How do autistic girls present differently than boys?

It is becoming more acknowledged and recognized that girls on the autism spectrum present differently than boys do. The diagnostic ratio has been 3 boys to every 1 girl diagnosed, but is this a true representation of the female population? Autistic females are not being diagnosed due to their differences in presentation, and on average are diagnosed 2 – 3 years later than boys are. Girls are often missed for a number of complex reasons, but two of the main ones are masking and presenting internally.

Autistic masking, camouflaging, or compensating is a conscious or unconscious suppression of natural autistic responses. It is hiding or controlling behaviors associated with autism spectrum disorder (ASD) that may be viewed as inappropriate in situations. Autistic people may feel the need to present or perform social behaviors that are considered neurotypical or may hide neurodiverse behaviors in order to be accepted and fit in.

Regular masking can have a profound impact on a person’s well-being. Some of the negative effects of masking are:

• exhaustion and fatigue – masking takes a lot of effort
• change in self-perception or self-identity (not feeling like one’s true self, feeling like a “fake”)
• increased stress and anxiety
• depression
• autistic burnout
• a delayed autism diagnosis
• increased risk of experiencing thwarted belongingness and lifetime suicidality

Why are autistic traits in girls missed, dismissed, or overlooked?

Autism is diagnosed by observing behaviors. If those behaviors are shown in an external way, a referral will be made. If behaviors are internalized like in the case of masking/camouflaging and the person doesn’t cause any disruptions or problems, they may be overlooked. It is not until the point that mental health has deteriorated to the stage where behaviors have become more visible that help is sought.

Female behaviors are often stereotyped. Society accepts certain behaviors as being typically female such as being shy, quiet, or withdrawn. For example, if an autistic girl doesn’t want to get her hands messy, that is acceptable because girls are neat and tidy and boys aren’t. If she is quiet in the classroom and not causing any disruptions, she is not singled out for concern.

Interests of autistic girls may be deemed more typical and socially acceptable than males interests are.  Interests such as drawing, reading, animals, and figurines are common among girls. No one sounds the alarm when a girl in engaged in these pursuits for long periods of time. Trying to fit in with non-autistic friends, studying how to behave and what to say in order to fit in (think of masking), can become an interest on its own.

Repetitive and restrictive behaviors may not be the ones typically thought of such as lining up objects or using echolalia. Girls may like re-reading the same book, watching the same program over and over, and writing about the same thing because it satisfies the need for predictability. My daughter engages in all of these repetitive behaviors.

In the publication Autism, Girls and Keeping It All Inside from the Autistic Girls Network, the authors stated:

Autistic girls, and boys or non-binary young people, who present in an internal way may tend to internalize problems too, and this can cause damage to their mental health which is already in peril
from camouflaging their autism. It can lead to increased anxiety and situational mutism (being unable to speak in situations which cause high anxiety or feel unsafe). Because this is an internal behavior and is not a core feature of the diagnostic criteria of autism, despite being common in the cohort we’re looking at, it can also cause these young people to be misdiagnosed if the assessor doesn’t understand internal presentations (Hull, Petrides and Mandy, 2020).

What does an internal presentation of autism look like?

The following lists are highlights from the Autism, Girls and Keeping It All Inside publication. This is not the entire list, so I would encourage readers to investigate further by reading excellent this publication. (Note – autistic girls and boys or non-binary young people can present in an internal way.)

Friendships

• May be on the edge of friendship groups or have intense friendships vulnerable to falling out.
• May be very uncomfortable with conflict.
• May prefer to play in their own way.

School

• May not raise a hand in class or be reluctant to speak when called on.
• May be unable to use strategies like Time Out cards because of situational mutism.
• May misunderstand pop culture or trends.
• May experience less difficulty and anxiety if seated with a friend, and if the seating doesn’t change.
• May also vastly prefer pair or group work with a friend – it’s difficult and anxiety-inducing to speak to someone they don’t know well.
• May mask at school, explode at home.
• May be disinterested in sport.
• May use compensation techniques to disguise difficulties from teachers.
• May get by in primary school but transition to secondary is an explosion in sensory and cognitive input – a step too far.
• May have an ability to spot patterns and/or consider a subject without bias (if you can get them talking in the first place).
• May avoid or be uncomfortable with unstructured time at school and need support for these times more than lessons.
• May find aspects of a school uniform (or other clothes) difficult or impossible – reasonable adjustment needed.
• May find transitions between classrooms very difficult.
• May be unable to eat in the cafeteria due to the sensory aspect of smell and so many people.
• May find assemblies difficult due to proximity of so many people.
• Will be startled and scared by teachers shouting at them or at the class.
• May find lessons like PE (or perhaps Food Tech and Design and Technology) difficult due to lack of structure or predictability and sensory reasons.
• Will need specific and adapted sex education.

Anxiety

• May have situational mutism.
• May be prone to extended absence from school.
• May have an eating disorder.
• May self harm.
• May have anxiety manifesting in physical symptoms eg. stomachache.
• May be more likely than peers to have mental health issues.

Autistic Inertia (difficulty stopping and starting activities)

Autistic inertia makes transitions difficult and also accounts for processing delays, because when the brain is devoting its processing energy to an interest of choice, there’s not much left over to deal with interruptions.

• May have difficulty with organization.
• May find it difficult to get started on a project or assignment.
• May find it difficult to build a plan without breaking it down into smaller segments.
• Likely to have an intense focus on what is of interest.
• May find it difficult to be interrupted when ‘in flow’.
• Likely to find transitions of all kinds difficult.

Other Considerations

• May have a vivid imagination.
• May enjoy collections – collecting IS the play, rather than doing something with the items collected. (My daughter’s passion is Sonic plushes and Playmobil)
• Can be perfectionists.
• Stimming (repetitive behaviors) less likely to be noticeable – small movements or internalized.
• Likely to have strong opinions when not masking in a safe space, and difficult to convince they are wrong.
• May have trouble with directions.
• May have a large or advanced vocabulary.
• May make strong use of routine or ritual.
• May have poor posture.
• May have restricted eating choices.
• As likely to be creative as into STEM.

Why do girls need a diagnosis?

When girls do not receive a diagnosis and the supports that they need for their well-being, they often end up with mental health issues such as anxiety or depression. They are at a higher risk for suicide. They are more prone to eating disorders such as Avoidant and Restrictive Food Intake Disorder (ARFID). Feeling like you are struggling without a diagnosis can also lead to poor self-esteem. An autistic person has the right to know they are autistic and a chance to learn more about themselves and develop their identity. Girls have needs that are unique to them and deserve to be recognized and supported in a way that helps them to thrive.

I have an autistic son and daughter and I see how autism manifests itself differently in each of them every day. My daughter fits much of the internalized presentation profile and has many of the autistic female traits. Had she not had a profound language delay, she may have flown under the diagnostic radar for much longer than she did. Early diagnosis and supports starting at the age of 23 months has had a positive impact on her development.

References

Autistic Girls Network (2022) Autism, Girls and Keeping It All Inside. Autistic Girls Network
https://autisticgirlsnetwork.org/wp-content/uploads/2022/03/Keeping-it-all-inside.pdf

Resources for Girls

Scottish Autism Online Support Programme for Autistic Women and Girls 
Autistic Girls Network
Autism in Girls (2015 Lecture by Tony Attwood)
Symptoms of Autism in Girls
Behind the Mask: Autism for Women and Girls 
Spotlight on Girls with Autism Booklet
Supporting Autistic Girls at School
What Every Autistic Girl Wishes Her Parents Knew – Article

Autistic Female Voices and Perspectives

Authentically Emily
Autistic Hoya
Everyday Autistic
Judy Endow – Aspects of Autism Translated 
Musings of an Aspie
Purple Ella