Signs of Autism in Women and Girls, and Why They Are Often Missed

Why autism is often missed in girls and women

The National Institute of Mental Health (NIMH) describes autism as a neurological and developmental condition that affects how people interact with others, communicate, learn and behave. It can be diagnosed at any age, and people of every sex and background can be autistic. Even so, many girls grow up without anyone naming it.

A review on sex and gender differences in autism, published in the Journal of the American Academy of Child and Adolescent Psychiatry, notes that girls and women are, on average, diagnosed later than boys and men. Given similar levels of autistic traits, males appear to be diagnosed more easily. The authors point to possible bias in the people who refer and diagnose, such as reading a girl's social difficulties as her just being shy.

A systematic review and meta-analysis in Neuropsychology Review adds another piece. Many of the standard tools used to assess autism were developed mostly with boys and men, and autistic females in the studies it reviewed used more camouflaging strategies than males. The authors say this supports the argument for a bias toward males in how autism is identified.

Camouflaging: blending in at a cost

Camouflaging, often called masking, means hiding or making up for autistic traits in social situations. In a study of autistic adults published in the Journal of Autism and Developmental Disorders, people described copying others, forcing eye contact, putting on facial expressions they did not feel, and preparing topics and scripts before conversations.

Camouflaging can help someone get through school, work and friendships. The cost people described most often was exhaustion, along with needing time alone to recover afterward. Some women in that study said camouflaging delayed their diagnosis, or led parents, teachers and even professionals to doubt it, because they did not fit the picture people expected. Others said their needs went unmet because they seemed to be coping.

Signs that are often noticed later

The review on sex and gender differences lists patterns that clinicians and autistic people have described as more common in females. These descriptions come mostly from clinical experience and personal accounts, so treat them as possibilities, not a checklist. Each one can have other explanations too.

• Wanting friends and working hard to connect, but finding friendships hard to keep going
• Having one or a few close friends rather than a wide group
• Being seen as quiet, passive or just shy
• Copying how other people talk or act in order to fit in, which may be exhausting
• Deep interests in topics such as animals, books, celebrities, music or fashion, which may not be recognized as related to autism
• Perfectionism and strong determination
• Episodes of eating problems

When anxiety or depression comes first

In a qualitative study of autistic girls, women and parents in Canada, published in Women's Health, many participants had been diagnosed with depression, anxiety, obsessive-compulsive disorder, bipolar disorder, eating disorders or ADHD before autism. Many felt those first diagnoses did not capture the full picture. For some, treatment aimed only at those conditions did not help much.

The same study notes that autistic girls and women tend to show more inward signs of distress, such as anxiety and low mood, while outward signs, such as disruptive behavior, are more often seen in autistic boys. NIMH adds that in adults, some autism traits can overlap with anxiety disorders or ADHD, which makes diagnosis harder.

None of this means an earlier diagnosis was wrong. Anxiety and depression are real, and they can occur alongside autism. If treatment has helped only partly, and social exhaustion, sensory strain or a sense of being different go back to childhood, it may be worth asking about autism.

Getting evaluated as an adult, or for your daughter

NIMH says adults with questions about autism can talk with a health care provider about an evaluation. The evaluator asks about social communication, sensory issues, repetitive behaviors and focused interests, and may talk with family members about early development. NIMH notes that a correct diagnosis as an adult can help people understand past challenges, identify personal strengths and find the right kind of help.

For older children and teens, NIMH says caregivers and teachers are often the first to notice signs. If you are unsure whether to take the next step for yourself or your daughter, our free autism signs checklist may help you decide whether to talk to someone. It is an informal checklist only: it is not a screening test, it has not been validated and it cannot diagnose.

1. 1Collect examples from childhoodFriendships, school reports, routines, interests and reactions to noise, clothing or food can all be useful.
2. 2Ask people who knew you thenA parent or sibling may remember early development that you do not.
3. 3Notice the effort behind copingWrite down when you mask, how long it takes to recover and what situations drain you most.
4. 4List earlier diagnosesNote past diagnoses of anxiety, depression or other conditions, and what did and did not help.

How we can help

Locascio Wellness offers an adult autism evaluation and a child autism evaluation by secure video. Evaluations are offered only to people who are physically located in Pennsylvania, West Virginia or Arizona during appointments. For a child or teen, a parent or guardian arranges the evaluation and takes part; tell us your child's age on the request form.

An evaluation usually involves an intake appointment, then one or two sessions, then a written report, which at the moment is usually ready about a month after the first evaluation appointment. We cannot predict what an evaluation will find. Evaluations are private-pay with a sliding scale available, and the cost is given in writing first; see what evaluations cost. To start, use the short evaluation request form or book a free 15-minute consultation.

Therapy is a separate service. The practice does not offer autism therapy, but therapists on our team offer anxiety therapy and depression therapy for what often comes with a late-recognized difference. Therapy clients must be physically located in Pennsylvania, West Virginia, Arizona, Colorado or Florida during sessions, and not every service is offered in every state. A diagnosis may also open other supports that you arrange with your doctor, school or workplace.

If you are in crisis or thinking about harming yourself, call or text 988, or call 911. Locascio Wellness does not provide emergency services.