This is how these Female Autism tropes start. Girls fly under the radar, Females mask their Autism, women are going undiagnosed, there is a lost generation of women, it's the Female Autism Phenotype, female autistics have obsessions they just happen to be about ponies and Ariana Grande.
For the recent Channel 4 show Are You Autistic carried out an online survey using AQ (Autism Quotient screener diagnostic tool) type questions. The results seemed astonishing (if you're credulous). There were 750,000 responses and 87,000 scored above the threshold for autistic traits. Of these 47,000 were women.
So now you get articles like New Documentary Reveals Over Half of Undiagnosed Autistic Adults Could Be Women in Happiful Magazine claiming 50% of undiagnosed autistics are women.
Our correspondent at Happiful, Bonnie Evie-Gifford, seems to have fallen for the old confirmation let's ignore scientific enquiry the internet doesn't lie, does it, really? bias...
While normally I'd not be bothered by an obscure female wellbeing online magazine I think Gifford won't be the first to extrapolate this result and spread the word that zillions of women are going undiagnosed with Autism now and here's research science proof.
An online anonymous survey sourced through social media (not ISP restricted) that could, of course, be completed multiple times by individuals, with no breakdown of how many respondents were male or female showed a slightly higher incidence of passing a trait screener among women. If 90% of the respondents were female and 10% male, for instance, that would show an incidence of 7% in women and 54% in men or around a 1 to 8 ratio. I have no idea of the gender ratio of respondents but then neither does Gifford. But that won't stop those who think that there are swathes wof women going undiagnosed from extrapolating, say...
"The online survey, completed by over 750,000 adults across the UK, aimed to see how autistic traits are spread out across the British population, and to see if expert theories around a ‘lost generation’ of autistic adults (as highlighted within the documentary) may have statistical backing...
Of the 87,000 who scored above the diagnostic threshold, 54% (47,000) were women. Current estimates vary widely, putting the male to female ratio of diagnosed individuals on the autism spectrum at anywhere between 2:1 males to females through to 16:1."
The AQ merely measures autistic traits and they crossover with a wide range of psychiatric conditions like anxiety, eating disorders and depression, OCD, etc.. Typical questions:
I prefer to do things the same way over and over again.
I don't find social situations easy.
I would rather go to a library than to a party.
I don't enjoy social chitchat.
and so on. Of the 50 questions 23 have direct relevance to anxiety, depression and eating disorders. As the threshold is 35, self reporting difficulties among the remaining 27 questions should prove to be not difficult to reach if you have a psychological condition. In fact I just filled it out using only "Strongly agree"/"strongly disagree" descriptors for each question imagining I suffered from generalized anxiety only (which isn't hard).
Thus scoring strongly agree for questions like "I like to carefully plan any activities I participate in," "New situations make me anxious," etc. and strongly disagree for questions like " When I was young, I used to enjoy playing games involving pretending with other children," " I notice patterns in things all the time." Even discounting the descriptors slightly disagree/slightly agree and ignoring individual personality traits (you might well remember number plates or be good at remembering phone numbers, etc.) I still scored 31 out of 50. It's relatively easy for anyone with a psychiatric condition to hit 35.
After all, depression and anxiety is usually measured by The Beck Inventory. A 21 question screener with similar gems like:
I am dissatisfied or bored with everything.
It's kind of like a hardcore AQ.
Gifford suggests "These new figures potentially support expert theories that have suggested females on the spectrum may unconsciously practice social masking. Combined with fewer experts considering an ASD (autism spectrum disorder, also known as autism spectrum condition) or ASC diagnosis when presented with the same indicators in females as males, this new research suggests the numbers of undiagnosed females may be higher than previously thought."
Except, of course, it does no such thing. Unless you think blind internet surveys are science (or "research") in some unspecified way.
Women are twice as likely to experience anxiety as men NHS, the ratio of eating disorders for women and men is 10 to 1 and depression and other affective disorders is around twice as high in women. Though oddly suicide is very much the opposite.
And the further north you live the more likely you are to kill yourself. I think that might have something to do with wealth.
So it's both much more likely that women would be drawn to completing such a survey and that women are likely to score high for anxiety, depression, eating disorder descriptors.
Since I wrote a blog on the Channel 4 show a couple of newspaper reviews have given more sober assessments of it and the ideas underpinning the show.
Over at The Express Matt Bayliss highlights the confusion around Autism that the show did nothing to dispel:
"Bored by chit-chat? Prefer taking apart an old clock to attending a cocktail party? Get annoyed when your routines change? We recognise these traits because they’re in ourselves and people around us.
Much of what we might call typical male behaviour, such as loving facts and lists and not being able to read peoples’ emotions, comes under the umbrella of autistic traits.
It’s as if, for reasons not fully understood (or explored here), some have a concentrated version of the traits everyone has."
Indeed, that's the rationale of the Autism Spectrum. We're all autistic but autistic people are very autistic. The concept of ASD is that the syndrome is "dimensional" across a scale, rather than "longitudinal" a discrete category. It is, of course, nonsensical, and confusing, it confuses Bayliss, understandably. If he likes to pull apart clocks, likes to do this between the hours of 8 and 5pm every day, keeping extensive data on clock repairing, is he autistic or just a watch repairer?
I'm being flippant but who says what the cut off point is?
And thus we get to the masking Female Autism phenotype camouflaging ability where women appear near normal.
"More frustratingly, it spent a lot of time with Professor Baron-Cohen who has himself, previously suggested the condition might be an exaggerated kind of maleness. So why not ask him what he thinks now?
It was also suggested (again, minus detail) that perhaps female autism is better equipped at disguising itself.
An experiment, of sorts, got some blokes speed-dating with a roomful of young women.
The conversation flowed, the eye contact zinged and at the end, not one man realised he’d been speaking to an autistic woman.
So if autistic women can learn social behaviour or use it better than autistic men, then how and why?
More importantly, what use are surveys without some insight?" my bold.
And Michael Hogan at The Telegraph rightly points out:
"Unfortunately, from its crass title onwards, this film was a muddled mess, resembling three different documentaries clumsily welded together. Anna Richardson was roped in as rent-a-presenter – did producers suddenly panic that the autistic duo weren’t slick enough? – and proceeded to play the plain-speaking layperson to a patronising degree. Richardson’s sole credentials were that her nephew was autistic.
There were surveys, stunts, whizzy graphics, a speed-dating night, a cutesy robot and the obligatory Rain Man clips. Five different experts were consulted. Programme-makers threw everything at the screen to see what stuck. The more they did so, the weaker it became.
There was a half-decent documentary in here somewhere – perhaps about why so many women go undiagnosed, presented by Harper, the more engaging of the two campaigners – but it was hidden under a hotchpotch of gimmicks. The result was a surface-skimming hour which wasn’t worthy of its subject." my bold
Interesting that Hogan should find the woman who most clearly exhibited Autism the most engaging. Me too.
Sadly the survey was taken down before I could get my grubby mitts on it. But there's a helpful Autism forum debate among people who did take it which is enlightening: autismforums. Obviously this is just self reporting but hey, that's what all the "studies" on the Female Autism Phenotype and camouflaging use so when in Rome...
The people on here claim that the gender ratio was problematic because "Transgender" was included as a definer. What happened to the TGs?
One says "you can do the test without agreeing to the terms and conditions and there is a 'prefer not to say' option for all the biographical info, so I did the test. I don't think the questions were very well formed, like often I would want to say 'sometimes this happens' rather than 'it happens', but what the hell - I got a 10."
If that's the case then the data was even more irrelevant.
Another said "And I do think there is something in the 'extreme male brain theory. It's something that has always bothered me: I don't feel like I have anything in common with other women. I've always been happier around men, and doing/talking about traditionally male stuff (engines/weaponry/aircraft/motorsport...) and have never been interested in the things more associated with females. I have always worn trousers (dresses and skirts always seem so impractical) and I can't bear talking as a pastime, although I see how other women use it to strengthen bonds and keep up with developments in eachothers' lives. I am fully aware that, were I a man, I would probably have been left by my spouse years ago."
Clearly she's not autistic then. Why isn't she masking?
smnmy says: "i was going to have a look at the survey but this picture scared me!"
"are we seriously expected to believe that this is the face of normality and WE are the weirdos?"
There's a lot on here self identifying as Trans too, interestingly.
"i never chose to be trans anymore than i chose to be autistic,plus my brain is wired to be male not female,my parents recognise ive been outwardly trans since a young toddler when they look back-but back then they saw it as tom boyism.
i am not a tom boy,i am not simply a masculine female,i have a male brain in a biologically female body.
however,i do not apreciate anyone making jokes about trans;more so when its using me-we are bullied enough without 'our own' mocking us."
Some include their scores and data (complete with the scary face.
"i know i like a good moan about stuff like this but its just annoyed me, and when it got to the results page,it didnt even give any results for transgender autistics,meaning theyve never bothered to research us."
It's an interesting point.
Gifford over at Happiful central fortunately explains everything in Autistic Girls and Women: Signs We Might Be Missing.
"Many common misconceptions about autism still widely circulate. From people thinking children will ‘grow out’ of autism to assuming all autistic people are geniuses, perhaps one of the most common misconceptions is that autism just affects boys and men."
And that women go undiagnosed because they mask characteristics they don't have.
"According to the Journal of Autism and Developmental Disorders, ‘many females who, if skilfulls [sic] assessed, would meet full diagnostic criteria for ASC, never recieve [sic] a diagnosis and the help that, potentially, comes with it’. Women are more frequently diagnosed later in life compared to their male counterparts, whilst many girls go undiagnosed or recieve [sic] a different diagnosis entirely."
Ha, the Journal of ADD is the "study" by Bargiela, Steward & Mandy asking fourteen women about their experiences of late diagnosis.
They receive a different diagnosis because the tend to fit the descriptors for Generalized Anxiety Disorder. Frequently those diagnosed late in life gain private diagnosis. I simply can't find data on private diagnosis rates vs health service diagnosis rates but the cynic in me thinks it's simply buying a diagnosis. You could theoretically just keep paying for diagnosis until you pass. Like a driving test.
But why would anyone? I mean who goes to get a private depression, anxiety or eating disorder diagnosis? Of course, if you get an Autism diagnosis it counts as a recognized disability (for things like public transport passes, Personal Independence Payments, etc.). There are incentives apart from the way Autism is now portrayed as a gift, oooh Einstein probably "had Autism."
Gifford asks: "Why aren’t women and girls diagnosed as often?
Research suggests that teachers under-report autistic traits in female students. Unless showing signs of more severe autistic traits, cognitive or behavioural problems, many telltale signs are dismissed as neurotypical behavior.
Research reported in the Journal of Autism and Developmental Disorders suggests there may be a female-specific autism type that has different signs and ways of presenting than it does in males, resulting in current diagnostic methods missing the signs."
The research is that study of fourteen women self reporting. What be these signs? Oh yeah, no one actually says. I've just written a book length post trying to find out what these signs are. Masking. Of what? Who knows.
"The original definition from Hans Asperger in 1944 focused on boys, as he believed girls were not affected by the confition. [sic]"
Sigh. Asperger was a paediatrician who observed these unusual behaviours in a number of the children in the hospital in Vienna. He didn't focus on boys, he found these behaviours only in boys in his care. The suggestion here is that he dismissed the idea of autistic girls and focused on boys which is simply untrue. No girls presented the same characteristics which led to him asking the question, is this a male condition?
"One 2015 study suggested that autism is under-diagnosed in girls, skewing the ratio of male to female autism statistics as the diagnostic criteria is largely based on the behavioural characteristics of boys and men."
The study is no such thing. It's just a link to a BBC page linking to the NAS Gender and Autism page. Oh dear.
"Another popular theory explores the idea that girls and women are better at camouflaging, or masking, their difficulties. Dr Louis Kraus, a psychiatrist specialising in autism, suggests that the signs and symptoms of autism can often be less obvious in girls. Many girls and women can blend in, learning to mimic the behaviour around them, whereas boys may lean towards more isolated behavior which can be easier to spot. Male traits may stand out more amongst their peers, whilst female traits can be dismissed a ‘quirks’. The very behaviour that helps girls to blend in can delay diagnosis and support."
This just links to an NPR opinion piece in which:
"Girls can be better at blending in, says Dr. Louis Kraus, a psychiatrist at Rush University Medical Center in Chicago, who specializes in autism.
"Girls tend to want to socialize and be part of a group," he says, even though it may be awkward. Boys, on the other hand, "tend to be more isolative," says Kraus."
Evidence? Schmevidence. Kraus specializes in Autism. Unfortunately, this quote is regurgitated in a number of articles but there's no research or study data by Kraus.
"Girls appear to have mastered what some call "social camouflaging," says Amanda Gulsrud, clincial director of the Child and Adult Neurodevelopmental Clinic at University of California, Los Angeles. Gulsrud develops school interventions for children with autism. The interventions are based, in part, on earlier research done by colleagues at UCLA, who did a study looking at how boys and girls with autism interact with their peers on the school playground. The boys clearly stood out as being different, Gulsrud says. They were very isolated from the other boys, who were in a large group playing sports. The boys with autism were the ones "circling the perimeter of the yard, or off by the tree in the back.""
The study does indeed find:
"Consistent with typically developing populations, children with ASD preferred, were accepted by, and primarily socialized with same-gender friends. With fewer nominations and social relationships, girls and boys with ASD appear more socially similar to each other than to the same-gender control group. Additionally, girls and boys with ASD showed higher rates of social exclusion than their typically developing peers. However, boys with ASD were more overtly socially excluded compared to girls with ASD, who seemed to be overlooked, rather than rejected."
That is, that boys and girls play differently in playgrounds and so boys stand out more. This shows nothing about girls camouflaging behaviours. The study is here The peer relationships of girls with ASD at school: Comparison to boys and girls with and without ASD.
This is simple sociology.
A further study is mentioned in the NPR piece that raises the same questions as ever:
"Girls with autism tend to be quiet and "behave more appropriately," says Marisela Huerta, a psychologist with the Weill Cornell Medical College. She co-authored a survey of clinicians who specialize in autism. The clinicians were asked to compare the severity of symptoms in females, compared to males. Seventy percent of them reported clear gender differences in autism symptoms, with boys more likely to exhibit repetitive behaviors, fixated interests and being less likely to engage in social interactions. Girls tend to be more verbal and socially interactive, at least at younger ages. This may be why parents and teachers often don't pick up on girls' symptoms and don't refer as many girls for evaluation."
If camouflaging were the reason for these supposed behavioural differences surely verbal and socially interactive behaviours would be more apparent as children got older not when they were younger?
The study then perversely found:
"Research studies using existing samples of individuals with autism spectrum disorders have identified differences in symptoms between males and females. Differences are typically reported in school age and adolescence, with similarities in symptom presentation at earlier ages. However, existing studies on sex differences are significantly limited, making it challenging to discern if, how, and at what point in development females with autism spectrum disorder actually exhibit a different behavioral presentation than males."
These studies use diagnosed children. So presentation in children and adolescents appears different. This isn't camouflage, because if they are diagnosed why would they mask?
"Consistent with previous literature, clinicians noted more sex-related differences in restricted and repetitive behaviors and fewer differences for social communication features."
So actually, the study found repetitive behaviours were different but social communication wasn't. This is slightly confusing.
The clinician perspective on sex differences in autism spectrum disorders
Studies in reporting of autistic traits in women in the general population, however, show exactly the opposite.
This makes absolutely no sense from the perspective of the camouflaging theory of undiagnosed women. School and adolescence should be where and when girls learn to mask from peers, so why then would the behaviours become more noticeable just when girls are supposedly learn to mask? Yet diagnosed girls begin to look similar. They couldn't learn to mask in their early years (who from?) and then at school begin to show autistic behaviours. What is more likely is that it's good old sociology again. In a home setting autistic behaviours will be less noticeable because in families with only one child these behaviours won't necessarily have anything to compare with, in a boy/girl two child family behaviours could be seen as gender differences, in more than one daughter families (just assuming heritability of Autism for a moment) both or more daughters might exhibit the same behaviours. Such behaviours would become noticeable in a school setting among peers. However, the masking hypothesis claims this is the time when girls learn to camouflage, specifically around puberty. Whereas, if you include sociology, it would be logical that girls' behaviours would become exacerbated by puberty and thus more noticeable. So why then do they go undetected?
Well, firstly, perhaps because they aren't actually autistic and hence gain diagnosis for anxiety, depression, etc. and these are actually the correct diagnoses.
Secondly, the number of girls/women exhibiting such behaviours are so small that the anomalies go unnoticed.
Third, that the behaviours are hard to extract from the typical behaviours of girls going through particularly difficult life changes.
"Another characteristic of autism is a tendency toward compulsive behavior. And here again, girls and boys can differ quite a bit, says psychiatrist Kraus. Boys can get obsessed with objects like rocks, for example, to the point that they carry pounds and pounds of them around in a backpack and talk about them endlessly. "This fixation can drive them away from socializing," Kraus says, whereas girls' obsessions don't seem to ostracize them from social development. They may get fixated on collecting shells, for example, but this behavior seems "endearing and culturally acceptable," Kraus says."
That seems reasonable to assume. And indeed, once more, undermines the masking theory. Repetitive behaviours simply present differently, they aren't masked. Obsessive collective of random objects would still be unusual behaviour.
I've been confused by the masking trope (not only because it's obviously nonsense) because some claim they consciously mimicked others, Lianne Holliday Willey, for instance describes enacting conversations etc. and Tony Attwood diagnosed her based on this. Most of the women in my previous post on Autism and Women claim they learned consciously to copy popular girls in order to fit in.
Gifford suggests "These new figures potentially support expert theories that have suggested females on the spectrum may unconsciously practice social masking."
This is common too. That girls don't know they're masking their behaviours so they never realize they are autistic (see some other women in previous post). Until later in life when they read a blog post by another woman who has had anxiety too then suddenly "it all made sense."
If you consciously masked it would almost certainly have to be some time after first coming into contact with your peer group in infancy. However, if you 'lack' the unconscious development of social imagination, communication and interaction, the core descriptors of Autism, it would be logical to assume that much of what we consider normal development in social communication (socialization) would be problematized or non-existent. To then learn to copy others and "pass for normal" must take a great length of time, after all, the 'normally developing' children have done all this unconsciously over infancy. So why then, if masking were conscious, would behaviours then become more noticeable at exactly that time, late infancy and early adolescence, when one is learning to consciously mask? If one is unconsciously masking then that is typical behaviour. We all do that.
"New diagnostic criteria coming into effect from 2018 within the UK was also raised," in Are You Autistic, according to Gifford. Though I missed that. What criteria? How? We diagnose based on descriptors in the DSM (Lorna Wing of the NAS helped draw them up, hence the "may learn masking strategies").
Gifford offers an interesting list of :
"Signs to look out for in girls VS boys
"Girls may have a range of ‘autistic traits’ that present in a more subtle way than their male counterparts. Some better known traits, such as repetitive or ritualistic behaviour are more likely in males than females."
I thought they masked to the point where they appeared normal?
"Autistic boys may appear to spend more time alone or seem isolated whilst other children appear to be playing together. Autistic girls may stay close to their peers, but may not feel socially connected or can come across as overlooked in social situations. This can come across as them ‘flitting in and out’ of different activities or social groups."
Sociology. I'd agree that girls appear to present differently because of sociological roles.
"They may appear more social however they may struggle with socially acceptable responses and behaviour. Girls may be more likely to learn conversational phrases they can reuse, imitate social behaviour of their friends or from TV shows, or create their own ‘social script’ to help them through regular interactions."
How does this go unnoticed? Surely their behaviour would be different? if it isn't then what's the problem? If one is so good at "passing for normal" why then would you want a diagnose of Autism?
"Autistic girls are often quiet and well-behaved compared to their male counterparts. Many are sticklers for the rules, following them closely and striving for perfection (which can come across as being overly-critical of themselves, or showing frustration or upset when making small or large mistakes). According to child psychologist Kevin Pelphrey, director at the Autism and Neurodevelopmental Disorders Institute, autistic girls may be more likely to understand social expectations, even if they can’t fully meet them."
Then how is this masking? Surely these "meltdowns" when they aren't perfect or break rules or don't fully understand social interaction would be noticed?
"High levels of anxiety can often arise as girls try to adapt and understand social situations and cues others may take for granted."
The trouble is with claiming Female Autism Phenotyped girls get very anxious is that NT girls get very anxious, as do real autistic girls because they don't understand social rules. So how do you spot these unique masking girls who weirdly show all these anxiety/meltdown symptoms?
"Having fewer or just one intense friendship, or no close friendships at all can both be typical for autistic girls."
Surely this is the same for boys? Or NT girls? Or NT boys?
"A common characteristic amongst both genders can involve compulsive behaviour, particularly around collecting certain objects or having a specific special interest. While boys may develop a more niche special interest, girls may focus on a more socially acceptable or more common interest shared by their friends (such as focusing on a specific band or show), but with higher levels of intensity. Research suggests autistic girls may lean towards special interests with a more social or nurturing nature (focusing on animals, specific shows or celebrities) while boys can be more likely to focus on technical hobbies or facts. Both may have an interest in collecting, organising and cataloguing items around a specific interest or hobby."
But then surely these FAP girls can mask these behaviours too? How can they exhibit heightened compulsive behaviours whilst also mask to "pretend to be normal" at the same time? Surely it's either they mask so well that they "pass as normal" or they have all these characteristics that present differently to boys. It can't be both.
As I began so shall I end. Gifford's piece is essentially a blog post but then that's how these fake news stories about new super female Autism with all the characteristics of Autism with none of the characteristics of Autism but no visible signs or sometimes visible signs with conscious masking by women who get terrible anxiety because of the pressure of masking or unconscious masking where even the women live for 30 years without realizing they were different paradigms start. So...
Keep watching the skies (for girls flying under the radar).
For the recent Channel 4 show Are You Autistic carried out an online survey using AQ (Autism Quotient screener diagnostic tool) type questions. The results seemed astonishing (if you're credulous). There were 750,000 responses and 87,000 scored above the threshold for autistic traits. Of these 47,000 were women.
So now you get articles like New Documentary Reveals Over Half of Undiagnosed Autistic Adults Could Be Women in Happiful Magazine claiming 50% of undiagnosed autistics are women.
Our correspondent at Happiful, Bonnie Evie-Gifford, seems to have fallen for the old confirmation let's ignore scientific enquiry the internet doesn't lie, does it, really? bias...
While normally I'd not be bothered by an obscure female wellbeing online magazine I think Gifford won't be the first to extrapolate this result and spread the word that zillions of women are going undiagnosed with Autism now and here's research science proof.
An online anonymous survey sourced through social media (not ISP restricted) that could, of course, be completed multiple times by individuals, with no breakdown of how many respondents were male or female showed a slightly higher incidence of passing a trait screener among women. If 90% of the respondents were female and 10% male, for instance, that would show an incidence of 7% in women and 54% in men or around a 1 to 8 ratio. I have no idea of the gender ratio of respondents but then neither does Gifford. But that won't stop those who think that there are swathes wof women going undiagnosed from extrapolating, say...
"The online survey, completed by over 750,000 adults across the UK, aimed to see how autistic traits are spread out across the British population, and to see if expert theories around a ‘lost generation’ of autistic adults (as highlighted within the documentary) may have statistical backing...
Of the 87,000 who scored above the diagnostic threshold, 54% (47,000) were women. Current estimates vary widely, putting the male to female ratio of diagnosed individuals on the autism spectrum at anywhere between 2:1 males to females through to 16:1."
The AQ merely measures autistic traits and they crossover with a wide range of psychiatric conditions like anxiety, eating disorders and depression, OCD, etc.. Typical questions:
I prefer to do things the same way over and over again.
I don't find social situations easy.
I would rather go to a library than to a party.
I don't enjoy social chitchat.
and so on. Of the 50 questions 23 have direct relevance to anxiety, depression and eating disorders. As the threshold is 35, self reporting difficulties among the remaining 27 questions should prove to be not difficult to reach if you have a psychological condition. In fact I just filled it out using only "Strongly agree"/"strongly disagree" descriptors for each question imagining I suffered from generalized anxiety only (which isn't hard).
Thus scoring strongly agree for questions like "I like to carefully plan any activities I participate in," "New situations make me anxious," etc. and strongly disagree for questions like " When I was young, I used to enjoy playing games involving pretending with other children," " I notice patterns in things all the time." Even discounting the descriptors slightly disagree/slightly agree and ignoring individual personality traits (you might well remember number plates or be good at remembering phone numbers, etc.) I still scored 31 out of 50. It's relatively easy for anyone with a psychiatric condition to hit 35.
After all, depression and anxiety is usually measured by The Beck Inventory. A 21 question screener with similar gems like:
I am dissatisfied or bored with everything.
I am so sad and unhappy that I can't stand it.
I feel irritated all the time.
I hate my life and I hate this test and I hate you for making me take it.
I hate my life and I hate this test and I hate you for making me take it.
It's kind of like a hardcore AQ.
Gifford suggests "These new figures potentially support expert theories that have suggested females on the spectrum may unconsciously practice social masking. Combined with fewer experts considering an ASD (autism spectrum disorder, also known as autism spectrum condition) or ASC diagnosis when presented with the same indicators in females as males, this new research suggests the numbers of undiagnosed females may be higher than previously thought."
Except, of course, it does no such thing. Unless you think blind internet surveys are science (or "research") in some unspecified way.
Women are twice as likely to experience anxiety as men NHS, the ratio of eating disorders for women and men is 10 to 1 and depression and other affective disorders is around twice as high in women. Though oddly suicide is very much the opposite.
Since I wrote a blog on the Channel 4 show a couple of newspaper reviews have given more sober assessments of it and the ideas underpinning the show.
Over at The Express Matt Bayliss highlights the confusion around Autism that the show did nothing to dispel:
"Bored by chit-chat? Prefer taking apart an old clock to attending a cocktail party? Get annoyed when your routines change? We recognise these traits because they’re in ourselves and people around us.
Much of what we might call typical male behaviour, such as loving facts and lists and not being able to read peoples’ emotions, comes under the umbrella of autistic traits.
It’s as if, for reasons not fully understood (or explored here), some have a concentrated version of the traits everyone has."
Indeed, that's the rationale of the Autism Spectrum. We're all autistic but autistic people are very autistic. The concept of ASD is that the syndrome is "dimensional" across a scale, rather than "longitudinal" a discrete category. It is, of course, nonsensical, and confusing, it confuses Bayliss, understandably. If he likes to pull apart clocks, likes to do this between the hours of 8 and 5pm every day, keeping extensive data on clock repairing, is he autistic or just a watch repairer?
I'm being flippant but who says what the cut off point is?
And thus we get to the masking Female Autism phenotype camouflaging ability where women appear near normal.
"More frustratingly, it spent a lot of time with Professor Baron-Cohen who has himself, previously suggested the condition might be an exaggerated kind of maleness. So why not ask him what he thinks now?
It was also suggested (again, minus detail) that perhaps female autism is better equipped at disguising itself.
An experiment, of sorts, got some blokes speed-dating with a roomful of young women.
The conversation flowed, the eye contact zinged and at the end, not one man realised he’d been speaking to an autistic woman.
So if autistic women can learn social behaviour or use it better than autistic men, then how and why?
More importantly, what use are surveys without some insight?" my bold.
And Michael Hogan at The Telegraph rightly points out:
"Unfortunately, from its crass title onwards, this film was a muddled mess, resembling three different documentaries clumsily welded together. Anna Richardson was roped in as rent-a-presenter – did producers suddenly panic that the autistic duo weren’t slick enough? – and proceeded to play the plain-speaking layperson to a patronising degree. Richardson’s sole credentials were that her nephew was autistic.
There were surveys, stunts, whizzy graphics, a speed-dating night, a cutesy robot and the obligatory Rain Man clips. Five different experts were consulted. Programme-makers threw everything at the screen to see what stuck. The more they did so, the weaker it became.
There was a half-decent documentary in here somewhere – perhaps about why so many women go undiagnosed, presented by Harper, the more engaging of the two campaigners – but it was hidden under a hotchpotch of gimmicks. The result was a surface-skimming hour which wasn’t worthy of its subject." my bold
Interesting that Hogan should find the woman who most clearly exhibited Autism the most engaging. Me too.
Sadly the survey was taken down before I could get my grubby mitts on it. But there's a helpful Autism forum debate among people who did take it which is enlightening: autismforums. Obviously this is just self reporting but hey, that's what all the "studies" on the Female Autism Phenotype and camouflaging use so when in Rome...
The people on here claim that the gender ratio was problematic because "Transgender" was included as a definer. What happened to the TGs?
One says "you can do the test without agreeing to the terms and conditions and there is a 'prefer not to say' option for all the biographical info, so I did the test. I don't think the questions were very well formed, like often I would want to say 'sometimes this happens' rather than 'it happens', but what the hell - I got a 10."
If that's the case then the data was even more irrelevant.
Another said "And I do think there is something in the 'extreme male brain theory. It's something that has always bothered me: I don't feel like I have anything in common with other women. I've always been happier around men, and doing/talking about traditionally male stuff (engines/weaponry/aircraft/motorsport...) and have never been interested in the things more associated with females. I have always worn trousers (dresses and skirts always seem so impractical) and I can't bear talking as a pastime, although I see how other women use it to strengthen bonds and keep up with developments in eachothers' lives. I am fully aware that, were I a man, I would probably have been left by my spouse years ago."
Clearly she's not autistic then. Why isn't she masking?
smnmy says: "i was going to have a look at the survey but this picture scared me!"
There's a lot on here self identifying as Trans too, interestingly.
"i never chose to be trans anymore than i chose to be autistic,plus my brain is wired to be male not female,my parents recognise ive been outwardly trans since a young toddler when they look back-but back then they saw it as tom boyism.
i am not a tom boy,i am not simply a masculine female,i have a male brain in a biologically female body.
however,i do not apreciate anyone making jokes about trans;more so when its using me-we are bullied enough without 'our own' mocking us."
"i know i like a good moan about stuff like this but its just annoyed me, and when it got to the results page,it didnt even give any results for transgender autistics,meaning theyve never bothered to research us."
It's an interesting point.
Gifford over at Happiful central fortunately explains everything in Autistic Girls and Women: Signs We Might Be Missing.
"Many common misconceptions about autism still widely circulate. From people thinking children will ‘grow out’ of autism to assuming all autistic people are geniuses, perhaps one of the most common misconceptions is that autism just affects boys and men."
And that women go undiagnosed because they mask characteristics they don't have.
"According to the Journal of Autism and Developmental Disorders, ‘many females who, if skilfulls [sic] assessed, would meet full diagnostic criteria for ASC, never recieve [sic] a diagnosis and the help that, potentially, comes with it’. Women are more frequently diagnosed later in life compared to their male counterparts, whilst many girls go undiagnosed or recieve [sic] a different diagnosis entirely."
Ha, the Journal of ADD is the "study" by Bargiela, Steward & Mandy asking fourteen women about their experiences of late diagnosis.
They receive a different diagnosis because the tend to fit the descriptors for Generalized Anxiety Disorder. Frequently those diagnosed late in life gain private diagnosis. I simply can't find data on private diagnosis rates vs health service diagnosis rates but the cynic in me thinks it's simply buying a diagnosis. You could theoretically just keep paying for diagnosis until you pass. Like a driving test.
But why would anyone? I mean who goes to get a private depression, anxiety or eating disorder diagnosis? Of course, if you get an Autism diagnosis it counts as a recognized disability (for things like public transport passes, Personal Independence Payments, etc.). There are incentives apart from the way Autism is now portrayed as a gift, oooh Einstein probably "had Autism."
Gifford asks: "Why aren’t women and girls diagnosed as often?
Research suggests that teachers under-report autistic traits in female students. Unless showing signs of more severe autistic traits, cognitive or behavioural problems, many telltale signs are dismissed as neurotypical behavior.
Research reported in the Journal of Autism and Developmental Disorders suggests there may be a female-specific autism type that has different signs and ways of presenting than it does in males, resulting in current diagnostic methods missing the signs."
The research is that study of fourteen women self reporting. What be these signs? Oh yeah, no one actually says. I've just written a book length post trying to find out what these signs are. Masking. Of what? Who knows.
"The original definition from Hans Asperger in 1944 focused on boys, as he believed girls were not affected by the confition. [sic]"
Sigh. Asperger was a paediatrician who observed these unusual behaviours in a number of the children in the hospital in Vienna. He didn't focus on boys, he found these behaviours only in boys in his care. The suggestion here is that he dismissed the idea of autistic girls and focused on boys which is simply untrue. No girls presented the same characteristics which led to him asking the question, is this a male condition?
"One 2015 study suggested that autism is under-diagnosed in girls, skewing the ratio of male to female autism statistics as the diagnostic criteria is largely based on the behavioural characteristics of boys and men."
The study is no such thing. It's just a link to a BBC page linking to the NAS Gender and Autism page. Oh dear.
"Another popular theory explores the idea that girls and women are better at camouflaging, or masking, their difficulties. Dr Louis Kraus, a psychiatrist specialising in autism, suggests that the signs and symptoms of autism can often be less obvious in girls. Many girls and women can blend in, learning to mimic the behaviour around them, whereas boys may lean towards more isolated behavior which can be easier to spot. Male traits may stand out more amongst their peers, whilst female traits can be dismissed a ‘quirks’. The very behaviour that helps girls to blend in can delay diagnosis and support."
This just links to an NPR opinion piece in which:
"Girls can be better at blending in, says Dr. Louis Kraus, a psychiatrist at Rush University Medical Center in Chicago, who specializes in autism.
"Girls tend to want to socialize and be part of a group," he says, even though it may be awkward. Boys, on the other hand, "tend to be more isolative," says Kraus."
Evidence? Schmevidence. Kraus specializes in Autism. Unfortunately, this quote is regurgitated in a number of articles but there's no research or study data by Kraus.
"Girls appear to have mastered what some call "social camouflaging," says Amanda Gulsrud, clincial director of the Child and Adult Neurodevelopmental Clinic at University of California, Los Angeles. Gulsrud develops school interventions for children with autism. The interventions are based, in part, on earlier research done by colleagues at UCLA, who did a study looking at how boys and girls with autism interact with their peers on the school playground. The boys clearly stood out as being different, Gulsrud says. They were very isolated from the other boys, who were in a large group playing sports. The boys with autism were the ones "circling the perimeter of the yard, or off by the tree in the back.""
The study does indeed find:
"Consistent with typically developing populations, children with ASD preferred, were accepted by, and primarily socialized with same-gender friends. With fewer nominations and social relationships, girls and boys with ASD appear more socially similar to each other than to the same-gender control group. Additionally, girls and boys with ASD showed higher rates of social exclusion than their typically developing peers. However, boys with ASD were more overtly socially excluded compared to girls with ASD, who seemed to be overlooked, rather than rejected."
That is, that boys and girls play differently in playgrounds and so boys stand out more. This shows nothing about girls camouflaging behaviours. The study is here The peer relationships of girls with ASD at school: Comparison to boys and girls with and without ASD.
This is simple sociology.
A further study is mentioned in the NPR piece that raises the same questions as ever:
"Girls with autism tend to be quiet and "behave more appropriately," says Marisela Huerta, a psychologist with the Weill Cornell Medical College. She co-authored a survey of clinicians who specialize in autism. The clinicians were asked to compare the severity of symptoms in females, compared to males. Seventy percent of them reported clear gender differences in autism symptoms, with boys more likely to exhibit repetitive behaviors, fixated interests and being less likely to engage in social interactions. Girls tend to be more verbal and socially interactive, at least at younger ages. This may be why parents and teachers often don't pick up on girls' symptoms and don't refer as many girls for evaluation."
If camouflaging were the reason for these supposed behavioural differences surely verbal and socially interactive behaviours would be more apparent as children got older not when they were younger?
The study then perversely found:
"Research studies using existing samples of individuals with autism spectrum disorders have identified differences in symptoms between males and females. Differences are typically reported in school age and adolescence, with similarities in symptom presentation at earlier ages. However, existing studies on sex differences are significantly limited, making it challenging to discern if, how, and at what point in development females with autism spectrum disorder actually exhibit a different behavioral presentation than males."
These studies use diagnosed children. So presentation in children and adolescents appears different. This isn't camouflage, because if they are diagnosed why would they mask?
"Consistent with previous literature, clinicians noted more sex-related differences in restricted and repetitive behaviors and fewer differences for social communication features."
So actually, the study found repetitive behaviours were different but social communication wasn't. This is slightly confusing.
The clinician perspective on sex differences in autism spectrum disorders
Studies in reporting of autistic traits in women in the general population, however, show exactly the opposite.
This makes absolutely no sense from the perspective of the camouflaging theory of undiagnosed women. School and adolescence should be where and when girls learn to mask from peers, so why then would the behaviours become more noticeable just when girls are supposedly learn to mask? Yet diagnosed girls begin to look similar. They couldn't learn to mask in their early years (who from?) and then at school begin to show autistic behaviours. What is more likely is that it's good old sociology again. In a home setting autistic behaviours will be less noticeable because in families with only one child these behaviours won't necessarily have anything to compare with, in a boy/girl two child family behaviours could be seen as gender differences, in more than one daughter families (just assuming heritability of Autism for a moment) both or more daughters might exhibit the same behaviours. Such behaviours would become noticeable in a school setting among peers. However, the masking hypothesis claims this is the time when girls learn to camouflage, specifically around puberty. Whereas, if you include sociology, it would be logical that girls' behaviours would become exacerbated by puberty and thus more noticeable. So why then do they go undetected?
Well, firstly, perhaps because they aren't actually autistic and hence gain diagnosis for anxiety, depression, etc. and these are actually the correct diagnoses.
Secondly, the number of girls/women exhibiting such behaviours are so small that the anomalies go unnoticed.
Third, that the behaviours are hard to extract from the typical behaviours of girls going through particularly difficult life changes.
"Another characteristic of autism is a tendency toward compulsive behavior. And here again, girls and boys can differ quite a bit, says psychiatrist Kraus. Boys can get obsessed with objects like rocks, for example, to the point that they carry pounds and pounds of them around in a backpack and talk about them endlessly. "This fixation can drive them away from socializing," Kraus says, whereas girls' obsessions don't seem to ostracize them from social development. They may get fixated on collecting shells, for example, but this behavior seems "endearing and culturally acceptable," Kraus says."
That seems reasonable to assume. And indeed, once more, undermines the masking theory. Repetitive behaviours simply present differently, they aren't masked. Obsessive collective of random objects would still be unusual behaviour.
I've been confused by the masking trope (not only because it's obviously nonsense) because some claim they consciously mimicked others, Lianne Holliday Willey, for instance describes enacting conversations etc. and Tony Attwood diagnosed her based on this. Most of the women in my previous post on Autism and Women claim they learned consciously to copy popular girls in order to fit in.
Gifford suggests "These new figures potentially support expert theories that have suggested females on the spectrum may unconsciously practice social masking."
This is common too. That girls don't know they're masking their behaviours so they never realize they are autistic (see some other women in previous post). Until later in life when they read a blog post by another woman who has had anxiety too then suddenly "it all made sense."
If you consciously masked it would almost certainly have to be some time after first coming into contact with your peer group in infancy. However, if you 'lack' the unconscious development of social imagination, communication and interaction, the core descriptors of Autism, it would be logical to assume that much of what we consider normal development in social communication (socialization) would be problematized or non-existent. To then learn to copy others and "pass for normal" must take a great length of time, after all, the 'normally developing' children have done all this unconsciously over infancy. So why then, if masking were conscious, would behaviours then become more noticeable at exactly that time, late infancy and early adolescence, when one is learning to consciously mask? If one is unconsciously masking then that is typical behaviour. We all do that.
"New diagnostic criteria coming into effect from 2018 within the UK was also raised," in Are You Autistic, according to Gifford. Though I missed that. What criteria? How? We diagnose based on descriptors in the DSM (Lorna Wing of the NAS helped draw them up, hence the "may learn masking strategies").
Gifford offers an interesting list of :
"Signs to look out for in girls VS boys
"Girls may have a range of ‘autistic traits’ that present in a more subtle way than their male counterparts. Some better known traits, such as repetitive or ritualistic behaviour are more likely in males than females."
I thought they masked to the point where they appeared normal?
"Autistic boys may appear to spend more time alone or seem isolated whilst other children appear to be playing together. Autistic girls may stay close to their peers, but may not feel socially connected or can come across as overlooked in social situations. This can come across as them ‘flitting in and out’ of different activities or social groups."
Sociology. I'd agree that girls appear to present differently because of sociological roles.
"They may appear more social however they may struggle with socially acceptable responses and behaviour. Girls may be more likely to learn conversational phrases they can reuse, imitate social behaviour of their friends or from TV shows, or create their own ‘social script’ to help them through regular interactions."
How does this go unnoticed? Surely their behaviour would be different? if it isn't then what's the problem? If one is so good at "passing for normal" why then would you want a diagnose of Autism?
"Autistic girls are often quiet and well-behaved compared to their male counterparts. Many are sticklers for the rules, following them closely and striving for perfection (which can come across as being overly-critical of themselves, or showing frustration or upset when making small or large mistakes). According to child psychologist Kevin Pelphrey, director at the Autism and Neurodevelopmental Disorders Institute, autistic girls may be more likely to understand social expectations, even if they can’t fully meet them."
Then how is this masking? Surely these "meltdowns" when they aren't perfect or break rules or don't fully understand social interaction would be noticed?
"High levels of anxiety can often arise as girls try to adapt and understand social situations and cues others may take for granted."
The trouble is with claiming Female Autism Phenotyped girls get very anxious is that NT girls get very anxious, as do real autistic girls because they don't understand social rules. So how do you spot these unique masking girls who weirdly show all these anxiety/meltdown symptoms?
"Having fewer or just one intense friendship, or no close friendships at all can both be typical for autistic girls."
Surely this is the same for boys? Or NT girls? Or NT boys?
"A common characteristic amongst both genders can involve compulsive behaviour, particularly around collecting certain objects or having a specific special interest. While boys may develop a more niche special interest, girls may focus on a more socially acceptable or more common interest shared by their friends (such as focusing on a specific band or show), but with higher levels of intensity. Research suggests autistic girls may lean towards special interests with a more social or nurturing nature (focusing on animals, specific shows or celebrities) while boys can be more likely to focus on technical hobbies or facts. Both may have an interest in collecting, organising and cataloguing items around a specific interest or hobby."
But then surely these FAP girls can mask these behaviours too? How can they exhibit heightened compulsive behaviours whilst also mask to "pretend to be normal" at the same time? Surely it's either they mask so well that they "pass as normal" or they have all these characteristics that present differently to boys. It can't be both.
As I began so shall I end. Gifford's piece is essentially a blog post but then that's how these fake news stories about new super female Autism with all the characteristics of Autism with none of the characteristics of Autism but no visible signs or sometimes visible signs with conscious masking by women who get terrible anxiety because of the pressure of masking or unconscious masking where even the women live for 30 years without realizing they were different paradigms start. So...
Keep watching the skies (for girls flying under the radar).
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