Below is an article adapted from Gould, J. and Ashton, J. (2011) "Good Autism Practice", exploring some of the issues related to autism and gender, including research into autism in women and girls.
In recent years, questions have been raised about the ratio of males to females diagnosed as having an autism spectrum disorder (ASD). Overall the most recent studies suggest that the prevalence of autism spectrum disorder is about one in 100, but what of the male/female ratio?
There is no hard evidence of numbers. Various studies, together with anecdotal evidence, have come up with male/female ratios ranging from 2:1 to 16:1. Whatever the true ratio, clinical referrals to a specialist diagnostic centre have seen a steady increase in the number of girls and women referred. Because of the male gender bias, girls are less likely to be identified with ASD, even when their symptoms are equally severe. Many girls are never referred for diagnosis and are missed from the statistics. Emphasis is placed on the different manifestations of behaviour in autism spectrum conditions as seen in girls and women compared with boys and men.
The different way in which girls and women present under the following headings have been identified below; social understanding, social communication, social imagination which is highly associated with routines, rituals and special interests. Some examples are:
The presence of repetitive behaviour and special interests is part of the diagnostic criteria for an autism spectrum disorder. This is a crucial area in which the male stereotype of autism has clouded the issue in diagnosing girls and women.
As highlighted above, the current international diagnostic criteria do not give examples of the types of difficulties experienced by girls and women. In order to recognise the different behavioural manifestations, it is important to take a much wider perspective regarding the social, communication and imagination dimensions in addition to the special interests and rigidity of behaviour. The girls and women learn to act in social settings. Unenlightened diagnosticians perceive someone who appears able and who has reciprocal conversation and who uses appropriate affect and gestures as not fulfilling the criteria set out in the international classification systems. Therefore a diagnosis is missed. It is only by asking the right questions, taking a developmental history, and observing the person in different settings, that it becomes clear that the individual has adopted a social role which is based on intellect rather than social intuition. To quote: “The fact that girls with undiagnosed autism are painstakingly copying some behaviour is not picked up and therefore any social and communication problems they may be having are also overlooked. This sort of mimicking and repressing their autistic behaviour is exhausting, perhaps resulting in the high statistics of women with mental health problems.” (Yaull-Smith, 2008).
It is important to prepare girls for a life of quality as adult women. Schools need better trained staff to recognise and address the needs of pupils on the autism spectrum and especially the more ‘subtle’ presentation in girls. Schools need to be more ‘girl-friendly’ with girl orientated personal, social skills classes. There needs to be a focus on the ‘hidden curriculum’, which directly teaches the skills that typically-developing girls learn indirectly and intuitively, such as the unwritten rules of girls’ social interactions. Girl orientated personal, social and health education should be part of the curriculum. Schools educating girls on the autism spectrum should focus on teaching independence and strategies to reduce vulnerability. They also need to address self-image, self-esteem and confidence building. Gender identity is a big issue for girls (Cooper et al, 2018), as is emotional well-being and fostering mental health. Society has expectations of both men and women, but many women on the autism spectrum believe that these expectations are greater for women.
In the book Asperger’s Syndrome for Dummies (Gomez de la Cuesta & Mason, 2010), the authors touch on this issue and describe different ‘types’ of women on the autism spectrum. At work, women experience ‘a glass ceiling that is double glazed’ according to the authors. Women experience the same difficulties as other women, plus the difficulties experienced by women on the autism spectrum. These women often go into professions that are traditionally male-orientated. Harder (2010) has produced a book called Illustrated glimpses of Asperger's for Friends and Colleagues. This gives a valuable insight into the difficulties women on the autism spectrum experience at work and provides explanations to colleagues of the different ways in which such women perceive the world.
The difficulties in the diagnosis of girls and women arise if clinicians continue to use the narrow definitions set out in the International Classification Systems. It cannot be stressed enough that diagnosis and full assessment of needs cannot be carried out by following a checklist. Proper assessment takes time and detailed evaluation is necessary to enable a clinician to systematically collect information which not only provides a diagnostic label, but more importantly, a detailed profile of the person.
We wish to draw attention to the fact that many women with an autism spectrum condition are not being diagnosed and are therefore not receiving the help and support needed throughout their lives. Having a diagnosis is the starting point in providing appropriate support for girls and women in the spectrum. A timely diagnosis can avoid many of the difficulties women and girls with an autism spectrum disorder experience throughout their lives.
Asperger, H. (1944). Die autistischen Psychopathen im Kindesalter. Archiv fur Psychiatrie und Nervenkrankheiten, 117, pp. 76-136
Attwood, T. (2000). Asperger syndrome: Some common questions: Do girls have a different expression of the syndrome? Available from: www.asperger.org/asperger/asperger_questions.htm#girls
Brugha, T. (2009). Autism spectrum disorders in adults living in households throughout England: report from the Adult Psychiatric Morbidity Survey 2007. The NHS Information Centre for Health and Social Care. Available from: https://files.digital.nhs.uk/publicationimport/pub...
Ehlers, S. & Gillberg, C. (1993). The Epidemiology of Asperger syndrome. A total population study. Journal of Child Psychology and Psychiatry, 34 (8), pp. 1327-1350
Gould, J. & Ashton-Smith, J. (2011). Missed diagnosis or misdiagnosis: girls and women on the autism spectrum. Good Autism Practice, 2011, Vol.12 (1), pp. 34-41
Kanner, L. (1943). Autistic disturbances of affective contact.Nervous child, 2, pp. 217-50
Lord, C. & Schopler, E. (1987). Neurobiological implications of sex differences in autism. In: Schopler, E. & Mesibov, G.M. (Eds.). Neurobiological issues in autism. New York: Plenum Press, pp. 191-211
Rimland, B. (1964). The etiology of infantile autism. In: Infantile autism: the syndrome and its implications for a neural theory of behaviour. New York: Appleton-Century-Crofts. p. 54
Skuse, D.H. (2000). Imprinting the X-chromosome, and the male brain: explaining sex differences in the liability to autism. Pediatric Research, 47 (1), pp. 9-16
Wing, L. (1981). Sex ratios in early childhood autism and related conditions. Psychiatry Research, 5, pp129-37