Updated: Jul 28
‘’The question is not what you look at but what you see’’- Henry David Thoreau
Current data tells us that approximately 4 times as many boys are diagnosed with autism than girls. In reverence of international women’s day theme ‘choose to challenge’ this article explores how this discrepancy helps us to challenge assumptions about not only autism but also about our understanding of gender.
Autism is currently diagnosed by looking at behavioral differences. To receive a diagnosis of autism you need to display difficulties with social interactions and communication as well as displaying restrictive or repetitive behaviors. There is no genetic test for autism and even though about 100 genes have been implicated in the development of autism there is no one gene abnormality that is seen in every case of autism. In my previous article ‘The Butterfly Effect of Autism’ I explored how autism may be the result of early sensory sensitivities (including social sensitivities such as an aversion to eye contact) that lead the child’s brain to adapt in different ways to cope with a different sensory experience of the world. Babies who avoid social or sensory stimulation can also miss out on many important developmental experiences of infancy such as learning to recognize and regulate emotions through interactions with caregivers. The diagnosis of autism is not an exact science and no two autistic people will present in the same way. If we consider the behavioral symptoms of autism to be an adaptive response to early sensory differences, then this might begin to explain the wide spectrum we see in autism. We are all born different and have different life experiences and so it stands to reason that how we adapt to a common experience (sensory sensitivities) will also be different.
The difference between boys and girls
In his 2002 paper, the researcher, Simon Baron Cohen proposed the theory of the ‘extreme male brain’ to explain the higher prevalence of autism in males rather than females. The extreme male brain theory of autism proposes that males are naturally more logical thinkers and females are naturally more intuitive thinkers. His theory is that the autistic brain is an example of an ‘extreme male brain’. A person with an extreme male brain would be highly skilled at tasks requiring logic such as recognizing and interpreting patterns and rules such as those seen in science and engineering but limited in their ability to manage tasks that involve intuition and tasks that are less likely to follow a predictable pattern such as social interaction. Based on this theory he predicted that boys would be more likely to develop autism as the shift from a typical male brain to an extreme male brain would not be as large as the shift from a typical female brain to an extreme male brain. But are there really any differences between the male and female brain? The neuroscientist Gina Rippon would say no. In her 2019 interview with the Guardian she explains, ‘“The idea of the male brain and the female brain suggests that each is a characteristically homogenous thing and that whoever has got a male brain, say, will have the same kind of aptitudes, preferences and personalities as everyone else with that ‘type’ of brain. We now know that is not the case. We are at the point where we need to say, ‘Forget the male and female brain; it’s a distraction, it’s inaccurate.’ It’s possibly harmful, too, because it’s used as a hook to say, well, there’s no point girls doing science because they haven’t got a science brain, or boys shouldn’t be emotional or should want to lead.”
The social experience of sex
The brain as we now know is malleable and can adapt and change based on the experiences we have in our lives and there are few differences that have as big an impact on our life experiences than our biological sex. There are the obvious ways that boys and girls are treated differently for example the colours associated with different sexes or the toys they are given as presents but there are also much more subtle influences at play. There are studies that show that the way we interact with male and female babies is quite different, the ways babies are held differs based on their sex as does the amount and how we talk to them and our interpretations of their emotions and abilities. Gender is an intrinsic part of our self-identity and if you don’t believe that then think back to some of your early experiences where you felt shame as a child, it is likely some if not all of them involved a gendered issue whether that was being mislabeled as the wrong gender, an issue of sexuality or behaving in a way that was not acceptable for your gender or conversely in a way that brought attention to your gender. All these experiences will shape how your brain develops and grows and your expectations for how you will be treated by the world. Does this mean that girls are less likely to have autism? Well not necessarily, but it does mean that autism may present differently in girls and that girls may go to more effort to mask and hide their autism than boys. We know that not only is autism diagnosed less often in girls than boys but that autism is on average diagnosed 1.5 years later in girls than in boys and many females will not receive a diagnosis at all until adulthood.
Mental health in women
Whilst autism may be under diagnosed in girls, women are leading the charge when in comes to mental health diagnoses and women with autism are particularly susceptible. Women are far more likely than men to be diagnosed with a range of mental health problems such as depression, anxiety and eating disorders. If we consider that society considers ‘autistic’ behaviors such as an interest in objects over people more acceptable in boys, then it is also true that many behaviors associated with mental health difficulties such as being vulnerable and showing emotion are more acceptable in girls. Therefore, just as may autistic women attempt to mask and hide their autism many men attempt to hide their mental health problems. It is not just the case that autistic women as well as men with mental health problems may try to hide their difficulties but that we do not see them even when it is apparent due to our own gender biases. We often miss things that we are not looking for and misinterpret what we see so that it fits our own assumptions. We might then consider that some women with autism are being misdiagnosed with mental health problems (and the reverse may also be true that some men with mental health problems are being misdiagnosed with autism although that is not something I have investigated at this time). One mental health difficultly which is diagnosed at a much higher prevalence in women than men is borderline personality disorder.
Borderline personality disorder and autism
Borderline personality disorder (BPD) is a personality disorder that is diagnosed mainly in women with as many as 75% of people receiving the diagnosis being female. Symptoms of BPD include:
· A fragile sense of self
· Impulsive behavior
· Self-harming or suicidal behavior
· Intense emotions
· Unstable relationships
· Feeling disconnected from reality
Whilst there is no mention of the communication difficulties or repetitive behaviors, we normally associate with autism there is some significant cross over. Social difficulties, emotional regulation problems and having a fragile sense of self are evident in both BPD and autism. Studies comparing borderline personality disorder and autism have also found both groups score higher than average in their systemising (logic) abilities. Dr Robert Dudas who lead this study has met many people diagnosed as having BPD who believe they actually have autism and, in many cases, he believes that they are right.
Whilst we are entering an age where gender and sexual fluidity are beginning to become more acceptable, we must continue to consider how our own biases influence our children. Challenge is a choice and the most important challenge we can choose is to challenge our own stereotypes and prejudices however deeply they may be hidden.