Imposex, i.e., the imposition of male sexual characteristics on female neograstropods, has been used worldwide as a bioindicator of pollution by the antifouling agent TBT as well as to assess the related ecological impact. The recent total ban on the use of TBT in the maritime industry has been partly based on the use of such a biomarker. This is mainly based on the assumption that no other pollutant, or environmental stress, is able to induce such a biological response. Nonetheless, several authors had challenged this idea. The present paper will present further field observations on imposex in Hexaplex trunculus from Malta (Central Mediterranean) which may help clarify this issue. Furthermore, the incidence of imposex in this species will be related to body burdens and to the environmental levels of organotins as measured analytically. First histological observations will also be presented which may help clarify the ecological significance of this response in this species. Finally a number of alternative scenarios regarding the relationship between imposex and TBT will be discussed.