Women and girls with Autism Spectrum Disorder (ASD) often navigate a complex landscape of social expectations and internalised traits. Current diagnostic criteria can struggle to account for internalised behaviours and traits that can often be exhibited in women and girls, which can lead to misdiagnosis of persistent mental health concerns such as anxiety and depression, rather than a diagnosis of ASD. Frequent misdiagnosis and misunderstanding of these differences in the presentation of autism between genders can then lead to further challenges in accessing appropriate support and accommodations to adequately support these women and girls within the various domains of their lives.
Masters of Masking
Many women and girls on the autism spectrum become adept at masking their traits in order to fit into societal norms. Women and girls can be experts at masking, mimicking and internalising their autistic traits in order to "fit in", to be accepted, or to keep themselves safe in social settings.
The perceived adherence to some social rules and norms due to the internalisation of their traits can lead to the behaviours of women and girls with autism often being explained away and stereotyped as purposeful behaviour or personality traits rather than being understood as behaviours and skill deficits associated with ASD.
While this can facilitate social acceptance, it often comes at a significant emotional cost. The pressure to conform can lead to ongoing suppression of emotions, distress and needs which can in turn lead to negative mental health outcomes over time, and challenges in forming a sense of self or personal identity.
Delayed Diagnosis = Delayed Support
The current diagnostic criteria for autism were primarily developed based on male presentations, where behaviours and struggles can often be more externalised or visible. Consequently, many women and girls may not fit the stereotypical or externalised presentation, leading to misdiagnosis or a lack of diagnosis altogether. Instead of receiving appropriate support for their ASD, they may be diagnosed with anxiety, depression, or other mental health concerns, or not receive a diagnosis until much later in life, once they have exceeded their capacity to cope.
Late and delayed diagnosis can leave women and girls struggling without support for significant time, limiting early interventions and increasing the likelihood that maladaptive coping strategies are developed and embedded into daily rituals and routines over time. Limited early interventions can impact on the development of positive skills, as without appropriate support and guidance, developing positive strategies for coping with distress and problem solving can be challenging.
Late diagnosis can also bring additional challenges, as individuals may experience struggles with internal grief at the sudden loss of their already established identity that can come with receiving a diagnosis.
Understanding Behaviours
Our perception of behaviours and traits can sometimes cloud our understanding of why these behaviours might occur. Behaviours and actions that may be a part of a person's diagnosis may be misunderstood and labelled as socially inappropriate behaviour such as attention seeking, nagging, defiance and bossiness.
When behaviours and actions are labelled this way, it can often lead to criticism, correction and punishment, instead of understanding, support and adjustment. When behaviours are met with criticism and punishment, it can lead to the development of maladaptive coping strategies, such as further internalisation of struggles to fit societal standards and avoid negative responses or the expression of behaviours of concern to express and cope with distress.
To foster a more supportive environment, it's crucial to understand the underlying reasons for certain behaviours. Understanding the why behind the behaviour can help reframe the way we view the person and their behaviour and shape the way we respond to and provide them with support.
The Need for Compassionate Responses
One way this can be achieved is through education and understanding. By understanding how current diagnostic criteria for ASD can be expressed (or internalised) in women and girls, the why behind the behaviours can become more apparent and challenge the previously applied labels and stereotypes, allowing for more compassionate and supportive responses.
For example, a girl within a school setting may be seen to be social, have ongoing friendships and to engage in activities and games with others socially. This apparent appropriate social behaviour with other children within the school setting does not appear to fit with the social deficits outlined in current diagnostic criteria for ASD. However, this same girl is constantly reported to become controlling and "bossy" during play and group activities, is always setting rules for others to follow, and can struggle to be flexible when others attempt to redirect activities, which can create some challenges during play with peers. This student would likely be labelled as a "bossy" child, rather than being understood to be exhibiting behaviours consistent with ASD in girls.
This student, who is labelled as "bossy" for controlling aspects of play or group activities with others and struggling to follow the rules set by others, may be experiencing challenges with restrictive and repetitive behaviours. This perceived "bossiness" may be a way in which this person has learned to gain control in situations where expectations or rules not being met causes them significant distress, rather than a deliberate or intentional act.
When this behaviour is understood as a part of their diagnostic profile, the person is more likely to be met with support, such as assistance to facilitate collaborative problem solving and supportive strategies, which will aid in overall skill development and social inclusion. A girl who is labelled as "bossy" and is not understood to be needing support is more likely to be met with corrective comments or punishment for negative behaviour, likely leading her to internalise the distress she feels in the future to avoid repeated punishment or social exclusion.
By reframing our perceptions and responses, we can create a more empathetic approach that prioritises understanding and support over judgment. There is currently a dire need for greater education in the presentation of autism in women and girls, to shift these views and stereotypes and create more understanding and inclusive environments that foster the development of positive skills and avoid placing blame on the individuals for their behaviours.
Promoting Awareness and Ongoing Learning
As people supporting women and girls with ASD, it is up to us to seek education in this space to provide a more inclusive approach to support and care. We cannot correct what we do not know.
With further education and understanding, we can begin to see through some of the negative stereotypes and labels, and provide a safe, understanding and supportive space that uplifts women and girls on the spectrum and empowers them to be their authentic selves, rather than forcing them to suppress and hide their needs and identities.
Raising awareness about the distinct experiences of women and girls with ASD is essential for creating a more inclusive society.
Conclusion
Understanding the experiences of women and girls with ASD is crucial for fostering an inclusive environment that understands and supports their needs, rather than shaming their behaviour. By recognising the difference in the expression of characteristics, such as masking, internalised behaviours and how current diagnostic criteria applies to women and girls, we can shift our approach from criticism to compassion. Through education, advocacy, and support, we can help empower women and girls with ASD to thrive in all aspects of their lives.
By continuing to promote awareness and understanding, we can ensure that all individuals on the spectrum receive the recognition and support they deserve.
References
Autism Spectrum Disorder (ASD) in the DSM-5-TR | Autism Aspergers Advocacy Australia. (n.d.). https://a4.org.au/dsm5-asd
McCrossin R. Finding the True Number of Females with Autistic Spectrum Disorder by Estimating the Biases in Initial Recognition and Clinical Diagnosis. Children (Basel). 2022 Feb 17;9(2):272.
Women in Autism. (n.d.). Autism Research Institute. https://autism.org/women-in-autism/
Loomes R, Hull L, Mandy WPL. What Is the Male-to-Female Ratio in Autism Spectrum Disorder? A Systematic Review and Meta-Analysis. J Am Acad Child Adolesc Psychiatry. 2017 Jun;56(6):466-474.
Arky, B. (n.d.). Why Many Autistic Girls Are Overlooked. Child Mind Institute. https://childmind.org/article/autistic-girls-overlooked-undiagnosed-autism/
Resources
- Aspect — One of Australia's largest autism-specific service providers. autismspectrum.org.au
- Autism Awareness Australia — Improving the lives of all Australians on the autism spectrum and the families who love them. autismawareness.com.au
- Yellow Ladybugs — Dedicated to the happiness, success and celebration of autistic girls, women and gender diverse individuals. yellowladybugs.com.au