Gender Differences in Autism – Hermione Walker
In any specialist education provision, among the children with autism spectrum condition (ASC), it is most likely that boys will outnumber girls. Children who have autism spectrum are increasingly being placed in pupil referral units, where the ratio of boys to girls is far higher.
The number of people diagnosed with autism has seen a steep rise since the 1980s. It is generally believed that there are three main reasons for this. These are increased awareness of the condition, improved diagnostic practices and redefining of autism to include a wider range of associated conditions and subtypes.
Statistics show that a greater proportion of males have been diagnosed with autism compared to females, generally said to be four boys to every girl. A study commissioned by the Health and Social Care Information Centre (HSCIC) found that autism affects 2% of the male population compared to 0.3% of females. However, there are variations according to different studies and according to the National Autistic Society (2018), this could amount to 15 times more men to women who are ‘high-functioning’ autism or Asperger syndrome.
It’s different for girls
The difference in prevalence between males and females is thought to be partly due to the fact that autism is more difficult to recognise in females and there is growing evidence to suggest that a large number of girls remain undiagnosed. Research Autism (2017) explains that girls and women may be harder to diagnose because they learn to ‘mask’ their autism. They are also more likely to be misdiagnosed with other conditions, such as obsessive compulsive disorder (OCD).
Girls may be falling under the radar for the following reasons:
- Differences in presentation
- Perceived stereotypes about autism
- Gender stereotypes and expectations
- The diagnostic process
Differences in presentation
Autism affects two main areas: social interaction and communication and restricted and repetitive interests and activities. Sensory processing difficulties are also commonly experienced by people with autism. These characteristics will influence a child’s development and behaviour and so it is important that they are recognised and an early diagnosis is important in order to provide appropriate support.
Girls may appear to have advanced social skills and language and are adept at imitating peers, often acting out a ‘script’ when with others, known as ‘delayed imitation’. They may become effective at ‘masking’ their difficulties which can be exhausting for them, so they often experience high levels of anxiety. Some of their behaviours are found in neurotypical children, however it is the intensity and quality of these which differentiates them.
This table gives an overview of some of the key differences in the way that girls and boys may present.
More recently, conditions such as pathological demand avoidance (PDA) have been recognised as a type of autism that is associated with girls. Girls show different behaviour patterns associated with ‘demand avoidance’ behaviour, for example controlling, domineering and passive/aggressive behaviour. Even the most everyday tasks can be seen as threatening and demand-avoidant behaviour can involve manipulation, aggression and even violence on the part of the individual. Children with PDA can change from being happy and co-operative one moment to becoming distressed and aggressive the next. This leads to the description of a ‘Jekyll and Hyde’ personality. This behaviour is often misunderstood in schools, particularly as it can be socially shocking, however it is important to recognise that it is driven by high levels of anxiety.
Perceived stereotypes about autism
Stereotypes about autism can have a negative effect for both boys and girls. Autism is a spectrum condition and although this includes shared characteristics, there is a huge variation between all individuals in the intensity of characteristics and behaviour.
Not all individuals who are on the autism spectrum avoid eye contact, some people may use it inappropriately – think of this as two sides of the same coin. Girls’ interests may be focused on topics that would be expected of their peer group, it is their intensity and obsessive nature that makes them different.
Many people base their knowledge of autism on someone they know and may have a fixed view of how autism affects people. In this way, some professionals are more familiar with the way boys present which can limit their ability to recognise the characteristics in girls.
Gender stereotypes and expectations
Gender differences and expectations may affect the social behaviour of all children during their formative years. They may also affect the way girls repress their autistic characteristics, particularly in relation to social interaction and communication. Speech and language development is usually more advanced in girls and so speech delay may be limited and they are able to catch up earlier.
Many characteristics such as perfectionism and ‘shyness’ are seen as usual with girls and so may go unnoticed. In the same way, anxiety might be put down to girls being ‘highly strung’, the word hysteria is derived from the Greek word ‘hysterika’ meaning uterus (womb)!
Parental attitudes to girls can impact the situation, for example they may intervene to support social interaction with girls. For example, they often work harder to nurture friendships with other girls. Traditionally, girls are more likely to attend speech and drama lessons which helps in masking difficulties and special interests involving animals, fiction or celebrities would not cause any concerns (Attwood 1999).
Gender bias in diagnosis
Dr Gould (2011) suggests that there is a gender bias within the process of diagnosis and diagnostic tools used. Because autism is traditionally seen as a condition that affects males, the criteria used for diagnosis do not fully capture how the characteristics would present in females. Her extensive research also indicates that there is a gender bias among professionals towards diagnosis of males.
What does this mean for girls and women with autism?
Women are generally diagnosed later in life meaning that they are more likely to struggle with the legacy of negative educational experiences in all aspects of their adult lives. Diagnosis brings an explanation of their difficulties and fosters an understanding, both for themselves and for others.
It is quite common for girls with autism to be given an alternative diagnosis, such as attention deficit and hyperactivity disorder (ADHD), obsessive compulsive disorder, depression or anxiety. This means that they do not have the specialist support they need throughout their school years and adult life and may be inappropriately placed in schools.
The consequences of this lack of support and understanding can be devastating. Dealing with high levels of anxiety and repressing characteristics on a daily basis is mentally and physically exhausting and can harm their mental health. Chronic anxiety can also have harmful effects on physical health.
Girls and women with autism may have difficulty seeing the consequences of their actions and others which puts them at risk and increases their vulnerability (Gould 2017).
The PDA Society uses a panda to symbolist the needs of individuals with PDA.
Individuals with PDA need very specific support in order to thrive and may otherwise have an increased likelihood of poor outcomes, just like giant pandas.
And just like pandas, individuals who have PDA can flourish in the right conditions.
All professionals can help by being alert and open to understanding the behaviour of those they support. Whilst a diagnosis is important in helping individuals to access resources and appropriate support, being understood by those around them can help to reduce anxiety and enable individuals to achieve their potential.
Hermione Walker has extensive experience of health and social care training, gained from both within the sector itself and from within the education and training sector. Having practised as a nurse for 20 years, she also worked in further education for 15 years, delivering training to health, social care and early years workers up to Level 5. Since 1999, Hermione’s work with Awarding Organisations has involved developing qualifications and more recently as an External Quality Assurer (EQA). She is currently Chief EQA at NCFE for a wide range of qualifications in health and social care.
Attwood, Tony (1999), The Pattern of Abilities and Development of Girls with Asperger’s Syndrome,
Gould, Judith (2011), Missed diagnosis or misdiagnosis: girls and women in the autism spectrum, www.autism.org.uk
Gould Judith (2017), The diagnosis of women and girls on the autism spectrum, Autismin talvipäivät
nasen (20116), Girls and Autism: Flying under the radar, www.nasen.org.uk
National Autistic Society (2018), Gender and autism, www.autism.org.uk
The National Autistic Society (2013), Getting on? Growing old with autism, www.autism.org.uk
National Institute for Health and Care Excellence (2014), NICE support for commissioning for autism, www.nice.org.uk
National Institute for Health and Care Excellence, (2013), The Management and Support of Children and Young People on the Autism Spectrum, [CG170], www.nice.org.uk
National Institute for Health and Care Excellence, (2011), Autism diagnosis in children and young people: Recognition, referral and diagnosis of children and young people on the autism spectrum [CG128] www.nice.org.uk
The NHS Health and Social Care Information Centre (2012), Estimating the Prevalence of Autism Spectrum Conditions in Adults: Extending the 2007 Adult Psychiatric Morbidity Survey, www.hscic.gov.uk
Research Autism (2017), http://www.researchautism.net/autism/diagnosis