Four years ago I saw “Sarah”. therapy acceptance. When asked what brought him, he tearfully explained that he had used it social networks to watch videos about his interests, and the videos started filtering in content related to late diagnosis autistic adults. Wondering why these videos were appearing in his feed, he watched a few. As he observed this, he realized he was autistic. He scheduled therapy with me to learn more and scheduled testing with a clinical psychologist who diagnosed him with autism.
Sarah is the first “up” though masking” the woman came to me for therapy, she was not the last. I came for other reasons:
- Social networks
- After their child(ren) were diagnosed, they realized they were autistic
- Coping with autism tiredness
- A review of recent research on the female autism phenotype
Personally, I fall into the latter category. When I learned about how neurodivergence manifests in women and realized I was autistic, I was embarrassed. How could I have worked with autistic people for over 20 years and not know? I then reflected that most of the research was under 5 years old. I already knew that historical research on autism used to focus on men. Therefore, I primarily researched autistic women/girls. I have now seen the impact of this missing information not only in my therapy practice, but in my own life.
If you are familiar with this history, in the United States, Leo Kanner conducted research on autism beginning in the late 1930s and published his findings on early infantile autism in 1943. His sample included only white men. Hans Asperger’s Germany admitted girls, but then focused on boys, and its “little professors” should be kept because their unique brains would benefit the Nazi regime. The same situation was not applied to the girls who were sentenced to death.
For males, this focus has continued, leading to the development of standardized and validated test measures for male-specific symptoms of autism. Currently, the diagnosis rate is 3-4 boys for every girl diagnosed. When you look at individuals with intellectual disabilities together, the rate of diagnosis is close to 1:1. Is this because autism is more likely to occur in males if there is no co-occurring intellectual disability, or is it because the psychological community is not aware of and therefore not looking for autism symptoms in women and girls?
A recent Swedish study shows that it is. Fyfe et al. (2026) followed 2.7 million people born between 1985 and 2020 and found that the diagnostic gap between the sexes disappeared during early adulthood. This study shows that the psychological community fails to identify 75% of girls with autism.
For women who come to my clinic with their recent diagnosis, many feel relief. They have always felt different or broken; now they knew they were autistic. Many needed processing sadness living without this information for a long time. Many are misdiagnosed, and when they don’t get better with the usual treatment, providers tell them they’re not doing enough. Because I had the missing information, I was able to support them, I had other autistic clients with high support needs, and they experienced breakthroughs that they never had before because previous therapies did not include changes for their neurodivergent brains.
In the past 4 years, I have rarely questioned the validity of an autism diagnosis, whether or not a person has been officially diagnosed. I would generally agree that the traits reported are consistent with autism, and I’m starting to wonder if I’m biased. Then I came across a book by Hartman et al. (2023) and was relieved to read that the authors also tended to agree with their clients, noting that clients often did extensive research before ordering a test.
However, this is not the experience or opinion of many experts. Recently, I’ve been pushing back against the increasing number of women being diagnosed with autism. The blowback has ranged from sarcastic posts on social media to going to see other providers who say clients can’t be diagnosed with autism for a variety of reasons, despite reports on neuropsychological tests. This month, prominent autism researcher Uta Frith said in an interview that she does not believe autism is a spectrum. She acknowledged that most women diagnosed with autism have “problems” but believes they should be labeled as “hypersensitive”.
This backlash against women diagnosed with autism sounds all too familiar. Women have a history of being misunderstood and misdiagnosed. This included diagnoses of “hysteria” or a spinning uterus, and indications that women should be sent to asylums, lobotomized, given tranquilizers, or sterilized.
Is it too much of an exaggeration to compare autism skepticism in masked women to lobotomy and eugenics? Am I engaging in my own histrionics? Sitting across from client after client crying that the specialist told them their autism diagnosis was wrong, it doesn’t seem like an exaggeration. Given the history of how the mental health system has treated women, it seems that way. As a profession, we need to examine our biases and continue to research. I have to check myself, for example bias and make sure I think critically through differential diagnoses. Other mental health professionals need to examine their biases and adjust accordingly. If you haven’t seen the research in the past few years about how autism manifests in women and girls, it’s long past time to do so. This is how we ensure that we do no harm as a profession.
