Hi,

Here are a few references on this topic:

Kissel LT, Werling DM. Neural Transcriptomic Analysis of Sex Differences in Autism Spectrum Disorder: Current Insights and Future Directions. Biol Psychiatry. 2022 Jan 1;91(1):53-60. doi: 10.1016/j.biopsych.2020.11.023. Epub 2020 Dec 7. PMID: 33551190.

Williams OOF, Coppolino M, Perreault ML. Sex differences in neuronal systems function and behaviour: beyond a single diagnosis in autism spectrum disorders. Transl Psychiatry. 2021 Dec 9;11(1):625. doi: 10.1038/s41398-021-01757-1. PMID: 34887388; PMCID: PMC8660826.

Beggiato A, Peyre H, Maruani A, Scheid I, Rastam M, Amsellem F, Gillberg CI, Leboyer M, Bourgeron T, Gillberg C, Delorme R. Gender differences in autism spectrum disorders: Divergence among specific core symptoms. Autism Res. 2017 Apr;10(4):680-689. doi: 10.1002/aur.1715. Epub 2016 Nov 3. PMID: 27809408.

Lainhart JE. Sex Differences in Cerebral Development in Autism. Biol Psychiatry. 2021 Sep 1;90(5):278-280. doi: 10.1016/j.biopsych.2021.06.015. PMID: 34384526

Lai MC, Lombardo MV, Auyeung B, Chakrabarti B, Baron-Cohen S. Sex/gender differences and autism: setting the scene for future research. J Am Acad Child Adolesc Psychiatry. 2015 Jan;54(1):11-24. doi: 10.1016/j.jaac.2014.10.003. Epub 2014 Oct 16. PMID: 25524786; PMCID: PMC4284309.

Werling DM, Geschwind DH. Sex differences in autism spectrum disorders. Curr Opin Neurol. 2013 Apr;26(2):146-53. doi: 10.1097/WCO.0b013e32835ee548. PMID: 23406909; PMCID: PMC4164392.

Ruigrok ANV, Lai MC. Sex/gender differences in neurology and psychiatry: Autism. Handb Clin Neurol. 2020;175:283-297. doi: 10.1016/B978-0-444-64123-6.00020-5. PMID: 33008532

Wood-Downie H, Wong B, Kovshoff H, Mandy W, Hull L, Hadwin JA. Sex/Gender Differences in Camouflaging in Children and Adolescents with Autism. J Autism Dev Disord. 2021 Apr;51(4):1353-1364. doi: 10.1007/s10803-020-04615-z. PMID: 32691191; PMCID: PMC7985051.

Zeidan J, Fombonne E, Scorah J, Ibrahim A, Durkin MS, Saxena S, Yusuf A, Shih A, Elsabbagh M. Global prevalence of autism: A systematic review update. Autism Res. 2022 May;15(5):778-790. doi: 10.1002/aur.2696. Epub 2022 Mar 3. PMID: 35238171; PMCID: PMC9310578.

That is an outdated statistic grounded in historical concepts of autism from 80 years ago and is steeped in questionable ethics. It has a potential to perpetuate continued inaccessibility to diagnosis for AFAB autistic people. I would think that the more pertinant question is: What is the current prevalnce? accounting for gender identities as being higher non binary and trans in autistic community. or what are professionals doing to support AFAB access autism diagnosis- and why this matters!?

I have been working with various people with Autism for over 40 years. I am also married to a man on the spectrum, and I have three children and two grandchildren diagnosed with Autism Spectrum Disorder. Those in my family not diagnosed with Autism Spectrum Disorder are diagnosed with ADHD. Both appear to be spectrum disorders and share many of the same traits but have some distinct differences.

Both have difficulty with social awareness and the ability to make and keep friends. Both also have problems with attention and focus. However, I have observed that those with ASD have a more challenging time with changes in routine and are highly compulsive. My oldest daughter was told she could just as easily be diagnosed with both ASD and ADHD. What is the issue of having both diagnosed?

Thank you Anita.

Hi Dawn,

Not sure what country you are in Dawn- but there is no issue with having a dual/ co- occuring diagnosis. There is extensive research and work on this and the challenges that it can present. statistics suggest roughly 70% of autistic people also meet the criteria for ADHD diagnosis. A lot of the time it is a challenge in the UK as the NHS services are commisioned seperately and therefore people sometimes need seperate referrals- in addition to this bureacracy sometimes means that people have to wait for one diagnosis to be complete before going on a wait list for the second which means that people can be waiting for a good part of a decade before they have a clear picture of their diagnostic profile. The cross over will include complexities as per individual. I have a dual diagnosis my need for predictable life is necessitated by the vaguness and euphemistic way that non autistic people communicate coupled with my extensively busy detail orientated focussed brain which means that there is a constant stream of unfiltered information from sensory information to communication etc; having clarity and tangible plans contains that overwhelm. However maintaining a predictable unchanging life can be difficult when you have a tendancy to be distracted and have short term memory differences.

I totally agree with Lynette Morgan. Many of the individuals with ASD have other dx. as well not just ADHD with other disorders and medical conditions.

As for as your question is concerned about why it is 4x more in males then females. the one reason I came to know while working with individuals on spectrum is: MASKING over time. The culture, norms and values are more rigidly applied and dictated too girls and their behavior masks over time as compare to males. That's is reason we see more males on the spectrum then females. Otherwise I don't think this ratio has much impact on gender.

I do have issue with the portrayal of the 4:1 ratio being definitive fact. As research continues regarding ASD, two things continuously pop up regarding women with ASD:

As previously clarified, both the ratio and the "types" of Autism you mention are based on outdated findings that have been widely falsified. These findings and assumptions are heavily influenced by the history of exclusive and hegemonic psychiatric and autism science practices. This persistant epistemic injustice causes a lot of harm to Autistic people (Botha & Cage, 2022). Autistic scholars and advocates have been calling for a shift in research, namely more participatory research methods and following certain ethical guidelines that ensure respectful practices and acceptable, humane conditions. Including certain linguistic considerations, like avoiding ableist terms that have been and are still often used in autism research (Bottema-Beutel et al., 2021). For example, the notion of Autism being "mysterious" or a "problem" is a micro-aggression for me personally, but also for many others due to the harmful image it conveys (Dunn, 2023; Gernsbacher et al., 2017).

Even though many disproven assumptions about Autism, like only children being autistic or the subtypes you mentioned, are no longer a part of the diagnostic criteria, the validity of diagnostic criteria and the sensitivity and specificity of the screening tools are still heavily debated (Ratto et al, 2023).

There have been attempts to finding the true (unbiased) ratio of Autism prevalence, e.g. by McCrossin et al. (2022) who found a ratio of 3:4 rather than 4:1. The suitability of splitting Autistic people in binary gender categories remains questionable, since a lot of us are gender non-conforming, seemingly significantly more often than the general population (George & Stokes, 2017).

Scholars prioritising inclusive and non-discriminatory autism research, some of whose work I refer to in this comment:

Bottema-Beutel, Gillespie-Lynch, Botha, Cage, Cooper, Pearson, Pellicano, Han, Linden, Remington and Crane and their whole CRAE research team. And many more. There are some new(er) journals like "Autism in Adulthood", edited by some of the mentioned scholars.

Fortunately there is a growing interest in or rather awareness of the need for dismantling the epistemic injustice in autism research.

A thorough and helpful response thank you Daria