Objectives: To elucidate current trends and geographical patterns in the sex ratio at birth and in the population aged under 20 in China and to determine the roles played by sex selective abortion and the one child policy.

Design: Analysis of household based cross sectional population survey done in November 2005.

Setting: All of China's 2861 counties. Population 1% of the total population, selected to be broadly representative of the total.

Main outcome measure: Sex ratio defined as males per 100 females.

Results: 4 764 512 people under the age of 20 were included. Overall sex ratios were high across all age groups and residency types, but they were highest in the 1-4 years age group, peaking at 126 (95% confidence interval 125 to 126) in rural areas. Six provinces had sex ratios of over 130 in the 1-4 age group. The sex ratio at birth was close to normal for first order births but rose steeply for second order births, especially in rural areas, where it reached 146 (143 to 149). Nine provinces had ratios of over 160 for second order births. The highest sex ratios were seen in provinces that allow rural inhabitants a second child if the first is a girl. Sex selective abortion accounts for almost all the excess males. One particular variant of the one child policy, which allows a second child if the first is a girl, leads to the highest sex ratios.

Conclusions: In 2005 males under the age of 20 exceeded females by more than 32 million in China, and more than 1.1 million excess births of boys occurred. China will see very high and steadily worsening sex ratios in the reproductive age group over the next two decades. Enforcing the existing ban on sex selective abortion could lead to normalisation of the ratios.