Autism, typically described as a spectrum neurodevelopmental disorder characterized by impairments in verbal ability and social reciprocity as well as obsessive or repetitious behaviours, is currently thought to markedly affect more males than females. Not surprisingly, this encourages a gendered understanding of the Autism Spectrum. Simon Baron-Cohen, a prominent authority in the field of autism research, characterizes the male brain type as biased toward systemizing. In contrast, the female brain type is understood to be biased toward empathizing. Since persons with autism are characterized as hyper-systemizers and hypo-empathizers, Baron-Cohen suggests that, whether they are male or female, most possess an “extreme male brain profile.” We argue that Baron-Cohen is misled by an unpersuasive gendering of certain capacities or aptitudes in the human population. Moreover, we suggest that this may inadvertently favour boys in diagnosing children with Autism Spectrum Disorders. If this is correct, it could also have rather serious consequences for treatment and services for girls (and women) on the Autism Spectrum.
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London has pointed out that the triad of basic symptoms defining autism do not associate highly, “thus leaving undetermined the validity of studying autism in its currently defined triad of symptoms” (London 2007, 408). This is to say, with recent population-based studies, although the three areas of autistic-like behaviours have been found to occur at above-chance rates, in the vast majority of cases they do not reliably occur together. Happé and colleagues have therefore contended that the triad of (so-called) “impairments” of autism should be studied separately rather than explained collectively as they have been for the past half-century, since Kanner originally proposed the co-occurrence of the three symptoms as indicative of a unifying syndrome (Happé, Ronald, and Plomin 2006; London 2007, 409).
Though we do not have the space for counterpoints to all of what is implied in this kind of claim, Harvard cognitive psychologist Elizabeth Spelke points out that “[r]esearch on the cognitive abilities of males and females, from birth to maturity, does not support the claim that men have greater intrinsic aptitude for mathematics and science. … [T]he wealth of research on cognition and cognitive development, conducted over 40 years, provides no reason to believe that the gender imbalances on science faculties, or among physics majors, stem from sex differences in intrinsic aptitude” (2005, 956).
For trenchant theoretical as well as detailed methodological critiques of those studies through which the Baron-Cohen team would try to vindicate the “hardwiring” of essential sex differences across brains, see Fine (2010a, especially chapters 2, 9, and 10), Fine (2010b), Jordan-Young (2010, especially chapters 4 and 8), and Nash and Grossi (2007).
Neil Levy makes the astute observations that “[i]t is worth remarking that Baron-Cohen’s conception of innateness is far from perspicuous. The notion with which he works is essentially negative: a trait is ‘biological’ (as he says) just insofar as it is the [sic] not the result of socialization (see, for instance, Connellan et al. 2000, pp. 113–118). But since what evolves is not phenotypic traits as such, but phenotypic plasticity—i.e., a range of traits is generally selected for—the relative strength of a disposition in a neonate is not evidence for the ‘biological’ origin of a trait. Socialization is not a pattern of interferences, which obscures the underlying design of the infant: it is an essential part of the process whereby the phenotype is completed” (Levy 2004, 323, note 5).
We decided to use “gender representation” here rather than “sex representation” because of the use of gender stereotypes in the evidence Baron-Cohen cites in favor of his view.
Some investigations have revealed a noteworthy number of cases of undiagnosed Autism Spectrum amongst adolescent and adult females with previous diagnoses of (1) anorexia nervosa (Gillberg and Rastam 1992; Nilsson et al. 1999; North 2009), (2) anxiety disorders and selective mutism (Kopp and Gillberg 1997), (3) paranoid disorders or mild paranoid problems, and (4) obsessive compulsive disorders (Kopp and Gillberg 1992; North 2009; cf. also Wolff and Mcguire 1995).
Admittedly, the risks of either under- or misdiagnosis are not one-sided for girls or boys. To explain, according to Smith, “the diagnostic criteria for autism emphasize, among other things, language deficits and extreme reactions such as tantrums and aggression in response to changes in routine” (2002, section 4). It stands to reason that girls who manifest these signs or behaviours may be all the more conspicuous, judged as “non-normal” (in certain cultures), and therefore considered deserving of clinical attention, whereas relevant boys who manifest these signs or behaviours may be comparatively less conspicuous, judged as quite “normal” (in certain cultures), and for this reason escape early clinical notice. Be that as it may, we should be cautious in presuming that reasons for under-diagnosis of ASD in girls (the focus of this paper) necessarily imply over-diagnosis for boys: i.e., that the reasons to explain the former are the same as those to explain the latter. Sorting this out is beyond the scope of this paper. Our point here is to simply underscore that a theory of autism that bootstraps itself upon a theory of gender expectations is at risk of being insufficiently or improperly discriminating as a diagnostic tool in its practical application.
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Thanks to Susan Sherwin and the Novel Tech Ethics research team for feedback on previous drafts of this paper as well as audience members who attended an oral conference presentation on the topic at the American Society for Bioethics and Humanities annual conference in 2009. Funding for this project was provided by the Canadian Institutes of Health Research, NNF 80045, States of Mind: Emerging Issues in Neuroethics.
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Krahn, T.M., Fenton, A. The Extreme Male Brain Theory of Autism and the Potential Adverse Effects for Boys and Girls with Autism. Bioethical Inquiry 9, 93–103 (2012). https://doi.org/10.1007/s11673-011-9350-y