Mental Health

The Autism Spectrum Gender Gap

The behavioral health field has made great strides in diagnosing autism spectrum disorder and providing interventions and supports to help people living with autism thrive. But many girls and women with autism are still falling through the cracks.

Three to four times as many boys as girls are diagnosed with autism, a long-standing pattern confirmed in a 2023 autism research article that argues for gender balanced studies of autism. The skewed ratio almost certainly does not reflect the true incidence of autism, says Michael J. Murray, MD, medical director for autism and developmental disabilities at Sheppard Pratt. “The criteria for diagnosing autism are largely defined by the way it presents in men and boys. But girls’ brains and biology are different, so it makes sense that autism would present differently,” Dr. Murray says. “We’re vastly underdiagnosing autism in women and girls."

“There are a number of useful assessments that test for autism, many of which are considered the gold-standard. But considering how many women and girls are going undiagnosed, these assessments must be normed more towards the male presentation of autism spectrum disorder,” says Tom Flis, MS, BCBA, LBA, LCPC, clinical director of the Center for Autism at Sheppard Pratt. Many girls and women with autism don’t receive a diagnosis until adolescence or early adulthood. That’s a missed opportunity for providing accommodations that can help them be more successful, and it can lead to a cascade of mental health difficulties.

At the Center for Autism at Sheppard Pratt, a multidisciplinary team of experts provides thorough diagnostic assessments for patients who may be on the spectrum, providing new hope for those who have been overlooked or misdiagnosed.

How gender affects autism spectrum disorder

Autism can present in many different ways. Boys with autism tend to be interested in objects, Dr. Murray says. “They may be really focused on trains, or on building blocks—behaviors that are more easily seen by others as being unusual or overly intense,” he explains, adding that girls with autism more often are interested in people or animals. “Girls may be fixated on TV shows or watching people from afar to try out their behaviors. That interest in relationships isn’t usually seen as an autistic way of looking at the world.”

Because of that interest in people and relationships, girls tend to develop strategies at a young age that enable them to “pass,” or mask autistic behaviors. They often make eye contact and have good early language skills. But below the surface, there are signs of autism. Girls might make too much eye contact or hold a stranger’s gaze too intently. They might be good at introducing themselves to peers but struggle to understand the nuances of inside jokes or tones of voice—especially as they get older and social interactions become more complex.

Those more subtle behaviors aren’t always obvious in a psychiatrist’s office. As a result, many girls with autism are misdiagnosed with other things, including anxiety, depression, or obsessive-compulsive disorder (OCD).

Such misdiagnoses can lead to treatments that are not effective, and they can delay therapies and supports that can make a critical difference.

Getting an autism diagnosis for girls and women

So how can you tell if women or girls in your life may have undiagnosed autism? Dr. suggests looking for these red flags:

  • Frequently changing diagnoses
  • A history of medications that do not provide relief
  • Difficulty grasping key concepts in therapy 
  • Difficulty developing and sustaining peer relationships
  • Increased sensitivity to sensory inputs like loud noises or crowds

Many young women with autism have co-occurring conditions like anxiety, depression, or OCD, but those conditions can look different in someone on the spectrum and may respond differently to medications. Interventions like cognitive behavioral therapy can be useful, but only if they are tailored to the needs of the individual with autism. Tragically, women on the spectrum are two to three times more likely than the general population to experience sexual violence, so they may also have a history of trauma that requires treatment. To provide effective treatment, a care provider needs to have a full picture of their patient. When an autism diagnosis is missed, Dr. Murray says, that picture can be distorted, making treatment less effective.

At Sheppard Pratt, our expert teams—including psychiatrists, occupational therapists, psychologists, speech therapists, social workers, and other experts—can provide comprehensive evaluations. “We have all of the necessary experts in-house to consult with one another,” Dr. Murray says. “A good evaluation leads to a good understanding of a patient’s needs—and identifies a person’s strengths and talents.” That interdisciplinary approach allows Sheppard Pratt’s experts to consider each patient holistically and provide the best combination of services and supports that will allow them to thrive. 

The Center for Autism provides evaluation and diagnosis, as well as treatment and case management services. “We want to serve as a resource within our community and across the country,” Dr. Murray says. “There are many women and girls who are suffering and don’t need to be.”

If you or a loved one who would benefit from an autism diagnostic assessment, contact our Center for Autism.

Sheppard Pratt’s Center for Autism