Considering biological sex is essential for assessing perioperative risk and tailoring anesthetic care, yet this issue remains under-addressed. Preoperative risk scores rarely incorporate sex, despite growing evidence of sex-based differences across the perioperative continuum. Sex influences both anesthetic pharmacokinetics and pharmacodynamics. Women exhibit reduced sensitivity to propofol, experience more rapid emergence from general anesthesia, but demonstrate increased sensitivity to opioids and neuromuscular blockers like rocuronium. Postoperatively, women experience more severe and chronic pain, yet exhibit lower mortality rates. Complication profiles also vary by sex and type of surgery. This narrative review aims to summarize current evidence on sex-related differences in anesthesia and highlights key gaps in the literature according to recent considerations. While emerging data suggest meaningful sex-based variations, further research is needed to elucidate underlying mechanisms and promote a more personalized approach to perioperative management.