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Key Takeaways
- Autism can present differently in different genders.
- Autistic women are more likely to mask social differences, exhibit less discernible repetitive behaviors and have different special interests.
- Many people believe women are underdiagnosed with autism because clinical models, research and cultural biases have not adapted to the ways autism actually presents in women.
- Autistic women are more likely to be diagnosed with a mental health condition than autistic men, making it even more important for autistic women to find connections to support.
When you think of autism, who do you picture? Many people may envision a young boy—maybe he’s fixated on toys like model trains or rocking back and forth to stim. But what about a little girl playing out the same scenes with her dolls on a loop or a woman constantly playing with her hair?
There’s a reason these images don’t come to mind for many—men and boys are around 3 to 4 times more likely to be diagnosed with autism spectrum disorder than women and girls. This isn’t because of sex-based neurobiological differences, or at least not fully. Most researchers and advocates recognize that autism presents differently in women and girls than in men and boys. Autistic women are underdiagnosed because traditional models don’t recognize their traits as autistic, leaving huge gaps in support for autistic adult women and in broader awareness of their experiences.
Does autism present differently in women?
Advocates and researchers increasingly believe that autism spectrum disorder (ASD) can present differently in girls and women. Autistic women exhibit autistic traits and behaviors that ultimately align with traditional diagnostic criteria but manifest in ways that are not typically expected. For example, autistic traits in women, particularly social differences, may not be as discernible to others.
This particular expression of autism in adult women and girls is often described as the Female Autism Phenotype (FAP). FAP theory was first introduced in 1992 but didn’t garner much attention from researchers until more recently. This theory proposes a number of reasons autism may present differently in women and girls, including higher levels of masking among women than men.
Though this article will focus on the experiences of autistic adult women, it’s worth noting the unique ways autism may also present in nonbinary people. Nonbinary individuals are well-represented among the autistic population; transgender and nonbinary people are around five times more likely to be autistic. Autism research hasn’t yet focused on nonbinary individuals' experiences, although many nonbinary advocates, writers and creators have shared their own perspectives. The Autistic Women & Nonbinary Network’s website is one of many places where you can find autistic nonbinary individuals writing about their experiences.
Differences in autistic traits across genders
Autistic women tend to exhibit differences from autistic men across a number of characteristics. Most often, autistic women report differences in their social behaviors, repetitive behaviors and special interests.
Social motivation and relationships
Autistic women are more likely to exhibit higher social motivation than autistic men. In fact, autistic women demonstrate similar levels of motivation to pursue and maintain social relationships to that of allistic (non-autistic) women. Autistic women participate in group activities at higher rates than autistic men and often have a larger number of friends.
However, autistic women may have a harder time coping with conflict in social relationships than autistic men or allistic women. There is also some evidence that autistic women struggle more than other groups with the maintenance of long-term social relationships.
Masking
Studies consistently find that autistic women are more likely to be high-masking than autistic men. Masking refers to the act of camouflaging one’s autistic traits to blend in with neurotypical people and avoid social judgment, stigma and loss of opportunities. Not all autistic people mask, and for those who do, masking can be both intentional and unintentional. Often, it is a mixture of both.
Girls learn, often at a young age, that they are expected to be emotionally intelligent and socially adept. In social groups, women and girls are expected to function as mediators and caregivers, and can receive harsh reinforcement when they don’t fit these molds. For autistic girls, this can be incredibly demoralizing. It’s alienating and confusing to be herded towards social expectations that feel opaque and illogical and reprimanded for behaving authentically instead. Because of this, many autistic girls learn to start masking young.
Repetitive behaviors
Autistic women also tend to exhibit less obvious repeated behaviors, often because of conscious or unconscious masking. Autistic women may adopt stims like twirling their hair, playing with jewelry or doodling, among many other behaviors that are not typically associated with autism.
These differences extend beyond stims. Repetition and restriction in autistic women are also more likely to manifest as perfectionist behaviors. They can also show up as disordered eating. For example, research shows that between 20 and 35% of women with anorexia nervosa are also autistic. In that same study, autistic women with anorexia nervosa shared that their two diagnoses interacted closely, identifying disordered eating as a manifestation of their intrinsic desires to repeat and limit behaviors.
If you or a loved one is struggling with an eating disorder, the National Eating Disorders Association (NEDA) can direct you to the support you need.
Special interests
Historically, research has suggested autistic women are less likely to have special interests than autistic men and boys. While this may be true in part, autistic women also tend to develop different interests than men. It’s possible that to others, these interests simply don’t appear to be autistic special interests because they diverge from stereotypes.
Even after I began to suspect I was autistic, it took me a long time to discover I had special interests. I had strong fixations, but they did not match my (stereotyped) understanding of autistic interests. Instead of trains or planes, I’m passionate about vintage fashion from the mid-1960s through the early 1970s. It’s a stereotypically feminine interest, and it generally isn’t read as autistic—that is, unless you know how much time I spend perusing clothing resale apps and vintage stores, looking through old photos and fashion magazines and learning to sew clothing from 1960s patterns.
In general, it seems that autistic women are more likely to exhibit relational special interests, gravitating towards subjects like TV shows, movies, animals or art. Often, they fixate on subjects that neurotypical people may also favor. Autistic men can exhibit a wide array of interests but are more likely to hone in on topics more traditionally associated with autism, like transportation, mechanics or gaming.
Why are fewer women diagnosed with autism?
The gender gap in autism diagnosis rates seems to be somewhat of a self-fulfilling prophecy. Stereotypes and cultural notions of autism are based on boys and men, leading more boys and men to be referred for diagnosis. Clinicians are not immune to cultural biases, which are reinforced by the overrepresentation of men and boys among diagnosed autistics—so they are more likely to miss autistic women. Diagnostic criteria and assessment tools are developed based upon the diagnosed autistic population, making women and girls less likely to meet these criteria. Researchers who initially recruit equal numbers of autistic men and women for studies end up with samples biased towards men because fewer of the women they recruited meet the diagnostic criteria.
In this ongoing circle, a few inflection points stand out. Cultural and clinical biases, as well as masking among women, are important drivers behind the different diagnosis rates among men and women.
Camouflaging
Masking seems to be an important driver in the underdiagnosis of autism in women. Because autistic women mask at higher rates than autistic men, women are more likely to avoid detection as autistic. While this can serve women in gaining social acceptance and mobility, it can also present a significant barrier to accessing support.
While unmasking can bring autistic people enormous relief, for many, masking has its place. Masking can be necessary to get by in a world that doesn’t understand autistic people’s experiences. Ultimately, the onus falls on the healthcare industry, autism researchers and community leaders to make diagnosis ––and the support that often follows it––more accessible to women and girls, even if they are high-masking.
Cultural biases
Often, childhood diagnoses result from a referral from a teacher, caregiver or doctor. When girls express autistic characteristics in more “feminine” ways, or perhaps even begin to mask young, these adults are less likely to identify autistic traits and make a referral. Many of these girls don’t get diagnosed until they decide to pursue diagnosis themselves, often as adults. Many won’t get diagnosed at all.
Diagnostic biases
Autistic women are also more likely to be missed or misdiagnosed by clinicians, who may attribute autistic characteristics to other mental health conditions like anxiety, bipolar disorder or borderline personality disorder.
The tools and criteria we currently use to diagnose autism also don’t fully reflect the ways autism can present in women. Diagnostic criteria for autism do not include masking as a potential autistic behavior, nor do they specify the myriad ways autistic traits can present differently, particularly across genders. Women tend to score lower than men on the Autism Spectrum Quotient, a non-diagnostic preliminary screening tool, where a higher score indicates a higher alignment with potential autistic traits.
Potential biological differences
Some have hypothesized that sex differences, including genetic and hormonal differences, may contribute to lower diagnosis rates among cisgender women compared to cisgender men. However, researchers have not yet determined conclusively whether sex differences play a role, or to what extent. What we do know is that biological differences do not paint a complete picture of the difference in diagnosis rates across gender and sex.
Mental health outcomes for autistic women
A large 2022 study suggests that 77% of autistic women are diagnosed with a mental health condition by age 25, compared to 62% of autistic men. By contrast, 23% of U.S. adults at large experience a mental illness at some point in their lives. Co-occurring mental health conditions like anxiety and depression are prevalent among autistic individuals, regardless of gender. However, autistic women seem more likely to develop one.
The reasons for this are nuanced and multi-faceted. One appears to be that autistic women face heightened pressure to exercise social literacy and form intimate social relationships, which can become onerous when social skills don’t feel intuitive, and when many social situations threaten challenges like sensory overload.
Masking is often an autistic woman’s answer to these social expectations, and it can present its own cost to a person’s well-being. Masking can take enormous effort to sustain over time and can contribute to other difficulties like autistic burnout. Feeling the need to camouflage one’s authentic self can also chip away at a person’s self-esteem.
Lower diagnosis rates among autistic women also mean that autistic women are less likely to receive appropriate, tailored support for the challenges that can come with autism. Those who do get diagnosed are more likely to receive a diagnosis in adulthood, leaving many women without support for years of their lives.
Support for autistic women with Prosper Health
If you’ve had a hard time finding clinicians who can diagnose and support autistic adult women, Prosper Health can help. Our clinicians don’t rely on stereotypes––they are highly experienced in working with autistic adults and use the most up-to-date, evidence-based practices for diagnosing and treating autism, including autism in adult women.
Prosper Health offers telehealth autism assessments that are specifically for adults and covered by insurance. Before I found Prosper Health, I spent about six years looking for resources for autistic adult women. I never had much luck, though, and one time, I was practically laughed out of a psychiatrist’s office when I asked about an autism assessment. Prosper Health was able to schedule me quickly for an assessment, and my experience was easy, affirming and very supportive.
If you aren’t looking for a diagnosis right now, or if you already have one, Prosper Health also offers therapy that’s covered by insurance and 100% online. Prosper Health therapists specialize in supporting adults with common challenges autistic individuals face, like burnout, unmasking and coping with sensory overload. Therapy with Prosper Health is goal and progress-oriented, and clients report a noticeable improvement in their quality of life in as few as four sessions.
Regardless of what your needs are right now, Prosper Health can meet you where you are and get you the support you need to help you thrive.
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