Context: Sexual and ancestral differences in driver gene prevalence have been described in many cancers but have not yet been investigated in pheochromocytoma and paraganglioma (PPGL). Objective: This study aims to assess whether sex and ancestry influence prevalence of PPGL driver genes and clinical presentation. Methods: We conducted a retrospective analysis of patients with PPGL considering studies from 2010 onwards that included minimal data of type of disease, sex, mutated gene, and country of origin. Additional features were recorded when available (age, tumor location, bilateral or multifocal, somatic or germline, and metastatic disease). Results: We included 2162 patients: 877 in Europe and 757 in Asia. Males presented more often with germline pathogenic variants (PVs) in genes activating hypoxia pathways (P =. 0006) and had more often sympathetic paragangliomas (P =. 0005) and metastasis (P =. 0039). On the other hand, females with PPGLs due to MAX PVs were diagnosed later than males (P =. 0378) and more often developed metastasis (P =. 0497). European but not Asian females presented more often with PPGLs due to PVs in genes related to kinase signaling (P =. 0052), particularly RET and TMEM127. Contrary to experiences from Europe, Asian patients with PPGL due to PVs in kinase signaling genes NF1, HRAS, and FGFR1 showed a high proportion of sympathetic tumors, while European patients almost exclusively had adrenal tumors (P <. 005). Conclusion: Personalized management of patients with PPGL might benefit from considering sexual and ancestral differences. Further studies with better clinically aligned cohorts from various origins are required to better dissect ancestral influences on PPGL development.