Autism Spectrum Disorder (ASD) has historically been regarded as a condition which affected males significantly more often than females. In 2016 the Center for Disease Control (CDC) gave a ratio of approximately 1:4, with boys being diagnosed about four times as often as girls.
But are there really four times as many autistic boys and men, or just four times as many receiving a diagnosis?
Because of that notion about male-to-female ratios, formal tests for ASD are typically normed on a population that includes more males than females. This means the tests will give more accurate results for boys and men as compared to girls and women.
Diagnosticians expect that males are far more likely to be autistic than females, so they may look at the same symptoms and attribute them to ASD for males, but not for females.
A 2017 study in the Journal of the American Academy of Child & Adolescent Psychiatry suggested that the true male-to-female ratio is not as heavily skewed toward males as previously thought, and that a diagnostic gender bias appeared to be the cause. The problem this poses is that girls who meet criteria for ASD face a disproportionate risk of not being identified.
Why is it so difficult for autistic girls and women to get a proper diagnosis?
Girls are better able to mask or hide their autistic symptoms, to watch and imitate other girls to figure out what’s going on socially, and to fade into the background rather than standing out.
When boys fail to figure out social expectations, they tend to act out in ways that are noticed by parents and teachers. When a girl sits quietly watching rather than joining in, adults assume she is simply shy. It never occurs to them that she is completely baffled by the unwritten social rules of play that all of her peers are privy to.
When faced with a high-stress, fight-flight-or-freeze situation, boys usually engage in fight-or-flight, bringing their issues to the attention of parents or teachers. Girls, on the other hand, are more likely to freeze instead of fighting or running, and no one notices her distress.
Boys flap their hands and adults wonder if it’s a sign of autism, but when girls do “jazz hands” or flutter their fingers, people think it’s cute.
When they were younger girls’ autistic symptoms went unnoticed, and as they grew older they learned to consciously hide them. Many masked so well that they make it all the way through school without ever being evaluated for ASD.
The important take-away here is that we, as educators and evaluators, need to improve our awareness of the different ways autistic girls and women present their symptoms. They really do look different from their male counterparts. The fact that they can mask their symptoms doesn’t mean they don’t deserve to be properly diagnosed and receive any needed services. It is up to us to look behind the mask and discover the girl who is trying to cover up her autism, or the woman who has successfully hidden her symptoms for decades. They deserve to be seen and understood.