Are the current clinical guidelines for autism spectrum disorder (ASD) weighted too heavily toward male patients?

That’s the conclusion of a team of researchers from the Lurie Center for Autism at Massachusetts General Hospital, who are working to increase awareness of gender-specific differences in ASD to improve early diagnosis rates and identify better treatment strategies for female patients.

In a recent article in Current Psychiatry Reports, the researchers argue that many of the current diagnostic criteria and symptom descriptions for ASD are biased toward male patients.

This is in part due to the higher prevalence of autism in males, but also that the clinical description of autism was derived almost entirely from male patients, the researchers write. As a result, many females with autism do not receive a diagnosis until much later—if at all.

Early diagnosis is important in ASD, as research has shown that early treatment interventions are more likely to have major long-term positive effects on symptoms and skills.  

Receiving a diagnosis can also help reduce the emotional stress that many females with autism experience trying to understand their symptoms. Diagnosis and treatment can also help to protect those who may be vulnerable to victimization in the form of unhealthy relationships or abuse.

How Autism Differs in Females

One key step in reducing this gender disparity is to raise awareness of the differences in clinical presentation between male and female ASD patients.

Studies have shown that in comparison to males, females with ASD tend to engage in more imaginative and pretend play from a young age. Their speech also contains more vocabulary words related to emotions.

Females with ASD also tend to have a greater awareness and desire for social interaction and may develop one or two close friends. They may try to camouflage their social difficulties by making eye contact despite their discomfort in doing so, using learned phrases or jokes in conversation and mimicking the gestures and facial expressions of others.

Many females with ASD develop restricted interests (intense, highly focused interests) related to people and animals (such as celebrities and pets) as opposed to males who tend to focus on objects.

Female ASD patients also have heightened rates of internalizing disorders such as anxiety, depression and eating disorders. These could be triggered in part by the pressure of striving to live up to feminine gender norms regarding appearance, relationships and taking care of others.

More troubling, they may be more vulnerable to victimization in the form of unhealthy relationships and emotional, physical and sexual abuse due to passivity or social naivete.

Moving Forward

The team says that more research is needed to better define the gender-specific differences in ASD patients, and more outreach work is needed to make clinicians aware of these differences. This could reduce the barriers that many female ASD patients encounter when seeking a diagnosis.

Researchers should also take a closer look at how medications for ASD may affect female patients differently, as most of the drugs were developed using male patients.

More research is also needed to identify and test interventions that can address the unique challenges of female ASD patients, the team says.

“Sociocultural factors including social expectations for women have contributed to a climate that leaves women with ASD more likely to feel shame regarding their social or behavioral difficulties or fall victim to various forms of violence. As such, treatment targeting women with ASD will require more direct teaching in self-advocacy and safety skills.

“Ultimately, more research investigating the differences between men and women with ASD is essential for us in order to serve this population better.”

(The study team includes Renée M. (Poulin) Green, PhD, Alyssa Travers, PhD, Yamini Howe, MD, and Christopher McDougle, MD)

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