Autism Looks Different in Girls

The diagnostic criteria were built on boys — and girls are paying the price

STUDY: Bitensky DR et al, Behavioral Sciences 2026;16:396

STUDY TYPE: Narrative review

FUNDING: Independent

Background

Most of what we know about autism (ASD) comes from research on males. The diagnostic criteria reflect that history — and as a result, girls are diagnosed at a fraction of the rate of boys (roughly 1 for every 3.4). This review synthesizes evidence on how autism spectrum disorder (ASD) presents differently in girls and women.

How it Presents Differently

Camouflaging

Girls with ASD learn to mimic neurotypical behavior — maintaining eye contact, scripting conversations, imitating peers — in ways that mask the very symptoms clinicians look for. They often want friends and work hard to fit in, which makes their social difficulties easy to miss.

Repetitive behaviors

Less hand-flapping, more list-making, hair-twirling.

Intense interests

These are more likely to be socially typical interests like animals, makeup, or K-pop.

Improving the Diagnosis

When missed, girls tend to get misdiagnosed — most often with anxiety, social anxiety disorder, OCD, eating disorders, or borderline personality disorder — and spend years in treatment that doesn’t address the underlying neurodevelopmental profile.

The MAAGW model recommends moving beyond confirmatory cutoff scores (like those from the ADOS-2, which girls are 2.5 times more likely to fail despite having ASD) toward a community diagnosis approach: incorporating self-report, collateral history, observations across settings, and tools like the Camouflaging Autistic Traits Questionnaire (CAT-Q) and Girls Questionnaire for Autism Spectrum Condition (GQ-ASC). Re-testing at different developmental stages — especially adolescence, when social demands increase — is also recommended, since early testing frequently produces false negatives.

The X Factor

Separately, another new study from Nature suggests that female gender may protect against autism. How? Women have two X chromosomes, while men have one. Some genes that increase the risk for autism are located on the X chromosome. Girls have an extra X to balance that out, in case one of their X chromosomes contains an autism-risk gene.

Practice Implications

• If a female patient has been cycling through various diagnoses without sustained improvement, ASD belongs on your differential.
• Ask specifically about the experience of social interaction, not just the behavior. Does eye contact feel forced? Does she need hours of recovery after social events? Does she hold it together in public and fall apart at home? Those are the questions that open the diagnostic picture.
• The CAT-Q is free, validated, and takes minutes to complete.