Autism Spectrum Disorder and Gender: The Case for Expanding the Autistic Phenotype

As shown in figures 1 and 2, autistic females are more apt than males to hide their social shortcomings through camouflaging behaviors, making it so they don’t necessarily present traditional ASD characteristics.  This contributes to clinicians’ failure to spot ASD in females: ASD females are more skilled at masking their social difficulties. 

The underdiagnosis of the ASD female also arises from the limitations of ASD diagnostic assessments.  The criteria of many diagnostic assessments are centered on research on ASD males and do not include the unique female autistic phenotype.  Popular diagnostic instruments, such as the Autism Diagnostic Observation Schedule, Autism Diagnosis Interview-Revised, and the Social Communication Questionnaire are not sensitive enough to catch autistic tendencies in females, as their research was conducted with a largely male subject pool (Rynkiewicz et al., 2019).  This failure to document the unique female ASD symptomatology in diagnostic assessments has made it so females must display more severe autistic symptoms and greater cognitive and behavioral issues to be identified with ASD (Russell et al., 2010; Dworzynski et al., 2012).  Thus, many high-functioning women don’t receive an ASD diagnosis.    

Societal and cultural expectations and conceptions also fuel the misunderstanding surrounding the presentation of autistic traits in females.  Gender stereotypes may be conducive to camouflaging because females with ASD may be told to “act like a woman/girl,” which tends to translate to: be more socially active (Lai et al., 2016).  Furthermore, females may face a greater stigma for being disruptive, abrasive, or less empathic, all of which are stereotyped as more masculine traits (Goldman, 2013).  Behaviors that may be concerning when seen in a boy, such as shyness or passivity, may be overlooked when displayed by autistic females, as these are thought to be more feminine characteristics (Geelhand et al., 2019).  Society’s standards and gender expectations are a disservice to females with ASD.  These cultural norms may spur unnatural camouflaging behaviors in ASD girls and cause parents, teachers, and clinicians to be dismissive of females presenting autistic tendencies.  

Effects:  

During their youth, ASD females specifically are at high risk for a host of mental health issues, including anxiety disorder, depression, increased thoughts and/or attempts at suicide, and eating disorders (Rynkiewicz et al., 2019).  Among women with ASD, recurrent depressive disorder is most commonly diagnosed (50% of patients), though some authors imply the symptoms of bipolar affective disorders are just as, if not more, frequent (Rynkiewicz et al., 2019).  A study aimed at recording the experiences of late-diagnosed women with autism also measured women’s anxiety levels.  The average Hospital Anxiety and Depression Scale anxiety score of this sample was 13.5, which is higher than the recommended clinical cut-off, or clinically significant score, of 8 (Bargiela et al., 2016).  Although ASD in females is correlated with high occurrences of poor mental health, a timely diagnosis can diffuse the challenges ASD women face throughout their lifetimes (Rynkiewicz et al., 2019).

Along with negative impacts on mental health, women with autism are susceptible to sexual abuse and rape due to their social vulnerabilities and naivete (Rynkiewicz et al., 2019).  In a qualitative study researching the lives of females diagnosed with ASD later in life, 9 out of 14 participants reported sexual abuse, most of which occurred in relationships (Bargiela et al., 2016).  These women reported struggling to track a man’s intentions, meaning they had trouble discerning if he was acting friendly or making unwanted sexual advances (Bargiela et al., 2016).  Additionally, ASD women described isolation and rejection as teenagers, resulting in an inability to compare tips for safety with female peers and leaving them desperate for acceptance (Bargiela et al., 2016).  One woman shared “Because we don’t sense danger and can’t. That’s one reason, I think you not reading people to be able to tell if they’re being creepy, you’re that desperate for friends and relationships that if someone is showing an interest in you, you kind of go with it and tend not to learn from others’ safety skills.” (Bargiela et al., 2016).  ASD women need a diagnosis to gain insight into their potential for sexual abuse and to learn necessary preventative strategies.

A less quantifiable, but still poignantly important negative effect of underdiagnosing ASD in females is that these women often suffer from self-loathing, as they are unable to understand their differences and particular needs.  One qualitative study interviewed late-diagnosed females with ASD to investigate their shared experiences.  Women’s failed attempts at connection resulted in thoughts that they were “wrong,” “broken,” or “bad” (Leedham at al., 2019).  Some found camouflaging to be extremely draining and dissatisfying.  One woman relays, “… it started at school and it went on to college as well … [I wore] different clothes to everything that I wore at home … I hated this person that I put on” (Leedham at al., 2019). There were a number of common threads that ran through these women’s recollections after being diagnosed with ASD – many talked about a hidden condition, the process of acceptance, post diagnosis impact of others, and acceptance of their new identity on the autism spectrum, as seen in table 1 (Leedham., 2019).