Feature Fetal sex selection

The promise of a boy: Indian women are being mis-sold drugs to change their babies’ sex

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j913 (Published 06 March 2017) Cite this as: BMJ 2017;356:j913

The drugs don’t work and may even cause miscarriage, but their use is shrouded in secrecy, writes Sophie Cousins

Sitting on the floor of her home in the north Indian state of Haryana, 23 year old Meena covered her face with a red and blue sari as she spoke about her recent stillbirth.

“The doctor told me the child died in my womb. He said there was no heartbeat. There was no explanation,” she told The BMJ.

Six months earlier Meena had taken what are known as sex selection drugs (SSDs)— remedies that women take because they think that they will help them give birth to a boy.

“I took the drugs because we wanted a male child—because my first baby was female,” she said at her home in Sampla, a village in Rohtak district.

While the drugs contain legal compounds, selling them together as a “sex selection drug” is illegal.

The drugs are typically taken six to 10 weeks after conception when the sex of the child has already been determined.

Women are sold the drugs through an underground network that includes rickshaw drivers and midwives who connect families to sellers.

They are told to follow strict rituals—like wearing clothes of a certain colour or praying to a god—and to take “traditional remedies,” which come in powders or tablets. A woman might take the drugs in the morning with a glass of cow’s milk while looking at her husband, locals told The BMJ. The drugs—which are usually taken daily for a week but sometimes up to a month—are sold for as little as $3 (£2.41; €2.85) and as much as $50.

But what women are not told is that the sex of their child cannot be changed and that the drugs can have harmful consequences.

Skewed sex ratio

For more than 100 years, the Indian census has shown a marked gap between the number of boys and girls, men and women. India has one of the world’s most skewed sex ratios. According to the most recent census, in 2011,1 there were 914 girls to every 1000 boys for children up to 6. In some northern regions fewer than 850 girls are born for every 1000 boys.

The deeply rooted preference for male children stretches back centuries and is motivated by myriad factors including economic, religious, social, and emotional reasons that make females less desirable.

Anita Raj, director of the Centre on Gender Equity and Health at the University of California, San Diego, explained that parents expected sons to provide financial support, add to family wealth and property, carry on the family lineage, and perform important religious roles while girls were seen as an economic burden because of the dowry system, and as unable to exercise the family’s power.

“Traditional norms are the major driver. At the end of the day, boys are simply valued more than girls, and the rest is just a justification for that,” she said.

Because of the ingrained preference for a male child, India has a long history of sex selection, which manifests in many ways, from use of drugs to infanticide.

Missing girls

While India prohibits prenatal sex testing and sex selection abortions, every year 400 000 Indian girls go “missing,” according to the United Nations Population Fund, the result of abortion, infanticide, and neglect.2

In 1994—after an increase in the availability of sex screening technologies throughout the 1980s, and under pressure from activists—the Indian government outlawed the use of ultrasound machines to determine the sex of a fetus. In 2004 the law was amended to deter and punish prenatal sex screening and female feticide.

Despite laws and acts against such practices, the industry continues to thrive with impunity.

“The ultrasound was India’s biggest curse. A doctor wants money and a woman wants to know the sex of her child—it’s a mutual benefit and both keep their mouths shut,” Varun Arora, a doctor who works at the Post Graduate Institute of Medical Sciences in Rohtak, said.

“The demand in society for a male child is so high that even if the laws and acts are implemented, people will find a way.”

Limited research

SSDs are commonly taken for sex selection in India but research on prevalence, and consequences of use, is limited partly because their use is shrouded in secrecy.

“Women are told not to discuss it with anyone. The seller instils fear in them so they believe they will get in trouble if they talk about it,” said Pragya Rai, junior research fellow at the Public Health Foundation of India (PHFI), who researches the phenomenon in north India.

A recent study found that SSDs could be attributed to 20% of 325 stillbirths in Haryana over a two-month period in 2014, where the use of such drugs is extensive.3

“How grave is this problem? We just don’t know. In north India there’s a huge preference for a male child but it’s wrong to say that this practice is not happening elsewhere in India,” Sutapa Bandyopadhyay Neogi, a maternal and child health specialist at PHFI and lead author of the study, said.

Birth defects and developmental disorders

Neogi has found that the drugs often contain phytoestrogens. In large doses these have been linked to birth defects and developmental disorders that “could be detrimental to the growth and development of the fetus,” she said.

Abhijit Ganguli, a biotechnology expert who examined the samples Neogi and her team collected, said he was shocked.

“It is unnatural for the body to have these levels of phytoestrogens for any period of time,” he said, adding that they contained 100 times more phytoestrogens than would be considered safe.

Haryana government officials say that up to 60% of women whose first child is female take SSDs for their second birth.

In 2015, in response to the census that showed there were only 914 girls to every 1000 boys,1 prime minister Narendra Modi launched a national campaign to tackle the sex selection ratio, with a particular focus on 100 districts where the child sex ratio is particularly skewed.

The Beti Bachao Beti Padhao (Save Daughters, Educate Daughters) campaign aims to improve the sex ratio by better enforcing laws that prohibit sex selection abortion and diagnostic techniques that are used for female feticide. It also focuses on ensuring every girl child gets a quality education and devising new schemes to protect girls.

In response, police and health inspectors have begun arresting people who sell SSDs in Haryana. Over the past 17 months, 35 raids have taken place in Haryana, resulting in two convictions, according to figures seen by The BMJ.

In addition, since last May more than 300 complaints have been lodged against healthcare workers who carry out illegal ultrasounds.

But experts and government officials acknowledge that complaints and short term convictions only go so far—offenders are usually back in business within a few months.

Girls are equal to boys

“We need to empower the girl child with the idea that girls are equal to boys. We need to create an environment where girls are actually equal, but this is going to take some time,” said Rakesh Gupta, additional principal secretary to the chief minister of Haryana.

How to create an environment where girls and boys are equal, in Haryana and the rest of India, remains to be seen.

Raj said that no intervention had yet been effective at reducing the preference for sons at a national level. However, she said that engaging with schools and teachers as well as community elders and parents to change norms and prioritise girls could be useful.

For the time being Neogi and the non-profit organisation Apoorva Pande Foundation are concentrating on educating the public about the dangers of SSDs through short films and newspaper advertisements in north India, where the preference for a son seems greatest.

“I just want to see a change in the mindset of women so that they are scared to take these drugs,” she said.


  • Competing interests: None declared.

  • Commissioned; not externally peer reviewed.


View Abstract

Sign in

Log in through your institution

Free trial

Register for a free trial to thebmj.com to receive unlimited access to all content on thebmj.com for 14 days.
Sign up for a free trial