Introduction The fraction of female mesothelioma cases attributable to asbestos exposure is generally much lower than in men and significantly varying among published studies. The aim of this study is to analyse gender ratio for mesothelioma by mortality data and to test the relationship with the occurrence of the disease for country and income level.

Methods The numbers of mesothelioma deaths have been extracted from WHO mortality database (C45 or any subcategory of ICD 10 classification system). National population data have been obtained from the WHO health statistics and standardised mortality rates estimated using world reference population. Gender ratio has been estimated for each selected country and regression models with mortality rates have been tested.

Results Only country with more than 20 mesothelioma deaths in 2011 have been selected (N = 34), accounting for 14,483 deaths (3,074 and 11,409 in women and men respectively). Gender ratio (females cases/males) is 0.27 with a significant inverse trend with mortality rates. A linear decrease in gender ratio for increasing mortality can be observed (b = −0.22; R2 = 0.35; p < 0.001). Income level is strongly related with number of mesothelioma females cases with a gender ratio equal to 0.53 in upper medium income level countries (N = 9) and 0.25 in high income level countries (N = 25). Italy presents a specific pattern with a high standardised mortality rates (1.1 *100,000) and a number of women involved (gender ratio = 0.41) significantly higher than expected according to the linear model.

Conclusions The historical pattern of industrial activities involved in asbestos exposure includes in Italy textile sector (with direct use of raw asbestos) with a relevant number of female workers. Furthermore non occupational exposures (environmental and familial) play a relevant role. Analyses of mesothelioma in women can support the efficiency of welfare system and the prevention of asbestos exposure.