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90 Journal of Intellectual Disability - Diagnosis and Treatment, 2017, 5, 90-95
E-ISSN: 2292-2598/17 © 2017 Lifescience Global
Women & Girls on the Autism Spectrum: A Profile
Wenn B. Lawson*
ACRC, The University of Queensland, C/O PO Box 5033, Warrnambool, Vic. 3280, Australia
Abstract: Being female and autistic is poorly understood, but is autism really ‘rare’ in females? Historically, autism has
been associated with traditionally mascul ine features and stereotypes of behaviour, with some believing autism only
occurred in males [1]. This leads scientific enquiry to the critical question of whether there are more males living with
autism or, conversely, do females on the autistic spectrum present different ly to males and, therefore, are at risk of
remaining undiagnosed?
Keywords: Autism, Females, Presentation, Diagnosis, Gender.
Traditionally, over the last decade, only 1 female to
every 3 or 4 males has received a diagnosis of autism.
Often, females who are readily diagnosed as autistic
have tended toward the severe end of the spectrum,
being ‘classically’ autistic or having ‘Kanner’ type
autism with intellectual disability; or Autism level 3 [1-
3]. Even though Hans Asperger’s work eventually
opened doors to a deepening awareness of autism as
a spectrum, his original work was only with males [4].
Essentially, the question is, are there more males
living with autism or do females on the autistic
spectrum present differently to males? What we are
beginning to appreciate is the profile of autism’s impact
upon females is often different to that seen in males
(e.g. [5-8].
Sex and gender, both in biological sex and in
gender identity, are both concepts which are expressed
along a spectrum. However, this spectrum isn’t linear,
but circular. This understanding, and complexity, is
often over looked when it comes to autism. We have
been taught to believe chromosomes equal either XX
for females or XY for males. However, reality is
significantly more complex (http://www.who.int/
genomics/gender/en/index1.html).
Females differ in how they choose to express their
gender across different contexts and domains such as
physical presentation, communicative style and
behavior. This expression can vary between being
ultra-feminine, to the point of expressing almost
exaggerated femaleness, to almost resenting any hint
of stereotypical femininity where individuals live as
tomboys, even if they have XX chromosomes. Many
also lie between these two extremes. Research argues
*Address correspondenc e to this author at the ACRC, Long Pocket Campus,
The University of Queensland, PO Box 5033, Warrnambool, Vic. 3280,
Australia; E-mail: wenbe @bigpond.com
gender identity is not so much about chromosomes, as
it is about gender identity in the brain, but being female
and having different chromosomes to males and
different neurobiology than males will impact the profile
of autism in females. However, does this mean autism
presents differently to that seen in males, but may also
vary according to where a female ‘sits’ on the gender
spectrum [9,10]?
Until recently the idea of females having a different
profile of autism characteristics received very little
attention [11]. However, according to Lai, et al. as cited
in Moyse, et al. p. 187 [12]:
“girls who appear to be cognitively able or
appear to have better communication
skills may have been under-diagnosed”.
As well as being underdiagnosed or miss-diagnosed
with a mental health issue (Social Phobia; Depression;
Borderline Personality Disorder and so on) the needs
of females are being over looked and their difficulties
aren’t being understood [11].
Yet, despite this there is an increasing amount of
literature that discusses the differences in females
compared to males [12-19]. However, this is failing to
translate into practice. Although changing long-time
attitudes for practitioners, takes time, this is an
emerging need that warrants urgent attention. There
are many misconceptions about how autism looks and
this is getting in the way of seeing autism’s different
impact according to an individual’s cis-gender, or
otherwise.
In the past [20], details of the triad of impairments
that affected those with autism, were richly described.
The triad are listed as impairments of social interaction,
impairments of social communication and impairments
of social imagination [21]. However, the DSM-5 [2] has
now combined the three domains into two: issues with
Women & Girls on the Autism Sp ectrum Journal of Intellectual Disability - Diagnosis and Treatment, 2017, Volume 5, No. 3 91
social interaction and communication, as well as rigid
behaviours domains. Possibly the DSM-5, that has
drawn previous areas together as opposed to seeing
them separated (previous versions, for example, listed
Asperger’s syndrome, Pervasive developmental
disorder not otherwise specified (PDDNOS) and others,
as separate conditions) may not have helped here. We
are encouraged to view autism as a spectrum of
difficulty but, when so much is pooled within the same
pond, the danger is individual experiences can be over
looked.
The other issue that may be contributing to
misconceptions and reduced research attention on
females and autism, is the theory that autism is
influenced prenatally by testosterone leading to an
extreme male brain (EMB) [22]. However, while this
has predisposed many clinicians to think of autism only
as a predominantly male disposition, it has also meant
they have ‘missed’ the signs of autism in females and
given, due to their bias of thinking autism is the result
of an EMB, a mental health diagnosis instead.
Research has shown that although there is some
evidence that an EMB may impact autism in females,
this is not the case for males in autism [23], and how it
impacts on the female brain is still being debated.
For example, research by Carter et al. [6] shows
female toddlers with autism being less socially
competent than the boys. They are also better at non-
verbal problem-solving than the boys.
“The findings revealed a statistically
significant interaction between child sex
and cognitive domain (verbal versus
nonverbal) and child sex and the 5 Mullen
Scales of Early Learning (Visual
Reception, Fine Motor, Expressive
Language, Receptive Language, and
Gross Motor), indicating that girls and
boys with ASD show different cognitive
and developmental profiles. Consistent
with the expectation that boys would show
more advanced development, boys
evidenced stronger verbal and motor
skills, particularly once differences in
visual reception were covaried. Controlling
for language level, girls evidenced
significantly stronger skills in visual
reception, or the nonverbal problem-
solving domain. In addition, boys were
described as having more advanced social
functioning than girls….” P. 94.
As Bjorne [24] has pointed out:
“This all runs contrary to Baron-Cohen's
idea of the male brain. Or, if you wish, the
girls are more male than the boys. Given
the fact that there are so very few studies
addressing the cognitive profiles of autism
from a gender perspective, it is important
that the popular accounts are modified
somewhat by more rigorous studies”
Personal Communication.
If we look at the profile for many females, it seems
they may not have the same communicative difficulties
which typically trigger investigation into a potential
diagnostic referral for males.
Females on the spectrum often experience
Alexithymia. This means describing how they feel in
social situations is hard and this may lead to an
increase in their level of avoidance behaviours such as
complaints of headaches, stomach aches or incidents
of school refusal.
Autism is known to be a communication disorder.
Some females appear to communicate well, having
good eye contact and appropriate body language. Any
discrepancy is likely put down to bad manners, lacking
in discipline, or to the individual being strong willed or
extremely shy. However, the very names we give to
these behaviours should give us a hint that all is not
well. We need to look beyond the behavior and ask
certain questions. For example, is this behavior being
used out of frustration due to not comprehending social
norms; social expectations or processing social
‘instincts’?
In cognitively challenged female individuals with a
low IQ, autism operates at the severe end of the
spectrum and is rarely questioned. But, in high
functioning female individuals the double X
chromosome often gives them the feminine ability to
mask their difficulties; copy behaviour in social settings
that suggests they have an understanding and the true
nature of the effort this takes is not seen. Therefore,
when they appear not to understand or exhibit
‘challenging behaviour,’ they are thought of as being
naughty, difficult or attention seeking. How do these
females who society expects to be socially competent,
cope in a world that expects them to be able to read
body language, be friendly, sociable and happy in a
group, understand the hidden curriculum (the unspoken
rules of human interaction) and perform in society at
the expected level, manage their daily lives?
92 Journal of Intellectual Disability - Diagnosis and Treatment, 2017, Volume 5, No. 3 Wenn B. Lawson
With answers also not reflecting a deeper social
understanding, providing only a basic understanding,
lacking in social comprehension, cognition and
awareness as seen in their peers of typical developing
age, it must take significant courage to simply attempt
these interactions.
According to Attwood [5] girls fly under the radar as
they learn to develop coping mechanisms, may have
the ability to mask their social inadequacies through
copying or mimicking those around them and often
have passionate interests that are in line with typically
developing females. They also are more able to learn
and adhere to the social rules, learning acceptable
behaviours for certain situations. This is effective in
many situations, but often negatively affects the mental
health of many girls, with an increase in anxiety due to
the fear of rejection.
Girls become women and the expectations on
women only increase with social expectations
becoming highly complex.
Marshall [25] suggests the cultural expectations for
females to participate in social communication such as
chit-chat, small talk and gossip, is exhausting for those
with high functioning autism. There is also a lack of
social understanding which leads to confusion around
things such as teasing, bullying and bitchiness often
displayed by typically developing teens. Many high
functioning female teens on the autism spectrum prefer
to have their one, or select small group, of friends and
become anxious in large group situations. Facial
expressions of this group may not match their moods,
often saying they are fine and looking happy on the
outside but withdrawing internally. Females also tend to
be more passive-aggressive in their behavior and use
avoidance as a way of coping with the social demands
placed upon them. They may also blame others,
internalize their feelings or develop co-morbid
conditions such as anxiety, depression, eating
disorders or hyperactivity. As well as not being able to
communicate with their peers, this group also struggles
to understand the hierarchies within a societal structure
and can get into trouble with adult’s due to the way
they speak with them.
Nichols, et al. [16] state girls on the spectrum
present subtle differences in their behavior, when
compared to their typical peers. For example, they are
often able to answer questions about social situations,
social communication and friendships but are slower to
process the information. This would present great
difficulty in understanding the conversations that go on
between teenage girls within a group situation. Girls on
the spectrum often struggle at school in the
unstructured social play time. They may want to have
friends but lack the ‘innate’ knowledge and skills to
make and keep them [5]. Girls with autism are often
excluded from play and the social play that happens at
school, meaning they then miss out on the necessary
skills to help shape their identity [12].
If having difficulty navigating the teenage years is
hard for typically developing children how much more
so is it for girls with high-functioning autism? [25, p.37]:
“Girls on the autism spectrum are more
likely to come to the attention of health
professional’s due to difficulties with
anxiety, depression, eating disorders,
behavioural problems and/or social skills
challenges. The presenting problem then
becomes the ‘diagnosis’, with the larger
picture and explanation for feeling
“different” being missed”.
Yaull-Smith [26] suggests girls with autism have a
desire to please and fit in which makes them:
‘hypersensitive to the environment,
vulnerable and easily manipulated, so they
are conditioned to conform to the social
norm but, as a result risk losing a sense of
identify- not least because social etiquette
and mores change and develop over time
and because a large part of conformity for
girls, in particular, is to please others’ (p
30).
As a result of being a girl on the spectrum and also
having to contend with the societal pressures placed
upon girls throughout the teenage years, their physical,
mental and emotional health suffers. This road is often
fraught with difficulty, misunderstanding and anxiety for
the girl involved. It is important that for parents of girls
on the spectrum they provide space, a place of safety
within the home for the young person to feel they can
truly be themselves and to always show respect and
love towards them. A colleague of mine, in
conversation, suggested that during this time, role play,
meditation, yoga and understanding as well as
teaching the understanding of social communication
along with their feelings, could offer some support.
In many societies women are expected to marry,
have a family, run a household and often some form of
Women & Girls on the Autism Sp ectrum Journal of Intellectual Disability - Diagnosis and Treatment, 2017, Volume 5, No. 3 93
employment too. The DSM-5 [2] for the first time,
includes sensory issues in the criteria housing autism.
Women must face many challenging changes to their
bodies, including menstruation, growing through
puberty into the curves and shapely form of
womanhood. The expectation is ‘she will cope. It’s
natural, it’s happened to all women since time began,’
and so on. But, if an individual can’t cope with these
changes, the different smells, feelings and
expectations, they may decide these won’t happen to
them. I have met females who decide not to grow up,
so they continue to act like a child, stop eating to
restrict their growth and employ any other behavior
they believe will keep them from such a fate.
Then there’s the issue of sexuality and keeping
safe. For some female’s this is a major issue. Some
have little understanding of sexual etiquette, even if
they have a normal IQ. The literal, black and white
thinking processes in autism might mean if someone
says: ‘can you have sex with me’ the person may reply
‘yes’ because they perceive the question to mean ‘is it
possible for you to have sex with me?’ This is literal
thinking that fails to negotiate the bigger picture.
An edited summary of some issues for females on
the autism spectrum offered as, truth or myth.
Given to me by Katy Reid, a parent to two autistic
daughters.
1 ‘…She’s too social to be autistic’ because she
has friends or wants to have friends so she can’t
be autistic - MYTH
2. She looks at me when I speak to her, so she isn’t
autistic- MYTH. Girls may have good eye contact
3. Girls follow the rules – less likely to act out due
to need to please others (Often True).
4. Girls will mimic others so they blend in but, their
difficulties are often overlooked because of this
(Often True).
5. Girls may find communicating their feelings
unavailable to them and will become mute within
the classroom - TRUE
6. Girls may not want to be the center of attention
or have the spotlight on them - TRUE
7. Girls may have a love of technology, horses,
animals, and friends - TRUE
8. Girls may live their lives through others and find
personal autonomy allusive - TRUE
9. Girls live with severe anxiety (Often True)
10. Girls often have performance issues and won’t
settle for less than perfect (Often True)
11. Girls may be unable to stop certain behaviours
such as having to twirl or spin. They may pick at
their fingers, scrunch up their toes or face or
have to twitch, all seemingly involuntary (Often
True)
12. Girls may need to tune into their cues and follow
strictly to know what comes next (Often True)
13. Girls may find it difficult to process lots of
information at once. They need to do one thing
at a time (Often True, unless connected to
interest)
14. Girls need consistency, structure and continuity
(Usually True)
15. Girls exhibit rigid behaviours and resist change -
TRUE
16. Routine is very important to girls and if it
changes they need to have this visually
explained or written down - TRUE.
17. Girls find body language and facial expressions
difficult to read - TRUE.
18. Girls often have an inability to understand jokes
or make jokes that others don’t understand -
TRUE
19. Girls need to have others explain, in many
different ways, what is happening and how
things work (Often True)
20. LOTS and LOTS of questions about life are often
repeated and answers may fail to make sense
(Often True)
21. Girls show an inability to move on and let
negatives go, they fixate on things and don’t
know how to process them or let it go (Often
True)
In school Girls are often missed as they appear to
be conforming. The teachers and professionals don’t
see the issues that are going on at home, the lack of
94 Journal of Intellectual Disability - Diagnosis and Treatment, 2017, Volume 5, No. 3 Wenn B. Lawson
sleep, the outbursts, the lack of understanding.
Professionals would benefit from listening to the
parents and parents benefit from taking notes and
documenting what is happening [27-30].
The above is a tentative outline of what may be
happening for females on the autism spectrum. It is not
exhaustive or complete by any means. Not all females
will fit every aspect of the above descriptions.
When an autistic individual is interested, GAMMA is
enabled [31] and autistic females (like the males) are
motivated to do more than they might do otherwise.
Utilizing interests and strengths is the best way forward
in autism. Finding ways to explore the hidden
curriculum of any social society is made so much
easier and available when individuals can access it via
their interests. When individuals on the spectrum are
not interested, motivation is switched off. Working
together within individual interest is the remedy for this.
It is imperative professionals consider autism in girls as
an option, rather than only diagnosing various mental
health issues. Of course, these can co-occur, but may
not be the foundational issue so much as a secondary
one.
It seems that whatever one’s gender if the individual
is ‘somewhere’ on the spectrum of autism their thinking
and problem-solving abilities differ from that of the
typical world. However, just because one is different or
arrives at an understanding by taking a different rout,
this doesn’t mean there isn’t value in their processing
or problem-solving attributes. It makes no sense to say
just because they didn’t do it typically, the way they did
something is wrong. But, if females are losing
confidence, failing to thrive, appear to have a thought
disorder, are being very literal, showing signs of
demand avoidance and so on, the professional should
consider the wider option of an autism assessment.
Autism presents in all genders across the human
condition and is not only a male prerogative.
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HELPFUL WEB SITES
https://t aniaannmarshall.wordpress.com/2013/03/26/moving-towards-
a-female-prof ile-the-unique-characteristics-abilities-and-talents-of-
asperwomen-adult-women-with-asperger-syndrome/
https://www.amazon.com/Am-Aspiengirl-Characteristics-Females-
Spectrum/dp/0992360900
https://www.sci entificamerican.co m/article/autism-it-s-different-in-
girls/
https://iancommunity.org/ssc/girls-autism-hiding-plain-sight
https://www.youtube.c om/watc h?v=oZhZ0k1lyF8
https://www.youtube.c om/watc h?v=i4zMeIZfU-s
https://www.youtube.c om/watc h?v=IvhiW7ilTDk
Received on 26-08-2017 Accepted on 20-09-2017 Published on 17-10-2017
DOI: https://doi.org/10. 6000/2 292-2598.2017.05.03.4
© 2017 Wenn B. Lawson; Licensee Lifescience Global.
This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in
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