In recent years, practitioners have seen a surge in the number of girls and women requesting autism evaluations. That increase doesn’t necessarily reflect growth in the prevalence of autism; instead, it’s an indication that what we know about autism in girls and women is changing. Clinicians and educators are getting better at describing what the condition can look like in people who identify as female. And our culture is slowly becoming more accustomed to thinking about, talking about, and learning from autistic girls and women.

For Lindsey Sterling, PhD, clinical child psychologist and founder of the Sterling Institute for Autism, this shift in perspective is a welcome one. “We’re getting better at describing what autism is like in females both through research and in clinical experience, which means we have a better sense of what sets females apart so that we can incorporate that into our assessments,” Dr. Sterling says. “Even more exciting is the fact that neurodiverse women are starting to feel more comfortable speaking up and describing their firsthand experiences.” 

The growing number of autobiographies, podcasts, websites, and videos featuring autistic women is testament to the increasing acceptance. “We’re seeing women self-advocate, coming in for the assessments they need. There’s less shame around that. Women realize there is a community out there who understands them, and the neurodiversity movement, appreciating brain differences, is starting to gain momentum so there’s less stigma around an autism diagnosis,” Sterling says.

In the upcoming webinar, “Unmasking the Lives of Autistic Females,” Dr. Sterling will provide an overview of autism in girls and women across the life span, examining biological and neurological theories that might account for sex differences in autism expression. The course also explores diagnostic markers, unique strengths, and common lived experiences including camouflaging and masking. Dr. Sterling will describe the barriers to accurate and timely identification and explain which other neurodevelopmental and psychological conditions often co-occur with autism. And perhaps most important, she’ll outline an approach to accurate assessment of autistic females, including practical clinical recommendations. 

The course begins with some historical perspective. “Some of our earliest conceptions of autism, in the 1940s, involved picturing a little boy. That sort of stuck in people’s minds,” she notes. “In fact, when we did research, we would recruit participants, making sure that the ratio reflected what we thought was accurate—which was 4 males to 1 female. So the research findings and assessment measures were developed based on what we know about boys.”

Those findings shaped cultural attitudes about what autism was and wasn’t. “When we watch TV, we see portrayals of these quirky boys and men who are supposed to reflect autism, and that gets embedded in our understanding of what autism is: little professor-like males,” Dr. Sterling explains. “On top of that, there are additional cultural influences. For example, girls in general, not just autistic girls, are socialized to nod, smile, be affable and friendly. They are not given much room to be aloof or to check out. They’re supposed to be pleasers.” Those gender expectations, entrained at an early age, influenced how many autistic females presented publicly. 

“What we’ve learned over the years is that many girls are engaging in masking and camouflaging. They’re mimicking what they see around them. They’re learning what they’re supposed to be doing to blend in,” Dr. Sterling says. As a result, those who can mask or camouflage effectively may be overlooked or misdiagnosed by providers. Even family members and educators who interact daily with autistic female students can have a hard time recognizing autistic traits or characterizing behaviors as such.

As more research is conducted in alliance with autistic female subjects and researchers, practitioners are getting better at meeting the needs of this important population. “As psychologists, we’re trained to observe behavior and collect data from collaterals, which we should still do. But when it comes to females there’s this other piece that’s so important, and it’s listening and believing,” Dr. Sterling points out. “We have to rely on what people say is their experience of the world.”

Another step? Conducting a broad, thorough evaluation, including developmental histories and interviews with multiple sources.

“It’s really important to get a detailed developmental history. That’s important in any autism assessment, but especially with a female,” Sterling says, “because even though some of the challenges might not become apparent until later, when life gets more challenging and socialization gets more complex, it doesn’t mean that someone gets autism when they’re 20.” A developmental history can help you understand what life has been like for this person. 

If a parent isn’t available to provide that background or if few records exist, Dr. Sterling recommends a practical workaround. “We interview who we can to get other perspectives—a spouse, a partner, a sibling. We can ask, ‘What’s it like to live with this person? What have you noticed about what it’s like to social with them?’ With females, we have to be ready to be flexible, to dig a little bit deeper. Sometimes that means doing a longer assessment to really get to know the person, rather than basing our impressions on what we see on the surface,” she explains. “The more time we spend, the more likely it is that people will be able to unmask.” 

Dr. Sterling recommends that clinicians and educators take a close look at their own assumptions and experiences with autism, because they may lead to bias in assessment. She also advises a shift away from deficit-based evaluations and toward a more strengths-based approach, noting, “The assessment isn’t about finding out what’s wrong with someone. It’s about validating their experiences, recognizing what’s different, and empowering women so that they’re able to feel proud of their differences. We want to acknowledge and provide direction for the things that are hard.”

WPS is proud to shine a light on the outstanding work of Dr. Lindsey Sterling in “Unmasking the Lives of Autistic Females.” Learn more about the course and register here.