Autism in Females: Getting Past Autistic Stereotypes

All the info you wanted to know... or at least a good head start on it

Buckle in, folks: we’re getting ready for a giant info dump about understanding the unique presentation of autism in females [which likely extends to anyone exhibiting non-stereotypical autism!]. I’m sharing what I’ve learned from a training last month, so I’ve got LOTS of info on the front part, and a short reflection about my own ponderings about this information to wrap up!

I’mma be honest, almost every stock photo of “group of girls” struck a strange feeling of terror in my socially anxious heart, which… well, it might be a sign. Photo by Vitolda Klein on Unsplash

I’ve worked with a lot of undiagnosed autistic kids and adults in my years as a therapist in schools and in offices. I remember one girl in particular who was a clear shoo-in: didn’t fit in socially (and bless her, didn’t care!!), prone to meltdowns, even had an extensive collection of toys and items to stim with. Yet another healthcare provider, when I conveyed my suspicions, said no — because the girl made excellent eye contact! 🙄 I can’t be too annoyed at her personally, because research says that clinicians in general are biased against seeing the female phenotype of autism, and are less likely to take females’ symptom concerns seriously! Apologies in advance for the narrow-minded views of our health and behavioral health system.

Many of us here are unofficially or officially diagnosed autistic, too! So I know I’m preaching to the choir with this post, but it’s still aggravating how little we as a society understand about autism and its many manifestations. Maybe this will be a post you can share with your therapist or, if it doesn’t apply to you yourself, tuck away for a slightly broader understanding of autistic presentations, especially in females.

Much of this content will be pulled from a training I attended recently by Lindsey Sterling (PhD)¹ — an allistic [non-autistic] psychologist who I thought did a nice job pulling together a lot of new, important information but with fidelity to the DSM (Diagnostic Statistical Manual). Even though the DSM supports a medical model I don’t love or really agree with, it’s still the standards my field operates by, so… make of it what you will.

To officially diagnose someone with autism, they must meet criteria for social differences² in these three areas: social reciprocity (the back-and-forth in communication), integrating nonverbal communication (gestures, eye contact, body language), and developing and maintaining relationships. Then, they must meet two criteria in the “RRB” category (repetitive, restricted behavior): repetitive movements/speech; insistence on sameness/ inflexibility; highly restricted, intense interests; and hypo- or hyper-reactivity to sensory stimuli.

First we must acknowledge that autism shows up quite differently in most boys than girls³. The nature / nurture question with sex differences is complicated, but we do know that girls are socialized differently than boys, with a much stronger emphasis on being socially agreeable, polite, not making waves, and fitting in with peers (because there’s nothing like the subtle nuances of female bullying, right?!). Plus, we have the under-studied variables of how a brain less steeped in testosterone will display different manifestations of autism.

[For whatever reasons,] girls are typically more oriented towards creating social groups, fostering interpersonal relationships, and creating a sort of social code that everyone must abide by. Autistic girls are aware these are the expectations, and demonstrate a remarkable amount of skill to try and decode what those rules are, even though the rules don’t make much sense. Even if they’re able to learn the code (the best they can), it never feels first nature. One common sentiment autistic females might share is “it feels like there’s a secret language I was never quite privy to.” Another description is “I’m looking in on a fish bowl” — you see the fish all swimming together inside, but you don’t know how to get in there.

While autistic females’ social skills are closer to “neurotypical” than males’, they’ll often exhibit more repetitive behaviors, stronger reactions to change, and more sensory sensitivity (the RRB category). A high need for control and passive demand avoidance (so instead of externally protesting against demands, it’ll be an internal experience of resistance) are also common markers.

Frequent comorbidities of autism, especially in adolescence, include: anxiety, depression, suicidality, eating disorders, and tics. Autistic girls are much more likely to experience bullying and other forms of social victimization and, continuing into adulthood, have a greatly increased risk of experiencing sexual violence.

Many girls go undetected because they’re not problematic in school and their symptoms aren’t severe enough to warrant more attention (per the adults in their lives, who are perfectly fine with rule-following, compliant children). Highly intelligent girls are even less likely to receive a diagnosis. Additionally, girls are more likely to receive a secondary (or altogether inaccurate) diagnosis like social anxiety or borderline personality disorder, while the primary diagnosis of autism is never even considered. One study estimates that up to 80% of autistic females are still undiagnosed by the time they reach 18! Conventional knowledge has thought that the ratio of autism in boys to girls is 4:1. One 2022 research study (not just a meta-analysis analyzing data that we know under-represents females) suggests the true ratio of boys to girls may be 3:4! 😮

Many autistic folks develop a whole array of compensatory strategies (check out the CAT-Q quiz for an idea of how many ways there are to camouflage, and take it yourself to see how you score!). For instance, on the playground, girls might hover around social groups and flit from place to place, but if you look carefully, they’re not actually part of what’s going on⁴. They just know this is how they’re supposed to act, but they don’t know the rules of engagement enough to get in the game.

Females’ intense special interests are far more often going to be mainstream, socially acceptable special interests. Perhaps it was horses, or anime, or Taylor Swift! Or, as

D.L. Mayfield

spilled much metaphorical ink about (check out April 2022-23 posts in particular), religion was an intense special interest for many of us here!

Autistic girls are more often going to engage in imaginative play, contrary to stereotypes of autistic boys lining up their trains over and over. However, that play may be much more scripted and even obsessive. Autistic girls are more likely than boys to have some select close friendships, and will talk about their friends more often (more reasons why adults might overlook autism).

The array of compensatory strategies that autistic females utilize often break down as they get older. For instance, elementary school might go fine, until they get to middle and high school and other girls begin engaging in more elaborate social rituals (I think it is correct to call this “drama,” is it not?). They find their differences become more prominent and they can’t mask as well; plus, kids seem to have a sixth sense for sussing out who in the group doesn’t actually fit in.

Then, an autistic female hitting adulthood might be successful professionally, but struggle with other life tasks in the home or for personal care. Some might exhibit the “failure to launch” concept where they find themselves unable to meet the typical demands of adulthood. Or, they might receive mental health or psychiatric care for other conditions (depression, anxiety, OCD, social anxiety, ADHD) while still missing the autism diagnosis. This is why it’s so essential that mental health providers be well-versed in not just autism, but how autism looks different across genders!

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I wanted the bulk of the essay to be informative and objective, but let’s be real, this is a personal interest and question, too! So if you made it this far, you’re in it to win it. Let’s discuss how we’re connecting to the material.

Taking this training, I was hoping to finally have The Answer for whether *I* am on the spectrum, too! And… I’m still not sure. I connect very strongly with the common descriptions of autistic females: “quirky” and feeling like other people having access to secret social knowledge that I didn’t get. In the training, I felt like she was describing my childhood. [Side note, I have a very real question for neurotypicals about whether they feel this way too? Like are we all just figuring out the rules along the way, or are there people who like, just naturally understand this??]

I feel like I have more and stronger friendships than an autistic person supposedly has, per this material, but I can also recognize my friendships are more sporadic than what I guess neurotypical friendships are. My [emotionally] close people live across the country and I see them maybe 1-2 a year, and communicate irregularly with them.

If I’d been born a little more recently, I would have been diagnosed with every manifestation of anxiety as a child growing up (separation anxiety, social anxiety, general anxiety, specific phobia). I was extremely shy and mostly a loner until I found marching band in high school (where the other “quirky” kids go). I did not handle transition well and had a number of little rituals and mental games I felt compelled to do (like I remember needing to count the dashes of the numbers on the digital clock: 1 has 2 dashes, 2 has 6 dashes, 3 has 6 dashes, etc).

The part that I get stuck at is that I feel I’ve adapted really well as an adult! Mostly. I’m a good mom but I do think the same amount of parenting feels harder (energetically, mentally) for me than it does other people. I love my two kids like crazy but I think I might actually die if I had three. But otherwise…

I recognize I’ve been able to craft my life where it is generally able to meet my peculiar needs in a way that works really well for me. I work part-time-ish hours, for myself, meeting one-on-one with people. I create a space that feels pleasant to me sensorily. My work is not overstimulating. And I have a partner who balances childcare with me so I can prioritize taking care of my mental and physical health and get out of the house for my runs [is this an RRB repetitive behavior? I mean, it is technically] numerous times a week, which helps keep me feeling good. If I didn’t have that available to me? Yeah… I don’t think I’d be adapting nearly as well. I could feel guilty for being so lucky to have that, but that doesn’t do anyone any good, so I’ll choose gratitude instead.

Well, I think I’ve nearly talked myself into an affirmative self-diagnosis. Are you actually still here reading? Then go on, leave me a comment! Info dump right back at me! You know I love to hear it ;)

1. Information I’m sharing here is from her training through WPS (psychological testing company) webinar on April 17, 2024. The training was titled “Unmasking the Lives of Autistic Females: Developmental, Clinical, and Diagnostic Considerations.”

2. The DSM says “deficits,” of course, but I love emphasizing with my autistic or otherwise neurodivergent clients that neurotypical communication styles often just don’t make a lot of sense. Hence, differences!!

3. The trainer and I both acknowledge that this information is about autistic girls, but nonbinary and trans individuals, or other gender non-conformers, will probably find a lot of commonalities here.

4. I am called out.