Why Puberty Is a Turning Point for Autistic Girls
Autism spectrum disorder (ASD) is a complex neurodevelopmental condition characterized by differences in social interaction, communication, and patterns of behavior (American Psychiatric Association, 2013). These differences often include challenges in nonverbal communication, relationship development, and a strong reliance on routines and predictability. However, the development of diagnostic criteria and much of the existing research on autism have historically been shaped by a male-centered perspective (Happé & Frith, 2020). For decades, autism was widely viewed as a predominantly male condition, resulting in limited understanding of how autism presents in girls and women (Estrin et al., 2021; Moore et al., 2022; Saxe, 2017).
Adolescence is marked by rapid biological, psychological, and social change as individuals transition from childhood to adulthood (Collins & Steinberg, 2006; Steinberg, 2020). Puberty, a central component of this stage, involves significant hormonal and physical changes, including breast development, the onset of menstruation, and the growth of body hair. These biological changes occur alongside cognitive and emotional development, making adolescence a period of heightened vulnerability even for typically developing youth.
For autistic girls, puberty may begin earlier and feel more overwhelming. Research suggests that approximately 58% of autistic girls experience the onset of puberty before the age of 11 (Corbett et al., 2020). Early pubertal timing has been associated with increased anxiety and greater difficulty adapting to developmental change (Stenson et al., 2021). Despite these risks, the unique challenges autistic girls face during puberty often receive limited attention, and preparation for this transition is frequently delayed or insufficient (Larson et al., 2021). For adolescents with ASD, the convergence of biological, emotional, and social demands during puberty can intensify existing difficulties with regulation, communication, and adaptive functioning (Chan & John, 2012; Levy & Perry, 2011; Seltzer et al., 2004; Esbensen et al., 2010).
Why Autism in Girls Is Often Missed
Although boys are diagnosed with autism more frequently than girls, this difference does not indicate that autism is less prevalent among females (Loomes et al., 2017). Rather, autistic girls are less likely to present with the “classical” traits emphasized in traditional diagnostic criteria. Compared to autistic boys, girls often demonstrate stronger socio-cognitive skills, such as greater awareness of social norms, more expressive facial communication, and a stronger desire for social connection (Lehnhardt et al., 2016; Tubío-Fungueirino et al., 2020). These characteristics may mask underlying difficulties, allowing autistic girls to go unnoticed or misunderstood.
As a result, autistic girls remain understudied, unidentified, and under supported (Haney & Cullen, 2017). Research shows that girls are less likely than boys to receive an autism diagnosis even when they display comparable levels of symptom severity (Geelhand et al., 2019; Russell et al., 2011). This diagnostic disparity contributes to delayed access to supports and interventions that are critical during key developmental periods.
Gender bias in autism diagnosis has led many autistic girls to be overlooked, misdiagnosed, or identified later in life (Carpenter et al., 2019; Gould & Ashton-Smith, 2011). Delayed or missed diagnosis can have long-term consequences, limiting access to appropriate educational, emotional, and social supports and negatively affecting developmental outcomes and quality of life (Taylor & DaWalt, 2020).
Hormonal Changes and Emotional Regulation
Autism spectrum disorder (ASD) affects brain development in ways that influence communication, emotional regulation, flexibility, and sensory processing. Autistic individuals often experience heightened difficulty adapting to change and managing transitions, alongside patterns of rigid or repetitive thinking and behavior. Differences in sensory processing may include hypersensitivity or hyposensitivity to internal and external stimuli, which can significantly affect daily functioning. In addition, many autistic individuals experience co-occurring mental health conditions, including anxiety and depression (Lai et al., 2019).
Because predictability and routine are often central to emotional regulation in ASD, periods of rapid developmental change can be particularly challenging. Puberty introduces sudden biological and hormonal shifts that disrupt established routines and bodily expectations. Research suggests that autistic individuals may respond more intensely to these changes, sometimes in ways that appear maladaptive, as they attempt to regain a sense of control and stability (Chandler et al., 2022).
Despite the significance of these changes, relatively little is known about how autistic females experience reproductive transitions, including menstruation. This lack of understanding reflects several interconnected gaps in research. Historically, autism research has focused primarily on children, based on the assumption that ASD is a childhood condition, leaving adolescent and adult experiences underexplored (Kiehl et al., 2024). Additionally, research involving individuals with neurodevelopmental and communication differences often relies on caregiver reports rather than first-person perspectives, increasing the risk of recall bias and limiting insight into lived experience.
Gender inequities in medical and psychological research further contribute to this knowledge gap. Women and girls have long been underrepresented in clinical research, including autism studies, resulting in limited data on how biological processes such as hormonal fluctuations affect mental health across the lifespan (Merone et al., 2022; Liu & DiPietro Mager, 2016). As a result, the mental health effects of hormonal changes—whether naturally occurring during puberty or influenced by hormonal contraceptives—remain poorly understood. Notably, despite the widespread use of hormonal contraception globally, large-scale investigations into its mental health effects did not emerge until relatively recently (Skovlund et al., 2016).
Autistic females have been particularly excluded from autism research, reflecting a long-standing perception of autism as a predominantly male condition (D’Mello et al., 2022; Grove et al., 2024). This exclusion has reinforced clinical and societal biases and limited understanding of how autism manifests in females across developmental stages. Surveys conducted by autistic-led organizations further highlight this gap, with many autistic respondents identifying research focused on women and girls as a critical unmet need (Australian Autism Research Council, 2019).
Sensory Challenges during Puberty & Menstruation
Puberty involves significant hormonal and physiological changes, including the development of secondary sexual characteristics such as breast growth, body hair, and the onset of menstruation (Sawyer et al., 2018). For autistic girls, these changes may occur earlier than expected and can be seen as particularly distressing. Research indicates that approximately 58% of autistic females begin puberty before the age of 11, which may intensify anxiety and reduce their capacity to cope with rapid developmental transitions (Corbett et al., 2020; Stenson et al., 2021).
Menstrual-related challenges are consistently reported at higher rates among autistic individuals. These include dysmenorrhea, menorrhagia, amenorrhea, and irregular menstrual cycles (Ames et al., 2024; Hamilton et al., 2011; Ingudomnukul et al., 2007; Pohl et al., 2014; Skinner et al., 2005; Simantov et al., 2022). Sensory sensitivities, combined with differences in interoception—the ability to recognize and interpret internal bodily signals—may heighten awareness of menstrual discomfort while simultaneously limiting the ability to clearly communicate pain or distress (Cummins et al., 2020; Gray & Durand, 2023).
Communication differences can further complicate these experiences. Autistic individuals may struggle to label physical sensations, describe pain intensity, or recognize when discomfort warrants support. As a result, menstrual pain may go unrecognized or untreated, particularly when distress is expressed through behavioral changes rather than verbal complaints. Delays in seeking or receiving support may be compounded by social and cultural discomfort surrounding menstruation, increasing the risk of prolonged distress (Kapos et al., 2024).
Together, sensory sensitivities, communication challenges, and limited access to appropriate support create a complex landscape in which puberty and menstruation can significantly disrupt emotional regulation and daily functioning for autistic girls.
Mental Health Problems during Puberty
Puberty is initiated through activation of the hypothalamic–pituitary–gonadal (HPG) axis, which triggers a series of interconnected neuroendocrine processes, including gonadarche, adrenarche, and rapid physical growth (Buck Louis et al., 2008; Dahl, 2004). These hormonal changes play a central role in physical development and also influence emotional regulation, social motivation, and vulnerability to mental health difficulties (Forbes & Dahl, 2010; Sisk & Foster, 2004).
Atypical pubertal timing has been associated with increased psychological risk, particularly when puberty begins earlier than expected. Early pubertal onset has been linked to higher rates of depression and anxiety in females, as well as greater sensitivity to social stressors and body image concerns (Kaltiala-Heino et al., 2003; Waylen & Wolke, 2004; Llewellyn et al., 2012). These risks may be amplified for autistic girls, who already experience heightened vulnerability to internalizing mental health conditions.
Research suggests that puberty may coincide with a temporary or prolonged decline in functioning for some autistic individuals. Studies have documented increases in aggression, obsessive behaviors, emotional dysregulation, and repetitive behaviors during adolescence, along with declines in adaptive, linguistic, and cognitive functioning (Gillberg & Steffenburg, 1987). Girls appear particularly susceptible to extended periods of deterioration during pubertal transition, underscoring the need for early monitoring and targeted mental health support.
Despite these risks, the adolescent period remains underrepresented in autism research, and the role of pubertal development in shaping mental health trajectories is not yet fully understood (Picci & Scherf, 2015). This gap limits the ability of clinicians, educators, and families to anticipate challenges and provide timely; preventative supports during a critical developmental window.
School and Social Challenges
Adolescence is marked by significant environmental and social changes, including the transition to secondary school, which often coincides with pubertal development (Dane et al., 2025). During this period, relationships with peers increasingly take precedence over relationships with parents and teachers. This social reorientation is accompanied by a heightened desire for acceptance and increased sensitivity to peer evaluation and rejection (Brown, 2004).
For autistic adolescents, the growing complexity of social expectations can intensify existing challenges. Peer interactions become more nuanced and less structured, requiring greater flexibility, perspective-taking, and social inference—skills that may be particularly demanding for autistic youth (Tantam, 2003). As a result, social difficulties may become more visible during adolescence, contributing to increased feelings of loneliness, anxiety, and depression (Bellini, 2006).
Peer groups during adolescence also tend to become more self-selecting, often forming around shared interests, social norms, and communication styles. While puberty may increase opportunities for peer interaction, these dynamics can inadvertently heighten social exclusion for autistic students (Ryan, 2000). Research consistently shows that autistic adolescents are at greater risk of victimization and bullying compared to their non-autistic peers (Humphrey & Symes, 2011; Kloosterman et al., 2013; Rowley et al., 2012). Although the emotional and developmental consequences of bullying in autistic youth remain underexplored, existing evidence suggests a strong association with worsening mental health and social withdrawal.
Role of Parents and Caregivers
Adolescence represents a critical developmental period characterized by profound physical, cognitive, emotional, and social changes. When these developmental demands intersect with the core characteristics of autism, autistic girls may experience unique or intensified challenges during puberty (Corona et al., 2016; Visser et al., 2017). While family members, peers, and schools typically serve as primary sources of guidance during adolescence, autistic girls may have limited access to peer-based learning due to social communication difficulties, leaving families with an increased support burden (Erbaş & Kurt, 2022).
The physiological and emotional changes associated with puberty can generate significant anxiety for both autistic girls and their families. Many parents report feeling underprepared to support their children through menstruation, body changes, and emerging emotional needs (Cummins et al., 2020; Mademtzi et al., 2018; Güven, 2021). The onset of menstruation represents a major transition that requires new self-care skills, body awareness, and emotional adjustment (Bitsika & Sharpley, 2018; Gönenç et al., 2020).
Without clear guidance and appropriate supports, families may struggle to address sensory discomfort, hygiene routines, and emotional regulation during this stage. This highlights the importance of proactive education and collaborative support between caregivers, healthcare providers, and educators to reduce stress and promote adaptive coping during puberty.
How Professionals Can Better Support Autistic Girls
Because adolescents spend a significant portion of their time in school, educational settings play a central role in supporting developmental transitions such as puberty. School-based interventions commonly fall into peer-focused or student-focused approaches. Peer-focused interventions may include peer education and structured interaction opportunities, while student-focused interventions emphasize skill development and self-regulation strategies. Despite their differences, effective peer-focused programs share several core elements, including participant identification, training, opportunities for interaction, adult facilitation, and ongoing evaluation (Carter et al., 2014).
Educators also play a critical role in partnering with families to support autistic girls through pubertal transitions. Strong family–school collaboration promotes consistency, shared understanding, and early identification of emerging challenges (Garbacz et al., 2017). These partnerships enable targeted interventions that address social, emotional, and sensory needs during puberty (Barnett, 2025).
Evidence-based strategies such as visual supports, task analysis, self-management routines, and self-monitoring checklists can be particularly effective in reducing anxiety and improving comprehension for autistic students (Hart Barnett et al., 2018; Wong et al., 2015). By breaking complex or abstract tasks into predictable steps, these structured approaches support independence and emotional regulation. Practical tools—including step-by-step hygiene guides, clothing preference charts, emotion-regulation menus, and daily routines—can be integrated into both school and home environments to foster autonomy and well-being during this critical developmental stage.
Conclusion – Moving from Misunderstanding to Support Autistic Girls During Puberty
Autism spectrum disorder is a complex neurodevelopmental condition that has historically been understood through a predominantly male-centered lens. As a result, the unique experiences of autistic girls, particularly during puberty—have often been overlooked. Evidence indicates that many autistic girls experience pubertal onset earlier than expected, which may intensify anxiety and complicate emotional and behavioral regulation during adolescence.
Although boys continue to be diagnosed with autism more frequently than girls, this disparity reflects differences in identification rather than prevalence. Autistic girls may present with less overt or “classical” traits, contributing to delayed diagnosis and limited access to support. When puberty-related changes intersect with sensory sensitivities, communication differences, and social challenges, the risk for mental health difficulties increases.
Research highlights elevated rates of menstrual difficulties, emotional distress, social exclusion, and bullying among autistic adolescents, yet significant gaps remain in understanding their lived experiences. Families and educators often report feeling underprepared to support autistic girls through these transitions, underscoring the need for early, coordinated, and evidence-based approaches.
By increasing awareness, addressing gender bias in autism research and diagnosis, and strengthening collaboration among families, schools, and healthcare providers, it is possible to better support autistic girls during puberty. With timely preparation and appropriate supports, this critical developmental stage can become an opportunity to promote resilience, autonomy, and long-term well-being.
To contact the author, please email zainiftikharhussain@gmail.com.
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