‘’In the autistic individual the male pattern is exaggerated. Maybe there are no autistic girls. We just don’t know’’ (Asperger 1944)
Before I begin I would like to make it clear that the core features of autism are the same regardless of gender, and that the only thing that, on average, varies between men and women are their coping strategies and reaction to being different. All people with autism find it difficult to relate to, and communicate with, other people. They usually find change difficult, and often develop intense interests, routines and obsessions. Sensory difficulties are also extremely common.
Diagnosis, research and statistics
First of all I would like to provide you with a brief historical perspective.
As highlighted in the quote taken from Dr Hans Asperger, the original case studies of autistic people were all male. Furthermore, in 2006 Dr Ami Klin described autistic girls as ‘’research orphans’’ because the vast majority of research was carried out on these diagnosed boys. Consequently diagnostic tools are gender biased in favour of male characteristics, which has meant that you are far more likely to receive an autism diagnosis if you are male. Indeed, some studies have shown that as many as 10-15 boys to every 1 girl get an autism diagnosis at the Asperger end of the spectrum, and a 2012 survey carried out by the National Autistic Society revealed that 50 per cent of boys were diagnosed with autism by the age of 11, compared to only 20 per cent of girls. However research is now showing that there are probably just as many girls with autism as there are boys, but most of them are undiagnosed.
It was only between the years 2000 and 2004 that published research on gender differences in autism began to emerge. Therefore, all findings on gender differences at this stage are preliminary and open to review.
Stereotypes and differences in autism presentation
The stereotype or general image we have of autism is largely modelled on the male stereotype in general. Historically men have been described as logical, unemotional, aloof, independent, and as having interests that are technical, object or machine based. Conversely the female stereotype includes characteristics such as empathy, creativity, imagination, and good social and communication skills. Therefore, when doctors first discovered and described autism as a clinical entity, they noticed parallels between certain autistic characteristics, most notably impaired social skills, and the more general male stereotype. This has meant that, right up until the present day, professionals often turn a blind eye to autistic behaviour in women, even when the girl has very severe and obvious symptoms.
It has long been widely acknowledged that girls and boys are socialised differently, and that this can affect male and female behaviour and interests. For example, males on average show more externalising behaviour when they are faced with difficulties, such as hyperactivity and aggression, whereas girls are socialised to be compliant, passive, and socially agreeable. Autistic people are exposed to these same pressures and expectations, and this means that autistic behaviour can often appear different in girls and women than it does in boys and men.
I will now outline how these differences in presentation can be expressed.
Girls with autism often feel a greater need than boys with the same condition to mask or repress their overt autistic behaviour, such as hand flapping or jumping, and learn to blend in by bowing to the female expectation to be social. They are more likely to internalise their symptoms, which might be expressed as anxiety or shyness. For example, when I was at school I never had overt meltdowns but I regularly shut down. This meant that I day dreamed and passively avoided doing my work instead of causing any major trouble. Nevertheless teachers were concerned because they identified that I had learning difficulties.
When I was 9, an Educational Psychologist was called into the school, and carried out an in depth assessment of my learning profile. The report opened by saying the following: ‘’Anna was formally raised as a cause for concern by her class teacher, in the Autumn term of 1996. Anna’s reading accuracy was said to be in advance of her chronological age but her reading comprehension was almost two years below her chronological age. Anna also had spatial awareness difficulties. She had some interaction problems, particularly with her peer group, preferring to play with much younger children. Eye contact was poor and self- confidence low’’. It is interesting to note, however, that the Educational Psychologist observed that during the subsequent testing my ‘eye contact was felt to be good’’. It is likely that in the highly structured one to one atmosphere of the test environment, I felt more comfortable and therefore more able to make eye contact. The test revealed that I had strong verbal skills, which were high average, but had severe difficulties with visual perception and sequencing, organisation, maths and numeracy. This uneven profile, or being very advanced in some areas while severely behind in others, is very common in autism. The report also emphasised that I lacked confidence and had nervous anxieties, such as washing my hands repeatedly at home and having worries about getting dirty. Significantly the report said that I still seemed ‘’like a little girl, both physically and emotionally’’. In other words, as is is the case for many girls with undiagnosed autism, my difficulties were explained away as being the result of immaturity and shyness.
Sadly the school failed to adequately support my difficulties, and so I suffered in silence and became invisible to the system, probably because I did not make a huge fuss. Furthermore, I was not aloof or completely alone, and although I had difficulties making friends, I did try and initiate contact with other children. However, I did so in too forceful a manner, or I said inappropriate things because of difficulty with social skills. It is, in fact, common for girls, on average, to be more socially motivated than boys and even to have one friend. I finally made a friend with another girl in my year group when I was 9 years old, but the quality of my interaction was different because I was very possessive and got very upset when anyone one else wanted to play with her. Consequently, the friendship did not last.
Things became even harder at secondary school because socialising became more focused on small talk, feelings and relationships. Boy’s social activity is often focused on activities such as computer games, and there is generally less emphasis on conversation. Therefore girls with autism face the double whammy of having the same social impairment as boys with autism, but having the extra difficulty of having to navigate the incredibly complex female teenage social world. Initially I tried to blend in by being quiet and nice, but I did not have the social skills to do this successfully, and one girl after another rejected me because I was too ‘clingy’ or did not have enough to say. Eventually I gave up trying and spent lunch times locked in the toilets or hiding away in an empty classroom.
It was also during my teen years that I first learnt how to actively camouflage my autistic symptoms by learning compensatory strategies. I did this because I wanted to avoid ridicule and not draw attention to my differences. This meant that I studied the behaviour of the more popular girls in my class, and imitated the way they spoke. Gradually I used my intellect to absorb their personas into myself, and through continual practise I eventually learnt how to pull off a more or less fluent conversation with another person. Research has shown that this behaviour, which has been given the name social echolalia or advanced, mirroring, is more common in girls with autism than it is in boys. However, because the compensatory behaviour can be so convincing, it can be hard for other people to spot the underlying autism. Indeed, professor Simon Baron Cohen has said that ‘’if you were just judging on the basis of external behaviour, you might not really notice that there is anything different about this person’’, and that ‘’it relies much more on getting under the surface and listening to the experiences they’re having rather than how they present themselves to the world’’. What is important to understand is that masking and compensatory behaviour is incredibly exhausting and draining because it involves the intellect instead of social instinct, and so feels mechanical and unnatural. It can therefore lead to identity confusion, underestimation of needs, poor self-esteem, and severe mental health problems.
Research has identified that interests is the main area where males with autism, on average, differ from females. Historically clinicians looked out for very eccentric and peculiar interests in parts of objects or things like lights, street signs, or drainage facilities. Also the male autism stereotype emphasised the rote repetition of scientific facts in a monotone voice, with little interest in creative activities such as reading fiction or playing imaginatively.For example, one of Simon Baron Cohen’s autism screening questionnaires asks the recipient male centric questions such as whether ‘’when travelling by train, you often wonder exactly how the rail networks are coordinated’’ However, research from great Ormond street has shown that because of gender differences, ‘’girls obsessional interests are (often) centered around relationships and people’’. A girl with autism might have age appropriate interests in, for example, horses, fashion, makeup, dolls, celebrities, and reading fiction. Yet although the subject might be typical, the intensity of the interest is what sets the autistic girl apart from her typical peers.
For example, all my interests have been socially focused. As a child I was obsessed with food and what other people were eating. At school I memorised what every child in my class had to eat for lunch. I was also obsessed with other girls. I collected leaflets and cut out photographs of girls, which I stuck on a piece of paper, and then I wrote an imaginary story about that girl’s life, which mainly focused on food and her appearance. I was also obsessed with the Malory Towers girl at boarding school books, which I memorised off by heart. I loved the different character portrayals and was inherently interested in the lives of other people, real or fictional. But my biggest people based obsession of all was with the actress Kate Winslet, who I was interested in for a decade, between the age of 11 and 21. I watched and memorised all her films, watched all her interviews, collected every single Winslet picture, and spent hours learning everything there was to know about her life.
My biggest people based obsession of all was with the actress Kate Winslet. I watched and memorised all her films, watched all her interviews, collected every single Winslet picture, and spent hours learning everything there was to know about her life. It was through Winslet that I learnt many social skills and how to camouflage my autism.
After Winslet had a baby I became extremely interested in child development. I read parenting magazines from cover to cover. I also followed people with babies down the high street, and I took detailed notes in my baby spotting diary, as if I were a child psychologist examining a child in a laboratory. If I were a boy going train spotting and obsessively looking at those rail networks that Simon Baron Cohen mentioned, my interest might have appeared more characteristically autistic. But because being interested in babies is considered quite common in women, the interest was less noticeable. Furthermore, I was careful to mask my interest when out in public, and so I did not pursue the interest in a way that would draw attention to me.
Likewise, when at school, I did not lecture people about my interests, and I simply kept quiet. This might partly explain why the school did not raise the possibility of me being autistic to my parents. But when I got home I talked about nothing but Winslet and babies, which concerned my parents enough for them to eventually suspect autism.
The effects of gender differences and late diagnosis
Because it is the rule rather than the exception for girls to receive a very late diagnosis, they often have no way of explaining themselves to themselves, and no access to the support and positive sense of self that they need in order to prevent mental health problems. It is common for individuals without a diagnosis to accept the explanations that other give them for their difficulties. They are often labelled as rude, mean, uncaring, shy or lazy, and this means they might blame themselves for their failings, and believe that they are worthless. Moreover, because people assume that a woman will be naturally social and emotionally responsive, the fact that she struggles in these areas can make the girl with undiagnosed autism feel as though she is not a real woman. It is also common for undiagnosed women with autism not to suspect autism in themselves because of the assumption that it is a male condition. For example, my dad first suspected that I had autism when I was 12 years old, but because of my limited understanding, the image I had in my head of what autism looked like was a man with no empathy and an obsession with maths and computers. I therefore got very angry whenever autism was mentioned. Instead I worried that I might have a personality disorder or that I was a horrible person with no empathy or feelings. My lack of confidence and stress meant that my Obsessive Compulsive Disorder became very disabling, as it was my attempt to exert some control over my life.
It is very common for women to first be diagnosed with another condition instead of autism. The neuroscientist Francesca Happe calls this diagnostic substitution or overshadowing. What this means is that they get given a diagnosis that is assumed to be more likely in women, such as depression, OCD, or anxiety. The woman might well have one of these conditions as well as the autism, but the underlying reason or cause of the difficulty, the autism, is often overshadowed by the presenting behaviour. For example, when I eventually conceded that I needed help and had an assessment at the mental health team, I was initially diagnosed with OCD and social phobia. I only got diagnosed with Asperger’s when I asked for a referral to the adult autism team. If I had not taken that initiative, I might still lack the correct diagnosis.
Since being diagnosed with Asperger’s syndrome and finally getting the correct support, I have become more confident and can do many things that were impossible when I hardly left the house and lived an extremely isolated existence in my bedroom. Without a diagnosis I would not be standing up here speaking to you today.
It is encouraging that the updated diagnostic and statistical manual of mental disorders mentions sex differences in autism diagnosis for the first time. It states that ‘’girls without an accompanying intellectual disability may go unrecognised, perhaps because of a subtler manifestation of social and communication difficulties’’. There is also a new specifier that symptoms may not become fully manifest until social demands exceed limited capacities, or they may be masked by learned strategies in later life’’. The research into gender differences has also led to a reconceptualization of what autism might look like in both genders. For example, it is now widely understood that people with autism can be very empathetic, as well as often being caring, creative, and imaginative in certain areas.
The research into masking has shown how important it is not to ignore the often painful, inner realities of living with autism. A good quote is that mild autism does not mean that I experience autism mildly, mild autism means that you experience my autism mildly. There can be a huge amount of stress and confusion within the autistic individual that is not always overtly expressed, so it is important not to get fixated on looking for obvious behavioural markers of autism. In fact research has shown that there is no one behaviour that reliably identifies autism, and this is why it is described as a ‘hidden or invisible condition’.
Closing comments and summing up
Finally I would like to emphasise that this presentation has merely explored general trends, and autism is varied for all individuals, male or female. Boys and men can also present with the so called ‘feminine’ profile that I have outlined, and camouflage their autism in the ways described, and these individuals have also been historically under diagnosed. Conversely some women with autism will display the classic male profile. Gender is just one of the many variables that can influence how autism is expressed, and personality, sexuality, socio- economic status, ethnicity, culture, co-occurring conditions and disabilities, IQ, personal experience, upbringing, and stressful life events can all interact with autism to influence behaviour and presentation. It is therefore important to understand that once you have met one person with autism, you have quite literally only met one person with autism. Prepare to be surprised, and never assume anything.