The fragile male

BMJ 2000; 321 doi: http://dx.doi.org/10.1136/bmj.321.7276.1609 (Published 23 December 2000)
Cite this as: BMJ 2000;321:1609

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  1. Sebastian Kraemer, consultant child and adolescent psychiatrist (sebastian@kraemer-zurne.freeserve.co.uk)
  1. Child and Family Department, Tavistock and Portman NHS Trust, London NW3 5BA

The human male is, on most measures, more vulnerable than the female. Part of the explanation is the biological fragility of the male fetus, which is little understood and not widely known. A typical attitude to boys is that they are, or must be made, more resilient than girls. This adds “social insult to biological injury.” Culture and class make a difference to the health and survival of boys. The data presented here have implications for the clinical management of male patients as well as for the upbringing of boys.

Summary points

The disadvantages of the male are usually seen as socially mediated

Even from conception, before social effects come into play, males are more vulnerable than females

Social attitudes about the resilience of boys compound the biological deficit

Male mortality is greater than female mortality throughout life

The causes are a mixture of biological and social pressures: we need to be aware of both in order to promote better development and health for boys and men

Downhill from conception to birth

At conception there are more male than female embryos. This may be because the spermatozoa carrying the Y chromosome swim faster than those carrying X. The male's pole position is, however, immediately challenged. External maternal stress around the time of conception is associated with a reduction in the male to female sex ratio, suggesting that the male embryo is more vulnerable than the female.1 From this point on it is downhill all the way. The male fetus is at greater risk of death or damage from almost all the obstetric catastrophes that can happen before birth.2 Perinatal brain damage,3 cerebral palsy,4 congenital deformities of the genitalia and limbs, premature birth, and stillbirth are commoner in boys,5 and by the time a boy is born he is on average developmentally some …

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