The Girls We Missed: Rethinking Autism in Women and Girls

In recent months, one pattern has become increasingly clear in my practice. More adult women are reaching out with a quiet, persistent question: “Is it possible this was missed?” They are often thoughtful, insightful, and self-aware. Many have spent years, sometimes decades, navigating anxiety, burnout, or a sense of feeling different without a clear explanation. Some have received prior diagnoses, while others have simply learned to adapt. Underneath it all is a growing curiosity about whether autism may have been overlooked. When these women and girls show up in my practice, they are ready to not only understand themselves, but are ready to be kinder to who they intuitively are.

April is Autism Awareness Month, and it feels important to pause here, not only to raise awareness, but to reconsider who we have been aware of. For a long time, autism has been understood through a relatively narrow lens, one shaped largely by how it presents in boys. This has influenced early research, diagnostic criteria, and clinical training, contributing to a gender gap in identification (Loomes et al., 2017; Hull et al., 2020). As a result, many girls and women have gone unrecognized.

We are now beginning to understand that autism does not always look the way we were taught to expect. One of the most significant differences lies in what is often referred to as masking. Many girls, from an early age, develop a remarkable ability to observe and imitate social behavior. They may study how others interact, rehearse conversations internally, or follow social “scripts” that help them navigate relationships. On the surface, they can appear socially fluent, and at times even highly empathic.

However, this fluency is often effortful rather than intuitive (Hull et al., 2017; Lai & Baron- Cohen, 2015). What may go unnoticed is the amount of cognitive and emotional energy required to sustain this level of adaptation. Over time, the constant monitoring of tone, facial expressions, timing, and responses can lead to deep exhaustion. This is not simply shyness or introversion. It is an ongoing process of translating and responding to a social world that does not always feel natural or predictable.

Because of this, many girls do not fit the more visible behavioral patterns that have traditionally led to diagnosis. Instead of externalizing behaviors, they are more likely to internalize their experience. This can look like anxiety, perfectionism, people-pleasing, or a tendency to withdraw when overwhelmed (Mandy et al., 2012; Bargiela et al., 2016). Their distress is real, but it is often interpreted through a different lens. In clinical settings, this can lead to misdiagnosis. It is not uncommon for women on the spectrum to have previously been diagnosed with anxiety disorders, depression, or ADHD. These diagnoses may capture important aspects of their experience, but not the full picture. Without understanding the underlying neurodevelopmental differences, interventions can sometimes focus on managing symptoms without addressing the deeper source of strain (Lai et al., 2015).

Another important distinction lies in the nature of interests and social motivation. While autistic boys may show highly specific or visibly intense interests, girls’ interests often appear more typical on the surface, such as books, animals, art, psychology, or friendships. What differs is often the intensity and depth of engagement. These interests can be immersive, organizing, and deeply meaningful, even if they do not stand out as unusual (Attwood, 2007; Gould & Ashton- Smith, 2011).

Similarly, many girls and women on the spectrum are socially motivated. They want connection and value relationships. At the same time, the process of navigating them can feel effortful, confusing, or inconsistent. This gap between the desire for connection and the ease of connection is something that often goes unseen.

Over time, the cumulative impact of masking, sensory sensitivity, and social effort can take a toll on the nervous system. Many women describe cycles of burnout, with periods of functioning well followed by exhaustion, withdrawal, or overwhelm. Emerging research is beginning to. conceptualize this as “autistic burnout,” a state of chronic stress and depletion linked to sustained adaptation in non-accommodating environments (Raymaker et al., 2020).

What is shifting now is not just awareness, but understanding. As highlighted in Is This Autism? A Clinician’s Guide, autism in girls and women is not simply a milder presentation. It is often a different profile, shaped by internalized coping strategies, social learning, and diagnostic bias (Henderson et al., 2023). This invites clinicians and communities alike to look beyond surface behaviors and consider internal experience more carefully.

For those who find themselves wondering, whether about a child, a teen, or their own experience, it can be helpful to approach this with curiosity rather than urgency. Not every question requires an immediate answer. At the same time, some questions are worth gently exploring.

Sometimes understanding begins later than we expect. That does not make it any less meaningful. In many cases, it brings a kind of clarity that allows people to make sense of their experiences in a new and more compassionate way. My hope is that, together we can increase conversation about autism, stay curious about neurodivergence, and ultimately increase our potential to understand and relate to one another especially with consideration of our individual uniqueness as human beings.

References

Attwood, T. (2007). The complete guide to Asperger’s syndrome. Jessica Kingsley Publishers.

Bargiela, S., Steward, R., & Mandy, W. (2016). The experiences of late-diagnosed women with autism spectrum conditions: An investigation of the female autism phenotype. Journal of Autism and Developmental Disorders, 46(10), 3281–3294.

Gould, J., & Ashton-Smith, J. (2011). Missed diagnosis or misdiagnosis? Girls and women on the autism spectrum. Good Autism Practice, 12(1), 34–41.

Henderson, D., Wayland, S., White, S., & Attwood, T. (2023). Is this autism? A guide for clinicians and everyone else. W. W. Norton & Company.

Hull, L., Mandy, W., & Petrides, K. V. (2017). Behavioural and cognitive sex/gender differences in autism spectrum condition and typically developing males and females. Autism, 21(6), 706–727.

Hull, L., Petrides, K. V., & Mandy, W. (2020). The female autism phenotype and camouflaging: A narrative review. Review Journal of Autism and Developmental Disorders, 7, 306–317.

Lai, M.-C., & Baron-Cohen, S. (2015). Identifying the lost generation of adults with autism spectrum conditions. The Lancet Psychiatry, 2(11), 1013–1027.

Lai, M.-C., Lombardo, M. V., Auyeung, B., Chakrabarti, B., & Baron-Cohen, S. (2015). Sex/gender differences and autism: Setting the scene for future research. Journal of the American Academy of Child & Adolescent Psychiatry, 54(1), 11–24.

Loomes, R., Hull, L., & Mandy, W. P. L. (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.

Raymaker, D. M., Teo, A. R., Steckler, N. A., et al. (2020). “Having all of your internal resources exhausted beyond measure and being left with no clean-up crew”: Defining autistic burnout. Autism in Adulthood, 2(2), 132–143.