the missing millions

The missing millionsThe missing millions

The one hundred The one hundred million missing million missing femalesfemales are are deaddeadLet it happen never againLet it happen never againFathalla MF. 1994. Editorial. Int. J. Gynecol. Fathalla MF. 1994. Editorial. Int. J. Gynecol. Obstet.Obstet. 46:101-10446:101-104

More than More than 100 million100 million women women are missingare missing..

Sen A.: New York Review of Sen A.: New York Review of Books. 20 December; 61, Books. 20 December; 61, 19901990

160 Million160 Million and and CountingCounting

By ROSS DOUTHATBy ROSS DOUTHATNew York TimesNew York TimesJune 26, 2011June 26, 2011


FACTSFACTS, VIEWS & VISION, VIEWS & VISION

-The evidence-The evidence

The evidenceThe evidence

A careful demographic analysis A careful demographic analysis of the sex ratios in various of the sex ratios in various populations, compared to the populations, compared to the expected ratios if societies expected ratios if societies offered equal health conditions to offered equal health conditions to both males and females. both males and females.

The demography of The demography of sex ratiosex ratio

The ratio of males to females in the The ratio of males to females in the population is a maximum at birth and population is a maximum at birth and then declines steadily with age, then declines steadily with age, becoming less than unity at some becoming less than unity at some age point, which demographers refer age point, which demographers refer to as the "cross over" point when to as the "cross over" point when there will be more females than there will be more females than males in the population after that males in the population after that age.age.

The female of the species The female of the species is the stronger biological is the stronger biological sexsexWorld Life Expectancy at BirthWorld Life Expectancy at Birth

Total population Total population malemale FemaleFemale

CIA The World factbook (2012 estimate)CIA The World factbook (2012 estimate)

67.59 years67.59 years 65.59 years65.59 years 69.73 years69.73 years

The female of the species The female of the species is the stronger biological is the stronger biological sexsex

Total Total

MaleMale

FemaleFemaleCIA The World factbookCIA The World factbook ( 2012 estimate)( 2012 estimate)

World infant World infant mortality ratemortality rate

39.48 deaths 39.48 deaths /1,000 live births/1,000 live births



World sex ratioWorld sex ratio At birth At birth Under age 15 Under age 15 Age 15- 64Age 15- 64 Age 65 and aboveAge 65 and above

Total populationTotal population

CIA The World CIA The World factbookfactbook

2012 estimate2012 estimate

1.07 male /female1.07 male /female 1.07 male /female1.07 male /female 1.02 male /female1.02 male /female 0.79 male /female0.79 male /female

1.011.01 male /female male /female

Sex ratio in BelgiumSex ratio in Belgium at birthat birth under 15 years under 15 years 15- 64 years 15- 64 years 65 years and over65 years and over total population total population


( 2012 estimate)( 2012 estimate)

1.04 male /female1.04 male /female 1.04 male) 1.04 male)

/female/female 1.02 male /female1.02 male /female 0.72 male/ female0.72 male/ female 0.960.96 male /female male /female

Sex ratio in EgyptSex ratio in Egypt at birth at birth under 15 years under 15 years 15- 64 years15- 64 years 65 years and over65 years and over total populationtotal population



1.05 male /female1.05 male /female 1.05 male /female1.05 male /female 1.03 male /female1.03 male /female 0.82 male /female0.82 male /female 1.031.03 male /female male /female

The female deficitThe female deficit

The biological advantage of being The biological advantage of being a female can be more than a female can be more than counter-balanced by the social counter-balanced by the social disadvantage of being a female.disadvantage of being a female.

Population sex ratioPopulation sex ratio WorldWorld BelgiumBelgium EgyptEgypt IndiaIndia ChinaChina



1.01 male /female1.01 male /female 0.96 male /female0.96 male /female 1.03 male /female1.03 male /female 1.08 male /female1.08 male /female 1.06 male /female1.06 male /female

The female deficitThe female deficitfrom ratios to numbersfrom ratios to numbers

The numbers of missing females are very The numbers of missing females are very large. When a standard for comparison, large. When a standard for comparison, the female: male ratio of 1.022 observed the female: male ratio of 1.022 observed in sub-Saharan Africa was used (since in sub-Saharan Africa was used (since women in that region receive less biased women in that region receive less biased treatment), the number of missing treatment), the number of missing women in China was estimated to be 44 women in China was estimated to be 44 million, in India 37 million, and so on, million, in India 37 million, and so on, with a total that easily exceeded 100 with a total that easily exceeded 100 million worldwide.million worldwide.


FACTSFACTS, VIEWS & VISION, VIEWS & VISION- - The evidenceThe evidence- Causes- Causes

DirectDirect cause: cause: Less Less natalitynatality

More mortalityMore mortalityIntermediary causeIntermediary causeUnderlying causeUnderlying cause

The female deficitThe female deficitand female infanticideand female infanticide

Female infanticide, a practice that was Female infanticide, a practice that was prevalent in the past in several societies, prevalent in the past in several societies, has not been completely abolished. It has has not been completely abolished. It has taken a new guise. It has been brought taken a new guise. It has been brought earlier with the utilization of new earlier with the utilization of new technologies for the technologies for the selective abortion of selective abortion of the female foetusthe female foetus, and it has been , and it has been deferred and changed to a passive form deferred and changed to a passive form of child death through of child death through neglect and neglect and discriminationdiscrimination..Fathalla MF. 1994. Editorial: The one hundred million Fathalla MF. 1994. Editorial: The one hundred million missing females are dead: Let it happen never again. Int. J. missing females are dead: Let it happen never again. Int. J. Gynecol. Obstet. 46:101-104Gynecol. Obstet. 46:101-104

Sex ratio at birthSex ratio at birth WorldWorld BelgiumBelgium EgyptEgypt India India ChinaChina

CIA The World factbookCIA The World factbook ( 2012 estimate)( 2012 estimate)

1.07 male /female1.07 male /female 1.04 male /female1.04 male /female 1.05 male /female1.05 male /female 1.12 male / female1.12 male / female 1.13 male /female1.13 male /female

Discrimination against the girl Discrimination against the girl childchild

"Leaders at all levels of the society must "Leaders at all levels of the society must speak out and act forcefully against speak out and act forcefully against patterns of discrimination within the family, patterns of discrimination within the family, based on preference for sons. One of the based on preference for sons. One of the aims should be to eliminate excess aims should be to eliminate excess mortality of girls, whenever such a pattern mortality of girls, whenever such a pattern exists".exists".

International Conference on Population and International Conference on Population and Development convened in Cairo in SeptemberDevelopment convened in Cairo in September1994, Paragraph 4.171994, Paragraph 4.17

Gender differentials in infant Gender differentials in infant and child mortality, Egypt DHS and child mortality, Egypt DHS 20002000

MaleMale FemaleFemaleNeonatal Neonatal mortalitymortality

32.632.6 25.225.2

Post-Post-neonatal neonatal mortalitymortality

22.422.4 29.329.3

Child Child mortalitymortality

14.614.6 16.116.1



- - The evidenceThe evidence- Causes- Causes

DirectDirect cause: cause: Less natalityLess natalityMore mortalityMore mortalityIntermediaryIntermediary cause causeUnderlying causeUnderlying cause

The female deficitThe female deficitand female infanticideand female infanticide

Female infanticide, a practice that was Female infanticide, a practice that was prevalent in the past in many societies, prevalent in the past in many societies, has not been completely abolished. It has has not been completely abolished. It has taken new forms. It has been brought taken new forms. It has been brought earlier with the earlier with the utilization of new utilization of new technologies for the selective technologies for the selective abortion of the female foetusabortion of the female foetus, and it , and it has been deferred and changed to a has been deferred and changed to a passive form of child death through passive form of child death through neglect and discrimination.neglect and discrimination.Fathalla MF. 1994. Editorial: The one hundred million Fathalla MF. 1994. Editorial: The one hundred million missing females are dead: Let it happen never again. Int. J. missing females are dead: Let it happen never again. Int. J. Gynecol. Obstet. 46:101-104Gynecol. Obstet. 46:101-104



- - The evidenceThe evidence- Causes- CausesDirectDirect cause: cause: Less natalityLess natalityMore mortalityMore mortalityIntermediary causeIntermediary causeUnderlyingUnderlying cause: Son preference cause: Son preference

Son preference: An old Son preference: An old traditiontraditionA body of Chinese poetry, The Book of Songs, believed to date A body of Chinese poetry, The Book of Songs, believed to date from 1000-700 B.C., offers this advice to new parents:from 1000-700 B.C., offers this advice to new parents:

When a son is bornWhen a son is born Let him sleep on the bedLet him sleep on the bed Clothe him with fine clothes.Clothe him with fine clothes. And give him jade to play with. ... And give him jade to play with. ...

When a daughter is born,When a daughter is born, Let her sleep on the ground,Let her sleep on the ground, Wrap her in common wrappings,Wrap her in common wrappings, And give her broken tiles for playthings.And give her broken tiles for playthings.

(Glenn D. A dangerous surplus of sons. The Chronicle: (Glenn D. A dangerous surplus of sons. The Chronicle: 4/30/2004)4/30/2004)

Gender preferences for Gender preferences for childrenchildren

According to comparative data from Demographic According to comparative data from Demographic and Health Surveys, gender preferences for and Health Surveys, gender preferences for children vary dramatically from one country to children vary dramatically from one country to another. another. Son preferenceSon preference was most prominent in a band of was most prominent in a band of countries stretching from North Africa, through the countries stretching from North Africa, through the Near East, to South Asia. The extreme preference Near East, to South Asia. The extreme preference for sons is found in India, Bangladesh, Nepal, and for sons is found in India, Bangladesh, Nepal, and Egypt, but a distinct preference for sons is also Egypt, but a distinct preference for sons is also evident in Turkey, Tunisia, Pakistan, Sri Lanka, evident in Turkey, Tunisia, Pakistan, Sri Lanka, Jordan, and Morocco.Jordan, and Morocco.

(Arnold, 1997)(Arnold, 1997)


FACTS, FACTS, VIEWSVIEWS & VISION & VISION

- - Human rightsHuman rights- Public health- Public health- Economists- Economists- - DemographicDemographic- Social- Social

Impact of the female Impact of the female deficitdeficit

A dA demographic viewemographic view A society with fewer girls is A society with fewer girls is

guaranteed to reproduce itself at guaranteed to reproduce itself at lower rates.lower rates.

Fewer girls might be exactly what Fewer girls might be exactly what the teeming societies of the third the teeming societies of the third world needed. world needed.

Impact of son Impact of son preference on fertilitypreference on fertility

In the absence of any gender preferences, it In the absence of any gender preferences, it was estimated that contraceptive prevalence, was estimated that contraceptive prevalence, in seven countries where there is strong son in seven countries where there is strong son preference, would increase by 3-25 percent preference, would increase by 3-25 percent from its current level and that pregnancy from its current level and that pregnancy rates would decrease by 9-21 percent. rates would decrease by 9-21 percent. The corresponding percentages estimated for The corresponding percentages estimated for Egypt, were 7.7 and 11.6.Egypt, were 7.7 and 11.6.

(Arnold F. 1997. A comparative study of DHS (Arnold F. 1997. A comparative study of DHS data)data)


FACTS, FACTS, VIEWSVIEWS & VISION & VISION

- - Human rightsHuman rights- Public health- Public health- Economists- Economists- Demographic- Demographic- - SocialSocial

Impact of the female Impact of the female deficitdeficitSocial perspectiveSocial perspective

High sex ratios at birth in some Asian High sex ratios at birth in some Asian countries due to a strong preference countries due to a strong preference for sons will affect future marriage for sons will affect future marriage patterns and fertility patterns. patterns and fertility patterns. Eventually , it could cause unrest Eventually , it could cause unrest among young adult males who are among young adult males who are unable to find partners.unable to find partners.

CIA The World factbook 2012CIA The World factbook 2012


FACTS, VIEWS & FACTS, VIEWS & VISIONVISION

- Let it happen never again:- Let it happen never again: - - LawLaw

- The health profession- The health profession- Women empowerment - Women empowerment - Social change - Social change

Sex- selective abortion Sex- selective abortion and the law- The case of and the law- The case of IndiaIndiaFetal sex determination and Fetal sex determination and medical termination of pregnancy medical termination of pregnancy on the basis of foetal sex have on the basis of foetal sex have been illegal since 1994. Under the been illegal since 1994. Under the law, prenatal diagnostic scans are law, prenatal diagnostic scans are allowed for the detection of allowed for the detection of genetic abnormalities, but sex genetic abnormalities, but sex determination tests are forbidden. determination tests are forbidden. Those caught are subject to a fine, Those caught are subject to a fine, imprisonment, and suspension of imprisonment, and suspension of the medical practitioner's license. the medical practitioner's license.

Sex- selective abortion and Sex- selective abortion and the law- The case of India the law- The case of India (cont.)(cont.) However, in a national survey of 1.1 million households However, in a national survey of 1.1 million households

in India, Jha et al (2006) concluded that prenatal sex in India, Jha et al (2006) concluded that prenatal sex determination followed by selective abortion of female determination followed by selective abortion of female foetuses is the most plausible explanation for the low foetuses is the most plausible explanation for the low sex ratio at birth in India. Women most clearly at risk sex ratio at birth in India. Women most clearly at risk are those who already have one or two female children. are those who already have one or two female children.

Based on conservative assumptions, the practice was Based on conservative assumptions, the practice was estimated to account for about 0.5 million missing estimated to account for about 0.5 million missing female births yearly in India, translating over the past 2 female births yearly in India, translating over the past 2 decades into the abortion of some 10 million female decades into the abortion of some 10 million female foetuses.foetuses.

Jha P et al. Low female-to-male sex ratio of children born in India:national survey of 1.1 million households. Lancet 2006; 367: 1211-1218.



- Let it happen never again- Let it happen never again:: - Law- Law

- - The health professionThe health profession- Women empowerment - Women empowerment - Social change - Social change

The health profession The health profession and sex- selective and sex- selective abortionabortionIn 1986, the Federation of Obstetric and Gynaecological In 1986, the Federation of Obstetric and Gynaecological

SocietiesSocietiesof India passed a resolution against prenatal sex determination of India passed a resolution against prenatal sex determination and medical termination of pregnancy because of the sex of and medical termination of pregnancy because of the sex of

the the foetus. All members of the federation are asked to desist, foetus. All members of the federation are asked to desist, dissociate, and discourage female foeticide as it is a “crime dissociate, and discourage female foeticide as it is a “crime against humanity”.against humanity”.However, there is ample published evidence of rampant sex However, there is ample published evidence of rampant sex determination and female foeticide.determination and female foeticide.

Sheth s. 2006. Missing female births in India. Lancet 367: 185-Sheth s. 2006. Missing female births in India. Lancet 367: 185-186.186.



Let it happen never againLet it happen never again: : - Law- Law

- The health profession- The health profession- - Women empowermentWomen empowerment - Social change - Social change

Trends in sex-selective Trends in sex-selective abortions in Indiaabortions in India

Declines in the ratio of born girls were Declines in the ratio of born girls were much greater in mothers with 10 or much greater in mothers with 10 or more years of education than in more years of education than in mothers with no education, and in mothers with no education, and in wealthier households compared with wealthier households compared with poorer households. poorer households. Jha P. et al 2011. Trends in selective abortions of Jha P. et al 2011. Trends in selective abortions of girls in India: analysis of nationally representative girls in India: analysis of nationally representative birth histories from 1990 to 2005 and census databirth histories from 1990 to 2005 and census datafrom 1991 to 2011. Lancet 377; 1921 – 1928.from 1991 to 2011. Lancet 377; 1921 – 1928.

Women empowerment Women empowerment and sex selectionand sex selection Thus far, in India, female Thus far, in India, female

empowerment often seems to have empowerment often seems to have led to more sex selection, not less. led to more sex selection, not less.

In many communities, women use In many communities, women use their increased autonomy to select their increased autonomy to select for sons, because male offspring for sons, because male offspring brings higher social status.brings higher social status.



- Let it happen never again- Let it happen never again:: - Law- Law

- The health profession- The health profession- Women empowerment - Women empowerment - - Social changeSocial change

The Republic of Korea – a success story

In the 1980s and 1990s, the Republic of Korea had a highly imbalanced sex ratio at birth that reached almost 116. By 2007, the ratio had returned to 107.

It appears that a combination of factors contributed to this shift. Two decades of exceptional economic growth led to fundamental changes in Korean society. A “Love Your Daughter” media campaign was successful.

World Health Organization 2011. Preventing gender-biased sex selection: an interagency statement.


FACTS, VIEWS & FACTS, VIEWS & VISIONVISION- - Let it happen never again:Let it happen never again:

- Law- Law- The health profession- The health profession- Women empowerment - Women empowerment - Social change - Social change

- - New ethical challengesNew ethical challenges Sex selection: Sex selection: - Pre-fertilization - Pre-fertilization

Pre-implantationPre-implantation- for gender balance, not gender - for gender balance, not gender

biasbias

FIGO Resolution on “Sex FIGO Resolution on “Sex Selection for Non-medical Selection for Non-medical purposes"purposes"

FIGOFIGO Deplores all forms of discrimination against Deplores all forms of discrimination against

women and the use of any medical techniques women and the use of any medical techniques in any way that would exacerbate in any way that would exacerbate discrimination against either sex.discrimination against either sex.

Affirms that selection is of particular ethical Affirms that selection is of particular ethical concern when it is driven by value differences concern when it is driven by value differences ascribed to either sex or that arise from ascribed to either sex or that arise from pervasive gender stereotypes.pervasive gender stereotypes.

Adopted by the FIGO Genenal Assembly in Kuala Lampur, Malaysia on 7th November Adopted by the FIGO Genenal Assembly in Kuala Lampur, Malaysia on 7th November 20062006

Hartelijk dankHartelijk dankMerci beaucoupMerci beaucoup

Vielen DankVielen DankThank you very muchThank you very much

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