"I have lived forty years playing a role": why female autism goes unnoticed

“I have spent forty years performing a script that was not my own.” This is how writer and communicator Sara Codina, author of Neurodivina i punt, summarizes the vital void prior to her autism diagnosis. For decades, Codina carried the guilt of feeling like a “broken neurotypical,” a defective piece unable to understand the rules of the world. This daily theater to fit in makes female autism seem like a statistical rarity when, in reality, it is a condition hidden behind a social and genetic shield.

In Catalonia, the reality is measured by an abysmal diagnostic gap. According to the reference work in our country, conducted by a team of researchers from the Barcelona Institute for Global Health (ISGlobal) and the Hospital Universitari Mútua Terrassa, the prevalence of autism spectrum disorder in minors stands at 1.23%. The distortion, however, erupts when crossing the data by gender: while nearly 2% of boys (1.95%) have a diagnosis, the percentage falls to 0.46% for girls. This ratio of 4.5 boys for every girl is not a faithful reflection of the biology of the disorder, but rather proof of a historical clinical blindness that has left thousands of women on the margins.

Dr. Amaia Hervás, head of mental health at the Mútua Terrassa University Hospital and author of the first guide on autism from the European Society for Child and Adolescent Psychiatry, warns that this asymmetry is born at the very root of research: "Autism has been defined under a male pattern and diagnostic instruments were validated almost exclusively with men." This lack of a knowledge base has created a clinical blind spot: while in boys symptoms tend to be disruptive or "explosive," in girls the disorder is often camouflaged behind apparent social competence. Their interests – intense reading, animals, or fashion – align more with gender expectations and end up "deceiving" parents and teachers.

But the invisibility is not just cultural; it has a molecular basis. Dr. Bru Cormand, head of the genetics department at the University of Barcelona, points to a kind of biological "resistance" that protects girls from the severity of the most evident symptoms. Paradoxically, this strength becomes a trap: it keeps them under the system's radar and condemns them to a misunderstanding that, as in Sara's case, is often only broken in adulthood.

The invisible shield of the girls

Until recently, science wondered why autism seemed to have a statistical "preference" for men. The answer, however, is not that there are fewer girls with a predisposition to the disorder, but that their organism offers a molecular barrier: the so-called "female protective model". As Cormand explains, the female brain operates with a much higher biological tolerance threshold. This implies that, for autism to manifest and be detectable, the "storm" of genetic mutations must be much more virulent than in boys. It is this genetic buffer that allows many girls to compensate for the difficulties and remain invisible according to the rules of traditional diagnosis.

The secret of this shield lies in genetic redundancy: the second X chromosome. Research recently published in the journal Nature Genetics suggests that possessing two copies of this chromosome –unlike the single one that men have– provides women with an extra molecular safety net. Although in every female cell one of the two X chromosomes is disabled to maintain balance, it has been discovered that some genes manage to evade this silencing. They are genetic "fugitives" that act as a compensation mechanism, capable of mitigating the impact of alterations that, in a male brain, would cause functionality to fail much sooner. And this plunges many girls into a grey area: they live with the predisposition to autism, but their symptoms remain camouflaged below the detection threshold. Biology protects them from the most evident severity, but the system condemns them to an invisibility that deprives them of support during the most critical stages of their development.

The art of disappearing

Female autism often hides behind a mechanism as sophisticated as it is exhausting: social camouflage. This strategy, technically dubbed masking, consists of deploying an arsenal of behaviors – often unconscious – to blend in with the environment and dilute any neurodivergent trait. If in boys the disorder tends to emerge with more stereotyped or disruptive behaviors, for many girls the absolute priority is survival: learning to "act" to turn difference into invisibility.

Psychiatrist Hervás points out that this mimicry is one of the greatest barriers to early detection. "Girls have an innate ability to mimic social behaviors and blend into the group," she states. To achieve this, they rehearse expressions in front of the mirror, force eye contact, or copy the gestures of their classmates, even if they do not understand the underlying codes. This "performance" is so demanding that it causes a short circuit in the healthcare system: in clinical visits, many women camouflage their symptoms so effectively that the disorder remains invisible. The result is a misdiagnosis that haunts them for years: they are labeled with social phobia, depression, or personality disorders, while the true root of the problem remains hidden.

For Sara Codina, this reality has been a forced clandestinity for four decades. "It is a continuous act of behaving in a way that is not your own, doing things that are not designed for you or for your way of perceiving the world," she relates. This titanic effort to "seem normal" has a devastating cognitive and emotional cost. Recent research confirms that masking demands exhausting work from executive functions—such as impulse inhibition and emotional regulation—which leads to skyrocketing rates of anxiety and depression. "Spending so much time camouflaging who you are makes you eventually ask yourself: 'Okay, and who am I?'" confesses Codina regarding the profound blurring of one's own identity. But the void is not only mental, it is also physical. After a day of social "theater," the exhaustion is so extreme that the body ends up somatizing the pressure: chronic fatigue or fibromyalgia are, often, the final cry for help from an organism that can no longer pretend.

A diagnosis in a masculine key

If biology has endowed women with a "shield," the healthcare system has involuntarily added a veil to it. Amaia Hervás, a renowned international expert in autism spectrum disorder (ASD), maintains that the problem is methodological at its root: the foundations of the diagnosis were built under an exclusively androcentric gaze. The instruments considered the gold standard in clinical practice were validated with samples where girls were a statistical anecdote. The result is a criterion that accurately identifies the boy with disruptive behaviors, but ignores the girl who, for survival, conforms to social expectations.

This clinical blindness has fueled the myth of the 4:1 ratio, a proportion that Hervás and the research community now qualify as a statistical mirage. With gender-adapted tests, the gap shrinks drastically to stand at 2:1 or, even, 1.8:1. The problem is not a lack of cases, but a systemic interpretation bias. A pediatrician may dismiss autism when faced with a girl who smiles or maintains eye contact, without suspecting that behind this appearance hides a behavior of atypical quality: an immense cognitive effort to simulate a normality that the system takes for granted.

The partial gaze is also in the object of study. While the collective imagination looks for the obsession with trains or schedules, in girls, deep interests are mimicked under everyday themes like animals or devotion to a fictional character. "These are socially accepted behaviors," explains Hervás, but they hide the same rigidity, perfectionism, and intensity as in the case of boys.

This reality leaves out of the radar, especially, girls with preserved cognitive abilities. Those who can "compensate" for the difficulties are labeled as "shy" or "anxious," or are referred to eating disorder or personality disorder (BPD) circuits before considering autism. Without a clinical re-evaluation with a gender perspective, the diagnosis will continue to be a path full of thorns that thousands of women will only manage to complete, with luck, at the doors of maturity.

The relief of naming it

If memory is the architect of identity, diagnostic silence has forced thousands of women to build themselves upon the foundations of guilt and bewilderment. For Sara Codina, receiving the news at 40 years old was not a burden, but an act of vital liberation: “Being able to put the correct name to what you know is there, but that no one names, was almost a party, an euphoria”. This clinical “baptism” is the key to initiating a necessary process of deconstruction and mourning, but above all of reconciliation with the past. “By camouflaging your way of being so much to try to fit in, you end up distorting who you are; the diagnosis allows you, finally, to rediscover your original self”, reflects Codina.

The day after the diagnosis is, in reality, the beginning of a reconstruction. Hervás highlights that the majority of these women do not enter the system through autism, but through their cracks: severe cases of anxiety, depression, or eating disorders (ED) that often debut in adolescence. They are patients who drag a deep feeling of vital failure for not having met social expectations that were not made for them. But the price of the mask is not only emotional, but organic. “It is no coincidence that many of us end up with diagnoses of chronic fatigue or fibromyalgia; the body screams when it can no longer take it”, recalls Codina about the physical collapse that arrives when the social theater becomes unsustainable. The diagnosis, therefore, arrives as a balm, but also as a necessary explanation for a pain that for decades did not have a name.

Late diagnosis acts, above all, as a tool for reconciliation. According to Hervás, the goal is not to "fix" anyone, but to offer the strategies so that the world stops being a hostile place and they can study, work, and socialize while respecting their own nature. Understanding autism in women forces us to rethink the boundary between biology and identity, but it also confronts us with an uncomfortable truth: the system must learn to offer acceptance instead of demanding adaptation.