Autistic women and girls

Diagnosis

Why are autistic females being misdiagnosed, diagnosed later in life or not diagnosed at all?

• Some diagnostic tools used during an autism assessment are designed in a way that may identify more male centric characteristics.
• Lack of awareness of how autism can present in autistic women and girls which can lead to no diagnosis, or misdiagnosis, such as being diagnosed with anxiety or an eating disorder.
• Male based stereotypes of autistic traits. The ‘female autism phenotype’ refers to the characteristics of autistic women and girls, proposing there is a difference in these characteristics presented in autistic boys and men1, with the female expression of autism being one that does not meet the current diagnostic criteria.

Some examples of these differences in expression are broken down below into the three areas of the diagnostic criteria as defined by the DSM-5 (2013); social communication, interaction and restricted and ‘repetitive’ behaviours. When you are reading, consider how the male expression of autism may lend itself more towards an autism diagnosis than the female expression:

Social communication and interaction

Diagnostic criteria

‘difficulties adjusting behaviour to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers’

‘failure to initiate or respond to social interactions’

Social relationships

• Autistic males can be less motivated to form social relationships
• Autistic females show similar motivations to form social relationships as non-autistic females

Masking

Masking is a process where individuals imitate others, and hide or stop behaviours to ‘fit in’ with society. This can lead to difficulties such as mental health issues. While being more likely in females, it can occur with males and those who are gender fluid or non-binary. This is thought to be particularly evident in a school environment, with girls often only feeling safe to express themselves at home, whilst masking in school. This can often lead to further internalising distress, or expressing externalised distress when they get home from school.

Ways in which masking may present itself:

• adapts behaviour in order to fit in
• very observant in new activities/environments
• imitates behaviour of others
• subtle copying behaviours e.g., looking at others’ work and appearing to understand a concept
• may force eye contact that can appear more sustained than usual
• being a perfectionist
• highly sensitive to feedback/getting things wrong
• practising conversations in their mind
• suppressing self-stimulatory behaviours or adjusting “stims” to appear more subtle/be more “socially acceptable” e.g., biting a pen, or twirling hair or doodling

Restricted and ‘repetitive’ behaviours, activities and interests

Diagnostic criteria

‘stereotyped or repetitive motor movements, use of objects, or speech’

‘highly restricted, fixated interests that are abnormal in intensity or focus’

Over or under activity ‘to sensory input or unusual interest in sensory aspects of the environment’

Interests

• Autistic males are often more interested in ‘objects’
• Autistic females may be more interested in topics with ‘relational’ purposes, showing more motivation to form relationships with people or pets as opposed to ‘objects’

Self-stimulation

Individuals who mask, may supress their ‘stimming’ behaviours in order to ‘fit in’, or may engage in stimming behaviours that appear more ‘socially acceptable’, such as twirling their hair, or doodling.

They may also mask their response to sensory overload, where their sensory environment becomes too overwhelming.

Expressing distress

It is understood that there are further differences between autistic males and females in the ways in which they express distress:

• Autistic males are more likely to experience externalising distress.
• Autistic females are significantly more likely to have co-occurring internalising conditions than males.

What signs are there that may indicate autistic characteristics in females?

• Masking: You may hear from your child or young adult’s school that they appear to be ‘fine’ in school, however you have observed that they are avoiding going to school in the morning, and may express exhaustion at the end of the school day, which may present in behaviours that challenge.
• Camouflaging: Copying others, preparing a script for social interactions and rehearsing these prior to the social interaction, being highly observant of others e.g., if others laugh, laughing too, even if they have not understood the context or the joke.
• Having passionate but limited interests: Such as only watching one film, and watching this repeatedly.
• Difficulties in maintaining friendships: This can include overthinking every interaction, and/or having regular disputes with friends.
• Appearing to be ‘passive’: Often saying ‘yes’ to everything, and/or appearing to be shy.
• Difficulties in understanding emotions and seeing things from other people’s points of view: Can also be overly empathetic, and be very good in recognising emotions in other people, whilst experiencing difficulties in understanding and managing their own emotions.
• Highly sensitive to sensory experiences: E.g., sound and smell, and food selectivity. Although, this is just as common in autistic men, and not necessarily more common in females.

It is important to remember that due to autism being a ‘spectrum’, each person has different needs, meaning that males may also present with the female characteristics described in this factsheet, and that females may also present with the traditional, ‘male centric’ characteristics described.

Getting support

When speaking to professionals, it is important to emphasise your child’s characteristics if you feel they could be autistic, to ensure that they are not misdiagnosed. See our Navigating support factsheet for more information about the professionals that may be involved.

References

1 Hull et al, 2020, The Female Autism Phenotype and Camouflaging: a Narrative Review https://link.springer.com/article/10.1007/s40489-020-00197-9
2 Sedgewick et al., 2015 Gender Differences in the Social Motivation and Friendship Experiences of Autistic and Non-autistic Adolescents – PubMed (nih.gov)
3 Solomon et al., 2012 Autism Symptoms and Internalizing Psychopathology in Girls and Boys with Autism Spectrum Disorders – PMC (nih.gov)