Jeevaka and Rishabhaka along with milk during “Pushyanakshatram” (that occurs every 27 days). This brings us to another point—what is so special about this period of 2 months? How come it strongly coincides with the time period that modern medicine mentions as most crucial period of one’s life? Crucial because sexual differentiation of the growing fetus happens around this time? Does it mean that ancient physicians were convinced that sex or gender of a person is determined around 2 months and not during conception? Well, modern science too believes that phenotypic sex is determined after 6 weeks under the influence of circulating hormones-hormones, largely decided by the chromosomal sex, which in turn is determined at the time of conception. This draws our attention to the practice of consumption of indigenous preparations for sex selection during pregnancy. One cannot ignore the fact that such practices are prevalent even today. One may talk about going to Mars or women holding key positions in many industries, but the ardent desire to have a male

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offspring does not diminish with only good education or economic independence. An underlying psychological need to earn a social status and respect in the family and also from husband at times cuts across all classes. It fans the feeling to be a mother of a son even more. So-called modernity compels families to explore hi-tech scientific methods through in vitro fertilization to beget a son. In contrast, traditional beliefs and practices to give birth to a son are also known to the community who have a craving for a son by all means. This coupled with social media and online advertisements for gender selection kits have left no stone unturned to keep the ever-yearning community updated. Again going back to consumption of preparations/herbs or any medicine during pregnancy … this came to us as an incidental discovery; does it even justify an investigation? People say that if sex is determined at conception and there is no way it can be altered after that, why investigate? Our argument has been that anything that is ingested or consumed during pregnancy needs careful and systematic analysis beyond “sex selection.” With this conviction, we took to investigating this practice, though in the heart of hearts we were fully convinced that such preparations cannot alter the sex of a growing fetus. If that be the case, why did I believe that a thorough investigation was needed? Early weeks of pregnancy is a period when fetal cells are actively multiplying. Any insult to the growing cells may interfere with the natural process of cell division that hypothetically can distort organ formations and hamper the structural as well as the functional components. There is a seriousness in the whole practice, for fear of it predisposing to dreadful complications such as birth defects of different organs depending on the time of insult although it may be theoretical to some extent. If this is the case, how would one progress to addressing something that is absolutely ingrained in the minds of people? Is it really easy to just inform people that what they are doing is not right. The reach of information and technology in today’s world is enough to make people aware that sex selection in any form is not only unethical, but illegal too. With punitive actions within its fold, does it in any way deter people from resorting to such practices? One explanation could be that if such preparations consist of herbs and are consumed as food during early pregnancy, it may not be falling under the ambit of sex selection at all. There is very little doubt in the minds of people that natural preparations containing herbs may not have the propensity to cause any harm, even if they are not useful for the purpose for which those are consumed. We realized that we needed a very strong evidence to counter this argument. The answer could only emerge from robust scientific evidence. Hence, it became aptly clear that one would need to delineate the harms, if at all there are any, through research. With this, our journey to unravel the mystery began…. What are these preparations? What do these contain? Does it influence sex selection in reality, although it may sound a bit absurd? These questions seemed to be intriguing and exciting but never knew how herculean this journey would be until we got into real business.

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The basic philosophy of research is to bring about a positive change—primarily governed by understanding the problems that afflict the population within the social and economic realms, and intervening to avert/cure them. When we as public health professionals encounter such anecdotes, what stand should we take? Should we ignore them as age-old beliefs that have no rationale and because we cannot change them? Yes, it may be true but isn’t it necessary to at least explore? After all the entire system of traditional medicine thrived based on observations, when there was no scope of conducting randomized controlled trials. Many scientific discoveries resulted from unexpected observations. Even the great experiments of John Snow, Edward Jenner, James Lind, and Joseph Golberger started with observations. Who knew that the Grand Experiment by John Snow, based on keen observations, that led to massive sanitary campaign in London would have led to the discovery of the organism that causes cholera 25 years after his death? So why negate this observation, even if may sound trivial? The lure of imagination is great for a scientist. His mind jumps from conclusion to conclusion. He is liable to mistake an interesting theory for a verified fact. And therefore he/she needs to have patience and go on. It is only firm confidence in the power of human reason that enables a scientist to investigate such an alleged phenomenon. In the realm of science, men with determined purpose and single-minded vision without any fortuitous support made great achievements. They struggled unaffected by the challenges despite many a failure. In their process of investigations, nothing was regarded too laborious, nothing too insignificant, and nothing too painful. This is the path we all must tread to reach the truth … unfortunately there is no other easier way. Every researcher like me falls in love with his/her own research idea and seemingly fails to understand why it takes a toll to convince the other party? This story is about my journey from conception of the idea until the point I have reached today in my endeavor. The path that I have traversed has been fraught with several upheavals—some emotional, some psychological, some social too. These have taught me the lessons that every researcher has to face; especially for research, that is non-conventional in nature, that is not in tune with modern priorities, that does not follow a top down approach and one that is not decided by the ‘funding agencies’; these may not even lead to the discovery of new molecules or lead to any change in clinical practice. One therefore has to stop and ask oneself: Is it worth pursuing? Well, I leave it on to you to ponder over. It was March 2016 … The International conference on birth defects was held at Pune—the sprawling city in Western India. I was chitchatting with Dr. Arun Singh, a dedicated neonatologist who was heading the famous Rashtriya Bal Suraksha Karyakram, a flagship program of Government of India. I knew him for the past 5–6 years then. Ever since I got introduced to him, I saw in him a learned persona who lived up to his own thinking. As with all my previous encounters, I confided in him my work on sex selection drugs—a strange medicine that pregnant women

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consume to ensure the birth of a son. Having listened to my stories and experiences patiently—both bitter and sweet—he advised me, “please write a book on your experiences … begin with the genesis of the work … what prompted you to undertake this work … let today’s generation gain from your experiences…”. Book? Let my scientific papers be published first. My experiences may not interest everyone. Scientific papers probably would. Such thoughts crossed my mind. There were many experiences, some worth sharing while some were not—but why would he say this? For a scientific community, research questions and research findings are worthy enough. Nevertheless, as I internalized his statement I realized how much he made sense. I made up my mind to start penning down my thoughts but had to wait for the final push when I found someone else considering to present our research findings as a co-author at a high level meet on translational research, without any knowledge of mine—the originator of the topic. This book gives an account of the traditional practice for begetting a male child. The practice of consuming some medicinal preparations during pregnancy for having a son is a cultural norm in certain parts of our society. There are evidences of intake of herbal preparations during pregnancy from other parts of the world, albeit for different reasons and obviously less researched. Whatever may be the underlying factors, one has to be extremely cautious while consuming anything during pregnancy especially in early weeks. This practice calls for systematic exploration and advocating in front of the global audience that all natural/ herbal ingredients need not be safe. Years of research spanning from observations to community-based studies to laboratory investigations and experiments have yielded enough information to label this practice extremely dangerous. There is a clear-cut evidence that intake of such preparations increases the risk of birth defects and stillbirths, the most deleterious outcomes of any pregnancy. Anyone who is sensitive to gender issues, irrespective of his or her professions, must get familiar with phenomena that are omnipresent, yet less known. The manuscript takes the reader through different steps; the first chapter delineates how the idea was conceived based on a simple observation reported by a medical officer. The second chapter elaborates how this observation took the shape of a researchable topic, opportunities created and obtained as well as hurdles faced while trying to conduct research. The third chapter deals with in-depth research on sex selection drugs through population-based studies and laboratory analysis and experiments supported by none other than Government organizations; the fourth chapter highlights how the research findings were translated into actions to curb this dangerous practice … an example of Government commitment that is worth showcasing. The chapters are interspersed with a review of literature on the relevant topic to apprise the readers on the existing evidence. It concludes emphasizing that research needs to cross the rigid boundaries, protocols, and organizational mandate to explore facts that emerge from the field.

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Discovery of a new molecule or treatment may not be the only barometer to measure how science progresses; providing scientific explanations to label traditional customs and practices as useful or harmful should equally attract scientists, academia, Governments, and funding bodies in the larger interest of the society. This book is but one step in generating awareness among the global community in this direction. New Delhi, India

Sutapa Bandyopadhyay Neogi

Acknowledgements

Coming together is a beginning, keeping together is progress, and working together is success! This book is a collective effort of all who have helped me gather a wealth of knowledge over several years. First and foremost, I would like to express my most sincere thanks to Prof. Amarjeet Singh of Community Medicine Department, PGIMER, Chandigarh, India, for providing me the stimulus to undertake this mammoth task. His encouragement and recognition for the smallest achievements during the course of my journey provided me the impetus to go ahead. I would treasure those moments forever. I submit my heartiest gratitude to Dr. Abhijit Ganguli, for being with me during thick and thin … for this overwhelming support in helping me to identify the right person for the right kind of work at the right time. Be it for laboratory analysis, C. elegans study, or rat model study, his selfless contribution in making me traverse the most difficult times with utmost confidence is most valuable. Dr. Rakesh Gupta, an ever dynamic personality, came to our help at a time when it was needed the most … his reaching out to me for some research work turned round the ship for good which is something I will cherish throughout my life. His generous support to help us tide over the crises, lending administrative support and lending ears as a patient listener, recognizing our efforts, and most importantly applying them for societal benefit … there are multiple attributes that we have to learn from him. The support provided by National Rural Health Mission, Haryana; Department of Science and Technology (DST); and Science and Technology Council, Haryana, is invaluable. CIMAP, Lucknow; Alagappa University; and Venus Remedies provided necessary support for us to undertake the analysis and experiments. We worked on a shoestring budget often relying on the overwhelming generosity extended by these organizations. I am personally indebted to Dr. Rashmi Sharma, SEED Division, DST, for being a close friend and confidant. I vividly remember the emotional moments that we shared while we were on the project.

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Acknowledgements

In no order, I am extremely thankful to Dr. Puneet Misra (AIIMS, New Delhi), Dr. Sarala Balachandran (AcSIR), Dr. Anand Sachdeva and Dr. Dilip Roy (Venus Remedies), and Dr. Balamurugan (Alagappa University) for extending all support at very critical times of the project. The support extended by Haryana Government, especially Dr. Ravikant Gupta and Dr. G. S. Singhal, is praiseworthy. The work on SSD helped me come out of the confines of a vision that looks research as research only. Expanding the reach of research to common masses was something I learnt from Mr. LaxmiKant Tiwari (Apoorva Pande Foundation). His commitment to do something for the society and nobility in his approach taught me a great deal of things. I am also thankful to Mr. Nitin Chowdhry for showing his commitment for a noble cause. My introduction with him came as an inestimable blessing. I am thankful to Prof. K. Srinath Reddy, PHFI, for his constant support and inspiration. The entire family of Indian Institute of Public Health (IIPH), Delhi, stood by me during the course of data collection, analysis, experiments, and publication of papers. Right from the time I joined IIPH Delhi, the warmth and affection showered by faculty, staff, and notably Prof Sanjay Zodpey encouraged me to accomplish most of the tasks. Dr. Sapna Chopra and Mr Sham Sikri, our research staffs who worked with us for data collection in Haryana, deserve special mention here. I am thankful to Ms. Pragya Rai who transitioned to Dr. Pragya Rai as an able Ph.D. student and took utmost interest in the topic for its scientific and social relevance. No work is complete without the blessings of parents. Simple living and modest background are the virtues of my parents, Mrs. Maya and Mr. M. M. Bandyopadhyay, for whom my achievements and accomplishments surpass everything else. Their ability to instill a confidence in me that nothing is impossible has been the guiding principle of my life. No change is ever possible without inconvenience, and inconvenience comes in a package beset with frustrations and emotional upheavals. I am thankful to God for my two little sisters, Sulekha and Sujata, who have always been with me to listen to my woes and experiences—however small or big they might have been. My husband, Dr. Sushanto Neogi, a constant support with enviable patience, has been behind me for whatever little I have contributed till date. I am blessed to have him by my side who made me realize that I have to stand by my own convictions. There is no medicine like hope, no incentive so great, and no tonic so powerful as a supportive family. I feel lucky that I have one. Understanding parents-in-laws has been a great asset to me. My cutie pies—Shubho (Pronoy) and Shubhi (Bornali) —are the pillars of my strength. No amount of hard work or commitment would have enabled me to complete this book without their continuous stock checking. I am thankful to the media and local English and vernacular newspapers who covered our research extensively and generated awareness among naïve public, to international agencies such as Guardian, Wall Street Journal, and BBC UK for highlighting the issue among global audience.

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Last but not least, I am forever indebtful to the mothers, women, doctors, and other respondents from the community who have enlightened me with their knowledge and wisdom, triggering me to think and question relentlessly. I am grateful to my critics whose views and reviews illuminated the enveloping darkness in which my potential might have otherwise remained unseen. Not surprising enough, I have gained more from my critics than my admirers and friends. Our journey has been a series of experiences. Every organization that has witnessed me doing this research, starting from PGIMER, Chandigarh, to IIPH Delhi to IIHMR Delhi, has extended their warmest cooperation. Their love and hope have encouraged us to tread every step with confidence, each step that made us rise higher and higher. My sincerest thanks to the publisher, Springer Nature, for giving me an opportunity by providing a powerful platform to disseminate the findings among academicians, researchers, and policy makers as well people dedicated to gender issues. We do hope that this work inspires the young generation to think beyond bounds and carry forward the unfinished work that is long due!

Contents

1 Indigenous Preparations for Sex Selection: How Did Research Begin? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1 Uncovering the Practice of Sex Selection . . . . . . . . . . . . . . . 1.2 Sex Selection in the Past . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Exploring Preparations for Sex Selection: Opportunities and Hurdles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 An Exploratory Study to Unravel Facts About SSD . . 2.2 Sex Selection in Modern Era . . . . . . . . . . . . . . . . . . . 2.3 How Logical and Ethical Are Modern Sex Selection Techniques? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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3 Research on Sex Selection Drugs: Haryana Paves the Way 3.1 Physiology of Sexual Differentiation . . . . . . . . . . . . . . . 3.2 Haryana’s Commitment . . . . . . . . . . . . . . . . . . . . . . . . 3.3 Findings from Epidemiological Research and Predictive Toxicology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4 How SSDs Can Impact Lives? . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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4 Translation of Research into Action—Case Study 4.1 Administration in Action . . . . . . . . . . . . . . . . . 4.2 The Way Forward . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

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About the Author

Sutapa Bandyopadhyay Neogi is a public health specialist currently heading the International Institute of Health Management Research (IIHMR), Delhi. An MBBS from Nil Ratan Sircar Medical College, Calcutta, MD in Community Medicine from Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, and Diplomate of National Board (DNB) in Maternal and Child Health, she has excellent academic credentials. She aspires to facilitate and support transdisciplinary research, mentor enthusiastic scientists who can see through health and social problems, and explore them scientifically. She wishes to generate synergy between research and health related programs and promote interdisciplinary research in the country.

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Abbreviations

AcSIR AIIMS AIR AMH ANM BBC BMJ BPA BW C elegans CDC CEHAT CIMAP CM CPRO CSIR CVS DBT DEHP DES DHEA DHT DM DST EDC FC FDA FIR GFMER HFEA

Academy of Scientific and Innovative Research All India Institute of Medical Sciences All India Radio Anti-Mullerian Hormone Auxiliary Nurse Midwife British Broadcasting Corporation British Medical Journal Bisphenol A Barley and Wheat Caenorhabditis elegans Centre for Disease Control and Prevention The Centre for Enquiry into Health and Allied Themes Central Institute for Medicinal and Aromatic Plants Chief Minister Chief Public Relations Officer The Council of Scientific and Industrial Research Chorionic Villus Sampling Department of Biotechnology Diethylhexylphthalate Diethylstilbestrol Dehydroepiandrosterone Dihydrotestosterone District Magistrate Department of Science and Technology Endocrine Disruptor Compounds Flow Cytometry Food and Drug Administration First Information Report Geneva Foundation of Medical Education and Research Human Fertilization and Embryology Authority

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HIV HPG HPLC IAPP ICMR IMF INCLEN INR IUCD IVF JIMA KI LB LSHTM MASUM MD MD MPH mRNA MRSA MTP NFHS NGO NHM NHRC NIOH NIPER NRHM OECD OPD PCPNDT PCR PGD PGI PGIMER PHC Ph.D. PHFI PIL PM PNDT PPFA PTTDI

Abbreviations

Human Immunodeficiency Virus Hypothalamic Pituitary Gonadal High-Performance Liquid Chromatography Indian Association of Private Psychiatrists Indian Council of Medical Research International Monetary Fund International Clinical Epidemiology Network Indian Rupees Intra-Uterine Contraceptive Device In Vitro Fertilization Journal of Indian Medical Association Key Informant Liebermann–Burchard London School of Hygiene and Tropical Medicine Mahila Sarvangeen Utkarsh Mandal Doctor of Medicine Mission Director Masters of Public Health Messenger Ribonucleic Acid Methicillin-Resistant Staphylococcus aureus Medical Termination of Pregnancy National Family Health Survey Non Governmental Organization National Health Mission National Human Rights Commission National Institute of Occupational Health National Institute of Pharmaceutical Education and Research National Rural Health Mission Organisation for Economic Co-operation and Development Outdoor Patient Department Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Polymerase Chain Reaction Preimplantation Genetic Diagnosis Post Graduate Institute Post Graduate Institute of Medical Education and Research Primary Health Centre Doctor of Philosophy Public Health Foundation of India Public Interest Litigation Prime Minister Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Planned Parenthood Federation of America Provisional Tolerable Total Dietary Intake

Abbreviations

RP-HPLC RT S&T SDN SEED SIHFW SSD TCM TDF TLC TORCH UK UNFPA UNICEF USA WHO

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Reverse Phase–High-Performance Liquid Chromatography Retention Time Science and Technology Sexually Dimorphic Nucleus Science for Equity Empowerment and Development State Institute of Health and Family Welfare Sex Selection Drug Traditional and Complementary Medicine Testis Determining Factor Thin Layer Chromatography Toxoplasmosis, Rubella, Cytomegalovirus and Herpes Simplex United Kingdom United Nations Population Fund United Nations Children’s Fund United States of America World Health Organization

Chapter 1

Indigenous Preparations for Sex Selection: How Did Research Begin?

Minor things can become moments of great revelation when encountered for the first time. Margot Fonteyn

1.1

Uncovering the Practice of Sex Selection

It was the afternoon of October 22, 2002. A training program for medical officers was organized at State Institute of Health and Family Welfare (SIHFW), Panchkula, Haryana. It is usual in India to have such capacity building programs for continuous education of doctors, nurses, program managers in public health. I was doing my residency from Department of Community Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh. The head of my department was preoccupied with some work and requested me if I could go to take a session of his. I agreed willingly, not because it was an order from the head [the culture in India, especially in teaching institutions is never to refuse your seniors, leave alone professors], but because it would provide me with an opportunity to interact with doctors outside the confines of our departmental affairs. The training workshop happened in batches of 10–15 for 2 weeks duration every 6 months. I went and took the session with a lot of excitement. Attendees generally were tired of such programs because those were reportedly thrust upon them. According to them, their knowledge and skills did get refreshed, but those were in no way commensurate with the loss incurred by not being able to do private practice for two weeks. Private practice for doctors is not always allowed if one is in a Government job but people practice discreetly, and this is an open secret. I enjoy interacting with professionals on subjects beyond their professional arena for the insights that one can gain; no amount of reading or attending training public health programs can ever provide those invaluable knowledge. One just needs to be a patient and curious listener and be able to ask the right kind of questions to trigger a nonoffensive and noncontroversial discussion. After my class got over, I asked them, “If you are asked to start a surveillance on a topic that you feel is a public health problem, what would you choose?”. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 S. Bandyopadhyay Neogi, Gender Before Birth in India, https://doi.org/10.1007/978-981-16-3318-8_1

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1 Indigenous Preparations for Sex Selection …

One lady doctor replied, “I have seen five cases of spine bifida (a form of birth defect) in the last 6 months in my primary health center (PHC). [A PHC in India is a primary level hospital that caters to a population of 30,000 theoretically. In reality it is well above 30,000 to the tune of even 50,000 at certain places]. I feel this is a big number since I am practicing for years now and never ever I have seen so many cases in a short span of 6 months.” “What do you think could be the reason?” I asked. “I don’t know. I have investigated all the cases for diabetes, TORCH infections (that includes toxoplasmosis, rubella, cytomegalovirus and herpes simplex) and thyroid profile [these are usual investigations undertaken to identify the cause of birth defects so that treatment can be provided accordingly]. Everything seems to be fine. You must investigate this Madam. If a hospital like PGIMER does not do, who else will?” [PGIMER was created to develop a state of the art Centre for Medical Education and research by an Act of Parliament. Over the years, the centre grew up to be an island of excellence]. These are the tests that are normally not done in a PHC in a country like India or were not done at least in 2002. For someone to take up the initiative to investigate and not simply refer them as a mundane practice… indeed reflected her commitment. She got the tests from a private center. I really doubted the results from the private investigation centers of small places but then all could not be wrong. I then asked other participants if they too had similar observations. They denied. Whatever the reason may be, it did strike my thoughts. I decided to explore on my own. May be, there were some external unexplored causes existing, one never knows!. Fortunately, the feedback of the participants for my session was good. So, I became my department’s representative for the subsequent sessions in the training program. I was more eager than ever to meeting few more doctors with exciting observations and many more……. Unlike last time I wanted to finish my class a bit early so that I could get more time to discuss the issue raised in my last session. After the class, I repeated the same question but gave a twist to it. Instead of asking about problems I questioned, “A doctor informed me that she was seeing an unusual increase in the number of spina bifida cases in her area. Do you also have similar observations?”. The answer was a big NO. There were only men in the group. Women are more keen observers, I thought. “Well, if at all someone has reported a finding like this and if you are asked to investigate, what will you do?” “One of the reasons could be …..a doctor started off and then paused… then looking at his peers very hesitantly mentioned… people consume all kinds of indigenous preparations for varied reasons.” I could not understand much and asked him, “what preparations and for what reasons?”. “Something like…. for having a son?”. “What? Medicines for having a male child? But how are these related?” I could not contain my surprise.

1.1 Uncovering the Practice of Sex Selection

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“Because these are consumed during pregnancy,” one of them replied. “Medicines during pregnancy? For a male child?” I was stunned. “Yes, it is a common practice Madam. I have heard but I never have seen those medicines with my own eyes,” another doctor replied. I turned to rest of the group. There seemed to be a mixed response. Some agreed and some disagreed. But then, it set me thinking. “Can these medicines be related to spine bifida?” By the way, how could people consume such medicines during pregnancy—how ignorant people could be? But then I reconciled that yes—it is a boy which is the ultimate necessity of any family. I suddenly recalled an incident at pediatrics emergency at PGIMER where I was posted for a month. A family got their son admitted to the emergency. The son was the sixth child, and all the previous ones were girls. The baby was ill and had to be put on ventilator, indicating a poor prognosis. When the family was informed about it, the father said that they were willing to take the child back home. They would arrange for a support system to keep the baby breathing and live; even if that meant a life long business; all said and done, they would now be able to say that they have a son. For them, any amount of investment was less compared to having a son. My interest to explore this practice therefore increased even further. In every batch of training at SIHFW and elsewhere, I would ask if they knew about these medicines and the response was rarely positive. I began exploring with my colleagues, with those who accompanied me to the field, who assisted me in the rural clinics….. the health workers and field workers working with me in our Department. In some sense, they have a great deal of linkages with the community and an emotional connect that many “successful public health professionals” lack. “Why do you want to know more about all these?” one of them asked me. “Out of curiosity”, I replied. “No one will tell you, Madam. Better to avoid such controversial talks.” How could she not have a curiosity to know more, I thought. There must be something hidden. “Okay, could you please let me know who can tell me more about the medicines?” She feigned ignorance. The next day, when I went to the community, I asked an old woman “I have an elder sister who has a daughter. She wants to have a son. Would you please tell me who can give me some medicines that can help her have a son?”. I just blurted out in a fit of emotional outburst, and then I realized what I was talking. I always used to bring gender discrimination during my formal and informal interaction with the oldies and their daughters in law. Often, they would come to me, happy and satisfied with my treatment or counseling and would say, “may God bless you with a son.” No one would ever say, May you get a good husband. Having a son was the most precious of all blessings and gifts that people could think of. I would often reply back and say, “why not have a daughter?” And this would invite few more questions. “How many brothers do you have?”.

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“We are three sisters”, I would say. “Who would take care of your parents when they grow old?” would be the usual question. “Me!” would come out as an instant reply. “You? Who would take care of your in-laws?” “Their daughters.” I would say. The old ladies would look at each other and would burst into laughter. “May God give everyone a daughter like you!”. But their blessing for me.. only a son… and always a son…. No sooner did I utter the problem of my sister wanting a son, I realized that I should not have said that. I therefore changed my version. I said, people say it is possible to have a son with medicines. Is it true? The old woman, seemingly surprised at my question, referred me to a faith-healer in the neighboring village. But he does not entertain people if there is no client. I then asked her what other measures are required to be followed. She said, “I have heard people saying that one needs to consume the medicines with milk obtained from a bull calf at dawn. And these are taken 15–30 days after missed period.” I was completely amazed at the awful practice. Meanwhile I also started exploring whether there was an increase in birth defects in reality. I could not zero down on any concrete evidence, but yes, there were sporadic reports that birth defects were on the rise, although there was no registry or database to accept these facts. Neither was there any publication or report on the reason behind this apparent rise. Box: Some News Clippings to Indicate Rising Birth Defects Punjab is fast heading towards ecological disaster-scholars JAGMOHAN SINGH Wednesday, 06 August 2008 AMRITSAR: A galaxy of distinguished environmentalists, agriculturalists, social scientists, medical scientists, religious heads and academicians gathered here at the Guru Nanak Dev University to participate in a one-day Bhagat Puran Singh Memorial National Seminar have strongly warned that Punjab is fast heading towards an ecological disaster. They said it is also turning into a cradle for cancer and congenital defects due to large scale and indiscriminate use and abuse of chemical pesticides. Agriculture Campaigner from the Centre for Sustainable Agriculture, Hyderabad, Kavitha Kuruganthi, explained at length the environmental impact of intensive farming systems, and the social cost being borne by Punjab farmers. She also warned against an impending crisis emanating from the release of genetically modified crops.

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Environmental epidemiologist Dr S. G. Kabra from Jaipur explained about the ill effects of chemical pesticides and brought out the congenital defects that Punjab was now faced with as a result. “Punjab today as the dubious distinction of having the maximum number of brainless children being born.” Farmers suffer toxin-induced dent 29 Nov 2007, 0221 hrs IST, Priya Yadav, TNN Times of India CHANDIGARH/AMRITSAR: A highly damning report submitted by PGI, the region's top Government hospital, has confirmed fears of medical investigators here and said the high degree of groundwater contamination in large parts of Punjab has led to massive DNA toxicity and DNA damage among a substantial segment of Punjabis. Hinting at both the speed of industrialization and lack of checks by Government bodies on effluents being emptied into the state's various water bodies, the report, released last week, has confirmed the grim reality of poisonous pesticides and heavy metals entering the food chain and wreaking havoc on people's lives. In fact, it was a suspicion by medical experts in the region that there was an increasing prevalence of congenital deformities, cancer cases and kidney damage among people that led the Punjab Pollution Control Board (PPCB) to commission a study by PGI aimed at looking for solutions. “The report is very worrying indeed,” said Yogesh Goel, chairman, PPCB. “There is clear evidence that exposure to pesticides and irrigation of fields with highly contaminated drain water is leading to neuro, reproductive and gene toxicity,” added the research’s chief.

The incident took me back to my childhood days when my sister was born. Youngest of the three siblings, it took to nobody’s surprise when our well wishers rushed in with a volley of do’s and don’ts for my mother’s next pregnancy. I was too small to comprehend everything but the underlying message was clear. Conflicting advises, “over concern”, of our relatives and friends for not having a “BOY” in the family could not do much to pull down the excitement of having a fair and beautiful little angel in our family…. Though it did leave a scratch behind after I witnessed an incident. Our landlord in Delhi was an old couple who lived on the floor above ours. In one instance that I remember vividly, they were going out for an auspicious function when my mother was out in the courtyard busy spreading the wet clothes in the sun. It was the cold month of December in Delhi, and that year was the coldest December of that decade. Getting few rays of sunlight was much sought after or else room heaters were the only resort. My mother was trying to manage

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spreading the clothes and make some space for her to sit with her princess. The couple stepped out of their house and as soon as they found my mother near the gate, they turned around and went inside their house. I was busy with my younger sister but I could sense that something was amiss…. I heard the old couple discussing in whispers…. “How can we get out of the house seeing the face of a woman who doesn’t have a “son”? It was too much for me to understand but it left a lasting impression in my mind. Are women without a son considered inauspicious? My mother must have encountered such instances every now and then, I believe… once in a while I would find her getting upset at the sight of visitors. How I wondered … someone who was so happy-go-lucky could turn hostile to visitors… Another old granny from our neighborhood visited her one day with a box of sweets and said, “Saradamoyee has come in your family”… Saradamoyee is worshipped in West Bengal.. as someone akin to Goddess Kali. I could see the excitement in my mother’s eyes… “She will grow up into Saradamoyee one day. You will be proud of her.” She told my mother referring to my sister. There was a spark in her eyes as she spoke… something that reflected her faith and firm belief. My mother repeated those words to my father so many times when he was home in the evening… those words seemingly did bring some solace to her soul! This is not uncommon in our kind of societies. While number of Goddesses that are worshipped in the country and perhaps in the whole world outnumber that of Gods, the general feeling and preference of people are far too orthodox than one can imagine. Lack of education, female illiteracy and lack of women empowerment are but few factors that shape the thought processes of our people. These are the common elements that people tend to relate to whenever we talk about gender discrimination. I grew up with the impression that if one has to eliminate gender bias, women have to be educated. Great philosophers and thinkers of all times, Ishwarchandra Vidyasagar, Raja Ram Mohan Roy and few others held this belief in supreme and spent their lives advocating for women’s education. My father, too, is a strong believer of this principle. With the birth of my youngest sister, his belief grew firmer. Born and brought up in a small village in Purulia, West Bengal, he grew up to be an engineer.. the first one in his time from that village. Because of his environ outside the realms of the village or education or something else.. we don’t know… his outlook was much different from the usual folks.. He is a great proponent of women’s education. Occasionally I would hear him discussing with my mother.. “We will educate our daughters.. we will make our daughters more valuable than sons.” It was obvious that my parents took this as a challenge to make sure that our upbringing was good, something that they could boast of at a later stage. With time I could understand that I had to become the torch bearer of my family, something that a “BOY” is supposed to do in traditional Indian families. I sometimes wonder, “would I have become the ‘SON’ of my parents if I had a brother? I really do not know.

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Anyways, I grew up thinking that if we sisters are able to transform people around us… within our families or outside… if they stop demeaning or devaluing daughters, our purpose would be served. But my ordeal into ‘medicines for a male child’ taught me additional lessons that were contrary to what I believed while I grew up.” There are numerous instances where successful women of today have encountered challenges to create a position for themselves. My stay in Chandigarh during my postgraduation days widened my horizons. A friend of mine, Rina by name [name changed for ethical reasons], the eldest in her family had four siblings, including a younger brother. She hailed from an industrial city from the state of Jharkhand. Hard work and determination made her one of the outstanding students of her batch in school. She always dreamt of becoming a doctor since her childhood. The traditional conservative outlook of her family, however, did not prevent her from expressing her desire. Her parents, though not so forthcoming, did not dare to refuse. One, because days were changing; peers are bound to have some influence: positive or negative. Second, if children do exceedingly well, parents cannot be as blunt for fear of explanations from school teachers. But by agreeing to allow their daughters to pursue their dreams, they did not usually take away the other responsibilities imposed on them.. taking care of younger siblings… helping mothers in kitchen so on and so forth. It also went to the extent of independently managing cooking for a family size of seven, eight, ten….. Rina too bore the brunt of the familial responsibility, knowingly or unknowingly. Rina once told me, “ I used to keep my books open besides the oven while I was on job: making rice or chapatis. I have memorized most of the formulas and equations in the kitchen.” Such was her determination.. as hard as a rock… that would never give way to any complacency. Her sisters, all one to five years younger to her would empathize with their eldest sister.. they would also assist her in household chores. She often said, “We could not dare to compromise on the quality offood we prepared —right from its color to taste.. everything had to be in right proportion… according to the choice of the most important member of our family.. our BROTHER.” The so-called Chirag (the light source) of their family was all important…the fifth standard student’s exams were above everything else. … parents also tried their level best to give him the utmost comfort…. if he threw tantrums over food, Rina was reprimanded. He had a tutor who would come over everyday for one to two hours to teach him Maths and Science. The girls in that family had never seen the face of any tutors… not because they were intelligent and self dependent … but because spending money more than what was required was considered a waste. Rina, for obvious reasons became the role model for her sisters. All of them grew up to be successful professionals, on their own will and caliber, each one shining in their respective disciplines. When we were pursuing our postgraduation in Chandigarh, her brother was appearing for Engineering entrance exams. He was put in several coaching classes.. only to give him the best. As luck would have it, he could not clear any. His father accompanied him to every examination center, while her mother would visit the temple, pay obeisance to Gods and Goddesses, serve the

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poor people with food, not thinking twice about the expenses… but to no avail. The “Chirag” was now at home getting the usual pampering, not to let his morale down. Aunty and Uncle often came to Chandigarh to see their daughter, who was now of marriageable age. They were looking for a match within their caste, as the social norm would expect… Rina was very clear. “We will not give a single penny for dowry”. Her parents had nothing left with them for the purpose of dowry by having spent money to admit their ladlaa to a private engineering college. They naturally supported her decision. Aunty told me once, “We have taught our daughters to stand on their feet. Why should we give dowry?” I was happy to hear her say these sugar coated words, although I had a notion that those were only to appease me. My reading was that she could never be against the so called norm of a male dominated society….. When she again visited Chandigarh after 5 months, I very casually asked about her Ladlaa. “He is doing fine”, she said. “Is he interested in higher studies?” I asked. “No. As an engineer he will fetch a fat dowry. If his wife wants him to do more, let her family pay”, was her response. My intuitions were coming true. “If he finds a girl who stands on her feet, like Rina?”, I asked. “No, he will marry the girl of our choice,” she said. “After all we sold our piece of land for his studies. How shall we recover the amount?” Rina eventually got engaged to a doctor, a surgeon belonging to the same caste. The girl’s demand of “no dowry” was accepted to them, in the first go. All of us were happy for her. Soon the date of marriage was fixed. Things were going as per their plans, but Rina could feel that something was brewing between the families. In our kind of societies, usually, once the girl’s marriage is arranged and is announced, people, especially the bride’s parents, fall prey to societal pressure. They get ready to travel an extra mile, if need be, to make sure that the marriage does not get called off. The boy’s family, knowing Rina well, took advantage of the situation and raised the issue of dowry with her parents. They in fact went to the extent stating that they would cancel the marriage in case they were not able to meet their expectations. Her parents wanted to pacify the whole thing and acceded to their demands initially.. the agreement was that nothing would be told to Rina ever. Her brother, sisters.. no one confided anything in her out of fear. Fear that if Rina knows, she would cancel the marriage and once people know about it, finding another match would be even more difficult. For typical Indian parents, having an unmarried daughter at home is burdensome. This could lead to difficulties in getting matches for other sisters as well. The same is not true for son, though. I have heard people discussing a spinster… “she could not get married”. The same explanation for a man would be… “he did not marry”. This speaks a lot about attitude with which people look at a man and a woman. The social sanction is that a man can remain unmarried by choice, but for a daughter it is the opposite.. it is by compulsion and never by choice. In our kind of societies, while marriage of a daughter is bothersome, having a spinster sitting at home is even more worrying. So it was not unnatural for Rina’s

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parents to keep their conversation under the carpet. When their demands kept increasing, they had to reveal everything to Rina and as expected, she immediately called off her marriage. There were no second thoughts and no looking back. Finally she got married to another doctor of her caste, arranged by her family. He was a radiologist and his mother, a known medical practitioner. They belonged to a small district and it was natural for the doctor family to enjoy a privileged status. Their readiness for the marriage and that too at zero demand was enough to convey that they were eyeing on Rina’s education and qualification as a yardstick to improve their private practice. Whatever it is, even if they got blind over her degree from a reputed Institute, it was for good only. We all were happy for her, for in their kind of set up, getting a perfect match was unthinkable.. by perfect I do not mean same wavelength or thought process but a respectable professional within the confines of similar caste and religion. Many a times, a girl cannot dare to cross the boundaries as she is considered a liability for her younger siblings as well. Years rolled by. I met Rina after almost ten years. She was living separately in a different place soon after her second daughter was born. As a radiologist, it was her husband’s curiosity to look for the gender of the child at 3 months of pregnancy. The first daughter was acceptable to all. When she conceived the second time, she had to undergo ultrasonography to know the gender of the baby, against her wishes. They knew that it was again a girl child. As can be expected, she was asked to go for abortion. As an obstetrician, Rina always condemned female feticide like anything. Now she was in the shoes of thousands of women, who generally comply to unwarranted demands of elders in the family….. of those voiceless women who succumb to relentless pressure and for whom social and family commitments take precedence over everything else… only to pave their way toward female feticide. But Rina was not that sort. Having grown up in a family with orthodox mindset, she maintained her idealism as ever and could not come to terms with her in laws’ demands. Her husband was voiceless on this issue. His silence was nothing but a calm acceptance of the ever burgeoning customs of a male dominated society. Soon she moved to her parents’ house, as this is the tradition even today in most families. After the birth of her second daughter, she left her husband for an independent living, where she said she would not have her daughters grow up in an environment where they would be considered unwanted. She did not want to relive history. The farther backward you can look, the farther forward you can see. Winston Churchill

1.2

Sex Selection in the Past

Ancient civilization had a matrilineal society where women enjoyed equal rights as men. Women were viewed as superior powers considering their ability to withstand menstrual blood loss, reproduce without “apparent” male contribution, and feed

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their offsprings with their own milk “so magically created”. Women exhibited sexuality that seemed inexhaustible, powerful, and profound. However, with the advent of the Paleolithic hunter gatherer period, the matriarchal mindset started weakening. Nomadic lifestyle demanded more physical power. This was further compounded by a realization of the role of males in the process of reproduction. The growing knowledge that men have a role to play in procreation turned the ship around toward male preference leading to dwindling matriarchal mythologies. Ancient scriptures were skewed toward male preference as women began to be looked upon as those who were dependents on males. As Wester Marck stated “The ancient Indo European nations believed that the main happiness in the world depends upon his having a continuous line of male descendants whose duty would be to make the periodic offerings for the repose of his soul.” De Coulanges remarked, “Every father, therefore expected of his posterity that series of funeral repasts was to assure of his manes repose and happiness. This opinion was the fundamental principle of domestic law among the ancients.” This gave birth to a rule that every family must perpetrate itself. It was essential that the descendants should not die out [1]. Various Hindu rites and rituals devised by Brahmanica society gave more importance to sons as compared to daughters. Only males were given the privilege to perform certain rituals and religious ceremonies. According to Hindu scriptures, only sons can set fire to the funeral pyre of their parents, releasing them from the travails of the world and ensuring the soul’s entry into heaven. With the birth of a son, the father is released from his debt to his ancestors. This gets reflected from what Kautilya observed, “Wives are indeed for bearing sons. A husband is allowed to remarry or supersede a wife who is barren or bears only daughters or children who do not survive” [1]. Given the fact that the outcome of any pregnancy was known to our ancestors as being 50–50 chances of having a boy or a girl and the scenario where son preference gradually took strong roots, since antiquity, people have attempted to predict the sex of the child. They related these to some natural phenomenon since most of the things man had learnt, were through observing the Nature in his habitat (agriculture—the crops he grew or the animals he tended). And along with the prediction (i.e., the diagnosis) came the coping strategies (treatment) for undesirable outcome of the prediction. Many rituals were prescribed to be done by the couples. This gave birth to several theories on “guaranteed methods of ensuring a child of desired sex” like intercourse on specific time in relation to position of moon and tides, wind direction, rainfall and temperature and reciting chants during intercourse. In Austria, midwives often buried placenta under a nut tree to ensure that the next child would be a male [2]. Predicting the sex of a child and selecting it by natural means has intrigued several cultures. One of the oldest records is an ancient Egyptian papyrus scroll (1400–1600 BC) that mentions about tests for fertility and sex determination [3]. History records several assumptions surrounding reproductive physiology that led to scientific methods of sex selection. The Egyptians defined the role of testis in

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reproduction (200 BC). They described castration as leading to decreased libido and sterility; they however did not ascribe the male to source of gender selection. Greeks defined women as nurturer and men as the sources of genetic characteristics. They associated right side, light, excess heat and northern hemisphere with maleness using the Pythagorean table of opposites. These attributes were utilized for sex prediction. According to Aristotle (384–322 BC), cold southern winds increased the chances of conceiving a girl while facing north during intercourse increased the likelihood of male births. The Greek philosopher Anaxagorus (500–428 BC) contended that sperms from right testicle produced males [4]. Tying off one testicle would therefore determine the sex of the offspring. Keeping this in view, French noblemen in the eighteenth century were advised surgical removal of their left testicle. In Germany, if a couple wanted a boy, the man was supposed to carry an axe to bed at night. Other suggestions included intercourse in dry weather or when there is north wind, have the man wear boots to bed or hang his pants on the right bedpost or have the woman lie on her right side during intercourse or wear male clothing to bed on her wedding night [5]. In the Jewish tradition, Talmund suggested that sequence of orgasm predicted the sex of the child. If women emitted her semen first, she would bear a male child and vice versa [4, 6]. It suggested that if the marriage bed was placed in a north–south direction, it favored male conception [5]. Similar other cultures believed that exposing males to hotter climatic conditions would produce sons. According to Chinese concept of Yin and Yang, Yin symbolizes masculinity, light, heat, and activity. These could be detected from the pulse of pregnant women according to Chinese traditional medicine. According to Hindu beliefs, women with heavy menstrual flows were more likely to conceive daughters. In Vietnam, eating salty and high protein food prior to conception and during pregnancy was believed to increase the likelihood of male births. Several East and Southeast Asian cultures have a belief in the use of Chinese lunar calendar to time the birth of their children. Chinese birth chart (that predicted the gender of a baby with 93% accuracy) was buried in a tomb near Beijing for almost 700 years. It is now located at the Beijing Institute of Science [5]. The chart predicts the gender of an unborn child based on the mothers’ age and the month of conception. A theory behind this is that women’s secretions change by lunar month. The animal sign of the year in which a child is born is thought to be predictive of the child’s fate. Some years are considered unlucky for girls (e.g., Horse, Tiger, Dragon). In Vietnam, women combine traditional and modern methods, seek spiritual advice, change their diet, plan the time of conception, and pray at pagodas to conceive a son [3]. According to classical Chinese theory, a woman could choose her baby’s gender even during the third month of pregnancy. They believe that handling pearls would bring a girl, holding a bow and arrow a boy [5]. People have also related the timing of intercourse with full moon with a belief that it would increase their fertility. Primitive people, like the Botocudo tribe of East Africa, believed that the moon signified virility among men and fertility among women. Botocudo brides even flashed themselves to the full moon and prayed to it, in hopes that they could sexually satisfy their men [7]. Many African tribes, Eskimos in Alaska, and Bushmen in Australia, along with other indigenous people,

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believed that sexual intercourse under a full moon always resulted in pregnancy. On the other hand, people in India, held a belief that intercourse during a crescent moon would result in conceiving a baby girl, and full moon gives a boy. The Ayurvedic texts by Charaka (200 BC) and Sushruta (500 BC) mention the ancient art of sex selection by the name of Pumsavana karma. It is an ancient art of sex selection and healthy conception. According to Ayurveda, timing of intercourse or a special diet may influence the sex of the fetus, and it can even be changed in the early months of conception. “Pumsvan’ means “relating to son or a male child” and “karma” means a process. This defines the rituals to be adopted for helping in procreation along with getting a healthy male child. The procedure prescribes the steps to be adopted before manifestation of sex of the fetus (that is before 2 months). The woman should be made to drink curd added with either two “Dhanya Masas” or white variety of Sarsapa (mustard seeds) along with two intact (fresh) “sungas” buds from the Eastern and Northern side branches of a banyan tree grown in gosta (cow pen). Similarly, milk boiled with paste of “Apamarga,” “Sahacara,” Jeevata, Risabhaka all of them together or separately as per the requirement should be given to pregnant women. She should inhale the steam coming out of the paste of saili (a kind of rice) during roasting while sitting on Dehali (threshold) of the house. With the help of a cotton swab, she herself should drop the juice extracted from the same paste of Sali rice after adding water into the right nostril [1]. Furthermore, butter made from this milk decoction is to be burnt into ghee and instilled into right nostril for a boy or left nostril for a girl. These should be performed during astrological constellation of “Pusya Naksatram” or under the timing of this particular star that occurs every 27 days. Here Pushya Nakshatra is suggested because it is the masculinizing planet due to its masculine properties. These methods, if adopted in association with the excellence of locality and time produce the desired effect invariably. If there were any variation in these, the results would be otherwise. It is believed that drugs used for Pumsavana Karma directly or indirectly acts on the pituitary gland that stimulates the secretion of hormones responsible for particular gonadal and sex organs’ development [8]. To detect whether the conceptus is a male or female, a test namely BW test is done by observing the first sprouting of barley (B) or wheat (W) seeds when irrigated by subject’s urine. If barley seeds germinate first, the conceptus is a male and vice versa [1]. Even in the twentieth century, some people believed that the gender of the child is determined by the position of the moon at conception. Czech psychiatrist and gynecologist Eugene Jonas examined the idea of natal lunar fertile phase in 1950s. He reportedly discovered fertility cycle that is determined by the angular relationship between the sun and the moon [5]. Besides, other methods of sex selection emerged as societies advanced. The beliefs and traditions that shaped human behavior to practice sex selection were complemented with more harsh measures such as infanticide. Infanticide has been in practice from hunter-gatherers to modern civilization. The two most important reasons behind this practice were abject poverty and population control [9]. Since

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prehistoric times, dearth of food was an indirect check on human population growth. One way to curb the adversities resulting from starvation due to increased population was to reduce the numbers of children reaching adulthood. Not only infanticide, but infanticide of female children was considered an important restraint on the proliferation of early man. Apart from survival reasons, it has been also related to general discrimination and prejudice against females in male-dominant societies [10]. For families struggling to survive, the paternalistic Persian world viewed females as an undesirable burden. Burying a female child was believed to be a generous deed. However, ancient writings of Mohammed in Koran prohibited female infanticide. Anthropologists such as Marvin Harris estimated that 23–50% of newborns among Paleolithic hunters were killed. The purpose behind this was not to allow growth of population beyond 0.001%. Population growth could be curbed by limiting the number of potential mothers as well as by having increased fights among men for them to get access to wives that would also start reducing with time [11]. On the other hand, sociobiologists such as Mildred Dickemann opined that the same practice could serve as a means of expanding it [12, 13]. He argued that the biological differences between men and women meant that many more children could be produced among the affluent class through support for a male heir. The resultant could be a net gain in population. In many cultures, Governments permitted the killing of “unwanted” children that included handicapped or female infants. In Greece, as reported in 200 BC, female infanticide was rampant. Among 6000 families living in Delphi, for example, hardly 1% of families had two daughters [9]. In 84 similar societies spanning the Renaissance period, so-called defective children were killed in around one-third of them. Female gender was one of the reasons behind that “defect”. Notwithstanding the reasons thereof, sex selection practices including infanticide was in practice on every continent across varied cultural complexities [14]. Rather than being an exception, it was often observed as a rule. In a hunting economy, male heirs were much sought after. The Svans (an ethnic subgroup of the Georgians living mostly in Svaneti, a region in northwest Georgia) murdered newborn females by feeding them with hot ashes. In North America, there is no consensus on the actual numbers of newborn females who were subjected to infanticide in the Inuit population. Carmel Schrire predicts a range from 15–50% to as high as 80% [14]. In order to lessen the time for the next pregnancy (with a hope to get son), certain Eskimo tribes voluntarily reduced the time spent on breast feeding by killing female infants. Infanticide was known in China as early as the third century BC, and, during the time of the Song dynasty (960–1279 AD). Male infanticide was uncommon in the Ming Dynasty that spanned from 1368 till 1644. Thus, the prevalence of female infanticide remained high for a long period [11]. There is a historical documentation of selective infanticide during Tokugawa period (1600– 1868 AD) in Japan. During this time, some districts recorded nine male births for every one female birth [2]. There are reports that parents used to shy away from this crime of infanticide by convincing themselves that it was not yet a “child”. This paved the way for it to

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become formalized as a ritual. For instance, ancient Athens had a practice called “Amphidromia”, a naming ceremony week after the birth of a newborn [15]. The child could not be killed after that. Similarly, in early Scandinavia, it was considered illegal to kill a child after it had received baptism or been given food [16]. Not surprising enough, baptismal records in the seventeenth century showed a preponderance of male births. Customarily killing of neonates received a social sanction while there was little scope to get rid of older children [14]. Suffocating and overlaying were some of the accepted methods to kill female infants. Reports from Europe and colonial America witnessed an upsurge in infant deaths in mid-1800s, although infanticide continued to be considered a crime not a custom. Another way of getting rid of female children without committing murder was by deserting them. The practice of abandoning unwanted infants in an exposed place to die alone has been reported from England in medieval period. In China too, the children were reported to be placed in a basket which was then left under a tree. On similar lines, Buddhist nunneries created “baby towers” for people to leave a child. Drowning of babies were reported from China. In 1845 in the province of Jiangxi, a missionary wrote that these children survived for a maximum of two days. Between one-third and one-fourth of all female children were killed mercilessly at birth or soon after according to a report by Missionary David Abeel reported in 1844 [14]. Not surprisingly, most of these crimes were reportedly committed by mothers [17]. In many legal systems, the killing of a neonate by its mother was given the status of a crime, distinct from homicide and hence inflicted with less harsh punishments. In the late Middle Ages, when administration was geared up to punish the perpetrators, they were met by the public protests. In 1624, England introduced a draconian law to prevent mothers from declaring murdered newborns as stillbirths. Any woman who gave birth without a witness and couldn’t produce a living child was considered punishable by law [18]. This law remained in black and white for 180 years. It was rarely practiced as evident from very few prosecutions and convictions. Between 1730 and 1774, 61 cases of infanticide were subjected to trials at the Old Bailey in London. Of the 12 infanticide cases from 1680–88, nine were declared not guilty and three cases were dismissed for want of more evidence [19, 20]. It is reported that in USA, every year many women committed neonaticide. However, prosecutors did not prosecute, juries rarely convicted, and those found guilty were never imprisoned [9]. In order to address this menace, Thomas Coran founded the London Foundling Hospital in 1730s [21]. This was the first attempt at such a scale through charity. Mothers of unwanted children left their offsprings at a hospital anonymously. In 1818 in Paris, one-third of all babies born in the city were left in the foundlings [20]. Over a period of time, unwanted babies found their way to baby hatches that were constituted as alternatives to keep them under safe custody [22]. A baby hatch could be a crib or a room attached to a hospital, welfare center, orphanage, or other such organization that enabled a woman to leave her child in the care of another person. Some baby hatches even had provisions for women to give birth anonymously. Not surprisingly most of the abandoned children were and are still girls [9].

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China witnessed an upsurge in female infanticide in the 1980s, that is probably linked to the “one-child policy” [9]. Controversies still prevail around the number of deaths that can be labeled as infanticide. Under reporting of female births is a probable explanation that left families with a scope to go for further pregnancies in the quest to have a son. Unwanted and unregistered daughters were put up for adoption or were simply abandoned or killed. In case they survived, they faced discrimination and deprivation of basic rights and needs throughout their lives by virtue of not having legal existence. Several countries in the world currently have infanticide laws—Austria, Brazil, Canada, Colombia, Finland, Germany, Greece, Hong Kong, India, Italy, Japan, Korea, New Zealand, Norway, Philippines, Sweden, Switzerland, Turkey, and the UK. Majority of the nations that have infanticide laws have followed the British precedent and have reduced the penalty for mothers killing infants. It is important to emphasize here that the legal definition of infanticide varies among countries [17]. Little is known about the existence of infanticide in the ancient era or precolonial period in India. As reported, the practice of infanticide was fueled by gender discrimination as well as backed by political reasons in the modern periods [23]. Tax reforms, hypergamous marriages, and retention of local power propelled the need to eliminate female infants. The practice was particularly common among landowners. According to Marvin Harris, these killings of legitimate children happened majorly among affluent sections of the society such as Rajputs, but soon engulfed various parts of the country. With the introduction of land reforms, the landowners incurred heavy losses. To make up for their losses, the demand for dowry rose to new heights. The brunt fell on the girls of the lower castes, who till now considered hypergamous marriage a way to elevate their status by marrying their daughter off to a higher caste [23]. Thus, repercussions started showing up, and there came in an easy solution to get rid of girls! Documents left behind by the colonial administration in independent India showed a direct correlation between the taxation policies of the British East India Company and the rise in female infanticide. The vicious cycle of economy, heavy taxation, bride price and dowry saw girls as the easy prey. With time, infanticide became widespread as British exercised more control over Indian territory [23]. Documentation of this practice began during British rule and continued unabated. Reports started pouring in from different sectors of the country. In 1873, the Female Infanticide Act was enacted to abolish the practice. But by then, this became a trend and once set into motion, it became increasingly difficult to eradicate or to stop the practice, to say the least. The practice of infanticide which was all pervasive in some cultures was not a rare phenomenon till recent past. For example, in some villages in Tamil Nadu, newborn daughters were fed dry, unhulled rice that punctured their windpipes. Some were made to swallow poisonous powdered fertilizer [24]. Mothers were known to drown newborn infant girls in milk in some parts of Gujarat. Smothering with a wet towel, strangling or allowing girls to starve to death are also some brutal facts that find mention in modern literature. Those who survived the assault in their initial days of life became the obvious targeted victims of deliberate neglect in

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nutrition and health care in due course. In many states, girls were given less to eat and less often taken to healthcare providers for treatment in case of illnesses. These practices had received social sanction in the past, in most of the communities [9]. But as the law as an institution evolved, these practices were brought under the legal umbrella labeling them as punishable. However, the desire for a son was so strong that the methods of sex selection went a step ahead to by-pass the laws framed to curb these practices. Instead of clear-cut murders, methods to induce illnesses were also being followed. For example, diarrhea was induced by feeding alcohol to the female babies. Sometimes female infants were exposed to cold by dipping in cold water. They were then taken to doctors for a prescription for the label of a “certifiable disease”. The prescriptions were carefully preserved but medicines never bought eventually leading to their deaths [25]. Avoiding detection of frank killing became as important as killing itself. A 1986 report highlighted that for every 100 boys, 109 girls less than 1 year old and 300 girls between 1 and 4 years died. A comparison with other countries (Bangladesh, Pakistan, Peru, Nepal, Ecuador, Egypt) also showed a similar pattern but the degree varied [26]. In 1992, the Government of India started the “baby cradle scheme” [27]. This allowed families to give their children up for adoption anonymously without any formalities. The scheme could save the lives of thousands of baby girls. The initiative earned a lot of praise. At the same time, it faced criticisms from human rights groups, who said that the scheme encouraged child abandonment and also reinforced the low status of women. The scheme, which was piloted in Tamil Nadu, saw cradles placed outside state-operated health facilities [28]. The Chief Minister (CM) of Tamil Nadu added another incentive, giving money to families that had more than one daughter. A total of 136 baby girls were given for adoption during the first four years of the scheme. Baby hatches were put up in several parts of India. From 1992 through 2012, 2400 girls and 390 boys were saved because of baby hatches in select districts in India [29]. Here let me emphasize that any practice that becomes a custom has its origin as a necessity. Take the example of dowry. Multiple explanations are put forth justifying its practice. Dowry was meant to help the newly weds to set up their house. Some say that it was given to compensate for the amount spent by boy’s parents on groom’s upbringing. The practice dates back to antiquity when polygamy and polyandry was the norm. As long as those practices existed, there was nothing called dowry or bride price. Polyandrous and polygamous forms of marriage could have originated due to changes in sex ratio in the population for any reason whatsoever. For instance, a rise in the number of females as compared to males is a situation that is conducive to giving rise to polygamy. It is believed that as an obligatory measure to prevent more than one woman into a wedlock with a man, the price exacted by the man from the woman’s family took the form of dowry. Bride price could have resulted if circumstances favored more males for every female [30]. In Indian context, this was intertwined with measures to prevent intermarriages between members of different castes. One feature that was noted was that dowry

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17

was prevalent among higher castes while bride price existed mainly among lower castes and tribal population. The probable explanation could be that among lower castes, the coming of a bride into the family meant an increase in the number of working hands to add to the family’s income. While it meant a loss for the family from where the bride came. Hence, a bride price was paid to the bride’s parents as a compensation. In contrast, among the higher castes, the concept of manual laborers did not hold good as per the prevailing caste system and a conspicuously distinct logic applied [30]. Marriage meant addition of new members who would not have to work for a living and hence would not have any responsibility to add to the family’s income. She would in fact be an additional burden on the groom’s family. Dowry was therefore fetched as a compensatory measure. It is very surprising how we have come a full circle with polyandry and polygamy emanating from a demographic imbalance, thus giving rise to dowry.. dowry gradually earning a social acceptance…. Not only that, its acceptance as a status symbol and eventually to devaluation of women’s status… gradual weakening of women power… the low status and growing vision of viewing women as a burden on families… all these giving way to heinous crimes such as infanticide and feticide… distorting the demographic balance even more… and these in turn predisposing to increased incidence of polygamy in certain parts of India and neighbouring countries. A surplus of unmarried men has promoted women trafficking and even sale of girls, e.g., in Punjab, Haryana, and Rajasthan, brides are being brought from Bihar, Orissa, and West Bengal [31]. According to certain reports, the brides are shared among the brothers, a trend toward polyandry [32]. In Gujarat, men have been known to buy brides from tribal areas as there is acute shortage of girls in most communities. This is a bliss in disguise as the economics of rituals compel men to pay a huge sum of money to the girls’ families [33]. In the international market too, intercountry marriages are becoming a part of the social phenomenon [23]. It is but natural that the booming international marriage industry would affect the poor and vulnerable women. The scarcity of women has already resulted in kidnapping and trafficking of women for marriage and increased commercial sex workers, with a potential resultant rise in HIV and other sexually transmitted infections. Other than trafficking, abuse, and violence against women, polyandry may become a norm [25]. To complicate things further, the after effects of sex selection are taking a new dimension in parts of north Gujarat. These areas are witnessing a marked increase in gay activities, presumably due to a dearth of eligible brides [34]. Increasing homosexuality is seen as a reason of raised human immunodeficiency virus (HIV) prevalence and sexually transmitted infections in the region. Sociologists opine that skewing of sex ratio would fuel the trend further.

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References 1. Bandyopadhyay, S., Singh, A.: History of son preference and sex selection in India and in the west. Bull. Ind. Inst. Hist. Med. XXXIII, 149–167 (2003) 2. Zarutskie, P.W., Muller, C.H., Magone, M., Soules, M.R.: The clinical relevance of sex selection techniques. Fertil. Steril. 52(6), 891–905 (1989) 3. Rahm, L.: Gender Biased Sex Selection in South Korea, India and Vietnam. Springer, Cham, Switzerland (2020) 4. Reubinoff, B.E., Schenker, J.G.: New advances in sex preselection. Fertil. Steril. 66(3), 343– 350 (1996) 5. Thompson, J.M.: Chasing the Gender Dream. Aventine Press, USA (2004) 6. Schenker, J.G.: Gender selection: cultural and religious perspectives. J. Assist. Reprod. Gen. 19(9), 400–410 (2002) 7. Spacey Myth or Startling Fact? Having Sex Under a Full Moon Increases Pregnancy Chances?, vol. 2020 (2017). https://www.eivforg/post/spacey-myth-or-startling-fact-havingsex-under-a-full-moon-increases-pregnancy-chances 8. Ngmpv, J.: A literary review of Pumsavana Karama. Int. J. Curr. Res. 9(8), 55722–55724 (2017) 9. Female infanticide. Available at: https://www.gendercide.org/case_infanticide.html. Cited Jun 10, 2008 10. Afonso, C., Nociarova, D., Santos, C., Martinez-Labarga, C., Mestres, I., Duran, M., Malgosa, A.: Sex selection in late Iberian infant burials: integrating evidence from morphological and genetic data. Am. J. Hum. Biol. Off. J. Hum. Biol. Counc. 31(1), e23204 (2019) 11. Ben-Nun, L.: Neonaticide, Infanticide and Filicide, vol. 86. B.N. Publication House, Israel (2017) 12. Hawkes, K.: A third explanation for female infanticide. Hum. Ecol. 9(1), 79–96 (1981) 13. Female Infanticide: History of World Civilization II (2020). https://www. courseslumenlearningcom/atd-tcc-worldciv2/chapter/female-infanticide/ 14. Haentjens, A.: Reflections on female infanticide in the Greco-Roman world. L’Antiq. Class. 261–264 (2000) 15. van N. Viljoen, G.: Plato and Aristotle on the exposure of infants at Athens. Acta Class. 2, 58–69 (1959) 16. Milner, L.S.: Hardness of Heart/Hardness of Life: The Stain of Human Infanticide. University Press of America, USA (2000) 17. Hatters Friedman, S., Resnick, P.J.: Child murder by mothers: patterns and prevention. World Psychiatry Off J World Psychiatr Assoc (WPA) 6(3), 137–141 (2007) 18. Kilday, A.-M.: The archetype of infanticide in the early modern period. In: A History of Infanticide in Britain c 1600 the Present. Palgrave Macmillan, London (2013) 19. Callahan, K.: Women who kill: an analysis of cases in late eighteenth- and early nineteenth-century London. J. Soc. Hist. 46(4), 1013–1038 (2013) 20. Newman, S.: Infanticide (2017). https://www.aeonco/essays/the-roots-of-infanticide-rundeep-and-begin-with-poverty 21. McClure, R.K.: Coram’s Children—The London Foundling Hospital in the Eighteenth Century. Yale University Press (1981) 22. Child Abandonment and its Prevention in Europe, vol. 2020. The University of Nottingham, UK (2012). https://www.resourcecentresavethechildrennet/node/7082/pdf/7082pdf 23. Hvistendahl, M.: Unnatural Selection. Public Affairs, USA (2011) 24. Dasgupta, P.: Disappearing daughters and son preference in India-issues and challenges in the present scenario. Int. J. Adv. Res. 5, 1741–1748 (2017) 25. Bandypadhyay, S.S.A.: Sex selection techniques and declining sex ratio in India. Gyan Publishers, New Delhi (2010) 26. Joni Seager, A.O.: Women in the World: Pluto Press (1986)

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27. Srinivasan, S., Bedi, A.S.: Daughter elimination: cradle baby scheme in Tamil Nadu. Econ. Pol. Wkly. 45(23), 17–20 (2010) 28. Kumaravel, K.S.R.B., Pugalendhiraja, K.V., Karthick, N.R., Santhoshkumar, S.: Profile of babies admitted in cradle baby scheme and review of female infanticide in Dharmapuri. Pediatr. Oncall 13(2), 40–43 (2016) 29. Mohanty, R.I.: Trash Bin Babies: India’s female infanticide, vol. 2020. The Atlantic, India (2012). https://www.theatlanticcom/international/archive/2012/05/trash-bin-babies-indiasfemale-infanticide-crisis/257672/ 30. Kumar, M., Khanna, M.: A man of renaissance: Raja Ram Mohan Roy Delhi. Farsight Publishers and Distributors (2015) 31. Estal, E.: ‘I was bought for 50,000 rupees’: India’s trafficked brides—in pictures, vol. 2020. The Guardian (2018). https://www.theguardiancom/global-development/2018/mar/07/indiagirls-women-trafficked-brides-sexual-domestic-slavery 32. Dheer, G.: Brides purchased and exploited in Haryana, vol. 2020. Herald D (2019). https:// www.deccanheraldcom/exclusives/brides-purchased-and-exploited-720025html 33. Rupera, P.: Dowry system in reverse shields tribal girls. Times of India, India (2006). http:// www.timesofindiaindiatimescom/articleshow/1669255cms?utm_source=contentofinterest&utm_ medium=text&utm_campaign=cppst 34. Jelovsek, F.R., Mattison, D.R., Chen, J.J.: Prediction of risk for human developmental toxicity: how important are animal studies for hazard identification? Obstet. Gynecol. 74(4), 624–636 (1989)

Chapter 2

Exploring Preparations for Sex Selection: Opportunities and Hurdles

Be fearless in the pursuit of what sets your soul on fire. Jennifer Lee

2.1

An Exploratory Study to Unravel Facts About SSD

Our busy schedule of teaching and training at PGIMER kept us on toes. Nevertheless, I was quite persistent in asking people around us about those strange preparations—something that help women have sons if consumed during pregnancy. This kept happening for a few days. I discussed the issue with our colleagues also. They frowned at the practice but the topic did not seem to have caught their fancy. I found that there was a subtle avoidance on the part of the health workers probably because I was being quite pushy. But I had to do… I have this bad habit of nagging….once it enters my head! I remembered of a traditional medicine doctor, who used to run his own clinic in our field practice area. It was Naraingarh, a block in district Ambala, Haryana. PGIMER has been running its rural health training center for more than 30 years. Rural community from the surrounding villages, frequented the subdivisional hospital that stood in the heart of the city, where PGIMER provided outdoor patient department (OPD) services along with several other specialities from the Government. An old-fashioned building with high ceiling; windows positioned across the big doors to aid cross-ventilation and to circumvent the use of air-conditioners; scaly walls with worn out colors that were painted decades ago; ample space surrounding the main building that conveniently gave birth to bushes to shelter dogs and cats generations after generations… these were not enough to describe the place where doctors from Community Medicine Department spent a substantial period of their residency learning the essence of public health. In fact, most district hospitals conformed to these features in late 1990s. The community had a lot of regards for PGIMER doctors of the hospital that was otherwise manned by staff and doctors from the Government, for the quality of services provided at no cost. Other doctors too respected the young professionals in © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 S. Bandyopadhyay Neogi, Gender Before Birth in India, https://doi.org/10.1007/978-981-16-3318-8_2

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the making who spent few months of their residency, perhaps the most precious period during their lives to shape up their attitudes and orientation to serve the community later in their career. People from alternative system of medicine also had deep regards for PGIMER doctors. There was one who was posted to a center close to our hospital. Should I go and talk to him? I thought. I had never interacted with him earlier. One day, I visited his dispensary that was closeby and initiated a discussion around this topic. “Could you please brief me about the medicines taken for a son?” I asked abruptly without giving any background of the topic. He was taken aback. He looked at me probably thinking that it was a ploy to catch him red-handed doing things that were traditionally unacceptable to modern medicine community. “How do you know that such a practice exists?”, he reacted immediately. I could not take anyone’s name but said, “when someone wants a son, they generally come to you. I want to know more because if I come across such families in villages, I would refer them to you.” He apparently got convinced and said, “you people belong to the modern system of medicine. What would you understand about the Ancient system of medicine? It was much more scientific. Therapeutics of today’s generation evolved from ancient schools of thought. But see, how people condemn traditional medicine!”. I just accepted whatever he told me as my main purpose was to gather as much information as possible. He was an Ayurvedic (alternative system of medicine) doctor who wanted to do MD (Masters of Medicine). He briefed me about his MD thesis which was on changing sex of an unborn child with medicines. He was never awarded the degree because of the unethical nature of the topic. “What was the topic?” I asked. “You come to my house one day. I will explain everything to you,” he said. His body language somewhat made me feel uncomfortable but at the same time was fully aware that he could be very resourceful for my expedition. Any ways, having discovered this much, I felt like discussing it with my supervisor, Prof Amarjeet Singh who was always forthcoming. I told him everything and as I was speaking, I could see the excitement in him. He encouraged me to explore it further. Dr Singh, a simple clad man of medium height—he is a teacher, a true, sincere, eager man—especially when it comes to enthusiastic students. It is the eagerness of pursuit, the natural flow of ideas beyond the bounds of a restricted mind and honest advice… that inspires one to dream of great things. He is a perfect embodiment of the ideals of a great teacher! “I am hearing it for the first time during several years of my practice in public health. You should not stop exploring,” he said. I mentioned to him about the doctor and requested him to accompany me for another round of interaction. He was positive and I quickly fixed up a date when I could visit him.

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In the following week, Dr Singh and I reached his clinic at around 11 in the morning. His was a small room enough to accommodate 5–6 people, a table laden with white cover that seemed to have never been washed since it was bought. There were four wooden chairs, and he was surrounded by some patients. A boy about 16 years old, who had fever for few days, came with his mother. He prescribed him some antibiotics that he said would be available in the next door shop. Ayurvedic practitioners have the liberty to prescribe both allopathic and Ayurvedic preparations in this country. The moment he saw us, he greeted us warmly and ordered for some tea and biscuits. People in rural areas, till date, are warm hearted and are more courteous than their urban counterparts. They hold their guests at a higher esteem that may seem to be awkward to some. But I, who grew up in big cities, enjoy this sort of gesture… something that has still not been contaminated by the ethos of the so-called civilized urban culture. We waited for sometime for him to disperse the crowd and then our conversation began. I was trying to remind him about the medicines for a male child, but he stopped me before I could complete the sentence and said, “It is not a myth, it happens.” “What was your thesis about,” I asked inquisitively. “I gave some herbs to the pregnant women who were carrying female babies.” “How did you know who were pregnant with female babies?”… I asked instantly. “Once a woman gets to know that she is pregnant, we can test and tell with certainty whether she is carrying a male or a female baby,” he answered. “But, how is that possible?”. “There is a trick. Every morning the pregnant woman would have to irrigate barley and wheat seeds with her urine. If the wheat seeds germinate, it is a female baby and vice versa.” “What an easy and quick method” I thought. “And then? If it was a female baby, I gave her some medicines.” “What medicines?” Dr Singh asked. “Primarily Shivalingi seeds. The name suggests gender of Lord Shiva and the shape of the seeds also corroborates this,” he replied. “Strange!” Dr Singh said. “Can I have a look at your thesis?” I asked. “You have to come to my house. I will show you,” came the instant reply. I thought to myself, “he is hell bent on making me visit his house and without that he will not give me.” We left the place after our interaction but that left me with a lot more questions. I could not tell Dr Singh how much curious I was to see his thesis and at the same time my sixth sense would not allow me to visit him alone. This was during one of my residential postings at Naraingarh block in Haryana. When our duty was over, I asked my support staff to accompany me to the doctor’s house. There were two junior doctors posted with me. They along with our male

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health worker, security guard, gardener and a driver all drove to the doctor’s house the same evening. We knocked the door and there came out a young girl, barely 15–16 years old, perhaps a maid working in that house. We introduced ourselves and said, “Please call the doctor. Inform him that some PGI doctors have come to see him.” After a few minutes, he came out and was literary shocked to see the huge crowd entering his house. Offering tea was usual and I did not dare to say no. We introduced the other doctors to him, and they had a quick chat around working in rural areas, difficulties faced and so on. No sooner did we finish our tea, than I asked for his thesis. He went to his room and gladly got it … I could never get my degree ….he mentioned. “Can I get this photocopied?” I asked. “Yes, of course. Let others go and get it done. Meanwhile, you be here. I will tell you more about this medicine.” “But… I will have to indicate the pages because I cannot get the entire document copied. I will be back in an hour Sir.” I got up as I was completing my sentence and left the place in haste holding the thesis tightly in my hands, lest it got snatched by someone. I requested my staff to photocopy select pages, and the thesis was handed over to the doctor the same evening. Certain behaviors are not very difficult to assess. As soon as I reached the hostel, I was told that Dr Singh had called and was waiting to hear from me. Usually he would not, unless there was an emergency. Dr Singh with all his years of experience could easily gage people, their intentions, and outlook. He has the deepest sense of the sacred vocation of a teacher. “Please do not go to the doctor’s house. No need to look at his thesis. Try to explore the facts yourself,” he said. By then, I already had the copy with me. With this, my determination to explore increased even further. I realized that this is a rampant practice but no one talks about it so openly. Probably they are scared of the laws in place. I now became more confident and I knew how to extract this information from people. The following weeks I interacted with at least 50 Key Informants (KIs) ranging from village folks to doctors, Traditional Birth Attendants or Dais as is called in colloquial language, and many more. I was amazed seeing the similarities in the advices given Medicines for a male child are to be taken at one and a half months of pregnancy at dawn. One would have to identify a cow, who has recently given birth to a bull calf. The milk of that cow is of utmost importance. On the day of consuming the medicines, the prospective mother would have to get up early morning, pray for a son, look at the picture of a boy, consume the medicine with this milk and have only milk products made out of this milk throughout the day.

The instructions are stringent enough to justify the failure, if at all it happens.

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Dr Singh is a keen researcher and believes in documenting findings. He suggested that we should try and explore how many women are aware of such medicines and how many consume them on an average. He asked me to design a small study only to gage the extent of the use or abuse, whatever one may say. We planned to survey all the women in the reproductive age group in three villages and some 100 women randomly picked up among those who came to the Naraingarh subdivisional hospital. I got in touch with the health worker, Pooja [name changed for ethical reasons] who refused to divulge information when I asked her for the first time months back. I requested her to conduct the survey because she was familiar with the community and language both. People were fond of her implying that they would reveal the truth to her with ease and comfort. She was the right choice for the job. We designed a short and simple questionnaire and asked her to visit every woman in the reproductive age group (15–45 years) in the three selected villages. The questions included the number of children along with their gender, whether they had heard about the medicines and if they had ever consumed them. The results of the survey were mind boggling! Almost 90% of the women had heard of such medicines being consumed and 40% confessed having taken such drugs anytime during their lives. It was clear that women who had more numbers of daughters were more likely to have consumed such medicines [1]. Such a common practice it is, but academia, programmers, and researchers are completely unaware! So appalling it is! We named this medicine sex selection drugs or SSD in short. The next phase of my mission was to see how those medicines looked like. I went to a nearby chemist shop and asked if I could get some medicines for a son. He, who apparently knew me as a PGI doctor, frowned at me. I could read his thoughts…. Why is she asking for these? She seems to be unmarried.. but …?? Should I tell her or shouldn’t I? Then with a superficial grin, nodded his head conveying a kind of disapproval. I also could not dare to ask him anything else. I realized that it would not be possible for me to go around asking for such medicines. No one would give me those preparations, I was sure. Should I tell Pooja? Am not sure how she will take it… or should I go somewhere else? But where and how? I wondered. Several questions kept popping up in my mind for which I had no answers…. Neither I was in a position to discuss with anyone, nor was I able to come up with a solution on my own… perhaps the only option could be to approach people as a pregnant woman longing for a son… and I made up my mind. Acting was not my cup of tea and I dare not do it. But what is wrong in it? I may not do it in my close vicinity for fear of embarrassment, but in an unknown place? Where no one knows me??? Well. I would have to travel an extra mile if I have to pursue my interest.

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When we were contemplating how to go about it, there came in an assignment. We were roped in a study to evaluate safe injection practices in the entire country and were given the responsibility to do it in Haryana. The study was commissioned by International Clinical Epidemiology Network, InClen. The exact locations across Haryana where we were required to visit were predecided based on some sampling strategy. Dr Singh and I fortunately were in the same team. We decided to capitalize this opportunity to explore more about SSDs. It would mean taking out some time from our schedule to interact with the right kind of people. The first site for assessment was a private clinic in Yamunanagar district. When Dr Singh went to interview the doctor, I was busy finding out from the attendant about who could help me with the medicines. She said she knew someone but he stayed in the neighboring village. She continued, “Moreover, you have to place an order and collect the medicine on the following day. These have to be prepared. This is not something like paracetamol that you go to a medicine shop and buy.” It would mean revisiting every place twice. We would have to keep in mind wherever we visited next. In any case, the survey demanded 3 days visit to every district. Whatever it was, I did not want to miss the chance and confirmed that I would revisit her the next day. I now wanted to see with my own eyes how these looked like. I therefore agreed to pay Rs. 250 that he asked for and took his phone number. Very happy with our first positive attempt, we then moved to Ambala district. We enquired and learnt about two shops where those were sold. They sold the drugs over the counter but after one day of placing an order. These are given only to pregnant women. So, I pretended to be 1 and a half months pregnant with two daughters and no bachcha (child). That is what people commonly say, a “child” means a “son” in Haryana. A daughter can never get the status of a child. She remains a daughter forever. So, we now had three samples with us and felt that those were much more precious than anything else in the world. We knew that the ingredients were largely Shivalingi and Majuphal herbs that are commonly used for other purposes also. So, we got these from the grocer’s shops. People refer these medicines as ‘Su badalne ki dawai’. ‘Su’ in Haryanvi dialect means reproductive system. There is a belief that a daughter is born when there is some ‘defect’ in the reproductive tract of a woman. These medicines are meant to bring about some alterations in the reproductive tract so that she starts bearing sons.

Our next destination was Kurukshetra. We reached the District Hospital and went to the Emergency Ward to observe how the staffs were handling the injection wastes. I went to a sweeper who was busy cleaning and told him, “I am one and a half months pregnant and have 3 daughters. I want a son. I have heard that someone in this hospital gives such medicines.” I was so confident in saying that he could not refuse. Slowly, he said, “Come with me. The yellow building that you see from here.. is the place where you have to go. Some construction is going on, so be

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careful when you go. When you get there ask for a person named Kamal [name changed for ethical reasons]. He will help you. He is a gentleman and very helpful by nature. But please don’t take my name.” I did not even bother to know what his name was. I, however, thanked him and went to the yellow building to reach out to Kamal. We were successful in getting the fourth sample. While we were leaving, he said, “You do not have to give money Didi [elder sister]. You first take the medicines. Get an ultrasound done in the fourth month of pregnancy. Once you are sure that it is a boy, you can pay. Such was the level of confidence.”

Sex selection Drugs… at a glance

We traveled to various clinics in Kurukshetra. An interesting thing happened there. Dr Singh and I went to a man repairing bicycles enquiring about someone who could help us with the medicines. He referred us to another person who owned a small shop to repair utensils. He said that there was a clinic closeby and the doctor there prescribed such medicines. We went inside the clinic. The doctor had gone out for lunch. The guard asked us about the purpose of the visit, and we said that we came in search of drugs for male child. He said, “our doctor madam gives such medicines but you would have to wait.” We waited patiently for 30 min and then she turned up. “What do you want?” she asked. She sounded quite rough and looked like a person whose every minute was measured in terms of money. Well, private practice is meant for that. Dr Singh was quiet. So I said, “we have come here to get some medicines for a son.”

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So, both of you want to have a son. I became red seeing Dr Singh getting embarrassed. That was Dr Singh, a middle-aged gentleman with two grown up daughters and me, a young unmarried girl standing in front of the doctor wondering what could she have meant. In no time, Dr Singh said, “We are doing some research on something and we would like to talk to you.” Hearing this she became furious and frowned at both of us until we simply left the place in shame. We could hear her shouting at the guard for letting wrong people in. The moment we came out hurriedly and were searching for the men who were repairing the bicycle and utensils… both went missing. How could they simply vanish in no time? We wondered. But we realized that such messages spread very fast. We next moved to Panipat. This time I was even more self-reliant and I was alone. I went to a rickshaw puller and requested him to guide me to someone who sold such medicines. “I hope you wont mind,” I said. “It will be a blessing for me if I can help someone have a son,” he answered. How differently people behave and think, I thought. Even gestures like guiding people to find the right place for SSDs were also taken as an act of kindness. From here also I could get one more sample. “What will happen to this world?”, I wondered. The last place to be visited was Sonipat. As confident as ever, I reached out to a female health worker. I introduced myself as a doctor and told her that I was pregnant and that I needed medicines for a male child. She was very kind and helpful, may be because I was pregnant. Or it could also be because I came for an inspection and she wanted to impress upon me. She took me to a chemist shop and introduced me to the owner of the shop. He too treated me well because I was an acquaintance of someone familiar to him. He offered me some cold drinks and handed over a pack of capsules to be consumed for 21 days. Why the hell did I make up stories to convince people that I was genuinely needy for a son when it is so easy to get such medicines? There was no need to come again, no hanky-panky, no beating round the bush. A simple and straightforward demand and so was the supply. I thanked him a lot for the hospitality and the medicines of course. “We want to serve the community. We have helped many people till date to have a son. There has never been a single instance of failure. Yours will also be successful,” he said. What a way to serve the community. No campaign, no health education, no trainings… only by word of mouth—the message spreads. This can be the biggest game changer provided you have an innate desire. Such is the case here.

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Pamphlets with instructions to be followed while consuming sex selection drugs

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The preparations were strikingly different in terms of physical characteristics. Some were capsules, some small balls of paste made from herbs, some mixtures of seeds or concoctions. We also managed to get some ready-made pamphlets distributed along with the preparations. Amazing to see how people become organized when it comes to meeting clients’ demands. In my brief career till then, I had never seen anyone distributing pamphlets so meticulously on public health problems such as anemia or diarrhea or breast feeding, although the Government spends millions of rupees on such programs. With almost ten samples now, I felt I had conquered the world. Dr Singh as encouraging as ever never refused to share his excitement over our small yet big achievements. Now, what do we do with these samples? “Get them analyzed” was an obvious answer. But how and where? We had no clue. I first approached the Pharmacology Department of PGIMER. They listened to my request but said that they would not analyze unknown samples. If they don’t, who else will? After that I contacted NIPER, National Institute of Pharmaceutical Education and Research… They said, “You have to tell us what to look for.” Did I know what we were looking for? What exactly was in those medicines that we wanted to see? That was the whole mystery. “For analysis of unknown samples, you have to submit a proposal (worth 1–1.5 lakhs) and then we will see,” a scientist from NIPER remarked. From where the hell will I get so much of funds? I was taken aback. I discussed with Dr Singh but he too had no clue about how to go about it. We spent almost 15 days thinking about the way forward. There was a food and drugs laboratory adjacent to PGI. Just thought of visiting it one day. So, one fine afternoon I landed there. It was 4 PM. People were busy winding up their day’s work eager to leave as the clock struck 5. I approached a man who fetched some papers from one counter and took them to a scientist for his signature. I seemingly was looking lost, so he asked me, “Have you submitted your sample or are you here to collect your report?”. “Can you please tell me where should I deposit the sample?” He directed me to a counter. A man in 50 s was scribbling through some worn out papers and was purposefully avoiding eye contact with me… “Excuse me” I said, will you accept my sample for analysis?”. “What kind of sample?” he asked. “Sex selection drugs,” I answered. He could not make out anything. “What? We do not do anything unethical.” I did not understand what was unethical about it. The word “sex” must have embarrassed him. Anyways, he shunned me away, so there was no point irritating him anymore. I returned home upset. I decided to visit next day again. I thought I would approach someone else. The following day, I reached at 4. I walked in stealthily making sure that the man who saw me the previous day was not there.

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I saw him from a distance and quickly took a turn and then a flight of stairs to reach the upper floor. “Can you please help me?” I asked a man who looked quite sensible behind his pair of thick glasses. “What?” he asked me. I decided not to utter the word “sex selection” and said “some herbal preparations.” He sent me to a woman scientist in the adjacent room. I introduced myself as a student from PGIMER. “I have some samples and want to get them tested.” “What kind of samples?” she asked. “Some herbal preparations,” I replied. “What are you looking for?”. “I don’t know.” “Then why are you here?” she asked with an irritable expression on her face. That is why I came to you,” I replied. “How can I help you? I don’t understand. What to test? What is the point of testing if you yourself are not clear what you want?”, she said. She was right. I had no answer to satisfy her. I was confused and returned home. The next day, again I went to her. “Madam, I need your support for the analysis.” “Why don’t you ask PGI to do it?” I could not tell her that PGI’s response was negative. Why would someone listen to a student for no rhyme or reason? The following day when I went to her she said, “I see you are coming here everyday. I feel bad. What are these preparations? Show me.” “I don’t have them right now. I will get them now.” She stopped me. “You can get them tomorrow. By the way, how did you get these samples?”. I was in double minds whether to utter the word sex selection. Then I thought it is better to be honest with her at least. Said and done, she did not shy me away. I therefore, revealed everything. She became quite emotional listening to me. She offered some juice and began narrating her own story. “I am considered very lucky in my family. Do you know why?”. “Why?” I asked. “I am the sixth daughter of my parents and I have two BROTHERS after me.” Why is she lucky then, I wondered. “Because of me two BROTHERS were born,” she replied. I could sense the humiliation in her voice. “So ridiculous! But things have not changed in 50 years. Our mind set continues to be as primitive as before,” I thought. Soon we became good friends. The next day, I rushed with one capsule and handed over to her. “We should analyse these samples for steroids,” came out instantly. Steroids because these are known to be common ingredients of most irrationally prescribed products.

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Two days later, I went to collect the report. It was indeed positive for steroids. I was thrilled! “What next?” Madam asked. “Please see if it contains testosterone, a male hormone.” Why I told this, I had no clue. Because it has got something to do with gender? I still am clueless. “But I need some standards to compare these with.” “Please consider Injection testosterone. Will that do?”, I tried to satisfy her to the extent possible. And with this, I handed over a small portion of each sample to her.

The first laboratory report confirming the presence of steroids in sex selection drugs

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After a week, I went to collect the report. Six out of ten samples were positive for steroids and/or testosterone. I was overjoyed! I thanked this lady a million times in my mind and wished that all her wishes should come true. With the report in hand, I was literally running like mad till I reached my hostel. Cool down, I told myself. What is there to celebrate? Imagine the plight of the women of this country and the damage that these medicines can do. Steroids or steroidal preparations are a big NO NO in pregnancy. Still, I could not control myself. Those days, cellphones were not so much in fashion. Moreover, a traditional approach toward elders and teachers especially prohibited us from calling them any time of the day. I eagerly waited for the night to pass off and waited to reach the department and show the report to Dr Singh. He was delighted and as expected of him, he asked me to document the whole thing. “It should be documented that you are first person to have reported this practice and the first one to work on it. This has great social relevance and implications.” The whole world knows about it … but it has never surfaced up…. Probably because people cannot relate any natural products with any harms?? Or because it is mentioned in ancient texts? … I had no explanation whatsoever. Although I did appreciate his advice yet I somehow felt that it was an incomplete piece of work. Anyways, I started working on it. I kept discussing with my friends about this problem and how we were investigating. Someone from Tribune contacted me one day (he must have known through one of my acquaintances) saying that they wanted to cover a story on this issue. It was finally done on August 6, 2003. “From now on… SSD is your baby…” Dr Singh remarked. We kept looking at each other as he said. I was thinking why he has to tell this all the time. There were bound to be differences, for he was a man with lots of experiences and one who has seen and known people more closely and me, a clean slate, who was full of hopes and aspirations and yet to begin to see life as it is. I used to discuss with everyone about our work with a hope that someday someone would offer some kind of help. But who has time to think about all this which has no funds, or any other incentive attached to it? During one such conversation, I was talking to a senior scientist from the Experimental Medicine Department at PGIMER. I requested if he could analyze the drugs that we had collected. There was no need for reanalysis probably, but I felt that more in-depth analysis was required. If we had to claim that SSDs contain steroids, a much stronger evidence was required.

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First report of SSD use in the media

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He listened to me with interest and said he was traveling to Ahmedabad (National Institute for Occupational Health or NIOH) for some work. He said he would give them the samples for analysis. I gave a portion of every sample to him. I was longing for him to get back with some answer. After about 2 weeks or so, I went to his office. He said very coolly that he was told that the samples contained estrogens and testosterone both. I was surprised and at the same time quite excited. “Can I get the report, Sir?”. “Yes, I will tell them.” Days and months passed by waiting for some written communication to reach me. Though I shifted my base to Delhi, it did not stop me from following up with him. But finally I could not succeed. I always thought I was good at chasing people… so much so that I would irritate them to the core if I decided to do something. But here he turned out to be more adamant than me. What could have been the reason? For not giving me the results? Did he lie in the first place? If yes, why did he do so? If no, why was he so reluctant to share the information? Did NIOH people refuse to give him in writing? May be because it was not a funded project. Or what else could have been the reason? Or he thought that I would take his name when the analysis was not done by him. Or was there any restriction about sharing results by NIOH. I tried to imagine to get some answer but could not find one convincing enough. He could have frankly told me the reason, I thought. One thing I realized was that scientists cannot behave so irresponsibly when it comes to research. If not for anything else, they have no right to play around with the emotions of a researcher. As advised by Dr Singh, I started working on the manuscript with whatever results I had. After a lot many iterations, it got finalized. It was not a very robust paper but most precious output for me till date because that was my first visible tangible gain. The next question was, “which journal?”. I aspired to submit it to an international journal but knew well that it would not be accepted for the paper lacked the required scientific rigor. I got to know that Geneva Foundation of Medical Education and Research (GFMER) was launching its inaugural edition. I wanted to make an attempt but was a bit scared. “What worst can happen?” I thought. “It would be rejected. What more?” We then submitted it to the journal. After 2 months or so, we got a response saying that one of the reviewers requested for accepting the paper while the other one refused. On the whole, editorial decision was against accepting it. We then decided to send it to another journal. After months of wait, a response came, “the issue raised by the authors is pertinent. However, sex cannot be changed after conception. This is a myth. Publishing such papers would promote such wrong practices. Hence we cannot accept it.”

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“Gosh! What a response to get from the scientific community. Is it not the responsibility of the scientists to dig out more information to know if something is yet unexplored? I would have appreciated if they had mentioned that they would like to validate the information before publishing.” We then turned to another Indian public health journal. Again, after months, they said they would publish the paper provided we comply with some corrections which they indicated. We adhered to their instructions, and finally our first paper was published in 2007 [1]. By this time, I had relocated to Delhi. When I was leaving PGIMER, Dr Singh told me “Never stop working on SSDs. This is your baby and will continue to remain yours.” These words kept ringing in my ears every now and then. A true teacher… his love for his students is at the core of his being. There was a pathos in his tone and something very inspiring when he said, “SSD will take you very far. Be on it.” When in Delhi, I was surfing the net one day and I discovered that Center for Disease Control (CDC), Atlanta, had declared the year 2004 as the year of prevention of birth defects. I thought for a while whether I should write to them about this problem in India. And I did. After one day, there was a response from Jenny [name changed for ethical reasons]. She thanked me for the mail and said she would get in touch with few more experts from India and have their opinion. I was glad that at least she paid heed to my query. Along with her mail, there were 7–8 questions on sex ratio in India. SSDs cannot influence sex ratio. Nevertheless, I took no time to frame responses to those questions and was hoping that they made some sense. After that there was no response. I waited for a week or so and sent an email to know about an update. She replied saying that the experts from India working on birth defects mentioned that it was not a common practice. Why would CDC listen to me when there were experts in India much more qualified and experienced than me! I got disappointed but there was none I could share this with. “Why am I breaking my head for a thing that no one is willing to believe?” But I must not stop. I remembered Dr Singh’s words and went on. I thought to myself… if I have to popularize it, I need to have publications or I join an organization which is more receptive to such issues. Adversities beget ideas… it stretches our imagination. Few weeks back, I had received an assignment from UNICEF, India country office. I immediately agreed, firstly because it was UNICEF and any public health person would like to have a UN tag attached to his/her name. Secondly, I thought UNICEF works for children. The organization would be more sensitive to such malpractices that affects the health of mothers and children. It took me almost 3 months to settle down and after that I gathered courage to discuss this issue with my supervisor. He did not seem to have gotten interested in the topic and told me that SSD was not UNICEF’s mandate. Well it wasn’t. But is it not an organization’s responsibility to know the unknown? But why should they. Especially when a request comes from a small fry like me. Still, in order to satisfy the curiosity of a

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young professional, my supervisor asked me to get in touch with a Geneticist from a reputed private hospital in Delhi. I contacted him in no time and immediately came his response because the mail went from UNICEF. When I discussed with him he said, “It is not a very common problem as you think.” He seemed not so interested, I could make out. Then one day, an NGO representative from Uttarakhand visited UNICEF for a possible funding for their project. I was asked to discuss the proposal independently so I took that opportune moment to discuss if they were aware of SSDs. Their affirmative response was a big consolation for me since I felt quite lost amidst all meetings and hustle and bustle of Delhi life. As the city, so were people’s attitudes. “Can you get me some samples that pregnant women consume for a son?” “Yes, we can. How many do you want?” “Around 20,” I said. “Okay. We will collect the samples and parcel them to you.” Four months later, I left UNICEF. There was no response from the NGO. After almost a month, the lady from the NGO called me. “Madam, have you received our parcel?”. “The samples, you mean?”. “Oh yes, we have sent 25 samples to you.” I ran to UNICEF office the very next day. But there was no parcel in my name. Amidst all these, I got convinced that the practice is not only confined to Haryana and Punjab but is common in other parts of north India as well. Meanwhile, there was a news that sex selection for social reasons was banned in the UK. I wrote a small piece for an Indian journal—to ensure that the topic does not go off the radar. Otherwise also, people were grossly immersed campaigning against female feticide… the only equivalent of sex selection. My write up was accepted in Journal of Indian Medical Association (JIMA) in 2005 [2]. In 2006, an article by Dr Prabhat Jha was published in the Lancet [3]. The manuscript talked about sex ratio in India. I wrote a comment mentioning SSDs and that was accepted for online publication. At least something was happening. In 2007, our first research paper got published and now we had some evidence to say that this is a malpractice. As I write, I am reminded of my visit to Baroda, Gujarat, way back in 2004. We visited a PHC for training female health workers. Since the time, I have known SSDs, I have tried to capitalize every opportunity that has come in my way to explore more and more. The training comprised of 20 health workers from different parts of Gujarat, one pharmacist, and two medical officers. The duration was for 3 days. I had enough time in my hand and hence desisted from asking questions on the first day itself. Instead I used every moment to familiarize myself with their daily routine activities, family responsibilities, etc. All the participants were comfortable speaking Gujarati… they could follow Hindi clearly but could speak broken Hindi….. enough to express themselves. For the purpose of the training, many technical words were used. Even without having much knowledge about the language, one could easily join the dots and give it a meaning…. In many instances, I would

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paraphrase in Hindi and ask whether I was correct. Their positive nods and affirmative smile gave me confidence. But I wondered, how would I ask them about SSDs. In Haryana, people called it “Su badalne ki dawai.” That will not fit into Gujarati dialect. “Ladka paida karne ki dawa” [medicines to beget a son]—would it be okay? Can I use the word “select”? Select was a medicine that was popular in Gujarat… to be taken for a male child for 45 days after conception. Someone filed a Public Interest Litigation (PIL), and then the medicine was banned. This was documented in a study published in 1991 [4]. And the year was 2004… 13 years post that publication. I tried to identify an Auxillary Nurse Midwife (ANM) who was relatively older [In India, ANM refers to a female health worker] …. Younger ones may not know or may be reluctant to speak in front of their seniors… In our culture, this still holds good. Out of respect or humility or one may even say that, people who are junior in professional hierarchy maintain their modesty. This is quite a tradition in our culture and can be observed in rural settings till date. Urbanization is gradually breaking this barrier. This could be a Western influence… where every professional is treated equally. Everyone gets an equitable share of responsibility and respect in professional circles. My search continued for a day to identify the right person who could do my work—a relatively senior and someone who was more familiar with Hindi more than the working knowledge. I caught hold of one but was not very confident. Anyways on the second day during lunch, I purposefully went and sat next to her. Her name was Sheela [name changed for ethical reasons]. After few eyes breaking questions, I made up an anecdote and narrated: “I went to a friend’s house last week. Her aunt had came to her place. She was depressed as she was being tortured by her mother in law. She had a daughter who was studying in 10th standard. Her husband was after her life to give the family a son. She had already undergone abortion thrice.” She told me. I want another child but do not have the courage to abort it if turns out to be a girl… She therefore came for a solution. When she saw me, she confided in me. Doctors, I know give medicines for a male child. Can you please give me some? I didn’t know what to tell her. I don’t know about such medicines. But that lady said that these are available in this city. Is this true? While I was narrating the self-made story, I didn’t find her raising her eyebrows and for her expressions; I could guess, she wasn’t taken by surprise. It happens Madam. Your friend is not wrong. There is a doctor who has a clinic hardly 100 m from the center. People from far off places…. America, London visit him for this very purpose. The results are 100%. In our country till date, people hold America and London as supreme and a proof of authenticity of the highest order. “Can I visit him?”. “Yes you can. But he would want to meet the pregnant woman. He examines the patient to look for certain things before prescribing anything.” “People from America. London?”, I feigned ignorance. “Yes. They travel all the way,” she replied calmly.

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“During pregnancy?” I asked Sheela. “Why not? The distance and the pain of travel are worth the efforts. These are nothing compared to the agony that she would have to experience later… either through abortion or mental torture,” she said. My God. Things are the same everywhere. I thought to myself. “I would go and meet the doctor myself. But wouldn’t it spread a message that a doctor from Delhi wanted to have these medicines?” Or I can just tell them that I want to explore. That’s all. Anyways, I asked her to take me to the doctor. Can we go anytime or do we have to take an appointment? “We can go anytime. He gives preference to doctors.” We went to his clinic. It was a three-storied building, beautifully painted and maintained. There was a small garden in front and a big courtyard converted into a waiting area for patients. There was a security guard in proper uniform and a young lady, a receptionist to prepare the cards. As we walked in, the patients got aside to give us way… it seemed as if Sheela was a regular visitor to the clinic. “Namaste.. Namaste..” [greetings in Hindi]. “Namaste.” “I will go and inform the doctor” she said. She walked in and we were called inside after 5 min. “Namaste Madam. Please let me know how can I help you.” Sheela introduced me to him saying that she needed some medicines for her friend. I was in a fix. How should I begin? “Yes, a friend of mine has asked me to find out if she can get some medicines for a son. I don’t believe in such things but she is a firm believer that these work. I want to know more about it. Traditional medicines are sometimes quite scientific but we do not know. Can you please enlighten me on this?” “Who told you that you will get the medicines here?” he blurted out. “No.. no. I have not come to get the medicines. I just wanted to meet some learned people who can share their perspectives,” I said. “Oh ok. You know I also don’t know much about these medicines. But some quacks sell them. How can you change the sex of a child? … you tell me….” He said very convincingly. “That’s what I was wondering,” I replied. “But any idea what do the quacks give? You seem to be quite respected in this area. And people respect those who are honest and knowledgeable. I am sure you would know something about it.” He was looking quite hesitant to disclose anything. I have to ease the situation, I thought to myself. “Can I get a glass of water please?” “Yes, of course. Would you like to have some tea?” “Of course yes.”…. I was in fact longing for this. I tried hard to make him feel at home, but could not succeed.

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Then Sheela chipped in. “I have heard people say that you have to face the east and put something in the left nostril,” she remarked. “Yes.. yes.. you have to stand under a banyan tree and chant something and put a drop of concoction into the left nostril. These are mere beliefs. I don’t think these even work,” he continued. I was convinced that he had made up his mind not to reveal much… and that is very natural. Why would he? How could he believe a stranger? But whatever I gathered was not less…people here knew that some such thing existed. And awareness meant practices. That was clear. I finished my last sip and before I could get up, he pushed the bell fixed onto his table. His gesture clearly showed his willingness to get rid of me. I stood up hurriedly, thanked him for devoting his valuable time and left the room. Sheela, little disappointed attempted to justify the doctor’s behavior. “Don’t worry, Sheela. These are very natural reactions.” “He was scared.. Madam. Because someone from Delhi…” “You tried your best. Rest is not in your hands.” I interrupted her. “Ok Madam, Let us go shopping,” she was trying all means to please me. … I was in no mood but I too was obliged to her. “Ok I will. Can we visit a grocer’s shop?” “What do you want Madam?” she asked. “Those medicines.” She was surprised. Must be cursing herself for giving me the offer… “Ok Madam.” “I want to visit a local grocer who keeps herbs, seeds, traditional medicines etc.” We then visited a market- a local market where handicrafts were displayed on hangers, some spread on a sheet laid over a flat surface… beautiful, colourful crafts.. enough to impress anyone and everyone. On the top hanged a board with an inscription in Gujrati that read “All original items. No bargaining.” I picked up a few souvenirs and went on. We stopped by a person selling juice and asked, “Do you know anyone who sells herbs, desi dawai [indigenous medicines]?”. A young man, clad in colorful traditional dress pointed to a pole on the other side of the road and said, “Take a left turn from there and ask anyone for Amrit stores.” We followed and finally reached the spot. An old man, with gray hair and long beard was sitting on a chair with two helpers busy packing some seeds, nuts, and herbs in packets of different sizes. It was interesting to see them in action—one weighing the seeds using an old weighing machine, then passing on to the other to be put into packets with label. As we were observing, he asked, “What do you want?”, in Gujarati. “Can I get some jadibuti to have a son?” I asked in Hindi and Sheela translated into local language. He answered her. I could not understand but guessed he was asking if it was for her or me. Then he said that these are prepared in some other shop. We would have to place an order, give him some advance money and we would get them in two days’ time.

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“How much advance do you need?”. “3000 rupees.” We thanked him and said we would come back soon. Around that time, I published a brief note in Indian Pediatrics on polio. It caught attention of Epinews, an investigative journal from the USA. The editor got in touch with me. Congratulating me for the write up, he also requested me to inform him about any manuscript that I would like to publish in future. I had already had a topic ready, so I mentioned this to him. He wrote back saying that he could publish an interview of mine in Epinews, an investigative medical journal. I was very happy and felt as if I reached the top of the world. He sent a list of questions which I responded to in no time and my interview got published within a fortnight. In my interview, when asked what I wished to do next, I said I would like to do three things—conduct an analytical study to see if SSDs had any association with birth defects, have a birth defect registry for surveillance, and conduct an experiment on animals to see what more can these SSDs cause [5]. An excerpt from the interview with epiNews

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After this publication in Epinews, I enquired if any organization would be interested in funding this type of study. He got back after a week saying none was really interested. I was not at all surprised because by now my immunity had grown and I became quite resilient. I realized that I would have to keep writing (not always on SSDs) to be more communicative with the outside world, and this would open up more windows of opportunities in future. I badly missed Dr Singh for he used to emphasize the importance of writing in academics, and I would sometimes be rebuked for not writing so well. I felt quite lonely as I could not discuss this issue with anyone. It was one of those gloomy days…. I felt I was not going anywhere too many ideas but no scope to implement them. I had my son, less than 3 years old who needed my undivided attention. I was working in an NGO that worked primarily in chronic diseases…. Chronic diseases never interested me so much… prevention of chronic diseases lies in good maternal and child care… And with this worm of SSD going round and round in my head, I really was not able to concentrate on anything meaningful. I was randomly searching for sex selection measures on the net one day. There was a site on gender selection that apparently gave information to couples on how to conceive a boy or a girl. There was a sort of crash course offered free of cost. Online registration was, however, compulsory. I developed a temptation to enroll myself but was in dilemma––some weird thoughts crossed my mind. It is so very easy to track anyone in this era of digitalization. … How would people take it if anyone got to know that I have enrolled in such a course when I consider myself a big feminist? There were several ifs and buts … finally I decided to take it up… What will happen? I thought. I already was having a son then. At least people will not be able to say that I did it for a son. And then I registered myself. The lessons started coming in. All those that we had read in theory was coming back to me as operational tips on how to conceive a baby boy. It was amazing to find how the companies market their theories… how they influence one’s psyche and convince you that whatever you are doing is not wrong. As my tutorials were going on, I got even more interested in doing periodic searches on sex selection practices. In one such instance, I found a blog where a woman from USA was seeking some guidance on how to conceive a boy. She did mention about “Shivalingi”—her mother in law advised her to consume the seeds after conception. A response was given by a reader who quoted our study (published in 2007). She said that the authors had suggested that Shivalingi can be dangerous and that such medicines should never be consumed in pregnancy.

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Subject: Ayurvedic approach to beget a male child Dear ammas, I would greatly appreciate your help. We have been blessed by a beautiful 2 yr. old daughter. My husband would really like a son next. Ofcourse he would love another daughter too with all his heart. The question that I am asking is: My ma-in-law told me that shivlingi seeds (Bryonia laciniosa) and putrajeevak seeds are prescribed by Swami Ramdev to those who desire a son. The time to start these medicine is a month after the pregnancy has started. I am a little confused by this: Modern science tells us that the sex of the child is determined the moment conception happens i.e. the moment the sperm meets the egg. So how is it possible to change the sex later? Has there been any research which would assure that no birth-defects are caused and there are no harmful affects on the foetus? What does the medicine contain? If the baby is a female baby wouldn't it be harmful to take some medicine which might cause her sex organ to morph into a boys? And if it's a boy, then doesn't seem to be any point in it. Has anybody used these medicines to get a son? What was their experience. Was the kid born healthy and remained healthy. Were there any daughter's born even after taking this medicine? I am concerned that if the baby was a girl all along, it may have gotten exposed to some harmful chemicals in the medicine thereby creating health problems for her later in life. I would appreciate your thoughts and experience on this. Thanks in advance.

Response from: IA Council Member on Ammas.com Source: This information comes from my own knowledge. Hi, dear. You are right to be concerned. Personally, I have heard these things said, too, but the major proof for them to be false (as I believe) are that even though this is wide folk wisdom in parts of India, people still have baby girls. Let's face it, if in India there were any foolproof method to have a boy, few people would be having daughters. Sad, but true. Anyway, I found a study by S Bandyopadhyay and AJ Singh which found that these "sex selection" remedies are used widely in North India. Indeed when these supplements were analyzed in a laboratory they were found to have a high content of anabolic steroids/testosterone.

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2 Exploring Preparations for Sex Selection … A concept of changing the sex of a baby post- conceptionally has been documented in ancient Ayurvedic texts; the ‘Pumsavana karma’ by Charaka (2nd century BC), Sushruta (5th century BC) and in the 12th century AD texts of Bhawa Prakasha. ‘Pumsavan’ means relating to son or a male child’ and ‘karma’ means a process’. “Puman Suyate Anena Karmana iti Punsavana karma” (Charak Samhita is defined in the Vedas as the rituals adopted for helping in procreation along with getting a healthy male child. The Ayurvedic procedure described to change the sex of the foetus at 2 months of gestation is as follows “milk boiled with the paste of herbs like “Apamarga” (Achyranthus aspara), “Shahachara” (Berleria prionitis), Jeevaka, “Rishabhaka”, all of them together or any one, two or three of them as per requirement should be given to the pregnant woman for the desired effect. This should be done only during astrological constellation of “Pushya nakshatram”, or under the timing of this particular star that occurs every 27 days. These methods, if adopted, in association with the excellence of locality and time invariably produce the desired effect. If there is any variation in these parameters, results become otherwise, i.e. a female child may be born. However, the researchers found the following, which confirms your fears: There are serious public health implications of use of various sex selection measures/ regimes. These tablets are consumed between 1-1/2 and 2 months of pregnancy – a very critical period of fetal development during which fetal sexual differentiation occurs under influence of both genetic and hormonal factors. Exposure of a female foetus to testosterone during this phase can lead to masculinization of genitalia. In fact, androgenic stimulation at any time during fetal life can cause clitoral hypertrophy. The authors have anecdotal reports of an apparent increase in congenital malformation in the study area (as reported by private nursing homes). Whether this is true and whether such use of these medicines produces only hermaphrodites or whether it leads to some congenital malformation should be the subject of further scientific inquiry. In addition, public at large, medical practitioners (both allopathic and Ayurvedic) also need to be educated on relevant aspects of this problem. In response to one of your earliest questions: Male and female genital systems are identical through the sixth week of gestation or the eighth week of your pregnancy. By week 12 to 14, your baby's external genitalia are recognizably male or female, but they're still not completely formed. So women do take this medication at a crucial point during baby's sex development. HOWEVER, it is important to note that you're right: sex of the baby is determined at conception, whereas genitalia develops later. Early in pregnancy, sex cannot be determined by ultrasound, but a baby destined to be a girl will have two X sex chromosomes; that which is destined to be a boy, an X and a Y. These chromosomes are what determines how your baby will develop from the day of conception onward, and they allow for the sex of your baby to be determined if procedures such as amniocentesis need to be performed at any time during your pregnancy. Female development will occur unless maleness is actively induced by the Y chromosome. In females, the gonads become ovaries; the uterus, cervix, fallopian tubes, and vagina form; the labia develop; and the phallus becomes a clitoris. In males, the Y chromosome causes the gonads to develop into testicles, which start to produce the male hormone testosterone by 9 to 10 weeks of pregnancy. Testosterone leads to development of the penis and scrotum and the internal tubular system that will later carry sperm. Another hormone produced by the testicles, anti-mullerian hormone (AMH), inhibits

2.1 An Exploratory Study to Unravel Facts About SSD the development of a uterus and vagina. In boys, the testicles remain inside the abdomen until late in the third trimester, when they usually descend into the scrotum. I am concerned that by taking this medication women cause their female fetuses to develop male genitalia-- which leads the child to be a hermaphrodite, not a boy. The upshot? You have a 50% chance of having a son. In the end, what matters most is a healthy baby. I'm sure when you weigh the possibility of having a healthy child, male or female, versus a child whose reproductive system is deformed, the choice is clear!!! Hope I've helped you make the right decision...good luck!

Thank this advisor Response from: GG Council Member on Ammas.com Source: This information comes from my own knowledge. Couples who are trying to get pregnant may be wondering if there is any way to conceive one specific gender over another, particularly this attitude is high to see among couples who are trying for a second child. As a general rule, many health professionals agree that there is no concrete way to pursue gender selection when conceiving a child. Another gender selection method which has been claimed to work for some individuals is the Chinese calendar for gender prediction. This entails the female to compare her age and the month of conception with the Chinese calendar and the calendar will show whether a boy or girl will be conceived. This too has an accuracy rating but it is about as accurate as flipping a coin to determine the baby's gender. Medical health professionals do not believe any form of gender selection method to be effective although certain laypersons swear by a particular method due to their past success. However i can point out some details derived from research articles which i had gone through. For Male child: Time intercourse as close to ovulation as possible: The idea is that since the Y-chromosome sperm are faster than the X-chromosome sperm, there will be more Y-chromosome sperm who reach the egg, making it more likely that a Y-chromosome carrying sperm will fertilize the egg. Abstain from intercourse for four to five days prior to ovulation. Have intercourse only just at the time of ovulation and just before. Have intercourse that allows for deep penetration. Shettles recommends rear-entry (aka, “doggy-style”). The idea is that the sperm will be deposited closer to the cervix where cervical fluid is most friendly to the Y-chromosome sperm and where the “boy sperm” are more likely to survive since there is less distance to travel. Men avoid tight clothes: heat kills off both types of sperm, but will kill off the less protected, smaller Y-chromosome sperm faster, according to Shettles. Women have an orgasm: According to Shettles, female orgasm increases the alkaline secretions in the vagina that are favorable to the Y-chromosome carrying sperm. Shettles recommends having an orgasm before or at the same time as the male partner. For female Child :Have intercourse 2-3 days before ovulation and avoid intercourse just before ovulation until 2 days after ovulation and when you have peak cervical fluid: The idea is that when you have sex a few days before ovulation, only the Xchromosome “girl sperm” will be left in the female reproductive tract waiting to fertilize the egg when it is released. Have intercourse with shallow penetration: Shettles recommends “missionary position”or any position that will deposit the sperm slightly away from the cervix, giving advantage to the longer living, but slower X-chromosome-carrying sperm. Women avoid orgasm: Shettles suggests women avoid orgasm because it makes the vaginal environment more alkaline, and less acidic and is disadvantageous to the X-chromosome “girl sperm”. The GenSelect System prepares a mother's body to produce a child of the desired sex, much as we exercise and take dietary supplements to make us healthier and

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live longer. All GenSelect mothers' bodies are better prepared to produce healthy babies. Once a foetus starts to grow or get conceived you cannot change the gendor of the foetus other than vanishing it and come out of pregnancy if found the gendor is not of your choice/interest. Gendor Selection during Ovulation and Intercourse.doc

(31.744k)

Response from: CR Council Member on Ammas.com Source: This information comes from my own knowledge. Subah, I think, you have to stick to your understanding. The gender of the child is natural selection and in today's world or in any ancient sciences, there are no methods, techniques, to ensure that the gender of the child is selectable. Ramdev, is a great person, a Yogi, specialist in Yoga and a great showman. No doubt about it. But if he is prescribing the above mentioned medication to ensure a male child, I think it quite wrong of him to do so. As you say, the gender of the child is decided as soon as the fusion takes place. The gender is not changable while the feotus is developing. There is no hard and fast proof of results from any source to prove that these techniques work.At the same time, there is no proof of any side effects or failures. This lack of knowledge is too risky to experiment on a unborn. If something were to go wrong, life of the entire family could be affected. As it is, many of Ramdev's medical solutions are under question and many medicines do not have clinical test records. It is risky. Thank this advisor Response from: S S, Council Member on Ammas.com Source: This information comes from my own knowledge. Subah, It is not easy and haven't heard anyone claimed yet. Please read the information from net. An Ayurvedic doctor told that Hindus believed in Pumsavana karma (rituals observed for a male offspring), which coincided with 2 months of gestation and the time of sex differentiation. He told that ‘Shivalngi’ herb is commonly used as an ingredient in SSD preparations. A homeopathic doctor claimed that sex change during pregnancy was possible and that it had nothing to do with. Ayurveda but rather spiritualism was involved in the process. It was found that the SSDs were known as “sau badalne ki dawai” (‘medicines for bringing about a change in the female reproductive system so that the women start bearing male children). The grocers, chemists and some villagers from whom various SSDs were procured were also asked about prescription regimes of SSDs. The cost, dosage and instructions regarding intake of SSDs are described in Table 1 The community-based survey revealed that more than 90% of the women were aware of the availability of SSDs. Fifty (45.5%) of them reported to have used these. Of them, 48 (96%) reported giving birth to male babies after taking SSDs. Failure in two cases was attributed to consumption of SSD after 3rd month of gestation. All the male children were reportedly normal. Use rate of SSDs was significantly more in women who did not have a son as compared to those who did (Table 2). Of the 7 samples collected, 3 contained testosterone while one contained

2.1 An Exploratory Study to Unravel Facts About SSD progesterone. ‘Shivalingi’ was found to be positive for testosterone while ‘Majuphal’ contained natural steroids. http://www.indmedica.com/journals.p… Response from: XXXXXX Registered Member on Ammas.com Source: This information comes from my own knowledge. You can go ahead with that. NO problem. There are so many things that medical science is yet to comprehend. Though it is true that sex is primarily determined at the time of conception, it is quite true that the sex of the womb CAN be changed harmlessly if the procedures are done before the 4/5th months. Apart from what Swami Ramdev says, there is a vedic procedure called "Pumsavana" that is done in the 3rd or 4th month of pregnancy for getting male child; it has worked in many practical cases. There will be no side-effect of this at all; at the best, you will get a son; if the process is unsuccessful due to deficiencies during any stage of the procedure, even then the female child born will have no genetic/ physical defects of any sort. That is the speciality of these procedures. You may go ahead with confidence. They have been successfully followed by many generations of our forefathers. Pumsavanam has no side-effect whatsoever. It can be done for all deliveries (not only for the first child); if it is done after the 5th month of pregnancy, it does not do sex change, but only ensures longevity and strength for the child in the womb. Best wishes.

Response from: Keep Smiling ., Council Member on Ammas.com Source: This information comes from my own knowledge. The mother has nothing to do with the sex of the baby — it's determined by the male partner's sperm. Aside from having an amniocentesis during the first trimester to check the sex of the foetus, I'm not aware of any reliable method of choosing your baby's gender. Some scientists think you can influence your baby's sex and many old wives' tales suggest things to try, but none has been proved in rigorous testing as far as I know. For more information, visit: http://www.babycenter.com/expert/pr…

Response from: LJ, Council Member on Ammas.com Source: This information comes from my own knowledge. Dear Subah, I am not too sure of the effects. Because like you I have also heard and believe that the sex of the baby is determined the moment conception occurs. So please be careful in taking medicines after the conception. It might harm the baby as you say. Then worrying till the baby is born to see if the baby is allright. If you like You can take it before and pray for a son Only GOD can help you. All the best Thank this advisor

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I was thrilled as I considered it as a success story—even if our efforts are able to caution one woman, our purpose is served. This increased my conviction even more…Somewhere someday people will read my research…………..This only fueled my desire to take it further that I have been longing for. Meanwhile, I had another publication on infant milk formulae. Giving reference to this paper, one day I received a call from a scientist from Thapar University. Dr Abhijit Ganguli, a biotechnologist by profession, whose main focus was food technology. An inquisitive voice, having an intense desire to do something meaningful in life… at the same time quite a seasoned approach toward practicalities. His frankness on what can be done and what cannot be done impressed me. I discussed SSDs with him and tried to align SSDs with his domain of food technology only to stimulate his interest. He instantly agreed as he justified that it was related to herbal preparations consumed as food and could very well fit into his portfolio. “When can I hand over the samples to you for analysis,” I asked. I continued to have a gut feeling that the samples required a greater in-depth analysis. Moreover for a laboratory person, only laboratory findings could arouse an interest. He had to come to Delhi for some meeting, and we fixed up an appointment to meet with him to discuss further. I handed over two samples to him. By now, the samples were 3 years old and I had exhausted most of them distributing. As usual my follow up continued. One day, he called me up and said, “the two samples contain very high levels of phytoestrogens.” “Can you give it to me in writing?” He sent me the written response in details. “What next?” I thought. After a few days, Dr Ganguli called me and requested me if we could develop a joint proposal in the topic. I was to say yes only. But who will fund for such a study? We had no answer. Thanks to the news items in local newspapers that kept the issue alive.

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Sex selection drugs in news..

Months passed by. By then I resumed my work after a short family break. I felt like discussing it with Dr Srinath K Reddy. Well-respected and a dynamic preventive cardiologist, he is considered a champion in public health. But will he even consider this a priority? I wondered. I just wanted someone to support me and say that yes, funds will be made available. After a lot of debate within myself, I decided to approach him. He looked at the papers meticulously arranged to impress him and

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listened to me very patiently. He then dialed up a number and started speaking to someone, “Hello Madam. A colleague of mine is working on a very important and interesting topic related to sex selection. I think we have to hit the nail. Will send her to you. Please guide her appropriately.” She was a famous advocate based out of Delhi. I was happy because if Dr Reddy was referring me to someone, she would not shun me away. I thanked him and left the place. I fixed up an appointment with her for the following week and got myself prepared for the interaction. I reached her office that was in the middle of a crowded street in south Delhi. The place looked like a lawyer’s colony. Rows of buildings on either side of the road, banners and posters outnumbering the number of flats or offices, each board boastful of the qualifications and expertise of its lawyers. I entered her office. Everyone knew that I was about to come. Her office looked very busy as people barely lifted their heads to look around. I am scared of lawyers, and this place looked equally frightening. I had to wait for sometime and then I was called in. Along with Madam was another advocate in the making sitting right on the table. It was Mini, a cute little pet dog. Seeing me it wagged its tail and I could not express myself lest it pounced on me. I greeted her and she looked at me with her head slightly tilted down through her thick glasses. I started off instantly to tell about the problem. “What do you want from me?” she asked. She was to the point. “I want you to direct me to someone who can support me for the cause,” I said. “What kind of support?”. Because she is a lawyer and I guessed she would not have an inkling toward research, I said “someone who can spread the message that these are illegal and harmful practices.” “Well, you come up with a proposal and meet me next week.” At least she was positive. I started dreaming about our new proposal, how it would be executed. The following week, I went to her again. The proposal described why we wanted to work on this area and what should be done to disseminate the message. I know I was deviating from my focus but I did not want to lose any chance to seek her support because Dr Reddy sent me to her. This time also, Mini kept ogling at me as if it was Madam’s secretary. Its expression made me feel scary that it would pounce on me if the proposal was found unsatisfactory. Madam had a quick look at the proposal. The movement of her head reflected how lawyers are quick to pick up facts that are critical. “Where is the evidence that SSDs are harmful?” “That is what I want to find out,” I said. I should have known that their lives revolve around generating and establishing evidence. “Well, please give me the names and addresses from where you got these medicinal samples,” she said. I would not in any case. “I do not have their addresses,” I replied.

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“What kind of researcher are you! A good researcher must preserve every detail of his/her work,” she said. The voice, tone, and attitude were a strategy to cull out the details… I guess every lawyer does that. It is a part of their profession. “Yes, madam. I agree. But my purpose was not to get their details but to collect the samples.” This answer of mine seemed to have annoyed her that I could make out from the way she shouted at Mini when Mini turned around and sat on one of her papers. “You should file a PIL.” “Me?” I was taken aback. “Yes,” she said. What’s wrong in this? “How can I file a PIL with no evidence? Will my organization back me up?” I thought. [PIL or Public Interest Litigation can be filed against an organization in the presence of a proof of a malpractice or nonperformance of an agreed upon activity for the benefit of the population or in public interest. For SSD, filing a PIL was a remote possibility. There is no organized sector, no single person, no branded preparation that could be directly held accountable. Even if SSD intake is covered under PCPNDT Act, there is no way to check and verify if someone has actually consumed it.] I felt like running away from the place as I did not know what to do or say. It requires a great deal of tact and smartness to face lawyers that I felt I lacked immensely. I left the place after some time promising myself never to turn back and visit this place again. After some months, I joined Public Health Foundation of India (PHFI). Many people from other universities used to visit PHFI every now and then. In one such meeting, Prof Anna [name changed for ethical reasons] for the London School of Hygiene and Tropical Medicine (LSHTM) visited us. She is a senior epidemiologist. It would be wonderful to meet her and discuss SSDs with her. I was keenly watching out and waiting to see if I could get an appointment to see her. When I found an opportune moment, I went up to her and began our conversation on SSDs. What I anticipated would get over in 10 min went on for more than an hour. She was quite impressed and asked me if I would be interested in doing a PhD under her. She would be an excellent mentor, I knew. I was overjoyed but I did not want to pursue any higher studies post MD. Because it would have meant leaving my little son for 6 months for my course work in London. I did not like the idea of being away from him for so long. I thought over it again and again….. This led to another round of debate—whether to cash on this chance to work on my dream project or forget about it. No one would ever fund for this kind of project, I was more than convinced… While I still was contemplating over it, during one of the interactive sessions with all the universities of UK, someone remarked, “you are overqualified for a Ph.D. Why don’t you go for a post doc?”. I filled in my applications but it was not accepted since they were looking for applicants who completed their MD/PhD within the past 5 years. I felt like crying. I was telling myself, “forget SSD. It is not your cup of tea. Be like other

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professionals. Learn to grab any opportunity that is more acceptable, has wider scope and acceptance.” By now I became quite a pessimist and lost all hope. My interaction albeit rarely with Dr Ganguli instilled some confidence and enthusiasm off and on. Once during our conversation, he was insisting that we work on a joint proposal without having the name of sex selection anywhere. It could go well as a herbal food item. Sex selection raises suspicion and makes it sound very controversial. “But who on this earth will fund for this?” I asked in despair. Then suddenly, an idea occurred to me. “You have so many students working under you. Why don’t you ask few of them to do a project on this topic? I will train them on how to collect samples and you can train them to do the analysis.” He liked the idea very much and soon we had a student to work on this topic. I was happy that something got started finally. The student, Ajit by name [name changed for ethical reasons], collected five samples, did the extraction following established scientific guidelines, and analyzed them. All the samples contained high levels of phytoestrogens. Another student of the subsequent batch, Ms Pallavi [name changed for ethical reasons] collected 200 samples from various parts of Punjab and she too got similar results. I was so thankful to Dr Ganguli for all his support. I could never imagine that someone who is not related to me in anyways would get involved so much in this study. There was no motive whatsoever—financial or anything else. After these preliminary results, he insisted that we submit a proposal to national funding agencies like Department of Biotechnology (DBT), Department of Science and Technology (DST), Indian Council of Medical Research (ICMR). He was one person whom I trusted whole heartedly and I knew what he was suggesting was not wrong. I approached UNFPA, WHO, and many NGOs where I knew people. Everyone seemed to appreciate the topic and would not commit anything regarding financial support. It was nobody’s mandate. I even discussed with a senior official at the Ministry of Health and Family Welfare. He was surprised at the practice and after contacting few people, declined to support the study financially. Public health is a small world. Every person in the field was contacted by me at some point of time for SSD work but to no effect. Then there was a “Call for proposal” floated by ICMR on setting up a birth defect surveillance or registry. It was a big endeavor and I knew we would not qualify. But I thought may be it would at least sensitize the reviewers of the proposal even if they do not select it. My pessimism was showing up all over. Dr Ganguli would pep me up from time to time, but the effects had a pretty short life span. I knew it was a remote possibility. My idea was to see the registry as a base and have an analytical study embedded within it. After a month or so of my submission, I got a reply that ICMR was having a meeting on birth defects. They wanted me to come over and make a presentation on my proposal. The meeting went off pretty well. In my presentation, I did mention about SSDs and that we wanted to set up an inquiry as part of a registry in Haryana. No one seemed to have got surprised at the mention of SSDs. Was it a good sign or a bad

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sign? I did not understand. I was informed that there would be a multicentric study on birth defects and our team would be a part of it. But the study never took off. We then applied to the DBT. DBT was set up in the year 1986 within the Ministry of Science and Technology to march toward development of biosciences and technological development in the country. This was much needed to provide necessary thrust to India’s progress as many of our macroeconomic issues of growth and development were subsumed within science’s development. People like me kept writing to funding organizations off and on. It is natural for such organizations to accept applications only against an announcement. But unfortunately, such announcements mostly pertain to a theme identified on the basis of national and/ or global priority. SSD was never to be recognized as a thematic area for obvious reasons. In a quest to get some advice and direction, I managed to get connected to a scientist who could probably guide me. He told me categorically over phone that DBT may not be interested in investing on drug-related projects that would not yield new molecules. I was not very surprised because by now I got used to receiving negative answers. But if the ultimate aim of research on any drug is related to discovery of new molecules only, who will work on existing practices that are harmful? I did not find an answer even after scratching my head for days together. Scientific advances do not always happen trying to improve over existing technologies. As Edouard Brezin puts it, “electricity was not invented by trying to make better candles.” My last attempt was to submit it to DST. I did not want to leave any stone unturned before putting in an application. I therefore approached an advisor at PHFI to seek his guidance. He advised me to submit it to Science for Equity Empowerment and Development (SEED) division of DST which supports scientific research on social issues. Our topic had both a scientific component and a social angle. I was quite apprehensive about the whole thing because it was in some sense the last resort. There were two research agendas: one to do an analytical study to explore the association between SSDs and birth defects and second to conduct animal studies to establish the harms. Thinking of DST, I thought that animal experiment would fit better into their mandate. I discussed with Dr Ganguli and both of us developed a proposal. I wanted him to lead it but he declined and said I should do it because it was my “baby.” We finally submitted it and kept our fingers crossed. Months after that I got a call from DST. The scientist who called me wanted to meet me in person and we fixed up an appointment. Varied thoughts crossed my mind. Does it indicate that they are interested in this proposal or do they want to say on my face that whatever I was doing was all meaningless. Quite nervous, I used to call up Dr Ganguli several times in a day. When I met the scientist, she asked me about my intention. Was this project meant to promote or condemn SSDs? How can it be to promote when it was very clearly written that there could be a linkage with birth defects. May be we could not make things very clear in the proposal.

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“The file has come back to me from the Director. She is not very happy with the proposal as the topic is very sensitive. It appears as if you want to show how SSDs can be useful.” I listened quietly. “But I understood the problem,” she continued. “During my second pregnancy, I was asked to consume such medicines because I already had a daughter. If this can happen in a family like ours, I can understand the plight of the poor women who succumb to societal pressures. I really want you to do the study because it is much needed.” She asked me to make some modifications and resubmit. I was then asked to make a presentation in front of a review panel. When I was presenting in front of 10–12 members, everyone was nodding their heads indicating thereby that most of them were not hearing it for the first time. I mentioned about our study in 2003, and this was 2013. The chair asked me “what were you doing all these years?”. “People were not eager to support the study because they were scared of the word sex selection,” came my spontaneous reply. How could I explain the turmoil that I had undergone all these years? Anyways, the study was approved. We were waiting for a formal approval and that came to us after almost 6 months. We were very happy. Life is indeed tricky. Sometimes you do not get what you want but you get what you need! Science and technology revolutionize our lives but memory, tradition and myth frame our response. Arthur M Schlesinger

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Sex Selection in Modern Era

As societies advanced, the birth rates reduced, fertility rates started falling and more and more people preferred small family size. This pattern was evident across the world at different stages and phases depending on their development. With a rise in desire to opt for a small family norm, which people relate to increased female literacy and economic development, the need for a “son” remained unchanged. Progressive societies condemned direct killing of female infants after birth. But the concept of sex determination kept intriguing the scientists all over. Loads and loads of funds were invested in identifying the sex of an unborn child. The possibility of determining the sex of the offspring became a subject of enduring interest. Observing natural variations became common as societies in 1950s and 60s wanted to restrict the family size [6]. Observations on when male or female babies were born were made and people related them to natural phenomena. Unlike those in the ancient period, where people linked birth of a son to supernatural power, they now became wiser. Many must have refuted the ancient observations as mere superstitions although they continued to be followed through

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generations. But the keenness of people to predict the sex of a child based on immediate observations led them to explore harder facts. Observations were documented on the relationship between maternal and paternal age, parity of women and sex of the child. It was suggested that the probability of conceiving a child of the opposite gender goes down with each subsequent birth of the original gender, e.g., the more girls a couple have, the less likely they are to conceive a boy [7]. Also, younger men with higher sperm counts have more boys than older men [7]. However preliminary these may be, this did influence the whole movement toward sex selection. By now, the measurement of the numbers of boys and girls was formalized as sex ratio. Sex ratio at birth was calculated to indicate the numbers of boys for every 100 girls. In India, it is defined as number of girls for every 1000 boys. In the USA during and after 1939–45, there was an increase in sex ratio in favor of males (from 105.7 to 106.1), born to mothers below 25 years of age and primipara [6]. The same has been reported among British servicemen. This could be explained by high coital rates during demobilization and short war time leaves [8]. Another explanation was nervous strain but that has been refuted through observations during epidemics and famines where alterations in sex ratios were not observed. Yet another observation was that the duration of marriage could be a predictor of sex ratio according to Berstein and Renkonen which is explained by increased coital rates immediately after marriage [8]. A review of social and economic factors and sex ratio renewed the interest on coital timing as a method of sex preselection [6]. Much controversies existed on the timing of coitus with sex ratio. Indirect evidence came from studies on ovulation induction. Women on ovulatory medications were advised to optimize the timing of coitus relative to ovulation. A review of evidence as reported by Zarutskie et al. remained inconclusive as these were known to be influenced by ovulatory or fertility drugs themselves [6]. “Sex of a zygote depends on the time during the menstrual cycle that it is formed”—was put forward by Guerrero and Harlap. Data came from women who had a failure with natural methods of contraception such as rhythm method or abstinence during the week following cessation of menses [8]. Also the frequency of coitus was reported to influence sex ratio. The U-shaped relationship of sex ratio on the cycle day of insemination could be due to maternal gonadotrophin levels [8]. As interests started picking up, in 1960s and 70s, a number of influential US experts expressed their approval for sex selection [9]. US funding on research and development increased by an average of 10% a year. The bulk of funds went into genetic research … ways to improve sex determination. By then medical advances were geared up to detect genetic abnormalities during pregnancy. Medical termination of pregnancy was looked upon as a means to prevent the birth of babies with such anomalies.

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More than 200 genetic disorders were known to affect males during that period that were labeled as sex-linked disorders. As a measure to prevent the occurrence of such births, sex determination during pregnancy became essential. Among many such efforts, one was amniocentesis—taking a sample of the amniotic fluid—fluid surrounding the developing fetus in the mother’s womb. The process was a bit risky but with great medical strides the safety profile of the procedure improved. Amniocentesis was introduced at AIIMS in India in 1975. It was done to promote early detection of genetic abnormalities. However, the technology seemed to be a breakthrough to determine the sex of the unborn child, thus paving the way for sex selective abortions. Such procedures became popular among care providers and clients alike. The naïve community viewed this as a well-accepted means to reduce the family size and at the same time maintain gender balance in their families. Female feticide spread like wildfire across public and private clinics. By 1979, amniocentesis could identify sex with 100% accuracy. Sex determination soon became pivotal to population control. Among the policy prescription described in the “the population bomb” was an increase in funding for sex determination research [9]. As technology advanced, research on identifying the target period for sex determination kept receding from third trimester to first trimester and later to preconceptional period. In 1960s, the goal set by the research community was to make sex determination possible in the first trimester. Other than amniocentesis, chorionic villus sampling (CVS) was another contender in the race. The process involved taking a biopsy of the chorion, which is a membrane separating the fetus from its mother in the womb. By looking for sex chromatin, the sex of the fetus could be ascertained. Initial work happened in Denmark due to liberal abortion laws. But when they found that it led to increased miscarriage, they abandoned the experiments. In 1975, when amniocentesis trials began in India, CVS trials began in China. The accuracy was 93%. But out of 93, 29 out of 30 who opted for abortion were carrying female fetuses [9]. Soon came in ultrasonography as a noninvasive, cheap, and safe method to detect fetal well-being. It was in no way a substitute to amniocentesis to detect genetic disorders but ultrasound could detect gross abnormalities and most importantly could detect the sex of the fetus. While the entire process seemed to be a medical boon in the larger interest of mankind, it was also viewed as a “family planning measure” to balance the family. Some proponents of these advancements looked at these through the lens of population control. Soon these became an integral part of family planning. Western funds had backed the creation of an extensive network of family planning advisors. As amniocentesis spread from AIIMS to other places, these advisors encouraged women to go in for the test free of cost. Doctors from India presented their findings on amniocentesis stating that sex selection was an effective ad ethical method of population control. By then, the technology had spread to other private institutions and soon acquired a commercial angle. Advertisements attracted people to undergo “sex test” and then sex selective abortions [9].

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In developing countries, the population control movement found an additional challenge. Although death rates from diseases began to fall, people were skeptical about the life expectancy of their sons and wanted two boys instead of one. It was estimated by demographer Mindel Sheps in 1963 that if all families stopped bearing children after having two sons, an average couple would have 3.88 children [10]. As research continued on this front, in 1969, a scientist from Johns Hopkins commented, “A type of research which would have great effect on population control would be that related to the discovery of methods for sex determination.” [9] It was suggested that if one could predetermine that the first offspring would be a male, families would voluntarily restrict the size of the family and ultimately it would have a great effect on the size of the family. If a reliable technology to determine sex of the unborn fetus could be made available, it could turn out to be an effective, uncontroversial, and ethical way of reducing population globally. Such was the commitment of the Western world. Ironically, an American educated Indian doctor (Jaswant Raj Mathur) submitted an appeal to Planned Parenthood Federation of America (PPFA) to fund his research on sex determination. PPFA is a nonprofit organization that provides sexual health care in the USA and globally. If only it would fund him, he would get to work searching for a way “to control sex in human reproduction.” Population Council declined to back the Indian scientists work because of bureaucratic hassles. The organization exclusively funded Indians whose proposals had been approved by a national committee in India [9]. As sex selection methods developed, abortion laws had to be liberalized for want of “successful” results. Starting with Japan, perhaps the first country in the world to allow abortions for a variety of reasons, it spread to other countries as well. In 1960s and 70 s, many developing countries liberalized their abortion laws—mostly due to surmounting pressure from USA. South Korea is a living example where proportion of health budget devoted to family planning increased to 25%. By 1977, doctors in Seoul performed 2.75 abortions for every birth—the highest documented rate of abortion in history [9]. Mobile clinics roamed around the country for IUCD and sterilizations. By 1983, the country attained replacement level fertility rate of 2.1. But that did not deter couples from resorting to sex selection abortions. China was also not far behind. In 1982, two-fifths of all pregnancies were aborted [9]. In 1980s, a skewness in sex ratio started showing up in Korea. Since the administrative data collection system was very strong, the skewed SRB could not have been the result of improper data collection. Thus, on January 31, 1990, Korea’s Ministry of Health and Social Affairs suspended the medical licenses of eight physicians who had performed sex determination tests on fetuses. This was widely reported in the media. In May in the same year, the Ministry announced that medical licenses be revoked for conducting sex determination procedures. Demographers believe that this draconian action effectively eliminated sex selective abortions in the country [11]. Starting in the mid-1990s, the Government of Korea launched a public awareness campaign highlighting the impact of distorted sex

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ratio, focusing on the anticipated shortage in women in the marriage market. The combination of strict legal enforcement and effective mass media campaigns led to an improvement in the SRB [12]. Back home in India, in 1973, within two years of MTP Act, an estimated 23,000 abortions were performed in India [9]. The reasons behind abortions are not so explicit. But the clauses within MTP Act were sufficient enough to accommodate any reason—legal or illegal, ethical or unethical, those directly or indirectly related to sex selection. Sex selection also increased. Abortions carried out in the name of population control made it easier for women to abort for reasons as “trivial” as fetal gender. Over the past few decades in India, a declining child sex ratio favorable to males became a rule rather than an exception. It came down from 945 girls in 1991 to 927 for every 1000 boys in 2001. Figures came hovering from all over—demographers, researchers, policy makers… how many women are we losing every year? Various estimates mention that approximately 50 million women are “missing” in the Indian population [13]. According to more robust estimates, prenatal sex determination and selective abortion accounted for 0.5 million missing girls yearly, other estimates being anything between 2 and 5 million [3, 14, 15]. The widespread sex selection and female feticide caught the attention of activists in India. In late 1970s, women’s groups organized and marked the first anti-sex selection campaign in the world [9]. The use of amniocentesis was now restricted to suspected cases of genetic diseases through an order of ICMR. There were three circulars sent between 1977 and 1985 mentioning use of prenatal sex determination for the purpose of abortion a penal offense [16]. In 1984, a coalition forum against sex determination and sex preselection was formed. Their campaign for legislative action led to its ban in Maharashtra state in 1987. There was a mounting pressure to restrict information regarding sex of fetus, with the result that the practice went underground…it did not disappear [17]. The first ban on sex determination was enforced in 1978 on all Government institutions, when the demand for sex selective abortions came to the fore from a survey conducted by the All India Institute of Medical Sciences (AIIMS) in 1974 [18]. Through the 1980s and 1990s, there was intensive campaigning by NGOs and social activists. In 1988, the state of Maharashtra was the first state in the country to ban prenatal sex determination through a state Act. The Prenatal Diagnostic Techniques (Regulation and Prevention of Misuse) (PNDT) Act was enacted in 1994, as a legal tool based on the principle of deterrence [19]. As the name suggests, the PNDT Act regulated and prevented misuse of the diagnostic techniques to detect the sex of the fetus, keeping the focus on regulating and confining the use of technology to detecting abnormal and pathological conditions of the fetus and for protecting the health of mother and child. However, implementation of the PNDT Act, which came into force only in January 1996, was weak due to lack of awareness of the Act and insufficient and untrained manpower. In 2001, out of the 579 districts for which 1991 and 2001 data

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were available, 477 (i.e., more than 80%) recorded a decline in sex ratio. Studies conducted in diverse locations with different methodologies have provided varied assessments of the problem across Indian states. For example, in Jaipur, prenatal sex determination tests resulted in 3500 abortions of female fetuses annually approximately, as noted by Dahlburg [20]. In a study done in rural north India, 11% of women had undergone sex determination tests through ultrasound [21]. The deteriorating sex ratios ignited the activists, and a Public Interest Litigation (PIL) was filed by CEHAT (The Centre for Enquiry into Health and Allied Themes), an NGO and others, in an appeal to strengthen enforcement of the Act. The petitioners for the above PIL, two NGOs in this case, had to approach the court under Article 32 of the Indian Constitution in 2000 because despite the act being in place five years hence, Governments (both central and state) had not taken appropriate action for its implementation. Moreover, the erstwhile legislation did not take into account modern and advanced technologies to aid pre and postconceptional sex selection. PNDT was, therefore, amended to Preconception and Prenatal Diagnostic Techniques (PCPNDT) Act in 2003 [19, 22]. The focus of this Act is “to provide for the prohibition of sex selection, before or after conception, and for regulation of pre-natal diagnostic techniques for the purposes of detecting genetic abnormalities or metabolic disorders or chromosomal abnormalities or certain congenital malformations or sex linked disorders and for the prevention of their misuse for sex determination leading to sex selection and for matters connected therewith or incidental thereto.” Prenatal sex selection illustrated complicity of medical professionals and the Act has been set out to regulate the practices of such professionals [19]. The judgment was passed in favor of effective enforcement of the law. Consequently, the Supreme Court in its judgment issued detailed guidelines to the Central and State Governments for strengthening the implementation of the Act. It gave a proper structural framework to aid in its implementation and gave directions to the Central Government, central supervisory board, state Governments, and administrations and appropriate authorities. It is important to clarify here that the Medical Termination of Pregnancies (MTP) Act, 1971, legalizes abortion in India [23]. Sex selective abortions are not permitted and are punishable under Sections 312 and 315 of the Indian Penal Code [15, 23]. On the ground, the practices of sex determination/sex selection and abortion are not delineated very clearly, and the fact that they are regulated under two separate legislations, the PCPNDT Act and the MTP Act is also unclear. Sex selective abortion is not a stipulated condition for obtaining a legal abortion under the MTP Act. In the last few decades, the MTP Act has become synonymous with reproductive choice and health rights of women—the relevance of which in the contemporary world cannot be overstated. It is therefore a highly significant legal framework supportive of women’s reproductive rights.

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Demand for sex selection continued despite PCPNDT Act in

Unfortunately, the PCPNDT Act was caught in the web of intricacies that deterred its application and implementation. For a diverse number of reasons, the complexity of societal adherence to this legal instrument originally conceived with good intent for positive change has remained steadfast. Experts argue that the PCPNDT Act oversimplifies a complex problem by transferring the onus to physicians instead of patients undergoing sex selective abortions [24]. Till 2009 when a report was being compiled by PHFI with support from National Human Rights Commission (NHRC), there were 606 cases pending under the PCPNDT Act and there had been only one conviction thus far [25, 26]. While there were wide-ranging reasons for this reality—one that was reflected in the small number of convictions—a major influencing factor was that this was a legal instrument that had inadequate, if not nonexistent, sociological support. Many experts viewed the PCPNDT Act as different from other social legislations, as it involved changes in social behavior and practice apart from reinforcement of ethical medical practice and the regulation of medical technologies to avoid their misuse for sex selection.

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The overall findings of the study were that the implementation structures were constituted as per the Act but the regularity of meetings of these bodies remained a serious concern. The level of awareness among authorities on their roles as per the Act was inadequate. The frequency and the rigor of monitoring of activities at the state and district levels were abysmally low. While decoy operations were considered useful for improving implementation of the Act, they had largely not been conducted by authorities. The documentation of cases was suboptimal that led to poor drafting of complaints resulting in lack of convictions [26]. With a greater push and accountability imposed on the states, they gradually started demonstrating an improvement in implementation of PCPNDT Act. But people’s desire and imagination know no limits when it comes to issues as essential as a son. To illustrate this fact further, a case study reported from Haryana needs special mention. A team of local private doctors offer package deals to pregnant women and their families in rural areas. They have changed the strategy of sex determination from static van to mobile van like gorilla technique—come, perform, and disappear with zero accountability to the patients [27]. The fetal sex is determined at night using a portable ultrasonography machine. In case of a female fetus, abortion is induced immediately. Should any complications arise, they are referred to a hospital. A woman in early pregnancy presenting with bleeding is not unexpected and she can very well get managed as a case of threatened abortion. Thus, the enactment of legislation alone cannot address the problem of female feticide, as evident from the rise in illicit-induced abortions, with serious implications for women’s safety following the enforcement of the PCPNDT Act [28]. Besides India, several other countries took legal measures to curb sex selective abortion. Korea banned prenatal sex detection as early as 1987. China followed in 1989 [6]. In Korea, abortion is available on request and in India, on a range of social and medical grounds (including risk to the woman’s mental health) [29]. Female feticide is one of the practices that no educated woman would own up with pride although they would continue to adhere to the much deplorable practice. History of sex selection in the east or west, developed or developing countries showed how different traditions and customs expressed a common ideal. Ethics is knowing the difference between what you have a right to do and what is right to do. Potter Stewart

2.3

How Logical and Ethical Are Modern Sex Selection Techniques?

As science progressed, scientists now wanted to help conceive the baby of the desired gender. This would avert the cumbersome sex determination procedures during pregnancy, which was increasingly becoming a concern in several countries

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including India. Parts of the theories were derived from observations on natural conception followed by interventions to follow instructions that emerged from observational studies. Each one focused on a specific area that was further refined by getting inputs from emerging developments in pathology, histology, biochemistry, physiology, and many more. The biological sex ratio is commonly accepted to be 105 males per 100 females. Male infants have lower chances of survival after birth, and therefore, the sex ratio gradually evens out as they grow up in a gender unbiased environment. Evidence on the primary sex ratio was generated from different studies. The mean primary sex ratio of unmanipulated semen was found to be 1:1 as predicted from a study conducted on 98 samples. It concluded that primary X:Y chromosome ratio of 50:50 contrasted with secondary sex ratio of 106 males: 100 females suggesting that postejaculation factors have effect on selecting male offsprings [30]. Orzack et al. studied the spectrum of sex ratios from conception to birth by analyzing data from 3- to 6-days-old embryos, induced abortions, chorionic villus sampling, amniocentesis, and fetal deaths and live births. Their estimates of the sex ratio at conception were 50:50. The sex ratio among abnormal embryos was skewed toward males while normal embryos were female-biased. The study concluded that the sex ratio may reduce in the first week or so after conception (due to excess male mortality); it then increases for at least 10–15 weeks (due to excess female mortality), levels off after 20 weeks, and declines slowly from 28 to 35 weeks (due to excess male mortality). Total female mortality during pregnancy exceeds total male mortality [31]. In contrast, James and Grech studied the data at birth, and computed projections backward in relation to time, thus estimating fetal loss at each gestational stage [32]. The conclusions were that at the time of conception, there is a substantial excess of males, the excess probably being determined by the hormone levels of both parents in accordance with the hormonal hypothesis, and if conditions during pregnancy are stressful, then frail male fetuses are preferentially culled. In short, more males than females are conceived, and that more males are miscarried, and that more males still survive to birth. Researchers from Nottingham University followed more than 5000 women and found significant differences in the gender of babies born. Vegetarians were more likely to have female babies probably because vegetarian diet puts stress on the body, thereby supporting more resilient female fetuses. A vegetarian diet changes the acidity of the vaginal secretions and contains chemicals that mimic estrogens [7]. Diet supplements for gender selection also became an area of research. According to In-Gender, a sex selection information Web site, Lydia Pinkham’s Herbal Compound was originally the famous Lydia Pinkham’s Vegetable compound, a patent medicine tonic used to treat “female complaints’ and infertility in the Victorian age [7]. There was a spurt in the number of publications on different techniques for sex “preselection” as scientists called it in 1980s and 1990s. It was now clear that semen composed of X and Y sperms and gender of a child depended upon which sperms were able to fertilize the egg. There was a growing commitment to explore

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the differences between X and Y sperms that could be rationally tapped for sex selection. Scientific curiosity propelled researchers to explore the morphological differences between X and Y sperms, if any. Research showed that Y sperms were more energetic, motile, lighter in weight but more fragile compared to X sperms. Dr. Landrum Shettles in the 1960s developed a method, probably the first of its kind that employed the principle that sperms, which bear the Y chromosome, are lighter, energetic, and swim fast. Sperms bearing the X chromosome weigh more and are not swift as Y sperms, but are more resistant to the acidic vaginal environment than the fragile Y chromosome, thus surviving longer [7, 33]. Shettles’ method capitalized on the stamina of “X” sperms and motility of “Y” sperms on a variety of sexual positions, occurrence of female orgasm, and timing of intercourse relative to ovulation to result in male or female offspring. This method assumes that a woman's vaginal environment is normally acidic and becomes slightly more alkaline when closer to ovulation. Shettles also discussed the use of alkaline douche for a boy and acidic douche for a girl [7, 34]. The method advices to time sex on the day of ovulation in order to conceive a male child and two to three days before ovulation to conceive a female child. According to Shettles, it is also advised to follow abstinence for four to five days prior to ovulation, men to avoid tight undergarments as heat kills off the less protected and smaller Y chromosome sperm faster, and recommends rear entry to have a male child. The principle behind this is that the sperms will be deposited on the cervix where cervical fluid is most friendly to the Y chromosome sperm with an added advantage of Y sperms having to travel lesser distance. In 1977, Elizabeth Whelan developed a method of gender selection that was virtually the opposite of the Shettles method. It was based on a hypothesis that biochemical changes in a woman's body may favor the Y-bearing sperm and thus recommends to time sex about four to six days before ovulation to conceive a boy and two to three days before ovulation to conceive a girl [35]. Drs. Stolkowski and Lorrain recommended that a woman’s diet influences her reproductive tract’s pH. Alkaline environment favors conception with Y sperms while acidic environment favors conception with X sperms. For conceiving a girl, foods rich in calcium like fish, lettuce and lots of milk, cheese and yogurt, and magnesium but low in potassium, such as spinach are recommended. For a boy, foods rich in sodium and potassium like salty foods, meat, eggs, bananas, and a protein-based diet are recommended. Surveys have indicated success rates of up to 80% [35, 36]. Based on these findings, it is suggested that male conception would be favored when “Y” sperm reaches the ovum soon after it is released. Since it is fragile and weak and cannot survive for long, it should be available for fertilization around the time of ovulation. Therefore, the advice was to track ovulation. This could be done by measuring the basal body temperature. An elevation in the temperature predicts ovulation. Ovulation predictor kits are also available to aid in the process [7]. The second factor is to create an environment that is conducive to “Y” sperms. The internal tract of the mother becomes harsh to “Y” sperms when it is acidic. In order to maintain alkalinity, dietary changes are advised. pH strips are made available to

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monitor the change in the pH of vaginal fluid, by measuring the pH of urine or saliva. The third factor favoring “Y” sperms is to have relatively more “Y” sperms in the semen. For this reason, abstinence was advised for 4–5 days before conception. Besides wearing light undergarments, intake of zinc tablets is reported to increase the sperm counts. Increased access to information also led to certain malpractices. Since cervical fluid quality is important for male or female conception, some women in USA who wanted boys reportedly took the cold medicine, Benadryl to increase the cervical fluid. Women who wanted girls dried up their cervical mucus by taking Clomid [7]. In early 1990s, Dr Inderjit Barthakur had developed a method for heterosexual couples to conceive a child of their preferred gender. According to the method, temperature of the woman should be monitored, the couple should abstain from sex during that month until the time advised by the instructor and having daily ultrasound after ninth day of menstrual cycle to identify the exact date of rupture of Graafian follicle and hence the best time of intercourse [37]. The method was 80% successful as reported which generated international interest but ICMR, the Health Ministry turned out appeals not to support studies of this nature as they feared it would fuel gender discrimination. All expenses were jointly borne by the involved doctors and couples. Differences in the characteristics of “X” and “Y” sperms could be utilized to develop sex selected insemination programs, according to a correspondence published in Nature in 1993 [38]. Modern sex selection techniques, therefore, focus on three methods: in vivo clinical manipulation of timing of intercourse, ovulation and insemination; in vitro sperm separation techniques designed to enrich semen into either X or Y-bearing sperms and preimplantation diagnosis. The ability of sperm manipulation technique depends upon the completeness of separation of X and Y sperms, quantity of specimen available after separation, viability of sperms after separation, and capability of separated sperms to fertilize. The different techniques to separate sperms are based on sperm density, sperm motility, electrophoresis, and immunological techniques. Research focused on assessing the proportion of “X” and “Y” sperms that served as the basis of different sex selection techniques. Preliminary methods included fluorescent staining of Y chromosome (F body), DNA probe in situ hybridization, and sperm chromosome analysis after fusion with hamster oocytes. Each of these methods had its own limitations. Focused research led to the development of a rapid, objective, and quantitative polymerase chain reaction (PCR) assay. These developments led to packaging of instructions into marketable products. A gender selection kit named Smart Stork was marketed by an American-based company. It takes into consideration various proven methods and factors and hence is proclaimed to have high success rate. The factors included the woman’s biorhythm cycle primarily and the alternating pH of acidic and alkaline fractions within her reproductive tract, diet, herbal supplement, douching, and many other factors [39].

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Developed by a team of physicians, effectively allowing the determination of the gender of baby by harnessing clinically proven factors, GenSelect claimed to be the only scientifically validated kit. It works by greatly combining and augmenting natural key factors that include body condition, timing of intercourse, and vaginal environment. A single kit includes a guide, along with dietary instructions, predictors of ovulation to time intercourse, douche to adjust vaginal acidity, digital thermometer to measure basal body temperature, temperature body charts to track body temperature over time, two separate, natural nutraceutical supplements developed scientifically by a team of physicians and designed a comprehensive plan for best outcomes [40]. Semen manipulation using in vitro techniques involved separation of “Y” sperms followed by inoculation. Among the various methods was separation by albumin column that resulted in more births suggesting selection of highly motile sperms [41]. Reports by Beernink show a great preponderance of male births and concluded a three-step three-layer separation using bovine serum albumin as an effective method for male preselection [42]. Among the more advanced methods, sperm sorting (Ericsson’s Method) technique, discovered by Dr. Ronald J. Ericsson (1970s), has been widely used in many forms for over 40 years. These methods work on the premise of separation of X and Y sperms by the use of centrifugation. During centrifugation, controlled spinning separates the particulates and gets sorted into layers based on their density. By altering the number of one chromosome or by separating the layers, the chances of producing a child of a specific gender could be manipulated [43–45]. MicroSort is another form of such technique that involves the sperm being stained with a vital fluorescent stain and then running it through a machine that can distinguish X from Y in the sperm and sort out the sperms based on gender preference. The method employed here is flow cytometry (FC), which has the ability to differentiate the characteristics of particles in a fluid as it passes through at least one laser and “sort” spermatozoa based on physical and chemical features. For this technique, there are strict guidelines that need to be met—marital status, health status, parents must have at least one child and must be opting for child of opposite sex [46–49]. Another recent and more successful gender selection technique and disease diagnosis is US Preimplantation Genetic Diagnosis (PGD). Eight-celled embryos are developed in this procedure through in vitro fertilization (IVF), which are examined for the genetic makeup of the embryos that includes both genetic diseases and gender. These embryos are then biopsied on the third day of growth by allowing a single cell for male or female chromosomes analysis. The desirable healthy embryos of the gender are selected for implantation in the mother. In addition to PGD, a fetus’s gender can also be tested using CVS at around 11 weeks, followed by abortion if it is the unwanted sex. It is not completely reliable and being an expensive experimental procedure, tests only for specific defects. Extremely stringent methods are laid down for screening, and in most cases it can only be accepted if the couple has a genetic abnormality they are attempting to

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avoid. According to the Center for Disease Control and Prevention (CDC), more than 1% of all US born babies are conceived via IVF today [43, 50, 51]. Urobiologics LLC, a US company, also runs PreGender Preconception Test which is a urine-based gender selection commercial program. It utilizes the principle of alternating gender-specific hormonal environment of the uterus. The hormonal levels undergo cyclical changes during the menstrual cycle. It either has higher concentration of testosterone or estrogen, thus improving the chances of conceiving a boy or a girl, respectively. The process of conception “locks” the existing hormonal environment, and it stops alternating until the baby is miscarried or delivered. The PreGender test is a method to identify the differences in those environments by testing mid-cycle urine which is otherwise not possible to detect through testing of blood or saliva. The test helps to identify the gender-specific cycle and guiding through conception [52]. IVF PGD includes possible side effects like the chances of contracting vaginal infections and disorders such as ovarian hyperstimulation syndrome due to repeated cycles of hormonal supplementation and egg extraction procedures [53]. The woman is also at the risk of multiple pregnancies with death rate being six times higher for IVF twins, between five to nine months of pregnancy, than for single baby pregnancies; mortality rate following birth is nearly one in 20 or 4.5% [47, 50, 54]. The observed major congenital abnormality rate is 2.05%, similar to the incidence occurring naturally [55]. A new breakthrough in the process of sex selection is by using a microfluidic chip for sperm sorting which is a cheap and noninvasive method [56]. At home application runs the advantages of significantly reducing the costs of sex selection and bringing it outside of the medicalized domain. It positions itself as ethical despite all oddities because it fosters the principles of nonmaleficence since it is noninvasive and bypasses the possibilities of involving embryos. Some scientists working on sex selection believe in electromagnetic forces in the process of fertilization. Electric charges on the ovum are not fixed but alternate from positive to neutral and to a negative charge in cycle. Also X sperms are negatively charged, while Y sperms bear a positive charge. And the sex of the baby is influenced by what scientists call “ionic factors” which generate the charges on the ovum membrane and on the sperms. This means that when the ovum membrane is positively charged, it will attract the sperms carrying X chromosome and a baby girl is produced and vice versa. This suggests that the “mating rights” are exclusively with the ovum. Once fertilized, the X or Y sperm determines the sex of the baby. So it would be most appropriate to say that it is the female that chooses the sex of the baby and the male only determines the sex after conception [57]. Maheshwari in his explanation says that sex selection at cellular level is reflective of what happens at the macroscopic level. For example, in man–woman relationship, man is the proposer and woman is the chooser and never vice versa [58]. He concludes saying that female species is more powerful than male. While this may be taken by feminists to demonstrate their supremacy, this could prove another explanation for the age-old discrimination against women for not bearing sons. With the advancements in science and technology, semen manipulation techniques could be designed to increase the chances of giving birth to males compared

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to females. Despite reported successes, their reliability was still questionable for genuine medical indications other than sex selection. As scientific inquisitiveness on sex determination continued, the medical community desired sex preselection to control X-linked genetic disorders [59]. Lack of well-designed prospective controlled trials has resulted in uncertainty around clinical efficiency of sex selection techniques. Most clinical trials included a small number of conceptions or control group was visibly absent [60]. However, these were aptly picked up by centers offering assisted reproduction facilities [30]. In a report presented by Zarutskie in 1989, a review of eight trials showed that males were preferred exclusively in five trials while in another three, and preference was a combination of males and females with males outnumbering females [6]. In another controlled study on sex preselection on 249 couples in USA, 65% preferred a male while 35% desired a female. Only 2.4% of the couples requested sex preselection for genetic reasons. The rest stated a personal desire and/or husband’s desire. It is worth noting here that 54% of the couples were from Asian, Mideastern, and Afro American background [61]. As time rolled by, sex selection got into a web of controversy with some proponents supporting it while others opposing it on ethical and moral grounds. Modern sex selective technologies developed in the West but their clients and target population were/are in developing countries, including India. It saw a lucrative business and avenue to fulfill the needs of son preference [62, 63]. Thus, the science of genetics and sex selection went into ethical debate. Reubinoff in 1996 reviewed different sex selection measures but suggested that though reliable sex selection would result in favorable births, yet these may have long-term social and demographic consequences [60]. It is evident from both published and unpublished literature across different continents that there is a predominance in preference to males, though the degree may vary. It speculates that on a larger scale it will create an “imbalance” that would be transient, and this could result in a compensatory demand for girls. This is turn would increase their “market value.” If preselection is approved, monitoring of sex ratio should also be considered. Reubinoff urged medical community to adopt an ethical approach toward sex selection [60]. While one argument is that it may lead to more “wanted” children and hence reduce infanticide, the debate remains unsettled for want of more reliable data [64]. Dickens highlighted that in countries where gender discrimination is common, caution should be exercised. Where there is no obvious bias, sex selection may be allowed to assist females that want children of both sexes [65]. The prospects of using “new” reproductive technologies must be considered in the light of cultural values [66, 67]. Schenker highlighted in his paper that according to Jewish law, it is essential for a man to procreate by having a minimum of two children—a boy and a girl. According to both schools, Beit Shamai and Beit Hillel, one son is required to fulfill the obligation of procreation. Hence, sex preselection of nonmedical reasons is justified [68]. However, the ethical issues are profound and legislating its appropriate use will be difficult if not regulated [29, 69]. While exercising a choice for sex selection may

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be viewed as a woman’s right and autonomy, one needs to take a deep dive and analyze it more closely. The decision is often a reaction to intense pressure to produce male heirs, threats of violence, and devaluing the women’s status. It is natural to predict that under such circumstances, her individual choices will take precedence over the right to justice and equality, which are violated greatly in a gender-biased society [29]. It is feared that new reproductive technologies would lead to a future where “designer babies” are created based on the factors desired by most individuals such as cloning and gender selection [70]. Only improved status of girls will probably reduce demand for sex selection. Carson in 1988 set forth that sex selection is the ultimate in family planning. Preselection methods overcome the complications resulting from CVS or amniocentesis and may be seen a safe and efficacious resort to families wanting a child of a particular gender [71]. She inferred that large-scale or controlled studies would be required before concluding if in vivo methods would result in an alteration in secondary sex ratio. Her argument was that a successful method of sex preselection would allow couples desiring children of a particular gender to limit the family size. She concluded saying that “in seeking to develop successful techniques, we also gain knowledge and benefits that surely outweigh any potential demographic and socio economic harm that these techniques pose” [71]. USA, as a society, has given constitutionally guaranteed right to allow personal freedom of judgment. Hill argues that compared to the billions spent annually on nutritional supplements, homeopathic nostrums, surgical body sculpturing, and innumerable diet regimes, the money spent on PGD would be a miniscule amount. Moreover, the effect of sex selection might even reduce (taxpayer-borne) Government spending on health and human services over the long run [72]. It was also suggested that if sex selective practices are made accessible through insurance coverage, the family size and constitution could become a matter of choice rather than being a chance finding. Data shows that the proportion of assisted reproductive technology clinics offering sex selection services has increased from 45% in 2006 to 73% in 2017 [73]. In order to indirectly assess the impact that availability and access to preselection measures may cause, Dahl et al. opined that for a serious skewness in sex ratio to happen, there must be a considerable preference for children of a particular gender, and secondly, there must be a significant interest in employing sex selection technology. A web-based survey on 1197 men and women in USA showed that only 8% would go for sex selective technology, and 50% wished to have a family with an equal number of boys and girls [74]. Another analysis of a large series of PGD procedures for gender selection in the USA showed that there was no deviation in preference toward any specific gender except for a preference of males in some ethnic populations of Chinese, Indian, and Middle Eastern origin that represent a small percentage of the US population [75]. The use of sex selection technology seemed unlikely to have a significant impact on sex ratio, based on available facts. On the other hand, a public opinion poll of more than 2000 people in UK followed by discussions with focus groups and responses from 600 people to a

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consultation showed that more than 80% of respondents were against the use of sex selection technologies for nonmedical reasons [76]. Based on these results, Human Fertilization and Embryology Authority (HFEA), UK restricted all nonmedical uses of on sex selection techniques when it became clear that modern technologies were being misused. The decision came in 2002. Although the move was supported by some, it was criticized by some activists, who claimed that the recommendations were based on unsupported allegations, and it overlooked the genuine and legitimate interest of some families to have children of opposite genders [77–80]. It was looked upon as a step betraying the commonly held presumption in favor of liberty. The other school of thought was that those expensive procedures were likely to divert medical resources from genuine medical needs [81]. Sex selection for social reasons banned in UK

Acceptance of sex selection in other countries for nonmedical purposes was analyzed through nationally representative surveys (Australian Survey of Social Attitudes) in 2007 and 2016 [82]. Around two-thirds of respondents in both the surveys disapproved or strongly disapproved the use of IVF for sex selection. Proportion of respondents who disapproved the use of abortion for sex selection demonstrated a rise from 74% in 2007 to 81% in 2016. Interestingly female, young, more-educated, and more religious respondents were more likely to strongly disapprove of sex selection via IVF or abortion. The study concluded that if legislation is to be guided by community attitudes, then the prohibition against sex selection

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for nonmedical purposes through assisted reproductive technology should be maintained. In Germany, a survey was conducted among 114 specialists of reproductive medicine to assess their attitude toward preimplantation sex selection [83]. Majority (79%) favored a regulation to limit its use for medical use only. This has reduced compared to 90% in 1995 and 98% in 1985. When asked about counselling guidelines, they favored advising people to go for normal pregnancy instead of assisted reproduction for sex selection, for fear of a tilt in sex ratio in favor of boys. Previous surveys done in 2005 showed that preference of clients to boys was more (14% v/s 10%), while in 2007, it reversed (11% v/s 19%) [84, 85]. This supports that the sex selection measures may not significantly impact sex ratio. Yet, on moral grounds, people usually opposed sex selection measures for family balancing. On the other hand, in Pakistan, a survey among 301 pregnant women on gender preferences revealed that 41.5% wished to have a family with an equal number of boys and girls, 3.3% would like to have only boys, 1.0% only girls, 27.6% more boys than girls, and 4.3% more girls than boys [86]. About 27.2% felt that social sex selection ought to be legal and 48.8% thought, it should to be illegal. In a cross-sectional study reported from Jordan on 335 women presenting with infertility, it was found that 83% did not have any gender preference in particular, although 15% preferred a boy [87]. Preference for a boy was associated with an increased interest in sex selection measures. Advertisement of sex selection products in leading newspapers in India

2.3 How Logical and Ethical Are Modern Sex Selection Techniques?

Reaction of public to advertisement of sex selection products in the media

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India, by virtue of its size and population, gradually got drawn into the vortex of international competition. The sex selection kits that pronounced the use of preconception methods found a huge market in India. Advertisements of GenSelect in

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leading newspapers as well as on the Internet evoked an enthusiastic response from couples longing for a son. However, it kicked up a lot of criticisms. Petitions were filed in courts of some parts in the country challenging the legality of the marketing of this product and program (31, 45). A protest demonstration steered by Vimochana, a women led organization sent out messages on the sentiments of women activists in India. It filed a complaint against the product stating that it violates PNDT Act. The promoters stated that it was not for commercial opportunities but for deeper moral and ethical reasons that they were marketing in India. They claimed that a part of the proceeds from sale of every GenSelect kit sold in India would be donated to the cause of prevention of feticide [22]. GenSelect could not be prosecuted under the provisions of Indian law during that time as PNDT applied to prenatal measures and not to preconception measures. Lawyers collective took the lead to file a PIL in the Supreme Court seeking changes in the PNDT Act. The Centre of Equity into Health and Allied Themes (CEHAT), Mumbai; the Mahila Srvangeen Utkarsh Mandal (MASUM), Pune, and Dr Sabu George, a health policy expert and activist, filed it jointly. Following this, PNDT Act was then amended to PCPNDT Act [22]. National Family Health Survey (NHFS) data sets for India across different time periods contain nationally representative samples of birth histories. Data among women aged 15–49 years in 1992–1993, 1998–1999 and 2005–2006 showed that prenatal sex selection was used mostly in wealthier households at the second and third birth order, when the firstborn, or firstborn and secondborn, siblings were females [88]. Having female siblings was a significant risk factor for female infant mortality, but surprisingly was not correlated with household wealth. There was no evidence that increasing use of prenatal sex selection prevented female infant mortality. Sterri puts forward a case against banning sex selection in India. It argues that a ban on sex selection will only succeed if it is successfully defended against a common objection that parents have a right to procreative autonomy. Sex selection in favor of boys is presumed to be a procreative autonomy. There is no evidence that the ban has been able to avert discriminatory actions or a reduction in sex selection. The felt need for sons is so strong in India that it has led to a flourishing black market sex selection. Illegal abortions are more expensive and dangerous. If women do not avail sex selection measures, they may be at risk of abuse and divorce if they cannot deliver a son. With more numbers of unwanted daughters, it is likely to impede economic growth and likelihood of a desirable social change for a just and equitable society [89].

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3. Jha, P., Kumar, R., Vasa, P., Dhingra, N., Thiruchelvam, D., Moineddin, R.: Low female [corrected]-to-male [corrected] sex ratio of children born in India: national survey of 1.1 million households. Lancet 367(9506):211–218 (2006) 4. Unnikrishnan, P.: Banned—select: “a drug to alter the sex of the foetus. Health Millions 1(2), 29–30 (1993) 5. Neogi, S.: Sutapa Neogi speaks with epiNews about India's growing problem. In: Furlow, B. (ed.) Fetal “Gender Selection” Epinews, USA (2006) 6. Zarutskie, P.W., Muller, C.H., Magone, M., Soules, M.R.: The clinical relevance of sex selection techniques. Fertil. Steril. 52(6), 891–905 (1989) 7. Thompson, J.M.: Chasing the gender dream. Aventine Press, USA (2004) 8. James, W.H.: Time of fertilisation and sex of infants. Lancet 1(8178), 1124–1126 (1980) 9. Hvistendahl, M.: Unnatural selection. Public Affairs, USA (2011) 10. Ridley, J.C., Sheps, M.C.: An analytic simulation model of human reproduction with demographic and biological components. Popul. Stud. 19(3), 297–310 (1966) 11. Park, C.B., Cho, N.-H.: Consequences of son preference in a low-fertility society: imbalance of the sex ratio at birth in Korea. Popul. Dev. Rev. 21(1), 59–84 (1995) 12. Hesketh, T., Xing, Z.W.: Abnormal sex ratios in human populations: causes and consequences. Proc. Natl. Acad. Sci. U.S.A. 103(36), 13271–13275 (2006) 13. Allahbadia, G.N.: The 50 million missing women. J. Assist. Reprod. Genet. 19(9), 411–416 (2002) 14. George, S.M.: Millions of missing girls: from fetal sexing to high technology sex selection in India. Prenat. Diagn. 26(7), 604–609 (2006) 15. Jaising, I., Sathyamala, C., Basu, A.: Lawyers collective women’s rights I: from the abnormal to the normal: preventing sex selective abortions through the law. Lawyers Collective (Women’s Rights Initiative), New Delhi (2007) 16. https://shodhganga.inflibnet.ac.in/bitstream/10603/132942/5/06_chapter%202%20pdf.pdf 17. Balakrishnan, R.: The social context of sex selection and the politics of abortions in India (2004). http://www.hsphharvardedu/rt21/medicalization/BALAKRISHNANSSocial 18. De NBSSCDVSBAKR: Women’s Right to Health. NHRC, New Delhi (2006) 19. Annual report on implementation of the Pre-conception and Pre-natal Diagnostic Techniques (Prohibition of Sex Selection) Act. Ministry of Health and Family Welfare, New Delhi (2005) 20. Watch, G.: Female infanticide (2008). www.gendercide.org/case_infanticide.html 21. Arora, A.S.A.: Status of sex determination test in North Indian villages. Indian J. Comm. Med. 31, 41–43 (2006) 22. Women: an endangered species? Media House, New Delhi (2006) 23. The Medical Termination of Pregnancy Act, 1971: Welfare MoHaF, Act No. 34 of 1971. Government of India, New Delhi (1971). https://www.mainmohfwgovin/acts-rules-andstandards-health-sector/acts/mtp-act-1971 24. Tabaie, S.: Stopping female feticide in India: the failure and unintended consequence of ultrasound restriction. J. Glob. Health 7(1), 010304–010304 (2017) 25. PHFI: Research and Review to Strengthen Pre-conception and Pre-natal Diagnostic Techniques (Prohibition of Sex Selection) Acts’s Implementation Across Key States 2009–10 26. UNFPA PHFoITNHRC: Implementation of the PCPNDT Act in India Perspectives and Challenges. New Delhi (2010). http://countryoffice.unfpa.org/india/drive/ IMPLEMENTATIONOFTHEPCPNDTACTININDIAPerspectivesandChallenges.pdf 27. Singh, S.B.A.: Changing strategies of female foeticide in India: a never ending story. Int. J. Community Med. Public Health 3(9), 2672–2676 (2016) 28. Bhattacharya, S., Singh, A.: ‘The more we change, the more we remain the same’: female feticide continues unabated in India. BMJ Case Rep (2017). https://doi.org/10.1136/bcr-2017220456 29. Oomman, N., Ganatra, B.R.: Sex selection: the systematic elimination of girls. Reprod. Health Matter. 10(19), 184–188 (2002) 30. Lobel, S.M., Pomponio, R.J., Mutter, G.L.: The sex ratio of normal and manipulated human sperm quantitated by the polymerase chain reaction. Presented in part at the 8th International

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58. Bandypadhyay, S.S.A.: Sex selection techniques and declining sex ratio in India. Gyan Publishers, New Delhi (2010) 59. Corson, S.L., Batzer, F.R., Schlaff, S.: Preconceptual female gender selection. Fertil. Steril. 40 (3), 384–385 (1983) 60. Reubinoff, B.E., Schenker, J.G.: New advances in sex preselection. Fertil. Steril. 66(3), 343– 350 (1996) 61. Jaffe, S.B., Jewelewicz, R., Wahl, E., Khatamee, M.A.: A controlled study for gender selection. Fertil. Steril. 56(2), 254–258 (1991) 62. Kilani, Z., Haj Hassan, L.: Sex selection and preimplantation genetic diagnosis at the Farah hospital. Reprod. Biomed. Online 4(1), 68–70 (2002) 63. Malpani, A., Malpani, A., Modi, D.: The use of preimplantation genetic diagnosis in sex selection for family balancing in India. Reprod. Biomed. Online 4(1), 16–20 (2002) 64. Watt, H.: Preimplantation genetic diagnosis: choosing the “good enough” child. Health Care Anal. HCA J. Health Philos. Policy 12(1), 51–60 (2004) 65. Dickens, B.M., Serour, G.I., Cook, R.J., Qiu, R.Z.: Sex selection: treating different cases differently. Int. J. Gynaecol. Obstet. Off. Organ. Int. Fed. Gynaecol. Obstet. 90(2), 171–177 (2005) 66. van Balen, F., Inhorn, M.C.: Son preference, sex selection, and the “new” new reproductive technologies. Int. J. Health Serv. Plann. Adm. Eval. 33(2), 235–252 (2003) 67. Chan, C.L., Yip, P.S., Ng, E.H., Ho, P.C., Chan, C.H., Au, J.S.: Gender selection in China: its meanings and implications. J. Assist. Reprod. Genet. 19(9), 426–430 (2002) 68. Schenker, J.G.: Gender selection: cultural and religious perspectives. J. Assist. Reprod. Genet. 19(9), 400–410 (2002) 69. Macklin, R.: The ethics of sex selection and family balancing. Semin. Reprod. Med. 28(4), 315–321 (2010) 70. Campbell, A.V.: Reproductive medicine: the ethical issues in the twenty-first century. Hum. Fertil. (Camb.) 5(Suppl 1), S33-36 (2002) 71. Carson, S.A.: Sex selection: the ultimate in family planning. Fertil. Steril. 50(1), 16–19 (1988) 72. Hill, D.L., Surrey, M.W., Danzer, H.C.: Is gender selection an appropriate use of medical resources? J. Assist. Reprod. Genet. 19(9), 438–439 (2002) 73. Capelouto, S.M., Archer, S.R., Morris, J.R., Kawwass, J.F., Hipp, H.S.: Sex selection for non-medical indications: a survey of current pre-implantation genetic screening practices among U.S. ART clinics. J. Assist. Reprod. Genet. 35(3), 409–416 (2018) 74. Dahl, E., Gupta, R.S., Beutel, M., Stoebel-Richter, Y., Brosig, B., Tinneberg, H.R., Jain, T.: Preconception sex selection demand and preferences in the United States. Fertil. Steril. 85(2), 468–473 (2006) 75. Colls, P., Silver, L., Olivera, G., Weier, J., Escudero, T., Goodall, N., Tomkin, G., Munné, S.: Preimplantation genetic diagnosis for gender selection in the USA. Reprod. Biomed. Online 19(Suppl 2), 16–22 (2009) 76. Kmietowicz, Z.: Fertilisation authority recommends a ban on sex selection. BMJ 327(7424), 1123 (2003) 77. McDougall, R.: Acting parentally: an argument against sex selection. J Med Ethics 31(10), 601–605 (2005) 78. Robertson, J.A.: Gender variety as a valid choice: a comment on the HFEA - response to Edgar Dahl’s ‘the presumption in favour of liberty.’ Reprod. Biomed. Online 8(3), 270–271 (2004) 79. Pennings, G.: Sex selection, public policy and the HFEA’s role in political decision making— response to Edgar Dahl’s ‘the presumption in favour of liberty.’ Reprod. Biomed. Online 8(3), 268–269 (2004) 80. Dahl, E.: The presumption in favour of liberty: a comment on the HFEA’s public consultation on sex selection. Reprod. Biomed. Online 8(3), 266–267 (2004) 81. Savulescu, J., Dahl, E.: Sex selection and preimplantation diagnosis: a response to the ethics committee of the American Society of reproductive medicine. Hum. Reprod. (Oxford, Engl.) 15(9), 1879–1880 (2000)

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Chapter 3

Research on Sex Selection Drugs: Haryana Paves the Way

An investment in knowledge pays the best interest. Ben Franklin

3.1

Physiology of Sexual Differentiation

Advances in embryology, molecular biology, steroid biochemistry, cytogenetics, cell biology, and immunology have contributed to the advancement of the field of sex determination. Sex determination and differentiation involve establishment of chromosomal (genetic) sex in the zygote at conception, determination of gonadal (primary) sex by the genetic sex, regulation of the genital apparatus by the gonadal sex, and manifestation of phenotypic sex as a sequential process [1, 2]. Development of sex specific secondary sexual characters provides phenotypic manifestations at puberty. “Sex determination” is concerned with control of the development of the primary or gonadal sex. “Sex differentiation”, on the other hand, encompasses the events in gonadal organogenesis. Sequentially, through a series of events, the sexually indifferent gonads and genitalia progressively acquire male or female characteristics. These are regulated by different genes located on sex chromosome and autosomes and act through gonadal steroids, peptide hormones, and tissue receptors [1, 3]. After fertilization of the ovum in the uterine tube, the zygote undergoes division into two-celled, then four-celled, twelve-celled, and sixteen-celled structures— which gets completed after about 96 h. Blastocyst is formed on the fourth or fifth day of fertilization. Implantation of the blastocyst takes place on the sixth or seventh day, which is completed by the twelth day. The first three weeks of gestation comprise the germinal period. Embryonic period extends from the beginning of fourth week to the end of eighth week followed by the fetal period till delivery. Phenotypic sex becomes apparent at about third month of life [4]. The chromosomal or genetic sex of the embryo is established during conception. However, signs of sex differentiation are not noticed before six weeks after conception. Undifferentiated gonads irrespective of chromosomal sex are apparently identical and can develop into either ovaries or testes. This period is labeled as bipotential stage of gonadal development. The tissue of the indifferent gonads © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 S. Bandyopadhyay Neogi, Gender Before Birth in India, https://doi.org/10.1007/978-981-16-3318-8_3

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consists of primordial germ cells, mesoblastic cells, and supportive mesenchymal cells [5]. The gonads develop a cortex and a medulla. In genetic males, the medulla develops during the seventh or eighth week into testis, and the cortex regresses. In genetic females, the medulla regresses, and the cortex develops into an ovary [6]. All testicular or ovarian germ cells are derivatives of primordial germ cells. They are the primitive cells of the inner cell mass of the blastocyst. One cell of the eight-celled inner cell mass of 4½ day-old human blastocyst might be a germ cell. By the fifth week, primordial germ cells migrate to the urogenital ridge and differentiate into genital and extragenital primordial germ cells. By the sixth week, genital cells develop into gametes. The population of primordial germ cells reaching the gonadal blastema is 1000–2000. Gonads are subsequently colonized by the primordial germ cells, of extra-gonadal origin. Germ cells then transform into spermatogonia or oogonia which is under genetic control [4]. During the seventh week of gestation in the XY fetus, testicular cords and interstitial tissue develop from the amorphous cluster of gonadal cells. Under the influence of testis determining factor (TDF) located on the Y chromosome, primordial germ cells get incorporated into testicular cords [2]. Within that, the cells differentiate into primitive Sertoli cells. Leydig cells develop in the interstitial space filled by the mesenchymal cells. Sertoli cells produce anti-Mullerian hormone (AMH), while Leydig cells secrete testosterone. Interaction of germ cells with mesoblastic cells inhibits the mitotic activity of germ cells till puberty. In the absence of TDF, primordial germ cells do not interact with the mesoblastic cells, and mitosis continues till birth. Ovarian germ cells do not proliferate after birth. The influence of germ cells on the developing gonad is sexually dimorphic. Germ cell progression through meiosis is essential for the maintenance of the fetal ovary. In contrast, the development of the testes is not hindered by the lack of germ cells. In the human fetus, Leydig cells can be identified in the interstitial tissue by the eighth week after testicular cords have been completely formed. These Leydig cells then begin to produce testosterone, which plays an essential role in the stabilization of Wolffian ducts and the masculinization of external genitalia. Gametocyte proliferation in the fetal testis is inhibited by androgens. At the indifferent stage of genital development (up to eight weeks), all embryos have two pairs of unipotential genital ducts: the mesonephric (Wolffian) duct and the paramesonephric (Mullerian) ducts. Wolffian duct serves as the excreting duct of the mesonephros and is crucial for development of kidneys. When the kidneys becomes functional, the Wolffian duct that is dependent on androgens becomes the vas deferens [7]. In female fetus, it degenerates. The male transformation of genital ducts is dependent on testosterone, which is only active during a “critical” period during which the Wolffian duct is sensitive. Müllerian (paramesonephric) ducts, which give rise to most of the female reproductive tract, develop after Wolffian ducts in the urogenital ridges of both XX and XY embryos. In the female embryo, Mullerian ducts differentiate into fallopian tubes, uterus, and part of vagina. Estrogens are not necessary for the differentiation of female internal genitalia.

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Masculinization of the internal genital tract is marked by the regression of Müllerian ducts and differentiation of the Wolffian duct into male accessory organs. Müllerian regression, which is considered to be the first sign of male differentiation of the genital tract, occurs in 55 to 60 day-old human embryos, triggered by AMH at the center of a complex gene regulatory network. Female differentiation of the internal genital tract is characterized by the disappearance of the Wolffian ducts, which is completed by 90 days of fetal development. The regression of Wolffian ducts in the female fetus has been ascribed to a passive process deriving from the lack of androgen action. Molecular genetic studies in the mouse have contributed to the identification of growth factors essential for the formation of the sexual ducts. The ontogeny of AMH expression is different between males and females [3]. In the fetal testis, Sertoli cells begin to form cord-like structures which develop into future seminiferous tubules from the eighth week, and AMH mRNA and protein can be detected. High amounts of AMH must be expressed before Müllerian ducts lose their responsiveness, i.e., before the end of the eighth week in the human fetus for it to develop into male. In the ovary too, AMH is detectable in granulosa cells of preantral follicles but at 24 weeks of gestation. It must be expressed after the window of sensitivity of the Müllerian ducts to its action has closed. The timing of the expression of AMH is crucial to differentiate males from females. Thus, the initiation of AMH transcription is under tight transcriptional control. For the fetal testis to secrete masculinizing hormones and undergo morphological changes, these factors need to be present at sufficient levels in the right cell lineage. What is more important is that the expression must also be initiated within a narrow critical time window [3]. Up to approximately nine weeks, the external genitalia remain undifferentiated. Masculinization of the external genitalia begins in human male fetuses around nine weeks. Testosterone is produced from cholesterol by chorionic gonadotropin stimulation of fetal Leydig cells through the coordinated action of steroidogenic enzymes. It peaks between 14 and 17 weeks and then falls sharply, so that in late pregnancy the serum concentrations of testosterone overlap in males and females [3]. Testosterone itself is not a very active androgen; its metabolite dihydrotestosterone (DHT) is the main virilizing agent during male reproductive development. The conversion of testosterone to DHT augments the androgenic signal. DHT cannot be aromatized to estrogen, and thus, its effects are purely androgenic. Moreover, it has a greater affinity to androgen receptor than testosterone. Differentiation of Wolffian ducts into epididymis, vas deferens, and seminal vesicles occurs under the direct influence of testosterone. DHT regulates differentiation of external genitalia [5]. Testosterone, however, is not an obligatory precursor of DHT. Testis can produce biologically significant amounts of DHT through an alternate or “backdoor” pathway without using testosterone, dehydroepiandrosterone (DHEA) or androstenediol as intermediates as observed in tamma wallaby, a marsupial [3]. In fetal Wolffian ducts, 5a-reductase is expressed only after the ambisexual, critical stage of male sex differentiation, and thus, testosterone itself, not DHT, saves them from degeneration. Because of its close proximity to the testis, the Wolffian duct is exposed to a very high local concentration of testosterone, a source of androgen not available to organs receiving testosterone only via the peripheral circulation.

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The reason why Y chromosome is incriminated as the basis for primary sex is the presence of some factor on the Y chromosome. The discovery of the TDF SRY in 1990 was followed by the progressive unveiling of robust networks of genes, whose balanced expression levels either activate the testis pathway and simultaneously repress the ovarian pathway or vice versa. It has become clear that sex determination is a far more complex process, regulated by competing molecular pathways in the supporting cell lineage of the bipotential gonad. Testis development process involves several steps controlled by other non-OY-linked genes, such as Wilms tumor gene 1 (WT1), EMX2, LIM1, steroidogenic factor 1(SF-1), and SRY box-related gene 9 (SOX9). Since other genes, such as Wnt-4 and DAX-1, are necessary for the initiation of female pathway in sex determination, female development cannot be considered a completely default process [8]. Under physiological conditions in the XY gonad, the upregulation of SRY tilts the balance that initiates the testis cascade. The prime function of SRY consists of upregulating the expression of SOX9, the transcription factor, during the critical period. The target gene encoding SOX9 is the regulating factor behind sex determination. Beyond this period, SOX9, once expressed, is able to channelize the mechanisms triggering Sertoli cell differentiation. If it is not expressed, it is countered by an opposing set of genes that stimulates ovarian differentiation. SOX9 mimics the effects of SRY independent of SRY expression. In fact, overexpression of SOX9 during early embryogenesis period can induce testicular differentiation as reported from two different models of transgenic XX mice. SOX9 also affects the differentiation of the reproductive tract by upregulating the expression of AMH [3]. Because of the Y chromosome localization of SRY, it can be expressed in the XY gonadal ridge, playing a prominent role in tipping the balance between testicular and ovarian promoting genes toward male differentiation. A stringent regulatory mechanism for SRY expression is essential, in terms of timing and levels of expression to reach a certain threshold for induction of testicular differentiation. The expression usually takes place between 41 and 44 days postfertilization in humans. Experimental results have demonstrated that when SRY is expressed in early gonadal ridge but has impaired expression of signaling molecules resulting in reduced or absent SRY expression, gonadal agenesis and female phenotypic characters develop. Moreover, the SRY gene is not detected in 20% of XX males. Other genes required for testis determination in humans remain to be identified, although we have enough evidence from mice studies [9]. It is now clear that in the absence of the SRY gene, a gonad develops into an ovary even if the genetic make-up of the embryo is XY. Testis development is possible through the interaction of SRY gene with other genes located on autosomal chromosomes, some of which being involved in the regulation of SRY expression [9]. Jost’s experiments have shown that the reproductive tract, irrespective of its genetic sex, will develop following the female pathway if not exposed to testicular hormones, indicating thereby that female is the default sex, which is not completely in sync with what modern geneticists believe [3]. The common factors that emerge are that the main forces behind male differentiation are the male hormones. On the

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other hand, XX germ cells surrounded by Sertoli cells differentiate into spermatogonia, whereas XY germ cells in an ovarian context differentiate into oogonia and then enter meiosis. The existence of the testes determines the fate of sexually dimorphic physiology of internal and external genitalia. Irrespective of their chromosomal constitution, when the gonadal primordia differentiate into testes, all internal and external genitalia develop along the male lines. When no testes are present, the genitalia develop along the female pathway. The presence of ovaries has no effect on fetal differentiation of the genitalia. Therefore, it is said that a female is a female not because she has ovaries but because she lacks testis. The role of testicular differentiation in fetal sex development has prompted the use of “sex determination” equivalent to differentiation of the bipotential or primitive gonads into testes. Sex determination does not always require germ cells. In a variety of situations in which there are no germ cells, testes are apparently normal except for the absence of germ cells [5]. Sertoli cells require a Y chromosome, whereas Leydig cells do not require a Y chromosome. SRY expression is epigenetically regulated. Environmental chemicals (endocrine disruptors) are of paramount importance that exerts deleterious effects upon the endocrine axis. They bind to nuclear hormone receptors, and this may affect sexual differentiation. For instance, unregulated exposure to xenoestrogens such as bisphenol A is associated with cryptorchidism and hypospadias. Phthalates adversely affect male differentiation by increasing the expression of COUP-TF2, a transcription factor which represses steroidogenic enzymes [10]. Phthalates may also act as pseudo-estrogens (bisphenol A, alias BPA) or as anti-androgens (diethylhexylphthalate, alias DEHP). In human testes, germ cells are highly susceptible to phthalates. Atrazine, an herbicide widely used in the United States is reported to demasculinize male gonads and reduce sperm counts by interfering with phosphodiesterase enzymes and SF1. High dose of estrogens administered to pregnant animals is also likely to cause abnormal development of male genitalia. Understanding the physiology of sex differentiation and sex determination was extremely important for us to be able to decipher what effects SSDs can result in. The firm belief that sex is determined at the time of conception and in no way can be altered seems to be partially true. The physiology of sex differentiation is a complex interplay of genetic factors and is seemingly not as simple as was presumed earlier. What is amazing in the whole concept is that modern medicine armed with multiple hi-tech disciplines is still reeling under several challenges and gray zones to decipher the truth. Compare it with the documents published centuries ago. According to Charaka Samhita [11], an embryo is originated by the aggregate of these entities: mother, father, self, sustainability, nutrition and psyche. It is the product of ‘akasa’, ‘vayu’, ‘tejas’ and ‘prithvi’ being the seat of consciousness. Endowed with all the qualities while taking the form of embryo, during the first month, it is completely mixed up and made turbid with all the constituents and like phlegm having unmanifest form and body parts both as manifest and unmanifest.

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3 Research on Sex Selection Drugs: Haryana Paves the Way During the second month, it is solidified as small bolus, elongated muscle or tumour like which indicate male, female and eunuch respectively. During the third month, all the body parts are formed. Simultaneously, all the sense organs and other body parts appear except those entities which come forth after such as teeth, secondary sex characters, manifestation of sex characters and other similar entities. Change of sex is affected before its manifestation by vedic rites [are] properly performed because the actions preferred with excellence of place and time certainly produced results otherwise not. Hence considering the woman as pregnant she should be administered ‘pumsavana’ (measures which help procreating a male progeny) before the foetus is manifested. It clearly delineates the methods to be adopted for male and female progeny.

If one critically examines both schools of thought (ancient text as Charaka status and the one modern physiology emphasizes), one can relate the synchronicity and similarities in the crudest form. Ancient medicine enjoys remarkable symbiosis with some of the most significant findings of modern embryology. The theory of sex determination is so puzzling that it will continue to be a source of fascination for several years to come. Centuries have elapsed attempting to unravel the mystery behind sex determination and differentiation—but the issue of male preference has remained unchanged ever since. Desire is the key to motivation, but it’s determination and commitment to an unrelenting pursuit of your goal- a commitment to excellence- that will enable you to attain the success you seek Mario Andretti

3.2

Haryana’s Commitment

Field visits are integral to public health. On one such occasion, we were traveling to Chandigarh. That was December 29, 2013. On my way, I saw a missed call from an unknown number. I did not pay heed to it. Then, I received a message that read ‘Hello, Dr Sutapa. Please let me know a convenient time when we cud chat. I need to discuss an issue of great importance. Its kind of urgent.’ Regards. Dr Rakesh Gupta, IAS, MD, NRHM, Haryana. Then there were 3 missed calls from the same number.

“What could be this important topic!” I thought. And it is so urgent. Getting messages and calls from MD, NRHM! I was amazed. Our previous experience has always been quite tricky. One would have to request for an appointment, then get it after a dozen of follow-ups; when fixed, one would have to wait for hours before getting inside his/ her cabin. And here is an MD who is trying to contact me. What could be more important than SSDs, I said to myself. Whatever it is, I would bring up this issue during our discussion, I thought. I finally called him up. From his voice, I could make out that he wanted to get maximum information in minimum time. He asked me about SSDs.

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What was I hearing? I could not believe my ears. How does he know about SSDs? For a moment, I thought I was hallucinating. I kept looking at my mobile once, twice, thrice to be sure what I was hearing was SSDs and nothing else. He asked me what we did in our previous study and said he would like me to submit a proposal to him. I was in seventh heaven. But how did he get my number? I wondered. And then I recalled. I had traveled from Ahmedabad to Delhi with Dr. RaviKant Gupta, Director of Reproductive and Child Health, Haryana, a few days back. A young medico, who joined administrative services, was full of enthusiasm and always proactive about projecting the achievements and activities of Haryana. During our conversation, I did mention to him about SSDs. And his reaction was, “are we creating hermaphrodites”? “God knows,” I said, “but we should admit that it is a harmful practice.” We had exchanged our phone numbers also. He had passed on my number to him. We reached Chandigarh in the evening. No sooner did I reach the hotel, than I called up my Director. I could not contain my excitement as I was speaking with him. But he sounded quite composed. “Doing such kind of studies could be a bit risky because our Ethics Committee would not give clearance. Since it is very close to your heart, I would suggest that you request NRHM to lead and you provide technical support.” I could not argue much with him but that set me thinking …what was wrong in my leading it. In many institutions and Medical Colleges, the Head of the Department or the Institute becomes the Chief Investigator by default. However, in my organization, this has never been the case. We were always encouraged to get research grants as the Principal Investigators. So why was he so reluctant in this case? Was he scared of the risk involved? Well, every research entails certain amount of risk. Imagine, if Edward Jenner had not taken the risk of scratching the pus of cowpox rash into the hand of 8 years old boy, would we have enjoyed the privilege of a massive immunization program today? Certainly not. Our Ethics Committee had created a lot of problems giving approval on a previous study, and hence, he was incredulous. Ethics Committees were assuming lot more independence and credibility those days, and in many cases, they had the power to override the decisions of the institute even. I could understand his point of view also, but I strongly opined that the need to do research should not come in the way of bureaucracy. Anyways, my main aim was to get some data to show how harmful SSDs are. This is what I have been wanting to do since long. “How can I give away something that I am so passionate about?”, I thought. The next day, we went to his office all prepared with the presentation. I was waiting outside his room when two more people from Department of Food and Drug Administration (FDA) also came and sat next to me. “Are you Dr. Sutapa?,” one of them asked. “Yes,” I answered.

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“You want to do a study on those medicines? You call them drugs? Do you think sex of a baby can be changed? We don’t agree with your proposal,” one of them said. He was from FDA. [The word ‘drug’ in SSD had drawn criticisms from those who followed our work from close quarters. A drug is a molecule thoroughly investigated and authenticated for some purpose. I too realized my mistake of labelling it as drug. But then I was too naïve to understand the repercussions when we started the work.]

They did not know what I had to say. How and why were they commenting like this? I did not understand. That is why I am a bit skeptical about talking to people in health systems. “Why can’t they open up their eyes and mind to see what is happening around them? “I never said that sex of a baby can be changed. This is a myth that needs to be dispelled”, I replied sternly. I was about to say more, when we were called inside the MD’s room. After a brief introduction, I was asked to present about the plan of the study. The presentation was over. Dr. Rakesh Gupta was happy. “We will take it to the international level”, he said. His PhD in Public Health from Johns Hopkins University was the factor behind his eagerness to gel research with program implementation in real practice. “International level?” How ambitious he is! He looked quite a dynamic personality as he kept checking his messages and mails while he was discussing things with us… one should master the art of multi tasking. India needs people like him. I was quiet as I was waiting for him to look at me when I would say that the study would have to be led by him. Finally, I gathered enough courage and said, ‘Sir, I can provide all the technical help. But you have to lead it.” “It has to be the other way round,” he replied back. “But I cant.” “Why?” I had no answer. He immediately called up my Director. There was a communication going on between both of them where each one was trying to convince the other. Finally, Dr. Gupta had the final word that I would lead the proposal. He asked me to submit the proposal and complete the study in three months time. I was extremely happy and surprised to see his will and determination, his charismatic personality, and the way he was multitasking and yet pursuing his research interests. “It is my dream project Sir.” I thanked him wholeheartedly and left. After I reached the hotel, I kept pondering over it, and tears started rolling down my cheeks all of a sudden. He is a God-sent creature for me. May God bless him and give all successes! I was reminded of a quote by John S Herrington, “There are no dreams too large, no innovations unimaginable and no frontiers beyond our reach.” I shared my experiences with few of my friends and colleagues. Some of them said, “never believe in these IAS officers. Don’t think he is supporting you for your work. He wants to get mileage out of it.” In India, some people jokingly say, “IAS

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stands for I Agree Sir. Their stance keeps changing with the change in the political environment.” Some one else said, “IAS officers keep changing sides and are very capable of hijacking ideas.” Hijacking what? If that had been the case, he would never have requested me to lead the project. People both in his Department and outside used to say, “Dr Gupta is hyperdynamic. In his dictionary, the word tomorrow does not exist. He will give you work today and want it to be submitted yesterday.” The same day, one of the correspondents from Government of Haryana wanted to have a press release on SSDs from the office of MD, NRHM. They obviously contacted me and wanted to have the documents shared. Very happily I shared every bit of information with him. I wanted to inform the Communications Department of my Institute as a protocol. They have a responsibility to scan every information that goes out of the organization. After going through the write-up, they asked me not to be a part of it. “But this is my original work? How can I part myself away from it?” The reason was the sensitive nature of the topic! I became sick and tired of hearing the same thing time and again. Anyways, we mutually came to the conclusion that the papers may be shared because those were in the public domain and anyone could access them. However, I would refrain myself from putting my name. I was a bit disappointed at the whole thing. At last, I consoled myself saying that interest of the organization surpasses that of an individual. I gradually calmed down, for want of more and better evidence and better cooperation for future work. “Research from PGIMER conducted in 2003 highlights use of sex selection drugs…” was the headlines in many newspapers the following day. As I was contemplating on how to go about doing the study, I discussed this with few of my friends and colleagues. I was involved in yet another study on birth defects, and I was asked to step down from that project till I completed the work on SSDs. Reason? For fear of conflict of interest. I was not really convinced by the logic but quietly agreed because my SSD work was more important than anything else. I kept thinking… “where is the problem when someone is providing financial support and that too from the Government? Why is the word sex selection creating so many glitches? Why do people always prefer to stay away from controversies? May be it’s an instinct… quite natural and understandable.” But how can science progress without controversies? I still fail to understand. If everything becomes noncontentious, what will happen to research? For me, research are of two types. One, where you submit a proposal against a “call for applications”. Several proposals are floated by different donor agencies. Here, the problem statement has been identified by someone else. The job of a researcher is simply to execute the “terms of reference”. Although the skills of a researcher are of utmost importance but isn’t it obvious that it lacks the originality and luster of a researcher? Another question that follows is… who applies for such grants and what drives a researcher to apply? The name of the funding agency and money and

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hence chances of publications—all required for strengthening the CVs and of course promotion! I am sure if one asks the organizations and scientists to spell “research”, most of them would spell it as MONEY… where passion and love to do research are at the backburner. The tyranny of money is simply horrible. That is why one would often find researchers switching from one field to another … hunting for a suitable window of opportunity… and working without too much of an emotional involvement. People who jump fence with no compunction when a more lucrative research offer comes their way… are bound to be more successful. It is important for a researcher to be emotionally indifferent at times… I agree because this can affect research negatively. But how can one always be driven by such tangible gains? Though many dedicated researchers would understand the rules of the game, not many would embrace every bit of it. The second type of research is when a researcher discovers a problem and aims to address or solve the issue. If this is the first of its kind, there are bound to be no prior publications to back it up; result? It may not be accepted by funding bodies for fear of a flop show… My teacher Professor Rajesh Kumar used to say that once you develop a good and valid research question, 50% of your research is done. Today, I realize how true it is. If research is meant for people, patients and community, research ideas should also come from these very people. Such ideas may not be in the interest of organizational growth, nor it would be of any appeal to any funding body. It would not bring in money and recognition, that one has to reconcile, and even if it does, it would come late in his/her career when hurdles and obstacles would have demotivated the person to the core. Many research ideas thus never get to see the light of the day! What a contrast this is from the real life situation! Our conventional teachings say… first develop the research question.. then the methodology.. and then the budget…and then identify a suitable funder who can support the study. In real life, we follow the reverse gear… look at the budget first, then the funding body …and last of all the research question is developed to suit the budgetary requirements. Such research can never imbibe the emotional appeal that is so very necessary for it to mature and be of some use to the mankind. The life of a researcher is very difficult. Every day I used to find myself beset with so many difficulties and challenges. Besides the problems of finance, I found we were living in such stirring times. There were a thousand things that I wanted to do, but one had to exercise self-control to keep oneself to work and concentrate on it. I was once reading a book “Front of the class” by Brad Cohen. There were few lines written in the book that inspires me each time I read them: If you want to feel secure, do what you already know how to do If you want to be a true professional and continue to grow…. Go to the cutting edge of your competence, which means loss of security… So whenever you don’t quite know what you’re doing… know you are growing….

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Till now I understood that research is for society. With each passing event, a new realization dawned on me… I cannot and should not give up. Success for me is not earning a lot of money. It is considering myself useful to the society, to policy makers who strive to improve public health, earning gratitude and respect from my colleagues and friends who would benefit from my companionship and develop the courage to keep dreaming relentlessly. Dream? Yes. We need people who can dream and think out great problems of life and make this world a richer place by their thoughts. But at the same time, we need workers who can toil hard, whose incessant knowledge can increase the bounds of human knowledge. I completely agree with what Dr. Abdul Kalam said, “dream is not something that you see when you are sleeping, it is something that will not let you sleep.” The fundamental quality of a good researcher is doing things differently. It calls for three important qualities: the willingness to look with a new perspective, thinking about any matter with an open mind and enjoying the challenges which come in the newer ways of doing things. I had the fire in my belly, which I wanted to keep live by continually discussing with my friends and confidants, with a hope that someone someday will splash water on it only to raise the size of the flame… not to extinguish it altogether. With all these going on in the background, I was determined that I would complete the study and would publish it someday. I formed a small team and began my work. Dr. Gupta was always very welcoming. He instructed me to keep him updated periodically through SMSs and so did I. His way of monitoring things remotely was incredible… something that one should master. The process of scientific discovery is in effect a continual flight from wonder Albert Einstein

3.3

Findings from Epidemiological Research and Predictive Toxicology

Going by the physiology of fetal development, it became apparent that any insult during the phase of active and rapid multiplication of fetal cells would cause harms. If interference with cell division is the concern, then congenital malformation or birth defects could be the probable outcomes. If we relate the timing of intake of SSDs with timing when these organs are formed, it shows a strong correlation with the structural and functional development of nervous system, palate, … and sexual differentiation. We therefore came up with a hypothesis that SSDs could be related to malformation of these organs. The principles of epidemiology suggest that it is essential to assess if there is an association between exposure (SSDs in this case) and the outcome (birth defects) to test our hypothesis. We designed a case control study to explore the risk factors of

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birth defects that were apparent and visible to the naked eye, for the sake of simplicity. In studies like these, one has to consider all the probable factors that are associated with the outcome. We enumerated all the risk factors from the literature. Our study demanded procuring a line list of confirmed cases who were born in the past 18 months of the study. That was provided to us by National Health Mission, Haryana. Our team actively reached out to those families to confirm the cases, current status of the child (alive/dead), exact addresses and location of the household and obtained verbal consent before visiting the families. Accordingly, the team’s travel plan was decided, and physical visits ensued. The strength of any study depends on the quality of controls. For the best possible option among case control study designs, controls could come from the same community as the cases. We too followed this and decided to choose the controls who belonged to the same locality as the cases and those who were born around that time (±2 months) as the cases. The sample size was 175 cases and 175 controls. Our proposal was approved by the Ethics Committee. We advertised and soon we had Sham and Dr. Sapna work with us as two hardworking young enthusiasts, always eager to learn new things. Data collection happened during summer season, when heat was at its peak in north India. Our team was dedicated and committed enough not to leave any stone unturned to reach the targets set out for the week. Sometimes they would have to travel almost 250 km just for one case. I was very lucky to have had a team so very motivated to take up this upheaval task. They took three months to complete data collection. Needless to mention here… I was forever biased on the topic… hence refrained myself from going to the field. I had a feeling that my style of questioning would be different and I might run a chance of probing beyond what was desired. It is important to maintain equipoise in research, and hence, data collection should be left to people who are emotionally not connected to the topic but sound in research techniques. I could see a visible transformation in the attitude of our research staff as data collection progressed. When they started, they were working for a project to get some stipend and an experience certificate at the end of their job. By the time data collection matured, they had developed a bonding with the study… with the issue… they could connect and empathize with people who were duped into taking these medicines for fulfilling their own and their families’ wishes. They had several interesting stories to share—how they innovated ways to extract sensitive information through interviews, how they gained the confidence of mother in laws to elicit the ‘truth’… or how they managed to engage mother in laws in diverse superfluous chat…only to dissuade them from the main conversation… when the mother was being interviewed in a corner of the same room or in a different room by another interviewer… these are not simple tasks, whatsoever! Moreover, the interviewers had to maintain a calm composure in front of the mother so as not to instill in her a feeling of guilt or remorse…. In no time our research staff too developed an emotional connect and a concern looking at the pitiable situation of the women of our country.

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As was expected our analysis did show a strong association between SSDs and birth defects. In epidemiological terms, the odds ratio was 3; meaning thereby that there was three times more likelihood of having an exposure to SSDs among those who had birth defects as compared who were normal. These were the findings after adjusting for other covariates and confounders (that might have influenced the results positively or negatively). Given the rarity of the condition, it could be well interpreted that a mother who consumed SSDs was three times more likely to give birth to babies with birth defects as compared to those who did not take SSDs [12]. We also went ahead and did a subgroup analysis only to derive that those having a daughter were 3.5 times more likely to have birth defects with SSDs. Interestingly more than 2 living children emerged as an independent risk factor which underscores the fact that chances of consumption of SSDs increased with increasing parity... understandably so if the existing children were not boys. The distribution of mothers with a positive history of SSDs was across all the districts. Distribution of mothers who reported consumption of SSDs in the Haryana study

The results were pretty exciting… although those were in the lines of our expectations, I had mixed feelings… I was happy that now we had some solid proof to advance our advocacy efforts with more confidence… at the same time I was sad imagining the havoc that such ruthless practices have had on the children of our country. If only we had these findings 10 years back! I am not quite sure whether there would have been someone like the current Haryana Government to take things

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3 Research on Sex Selection Drugs: Haryana Paves the Way

on its stride and initiate actions a decade back. However, certainly delaying research is not considered ethical, more so if one is anticipating harms. The excitement behind scientific discovery is the in-depth knowledge it gives us, a satisfaction albeit subtle, at something understood. In scientific world, when you discover something new, however small it may be, you feel you are at the top of the sky. That is the best part of it. Anyways I informed Dr. Gupta immediately and instant came his congratulatory message. He never shied away from encouraging people! He told me very clearly that the paper should get published in a good journal. I also wished the same but only if journals agreed. Then, as with any hyperdynamic personality, he was ready with his next assignment—to explore the association between SSDs and stillbirths (a newborn who is born dead). He had heard about some anecdotes from elsewhere and had a gut feeling that these two could be associated. Meanwhile, another study was conducted by a student pursuing Masters of Public Health (MPH) from PGI. She performed a matched case control study, cases being the critical infants admitted to pediatric emergency of PGI with severe degree of malformations. The association was even stronger (odds ratio 4) [13]. If we now have to put 2 and 2 together, biologically it is plausible that SSDs may lead to severe malformations resulting in stillbirths. For our community-based case control study on birth defects, we deliberately excluded severe malformations for ethical reasons. Moreover, it was highly possible that the newborns whom we were labeling as “birth defect absent’ might have had malformation of internal organs— not severe enough to have caused symptoms at the time of the study—thus erroneously classifying them as normal, and this could have biased the study results. Against this background, we conceived the next phase of the study, this time taking stillbirths as the outcome. We started with the proposal. The sample size required for exploring the association between SSD and still births was 326 stillbirths and 326 livebirths. By then our team became very conversant with the methods. More members were added to tide over the limitations of time. Data collection happened in peak winters when minimum temperature touched almost 2–3 °C in some places. Commendable work —the team completed data collection and entry and presented the data to us for analysis. I must salute the young vibrant members of our team whose untiring efforts led us to this stage. Here also, we found a very strong association between SSDs and stillbirths. The study findings were mind-blowing. Stillbirth is a condition that can result due to an array of maternal and fetal factors. The questionnaire was pretty long capturing all details. Among the various risk factors studied, exposure to active or passive smoking, vaginal bleeding during pregnancy, high blood pressure during pregnancy, any complications during labor, intake of SSD during pregnancy, history of previous stillbirth, passage of foul smelling liquor, and preterm deliveries (