Changing sex ratio in the United States, 1969-1995

Inequity in US Racial/Ethnic Infant Health and Birth Outcomes: The Role of the Adult Sex Ratio as a Potential Indicator of Structural Anti-Black Racism

BACKGROUND

Structural racism accounts for inequity in health outcomes in ways that are difficult to measure. To conduct more actionable research and measure the impact of intervention programs, there is a need to develop indicator measures of structural racism. One potential candidate is the Adult Sex Ratio (ASR), which was identified by Du Bois as an important indicator of social life functioning over 100 years ago and has remained significant up to the present day. This study investigated the utility of this measure.

METHODS

We compared birth/infant health outcomes using the US 2000 Linked Birth/Infant Death Cohort Data Set matched with 2000 Census data on adult sex ratios in multilevel logistic regression models, stratified by the racial/ethnic category of the mothers.

RESULTS

In an adjusted model, the odds of infant death was 21% higher among non-Hispanic Black (NHB) women living in counties in the lowest ASR tertile category when compared to their counterparts in counties in the highest ASR tertile. Similarly, the odds of giving birth to a preterm or a low birth weight infant were each 20% higher among NHB women living in counties in the lowest ASR tertile compared to their counterparts in counties in the highest ASR tertile.

CONCLUSION

ASRs may serve as a useful indicator of anti-Black structural racism at the local level. More research is needed to determine the circumstances under which this factor may serve to improve assessment of structural racism and facilitate health equity research.

Factors influencing the sex ratio at birth in the United States from a historical perspective

Many of the studies on the sex ratio at birth (SRB) are based on a small number of cases over a short period of time. Taking a multivariate approach to a dataset consisting of nearly 199 million birth records in the United States from 1968 to 2019, we present a detailed analysis of several possible factors that might affect the sex ratio at birth (SRB) and its patterns of variation. We found that race/ethnicity is the variable with the strongest influence on this index. Parental age, birth order and solar radiation also have a bearing on the SRB, albeit only to a moderate degree. The historical evolution of the SRB among Black and American Indian and Alaska Native populations remains unexplained.

Estimation and probabilistic projection of levels and trends in the sex ratio at birth in seven provinces of Nepal from 1980 to 2050: a Bayesian modeling approach

Background

The sex ratio at birth (SRB; ratio of male to female births) in Nepal has been reported around the normal level on the national level. However, the national SRB could mask the disparity within the country. Given the demographic and cultural heterogeneities in Nepal, it is crucial to model Nepal SRB on the subnational level. Prior studies on subnational SRB in Nepal are mostly based on reporting observed values from surveys and census, and no study has provided probabilistic projections. We aim to estimate and project SRB for the seven provinces of Nepal from 1980 to 2050 using a Bayesian modeling approach.

Methods

We compiled an extensive database on provincial SRB of Nepal, consisting 2001, 2006, 2011, and 2016 Nepal Demographic and Health Surveys and 2011 Census. We adopted a Bayesian hierarchical time series model to estimate and project the provincial SRB, with a focus on modelling the potential SRB imbalance.

Results

In 2016, the highest SRB is estimated in Province 5 (Lumbini Pradesh) at 1.102, corresponding to 110.2 male births per 100 female births, with a 95% credible interval (1.044, 1.127) and the lowest SRB is in Province 2 at 1.053 (1.035, 1.109). The SRB imbalance probabilities in all provinces are generally low and vary from 16% in Province 2 to 81% in Province 5 (Lumbini Pradesh). SRB imbalances are estimated to have begun at the earliest in 2001 in Province 5 (Lumbini Pradesh) with a 95% credible interval (1992, 2022) and the latest in 2017 (1998, 2040) in Province 2. We project SRB in all provinces to begin converging back to the national baseline in the mid-2030s. By 2050, the SRBs in all provinces are projected to be around the SRB baseline level.

Conclusions

Our findings imply that the majority of provinces in Nepal have low risks of SRB imbalance for the period 1980–2016. However, we identify a few provinces with higher probabilities of having SRB inflation. The projected SRB is an important illustration of potential future prenatal sex discrimination and shows the need to monitor SRB in provinces with higher possibilities of SRB imbalance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12693-0.

The human sex ratio at birth and late fetal mortality: the Italian case

This study explores the short-term relationships between sex ratio at birth and late fetal mortality in Italy from 1910 to 2016. As the leading scholars' attention traditionally focused on long-term trends and variations in the sex ratios at birth among different populations, less interest regarded short-term fluctuations as they were mainly seen as an effect of random variability. We detrended the national series of males proportion among live births and stillbirths by their medium-term component to consider the annual deviations from a normal trend. After controlling for fertility tendencies and wars effects, regression models seem to show the effects of stillbirth on the proportion of male newborns. A sensitivity analysis was also carried out to assess the effects of the perinatal deaths on the proportion of males at birth, combining stillbirths and early neonatal losses to control the possible misspecification between stillborn infants and early neonatal deaths. The significance of late fetal mortality reflects the mortality excess among male fetuses during the intrauterine life, showing evidence for the in utero hypothesis selection.

The relationship between Toxoplasma gondii infection in mothers and neonate's gender

BACKGROUND

The secondary sex ratio can be affected by various factors such as stress, immunosuppression, and age of parents in addition to mother infectious disease (Maternal infections). Toxoplasmosis is one of the critical maternal parasitic infections during pregnancy. Besides the complications of the acute form of the disease, hormonal shifts, and even alterations in the secondary sex ratio can be induced by the manipulative activity of the chronic form of the disease. Therefore, this study aimed to evaluate the correlation between Toxoplasma gondii infection in mothers and neonate's gender.

METHODS

In this case-control study, 137 seropositive mothers to Anti-Toxoplasma IgG(case) was compared to 137 age-matched subject Toxoplasma-seronegative mothers(control) in terms of their neonate's gender. These individuals were randomly selected based on exclusions and inclusions criteria of the study from among 2014 mothers who had been tested for Toxoplasma infection during pregnancy from 2015 to 2018 in Shiraz, Iran.

RESULTS

From a total of 2014 studied pregnant mothers, 326 (16.2%) mothers were seropositive to anti-Toxoplasma IgG, and 1688 (83.8%) were negative for IgG. It was found that the numbers of female and male neonates were 136 (45.48%) and 163 (54.51%) in the control group whereas, they were 165 (49.84%) and 166 (50.15%) in the case group, respectively. The sex ratio was 1.006:1 in Toxoplasma-seropositive and 1.2:1 in Toxoplasma-seronegative mothers. The number of male and females offsprings indicated a significant difference in Toxoplasma-seronegative mothers (54.5%, p = .015). Moreover, comparing the number of males and females between the two randomly selected groups showed that female gender is significantly more than male gender in seropositive mothers to Toxoplasma (54.8%, p = .014), which means that of 301 females, 165 offspring were born to seropositive mothers. No significant difference was observed for the sex ratio of aborted fetuses between groups. However, in the Toxoplasma-seropositive group, the sex ratio of aborted fetuses showed that the aborted male fetuses were significantly higher in number. (31 male vs 13 female, p < .001).

CONCLUSION

Comprehensively, a significant relationship was found between chronic Toxoplasma infection and secondary sex ratio. However, it is suggested that this relationship be investigated in further studies as well as an animal study.

The aryl hydrocarbon receptor mediates sex ratio distortion in the embryos sired by TCDD-exposed male mice

Many reports describe an association between preconceptional paternal exposure to environmental chemicals, including the persistent organic pollutant 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) with an increased number of female offspring. We chronically treated wild-type C57BL/6 male mice with TCDD to investigate a role for the aryl hydrocarbon receptor (AHR) transcription factor. These mice had a 14 % lower male:female sex ratio than control mice, which was not observed in TCDD-treated Ahr knock out mice. AHR target genes Cyp1a1 and Ahrr were upregulated in the liver and testis of WT mice and Ahr expression was higher in the epididymis (2-fold) and liver (18-fold) than in whole testis tissue. The AHR protein was localized to round spermatids, elongating spermatids, and Leydig cells in the testis of WT mice. These studies demonstrate AHR involvement in the sex ratio distortion of TCDD-exposed males and the need for evaluating the molecular and genetic mechanism of this process.

Systematic assessment of the sex ratio at birth for all countries and estimation of national imbalances and regional reference levels

This study provides information on sex ratio at birth (SRB) reference levels and SRB imbalance. Using a comprehensive database and a Bayesian estimation model, we estimate that SRB reference levels are significantly different from the commonly assumed historical norm of 1.05 for most regions. We identify 12 countries with strong statistical evidence of SRB imbalance: Albania, Armenia, Azerbaijan, China, Georgia, Hong Kong (SAR of China), India, Republic of Korea, Montenegro, Taiwan (Province of China), Tunisia, and Vietnam.

The sex ratio at birth (SRB; ratio of male to female live births) imbalance in parts of the world over the past few decades is a direct consequence of sex-selective abortion, driven by the coexistence of son preference, readily available technology of prenatal sex determination, and fertility decline. Estimation of the degree of SRB imbalance is complicated because of unknown SRB reference levels and because of the uncertainty associated with SRB observations. There are needs for reproducible methods to construct SRB estimates with uncertainty, and to assess SRB inflation due to sex-selective abortion. We compile an extensive database from vital registration systems, censuses and surveys with 10,835 observations, and 16,602 country-years of information from 202 countries. We develop Bayesian methods for SRB estimation for all countries from 1950 to 2017. We model the SRB regional and national reference levels, the fluctuation around national reference levels, and the inflation. The estimated regional reference levels range from 1.031 (95% uncertainty interval [1.027; 1.036]) in sub-Saharan Africa to 1.063 [1.055; 1.072] in southeastern Asia, 1.063 [1.054; 1.072] in eastern Asia, and 1.067 [1.058; 1.077] in Oceania. We identify 12 countries with strong statistical evidence of SRB imbalance during 1970–2017, resulting in 23.1 [19.0; 28.3] million missing female births globally. The majority of those missing female births are in China, with 11.9 [8.5; 15.8] million, and in India, with 10.6 [8.0; 13.6] million.

Association of paternal age with perinatal outcomes between 2007 and 2016 in the United States: population based cohort study

OBJECTIVE

To evaluate the impact of advanced paternal age on maternal and perinatal outcomes in the United States.

DESIGN

Retrospective, population based cohort study.

SETTING

US.

POPULATION

40 529 905 documented live births between 2007 and 2016.

MAIN OUTCOME MEASURES

Primary perinatal outcomes were gestational age, birth weight, Apgar score at five minutes, admission to a neonatal intensive care unit, need for postpartum antibiotics, and seizures. Primary maternal outcomes were gestational diabetes and pre-eclampsia. Secondary outcome was the number of preventable perinatal events.

RESULTS

Higher paternal age was associated with an increased risk of premature birth, low birth weight, and low Apgar score. After adjustment for maternal age, infants born to fathers aged 45 years or older had 14% higher odds of premature birth (odds ratio 1.14, 95% confidence interval 1.13 to 1.15), independent of gestational age, and 18% higher odds of seizures (1.18, 0.97 to 1.44) compared with infants of fathers aged 25 to 34 years. The odds of gestational diabetes was 34% higher (1.34, 1.29 to 1.38) in mothers with the oldest partners. 13.2% (95% confidence interval 12.5% to 13.9%) of premature births and 18.2% (17.5% to 18.9%) of gestational diabetes in births associated with older fathers were estimated to be attributable to advanced paternal age.

CONCLUSIONS

Advanced paternal age is associated with negative effects on both mothers and offspring. Given the relatively low prevalence of advanced paternal age in the US, population level impacts are currently modest. Nevertheless, as advanced paternal age has doubled in the US over the past generation, further investigation is warranted of the impact on birth outcomes and public health.

Air Pollution and Human Sperm Sex Ratio

The present study was designed to address the hypothesis that exposure to specific air pollutants may impact human sperm Y:X chromosome ratio. The study population consisted of 195 men who were attending an infertility clinic for diagnostic purposes and who had normal semen concentration of 15–300 mln/ml (WHO, 2010). Participants represented a subset of men in a multicenter parent study conducted in Poland to evaluate environmental factors and male fertility. Participants were interviewed and provided a semen sample. The Y:X ratio was assessed by fluorescent in situ hybridization (FISH). Air quality data were obtained from the AirBase database. In multivariate analysis the significant reduction was observed in the proportion of Y/X chromosome bearing sperm and exposure to particulate matter >10 μm in aerodynamic diameter PM₁₀ (p = .009) and particulate matter <10 μm in aerodynamic diameter PM_2.5 (p = .023). The observed effects of a lower Y:X sperm chromosome ratio among men exposed to air pollution support the evidence that the trend of declining sex ratio in several societies over past decades has been due to exposure to air pollution; however due to limited data on this issue, the obtained results should be confirmed in longitudinal studies.

Social determinants of adult sex ratios and racial/ethnic disparities in transmission of HIV and other sexually transmitted infections in the USA

In Black population centres in the USA, adult sex ratios (ASRs) are strongly female-biased primarily due to high male incarceration and early mortality rates. I explore the system of social determinants that shape these ASRs, and describe their apparent consequences. Evidence suggests that female-biased ASRs play a role, along with racial residential segregation, to increase mixing between core and peripheral members of sexual networks, facilitating transmission of human immunodeficiency virus and other sexually transmitted infections. Unique historical factors underlie Black male incarceration and mortality rates in the USA, making comparisons with other groups or other countries challenging.This article is part of the themed issue 'Adult sex ratios and reproductive decisions: a critical re-examination of sex differences in human and animal societies'.

Live birth sex ratios and father's geographic origins in Jerusalem, 1964-1976

OBJECTIVE

To examine whether ancestry influenced sex ratios of offspring in a birth cohort before parental antenatal sex selection influenced offspring sex.

METHODS

We measured the sex ratio as the percent of males according to countries of birth of paternal and maternal grandfathers in 91,459 live births from 1964 to 1976 in the Jerusalem Perinatal Study. Confidence limits (CI) were computed based on an expected sex ratio of 1.05, which is 51.4% male.

RESULTS

Of all live births recorded, 51.4% were male. Relative to Jewish ancestry (51.4% males), significantly more males (1,761) were born to Muslim ancestry (54.5, 95% CI = 52.1-56.8, P = 0.01). Among the former, sex ratios were not significantly associated with paternal or maternal age, education, or offspring's birth order. Consistent with a preference for male offspring, the sex ratio decreased despite increasing numbers of births over the 13-year period. Sex ratios were not affected by maternal or paternal origins in North Africa or Europe. However, the offspring whose paternal grandfathers were born in Western Asia included fewer males than expected (50.7, 50.1-51.3, P = 0.02), whether the father was born abroad (50.7) or in Israel (50.8). This was observed for descendents of paternal grandfathers born in Lebanon (47.6), Turkey (49.9), Yemen & Aden (50.2), Iraq (50.5), Afghanistan (50.5), Syria (50.6), and Cyprus (50.7); but not for those from India (51.5) or Iran (51.9). The West Asian group showed the strongest decline in sex ratios with increasing paternal family size.

CONCLUSIONS

A decreased sex ratio associated with ancestry in Western Asia is consistent with reduced ability to bear sons by a subset of Jewish men in the Jerusalem cohort. Lower sex ratios may be because of pregnancy stress, which may be higher in this subgroup. Alternatively, a degrading Y chromosome haplogroup or other genetic or epigenetic differences on male germ lines could affect birth ratios, such as differential exposure to an environmental agent, dietary differences, or stress. Differential stopping behaviors that favor additional pregnancies following the birth of a daughter might exacerbate these lower sex ratios.

The sex ratio at birth in South Africa may be a sentinel health indicator

INTRODUCTION

The sex ratio at birth is commonly expressed as M/T, denoting male births divided by total births. Males are almost invariably born slightly in excess. Stress and negative socioeconomic conditions lower M/T and this has been mooted as a possible reason for the observed low M/T for Black births worldwide. South Africa is experiencing a period of economic prosperity. This study was carried out in order to ascertain whether improving conditions in South Africa as measured by available health indicators, were associated with a rise in M/T in this country.

METHODS

Annual male and female births were obtained from Statistics South Africa along with key health indicators: total fertility rate, life expectancy, infant mortality and under 5year mortality, for 2003-2014.

RESULTS

There were a total of 12,409,437 births (M/T 0.5035, 95% CI 0.5032-0.5037). There was a rise in M/T over the initial period studied (2003-2010) with a plateau thereafter. The rise over the entire period studied was significant (Chi for linear trend=30.3, p<0.0001). M/T was significantly positively correlated with life expectancy and significantly negatively correlated with infant mortality, under 5year mortality and total fertility rate.

DISCUSSION

It has been mooted that the lower M/T observed in Blacks may be stress-related. The observed rise in M/T associated with health improvements in South Africa support this contention. Moreover, this study suggests that M/T may serve as a sentinel health indicator, and may not only highlight adverse conditions through its decline, but also improvements in overall conditions with its rise.

Sex ratio at birth: scenario from normal- and high-level natural radiation areas of Kerala coast in south-west India

Newborns were monitored for congenital malformations in four government hospitals located in high-level (ambient dose >1.5 mGy/year) and normal-level (≤ 1.5 mGy/year) natural radiation areas of Kerala, India, from August 1995 to December 2012. Sex ratio at birth (SRB) among live singleton newborns and among previous children, if any, of their mothers without history of any abortion, stillbirth or twins is reported here. In the absence of environmental stress or selective abortion of females, global average of SRB is about 1050 males to 1000 females. A total of 151,478 singleton, 1031 twins, 12 triplets and 1 quadruplet deliveries were monitored during the study period. Sex ratio among live singleton newborns was 1046 males (95 % CI 1036-1057) for 1000 females (77,153 males:73,730 females) and was comparable to the global average. It was similar in high-level and normal-level radiation areas of Kerala with SRB of 1050 and 1041, respectively. It was consistently more than 1000 and had no association with background radiation levels, maternal and paternal age at birth, parental age difference, gravida status, ethnicity, consanguinity or year of birth. Analysis of SRB of the children of 139,556 women whose reproductive histories were available suggested that couples having male child were likely to opt for more children and this, together with enhanced rate of males at all birth order, was skewing the overall SRB in favour of male children. Though preference for male child was apparent, extreme steps of sex-selective abortion or infanticide were not prevalent.

Do daughters really cause divorce? Stress, pregnancy, and family composition

Provocative studies have reported that in the United States, marriages producing firstborn daughters are more likely to divorce than those producing firstborn sons. The findings have been interpreted as contemporary evidence of fathers' son preference. Our study explores the potential role of another set of dynamics that may drive these patterns: namely, selection into live birth. Epidemiological evidence indicates that the characteristic female survival advantage may begin before birth. If stress accompanying unstable marriages has biological effects on fecundity, a female survival advantage could generate an association between stability and the sex composition of offspring. Combining regression and simulation techniques to analyze real-world data, we ask, How much of the observed association between sex of the firstborn child and risk of divorce could plausibly be accounted for by the joint effects of female survival advantage and reduced fecundity associated with unstable marriage? Using data from the National Longitudinal Survey of Youth (NLSY79), we find that relationship conflict predicts the sex of children born after conflict was measured; conflict also predicts subsequent divorce. Conservative specification of parameters linking pregnancy characteristics, selection into live birth, and divorce are sufficient to generate a selection-driven association between offspring sex and divorce, which is consequential in magnitude. Our findings illustrate the value of demographic accounting of processes which occur before birth-a period when many outcomes of central interest in the population sciences begin to take shape.

Human sex ratio at amniocentesis and at birth in Taiwan

OBJECTIVES

An increase in the proportion of male-to-female live births has raised concerns in Taiwan. Disclosure of fetal sex during prenatal screening is not allowed by the Taiwan government. Fetal sex annotation in clinical genetic reports is also prohibited. This study tested the hypothesis that the male-to-female sex ratio at amniocentesis should be lower than the sex ratio at birth, if a certain percentage of female fetuses are being selectively aborted after amniocentesis. Therefore, we examined the differences between fetal sex ratio at amniocentesis at a tertiary medical center in southern Taiwan and the nationwide sex ratio at birth in Taiwan from 1992 to 2011.

MATERIALS AND METHODS

Data of normal male and female karyotypes during the study period were collected from the cytogenetic laboratory of the National Cheng Kung University Hospital (NCKUH) in southern Taiwan. Data of sex ratio at birth nationwide in Taiwan were obtained from the Department of Statistics, Ministry of the Interior, Taiwan. We calculated 95% binominal confidence intervals for the sex ratios and differences between fetal sex ratio at amniocentesis, and nationwide sex ratio at birth were tested by the χ(2) test and Bonferroni correction.

RESULTS

The nationwide sex ratio at birth ranged from 1.07 to 1.11 during the period from 1992 to 2011 in Taiwan, with the highest in 2004 and the lowest in 1993. The fetal sex ratio at amniocentesis at NCKUH ranged more widely (0.82-1.28), with the lowest in 1993 and the highest in 2007. After regression analysis, both trends of sex ratio at amniocentesis during midtrimester and at birth were not significantly increased by years. Furthermore, the sex distribution at amniocentesis during midtrimester did not differ significantly from the nationwide sex ratio at birth (1.113 vs. 1.092, p = 0.151).

CONCLUSIONS

The results showed that sex ratio was already skewed toward male at midtrimester. Our data imply that artificial sex selection, if it were present, might have already emerged prior to the timing of amniocentesis. However, more large nationwide studies on sex ratios in Taiwan are warranted.

Factors affecting sex ratio at birth in Croatia 1998-2008

This investigation aims to contribute to the existing literature on demographic and ecological factors affecting the sex ratio at birth, by analysing the births in Croatia from 1998 to 2008. Data from birth certificates for all Croatian births for the investigated period (n=420,256) were used to establish the link between parental ages, birth order, region of birth, parental occupation and parental education level, and sex of the child. The χ² test and t-test were used to assess the significance of each of the factors, along with multiple logistic regression to control for possible confounding effects. The results suggest that a joint higher age of both parents significantly lowers the sex ratio at birth. There is also a regional variation in sex ratio at birth, the lowest value being in Central Croatia and the highest in the City of Zagreb. Changes in the reproductive physiology of older parents are most probably responsible for the lower sex ratio, although the limited sample size warns against widespread generalizations. The causes of the regional variation in sex ratio at birth are most likely the different regional levels of obesity and physical inactivity.

Can environmental or occupational hazards alter the sex ratio at birth? A systematic review

More than 100 studies have examined whether environmental or occupational exposures of parents affect the sex ratio of their offspring at birth. For this review, we searched Medline and Web of Science using the terms ‘sex ratio at birth’ and ‘sex ratio and exposure’ for all dates, and reviewed bibliographies of relevant studies to find additional articles. This review focuses on exposures that have been the subject of at least four studies including polychlorinated biphenyls (PCBs), dioxins, pesticides, lead and other metals, radiation, boron, and g-forces. For paternal exposures, only dioxins and PCBs were consistently associated with sex ratios higher or lower than the expected 1.06. Dioxins were associated with a decreased proportion of male births, whereas PCBs were associated with an increased proportion of male births. There was limited evidence for a decrease in the proportion of male births after paternal exposure to DBCP, lead, methylmercury, non-ionizing radiation, ionizing radiation treatment for childhood cancer, boron, or g-forces. Few studies have found higher or lower sex ratios associated with maternal exposures. Studies in humans and animals have found a reduction in the number of male births associated with lower male fertility, but the mechanism by which environmental hazards might change the sex ratio has not yet been established.

Maternal socioeconomic and demographic factors associated with the sex ratio at birth in Vietnam

In recent years Vietnam has experienced a high sex ratio at birth (SRB) amidst rapid socioeconomic and demographic changes. However, little is known about the differentials in SRB between maternal socioeconomic and demographic groups. The paper uses data from the annual Population Change Survey (PCS) in 2006 to examine the relationship of the sex ratio of the most recent birth with maternal socioeconomic and demographic characteristics and the number of previous female births. The SRB of Vietnam was significantly high at 111.4 (95% CI 109.7-113.1) for the period 1st April 2000 to 31st March 2006. Multivariate analysis reveals that sex of the most recent birth is strongly related with the number of previous female births. This association is consistent across different socioeconomic and demographic groups of women. Given the high SRB in Vietnam, further research into the reasons for high SRB in these groups is required, as are intervention programmes such as those raising the public awareness of its negative consequences.

Alcohol, drugs, caffeine, tobacco, and environmental contaminant exposure: reproductive health consequences and clinical implications

Reproductive function and fertility are thought to be compromised by behaviors such as cigarette smoking, substance abuse, and alcohol consumption; however, the strength of these associations are uncertain. Furthermore, the reproductive system is thought to be under attack from exposure to environmental contaminants, particularly those chemicals shown to affect endocrine homeostasis. The relationship between exposure to environmental contaminants and adverse effects on human reproductive health are frequently debated in the scientific literature and these controversies have spread into the lay press drawing increased public and regulatory attention. Therefore, the objective of the present review was to critically evaluate the literature concerning the relationship between lifestyle exposures and adverse effects on fertility as well as examining the evidence for a role of environmental contaminants in the purported decline of semen quality and the pathophysiology of subfertility, polycystic ovarian syndrome, and endometriosis. The authors conclude that whereas cigarette smoking is strongly associated with adverse reproductive outcomes, high-level exposures to other lifestyle factors are only weakly linked with negative fertility impacts. Finally, there is no compelling evidence that environmental contaminants, at concentrations representative of the levels measured in contemporary biomonitoring studies, have any effect, positive or negative, on reproductive health in the general population. Further research using prospective study designs with robust sample sizes are needed to evaluate testable hypotheses that address the relationship between exposure and adverse reproductive health effects.

Exploring the causal machinery behind sex ratios at birth: does hepatitis B play a role?

The causal machinery underlying sex determination is directly relevant to many questions relating gender and family composition to social and economic outcomes. In recent work, Oster highlighted a correlation between parental hepatitis B carrier status and sex of the child. One of her analyses went further, speaking directly to causality. That analysis appeared to have answered an important question that had remained unresolved in medical and biological literatures—namely, does chronic infection with hepatitis B cause male‐skewed sex ratios at birth? Oster’s creative empirical analysis appeared to suggest that it does; however, in this article I reassess the result and present evidence that, at the very least, the question remains open. Further investigation into questions around the causal machinery of sex determination is warranted in the social science literature, as well as in that of biology and medicine. However, my results suggest that it is extremely unlikely that chronic hepatitis B infection plays a biologically significant role.

A cohort study of the association between secondary sex ratio and parental exposure to polybrominated biphenyl (PBB) and polychlorinated biphenyl (PCB)

BACKGROUND

Polybrominated biphenyl (PBB), a brominated flame retardant, was accidently mixed into animal feed in Michigan (1973-1974) resulting in human exposure through consumption of contaminated meat, milk and eggs. Beginning in 1976 individuals who consumed contaminated products were enrolled in the Michigan Long-Term PBB Study. This cohort presents a unique opportunity to study the association between parental exposures to PBB and offspring sex ratio.

METHODS

We identified offspring of female PBB cohort participants (born 1975-1988) and obtained electronic birth records for those born in the state of Michigan. We linked this information to parental serum PBB and PCB concentrations collected at enrollment into the cohort. We modeled the odds of a male birth with generalized estimating equations accounting for the non-independence of siblings born to the same parents. We explored potential confounders: parental age and education at offspring's birth, parental body mass index at cohort enrollment, birth order, gestational age and year of offspring's birth.

RESULTS

The overall proportion of male offspring among 865 live births to cohort mothers was 0.542. This was higher than the national male proportion of 0.514 (binomial test: p = 0.10). When both parents were in the cohort (n = 300), we found increased odds of a male birth with combined parents' enrollment PBB exposure > or = the median concentrations (3 microg/L for mothers; 6 microg/L for fathers) compared to combined parents' PBB exposure < the median concentrations (AOR = 1.43, 95% CI: 0.89-2.29), although this did not reach statistical significance. In addition, there was a suggestion of increased odds of a male birth for combined parents' enrollment PCB exposure > or = the median concentrations (6 microg/L for mothers; 8 microg/L for fathers) compared to combined parents' enrollment PCB exposure < the median concentrations (AOR = 1.53, 95% CI: 0.93-2.52).

CONCLUSION

This study adds to the body of literature on secondary sex ratio and exposure to environmental contaminants. In this population, combined parental exposure to PBBs or PCBs increased the odds of a male birth. Further research is needed to corroborate these findings and shed light on the biological mechanisms by which these types of chemicals may influence the secondary sex ratio.

Analysis of socio-political and health practices influencing sex ratio at birth in Viet Nam

Viet Nam has experienced rapid social change over the last decade, with a remarkable decline in fertility to just below replacement level. The combination of fertility decline, son preference, antenatal sex determination using ultrasound and sex selective abortion are key factors driving increased sex ratios at birth in favour of boys in some Asian countries. Whether or not this is taking place in Viet Nam as well is the subject of heightened debate. In this paper, we analyse the nature and determinants of sex ratio at birth in Viet Nam, including a small family size norm, recent reinforcement by the Government of the "one-to-two child" family policy, traditional son preference, easy access to antenatal ultrasound screening and legal abortion, and an increase in the proportion of one-child families. In order to prevent an increased sex ratio at birth in Viet Nam, we argue for the relaxation of the one-to-two child family policy and a return to the policy of "small family size" as determined by families, in tandem with a comprehensive approach to promoting the value of women and girls in society, countering traditional gender roles, and raising public awareness of the negative social consequences of a high sex ratio at birth.

The sex ratio of singleton offspring in assisted-conception pregnancies

OBJECTIVE

To evaluate the effect of intracytoplasmic sperm injection (ICSI) and male factor infertility on the sex ratio in births from assisted reproductive technology.

DESIGN

Historic cohort study.

SETTING

Clinic-based data.

PATIENT(S)

The study population included 15,164 singleton live births in the Society for Assisted Reproductive Technology national database for 2005 from cycles using ejaculated sperm, categorized by the use of insemination or ICSI and the absence or presence of male factor infertility, and cleavage- versus blastocyst-stage embryo transfers (ETs).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The probability of a male infant with and without the use of ICSI and in the presence or absence of male factor infertility.

RESULT(S)

The sex ratio for all U.S. live births in 2005 was 52.5%, versus 48.9% for cleavage-stage and 51.6% for blastocyst-stage embryos. With blastocyst-stage embryos, the sex ratios were 49.6% and 54.9% with and without ICSI and 52.6% and 50.0% with and without male factor infertility, respectively. With cleavage-stage embryos, the sex ratio was not significantly affected by ICSI or male factor infertility, singly or in combination.

CONCLUSION(S)

The use of ICSI, particularly with blastocyst-stage embryos, is associated with a decrease in the sex ratio of male infants.

Declines in sex ratio at birth and fetal deaths in Japan, and in U.S. whites but not African Americans

BACKGROUND

The expected ratio of male to female births is generally believed to be 1.05, also described as the male proportion of 0.515.

OBJECTIVES

We describe trends in sex ratio at birth and in fetal deaths in the United States, in African Americans and in whites, and in Japan, two industrial countries with well-characterized health data infrastructures, and we speculate about possible explanations.

METHODS

Public health records from national statistical agencies were assembled to create information on sex ratio at birth and in fetal deaths in the United States (1970-2002) and Japan (1970-1999), using SPSS.

RESULTS

Sex ratio at birth has declined significantly in Japan and in U.S. whites, but not for African Americans, for whom sex ratio remains significantly lower than that of whites. The male proportion of fetal death has increased overall in Japan and in the United States.

CONCLUSIONS

Sex ratio declines are equivalent to a shift from male to female births of 135,000 white males in the United States and 127,000 males in Japan. Known and hypothesized risk factors for reduced sex ratio at birth and in fetal deaths cannot account fully for recent trends or racial or national differences. Whether avoidable environmental or other factors--such as widespread exposure to metalloestrogens or other known or suspected endocrine-disrupting materials, changes in parental age, obesity, assisted reproduction, or nutrition--may account for some of these patterns is a matter that merits serious concern.

Monitoring reproductive health in Europe: what are the best indicators?

The Reprostat Steering Committee asks for the best monitors of reproductive health. In many European countries, some deleterious agents have caused declines over the past half-century in both dizygotic (DZ) twinning rates and sperm counts. No strong evidence suggests that these declines have reversed, though they may have ceased in some countries. Here attention is only directed at potential secular changes in the proximate biological determinants of fertility (ovulation, coitus, semen quality, fertilization, spontaneous fetal loss and 'dead time'). The most comprehensive biological monitor of reproductive health is the 'natural' DZ twinning rate (viz the rate of DZ twinning in the absence of any medical intervention around the time of conception). At present, natural DZ twins are augmented by twins produced by new techniques. So efforts should be made to estimate the annual numbers of these iatrogenic twins in each European country. Then it would be possible to follow the movements of each national natural DZ twinning rate, and thus to continue monitoring a useful measure of reproductive health that has been available in most European countries for many years. Efforts should be made to assess the sperm quality of volunteer donors in each European country.

Modifying effect of the AR gene trinucleotide repeats and SNPs in the AHR and AHRR genes on the association between persistent organohalogen pollutant exposure and human sperm Y : X ratio

Persistent organohalogen pollutants (POPs) have been suggested to be involved in changing the proportion of ejaculated Y-bearing sperm. The androgen receptor (AR), aryl hydrocarbon receptor (AHR) and aryl hydrocarbon receptor repressor (AHRR) may modulate the effect of POPs with regard to previously observed sperm Y:X ratio changes. The objective of this study was to investigate whether sperm Y:X ratio changes in subjects exposed to 2,2'4,4'5,5'-hexachlorobiphenyl (CB-153) and dichlorodiphenyl dichloroethene (p,p'-DDE) were modified by polymorphisms in the AR, AHR and AHRR genes. Semen for analysis of Y- and X-bearing sperm by two-colour fluorescence in situ hybridization and blood for leukocyte DNA genotyping and analysis of CB-153 and p,p'-DDE concentrations were obtained from 195 Swedish fishermen. The polymorphic CAG and GGN repeats in the AR and the R554K and P185A single-nucleotide polymorphisms in the AHR and AHRR genes, respectively, were determined by direct sequencing and allele-specific PCR. The effect of p,p'-DDE was modified by CAG or GGN repeat category in relation to the proportion of Y-bearing sperm (P = 0.005 and 0.02 for CAG and GGN, respectively). Moreover, p,p'-DDE, but not CB-153, levels were associated with Y-sperm proportion in men with CAG < 22 (P < 0.001), but not in those carrying CAG > or = 22 (P = 0.73). This association was even more pronounced in subjects carrying a short CAG repeat in combination with an AHRR G-allele. The association in regard to p,p'-DDE was found for GGN = 23 but not for the GGN < 23 or GGN > 23 subgroups (P = 0.01, 0.44 and 0.99, respectively). In conclusion The endocrine-disrupting action of POPs, in relation to the observed changes in sperm Y:X ratio, may be modulated by the genes involved in sex steroid and dioxin-mediated pathways.

Preconception maternal polychlorinated biphenyl concentrations and the secondary sex ratio

The secondary sex ratio is the ratio of male to female live births and historically has ranged from 102 to 106 males to 100 females. Temporal declines have been reported in many countries prompting authors to hypothesize an environmental etiology. Blood specimens were obtained from 99 women aged 24-34 prior to attempting pregnancy and quantified for 76 polychlorinated biphenyl (PCB) congeners using dual column gas chromatography with electron capture detection. Women were prospectively followed until pregnancy or 12 cycles of trying. The odds of a male birth for three PCB groupings (total, estrogenic, anti-estrogenic) controlling for maternal characteristics were estimated using logistic regression. Among the 50 women with live births and PCB data, 26 female and 24 male infants were born (ratio 0.92). After adjusting for age and body mass index, odds of a male birth were elevated among women in the second (OR=1.29) and third (OR=1.48) tertiles of estrogenic PCBs; odds (OR=0.70) were reduced among women in the highest tertile of anti-estrogenic PCBs. All confidence intervals included one. The direction of the odds ratios in this preliminary study varied by PCB groupings, supporting the need to study specific PCB patterns when assessing environmental influences on the secondary sex ratio.

Trends in the sex ratio of California births, 1960-1996

STUDY OBJECTIVE

The male sex ratio at birth (or the proportion of male births in a population) has been suggested as a sentinel environmental health indicator. Usually around 51%, the proportion may be dramatically decreased in offspring of persons with chemical exposures. Recent publications from the USA and elsewhere have noted a small but apparently declining male birth proportion, suggesting the effect of some environmental exposures. This paper sought to examine these trends more closely in California's large and diverse population.

DESIGN

Using computerised birth certificate data, time trends were examined by multivariate linear and spline regression, controlling for demographic factors.

SETTING

California.

PARTICIPANTS

About 15 million births from 1960 to 1996.

MAIN RESULTS

In the raw data, the male birth proportion is indeed declining. However, during this period, there were also shifts in demographics that influence the sex ratio. Controlling for birth order, parents' age, and race/ethnicity, different trends emerged. White births (which account for over 80%) continued to show a statistically significant decline, while other racial groups showed non-statistically significant declines (Japanese, Native American, other), little or no change (black), or an increase (Chinese). Finally, when the white births were divided into Hispanic and non-Hispanic (possible since 1982), it was found that both white subgroups suggest an increase in male births.

CONCLUSION

This analysis shows that the decline in male births in California is largely attributable to changes in demographics.

Impact of PCB and p,p'-DDE contaminants on human sperm Y:X chromosome ratio: studies in three European populations and the Inuit population in Greenland

OBJECTIVE

Recent studies indicate that persistent organohalogen pollutants (POPs) may contribute to sex ratio changes in offspring of exposed populations. Our aim in the present study was to investigate whether exposure to 2,2 ,4,4 ,5,5 -hexachlorobiphenyl (PCB-153) and dichlorodiphenyldichloroethene (p,p -DDE) affects sperm Y:X chromosome distribution.

SUBJECTS AND METHODS

We obtained semen and blood for analysis of PCB-153 and p,p -DDE levels from 547 men from Sweden, Greenland, Poland (Warsaw), and Ukraine (Kharkiv), with regionally different levels of POP exposure. The proportion of Y- and X-chromosome-bearing sperm in the semen samples was determined by two-color fluorescence in situ hybridization analysis.

RESULTS

Swedish and Greenlandic men had on average significantly higher proportions of Y sperm (in both cohorts, 51.2%) and correspondingly higher lipid-adjusted concentrations of PCB-153 (260 ng/g and 350 ng/g, respectively) compared with men from Warsaw (50.3% and 22 ng/g) and Kharkiv (50.7% and 54 ng/g). In the Swedish cohort, log-transformed PCB-153 and log-transformed p,p -DDE variables were significantly positively associated with Y-chromosome fractions (p-values 0.04 and <0.001, respectively). On the contrary, in the Polish cohort PCB-153 correlated negatively with the proportion of Y-bearing fraction of spermatozoa (p=0.008).

CONCLUSIONS

The present study indicates that POP exposure might be involved in changing the proportion of ejaculated Y-bearing spermatozoa in human populations. Intercountry differences, with different exposure situations and doses, may contribute to varying Y:X chromosome ratios.

Clinical correlates of environmental endocrine disruptors

Endocrine disrupting chemicals (EDCs), such as environmental estrogens, are hypothesized to be associated with a global decrease in sperm counts, other male reproductive tract problems and increasing rates of female breast cancer. Results of human population studies do not support the association between certain organochlorine EDCs and female breast cancer. Moreover, there is minimal evidence linking EDCs or exposure to other environmental chemicals with male reproductive tract problems. With the exception of the increasing incidence of testicular cancer, it is also questionable whether male reproductive tract problems are increasing, decreasing or unchanged. However, several studies report large differences in sperm count and quality and other endocrine-related problems within countries and regions, but the environmental, dietary and/or lifestyle factors responsible remain unknown.

Exposure to persistent organochlorine pollutants associates with human sperm Y:X chromosome ratio

BACKGROUND

During the last decades, there has been concern that exposure to endocrine disruptors, such as persistent organochlorine pollutants (POPs), may contribute to sex ratio changes in offspring of exposed populations.

METHODS

To investigate whether exposure to 2,2'4,4'5,5'-hexachlorobiphenyl (CB-153) and dichlorodiphenyl dichloroethene (p,p'-DDE) affect Y:X chromosome proportion, semen of 149 Swedish fishermen, aged 27-67 years, was investigated. The men provided semen and blood for analysis of hormone, CB-153 and p,p'-DDE levels. The proportion of Y- and X-chromosome bearing sperm in semen samples was determined by two-colour fluorescence in situ hybridization (FISH) analysis.

RESULTS

Log transformed CB-153 as well as log transformed p,p'-DDE variables were both significantly positively associated with Y chromosome fractions (P-values = 0.05 and <0.001, respectively). Neither age, smoking nor hormone levels showed any association with Y-chromosome fractions.

CONCLUSIONS

This is the first study to indicate that exposure to POPs may increase the proportion of ejaculated Y-bearing spermatozoa. These data add to the growing body of evidence that exposure to POPs may alter the offspring sex ratio.

Relationship between urinary estrogen levels before conception and sex ratio at birth in a primate, the gray mouse lemur

BACKGROUND

In primates, including humans, bias of sex ratio at birth has been reported to depend on maternal condition at conception. In a Malagasy primate, the gray mouse lemur, male-biased sex ratio at birth occurred in captive parous females. The male bias was previously demonstrated to be pre-conceptual and independent of the female's nutritional state. It was hypothesized to be related to changes in hormonal state at ovulation.

METHODS AND RESULTS

The relationship between urinary estradiol (E2) levels during the follicular phase until estrus and litter production (number and sex of newborns) was assessed in 91 females mated under controlled conditions. Changes in E2 levels prior to ovulation followed the typical primate pattern characterized by a gradual rise during the 10 days preceding the sharp increase at estrus. A clear decline in E2 levels occurred with ageing. Direction of the sex ratio bias was unrelated to E2 levels at ovulation time but was significantly dependent on E2 levels during the follicular phase. Reduced E2 levels prior to estrus led to male-biased litters.

CONCLUSION

This study suggests that hormonal stimulation during the follicular phase plays a role in shifting sex ratio at conception through changes in the local environment of the ova. This hypothesis deserves testing by assessing estrogen levels throughout the follicular phase in other primate species including humans.

Partnership status and the human sex ratio at birth

If two-parent care has different consequences for the reproductive success of sons and daughters, then natural selection may favour adjustment of the sex ratio at birth according to circumstances that forecast later family structure. In humans, this partnership-status hypothesis predicts fewer sons among extra-pair conceptions, but the rival 'attractiveness' hypothesis predicts more sons among extra-pair conceptions, and the 'fixed-phenotype' hypothesis predicts a constant probability of having a son, regardless of partnership status. In a sample of 86 436 human births pooled from five US population-based surveys, I found 51.5% male births reported by respondents who were living with a spouse or partner before the child's conception or birth, and 49.9% male births reported by respondents who were not (chi(2)=16.77 d.f.=1 p<0.0001). The effect was not explained by paternal bias against daughters, by parental age, education, income, ethnicity or by year of observation, and was larger when comparisons were made between siblings. To my knowledge, this is the first direct evidence for conditional adjustment of the sex ratio at birth in humans, and could explain the recent decline in the sex ratio at birth in some developed countries.

Environmental and occupational factors affecting fertility and IVF success

Reproductive function has been shown to be sensitive to changes in the physical, psychosocial and chemical environments. Although reproductive effects of occupational exposure to hazardous chemicals have been well documented in the literature, the potential effects of chemical contaminants at levels representative of contemporary exposures in the general population are much less certain. Evidence for adverse effects of exposure to environmental contaminants is more conclusive among the lower animals than for humans where considerable controversy remains. In addition to potential reproductive hazards of exposure to environmental contaminants, there is also evidence for adverse reproductive effects of the physical and psychosocial environments. In this review we focus on the difficulties involved in linking exposure to putative hazardous substances in environmental and occupational settings to adverse reproductive outcomes, especially success of IVF procedures. We highlight the plausibility of adverse events through animal and cell studies and the application of these results to the interpretation of human data. We consider both the male and female partners since it is essentially their combined contributions of gametes which may be affected by chemicals, which lead to successful outcomes.

Secular trends in uncertain-sex births and proportion of male births in Norway, 1967-1998

It has been hypothesized that environmental factors influence sex differentiation in the fetus, thus causing a reduced sex ratio (male/female) at birth, an increase in the prevalence of ambiguous-sex infants, and possibly an increase in spontaneous abortion rates. In Norway, subsequent to 1967, all deliveries, including late abortions after 16 wk of gestation, have been reported to the Medical Birth Registry of Norway. The authors used these data to assess birth-weight-specific secular trends of uncertain-sex infants and the proportion of male births, from 1967 through 1998. Total rates of uncertain-sex infants increased from 2.3/10,000 births in 1967 to 8.0/10,000 births in 1998 in the birth weight strata of less than 600 gm. The total proportion of male births was stable; however, there was a reduction in the proportion of male births among births weighing less than 400 gm--from 58.4% to 53.4%. Incomplete ascertainment of abortions may have biased the results, but it would not have accounted for the increased occurrence of uncertain-sex infants and the decreased proportion of males observed among late-term abortions.

Secular trends in sex ratios at birth in North America and Europe over the second half of the 20th century

CONTEXT

A previous study showed that significantly more boys were born in southern latitudes in Europe than in northern latitudes and the converse pattern was observed in North America.

OBJECTIVE

This study analyses secular trends in gender ratios for live births over the second half of the 20th century.

DESIGN, SETTING, PARTICIPANTS

Analysis was carried out from a World Health Organisation dataset comprising live births over the above period. This included 127034732 North American and 157947117 European live births.

MAIN OUTCOME MEASURES

Analysis of trends in gender ratios for countries in both continents.

RESULTS

The findings show a highly significant overall decline in male births in both Europe and North America (p<0.0001), particularly in Mexico (p<0.0001). Interestingly, in Europe, male births declined in North European countries (latitude>40 degrees, p<0.0001) while rising in Mediterranean countries (latitude congruent with 35-40 degrees, p<0.0001). These trends produced an overall European male live birth deficit 238693 and a North American deficit of 954714 (total male live birth deficit 1193407).

CONCLUSIONS

No reasonable explanation/s for the observed trends have been identified and the causes for these trends may well be multifactorial.

Sex ratio: a biological perspective of 'Sex and the City'

The primary sex ratio in humans differs remarkably from the theoretically expected equality of 1:1, and may be as high as 170 males to 100 females. A number of environmental, physiological and genetic factors have been observed to impact on the primary sex ratio: sexual behaviour, variation in hormonal concentrations, natural disasters, environmental pollutants and timing of conception. Nevertheless, no biological mechanism or interaction of factors has suitably explained this phenomenon, or that of the prenatal vulnerability of the male, the suspected higher sex ratio in spontaneous abortion and the male excesses in adult diseases related to the intrauterine environment. Knowledge of the environmental effects and causes of natural variation in the primary sex ratio will make possible its manipulation, which will have public health implications as well as cultural and social consequences.

Reproductive outcomes in the women of the Red River Valley of the north. I. The spouses of pesticide applicators: pregnancy loss, age at menarche, and exposures to pesticides

In the current study, there was a modest but significant increase in risk (1.6- to 2-fold) for miscarriages and/or fetal loss occurring throughout the year in the spouses of applicators who use fungicides. There is a surprisingly significant deficit in the number of male children born to the spouses of fungicide applicators. First-trimester miscarriages occur most frequently in the spring, during the time when herbicides are applied. Use of sulfonylurea (odds ratio OR = 2.1), imidizolinone (OR = 2.6) containing herbicides, and the herbicide combination Cheyenne (OR = 2.9) by male applicators was statistically associated with increased miscarriage risk in the spring. Limited survey data from women who are the spouses of applicators did not show major alterations of long-term endocrinologic status (menarche, menopause, endometriosis). With regard to personal pesticide exposures, only women who engaged in pesticide application where there is direct exposure to these products are at demonstrable risk (OR = 1.8) for miscarriage. It was hypothesized that the overall reproductive toxicity observed in this population is, for the greater part, a male-mediated event. Clarification of exposure events leading to reproductive toxicity through direct measurements of exposure in both men and women is needed to resolve this issue.

Rationale for the study of the human sex ratio in population studies of polluted environments

The human secondary sex ratio remains a subject of substantial interest. The possibility has been raised that environmental chemical exposures have played a role in the changes associated with the sex ratio in a number of countries. The possibility that such an effect may be present is supported at least theoretically by the observation that clomiphene citrate, a drug used in the treatment of infertility with powerful estrogenic and anti-estrogenic properties, has profound effects on the sex ratio resulting in significantly fewer males at birth. Using a model of causality based on the clinical identification of adverse drug effect methodology one may improve the objectivity of the assessment of significant environmental exposures on this human reproductive outcome.

Endocrine disruptors and congenital anomalies

The specialized literature was reviewed concerning the suspected increasing secular trends in the frequency of female births, male genital congenital anomalies, abnormal sperm counts, and testicular cancer. Although no risk factors could be identified yet, the observed sex ratio decline during the last decades has been considered to be an effect of certain pollutants on normal hormone activity, and human reproductive development. Reported increasing trends in the frequencies of hypospadias and cryptorchidism are very difficult to be interpreted due to the large variability in the registered frequency of these malformations due to operational as well as biological reasons.

Endocrine disruptors: a new scientific role for clinical pharmacologists? Impact on human health, wildlife, and the environment

It is important for the clinical pharmacologist to understand the potential human health implications of exposure to environmental chemicals that may act as hormonally active agents. It is necessary to have an understanding of how pharmaceutical and personal care products and other chemicals affect the ecosystem of planet Earth and to understand how they may negatively contribute to human disease. Clinical pharmacologists must understand the various definitions of endocrine disruptors and be able to "decipher" these terms for their patients. Understanding the need for the EPA endocrine disruptor screening program and possessing knowledge of the screening assays used to assess endocrine activity potential are two essential components relevant to the topic of endocrine disruptors. Clinical pharmacologists have an opportunity to play an important role in resolving the question of what role endocrine disruptors play in initiating human disease since some scientists argue that the present evidence is not compelling. Clinical pharmacologists can also play an important role in the evaluation of the risk assessment and use of risk management and risk communication tools required to address public health concerns related to actions of endocrine disruptors. It is important that clinical pharmacologists work with veterinary clinical pharmacologists, toxicologists, industrial chemists, regulators, the scientific community, the general public, and environmental groups to understand the impact of endocrine disruptors on human health, wildlife, and the environment with an ultimate goal to minimize and/or alleviate the unwanted, detrimental effects of the endocrine disruptors.

Environmental exposure to dioxin: the Seveso experience

The toxicity in humans of 2,3,7,8-tetrachlorodibenzo-p-dioxin, a man-made compound and environmental pollutant, is still debated. The industrial accident at Seveso, Italy, in 1976 exposed a large population of both sexes and of all ages to a massive concentration of 2,3,7,8-tetrachlorodibenzo-p-dioxin. Monitoring of soil and measurement of blood samples allowed classification of the exposed population into three categories: A, B and R (high, medium and low exposure, respectively). This article presents data from longitudinal health monitoring of the population, including liver function, immune function, neurological impairment, dermatological effects, reproductive pathology, and mortality.

Paternal concentrations of dioxin and sex ratio of offspring

BACKGROUND

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD or dioxin), is commonly considered the most toxic man-made substance. We have previously shown that high serum concentrations of TCDD in parents from Seveso, Italy, were linked to their having a relative increase in the number of female births after the parents exposure to a release of dioxin in 1976. We have continued the study to determine whether the parents' sex and/or age at exposure affected the sex ratio of their children.

METHODS

We measured the TCDD concentrations in serum samples from potentially exposed parents collected in 1976 and 1977, and investigated the sex ratio of their offspring.

FINDINGS

Serum samples were collected from 239 men and 296 women. 346 girls and 328 boys were born to potentially exposed parents between 1977 and 1996, showing an increased probability of female births (lower sex ratio) with increasing TCDD concentrations in the serum samples from the fathers (p=0.008). This effect starts at concentrations less than 20 ng per kg bodyweight. Fathers exposed when they were younger than 19 years of age sired significantly more girls than boys (sex ratio 0.38 [95% CI 0.30-0.47]).

INTERPRETATION

Exposure of men to TCDD is linked to a lowered male/female sex ratio in their offspring, which may persist for years after exposure. The median concentration of dioxin in fathers in this study is similar to doses that induce epididymal impairments in rats and is about 20 times the estimated average concentration of TCDD currently found in human beings in industrialised countries. These observations could have important public-health implications.