Underdiagnosis of Autism in females: implications for mental health and access to care

Introduction: Autism Spectrum Disorder has historically been conceptualized within malecentered diagnostic frameworks, contributing to the systematic underrecognition of females. Although the male-to-female diagnostic ratio is commonly reported as 4:1, emerging evidence suggests that this disparity is partly driven by diagnostic, behavioral, and systemic biases. This study examines the mechanisms underlying underdiagnosis in females and their consequences for mental health.

Findings: The analysis identifies six interacting mechanisms contributing to the gender diagnostic gap. First, diagnostic instruments—largely validated on male samples—show reduced sensitivity to female-typical presentations. Second, social camouflaging obscures observable symptoms while imposing significant psychological costs. Third, diagnostic overshadowing leads to frequent misdiagnoses, delaying appropriate identification. Fourth, developmental and sociocultural factors contribute to the normalization or misinterpretation of subtler symptoms in girls. Fifth, the female protective effect may influence phenotypic expression and diagnostic thresholds. Sixth, structural barriers within healthcare and educational systems limit access to assessment and referral pathways. These mechanisms operate cumulatively, reducing the likelihood of timely and accurate diagnosis.

Mental health consequences: Underdiagnosis is associated with increased psychiatric comorbidity, including anxiety, depression, and burnout. Chronic camouflaging, diagnostic delay, and lack of support contribute to identity disturbance, functional impairment, and longterm psychosocial burden.

Conclusions: The underdiagnosis of autism in females reflects systemic limitations in current diagnostic and care frameworks. Addressing this disparity requires gender- sensitive assessment approaches, improved clinical awareness, and structural reforms to ensure earlier identification and equitable access to support.