Autism and gender: or why talking about ‘male’ and ‘female’ autism is too reductive

Historically, the view that autism was a ‘male condition’ was widespread – this led to a focus on autistic boys and men in research which, in turn, informed the autism diagnostic criteria and assessment tools. Many of those were based on a presentation of autism that is more common in boys and men, and simplistic stereotypes about what it means to be autistic (e.g., someone who is direct, interested in science, trains and machines, and prefers to be by themselves). This meant that autistic people who didn’t conform to this stereotype went undetected – and that’s still the case to some extent. We know from research that girls tend to get diagnosed later in life, and that their differences can be more subtle or manifest themselves differently compared to boys.

So, the next logical question here might be: does that mean that there are ‘male’ and ‘female’ types of autism? This, however, would be a rather reductive and ultimately inaccurate take. While it is true that there can be some general differences in autistic girls’ and autistic boys’ presentation, this doesn’t mean that there is such thing as boys’ autism and girls’ autism. A more useful way of looking at those differences is from the perspective of internalised and externalised expressions of autism. While autistic girls are more likely to internalise their distress and mask some of their differences compared to boys, masking and internalising aren’t restricted to autistic girls. Similarly, while boys may generally be more likely to externalise, girls can externalise too. It’s also important to bear in mind that autistic people might internalise their distress in some situations and externalise it in others. But before continuing on, let’s explore what is meant by ‘internalising’ and ‘externalising’ in more detail.

Internalising vs externalising expressions of neurodivergence

Some people are more likely to express their emotions and reactions in an overt, easy-to-notice way. In other words, they externalise their emotions. Others are more likely to keep their feelings in, meaning they might appear calm when they are, in fact, in considerable distress. These are people who internalise their emotions. Most of us will do both, depending on the context and situation we’re in, and who we are with – this, of course, is also true for autistic people.

Externalising

An example of externalising could be a child at school expressing their distress by slamming a door – a reaction that is immediately obvious to those around them, and one that is hard to ignore. It’s important to bear in mind, though, that while externalising might seem to be more straightforward to interpret on the surface level, this isn’t necessarily the case. In this particular example, the child’s behaviour could be interpreted very literally, as a sign that they are disruptive, angry or aggressive, rather than that they are overwhelmed.

If we look at behaviour as a form of communication, what the child may be trying to communicate could be their distress or discomfort. As such, the slamming of the door may have been the end result of a long cycle of frustration and their needs not being met. Externalising emotions and reactions could mean that their needs are identified early. However, they may also be interpreted wrongly or in an overly simplistic, superficial manner.

Internalising

In contrast, someone who internalises would be less likely to show overt or immediately obvious signs of distress, and they would be more likely to direct their frustration, anger or disappointment inwards. They might be in quiet distress and experience very high anxiety levels, with very little external sign of it. This could also apply to positive emotions, where a person feels intense joy, empathy, love or care but does not express those overtly. Internalising is a particularly important concept to understand in autism, as some autistic people tend to internalise their difficulties, meaning that their needs may not be detected as early as the needs of autistic people who present with a more externalising profile and accompanying learning disabilities, for example. The ‘internalised presentation of autism’, which is prevalent across genders but appears to be more common in girls and women, can lead to delayed or inaccurate diagnosis, and lack of adequate support.

If a young person is autistic and internalises their difficulties, they may appear very ‘calm and collected’ on the surface level, and those around them may not realise the extent to which they’re struggling in certain situations. If they fit this profile, masking their discomfort for prolonged periods of time could lead to exhaustion and burnout, which, in turn, could result in mental health difficulties. Some autistic people may internalise in specific contexts (e.g., school, work, social situations) but externalise in the safer and more familiar environment of the home.

The role of masking or camouflaging

Some autistic people develop strategies and behaviours to fit in socially or to appear ‘less autistic’, and this is known as ‘masking’ or ‘camouflaging’.

For example, they might:

• make eye contact, even when this feels uncomfortable, in order to conform to social norms
• rehearse conversations and plan ‘scripts’ for conversations and social interactions
• try to suppress their discomfort with sensory overload in social contexts (e.g., loud noises, bright lights, multiple conversations overlapping), which can leave them feeling exhausted
• pay close attention to the behaviours, reactions, clothing styles, interests (and so on) of neurotypical people, and try to copy those.

These are not necessarily behaviours or strategies that autistic people are using consciously or on purpose. Some of those may have become intuitive to them after many years of ‘practice’, and they may not realise that they’re masking. Masking can have an important protective and adaptive function that helps autistic people navigate a neurotypical world where people can be judged harshly unless very specific social scripts are followed (for example, not smiling or making eye contact can be interpreted as ‘rude’, ‘bad manners’ or as a sign of not listening).

Masking can be an exceptionally laborious process that can leave autistic people feeling exhausted and burnt out. They may find that they need time to recover after masking for longer periods of time (e.g., after school; or after a big social event, such as a birthday party or a wedding) – this is sometimes informally referred to as ‘social hangover’ – or they may entirely avoid situations where they need to mask. The harmful impact of long-term masking on autistic people’s mental health is beginning to get its due recognition and understanding.

Diagnostic overshadowing and misdiagnosis

Diagnostic overshadowing happens when all the differences and difficulties a person experiences are attributed to one primary diagnosis, without considering other explanations or diagnoses. For example, an autistic person who masks their differences and has high anxiety levels as a result may initially be diagnosed with anxiety. While this may not be an inaccurate diagnosis, it does not offer a complete picture of their needs. All of this individual’s subsequent difficulties may be attributed to the anxiety, without considering that they might, in fact, be autistic. This could also mean that some autistic people don’t have access to the support they need in education, at work or in society, because their needs are not fully recognised.