Authors: Lauren Wallace, Rhea Manohar, MPH, Meghan Etsey, Yun Weisholtz, MD-PhD on behalf of the AMWA Gender Equity Task Force

She sits quietly in the exam room. She makes appropriate eye contact. She smiles when spoken to. She describes her interests: books, animals, and maybe a favorite show. There are no obvious red flags. No disruptive behaviors. No clear social withdrawal. Her quietness is viewed as shyness. Her smile and demeanor are considered poised. For these young girls, the lack of “typical” manifestation of autism spectrum disorder (ASD) and gendered societal mislabeling of actions allows some patients to fall through the cracks. 

Historically, diagnostic criteria for ASD have been developed and validated using predominantly male populations. Early characterizations emphasized overt social deficits, unusual restricted interests, and externally visible repetitive behaviors. This framework continues to shape clinical intuition and persists through medical training. Emerging literature paints a different picture, highlighting the varied clinical signs observed in girls versus boys. Their interests may align with socially acceptable norms, such as animals, literature, or peer-related themes, but are often marked by heightened intensity or mental rigidity. In fact, they may even engage in imaginative play and demonstrate superficially intact social reciprocity, particularly in structured settings (Hull et al., 2020; Lai et al., 2020). As a result of these “socially acceptable” or “normal” manifestations, girls who do not conform to the traditional “male prototype” may fall below the threshold of clinical suspicion, by parents and pediatricians alike. When diagnostic frameworks are calibrated to one phenotype, alternative presentations are systematically overlooked (Hull et al., 2020; Lai et al., 2020).

One of the most significant contributors to missed diagnoses is camouflaging, which is the conscious or unconscious masking of autistic traits in social settings (Hull et al., 2020). Autistic girls are more likely than boys to mimic peers’ social behaviors, rehearse conversations, suppress stimming behaviors, and force eye contact despite discomfort (Hull et al., 2020; Rynkiewicz et al., 2019). In structured clinical environments, this compensation can make a child appear socially typical during short encounters and in day-to-day interactions (Cook et al., 2021). Notably, the current screening paradigm is often triggered by parental concerns about a child’s development or by concerns within school settings, so camouflaging of “typical” signs may go unnoticed by caregivers and educators who have regular interactions as well (Westby & Coburn-Pierce, 2025). While camouflaging may help girls navigate social expectations, research shows it is associated with higher rates of anxiety, depression, and suicidality long-term (Hull et al., 2020; Cook et al., 2021; Cassidy et al., 2021). The effort required to mask differences constantly can lead to emotional exhaustion and internal distress that remains invisible to clinicians even into the teenage years and adulthood (Cassidy et al., 2021).

Compared to males, autistic females are more likely to present with internalizing symptoms rather than disruptive behaviors (Mandy et al., 2018; Rynkiewicz et al., 2019). Common presenting concerns may include anxiety, perfectionism, selective mutism, social withdrawal, or eating disturbances (Mandy et al., 2018; May et al., 2023). Without a high index of suspicion, providers may treat these as isolated psychiatric conditions rather than manifestations of underlying ASD (Rynkiewicz et al., 2019). Additionally, autistic girls demonstrate higher rates of co-occurring anxiety and mood disorders compared to boys, which can further obscure the primary neurodevelopmental diagnosis (Mandy et al., 2018; May et al., 2023). When clinicians focus solely on supporting and treating the most prominent symptom, the broader developmental pattern may be missed (Rynkiewicz et al., 2019; May et al., 2023).

Despite growing awareness of ASD, research consistently shows that girls are diagnosed later than boys, even when they present with comparable symptom severity, highlighting a critical gap in recognition rather than true prevalence differences (Maenner et al., 2023). This delay is not benign. Autistic females, in particular, experience disproportionately elevated rates of suicidal ideation compared to both autistic males and neurotypical females, underscoring a uniquely vulnerable population (Cassidy et al., 2021). Without an early and accurate diagnosis, many girls spend years internalizing a sense of being “different,” often misattributing their social and emotional challenges to personal inadequacy rather than recognizing them as manifestations of neurodivergence. This prolonged misunderstanding can compound psychological distress and delay access to supportive interventions. Ultimately, this reinforces the reality that delayed recognition of ASD in girls carries measurable and preventable psychiatric risk (Rutherford et al., 2016; Cassidy et al., 2021; Maenner et al., 2023).

Many commonly used ASD screening and diagnostic tools were developed and normed on predominantly male samples, which raises important concerns about their sensitivity to female presentations (Ratto et al., 2018; Lai et al., 2020). As a result, girls who do not fit the “classic” presentation of ASD may be underidentified or mischaracterized (Hull et al., 2020; Rynkiewicz et al., 2019). While the current clinical screening tools remain valuable, their limitations highlight the need for more nuanced interpretation and the expansion of screening guid​​elines, and strong clinical judgment that accounts for sex-based differences in presentation (Lai et al., 2020). Incorporating comprehensive evaluations, including detailed developmental histories, caregiver interviews, and attention to features such as social fatigue and sensory sensitivities, can improve detection in this population (Ratto et al., 2018; Mandy et al., 2018). Additionally, providing more caregiver- and educator-facing educational materials and initiating conversations will help physicians trigger additional screening in early adolescence. Expanding the conceptualization of phenotypical presentations of ASD is essential to support more accurate and equitable identification across genders (Lai et al., 2020; Hull et al., 2020).

Improving the identification of ASD in girls requires both systemic change and increased clinical awareness of how presentations may differ from traditional diagnostic expectations (Lai et al., 2020; Mandy et al., 2018). Expanding medical education to include sex and gender differences in neurodevelopment is a critical first step toward reducing diagnostic disparities (Lai et al., 2020). Clinicians should also be encouraged to ask targeted questions about social exhaustion, masking behaviors, and sensory distress, which are frequently reported in girls and women living with ASD but may be overlooked in standard assessments (Hull et al., 2020; Cook et al., 2021). Greater emphasis on evaluating the intensity and rigidity of interests, rather than their specific content, may further improve recognition, particularly when interests appear socially typical on the surface (Mandy et al., 2018; Rynkiewicz et al., 2019). Additionally, concurrent screening for ASD should be considered in girls presenting with chronic anxiety or persistent social difficulties that do not respond to conventional treatments, as misdiagnosis or delayed diagnosis is common in this group (May et al., 2023; Loomes et al., 2017). Ultimately, recognizing ASD in girls is not about overdiagnosis, but about improving diagnostic accuracy and ensuring timely access to appropriate support, which can significantly influence long-term developmental and mental health outcomes (Lai et al., 2020; May et al., 2023).

That little girl has grown up now. She is still sitting there in your classroom, in your boardroom, across your lab bench. She smiles, answers your questions, and looks “fine,’ but if you look closer and ask differently, you may finally hear the part of her story that never reaches the surface, the part that reflects her raw, unfiltered self that others have missed, but that you are willing to recognize because the goal is not simply to find more diagnoses, but to recognize and support the individuals who have been overlooked all along. 

References

  1. Cassidy, S., Bradley, P., Shaw, R., & Baron-Cohen, S. (2021). Risk markers for suicidality in autistic adults. Molecular Autism, 12(1), 49.
  2. Cook, J., Hull, L., Crane, L., & Mandy, W. (2021). Camouflaging in autism: A systematic review. Clinical Psychology Review, 89, 102080.
  3. 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.
  4. Lai, M.-C., Lombardo, M. V., Auyeung, B., Chakrabarti, B., & Baron-Cohen, S. (2020). Sex/gender differences and autism: Setting the scene for future research. Journal of the American Academy of Child & Adolescent Psychiatry, 59(5), 537–539.
  5. Loomes, R., Hull, L., & Mandy, W. (2017). What is the male-to-female ratio in autism spectrum disorder? A meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry, 56(6), 466–474.
  6. Maenner, M. J., Shaw, K. A., Bakian, A. V., et al. (2023). Prevalence and characteristics of autism spectrum disorder among children aged 8 years — United States, 2020. MMWR Surveillance Summaries, 72(2), 1–14.
  7. Mandy, W., Chilvers, R., Chowdhury, U., et al. (2018). Sex differences in autism spectrum disorder: Evidence from a large sample of children and adolescents. Journal of Autism and Developmental Disorders, 48, 297–306.
  8. May, T., Cornish, K., & Rinehart, N. (2023). Mental health in autistic girls and women: A systematic review. Autism Research, 16(2), 235–252.
  9. Ratto, A. B., Kenworthy, L., Yerys, B. E., et al. (2018). What about the girls? Sex-based differences in autistic traits and adaptive skills. Journal of Autism and Developmental Disorders, 48, 1698–1711.
  10. Rutherford, M., McKenzie, K., Johnson, T., et al. (2016). Gender ratio in a clinical population sample, age of diagnosis and duration of assessment in children and adults with autism spectrum disorder. Autism, 20(5), 628–634.
  11. Rynkiewicz, A., et al. (2019). An investigation of the “female camouflage effect” in autism. Research in Autism Spectrum Disorders, 64, 1–10.
  12. Westby, A., & Coburn-Pierce, M. (2025, September 15). Autism spectrum disorder in primary care. American Family Physician. https://www.aafp.org/pubs/afp/issues/2025/0900/autism-spectrum-disorder.html 

About the Authors

Lauren Wallace, MS3

Lauren Wallace is a third-year medical student at St. George’s University School of Medicine and earned her Bachelor’s degree in Cell and Molecular Biology from the University of Tennessee at Martin. She has served as student lead for her Psychiatry and Obstetrics/Gynecology core rotations and is an active member of the Gender Equity Task Force, demonstrating her dedication to advancing equitable care. Passionate about Psychiatry, Lauren volunteers for the Crisis Text Line and focuses on improving access to mental health services in underserved rural communities, a commitment rooted in her upbringing in rural Tennessee. Outside of medicine, she enjoys staying active and scuba diving with her husband.

Rhea Manohar, MPH, MS3

Rhea Manohar is a third year medical student from St. George’s University. She has a Masters in Public Health with a concentration in Maternal and Child Health from George Washington University Milken Institute of Public Health and a Bachelors of Science in Microbiology & Immunology, and Public Health from the University of Miami. She served as Co-VP of OB/GYN Education for St. George’s University’s Women in Medicine chapter in St. George, Grenada where she developed hands-on workshops to further reproductive health issues and navigating challenging physician-patient communication scenarios. Prior to medical school, she was a Research Associate for Fors Marsh Group, where she led qualitative and quantitative public health research and campaign development for federal agencies (e.g., CDC, NIH, DHHS, CPSC). She is also a member of the Gender Equity Task Force of the American Medical Women’s Association. When she is not pursuing medicine, you can find her reading, exploring artistic passions, and spending time connecting with friends and family.

Meghan Etsey, MS4

Meghan Etsey is a fourth year medical student from St. George’s University. She has a Bachelors of Arts in Biology and a Bachelors of Arts in Nutrition and Dietetics from Bluffton University in Bluffton, Ohio. She served as the President of the St. George’s University’s Women in Medicine chapter in St. George, Grenada where she expanded relationships with the community and worked towards educating women and helping the youth. She is also a member of the Gender Equity Task Force and Sex and Gender Health Collaborative Committees within the American Medical Women’s Association. When she is not pursuing medicine, you can find her with her friends and family on different road trips and adventures exploring the world. 

Yun Weisholtz, MD-PhD

Dr. Yun Weisholtz is a physician-scientist and advisor with a deep commitment to mentorship and advancing equity in medicine. She completed her undergraduate studies at Stanford University, where she double-majored in Biological Sciences and Chemistry, and spent a year in Germany as a Fulbright Scholar. She went on to enter the MD-PhD program in Neuroscience at Harvard Medical School and MIT, where she developed her passion for research, teaching, and mentoring. Dr. Weisholtz is a Physician Advisor with MedSchoolCoach and the founder of MD-PhD Advising, a consulting practice dedicated to helping students navigate the medical school and residency application process. Outside of work, she enjoys collecting Delft pottery from the Netherlands and spending time with her family and pets.