The presentation, recognition and

diagnosis of autism in women and girls

Bethany Driver and Verity Chester

Bethany Driver is based at Abstract

the Psychology Purpose – Autistic women and girls have received comparatively less attention within clinical practice
department, Norfolk and and research. Research suggests women tend to be diagnosed later than men, and are more likely to
Suffolk NHS Foundation experience misdiagnosis.
Trust, Norwich, UK. Design/methodology/approach – This paper aims to report a narrative literature review that examines
Verity Chester is based at research on the presentation, recognition, and diagnosis of autistic women and girls.
the Psychiatry department, Findings – Findings suggest that autistic females present differently to males and highlight low
recognition of the female presentation of autism among the general public, in social spheres, educational,
Hertfordshire Partnership
clinical and forensic settings. This lack of recognition appears to affect the likelihood of females being
University NHS Trust,
referred for diagnosis, the reliability of diagnostic assessments and subsequent access to support.
Norwich, UK.
Originality/value – Recommendations for clinical practice focus on initiatives to increase awareness of
the female presentation of autism, improving the diagnostic process for females, increasing female
representation within autism training and for future research to support these goals.
Keywords Gender, Female, Autism spectrum disorder, Asperger syndrome, Neurodevelopmental,
Pervasive developmental disorder, Developmental disorder, Sex differences
Paper type Literature review

Introduction
Historically, autism [1] has been regarded as more prevalent in men. Initial conceptualisations
of autism, first described by child psychiatrist Leo Kanner and paediatrician Hans Asperger
(Silberman, 2015), were largely based on boys, and research samples contributing to autism
understanding have been majority male (Grove et al., 2017). This has led to the development
of an autistic profile which is predominantly male. While most professionals are aware of
autism diagnostic criteria, it is suggested that girls do not fit this profile (Happé et al., 2006).
Furthermore, autism theories have paid little attention to gender differences within the
spectrum. Indeed, Baron-Cohen’s “extreme male brain” theory suggested that autistic people
of both sexes had brains that were more masculine than expected (Happé, 2019). As such,
autistic women and girls have received less attention within clinical practice and research
(Chester, 2019). However, there is a developing evidence base, which has focused on a
range of issues that affect autistic females. Previous literature reviews have focused on
Repetitive Behaviours and Restricted Interests (RBRIs) (Allely, 2019) and camouflaging (Allely,
2019; Hull et al., 2020). This paper will synthesise and review the literature on autistic women
and girls, focusing on presentation, diagnosis and autism recognition within the general
public, family, social, educational, clinical and forensic settings.

Methodology
Received 15 December 2019
Revised 25 July 2020 A narrative literature review was conducted, seeking published articles discussing the
16 November 2020
Accepted 16 November 2020 review topic. Key databases, including Allied and Complementary Medicine, Cumulative

PAGE 194 j ADVANCES IN AUTISM j VOL. 7 NO. 3 2021, pp. 194-207, © Emerald Publishing Limited, ISSN 2056-3868 DOI 10.1108/AIA-12-2019-0050
Index to Nursing and Allied Health Literature, Excerpta Medica Database, EMCARE,
MEDLINE, PsycINFO and Pubmed were searched using variations of terms for autism, as
well as terms relative to sex and gender. In keeping with a narrative review design, strict
eligibility criteria were not applied (Ferrari, 2015). The search was limited to articles written
in English language and retrieved articles were largely published in the past 10 years. Data
relating to presentation, recognition and diagnosis of autistic women was extracted from the
papers.

Findings
The literature search highlighted papers describing gender differences in the presentation
of autism, on both domains of the diagnostic dyad, which contribute to difficulties
experienced by females in obtaining a diagnosis, alongside the low recognition of the
female presentation of autism. These findings will be presented under headings which were
emergent from the papers reviewed.

Diagnosis
Gender bias in the diagnosis of autistic women and girls is evident (Carpenter et al., 2019).
Women and girls often have their autism diagnosis missed, or diagnosed later in life than
males (Gould and Ashton-Smith, 2011; Mandy and Lai, 2017; Zener, 2019). Autism is more
frequently diagnosed in boys than girls, with a ratio of 4:1 (Barnard-Brak et al., 2019). These
ratios vary when age and intellectual ability are considered (Zener, 2019). A male-to-female
ratio of approximately 2:1 when examining individuals with a comorbid intellectual disability
(ID) has been reported (Mattila et al., 2011) and 10:1 in the absence of an ID (Barnard-Brak
et al., 2019). Barnard-Brak et al. (2019) examined how many girls may be missing an autism
diagnosis, by comparing clinic and community based data sets to national population
estimates for sex distribution. The authors reported that 39% more girls should be
diagnosed with autism than actually were, and that the sex distribution should be
approximately 28% female, rather than 18% female as reported within corresponding
population estimates. Autistic females without ID appear at particular risk of having their
needs overlooked (Zener, 2019) and are likely to “fly under the radar” (Carpenter et al.,
2019). Higher levels of parent-reported emotional and behavioural problems increase the
probability of girls having a diagnosis of autism, suggesting autistic girls may need to
present with more impairments to receive an autism diagnosis (Duvekot et al., 2017).
Potential explanations for under-diagnosis include a lack of knowledge of the female autism
profile, gendered expectations of autistic traits and stereotypes of expected female social
behaviour (Jamison et al., 2017).
Zener (2019) highlighted common pathways for women receiving diagnosis. These include
having a family member or partner receiving an autism diagnosis and then identifying signs
in themselves, recognising personal traits in accounts by autistic women, or exploring the
possibility of autism when they experience employment difficulties or burnout. Females may
therefore be more negatively affected by the time they reach adolescence and adulthood,
through experiencing mental strain from encountering difficulties, without the knowledge
these may be related to autism (Jamison et al., 2017; Zener, 2019). The below sections
describe the literature on sex differences in the diagnostic dyad of autism.

Social communication and social interaction

The Diagnostic and Statistical Manual of Mental Disorders (DSM, American Psychiatric
Association, 2013) characterises social communication and social interaction as central to
autism. Autistic women have been observed to present with fewer socio-communication
difficulties than males, which may contribute towards their under-recognition (Lai et al.,
2017). Dean et al. (2017) felt that the social difficulties of autistic girls are less visible than of

VOL. 7 NO. 3 2021 j ADVANCES IN AUTISM j PAGE 195

 autistic boys or typically developing (TD) boys, with a tendency to play alone, rather than in
organised games where social difficulties may be more observable. Therefore, social
isolation may be missed within the assessments of girls, leading to under-recognition
(Gould, 2017). Furthermore, subtle impairments of reciprocal behaviour of autistic girls in
social relationships have been identified. Backer van Ommeren et al. (2017) observed that
autistic girls showed more reciprocal behaviour than autistic boys, but lower reciprocity
than their TD peers.
Difficulties developing and maintaining relationships are core diagnostic criteria for autism.
Sedgewick et al. (2019) explored the relationships of autistic women, reporting they found it
harder to interpret social situations, had fewer and more intense relationships and more
difficulties within their relationships than non-autistic women. Autistic women reported that
their negative experiences in interpersonal situations were largely related to their difficulties
with social inference. Parents of autistic girls have recognised the importance of
relationships to their daughters, while also highlighting the negative impacts peer
relationships can have on their mental health and potential vulnerability to exploitation in
intimate relationships (Sedgewick et al., 2018). Parents reported improvements in their
daughters’ relationships over time, which they attributed to maturing of social skills with age
(Sedgewick et al., 2018). Autistic women also report feeling happier in their relationships
and more confident in their social skills as they progressed into adulthood (Sedgewick
et al., 2019). Kock et al. (2019) explored the intimate relationship experiences of autistic
women. The research highlighted a number of themes, including dating and sexual
experiences, victimisation, the decision regarding whether to disclose their diagnosis,
challenges and positive aspects of relationships. The authors concluded that post-
diagnostic counselling with a specific focus on intimate relationships may be of benefit.

Camouflaging/masking
Research indicates that autistic females “camouflage” or “mask” their social communication
difficulties to a greater degree than males. Camouflaging has been described as the most
common reason that healthcare professionals believed autistic profiles presented differently
between sexes (Tromans et al., 2019). Lai et al. (2011) reported that male and female
autism participants were not different on childhood core autistic symptom severity
measured by the Autism Diagnostic Interview-Revised (ADI-R). However, women
demonstrated fewer current symptoms on the Autism Diagnostic Observation Schedule
(ADOS). The authors concluded that the two groups were ‘equally autistic’ as children and
speculated that autistic females may achieve more progress in socio-communication ability
in adulthood. Autistic girls have been found to use compensatory behaviours to mask their
social challenges around their peers, involving spending time “flitting” between joint and
solitary engagement, compared to TD girls who maintained joint engagement whilst moving
between groups (Dean et al., 2017). The authors felt this might indicate autistic girls have
difficulties with social synchronisation (e.g. joint attention, imitation and turn taking).
Autobiographical accounts written by autistic women describe the use of social tactics to
help them cope (Davidson, 2007).
Parents have reported that their autistic daughters were acutely aware of their differences to
their peers and that they explicitly tried to manage social difficulties at school by becoming
more quiet or cautious in their communication than at home (Sutherland et al., 2017). Stark
(2019) reported that autistic girls are more socially motivated than boys, craving friendships
and a social group. In an eye-tracking study investigating the visual attention of autistic
children towards images of faces compared to images of circumscribed interests, autistic
girls attended to faces similarly to TD girls and more than autistic males (Harrop et al.,
2018). The authors argued this could be a protective factor for social functioning, as greater
interest in social images may increase social learning and abilities. Lehnhardt et al. (2016)
found autistic women had higher processing speed and executive functions than men,

PAGE 196 j ADVANCES IN AUTISM j VOL. 7 NO. 3 2021

which could provide indirect evidence for the cognitive underpinnings related to
camouflaging, aiding in reciprocal behaviour and social mimicry skills.
Lai et al. (2017) conceptualised camouflaging in autistic adults by developing a measure,
which examines discrepancy between the person’s “external” behavioural presentation in
interpersonal contexts and the person’s “internal” status. Autistic women had higher
camouflaging scores than men, independent of age, suggesting that camouflaging is not a
simple reflection of life experience. The authors speculated that sex differences in
camouflaging may be due to gender-based expectations and socialisation. The authors
also noted that although greater camouflaging was found in autistic females, there was
variability within male and female groups, with some women showing little camouflaging,
and some men who presented greater camouflaging. Thus, camouflaging is not specific to
females and may reflect individual differences in social coping.
Females’ tendency to mask their autism has drawbacks. While masking may help women to
“fit in”, it has been described as mentally exhausting (Lai et al., 2017). Cassidy et al (2019)
found that camouflaging of autistic traits was associated with increased suicide risk
amongst an undergraduate student population. Appearing more socially competent, then
behaving in ways which appear unusual to peers, may lead to women being criticised, but
not having the skills or knowledge of how to respond (Zener, 2019). Camouflaging may
damage females’ sense of self and identity, as they feel unable to express who they really
are (Zener, 2019). Camouflaging can also affect access to diagnosis, or prevent diagnosis
altogether, when women are dismissed because they “do not look the part” (Tint and Weiss,
2018).

Restricted, repetitive patterns of behaviour, interests or activities

RBRIs are intrinsic to the diagnosis of autism (American Psychiatric Association, 2013) and
sex differences have been reported. A recent systematic review reported 19 studies which
investigated RBRIs in autistic females or sex differences (Allely, 2019). Of these, 12 found
evidence that autistic males had significantly more RBRIs compared to females, whereas
one found that autistic girls exhibit more RBRIs than boys (Antezana et al., 2019),
specifically, that girls demonstrated more compulsive, sameness, restricted and self-
injurious behaviour.
However, RBRIs are recognised more easily than socio-communication difficulties (Allely,
2019), and clinicians are familiar with the male profile of RBRIs. Parent-reported RBRIs have
been found to be less predictive of diagnosis in girls (Duvekot et al., 2017). Sutherland et al.
(2017) identified that autistic girls were as likely as boys to have special interests, but these
interests differed significantly in topic. Relatedly, parents reported similar rates of repetitive
behaviours across sexes, but differences in behaviour types, with boys demonstrating
increased movement and obsessive behaviours which are more obvious to observe. Thus,
autistic females may demonstrate different rather than fewer RBRIs. Similar findings were
reported in a study investigating sex differences in circumscribed interests of children
(Nowell et al., 2019), which found that the content of interests differed and aligned more
with the interests of same sex TD peers. Autistic females were typically interested in
“television” or “psychology” (e.g. people, religion or politics), while males typically preferred
“physics” (e.g. machines, mechanical systems, transportation, building, computers). It was
concluded that the interests of autistic females fall on a continuum between those of autistic
males and TD females. The authors noted that both autistic boys and girls were found to
have greater non-social interests compared to TD peers, alongside greater functional
impairments associated with their interests (e.g. interference with other activities, resistance
when interrupted). Nowell et al. (2019) suggested that the restricted interests of girls may
be under recognised by clinicians as they may not reflect the typical male presentation of
restricted interests. While the interests of autistic girls appear similar to their TD peers, it is

VOL. 7 NO. 3 2021 j ADVANCES IN AUTISM j PAGE 197

 the quality and intensity of these interests that differentiates them (Duvekot et al., 2017;
Gould and Ashton-Smith, 2011).

Sensory issues
Sensory issues were recently incorporated into DSM-5 autism diagnostic criteria (Duvekot
et al., 2017). Research exploring gender differences in sensory impairment is currently
limited (Gould, 2017), however preliminary evidence suggests females may have increased
sensory issues in comparison to males (Lai et al., 2011). Qualitative work has demonstrated
that autistic women experience unusual sensory issues that can contribute to feelings of
alienation from society (Davidson, 2007). As such, sensory profiles appear important within
the evaluation of autistic girls.

Screening and diagnostic tools

Existing screening and diagnostic criteria have largely developed from the observation of
autistic boys by Kanner and Asperger in the 1930s and 40 s (Carpenter et al., 2019).
Diagnostic tools for autism were validated and normed on predominantly male samples,
creating a male-biased conceptualisation and diagnostic process (Lai et al., 2017), which
are insensitive to the female phenotype (Barnard-Brak et al., 2019; Gould and Ashton-
Smith, 2011; Lai et al., 2011; Mussey et al., 2017; Ratto et al., 2018) and therefore lack
validity in girls and women (Carpenter et al., 2019).
Duvekot et al. (2017) found autistic girls were less likely to receive a diagnosis based on
standardised diagnostic tools. Mussey et al. (2017) observed that autistic boys and girls
scored similarly on the Childhood Autism Rating Scale (CARS), however girls scored lower
on the ADOS–Generic (ADOS-G), suggesting that the ADOS-G may be less sensitive to
females. In contrast, Grove et al. (2017) evaluated whether specific items on the Autism
Spectrum Quotient Short (AQ-Short) may have an increased sensitivity towards autistic
females. The study found the AQ-Short detects autism symptomology equivalently in males
and females, but two social behaviour items had a subtle bias towards autistic females and
could make women appear to be more impaired. Females were less likely to meet criteria
on the ADI-R, with an absence of early developmental differences being the strongest
predictor of failing to meet ADI-R criteria, particularly among females with higher
intelligence (Ratto et al., 2018).
The Autism Spectrum Screening Questionnaire (ASSQ) has been extended by Kopp and
Gillberg (2011) to the ASSQ-GIRL, combining an additional 18 items aiming to better
capture the presentation of autistic females. The authors reported that single ASSQ-GIRL
items were much more typical of autistic girls than of boys, including ‘avoids demands’,
‘very determined’, ‘careless with physical appearance and dress’ and ‘interacts mostly with
younger children’. The ASSQ-GIRL sum score did not capture clinically diagnosed autistic
girls better, but distinguished between those with and without autism more accurately within
female groups than male groups, suggesting the ASSQ-GIRL shows promise in the
assessment of autism in females.
Screening tools and diagnostic instruments therefore need developing or adapting to
improve the identification of autistic females (Gould and Ashton-Smith, 2011; Duvekot et al.,
2017; Lai et al., 2017; Tillmann et al., 2018). Current diagnostic criteria do not provide
examples of the types of difficulties experienced by autistic girls and women, nor capture
these difficulties adequately (Gould and Ashton-Smith, 2011; Lai et al., 2017). This appears
particularly important for identifying RBRIs. Until more female-sensitive screening and
diagnostic tools are developed, it is important that clinicians modify their approach. Nowell
et al. (2019) recommended that clinicians familiarise themselves with the interests of similar
aged TD girls when assessing autism in females. Jamison et al. (2017) noted that the
majority of clinicians reported not modifying their methodology or instruments when making

PAGE 198 j ADVANCES IN AUTISM j VOL. 7 NO. 3 2021

a diagnosis in females, but that some rely more on clinical impressions and “less” on
standardized instruments. It is important to include the views of the female being assessed
within the diagnostic process (Markham, 2019), as autistic women often reveal their social
difficulties in self-report, rather than difficulties being directly observable (Lai et al., 2017).

Misdiagnosis, diagnostic overshadowing and comorbidity

Undiagnosed autistic women often seek support for mental health difficulties, but their
autism can be missed (Zener, 2019). As professionals do not have sufficient awareness or
knowledge of autism in females, they may not consider autism as an underlying cause of
mental health difficulties (Carpenter et al., 2019). These women may receive a diagnosis of
a mental health condition, but not their autism. Any difficulties are then attributed to the initial
mental health issue(s), a phenomena known as diagnostic overshadowing, which
contributes to under-recognition of autism in females (Lai et al., 2015; Zener, 2019).
The initial diagnosis formulated may be incorrect, and misdiagnosis may be due to shared
features between autism and mental health conditions. Many autistic women are first
perceived as having Borderline Personality Disorder (BPD), due to overlap in areas such as
verbalising emotions, intense relationships, superficial friendships and impairments in social
functioning (Dell’Osso et al., 2018). Similarities have also been noted between autism and
anorexia nervosa (Baron-Cohen et al., 2013; Zucker et al., 2007), with overlapping symptom
domains including executive functioning issues, emotional recognition and regulation, lack
of interest in social contact, difficulties within relationships and social leisure activities
(Tchanturia et al., 2013). Furthermore, autism may be misdiagnosed as Obsessive
Compulsive Disorder due to shared features of compulsive repetitive behaviours and
obsessive thoughts (Zener, 2019). Women also commonly receive a diagnosis of Attention
Deficit Hyperactivity Disorder (ADHD) before autism is identified. Although this may direct
interventions for attentional, behavioural and executive functioning challenges, autistic
difficulties may be neglected (Zener, 2019). Autistic individuals, particularly females, have
reported greater Gender Dysphoria (GD) traits than TD peers (George and Stokes, 2018),
and autism is highly prevalent in prevalent in GD populations and clinics (Bargiela et al.,
2016; Fielding and Bass, 2018; Glidden et al., 2016; Nobili et al., 2018; Van Der Miesen
et al., 2016). Research revealed some autistic women self-reported not conforming to
gendered expectations and identifying more with male peers or constructs other than
femininity (Kanfiszer et al., 2017). Kourti and MacLeod (2019) highlighted how both groups
of autistic individuals and those with atypical gender identities have increased risk of mental
health difficulties, therefore the mental health of autistic people who may experience
atypical gender identities may be particularly compromised.
The initial diagnosis may also be correct, but comorbid with autism. Just as a primary
mental health diagnosis can overshadow a possible autism diagnosis, an autism diagnosis
can overshadow a possible mental health diagnosis. Autistic girls appear more likely to
internalise their difficulties, where boys tend to externalise (Carpenter et al., 2019; Hull et al.,
2020), and this could render autistic girls more vulnerable to emotional and behavioural
difficulties (Duvekot et al., 2017). It is likely the identification of mental health issues in
autistic individuals may be complicated by communication impairments, difficulties building
therapeutic relationships, or difficulties with emotional introspection impeding assessment.
However, autistic people are equally, if not more vulnerable to mental health issues. Rydén
et al. (2008) reported that 15% of a sample with BPD had co-occuring autism, and those
with this dual diagnosis had significantly higher suicidal acts and lower adaptive functioning
scores than those with BPD alone. Kuhl-Meltzoff Stavropoulos et al. (2018) discussed cases
where autistic children had difficulty obtaining a diagnosis of Post Traumatic Stress
Disorder (PTSD), despite this populations’ increased risk of maltreatment. Sedgewick et al.
(2020) investigated self-reported gender differences in mental health amongst 948 autistic
people between 18 and 81 years old. The findings suggested that autistic people are more

VOL. 7 NO. 3 2021 j ADVANCES IN AUTISM j PAGE 199

 likely to have anxiety, depression and eating disorders than non-autistic people, and when
autistic symptomatology increased, so did the prevalence of mental health issues. Autistic
women and non-binary people experienced mental health difficulties at higher rates than
men, and at similar rates to each other.

Recognition of autism in women and girls

Delayed or missed diagnosis puts the individual at risk of not receiving the support they
require (Gould and Ashton-Smith, 2011; Mandy and Lai, 2017; Zener, 2019), and reduces
the likelihood of earlier intervention (Daley, 2004). Receiving a timely diagnosis can provide
essential validation, education and help guide interventions (Gould and Ashton-Smith,
2011; Zener, 2019). Prior to diagnosis, there is a stage of recognition, whereby signs of
autism are noticed or observed, and the individual is subsequently referred for autism
assessment. This stage is of interest because recognition is reliant on autism knowledge in
the general public, and in social, educational and clinical settings.

General public, family and social

When identifying autism in young children, recognition of autism often begins with a
caregiver’s awareness of signs (Daley, 2004). The ability of family members to recognise
autism is likely aligned with autism awareness in the general public. Studies have examined
public knowledge of autism (Alsehemi et al., 2017; Dillenburger et al., 2013a, 2013b;
Durand-Zaleski et al., 2012; Stewart, 2008). While participants across studies reported
superficial awareness of autism, e.g. had heard of autism, few were confident in the depth
of their knowledge, and many endorsed myths and stereotypes, such as that all autistic
people have a special talent or are highly intelligent.
Furthermore, male portrayals predominate in the media, which affects the public conception
of autism (Carpenter et al., 2019). Tharian et al. (2019) highlighted the role of fictional media
in increasing awareness of the female phenotype and in providing higher-quality information
to the public. The role of social contacts is largely unexplored, however, it is likely that
perceptions, comments and reactions from acquaintances, friends, or even members of the
public can impact the recognition of autism. Leedham et al. (2019) reported the experience
of an autistic woman who discussed the anger she experienced when she learned that
others had suspected she was autistic but did not say anything. This highlights the
importance of increasing the awareness of autistic females amongst the general public.

Education
Sproston et al. (2017) summarised the literature on awareness of autism in girls within
education, reporting that teachers may be unaware of the inconspicuous behaviour of
autistic females, due to their more amenable classroom demeanour, a lack of behavioural
problems and the tendency to camouflage. As such, it is likely that girls are less likely to
have their autism recognised in schools. This lack of recognition can cause issues for girls
within educational environments. Three key themes were reported from the interviews
conducted with autistic girls and their parents: inappropriate school environments
(including sensory problems, difficulties with peers and general pressures of mainstream
classrooms); tensions in school relationships (including problems with staff and peers); and
problems with staff responses (including a perceived lack of understanding of the girls’
needs and a lack of appropriate support being provided).

Clinical
Focus on autistic women within clinical settings is limited. Crane et al. (2019) examined
autism awareness among professionals such as psychiatrists, psychologists, neurologists,

PAGE 200 j ADVANCES IN AUTISM j VOL. 7 NO. 3 2021

paediatricians, speech and language therapists. This study highlighted that autism
awareness was highly variable, with substantial discrepancies in professionals’ assessment
and diagnostic practices. Crane et al. (2019) stated that while psychiatrists play a critical
role in the recognition, assessment and health care of autistic patients, approximately 30%
reported that they received no teaching on autism during any of their training. Tromans et al.
(2019) stated that a considerable proportion of health professionals were less confident in
recognising, screening and diagnosing autism in female patients but were keen to improve
their skills and endorsed a desire for further training.
A recent systematic review researching autism prevalence within psychiatric inpatient
settings reported that the study populations were predominantly male (Tromans et al., 2018)
and one study only screened for autism in men (Scragg and Shah, 1994). Therefore, the
number of autistic women who receive inpatient treatment for mental health difficulties is
largely unknown and their experiences of care unexplored. It is unclear whether females are
being excluded from research or whether females are under recognised as being autistic
within clinical settings.
Health issues of autistic women and girls also remain under-researched. Although the
research base is limited, there is growing evidence to suggest that autistic women
may experience health issues differently and therefore may benefit from more tailored
support. Increased issues relating to menstruation for autistic women and girls,
including withdrawal and increased anxiety affecting work, social and community life
have been raised (Steward et al., 2018). Sensory issues, repetitive behaviours and
difficulties regulating emotions and behaviour reportedly become exacerbated
before, during and after menses (Burke et al., 2010; Hamilton et al., 2011; Obaydi and
Puri, 2008; Steward et al., 2018). The causes are mostly unknown and there is a lack
of awareness, consequently meaning that gynaecological care needs are unmet
(Steward et al., 2018). Some autistic women have been found to experience aspects
of pregnancy and motherhood more challenging than non-autistic women, including
changes to the body through pregnancy and sensory sensitivity to breastfeeding
(Pohl et al., 2020). Pohl et al. (2020) found that autistic mothers were more likely to
experience pre and post-partum depression, anxiety, selective mutism, feelings of
being misunderstood by professionals and to experience motherhood as isolating. It
is likely that autistic mothers need support which acknowledges their unique
challenges.

Forensic
Studies investigating autism in prisons have largely focused on male populations
(McCarthy et al., 2015). There is no data known to the authors which has examined
autistic female prisoners, however, research has been conducted in secure/forensic
mental health or ID services. Hare et al. (1999) screened 1,305 patients for autism in the
three high secure hospitals in England. Of those who were autistic (n = 31), 29 (93.5%)
were male and two female (6.5%), a 15.5:1 ratio. In a cohort of 138 patients treated
within a forensic ID service, the authors reported that of the 42 patients who were
autistic, 6 were female (Esan et al., 2015). These studies indicate that autistic women
are present in forensic settings, yet minimal research has examined their prevalence,
characteristics, needs, experiences or treatment outcomes. A recent autobiographical
case study written by an autistic female previously detained in a forensic mental health
service described her perspective (Markham, 2019). In her account, she describes
feeling different from other patients, being misunderstood by her care team and a lack
of involvement in her care, recommending that forensic staff should receive autism
training. It is therefore possible that the needs of autistic women within the criminal
justice system are not currently being met.

VOL. 7 NO. 3 2021 j ADVANCES IN AUTISM j PAGE 201

 Discussion
This narrative review has summarised the literature on autistic women and girls, in relation to
presentation, diagnosis and recognition across settings. The research reviewed has noted
sex differences in the presentation of autism. Women appear to have more subtle
impairments in social communication and interaction, possibly due to increased social
motivation and tendency to camouflage. Females appear as likely as males to demonstrate
RBRIs, but which are less easily observable, or are not picked up by diagnosticians due to
their reduced familiarity with their presentation in girls and women. A number of authors
suggest that the presentation of females falls on a continuum between autistic males and
TD females. Women appear likely to experience diagnostic overshadowing or misdiagnosis.
This is possibly linked to the higher likelihood of internalising difficulties, mental illness
comorbidity, low recognition of the female autistic profile among the general public and
professionals in schools and clinical settings, and lacking female sensitive screening tools
and assessments. Therefore, it appears that females are disadvantaged throughout the
recognition and diagnostic process.
This paper has a number of limitations. The exclusion of non-English language articles
could have overlooked relevant evidence published in foreign languages. As with any
narrative review, quality is affected by its constituent studies. A majority of included articles
discuss differences in relation to biological sex, which should be taken into account,
particularly given that autistic people appear more likely to identify as transgender or non-
binary (Jacobs et al., 2014). Finally, the narrative review methodology itself has limitations,
given the non-systematic nature of the literature search (Ferrari, 2015). Nevertheless, the
findings of this review have implications for practice and research, which relate to improving
recognition of autistic women and girls, improving the autism diagnostic process and future
research.
To improve recognition in girls and women, it is essential that awareness of the female
profile of autism is raised. Public awareness campaigns have an integral role in increasing
recognition of autism, yet the majority of such resources often feature male characters
(Carpenter et al., 2019). The representation of female autistic characters within fictional
media, such as television and film could also increase awareness (Tharian et al., 2019).
Professionals’ knowledge of autism is highly variable, particularly in relation to the
presentation of females. As such, training is needed across settings, including schools,
health care and public services. The level of knowledge required is likely to vary
considerably dependent on the type of role. For example, teachers may be required to
identify the signs of autism among females, as well as types of practical support which can
be offered to support learning and improve the experience of school. Professionals in a
diagnostic role require a detailed knowledge of the female presentation of autism, as well as
of common differential diagnoses and symptom overlap with other conditions, with a “think
autism” message. Training should also cover the diagnosis of mental health conditions in
people who already have a diagnosis of autism, including the need to attend to any change
to an autistic person’s baseline presentation and functioning, placing value on self-report,
alongside input from friends, partners and relatives. It is recommended that professional
bodies and service providers review their training needs and curriculum to ensure that
training is inclusive of the female presentation of autism, e.g. by including female specific
examples of diagnostic criteria. It is imperative that training is offered to all staff, not only
new entrants. Consultation and collaboration is required to ensure that any training provided
is aligned to the needs perceived by autistic individuals themselves and their carers
(Tromans et al., 2019). Ideally, training should be delivered by, or alongside autistic
individuals.
Research findings regarding gender differences in the presentation of autism, and the
female autism profile should be incorporated into diagnostic criteria, screening and

PAGE 202 j ADVANCES IN AUTISM j VOL. 7 NO. 3 2021

assessment tools. When developing psychometric questionnaires, items should provide
examples that are more characteristic of autistic girls and women. This would improve the
confidence of clinicians and reliability of the diagnostic process. It is imperative that future
research uses female sensitive measures to extend knowledge of autism, as research
utilising currently available measures, aligned to the male profile, may contribute towards
equivocal findings (Baron-Cohen et al., 2015). Research on autistic females should be of a
high standard and representative. Larger studies with more sex-balanced sample sizes,
including TD age and IQ matched peers may enhance the likelihood of detecting sex
differences (Baron-Cohen et al., 2015). Longitudinal studies are desirable to capture
potential developmental trajectories of autism presentation (Dean et al., 2017; Lai et al.,
2017; Lai et al., 2015).
All efforts to improve practice should incorporate the priorities of autistic women and girls,
as these may not be aligned with researchers. Exploring autism from an intersectional
perspective is imperative (Kourti and MacLeod, 2019) as there is a significant lack of
research on the experiences of autistic females from minority ethnic backgrounds (Tromans
et al., 2020), those with ID, mental or physical health comorbidities, gender identity
difficulties or those who identify as lesbian, gay, bisexual, transgender, queer and intersex.
Future research and practice initiatives should focus on post diagnosis counselling and the
support needs of females, as this is currently an overlooked area.

Note
1. Research has suggested that there is no single way of describing autism that is universally
accepted and preferred by the UK’s autism community (Kenny et al., 2016). This paper uses
identity-first (autistic person) where possible.

References
Allely, C.S. (2019), “Exploring the female autism phenotype of repetitive behaviours and restricted
interests (RBRIs): a systematic PRISMA review”, Advances in Autism, Vol. 5 No. 3, pp. 171-186.
Allely, C.S. (2019), “Understanding and recognising the female phenotype of autism spectrum disorder
and the ‘camouflage’ hypothesis: a systematic PRISMA review”, Advances in Autism, Vol. 5 No. 1,
pp. 14-37.
Alsehemi, M.A., Abousaadah, M.M., Sairafi, R.A. and Jan, M.M. (2017), “Public awareness of autism
spectrum disorder”, Neurosciences ( Neurosciences), Vol. 22 No. 3, pp. 213-215.

American Psychiatric Association (2013), Diagnostic and Statistical Manual of Mental Disorders, 5th ed.,
American Psychiatric Publishing, Arlington, VA.
Antezana, L., Factor, R.S., Condy, E.E., Strege, M.V., Scarpa, A. and Richey, J.A. (2019), “Gender
differences in restricted and repetitive behaviors and interests in youth with autism”, Autism Research,
Vol. 12 No. 2, pp. 274-283.

Backer van Ommeren, T., Koot, H.M., Scheeren, A.M. and Begeer, S. (2017), “Sex differences in the
reciprocal behaviour of children with autism”, Autism, Vol. 21 No. 6, pp. 795-803.
Bargiela, S., Steward, R. and Mandy, W. (2016), “The experiences of late-diagnosed women with autism
spectrum conditions: an investigation of the female autism phenotype”, Journal of Autism and
Developmental Disorders, Vol. 46 No. 10, pp. 3281-3294.
Barnard-Brak, L., Richman, D. and Almekdash, M.H. (2019), “How many girls are we missing in ASD? An
examination from a clinic- and community-based sample”, Advances in Autism, Vol. 5 No. 3, pp. 214-224.
Baron-Cohen, S., Jaffa, T., Davies, S., Auyeung, B., Allison, C. and Wheelwright, S. (2013), “Do girls with
anorexia nervosa have elevated autistic traits? ”, Molecular Autism 2013 Autism, Vol. 4 No. 1, p. 24.
Baron-Cohen, S., Bowen, D.C., Holt, R.J., Allison, C., Auyeung, B., Lombardo, M.V., Lai, M.-C. (2015),
“The “reading the mind in the eyes” test: complete absence of typical sex difference in 400 men and
women with autism”, Plos One, Vol. 10 No. 8, p. e0136521.

VOL. 7 NO. 3 2021 j ADVANCES IN AUTISM j PAGE 203

 Burke, L.M., Kalpakjian, C.Z., Smith, Y.R. and Quint, E.H. (2010), “Gynecologic issues of adolescents
with down syndrome”, Autism, and Cerebral Palsy. Journal of Pediatric and Adolescent Gynecology,
Vol. 23 No. 1, pp. 11-15.

Carpenter, B. Happé, F. and Egerton, J. (2019), “Girls and autism: educational, family and personal
perspectives”.
Cassidy, S.A., Gould, K., Townsend, E., Pelton, M., Robertson, A.E. and Rodgers, J. (2020), “Is
camouflaging autistic traits associated with suicidal thoughts and behaviours? Expanding the
interpersonal psychological theory of suicide in an undergraduate student sample”, Journal of Autism
and Developmental Disorders, Vol. 50, pp. 3638-3648, doi: 10.1007/s10803-019-04323-3.
Chester, V. (2019), “Autistic women and girls: under-recognised, under-researched and under-served”,
Advances in Autism, Vol. 5 No. 1, pp. 1-1.

Crane, L., Davidson, I., Prosser, R. and Pellicano, E. (2019), “Understanding psychiatrists’ knowledge,
attitudes and experiences in identifying and supporting their patients on the autism spectrum: online
survey”, BJPsych Open, Vol. 5 No. 3, p. e33.
Daley, T.C. (2004), “From symptom recognition to diagnosis: children with autism in urban India”, Social
Science & Medicine (1982), Vol. 58 No. 7, pp. 1323-1335.
Davidson, J. (2007), “‘In a world of her own. . .’: re-presenting alienation and emotion in the lives and
writings of women with autism”, Gender, Place & Culture, Vol. 14 No. 6, pp. 659-677.
Dean, M., Harwood, R. and Kasari, C. (2017), “The art of camouflage: gender differences in the social
behaviors of girls and boys with autism spectrum disorder”, Autism, Vol. 21 No. 6, pp. 678-689.
Dell’Osso, L., Cremone, I.M., Carpita, B., Fagiolini, A., Massimetti, G., Bossini, L., . . . Gesi, C. (2018),
“Correlates of autistic traits among patients with borderline personality disorder”, Comprehensive
Psychiatry, Vol. 83, pp. 7-11.

Dillenburger, K., Jordan, J.-A. and McKerr, L. (2013a), “Autism spectrum disorder: public awareness and
attitudes”, Research Update, Vol. 84.
Dillenburger, K., Jordan, J.A., McKerr, L., Devine, P. and Keenan, M. (2013b), “Awareness and
knowledge of autism and autism interventions: a general population survey”, Research in Autism
Spectrum Disorders, Vol. 7 No. 12.
Durand-Zaleski, I. Scott, J. Rouillon, F. and Leboyer, M. (2012), “A first national survey of knowledge,
attitudes and behaviours towards schizophrenia, bipolar disorders and autism in France”, BMC
Psychiatry, doi: 10.1186/1471-244X-12-128.

Duvekot, J., van der Ende, J., Verhulst, F.C., Slappendel, G., van Daalen, E., Maras, A. and Greaves-
Lord, K. (2017), “Factors influencing the probability of a diagnosis of autism spectrum disorder in girls
versus boys”, Autism, Vol. 21 No. 6, pp. 646-658.
Esan, F., Chester, V., Gunaratna, I.J., Hoare, S. and Alexander, R. (2015), “The clinical, forensic and
treatment outcome factors of patients with autism spectrum disorder treated in a forensic intellectual
disability service”, Journal of Applied Research in Intellectual Disabilities, Vol. 28 No. 3, pp. 193-200.
Ferrari, R. (2015), “Writing narrative style literature reviews”, Medical Writing, Vol. 24 No. 4, pp. 230-235.
Fielding, J. and Bass, C. (2018), “Individuals seeking gender reassignment: marked increase in demand
for services”, BJPsych Bulletin, Vol. 42 No. 5, pp. 206-210.
George, R. and Stokes, M.A. (2018), “Gender identity and sexual orientation in autism spectrum
disorder”, Autism, Vol. 22 No. 8, pp. 970-982.
Glidden, D., Bouman, W.P., Jones, B.A. and Arcelus, J. (2016), “Gender dysphoria and autism spectrum
disorder: a systematic review of the literature”, Sexual Medicine Reviews, Vol. 4 No. 1, pp. 3-14.

Gould, J. (2017), “Towards understanding the under-recognition of girls and women on the autism
spectrum”, Autism, Vol. 21 No. 6, pp. 703-705.
Gould, J. and Ashton-Smith, J. (2011), “Missed diagnosis or misdiagnosis? Girls and women on the
autism spectrum”, Good Autism Practice, Vol. 12 No. 1, pp. 34-41.

Grove, R., Hoekstra, R.A., Wierda, M. and Begeer, S. (2017), “Exploring sex differences in autistic traits: a
factor analytic study of adults with autism”, Autism, Vol. 21 No. 6, pp. 760-768.
Hamilton, A., Marshal, M.P. and Murray, P.J. (2011), “Autism spectrum disorders and menstruation”,
Journal of Adolescent Health, Vol. 49 No. 4, pp. 443-445.

PAGE 204 j ADVANCES IN AUTISM j VOL. 7 NO. 3 2021

Happé, F. (2019), What Does Research Tell us about Girls on the Autism Spectrum? In Girls and Autism,
Education, Family and Personal Perspectives.
Happé, F., Ronald, A. and Plomin, R. (2006), “Time to give up on a single explanation for autism”, Nature
Neuroscience, Vol. 9 No. 10, pp. 1218-1220.
Hare, D.J. Gould, J. Mills, R. and Wing, L. (1999), “A preliminary study of individuals with autistic
spectrum disorders in three special hospitals in England”.
Harrop, C., Jones, D., Zheng, S., Nowell, S.W., Boyd, B.A. and Sasson, N. (2018), “Sex differences in
social attention in autism spectrum disorder”, Autism Research, Vol. 11 No. 9, pp. 1264-1275.
Hull, L., Petrides, K.V. and Mandy, W. (2020), “The female autism phenotype and camouflaging: a
narrative review”, Review Journal of Autism and Developmental Disorders, Vol. 7 No. 4, pp. 1-12.
Jacobs, L.A., Rachlin, K., Erickson-Schroth, L. and Janssen, A. (2014), “Gender dysphoria and co-
occurring autism spectrum disorders: review, case examples, and treatment considerations”, LGBT
Health, Vol. 1 No. 4, pp. 277-282.
Jamison, R., Bishop, S.L., Huerta, M. and Halladay, A.K. (2017), “The clinician perspective on sex
differences in autism spectrum disorders”, Autism, Vol. 21 No. 6, pp. 772-784.
Kanfiszer, L., Davies, F. and Collins, S. (2017), “‘I was just so different’: the experiences of women
diagnosed with an autism spectrum disorder in adulthood in relation to gender and social relationships”,
Autism, Vol. 21 No. 6, pp. 661-669.
Kock, E., Strydom, A., O’Brady, D. and Tantam, D. (2019), “Autistic women’s experience of intimate
relationships: the impact of an adult diagnosis”, Advances in Autism, Vol. 5 No. 1, pp. 38-49.
Kopp, S. and Gillberg, C. (2011), “The autism spectrum screening questionnaire (ASSQ)-revised
extended version (ASSQ-REV): an instrument for better capturing the autism phenotype in girls? A
preliminary study involving 191 clinical cases and community controls”, Research in Developmental
Disabilities, Vol. 32 No. 6, pp. 2875-2888, doi: 10.1016/j.ridd.2011.05.017.

Kourti, M. and MacLeod, A. (2019), “‘I don’t feel like a gender, I feel like myself’: autistic individuals raised
as girls exploring gender identity”, Autism in Adulthood, Vol. 1 No. 1, pp. 52-59.

Kuhl-Meltzoff Stavropoulos, K., Bolourian, Y. and Blacher, J. (2018), “Differential diagnosis of autism
spectrum disorder and post traumatic stress disorder: two clinical cases”, Journal of Clinical Medicine,
Vol. 7 No. 4, p. 71.

Lai, M.-C., Lombardo, M.V., Auyeung, B., Chakrabarti, B. and Baron-Cohen, S. (2015), “Sex/gender
differences and autism: setting the scene for future research”, Journal of the American Academy of Child
& Adolescent Psychiatry, Vol. 54 No. 1, pp. 11-24.
Lai, M.-C., Lombardo, M.V., Pasco, G., Ruigrok, A.N.V., Wheelwright, S.J., Sadek, S.A., . . . Baron-Cohen,
S. (2011), “A behavioral comparison of male and female adults with high functioning autism spectrum
conditions”, PloS One, Vol. 6 No. 6, p. e20835, doi: 10.1371/journal.pone.0020835.
Lai, M.-C., Lombardo, M.V., Ruigrok, A.N., Chakrabarti, B., Auyeung, B. and Szatmari, P, MRC AIMS
Consortium (2017), “Quantifying and exploring camouflaging in men and women with autism”, Autism,
Vol. 21 No. 6, pp. 690-702.
Leedham, A. Thompson, A. Smith, R. and Freeth, M. (2019), “I was exhausted trying to figure it out’: the
experiences of females receiving an autism diagnosis in Middle to late adulthood”, Autism,
136236131985344.
Lehnhardt, F.-G., Falter, C.M., Gawronski, A., Pfeiffer, K., Tepest, R., Franklin, J., . . . Pfeiffer, K.
(2016), “Sex-Related cognitive profile in autism spectrum disorders diagnosed late in life:
implications for the female autistic phenotype”, Journal of Autism and Developmental Disorders,
Vol. 46 No. 1, pp. 139-154.

McCarthy, J., Chaplin, E., Underwood, L., Forrester, A., Hayward, H., Sabet, J. and Murphy, D. (2015),
“Screening and diagnostic assessment of neurodevelopmental disorders in a male prison”, Journal of
Intellectual Disabilities and Offending Behaviour, Vol. 6 No. 2, pp. 102-111.

Mandy, W. and Lai, M.-C. (2017), “Towards sex- and gender-informed autism research”, Autism, Vol. 21
No. 6, pp. 643-645.

Markham, S. (2019), “Diagnosis and treatment of ASD in women in secure and forensic hospitals”,
Advances in Autism, Vol. 5 No. 1, pp. 64-76.

VOL. 7 NO. 3 2021 j ADVANCES IN AUTISM j PAGE 205

 Mattila, M.L., Kielinen, M., Linna, S.L., Jussila, K., Ebeling, H., Bloigu, R. and Moilanen, I. (2011), “Autism
spectrum disorders according to DSM-IV-TR and comparison with DSM-5 draft criteria: an
epidemiological study”, Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 50
No. 6, pp. 583-592.e11.
Mussey, J.L., Ginn, N.C. and Klinger, L.G. (2017), “Are males and females with autism spectrum disorder
more similar than we thought? ”, Autism, Vol. 21 No. 6, pp. 733-737.
Nobili, A., Glazebrook, C., Bouman, W.P., Glidden, D., Baron-Cohen, S., Allison, C., . . . Arcelus, J. (2018),
“Autistic traits in Treatment-Seeking transgender adults”, Journal of Autism and Developmental
Disorders, Vol. 48 No. 12, pp. 3984-3994.
Nowell, S.W., Jones, D.R. and Harrop, C. (2019), “Circumscribed interests in autism: are there sex
differences? ”, Advances in Autism, Vol. 5 No. 3, pp. 187-198.

Obaydi, H. and Puri, B.K. (2008), “Prevalence of premenstrual syndrome in autism: a prospective
observer-rated study”, Journal of International Medical Research, Vol. 36 No. 2, pp. 268-272.
Pohl, A.L., Crockford, S.K., Blakemore, M., Allison, C. and Baron-Cohen, S. (2020), “A comparative study
of autistic and non-autistic women’s experience of motherhood”, Molecular Autism, Vol. 11 No. 1, p. 3.

Ratto, A.B., Kenworthy, L., Yerys, B.E., Bascom, J., Wieckowski, A.T., White, S.W., . . . Anthony, L.G.
(2018), “What about the girls? Sex-Based differences in autistic traits and adaptive skills”, Journal of
Autism and Developmental Disorders, Vol. 48 No. 5, pp. 1698-1711.
Rydén, G., Rydén, E. and Hetta, J. (2008), “Borderline personality disorder and autism spectrum disorder
in females: a cross-sectional study. – PsycNET”, Clinical Neuropsychiatry: Journal of Treatment
Evaluation, Vol. 5 No. 1, pp. 22-30.
Scragg, P. and Shah, A. (1994), “Prevalence of asperger’s syndrome in a secure hospital”, British Journal
of Psychiatry, Vol. 165 No. 5, pp. 679-682.

Sedgewick, F., Hill, V. and Pellicano, E. (2018), “Parent perspectives on autistic girls’ friendships and
futures”, Autism & Developmental Language Impairments, Vol. 3, p. 239694151879449.
Sedgewick, F., Leppanen, J. and Tchanturia, K. (2020), “Gender differences in mental health prevalence
in autism”, Advances in Autism, doi: 10.1108/AIA-01-2020-0007.

Sedgewick, F., Crane, L., Hill, V. and Pellicano, E. (2019), “Friends and lovers: the relationships of autistic
and neurotypical women”, Autism in Adulthood, Vol. 1 No. 2, pp. 112-123.
Silberman, S. (2015), NeuroTribes: The Legacy of Autism and How to Think Smarter about People Who
Think Differently, Allan and Unwin.

Sproston, K., Sedgewick, F. and Crane, L. (2017), “Autistic girls and school exclusion: perspectives of
students and their parents”, Autism & Developmental Language Impairments, Vol. 2, 239694151770617.
Stark, E. (2019), “Autism in women”, The Psychologist, Vol. 32, pp. 38-41.
Steward, R., Crane, L., Mairi Roy, E., Remington, A. and Pellicano, E. (2018), “‘Life is much more difficult
to manage during periods’: autistic experiences of menstruation”, Journal of Autism and Developmental
Disorders, Vol. 48 No. 12, pp. 4287-4292.
Stewart, S. (2008), “I exist: the message from adults with autism in Northern Ireland”, Belfast.
Sutherland, R., Hodge, A., Bruck, S., Costley, D. and Klieve, H. (2017), “Parent-reported
differences between school-aged girls and boys on the autism spectrum”, Autism, Vol. 21 No. 6,
pp. 785-794.
Tchanturia, K., Smith, E., Weineck, F., Fidanboylu, E., Kern, N., Treasure, J. and Baron Cohen, S. (2013),
“Exploring autistic traits in anorexia: a clinical study”, Molecular Autism, Vol. 4 No. 1, p. 44.
Tharian, P.R., Henderson, S., Wathanasin, N., Hayden, N., Chester, V. and Tromans, S. (2019),
“Characters with autism spectrum disorder in fiction: where are the women and girls?”, Advances in
Autism, Vol. 5 No. 1, pp. 50-63.
Tillmann, J., Ashwood, K., Absoud, M., Bölte, S., Bonnet-Brilhault, F., Buitelaar, J.K., . . . Charman, T.
(2018), “Evaluating sex and age differences in ADI-R and ADOS scores in a large european multi-site
sample of individuals with autism spectrum disorder”, Journal of Autism and Developmental Disorders,
Vol. 48 No. 7, pp. 2490-2505.
Tint, A. and Weiss, J.A. (2018), “A qualitative study of the service experiences of women with autism
spectrum disorder”, Autism, Vol. 22 No. 8, pp. 928-937.

PAGE 206 j ADVANCES IN AUTISM j VOL. 7 NO. 3 2021

Tromans, S., Chester, V., Kiani, R., Alexander, R. and Brugha, T. (2018), “The prevalence of autism
spectrum disorders in adult psychiatric inpatients: a systematic review”, Clinical Practice and
Epidemiology in Mental Health : CP & Emh, Vol. 14 No. 1, pp. 177-187.
Tromans, S., Chester, V., Kapugama, C., Elliott, A., Robertson, S. and Barrett, M. (2019), “The PAAFID
project: exploring the perspectives of autism in adult females among intellectual disability healthcare
professionals”, Advances in Autism, Vol. 5 No. 3.
Tromans, S., Chester, V., Gemegah, E., Roberts, K., Morgan, Z., Yao, Q.L. and Brugha, T. (2020), “Autism
identification across ethnic groups: a review”, Advances in Autism, doi: 10.1108/AIA-03-2020-0017.

Van Der Miesen, A.I.R., Hurley, H. and De Vries, A.L.C. (2016), “Gender dysphoria and autism spectrum
disorder: a narrative review”, International Review of Psychiatry, Vol. 28 No. 1.
Zener, D. (2019), “Journey to diagnosis for women with autism”, Advances in Autism, Vol. 5 No. 1,
pp. 2-13.
Zucker, N.L., Losh, M., Bulik, C.M., LaBar, K.S., Piven, J. and Pelphrey, K.A. (2007), “Anorexia nervosa
and autism spectrum disorders: guided investigation of social cognitive endophenotypes”,
Psychological Bulletin, Vol. 133 No. 6, pp. 976-1006.

Corresponding author
Verity Chester can be contacted at: v.chester@nhs.net

For instructions on how to order reprints of this article, please visit our website:
www.emeraldgrouppublishing.com/licensing/reprints.htm
Or contact us for further details: permissions@emeraldinsight.com

VOL. 7 NO. 3 2021 j ADVANCES IN AUTISM j PAGE 207

Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.