Hidden Signals: Why Autism in Women and AFAB People Is Often Missed

Understanding the Barriers to Identification and What Can Improve Diagnosis

In this month’s edition, Senior Clinical Psychologist Dr Joseph Allan Sakdalan and Doctor of Psychology (Clinical Psychology) Candidate, Melissa Strang shares insights into one of the most persistent diagnostic gaps in mental health: the under-identification of autistic women and people assigned female at birth (AFAB). This article highlights how longstanding biases, masking, and gendered expectations continue to obscure autistic profiles, and why a neurodiversity‑affirming approach is critical for accurate assessment. Read on to explore these hidden diagnostic signals.

 

Systemic Diagnostic Bias and the ‘Male’ Autism Model

Systemic diagnostic bias persists across clinical settings, often leading to the underdiagnosis of autistic women and AFAB individuals. This occurs because diagnostic tools and clinical expectations have focused on stereotypical ‘male’ presentations of autism. Consequently, assessments that emphasise male-coded, easily observable childhood markers, such as conspicuous repetitive behaviours or obvious social-communication difficulties, fail to account for camouflaging, sensory sensitivities, or social coping strategies that lead to exhaustion or shutdown. As a result, many autistic women and AFAB people are overlooked or their presentations misinterpreted as mood disorders, personality issues, or psychosocial stress (3,9,11)

 

Masking, Camouflaging, and Diagnostic Overshadowing

Masking and camouflaging are common among autistic women. Many learn to mimic typical social behaviour, suppress stimming, or adapt routines to meet neurotypical expectations, thereby obscuring the severity of underlying difficulties. Masking can create a misleading impression of resilience, but it is associated with higher anxiety, depressive symptoms, and emotional exhaustion and dysregulation, that may emerge later, especially under stress. Diagnostic overshadowing compounds this risk, with presentations misattributed to anxiety, trauma, or relational challenges rather than neurodevelopmental differences (7).

 

The Cumulative Impact of Late Diagnosis

Late diagnosis can carry cumulative consequences. Without timely identification, autistic women and AFAB individuals may experience trauma, invalidation, exacerbated mental health issues, and fragmented access to supports. Stigma around labels may compound barriers, and retrospective recollections of childhood struggles may be normalised or minimised within families where traits were present but not recognised. The result can be a cycle of under-recognition that shapes self-understanding and help-seeking (2, 4, 13).

 

A Culturally Safe and Neurodiversity‑Affirming Path Forward

A culturally safe, evidence-informed approach offers a path forward. Neurodiversity-affirming, strength-based, and trauma-informed practices help clinicians view autistic and ADHD traits as part of a broader neurodevelopmental profile rather than deficits (5). Comprehensive assessments should evaluate co-occurring conditions, gather reliable collateral information, and rely on thoughtful clinical formulation to guide recommendations. Screening instruments validated for women and AFAB populations and for autism-ADHD overlap should be used alongside structured interviews, collateral history, and functional observations (3,11).

 

Guidance for Clinicians: When to Refer and What to Consider

When autism and/or ADHD are suspected, it is advisable to refer clients for a comprehensive psychological and neurodevelopmental assessment, particularly when they exhibit persistent anxiety or depression, emotion regulation difficulties, burnout, or complex trauma that has not improved with standard treatments. Indicators that may justify a referral include enduring social exhaustion or shutdown after interactions; significant effort to mask and fit in, followed by fatigue; sensory sensitivities and overwhelm; a lifelong tendency toward the need for predictability or sameness; attentional fluctuations, procrastination, time management challenges, or inconsistent performance across different settings; and repeated misdiagnoses or treatment stagnation. A practical initial step involves explicitly asking about masking behaviours and sensory experiences, conducting a brief neurodevelopmental screening, and collecting collateral information such as school reports or family history before making a referral. It is important to incorporate multiple data sources and adopt a trauma-informed approach to ensure accurate diagnosis and appropriate interventions.

At the Cairnmillar Institute Counselling Clinic, the Complex Psychological Assessment Service (CPAS) is structured around a comprehensive, formulation-driven model. CPAS offers psychological evaluations for clients with complex presentations, including mental health, trauma, personality, neurodevelopmental, neurocognitive/neuropsychological, and forensic issues. Our approach is neurodiversity-affirming, trauma-informed, and evidence-based, emphasising the integration of multiple data sources to clarify diagnoses and provide practical recommendations, aligning with the detailed assessment process outlined above.

 

The Role of Complex Psychological Assessment Services

High-quality assessment services exemplify best practice by combining structured diagnostic interviews, validated screening tools, collateral developmental history, and functional observations. Additionally, neurocognitive, mental health, and personality assessments are included, and when clinically necessary, further evaluations are conducted. This comprehensive approach ensures accurate differential diagnosis, especially when differentiating between trauma responses, mood and anxiety disorders, ADHD, and autism. It also aids in identifying co-occurring conditions and guides effective treatment planning and ongoing support.

For clinicians, it is essential to recognise that many individuals diagnosed with autism later in life have had their experiences misinterpreted as stress or simply mood related. A thorough exploration of longstanding fatigue, social exhaustion, sensory overload, or ongoing attention difficulties can offer valuable insights and lead to more accurate screening. Clinicians should enhance referral quality by collecting collateral information such as school reports, family history, or observations from partners or family members. Continuing professional development regarding masking, gender-specific expectations, and culturally sensitive practices remains crucial.

Curious to know more? Listen to our latest episode of How’s That Working for You? – on Late‑diagnosed autistic women (Episode 7) featuring Dr Zoë Krupka with Annie Pollock (she/her), a clinical naturopath & Psychology Honours graduate at Cairnmillar, who brings both research insight and lived experience of late autism diagnosis. Their discussion offers a grounded and accessible extension of the issues raised in this article.

Whether you are a practitioner or someone curious about late diagnosis, these resources offer grounded and compassionate insights to support more accurate and affirming care.

 

About Dr Joseph Sakdalan: Dr Joseph Sakdalan is a Senior Clinical Psychologist who specialises in complex presentations and neurodevelopmental assessment. He is committed to neurodiversity‑affirming, evidence‑based practice and supporting clients to develop insight, resilience, and meaningful change. Clients aged 12 and older who require complex assessments can see him in the North Melbourne Clinic.

 

About The Cairnmillar Institute: Established over 60 years ago, The Cairnmillar Institute is a not-for-profit organisation solely focused on advancing better mental health. We offer a range of high-quality psychology and counselling programmes that focus on evidence-informed treatments and education. We are committed to making a positive impact on the lives of individuals, families, and communities by providing innovative and accessible mental health care. If you or someone you know could benefit from extra support, our clinic also offers free counselling and low-cost assessments and has a variety of practitioners available for appointments across our 4 sites. Click here to request an appointment.

 

References

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