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Exploring Autism in Girls and Women: How is it Different? (Part 1 of 3)
Dani Kinsley, M.S., OTR/L
It is no secret that there is a significant difference in the rates of diagnosed autism between males and females. Currently, the male-to-female autism diagnosis ratio is 4:1. Some researchers believe the actual ratio is closer to 3:1 but note that there are a significant number of girls or women who go undiagnosed for longer periods of time (or who are never formally diagnosed) due to the fact that autism can present very differently in females than it does in males. Are females actually biologically or genetically less likely to be autistic*, or is there something else going on to skew the numbers? Let’s dive deeper.
How is Autism Diagnosed?
According to the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5), a diagnosis of autism can be made if a person meets the following criteria:
  • Difficulty with social-emotional reciprocity (social back-and-forth), atypical nonverbal communication, and issues developing, maintaining, and understanding relationships.
  • Exhibits at least two of the following four restricted, repetitive patterns of behavior, interests, or activities:
  1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., “stims”, echolalia)
  2. Insistence on adherence to routines or ritualized patterns of behavior
  3. Highly restricted, fixated interests that are abnormal in intensity or focus (also known as “monotropism”)
  4. Over- or under-reactivity to sensory input or unusual interest in sensory aspects of the environment
The DSM-5, unlike the earlier versions of the DSM, also makes a few brief but important points about these characteristics which are especially important when we consider how girls often fail to receive an early diagnosis. First, that “symptoms must be present in the early developmental period but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life” (DSM-5). This explains how many girls learn to “mask” (or camouflage) their autistic traits until adolescence, when social demands dramatically increase and the stress of peer interactions and puberty may cause an increase in visible autistic traits. This can consequently lead to an increase in social problems and can further stress the individual’s ability to maintain peer relationships, especially with “neurotypical” children.
It is important to remember that—although the diagnostic criteria for autism has changed over the last 30 years or so—the characteristics that most often lead to identification and diagnosis are often noticed more in boys than in girls due to pervasive societal gender norms. For example, if a girl is observed to be “socially withdrawn,” she may be labeled as “shy”. This personality trait is often more socially acceptable in females than it is in males in many cultures. Social passivity in females is often even rewarded or reinforced in some societies. It is also a commonly-held misconception that all autistic individuals are also intellectually disabled. This is not always the case. Girls or women who are talented with masking and who do not also present with intellectual disabilities may be especially likely to be misdiagnosed or never diagnosed.
*The identity-affirming term “autistic” is used in this article series instead of the previously promoted person-first term, “person with autism”. Based on recent research findings, many adults on the spectrum prefer the term autistic and reject person-first language which they feel pathologizes autism as one might a disease.
“Diagnostic Criteria.” Centers for Disease Control and Prevention, April 6, 2022.
Mandy, William. “In DSM-5, Guidance on Girls with Autism Is Short but Savvy.” Spectrum, May 9, 2018.
May, Tamara, and Carol Adams. “Autism Is Still Underdiagnosed in Girls and Women. That Can Compound the Challenges They Face.” The Conversation, May 16, 2022.
Rudy, Lisa Jo. “Could Your Daughter Be Autistic? 11 Signs of Autism in Girls.” Verywell Health, November 2, 2021.

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