Signs of Autism in Women

Autism spectrum disorder (ASD), known also as “autism,” is a neurodevelopmental condition typically diagnosed in childhood. Traditional estimates find that boys are four times as likely as girls to receive an autism diagnosis. However, experts are now realizing that almost as many females as males may have autism, they are simply missed or diagnosed later in life. Recent research shows that nearly 80% of autistic females are undiagnosed as of age 18.

Experts believe family, teachers and primary care physicians may miss the signs due to numerous reasons. First, women tend to have fewer repetitive behaviors or more subtle stimming behaviors, and fewer restricted interests or more “socially acceptable” interests (e.g., human behavior, pop culture, animals) as compared to boys.

Second, girls and women on the spectrum are more likely to “mask” or camouflage their differences. For example, girls may watch others and mimic their behavior to better blend in. This is particularly the case when girls have an average or high range IQ.  Because young women have a greater expectation or desire/motivation to fit in with their peers and be social, they are more likely to engage in “masking” than their male peers. Those efforts can delay diagnosis and cause exhaustion, stress and anxiety.

Accordingly, many women on the spectrum are first diagnosed with anxiety or another mental health disorder. However, traditional anxiety psychotherapy and psychopharmacological intervention may not lead to significant improvement in their symptoms since the underlying disorder is being missed.

As a result, women who have late-diagnosed autism tend to judge themselves harshly for finding life more difficult than their peers or feeling different, but not knowing why. Leading to greater rates of mental health issues and suicidal ideation among women with autism. In contrast, women who do receive a diagnosis often find that it has a positive impact on their confidence and self-esteem, with many becoming advocates or mentors for other women with autism. Receiving an autism diagnosis can be a relief for many adults. It may explain symptoms they’ve always had but have never been able to explain. It can also open doors to much-needed health resources and support.

 Autism is a highly individualistic disorder and females with autism may experience the following and more:

Camouflaging or Masking

• Women on the spectrum are known to be exceptional 'social blenders' camouflaging into the background ensuring they get no attention, so more likely to be ignored or overlooked. This is also referred to as 'social masking' and can have significant and detrimental long-term mental health side effects

• Due to not inherently understanding social conventions, many females with autism learn or mimic socially acceptable behavior by watching television shows, movies and the people around them.

• Adults on the spectrum may be uncomfortable making eye contact but force themselves to do it even though it is difficult and uncomfortable. Thus, a woman with autism may be OK at making eye contact because she's learned to, but if it feels unnatural or hard, it could potentially be a sign of autism.

• They may copy the facial expressions of others to hide social communication challenges.

• They practice or rehearse conversations before having them, to feel more comfortable or ease anxiety.

• Individuals on the spectrum may feel like they become whoever they are around the most due to their subconscious and conscious camouflaging.

Social and Communication Difficulties

• Women on the spectrum often have trouble reading and responding to social cues and body language, leaving them anxious before a social situation and after.

• They often feel socially anxious, ruminate on their social interactions, and may end up feeling left out and lonely, despite their best efforts to be sociable.

• While autistic women may interact well in one-on-one situations, they often find it very hard to be in groups and may feel exhausted after too much social interaction. In particular, they struggle in large groups due to the number of social cues, body language and tone of voices that need to be decoded to understand the social interaction (and possibly sensory challenges that need to be managed/drowned out).

• They may have preferred the company of older or younger peers throughout their life, as opposed to same-aged peers.

• They may have a preference for alone time and be seen as shy or introverted.

• They may display difficulties with starting or maintaining a conversation, especially about something that does not interest them.

• They may have difficulty recognizing social cues and non-verbal forms of communication. They may miss sarcasm or subtleties while others are speaking.

• They may have difficulty understanding the social hierarchy and what is appropriate behavior.

• They may be seen as too literal or have difficulty understanding metaphors or sayings.

• They may talk excessively about a select subject, even if others are not responsive.

• They may have a reduced ability to express emotions or display facial expressions that do not match the situation. For example, they may have flat or blunted affect, exaggerated facial expressions (e.g., smile), or inappropriate body language.

• They may be seen as socially or emotionally immature for their age.

• They may have difficulty making or keeping friends. They may have difficulty getting along with others despite their best efforts to be liked. They may have few close friends and not many acquaintances

• They may not understand why blunt honesty is seen as rude.

• They may feel as though they are always on a stage and not like “being perceived” by others.  

• They may struggle to keep track of fast conversations.

• They may prefer to communicate over text or email than by phone or in person.

• They may perfectionistic traits and/or be extremely strong-willed. They may respond or present themselves in a passive-aggressive manner and insist that everything has to be done 'their way'.

Literal Thinking and Social Justice Focus

• They may be rigid or black and white thinkers, and have a problem being “too literal” (e.g., taking a joke very literally) and not understand teasing.

• They may have a strong justice sensitivity. This refers to an individual’s sense of fairness, equity, and inclusion, as well as their need to address and correct injustices. They may obsess about situations that feel unfair or wrong.

• Women on the spectrum often experience a high sense of social justice and concern about the 'rules', (often too rule-bound). They may struggle with other people breaking rules.

Sensory Sensitivities

• They may experience sensory input more powerfully than others (e.g., notice smells that others do not, or flickering lights that others see as solid).

• They may have a heightened sense of smell, light, sound or touch which can overload the senses.

• Some sensory sensitivities may be so strong that they must remove themselves from the trigger.

• They may have food aversions or limited food preferences, especially in relation to textures.

• They may be a very picky eater with few preferred foods.

• They may be especially bothered by others eating food around them, either by the sound or smell.

• They may be overwhelmed by the lights of grocery stores and malls, or by large crowds.

• They may be more aware of their clothing on their skin and be bothered by certain types of clothing or tags.

• They may display a resistance to touching or hugging, not liking being touched.

Sleep Issues

• Many women with autism experience difficulty sleeping. Often, this is caused by sensory issues, including a high sensitivity to noise at night and problems feeling comfortable in their bed. They may use white noise machines to block out noise.

• The presence of another person can exacerbate sleep issues (e.g., a partner’s breathing).

• They may struggle to settle their body down enough for restful sleep.

Difficulty With Executive Function

• Autism can make it hard to stay organized or finish tasks, especially if the person affected doesn’t find those tasks interesting. Their working memory, self-control and ability to adapt thinking may present challenges, especially at work. Executive dysfunction is also experienced  by those with ADHD, and ADHD and Autism co-occur at high rates.

• Whether in the workplace or at home, it can be hard for women to complete tasks that are deemed less interesting, like keeping a clean house, maintaining healthy habits, or carrying out daily tasks such as showering and eating breakfast.

• They may struggle with forgetfulness and inattention.

Difficulty with Emotion Regulation

• Adults with autism may struggle to manage their emotions and stay emotionally in control. Due to a poor connection between the frontal cortex and amygdala, women with autism may find it hard to rationalize situations and stay in control.

• Women on the spectrum can be highly sensitive, anxious and may get upset easily, in addition, they tend to over-apologize and be told they over-react. Many describe having meltdowns: extreme emotional reactions to situations that might result in losing their temper, crying, or going into shutdown mode.

• Women on the spectrum have been observed to internalize their thoughts, be compliant and well-behaved at work/school. When they get home, however, or feel safe, they tend to release their valve with their partner or family.

• For women, a large majority of those on the spectrum experience pre-menstrual dysphoric disorder, or extreme changes in cognition and affect in the two weeks before their cycle. Meltdowns and mood changes are more common during this time.

Intense Interests

• While boys’ and men’s interests often focus on specific objects or things, women often display an intense interest in a wider range of subjects—including how the mind works or people (particularly romantic partners, “crushes,” or celebrities). Their interests may also be to collect information instead of things.

• Females with ASD tend to obsess over their interests, even in adulthood they need to know every fact about their interest and focus on every detail. They may have typical or mainstream interests similar to their peers but be more intense in their pursuing their interest.

• People with autism display “what if-then” thinking and often want to get to the bottom of how something works. Many women with autism are skilled researchers and may gravitate toward careers or hobbies which require a high level of intense focus.

Repetitive Behaviors

• Autistic people may adopt certain repetitive behaviors, “stimming” or self-stimulating behavior, to help them self-regulate.

• Among males, typical stimming behavior includes rocking, repeating words or phrases and hand flapping. However, women often adopt more subtle behaviors like skin/nail picking, feet rubbing, pacing, bouncing their legs, or twirling their hair.

Co-Occurring Mental Health Conditions

• People on the spectrum, especially undiagnosed, often develop other mental health disorders after living with autism for some time. Coexisting conditions are more common in females than in males, especially when diagnosed later in life. Common co-occurring conditions include anxiety, ADHD, depression, eating disorders, OCD, sleep disorders, and tic disorders.

• There is also a far higher than average rate of suicidality in women with autism, which appears to be related to the degree of camouflaging they engage in.

Perception Difficulties or Differences

• They may be overly sensitive to pain, or extremely under sensitive to pain.

• They may have trouble knowing how they are feeling internally, including hunger and thirst cues, sometimes forgetting to eat.

• Because of the sensory integration differences in ASD, they can have a harder time with visuo-spatial processing which may account in part for clumsiness or bumping into things.

• They may struggle to process visual or auditory information.

Routines

• Individuals on the spectrum tend to like to stick to their routines and often not respond well to sudden changes in their routines without warning.

• They often find change of any kind more difficult to manage and may struggle in situations that are unfamiliar.

• They may have routines that don’t seem to have a real purpose.

During Childhood, Girls with Autism Tend To:

• Spend playtime alone, walking around in the library, or looking for opportunities to help others rather than socialize with peers.

• Position themselves as the class helper, and be called 'the teacher's pet', or spend a lot of time following or being with teachers, preferring the company of older people to peers (or younger children).

• Generally, lack reciprocity in social play and find back and forth conversation challenging and tend to flitter between groups or people or may have one best friend (female or male) that they find difficult to share.

• Be described as 'intense', quiet, mute, or even that talk too much if co-occurring with ADHD. They may appear to be bossy, or rude or take on the teacher or custodian role telling others what to do.

• Have an intense focus and determination and have a high sense of social justice and concern about the 'rules', (often too rule-bound) and be too interested in what others are doing.

• Have imaginary animals or friends who are very real; often very imaginative and creative; 'off in their own world'.