- Girls might mask their symptoms 
 - Problems with Diagnostic Criteria 


Potential Reasons Why Girls are Diagnosed with Autism Spectrum Disorder  Later Than Boys

Girls are diagnosed with autism spectrum disorder much less frequently than boys. When they are diagnosed, it is much later. Girls are diagnosed five and a half years later than boys are. 


Xavier University

A 1981 epidemiological study conducted by Lorna Wing to examine sex ratios in children diagnosed with autism revealed the following:
- difference b/w men and women in language and social impairments, and in the way they reacted to their respective environments
- prompted further sex ratio research

Ehlers and Gillberg (1998):
- study on epidemiology of Asperger's syndrome
- found smaller male:female ratio than expected

Matille et. al, (2007):
- hypothesizied that women with autism display superficial social skills and this is what causes them to be misdiagnosed

Koenig and Tsatsanis (2005):
- found that most autism research stemmed from male experiences alone
- Hartrung and Widiger (1998): concluded that when a disorder's symptoms change based on gender, diagnosis will be skewed towards those who outwardly express symptoms that are out of the social norm



Gender Bias in Autism and Asperger's Syndrome

Johnson, S.A. (2019). Understanding the violent personality: Antisocial Personality Disorder, psychopathy, & sociopathy explored. Forensic Research & Criminology International Journal, 7(2), 76-88. DOI: : 10.15406/frcij.2019.07.00267. 


Understanding the violent personality: Antisocial personality disorder, psychopathy, & sociopathy explored 

Changes from the DSM-IV to DSM-V:
- the term 'pervasive developmental disorders' was replaced by 'neurodevelopmental disorders' and subsumed under ASD
- autism was renamed as autism spectrum disorder
- merging of social and communication symptoms of autism into one domain
-including abnormalities in sensory processing under restricted behaviors
-changing the onset age criteria

These changes were supposedly created to ensure that autism was known as multi-dimensional, and would give clinicians a better understanding of cultural and gender-related factors.

Huerta et.al,:
-DSM-V is no better than DSM-IV at diagnosing women with autism
-looked at clinical records to see how sensitive the new criteria was, and compared estimated sensitivities for both men and women
- diagnostic sensitivity for women: .88 - .93
- diagnostic sensitivity for men: .89 - .92
This does not display a significant difference between DSM-IV and DSM-V.

Kim et, al,:
- epidemiological study in South Korean community comparing male to female ratio in DSM-IV versus DSM-V
- DSM-IV: 2.5:1 (male:female)
- DSM-V: 2.7:1 (male:female)


The DSM-V and Gender Bias in Autism and Asperger's Syndrome

Autism screening tools have all been developed on the 'male phenotype', and therefore are not helpful in diagnosing women. 

ASSQ (Autism Spectrum Screening Questionnaire):
- developed by Kopp and Gillberg in 1999 to test for Asperger's and high-functioning autism
- in 2011, they added 18 items onto the questionnaire that they believed would better address the female phenotype
- found that these questions better addressed female phenotype, and were able to differentiate between women with autism and women without autism through this questionnaire

ex.) Girls tended to respond 'yes' to four questions where boys tended to respond 'no' - avoiding chores or demands, daily activities hindered by repetitive behaviors, changing voice or speech, interacting mostly with younger children 

Limitations: in the original study, because the ASSQ was based on the male phenotype, any changes made may still not be fully representative of the female phenotype, needs more research

The Role of Diagnostic Screening Instruments in Gender Bias in Autism and Asperger's Syndrome

Essentially. what these studies are concluding is that:
- there are marked gender differences in women and men when it comes to autism spectrum disorder or asperger's syndrome 
- women may not always exhibit outwardly 'odd' behaviors, like men. This leads to a bias in diagnoses.
- lack of a 'female phenotype' when it comes to autism or asperger's
- most current autism or asperger's research is based in the male experience, therefore, it's harder to diagnose women when their symptoms have not been researched

Therefore, this paper proposes that there should be more research done on the female phenotype in autism.

Conclusions of studies on  Gender Bias in Autism and Asperger's Syndrome

- clinical or social work practice without up-to-date knowledge is harmful for patients
- clinicians. and social workers should keep tabs on developments in autism research, specifically with new diagnostic tools emerging
- autism has a high comorbidity with depression, anxiety, and other mental health concerns due to its isolating effects, but social workers and clinicians need to recognize this and treat accordingly
- diagnostic models are only models, they need critical thinking and examining of the clinician's own gender biases to be correctly used

ex.) Patient 'Sue' who had Asperger's syndrome, but was misdiagnosed as being depressed at age 14. The depression treatments she received were contradictory to the autism stimuli, resulting in a painful three years until she was correctly diagnosed at age 17.

Further Implications of the Gender Bias in Autism and Asperger's Syndrome

People with autism are more likely to rate themselves as being trans or nonconforming, reaching around 25% compared to the general population that shows 5% identifying as trans or nonconforming.

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