Autism: a Gender Spectrum
Can a neurotypical person understand autism?
I became particularly interested in autism in 1994 as a psychology undergraduate at Sussex University, where the concept of ‘Theory of Mind’ became the focus of my final thesis. One thing that sparked my interest then, and still does many years later, was the conundrum that a neurotypical person could never truly understand nor empathise with what being autistic feels like, as understanding the world from another person’s perspective is something with which autistic people struggle. In other words, nothing I could possibly imagine as a neurotypical person would be right. This both intrigued me and taught me that as a teacher and as an educational psychologist, I’d have to always rely on my best guess, based on my experience and on academic pursuit.
Autism and gender
I was also intrigued by the notion that autism affected boys more than girls. As a rule of thumb I was taught that the prevalence of autism in boys compared to girls was a ratio of about 3:1. In 2002, Simon Baron-Cohen proposed the ‘extreme male brain’ theory of autism, citing gender differences in the brain by saying that “The female brain [being] predominantly hard- wired for empathy… the male brain [being] predominantly hard-wired for understanding and building systems.” Baron-Cohen based this on research conducted in the 1990s in which he found that women perform better on tests of social intelligence, whereas men did better at following rules and recognising patterns. He found that autistic people generally have trouble with the former but do well with the latter. I struggled to understand why the root of this might be gender.
In her 2020 book ‘The Gendered Brain,’ author Gina Rippon challenged the extreme male autism hypothesis, dissecting the scientific research surrounding sex differences in the brain. She highlighted Baron-Cohen’s later, rather surprising, qualification that “your sex does not dictate your brain type… not all men have the male brain, and not all women have the female brain.” If this was the case, Rippon argued, “if you don't have to be a male to have a male brain, why are we calling it a male brain? In the world of gender stereotypes, language matters.” I couldn’t agree more.
But the theory that autism is a male rather than female thing held fast and seemed to become a self-fulfilling prophecy. Autism was noticed more in boys because autism was looked for more in boys. In 2003, Thompson and colleagues conducted a large-scale review of 392 empirical articles on autism, estimating that 80% of the collective samples were male and only 5% included both sexes. They concluded that the current knowledge and capacity to diagnose autism is biased towards the males. Females are falling under the radar.
How does Autism affect girls and women?
Not long after I qualified in 2001, I started working as an educational psychologist in an inner London borough. There, in a primary school in central London, I met the mother of a young girl I was assessing. She told me her own story which was that she’d recently been diagnosed with autism, in her thirties, after years of misery, misdiagnoses and failed relationships. She’d been prescribed a list of medications as long as her arm, but none of it had helped. Her life had been a difficult one of feeling different and trying to fit in. She’d been bullied at school and victimised as an adult, because without a diagnosis she hadn’t been aware that she was vulnerable to manipulation and abuse. She instinctively knew that her daughter, who was showing early signs of similar traits, would need the right support in place from as early as possible if she was going to be able to navigate the social world and take control of her future.
One survey found that 42% of women and girls with autism received at least one misdiagnosis before securing an autism diagnosis, and other evidence indicates that while many women are diagnosed later in life, many more are never diagnosed at all.
One reason, suggested by Susan Epstein, clinical neuropsychologist, is that “the model that we have for a classic autism diagnosis has really turned out to be a male model. That’s not to say that girls don’t ever fit it, but girls tend to have a quieter presentation, with not necessarily as much of the repetitive and restricted behaviour, or it shows up in a different way.” Though the reason for female misdiagnosis isn't always clear, women's ability to "camouflage" autistic characteristics may play an important role; similarly, women's restrictive and repetitive behaviours (common features of autism) may be less noticeable than in men.
The 6 Most Common Symptoms of Autism in Girls:
But the world is finally waking up to the idea that autism crosses gender. In the last two decades, society has seen an exponential rise in the number of women being diagnosed with autism, some in mid-life or even later. Melanie Sykes and Christine McGuinness, both famous in their own rights and parents to autistic children, have recently been diagnosed mid-life. Sykes described her own recent diagnosis at the age of 51 as “life changing” and said that it was “such a positive diagnosis for me because it makes sense of my life.. I wish I’d known sooner.”
So what are the most common symptoms of autism in girls that parents and schools should be on the lookout for?
Social skills and communication. Difficulties in this area are much easier to spot in males than females, who tend to adapt to social situations more easily. Autistic females are more driven to try and fit in. They put a lot of effort into masking their differences but this can’t be sustained. Autistic females find it hard to form intimate social interaction and to adapt to different situations. They often need more time for processing in social situations and they can come across as awkward, finding it hard to communicate without a pre-prepared ‘script’. They struggle with eye contact and may have learned ways to fake it. The effort of maintaining this behaviour is enormous.
Camouflaging. Often girls with traits of autism are able to hide and blend in, which is known as camouflaging. Some examples of camouflaging include mimicking facial expressions, making intentional eye contact (despite the internal discomfort or anxiety this causes) and giving scripted responses to questions. Typically girls camouflage in order to “fit in” or avoid standing out. This ability is often learned via social media, TV or by everyday observation.
Special interests. Autistic females are just as likely to have areas of special interest as autistic males, but their interests are more likely to be accepted as ‘socially acceptable’ feminine interests, pursuits (think boybands, Disney and celebrities) and therefore slip under the radar of concern.
Social touch. This is one area in which autistic females are quite easy to spot as rather than being tactile with others, as neuro-typical girls tend to be, those with autism can be averse to hugging or any kind of touch.
Trust. Autistic females tend to be more trusting than their neuro-typical counterparts. This can make them particularly vulnerable to advantage being taken of them.
Eating disorders. For many autistic females, eating disorders are common and typically begin as a means to control food intake.
When girls and women are misdiagnosed, or not diagnosed at all, the result can be catastrophic. They may wonder what’s wrong with them and this could lead to a lifetime of anxiety, depression, low confidence and low self esteem. They may be exhausted by the effort of camouflaging which in itself can cause them mental health difficulties. Crucially, though, when we don’t spot the signs and start supporting these girls and women early enough, we take away the opportunity for them to get the right support from a young enough age to make the difference. It is vital that parents, teachers and practitioners are aware and sensitive to these issues to ensure that no one falls through the net.
