Autism’s invisible half

At 22, Aanya was called anxious, depressed — even dramatic. Autism was never mentioned. She had learned to make eye contact, memorise small talk, and disappear in plain sight. By the time she was diagnosed at 28, she had cycled through a carousel of misdiagnoses — none of them quite fitting.

Her story is not rare. It’s routine. For decades, autism has been cast in the image of boys — often obsessed with trains or maths, often easy to spot. Girls, who tend to be more verbal, more socially attuned, and more adept at masking, were missed. Misdiagnosed. Mislabelled. And so, the science followed the visibility. From psychiatrist and physician Leo Kanner’s foundational studies to modern diagnostic tools, autism’s definition has been shaped by those who stood out — not those who struggled quietly.

A spectrum built for boys

Autism Spectrum Disorder (ASD) is a neuro-developmental condition characterised by differences in communication, social interaction, and behaviour. As a spectrum, it manifests in a range of ways, with varying degrees of intensity. Yet for years, the prevailing understanding — and diagnostic approach — has skewed male.

Recent studies show that girls, on average, are diagnosed with autism between 1.5 and 2 years later than boys. While many boys are identified between the ages of 3 and 4, girls often aren’t diagnosed until age 6 — or even later.

“Research points to two primary factors,” explains Dr Himani Narula Khanna, developmental-behavioural paediatrician and adolescent mental health expert, and co-founder of a neurotherapy centre for uniquely abled children. “First, many girls on the autism spectrum tend to be more verbal and exhibit stronger social mimicry skills than boys. As a result, their behaviours often go unnoticed. Second, these differences frequently lead to mislabeling — girls are commonly diagnosed with anxiety, obsessive-compulsive disorder, or even eating disorders instead.”

Two years ago, in a webinar hosted by the Autism Research Institute, autistic researcher and author Hannah Belcher noted that autistic women are often diagnosed only after a series of psychiatric conditions — such as depression, anxiety, or borderline personality disorder — have been ruled out.

Of particular concern is the diagnostic overlap between autism and Borderline Personality Disorder (BPD), sometimes called emotional regulation disorder. Belcher cited one study in which 15 per cent of patients at a BPD clinic were found to meet the criteria for autism.

Given BPD’s higher prevalence in women, this symptomatic overlap has only deepened the bias — leaving many autistic women misdiagnosed, misunderstood, and without access to the services or validation they need.

Wrong questions, wrong tools

One of the most widely used adult screening tools for autism is the Autism-Spectrum Quotient, or AQ — a 50-question test designed to identify patterns in thinking, social interaction, and perception.

But like much of the diagnostic landscape, the AQ was created with boys in mind. Developed in 2001 by psychologist Simon Baron-Cohen and his team, the AQ focused on traits commonly observed in autistic men and boys: an intense focus on systems, challenges with social cues, a preference for routine. These patterns, in turn, became the standard. The problem? Autism doesn’t always look the same in women.

“Traditional diagnostic criteria often fail to capture the nuanced ways autism can present in girls — particularly those who are cognitively able and verbally proficient,” says Dr Khanna. “These traits can mask underlying challenges, leading to under-diagnosis.”

Older studies suggested a male-to-female autism ratio of 4:1. But newer research paints a different picture —one that may be closer to 3:1, or even 2:1 among individuals without intellectual disabilities. That gap points to more than statistics. It reflects decades of missed stories, overlooked symptoms, and silent struggles. Autism in girls often flies under the radar — but it was never absent. It was merely hiding in plain sight.

“Newer tools like ADOS (Autism Diagnostic Observation Schedule), M-CHAT, and STAT are there to diagnose ASD. A few more, which are suggested by the National Autistic Society — like ASQ and EQ (Empathy Quotient) — help in better diagnosis of ASD in girls,” says Dr Aparna Jha, obstetrician-gynaecologist at a leading children’s hospital in Bengaluru.

Beyond the checklist

For generations, women have been conditioned to suppress behaviour —“Sit properly,” “Don’t make noise,” “Don’t draw attention.” As a result, autistic traits in girls are often masked or internalised. The experience doesn’t vanish; it morphs —into anxiety, depression, or burnout.

Devangana Mishra, CEO and Founder of a Mumbai-based nonprofit working to empower students on the autism spectrum, explains, “Women on the spectrum often navigate the world differently: they may prefer solitude, communicate atypically, experience heightened sensory sensitivity, and harbour intense interests. But most crucially, they mask. They mimic social cues to blend in, often at great psychological cost. What looks like success may hide profound exhaustion.”

And when women say, “This light is too bright,” “This fabric is unbearable”— they’re often dismissed. Their sensory experiences are minimised, their instincts doubted. 

She adds, “Celebrities and public figures on the spectrum bring visibility, but they also risk reinforcing narrow stereotypes. The challenge is broader: how do we create a world where autistic women can live not as poster children for a diagnosis, but as complex, thriving individuals?”

It’s important that education, policy, and healthcare needs to be reimagined — not just for inclusion, but for transformation. “Around 10 to 15 per cent of women/girls misdiagnosed with depression, anxiety, and other mental issues are being diagnosed with ASD in adulthood. Better awareness, early approach, more acceptability, and better tools are the key factors for the diagnosis of ASD in females and recovery,” says Dr Jha.

In India, a quiet push for autism screening

In spite of a lack of national policy, India is witnessing a quiet yet significant shift in how autism is being identified in its schools. Recent initiatives reveal a growing recognition of neuro-developmental disorders in classrooms — though often fragmented, underfunded, and region-specific. A 2024 workshop by the Young Indians (Yi) Guwahati chapter (according to a report in the Indian Journal of Paediatrics) brought together teachers and psychologists to build capacity for early detection of ASD. Despite 91.2 per cent of educators claiming awareness of autism, only a third had received any structured training. In Kolkata, a school-based study screened 11,849 children aged 3 to 8 using validated diagnostic tools. The study identified six undiagnosed children on the spectrum, yielding a prevalence estimate of 0.23 per cent. The findings, published by Spectrum News, suggest that without structured screenings, many cases remain invisible—particularly in low-resource settings.

Meanwhile, researchers from a private deemed university in India have rolled out an educator-focused autism awareness programme across several Indian schools. Presented at INSAR 2024, the initiative trains teachers to observe signs of autism and refer students for diagnosis, while incorporating action research to evaluate effectiveness.

Many young Indian women, who were diagnosed in their late twenties or early thirties, are now speaking out about their neurodivergence on social media platforms.

“Their public coming out is not just personal catharsis — it’s a cultural reckoning. In a society that often conflates femininity with emotional fluency and social grace, their stories challenge the invisibility of autism in Indian women and expose the high cost of camouflage,” concludes obstetrician-gynaecologist Dr Jha.