AUTISM IN WOMEN: THE DECADES-LONG DIAGNOSTIC GAP

For decades, autism has been largely understood through a male lens. Research, diagnostic criteria, and societal perceptions have predominantly focused on how autism manifests in boys and men.  This has left a significant and often devastating diagnostic gap for women and girls.  In the UK, this gap means countless women have gone through life without understanding their neurodivergence, facing unnecessary challenges and often misdiagnosis.  Why has this been the case, and what are the far-reaching consequences?

One of the primary reasons for this diagnostic disparity lies in the historical development of diagnostic criteria.  Early research, such as that by Leo Kanner, focused on the presentation of autism in young boys (Kanner, 1943).  This initial framework heavily emphasized traits like repetitive motor behaviours, intense fixations on specific, often inanimate, objects, and a clear lack of social interest.  While these traits can certainly be present in autistic girls and women, their presentation can often be markedly different.

The presentation of autism symptoms can differ between men and women due to a complex interplay of factors, including biological differences, social expectations, and the phenomenon of masking.  The key differences and the underlying reasons are as follows:

Social Communication and Interaction

For people with autistic tendencies, social communication and interaction are frequently different between men and women.  Men may exhibit more overt difficulties in initiating and maintaining conversations, making eye contact, and understanding social cues.  Men might show less desire for social interaction and have difficulty forming friendships (EmpowerBH, 2023; Healthline, 2023).  In contrast, women may show a greater motivation for social connection and put more effort into forming friendships and participating in conversations.  They might develop strategies to mask social difficulties, such as mimicking social behaviours, preparing scripts for conversations, and forcing eye contact (UCLA Health, 2023; The Autism Service, 2023).  However, these efforts can be exhausting and may not lead to deep, meaningful relationships due to challenges in understanding subtle social nuances (EmpowerBH, 2023).

Restrictive and Repetitive Behaviours (RRBs)

Restrictive and repetitive behaviours (RRBs) are a core characteristic of autism spectrum disorder (ASD).  They encompass a wide range of actions, interests, and patterns of behaviour that are characterized by their repetitive nature and/or their restricted focus.  These behaviours can manifest in various ways and can vary in intensity and impact on daily life.  Understanding RRBs is crucial for supporting individuals with autism. Recognizing the function of these behaviours can help in developing strategies to manage challenging behaviours and provide appropriate accommodations and supports.  However, the presentation of RRBs can be markedly different in men and women.

Men often display more pronounced and stereotypical RRBs, such as lining up toys, repetitive motor movements, and intense fixations on specific, often non-social, interests that might be seen as unusual (EmpowerBH, 2023; Healthline, 2023).   Women may exhibit fewer or less noticeable RRBs.  Their intense interests might align more with typical female hobbies (for example, animals, literature, celebrities), making them less likely to be flagged as unusual.  Repetitive behaviours in women might be more subtle, like hair twirling, or internalized (Behavioral Innovations, 2023; UCLA Health, 2023).

Internalizing vs. Externalising Behaviours

The extent to which men and women express behaviours externally, as opposed to internalising their actions can differ greatly.  Research suggests autistic men may exhibit more externalizing behaviours, such as hyperactivity, aggression, and conduct issues (The Transmitter, 2020; PMC, 2014).  In contrast, autistic women are more prone to internalizing symptoms like anxiety, depression, social withdrawal, and emotional regulation difficulties (Healthline, 2023; UCLA Health, 2023; ResearchGate, 2024).  These internalising symptoms can sometimes overshadow the underlying autism, making a correct diagnosis of autism in women difficult, if not impossible in many cases.

Sensory Sensitivities and Cognitive and Adaptive Functioning

Both men and women with autism experience sensory sensitivities.  However, women may report more sensory symptoms than communication difficulties compared to men (UCLA Health, 2023).   Some research suggests autistic women might present with lower cognitive ability and adaptive functions compared to autistic men, although this is still being investigated (Healthline, 2023).  It follows that a model for diagnosis based predominantly on the behaviour of men will likely fail to fully appreciate the situation of many women, leading to misdiagnosis in many cases.

So, what are the reasons for the different presentations between men and women?

• Masking (Camouflaging): Women are often more motivated and adept at masking their autistic traits to fit in socially.  Masking is a conscious or unconscious effort to suppress autistic traits and fit in with social norms.  This is often more prevalent and sophisticated in girls and women (Hull et al., 2017).  Societal pressures on girls to be socially adept and agreeable can lead them to develop elaborate strategies to mimic neurotypical behaviour.  This might involve learning social scripts, forcing eye contact, or camouflaging their intense interests.  As a result, clinicians relying on traditional diagnostic criteria may miss the underlying autistic traits, mistaking a carefully constructed facade for genuine neurotypicality.
• Socialization and Gender Expectations: From a young age, girls are often socialized differently than boys, with greater emphasis on social skills and emotional expression (Autism.org.uk, 2023; Gender and Autism, 2024).  This might lead autistic girls to develop different coping mechanisms and present their autism in ways that are more socially acceptable, even if it requires significant effort.
• Historical Bias in Research and Diagnostic Criteria: As noted above, autism was initially studied predominantly in males, and diagnostic criteria were developed based on male presentations (UCLA Health, 2023; Autism.org.uk, 2023; Frontiers, 2021).  This male-centric view has led to assessment tools and clinical understanding that may not adequately capture the autistic traits more commonly seen in women.
• “Extreme Male Brain” Theory: This theory suggests that autism is an extreme of typical male cognitive traits, with a focus on systemizing and lower empathizing (Baron-Cohen, 2002; Wikipedia, 2025).  While controversial, this theory might have inadvertently contributed to a diagnostic bias, where traits aligning with this “male” profile were more readily identified as autistic.   The unique and often socially-oriented special interests of autistic women, such as literature, animals, or specific historical periods, might be dismissed as typical female hobbies rather than recognized as the intense, focused interests characteristic of autism.
• Female Protective Effect: Some theories propose that females may have a higher genetic threshold for developing autism, requiring a greater accumulation of genetic and environmental risk factors for autistic traits to become apparent (Wikipedia, 2025; PMC, 2014).  This could mean that women who do present with autism might have a more significant “load” of autistic-related factors, potentially leading to more severe co-occurring conditions.
• Comorbidity of Mental Health Conditions:  This can be a significant factor in the misdiagnosis of autism in a woman patient.  Autistic women are more likely to experience anxiety, depression, and eating disorders, often as a direct result of navigating a neurotypical world without understanding their own differences (Lai et al., 2014).  These co-occurring conditions can sometimes overshadow the underlying autism, leading to misdiagnosis and treatment that fails to address the root cause of their difficulties.  A woman presenting with severe anxiety, for example, might be treated solely for anxiety without exploring the sensory sensitivities or social communication differences that could be contributing to her distress.

The consequences of this decades-long diagnostic gap are profound and truly troubling.  Without a diagnosis, women may experience:

• A lifetime of feeling “different” or “wrong”: Leading to low self-esteem, internalized stigma, and a constant sense of not fitting in.
• Increased vulnerability to mental health issues: The chronic stress of masking and navigating a world not built for them takes a significant toll on mental well-being.
• Difficulties in relationships and social interactions: Without understanding their communication style and social needs, forming and maintaining meaningful connections can be incredibly challenging.
• Struggles in education and employment: Sensory sensitivities, executive function differences, and communication challenges can impact academic and professional success without appropriate support.
• Delayed access to appropriate support and understanding: A late diagnosis can finally provide answers and access to communities, therapies, and accommodations that can significantly improve quality of life.

Recognizing and addressing the diagnostic gap in autistic women in the UK is crucial. This requires:

• Raising awareness among clinicians, educators, and the general public about the diverse presentation of autism in women and girls.
• Revising diagnostic criteria to be more inclusive and account for the nuances of female presentation, including the impact of masking.
• Investing in research specifically focused on understanding autism in women and girls.
• Providing better training for professionals to recognize the subtle signs of autism in females and to differentiate it from other conditions.
• Listening to the lived experiences of autistic women and incorporating their insights into research and practice.

Closing the decades-long diagnostic gap for autistic women in the UK is not just about providing a label; it’s about offering understanding, validation, and access to the support they desperately need and deserve. By shifting our understanding of autism beyond the traditional male profile, we can empower countless women to finally understand themselves and live more fulfilling lives.

References:

Baron-Cohen, S. (2002). The extreme male brain theory of autism. Trends in Cognitive Sciences, 6(6), 248-254.

Hull, L., Petrides, K. V., Allison, C., Smith, P., Baron-Cohen, S., Lai, M. C., & Mandy, W. (2017). “Putting on My Best Normal”: Social Camouflaging in Adults with Autism Spectrum Condition. ¹ Journal of Autism and Developmental Disorders, ² 47(9), 2519-2532.

www.oregon.gov

decouverteaspi.wordpress.com

Kanner, L. (1943). Autistic disturbances of affective contact. Nervous Child, 2(3), 217-250.

Lai, M. C., Baron-Cohen, S., Buxbaum, J. D., & Szatmari, P. (2014). Understanding autism in the context of sex/gender. Molecular Autism, 5(1), 1-11.

Consequences of Different Presentations and Underdiagnosis in Women:

The differences in how autism presents in women often lead to underdiagnosis or misdiagnosis. Autistic women may be misdiagnosed with anxiety, depression, or personality disorders (UCLA Health, 2023; Sheppard Pratt, 2024). This lack of accurate diagnosis can result in:

• Delayed or no access to appropriate support and interventions.
• Increased risk of mental health issues due to the stress of navigating a neurotypical world without understanding their differences.
• Difficulties in forming and maintaining relationships.
• Challenges in education and employment.
• A lifetime of feeling misunderstood and “different.”

Recognizing the diverse ways autism can manifest in women and addressing the historical biases in research and diagnostic practices are crucial steps toward closing the diagnostic gap and ensuring autistic women receive the understanding and support they need.

References:

Baron-Cohen, S. (2002). The extreme male brain theory of autism. Trends in Cognitive Sciences, 6(6), 248-254.

Behavioral Innovations. (2022). Boys Vs. Girls with Autism; Gender Differences in Males & Females with ASD. Retrieved from https://behavioral-innovations.com/blog/autism-gender-differences/

EmpowerBH. (2023, May 17). How Does Autism Differ in Males and Females. Retrieved from https://www.empowerbh.com/blog/how-does-autism-differ-in-males-and-females/

Frontiers. (2021). Sex Differences in Autism Spectrum Disorder: Focus on High Functioning Children and Adolescents. Retrieved from https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2021.539835/full

Gender and Autism. (2024, March 7). Gender and Autism. Retrieved from https://autism.org/gender-and-autism/

Healthline. (2023, October 12). Autism in Women: Symptoms, Causes, Diagnosis, and Treatment. Retrieved from https://www.healthline.com/health/autism-in-women

Hull, L., Petrides, K. V., Allison, C., Smith, P., Baron-Cohen, S., Lai, M. C., & Mandy, W. (2017). “Putting on My Best Normal”: Social Camouflaging in Adults with Autism Spectrum Condition. Journal of Autism and Developmental Disorders, 47(9), 2519-2532.

PMC. (2014). Sex differences in autism spectrum disorders. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC4164392/

ResearchGate. (2024). (PDF) Gender Differences in Autism Spectrum Disorder: A Systematic Review of Diagnosis, Intervention, and Outcomes. Retrieved from https://www.researchgate.net/publication/387269368_Gender_Differences_in_Autism_Spectrum_Disorder_A_Systematic_Review_of_Diagnosis_Intervention_and_Outcomes

Sheppard Pratt. (2024, April 15). The Autism Spectrum Gender Gap. Retrieved from https://www.sheppardpratt.org/insights/story/the-autism-spectrum-gender-gap/

The Autism Service. (2023, June 27). What are the main signs of autism masking in women? Retrieved from https://www.theautismservice.co.uk/news/what-are-the-main-signs-of-autism-masking-in-women/

The Transmitter. (2020, June 21). Autism characteristics differ by gender, studies find. Retrieved from https://www.thetransmitter.org/spectrum/autism-characteristics-differ-by-gender-studies-find/

UCLA Health. (2023, October 12). Understanding undiagnosed autism in adult females. Retrieved from https://www.uclahealth.org/news/article/understanding-undiagnosed-autism-adult-females

Wikipedia. (2025, February 28). Sex and gender differences in autism. Retrieved from https://en.wikipedia.org/wiki/Sex_and_gender_differences_in_autism

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) categorizes RRBs in autism into four main areas:

• Stereotyped or repetitive motor movements, use of objects, or speech: These are often referred to as “stimming” or self-stimulatory behaviors. Examples include:
  • Motor: Hand flapping, body rocking, finger-flicking, spinning, pacing, toe walking.
  • Object use: Lining up toys, repeatedly opening and closing doors, flicking switches.
  • Speech: Echolalia (repeating words or phrases), scripting from movies or TV shows, repetitive questioning.
• Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior: This involves a strong need for predictability and resistance to change. Examples include:
  • Following very specific routines for daily activities (e.g., getting dressed, eating meals).
  • Distress over minor changes in routine or environment.
  • Ritualistic behaviors (e.g., touching objects in a specific order, saying certain phrases).
• Highly restricted, fixated interests that are abnormal in intensity or focus: This involves having intense preoccupations with specific topics, objects, or activities, often to the exclusion of other interests. Examples include:
  • Becoming deeply engrossed in a narrow subject (e.g., trains, dinosaurs, specific historical events).
  • Collecting specific items.
  • Spending a significant amount of time thinking or talking about their special interest.
• Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment: This involves atypical responses to sensory stimuli. Examples include:
  • Hyperreactivity: Being overly sensitive to loud noises, bright lights, certain textures, or smells.
  • Hyporeactivity: Having a reduced sensitivity to pain or temperature, seeking out intense sensory experiences (e.g., spinning, crashing into things).
  • Unusual sensory interests: Fascination with lights or spinning objects, smelling or touching objects repeatedly.

It’s important to note that:

• The presence and presentation of RRBs vary widely among individuals with autism.
• These behaviors can serve various functions, such as self-regulation, seeking sensory input, reducing anxiety, or providing a sense of predictability and control.
• While RRBs are a core diagnostic criterion for autism, some individuals without autism may also exhibit some repetitive behaviors. However, in autism, these behaviors tend to be more frequent, intense, and impairing.

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