Background <p>Axial spondyloarthritis (axSpA) exhibits notable sex-related differences, particularly in Asian populations, influenced by genetic, cultural, and healthcare factors. This systematic review and meta-analysis assess sex-specific disparities in axSpA among Asian patients.</p> Methods <p>A systematic search in PubMed, Embase, and Google Scholar (up to January 30, 2025) included studies reporting sex-specific differences in clinical presentation, diagnostic delay, treatment response, and quality of life. The study included 31,523 males and 10,815 females. Risk of bias was assessed using the ROBINS-I tool. Meta-analysis was performed using R and Jamovi, with heterogeneity assessed via I² statistics.</p> Results <p>Thirty studies comprising 31,523 male and 10,815 female axSpA patients were included. Males had an younger age of onset and diagnosis (MD: −3.48 years; 95% CI: −4.78 to −2.17; −3.57 years; 95% CI: −5.25 to −1.89). No significant differences in diagnostic delay were observed. (MD: −0.62 years; 95% CI: −1.55 to 0.32; <i>p</i> = 0.0551). Females exhibited higher disease activity scores (BASDAI MD: −0.57; 95% CI: −0.86 to −0.27; <i>p</i> = 0.00211) and inflammatory markers (ESR MD: −3.99 mm/h; <i>p</i> = 0.0476), whereas males showed greater radiographic progression (BASRI MD: 2.60; 95% CI: 1.86–3.34; <i>p</i> &lt; 0.001). HLA-B27 positivity was higher in males (79.5% vs. 69.2%). Treatment adherence was lower in females.</p> Discussion <p>This study highlights critical sex-based disparities in axSpA among Asian populations, particularly regarding disease onset, progression, and treatment response. The findings emphasize the need for sex-specific diagnostic and therapeutic strategies to improve patient outcomes.</p> Registration <p>The review protocol was registered on PROSPERO (CRD42025637163). </p>