How should autism assessments be adapted for women and girls?
Autism assessments have historically been shaped by research and diagnostic tools that were largely developed using male samples. As a result, many autistic women and girls have been overlooked, misunderstood, or diagnosed later in life. Increasingly, clinicians and researchers are recognising that autism can present differently across genders, and that assessment approaches need to adapt in order to provide more accurate and compassionate care. Recent research highlights several important ways that assessments can become more responsive to the lived experiences of autistic women and girls.
Camouflaging
One of the most significant areas requiring adaptation is the assessment of camouflaging, sometimes referred to as social compensation or ‘masking’. Many autistic women and girls develop strategies to hide autistic traits in social situations. They may rehearse conversations in advance, copy the facial expressions or body language of others, or rely on learned social scripts to navigate interactions. On the surface, this can make social communication appear more fluent or typical, particularly during structured assessment appointments. However, masking often comes at a substantial emotional cost, leaving individuals feeling exhausted. Research has emphasised the importance of directly asking about masking behaviours during assessments, including whether someone practises social interactions beforehand, studies how others behave, or feels they are ‘performing’ socially.
Traditional autism assessments can unintentionally privilege observable behaviours over internal experience. This can create difficulties when assessing autistic girls and women who have learned to use social compensation effectively. A neuroaffirmative assessment therefore moves beyond simply asking whether eye contact is present or whether someone appears socially engaged. Instead, clinicians should explore how natural or effortful these behaviours feel. For example, someone may maintain eye contact because they have memorised rules about how long to look at a person, rather than because it feels intuitive or comfortable. Similarly, a young person may appear socially confident while privately experiencing intense anxiety, confusion, or exhaustion after social interaction. Good quality assessments make space for these internal experiences and validate the energy that camouflaging can require.
Adaptations to assessment also involve observing behaviour across different contexts. Many autistic girls and women present differently at school, work, home, or in unfamiliar environments. Some may hold themselves together throughout the day and only show signs of distress, sensory overwhelm, or shutdown once they are in a safe environment. Parents frequently describe children who appear compliant and socially capable in school, but become emotionally exhausted or dysregulated at home. Research has highlighted the importance of gathering information from multiple sources and recognising that behaviours may not look the same in every setting. This broader understanding helps clinicians avoid relying too heavily on single observations or questionnaires that may not capture the full picture.
Restricted and Repetitive Behaviours
Another important adaptation relates to restricted and repetitive behaviours and interests, sometimes abbreviated as RRBIs. Diagnostic criteria for autism include repetitive behaviours, routines, sensory differences, and focused interests, but autistic girls and women may experience these differently or express them in more socially accepted ways. Research suggests they are often less likely to show the more overt repetitive behaviours traditionally associated with autism, or that their interests may appear ‘typical’ for their age or gender. For example, a deep and highly focused interest in animals, books, celebrities, psychology, or fictional worlds may not immediately stand out as unusual, despite occupying a significant amount of emotional energy and time.
As a result, clinicians need to ask more nuanced questions about interests and routines, rather than assuming that the absence of clear repetitive behaviours means that autism is unlikely. Assessors should explore the intensity, rigidity, emotional importance, and functional impact of interests and routines. Questions such as “What happens if they cannot engage in this interest?” or “How much time do they spend thinking about it?” can reveal patterns that might otherwise be missed. A neuroaffirmative approach also recognises that focused interests are not inherently problematic. In many cases, they provide joy, emotional regulation, identity, and expertise. The aim of assessment is not to pathologise interests, but to understand how they function within the person’s life.
Social interaction
Friendships and social relationships are another area where assessments may need to change focus. Autistic girls and women are sometimes assumed not to be autistic if they have friends or appear socially motivated. However, many autistic individuals deeply value connection while still experiencing significant social differences. Assessments should therefore explore the quality and maintenance of relationships, rather than simply whether friendships exist. Research has highlighted the importance of understanding how effortful social interaction feels, whether friendships rely on following rigid rules, and what happens when relationships become more socially demanding or change unexpectedly.
Transitions and increasing social expectations are also important areas for exploration. Some autistic girls cope relatively well during early childhood, only beginning to struggle when social interactions become more complex in adolescence. Changing friendship dynamics, unspoken social rules, academic pressures, and the challenges of adolescence can all amplify the need to use social camouflaging, and the resulting exhaustion. In particular, the transition between primary and secondary school has been identified as a period where difficulties may become more apparent and mental health challenges may emerge.
Mental Health
A neuroaffirmative assessment also requires clinicians to think carefully about co-occurring mental health presentations. Many autistic women and girls are initially identified through anxiety, eating differences, depression, trauma responses, self-harm, or burnout. These experiences are deserving of support in their own right, but they can sometimes overshadow underlying autistic experiences. Research has emphasised that clinicians should continue considering autism even when someone already has diagnoses such as social anxiety or selective mutism. Rather than only viewing autism and mental health difficulties as separate or competing explanations, neuroaffirmative practice recognises how chronic masking, sensory overwhelm, misunderstanding, and unmet needs can contribute to emotional distress.
Ultimately, adapting autism assessments for women and girls is not about creating entirely separate diagnostic criteria. The core characteristics of autism remain the same, but the way these characteristics are expressed can differ due to the person’s coping strategies, personality, social context, and culture. For many autistic women and girls, receiving an assessment from a service that genuinely understands the overlap between social compensation, mental health, and autism and can be profoundly validating. Adaptations to assessment processes can reduce the risk of missed diagnoses, support earlier access to appropriate support, and help individuals better understand themselves in a way that is empowering and respectful of their differences.
