Content of the article.
In Peru, 7,058 people with Autism Spectrum Disorder (ASD) are registered[1] in CONADIS’s National Registry of Persons with Disabilities; of these, “82.3% are male and 17.6% are female” (MIMP, 2020). This proportion is consistent with international evidence showing “a differentiated prevalence by sex, such that males are diagnosed approximately four times more often than females” (Loomes, Hull & Mandy, 2017, cited in Montagut, Romero, Fernández & Pastor, 2018). This sex difference raises a question for specialists who study the condition: Why are more cases of autism diagnosed in males than in females?
In Peru, the National Plan[2] for People with ASD, approved in 2019, establishes actions across different sectors, prioritising early detection, diagnosis and intervention to support personal development (MIMP, 2020). It is therefore very important to understand current findings on possible answers to this question.
A first hypothesis is that, although the variability of autism is recognised, the tools used for diagnosis have not yet been updated sufficiently (Volkers, 2018). This is problematic because most of these tools were developed using predominantly male study populations, creating an assessment bias in which the diagnostic instruments themselves may not adequately capture differences between males and females. The situation is further complicated by evidence suggesting that a girl with ASD may show development that appears similar to that of an average neurotypical boy, even when there are significant differences compared with neurotypical girls (Szalavitz, 2016).
A second hypothesis proposes that the difference in diagnosis rates arises because people, including professionals themselves, may fail to recognise ASD characteristics in girls because they do not match the “autism stereotype”[3] they expect. This difference in how autism manifests is especially important in childhood and can hinder early detection and intervention for girls. On average, girls are diagnosed 1.8 years later than boys (Montagut, Romero, Fernández & Pastor, 2018). What exactly are these differences in girls with ASD?
First, the restricted behaviours or interests of girls with ASD may appear less different from those socially expected for their gender. They may have more typical interests such as books, celebrities, fashion or dolls; nevertheless, their interests can still differ qualitatively because of their restricted or intense nature (Ruggieri & Arberas, 2016). Second, girls may show greater motivation to perform “well” in the social world, which can lead them to camouflage characteristics associated with autism. This motivation to “fit in” can help them conceal difficulties reading social situations by imitating others and may increase the likelihood of forming friendships (Sissons, 2019). Nevertheless, camouflage camouflaging can be extremely exhausting because it involves substantial cognitive, emotional and physical effort, which is linked to high levels of stress, anxiety and depression in this group. Third, the strain and stress generated by pressure to act according to social norms may manifest differently than in boys, for whom behaviours such as hyperactivity and disobedience may be more visible (Bargiela, Steward & Mandy, 2016).
This inequality becomes problematic when people close to a girl retain an “autism stereotype” centred on a boy who shows little interest in the social world, is isolated, and has restricted interests such as mathematics or trains (Sissons, 2019). As a result, people around the girl may judge her against average children and not seek a specialist opinion. The hypothesis also considers that professionals who have not reflected on their own preconceptions about autism may be guided by this apparent social functioning and focus on other characteristics. ASD may then be ruled out and an incorrect diagnosis such as ADHD[4] or OCD[5]may be given instead of investigating the characteristics more deeply. A third hypothesis attributes the difference in diagnosis rates to neurobiological differences associated with sex (Szalavitz, 2016). This position is based on theories linking autism to so-called male-brain traits and suggesting that women may have protective neurological factors, such as a greater disposition toward empathy. According to this view, even with better diagnostic tools and the elimination of stereotypes, a difference in the proportion of cases between males and females may remain.
Overall, the literature on this subject is relatively recent and much remains to be studied. What can be taken from these positions is that gender clearly plays a role in the experience of people with ASD (Mandavilli, 2015). There is also evidence that autistic women may be more vulnerable to manipulation and abuse (Bargiela, Steward & Mandy, 2016; Szalavitz, 2016). This creates a need to update and refine understanding of ASD in women in order to ensure accurate diagnosis, since this can enable early intervention and improve future quality of life. Did you already know about these differences in ASD among girls? What do you think about this gap in early detection?
Bibliography:
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Bibliographic references:[1] Autism spectrum disorder. According to the World Health Organization (2016), ASD is understood as a neurodevelopmental condition associated with difficulties in the development of social and communication skills and with restricted and repetitive behaviours. This is a broad definition because the characteristics of the condition vary from person to person, in addition to the barriers that may hinder each person’s development.
[2] The National Plan for People with Autism Spectrum Disorder (ASD) 2019–2021 was approved through Supreme Decree 01-2019-MIMP (MIMP, 2020).
[3] A stereotype is a widely used and therefore widespread representation of an object or group from which that object or group is characterised. In the case of autism, the media have reinforced a predominantly male representation of the condition, with characteristics such as social isolation, lack of eye contact, and interests such as mathematics or trains. The problem is that these characteristics do not fit every case of autism because, as with most conditions, its manifestation is neither unique nor uniform across the lifespan, and this is particularly clear in differences between autistic boys and girls (Sissons, 2019).
[4] Attention deficit hyperactivity disorder. ADHD has been defined as a neuropsychological disorder affecting the development of executive-control and behavioural-inhibition mechanisms, with a strong genetic component. Its characteristics usually appear in childhood and include difficulty sustaining attention, inhibiting behavioural impulses and, in some cases, hyperactivity (Cerván & Romero, 2017; Fernándes, Piñon and Vázquez, 2017).
[5] Obsessive-compulsive disorder. This disorder is characterised by recurrent and intrusive thoughts known as obsessions, which cause anxiety. The distress produced by these thoughts is followed by repetitive behavioural or cognitive actions known as compulsions (NIMH, 2020; Vellosillo & Vicario, 2015).
