Abstract
Purpose of Review
We review the recent literature regarding the implications of gender on the diagnosis and treatment of autism spectrum disorder (ASD) in women and adolescent females. We also discuss important clinical observations in treating this population.
Recent Findings
Growing research supports gender specificity in ASD symptom presentation. Differing phenotypes, psychiatric co-morbidities, and level of “camouflaging” (behavioral coping strategies to conceal symptoms for use in social situations) are thought to further contribute to the discrepancy in prevalence rates and resulting misdiagnosis or delayed diagnosis in adolescent females and women.
Summary
Both nosological and cultural factors appear to be contributing to differences in the diagnosis of ASD in women. These differences in presentation have important implications for late diagnosis, treatment of ASD, and the quality of life for women with autism.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
American Psychiatric Association, American Psychiatric Association, editor. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, D.C: American Psychiatric Association; 2013.
Asperger H. Die “autistichen psychopathen” im kindersalter [Autistic psychopathy in childhood]. Archive fur Psychiatrie und Nervenkrankheiten. 1944;117:76–136.
Kanner L. Autistic disturbances of affective contact. Nervous Child. 1943;2:217.
Ritvo ER, Cantwell D, Johnson E, Clements M, Benbrook F, Slagle S, et al. Social class factors in autism. J Autism Dev Disord. 1971;1:297–310.
Rutter M, Lockyer L. A five to fifteen year follow-up study of infantile psychosis: I. Description of sample. Br J Psychiatry. 1967;113:1169–82.
Lotter V. Epidemiology of autistic conditions in young children. Soc Psychiatry. 1966;1:124–35.
Fombonne E. The changing epidemiology of autism. J Appl Res Intellect Disabil. 2005;18:281–94.
Baird G, Simonoff E, Pickles A, Chandler S, Loucas T, Meldrum D, et al. Prevalence of disorders of the autism spectrum in a population cohort of children in South Thames: the Special Needs and Autism Project (SNAP). Lancet. 2006;368:210–5.
World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992.
• Baio J, Wiggins L, Christensen DL, Maenner MJ, Daniels J, Warren Z, et al. Prevalence of autism spectrum disorder among children aged 8 years - autism and developmental disabilities monitoring network, 11 Sites, United States, 2014. MMWR Surveill Summ. 2018;67:1–23 A very recent study examining the prevalence rate of ASD in a population cohort in London.
•• Loomes R, Hull L, Mandy WPL. What is the male-to-female ratio in autism Spectrum disorder? A systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2017;56:466–74 A systematic review and meta-analysis of prevalence studies examining the male-to-female ratio in ASD.
Kreiser NL, White SW. ASD in females: are we overstating the gender difference in diagnosis? Clin Child Fam Psychol Rev. 2014;17:67–84.
Lai M-C, Baron-Cohen S. Identifying the lost generation of adults with autism spectrum conditions- ClinicalKey. Lancet Psychiatry. 2015;2:1013–27.
•• Bargiela S, Steward R, Mandy W. The experiences of late-diagnosed women with autism spectrum conditions: an investigation of the female autism phenotype. J Autism Dev Disord. 2016;46:3281–94 A qualitative study examining the female ASD phenotype and its effect on diagnosis.
Howlin P, Moss P, Savage S, Rutter M. Social outcomes in mid- to later adulthood among individuals diagnosed with autism and average nonverbal IQ as children. J Am Acad Child Adolesc Psychiatry. 2013;52:572–581.e1.
• Hull L, Petrides KV, Allison C, Smith P, Baron-Cohen S, Lai M-C, et al. “Putting on my best normal”: social camouflaging in adults with autism spectrum conditions. J Autism Dev Disord. 2017;47:2519–34 Qualitative study using thematic analysis to examine social camouflaging in adults with ASD and focusing on the nature, motivations, and consequences of camouflaging.
•• Lai M-C, Lombardo MV, Ruigrok AN, Chakrabarti B, Auyeung B, Szatmari P, et al. Quantifying and exploring camouflaging in men and women with autism. Autism. 2017;21:690–702 A quantitative analysis of camouflaging in ASD confirms gender disparities with women reporting greater camouflaging.
• Lai M-C, Lombardo MV, Pasco G, Ruigrok ANV, Wheelwright SJ, Sadek SA, et al. A behavioral comparison of male and female adults with high functioning autism spectrum conditions. PLoS ONE. 2011 [cited 2018 Jul 3];6. Available from: http://ezp-prod1.hul.harvard.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2011-14242-001&site=ehost-live&scope=site. A behavioral comparison between sexes found women with high-functioning ASD to show more lifetime sensory symptoms, fewer socio-communication difficulties, and more self-reported autistic traits.
Lehnhardt F-G, Falter C, Gawronski A, Pfeiffer K, Tepest R, Franklin J, et al. Sex-related cognitive profile in autism spectrum disorders diagnosed late in life: implications for the female autistic phenotype. J Autism Dev Disord. 2016;46:139–54.
Koyama T, Kamio Y, Inada N, Kurita H. Sex Differences in WISC-III profiles of children with high-functioning pervasive developmental disorders. J Autism Dev Disord. 2009;39:135–41.
Bölte S, Duketis E, Poustka F, Holtmann M. Sex differences in cognitive domains and their clinical correlates in higher-functioning autism spectrum disorders. Autism. 2011;15:497–511.
• Kiep M, Spek AA. Executive functioning in men and women with an autism spectrum disorder. Autism Res. 2017;10:940–8 This study demonstrated differences in executive functioning between men and women with ASD and discussed possible implications.
Hill EL. Evaluating the theory of executive dysfunction in autism. Dev Rev. 2004;24:189–233.
Lai M-C, Lombardo MV, Suckling J, Ruigrok ANV, Chakrabarti B, Ecker C, et al. Biological sex affects the neurobiology of autism. Brain. 2013;136:2799–815.
Alaerts K, Swinnen SP, Wenderoth N. Sex differences in autism: a resting-state fMRI investigation of functional brain connectivity in males and females. Soc Cogn Affect Neurosci. 2016;11:1002–16.
Beacher FDCC, Radulescu E, Minati L, Baron-Cohen S, Lombardo MV, Lai M-C, et al. Sex differences and autism: brain function during verbal fluency and mental rotation. PLoS One; San Francisco. 2012;7:e38355.
Beacher FD, Minati L, Baron-Cohen S, Lombardo MV, Lai M-C, Gray MA, et al. Autism attenuates sex differences in brain structure: a combined voxel-based morphometry and diffusion tensor imaging study. Am J Neuroradiol. 2012;33:83–9.
Baron-Cohen S. The extreme male brain theory of autism. Trends Cogn Sci. 2002;6:248–54.
Joshi G, Wozniak J, Petty C, Martelon MK, Fried R, Bolfek A, et al. Psychiatric comorbidity and functioning in a clinically referred population of adults with autism Spectrum disorders: a comparative study. J Autism Dev Disord. 2013;43:1314–25.
Lugnegård T, Hallerbäck MU, Gillberg C. Psychiatric comorbidity in young adults with a clinical diagnosis of Asperger syndrome. Res Dev Disabil. 2011;32:1910–7.
Nolen-Hoeksema S, Girgus JS. The emergence of gender differences in depression during adolescence. Psychol Bull. 1994;115:424–43.
Sukhodolsky DG, Scahill L, Gadow KD, Arnold LE, Aman MG, McDougle CJ, et al. Parent-rated anxiety symptoms in children with pervasive developmental disorders: frequency and association with core autism symptoms and cognitive functioning. J Abnorm Child Psychol. 2008;36:117–28.
May T, Cornish K, Rinehart N. Does gender matter? A one year follow-up of autistic, attention and anxiety symptoms in high-functioning children with autism Spectrum disorder. J Autism Dev Disord. 2014;44:1077–86.
Mandy W, Chilvers R, Chowdhury U, Salter G, Seigal A, Skuse D. Sex Differences in autism spectrum disorder: evidence from a large sample of children and adolescents. J Autism Dev Disord. 2012;42:1304–13.
Solomon M, Miller M, Taylor SL, Hinshaw SP, Carter CS. Autism symptoms and internalizing psychopathology in girls and boys with autism spectrum disorders. J Autism Dev Disord. 2012;42:48–59.
Larson R, Richards MH. Introduction: the changing life space of early adolescence. J Youth Adolesc. 1989;18:501–9.
Mahalik JR, Morray EB, Coonerty-Femiano A, Ludlow LH, Slattery SM, Smiler A. Development of the conformity to feminine norms inventory. Sex Roles. 2005;52:417–35.
Barrett AE, Raskin WH. Trajectories of gender role orientations in adolescence and early adulthood: a prospective study of the mental health effects of masculinity and femininity. J Health Soc Behav. 2002;43:451–68.
Broderick PC, Korteland C. Coping style and depression in early adolescence: relationships to gender, gender role, and implicit beliefs. Sex Roles. 2002;46:201–13.
Fiese BH, Skillman G. Gender differences in family stories: moderating influence of parent gender role and child gender. Sex Roles. 2000;43:267–83.
Danielsson UE, Bengs C, Samuelsson E, Johansson EE. “My greatest dream is to be normal”: the impact of gender on the depression narratives of young Swedish men and women. Qual Health Res. 2011;21:612–24.
Tolman DL, Impett EA, Tracy AJ, Michael A. Looking good, sounding good: femininity ideology and adolescent girls’ mental health. Psychol Women Q. 2006;30:85–95.
Tjaden P, Thoennes N. Prevalence and consequences of male-to-female and female-to-male intimate partner violence as measured by the National Violence Against Women Survey. Violence Against Women. 2000;6:142–61.
Safety Skills for Asperger Women: How to Save a Perfectly Good Female Life by Liane Holliday Willey [Internet]. [cited 2018 Jul 31]. Available from: https://www.goodreads.com/book/show/11187137-safety-skills-for-asperger-women.
• Wood JJ, Klebanoff S, Renno P, Fujii C, Danial J. Chapter 7 - Individual CBT for anxiety and related symptoms in children with autism spectrum disorders. In: Kerns CM, Renno P, Storch EA, Kendall PC, Wood JJ, editors. Anxiety in Children and Adolescents with Autism Spectrum Disorder [Internet]. Academic Press; 2017 [cited 2018 Jul 31]. p. 123–41. Available from: http://www.sciencedirect.com/science/article/pii/B9780128051221000077 A chapter reviewing the effectiveness of CBT therapy in treating both children and adults with ASD.
Spain D, Blainey SH, Vaillancourt K. Group cognitive behaviour therapy (CBT) for social interaction anxiety in adults with autism spectrum disorders (ASD). Res Autism Spectr Disord. 2017;41–42:20–30.
Spek AA, van Ham NC, Nyklíček I. Mindfulness-based therapy in adults with an autism spectrum disorder: a randomized controlled trial. Res Dev Disabil. 2013;34:246–53.
Jones RM, Wheelwright S, Farrell K, Martin E, Green R, Di Ceglie D, et al. Brief report: female-to-male transsexual people and autistic traits. J Autism Dev Disord. 2012;42:301–6.
• Accordino RE, Kidd C, Politte LC, Henry CA, McDougle CJ. Psychopharmacological interventions in autism spectrum disorder. Expert Opin Pharmacother. 2016;17:937–52 Opinion piece on psychopharmacological treatment of core and associated symptoms of ASD.
McCracken JT, McGough J, Shah B, Cronin P, Hong D, Aman MG, et al. Risperidone in children with autism and serious behavioral problems. N Engl J Med. 2002;347:314–21.
Owen R, Sikich L, Marcus RN, Corey-Lisle P, Manos G, McQuade RD, et al. Aripiprazole in the treatment of irritability in children and adolescents with autistic disorder. Pediatrics. 2009;124:1533–40.
Pasquali R, Stener-Victorin E, Yildiz BO, Duleba AJ, Hoeger K, Mason H, et al. PCOS Forum: research in polycystic ovary syndrome today and tomorrow. Clin Endocrinol. 2011;74:424–33.
Oswald TM, Winder-Patel B, Ruder S, Xing G, Stahmer A, Solomon M. A pilot randomized controlled trial of the ACCESS program: a group intervention to improve social, adaptive functioning, stress coping, and self-determination outcomes in young adults with autism spectrum disorder. J Autism Dev Disord. 2018;48:1742–60.
Farley M, Cottle KJ, Bilder D, Viskochil J, Coon H, McMahon W. Mid-life social outcomes for a population-based sample of adults with ASD. Autism Res. 2018;11:142–52.
Kamio Y, Inada N, Koyama T. A nationwide survey on quality of life and associated factors of adults with high-functioning autism spectrum disorders. Autism. 2013;17:15–26.
• Mason D, McConachie H, Garland D, Petrou A, Rodgers J, Parr JR. Predictors of quality of life for autistic adults. Autism Research [Internet]. [cited 2018 Sep 23];0. Available from: http://onlinelibrary.wiley.com/doi/abs/10.1002/aur.1965 This study includes the largest study sample to date examining the quality of life of individuals with ASD and examines gender differences.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
The authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This article is part of the Topical Collection on Autism Spectrum Disorders: Treatment, Services, Outcomes, and Community Functioning in Adolescents and Adults
Rights and permissions
About this article
Cite this article
Green, R.M., Travers, A.M., Howe, Y. et al. Women and Autism Spectrum Disorder: Diagnosis and Implications for Treatment of Adolescents and Adults. Curr Psychiatry Rep 21, 22 (2019). https://doi.org/10.1007/s11920-019-1006-3
Published:
DOI: https://doi.org/10.1007/s11920-019-1006-3