Autism Spectrum Disorder (ASD) in Women and Girls

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Autism spectrum disorder (ASD) is a developmental disorder that is characterized by challenges in social communication and interaction, as well as restricted, repetitive patterns of behavior, interest, or activities. According to the CDC, ASD is approximately 4 times more common in boys than girls. This statistic is likely an underrepresentation given that there is a well-established gender bias in the realm of autism assessment and diagnosis. Consequently, people assigned female at birth tend to be misdiagnosed or diagnosed with ASD later in life. Although this post will focus on the experiences of girls and women, non-binary and gender non-conforming people may experience similar challenges with regard to ASD diagnosis.

Barriers to Diagnosis

Although research continues to develop, there are currently no reliable biomarkers for autism. Therefore, ASD is diagnosed based on observation and evidence of core characteristics (e.g., stimming, meltdowns, sensory differences). ASD diagnostic materials, however, were developed and normed for males. As a result, girls typically need to experience more significant impairments in order to receive a diagnosis.

Female Autism Phenotype

Emerging research also suggests that the behavioral expression of ASD in females (i.e., the female autism phenotype) differs from the traditional diagnostic criteria.

Masking/Camouflaging

Girls and women are more likely to intentionally or unintentionally “mask” their symptoms and behaviors in order to fit in with peers.

Common masking behaviors may include:

  • Mimicking social behaviors (e.g., facial expressions, tone, body language)
  • Forcing oneself to make eye contact during conversation because it is socially appropriate
  • Preparing for conversations ahead of time by rehearsing jokes or conversation topics

Although both men and women can engage in masking behaviors, this tends to be more common in women. These masking behaviors may help explain why women are less likely to be diagnosed with ASD.

Social Communication and Interaction

ASD diagnostic criteria also include difficulties with social communication and interaction. Girls and women with ASD tend to have higher levels of social motivation compared to boys and men. However, girls and women with ASD tend to have more challenges maintaining long-term friendships and also experience more conflict in friendships.

Restricted and Unusual Interests

Restricted and repetitive interests are also a hallmark of ASD. Restricted and unusual interests tend to be underestimated in girls because they are different from the classic ASD boy interests (e.g., vehicles, computers) or are not considered “atypical.” For example, ASD girls tend to have highly fixated interests related to animals or fictional characters. These interests tend to be considered more age and gender appropriate for girls, so they are often not identified as unusual or restricted.

Co-occurring Internalizing Problems

Girls and women with ASD are also more likely to experience co-occurring internalizing problems (e.g., anxiety, depression, eating disorders, etc.). The expression of these internalizing problems can mask underlying ASD characteristics and result in non-diagnosis of ASD. Girls and women are also more likely to be misdiagnosed due to the overlap of characteristics with a variety of other conditions (e.g., personality disorder, bipolar disorder).

Summary

ASD tends to be underdiagnosed and misdiagnosed in girls and women. One primary reason is that diagnostic materials were developed and normed for boys. Additionally, the female autism phenotype results in the differential expression of ASD characteristics. For example, girls and women are more likely to mask or camouflage symptoms, have higher levels of social motivation, and tend to have more “socially appropriate” restricted interests. Additionally, high levels of co-occurring internalizing problems can result in non-diagnosis or misdiagnosis. Women who are diagnosed with ASD, tend to be diagnosed later in life.

If you think that you have ASD and would like to be formally evaluated, consult with a mental health professional or your primary care doctor. Especially for women seeking a diagnosis later in life, it is helpful to seek an evaluation with providers who have experience assessing for ASD in women.

Providers at Upside Therapy recognize the complexities of ASD in women and adults and recognize the importance of maintaining a nuanced understanding of diverse autism presentations. If you are interested in seeking an evaluation or would like to consult with a provider about the evaluation process, please call 972-519-1692 or email info@upsidetherapy.com

Additional Resources

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Bargiela, S., Steward, R., & Mandy, W. (2016). The experiences of late-diagnosed women with autism spectrum conditions: An investigation of the female autism phenotype. Journal of Autism and Developmental Disorders, 46, 3281-3294

Center for Disease Control and Prevention. (2023). Data & statistics on autism spectrum disorder. Retrieved from: https://www.cdc.gov/ncbddd/autism/data.html

Estrin, G. L., Milner, V., Spain, D., Happe, F., & Colvert, E. (2021). Barriers to autism spectrum disorder diagnosis for young women and girls: A systematic review. Review Journal of Autism and Developmental Disorders, 8, 454-470

Gesi, C., Migliarese, G., Torriero, S., Capellazzi, M., Omboni, A. C., Cerveri, G., & Mencacci, C. (2021). Gender differences in misdiagnosis and delayed diagnosis among adults with autism spectrum disorder with no language or intellectual disability. Brain Sciences, 11(7), 912

Hull, L., Petrides, K. V., & Mandy, W. (2020). The female autism phenotype and camouflaging: A narrative review. Review Journal of Autism and Developmental Disorders, 7, 306-317

Lai, M. & Baron-Cohen, S. (2015). Identifying the lost generation of adults with autism spectrum conditions. Lancet Psychiatry, 2(11), 1013-1027