This article was originally published in issue 12 of the ABC Journal.
Autism Spectrum Condition (ASC)* is a developmental condition comprising impaired social interaction, impaired social communication, and rigid and repetitive behaviours, coined “The Triad of Impairments” (Cashin et al., 2009). ASC also encompasses executive function (EF) impairments (Sandson & Albert, 1984), and may be comorbid with sensory processing disorders (Tomcheck & Dunn, 2007), or language impairment (Bishop, 2010). Furthermore, ASC presents with a number of benefits, including an increased capacity for perceptual information according to Load Theory (Remington et al., 2012; Lavie, 2005), and improved local processing (Mottron et al., 2006). The literature has consistently found a higher prevalence of ASC in males than females, with Loomes et al. (2017) reporting the ratio of males:females as 3:1. It was previously accepted that this observation resulted from an increased prevalence in males than females (Robinson et al., 2013), with some researchers even describing ASC as an “extreme male brain” (Baron-Cohen, 2010). However, recent investigations have revealed that ASC presentation differs significantly between males and females (Ratto et al., 2018). Because past research was primarily conducted on males, our current diagnostic criteria and understanding of ASC primarily expresses the male experience, leaving many females with ASC under- and misdiagnosed (Haney, 2015; Loomes et al., 2017). Therefore, it is possible that the gender ratio is closer to even. Regardless of whether the gender ratio is, in fact, more even, an increased understanding of ASC in females is required to improve clinical outcomes. This article will discuss the behavioral, cognitive, and biological differences between males and females with ASC. It should be noted that there is evidence that the experience of non-binary individuals further differs from those of males and females with ASC (Kung, 2020). However, this article will discuss the differences between males and females as this is a new area of research and there is insufficient data about the non-binary experience to build a well-rounded picture here.
* The condition described in this paper as Autism Spectrum Condition (ASC) is scientifically and medically referred to as Autism Spectrum Disorder (ASD) in the DSM-V (American Psychiatric Association, 2013). Prior to 2013, it was split into four separate diagnoses: Autism, Asperger’s Syndrome, Pervasive Developmental Disorder – Not Otherwise Specified, and Childhood Disintegrative Disorder. The choice to refer to it as ASC was made due to social calls from Autistic people to avoid the classification of ASC as a disorder.
As noted above, the majority of ASC research participants are male. Therefore, Milner et al. (2019) aimed to build a broad, qualitative understanding of the female experience with ASC. They interviewed eighteen Autistic females and four parents of female Autistic children. A thematic analysis revealed five core themes within these interviews:
1. “Fitting in with the norm”. Participants reported difficulty forming and maintaining meaningful relationships and felt unaccepted in social groups. They also reported significant social conflict, and found everyday life exhausting. Interestingly, participants declared that if society were more accepting, these difficulties would be reduced. Finally, several participants reported that binary gender norms confused them.
2. “Potential obstacles for Autistic women and girls”. Participants reported difficulty in diagnostic processes, due to their masking and camouflaging behaviors resulting in missed or incorrect diagnoses. Furthermore, participants reported a “lack of appropriate support”, and poor responses by school staff.
3. “Negative aspects of Autism”. Sixteen of the eighteen participants reported comorbid conditions, including depression, which some believed to have been misdiagnosed in place of ASC. Eleven participants also reported differences in sensory processing. For example, certain sensory experiences were overwhelming, while others, like music, were more intensely positively felt. Participants further reported vulnerability in sexual relationships, with sexual partners taking advantage of social naivety.
4. “The perspective of others”. Participants reported that others didn’t understand their needs, with people often overlooking the existence of females with ASC.
5. “Positive aspects of Autism”. Participants reported several benefits of ASC, including having a unique perspective, increased attention span, memory, creativity, and empathy.
This data presents key topics for future quantitative research into the female experience with ASC, which will hopefully result in an increased sensitivity of the diagnostic criteria to the detection of females with ASC.
While qualitative research provides a more holistic understanding of the Autistic female experience, quantitative research specifies the domains in which differences between males and females exist. The following section describes some of this research in terms of behavior, cognition, and neural activity.
Masking behaviors refer to the repression of the spontaneous responses typically associated with ASC in favour of more socially acceptable behaviors. This occurs consciously and unconsciously, and can occur during social interaction, movement and sensory processing (Pearson & Rose, 2021). Some psychologists differentiate these behaviors into three categories: camouflaging, masking, and compensation. Hull et al. (2017), for example, describes camouflaging as attempting to conceal Autistic behaviors from other people. This camouflaging encompasses masking and compensatory behaviors. They define masking as the use of specific techniques to hide their ASC traits by concealing their true feelings and responses, such as mimicking the facial expressions of interlocutors. Meanwhile, they define compensation as the use of techniques to compensate for social deficits, such as practicing social behaviors that they struggle with. However, some psychologists choose to use “masking” to refer to all of these behaviors (Pearson & Rose, 2021), as this is the term that Autistic people prefer (Willey, 2014). The following studies are described using the terms chosen by the respective authors.
To assess whether camouflaging was more common in females than males with ASC, Schuck et al. (2019) conducted post-hoc analysis on data collected from 62 adult participants (28 with ASC) for a GABAergic neuroimaging study. During the study, participants had conducted the 50-question Autism Quotient (AQ; Baron-Cohen, 2001), the Berkeley Expressivity Questionnaire (Gross & John, 1995), and the Social Phobia and Anxiety Inventory (Turner et al., 1989). The authors conducted independent-samples t-tests to investigate gender differences in scores. They found that females with ASC reported significantly more camouflaging behaviors than their male peers. The authors discussed that this may result from a societal bias for females to fulfill traditional gender roles (Kreiser & White, 2014), and it was not found to be related to anxiety.
Their finding supports previous research by Lai et al. (2016) who assessed gender differences in ASC camouflaging. They operationalized camouflaging as the difference between the external behavioral representation of an individual’s internal state, measured using the Autism Diagnostic Observation Schedule (Lord et al., 2000), and the reality of the individual’s internal state, measured using the AQ and the Reading the Mind in the Eyes Test (Baron-Cohen et al., 2015). They found that camouflaging scores were significantly higher in females than males with ASC.
While masking and camouflaging seem more common in females with ASC, Pearson and Rose (2021) stress that they should not be considered female behaviors because they may be adopted by both males and females, and a gender-specific bias may hinder the diagnosis of males going forward.
ASC is associated with a number of cognitive differences compared with typically developing (TD) populations. One such difference is impaired Executive Function (Sandson & Albert, 1984), which also appears to differ between males and females with ASC.
Executive Function (EF)
EF encompasses the abilities to inhibit responses, manage attention, and utilize working memory (Miyake et al., 2000). These skills are impaired in ASC (Sandson & Albert, 1984; South, Ozonoff & McMahon, 2007; American Psychological Association, 2013). EF also appears to differ between males and females with ASC. For example, Lemon et al. (2011) assessed response inhibition ability, an EF, in ten Autistic males, fourteen Autistic females, eight TD males, and fourteen TD females. Response inhibition was assessed using a stop task in which participants were instructed to press one of two keys when a green LED shone for that key. However, sometimes the LED would switch to red, in which case, participants were instructed to try to stop themselves from pressing the key, thus performing response inhibition. Autistic females demonstrated significantly longer stopping times than both Autistic males and TD females. However, their triggering of stopping processes was not significantly different, indicating that the Autistic female difference in response inhibition is specifically localized to response inhibition speed. The authors note that their sample size is quite small. Despite Lemon et al.’s (2011) finding, the literature surrounding gender differences in EF and other cognitive domains in ASC is lacking.
There is also evidence of neural differences between males and females with ASC, specifically relating to camouflaging. Lai et al. (2018) followed up on their earlier finding that camouflaging was more common in females than males by investigating its possible association with sex-dependent neural activity. 119 participants (57 with ASC) completed mentalizing and self-representation tasks during an fMRI scan. They found that increased camouflaging was related to an increase in ventromedial prefrontal cortex (vmPFC) self-representation activity in Autistic women but not in Autistic men or TD men or women.
Early investigations into ASC gender differences have revealed differences in cognition (response inhibition), behavior (camouflaging), and neural activity (vmPFC activity). However, this research area is new and, therefore, our understanding of gender differences in ASC may continue to change as research progresses. Going forward, further research should continue to identify differences between males and females and investigate how they arise. Furthermore, investigating how camouflaging impacts mental wellbeing is prudent as Cage and Whitman (2019) found a relationship between camouflaging and poor mental health. Finally, researchers should investigate non-binary and transgender experiences with ASC as 11.4% of Autistic adults identify as the opposite sexuality as that which they were assigned at birth (van der Meisen et al, 2018).
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, (2013).
Baron-Cohen, S., Wheelwright, S., Skinner, R., Martin, J., & Clubley, E. (2001). Journal Of Autism And Developmental Disorders, 31(1), 5-17. doi: 10.1023/a:1005653411471
Baron-Cohen, S. (2010). Empathizing, systemizing, and the extreme male brain theory of autism. Sex Differences In The Human Brain, Their Underpinnings And Implications, 167-175. doi: 10.1016/b978-0-444-53630-3.00011-7
Baron-Cohen, S., Bowen, D., Holt, R., Allison, C., Auyeung, B., & Lombardo, M. et al. (2015). The “Reading the Mind in the Eyes” Test: Complete Absence of Typical Sex Difference in ~400 Men and Women with Autism. PLOS ONE, 10(8), e0136521. doi: 10.1371/journal.pone.0136521
Bishop, D. (2010). Overlaps Between Autism and Language Impairment: Phenomimicry or Shared Etiology?. Behavior Genetics, 40(5), 618-629. doi: 10.1007/s10519-010-9381-x
Cage, E., & Troxell-Whitman, Z. (2019). Understanding the Reasons, Contexts and Costs of Camouflaging for Autistic Adults. Journal Of Autism And Developmental Disorders, 49(5), 1899-1911. doi: 10.1007/s10803-018-03878-x
Cashin, A., Sci, D., & Barker, P. (2009). The Triad of Impairment in Autism Revisited. Journal Of Child And Adolescent Psychiatric Nursing, 22(4), 189-193.
Gross, J., & John, O. (1997). Revealing feelings: Facets of emotional expressivity in self-reports, peer ratings, and behavior. Journal Of Personality And Social Psychology, 72(2), 435-448. doi: 10.1037/0022-3518.104.22.1685
Haney, J. (2015). Autism, females, and the DSM-5: Gender bias in autism diagnosis. Social Work In Mental Health, 14(4), 396-407. doi: 10.1080/15332985.2015.1031858
Hull, L., Petrides, K., Allison, C., Smith, P., Baron-Cohen, S., Lai, M., & Mandy, W. (2017). “Putting on My Best Normal”: Social Camouflaging in Adults with Autism Spectrum Conditions. Journal Of Autism And Developmental Disorders, 47(8), 2519-2534. doi: 10.1007/s10803-017-3166-5
Kreiser, N., & White, S. (2013). ASD in Females: Are We Overstating the Gender Difference in Diagnosis?. Clinical Child And Family Psychology Review, 17(1), 67-84. doi: 10.1007/s10567-013-0148-9
Kung, K. (2020). Autistic traits, systemising, empathising, and theory of mind in transgender and non-binary adults. Molecular Autism, 11(1). doi: 10.1186/s13229-020-00378-7
Lai, M., Lombardo, M., Ruigrok, A., Chakrabarti, B., Auyeung, B., & Szatmari, P. et al. (2016). Quantifying and exploring camouflaging in men and women with autism. Autism, 21(6), 690-702. doi: 10.1177/1362361316671012
Lai, M., Lombardo, M., Chakrabarti, B., Ruigrok, A., Bullmore, E., & Suckling, J. et al. (2018). Neural self-representation in autistic women and association with ‘compensatory camouflaging’. Autism, 23(5), 1210-1223. doi: 10.1177/1362361318807159
Lavie N. (2005). Distracted and confused?: Selective attention under load. Trends in Cognitive Sciences, 9, 75–82. doi:10.1016/j.tics.2004.12.004
Lemon, J, M., Garago, B., Entticott, P, G., & Rinehart, N, J. (2011). Brief Report: Executive Functioning in Autism Spectrum Disorders: A Gender Comparison of Response Inhibition, J Autism Dev Discord, 41: 352-356. DOI: 10.1007/s10803-010-1039-2
Loomes, R., Hull, L., & Mandy, W. (2017). What Is the Male-to-Female Ratio in Autism Spectrum Disorder? A Systematic Review and Meta-Analysis. Journal Of The American Academy Of Child & Adolescent Psychiatry, 56(6), 466-474. doi: 10.1016/j.jaac.2017.03.013
Lord, C., Risi, S., Lambrecht, L., Cook, Jr., E., Leventhal, B., & DiLavore, P. et al. (2000). Journal Of Autism And Developmental Disorders, 30(3), 205-223. doi: 10.1023/a:1005592401947
Milner, V., McIntosh, H., Colvert, E., & Happé, F. (2019). A Qualitative Exploration of the Female Experience of Autism Spectrum Disorder (ASD). Journal Of Autism And Developmental Disorders, 49(6), 2389-2402. doi: 10.1007/s10803-019-03906-4
Miyake, A., Friedman, N., Emerson, M., Witzki, A., Howerter, A., & Wager, T. (2000). The Unity and Diversity of Executive Functions and Their Contributions to Complex “Frontal Lobe” Tasks: A Latent Variable Analysis. Cognitive Psychology, 41(1), 49-100. doi: 10.1006/cogp.1999.0734
Mottron et al. (2006) Mottron L, Dawson M, Soulières I, Hubert B, Burack J. Enhanced perceptual functioning in autism: an update, and eight principles of autistic perception. Journal of Autism and Developmental Disorders. 2006;36(1):27–43. doi: 10.1007/s10803-005-0040-7
Pearson, A., & Rose, K. (2021). A Conceptual Analysis of Autistic Masking: Understanding the Narrative of Stigma and the Illusion of Choice. Autism In Adulthood, 3(1), 52-60. doi: 10.1089/aut.2020.0043
Premack, D., & Woodruff, G. (1978). Does the chimpanzee have a “theory of mind”?
Behavioural and Brain Sciences, 4, 515-526.
Remington, A., Swettenham, J., & Lavie, N. (2012). Lightening the load: Perceptual load impairs visual detection in typical adults but not in autism. Journal Of Abnormal Psychology, 121(2), 544-551. doi: 10.1037/a0027670
Ratto, A., Kenworthy, L., Yerys, B., Bascom, J., Wieckowski, A., & White, S. et al. (2017). What About the Girls? Sex-Based Differences in Autistic Traits and Adaptive Skills. Journal Of Autism And Developmental Disorders, 48(5), 1698-1711. doi: 10.1007/s10803-017-3413-9
Robinson EB, Lichtenstein P, Anckarsater H, Happé F, Ronald A. (2013). Examining and interpreting the female protective effect against autistic behavior. Proceedings of the National Academy of Sciences, 110(13): 5258–5262. https://doi.org/10.1073/pnas.1211070110.
Sandson, J., & Albert, M, L. (1984). Varieties of Preservation. Neuropsychologia 22, 715-732.
Schuck, R., Flores, R., & Fung, L. (2019). Brief Report: Sex/Gender Differences in Symptomology and Camouflaging in Adults with Autism Spectrum Disorder. Journal Of Autism And Developmental Disorders, 49(6), 2597-2604. doi: 10.1007/s10803-019-03998-y
South, M., Ozonoff, S., & Mcmahon, W. (2007). The relationship between executive functioning, central coherence, and repetitive behaviors in the high-functioning autism spectrum. Autism, 11(5), 437-451. doi: 10.1177/1362361307079606
Tiimo. (2019). The Art of Masking: Autistic Women who Mask [Image]. Retrieved from https://www.tiimoapp.com/blog/art-of-masking-women-with-autism/
Tomchek, S., & Dunn, W. (2007). Sensory Processing in Children With and Without Autism: A Comparative Study Using the Short Sensory Profile. American Journal Of Occupational Therapy, 61(2), 190-200. doi: 10.5014/ajot.61.2.190
Turner, S., Beidel, D., Dancu, C., & Stanley, M. (1989). An empirically derived inventory to measure social fears and anxiety: The Social Phobia and Anxiety Inventory. Psychological Assessment: A Journal Of Consulting And Clinical Psychology, 1(1), 35-40. doi: 10.1037/1040-3522.214.171.124
Van der Meisen, A., Hurley, H., Bal, A, M., & de Vries, A, L, C. (2018). Prevalence of the Wish to be of the Opposite Gender in Adolescents and Adults with Autism Spectrum Disorder. Arch Sex Behav, 47(8): 2307-2317. DOI: 10.1007/s10508-018-1218-3
Willey LH. (2014). Pretending to Be Normal: Living with Asperger’s Syndrome (Autism Spectrum Disorder) Expanded Edition. Jessica Kingsley Publishers.