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Women and Girls With Autism: How Autistic Traits May Differ
- Common Signs
- Autism in Women
Support and Treatment
Frequently asked questions.
Autism spectrum disorder (ASD) is a developmental disability that is usually diagnosed at or before the age of 3. While people of any sex and gender can be autistic, it is common for people assigned female at birth to be diagnosed with ASD later in life. Many autistic women and nonbinary people are not diagnosed until they reach adulthood.
According to the Centers for Disease Control and Prevention (CDC), the prevalence of ASD in the United States in 2020 was 3.8 higher for boys than girls—or about 4% of boys and 1% of girls aged 8 years old.
Autistic women might be diagnosed later in life for a few reasons, including because the set of autistic traits listed by the American Psychiatric Association most accurately reflect the realities of autistic boys and men. Girls and women with ASD are also socialized to be better at masking, or hiding their autistic traits.
Sex and Gender
People assigned female at birth are not all girls/women. Women, nonbinary people, and trans men all face certain challenges in getting an autism diagnosis compared to cisgender men.
While this article is focused on the challenges faced by women and girls, it should be noted that people who are nonbinary or gender non-conforming face similar challenges with autism diagnosis.
This article will go over how autism might be different along gender lines, and what some of the challenges are in diagnosing autism in girls and women.
Verywell / Nez Riaz
Common Traits of Autism
People of all sexes, genders , races, ethnicities, and backgrounds can be autistic. Just like autism is a spectrum, autistic people are a varied group. The mix of traits that each autistic person displays, how they experience and interact with the world, as well as how much support they need, will vary.
There is also evidence that the traits of autism can look different in women than it does in men, which may partly explain why there is a gap in early diagnosis for autistic girls.
The most common signs of autism include:
- Social and communication differences
- Repetitive behaviors
- Highly specific interests
- Sensory sensitivity to light, sound, or touch
The criteria for diagnosing autism have changed over time. In 2013, several categories of autism—including Asperger syndrome and pervasive developmental disorder not otherwise specified—were removed from the "Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition" (DSM-5).
To make a formal diagnosis of autism according to the DSM-5, the traits must have been present before the age of 3—even if the diagnosis is not made until much later in a person's life.
First-Person Language
Many people diagnosed with autism spectrum disorder prefer using identity-first language rather than person-first language. For example, they may prefer saying “an autistic person" rather than “a person who has autism.”
Communication Differences
To be diagnosed with autism, a person will have differences concerning communication. There is some evidence that autistic girls and women might be better at "studying" their peers to learn about neurotypical socializing and can imitate these behaviors, or mask, to try to fit in.
Some of the most common speech-related differences autistic people have include:
- Repetitive use of language (e.g., repeating phrases from TV or the internet, using the same words in the same way over and over again, etc.)
- Flat prosody (e.g., vocalization without tone changes)
- Difficulty with picking up speech patterns and body language signifying humor, sarcasm, etc
- Being non-verbal some or all of the time (e.g., communicating primarily with sign language or an augmentative and alternative communication (AAC) device)
In addition to differences with speech and body language, autistic people have challenges with social communication:
- Inability to distinguish between platonic and romantic conversation
- Difficulty discussing anything except a favored topic (e.g., will only talk about a favorite TV show)
- Difficulty determining when it is or is not appropriate to speak, ask questions, or participate in a social group
- Speaking quickly, loudly, and frequently in partnered or group settings
Behavioral Differences
Autistic behaviors are not always easy to spot, depending on their frequency and intensity. There is also evidence that autistic girls may have more socially acceptable behaviors or are better at hiding these behaviors than boys, which makes diagnosis harder.
Common autistic behaviors can include:
- Stimming . Movements and sounds autistic people make to self-calm (e.g., rocking, humming, pacing, or repeating phrases). Some autistic people stim by touching certain textures or listening to certain sounds.
- Meltdowns . These intense emotional and physical reactions generally occur when an autistic person gets overwhelmed and is feeling panicky or stressed.
- Aggressive or self-harming behavior. Some, but not all, autistic people can display self-injuring behaviors, particularly during meltdowns. They may also do aggressive behaviors like hitting or throwing objects when they are overloaded.
- Preference for solitude or lack of interest in others' social overtures. Many autistic people are quite happy on their own and often need solitary time to recharge. Many autistic people who are interested in socializing still find it difficult to form and/or maintain social relationships with neurotypical people.
Sensory Differences
When the criteria for autism changed in 2013, the DSM-5 added a new set of traits to the list that considered sensory differences. The update included an autistic person's increased sensitivity to or interest in sensory factors in their environment like pain, temperature, sounds, textures, light, and movement.
Most autistic people have sensory sensitivities—though what they are and how severe they are will vary. Autistic people may find some sounds incredibly overstimulating—even painful. Other people seek out certain textures that they find soothing and enjoyable.
For example, an autistic person might:
- Not be able to tolerate the feeling of their hair on their neck because it's overstimulating or find repeatedly playing with their hair to be soothing
- Be overloaded by the sound of a hair dryer or be calmed by the "white noise" it generates
Some autistic people also experience understimulation, a feeling of boredom, discomfort, and stagnancy that can grow until it becomes painful. Dancing, listening to loud music, watching an interesting video, or playing a game can all help with understimulation.
Autistic people may seek out sensory stimulation and comfort through food or drink. Some autistic people have a specific (and often short) list of foods that they are always comfortable eating. These foods are referred to as "safe foods." Depending on how restrictive their eating requirements are, it can be difficult for autistic people to get all their necessary nutrients and calories.
Eating disorders such as avoidant-restrictive food intake disorder (ARFID) are conditions that often co-occur with being autistic. While ARFID is not about weight and body image, it can lead to weight loss. On the surface, it can easily look like more well-known eating disorders like anorexia or bulimia nervosa.
Sometimes, autistic girls and women are mistakenly diagnosed with anorexia nervosa (AN) because of their restrictive eating patterns. However, it's also possible for autistic people to have eating disorders other than ARFID, including AN.
Autism and Self-Care
Autistic people often have difficulty with motor skills and planning actions ( executive function ), which can make self-care tasks challenging.
While it's true that some autistic girls and women are not interested in nor understand the gendered social expectations attached to activities like putting on makeup and shaving body hair, other autistic people may want to partake but struggle because of the complex planning and motor skills needed to do them. Autistic people of all genders may also find it difficult to brush and shower daily. When you add sensory sensitivities to the mix, an autistic person may have a very hard time doing something as "simple" as washing their hair in the shower.
Autistic people who menstruate may also find managing their periods extremely difficult, since there are many changes involved that can be overstimulating (e.g., painful cramps, new smells, the sight of blood, the discomfort of wearing a pad, tampon, or cup), including having to change their routines (e.g., needing to change pads/tampons, having to avoid certain activities or certain safe foods).
Understanding Autism in Women
Some researchers have asserted that autism is a manifestation of the "extreme male brain (EMB)." The foundation of the EMB autism theory is that lack of empathy is essential to being autistic and that testosterone impairs cognitive empathy, but both theories have been proven false. While there does seem to be a difference in the number of women and girls diagnosed as autistic compared to the number of males, the so-called "female protective effect" is still being explored by researchers.
Many autistic people are over-empathetic to people, animals, and non-living objects, especially autistic women and nonbinary people who are socialized as such. Autistic people often just do not express, feel, or display empathy in ways that allistic (non-autistic) people are used to recognizing.
In recent years, it has become clear that autism is underdiagnosed in people who aren't cisgender men. The possible reasons for the disparity include:
- Children who identify as girls are more likely to internalize anxiety related to autism than children who identify as boys. Instead of behaving aggressively, they are more likely to become depressed or anti-social.
- Many cultures make it acceptable for girls to be "shy" whereas shyness is less acceptable in boys.
- When autistic girls focus exclusively on a particular interest, they are more likely than boys to choose a “socially acceptable” fascination such as unicorns or dolls.
Researchers are still trying to understand how autism is different for girls and women. However, the lack of gender diversity in diagnosed autistic people is a hindrance for scientists, as is the widespread delegitimization of thoughtful self-diagnosis.
Autistic women, nonbinary people, and all people of color are less likely to have professional diagnoses due to discrimination, being underinsured, or not possessing the hundreds to thousands of dollars a professional diagnosis costs. Until things change, there will continue to be a lack of gender diversity in studies on, and knowledge about, autistic people.
Masking/Camouflaging
Some research has suggested that autistic girls might be more likely than boys to intentionally or unintentionally hide or cover up their traits. This is called camouflaging or, more commonly, masking.
For example, autistic girls might be better at:
- Mimicking their peers' facial expressions, vocal tones, and other behaviors, which can make it harder for providers and caregivers to spot the signs of autism
- Using resources like TV, social media, and their observations of others to learn about social rules and practice them
- Forcing themselves to make eye contact and suppress autistic behaviors such as hand-flapping
While girls on the spectrum might be better than boys at masking, doing so takes considerable effort to maintain, and autistic girls often have trouble forming and maintaining peer relationships with allistic (non-autistic) people. Finding community with other autistic and neurodivergent people can be a homecoming experience for many people.
It is very important that everyone, especially marginalized people, have people around them who they can relate with and who understand them. Many adults coming into their autistic identity are discovering such community online and in person.
Long term masking is dangerous as it will always lead to autistic burnout. Autistic burnout is an intense, chronic experience of physical, mental, and emotional exhaustion that is often accompanied by a loss of skills and a lower tolerance to sensory stimuli. Autistic women and nonbinary people are most at risk for burnout as well as the co-occurring depression, anxiety, and suicidal ideation.
Suicide Prevention Hotline
If you or someone you know are having suicidal thoughts, dial 988 to contact the 988 Suicide & Crisis Lifeline and connect with a trained counselor. For more mental health resources, see our National Helpline Database.
Co-occuring Conditions
Co-occuring conditions are diagnoses that are commonly given in addition to a main diagnosis. Research suggests that co-occurring conditions are more common with autistic girls than boys. Co-occurring conditions are also more likely when a person is diagnosed with autism at a later age, as they most likely have not received the care, understanding, and support they've needed their whole lives.
Some common co-occurring conditions in autistic girls and women include:
- Attention deficit hyperactivity disorder (ADHD)
- Anorexia nervosa, ARFID and other eating disorders
- Obsessive-compulsive disorder (OCD)
- Tic disorders
- Sleep disorders
There is no proven cause of autism , though being autistic tends to run in families. Thankfully, it is not necessary to discover why people are autistic. As autistic self-advocacy has become more prominent, autistic advocates have begun pushing back against the idea that autism is a disease or syndrome that needs a cure or research done concerning its origin.
Autistic advocates point to the ongoing field of eugenics that shows that when marginalized traits have their causes known, they are systematically eradicated via infanticide or genetic selection. We see this phenomenon happening today with the population of people with Down Syndrome being nearly zero due to medical intervention in multiple European countries.
Finding the origin of autism will not better the lives of autistic people and actually endangers them. The search for the "cause" of autism is inextricably linked to the search for a cure, and both manifest in deadly ways for autistic people, as seen with the many parents who have fed their autistic children bleach in order to cure them.
It is more important for loved ones of autistic people to seek to learn about autistic people and to learn from autistic adults, advocates, and communities about what is best for them.
For people wanting to support autistic populations at large, housing instability and homelessness, economic insecurity, and lack of access to medical, dental, and mental health care are some of the prevailing issues autistic people face that need more focus. Research and funding needs to be directed at these disparities as well as organizations and systems aiming to rectify them.
There is no single medical test for autism spectrum disorder. The diagnosis is based on observations and specific screening tools.
A child’s caregivers will usually fill out a variety of questionnaires about their child's infancy and toddlerhood and respond to questions about their child's development, behavior, and skills. Healthcare professionals may ask this of adults seeking diagnoses as well. Providers can also use hands-on and observational tools to see if a person meets the criteria for autism and whether they have any co-occurring conditions.
According to the Centers for Disease Control and Prevention (CDC), about 1 in 54 American children are autistic—and only about 1 in 4 autistic children are girls . While the 1-to-4 ratio is considered accurate, researchers have found that the ratio might actually be closer to 1-to-3.
The difference comes in part from the "gold standard" diagnostic tools that primarily reflect the autistic experiences of men and boys. Autistic adults are often diagnosed by psychologists and psychiatrists with strong expertise in autism.
Self-Diagnosis
Getting professionally diagnosed with autism as an adult can be a time-consuming and costly process. For marginalized communities, including women, self-diagnosis is the only option when placed against the cost of a professional diagnosis. Due to growing awareness of this disparity, self-diagnosis is becoming more accepted within the autistic community.
There is no cure for autism but there are therapies and resources available to help autistic people. While some them need to be prescribed by a provider, others are behavioral and/or developmental and can be provided by a therapist, caregiver, or even something an autistic person can undertake on their own.
There is no "best" treatment for autism. Some possible treatments for autism include:
- Speech therapy
- Play therapy
- Social skills therapy
- Occupational therapy
- Developmental therapies such as Floortime , SCERTS , and relationship development intervention (RDI)
- Medications such as Risperdal (risperidone) or selective serotonin receptor inhibitors (SSRIs) to help with specific symptoms
- Applied Behavioral Analysis
Applied Behavioral Analysis (ABA) is endorsed by scientific organizations as the premier therapy for autistic people, but autistic people and self-advocates say otherwise. Opposition to ABA is grounded in the fact that the therapy aims to make autistic people behave like allistic people, and in that autistic people who undergo ABA develop post-traumatic stress symptoms correlating with the treatment.
People who are diagnosed with autism as adults often have low support needs (what used to be called “high functioning”) but that does not mean they would not benefit from having support. These people are also likely to have been masking for years or decades and might need more support when they stop masking or reach burnout.
Autistic adults often seek support on their own, like talk therapy. Some people find social skills coaching, sensory integration therapy , and support groups with other autistic adults helpful.
Autism in women and girls is underdiagnosed and/or diagnosed at a later age. There are some possible reasons for the disparity.
The basis for diagnosing autism is often skewed toward behaviors that are more common in boys. Some evidence suggests that girls might be better at masking, hiding autistic behaviors, or are more likely to have “socially acceptable" special interests.
It’s not uncommon for women to only find out they are autistic as adults; however, the process of getting a formal diagnosis as an adult can be timely and costly. Autistic women are also more likely to have other mental health conditions including anxiety, an eating disorder, and obsessive-compulsive disorder.
Getting support can make a positive difference at any age for autistic people, though earlier intervention is ideal.
The primary traits of autism include difficulties with speech and social communication, sensory sensitivities, and repetitive behaviors. Autistic people may also have trouble expressing their ideas and emotions, and struggle with understanding others' points of view.
Because it is a spectrum disorder, autism can look different in every individual, and traits can range in presentation and intensity.
According to the official diagnostic criteria, signs of autism must appear before the age of 3. However, when someone is very good at masking or hiding their autistic traits, autism may not be diagnosed until later.
Autism is not a degenerative disease. In general, people with autism build skills as they get older. In some cases, however, co-occurring issues such as anxiety or autistic burnout can get in the way of progress and even cause skill regression. In addition, some issues such as social communication differences can become more of a problem as a child grows up.
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Milner V, McIntosh H, Colvert E, Happé F. A qualitative exploration of the female experience of autism spectrum disorder (ASD). Journal of autism and developmental disorders. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6546643/. Published June 2019. Accessed November 12, 2021.
Prevalence of autism spectrum disorder among children aged 8 years - autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2016. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/69/ss/ss6904a1.htm?s_cid=ss6904a1_w. Published March 26, 2020.
Rødgaard EM, Jensen K, Miskowiak KW, Mottron L. Autism comorbidities show elevated female-to-male odds ratios and are associated with the age of first autism diagnosis. Acta Psychiatr Scand. 2021 Nov;144(5):475-486. doi: 10.1111/acps.13345. Epub 2021 Jul 14. PMID: 34228813.
By Lisa Jo Rudy Lisa Jo Rudy, MDiv, is a writer, advocate, author, and consultant specializing in the field of autism.
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Presentation of Autism Spectrum Disorder in Females: Diagnostic Complexities and Implications for Clinicians
- By: Jessica Scher Lisa, PsyD Harry Voulgarakis, PhD, BCBA St. Joseph’s College
- April 1st, 2020
- assessment , behaviors , diagnosis , females , research , Spring 2020 Issue
- 9489 0
Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by pervasive deficits in social communication and patterns of restricted, repetitive, stereotyped behaviors and interests (American Psychiatric Association, 2013). Beyond the […]
Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by pervasive deficits in social communication and patterns of restricted, repetitive, stereotyped behaviors and interests (American Psychiatric Association, 2013). Beyond the main diagnostic criteria, however, there is considerable heterogeneity in the symptom presentations that is demonstrated by people with ASD, including severity, language, cognitive skills, and related deficits (Evans et al, 2018). Regarding sex differences, it has been well established that ASD is diagnosed more often in males than in females, with recent estimates suggesting a 3:3:1 ratio (Hull & Mandy, 2017). Despite the fact that this is well known, there is considerable uncertainty about the nature of this sex discrepancy and how it relates to the ASD diagnostic assessment practice (Evans et al, 2018). Additionally, it has been widely accepted that males and females with ASD present differently, which has implications for the sex discrepancy in diagnostic practices, thus females are generally under-identified (Evans et al, 2018).
The fact that females with ASD are under-identified and often overlooked can be due to a number of factors. First, they often don’t fit the “classic” presentation that is most often associated with the ASD diagnosis; specifically, there is a distinct ASD female phenotype that looks dissimilar to the typical ASD male presentation. Females with ASD tend to present with less restricted interests and repetitive behaviors (RRBs) (Supekar and Menon, 2015), thus standing out less both in society, as well as on screening and diagnostic measures. Fewer RRBs makes ASD appear in a different way, often more subtle, than what is considered to be the norm. It is also important to note that evidence suggests that even when females with ASD are identified, they receive their diagnosis (and related support) later than equivalent males with ASD (Giarelli et al, 2010). The implications for under- or late-identification are enormous and deserve empirical attention in an effort to improve diagnostic methods for ASD in females.
Harry Voulgarakis, PhD, BCBA
Jessica Scher Lisa, PsyD
While no consistent, reliable differences have been found between sex and core ASD symptoms (e.g. Bolte et al, 2011; Holzmann et al, 2007; Mandy et al, 2012), it has been well documented that compared to males, females with ASD that are undiagnosed or are diagnosed at a later age generally present with less severe ASD symptoms and more intact language and cognitive skills (Begeer et al, 2013; Giarelli et al, 2010; Rutherford et al, 2016). Research has also noted that females with ASD may be better able to compensate for symptoms despite having core deficits associated with ASD (Livingston & Happe, 2017; Hull et al, 2017). There has been some suggestion that females must exhibit more severe symptoms, impairment, or co-occurring problems in order to receive diagnoses of ASD (Evans et al, 2018). This finding is due to an analysis of previous research that demonstrates the following: females with ASD perform better on measures of nonverbal communication (which may mask other symptoms), females with ASD face more social, friendship, and language demands than males with ASD, and that females with ASD can exhibit patters of restricted interests and repetitive behaviors, as well as social and communicative problems that are deemed more socially acceptable as compared to the patterns seen in males with ASD (Lai et al, 2015; Rynkiewicz et al, 2016; Dean et al, 2014). This theory also accounts for the findings that females with ASD in general present with more severe behavioral, emotional, and cognitive problems compared to males (Frazier, et al, 2014; Holtmann et al, 2007; Horiuchi et al, 2014; Stacy et al, 2014). Further, Hiller and colleagues (2014) found that females were more likely to show an ability to integrate non-verbal and verbal behaviors, and initiate friendships, and exhibited less restricted interests. Teachers reported fewer concerns for females with ASD than for males, including concerns about behaviors and social skills. These data support the idea that that females with ASD may “look” different from the considerable “classic” presentation of ASD and may also present as less impaired in an academic setting.
The vast differences associated with gender presentation in ASD require that clinicians involved in diagnostic work become more cognizant of these broader phenotypes and adjust their assessment practices accordingly to better detect females presenting with atypical symptoms that still fall on the autism spectrum. Notably, many common diagnostic tools lack sensitivity to such a presentation. To that end, it is important to recognize that generally speaking, the evidence base, and hence the diagnostic criteria for ASD in itself comes from research among male-predominant samples (e.g. Edwards et al, 2012; Watkins et al, 2014). Therefore, while the efforts to study this area further are prominent, it is important to be mindful of the fact that existing assessment tools and diagnostic criteria likely contain sex/gender bias (Evans et al, 2018). Without addressing the neurological and diagnostic challenges pertaining to these sex/gender issues, any research in this area will be influenced by the underlying problem of not knowing how ASD should be defined and diagnosed in males as compared to females (Lai et al, 2015).
Currently, the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) is arguably the most commonly relied upon diagnostic instrument for ASD. The ADOS-2 is a semi-structured observational assessment designed to evaluate aspects of communication, social interaction, and stereotyped behaviors and restricted interests (Lord et al, 2000; 2012). In contrast to what has been documented with regard to the strong differences in the prevalence of ASD, differences between the sexes in the phenotypic presentation of ASD have been found to be much smaller in size, with inconsistencies in the findings with regard to severity level of the core symptoms, as well as age and general level of functioning. For example, some studies have found no significant differences between sexes with regard to the behavioral presentation of ASD on the ADOS (e.g. Lord et al., 2000; Lord et al., 2012, Ratto et al, 2017), while others have reported some differences (e.g. Lai et al., 2015).
In order to examine these inconclusive findings further, Tillman et al (2018) looked at data containing 2684 individuals with ASD from over 100 different sites across 37 countries. Children and adults were administered one of four ADOS modules (modules are determined by expressive language level). The Autism Diagnostic Interview, Revised (ADI-R) was also administered as well as a general intellectual ability instrument, such as the Wechsler Intelligence Scale for Children, or a different measure depending on age and verbal capabilities. Effects of sex were determined after excluding non-verbal IQ as a predictor. No main effect of sex was found for ADOS symptom severity, or on the specific ADOS subscales. Females showed lower scores on the RRB scale with increasing age. This result is similar to previous meta-analytic research on small-scale studies as well as large-scale studies (Van Wijngaarden-Cremers et al, 2014; Mandy et al, 2012, Supekar & Menon, 2015; Wilson et al, 2016; Charman et al., 2017). The researchers concluded that this adds to the current body of literature that supports the notion that females with ASD show lower levels of RRBs than males, but exhibit a more similar autistic phenotype to boys in relation to social communication deficits across ages (Tillman et al, 2018). Thus, it is possible to surmise that females with ASD are being under-identified as a result of exhibiting fewer RRBs. Notably, research has found that clinicians are hesitant to diagnose ASD without the presence of RRB (Mandy et al, 2012), as the diagnosis of ASD in the DSM-5 requires at least two types of RRBs. Lai et al. (2015) made the case that females with ASD may simply be exhibiting different RRBs rather than fewer, and it is possible that these less common forms of RRBs are being missed during diagnostic assessments.
Understanding the phenotypic differences in the presentation of autism is critical for diagnosticians for several reasons. It is crucial to understand that aspects of the diagnostic criteria for ASD may present on other ways in females though not be elevated on standard measure scales. As a result, those who do not receive an appropriate diagnosis will subsequently not receive an appropriate intervention. Beyond the obvious concern associated with females on the autism spectrum not receiving intervention associated with their autism symptomatology, there are a range of other mental health concerns that may dually go unaddressed. Higher functioning adolescents with ASD, which is often the presentation consistent with females that get “missed” in the diagnostic process, are at greater risk for developing depression (Greenlee et al, 2016) and anxiety (Steensel, Bogels, & Dirksen, 2012). Adults with high-functioning ASD are also at increased risk for suicidality (Hedley et al, 2017). More recent, emerging research suggests that while those with ASD may be able to mask their symptoms the majority of the day and thus not reach the diagnostic threshold in scandalized measures, doing so causes them significant distress and puts them at increased risks for such co-occurring mental health concerns.
The under-diagnosis of ASD in females with ASD lends itself to a population of women who end up wondering “what is wrong” with them. Females who do not have the opportunity to understand themselves in the context of neurodiversity tend to waste time and efforts on imitating and trying to fit-in (Bargiela et al, 2016). They are at far greater risk of bullying, as well as being taken advantage of socially, with subtle difficulties in perceiving and responding appropriately to social cues rendering them inept in certain situations that require a degree of social assimilation. These females have missed out on the benefits of early intervention, most often in the social realm, and can be plagued with identity issues later in life as they try to play catch-up in light of a new diagnosis. The timely identification of ASD can mitigate some of these risks and problems by improving the quality of life, increasing access to services, reducing self-criticism, and helping to foster a positive sense of identity. As such, diagnostic experts have a responsibility to continue to stay abreast of research developing in this area and adjusting their assessment practices accordingly.
Drs. Scher Lisa and Voulgarakis are Assistant Professors in the Department of Child Study at Saint Joseph’s College, New York. They are both also clinicians in private practice. You can find more information about their respective practices at www.drjessicascherlisa.com and www.drharryv.com .
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Holtmann, M., Bolte, S., & Poustka, F. (2007). Autism spectrum disorders: Sex differences in autistic behavior domains and coexisting psychopathology. Developmental Medicine & Child Neurology, 49, 361-366. doi: 10.1111/dmcn.2007.49.issue-5
Horiuchi, F., Oka, Y., Uno, H., Kawabe, K., Okada, F., Saito, I., Ueno, S. I. (2014). Age-and sex-related emotional and behavioral problems in children with autism spectrum disorders: Comparison with control children. Psychiatry and Clinical Neurosciences, 68, 542-550. doi:10.1111/psc.12164
Hull, L., Petrides, K.V., Allison, C., Smith, P., Baron-Cohen, S., Lai, M.C., & Mandy, W. (2017). “Putting on my best normal”: Social camouflaging in adults with autism spectrum conditions. Journal of Autism and Developmental Disorders, 47, 2519-2534. doi:10.1007/s10803-017-3166-5
Lai, M.C., Lombardo, M., Auyeung, B., Chakrabarti, B., & Baron-Cohen, S. (2015). Sex/gender differences and autism: Setting the scene for future research. Journal of the American Academy of Child and Adolescent Psychiatry, 54, 11-24.
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Autistic women and girls
More women and girls than ever before are discovering that they are autistic. Many had been missed or misdiagnosed due to outdated stereotypes about autism. But that is slowly changing.
In the past, it was assumed that autistic people were overwhelmingly men and boys, and only very rarely women and girls. This is wrong. There are many women, girls and non-binary people on the autism spectrum.
Although we now know much more about the experiences of autistic women and girls, society's understanding of autism has been limited by outdated stereotypes and incorrect assumptions. Although autism research and professional practice are slowly catching up to the realities of life for autistic women and girls, many barriers to diagnosis and support remain.
Does autism present differently in women and girls?
It is important that autistic women and girls receive a diagnosis (or recognise that they are autistic) so they can understand themselves and access support. However, because of stereotyped ideas about what autism looks like and who can be autistic, many autistic women and girls struggle to get a diagnosis, receive a diagnosis late in life or are misdiagnosed with conditions other than autism.
Autistic characteristics in women and girls may differ from those of other autistic people. They might seem to have fewer social difficulties than autistic men and boys, but this could be because they are more likely to 'mask' their autistic traits (though the stress of doing so can result in anxiety and overwhelm). At school, autistic girls may be more likely to be part of a friendship group and this could be a reason that teachers don't notice their differences. They may also be missed if their academic achievement masks difficulties they are facing in other areas.
Some of the core characteristics of autism are having ‘repetitive behaviours’ and highly-focused interests. Stereotyped examples of these include rocking backwards and forwards, and a fascination with trains. However, in autistic women and girls these behaviours and interests may be similar to those of non-autistic women and girls, such as twirling hair and reading books, and as such may go unnoticed despite the greater intensity or focus typical for autistic people.
Doctors and other healthcare professionals can lack knowledge about how autism may present differently in women and girls. This means women and girls may be misdiagnosed with mental health issues or their autistic traits may be missed amid the symptoms of co-occurring conditions. Some tools used to diagnose autism are designed to identify autistic characteristics that may be more common in autistic men and boys. This means the process may not be as sensitive to characteristics more commonly found in autistic women and girls.
In November 2022, NAS launched ‘Now I Know’, a campaign highlighting the experiences of late-diagnosed autistic women and non-binary people from across the country.
The campaign was photographed by autistic photographer Alex Heron, who works at Rankin Studio. You can watch short films or read longer interviews with the six people featured in the campaign. A series of additional interviews will be published at regular intervals sharing the stories of autistic women and non-binary people who responded to the #NowIKnow campaign on social media.
Stories from the Spectrum: autistic women
Many of the autistic women we’ve spoken to have talked about getting a late diagnosis, or have had difficulty getting the support they need.
As part of our Stories from the Spectrum series, we interviewed several women and girls, who shared their experiences with us.
"I feel autistic women are more likely to be described as ‘anxious’ and an autism diagnosis overlooked, since it can challenge gender stereotypes." Dr Camilla Pang
Sara Gibbs , autistic comedy writer, told us: "I think there is a lack of understanding of how autism can present in girls, who are often socialised differently."
Charl Davies , autistic tattoo artist, said: "I find that being a female I am expected to behave a certain way to fit in socially which is why I have spent so much time masking."
Dr Camilla Pang , autistic scientist and author, explained: "I feel autistic women are more likely to be described as ‘anxious’ and an autism diagnosis overlooked, since it can challenge gender stereotypes."
Dr Kate Fox , autistic poet and comedian, said: "I don’t think there’s an inherent difference between autistic men and women. What there is a difference in, is how society treats and socialises males and females."
Are men more likely to be diagnosed as autistic than women?
Studies and statistics .
- Various studies suggest that the ratio of autistic males to females ranges from 2:1 to 16:1. The most-up-to-date estimate is 3:1.
- In Leo Kanner's 1943 study of a small group of autistic children, there were four times as many boys as girls.
- Lorna Wing (renowned psychiatrist and co-founder of our charity's first diagnosis centre) found in her 1981 paper on autism and sex ratios in early childhood, that among people with a diagnosis of Asperger syndrome (as it was called at the time) there were 15 times more men and boys than women and girls, while in autistic people with learning difficulties, the ratio of men and boys to women and girls was closer to 2:1.
- In a much larger 1993 study of Asperger syndrome in mainstream schools in Sweden, Ehlers and Gillberg found a boy to girl ratio of 4:1.
- Brugha's 2009 survey of adults living in households throughout England found that 1.8% of men and boys surveyed had a diagnosis of autism, compared to 0.2% of women and girls.
- In 2015, the ratio of men to women supported by the National Autistic Society’s adult services was approximately 3:1, and the ratio of boys to girls in our charity’s schools was approximately 5:1.
- In a 2017 study, Loomes and other researchers analysed existing prevalence studies and found that the male-to-female ratio was nearer 3:1.
Why are more men diagnosed as autistic?
We don’t know exactly why more men and boys are diagnosed as autistic than women and girls. It is clear that many autistic women and girls are missed or misdiagnosed. It was previously thought that there were many more autistic men than women, but estimates of the ratio have gotten closer and closer over time.
Many theories to explain the diagnosis gap have been put forward, but none have been conclusively proven. Some of the theories are:
Please note:
Research and knowledge about autism changes constantly. Some of these theories may not reflect how we think about autism today.
- a potential 'female autism phenotype' – in other words, autistic women and girls have characteristics that don’t fit with the traditional profile of autism
- autism assessments are less sensitive to autistic traits more commonly found in women and girls
- women and girls are more likely to ‘mask’ or camouflage their differences
- autistic traits in girls are under-reported by teachers
- a range of biological and environmental factors may mean men and boys have a higher prevalence of autism
- the 'extreme male brain' theory of autism, which focuses on the effects of foetal testosterone on brain development
Critiques of the 'extreme male brain' theory
A critique of the extreme-male-brain theory of autism.
By Rachel Cohen-Rottenberg
Sexing the Autistic brain: Extreme Male?
By Dr Daniel Voyer
Books by autistic women and girls
The following books were suggested by NAS staff. Inclusion on this list should not be considered an endorsement by NAS as these books have not been reviewed through the same rigorous process as our advice and guidance content sources.
Non-fiction
- Autism and masking: how and why people do it, and the impact it can have, Helen Ellis, with Dr Felicity Sedgewick and Dr Laura Hull
- Safeguarding autistic girls: strategies for professionals, Dr Carly Jones MBE
- Spectrum women , Barb Cook and Dr Michelle Garnett (editors)
- Supporting spectacular girls: a practical guide to developing autistic girls' wellbeing and self-esteem, Helen Clarke
- Taking off the mask: practical exercises to help understand and minimise the effects of autistic camouflaging, Hannah Belcher
- The independent woman's handbook for super safe living on the autistic spectrum; The autism-friendly guide to periods; The autism-friendly guide to self-employment, Robyn Steward
- Women and girls with autism spectrum disorder, Sarah Hendrickx
Autobiography
- Drama queen: one autistic woman and a life of unhelpful labels, Sara Gibbs
- Odd girl out: an autistic woman in a neurotypical world, Laura James
- Travelling by train: the journey of an autistic mother, Laurie Morgan
Fiction
- A Kind of Spark, Elle McNicoll
- Can You See Me?, Libby Scott and Rebecca Westcott
Links, resources and article sources
National autistic society.
- Autism Services Directory : for services and support
- Branches : offering support, information and social activities for autistic adults, children and their families in their local areas
- Community : our online community is a place for autistic people and their families to meet like-minded people and share their experiences
Other advice, information and support
- Autistic Girls Network
- Scottish Women’s Autism Network
Article sources
Research
Author: Kock et al (2019)
Title: Autistic women’s experience of intimate relationships: the impact of an adult diagnosis
Source: Advances in Autism, 5(1):12.
Author: Kanfiszer et al (2017)
Title: ‘I was just so different’: The experiences of women diagnosed with an autism spectrum disorder in adulthood in relation to gender and social relationships
Source: Autism: The International Journal of Research and Practice, 21(6):9.
Author: Bargiela et al (2016)
Title: The experiences of late-diagnosed women with autism spectrum conditions: an investigation of the female autism phenotype
Source: Journal of Autism and Developmental Disorders, 46(10).
Author: Baldwin and Costley (2016)
Title: The experiences and needs of females adults with high-functioning autism spectrum disorder
Source: Autism: The International Journal of Research and Practice, 20(4):13.
Author: Wilson and Andrassy (2022)
Title: Breastfeeding experiences of autistic women
Source: MCN, American Journal of maternal Child Nursing, 47(1).
Author: Steward et al (2018)
Title: “Life is much more difficult to manage during periods”: Autistic experiences of menstruation
Source: Journal of Autism and Developmental Disorders, 48(12).
Author: Simantov et al (2022)
Title: Medical symptoms and conditions in autistic women
Source: Autism: The International Journal of Research and Practice, 26(2):16.
Author: Seers and Hogg (2021)
Title: ‘You don’t look autistic’: A qualitative exploration of women’s experiences of being the ‘autistic other’
Source: Autism, 25(6):12.
Author: Cumin et al (2021)
Title: Positive and differential diagnosis of autism in verbal women of typical intelligence: A Delphi study
Source: Autism, Volume Online First:1.
Author: Samuel et al (2022)
Title: Sensory challenges experienced by autistic women during pregnancy and childbirth: a systematic review
Source: Archives of Gynaecology and Obstetrics, 305.
Author: Corbett et al (2020)
Title: Pubertal timing during early adolescence: Advanced pubertal onset in females with autism spectrum disorder
Source: Autism Research, 13(12).
Author: Moseley et al (2020)
Title: ‘When my autism broke’: A qualitative study spotlighting autistic voices on menopause
Source: Autism, 24(6).
Author: Dugdale et al (2021)
Title: Intense connection and love: the experiences of autistic mothers
Source: Autism, 25(7).
Author: Seers and Hogg (2022)
Title: “Fake it ‘till you make it”: Authenticity and wellbeing in late diagnosed autistic women
Source: Feminism & Psychology: An International Journal, Volume Online First:1.
Author: Pohl et al (2020)
Title: A comparative study of autistic and non-autistic women’s experience of motherhood
Source: Molecular Autism, 11(1).
Author: Cazalis et al (2022)
Title: Evidence that nine autistic women out of ten have been victims of sexual violence
Source: Frontiers in Behavioral Neuroscience, 16.
Author: Grant et al (2022)
Title: Autistic women’s views and experiences of infant feeding: A systematic review of qualitative evidence
Source: Autism: The International Journal of Research and Practice, Volume Online First:1.
Author: Pecora et al (2019)
Title: Characterising the sexuality and sexual experiences of autistic females
Source: Journal of Autism and Developmental Disorders, 49(12).
Author: Milner et al (2019)
Title: A qualitative exploration of the female experience of autism spectrum disorder (ASD)
Source: Journal of Autism and Developmental Disorders, 49(6).
Author: Hampton et al (2021)
Title: A qualitative exploration of autistic mothers’ experiences II: Childbirth and postnatal experiences
Author: Sedgewick et al (2021)
Title: Gender differences in mental health prevalence in autism
Source: Advances in Autism, 7(3):17.
Author: Dubreucq and Dubreucq (2021)
Title: Toward a gender-sensitive approach of psychiatric rehabilitation in autism spectrum disorder (ASD): A systematic review of women needs in the domains of romantic relationships and reproductive health
Source: Frontiers in Psychiatry, 12.
Author: Moseley et al (2021)
Title: Autism research is ‘all about the blokes and the kids’: Autistic women breaking the silence on menopause
Source: British Journal of Health Psychology, 26(3).
Author: Sedgewick et al (2019a)
Title: the friendship questionnaire, autism, and gender differences: a study revisited
Source: Molecular Autism, 10(40).
Author: Cook et al (2017)
Title: Friendship motivations, challenges and the role of masking for girls with autism in contrasting school settings
Source: European Journal of Special Needs Education, 33(3).
Author: Schalbroeck, F. et al (2019)
Title: Risk of non-affective psychotic disorder or bipolar disorder in autism spectrum disorder: a longitudinal register-based study in the Netherlands
Source: Psychological Medicine, 49(15), pp. 2543-2550.
Author: Croen, L. et al (2015)
Title: The health status of adults on the autism spectrum
Source: Autism, 19 (7), 814-823
Author: Kirsch et al (2020 )
Title: Association of comorbid mood and anxiety disorders with autism spectrum disorder
Source: JAMA Paediatrics, 174(1), pp. 63-70.
Author: Cumin et al (2021)
Title: Positive and differential diagnosis of autism in verbal women of typical intelligence: A Delphi study
Source: Autism, Online ahead of print.
Author: Supekar et al (2017)
Title: The influence of sex and age on prevalence rates of comorbid conditions in autism
Source: Autism Research, 10(5).
Author: Wood-Downie et al (2021)
Title: Sex/Gender Differences in Camouflaging in Children and Adolescents with Autism
Source: Journal of Autism and Developmental Disorders. Vol. 51, pp. 1353-1364
Author: Sedgewick et al (2019b)
Title: “It’s different for girls”: gender differences in the friendships and conflict of autistic and neurotypical adolescents
Source: Autism, 23(5), pp. 1119-1132.
Author: Donovan, 2020
Title: Childbirth experiences of women with autism spectrum disorder in an acute care setting
Source: Nursing for Women’s Health, 24(3).
Author: Fusar-Poli et al, 2022
Title: Missed diagnoses and misdiagnoses of adults with autism spectrum disorder | SpringerLink
Source: European Archives of Psychiatry and Clinical Neuroscience volume 272, pages187–198 (2022)
Author: Kentrou et al, 2021
Title: Stability of co-occurring psychiatric diagnoses in autistic men and women - ScienceDirect
Source: Research in Autism Spectrum Disorders. Volume 82, April 2021, 101736
Author: Angell et al, 2021
Title: Sex Differences in Co-occurring Conditions Among Autistic Children and Youth in Florida: A Retrospective Cohort Study (2012–2019) | SpringerLink
Source: Journal of Autism and Developmental Disorders volume 51, pages3759–3765 (2021)
Author: Lockwood Estrin et al, 2021
Title: Barriers to Autism Spectrum Disorder Diagnosis for Young Women and Girls: a Systematic Review | SpringerLink
Source: Review Journal of Autism and Developmental Disorders volume 8, pages454–470 (2021)
Author: Anderson et al, 2020
Title: When the mask comes off: Mothers’ experiences of parenting a daughter with autism spectrum condition (sagepub.com)
Source: Autism. Volume 24, Issue 6
Author: Moseley et al, 2018
Title: Self-reported sex differences in high-functioning adults with autism: a meta-analysis
Source: Autism volume 9, Article number: 33 (2018)
Author: Cola et al, 2022
Title: Friend matters: sex differences in social language during autism diagnostic interviews | SpringerLink
Source: Molecular Autism volume 13, Article number: 5 (2022)
Author: Rynkiewicz et al, 2016
Title: An investigation of the ‘female camouflage effect’ in autism using a computerized ADOS-2 and a test of sex/gender differences | SpringerLink
Source: Molecular Autism volume 7, Article number: 10 (2016)
Author: Rea et al, 2022
Title: Sex Differences on the ADOS-2 (researchgate.net)
Source: Journal of Autism and Developmental Disorders · April 2022
Author: Whitlock et al, 2020
Title: Recognition of Girls on the Autism Spectrum by Primary School Educators: An Experimental Study - Whitlock - 2020 - Autism Research - Wiley Online Library
Source: Autism Research 13: 1358–1372, 2020
Author: Dillon et al, 2021
Title: Sex Differences in Autism: Examining Intrinsic and Extrinsic Factors in Children and Adolescents Enrolled in a National ASD Cohort | SpringerLink
Source: Journal of Autism and Developmental Disorders (2021)
Author: Leedham et al, 2020
Title: ‘I was exhausted trying to figure it out’: The experiences of females receiving an autism diagnosis in middle to late adulthood (sagepub.com)
Source: Autism. 2020, Vol. 24(1) 135–146
Author: Moseley et al, 2021a
Title: Autism research is ‘all about the blokes and the kids’: Autistic women breaking the silence on menopause - Moseley - 2021 - British Journal of Health Psychology - Wiley Online Library
Source: British Journal of Health Psychology (2021), 26, 709–726
Author: Kelly et al, 2022
Title: Sense-making narratives of autistic women diagnosed in adulthood: a systematic review of the qualita (tandfonline.com)
Source: Disability & Society
Author: Rogers et al, 2016
Title: Experiences of diagnosing autism spectrum disorder: A survey of professionals in the United Kingdom
Source: Autism: the international journal of research and practice
Author: Tsirgiotis et al, 2022
Title: A Mixed-Methods Investigation of Diagnostician Sex/Gender-Bias and Challenges in Assessing Females for Autism Spectrum Disorder | SpringerLink
Source: Journal of Autism and Developmental Disorders volume 52, pages4474–4489 (2022)
Author: Tubío-Fungueiriño, 2020
Title: Social Camouflaging in Females with Autism Spectrum Disorder: A Systematic Review | SpringerLink
Source: Journal of Autism and Developmental Disorders volume 51, pages2190–2199 (2021)
Author: Fowler and O’Connor, 2021
Title: ‘I just rolled up my sleeves’: Mothers’ perspectives on raising girls on the autism spectrum (sagepub.com)
Source: Autism. 2021, Vol. 25(1) 275–287
Author: Jadav and Bal, 2022
Title: Associations between co‐occurring conditions and age of autism diagnosis: Implications for mental health training and adult autism research - Jadav - Autism Research - Wiley Online Library
Source: Autism Research. Volume15, Issue11, November 2022, Pages 2112-2125
Author: Mandy et al, 2022
Title: Mental health and social difficulties of late‐diagnosed autistic children, across childhood and adolescence (wiley.com)
Source: Journal of Child Psychology and Psychiatry 63:11 (2022), pp 1405–1414
Author: Huang et al, 2021
Title: Factors associated with age at autism diagnosis in a community sample of Australian adults - Huang - 2021 - Autism Research - Wiley Online Library
Source: Autism Research. Volume14, Issue12, December 2021, Pages 2677-2687
Author: D’Mello et al, 2022
Title: Exclusion of females in autism research: Empirical evidence for a “leaky” recruitment‐to‐research pipeline - D'Mello - Autism Research - Wiley Online Library
Source: Autism Research
Author: Bourson and Prevost, 2022
Title: Characteristics of restricted interests in girls with ASD compared to boys: a systematic review of the literature | SpringerLink
Source: European Child & Adolescent Psychiatry (2022)
Author: Tillman et al, 2018
Title: Evaluating Sex and Age Differences in ADI-R and ADOS Scores in a Large European Multi-site Sample of Individuals with Autism Spectrum Disorder | SpringerLink
Source: Journal of Autism and Developmental Disorders volume 48, pages2490–2505 (2018)
Author: Kaat et al, 2021
Title: Sex differences in scores on standardized measures of autism symptoms: a multisite integrative data analysis (wiley.com)
Source: The Journal of Child Psychology and Psychiatry. Volume62, Issue1, January 2021, Pages 97-106
Author: Kalb et al, 2022
Title: Analysis of Race and Sex Bias in the Autism Diagnostic Observation Schedule (ADOS-2) | Autism Spectrum Disorders | JAMA Network Open | JAMA Network
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Author: Song et al, 2021
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Author: Reindal et al, 2021
Title: Structural and Pragmatic Language Impairments in Children Evaluated for Autism Spectrum Disorder (ASD) | SpringerLink
Author: Wallisch et al, 2020
Title: Brief Report: Predicting Sex Differences and Diagnosis from Early Parent Concerns (researchgate.net)
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Author: Del Bianco et al, 2022
Title: Unique dynamic profiles of social attention in autistic females - Del Bianco - Journal of Child Psychology and Psychiatry - Wiley Online Library
Source: Journal of Child Psychology and Psychiatry 63:12 (2022), pp 1602–1614
Author: Kourti and MacLeod, 2019
Title: "I Don't Feel Like a Gender, I Feel Like Myself": Autistic Individuals Raised as Girls Exploring Gender Identity
Source: Autism in Adulthood: challenges and management
Author: Brown et al, 2020
Title: Am I Autistic? Utility of the Girls Questionnaire for Autism Spectrum Condition as an Autism Assessment in Adult Women
Source: Autism in Adulthood
Author: Moore et al, 2022
Title: The intersection of autism and gender in the negotiation of identity: A systematic review and metasynthesis
Source: Feminism and Psychology
Author: Hayward et al, 2022
Short report: Gendered workplace social interaction processes in autism – ScienceDirect
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Author: Cummins et al, 2018
Title: Supporting Minimally Verbal Autistic Girls with Intellectual Disabilities Through Puberty: Perspectives of Parents and Educators | SpringerLink
Source: Journal of Autism and Developmental Disorders volume 50, pages2439–2448 (2020)
Author: Corbett et al, 2022
Title: Examination of pubertal timing and tempo in females and males with autism spectrum disorder compared to typically developing youth - Corbett - Autism Research - Wiley Online Library
Source: Autism Research. Volume 15, Issue10, October 2022
Author: Karavidas and de Visser, 2022
Title: “It's Not Just in My Head, and It's Not Just Irrelevant”: Autistic Negotiations of Menopausal Transitions | SpringerLink
Source: Journal of Autism and Developmental Disorders volume 52, pages1143–1155 (2022)
Author: May et al, 2021
Title: Overlap of autism spectrum disorder and borderline personality disorder: A systematic review and meta‐analysis - May - 2021 - Autism Research - Wiley Online Library
Source: Autism Research. Volume14, Issue12, December 2021
Author: Maddox et al, 2017
Title: Untended wounds: Non-suicidal self-injury in adults with autism spectrum disorder (sagepub.com)
Source: Autism. Volume 21, Issue 4
Author: Halsall et al, 2021
Title: “Camouflaging” by adolescent autistic girls who attend both mainstream and specialist resource classes: Perspectives of girls, their mothers and their educators (sagepub.com)
Source: Autism. Vol. 25(7) 2074–2086
Author: Bernardin et al, 2021
Title: “You Must Become a Chameleon to Survive”: Adolescent Experiences of Camouflaging | SpringerLink
Source: Journal of Autism and Developmental Disorders volume 51, pages4422–4435 (2021)
Author: Holden et al, 2020
Title: Investigating Bullying as a Predictor of Suicidality in a Clinical Sample of Adolescents with Autism Spectrum Disorder - Holden - 2020 - Autism Research - Wiley Online Library
Source: Autism Research 13: 988–997, 2020
Professional practice
Author: Robyn Steward, 2018
Title: Autistic people and menstruation
Source: National Autistic Society
Author: Felicity Sedgewick, 2018
Title: Autistic female friendships
Author: Autism NI, accessed August 2022
Title: Autistic girls and women
Source: Autism NI
Author: The Autism Community in Action, accessed August 2022
Title: Puberty
Source: The Autism Community in Action
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Please note you do not have access to teaching notes, the presentation, recognition and diagnosis of autism in women and girls.
Advances in Autism
ISSN : 2056-3868
Article publication date: 11 March 2021
Issue publication date: 11 August 2021
Autistic women and girls have received comparatively less attention within clinical practice and research. Research suggests women tend to be diagnosed later than men, and are more likely to experience misdiagnosis.
Design/methodology/approach
This paper aims to report a narrative literature review that examines research on the presentation, recognition, and diagnosis of autistic women and girls.
Findings suggest that autistic females present differently to males and highlight low recognition of the female presentation of autism among the general public, in social spheres, educational, clinical and forensic settings. This lack of recognition appears to affect the likelihood of females being referred for diagnosis, the reliability of diagnostic assessments and subsequent access to support.
Originality/value
Recommendations for clinical practice focus on initiatives to increase awareness of the female presentation of autism, improving the diagnostic process for females, increasing female representation within autism training and for future research to support these goals.
- Autism spectrum disorder
- Asperger syndrome
- Neurodevelopmental
- Pervasive developmental disorder
- Developmental disorder
- Sex differences
Driver, B. and Chester, V. (2021), "The presentation, recognition and diagnosis of autism in women and girls", Advances in Autism , Vol. 7 No. 3, pp. 194-207. https://doi.org/10.1108/AIA-12-2019-0050
Emerald Publishing Limited
Copyright © 2020, Emerald Publishing Limited
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- © 2023
Assessment of Autism in Females and Nuanced Presentations
Integrating Research into Practice
- Terisa P. Gabrielsen ORCID: https://orcid.org/0000-0002-4955-6419 0 ,
- K. Kawena Begay ORCID: https://orcid.org/0000-0001-7978-9996 1 ,
- Kathleen Campbell ORCID: https://orcid.org/0000-0003-0923-8659 2 ,
- Katrina Hahn 3 ,
- Lucas T. Harrington 4
School of Education, Brigham Young Univeristy, Provo, USA
You can also search for this author in PubMed Google Scholar
School of Education, University of Washington Tacoma, Tacoma, USA
Developmental and behavioral pediatrics, children’s hospital of philadelphia, phildelphia, usa, developmental assessment clinics, university of utah, salt lake city, usa, autism center, university of washington, seattle, usa.
Examines characteristics of autism in females and atypical presentations
Provides a comprehensive framework and sensitive approach for assessing autism in females and others
Discusses improved treatment and support across the lifespan for females and others with autism
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- Table of contents
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Table of contents (13 chapters)
Front matter, sex, gender, autism, assessment, and equity for females.
- Terisa P. Gabrielsen, K. Kawena Begay, Kathleen Campbell, Katrina Hahn, Lucas T. Harrington
Early Identification of Females with Autism: Comprehensive Evaluation
Communication and language assessment in females with autism, assessment for sleep, feeding, sensory issues, and motor skills in females with autism, autism assessment of female social skills, play, imitation, camouflaging, intense interests, stimming behaviors, and safety, interpreting female social relationships: autism friendships and pragmatic language, autism assessment including reading, learning, and executive function in females, differential or co-occurring other common diagnoses prior to autism assessment, guidance for medical issues in female puberty, gender identity, pregnancy, parenting and menopause, underlying autism female eating disorders, self-injury, suicide, sexual victimization, and substance abuse, autism diagnosis in adult females: post-secondary education, careers, and autistic burnout, adult autism and social connections: living authentically, sexuality, partnering, parenting, and vulnerabilities, advocacy for neurodiversity, back matter.
This book examines autism characteristics that may be different than expected (atypical), primarily found in females, but also in others and are likely to be missed or misdiagnosed when identification and support are needed. It follows a lifespan framework, guiding readers through comprehensive assessment processes at any age. The book integrates interpretations of standardized measures, information from scientific literature, and context from first-person accounts to provide a more nuanced and sensitive approach to assessment. It addresses implications for improved treatment and supports based on comprehensive assessment processes and includes case studies within each age range to consolidate and illustrate assessment processes.
Key areas of coverage include:
- Interdisciplinary assessment processes, including psychology, speech and language pathology, education, and health care disciplines.
- Lifespan approach to comprehensive assessment of autism in females/atypical autism.
- Guide to interpretation of standardized measures in females/atypical autism.
- Additional assessment tools and processes to provide diagnostic clarity.
- Descriptions of barriers in diagnostic processes from first-person accounts.
- Intervention and support strategies tied to assessment data.
- In-depth explanations of evidence and at-a-glance summaries.
Assessment of Autism in Females and Nuanced Presentations is a must-have resource for researchers, professors, and graduate students as well as clinicians, practitioners, and policymakers in developmental and clinical psychology, speech language pathology, medicine, education, social work, mental health, and all interrelated disciplines.
- Autism, assessment, females
- ASD, identification, females
- Asperger syndrome, females
- Atypical autism, females
- Autism spectrum disorder (ASD), females
- Autism spectrum disorder diagnosis, females
- Autism, females
- Camouflaging, masking behaviors, autism
- Culture, autism, females
- Early childhood development, females, autism
- Eating disorder, autism, females
- Gender identity, autism, females
- Girls, autism, assessment
- Infants, toddlers, females, autism
- Language differences, autism, females
- Misdiagnosis, autism, females
- Race, autism, females
- Sex differences, autism, females
- Suicide, autism, females,
- Women, autism, assessment
Terisa P. Gabrielsen
K. Kawena Begay
Kathleen Campbell
Katrina Hahn
Lucas T. Harrington
Terisa P. Gabrielsen, Ph.D., NCSP, is an associate professor of School Psychology in the School of Education at Brigham Young University and a licensed psychologist. She has 15 years of interdisciplinary clinical and research experience in toddler, PreK-12, hospital, clinical, and research settings. Her specialties are early identification of autism, social skills interventions, and building community capacity in autism services.
Kristin Kawena Begay, Ph.D., NCSP, is an assistant professor in the School of Education at the University of Washington, Tacoma. She is a licensed psychologist and nationally certified school psychologist with 20 years of experience working in culturally and linguistically diverse PreK-12, university, and clinic settings. Dr. Begay has served in a variety of roles, including classroom teacher, counselor, school psychologist, licensed psychologist, trainer, and consultant.
Kathleen Campbell, M.D., MHSc, is a pediatrician and pursuing fellowship training in developmental and behavioral pediatrics at the Children’s Hospital of Philadelphia. She has clinical experience and has published research relating to screening, diagnosis, and medical care of autistic children.
Katrina Hahn, MEd, CCC-SLP, is a speech and language pathologist with the University of Utah Developmental Assessment Clinics. She has 19 years of experience in various capacities in early intervention, PreK-12, and clinical settings. Ms. Hahn specializes in the identification, evaluation, and therapy planning for social-emotional development and pragmatic language for individuals with autism.
Lucas T. Harrington, PsyD is a licensed clinical psychologist at the University of Washington Autism Center. He is autistic and personally experienced the challenges of seeking evaluation as an adult who was assigned female at birth. Dr. Harrington provides neurodiversity-affirming services for autistic people and their supporters in various areas, including diagnostic evaluation, individual therapy, parent coaching, and consultation/training. Dr. Harrington has also been known professionally as Natasha Harrington, PsyD.
Book Title : Assessment of Autism in Females and Nuanced Presentations
Book Subtitle : Integrating Research into Practice
Authors : Terisa P. Gabrielsen, K. Kawena Begay, Kathleen Campbell, Katrina Hahn, Lucas T. Harrington
DOI : https://doi.org/10.1007/978-3-031-33969-1
Publisher : Springer Cham
eBook Packages : Behavioral Science and Psychology , Behavioral Science and Psychology (R0)
Copyright Information : The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Hardcover ISBN : 978-3-031-33968-4 Published: 10 September 2023
Softcover ISBN : 978-3-031-33971-4 Due: 24 September 2024
eBook ISBN : 978-3-031-33969-1 Published: 09 September 2023
Edition Number : 1
Number of Pages : XXX, 259
Number of Illustrations : 3 b/w illustrations
Topics : Developmental Psychology , Child and Adolescent Psychiatry , Child and School Psychology , Education, general , Clinical Psychology , Public Health
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Girls and women with autism
Affiliations.
- 1 Pracownia Badań Zaburzeń Neurorozwojowych, Instytut Medycyny Doświadczalnej i Klinicznej, Wydział Medyczny, Uniwersytet Rzeszowski.
- 2 Oddział Kliniczny Psychiatrii i Psychoterapii Wieku Rozwojowego,Katedra Psychiatrii i Psychoterapii, Śląski Uniwersytet Medyczny, Katowice.
- 3 Klinika Psychiatrii Dzieci i Młodzieży, Uniwersytet Medyczny, Poznań.
- PMID: 31760407
- DOI: 10.12740/PP/OnlineFirst/95098
Girls and women with autism are often undiagnosed, misdiagnosed or receive a diagnosis of autism at later age. This can result in adverse outcomes in their well-being, mental health, education, employment, and independence. The diagnosis of autism spectrum condition/disorder (hereinafter referred to as autism), with its current features linked with descriptions in the major diagnostic classification systems, is based primarily on observations and research on males. The term 'Autism Spectrum Condition' (ASC), used in this paper, has been coined by Simon Baron-Cohen and used in the professional literature for a decade to respect these individuals on the autism spectrum who feel that the term 'disorder'is stigmatizing, whereas ASC presents both the strengths of these people and difficulties they experience. The research shows that autism in females has unique symptomatology and manifests itself differently, more subtly, especially in high-functioning girls and women, i.e., those with fluent speech, average or above-average intelligence quotient. The research also shows diagnostic stereotypes and lack of required sensitivity to identify autistic females. Additionally they do not reflect the unique presentation of autism in females demonstrated by greater compensatory capacity and an ability to develop sophisticated methods of 'camouflaging'and masquerading. Furthermore, autism in females is associated with high comorbidity during adolescence including anxiety disorder, tic disorder, depression, high incidence of suicide, eating disorders, and high rates of other medical problems. Timely diagnosis, however, can reduce the difficulties that females with autism experience over their lifetime, allowing for the assessment of their needs regarding health, education, leisure, social relationships, and employment.
Keywords: autism; girls; women.
Publication types
- Autism Spectrum Disorder / diagnosis*
- Autism Spectrum Disorder / psychology*
- Cognition / physiology
- Depression / diagnosis
- Depression / psychology
- Disease Management
- Psychiatric Status Rating Scales
- Severity of Illness Index*
- Sex Factors
- Social Behavior
- Stereotyped Behavior*
Understanding autism
Women and girls, autism in women and girls, rates of autism prevalence suggest that boys are, on average, 4 times more likely to have autism than girls..
But this figure may hide the true incidence of autism in girls and women, with some estimates ranging from 7:1 to as low as 2:1 (that is, 2 boys for every girl). Parents with daughters on the spectrum will often share frustrating tales of how difficult it was to get a proper diagnosis for their daughters, while many autistic women did not receive diagnoses until adulthood .
Why does autism seem more common in males?
Being female does appear to protect the brain from many developmental disabilities, not just autism. There is emerging evidence that girls with autism need more extreme genetic mutations than boys to develop autism.
However, there is a growing body of work that indicates that autism just presents differently in girls and therefore often goes unrecognised, especially in verbally fluent girls with normal intelligence. Girls with autism also appear to be better at ‘camouflaging’ their symptoms in order to fit in.
With the diagnostic criteria for ASD based largely in how autism presents in males, girls can often ‘slip under the radar’ or get misdiagnosed. Girls with ASD seem to have less restricted and repetitive behaviours than boys, but it’s also possible that some of these behaviours go unrecognised — for example, an obsessive interest in collecting dolls may be misinterpreted as pretend play.
What does autism look like in girls?
Although every child with autism is different, here are some common characteristics in girls with autism:
- A special interest in animals, music, art, and literature
- A strong imagination (might escape into the worlds of nature or fiction)
- A desire to arrange and organise objects
- Not wanting to play cooperatively with female peers (for example, wanting to dictate the rules of play or preferring to play alone to maintain control)
- A tendency to ‘mimic’ others in social situations in order to blend in
- An ability to hold their emotions in check at school, but be prone to meltdowns or explosive behaviour at home
- Strong sensory sensitivities, especially to sounds and touch (for example; clothing tags, socks or even deodorant).
For autistic girls to thrive, it’s important they have access to a timely and accurate diagnosis, and the informed supports that come with it. A delayed or missed diagnosis can impede their education and development, as well as their social and community participation.
While boys with autism are more likely to have outwardly challenging behaviours, (indicating underlying issues, such as anxiety) girls with autism are more vulnerable to internalising problems.
As our understanding of how autism affects females is still emerging, it is important parents and professionals alike stay updated on the best ways to specifically support girls and women on the spectrum.
Helpful resources
“We always knew our daughter was different. She has a cousin (boy) who is autistic but presents very differently”
Signs of Autism in Adult Females
Understanding Autism in Women
Autism spectrum disorder (ASD) is a complex, lifelong developmental condition that affects social interaction, communication, interests, and behavior. While ASD affects individuals regardless of gender, it is more prevalent in males than in females with a ratio of 4:1. However, the presentation of ASD in females can differ significantly, often leading to underdiagnosis and lack of appropriate support.
Prevalence and Underdiagnosis
Statistics indicate that autism is more common in males than females. However, these figures may not paint the complete picture as females with ASD often exhibit different symptoms and may engage in camouflaging, potentially leading to underdiagnosis. Furthermore, diagnostic tools originally developed for males may not capture the full range of symptoms in females, leading to misdiagnosis or delayed diagnosis.
As per the data, females with ASD tend to score higher on the Autism Spectrum Quotient (AQ), indicating more severe symptoms compared to males with ASD.
The Role of Camouflaging
Camouflaging or masking of autistic symptoms is a common behavior observed in females with ASD. This involves the conscious or unconscious masking of behavior that is perceived as socially unacceptable or different. Females with ASD are often more adept at camouflaging than males, which can make it harder to recognize their symptoms and consequently lead to delayed diagnosis or misdiagnosis [1] .
Interestingly, camouflaging in females with ASD is negatively correlated with emotional expressivity, indicating that those who camouflage their symptoms may have difficulties expressing emotions. This correlation is not seen in males with ASD.
Recognizing the signs of autism in adult females requires a nuanced understanding of the disorder and its potential presentations. This includes acknowledging the prevalence of camouflaging and the impact it can have on diagnosis and support. By doing so, we can ensure that all individuals with ASD, regardless of gender, receive the appropriate recognition and support they need.
Identifying Autism in Adult Females
Understanding the signs of autism in adult females can be complex due to underdiagnosis and the common practice of camouflaging symptoms. Nonetheless, certain characteristics and co-occurring conditions can provide insight into the identification of Autism Spectrum Disorder (ASD) in this population.
Common Characteristics
While ASD is more prevalent in males than females, females with ASD often exhibit more severe symptoms, as evidenced by higher scores on the Autism Spectrum Quotient (AQ) Source .
Yet, the presentation of ASD in females often differs from males, which can lead to misdiagnosis or delayed diagnosis. Diagnostic tools initially developed for males might not capture the full range of symptoms in females Source .
One of the common characteristics of ASD in females is camouflaging or masking of autistic symptoms. This behavior is more prevalent in females with ASD compared to males with ASD and is not linked to social phobia Source .
Camouflaging in females with ASD is negatively correlated with emotional expressivity, indicating that those who camouflage their symptoms may have difficulties expressing emotions. This correlation is not seen in males with ASD Source .
Co-occurring Conditions
Co-occurring conditions can provide additional insight into the identification of ASD in adult females. While these conditions are not exclusive to ASD, their presence in conjunction with other signs of autism can strengthen the likelihood of a correct diagnosis.
The list of potential co-occurring conditions includes but is not limited to:
- Attention-deficit/hyperactivity disorder (ADHD)
- Anxiety disorders
- Eating disorders
- Mood disorders, such as depression
- Sleep disorders
- Sensory processing issues
It's important to note that these conditions can also be present in individuals who do not have ASD. Therefore, a comprehensive evaluation that includes consideration of all symptoms, behaviors, and co-occurring conditions is crucial for an accurate diagnosis of ASD in adult women.
Understanding these signs of autism in adult females can help improve diagnosis rates and ensure that those affected receive the necessary support and accommodations.
The Unique Presentation of Autism
Autism spectrum disorder (ASD) presents differently in each individual, and the signs of autism in adult females can be quite distinct. It's essential to understand these unique traits to ensure accurate diagnosis and effective support.
Differences in Social Communication
In the realm of social communication, adult females with ASD often exhibit unique characteristics. Despite facing challenges in understanding the social world, including recognizing social cues, interpreting subtle nonverbal communication, and understanding social norms, many women with autism display a pronounced drive to be sociable.
These individuals may become skilled at mimicking social behaviors, which can mask their difficulties and often lead to the underdiagnosis of autism in females. This ability to imitate social interactions, while potentially beneficial in certain situations, can delay the recognition of symptoms and contribute to the individual's stress and anxiety.
Intense Interests and Hobbies
Like many individuals with ASD, women on the spectrum often have intense interests and hobbies. However, their areas of focus may often align more closely with societal norms or expectations, making these interests less noticeable as potential signs of autism. These interests can range from a specific genre of books or movies to detailed knowledge about fashion, animals, or historical events.
It's important to note that these intense interests are not merely 'passions' – they often provide comfort, structure, and a means of coping with the uncertainties of the social world. For women with ASD, these interests can also provide a means of connection with others, serving as a bridge to social interactions.
Sensory Sensitivities
Sensory sensitivities are a common aspect of ASD, and women on the spectrum are no exception. These can manifest as an over- or under-sensitivity to sensory stimuli such as lights, sounds, textures, tastes, and smells. For example, an individual may find certain fabric textures unbearable, or be overwhelmed by loud noises or bright lights. Conversely, they may seek out certain sensory experiences, finding comfort in specific textures, sounds, or movements.
These sensory sensitivities can impact various areas of life, from clothing choices and food preferences to social activities and environments. Understanding and accommodating these sensory needs can play a significant role in supporting women with ASD and enhancing their comfort and wellbeing.
As we delve deeper into the unique presentation of autism in adult females, it's clear that these traits can often be overlooked or misinterpreted. Increased awareness and understanding of these signs are critical in ensuring that women with ASD are accurately diagnosed and effectively supported throughout their lives.
The Impact of Autism on Daily Life
Autism can impact various aspects of an individual's daily life. For women with autism, these impacts often surround social challenges and issues with emotional regulation.
Social Challenges
Women with autism often struggle with executive function skills, which can affect their ability to organize tasks, complete chores, maintain emotional control, and perform daily activities such as work tasks, household chores, and personal hygiene.
In addition to these functional challenges, social interactions can also pose difficulties. Autistic women frequently exhibit obsessive interests, engaging in in-depth research on various subjects and demonstrating a strong focus on specific topics. While this intense focus often leads them to pursue careers or hobbies requiring deep concentration, it can also create challenges in social settings, where the conversation often shifts between different topics [4] .
Furthermore, women with autism often use camouflaging tactics more extensively and differently than men to pass as "normal." This practice, while common among people with autism, can lead to mental health issues such as depression and anxiety.
Emotional Regulation and Meltdowns
Emotional regulation issues and meltdowns are common among women with autism due to poor connections between the frontal cortex and the amygdala. This can result in difficulties rationalizing situations, leading to extreme emotional reactions like temper outbursts, crying, or shutdown modes.
The pressure to conform to societal and gender expectations often exacerbates these emotional challenges. Women with autism may struggle to manage their autistic needs while fulfilling societal roles expected of daughters, mothers, or wives. The pressure to conform to gendered expectations often leads women with autism to camouflage their behaviors, which can result in a loss of sense of self and increased mental health challenges.
Understanding these challenges is crucial for providing appropriate support and accommodations to adult females with autism. Recognizing the unique, often hidden signs of autism in adult females can help ensure they receive the necessary care and understanding to live fulfilling, authentic lives.
Recognition and Support for Autistic Women
In the journey towards understanding and managing autism in adult females, recognition and support play a crucial role. From ensuring an accurate diagnosis to providing tailored support services, these elements contribute significantly to the overall well-being of autistic women.
The Importance of Accurate Diagnosis
The stereotype of autism as a 'male' disorder can often be a barrier to women gaining an autism diagnosis [6] . This stereotype, coupled with the prevalent use of camouflaging tactics by women to pass as "normal", might lead to a delay or even an absence of a formal diagnosis. Women with autism often camouflage their symptoms more extensively and differently than men, which can make the signs of autism in adult females harder to identify.
An accurate diagnosis is essential not just for understanding the unique challenges faced by these women but also for their overall well-being. The extent to which diagnosis improves well-being relies heavily on the level of acceptance both by oneself and others. Understanding and accepting one's diagnosis can lead to better self-awareness and an improved ability to advocate for personal needs.
The Need for Tailored Support Services
Given the unique experiences of women on the autism spectrum, the need for tailored support services cannot be overstated. Women with autism may struggle to manage their autistic needs while fulfilling societal roles expected of daughters, mothers, or wives.
Research indicates that adult women on the autism spectrum often camouflage their symptoms to conform to societal expectations, resulting in exhaustion, stress, and burnout. Therefore, support services need to address these unique needs and challenges.
Tailored support can involve therapy and counseling services, social skills training, and support groups specifically designed for women on the autism spectrum. Additionally, occupational therapy can help women manage their daily tasks and roles more effectively, while cognitive-behavioral therapy can help them cope with anxiety and depression often associated with camouflaging and societal pressures.
In summary, recognition and support for autistic women are vital elements in understanding the unique manifestations and challenges of autism in adult females. An accurate diagnosis can pave the way for self-acceptance and advocacy, while tailored support services can provide the necessary tools and strategies to navigate societal roles and expectations.
Autism and Mental Health
Exploring the mental health aspect of autism in adult females, the intersection of autism and mental health conditions such as anxiety and depression is often observed. This co-occurrence can complicate the signs of autism in adult females, making diagnosis and support even more critical.
The Link Between Autism and Anxiety
Women with autism often experience social difficulties, such as challenges in reading and responding to social cues. This can lead to feelings of social anxiety and loneliness, despite efforts to be sociable. Autistic women may excel in one-on-one interactions but struggle in group settings, often feeling drained after social interactions.
Moreover, adult females with Autism Spectrum Disorder (ASD) often face challenges understanding the social world, including recognizing social cues, understanding social norms, and interpreting subtle nonverbal communication. This can enhance feelings of anxiety, particularly in social situations.
Autism and Depression
Depression is another mental health condition frequently observed in women with autism. The stress of trying to fit in and be accepted, combined with feelings of not belonging or feeling different, can significantly contribute to the onset of depressive symptoms in these women [2] .
Difficulties with emotional regulation, another common characteristic of autism in women, can exacerbate these feelings. Difficulties rationalizing situations due to poor connections between the frontal cortex and the amygdala often result in extreme emotional reactions, which can further contribute to depressive symptoms.
It's important to note that while these mental health conditions are often observed in women with autism, they are not defining features of autism itself. Instead, they highlight the need for comprehensive mental health support and tailored services for women with autism, to help them navigate these challenges and maintain their overall well-being.
[1]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6753236/
[2]: https://autismspectrumnews.org/social-connections-for-women-with-asd-in-transition-5-areas-of-importance/
[3]: https://autismspectrumnews.org/the-social-needs-of-women-on-the-autism-spectrum/
[4]: https://www.psychologytoday.com/us/blog/women-with-autism-spectrum-disorder/202104/10-signs-of-autism-in-women
[5]: https://www.psychologytoday.com/us/blog/women-autism-spectrum-disorder/202104/how-men-and-women-experience-autism-differently
[6]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9666868/
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A Subtle Profile With a Significant Impact: Language and Communication Difficulties for Autistic Females Without Intellectual Disability
Associated data.
The original contributions presented in the study are included in the article/ Supplementary Material , further inquiries can be directed to the corresponding author/s.
The presentation of autism in females is poorly understood, which is thought to contribute to missed or later- age diagnosis, especially for those without intellectual disability. Dedicated research into social and behavioral differences has indicated a specific female phenotype of autism. However, less has been done to explore language and communication profiles, despite known sex/gender differences in typically developing populations. This article provides a synthesis of recent work from this small but emerging field. It focuses on a series of four preliminary and explorative studies conducted by the authors and embeds this within the wider literature. Findings suggest a specific profile of language and communication strengths and weaknesses for autistic females without intellectual disability (compared to autistic males and typically developing females). Furthermore, despite the relatively subtle presentation of difficulties (compared to autistic males), the impact on functionality, social inter-relations and emotional well-being, appears to be equitable and significant. The discussion highlights the need for further empirical research and proposes areas for investigation. Implications for clinical practice include the need for better recognition, testing and provision of interventions dedicated to the language and communication difficulties for autistic females. This has relevance for diagnostic, mental health and speech and language therapy services.
Introduction
Sex/gender 1 differences in language and communication profiles for typically developing individuals are well documented in the literature. Females demonstrate earlier acquisition of first words ( Bleses et al., 2008 ), better and earlier integration of language with gesture ( Eriksson et al., 2012 ), earlier examples of social-emotional vocabulary (e.g., “like,” “please”), and use of more complex linguistic forms during spontaneous speech ( Bouchard et al., 2009 ). They also use language and communication differently from males, focusing on person-centered topics and emotions ( Newman et al., 2008 ), and using collaborative and negotiated discourse ( Ladegaard and Bleses, 2003 ). Importantly, this profile appears to be expected within interactions ( Newman et al., 2008 ) and is linked to successful integration with female social groups ( Tierney et al., 2016 ).
Sex/gender differences in autism have received growing attention in recent years, although this has focused on social and behavioral domains rather than language and communication. Currently females are diagnosed in lower numbers (1:3) than males ( Loomes et al., 2017 ) especially in groups with higher cognitive function (1:7; Nicholas et al., 2008 ). This is despite autistic symptomatology existing with relative parity (2:1) in whole population samples ( Giarelli et al., 2010 ). Clinical concerns are that females are being missed from diagnosis due to poor recognition of the autistic female phenotype ( Kreiser and White, 2014 ). Sex/gender differences have been identified in rigid/repetitive behaviors using diagnostic measures ( Van Wijngaarden-Cremer et al., 2014 ; Hull et al., 2017a ) with males typically exhibiting increased frequency and severity compared to females. Differences in social interactions have been better identified using specific measures, avoiding the homogenizing effect of collecting data and constraining participant groups using the same diagnostic tools ( Lai et al., 2015 ). Several studies now point toward a distinct profile of social-interaction difficulties for females compared to males, using measures of empathizing ( Rieffe et al., 2021 ), friendship ( Sedgewick et al., 2016 ), play-behaviors ( Dean et al., 2014 ), and emotional reciprocity ( Head et al., 2014 ). A review of the literature found little evidence of language and communication differences between sex/gender in autism ( Hull et al., 2017a ). However, data in those studies were collected using isolated measures (parental reports or basic vocabulary tasks), where difference may be under-identified for reasons discussed in this paper. Others used diagnostic measures, which may incur a homogenizing effect by constraining participants and measuring difference using the same tools ( Lai et al., 2015 ). This current article focuses on the smaller body of work investigating subtle sex/gender difference using specific measures of language and communication, in pragmatic and above sentence-level language. Principally, it will consider four clinically driven studies from the authors’ research group; using direct assessment ( Sturrock et al., 2019b ), observation and report measures ( Sturrock et al., 2019a ), child interviews ( Sturrock et al., 2021 ) and parental interviews (Sturrock et al.,), and synthesizes these with recent findings from the wider literature. It proposes that autistic females most likely to be missed from diagnosis (those without intellectual disability: IQ ≥ 70) have a specific profile of language and communication skills, different from both autistic males and typically developing females, and that these differences make them prone to negative social, functional and emotional sequelae. It calls for further research and proposes areas for investigation.
Assessment of a Subtle Profile of Difficulties
While subtle language and communication differences are identified between autistic individuals (without intellectual disability) and typically developing (TD) controls ( Howlin, 2003 ; Kelley et al., 2006 ), this is rarely achieved through basic structural language assessment (e.g., testing vocabulary and sentence-level grammar). Neither is basic structural language expected to differ between school-aged and above TD females and males ( Newman et al., 2008 ). An attempt to explore sex/gender difference must therefore utilize measures with the capacity to compare subtly differing profiles.
Sturrock et al. (2019b) proposed a battery of direct assessments targeting language (expressive and receptive) at multiple levels (word, sentence and above sentence-level/narrative), word knowledge (semantics), inference and vocabulary of emotion. In subsequent work, the authors proposed a series of functional communication measures ( Sturrock et al., 2019a ) including parent and child questionnaires and observational checklists for social use of language (pragmatic skills). Details of assessment measures are found in Supplementary Appendix 1 . These measures were undertaken with a cohort of 52 children without intellectual disability in a 2 (diagnosis: Autism/TD) by 2 (sex/gender: female/male) design. Children were recruited from a narrow age range (8y11m–11y6m), to minimize the effect of increasing language abilities across development. Children in middle childhood were purposefully selected, being young enough to avoid interference of secondary mental health conditions (social communication difficulties are thought to increase in secondary school for autistic girls; 6) but old enough to be post- diagnosis (likely to occur much later for autistic girls ( Rutherford et al., 2016 ). Overall, participants had PIQ ≥ 70, and there were no statistical differences on basic vocabulary and grammar skills or autism severity between groups (see Supplementary Appendix 2 ). Figure 1 provides a depiction of assessment measures per child.
Flow diagram of participants and measures over four studies of language and communication.
As predicted from the literature ( Howlin, 2003 ; Kelley et al., 2006 ) no group differences were identified in receptive or expressive vocabulary or sentence-level language. However, it is possible that other measures may have provided a more discrete assessment of difference; for example, The Index of Productive Syntax ( Scarborough, 1990 ) showed group differences in expressive sentence-level grammar when comparing spontaneous language samples of autistic children without learning disability and TDs ( Eigsti et al., 2007 ). Similarly, subtests for following oral instruction within the CELF ( Semel et al., 1987 ) and NEPSY ( Korkman et al., 1997 ) assessment batteries, demonstrated problems in receptive ability ( Koning and Magill-Evans, 2001 ; Saalasti et al., 2008 ) for autistic children without intellectual disability compared to controls. Sex/gender differences in these language subtests have not been explored but may have better capacity for identifying subtle variations and are worthy of investigation. Another consideration is the existence of heterogeneity amongst autistic individuals and the probable existence of a subgroup with specific grammatical language impairment ( Roberts et al., 2004 ; Wittke et al., 2017 ). Similar to the non-autistic population specific language difficulties can occur in autism without other intellectual disability, the prevalence of this within autistic girls is currently unknown. In larger population studies, it would be important to isolate this group for separate consideration in analysis. The findings from the author’s series of studies focuses on the profile of autistic girls without such additional and specific grammatical difficulties, as evidenced by the children’s performance on the basic structural language tasks.
Sex/Gender Difference in Narratives
Narrative has been used to demonstrate subtle deficits in the language and communication skills of autistic individuals without intellectual disability, even when basic structural language is in normal range. Narrative requires the individual to recall, organize and present information in a way that orients the listener to story meaning; blending cognitive and linguistic skills ( Norbury et al., 2014 ) with an ability to interpret social cues from the listener ( Volden et al., 2017 ). Mixed-sex/gender or male autistic groups without intellectual disability have demonstrated deficits in structural ( Diehl et al., 2006 ; Rumpf et al., 2012 ; McCabe et al., 2013 ) and pragmatic ( Capps et al., 2000 ; Losh and Gordon, 2014 ; Banney et al., 2015 ; Kauschke et al., 2016 ) features of narrative. It therefore provides scope for demonstrating differences in higher-level language and communication profiles and potentially between sex/gender.
Sturrock et al. (2019b) found autistic females and males performed similarly but behind TDs in their use of temporal connectors (“and then.”) and number and range of causal connectors (“so.”) leading to overall limitations with structural complexity and pragmatic coherence. This may potentially support the argument for subtle group differences in higher-level linguistic competency ( Kelley et al., 2006 ; Eigsti et al., 2007 ; Saalasti et al., 2008 ). Other studies have demonstrated sex/gender differences in pragmatic elements of narrative, with autistic females generating richer character depictions and descriptions of internal states, cognition, perception and judgment ( Kauschke et al., 2016 ; Boorse et al., 2019 ; Conlon et al., 2019 ) and overall better skills in retelling salient story elements ( Conlon et al., 2019 ). When compared to typically developing peers, however, autistic girls experienced difficulties on these measures ( Kauschke et al., 2016 ). Sturrock et al. (2019b) also found autistic females and males performed behind typically developing children in their use of vocabulary of emotion in narrative. These relative difficulties for autistic girls compared to TDs may put them at a functional disadvantage in terms of social integration ( Dean et al., 2014 ) and self-advocacy ( Sillar et al., 2014 ). The need for integrating linguistic information with social cues ( Volden et al., 2017 ) may explain better outcomes for autistic females on pragmatic elements of narrative. This may be grounded in other noted advantages for females; in social motivation ( Head et al., 2014 ; Sedgewick et al., 2016 ) and social attention ( Harrop et al., 2018 ). It would therefore be of interest to isolate underpinning linguistic and socio-cognitive skills in narrative and investigate the influence of sex/gender on those.
Semantic Sex/Gender Differences
Sex/gender difference in this language and communication domain are particularly poorly investigated, despite being one of the more widely recognized linguistic impairments in autism more generally ( Groen et al., 2008 ). However, Sturrock et al. (2019b) and Goddard et al. (2014) found that autistic females performed better than autistic males using similar word-generation/fluency tasks. They also both found that autistic girls performed behind TDs on the same measures. Sturrock et al. (2019b) asked participants to name as many words as they could from four categories (animals, food, occupations and emotions) within a 60-s limit. Raw scores for “animals,” “food,” and “occupations” were amalgamated into one composite score and analyzed separately from the category “emotions.” Unlike expressive vocabulary tasks (like the TOWK), word-generation tasks require the individual to generate multiple word examples from a single category (relying on a flexible interpretation of word meaning) and does not provide visual stimulation to aid recall. These features may explain why semantic/word-generation tasks are more commonly occur in autism ( Groen et al., 2008 ) while expressive vocabulary may be unimpaired. Secondary analysis in Sturrock et al. (2019b) , study suggested that the sex/gender differences occurred within categories as well as using the composite score. Autistic boys demonstrated relatively elevated performance in the category of “animals” which observationally was associated with specialist knowledge in this area (typified by low-frequency, highly specialist exemplars; lion-mane jellyfish, stork-eyed beetle, goblin shark). The interaction between special interests and vocabulary acquisition is an area of potential future research, which might help explain elevated idiosyncratic word choices reported in autistic groups ( Walenski et al., 2008 ). Further, differences in performance on semantic category word-generation tasks have been associated with differences in lexical organization between autistic and non-autistic groups ( Gaffrey et al., 2007 ), highlighting the need for investigations of sex/gender differences in mechanisms of the development of semantic organization and their relationship to outcomes on these tasks.
Sex/Gender Differences in Pragmatics: Inference and Discourse Behaviors
Inference is identified as a persistent difficulty for autistic individuals without intellectual disability ( Loukusa and Moilanen, 2009 ), relying on core language ( Tzuriel and Groman, 2017 ) and social-cognition skills ( Martin and McDonald, 2004 ). Currently, there is very limited investigation into sex/gender differences in pragmatic inference. Two tasks in Sturrock et al. (2019b) provide some early insight: one interpreting meaning from figurative language ( MacKay and Shaw, 2004 ), the other interpreting coherence within text using world knowledge ( Jolliffe and Baron-Cohen, 1999 ). The children were asked to explain speaker’s intended meaning and demonstrate meta-awareness of a range of figurative language examples in the first task, then asked to identify missing information implied within a short story in the second. These early investigations suggested that autistic females perform better than autistic males and worse than typically developing females on tasks requiring inferential interpretation. Further investigation is of course required. However, it is in keeping with the literature that underlying skills in social awareness may put autistic females at an advantage on these tasks. These early findings suggest important differences in inference between autistic females and males, with consequent implications for diagnosis. They point to fruitful further work investigating sex/gender difference in other measures of inference, and highlight the importance of isolating the relative impact of social cognition or linguistic ability on performance.
By contrast, sex/gender differences in pragmatic behaviors during discourse have had more attention in the wider literature. Sturrock et al. (2019a) used the Pragmatic Rating Scale (PRS; Landa et al., 1992 ) as a measure of observable pragmatic features within semi-structured discourse (using the Autism Diagnostic Observation Schedule-Second Edition; Lord et al., 2012 ). Total PRS scores ( Sturrock et al., 2019a ) again showed autistic females performing better than autistic males but behind typically-developing females, replicating the pattern found in pragmatic (inference) tasks ( Sturrock et al., 2019b ). Differences were driven by performance on discourse management, communicative use of speech and language and non-verbal skills. Although specific analysis of sex/gender differences in discourse have not yet been undertaken, they will certainly have an important impact on the social experiences of autistic individuals. For example, Cola et al. (2020) found autistic females performed better than autistic males on a measure of first impressions during naturalistic conversations. The authors proposed first impressions would be based on judgments of pragmatic behaviors such as vocal prosody, gesture, facial expressivity and general awkwardness, although this was not expressly tested. Similar findings occurred during observation of video-recorded interactions in a study by Cage and Burton (2019) . Better conversational reciprocity for autistic females compared to autistic males was also identified using diagnostic criteria in DSM-IV and DSM-5 ( Hiller et al., 2014 ) and through analysis of appropriate pause markers, e.g., “um” as opposed to “uh” during speech samples ( Parish-Morris et al., 2017 ). It has been suggested that this could be associated with females’ masking of autistic features ( Parish-Morris et al., 2017 ), a phenomenon associated with camouflaging autistic behaviors more generally ( Hull et al., 2017b ). However, pragmatic language requires skills which integrate linguistic content with social context ( Baird and Norbury, 2016 ), and as previously described autistic females’ elevated outcomes on social measures (compared to autistic males) may be due to natural differences in social attention and motivation ( Head et al., 2014 ; Sedgewick et al., 2016 ; Harrop et al., 2018 ). Detailed discourse analysis could contribute to better understanding of subtle differences in conversational behaviors between autistic females and males and should be compared to normative data.
Subtle Profile and Significant Impact
Overall, then, early findings suggest that autistic females will present with a subtle profile of language and communication difficulties compared to autistic males, yet they continue to demonstrate difficulties compared to typically developing females. This mirrors findings from research into social interactions ( Sedgewick et al., 2016 ) and play behaviors ( Knickmeyer et al., 2008 ). Their subtle presentation, compared to autistic males, may easily confound diagnosis, limiting access to appropriate services and indirectly leading to poorer functional outcomes and emotional well-being ( Bargiela et al., 2016 ). However, it is also important to consider whether fewer language and communication difficulties as measured by direct assessment, will equate with fewer perceived difficulties as reported by the individual or their parent.
The limited data appear to suggest that when asked to rate language and communication difficulties autistic females and their parents perceive a similar level of deficit as autistic males and their parents ( Sturrock et al., 2019a ). This was shown using the CC-SR ( Bishop et al., 2009 ), and CCC-2 ( Bishop, 2003 ). This may indicate equal levels of perceived difficulties experienced by autistic females and males.
Although hard to interpret, similar findings were identified when autistic individuals ( Holtmann et al., 2007 ) and their parents ( Lai et al., 2011 ) were asked to rate their autism severity. As with the language and communication data, females and males perceived their levels of difficulty to be equally severe, despite females presenting with lower severity on more objective measures of clinical observation. It has been hypothesized that this phenomenon is related to the higher social expectations placed on females ( Holtmann et al., 2007 ), meaning their reduced level of difficulty could be offset by an increased level of demand. It could also demonstrate that autistic females and their parents are acutely aware of subtle functional difficulties when compared to typically developing peers, a disparity reflected in the comparative data already discussed ( Knickmeyer et al., 2008 ; Sedgewick et al., 2016 ; Sturrock et al., 2019b ).
Therefore, despite a relatively subtle presentation of language and communication difficulties, autistic girls and boys without intellectual disability might be expected to experience a similar level of impact. Detail of that impact was provided in qualitative accounts ( Sturrock et al., 2021 ) from 12 autistic children (6 girls, 6 boys). Daily living (participation and self-advocacy), social interrelations (social interactions and relationship-building) and emotional wellbeing (reactive and longer-term negative emotions and difficulties help-seeking) were all identified as areas of direct impact. Preliminary analysis of parental interviews ( n = 12) seems to support these assumptions ( Sturrock et al., in preparation ). Supplementary Appendix 3 provides details of interviewee characteristics.
Thematic analysis found that difficulties with discourse, listening and word-finding were strongly associated with breakdown of conversations. These may contribute to results from recent empirical research, which suggests language difficulties will predict poorer social performance in autistic individuals ( Levinson et al., 2020 ). Additionally, the associated effort incurred in managing these difficulties often resulted in avoidance or limitations to social participation. In child accounts, narrative difficulties were closely associated with limitations in explaining events, thoughts and ideas, and this in turn was related to difficulties with self-advocacy and social integration, as predicted in the literature ( Dean et al., 2014 ; Sillar et al., 2014 ). Supplementary Appendix 4 shows a representative sample of quotes and themes.
These subtle difficulties experienced by autistic girls were also commonly associated with feelings of frustration, anxiety and negative sense of self-worth. The negative impact of communication difficulties on mental health are recognized in non-autistic populations ( Levickis et al., 2018 ), but less well explored in the autism literature. This is an area of particular interest for future research due to the higher rates of associated mental health conditions in autistic individuals without intellectual disability ( Leyfer et al., 2006 ).
The children interviewed not only described a negative emotional impact from communication difficulties, they (and their parents) also reported specific difficulties expressing emotional content in personal narratives. Recognition of emotion is thought to be limited in autistic individuals ( Uljarevic and Hamilton, 2013 ) and this may be linked to underpinning difficulties with social cognition for the group ( Löytömäki et al., 2020 ). However, recent research suggests that relative to autistic males, autistic females may be more inclined to comment on the emotions of others ( Rieffe et al., 2021 ), they may have better skills in recalling emotional memory ( Goddard et al., 2014 ), more advanced receptive and expressive use of vocabulary of emotion ( Sturrock et al., 2019b ) and improved narration of the internal states of others ( Conlon et al., 2019 ; Kauschke et al., 2016 ). As emotional literacy is linked to better well-being ( Eisenberg et al., 2005 ) through support-seeking and self-regulatory mechanisms, its relationship with sex/gender and communication difficulties is an important area of research interest.
Discussion and Future Directions
This overview of the current literature strongly suggests that language and communication difficulties present differently for autistic females without intellectual disability, compared to autistic males with the same IQ and autism severity. This may contribute to poorer recognition and lower diagnostic rates of autism in this group. Areas of greatest sex/gender difference appear to exist in domains where meaning of structural language is mediated by social context; inference; language of emotion and internal state; and pragmatic behaviors (discourse and pragmatic features of narrative). See Table 1 for an overview of those findings.
An overview of key findings showing a comparison between autistic females, autistic males, and TD females.
Female advantages in pragmatic and semantic tasks may be linked to natural advantages in social motivation and attention, when compared to autistic males. This interaction should be explored and compared to the influence of higher-level linguistic skills.
Fewer studies provide sex/gender norms but where they do exist, autistic females appear to perform behind typically developing females on measures of pragmatics, semantics, and above sentence-level structural language. However, vocabulary and basic grammar (receptive and expressive) appear to be unaffected. Thus, the evidence reviewed suggests that measures of vocabulary and basic grammar cannot rule out higher-level language difficulty.
Further investigations are required to validate existing findings in a wider group, across different age ranges and with different IQ and autism severity. Other measures could also be explored with a particular focus on discourse analysis, spontaneously produced syntax and following instructions.
Perhaps surprisingly given these sex/gender differences in higher-level language abilities, questionnaire and interview data suggest that autistic females experience their language and communication difficulties similarly to autistic males, both in degree and type of impact reported. The parity of respondent accounts suggests that questionnaire and interview data may not be the best method for investigating sex/gender differences. The lack of observable differences when using these methods may reflect societal factors, with females and their parents naturally comparing their performance against the higher demands set by typically developing female groups. However, qualitative methods remain a critical tool for demonstrating the experience of the individual in both research and clinical domains.
Overall, then, it appears that the subtle language and communication difficulties outlined here may contribute to impact on functionality, social-interrelations and emotional well-being. These early findings should be consolidated with further empirical research. The relationship between subtle difficulties and emotional well-being is an area of particular concern due to the prevalence of mental health difficulties for this group.
Clinical Implications
This paper supports the notion of a specific female autism phenotype and extends this to the domain of language and communication differences. Awareness of this presentation is essential for accurate identification and diagnosis of autistic females without intellectual disability.
The presentation of subtle language and communication difficulties, in particular above sentence-level language, pragmatics (inference and discourse) and semantics, should be assessed in clinical settings. This should include direct assessment, observations and facilitated self-report. Basic structural language measures of vocabulary and sentence-level grammar should not be used to rule out communication difficulties.
Results from appropriate assessments of need should be used to guide targeted interventions. This should include managing the negative impact of language and communication difficulties on functionality, social-interrelations and emotional well-being.
Limitations
The literature in this area is sparse. It is also typified by smaller studies, and due to the wide range of measures, used overarching assumptions cannot be made with any certainty. In addition, many of the studies discussed are by necessity preliminary and exploratory. While these limitations mean that any conclusions drawn from the current paper must remain tentative, in itself this issue highlights an important point: linguistic profiles in the female autism phenotype are currently extremely poorly understood, and these gaps in our understanding may contribute to problems of mis- or under-diagnosis in this group. The current paper therefore highlights important avenues for future empirical work in this under-researched area.
Data Availability Statement
Ethics statement.
The studies involving human participants were reviewed and approved by South West—Central Bristol Research Ethics Committee (November 2015). Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.
Author Contributions
AS devised the research questions and was the lead researcher on the series of studies, which are discussed in this article. They were undertaken as part of her Ph.D., during which time she was supervised by JF and CA. All authors contributed to the development of methodology and data analysis across these studies. AS wrote this manuscript in consultation with this team of authors.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s Note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Acknowledgments
We thank to all the fantastic families, children, and professionals who took part in this research, as well as the charitable support groups who helped promote our participant recruitment. Much appreciation also to North West Borough Heath and Bridgewater NHS trusts for providing ethical approval for recruitment and the individual staff who put us in touch with interested study participants. We thank to Kelly Burgoyne, Antonia Marsden, Helen Chilton, Katie Foy, and Kathy Leadbitter for their support with quantitative and qualitative analysis over concurrent studies, as well as volunteers who were inspired by the subject area to contribute their time for data collection; Natalie Yau, Charlotte Bown. We are particularly grateful to the autism community who supported this series of studies advice, critical evaluation and development of research questions and materials, in particular the many fine individuals at autism@manchester (public and patient involvement and engagement group) and good friend Katie Twomey, for her continuing support and insight into language research from lived experience. This research was supported by the NIHR Manchester Biomedical Research Centre.
Funding. We thank the NIHR Manchester Biomedical Research Centre for supporting this project.
1 The term “sex/gender” is used to reflect the understanding that individuals’ identities are composed of hard to distinguish features of biological “sex” and socially constructed “gender.”
Supplementary Material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2021.621742/full#supplementary-material
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The Female/'Internalised' Presentation of Autism
How gender impacts autistic traits, far more males than females are diagnosed with autism in australia. in fact, four australian males are diagnosed on the spectrum to every one female mostly because almost everything that's known about autism has come from studying boys..
Evidence has shown that most Autistic females are better able to ‘camouflage’ their symptoms by using strategies to mask communication and social difficulties and even act in ways that are considered more ‘socially acceptable’ for girls compared to boys. For example, girls may watch others and mimic their behaviour to better blend in. This is particularly the case when girls have an average or high range IQ. This means girls are often diagnosed later in life, or even as adults.
Diagnostic Criteria
The criteria for diagnosing Autism isn’t different for boys compared to girls, but because the presentation of traits is quite different, it makes it harder to diagnose.
It's important to mention that the behaviours, traits, demeanour and presentation listed below have been identified as 'female', however, it needs to be acknowledged there are indeed boys that display the same characteristics and equally get overlooked, are harder to diagnose and/or are diagnosed later due not exhibiting the traditional male behaviour.
A Word on Gender
It's important for me to acknowledge that I am and will be using gendered terminology and references in the identification of Autism in Girls/Women/Females. I do so knowing that not everyone identifies themselves in these 'traditional' ways and it's important for me to make this known as I don't ever want to offend, alienate, invalidate or minimise anyone, especially when the matter is something that is at the core of their, or your, identity.
It's important for me to explain Autism (and all neurological differences) in gendered ways as this is the experience of so many women who have received an Autism diagnosis as adults.
Women have long been overlooked, misdiagnosed and literally misgendered not fitting into the 'male' model, presentations, traits and stereotypes of most neurological differences. I separate the gender distinctions knowing that the conversation needs to be had, no matter how a person identifies themselves as.
We've waited far too long for our traits and presentations to be recognised, categorised and acknowledged, for them to be ignored or dismissed because of the way some people identify. I say this with all the respect in the world.
Female Autistic Traits
Autistic girls often appear shy. Their shyness, however, is often a strategy used to avoid or approach social interactions with caution due to (their social communication difficulties) being unsure how to engage and/or behave.
Autistic girls have also been described as 'intense', quiet, mute, or even that talk too much. They may appear to be bossy, or rude or take on the teacher or custodian role telling others what to do. Girls are likely to avoid demands, have an intense focus and determination and have a high sense of social justice and concern about the 'rules', (often too rule-bound) and be too interested in what others are doing.
Emotional Characteristics
Autistic girls can be highly sensitive, anxious and may get upset easily, in addition, tend to over-apologise and, over-react, taking on characteristics of others (by mimicking), have perfectionistic traits and be extremely strong-willed.
Autistic girls have been observed to internalise their thoughts, be compliant and well-behaved and therefore overlooked. When they get home however or feel safe, they tend to release their valve. They often respond or present themselves in a passive-aggressive manner and insist that everything has to be done 'their way'.
Social Characteristics
Girls generally lack reciprocity in social play and find back and forth conversation challenging and tend to flitter between groups or people or may have one best friend (female or male) that they find difficult to share.
Girls struggle socialising in large groups due to the number of social cues, body language and tone of voices that need to be decoded to understand the social interaction (and possibly sensory challenges that need to be managed/drowned out). Some girls prefer the company of older or younger peers.
Girls watch and observe others using their intelligence to understand social situations, mimicking the behaviour of those around them, use 'compensatory strategies' from an early age often showing their peers, imitating peer behaviour to initiate social contact.
As socialisation becomes more sophisticated (usually around the age of nine/ten) the gap between their social understanding, mimicking etc tends not to work anymore resulting in higher than usual social anxiety, sleep disturbances and/or school refusal.
Girls at school tend to spend playtime alone, walking around in the library, or looking for opportunities to help others rather than socialise with peers. She may position herself as the class helper, and called 'the teacher's pet', or spend a lot of time following or being with teachers, as mentioned above, preferring the company of older people.
Girls are known to be exceptional 'social blenders' camouflaging into the background ensuring they get no attention, so more likely to be ignored or overlooked. This is also referred to as 'social masking' and can have significant and detrimental long-term mental health side effects.
Special Interests
Girls' 'special interests' are similar to their peers, but more intense.
Their interests are considered more socially acceptable, meaning they tend to be more mainstream than that of boys, like, animals, fashion, historical facts or age-appropriate trends e.g. playing Minecraft.
Their interests might also be to collect information on people instead of things.
Girls may have imaginary animals or friends who are very real; often very imaginative and creative; 'off in their own world'.
Repetitive and restricted behaviours
Girls/females appear to have less repetitive and restricted behaviours compared to boys but could also just have behaviours that go unrecognised.
Sadly, girls who show these traits are more likely to be ignored or misunderstood rather than diagnosed and treated.
Academic Considerations
Girls can get very good grades, have no academic or learning difficulties or can be cognitively gifted.
Their social challenges are attributed to being 'too bright' for their peers.
Diagnosis Difficulties
Families of Autistic girls/females report on how frustrating and difficult a proper diagnosis is to gain due to the lack of information amongst health professionals and mental health practitioners on the presentation of Autistic girls/women and therefore fail to identify their traits correctly.
Source: The Little Black Duck , ' Females on the Autism Spectrum '
Autistic Girls and Females
Due to the differences in how Autism is presented in girls and how well they're able to mask, girls are typically diagnosed much later than boys, or miss-diagnosed completely with conditions that 'appear' to fit the profile.
Source: @theaspieworld , 'Autism and Girls'
See more infographics on the presentation of Autism in girls/females, here .
Source: Clinical Partners , ' Tackling low diagnosis of autism in girls '
Source: Attwood and Garnett Events , ' Why are autistic girls and women underdiagnosed '?
Source: Attwood and Garnett Events , ' Pathway and reasons to diagnosis for an autistic girl or woman? '
1 hr 19 min
Autism and the Female Phenotype. Prof. Robyn Young Clinically Thinking
Professor Robyn Young from Flinders University is our guest discussing the presentation and diagnosis of Autism specifically in female clients. Our wide ranging discussion covered broader issues including Autism and the criminal justice system, changes in Autistic presentation with age, training for Autism assessments, clients who camouflage Autistic characteristics, the impact of Australia's NDIS funding on the diagnosis and assistance for Autism, and much, much more. Follow our Clinically Thinking Facebook page to find links or resources mentioned in the show.
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How We Talk About Autism and Why it Matters
A personal perspective: why including all autistic people's voices is important..
Posted February 20, 2024 | Reviewed by Devon Frye
- What Is Autism?
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- Neurodiversity-affirming language represents a positive shift in how autistic people express themselves.
- Some people prefer to adopt a medical model to discuss their, or their children’s, autism.
- Making room for all autistic people’s viewpoints is essential to avoid silencing autistic people.
In an online attack, I was recently accused of being "dangerous and damaging" to the autistic community. Why? Because I used the phrase "level 1 autism" which was, I was informed, "outdated and ableist."
As an autistic woman and mother of an autistic son, I consider myself a neurodiversity advocate. Much of my time is spent helping people to accept, normalise, and embrace their autistic traits and experiences and encouraging them to ask for accommodations that help them adapt the world around them to their needs or differences.
But this doesn't mean I reject the fact that there are vastly differing experiences of autism and that people, including parents of autistic children, should be allowed to choose language that makes sense to them and fits with their values without risking being silenced for doing so.
Levels of Autism
Per the DSM , there are three levels of autism. Level 1 autism includes people of average or above-average intelligence who can lead largely independent lives. Level 2 autism includes people who need higher levels of support, and level 3 autism includes people who need significant support. Since changes to the DSM in 2013, people who would previously have been diagnosed with Asperger's syndrome have been diagnosed with level 1 autism.
From a personal perspective, when I was going through the research and diagnostic process a few years ago, the levels of autism made, and continue to make, complete sense to me. My experience of being autistic contrasts significantly with someone with level 2 or 3 autism. My experience of parenting a child who will, one day, be able to leave home and be financially independent and have a range of options available to him is also completely different from someone who is parenting a child who will always require a significant level of support.
It doesn't mean my experience is "better"—having level 1 autism comes with a substantial series of challenges—but it means that it is significantly different. Having the vocabulary to express that difference, particularly to people who know very little about autism, is important to me.
It's also important to most of my clients, who are predominantly adult women seeking out a diagnosis later in life. When I explain what autism is, or when they have conducted their own research, they can identify with other autistic people who, like them, have led a life so far which has allowed their autism to go undetected. It also provides them with the vocabulary to talk to employers or access a level of therapeutic support appropriate for their needs.
Medical Model
While the "medical model" of autism is criticised for identifying autism as a disorder characterised by deficits or impairments, it provides a voice for some parents of autistic children who are severely impacted by autism. It also provides a voice for people not in a position to view autism positively.
Some of my clients cannot cope in their jobs, even with appropriate accommodations. They struggle with the demands of daily life, including parenting and running households. Many have anxiety , depression , and other mental health conditions. They may have sought a diagnosis to access disability benefits and support.
Some also find that medicalising their condition, through their use of language, helps them acknowledge the devastating impact it has had on their life. Symptoms like severe and potentially violent or self-injurious meltdowns, perseverative thinking, executive function issues, extreme distress around change, sensory processing issues—sometimes to the point of being unable to sit in a classroom or restaurant—consistent anxiety, and a need for sameness affect autistic people daily. Calling for language that "neutralises" their experience—to the point where it is unacceptable for them to talk about autism in terms of severity or disability—reduces their means of expression. If someone finds it more accessible to talk in terms of autistic symptoms that they feel are limiting, disabling, or severe, they should have the right to do so.
Neurodiversity-affirming language represents a generally positive shift for many autistic people. But those who choose to think and talk about their, or their children's, experience in ways which draw more heavily on a medical model, or which stress the negative impacts of autism, should be allowed to do so. If we replace one exclusionary discourse with another, we're simply silencing an entire section of the autistic community.
Claire Jack, Ph.D. , is a hypnotherapist, life coach, researcher, and training provider who specialises in working with women with autism spectrum disorder (ASD). She was herself diagnosed with ASD in her forties.
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Autism in Women Causes Diagnosis Support and Treatment Autism spectrum disorder (ASD) is a developmental disability that is usually diagnosed at or before the age of 3. While people of any sex and gender can be autistic, it is common for people assigned female at birth to be diagnosed with ASD later in life.
Females with ASD tend to present with less restricted interests and repetitive behaviors (RRBs) (Supekar and Menon, 2015), thus standing out less both in society, as well as on screening and diagnostic measures. Fewer RRBs makes ASD appear in a different way, often more subtle, than what is considered to be the norm.
Women with Autism Spectrum Disorder Autism 10 Key Signs of Autism in Women Sensory sensitivity, camouflaging, and more. Posted April 29, 2021 | Reviewed by Devon Frye Key points Male and...
Females with high functioning autism may internalize and mask their symptoms, leaving them without the right support. Colloquially known as autism, autism spectrum disorder (ASD) refers to...
A striking feature of autism is the high male to female ratio, which has traditionally been reported to vary across the spectrum; most studies quote 4-5:1, falling to 2:1 where autism is accompanied by significant intellectual disability, and rising to perhaps 10:1 amongst autistic individuals with average or superior intellectual ability (Dworz...
Some of the core characteristics of autism are having 'repetitive behaviours' and highly-focused interests. Stereotyped examples of these include rocking backwards and forwards, and a fascination with trains.
Social awareness. Autistic girls may be more socially aware, overall, than their male counterparts. They may have a higher ability to maintain relationships with other people and adjust their ...
The Early Childhood Signs of Autism in Females: a Systematic Review Article Open access 30 July 2022 Autism Diagnosis and Prevalence Autism diagnosis has traditionally been most common in childhood, when differences from neurotypical peers may first become obvious.
Males and females both have hyper-fixated and restricted interests but many of my female clients get fixated on things like Dungeons and Dragons, animals, world-building, books, bones, autism ...
Autism is characterized by social communication and interaction difficulties as well as restricted and repetitive behavioural patterns and sensory sensitivities. 1 Gender differences in autism diagnosis in adulthood have been found, with the proportion of women seeking a diagnosis increasing with age, and gender ratios of prevalence ranging from...
Abstract Purpose Autistic women and girls have received comparatively less attention within clinical practice and research. Research suggests women tend to be diagnosed later than men, and are more likely to experience misdiagnosis.
The theory placed empathizing (female) and systemizing (male) on opposite ends of a gender spectrum and posited that, regardless of sex, autistic individuals tend to present more "male" characteristics (i.e., patterns and systemizing) instead of "female" traits (i.e., social literacy and empathy) (Baron-Cohen, 2002; Greenberg et al., 2018).
Due to the underrepresentation of females in both research and clinical practice, one hypothesis is that our conceptualisation of autism and the development of diagnostic criteria and assessment tools is based upon the 'male' presentation (Kopp & Gillberg, 1992; Kreiser & White, 2014 ).
Here are five signs of autism in women: 1. Intense focus on a person/band/celebrity. One of the criteria used for determining ASD—for instance, in Simon Baron-Cohen's Asperger 's Test 1 —is an...
The Autism Spectrum Screening Questionnaire - Girls (ASSQ-GIRL; Kopp & Gillberg, 2011) is an 18-item parent or caregiver-rated questionnaire designed to assess behavioural characteristics consistent with an emerging female presentation of autism in child and adolescent females.
Assessment of Autism in Females and Nuanced Presentations Integrating Research into Practice Home Book Authors: Terisa P. Gabrielsen, K. Kawena Begay, Kathleen Campbell, Katrina Hahn, Lucas T. Harrington Examines characteristics of autism in females and atypical presentations
Findings - Findings suggest that autistic females present differently to males, and highlight low recognition of the female presentation of autism among the general public, in social...
Girls and women with autism are often undiagnosed, misdiagnosed or receive a diagnosis of autism at later age. This can result in adverse outcomes in their well-being, mental health, education, employment, and independence. ... Additionally they do not reflect the unique presentation of autism in females demonstrated by greater compensatory ...
Autism is a highly heterogeneous neurodevelopmental disorder (1:00). Supekar discusses the skewed gender ratio of women to men (ratio of 1 to 4) in autism diagnoses and asserts that this lack of female representation is a key source of heterogeneity in autism symptom presentation, treatments, and research (2:20).
Strong sensory sensitivities, especially to sounds and touch (for example; clothing tags, socks or even deodorant). For autistic girls to thrive, it's important they have access to a timely and accurate diagnosis, and the informed supports that come with it.
Understanding Autism in Women. Autism spectrum disorder (ASD) is a complex, lifelong developmental condition that affects social interaction, communication, interests, and behavior. While ASD affects individuals regardless of gender, it is more prevalent in males than in females with a ratio of 4:1.
The presentation of autism in females is poorly understood, which is thought to contribute to missed or later- age diagnosis, especially for those without intellectual disability. Dedicated research into social and behavioral differences has indicated a specific female phenotype of autism. However, less has been done to explore language and ...
Evidence Evidence has shown that most Autistic females are better able to 'camouflage' their symptoms by using strategies to mask communication and social difficulties and even act in ways that are considered more 'socially acceptable' for girls compared to boys. For example, girls may watch others and mimic their behaviour to better blend in.
Professor Robyn Young from Flinders University is our guest discussing the presentation and diagnosis of Autism specifically in female clients. Our wide ranging discussion covered broader issues including Autism and the criminal justice system, changes in Autistic presentation with age, training for…
Levels of Autism. Per the DSM, there are three levels of autism. Level 1 autism includes people of average or above-average intelligence who can lead largely independent lives. Level 2 autism ...
A new study suggests that there are significant differences in how male and female children with high autistic traits process visual information. Andrew Silva and colleagues asked 381 nine-year-old children who exhibited a range of autistic traits on the Autism Spectrum Quotient (AQ) to perform tests involving dorsal or ventral processing of ...