Neurodiversity 101: how does gender bias play out today?

Why has it taken so long for girls and women to have their own ND traits recognised?

Does neurosexism still exist?

Neurosexism is an alleged bias in the neuroscience of sex differences towards reinforcing harmful gender stereotypes. The term was coined by feminist scholar Cordelia Fine in a 2008 article and popularised by her 2010 book 'Delusions of Gender' Gina Rippon has also written about this too in the 'Gendered Brain'.

Researchers Joel and colleagues in 2015 concluded that every brain is actually a mosaic of different patterns, some more commonly found in men’s brains and some in women’s. But none could be described as fully male or fully female.They went on to say in 2021 that we need to move from a binary view of brains by gender to seeing the mosaic of differences that in reality exist.

Big brains and small brains...

The myths relating to male and female brain differences have been around for a long time.In 1879, where Gustave Le Bon, made a most vicious attack upon women in the scientific literature of the day. He concluded:

"In the most intelligent races, as among the Parisians, there are a large number of women whose brains are closer in size to those of gorillas than to the most developed male brains. This inferiority is so obvious that no one can contest it for a moment; only its degree is worth discussion. All psychologists who have studied the intelligence of women, as well as poets and novelists, recognize today that they represent the most inferior forms of human evolution and that they are closer to children and savages than to an adult, civilized man. They excel in fickleness, inconstancy, absence of thought and logic, and incapacity to reason. Without doubt there exist some distinguished women, very superior to the average man, but they are as exceptional as the birth of any monstrosity, as, for example, of a gorilla with two heads; consequently, we may neglect them entirely."

WOW!

This categorical approach provided a somewhat limited view of the world retaining the dichotomy of views that still seem to exist when I walk down the toy shelves today that ‘blue is for boys and pink for girls’ and that this divide is a clean one. Lego h as made some changes recognising this is still a real challenge.

21st Century thinking in relation to Neurodiversity...

If this is the back drop then it is not surprising that there has been a dominant view of males having certain sort of brains compared to females when it comes to cognitive diversity.

While Autism Spectrum Disorder (ASD) has been noted to occur more frequently in males more than in females, one reason for this was that females with Autism Spectrum Conditions for example have historically been virtually absent from studies investigating ASC/D (Constantino & Charman, 2012; Fountain, King, & Bearman, 2011). Diagnostic criteria for ASD have also been developed almost entirely using the male behavioural and symptomatic presentation of ASD (Goldman, 2013). Some of the instruments or specific items used to diagnose ASD may also have a male bias (Adamou, Johnson and Alty, 2018).

One rationale for this proposed view was the 'Extreme Male Brain' hypothesis. In simple terms, this theory suggested that the brains of individuals with ASD are an exaggerated version of a 'typical' male brain.

However..when researchers in more recent times looked at brain scans(2022) from over 2,000 people to look how different they were they found on average, the ASD group had a higher "brain maleness" score compared to those without ASD. Interestingly, higher scores also seemed to be linked with more severe autistic symptoms. BUT When the researchers looked closer, they noticed that individuals with ASD generally had larger brains compared to those without ASD. This is crucial because, in general, males have larger brains than females. When they adjusted their analysis to account for brain size, the difference in "brain maleness" between the ASD and non-ASD groups vanished.

Bias is far more than about brain size....

Gender biases in expectation, presentation and identification relating to neurodivergent traits and conditions can and does lead to different pathways leading to different outcomes.

• ADHD
• Historically,underdiagnosis in females due to focus on hyperactivity in males; societal expectations for girls' behaviour.Girls may nternalise their challenges and mimic others to survive different social settings.
• ASD
• Research bias towards males; females may exhibit different symptoms and masking or camouflaging behaviours. This may show in other ways such as 'meltdown's, anxiety, eating disorders and self harm.Areas of specific interest may be more similar to other females.
• DLD
• Language delays may be attributed to personality; girls may develop compensatorystrategies, masking their difficulties. This may show in other ways such as meltdown's, anxiety, eating disorders and self harm.
• DCD
• Gender norms influence recognition such as expectation of sporting skills; girls may avoid activities that highlight struggles.
• Dyslexia
• Compensation with strong verbal skills; expectations of better academic performance in females.
• Dyscalculia
• Compensation with verbal skills; stereotypes linking math difficulties to boys; under recognition in females.
• Tic Disorders
• Tics in females may be perceived as less disruptive; stereotypes associating tics with males; tics may be masked or suppressed.

What about ascertainment and referral biases?

"We see the world, not as it is, but as we are or, as we are conditioned to see it.” Stephen R. Covey

Current diagnostic criteria for ADHD have also been developed in predominantly male samples, so that many diagnostic instruments may not generalise to females (Nussbaum, 2012).

A recent review (2023) of ADHD in adult females emphasises that in childhood, the ratio of boys to girls with ADHD is about 3:1 whereas in adulthood it is closer to 1:1, suggesting that women and girls have been underdiagnosed in childhood (Da Silva et al., 2020).

One view considers gender differences to reflect a methodological artifact arising from Ascertainment bias. This refers to males being more likely to be referred for evaluation than females with equivalent challenges. For example, more boys could end up being referred with reading problems is they openly express frustration and exhibit disruptive more overt behaviours in the classroom.

One article from Uppsala (Ghosh et al, 2019) identified bias in reporting of ADHD characteristics by gender. That is the male participants in the study reported ADHD characteristics more in boys more accurately, and female adults reported girls with ADHD more accurately. Interestingly, women have been shown to be better at determining a character’s behaviour, if the vignette character is female (Wacker et al, 2017)

We know that presentation results in different responses by professionals. As a result of this females may have less opportunity to gain a referral for a diagnosis. For example, males may demonstrate more externalising behaviours (Kreiser and White., 2014), which may be one reason for gaining the attention of health professionals or therapists.

Females may also be missed because of the ‘type’ of ADHD that they have which is a predominantly inattentive ADHD (dreamy type).The symptoms of inattentive ADHD are also much less disruptive to others( important to note that.. I am not underestimating the impact on the person) than those of hyperactive/ impulsive ADHD(APA, 2013). A study of primary school teachers found that they frequently did not identify the inattentive ADHD type and were not aware that medication could be helpful in this context (Moldavsky et al, 2014).

This bias is also seen in other conditions including Developmental Co-ordination Disorder (also known as Dyspraxia). One survey of elementary school teachers showed that they were more likely to report concerns about the gross motor skills performance of boys than the fine motor performance of girls and also considered it more important to intervene with the children with gross motor problems (Rivard et al., 2007).

Masking, missing, misidentified, and misunderstood

Neurodivergent traits in women and girls have been missed, misidentified and misunderstood leading to very different outcomes and perceptions about ourselves and how others see us too.Many women end up with psychiatric diagnoses without a range of neurodivergent conditions ever having been considered. This has a cost to them, their families and society. Masking comes at a cost and may have been done as a survival mechanism from a young age and not be even thought that this was masking. I developed from a very early age 'helpful' personas as it was socially appropriate to get me away from settings I didn't feel comfortable in. I was also promoted for my helpfullness....

Future you... needs to deal with past you too...

Many women who are neurodivergent but haven't been diagnosed often go through life feeling like they're "different" or "not good enough." They might even blame themselves for not achieving as much as they'd like to. Because of this, getting a diagnosis can be a game-changer for self-esteem and how they see themselves.

For a lot of women, getting that diagnosis can be like a lightbulb turning on. It helps them understand that their challenges aren't because they're lazy or unintelligent; it's because they have ADHD or Dyslexia for example. This realisation can be truly liberating, making it easier for them to accept themselves and tackle their struggles head-on.However it may come with feelings of loss, grief and anger especially if survival hacks had to be put in place which took their toil.

There is no doubt in the last few years we are seeing greater understanding of what it means to be a female who is ND but more education is required; more research is required; and more services need to be designed understanding ND in females and not just an adapted version of a clinical model designed for boys and men.

We need to check the biases we had are not just gone into hiding but are actually no longer present.

Blog Author

I am Amanda Kirby, CEO of?Do-IT Solutions ?a tech-for-good company that delivers thought provoking consultancy and neuroinclusive guidance and training. We have developed cutting edge web-based screening tools that have helped 10s of 1000s of people. We strive to deliver person-centered solutions relating to neurodiversity and wellbeing.

I am a mixed bag of experiences and skills, an odd ball... and have 25+ years of working in the field of neurodiversity.

I am a medical doctor, Professor, and have a Ph.D. in the field of neurodiversity; parent and grandparent to neurodivergent wonderful kids and am neurodivergent myself.

Theo Smith and I wrote the UK award-winning book?Neurodiversity at Work?Drive Innovation, Performance, and Productivity with a Neurodiverse Workforce . My 10th book came out called?Neurodiversity and Education ?in March this year. Excitingly, Theo and I have another book coming out next year!