Sex differentiation of brain structures in autism: Findings from a gray matter asymmetry study.

Autism spectrum disorder (ASD) is diagnosed much more often in males than females. This male predominance has prompted a number of studies to examine how sex differences are related to the neural expression of ASD. Different theories, such as the "extreme male brain" theory, the "female protective effect" (FPE) theory, and the gender incoherence (GI) theory, provide different explanations for the mixed findings of sex-related neural expression of ASD. This study sought to clarify whether either theory applies to the brain structure in individuals with ASD by analyzing a selective high-quality data subset from an open data resource (Autism Brain Imaging Data Exchange I and II) including 35 males/35 females with ASD and 86 male/86 female typical-controls (TCs). We examined the sex-related changes in ASD in gray matter asymmetry measures (i.e., asymmetry index, AI) derived from voxel-based morphometry using a 2 (diagnosis: ASD vs. TC) ×  2 (sex: female vs. male) factorial design. A diagnosis-by-sex interaction effect was identified in the planum temporale/Heschl's gyrus: (i) compared to females, males exhibited decreased AI (indicating more leftward brain asymmetry) in the TC group, whereas AI was greater (indicating less leftward brain asymmetry) for males than for females in the ASD group; and (ii) females with ASD showed reduced AI (indicating more leftward brain asymmetry) compared to female TCs, whereas there were no differences between ASDs and TCs in the male group. This interaction pattern supports the FPE theory in showing greater brain structure changes (masculinization) in females with ASD. LAY SUMMARY: To understand the neural mechanisms underlying male predominance in autism spectrum disorder (ASD), we investigated the sex differences in ASD-related alterations in brain asymmetry. We found greater changes in females with ASD compared with males with ASD, revealing a female protective effect. These findings provide novel insights into the neurobiology of sex differences in ASD.