Autism spectrum conditions in women: diagnosis, mental health, and the role of camouflaging

The female phenotype of autism may cause a delay in diagnosis for autistic women. Studies show autistic females may camouflage their autistic traits and may have more mental health difficulties as a result. It has also been hypothesised that autistic women might be misdiagnosed with other conditions. The current investigation aimed to explore social and behavioural factors that might delay or prevent diagnosis, and factors that may influence the mental health pathways to diagnosis for autistic women. In the first and second study a nationwide survey was conducted to identify potentially autistic individuals, defined as those who score highly for autistic traits on the Autism Quotient (AQ) screening tool but have no formal diagnosis of autism (Study 1 n = 834, Study 2 n = 88), and comparing them to diagnosed autistic individuals (Study 1 n = 179, Study 2 n = 121) on a number of questionnaires measuring emotional and social abilities and mental health. In Study 3, eighty participants (40 autistic and 40 non-autistic) completed a self-reported camouflaging measure, a battery of executive functioning tasks, and theory of mind test. They were also video-recorded having a natural conversation with a researcher, which a further 127 non-autistic participants rated using a first-impression scale. In Studies 1 and 2, potentially autistic women had a significant empathy and social functioning advantage over diagnosed women, and were more likely to be diagnosed with Borderline Personality Disorder. However, they were less likely to have other psychiatric diagnoses, and had similar difficulties in friendship, theory of mind, self-monitoring, anxiety, and depression. Strong correlations were not found between social performance and age of Autism Spectrum Condition (ASC) diagnoses, or with mental health traits. Diagnosed autistic women were more likely than men to have other psychiatric diagnoses, and these were more likely to be received prior to an ASC diagnosis. In Study 3, no differences on self-reported camouflaging were found between autistic men and women, although both groups scored more highly than non-autistic controls, and camouflaging was not associated with theory of mind or executive functioning. However, autistic people were rated less favourably on first-impressions than non-autistic people, and males were rated less favourably than females. Furthermore, male raters were harsher in their judgements of autistic males. These ratings correlated with age of diagnosis, but not with camouflaging scores. Findings suggest that a combination of factors may delay diagnosis in women. Clinicians may be biased towards diagnosing other psychiatric conditions before ASC is identified. This may be because women present less typically than males and are judged less harshly by peers.