Why Many Autistic Girls Are Overlooked

Autism is diagnosed three times more often in boys than in girls. But researchers say it may not be because three times as many boys are actually autistic. Instead, they think it’s because autism in girls can look a little different — and as a result, girls are more likely to be misdiagnosed, underdiagnosed, or diagnosed later in life.

People with autism share the same kinds of symptoms, but the symptoms tend to be less noticeable in girls — and girls frequently work harder to mask their differences. Clinicians accustomed to seeing autism in boys may have what’s called a diagnostic bias: Without realizing it, they may be looking for a more male presentation of autism.

A growing body of research suggests the same diagnostic biases might affect how and when trans people and people of other gender identities are diagnosed, too.

Masking and social communication

Traits of autism are divided into two main categories. One of them is social communication challenges — meaning you might struggle to communicate with other people (verbally, nonverbally, or both) or to understand social situations. Research says that girls are more likely to hide, or mask, these challenges, making them harder for other people to see.

“A lot of autistic girls get ruled out because they may share a smile or may have a bit better eye contact,” says Wendy Nash, MD, a child and adolescent psychiatrist. “It can be a more subtle presentation.”

There is also evidence that autistic girls tend to mask to be part of a friend group or fit in. This could look like:

• Rehearsing social situations — You might rehearse everyday conversations by yourself, practice not holding your body in a certain way or not fidgeting, or practice using a more “natural” tone of voice

• Copying other people’s behaviors — In conversations, you might mimic what other people are doing. Like if someone makes a joke and everyone laughs, you’ll laugh, too, even if you’re not sure if it was funny or not

• Keeping a script — You might feel like you need to keep a script of words and phrases in your back pocket. Sometimes this can seem helpful, like when people always ask the same question, you can reach for, “I’m fine. How are you?” But you’ve also got things like, “Interesting” or “That’s crazy!” to deploy in case conversation stalls and you’re not sure what to do

• Forced eye contact — Some autistic people feel really uncomfortable making eye contact. But you might force yourself to do it in one-on-one conversation, just because you’re worried someone will think you’re weird or not interested if you don’t

These behaviors are often prompted by feedback from teachers or peers — “Why are you being so rude?” “Are you even paying attention?” — so girls with autism might be constantly adjusting and refining how they mask to do it more effectively. And when struggles with social communication are hidden, they’re harder to recognize and diagnose, especially at a young age.

Repetitive behaviors and special interests

People with autism also have traits that fall under a second category called restrictive, repetitive behaviors — that is, they fixate on a limited set of interests and/or repeating words, phrases, or physical motions over and over.

“Girls tend to have a quieter presentation, with not necessarily as much of the repetitive and restricted behavior, or it shows up in a different way,” says Susan F. Epstein, PhD, a pediatric neuropsychologist. Again, this isn’t true of all girls, and there is some evidence that girls tend to hide or downplay their repetitive behaviors and interests, too.

But when girls do have certain patterns of behavior, they might not be seen as autistic traits. Repetitive behaviors can include hand flapping, rocking, or spinning — they can also include things like twirling your hair, which is easier to overlook and can be written off as “typical” behavior for a girl.

And when it comes to special interests, girls, especially young girls, might be really into horses or unicorns — things that might also read as typical for their gender and not especially unusual.

“The model that we have for a classic autism diagnosis has really turned out to be a male model,” says Dr. Epstein. That’s not to say that girls don’t ever fit it, she adds. But in addition to how clinicians might expect autistic people to present, traditional examples of special interests — like trains — tend to be stereotypically male.

Why it matters

Because social communication challenges and restrictive, repetitive behaviors are misinterpreted or overlooked, girls tend to be diagnosed later than boys. This means they miss out on supports that could have helped them earlier in life. And sometimes girls are misdiagnosed, often with ADHD but also anxiety or depression, because struggling with undiagnosed autism can take a serious toll on your mental health — another cost of a late diagnosis.

Dr. Epstein says undiagnosed autistic girls often end up wondering “what’s wrong” with them, which can lead to poor mental health and a loss of self-esteem. Masking has also been associated with higher rates of anxiety and depression. Charl Davis, a tattoo artist who was diagnosed with autism at 25, spoke to the National Autistic Society in the U.K. about masking and its impact on her life.

“I find that being a female I am expected to behave a certain way to fit in socially, which is why I have spent so much time masking,” Davis says.

“I became so good at hiding my traits, as well as mimicking and copying other peoples' behavior. I had a major breakdown when I was 19 because I had massive identity problems and felt I didn’t recognize myself or know who I was,” she says. “Now that I'm diagnosed, I'm on a mission to find myself again.”