913192
editorial2020
AUT0010.1177/1362361320913192AutismEditorial
Editorial
Both sex- and gender-related factors
should be considered in autism research
and clinical practice
Recently, there has been increasing attention to key inter-
sections between sex, gender and autism (Lai et al., 2015),
including the so-called ‘female autism phenotype’ (Mandy
et al., 2012), social ‘camouflaging’ (Hull et al., 2017) and
experiences of gender diversity in autistic people (van der
Miesen et al., 2016). This research and related clinical
practice have increased awareness of the breadth of autis-
tic experience. However, sex and gender often have been
conflated in this work, and gender viewed through a binary
lens. The term ‘gender’ refers to a range of experiences,
both internal and external (Becker et al., 2017; Ehrtmann
et al., 2019), and the intricate interplay between social
gender and inner gender-related experiences has yet to be
articulated in autism (Cooper et al., 2018). In this editorial,
written as a collaboration between clinician researchers
and autistic advocates (Fletcher-Watson et al., 2019), we
explore key topics in the field and offer recommendations
for advancing this work through more diversified, sex- and
gender-informed lenses, and with a focus on the lived
experiences of autistic people.
The ‘female autism phenotype’
Increased attention to expressions of autism in girls and
women has led to descriptions of a putative ‘female autism
phenotype’ (Hull et al., 2020). Typically, these descrip-
tions are presented as contrasts to common expressions of
autism in boys and men (Lai et al., 2015). For example, it
has been noted that many autistic girls and women have
fewer signs of repetitive behaviours and narrow interests
than autistic boys and men, and when narrow interests are
present, they may be less immediately obvious (Lai &
Szatmari, 2020). There is emerging evidence that individu-
als with XX sex chromosomes, the sex chromosomes
most women have, may be less likely to express character-
istics commonly understood to be autistic (the so-called
‘female protective effect’; Werling, 2016), although such
effect does not seem to come from the X chromosome per
se. Autistic girls and women appear to have overall
stronger social motivation compared to autistic boys and
men (Sedgewick et al., 2016, 2019); this could be
driven by female sex-specific neurodevelopmental fac-
tors (Chawarska et al., 2016; Werling, 2016) and the
greater social gender expectations placed on girls and
women (Kreiser & White, 2014). Some autistic girls and
Autism
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women may focus on social information, social learning
and efforts towards compensatory social coping, which
may come at a cost in terms of fatigue and poorer mental
health (Hull et al., 2020). The experience of compensatory
social coping (e.g. trying to act as ‘non-autistic’) has been
described by some as ‘camouflaging’ or ‘masking’ (Hull
et al., 2017); however, these terms are not universally
embraced in the autism advocacy communities. Overall,
these lines of research point to multiple factors associated
with the male preponderance of autism diagnosis preva-
lence and patterns of underidentification of autism in girls
and women.
Sex and gender as separate,
multi-component dimensions
Patterns of differences between females and males, girls and
boys, and women and men in autism are clearly important
and relevant for research and clinical practice, but current
approaches to this work will be enhanced with a broader
focus on the various facets of gender, as opposed to sex
alone. For example, gendered expectations and social con-
ditioning, beyond sex-related biological mechanisms, play a
role in shaping the individual development of autistic girls
and women (Lai & Szatmari, 2020). According to the World
Health Organization, sex refers to biological and physiolog-
ical characteristics, which include sex-related chromosomes
(http://www.euro.who.int/en/health-topics/health-determi-
nants/gender/gender-definitions); sex is often perceived as a
binary construct, but in fact, its components can be multi-
categorical or dimensional (Joel & McCarthy, 2017).
Gender encompasses experiential, social and cultural com-
ponents including ‘gender norms’ (Barnett, 1997), ‘gender
roles’ (Witt, 1997), ‘gender-related interests’ (Davis &
Hines, 2020; Dittmann et al., 1990; Fast & Olson, 2018),
‘gender-related expressions’ (Becker et al., 2017; Toomey
et al., 2010) and ‘gender identity’ (i.e. the internal gender
that a person experiences themselves as; American
Psychological Association, 2015). Autism-related charac-
teristics may facilitate greater freedom regarding social gen-
der roles and societal gender expectations; autistic
individuals may feel less pressure to conform to such roles
(Strang et al., 2018). This may allow for increased expres-
sion of gender diversity, such as with gender expressions,
interests and identities. There is substantial evidence that
540 Autism 24(3)
many autistic individuals experience an incongruence
between assigned sex and gender identity (van der Miesen
et al., 2016). In a recent Dutch study, around 15% of autistic
adults reported a gender identity different from their sex
assigned at birth (Walsh et al., 2018). The associations of
autism and gender diversity characteristics have also been
found in a large general population sample of school-age
children in Canada (Nabbijohn et al., 2019). Community
expressions of gender diversity in autism are common. For
example, the Autistic Women’s Network recently renamed
itself the Autistic Women & Nonbinary Network in response
to its constituency’s gender diversity (Allison, 2018). We
still do not know the various gender developmental trajecto-
ries across the lifespan in autistic individuals and how they
intersect with evolving gender narratives and conceptualiza-
tions in societies and cultures.
The importance of nonbinary
conceptualizations of gender
There is an increasing recognition of the prevalence of
gender experiences that fall outside of the ‘male’ and
‘female’ binary categories (Vincent, 2019), including
experiences of having components of both, neither or flu-
idity of the binary genders. Emerging evidence suggests
that nonbinary experiences and identities may be particu-
larly common in autism (Dewinter et al., 2017; Stagg &
Vincent, 2019; Walsh et al., 2018). We currently have no
validated means of measuring nonbinary gender experi-
ences in autism, and there is limited information on nonbi-
nary autistic individuals’ gender-related needs, experiences
or mental health. Community-based accounts of gender
development in autism suggest that societal expectations
for binary gender expressions may lead some autistic peo-
ple to feel uncomfortable with their gender (Griffin, 2016).
Understanding gender in autism
With the tendency to focus on differences in self-aware-
ness in some autistic people (Huang et al., 2017), there
has been a general lack of attention to autistic people’s
inner experiences (Gillespie-Lynch et al., 2017) or, in
some cases, even acknowledgement that autistic people
have an inner experience. Enhancing curiosity about inner
experiences in autism is critical as it pertains to issues
related to sex and gender. Gender includes elements that
are deeply personal – that another person would not
understand or know without direct communication. And
there are risks (for research, clinical care, personal free-
doms) associated with (1) incorrect assumptions about
sex and gender (e.g. concerning a person’s gender iden-
tity, traumatic experiences, comfort with gendered roles)
or (2) mistrust of the voiced experience of autistic people
who express gender-related characteristics and needs that
diverge from the ‘average’ experience. Understanding the
meanings of sex and gender in the lives of autistic people
will require an autism-informed framework. Some autis-
tic people may not communicate about gender-related
experiences and needs in ways that are immediately obvi-
ous (Strang et al., 2018). And for some autistic people,
understanding and integrating abstract social gender
norms and expectations with inner experiences may be
challenging, for example, ‘what is the difference between
a boy or a girl?’ (Strang et al., 2019) or ‘understanding
women [my own sex] doesn’t come naturally to me. I
needed a book to explain it to me’. (Griffin, 2016). So, to
better capture gender in autism, it will be important to
consider those autistic qualities that may affect (1) others’
understanding of the gender-related experiences and
needs of the autistic individual and (2) the autistic indi-
vidual’s own perceptions and comprehension of gender-
related meanings (e.g. how the autistic individual relates
to the neurotypical ‘gendered’ world).
Experiences of gender-related
expectations in autism
Amid the complex process of reconciling social gender
norms with one’s inner experiences, some autistic individ-
uals may feel unique pressure to conform to gender-related
expectations. Social intervention approaches often teach
relational skills as a set of fixed rules, which may reinforce
common gender stereotypes about how a person of a cer-
tain sex/gender should act (Tint et al., 2018; Tint & Weiss,
2017). In particular, compliance-based teaching, in which
specific social behaviours are rewarded, while actions
driven by internal guiding factors or motivations are not,
may contribute to strong adherence to stereotypical gender
norms and expectations, even if they are incongruent with
inner experience and needs (Jack, 2014). Gender stereo-
types might also be absorbed by autistic people through
the process of ‘camouflaging’ (i.e. internalizing gendered
social conventions to mask differences; Hull et al., 2017).
Gendered pressures resulting from structured social inter-
vention approaches (many of them being adopted as stand-
ard care for autistic people currently) or ‘camouflaging’
might be harmful to autistic people in some instances
(Cassidy et al., 2019). Although some autistic people can
overcome this pressure, other autistics may struggle to
challenge gender expectations, even if they experience
these expectations as repressive (Griffin, 2016).
Sex- and gender-related
considerations in the identification of
autism
Characteristics that have been associated with a ‘female’
versus ‘male’ version of autism are not isolated to one sex
or gender. The processes of ‘camouflaging’, though
described in many ‘female experiences’ of autism (Hull
Editorial 541
et al., 2020) and reportedly more intense overall in autistic
women, are present also in autistic men and nonbinary
autistic adults (Hull et al., 2019). Similar processes have
been described outside of autism research, such as among
gender-diverse people and LGBTQ+ people more broadly,
who may learn to ‘pass’, ‘code-switch’ or ‘blend in’ for
social or safety reasons (Fuller et al., 2009; Spradlin,
1998). The sex-based phenotypic descriptions as they per-
tain to autism identification and diagnostics, as well as tai-
loring of accommodations and supports, have insufficiently
integrated gender as an independent and critical second set
of variables (Kreiser & White, 2014; Lai & Szatmari,
2020). Consider, for example, an assigned male at birth
with female gender identity who has affirmed (formerly
known as ‘transitioned to’) a female gender role. How
does an informed clinician consider the question of autism
in such a gender-diverse individual? What gender norms
are to be used on normed autism screening tools (e.g. the
Social Responsiveness Scale)? Is the emerging putative
‘female autism phenotype’ to be expected and impactful
on diagnostic considerations? And what of the autistic cis-
gender boy who is subthreshold on so-called ‘gold-stand-
ard’ autism diagnostic measures, possibly due to factors
related to camouflaging? If researchers and clinicians are
broadening their understanding of what autism looks like
in girls and women based on emerging studies that support
such conceptualization, should the same be applied to
boys, men or gender-diverse people who embody the puta-
tive ‘female autism phenotype’ as well?
Initial recommendations for
embracing a sex- and gender-
informed framework in autism
research and clinical practice
1. Sex and gender should be included and measured as
separate constructs, comprising multiple compo-
nents that can be operationalized as continuous or
multi-categorical variables. New, autism-friendly
measures need to be developed, and these measures
should capture both binary and nonbinary experi-
ences of gender. Assessment and diagnosis should
also consider the impact of the gendered world and
gendered social milieus on autistic people (e.g. how
are social and cultural gender norms and expecta-
tions experienced by autistic people and how do
these experiences impact them developmentally?)
2. Concepts such as the ‘female autism phenotype’,
‘camouflaging’ and ‘female protective effect’
reflect important findings and constructs that
advance the field, but the terms and conceptualiza-
tions will be enriched with the engagement of
autistic people in defining the fullness of the con-
cepts. Further, we need to understand how these
concepts are experienced by autistic individuals
who may or may not find their own life journeys
concordant with them. Do they create new expecta-
tions and stereotypes that will need to be decon-
structed and contextualized? And how is the
specific language developed so far experienced by
autistic people (e.g. ‘female protective effect’)?
When new terms are coined, we must work with
the autistic communities to both understand the
lived experiences underlying the concepts and
avoid gender and/or autism-related stereotypes
which may be demeaning or lacking in precision.
3. The lived experiences of autistic people who
express distance from gender conventions or stere-
otypes and/or their sex assigned at birth reflect a
phenomenon that is more than just ‘social aware-
ness differences’. The ability of some autistic peo-
ple to exist more readily outside of social gen-
der expectations and boldly express their inner
gender needs has already positively impacted gen-
der-related social justice, as many gender diversity
advocates are autistic (e.g. Abeni, 2015; Brown,
2016; Callahan, 2018; McCool, 2017; National
Autistic Society, 2018). Take for example, Martine
Stonehouse, an autistic transgender woman who
drew upon her gender diversity and autistic neuro-
divergence to help change the law in Canada to pro-
vide gender-related medical interventions for
transgender people (Alon, 2016). Research should
focus not only on the differences in autism as ‘chal-
lenges’ or ‘symptoms’ but also on the ways in which
autistic characteristics and their overlap with gen-
der diversity may help to advance the understand-
ing of gender. And clearly, respect should be
afforded to autistic people who are experiencing
and/or exploring gender diversity. We increasingly
provide neurotypical youth the room to explore and
express their gender identities, and autistic people
deserve the same rights and opportunities.
Conclusions
Autistic accounts of gender experiences and gender diver-
sity encourage greater attention to the ways in which sex
and gender in autism must be examined separately and
dimensionally, and through autism-informed characteriza-
tion methods. Such work will allow for better understand-
ing of how autistic people experience gender, and how this
impacts their experiences of being autistic. As a field, we
are just beginning to recognize the inner experiences of
autistic people. With regard to sex and gender, such recog-
nition is important for science as well as for the respect of
the individual, and in some cases may be lifesaving (White,
2016). Inner experience is too commonly forgotten in
autism research and clinical practice. Yet, autistic people
who are less attached to, aware of or concerned with
542 Autism 24(3)
gender conventions may in fact be providing an important
window into what gender is and can be without the strict
overlays of gender-related expectations and social mean-
ings. Some autistic people may be seeing beyond the con-
ventions that bind neurotypical genders and expressions.
We encourage an openness to what autistic people have to
tell us and teach us about gender – about their own gender
experiences and journeys, and maybe even about the ways
the world can open to a more expansive view and accept-
ance of gender-related experiences, less confined by neu-
rotypical social and gender codes.
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to gender roles. Adolescence, 32(126), 253–259.
John F Strang1,2, Anna IR van der Miesen3, Reid
Caplan4, Cat Hughes5, Sharon daVanport6
and Meng-Chuan Lai7,8
1
Children’s National Hospital, USA
2
The George Washington University, USA
3
Amsterdam UMC, The Netherlands
4
Autistic Self Advocacy Network, USA
5
Autistica, UK
6
Autistic Women & Nonbinary Network (AWN), USA
7
University of Toronto, Canada
8
Centre for Addiction and Mental Health, Canada