What’s behind the mask: The diagnostic divide in the female autism phenotype

Authors

• Shelley Gies Alston, James Madison UniversityFollow

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial-No Derivative Works 4.0 International License.

Date of Graduation

5-14-2026

Semester of Graduation

Spring

Degree Name

Educational Specialist (EdS)

Department

Department of Graduate Psychology

First Advisor

Tiffany Hornsby

Second Advisor

Deborah Kipps-Vaughan

Third Advisor

Tonya Lambert Delp

Abstract

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by differences in social communication and restrictive, repetitive behaviors; however, women are diagnosed at significantly lower rates than men. This study examined whether DSM-5-TR diagnostic practices may contribute to the underdiagnosis and delayed identification of ASD in individuals assigned female at birth (AFAB), with attention to masking behaviors, gendered social expectations, and clinician interpretation of symptoms. Grounded in the Female Autism Phenotype (FAP), a retrospective mixed-methods study surveyed 12 AFAB individuals aged 18–24 who self-identified or were formally diagnosed with ASD. Participants completed a 44-item online survey including Likert-scale and open-ended questions regarding diagnostic history, autistic traits, masking behaviors, and perceived barriers to diagnosis. Data were analyzed using descriptive statistics and thematic analysis.

Results indicated a mean reported age of diagnosis of 14.3 years, suggesting delayed identification for many participants. Quantitative findings reflected endorsement of core autistic traits consistent with DSM-5-TR criteria. Qualitative findings indicated these traits were often overlooked or misinterpreted in clinical and educational contexts. Recurring themes included masking and camouflaging as barriers to recognition, diagnostic overshadowing by mental health conditions, and perceptions that participants were “too high functioning” or socially competent to meet diagnostic criteria.

Findings suggest that diagnostic disparities may be associated with clinician reliance on male-centered conceptualizations of autism and inconsistent recognition of the FAP. These results highlight the importance of increased clinical awareness and more consistent application of existing diagnostic frameworks to improve identification and reduce delays in diagnosis for women and AFAB individuals.