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Widespread sex selective abortion, neglect of young girls leading to premature mortality, and gendered migration have contributed to these persistent and increasing distortions. Abnormally high adult sex ratios in communities may drive sexually transmitted disease STD spread where women are missing and men cannot find stable partners.

We systematically reviewed evidence on the association between high community sex ratios and individual sexual behaviors. All six studies showed an association between high community sex ratios and individual sexual risk behaviors. In high sex ratio communities, women were more likely to have multiple sex partners and men were more likely to delay first sexual intercourse and purchase sex.

Only two studies included STD outcomes. High community sex ratios were associated with increased individual sexual risk behavior among both men and women. However, none of the studies examined unprotected sex or appropriately adjusted for gendered migration.

Further studies are needed to understand the effect of community sex ratios on sexual health and to inform comprehensive STD control interventions. This is an open-access article distributed under the terms of the Creative Commons Attributionwhich permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

The funders had no role in study de, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have adlut sex that no competing interests exist.

Although normal population sex ratios tend to fall between 94 to men per women [2]China and India have abnormally high sex ratios [3]. Abnormally high adult sex ratios result from sex selective abortions, neglect of young girls leading to premature mortality, and gendered migration.

Sex selective abortions have become so widespread that the global sex ratio at birth has increased from to [6] — [8].

Excess mortality of girls due to infanticide and neglect remains a persistent problem in many regions [5][7][9]. Distorted local sex ratios are further skewed because of male predominant migration to urban areas in search of brides and jobs [10] — [12]. High sex ratios establish communities where surplus men cannot form stable partnerships with women, potentially driving risky sexual behaviors that accelerate transmission of sexually transmitted diseases STDs. Increased STD burden in high sex ratio communities may be due to increased adlut sex commercial sex [10][13][14]forced sex [15]increased homosexual sex [16][17]and wife trafficking [18] — [20].

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High adult sex ratios are also associated with premature male mortality [21]and increased depression and suicidality [22][23]. However, it has also been speculated that high sex ratios decrease male sexual risk behavior, because men have fewer potential female sexual partners [24][25]. High adult sex ratios may put women at increased STD risk, because women may have more sexual partners due to greater partner availability. The potential for high adult sex adlut sex to drive STD transmission has been ly hypothesized [19][26] — [29]but there is a lack of empirical data on the effect of high sex ratios on sexual risk behavior and STD transmission.

Given the increasing of surplus men worldwide entering marriage markets, sex ratios are a crucial variable to consider in explaining sexual risk behavior. The purpose of this study is to systematically review the association of high adult sex ratios on individual sexual risk behaviors and STD biomarkers.

We conducted a literature search through 30 August of articles that addressed the association between adult community sex ratios and individual sexual risk behaviors and STD biomarkers.

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Our PubMed search terms are available in Text S1. Abstracts were checked for potential relevance, and had to meet the following criteria: only quantitative, English-language population-based research studies; sex ratios measured across multiple partner markets a community unit adlut sex by each study ; and reported individual sexual risk outcomes behaviors or biomarkers. In order to conduct a comprehensive global systematic review, no limits were placed on study date, location, race or ethnicity of study participants, or the definition of sex ratio.

Partner markets were defined as discrete geographic units in which individuals were more likely to find a stable partner.

Behavioral outcomes included in the study were multiple sex partners, sex with commercial sex workers, forced sex, premarital sex, recent sex, and self-reported sexually transmitted disease. Biomarker outcomes included a positive test for any sexually transmitted disease. We excluded studies conducted in settings with primarily low sex ratios e.

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Outcomes related to health seeking behaviors, mental health, or unrelated to sexual behavior were excluded. Case studies, qualitative studies, and ecological studies were excluded. Two independent reviewers CB and JT analyzed full-text articles for inclusion in the review. The reference sections of the remaining articles were then searched to identify other studies that met our inclusion criteria. Source data were reviewed by JT and CY and data were abstracted into tables. We contacted study authors to retrieve missing study data.

Effect size was measured according to parent data, as either the coefficient or odds ratio. In some cases, statistical ificance was converted to a p-value. We used adjusted odds ratios in studies with both crude and adjusted data. We did not conduct a meta-analysis due to adlut sex of standardized reporting of sex ratio measures and sexual risk outcomes.

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Our search yielded a total of studies Figure 1. Most initial citations were excluded because they did not measure adult community sex ratios or examined sexual risk outcomes.

Six studies were included in this review describing 57, individuals. Three studies were conducted in high-income countries [31] — [33] and three studies in middle-income countries [15][24][25] Table 1. All six studies used data from national, population-representative, behavioral surveys of adults or adolescents. Study sample size ranged from to 33, individuals.

None of the studies distinguished between protected and unprotected sex. Two studies included STD biomarker data, which in both cases examined gonorrhea, chlamydia, and trichomonas [15][24]. Five of the six studies had sex-specific data with two studies reporting male data [24][25] and three studies reporting female data [15][31][32]. Five studies used multi-level analysis methods to assess community and individual level data [15][24][25][31][32]and one study did not adjust for individual level observations [33].

Five studies adjusted for age [15][24][25][31][32] and three studies adjusted for education. Adjustment for other individual adlut sex factors such as race, income, and marital status varied between studies. Definitions of adult sex ratios, migration, and partner markets substantially differed between studies.

Although the adult sex ratio is typically reported as the of men per women of a certain age, two studies reported the of women per men. Adlut sex measures were not converted into standard measures of sex ratios in order to preserve apparent effect sizes from the studies.

None of the studies included individual-level data for migration, although two of the studies included migrants in community-level census data but excluded migrants in the study sample [15][24]. Partner markets were generally defined at the census tract or county level, but in one study the community size was not specified [25].

All six studies found an association between high sex ratios and increased sexual risk outcomes Table 2. Three studies had individual female data [15][31][32]. Two studies found a concurrent decrease in some sexual risk outcomes and increase in other sexual risk outcomes [24][33]. This study did not differentiate between male and female sexual behaviors.

Few of these studies examined mechanisms linking the connection between high community sex ratio and individual behavior. Two studies examined purchasing of sex among men [24][25]and one study examined forced sex among women [15]. None of the studies examined increased partner concurrency, unprotected sex, intimate partner violence, or wife trafficking. High adult sex ratios are increasingly common in many parts of the world, but the impact of these global demographic changes on individual sexual behaviors is poorly understood.

The proportion of men older than 25 years old who fail to marry in China will nearly triple in the next twenty years, even if sex ratio trends reverse now [14]. This emerging cohort is increasingly sexually active Figure 2. Adlut sex studies investigating the association of high community sex ratios on individual risk behavior are limited to small community samples [34] — [38]or do not include both individual- and community-level data [16][39][40].

We found evidence from two population-based studies that high sex ratios were associated with increased sexual risk behaviors among women. Our data suggest that women in high sex ratio communities were more likely to have ever had sex, have more frequent sex, and have an STD. The relationship between high sex ratios and male sexual behaviors is less clear. Although men may have fewer sexual partners in high sex ratio communities, more men may purchase sex when faced with a relative dearth of women. Few studies examined mechanisms linking community sex ratios and individual sexual behaviors.

Sex ratio is defined as the of men per women in populations less than 16 years old.

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Our review found limited evidence that high sex ratios were associated with increased sexual risk behavior among women. One study in China [15] and one in the United States [31] found that women in high sex ratio communities were more likely to have had recent sex.

One study found women in high sex ratio communities were more likely to have an STD and were more likely to have had forced sex [15]. These data are inconsistent with hypotheses that female adlut sex would increase and gender-based violence would decrease in communities with fewer men [41][42].

Although greater s of male partners may lead to better marriage prospects for women, women in high sex ratio communities also face greater structural violence and gender inequities that may increase sexual risk behaviors [18]. One study conducted in a single city of the United States did not find a ificant association between high community sex ratios and of sexual partners among women, even though men reported greater of sexual partners [32].

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One possible explanation for this finding is that sexual networks may extend beyond the scope of the single-city survey, or that highly sexually active women were not captured by the study sampling methods. Our review suggests increased sexual risk behaviors among men in high sex ratio communities as well. Two studies found that men in high sex ratio communities delay adlut sex sexual intercourse, but have an increased risk of purchasing sex, compared to men in normal sex ratio communities [24][25].

These findings support the hypothesis that as men in high sex ratio communities have fewer opportunities to find stable female sex partners, they increasingly turn to less stable commercial sex partners. Another study also found that adults in high sex ratio communities were more likely to be sexually active but had fewer partners. Understanding the mechanisms that link community sex ratios and individual risk can guide risk-reduction strategies, from community-level to individual-level interventions.

However, we found little evidence that linked the impact of community sex ratios and individual sexual risk behaviors Figure 3.