The fragile male

BMJ 2000; 321 doi: (Published 23 December 2000)
Cite this as: BMJ 2000;321:1609

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The subtleties of radiological fracture diagnosis are qualities of Orthopaedic surgeons, not always appreciated by other specialties. They often rely on understated radiological clues to aid diagnosis, including soft tissue shadows. Interest has been raised regarding the usefulness of phallic shadows on pelvic x-rays, as an aid to fracture diagnosis. The ‘John Thomas Sign’ (inclination of the penis towards the hip or pelvic fracture) has been thrust, from the intellectual banter of trauma meetings, into the spotlight by an article from New Zealand advocating its use1. The group found a positive sign in 70% (n=91/130) of hip fracture patients. However, the validity of this finding has not been tested for the northern hemisphere, in particular Yorkshire. We investigated whether the John Thomas (JT) sign was upstanding to scrutiny or a mere flop in Yorkshire.


60 randomly selected x-rays from male patients with proximal femoral fractures were reviewed independently by two researchers. Mean age was 78.2 years, 33 left and 27 right fractures. JT was positive in 37% (n=22/60), negative (declined from the fracture) in 20% (n=12/60) and equivocal (midline) in 43% (n=26/60). Distressingly, the JT positive predictive value was only 47.8%, sensitivity 45.8%, and specificity 64.7%. There was no correlation (p=0.84) between the JT and time of the year or severity of fracture (p=0.34).


The authors do not wish to go ‘head to head’ with the New Zealand group, but their findings could not be applied to the gentlemen of Yorkshire where the JT sign has little diagnostic or prognostic value. Environmental factors have been implicated in the genital asymmetry, included handedness2, however, we believe that geographical and social differences are responsible for the variation in results. Yorkshire men are renowned for their directness; however, being British gentleman, modesty and even- handedness are amongst their finer qualities. The outgoing antipodeans are often over exuberant about there successes and it may be this subconscious trait which overrides higher cerebral function.

It has long been recognised by tailors that gentleman often prefer to ‘dress’ to a side (more commonly left), and have traditionally made the legs of the trousers on the preferred side slightly more capacious. Cyclists have realised the advantage of a skewed saddle position3, allowing increased time in the saddle by reducing external pressure. Victorian fashionable gentlemen wore dressing rings, which controlled penile bent, so as not to spoil the line of tight fitting trousers, with Prince Albert being an exponent of this trend. Thus, it can be seen that then, as now, British gentleman have shied away from drawing attention to themselves. We feel that before routine screening of the JT sign is forced upon us by higher bodies, further research into the efficacy and reproducibility of this sign is warranted.


1. Thomas MC. Lyons BD. Walker RJ. John Thomas sign: common distraction or useful pointer?. [Letter] Medical Journal of Australia. 169(11-12):670, 1998 Dec 7-21.

2. Chang RH, Hsu FK, Chan ST, et al. Scrotal asymmetry and handedness. J Anat 1960; 94: 543-548.

3. ‘Rotating saddle nose slightly off center?’

Competing interests: None declared

Competing interests: None declared

Lee M Jeys, SpR Orthopaedic Surgery

Colin Holton

Hull Royal Infirmary

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A very simple observation seems to be eluding a large number of people. Whereas the X chromosome enjoys all the advantages, when passed from generation to generation, that sexual reproduction conveys; the Y chromosome is passed down solely from father to son: a process that suffers all the disadvantages that inbreeding would entail.

Competing interests:   None declared

Competing interests: None declared

Mark W Hopkins, N/A

On extended sabbatical

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Delighting in being controversial one might say that this discussion is rather silly [1]. Choosing a category such as 'males' and then proposing that all members of it must therefore possess many common features - apart from the usual anatomical ones [in most cases] - is probably highly misleading if not fictitious. Do Audi drivers, for example, all have common features? Should we try to search for and define them? And can those features be significantly distinguished from those possessed by BMW drivers? And if so, does it mean anything - or who even cares? Such categories are not real, they are constructed and imposed upon reality by our minds. Therefore, are any generalisations we choose to find in such categories real, or just stereotypes or even illusions? Is not this very impulse to categorise and generalise fundamentally flawed?

However, having said that, one can agree with Peter West when he says: "It is no accident that when a GP (middle aged perhaps, raised in a time when 'real men don't show their feelings') has to communicate, he often doesn't talk easily to another man about that man's body or his feelings." [2]. And even when he says: "Males stuck in the old certainties - 'real men don't read'; 'be slow to talk and quick to shoot' etc...many of us are now realising that the stuff they sold us about being a man was a big crock." [2]. A very 'right on' comment that I fully endorse. It is probably true that most men do not explore the feelings side of their nature very much and nor are they encouraged to do so by society. Do they actually have any feelings at all?

Although I agree with him that: "Our task is to do a better job of it - be better fathers - and help create better men, than our own fathers did." [2], I do not agree that "It's a very exciting time to be a man." [2]. Quite the reverse, it is the pits. But then, it probably always has been.

Men are a threat not only to their own health but to the planet in general, women and children, plants and animals, outer space and also wind up projecting their inner turmoil outwards as wars all over the place. It is therefore very hard to generate any evidence-based affection for men in general or in particular - en masse they are crude, rude and aggressive and thus repulsive, e.g. football crowds. That type of male claims to be the dominant or only 'correct' version of maleness and boys grow up in the shadow of an uglifying 'yob culuture' which destroys any chance they might have of becoming attuned to the more sensitive side of their nature; even if they want to, it is strongly discouraged by [male] society at large, acting in collusion with females like mothers. The inspired feminine side of men is probably the only side really worth talking about and as it is not explored in society very much, let alone celebrated, there seems to be very little nice to say about men in general.

Trying to be a caring father is not an easy task for that type of male, but for caring males it is easier. It is hardly supported by society at large. The main problem seems to be the way 'being a male' always takes precedence over 'being a human being' and thus one is stifled by and herded into rigid stereotypes of 'correct' or approved behaviour and attitudes. This rather blokeish attitude that predominates in an unquestioned sort of fashion in society blocks any more balanced development of men, because it is denounced as sissyish [effeminate, foppish] to explore or express feelings or to be anything other than the 'strong silent type'.

Thus, one might reasonably conclude, that apart from occasionally fertilising eggs, and a tiny minority of highly gifted individuals in art, music and literature, most men seem to serve no known useful social function in the world. By contrast, women do virtually everything of value in feeding, clothing, bathing, nurturing, loving, befriending, empathising etc with others of the human race - all of which men seem monumentally incapable of performing. They are selfish and moody, cannot socialise or empathise too well and have very limited social skills. And they are happy being like that! Maybe the extreme feminists are right when they say the world would be better off without men - if they could only find a way to do it! It would be nice to be regarded primarily as a human being most of all and gender to be irrelevant, but that is also impossible.

However, everything I have said here is contingent upon the belief that members of a category called 'males' must hold certain similarities that define them as a group - but which they may not possess at all.


[1] Lessons From Everywhere, The fragile male, Sebastian Kraemer, BMJ 2000; 321: 1609-1612,

[2] BMJ Letter, 20 Feb 2001, warning: masculinity is a danger to health, Peter West

Competing interests: None declared

Peter Morrell, Hon Research Associate, History of Medicine

Staffordshire University, ST4 2DE

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This is a useful article and the discussion is illuminating.

I'd like to make two observations. The first is on men's health. So often, men's health is conceptualised as about "men's bits" - prostate cancer, penile dysfunction and such. We are learning that men's health needs to be understood much more widely- as part of the whole business of being a male. It is no accident that when a GP (middle aged perhaps, raised in a time when 'real men don't show their feelings') has to communicate, he often doesn't talk easily to another man about that man's body or his feelings. My own issues came up recently when tingling and numbness in the penis pointed eventually to prostatitis. My GP was fairly helpful, but I got the help I needed from a website [] and a natural healer.We need to think further that men's health should be thought of positively not negatively: a saluto-genic way [keeping ourselves healthy] not a pathogenic way [which bits aren't working].We are holding a Mens Health Conference here in the Uni of Western Sydney in September to expand all these ideas and push the whole debate further.

Second, we need to think much harder about the way in which we raise boys. Over the last 30 years,girls' education has been transformed; boys' education has been largely left as it was. Yet we are raising boys in a very different environment from the one in which our fathers lived. The workplace is being transformed over and over. Employers want people who can read, re-learn, communicate, co-operate, talk the language of the firm or the policy of the government. Males stuck in the old certainties - 'real men don't read'; 'be slow to talk and quick to shoot' etc won't find many employment options, especially in the white collar world.Let alone have a fulfilled and productive life and enjoy relationships to the fullest. Many of us are now realising that the stuff they sold us about being a man was a big crock.

Thanks for the opportunity to raise these matters. It's a very exciting time to be a man. Our task is to do a better job of it - be better fathers - and help create better men, than our own fathers did.

Competing interests: None declared

Peter West, Research Grouip on Men and Families,

Uni of Western Sydney

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I enjoyed the article, "The Fragile Male" by Sebastian Kraemer. It is unfortunate that space did not permit a fuller discussion of the factors affecting the sex ratio, mentioned briefly in the second paragraph. Not only can stress affect the survival of males. It can determine whether or not they are born in the first place.

Many prospective parents strongly desire to have a child of a particular sex. Various folk remedies suggest methods of achieving this and from a more scientific outlook it is possible to separate X bearing from Y bearing spermatozoa for the purposes of in vitro fertilisation. However few among the general public are aware that a considerable amount of effort has been expended clarifying the natural phenomena that may determine the sex of offspring in vivo.

Evolutionary theory predicts a sex ratio of 1 to 1 at conception (1), assuming that the parents are physiologically blind to the society and the position in it that that their offspring will inhabit. If the conception ratio deviates either way then selective pressure will return it to this optimum. Consider the following thought experiment: a male or female parent develops a mutation that causes them to conceive only male offspring (either through selective production of Y bearing sperm in the father or selective facilitation of Y sperm in the mother). How can this gene spread through the population? It would lead to a surplus of males and any parents preferentially producing female offspring would then have a reproductive advantage and transmit more genes into the next generation. The conception ratio would therefore return to 1 to 1. The same applies in reverse to female producing mutations. This insight occurred to Sir Ronald Fisher in the 1920s.

What about in polygynous societies which may have existed briefly during our evolutionary history? Wouldn't it be better to produce only female offspring thereby virtually guaranteeing grandchildren rather than wasting resources on males who may never make it to the top. The problem is that those males that do make it to the top will sire a vast number of offspring, exactly cancelling out any advantages that would accrue to a mutant preferentially producing female offspring.

Whilst the conception ratio must always be 1 to 1, the same does not apply to the population ratio which varies according to which sex dies most through life. But even if we lived in a world where 90% of males died before reaching sexual maturity selective pressure would still demand a 1 to 1 ratio at conception. It would just be the polygynous situation in another guise. The same applies to selective female death or disablement.

Furthermore even if parents ardently desire to have children of one sex and keep having children until the desired sex appears then this too will not affect the evolved optimum conception ratio, which is blind to social preference. It won't even affect the population ratio. Even if there were families that persisted through nine daughters until finally a son was born, as happens in some developing countries, every birth would still have an equal chance of being male or female as determined by the conception ratio. Infanticide would of course affect the population ratio, as would any cause of mortality that favoured one sex over the other. However female infanticide or preferential male death during wars cannot affect the optimum conception ratio, which is 1 to 1, assuming the parents are physiologically blind to these effects.

Even efforts to manipulate the environment and mating of domestic animals have failed to breed strains that produce mainly female or male offspring. The question remains, with whom will the sex selected offspring mate? (2) Any selected effect would immediately be halved at the point of mating. It is possible that in the future farmers will achieve this end through cloning or in vitro fertilisation as mentioned above.

The above arguments follow from classical genetics. However there appear to be a number of environmental causes of an asymmetrical sex ratio and parents may not be physiologically blind to them. Natural disasters lead to a relative increase in female births. (3,4). It is open to debate whether this is due to selective death of the fragile male in utero or a change in the conception ratio. There is evidence indicating that both may play a part. (5c,6). In either case this is unlikely to represent an adaptive response to recurrent earthquakes and floods, even if one could be devised. No manipulation of the population can drive a universal change in the optimum conception ratio through classical selective mechanisms. There must be another explanation. This could consist of a flexible genetic effect, whereby feedback from the environment provides specific information regarding the optimum sex of offspring for those particular parents. It may be argued that this system, whilst adaptive under most circumstances misfires when rare environmental effects occur.

One possible mediator is the altered hormonal status of parents at the time of conception. Evidence in favour of this is firstly that various diseases are associated with a subsequent variation in the se ratio of offspring, such as prostatic cancer (more boys) and non Hodgkin's Lymphoma (more girls) (5a) and secondly that occupation is associated with hormonal status and a change in the sex ratio at birth, with doctors producing more sons than the rest of the population and ministers of religion producing more daughters (5b).

It has been noted that there was a change in the sex ratio (more females born) after The London smog of 1952, the Brisbane flood of 1965 and the Kobe earthquake of 1995. (3,4). This raised the question of whether exposure to severe personal events around the time of conception led to a similar alteration in the sex ratio. This was found to be the case in a study recently published in the BMJ. (7).

If we look at variations in the sex ratio in other primates then this has been linked to the social status of the parents at the time of conception, possibly mediated by stress hormones. (2). It is therefore reasonable to anticipate similar effects in humans. If the parents are of low social status then female children would be more likely to provide grandchildren. The same would apply in reverse if the parents were of high social status. Hence genes capable of making the distinction and influencing the sex ratio would spread through the population. It is difficult to argue this point in the modern world, but the modern world is not what counts. Rather it is the ancestral environment, in which such qualities might have evolved. The reasoning is that males are dependent on social status for their reproductive success and if this is inherited from parents and likely to be low then it is better to have female offspring, which can be expected to have children regardless of social status. (2). By way of warning I should remind readers that evolutionary explanations such as this are notoriously easy to devise and notoriously difficult to test.

Various studies have looked at social class and the birth ratio of offspring in humans and concluded that high social class is positively associated with male offspring. (2). However one difficulty is that social class and social status are different things. Parents could easily be of low social class and of high social status, as estimated by their peer group without tripping the stress mechanisms responsible for altering the gender of their offspring.

One hazard associated with stress hormones as proxy for social status, is that they are susceptible to stressful environmental stimuli such as earthquakes and floods, which are not connected, to social status.

Whilst natural disasters lead to the production of more female offspring at birth the status quo between disasters leads to a slight over production of males, at least in this country. For every 1,051 boys born there are 1,000 girls, although the population ratio is less than this because of the higher male mortality rate. (8). This could be because our high level of nourishment misleads our bodies into functioning as though our social status is higher than it actually is. The physiological estimation, if it exists may be set for ancestral conditions. If that were the case then we would expect to find a predominance of female births in countries where nutrition is poor. However we have to be careful when comparing populations which have spent so much of their recent evolutionary history under different conditions. As soon as an imbalance in the conception ratio develops as a result of mass shifts in nutrition then classical selective mechanisms will be activated to drive it back to 1 to 1. This might take a long time but sooner or later the responses to physiological indices will be reset to match the new conditions.

I will finish with two provisos for parents. Firstly the benefits of having a daughter may not justify the ordeal of extreme environmental stress around the time of conception and secondly even if such a measure can be endured it is unreliable, since the change in the sex ratio is likely to be small, from fifty-fifty to sixty-forty at best.(7).


1. Dawkins R., 1982, The Extended Phenotype, Oxford University Press, Oxford.

2. Ridley M., 1993, The Red Queen, Penguin Books, London.

3. Lyster W.R. Altered sex ratio after London smog of 1952 and the Brisbane flood of 1965. J. Obstet Gynaecol Br Commonwealth 1974; 81;626-31.

4. Fukuda M, Fukuda K.,Shimizu T., Moller H. Decline in sex ratio at birth after Kobe Earthquake. Human Reprod 1998; 13:2321-2.

5. James W. H.
a) Evidence that mammalian sex ratios at birth are partially controlled by parental hormones at the time of conception. J Theor Biol 1996;180:271-86.
b) The Hypothesised Hormonal Control of Mammalian Sex Ratio at Birth - A Second Update. J. Theor. Biol. (1992) 155, 121-128.
c) Parental Hormone Levels and the Possibility of Establishing that some Mammalian Sex Ratio Variation is Adaptive. J. Theor. Biol. (1989) 140, 39-40.

6. Pratt N.C., Lisk R.D. Effects of social stress during early pregnancy on litter size and sex ratio in the golden hamster (Mesocricetus auratus). J Reprod Fert 1989;87:736-69.

7. Hansen D., Moller H., Olsen J., Severe periconceptual life events and the sex ratio in offspring. British Medical Journal 1999; 319: 548-9.

8. O'Reilly J.,Jones L. The Sunday Times, P21, 25.7.99.

Competing interests: None declared

Colin Dewar, Staff Grade Psychiatrist

Larkfield Centre

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18 January 2001

Editor - There was no mention of infectious diseases and sex preponderance in the article by Kraemer about the fragile male (1).

However, the same pattern seems to occur with regard to the complications that arise in the classical childhood diseases . Although the infection rate is equal for both sexes, males are more prone to complications, as occurs e.g. with mumps encephalitis, hemophilus influenzae meningitis and severe pneumococcal infections (2,3). However, one striking exception stands out from the rest: whooping cough. This disease affects the sexes equally but, for reasons noy yet clarified, fatality rates have always been higher for females (3). This is of course changing as a result of effective vaccination programmes, leaving the male child with no intrinsic advantage as previously. Even as far as the classical childhood infectious diseases are concerned, male children are naturally disadvantaged, which contributes to the higher mortality and morbidity amongst their age/sex group.

(1) Kraemer S. The fragile male. BMJ 2000;321:1609-1612. (23-30 December)

(2) AS Evans ed. Viral Infections of Humans.Epidemiology and Control . 2nd ed. New York and London: Plenum Medical Book Company, 1982.

(3) AS Evans, HA Feldman eds. Bacterial Infections of Humans.Epidemiology and Control . 1st ed. New York and London: Plenum Medical Book Company, 1982.

Torbjörn Sundkvist
Consultant Infectious Diseases
Sunderby Sjukhus, 971 80 Luleå, Sweden

Competing interests: None declared

Torbjörn Sundkvist

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18 January 2001

Editor - As the author quite correctly points out, being a man can seriously damage your health. The Men's Health Forum with a membership over 180 organisations ranging from the BMA to the RCN, the Post Office to Marks & Spencer's, the DoH to the TUC has campaigned on this issue for 6 years. There now appears to be a realisation amongst politicians that men's health is often a contradiction in terms and urgently needs more attention and resources. Extensive research shows, however, that the health of both sexes is often inextricably entwined, clearly demonstrated by Chlamydia infection. A joint approach to the health of women and men is required rather than a 'them and us' confrontation. It is no coincidence that men's health is increasingly highlighted in areas, such as politics, medicine, education and employment where women are taking their rightful place as policy makers. Half of the Men's Health Forum executive elected representation is female with a woman as deputy chair. It was Tessa Jowell and especially Yvette Cooper not Frank Dobson or Alan Milburn who brought men's health as an issue to the attention of Parliament.

Perhaps men should take a leaf from the women's health movement's book rather than begrudge their success. With UK spending on women's health the lowest in Europe, it would serve both sexes well to improve spending generally in the NHS. As with present frontline army policy, men are more often prone to shooting themselves in the foot.

Chair, Men's Health Forum. (contact: Tavistock House, Tavistock Square, London, WC1H 9JP.

Competing interests: None declared

Ian Banks

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The opening sentence of a recent article is "At conception there are more male than female embryos" because there is a higher male birth rate than female birth rate (1). The alternative hypothesis (2) is that there is an equal number of male and female conceptions because there must be an identical number of X and Y sperms produced during spermatogenesis. During the very first days after conception, it is possible that there is excess female loss of the embryo before cell differentiation takes place and it becomes a recognizable fetus. For example, a problem with the required process of inactivation of one of the female's X-chromosomes, which the male embryo does not undergo, may lead to excess spontaneous loss of the female embryo before the mother is even aware that she is pregnant (3).

Because the spontaneously lost embryo in the first days of pregnancy cannot be found and sexed to determine its gender it is currently impossible to test and reject the alternative hypothesis that there is proportionally more excess female fetal loss in the first weeks of pregnancy than the observed male excess fetal loss in the remaining eight months of the full term. Therefore I suggest that the authors opening statement is unproven and is probably false. After the birth, the male fragility is well known, and it has been suggested that this frailty is caused by an X-linkage (4-6).

David T. Mage, Ph.D.

1. Kraemer S. 2000. The fragile male. BMJ 321:1609-1612 (23 December).

2. Waldron I. 1998. Factors determining the sex ratio at birth. In: Too Young to Die: Genes or Gender? Report ST/ESA/SER.A/155, Department of Economic and Social Affairs, United Nations, New York, p 53 - 63.

3. Gartler SM. 1990. The relevance of X-chromosome inactivation to gender differential in longevity. In: Ory MG, Warner HR eds. Gender, Health and Longevity: Multidisciplinary Perspectives, New York: Springer.

4. Naeye RL, Burt LS, Wright DL, Blanc WA, Tatter D. 1971. Neonatal mortality, the male disadvantage. Pediatrics 48:902-906.

5. Mage DT, Donner M. 1996. An X-linked genetic susceptibility for SIDS and respiratory failures. J SIDS & Infant Mortality 1 (4) 295-305.

6. Mage DT, Kretzschmar J. 2000. Are males more susceptible to ambient PM than females? Inhalation Toxicology 12:(Supplement 1) 145-155.

Competing interests: None declared

David T Mage, Senior Study Director

Institute for Survey Research, Temple University, Philadelphia, PA, USA

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You're article as I read it is more towards showing male inferiority vis a vis female superiority, You're statement of "Downhill from conception to birth" shows that there's nothing good from taking care of a baby boy than a baby girl. Just ask yourself this question if any radical feminist would read this article of yours she would NEVER want a baby boy (or they had never wanted one fron the first place). This is just my own opinion and not a scholarly or academically view of your article. This is a man's EMOTIONAL response as I see myself as more emotional than other men. I believe that more articles wuld be of great value if you try not to undermine the other sex but to try and focus which is EQUAL and would benefit both gender. Thank you and Godbless!

Competing interests: None declared

Vergel , Nurse

Solihull Hospital Ward 16 (Orthopaedic Ward

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To the Editor:

Kraemer's review contraindicates newborn male non-therapeutic circumcision.

Kraemer's review, The Fragile Male, is a valuable addition to the literature.1

Jacobson and colleagues have demonstrated that perinatal trauma causes self-destructive behavior including suicide.2,3 Jacobson et al. report that perinatal trauma is about 4 times more likely to cause suicides in men as compared with women.3

Non-therapeutic male neonatal circumcision is a traumatic procedure, which is usually carried out in the perinatal period. Studies of innate differences of the genders which are carried out in the United States usually involve male subjects who have been neonatally circumcised.4 Non-therapeutic male neonatal circumcision has been documented to cause behavioral changes at six month immunization.5. Non-therapeutic neonatal male circumcision has been documented to cause posttraumatic stress disorder in adult males.6 Male circumcision similarly has been documented to cause changes in sexual behavior.7

Kraemer reports developmental disorders in boys.1 Anand and Scalzo suggest that prevention of early insults and trauma are important in preventing brain changes and developmental disorders.8

Kraemer's review1 cites many studies of which a number were carried out in the United States. One can expect that the studies carried out in the U.S. had circumcised boys as subjects, although researchers usually fail to control circumcision status.4 Kraemer's review, thus, is weakened by the failure to distinguish between biological differences between the genders and iatrogenic differences caused by male circumcision. Nevertheless, his review provides a powerful witness to the urgent need to treat the fragile newborn male infant with especial care, including the avoidance of painful and stressful procedures, such as non-therapeutic male neonatal circumcision, as recommended by the Committee on Fetus and Newborn of the American Academy of Pediatrics.9

George Hill


Competing interests: None declared

George Hill, A Concerned Citizen

Port Allen, Louisiana, USA

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