Female Autism: Demystifying Underdiagnosis and Promoting Inclusion

Female Autism: Demystifying Underdiagnosis and Promoting Inclusion

The Invisibility of Autism in Women

By Andrea Dall'Ava Cortellazzi (Andréa Dias)

🙏 Acknowledgments

First, I thank God—for life, for encounters, and for guiding me with strength and courage, even on the most silent paths of the soul.

To my family, a solid foundation of affection and learning, who taught me, even on difficult days, the power of persistence and tenderness.

To Eduardo, a loving, supportive, and loyal presence through so many moments—thank you for walking with me with generosity and warmth.

To the teachers and students at Major Cosme de Faria State School, who, with every exchange, gesture, and word, contributed immensely to my journey of discovery and growth. It was with you that I learned the true meaning of inclusion—not as a concept, but as a living, daily practice.

To everyone who, directly or indirectly, contributed to my learning process: colleagues, mentors, friends, readers, and sensitive souls who crossed my path. You made a difference in the journey of this autistic woman, writer, and educator, who discovered her place on the spectrum late in life but never stopped seeking her space in the world.

This book is also yours. With love, respect, and gratitude.

💐 Dedication

To my mother, Maria Cortellazzi.

My strength on cloudy days, my safe harbor through all the seas of life.

It was with you that I learned to be strong, to never give up in the face of difficulties, to always strive to be better, to fight with dignity and faith.

You taught me, through words and silence, through gestures and resolve, to respect who I am. Through your unconditional love and daily courage, I discovered the true meaning of being a woman—and above all, of being myself.

This book is a reflection of the woman you helped shape.

With all my gratitude and eternal love, this work is yours as well.

Contents

    Introduction: The Invisibility of Autism in Women

    Characteristics of Female Autism

    Diagnostic Challenges

    Common Comorbidities

    The Importance of Accurate Diagnosis

    Recommendations for Families and Professionals

    Conclusion: Toward Real Inclusion

    Glossary

    Bibliography

1. Introduction: The Invisibility of Autism in Women

The Silent Invisibility

For decades, the socially constructed image of autism has been heavily influenced by gender bias. Cultural representations—in films, books, documentaries, or even awareness campaigns—have reinforced the figure of a white boy with restricted interests, significant difficulties in social interaction, and rigid behavioral patterns. While this image reflects part of the reality of many autistic individuals, it has completely erased an equally significant segment of the population: autistic girls and women.

The invisibility of female autism is not accidental but the result of a historical and scientific construction based almost exclusively on the behavior of boys. The first studies and diagnostic criteria were developed from clinical observation of boys, resulting in a "typical" profile that does not consider the unique ways the spectrum manifests in girls. As a result, women who do not fit this model are often overlooked, misunderstood, and frequently misdiagnosed.

A Life Without a Name: Misdiagnoses and Silencing

While boys with autism are often identified in early childhood due to more evident or disruptive behavior, girls often go unnoticed. Their challenges are misinterpreted as personality traits, emotional exaggeration, or simply a phase. Instead of receiving support, they are labeled “dramatic,” “weird,” “exaggerated,” “cold,” or “too intense.”

As a result, it's common for women on the spectrum to receive incorrect diagnoses, such as borderline personality disorder, bipolar disorder, depression, or anxiety disorders. Many receive multiple diagnoses throughout their lives, none of which fully explain their emotional and sensory experiences. This journey of confusion and lack of belonging leads to not only psychological suffering but also a profound sense of inadequacy in a world that constantly demands exhausting social performance.

A Masculinized Construction of Diagnosis

Science, like any other field, is influenced by historical, cultural, and social contexts. The way autism has been (and still is) studied and diagnosed reflects this. Diagnostic manuals such as the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) are largely based on male samples, making their criteria limited in capturing the spectrum’s diverse manifestations in women.

Girls are socially conditioned from a young age to adapt. They are taught to observe, imitate, and please. As a result, many develop what is now known as masking or social camouflage—a conscious and unconscious effort to hide their difficulties and behave in a socially "acceptable" way. They memorize phrases, mimic facial expressions, force interactions, and create versions of themselves to fit in. This social performance comes at a high cost: extreme fatigue, internal crises, silent emotional breakdowns, and, over time, deep exhaustion known as autistic burnout.

When Diagnosis Fails, Suffering Multiplies

Underdiagnosis and misdiagnosis in female autism have devastating consequences. Many women live their entire lives feeling "broken," not understanding why they struggle with social connection, sensory hypersensitivity, rigid routines, emotional outbursts, or exhaustion from seemingly simple interactions.

Without an accurate diagnosis, there is no access to specific therapies, proper psychological support, or social understanding. Instead, these women are often improperly medicated, receiving prescriptions to treat symptoms rather than addressing the root of the problem. The lack of self-understanding contributes to the emergence of comorbidities such as anxiety, depression, eating disorders, and low self-worth. The impact spreads across all areas of life: academic, professional, familial, and emotional.

Late diagnosis—often only in adulthood—also means lost opportunities for early intervention, school adaptation, and self-esteem development. Without knowing they are autistic, many grow up feeling something is wrong with them, which can lead to serious identity crises.

2. Characteristics of Female Autism

A Quiet Way of Being Autistic

Autism in girls and women often manifests more subtly and internally than in boys. While traditional criteria look for visible signs and more extreme behaviors, girls tend to "hide in plain sight," presenting traits often mistaken for personality quirks, shyness, or even perfectionism.

This doesn’t mean they suffer less—it simply means they suffer in silence.

Social Camouflage: The Burden of Being Someone You're Not

One of the most prominent traits in autistic women is social camouflage (masking). It's a skill developed consciously or unconsciously to hide autistic traits and adapt to social expectations.

These girls observe and mimic their peers' behavior, memorize conversation patterns, copy gestures and facial expressions, and try their best not to draw attention. Their camouflage may be so well done that they appear highly polite, intelligent, sensitive, and articulate. However, behind this “mask” is constant effort and a huge emotional and cognitive energy cost—often leading to deep exhaustion by the end of the day.

Additionally, the need to mask creates disconnection from their true identity. Many women report not knowing who they really are, having spent their whole lives trying to please others or fit into their surroundings.

Specific, Yet Socially Acceptable Interests

Another important aspect is how restricted interests—classic signs of the spectrum—manifest in girls. While boys may fixate on maps, trains, or complex systems, girls might develop intense passions for animals, books, astrology, pop culture, specific characters, mythology, makeup, or TV shows. Because these topics are more “socially acceptable” or common among girls, these obsessions are often not seen as atypical—despite being just as intense and systematic as those of boys on the spectrum.

Hyperempathy and Sensitivity

Contrary to the stereotype that links autism with emotional coldness, many autistic women show emotional hypersensitivity. They deeply feel others’ pain, pick up on subtle emotional cues, and are affected by injustice, sadness, or others' suffering—to the point of becoming emotionally overwhelmed.

This hypersensitivity also extends to the environment. Loud noises, bright lights, strong smells, or rough fabrics can cause extreme discomfort. Still, because they’re taught from an early age to “toughen up” or “not make a scene,” many ignore their limits and internalize the suffering.

Communication and Social Relationships

Autistic women may develop fluent and even sophisticated verbal language, which makes them even less likely to be recognized as neurodivergent. But social communication goes beyond words—it involves understanding context, irony, power dynamics, and facial expressions, which remain challenging.

In social interactions, they often seek deep connections but struggle with casual friendships or group dynamics. Many report feeling out of place, even when “included.” There is also a pattern of intense and unstable relationships, marked by idealization, disappointment, and difficulties establishing clear boundaries.

4. Paths to Inclusion and Recognition

The Importance of Listening and Representation

Recognizing autistic women is, above all, an act of listening and empathy. It is necessary to hear their experiences without prejudice and accept that autism can manifest in subtle, camouflaged, and silent ways. Representation is another essential step: seeing autistic women in positions of voice—within academic, professional, and cultural spaces—breaks stigmas and broadens society’s understanding of the spectrum.

We need real stories being told — by them, in their own words, in their own time. When autistic girls see other neurodivergent women living authentically and being respected, they begin to understand that they too can take up space and express themselves in a valid and legitimate way.

Training Professionals and Revising Diagnostic Criteria

Change starts with those who provide care, support, and diagnosis. Psychologists, psychiatrists, educators, and other health and education professionals must be trained to recognize signs of autism in girls and women. It is urgent to review the current diagnostic criteria, which are still largely based on male patterns.

More than just tools, what’s needed is a new perspective: one that is more attuned to nuance, more sensitive to gender differences, and less guided by stereotypes. Autism has no single “face” — it is multiple, diverse, and demands active listening and respect for individual traits.

The Role of Schools, Families, and Communities

Inclusion is not solely the responsibility of the autistic person. It is, above all, a social commitment. Schools must rethink their pedagogical and welcoming methods; families need guidance on signs that are often mistaken for “tantrums” or “drama”; and communities should create spaces where difference is not excluded, but embraced as natural.

Empathy, patience, and openness to dialogue are the foundations of this transformation. Every girl and woman has the right to be understood in her uniqueness, without having to fit into exclusionary standards.

Beyond Diagnosis: A Life with Authenticity

Diagnosis is a starting point, not a limiting label. The path to inclusion also means allowing these women to be who they are — without disguises, without masks, without fear. It's about creating space for them to express their interests, their worldview, their sensory and emotional uniqueness.

True inclusion happens when we stop demanding total adaptation from the person to the world — and begin adapting the world to embrace all legitimate ways of existing.

5. The Importance of an Accurate Diagnosis

🔍 To Name Is to Liberate

For many autistic women, receiving an autism spectrum diagnosis is like finding a missing piece of a lifelong puzzle. At last, their experiences, feelings, and worldview begin to make sense. Naming what one feels and lives is, above all, an act of validation and liberation.

For years, many endure a difficult journey marked by inaccurate labels, ineffective treatments, and a persistent sense of not belonging. A proper diagnosis can interrupt this cycle of silent suffering and open doors to more assertive, inclusive, and respectful care.

💬 "Why Only Now?"

This is a common question among women diagnosed in adulthood. The answer lies in the masked way autism often presents in them. Socially accepted behaviors such as perfectionism, hyperadaptation, emotional sensitivity, and introspection are often mistaken for personality traits rather than signs of neurodivergence.

Moreover, societal expectations that girls should be communicative, empathetic, and "nice" lead many to develop social camouflaging from an early age — a conscious (or unconscious) effort to mimic expected behaviors, often at the cost of their own mental well-being.

🧠 Positive Impacts of Diagnosis

    Self-Knowledge and Identity Reorganization

    Understanding oneself as being on the spectrum helps many women reinterpret life experiences through a new lens, now with more self-compassion.

    Reduced Psychological Distress

    By understanding their sensory, emotional, and cognitive needs, women can develop strategies to avoid overload, anxiety, and burnout.

    Access to Support and Accommodations

    A diagnosis enables access to legal resources, targeted therapies, support groups, and inclusive measures in school, university, and the workplace.

    Ending Unnecessary Overmedication

    Many women spend years on medication for conditions unrelated to their actual diagnosis. Accurate assessment helps revise these treatments.

    Stronger Relationships

    Recognizing autism traits helps improve family, romantic, and social connections by allowing others to understand their boundaries and needs.

🚧 The Path Still Has Barriers

Despite progress, access to autism diagnosis for women remains challenging. Many health professionals are still unprepared to identify the more subtle and masked traits of autism in women.

Thus, it's essential to promote continuous professional training, expand discussions about female autism in academic, school, and social spaces, and encourage empathetic listening from those who live and work with autistic women.

❤️ Diagnosis Is Not a Label — It's an Act of Care

More than a document, diagnosis should be seen as a tool for empowerment and inclusion. It opens the way for autistic women to not just survive in the world — but to truly live with dignity, freedom, and belonging.

6. Recommendations for Families and Professionals

👨‍👩‍👧 Support Networks Are Essential

An autistic woman’s journey can be lighter and more meaningful when accompanied by a network that understands, respects, and supports her. Families and professionals play a vital role in this process. However, it is necessary to undo myths, prejudices, and unrealistic expectations often placed on these women.

Below are practical, experience-based recommendations from clinical practice, testimonials, and research that can help in caring for and interacting with girls and women on the spectrum:

📌 For Families

    Welcome Without Judgment

    Avoid comparing your daughter, sister, or relative with others. Every autistic woman is unique, with her own way of expressing, feeling, and understanding the world.

    Listen to What She Has to Say

    Even if she has difficulty expressing herself verbally, there are other forms of communication: glances, gestures, repetitive interests, or even silence.

    Respect Sensory and Emotional Boundaries

    Many autistic women are sensitive to sounds, smells, lights, textures, or touch. Understanding and respecting these boundaries is an act of love and empathy.

    Don’t Force Her to “Be Like Everyone Else”

    Trying to "normalize" her can lead to suffering, anxiety, and a sense of inadequacy. Encourage her authenticity.

    Promote Autonomy with Structured Support

    Creating routines, offering clear explanations, and supporting transitions are helpful ways to foster autonomy without causing overwhelm.

    Seek Knowledge and Training

    Joining support groups, reading about female autism, and engaging in dialogue with other families can broaden your care approach and understanding.

📌 For Health, Education, and Social Care Professionals

    Stay Informed About Female Autism

    Autism traits in women often don’t follow the “classic” model described in manuals. Targeted training is essential.

    Adopt a Sensitive, Non-Pathologizing Approach

    Many women arrive in clinics tired of being labeled as "difficult" or "problematic." Listen to their experiences with empathy and respect.

    Don’t Mistake Camouflaging for Lack of Distress

    An autistic woman may seem sociable yet be internally exhausted. Appearances should not be the sole basis for assessment.

    Involve the Family — But Respect the Woman’s Autonomy

    If she is an adult, she must be heard and involved in all decisions concerning her life.

    Be Alert to Comorbidities

    Depression, anxiety, eating disorders, and ADHD are common in autistic women and should be carefully assessed without reducing them to a “difficult personality.”

    Promote True Inclusion

    Whether in clinics, schools, or workplaces, it's important to adapt communication, respect routines, and provide accessible alternatives suited to the autistic person’s reality.

💡 Humanizing Care Is Essential

In both family and professional settings, what most transforms the life of an autistic woman is the presence of people who see beyond the diagnosis. Those who can recognize the beauty of difference, offer kind support, and encourage the blossoming of her unique potential.

7. Conclusion: Toward Genuine Inclusion

🌈 To See and Recognize Is to Include

Talking about female autism is, above all, about breaking the silence and dismantling historical distortions that have kept so many women on the margins of understanding and empathy. It’s about recognizing that there are different ways of being, feeling, and experiencing the world — and that all of them are valid.

For years, the male model of diagnosis, behavior, and intervention has silenced female voices on the spectrum. This not only made access to appropriate support difficult, but also harmed identities, caused psychological suffering, and rendered invisible the talents, stories, and lives of autistic women.

That’s why true inclusion goes beyond acceptance. Inclusion is about understanding. It’s about respecting limitations and valuing strengths. It means transforming social spaces — schools, universities, workplaces, and institutions — into welcoming environments for all forms of existence.

✨ The Path of Authenticity

Autistic women do not need to be reshaped to fit neurotypical standards. What they need is freedom to be who they are — without masks, without fear, without judgment. They must be seen in their entirety — with their silences, intensities, uniqueness, and their own ways of perceiving the world.

Camouflaging, often used as a survival strategy, must give way to authenticity — to the comfort of being accepted and understood as a whole person. This is only possible when there is knowledge, empathy, and public policies committed to neurobiological diversity.

🤝 A Collective Commitment

This paradigm shift requires the involvement of all sectors of society: educators, health professionals, families, public administrators, and the broader community. We must demystify autism, break down stereotypes, and recognize that there are as many ways to be autistic as there are to be human.

By making female autism visible, we create space for these women not just to survive — but finally to live with dignity, freedom, and belonging.

8. Glossary

This glossary presents important terms used throughout the material, aiming to support the understanding of key concepts related to female autism.

Autism / Autism Spectrum Disorder (ASD)

A neurodevelopmental condition characterized by difficulties in social communication, and restricted and repetitive patterns of behavior, interests, or activities. The spectrum includes varying levels of support needs and manifestations.

Social Camouflaging

A strategy — often unconscious — used by autistic individuals (especially women) to appear "neurotypical." It includes mimicking behaviors, masking emotional expression, and constant effort to fit into social norms.

Late Diagnosis

A term used when autism is identified only in adolescence or adulthood. Common among women due to camouflaged symptoms or misinterpretation of signs.

DSM-5 (Diagnostic and Statistical Manual of Mental Disorders – 5th Edition)

Published by the American Psychiatric Association, it provides diagnostic criteria for mental disorders, including ASD. DSM-5 unified various autism subtypes into a single spectrum.

Neurodiversity

A concept that recognizes neurological differences as a natural part of human diversity. It views conditions like autism, ADHD, and dyslexia as legitimate brain variations — not disorders to be “cured.”

Neurotypical

A person whose neurological development follows what is considered “typical” by societal standards. Used in contrast to “neurodivergent.”

Neurodivergent

A person whose brain functions differently from the typical pattern, including individuals with autism, ADHD, dyslexia, among others.

Sensory Sensitivity

Heightened (or reduced) responses to sensory stimuli like light, sound, touch, smell, or texture. Common in autistic people and can impact daily life and well-being.

Comorbidity

The presence of two or more health conditions at the same time. In autism, common comorbidities include anxiety, depression, ADHD, and eating disorders.

9. Bibliography

Below is a selection of books, articles, and publications that supported and enriched the development of this material. It includes scientific studies, reference books, and reliable sources that address autism — with special attention to the specifics of female autism.

Books

    Attwood, Tony. The Complete Guide to Asperger’s Syndrome. Artmed, 2010.

    Grandin, Temple; Scariano, Margaret M. Emergence: Labeled Autistic. ARX, 2006.

    Simone, Rudy. Aspergirls: Empowering Females with Asperger Syndrome. Jessica Kingsley Publishers, 2010.

    Singer, Judy. Neurodiversity: The Birth of an Idea. Judy Singer, 2016.

    Lai, M.-C., Lombardo, M. V., Auyeung, B., Chakrabarti, B., & Baron-Cohen, S. (2015). Sex/gender differences and autism: setting the scene for future research.

    Hull, L. et al. (2020). Development and validation of the Camouflaging Autistic Traits Questionnaire (CAT-Q).

    Mandy, W., & Lai, M.-C. (2017). Towards sex- and gender-informed autism research.

    Bargiela, S., Steward, R., & Mandy, W. (2016). The experiences of late-diagnosed women with autism spectrum conditions.

    Gould, J., & Ashton-Smith, J. (2011). Missed diagnosis or misdiagnosis? Girls and women on the autism spectrum.

    Green, R. M., Travers, A. M., Howe, Y., & McDougle, C. J. (2019). Women and autism spectrum disorder: diagnosis and implications.

    Eaton, J. J. (2018). Autism in Heels: The Untold Story of a Female Life on the Spectrum. BenBella Books.

Articles and Scientific Studies

    Lai, M.C., Lombardo, M.V., & Baron-Cohen, S. (2014). Autism. The Lancet, 383(9920), 896-910.

    Hiller, R. M., Young, R. L., & Weber, N. (2016). Sex differences in autism spectrum disorder based on DSM-5 criteria.

    Mandy, W., & Tchanturia, K. (2015). Do women with autism who have eating disorders differ from those with eating disorders alone?.

    American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Official Documents and Guides

    American Psychiatric Association. DSM-5 – Diagnostic and Statistical Manual of Mental Disorders – 5th Edition. Artmed, 2014.

    World Health Organization. International Classification of Diseases (ICD-11).

Online Sources and Additional Materials

    Revista Autismo: https://www.revistaautismo.com.br

    Associação Brasileira de Autismo – ABRA: https://abraautismo.org.br

    TEA Brasil – Transtorno do Espectro Autista: https://teabrasil.org

Final Note | About the Author

This material was born from lived experience, attentive listening, and above all, the urgent need to expand our understanding of female autism — a field still so silenced, overlooked, and often neglected. Throughout these pages, we sought to shed light on lives interrupted by prejudice, late diagnoses, and lack of support, but also on the strength, diversity, and brilliance of autistic girls and women.

To you, reader, thank you deeply for making it this far. By dedicating your time to this subject, you too are contributing to a fairer, more sensitive, and more inclusive society. May this material serve as a seed for reflection, empathy, and transformation.

About the Author

Andrea Dias is autistic, an educator, psychoanalyst, and a specialist in Autism and Neuroprocesses, with a deep passion for inclusion. She is a master's student in Education, focusing on transitions between educational levels with an emphasis on inclusion. Andrea holds postgraduate degrees in Citizenship and Culture (UNICAMP), School Administration, Special Education (ID and ASD), School Councils, African Heritage Studies (UNB), and Psychoanalysis.

She holds degrees in Pedagogy and History and works as a Neuropsychopedagogue, with extensive training in neurolearning and applied neuroscience. Andrea is also a university professor in undergraduate and postgraduate courses, speaker, and coordinator of preparatory programs for public service exams.

Her professional path includes roles as supervisor, principal, vice-principal, pedagogical coordinator, and teacher in the São Paulo State Department of Education (SEDUC/SP). She has worked with both early and middle years of elementary education and was involved with the National Pact for Literacy at the Right Age (PNAIC) in the region of Itaquaquecetuba.

Deeply engaged in the Full-Time Education Program (PEI), Andrea is dedicated to teacher training, active listening to students, and the unwavering defense of education as a universal right.