Masking the Signs
What Clinicians Miss About Autism in Girls and Women
"For every one girl diagnosed with autism, roughly ten boys receive the same diagnosis... Girls and women are not less autistic. They are less recognized."
104625 What Clinicians Should Know: Understanding Girls and Women With Autism in a World Where They Are Commonly Overlooked and Misdiagnosed
Throughout the United States and abroad, boys are more commonly diagnosed with autism spectrum disorder (ASD). Many girls and even females in adulthood are overlooked as having ASD. While the manifestation and exhibited characteristics associated with ASD in females often appears different than for males, females with autism are often misdiagnosed and overlooked altogether-- requiring them to navigate a world...
For every one girl diagnosed with autism, roughly ten boys receive the same diagnosis, a ratio that (on its face), might suggest autism is simply less common in girls and women. Dr. Christina Marsack-Topolewski, PhD, LMSW, associate professor of social work at Eastern Michigan University and a 20-year veteran of work with individuals with intellectual and developmental disabilities, offers a different explanation: girls and women are not less autistic.
They are less recognized.
A Diagnosis Ratio Built on Missed Signals
The broader diagnosis ratio for autism spectrum disorder sits between three and four males diagnosed for every one female.
Among those considered to have low support needs (average to above-average intelligence, fewer visible behavioral markers) that ratio widens further, to roughly ten males for every one female diagnosed. The gap isn't fully explained by prevalence, but instead explained, in large part, by how autism actually looks in a female presentation, and how poorly current diagnostic tools are built to catch it.
According to Dr. Marsack-Topolewski, who presented on this topic back in 2025, and will again on October 22nd, several forces compound the problem at once. Diagnostic tools themselves are less sensitive to traits as they show up in women and girls. Teachers and school staff under-report autism-consistent behavior in female students. Research samples have historically skewed toward male participants, meaning the diagnostic criteria in use today were disproportionately built around how autism presents in boys. And underneath all of it sits a simpler dynamic: girls are socialized differently than boys from early childhood, encouraged toward social engagement in ways that, paradoxically, make it easier for them to develop compensatory strategies that keep their autism hidden from teachers, from parents, and sometimes from themselves.
The Work of Masking
That compensatory strategy has a name: social camouflaging, or "masking," the sustained, often exhausting effort to blend into neurotypical social expectations. Through masking, every social interaction becomes a performance requiring intense concentration: monitoring facial expressions, calculating when to make eye contact, rehearsing what to say before saying it, suppressing stimming behaviors in real time. "It's deliberate. It's almost like it's rehearsed," is how Dr. Marsack-Topolewski described it in their previous presentation on the topic. The pattern gets described as performative in the truest sense, executed so consistently that many who do it don't fully register how much labor it requires until years later.
In young girls, that masking often gets misread as something else entirely. A meltdown from sensory or emotional overload reads as a bad day rather than an autism-consistent response. A child who is shy or mute in certain settings is simply "quiet." A girl who gravitates toward playing with younger or older children (peer groups that tend to be more developmentally forgiving) is just described as mature for her age, or a late bloomer. None of these read as red flags on their own, and that's precisely the point: they don't rise to a threshold anyone thinks to question, which means the underlying pattern goes unaddressed for years, sometimes decades.
The cost of that sustained performance is eventually has to be paid somewhere. Camouflaging and masking are (by every account), exhausting and burnout is a documented consequence. Some individuals turn to substance use as a coping strategy directly tied to the effort of masking: drinking to fit in socially, drinking to feel "normal," using substances to manage the sensory and social over-stimulation that masking is designed to hide. A 2021 study by Dr. Weir and colleagues cataloged a range of reasons autistic individuals report for substance use including masking itself, fitting in, seeking help with social anxiety, and self-medicating to reduce repetitive behaviors. As Marsack-Topolewski put it in their previous presentation on the topic: "There are lots of invisible struggles at play."
What Late Diagnosis Actually Costs
Underdiagnosis, misdiagnosis, and late diagnosis aren't just administrative gaps but labeling that directly impede a person's access to appropriate treatment and support. Without an accurate diagnosis, a clinician may be treating someone for anxiety or depression without recognizing that what they're actually describing is a traumatic experience shaped by undiagnosed autism, context that would look meaningfully different with the right diagnostic frame in place.
One recurring pattern surfaced directly from clinicians in the room: women receiving an autism diagnosis for the first time in adulthood, often after becoming mothers. Masking becomes significantly harder to sustain when a person's bandwidth is already drained by the daily demands of parenting, and that depletion is often what finally makes years of quiet compensation impossible to keep hidden. Marsack-Topolewski described a recent, direct example from her own network: a woman diagnosed for the first time in adulthood with both ADHD and autism, the diagnoses surfacing only after she became a mother (a pattern she noted she's seeing more and more, echoed by clinicians describing the same trend in their own caseloads).
Complicating the picture further is a phenomenon called diagnostic overshadowing, where a co-occurring condition (anxiety, depression, an eating disorder) masks the underlying autism entirely, delaying an accurate diagnosis sometimes by decades. Getting the diagnosis right, and getting it early, opens the door to services and treatment that are actually tailored and affirming, rather than aimed at the wrong target altogether.
Reframing Behavior as Communication
Underneath the diagnostic conversation sits a broader clinical principle that shapes how this population should be understood in the first place: behavior is communication.
When a person struggles to express themselves, feels chronically misheard, or experiences ongoing frustration around communication, that frustration doesn't just disappear, but instead tends to surface behaviorally. For a woman or girl who has spent years camouflaging convincingly enough to avoid diagnosis, that behavioral signal is often the only visible thread a clinician has to pull on.
This is where recognizing trauma in the autistic community requires a genuinely different lens.
Trauma triggers and responses among autistic individuals are shaped by sensory sensitivities, communication differences, and co-occurring conditions in ways that can cause someone to experience an event as traumatic that wouldn't register as traumatic for a neurotypical person, and conversely, autism characteristics themselves can be mistaken for or mask the presence of trauma. Complex PTSD, in particular, shares overlapping symptoms with autism itself: reduced interest in social interaction, social withdrawal, difficulty trusting others. Distinguishing between the two (or recognizing that both may be present at once) depends on a clinician's willingness to look past a surface presentation and ask what's actually underneath it.
A Call for Accurate, Affirming Diagnosis
The throughline across all of this is deceptively simple: accurate diagnosis changes everything downstream.
It changes whether treatment actually addresses what a client is experiencing, or misses it entirely. It changes whether a woman understands her own decades of exhausting social effort as a diagnosable, explicable pattern, or continues to internalize it as a personal failing. And it changes whether the people around her (family, employers, clinicians) have any real framework for understanding what she's navigating.
For girls and women with autism, that understanding has, for too long, arrived late, if it arrives at all. Recognizing the pattern of missed diagnosis is the first step, and building the clinical tools to catch it earlier is the work still ahead. ◼
104625 What Clinicians Should Know: Understanding Girls and Women With Autism in a World Where They Are Commonly Overlooked and Misdiagnosed
Throughout the United States and abroad, boys are more commonly diagnosed with autism spectrum disorder (ASD). Many girls and even females in adulthood are overlooked as having ASD. While the manifestation and exhibited characteristics associated with ASD in females often appears different than for males, females with autism are often misdiagnosed and overlooked altogether-- requiring them to navigate a world...
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Resources
- Marsack-Topolewski, C. (2025, July 18). Autism and trauma: Understanding the trends and realities to provide a clinically responsive treatment approach [Webinar]. Impact CE.
References
- Weir, E., Allison, C., & Baron-Cohen, S. (2021). Understanding the substance use of autistic adolescents and adults: A mixed-methods approach. The Lancet Psychiatry, 8(8), 673–685.Weir, E., Allison, C., & Baron-Cohen, S. (2021). Understanding the substance use of autistic adolescents and adults: A mixed-methods approach. The Lancet Psychiatry, 8(8), 673–685.
