Over the past several years, there has been increased interest in gender differences within autism spectrum disorder (ASD) and how these differences impact initial diagnosis as well as treatment across the lifespan. According to recent research conducted by Kreiser and White (2014), females diagnosed with ASD present with unique characteristics in each aspect of the diagnostic criteria when compared to their male counterparts. For example, regarding social communication, females tend to engage in imaginative and pretend play from a young age. Their speech also contains more vocabulary words related to emotions, compared to traditional diagnostic criteria of ASD often found in males. It has also been observed that females with ASD tend to have greater awareness and desire for interpersonal social interaction, propensity to mimic others in social interactions, tendency to camouflage difficulties by developing coping strategies, and develop one or two close friends compared to their male counterparts. Different than the traditional restricted interests in inanimate objects often described within males with ASD, many females with ASD tend to have restricted interests related to people and animals (e.g., celebrities, pets). Additional characteristics found within women with ASD include perfectionist tendencies and disordered eating (Lai et al., 2015).
One explanation for the varied symptoms of males and females within ASD is our gender-specific societal expectations and norms in the US. Beginning in childhood, female play groups, for example, are often more intimate than male play groups and involve greater expectations for conversation skills, empathy, and emotion-focused language. These expectations can provide females with ASD more opportunities to observe and mimic socially expected interpersonal skills such as turn-taking and reciprocal conversation during their early development (Kreiser & White, 2014).
At the same time, the social intricacies and demands placed on women with ASD may also be greater than those placed on males with ASD across the lifespan in the US. As a key task of adolescence is gender role development, what it means to be a man or a woman, it is no surprise that differences in societal expectations for males and females surge during this time period (Mahalik et al, 2005). For example, the demands for feminine gender norms in dominant U.S. culture include the importance of developing caring relationships with others, being involved in romantic relationships, investment in one’s appearance, modesty, sexual fidelity, and responsibility for and enjoyment of domestic chores and childcare (Mahalik et al., 2005). In the general female population in the U.S., conformity to feminine norms (e.g., investment in interpersonal relationships) has been associated with mental health outcomes such as depression beginning in adolescence (Barrett & White, 2002) and continuing through adulthood (Broderick & Korteland, 2002). Since females are expected to value, act nicely in, and be engaged in relationships with family, peers, and romantic partners, they may experience pressure to maintain these relationships at costs to themselves (Fiese & Skillman, 2000). These costs include females silencing their own needs and opinions in order to maintain caring relationships with others (Brown & Gilligan, 1992). While their relationships stay successful, this silencing of one’s own needs and opinions is linked to greater symptoms of depression (Danielsson, Bengs, Samuelsson, & Johansson, 2011; Tolman et al., 2006). Males are also confronted with their own masculine gender norms including that they must control their emotions and rely solely on themselves to solve life’s problems. Masculine gender norms also include taking risks and competition, placing priority on work over family, and exhibiting power and even violence over women (Mahalik et al., 2003). Given that the fact that many feminine gender norms focus on interpersonal relationships, while masculine norms favor reliance on one’s own skills and resources, it is no surprise that this creates a challenging and unique crossroads for females with ASD, who face complex social challenges.
Some women with ASD may be interested in developing and navigating these roles, but find the inherent social demands of these multiple roles (e.g., friend, romantic partner, mother, daughter, caretaker) to be overwhelming and unattainable. Other women may not be attuned to and/or interested in investing in these roles. Additionally and unfortunately, statistics continue to show that women, due to a variety of factors including gender norms for both men and women, are more likely to be victims of intimate partner abuse and violence. Young women diagnosed with ASD may be even more susceptible to these dangers due to their difficulties both in recognizing social cues and engaging in self-advocacy (Willey, 2012). Because of the increasing social demands and complexity of interpersonal relationships during young adulthood, some studies have shown that young women diagnosed with ASD are more susceptible to anxiety, depression, somatic symptoms, eating disorders (i.e., anorexia nervosa), and difficulties with sleep (Kreiser & White, 2014).
Therefore, to help women with ASD understand, navigate, and make informed choices regarding how they want to successfully live their adult lives, gender-specific supports and interventions are necessary and required in today’s society. What might these supports look like? Beginning in adolescence, females with ASD (and females in general) would benefit from direct exposure to societal expectations and norms regarding expectations for investing in interpersonal relationships (e.g., friendships, romantic partnerships, children) and one’s appearance, as well as showing modesty towards others about one’s strengths and accomplishments (Mahalik et al., 2005). Female adolescents, including those with ASD, would benefit from viewing examples of societal attitudes in everyday media (e.g., television shows, commercials, magazines, etc.) to help build their awareness of these topics. Exposure to these societal norms helps to develop greater awareness and conscious-raising of societal attitudes and its impact on everyday life. After females have been exposed to these societal gender norms, it is important that they be provided with opportunities to discuss their own goals and values and how they relate to societal norms. For females with ASD, it is important to provide explicit discussions of both the costs and benefits of choosing to abide by or reject traditional female role norms. Their impairments in perspective taking may limit their ability to understand these social consequences. These discussions can be completed in psychoeducational support groups that provide a safe place to discuss one’s perspectives, ideas, and concerns as well as opportunities to gain peers and learn skills.
For those women with ASD who choose to conform to feminine norms, valuing an investment in interpersonal relationships (e.g., friendship, romantic partnership, motherhood, caregiver), it is essential that they have lifelong access to support groups to obtain social support and skills instruction regarding the unique demands (and benefits) of these varied interpersonal relationships. For example, direct skill instruction regarding communication skills necessary for each interpersonal role through discussion and role plays would be helpful. Example themes include honest communication with one’s romantic partner, self-disclosure of one’s challenges to a new friend, and limit setting with one’s children. In addition, specific examples presented through sharing of personal experiences, vignettes, or media images of both healthy and unhealthy interpersonal relationships (e.g., when a partner is taking advantage of another) would help to illuminate key signs to observe in one’s day-to-day interactions as suggested by Willey (2012).
In addition to direct skill instruction and social support around the development and maintenance of interpersonal relationships, women with ASD need opportunities to discuss and practice self-care practices as a means of relaxation as well as to treat co-occurring mental health symptoms such as anxiety and depression. Furthermore, there has been increased discussion of the need to more routinely discuss and utilize the strengths of women with ASD within social and mental health supports and interventions. More specifically, Australian psychologist Tania Marshall views women diagnosed with ASD as possessing an abundance of strengths that she describes in her popular book series Aspien Girls. Some examples include creativity, strong will, keen attention to detail, honesty, and special interests in areas such as nature, animals, children, and art that have the potential to yield activism and prosocial involvement with others in one’s community (Attwood, et al., 2006).
Outside of these structured social support and skill groups, a leading expert on women with ASD, Liane Holliday Willey Ed.D., suggests that women identify a trusted “go-to” person (e.g., family member, friend, or mentor) who understands the woman’s strengths and challenges. This person can be used as an additional resource to check in with when one feels unsure or confused about a friendship or potential romantic partner. This “go-to” person can provide feedback to allow one to further develop and generalize perspective taking skills learned in support groups to evaluate another person’s intentions (e.g., “Are they taking advantage of me? How will I know?”; “Is he being genuine?”; Willey, 2012).
Finally, what about the group of women with ASD who decide that their values are not aligned with traditional feminine gender norms? While somewhat controversial, recent research in the Netherlands showed that 8 percent of a sample of children and adolescents admitted into a gender identity clinic were also diagnosed with ASD (de Vries et al., 2010). Additionally, Jones and colleagues (2012) found that female-to-male transgender individuals had higher rates of autistic symptoms compared to male-to-female transgender individuals. While this perceived linkage between gender identity and ASD still requires investigation, the need to support individuals with ASD who do not conform to traditional gender role norms is clear. It is equally important that these individuals receive similar opportunities to gain support and skill instruction to attain their personal goals and values in society.
In summary, there has been much recent attention paid to gender differences in the manifestation of ASD across the lifespan. In light of these new insights, it has been made abundantly clear that gender-specific interventions are needed to support the social and general well-being of both men and women across the lifespan. Due to the increased pressure for interpersonal relationship investment and success for women, specific supports and interventions for women who choose their values (and for those who do not) are essential to supporting the overall and continued mental health and well-being for this population across the lifespan and particularly during adulthood.
Dr. Alyssa Milot is a licensed psychologist at Massachusetts General Hospital’s Lurie Center and Aspire. For more information, email amilot@mgh.harvard.edu.
References
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