Gender-Based Differences in Autism Spectrum Disorder: Evidence From an Indian Clinical Cohort.

PURPOSE: Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by impairments in social communication and repetitive, restricted behaviors or interests. The global male-to-female ratio ranges between 3:1 and 4:1, attributed to factors such as the female protective effect, extreme male brain theory, female autism phenotype, and camouflaging. Understanding gender-based differences is essential to reveal the true burden of ASD within the Indian context. METHODS: A cross-sectional retrospective study was conducted on 515 children diagnosed with ASD at a tertiary care center in Bengaluru, India. Participants aged 12 months to 21 years were assessed using standardized measures: WISC-IV, WPPSI-IV, VABS-II (cognitive functioning); ISAA, SRS (ASD severity and comorbidities); and COM DEALL, BSID-III (development). Sociodemographic and clinical variables were analyzed for gender differences after age adjustment. RESULTS: The male-to-female ratio was 4:1. Median annual family income was higher among females (₹14,00,000) than males (₹9,50,000). Girls exhibited greater ASD severity on the SRS-II, showing severe difficulties in social communication, autistic mannerisms, and social awareness. A positive family history of developmental disorders was more prevalent in females (11.8%) than males (4.9%; OR 2.57). Asthma was also more common in girls (5.8% vs. 1.8%; OR 3.35). CONCLUSION: Although the observed 4:1 ratio aligns with global trends, our findings suggest under-identification of females. Greater symptom severity, higher familial risk, and socioeconomic disparities support the female protective effect and camouflaging hypotheses. Gender-sensitive diagnostic tools are needed to improve detection and understanding of ASD in females.