“Autistic women are more likely to be described as ‘anxious’ and an autism diagnosis overlooked, since it can challenge gender stereotypes.”
Dr Camilla Pang
Autism Spectrum Disorder (ASD) is a complex neurodevelopmental condition characterised by difficulties in social interaction, communication challenges, and a tendency to engage in repetitive behaviours.
While autism has historically been associated with males, ASD in females presents unique challenges that can lead to underdiagnosis or misdiagnosis. Previous studies have focussed predominantly on males, which has led to a skewed understanding of how the disorder manifests in females. Various studies suggest that the ratio of autistic males:females ranges from 2:1 to 16:1, with the most up-to-date estimate being 3:11. However, experts are discovering that almost as many females as males may have autism, but the presentation of their symptoms often differs2. This can make it significantly harder for clinicians to identify ASD, leading to frequent misdiagnoses with conditions such as anxiety, depression, ADD/ADHD, or borderline personality disorder (BPD).
Understanding gender differences in autism is crucial for to ensure healthcare professionals can provide more accurate diagnoses, as well as more tailored and compassionate care. This is essential not just for the immediate benefit of the individual but also for long-term mental health outcomes and more effective interventions. By improving awareness and diagnostic criteria, it is possible to better support those who might otherwise go unnoticed, misdiagnosed or untreated.
Female ASD: how does it manifest and present itself?
ASD manifests differently in females compared to males, which often leads to underdiagnosis or misdiagnosis. In the UK for example, only 0.2% of adult females are given an autism diagnosis, compared to 1.8% of males1.
Historically, autism research has predominantly focused on males, leading to a skewed understanding of how ASD presents in females. Early studies may have overlooked females due to their ability to mask or camouflage their symptoms. This masking behaviour makes it difficult for even skilled clinicians to identify ASD. Consequently, many females have been misdiagnosed with other conditions such as anxiety, depression, or BPD3.
Autism in girls: a different presentation
Females with autism often experience fewer social difficulties but report more sensory symptoms than their male counterparts2. They are typically more socially motivated, which helps them form friendships and participate in conversations. However, they tend to internalise their symptoms, which can lead to the development of anxiety or depression – whereas boys might exhibit more overt behaviours like hyperactivity or aggression2. Autistic girls also often have restricted interests, similar to boys, but these interests usually align with socially acceptable norms for their age; such as interests in horses or celebrities. This can make their autism less noticeable.
Research indicates that while autistic females may have better social and communication abilities in childhood, they often face more severe social and communication difficulties as they reach adolescence and adulthood2. This highlights the importance of recognising the unique presentation of autism in females for accurate diagnosis and treatment.
Signs and symptoms of autism in females3
- Social difficulties: many autistic women navigate social interactions by creating social “checklists” and learning socially appropriate responses. Despite these efforts, they often feel anxious, ruminate on social interactions, and end up feeling lonely. They may interact well one-on-one but struggle in group settings, leading to social exhaustion.
- Sensory sensitivity: females with autism may have heightened awareness of smells, light, sounds, and touch, often finding these sensations intolerable.
- Executive functioning issues: challenges in organising tasks, completing less interesting work, maintaining healthy habits, and carrying out daily routines like showering or eating breakfast are common.
- Obsessive interests: while autistic males often focus on specific objects, females may display intense interest in a broader range of subjects, including the workings of the mind and people.
- Sleep issues: sensory sensitivities, such as high sensitivity to noise, can cause significant sleep disturbances.
- Stimming: autistic women may engage in stimming behaviours such as skin picking, feet rubbing, pacing, or hair twirling, often without awareness of these actions.
Recognising these gender-specific autism traits is crucial for healthcare professionals to provide accurate diagnoses and tailored treatments to better support these individuals and improve quality of life.
Female autism and co-occurring mental health conditions
The unique presentation of ASD in females can affect the identification and treatment of co-occurring mental health diagnoses, which often occurs at a higher rate than in males2-6. This is in part due to girls’ ability to mask or camouflage their autism symptoms, leading to delayed or incorrect diagnoses. A delay in ASD diagnosis means that these individuals may not have received the necessary care and services during childhood, and so had to figure out how to mentally cope with no external assistance. This, coupled with the pressure to fit in socially3 and the exhaustion that comes with the extent of their camouflaging efforts4, can all lead to the development of additional mental health challenges throughout their lives.
For example, a study from the Karolinska Institutet found that 77% of autistic women had received at least one psychiatric diagnosis by age 25, compared to 62% of autistic men6. These diagnoses included depression, anxiety disorders, self-harm, and sleep difficulties. Furthermore, 32% of autistic women had been hospitalised due to mental illness, compared to 19% of autistic men. In the non-autistic population, less than 5% had similar experiences.
Research has also specifically revealed a strong link between masking behaviours in females with ASD and a range of mental health issues7, including low self-esteem, stress, exhaustion, anxiety, depression, and suicidal tendancies8,9. The severity of these mental health issues is often more closely related to the extent of masking rather than the severity of autistic traits9. Additionally, masking can lead to substance dependency disorders as a coping mechanism for the stress and anxiety it causes8.
The difficulties of diagnosing ASD in girls – masking and misdiagnosis
It’s clear that the interplay between ASD and mental health conditions in females is multifaceted and complex. Understanding these connections is crucial for healthcare professionals to provide accurate diagnoses and effective treatments for autistic females. But, ASD in females present unique challenges that can lead to late or incorrect diagnoses. Firstly, this can be because there are many overlapping symptoms that are common in other mental health conditions, such as:
- Sensory sensitivities3, a common trait in autism, can be mistaken for anxiety disorders.
- Social imitation3, another typical behaviour, may be viewed as shyness or social anxiety.
- The need for control and routine3, often seen in autism, can be misinterpreted as OCD.
It is also important to realise that females often present ASD symptoms differently to males. For example, females with autism might have intense interests in areas that are more common and socially acceptable, such as animals or celebrities, which can go unnoticed7. They might also have fewer social difficulties in one-on-one interactions but struggle significantly in group settings, leading to exhaustion and a sense of isolation despite outward sociability3.
However, it is thought that one of the primary reasons for late-stage diagnosis or misdiagnosis is masking – the ability of females to camouflage their symptoms to fit in socially. This behaviour, although helpful in social settings, makes it difficult for healthcare professionals to recognise the underlying autism. For example, while boys with autism may exhibit overt behaviours such as repetitive movements or intense fixations, girls are often more subtle. They may mimic socially acceptable behaviours by observing others, using television shows and movies as guides, and learning to make eye contact and engage in conversations7. While masking can help women fit in and succeed professionally, it also places them at greater risk for mental health issues7. The energy required to maintain this façade can lead to burnout, mental exhaustion, stress, anxiety, and the constant effort to appear “normal” can exacerbate feelings of isolation and depression7. But regardless of the impact, many women with autism become so adept at masking that they don’t realise they’re doing it, and it may not be until later in life that social difficulties become too great to manage with the usual camouflaging strategies7 leading to a delayed diagnosis. Research has noted that nearly 80% of autistic females remain undiagnosed by age 182.
An autism diagnosis later in life, however, can be a relief. It helps to explain lifelong symptoms and opens doors to necessary health resources and support. But this also means that the impact of undiagnosed autism is profound. Undiagnosed or misdiagnosed females often do not receive the appropriate interventions during their critical developmental years, leading to an increased risk of co-occurring mental health conditions.
Understanding these challenges is crucial for healthcare professionals. Recognising the signs of masking, being aware of the differences in presentation, and appreciating the social impacts are essential steps in providing accurate diagnoses and effective treatments for females with autism.
Best practices for management of ASD in females
To provide optimal care for females with ASD, healthcare providers must adopt gender-sensitive diagnostic tools and tailored intervention strategies. Recognising that ASD presents differently in females, it’s crucial to recognise the nuances and develop diagnostic methods that consider these unique manifestations. This approach ensures that ASD is identified accurately, allowing for the appropriate support and intervention to be implemented.
Tailored intervention strategies should focus on managing co-occurring mental health conditions such as anxiety, depression, and substance dependencies. Personalised care plans, which take into account the individual’s strengths and challenges, can significantly improve outcomes. Comprehensive and individualised care plans enable healthcare providers to address the wide range of difficulties that accompany ASD, helping patients lead more fulfilling lives.
It is important to note that the treatment of ASD itself should not be viewed as a necessity. Rather, the focus should be on supporting individuals in managing the associated challenges and enhancing their quality of life. This perspective echoes the stance that neurodivergence is not an illness that needs a cure but a different way of experiencing the world.
The realm of female ASD research is still lagging behind, necessitating a stronger emphasis on studies that explore how autism affects females specifically. This research is vital for developing more effective diagnostic and therapeutic approaches tailored to their needs. Until then, incorporating gender-sensitive and individualised approaches will not only improve diagnosis and treatment, but also foster a more supportive environment where females with ASD can thrive.
Specialist care for females with ASD – the Orchestrate Health approach
Understanding ASD in females is crucial for accurate diagnosis and effective treatment. It often presents differently in females, with symptoms frequently masked or misdiagnosed as other mental health conditions such as anxiety, depression, ADD/ADHD, or BPD. Recognising these differences and adopting gender-sensitive diagnostic tools and tailored intervention strategies are essential for providing the best care.
GPs and psychiatrists should consider referring their complex patients for specialised care. At Orchestrate Health, we understand the intricate interplay between ASD and co-occurring mental health conditions. Our expertise in providing comprehensive, personalised at-home treatment ensures that females with ASD receive the support they need to manage stress, burnout, anxiety, and depression effectively.
Orchestrate Health offers a range of services including live-in mental health specialists, home assessments, and daily visits from professionals within the mental wellbeing field. By choosing Orchestrate Health, you are ensuring your patients receive the highest level of care tailored to their unique needs.
For more information or to refer a patient, please visit our website or contact us directly.
References
- https://www.autism.org.uk/advice-and-guidance/what-is-autism/autistic-women-and-girls
- https://www.uclahealth.org/news/article/understanding-undiagnosed-autism-adult-females
- https://www.psychologytoday.com/gb/blog/women-with-autism-spectrum-disorder/202104/10-signs-of-autism-in-women
- https://molecularautism.biomedcentral.com/articles/10.1186/s13229-018-0226-4
- https://www.sciencedirect.com/science/article/pii/S175094672200188X
- https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2797528
- https://www.psychologytoday.com/gb/blog/women-with-autism-spectrum-disorder/202104/masking-and-mental-health-in-women-with-autism
- https://link.springer.com/article/10.1007/s10803-018-03878-x
- https://journals.sagepub.com/doi/10.1177/1362361320912147
- https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/prevalence-of-autismspectrum-conditions-uk-schoolbased-population-study/BD4DEF69A99238234E6E39BD844083B9
