The fragile male
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7276.1609 (Published 23 December 2000) Cite this as: BMJ 2000;321:1609All rapid responses
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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: No competing interests
Sir,
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.
Sources
[1] Lessons From Everywhere, The fragile male, Sebastian Kraemer, BMJ
2000;
321: 1609-1612,
http://www.bmj.com/cgi/eletters/321/7276/1609
[2] BMJ Letter, 20 Feb 2001, warning: masculinity is a danger to
health, Peter West
Competing interests: No competing interests
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 [www.prostatitis.com]
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: No competing interests
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).
References:
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: No competing interests
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: No competing interests
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. www.menshealthforum.org.uk)
Competing interests: No competing interests
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: No competing interests
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: No competing interests
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 References
- Kraemer S. The fragile male. BMJ 2000;321:1609-1612.
- Jacobson B, Eklund G, Hamberger L, et al. Perinatal origin of adult self-destructive behavior. Acta Psychiatr Scand 1987;76(4):364-71.
- Jacobson B, Bygdeman M. Obstetric care and proneness of offspring to suicide as adults: case-control study. BMJ 1998;317:1346-1349.
- Richards MPM, Bernal JF, Brackbill Y. Early behavioral differences: gender or circumcision?Dev. Psychobiol 1976;9: 89-95.
- Taddio A, Katz J, Ilersich AL, et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. The Lancet 1997;349:599-603.
- Rhinehart J. Neonatal circumcision reconsidered. Transactional Analysis J 1999; 29(3):215-221.
- Laumann, EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997;277(13):1052-1057.
- Anand KJ, Scalzo FM. Can adverse neonatal experiences alter brain development and subsequent behavior?Biol Neonate 2000;77(2):69-82.
- American Academy of Pediatrics. Committee on Fetus and Newborn, Committee on Drugs, Section on Anesthesiology, Section on Surgery. Prevention and Management of Pain and Stress in the Neonate. Pediatrics 2000;105(2):454-461.
Competing interests: No competing interests
Yorkshire men straight to the point, or not? Validation of the John Thomas Sign
Sir,
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.
Results
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).
Comment
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.
REFERENCES
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?’
http://www.cyclingforums.com/t29056.html
Competing interests:
None declared
Competing interests: No competing interests