Autism in Women: Why It Is Often Missed, and How Mentalization Based Therapy Can Help

Autism has historically been understood through a male-centered lens. Much of the research, diagnostic criteria, and early screenings focused on patterns more commonly seen in boys (Lai et al., 2015). As a result, many women with autism grow up without a name for their inner experiences. They learn to adapt, compensate, and blend with their surroundings in ways that make their genuine struggles invisible to others.

Yet these experiences are deeply felt. Many women with autism describe a lifelong sense of observing social life rather than effortlessly participating in it. They often have rich inner emotional worlds, keen perceptual sensitivity, and strong intuitive understanding of others, but struggle to make sense of how to communicate their internal experiences clearly (Holliday Willey, 1999).

It is common for women to receive a diagnosis only in adulthood, sometimes after years of treatment for anxiety and depression or other diagnoses (Mandy & Tchanturia, 2015). These diagnoses may describe pieces of the presentation but do not capture the whole picture.

Why Autism Is Often Underdiagnosed in Women

1. Social Camouflaging
Girls and women often learn to “mask,” or consciously and subconsciously imitate social behavior to appear socially typical (Hull et al., 2017). Masking can include rehearsing conversational patterns, copying facial expressions, or over-efforting to fit in.
Masking can make autism nearly invisible from the outside while internally it may lead to exhaustion, self-doubt, and emotional burnout (Livingston et al., 2020).

2. Internalized Presentationic boys are often noticed because of behavioral differences. Many girls with autism internalize distress instead. Their struggles may show up as anxiety, people-pleasing, withdrawal, or perfectionism (Dean et al., 2017). This can lead clinicians to misinterpret symptoms as anxiety disorders rather than autism.

3. Misdiagnosis
Women with autism may be diagnosed with Borderline Personality Disorder, especially when emotional intensity and relational sensitivities are present (Dudas et al., 2017).
However, while BPD involves instability in identity and emotions, individuals with autism often describe emotional overwhelm related to sensory processing and social meaning-making, rather than fear-driven relational patterning. The two diagnoses can also co-exist and the autism diagnosis may be missed.

4. Strengths That Mask Struggles
Many women with autism are deeply empathetic, creative, perceptive, or academically gifted. These strengths can hide the effort it takes to navigate social situations (Bargiela et al., 2016).
Sensitivity is not the opposite of autism. For many women, it is central to their experience.

The Emotional Cost of Being Unrecognized

When a core part of identity goes unnamed, it can lead to:

• Chronic self-blame and confusion

• Feeling “out of sync” socially

• Shame around emotional intensity

• Difficulty maintaining boundaries

• Burnout from the effort of masking (Raymaker et al., 2020)

Receiving an accurate diagnosis is not about placing someone in a category. It is about offering language, coherence, and relief.

How Mentalization Based Therapy (MBT) Can Help

Mentalization Based Therapy focuses on understanding one’s own mental and emotional states while also being curious about the states of others (Bateman & Fonagy, 2016). For women with ASD, MBT provides a compassionate structure for making sense of social-emotional experience without judgment.

1. Strengthening Emotional Self-Understanding
Women with autism often report sensing emotions intensely but struggling to identify or explain them. MBT offers scaffolding to slow down and name what is happening internally (Lind et al., 2020).

2. Reducing Shame and Self-Blame
MBT emphasizes curiosity over correctness. The goal is not to “fix” behavior but to understand the emotional logic behind it. This approach can reduce internalized shame, especially for women who have spent years masking to avoid rejection.

3. Increasing Flexibility in Thinking About Others
Social interactions can feel confusing, unpredictable, or overwhelming. MBT helps expand the ability to imagine multiple interpretations of another person’s behavior, reducing black-and-white relational conclusions.

4. Supporting Sustainable, Authentic Relationships
Many women with autism desire deep, meaningful connection, but fear the emotional demand or intensity of relationships. MBT uses the therapeutic relationship itself as a safe space to understand patterns and build more trust in self and others.

A Final Note

Women with autism often possess profound capacity for empathy, creativity, emotional depth, loyalty, and insight. Diagnosis does not diminish individuality. It clarifies and honors it.

When women are given language for their experience, their lives often begin to feel more coherent, grounded, and possible.

References

• Bargiela, S., Steward, R., & Mandy, W. (2016). The experiences of late-diagnosed autistic women. Journal of Autism and Developmental Disorders.

• Bateman, A. & Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders. Oxford University Press.

• Dean, M., Harwood, R., & Kasari, C. (2017). The art of camouflage: Gender differences in the social behaviors of autistic children. Journal of Autism and Developmental Disorders.

• Dudas, R., et al. (2017). The overlap between autism and borderline personality disorder. Personality and Mental Health.

• Holliday Willey, L. (1999). Pretending to Be Normal. Jessica Kingsley Publishers.

• Hull, L., et al. (2017). Camouflaging in Autism. Journal of Autism and Developmental Disorders.

• Lai, M.-C., et al. (2015). Sex differences in autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry.

• Lind, S., et al. (2020). Mentalizing in autistic adults. Autism Research.

• Livingston, L., Shah, P., & Happé, F. (2020). Compensatory strategies in autism. Autism.

• Mandy, W., & Tchanturia, K. (2015). Autistic traits in anorexia and other conditions. Clinical Psychology Review.

• Raymaker, D., et al. (2020). Autistic burnout. Autism in Adulthood.