In their widely cited 2011 paper (1), Dr Prabhat Jha and colleagues used publicly available demographic data (the national census and household health survey data) to show that there were likely 4.2-12.1 million selectively aborted girls in India from 1980 to 2010. The authors convincingly suggested that selective abortion was the primary explanation for a steadily declining female-to-male sex ratio in India, which in turn is driven by cultural factors associated with a preference for boy children.

Their paper was not the first to point to a crisis in India’s sex ratio. In 2001, the UN estimated that there were 44 million “missing women” in India (2). And in 2008, Sahni et al examined hospital delivery data over 110 years to show that India’s national sex ratio fell dramatically after 1980, when ultrasound technology for antenatal sex determination became available (3). Many regional studies, such as that of Srinivasan & Bedi (4) in the state of Tamil Nadu, confirm that this trend is truly national.

Similar trends have been famously seen in other countries, especially in China, where the “one child policy” is thought to have resulted firstly in an epidemic of female infanticide, and secondly, after the arrival of antenatal sex determination technologies, in an increase in selective abortions of female foetuses (5).

Beyond the moral objections to female foeticide is the demographic crisis represented by a severely unequal sex ratio. However, the likely impacts of such imbalance are not well known, nor have they been well considered in the wider health literature. They include:

In India, the social drivers for sex selection are both deeply cultural and shallowly economic. Amongst orthodox Hindus, the care for elderly parents is traditionally the domain of the eldest son and his wife. Thus, the economic disincentive for having a girl is reflected in the local saying that raising a daughter is akin to “watering someone else’s garden”. A preference for sons manifests in many agrarian societies in which a male work force is valued for their wage-earning capacity (6). And the tradition of dowry, originally intended as a vehicle for assuring that a new bride had personal wealth, often in the form of jewellery, in the event that she was widowed or abandoned, has mutated into a form a “bride price”, in which families often go into debt to marry off their daughters. These are all economic disincentives for having girl children.

Interestingly, the Jha et al paper (1) found evidence that sex selection is most prominent amongst affluent households for whom the economic disincentives are less relevant. For them, it seems likely that a simple and sexist preference for sons is at play, which has at its heart, a cultural bias for the social cache and prestige that sons provide. The prime distinction between the affluent and the poor in this sense, then, is that the former can more readily afford expensive sex selection technologies. Importantly, the clustering of the trend in wealthier households also means that India’s vaunted economic expansion, especially in the middle class, is unlikely to assuage the sex ratio situation (15); indeed, as more families enter the realm of the affluent, it may exacerbate it.

With drivers and incentives for sex selection being social, cultural and economic, policies for addressing the crisis cannot be limited to the medical realm. In Jha’s paper (1), it is noted that India’s Pre-Natal Diagnostic Techniques Act of 1996, which seeks to penalize the misuse of prenatal sex determination technologies, is largely unenforced. The authors suggest that India’s traditional inability or unwillingness to police private medical practice is the greatest hindrance. The paper’s accompanying commentary (15) recommended better enforcement of existing policies as the appropriate solution. But it is possible that the desire to penalize sex selection, while evident at the policy-making level, has yet to penetrate to the street level, due to the depth and pervasiveness of cultural and economic drivers.

In the words of Sahni et al (3), “It is evident that mere legislation... cannot solve this social evil. Moves to address all forms of gender inequality... are needed to strike at the causes for distortion of the sex ratio.” Social change for improving women’s rights, both in India and elsewhere, is required. As noted by Hesketh et al, “Nothing can realistically be done in the short term to reduce the current excess of young males, but much can be done to reduce sex selection now” (6). While official policies have their place, in India, no progress will be made unless the social and economic drivers are addressed. For the former, this means public awareness and educational campaigns focusing on the value of girls. And for the latter, it means finding creative solutions to expand employment opportunities for both sexes, and to remake the social welfare infrastructure to limit the expectation of gender-based elder care, inasmuch as such is determined by an expectation of the roles of the eldest son and his wife.

Given the status of India and China as both the world’s fastest growing economies and our most populous lands, the demographic situation faced by both countries is relevant to all of us. To refer to those nations’ skewed sex ratio as a mere crisis is an understatement. Such profound demographic change may prove to be the basis for a host of pervasive social, economic and medical woes manifesting as the present generation of newborns reaches reproductive age.