Art by Samatha Miller
Gender biases in psychology and psychiatry impact how mental health professionals view the statistical likelihood of neurodiversity diagnosis, and influence diagnostic outcomes which gate keep diagnosis and support services. Males are three times more likely than females to be diagnosed with ADHD and autism, according to existing research ratios.
Diagnostic standards for autism and ADHD still revolve around research done on young males in previous decades. This gender-biased research leaves ADHD and autistic presentation in cisgender women, nonbinary people and other gender minorities under-researched and not adequately considered in the current diagnostic criteria.
It is frustrating that the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision (DSM-5-TR) missed the opportunity to create a more nuanced inclusive diagnostic model for autism. The American Psychiatric Association, which updated the DSM-5-TR in March, creates barriers against diagnosis by clinging to an outdated stereotyped model of autism.
The Center for Neurodivergence started a petition in March against this revised text, arguing it makes it harder for people to receive an autism diagnosis who do not present their autism in the stereotypical diagnostic pattern.
Research shows that many autistic girls and women present their autism differently than most boys and men. However despite some discussion of gender differences in autism presentation in its discussion section, the actual diagnostic model of autism in the DSM-5-TR created stricter autism diagnosis criteria which are more entrenched in male presentation stereotypes.
The autism diagnostic model now requires all stereotypical forms of presentation to be met for an autism diagnosis, whereas the standards prior to the text revision left clinicians with more discretion in diagnosis, because there was ambiguity if all criteria had to be met.
Examples of the stereotypical behavioral presentations in the DSM-5-TR include persistent deficits in social interactions and social communication seen in multiple contexts which must contain all of the following “deficits in social-emotional reciprocity, in nonverbal communicative behaviors used for social interaction, and in developing, maintaining and understanding relationships.”
For example, clinicians must look for “deficits in social-emotional reciprocity” which the DSM-5-TR defines as an “abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.”
How does that stereotype of autism make space for a chatty, extroverted autistic person who understands social relationships and has a lot of friends?
The old DSM-5 autism criteria did not require all diagnostic conditions to be met for an autism diagnosis, but the DSM-5-TR does. Additionally, the DSM-5-TR requires restricted patterns of repetitive interests, behavior or activities to be present or that all the autism diagnostic criteria previously manifested in the person’s developmental history.
These criteria do not apply to all autistic people and diagnosis requiring these stereotypes ignores how diverse autistic people are. People from various genders, sexual orientations and cultures may express themselves differently and do not fit clinicians stereotypes about autism.
Many autistic people are women and part of the LGBTQ+ community, but research on autism has traditionally been focused on cis boys and men. Past researchers not adequately studying autistic women and sexual and gender minorities created lost generations in autism research, and this makes diagnosis a harder process for those people that do not fit autism diagnosis stereotypes.
Film producer and Arizona State University professor Zhara Astra experienced navigating the gauntlet of late diagnosis herself. Astra has spoken openly about the challenges women often face seeking the correct diagnosis of their neurodiversity.
As Astra said because girls and women often experience signs of autism and ADHD internally and in ways that are not as externally visible, women’s internal experiences of neurodiversity get missed in diagnosis.
“Women may have less outwardly visible symptoms but there is a lot going on internally with us,” Astra said.
Autistic women are more likely to experience anxiety, depression and eating disorders than autistic men as well as receive later diagnosis of their autism. Late diagnosis puts people at increased risk for depression and anxiety due to not getting the mental health support they need.
Research from Anne Kirby and her colleagues found that suicide risk in autistic females is “over three times higher than in females without autism.”
Perhaps because many autistic girls do not show marked language delays and tend to camouflage their autism more than autistic boys, they have a harder time being appropriately diagnosed and getting support in a timely manner.
Research reveals gender and cultural biases impact assessment. Sometimes even when people disclose all aspects of their neurodiversity and life history — thereby creating a space to prove their neurodiversity — some clinicians do not feel people’s presentation, personal narrative or history matches that clinician’s interpretation of the diagnostic criteria. There is a degree of subjectivity in the diagnosis process.
Clinicians see all these variables through their own conscious and unconscious gender and cultural biases. Not all neurodiversity assessments are equally researched or deliberated in as bias-free a manner as possible.
Autism can also be hard to recognize sometimes even in oneself. Sometimes autistic people as a result of camouflaging do not even consciously realize they are autistic until adulthood.
Demi Burnett, who was on season 23 of The Bachelor, announced her official autism diagnosis via Instagram on Feb.19 and wrote about her realization she was autistic in her adulthood. Burnett wrote that discovering her autism helped her understand herself better and see herself in a more positive light.
“I want to make sure anyone who is feeling like me knows you aren’t alone. It can get better,” wrote Burnett in a February Instagram post.
Knowing she is autistic helped Burnett adjust her life to better meet her sensory needs. On March 27, she posted a picture of herself on Instagram, smiling and wearing headphones and shared how much the noise canceling function improved her sense of calm and prevented her from feeling “overwhelmed and overstimulated” by loud sounds.
California Institute of Integral Studies professor Nick Walker also advocates to better the lives of autistic people by focusing her advocacy on neurodiversity’s intersectionality with sexual and gender minorities. Walker wrote that LGBTQ+ people are also underrepresented in autistic research and future research needs to better reflect the intersectionality of the autistic community with the LGBTQ+ communities.
Research from Elizabeth Weir and her colleagues found individuals who do not identify as their sex assigned at birth are three to six times more likely to be autistic. Since autistic people are more likely to be members of sexual and gender minorities, representations of the LGBTQ+ community need to be better incorporated in neurodiversity research and diagnostic criteria.
Current criteria primarily based on research from cisgender heterosexual boys and men is a poor fit for the experiences of people who are not from those identity communities.
Seeing past heterosexist biases and giving all people the correct diagnosis and timely support they need is vital. More research is needed on how neurodiversity presents in varied genders and sexualities, and the heterogeneous nature of clinical presentations needs to be taken into account in diagnostic standards.
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Email Joshua Evans: josh.evans@pepperdine.edu
