Sex-Based Differences in Core Symptoms of Autism Spectrum Disorder: A Systematic Review and Meta-analysis of Female Presentation
5 affiliations
- 1Andrés Bello University
- 2Pontifical Catholic University of Chile
- 3University of Valparaíso
- 4University of the Americas
- 5University of Chile
Abstract
Introduction. Autism spectrum disorder (ASD) is more frequently diagnosed in males; however, evidence suggests that this disparity may partly reflect sex-related biases in diagnostic criteria and assessment tools.
Aim. To characterize core ASD symptoms in females across the two DSM-5 diagnostic domains (Social Communication and Interaction, and Restricted and Repetitive Behaviors) and to quantify sex-based differences in symptom severity using standardized diagnostic instruments.
Methodology. This systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. We included studies published between January 2013 and September 2025 that reported on diagnostic processes or symptom presentation and were identified through searches of PubMed/MEDLINE, Scopus, and Web of Science.
Results. Forty-eight studies were included in the qualitative narrative synthesis and seven in the meta-analyses, covering a total of 54,060 participants. Qualitative findings suggested inconsistent sex differences in social communication (DSM-5 Criterion A), whereas more domain-specific patterns emerged for restricted and repetitive behaviors (DSM-5 Criterion B), especially in sensory reactivity and restricted interests. Meta-analyses showed small but significant differences in overall ADOS-2 scores (d = −0.18; 95% CI [−0.35, −0.01]; p = 0.043) and the Social Affect domain (d = −0.23; 95% CI [−0.45, −0.02]; p = 0.033), with lower severity in females. No significant differences (d = −0.12; 95% CI [−0.39, 0.15]; p = 0.393) were found in the Restricted and Repetitive Behavior domain, but we observed high heterogeneity (I2 = 64.7%). Publication bias analyses suggested some funnel-plot asymmetry, although the overall interpretation of the findings remained unchanged.
Conclusion. These results highlight the need for sex-informed diagnostic approaches that incorporate comprehensive clinical assessments to enhance early detection and reduce diagnostic delays in females with ASD.
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BibTeX
@article{damianiarias2026sexbased,
title = {{Sex-Based Differences in Core Symptoms of Autism Spectrum Disorder: A Systematic Review and Meta-analysis of Female Presentation}},
author = {Dayna Damiani–Arias and Ignacio Wettling–Carpio and Teresa Julio–Ramos and Daniel Solomons and Macarena Torres–Cea and David Toloza–Ramirez},
journal = {Revista de Investigación e Innovación en Ciencias de la Salud},
year = {2026},
month = oct,
doi = {10.46634/riics.609},
url = {https://doi.org/10.46634/riics.609},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - Sex-Based Differences in Core Symptoms of Autism Spectrum Disorder: A Systematic Review and Meta-analysis of Female Presentation
AU - Dayna Damiani–Arias
AU - Ignacio Wettling–Carpio
AU - Teresa Julio–Ramos
AU - Daniel Solomons
AU - Macarena Torres–Cea
AU - David Toloza–Ramirez
PY - 2026
DA - 2026/10/01
JO - Revista de Investigación e Innovación en Ciencias de la Salud
DO - 10.46634/riics.609
UR - https://doi.org/10.46634/riics.609
AB - Introduction. Autism spectrum disorder (ASD) is more frequently diagnosed in males; however, evidence suggests that this disparity may partly reflect sex-related biases in diagnostic criteria and assessment tools. Aim. To characterize core ASD symptoms in females across the two DSM-5 diagnostic domains (Social Communication and Interaction, and Restricted and Repetitive Behaviors) and to quantify sex-based differences in symptom severity using standardized diagnostic instruments. Methodology. This systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. We included studies published between January 2013 and September 2025 that reported on diagnostic processes or symptom presentation and were identified through searches of PubMed/MEDLINE, Scopus, and Web of Science. Results. Forty-eight studies were included in the qualitative narrative synthesis and seven in the meta-analyses, covering a total of 54,060 participants. Qualitative findings suggested inconsistent sex differences in social communication (DSM-5 Criterion A), whereas more domain-specific patterns emerged for restricted and repetitive behaviors (DSM-5 Criterion B), especially in sensory reactivity and restricted interests. Meta-analyses showed small but significant differences in overall ADOS-2 scores (d = −0.18; 95% CI [−0.35, −0.01]; p = 0.043) and the Social Affect domain (d = −0.23; 95% CI [−0.45, −0.02]; p = 0.033), with lower severity in females. No significant differences (d = −0.12; 95% CI [−0.39, 0.15]; p = 0.393) were found in the Restricted and Repetitive Behavior domain, but we observed high heterogeneity (I2 = 64.7%). Publication bias analyses suggested some funnel-plot asymmetry, although the overall interpretation of the findings remained unchanged. Conclusion. These results highlight the need for sex-informed diagnostic approaches that incorporate comprehensive clinical assessments to enhance early detection and reduce diagnostic delays in females with ASD.
SN - 2665-2056
ER -