Behind the mask. Understanding autism in girls.
There is a gaping gender gap when it comes to autism diagnoses. Boys are up to four times more likely to be diagnosed as autistic than girls1. Does that mean that autism is simply more prevalent in males? In the past, that was certainly the belief. In fact, autism was once considered to be akin to having an “extreme male brain”.
It’s now clear, of course, that anyone can be autistic, but the gender diagnosis gap persists. Around 80% of autistic women remain undiagnosed by the time they reach 182.
Historically, the assumptions about how autism presents, and who it affects, left many autistic girls unseen and undiagnosed. So why hasn’t this changed?
There are a number of reasons that girls are not being diagnosed with autism at the same rate as boys. To start with, societal bias takes time to shift. Diagnostic criteria have previously been focused purely on male presentations, but autism in girls tends to present differently.
Autistic girls are much more likely to “mask” their autistic traits, making them more difficult to spot. Girls are also more likely to internalise their symptoms. Turning their challenges inward means there’s less external disruption, so there’s less imperative to take action. In other words, if there are no obvious negative effects, why look any deeper; there’s ‘nothing to see or fix here’. Girls’ masking and internalising can often lead to misdiagnosis too, such as low mood or anxiety.
Knowing the difference. Spotting the signs.
Autism typically presents differently in girls than in boys, so it’s important to look for the more subtle traits that often characterise autistic girls. These include strong social masking, intense but ‘socially acceptable’ special interests, perfectionism, and internalising.
Autistic girls often work hard to hide their difficulties, driven by a desire and an ability to ‘fit in’. This is “masking”. They can be extremely good at copying their peers' language and behaviours, so they can appear completely "normal" to everyone at school.
Many autistic girls will intensely focus on topics that are considered socially acceptable (common subjects include animals, books and celebrities). They tend not to follow the kinds of interests that are stereotypically associated with autistic boys.
Being a strict rule follower is another common trait of autism in girls. Girls are often highly compliant and extremely keen to avoid mistakes, as another way of masking their underlying anxiety.
Social confusion (not knowing if they’re liked; being unable to ‘read the signs’; being unsure how to behave towards others etc.) is common in autistic girls, along with difficulty with friendship boundaries. They may experience intense but fleeting friendships, or social exhaustion from masking.
Autistic girls can be hypersensitive to sounds, textures (such as clothing) and lights too, but this can often remain hidden until they become completely overwhelmed. They may have meltdowns at home after a day of "performing" and sensory overload at school.
Commonly seeming “shy” or “quiet”, rather than showing ‘overtly autistic’ behaviours, girls will nonetheless experience the same difficulties with social rules, unstructured time, and sensory input as boys.
All of this intense, internalised stress can lead to poor mental health for autistic girls, adding anxiety, depression or eating disorders to their load.
Autism Assessments
Thankfully, autism assessments have moved on to take account of the differences between male and female presentations. For example, differentiation in the scoring thresholds for questionnaires and individual assessments and in training the clinicians. As those in education and wider society become more aware of the nuances of autism in girls, the gender gap should close and more girls and women will be able to find the answers and support they need.
You can find more information and resources on the National Autistic Society’s website3.
At ACCESS Speech and Language Therapy, our clinicians understand the differences in presentation between girls and boys. And our Autism and ADHD Diagnostic Service follows all NICE guidelines. Find out more.
1 BMJ https://www.bmj.com/content/392/bmj-2025-084164
2 NCBI https://pmc.ncbi.nlm.nih.gov/articles/PMC8870038/
3 National Autistic Society https://www.autism.org.uk/advice-and-guidance/identity/autistic-women-and-girls