- Autism research often focuses on male subjects, but recent findings suggest that autism presents differently in men and women.
- Women with autism tend to have a greater drive to be sociable, engage in more masking behavior, and are expected to conform more to gender roles.
- Gender differences in autism have likely contributed to the misdiagnosis and under-diagnosis of autism in women.
The term “autism” was first used in 1908 by Eugen Bleuler to describe a subset of schizophrenic patients who were especially withdrawn and self-absorbed.1 However, it was not used as a diagnostic term until 1943 by the child psychiatrist, Leo Kanner.2 Kanner’s research on 11 children, who he identified as intelligent and who had a strong desire to be alone and displayed restricted interests, only included 3 girls in the sample.
The following year, Austrian physician Hans Asperger also used case studies to research autism; his sample only included boys. In fact, Asperger concluded that “the autistic personality is an extreme variant of male intelligence” and that women and girls could not have autism (although he later changed his mind).3
Historically, therefore, diagnostic criteria for autism have been based on studies predominantly or exclusively based on the male experience. Research into autism continues to focus on men and, in the case of neuroimaging research, there is an ascertainment bias (meaning that males are specifically selected in favour of females as research subjects) of up to 15:1.4
We now know that far more women and girls than previously thought have autism and that the gap between male and female autism is far smaller than previously thought.5 Given that autism was originally identified from exclusively or predominantly male samples—along with the dominance of the “extreme male brain” theory,6 which proposes that autistic people process the world through a “male” lens and have primarily stereotypically male interests—it’s easy to see how women and girls have been misdiagnosed.
Now that women and girls have been the subject of an increasing body of research, and we know that they present differently than men and boys, it's important for researchers and clinicians to ask: Why, exactly, does autism present differently in men and women?
Difference 1: The drive to be sociable
The fact that girls with autism tend to have a more pronounced drive to be sociable suggests that it stems from the inherent differences between boys and girls in terms of their need for social relationships. When you look at any groups of girls and boys, they often interact differently; girls, as a group, tend to appear to be more socially oriented than boys.7 From birth, girls tend to be more interested in human faces8 and appear to behave more prosocially than boys.9
Although autistic girls may face a whole host of problems when it comes to making and maintaining friends, they tend to display a greater desire to be sociable. Based on surface appearances, then, girls and women with autism appear to be more socially adept than their male counterparts. This difference is one of the main reasons for the misdiagnosis, and underdiagnosis, of female autism. Autistic women have to work really hard at being sociable, but they can become so skilled at it that other people can’t see the difficulties they’re having.
In my own experience, when I first approached my GP about a diagnosis, he dismissed me as being “too normal.” My client, Sandra, experienced a similar reaction. “My GP told me that I smiled, made eye contact, and that because I was married with kids and a job which involved a high degree of social interaction, there was no way I could have autism.”
Difference 2: Types of interests
Another way in which girls and women with autism tend to differ from boys is in terms of their interests. Part of the diagnostic criteria for autism in the DSM-5 is “restricted, repetitive patterns of behaviour, interests or activities”10—and in this area, girls and women often have different types of interests from men with autism.
Boys may be extremely interested in collecting items and gathering information about objects or categories of things—which fits into how we typically think of autism. But while girls may display the same intense level of interest as boys, their interests tend to appear more “normal.” Girls with autism are often interested in similar things as other girls of their age, such as celebrities, bands, or ponies. Thus, the fact that they are more interested, sometimes to the point of obsession, often goes unnoticed by parents.
Another client, Alison, told me, “It amazes me, looking back, that people didn’t think there was something strange about the level of my obsession with David Bowie. I guess it’s because my parents thought all girls were fans to the same degree, but I was totally obsessed. I knew every fact. I bought everything I could afford. My friends were fans, but they weren’t obsessed like me.“. Some girls develop a special interest in the workings of the brain and social interactions and some become obsessive about a “crush” or romantic partner, again displaying the intensity of interest but towards things which can be considered “normal."
Difference 3: The use of camouflaging tactics
Given that girls and women experience the drive to be more sociable than men and boys with autism, it makes sense that they also tend to use more, and different, camouflaging tactics than men.
"Camouflaging" is a technique used by both men and women with autism—as well as many neurotypical people—to pass as “normal” in a given situation. Women with autism use techniques such as developing a script for conversations, forcing themselves to make eye contact, or avoiding talking about subjects that interest them.
Many women with autism become particularly skilled at camouflaging, to a far greater degree than other people (including autistic men). But camouflaging is linked to mental health issues—including depression, anxiety, and suicidality—and the degree to which women camouflage is closely linked to their mental health.
Difference 4: Response to social pressures
All men and women, whether they have autism or not, are part of a wider society and face different societal pressures which shape how they experience autism. Because women still tend to take on a greater share of domestic responsibilities, many women with autism find it hard to manage their own autistic needs while still fulfilling their expected roles of daughter, mother, or wife. Much as they would like to pursue their special interests, carve out alone time, and lead a life that meets their needs, many women feel pressured to fulfill gendered expectations.
Client Sarah told me, “I was quite a solitary child and teenager and I loved university. When I got married, I felt I had to do all these things that women were 'supposed' to be good at, like sending cards to my husband’s family and kind of being the social hub of the family. I hated it.” Many women struggle in these roles and resort to camouflaging to keep their heads above water—but sadly, many women lose a sense of self in the process.
Difference 5: Having a female brain and body
The way we think and act is partly due to our hormones. While men and women share aspects of autism in common, we need to remember they have a lot that is not in common, too. In exactly the same way that there are differences in the ways neurotypical men and women think, act, and experience life in general, there are differences in the ways in which men and women with autism interpret and experience their world.
As we begin to learn more about how women experience autism, hopefully, it will be easier for girls and women to be correctly diagnosed as we move to a more encompassing definition of what autism is.
You can find out more about women and autism here.
1. Bleuler E. (1950) Dementia praecox or the group of schizophrenias. New York: International Universities
2. Kanner L (1943) ‘Autistic disturbances of affective contact’, The Nervous Child, 2, p217–50
3. Aspberger, H. (1944) ‘Die ‘Autistischen psychopathen im kindesalter’, Archiv für Psychiatrie und Nervenkrankenheiten, 117, p76-136.
4. Lai, MC, Lombardo, MV, 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 & Adolescent Psychiatry, 54(1), p11-24
5. Kim, YS, Leventhal, BL, Koh, YJ, Fombonne, E, Laska, E, Lim, EC, Song, DH (2011) Prevalence of autism spectrum disorders in a total population sample, American Journal of Psychiatry, 168(9), p904-912
6. Baron-Cohen, S (2002) The extreme male brain theory of autism, Trends in Cognitive Science, 6(6) p248-54
7. Blakemore JEO, Berenbaum SA, Liben LS. (2009) Gender development. New York: Psychology Press
8. Lutchmaya S, Baron-Cohen S, Ragatt P (2002) ‘Foetal testosterone and eye contact in 12-month-old human infants’, Infant Behaviour and Development, 25, p327–335
9. Eisenberg N, Fabes RA, Spinrad TL (2006) ‘Prosocial development’, in Eisenberg N (ed.) Social, emotional, and personality development. Hoboken, NJ: Wiley, p646–718
10. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) https://doi.org/10.1176/appi.books.9780890425596