1. The Other 25%: Autistic Girls and Women
Doris M. Greenberg, MD
Developmental and Behavioral Pediatrician
Associate Clinical Professor of Pediatrics
Mercer University School of Medicine
Memorial Health University Medical Center
Savannah, Georgia

2. Faculty Disclosure
Dr. Greenberg: Stockholder—Abbott, AbbVie, GlaxoSmithKline, Johnson & Johnson, Novartis, Novo Nordisk (and spouse); Son Employee—Sanofi Pasteur

3. Disclosure
The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational use(s) of drugs, products, and/or devices (any use not approved by the US Food and Drug Administration).
Applicable CME staff have no relationships to disclose relating to the subject matter of this activity.
This activity has been independently reviewed for balance.

4. Learning Objectives
Discuss the prevalence of autism spectrum disorders (ASD) in the United States, and specifically, in females
Examine the challenges females with ASD face during puberty, courtship, motherhood, and employment
Effectively communicate with and counsel female patients with ASD who may be very literal and require a different type of discussion than a “neurotypical” patient

5. DSM-5: Autism Spectrum Disorders
Deficits in social communication and interaction (all 3):
Understanding social- emotional reciprocity
Using non-verbal communication
Difficulty maintaining relationships
Repetitive and restrictive patterns of behavior, interests, or activities (2/4 needed):
Stereotypies
Insistence on sameness and inflexibility
Restricted and fixated interests of great intensity
Sensory issues
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Publishing, Inc.; 2013.

6. DSM-5 (continued)
Excessive resistance to change, verbal rituals and routines (excluding bedtime rituals unless very unusual), rigid and literal thinking, compulsions, difficulty with transitions
Difficulty with interpreting humor and inflexibility of thought, unable to appreciate irony
Highly restricted and fixated interests, obsessions with numbers or parts of objects, carrying items that are odd, preoccupations with certain things like tables, charts, being overly perfectionistic, unusual fears
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Publishing, Inc.; 2013.

7. DSM-5 (continued)
Sensory hypo- or hyper-reactivity, preoccupation with textures, tactile defensiveness—difficulty with having hair or nails cut, unusual visual activity—watching movement, reflections, light patterns, etc
Sound, smell, taste, vestibular, visual perceptual atypicalities, eg, smelling or licking
Symptoms need to be present in the early developmental years, but may not become impairing until social demand exceeds the limited capabilities of the patient
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Publishing, Inc.; 2013.

8. Severity, DSM-5
Depends on degree of communication difficulties and degree of restricted, repetitive patterns of behavior
SYMPTOMS MAY BE MASKED UNTIL LATER IN LIFE, BUT MUST BE PRESENT DURING EARLY DEVELOPMENT
Differentiate from those with just a social pragmatic communication disorder
Differentiate from intellectual deficits or global developmental delay
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Publishing, Inc.; 2013.

9. Interesting Numbers In the general population, males are 4.3:1 females
1.95:1 males to females in the population with intellectual disability
These numbers may not be accurate since females may camouflage their difficulties and may be undetected due to their ability to disguise their symptoms better than males
Fombonne E. In: Volkmar FR, et al (Eds). Handbook of Autism and Pervasive Developmental Disorders. John Wiley & Sons, Inc.: Hoboken, NJ; 2005: Attwood T. The pattern of abilities and development of girls with Asperger’s syndrome. Available at: development-of-girls-with-aspergers-syndrome. Accessed April 15, Kopp S, et al. Eur Child Adolesc Psychiatry. 1992;1(2):89-99.

10. Genetics Drive the Disorder
The severe symptoms with communication and restricted, repetitive behaviors are almost all determined by genetics, unlike the 2011 study that declared that the environment is responsible to a significant degree
Frazier TW, et al. J Autism Dev Disord. 2014;44(8): Hallmayer J, et al. Arch Gen Psychiatry ;68(11):

11. Genetic Architecture in ASDs
Not simple: 100s of genes are involved
Many genes encode proteins for synaptic formation, transcriptional regulation, and chromatin-remodeling pathways
ASD = autism spectrum disorder.
De Rubeis S, et al. Nature. 2014;515(7526):

12. Female Genetic Differences
Greater number of copy number variants in females diagnosed with autism compared to the males (45% vs 30% for males)
Likely gene-disrupting mutations (called LGD mutations) significantly overlap the targets in males of lower intelligence quotients
Iossifov I, et al. Nature. 2014;515(7526):

13. Epigenetic Differences in Identical Twins
In identical twins, if 1 has autism, the other will have autism only 70% of the time
DNA methylation differences are present in the twin with autism
Wong CC, et al. Mol Psychiatry. 2014;19(4):

14. MRI Differences in Females with Autism vs Normal Brains
Decrease in gray matter density bilaterally. In temporal lobes, orbito- frontal cortex—both medially and laterally, right medial occipital lobe, and left frontal lobe
Smaller white matter density in anterior temporal lobe and pons
Increase in density in association and projection fibers of the frontal, parietal, posterior temporal lobe, and occipital lobes
Increase in commissural fibers of the corpus callosum and anterior cerebellum
MRI = magnetic resonance imaging.
Craig MC, et al. Br J Psychiatry. 2007;191:

15. Similar Brain Abnormalities in Both Genders
Males and females with autism showed a negative correlation between decreased gray matter in the right limbic system and qualitative abnormalities in reciprocal interaction
Similar brain regions were affected in both genders
Women had an excess of white matter in the cerebellum
Craig MC, et al. Br J Psychiatry. 2007;191:

16. Lower Functioning Autistic Women and Girls
More likely to have severe problems than males with low function and autism
Autism can be the behavioral presentation with genetic disorders like tuberous sclerosis, fragile X syndrome, and epilepsy
Both genetic and epigenetic influences are often present
Volkmar FR, et al. J Autism Dev Disord. 1993;23(4):

17. Focusing on the Higher Functioning Females with Autism
Much more difficult to diagnose
Females often exhibit less challenging behavior than males
They are not as likely to have as many special and intense interests
Diagnosis can be made with examinations, good histories, and instruments, eg, ADOS or ADI-R
ADOS = Autism Diagnostic Observation Schedule; ADI-R = Autism Diagnostic Interview-Revised.
Lord C, et al. J Autism Dev Disord. 1989;19(2): Lord C, et al. J Autism Dev Disord. 1994;24(5):

18. Toddlers with Autism
Amygdala size is larger in autistic toddlers vs normal age mates
Size positively correlated with severity of symptoms in the social and communication skills
Girls had a more robust size difference than boys
Schumann C, et al. Biol Psychiatry. 2009;66(10):

19. Not All Diagnosed Early
Some patients on the autism spectrum, especially women, may be totally missed in the younger ages
It is only when reviewing a life history and detecting symptoms in retrospect that some may be diagnosed
Some may be diagnosed when a child in the family receives the diagnosis of autism, and a family history is obtained—peripheral and first-degree relatives may receive a late diagnosis
Cynthia Kim reveals receiving a diagnosis at age 42 when her quirks and socially inept behaviors were finally attributed to ASD
Kim C. Nerdy, Shy, and Socially Inappropriate: A User Guide to an Asperger Life. Philadelphia, PA: Jessica Kingsley Publishers; 2014.

20. Contrasting Females vs Males with ASD
In the high-functioning patients on the autism spectrum, females had more lifetime sensory symptoms acknowledged on questionnaires
Females had fewer socio- communication difficulties than the males
Females had more self- reported autistic traits
Because of better superficially socio- communication skills in adult females, they were often under-recognized and tended to receive diagnoses later in their lives than males
Females could be very controlling with typical peers
Lai MC, et al. PLoS One. 2011;6(6):e Gould J, et al. Good Autism Practice. 2011;12(1):34-41.

21. Girls and Boys Differ
Autistic boys may be more hyperactive than the girls; girls may be more controlling with typical peers
Girls may be more passive and collect information about people rather than things; may share interests with typical girls: horses, literature, animals, but intensity greater
Gould J, et al. Good Autism Practice. 2011;12(1):34-41.

22. Different Trajectories
Girls with autism were more likely to model and imitate social actions around them, disguising their symptoms and resulting in missed diagnoses
Socially immature girls tended to be “mothered” by other girls in social play
Girls worried, more than boys, about fitting in
Many of the boys of their age and diagnoses had no friends; girls may have 1 special friend, and the patient may appear shy and reticent compared to peers
Because they tended to be included in a group, teachers missed identifying them as loners
Attwood T. The Complete Guide to Asperger’s Syndrome. Philadelphia, PA: Jessica Kingsley Publishers; Gould J, et al. Good Autism Practice. 2011;12(1):34-41.

23. Theories Only
Perhaps different mechanisms involved with females and males
Females may be less vulnerable innately protective mechanisms
Females and males might have equal risk genetically, but other factors may allow females to better compensate for these risks
Schwarz E, et al. Mol Psychiatry. 2011;16(12): Skuse DH. Hum Mol Genet. 2005;14 Spec No 1:R27-R32.

24. More Theories
Females and males might have equal risk genetically, but other factors may allow females to better compensate for these risks
Is this an extreme of the male brain? Females with ASD may be more “male- like”
Skuse DH. Trends Genet. 2007;23(8): Baron-Cohen S, et al. Science. 2005;310(5749):

25. Currently, Diagnosis of ASD is Behavioral
Boys had more unusual visual responses, stereotypy, and less appropriate play than females
Since females tended to have better superficial and communication skills, they may have been underdiagnosed
Lord C, et al. J Autism Dev Disord. 1982;12(4):

26. Differences in Toddlers
157 boys and 42 girls between the ages of 1.5 and 3.9 years showed that in addition to better communication skills in females and more unusual play in males, females had more anxious and depressed symptoms
Females had more sleep problems
So much variation on the spectrum, it was hard to define definitive differences at this age
Hartley SL, et al. J Autism Dev Disord. 2009;39(12):

27. DISCO Interview
Helpful interview for patients in the adolescent and adult years
320 items, completed by parent or caregiver
Good inter-rater reliability
Excellent sensitivity, moderate specificity
Recently, shorter form: DISCO, DSM-5 which appears to be as reliable and correlates now with the current DSM-5
The most important indicators for ASD were those in the social-communication domain
DISCO = Diagnostic Interview for Social and Communication Disorders.
Billstedt E, et al. J Child Psychol Psychiatry. 2007;48(11): Carrington SJ, et al. Research in Autism Spectrum Disorders. 2014;8(6):

28. ADI-R Takes 1.5 to 2.5 hours to administer
Useful in patients with mental age over 2 years
Can be purchased by MDs and psychologists, but for some, training sessions necessary before use; MDs and PhDs do not require additional training
Lord C, et al. J Autism Dev Disord. 1994;24(5):

29. Diagnosing Adults with ASD
Direct interview and observation
Add Hx of childhood behaviors
Self-reports: very revealing in those who camouflage well
Old testing
Discussing female’s coping mechanisms in their social lives
Lai MC, et al. PLoS One. 2011;6(6):e20835.

30. Comparison of Adults with ASD and Normal Intelligence
Females
Males
As children, no difference from males
Less autistic behavior in adults than males
Cognitively about the same
Same amount of comorbid depression, anxiety, and OCD
As children, no difference from females
More autistic behavior than females
Cognitively about the same
Same amount of comorbid depression, anxiety, and OCD
OCD = obsessive-compulsive disorder.
Lai MC, et al. PLoS One. 2011;6(6):e20835.

31. Comorbidities Common in Both Genders
70% of both genders between ages 10 and 14 years had other comorbidities
Greatest prevalence at this age
Social anxiety disorder: 29%
ADHD: 28%, and among these, 84% had a second comorbid diagnosis
It is therefore important to look for “other branches on the autism tree”
ADHD = attention-deficit/hyperactivity disorder.
Simonoff E, et al. J Am Acad Child Adolesc Psychiatry. 2008;47(8):

32. How to “Camouflage Autism”
Females may be better at consciously learning a social script to act more typical
May learn by rote how to use reciprocal conversation, gestures, gaze, and socially appropriate affect—much like learning a part in a play
These skills allow the females to “fly under the radar,” compared to the males on the spectrum
Some may select the actions of popular peers, their dress, mannerisms, etc, and effectively imitate these in exquisite detail
The stress of this role- playing can be exhausting
Attwood T. The Complete Guide to Asperger’s Syndrome. Philadelphia, PA: Jessica Kingsley Publishers; 2007.

33. Special Interests May Differ
Interests are less quirky and eccentric than those of males
Females may have fewer stereotyped activities and behaviors
Standard interviews may miss the special interests and their intensity
Volkmar FR, et al. Am J Psychiatry. 1988;145(11):

34. Increased Sensory Issues in Females
DSM-5 now includes sensory issues as one of the key symptoms: “unusual sensory behaviors”
May include over- and under-sensitivity to sensory stimuli
Self-reporting questionnaires may be better in picking this up than interviews—since the questionnaires may ask more items to assess sensory behaviors
It may be that “women show fewer but perceive more autistic features than males”
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Publishing, Inc.; Lai MC, et al. PLoS One. 2011;6(6):e20835.

35. Challenging Times for Females
Early childhood
Grade school
Adolescence
College, vocational training
Dating, courtship, marriage
Parenthood
Working and careers

36. Early Years Are Less Problematic than Middle School Years and Later
Girls tend to be less disruptive in the early school years
As middle school approaches, Catherine Lord of the University of Michigan observed a subset, “literally dumbstruck by anxiety,” when social demands escalate
A New York Times article reported that psychiatrists observed that high functioning men are more likely to go on and marry than the women studied
Lainhart and Folstein showed that despite being 1:4 females to males with autism, half of the patients with mood disorders were females
Bazelon E. What Autistic Girls Are Made of. The New York Times Magazine. August 5, McLennan JD, et al. J Autism Dev Disord. 1993;23(2): Howlin P, et al. J Child Psychol Psychiatry. 2004;45(2): Lainhart JE, et al. J Autism Dev Disord. 1994;24(5):

37. Pubertal Challenges
Change, even small transitions, are difficult for both genders on the autism spectrum
Puberty changes: body changes, sexual feelings, new expectations regarding behavior
Many may rely on the computer/Internet to obtain information: may lead to pornographic depictions that “become the tutor”
Needing to understand the subtleties of peer interaction: becoming a greater problem—girls may model themselves after a particular popular girl to fit in
Naiveté of these teens may lead to difficulties with peers, adults, and relationships with boys
Attwood T, et al. The Autism Spectrum, Sexuality and the Law: What every parent and professional needs to know. Philadelphia, PA: Jessica Kingsley Publishers; 2014:

38. Low Functioning Autism, Sexual Challenges in Women
Dealing with menses
Teach hygiene: wearing panty liners daily to get used to sensory aspect of wearing menstrual pads
Consider the use of implants or hormonal control to eliminate periods or minimize them
Prevent pregnancy: low- functioning women may be abused and sexually assaulted despite best intentions of the family
Understanding premenstrual behavioral exacerbations and being prepared to treat for this
Greenberg D. Personal experience.

39. Vulnerability
Unable to know how to respond to teasing about romantic feelings or behaviors
Inability to read the dishonorable intentions of another
Unsure of courting rituals and conduct
May decide to be celibate and spend time with technology as a substitute friend
Often later in social and emotional development than peers: can be highly intelligent, but significantly delayed in other areas
Attwood T, et al. The Autism Spectrum, Sexuality and the Law: What every parent and professional needs to know. Philadelphia, PA: Jessica Kingsley Publishers; 2014:

40. Executive Function Difficulties
People on the autism spectrum “live in the now,” not looking at what the future consequences might be
This can result in problems with organization, planning, flexibility in solving problems, and with a one track mind and determination in acquiring information or obtaining a goal
Attwood T, et al. The Autism Spectrum, Sexuality and the Law: What every parent and professional needs to know. Philadelphia, PA: Jessica Kingsley Publishers; 2014:135.

41. Teaching Appropriate Sexual Behavior
Masturbatory behavior is normal in all levels of autism in both genders (and in neurotypical patients as well)
Teach the appropriate time, place, and safety
Teach that Internet sites may provide exaggerated or false information
Attwood T, et al. The Autism Spectrum, Sexuality and the Law: What every parent and professional needs to know. Philadelphia, PA: Jessica Kingsley Publishers; 2014.

42. Obtaining Sexual Information
It is very important to provide accurate and timely information about sexual matters to autistic individuals to prevent them from turning to peers or the Internet for information
The autistic patient should understand appropriate touch and mutual agreement about intimacy. This should be taught by parents and caregivers
Attwood T, et al. The Autism Spectrum, Sexuality and the Law: What every parent and professional needs to know. Philadelphia, PA: Jessica Kingsley Publishers; 2014:

43. Internet Misrepresentation
Pornographic sites give misinformation: sex games, physical pain, and exaggerated sexual behaviors
Relying on the Internet may make the person have an unrealistic idea of appropriate sexual practices
Attwood T, et al. The Autism Spectrum, Sexuality and the Law: What every parent and professional needs to know. Philadelphia, PA: Jessica Kingsley Publishers; 2014.

44. The Need for Parental Monitoring
Often high functioning patients are experts in computers, and it is important to have safeguards in place to prevent logging into illegal sites
Families and friends need to safeguard their credit card information to prevent unwarranted spending
Both of these measures need to be explained to the adolescent to avoid dangers in illegal sites and dangers to finances
Attwood T, et al. The Autism Spectrum, Sexuality and the Law: What every parent and professional needs to know. Philadelphia, PA: Jessica Kingsley Publishers; 2014:141.

45. Intimacy Continuum
Often, adolescents and young adults may not understand the gradual continuum of intimacy
If they rely on Internet sources, the early and subtle steps toward intimacy are overlooked, and the steps that are needed early in the relationship are skipped
What is legal at what age must be discussed
Attwood T, et al. The Autism Spectrum, Sexuality and the Law: What every parent and professional needs to know. Philadelphia, PA: Jessica Kingsley Publishers; 2014:140.

46. Navigating Courtship Rituals
Learning signs of courtship: physical touching, complimenting, looking into eyes for prolonged period, moving closer, kissing on the cheek
Knowing how to deflect flirting by moving or turning away
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014:

47. When Sensory Problems Interfere with Relationships
Hypersensitive females may find that handshakes, hugging, and touching used in sex can hurt
A refusal to touch may be interpreted by others as rejection
Teaching friends to understand what is and is not tolerable for the patient may be useful
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014:28.

48. Sensory Problems (continued)
Hyposensitivity may lead to painful sexual interaction and may require a gentler reciprocation to the partner in order to avoid injury or soreness
Some autistic people are very upset with change in routine, fearing the unknown
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014:30.

49. Difficulties with Literal Interpretation of Language
Misinterpretation of language, eg, “Would you like to sleep with me?” might be interpreted as wanting to share a bed for non-sexual reasons
Difficulty understanding voice intonation and body language—eye contact, facial expressions, hand gestures, and body movements
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014:19-20.

50. Like Males, Lack of Social Chit-Chat
May not be able to keep up with peers and their social chatter
Girls have better imaginative play than boys on the spectrum
Almost like they have a script and are socially in control
Rich imaginations, may escape into fiction with subjects like fairies, witches, and may have imaginary friends
May have rich solitary imaginary world
May continue with doll play into adulthood, remaining socially immature
Difficulty using imagination in social context
Nichols S. Girls Growing Up on the Autism Spectrum: What Parents and Professionals Should Know About the Pre-teen and Teenage Years. Philadelphia, PA: Jessica Kingsley Publishers; Knickmeyer RC, et al. J Autism Dev Disord ;38(6): Gould J, et al. Good Autism Practice. 2011;12(1):34-41.

51. Difficulty with Theory of Mind
Problems imagining what it would be like to be someone else
Difficulty imagining how another feels—lacking empathy
Difficulty imagining intent
Problems understanding a point-of-view and perspective
Sometimes physiologic cues can give a signal to an autistic person warning of danger when theory of mind does not seem to serve well
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014:23.

52. Being Safe
Physician or therapist can help autistic women understand sexual safety
Help patients understand sexual harassment, assault, rape, sexual boundaries
Teach patients to understand flirting behaviors
Instruct girls and women about suggestive dressing, posturing, conversations to avoid being interpreted as having sexual intent
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014:

53. How to Help Autistic Women with Relationships
These suggestions are offered by an autistic woman who relates how to be helpful to her and others she has interviewed
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014.

54. Teaching about Relationships
Understanding the difference between casual sexual relationships vs romantic relationships
Understanding intimacy and learning that having sex may not necessarily indicate shared feelings
Teach about the difference between feeling lust and love
Realizing that there may be casual sexual relationships
Help patients learn to decide whether she wants to have sex or not
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014:

55. Obsessions
Women with autism may have a subject that completely occupies her time
She can memorize lots of facts and information about the subject
She may see solutions and creative problem solving that is “outside the box”
When working with these patients, call these circumscribed interests rather than obsessive interests
A big problem may exist when the patient is obsessed about another person who may not feel the same and reciprocate
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014:

56. Helping the Patient Avoid Manipulation
Making a script if it is difficult to say no
Asking advocate to say no for her
Making a list of positive and negative things about maintaining a friendship with the person
Help the patient imagine what things she could do with the friend that she would miss and imagining how she could do these things without that person
Teach that loneliness is frightening, but being hurt is worse
Teach that friends come and go, and people drift in and out of friendships
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014:49-50.

57. Counseling on How to Sustain Relationships
Teach the autistic woman to let the partner know how she feels about him/her
Help her to use words to express how she feels
Possibly writing down feelings and leaving them for the other person to read
Understanding that change, albeit uncomfortable, may help to sustain relationships—new surroundings, schedules, and sexual behaviors
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014:

58. Helping the Patient Discuss Being Autistic
Suggest that the patient may say, “Sometimes I may become overwhelmed; at that time, please leave me alone.”
Point out that meltdowns may cause relationships to deteriorate
Telling others that the patient is autistic—may cause many reactions and may scare off some people
Autistic people may have the tendency to over-attach and become too intense in a relationship—and it is helpful to advise against this
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014.

59. Suggesting Appropriate Dress
Teach the patient that she should be careful about how much of her body she exposes
She should avoid wearing sexually suggestive slogans on her clothes
It is wise to avoid see- through clothing
At times, clothing that is suggestive may give the impression that the woman is promiscuous
Facial expressions and posturing may have hidden implications. Chewing gum may reduce the possible overly expressive facial expressions
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014:

60. Evaluating: When is it a Date?
Teach that it is okay to ask, “Is this a date?”
Early in the interaction, it is acceptable to meet in a public place rather than a private residence
If the other person refuses, don’t continue
Teach that certain topics should be avoided early in dating: religion, health, past relationships, how much money she makes, sexual experiences, abuse
Learning to ask the other person about themselves or topics and opinions they have
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014:

61. Counseling about Staying Out of Abusive Relationships
Autistic women, like neurotypical women, are often loyal to abuser, and may not know how to prevent abuse or leave
Realizing that it is abuse if the other person forces you to do things you don’t want and threatens to leave or kick you out if you don’t
Recognizing red flags
Red Flags
Partner refuses to give other time alone
Partner isolates you from friends and family
Partner hurts you physically or makes horrible derogatory remarks about you, humiliates you
Partner is excessively jealous
Partner takes control of the other person’s money
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014:

62. Teaching How to Apologize
It is not intuitive to admit responsibility when something goes wrong
It might be helpful to script how to apologize to help autistic woman to resolve arguments and handle criticisms
Steward R. The Independent Woman’s Handbook for Super Safe Living on the Autistic Spectrum. Philadelphia, PA: Jessica Kingsley Publishers; 2014:

63. Help Create an Autism Alert Card
At there is a template that can be used to make a personalized alert card that explains about the patient’s autism
It suggests what to do if an autistic person is in distress
It lists contact numbers in case of emergency
Also available from the National Autistic Society, wallet- sized, that can be produced during a difficult situation
Contains a leaflet about autism as well

64. Sample Autism Alert Card
The National Autistic Society Autism. Accessed April 20, 2015.

65. Some Take-Home Messages
Autistic women may be difficult to detect due to their ability to imitate more socially appropriate behaviors
Some women may not have a diagnosis until adulthood
The work of constantly “playing a role” may be exhausting and lead to anxiety and meltdowns
Women may have more sensory sensitivities than males with autism, but they may only reveal these on questionnaires rather than face-to-face history taking
Genetics may determine susceptibility to autism, but epigenetics may determine expression

66. More Take-Home Messages
Autistic women with normal intelligence may marry, have families, and be very productive
Women with autism have many comorbidities: anxiety, depression, panic disorders
In their school years, women, like men, may have ADHD as a common comorbidity
You may know a few autistic women and girls—they are among us, and now it makes sense as you understand them in the context of their autism

67. Women: “Research Orphans”
Ami Klin who directs the Yale Autism Program calls females on the spectrum “research orphans”
He notes that women and girls on the spectrum are often excluded from studies of medications used for autism, and they are often culled from studies on autism
Is the world more forgiving of boys on the spectrum and their quirky behaviors, than for girls?
The numbers for autistic girls and women are small in research studies
Bazelon E. What Autistic Girls Are Made of. The New York Times Magazine. August 5, 2007.

68. Work for the Future
Developing programs to mentor girls and women on the autism spectrum in schools, colleges, industry
Insistence on inclusion of females on the autism spectrum in pharmacologic research and other research projects
Searching for females on the spectrum when evaluating their children