“Where are all the autistic people?” asked Nicole Parish, otherwise known as @soundoftheforest, an autistic TikToker with 2.7 million followers to her name. It’s an innocuous question, but one that perhaps alludes to a harsh disparity between online conversations surrounding neurodivergence, and the relative lack of awareness and understanding of it in real-life situations, especially in relation to gender differences.
Indeed, the neurodivergent community online has flourished in recent years, with a growing number of neurodivergent influencers and professionals alike sharing their experiences and resources with being on the autism spectrum (ASD), attention deficit hyperactivity disorder (ADHD), and other neurodivergent conditions like dyslexia and dyspraxia.
GENDER GAP IN DIAGNOSIS
Interestingly, much of this online content is aimed at women. A simple search of ‘ADHD in women’ on TikTok, for instance, pulls up numerous videos made by women on being undiagnosed, or never realising they were neurodivergent. Earlier this year, Women’s Health[1] noted that more and more women are self-diagnosing with ASD and ADHD from TikTok alone.
Officially, however, studies indicate that men are still almost three times more likely to be diagnosed with ASD and ADHD than women. And while other studies have shown that ASD does tend to occur more in males than females, female ASD is still underreported[2]. Coupled with the rising trend of self-diagnosed women online, this suggests a huge unmet need for neurodivergent women in terms of early diagnoses (if at all), assessment, and treatment, with dire consequences on well-being and life outcomes further down the road.
Indeed, closer to home, the fact that there are no accurate local studies on the prevalence of ADHD and ASD in Singapore – let alone on gender gaps in neurodivergent diagnoses and treatment in the local context – points to a grievous lack of conversation on the subject.
So, what accounts for this glaring gender gap in neurodivergent diagnoses?
PINK AND BLUE BRAINS
To begin with, for decades, ASD and ADHD have been understood through a highly gendered ‘pink and blue brain’ lens that aggravated gender biases in understanding and identifying neurodivergence. In 2002, a controversial theory put forth by Simon Baron-Cohen proposed that ASD can be seen as an extreme form of the male brain, which is better at systemising and understanding how things work than the female brain. This inadvertently reinforced popular understandings of ASD as a ‘male affliction’ that originates from innate neurobiological sex differences, which in turn further aggravated the tendency to report and pay more attention to ASD symptoms in males than females.
The same bias is present in ADHD diagnoses, especially in childhood. The official diagnostic criteria for ADHD in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) describes ADHD as “a persistent form of inattention and/or hyperactivity impulsivity”. At the same time, it is well-established that ADHD tends to present as inattention in girls, and hyperactivity in boys. Prevalent gender stereotypes of ADHD also mean that it is more popularly associated with hyperactive boys, while inattentive girls tend to go unnoticed. Female symptoms of inattentive ADHD therefore often go undetected, leading to a much higher rate of undiagnosed ADHD in girls which carries into adulthood.
What’s more, the methodologies of psychological studies on ASD and ADHD tend to favour males over females, with reports of samples that underrepresent the afflicted female population[3], along with the use of psychometric tools and survey questions that are skewed towards male-based behaviours. This means that not only are neurodivergent girls consistently being underdiagnosed – they’re also constantly held up to standards that are backed up by male-biased research, putting them at a double disadvantage.
AGE AND GENDER INTERSECTIONS
Crucially, age also plays a huge role in affecting the way that gender differences in neurodivergence play out. Neurodivergent children who go undiagnosed miss out on early interventions that may play a critical role in equipping them with the necessary skills and coping strategies to live and excel with their conditions later in life. In other words, the later the diagnosis, the greater their struggle with being neurodivergent.
The effect is compounded in adolescence: while childhood diagnoses of ASD and ADHD are far less prevalent in girls than boys, research has shown that rates of female ADHD diagnoses tend to soar after puberty[4]. Similarly, teenage girls with Asperger’s or autistic disorder have also been found to be diagnosed later in adolescence than their male counterparts[5]. Compared to teenage boys, they also tend to endure longer waits between the time of their initial evaluation and eventual clinical diagnosis of ASD.
When combined with the inherent social pressures and difficulties of adjusting to the physiological havoc brought on by puberty, along with the academic stresses of adolescent life, the consequences can be disastrous. Studies show, for instance, that one explanation for the higher rates of ASD diagnosis in teenage girls than in childhood is that adolescence itself triggers the latent manifestation of autistic social traits in teenage girls[6]. It could be that the aforementioned additional stresses of adolescence compared to childhood present such a taxing strain on teenage autistic girls’ psyches, that previously manageable difficulties in cognitive function now become much more unmanageable. Female friendships, for example, are much harder to navigate in adolescence than in childhood owing to the greater risk and costs of being ostracised. The difference is understandably even more pronounced for neurodivergent women.
Teenage girls with ADHD, however, may have a different experience: research has found that they are better able to ‘mask’ or ‘camouflage’ their neurodivergent symptoms than teenage boys with ADHD. Here, neurotypical skills and behaviours are consciously and unconsciously learnt through the consumption of popular culture and literature, and replicated to uphold the appearance of relative normalcy, therefore hiding any neurodivergent symptoms. This comes with its own set of consequences, though: after all, flying under the radar only internalises the struggles of being neurodivergent, without eliminating them. They are therefore at far greater risk than their neurotypical teenage girls for ‘invisible struggles’ like depression, anxiety, and eating disorders, as are teenage girls with ASD. Worse, teenage ADHD girls are also more vulnerable to self-harming behaviours and suicidal ideation than their non- ADHD counterparts.
In contrast, neurodivergent teenage boys tend to ‘act out’, externalising their struggles in far more visibly detrimental ways than girls. Teenage boys with ADHD, for example, tend to rebel outright and underperform academically, being almost three to eight times more likely to drop out than non-ADHD teenage boys[7], and more likely to develop co-occurring behavioural disorders like conduct disorder and oppositional defiant disorder too. The increase in testosterone levels that naturally come with puberty may also interact more potently with hormones related to ADHD, leaving them more susceptible to risk-taking behaviours, and increasing their risk for developing substance abuse compared to non-ADHD teenage boys.
THE AVALANCHE OF ADULTHOOD
Ultimately, whether or not they were successfully diagnosed, the data suggests that in the long run, adult neurodivergent women suffer more from an eroded and lost sense of self than men.
One explanation for this is the mental and emotional toll taken through the practice of masking, which is more commonly found in neurodivergent women than men. Such a process requires constant self-monitoring, while also engendering acute anxiety from the constant possibility of being ‘found out’ and socially excluded.
Additionally, the more neurodivergent women mask, the more susceptible they may become to developing co-morbid psychological conditions and adverse experiences. Though more research is needed, we could surmise that the pain and loneliness of not feeling truly seen or heard, may coagulate into worsening mood disorders, which could explain why neurodivergent women are more likely to be misdiagnosed and mistreated. The frustration of being passed around from one psychological service to another, knowing that the real problem isn’t being tackled and without knowing how to articulate what that real problem is, further exacerbates the problem. It may even leave neurodivergent women more vulnerable to exploitation: studies have found that one-third of ADHD women have reported being sexually abused as minors[8] compared to 14% for neurotypical women, while a whopping nine out of 10 autistic women have been victims of sexual violence[9] – a threefold higher likelihood than for neurotypical women.
Adult ASD women, in particular, struggle with their gender identities more than men. As mentioned earlier, since autism is more associated with male behaviours, studies show that adult autistic women have difficulty with their identities as women with ASD. They reported discomfort with “[playing] the [role of] wife or girlfriend”, as well as conforming to “female” traits like being “caring [and] nurturing”[10].
Conversely, what stands out the most in the struggles of adult ADHD women compared to men, is the adverse impact of their condition on their self-beliefs. In the absence of a diagnosis, ADHD women tend to attribute their neurodivergent symptoms to character flaws much more than men. Even when diagnosed, compared to their male counterparts, they experience the pain of negative events more acutely and engage in much more self-blame and shame than ADHD men do, though research is inconclusive about why this is so.
Again, however, this might be attributable to the pressures of gender conformity that are more strongly felt by women. Popular archetypes of successful women, for instance, rest heavily on the appearance of perfection and ‘having it all’, as exemplified by tropes like the ‘SuperMom’ or the ‘LadyBoss’, the achievement of which require much more concerted effort – and are therefore much more psychologically taxing – for ADHD women than neurotypical women.
It’s not all doom and gloom, though: when eventually diagnosed, neurodivergent women report a sense of “pride and confidence” in themselves upon gaining access to a community of similar individuals, and at finally feeling “accepted and understood by others who have been through similar experiences”[11]. Indeed, finding other communities of neurodivergent women online has also proven to be an effective way of bypassing the real difficulties that neurodivergent women often encounter in forming and maintaining female friendships.
EQUITY AND EQUALITY
In some cases, a more equitable perspective of how gender affects neurodivergence is needed. Here, in order to close gender gaps in diagnosing and treating neurodivergence, we need to look at the ways in which different norms have led us to overlook different gender experiences of neurodivergence. For example, associating ADHD primarily with ‘masculine’ hyperactivity and neglecting ADHD as ‘feminine’ inattention immediately puts girls at a disadvantage in terms of diagnosis. Greater care is therefore needed in observing and studying the ways that inattentive ADHD shows up in girls and women, especially in childhood.
In other cases, a more equal perspective is needed. Here, we need to look at the ways in which males and females are similar in their neurodivergent symptoms, yet differently penalised for it. For instance, though ASD may show up in males and females in similar ways, female autism is more socially penalised than male autism, since autistic traits are generally considered ‘masculine’. This in turn may encourage masking, worsening the mental and emotional strain on autistic females.
Ultimately, it is crucial to understand that there is no ‘one size fits all’ approach to closing gender gaps in the diagnoses and experiences of neurodivergent conditions. Instead, we need to systematically interrogate ourselves and the communities we’re embedded in, and look at how different biological, demographic and social factors interact with one another to precipitate existing gender disparities. Only then can the gaps begin to be narrowed, until they’re one day almost closed. ⬛
1 Krouse, L. Women Are Discovering They May Have ADHD Or Be On The Autism Spectrum From Trending TikTok Videos. Women’s Health. 2022, August 17. Retrieved from: https://www.womenshealthmag.com/health/a40787937/adhd-autism-in-women-tiktok-self-diagnosis-neurodivergence/
2 Ratto, A. B., et. al.. What About the Girls? Sex-Based Differences in Autistic Traits and Adaptive Skills. J Autism Dev Disord. 48(5):1698-1711. May 2018. Retrieved from: https://doi.org/10.1007/s10803-017-3413-9
3 Littman, E. B. The Gender Myths (Or “Only Boys Have ADHD”). Attention Magazine. August 2021. Retrieved from: https://chadd.org/attention-article/the-gender-myths/
4 Ibid
5 Begeer, S., et. al. Sex Differences in the Timing of Identification Among Children and Adults with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders. Vol. 43, 1151–1156. 2012, September 22. Retrieved from: https://doi.org/10.1007/s10803-012-1656-z
6 Mandy, W., et. al. The development of autistic social traits across childhood and adolescence in males and females. Journal of Child Psychology and Psychiatry. 2018, April 19. Retrieved from: https://doi.org/10.1111/jcpp.12913
7 Kent, K. M., et. al. The Academic Experience of Male High School Students with ADHD. Journal of Abnormal Child Psychology. Vol. 39(3), 451–462. 2010, November 20. Retrieved from: https://doi.org/10.1007/s10802-010-9472-4
8 University of Toronto. One-third of women with ADHD report being sexually abused during childhood. ScienceDaily. 2015, April 15. Retrieved from: https://www.sciencedaily.com/releases/2015/04/150415114032.htm
9 Cazalis, F., et. al. Evidence That Nine Autistic Women Out of Ten Have Been Victims of Sexual Violence. Frontiers in Behavioral Neuroscience. 2022, April 26. Retrieved from: https://doi.org/10.3389/fnbeh.2022.852203
10 Bargiela, S., Steward, R., and Mandy, W. The Experiences of Late-diagnosed Women with Autism Spectrum Conditions: An Investigation of the Female Autism Phenotype. Journal of Autism and Developmental Disorders. Vol. 46(10), 3281–3294. 2016, July 25. Retrieved from: https://doi.org/10.1007/s10803-016-2872-8
11 Ibid
Santriani Bohari Jaon is a writer at a local production house. She holds a bachelor’s degree in Social Science, and enjoys deep dives into psychology, faith, human experience, and emotion. She strives to weave these elements together through the specific craft of storytelling and in her larger practice of writing as well.
