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

“I have lived forty years interpreting a script that was not mine.” This is how the writer and communicator summarizes In Catalonia, reality is measured in an abysmal diagnostic gap. According to the reference work in our country, done by a team of researchers from the Global Health Institute (ISGlobal) of Barcelona and the Mútua Terrassa University Hospital, the prevalence of autism spectrum disorder in minors stands at 1.23%. The distortion, however, explodes when crossing data by gender: while almost 2% of boys (1.95%) have a diagnosis, the percentage drops to 0.46% in girls. This ratio of 4.5 boys for every girl is not a faithful reflection of the disorder's biology, but 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 rooted in the very foundation of research: "Autism has been defined under a male pattern and diagnostic instruments were validated almost exclusively with men." This lack of knowledge base has created a clinical blind spot: while in boys symptoms tend to be disruptive or "explosive," in girls the disorder often disguises itself behind apparent social competence. Their interests – intense reading, animals, or fashion – align more with gender expectations and end up "deceiving" parents and teachers.

But 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, often only breaks in adulthood.

The girls' invisible shield

Until recently, science wondered why autism seemed to have a statistical "preference" for males. The answer, however, is not that there are fewer girls predisposed to the disorder, but that their bodies offer a molecular barrier: the so-called "female protective model." As explained by Cormand, women's brains operate with a much higher threshold of biological tolerance. This means 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 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 having two copies of this chromosome – unlike the single copy that men have – endows women with an extra molecular safety net. Although in each female cell one of the two X chromosomes is inactivated 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 collapse much sooner. And this plunges many girls into a gray area: they coexist with a 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 called masking, consists of deploying an arsenal of behaviors –often unconscious– to blend in with the environment and dilute any neurodivergent trait. While in children 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 biggest 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 classmates, even if they don't understand the underlying codes. This "performance" is so demanding that it causes a short circuit in the healthcare system: during clinical visits, many women camouflage their symptoms so effectively that the disorder becomes invisible. The result is a misdiagnosis that follows 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 clandestine existence for four decades. "It's a continuous act of behaving in a way that isn't yours, doing things that are not meant for you or your way of perceiving the world," she recounts. This titanic effort to "appear normal" has a devastating cognitive and emotional cost. Recent research confirms that masking requires exhausting work of executive functions – such as impulse inhibition and emotional regulation – which leads to soaring rates of anxiety and depression. "So much time spent camouflaging who you are makes you start to ask yourself: 'Okay, so who am I?'", Codina confesses about the profound blurring of one's own identity. But the void is not only emotional, 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 last cry for help from an organism that can no longer pretend.

A diagnosis in a male key

If biology has endowed women with a "shield", the healthcare system has unintentionally added a veil. Amaia Hervás, a recognized international expert on autism spectrum disorder (ASD), argues that the problem is methodological in origin: the foundations of the diagnosis were laid 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 child with disruptive behaviors, but ignores the girl who, out of 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 already describe as a statistical mirage. With gender-adapted tests, the gap shrinks drastically to sit at 2:1 or even 1.8:1. The problem is not a lack of cases, but a systemic bias in interpretation. A pediatrician may dismiss autism in a girl who smiles or maintains eye contact, without suspecting that behind this appearance lies an atypical quality of behavior: an immense cognitive effort to simulate a normality that the system takes for granted.

The partial gaze is also an object of study. While the collective imaginary seeks an obsession with trains or schedules, in girls, deep interests are mimicked under everyday themes such as animals or devotion to a fictional character. "They 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 difficulties are labeled as "shy" or "anxious," or are referred to circuits for eating disorders or personality disorders (BPD) before considering autism. Without a clinical re-evaluation with a gender perspective, the diagnosis will continue to be a thorny path that thousands of women will only manage to complete, with luck, at the threshold of maturity.

The relief of naming it

If memory is the architect of identity, diagnostic silence has forced thousands of women to build themselves on foundations of guilt and bewilderment. For Sara Codina, receiving the news at 40 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 celebration, an euphoria.” This clinical “baptism” is the key to initiating a necessary process of deconstruction and grief, 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 finally allows you to rediscover your original self,” reflects Codina.

The day after the diagnosis is, in reality, the beginning of a reconstruction. Hervás points out that most of these women do not enter the system through autism, but through its cracks: severe cases of anxiety, depression, or eating disorders (EDs) that often debut in adolescence. They are patients who carry a deep sense of life 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 end up with diagnoses of chronic fatigue or fibromyalgia; the body screams when it can no longer bear it,” recalls Codina about the physical collapse that comes when social theater becomes unsustainable. The diagnosis, therefore, arrives as a balm, but also as a necessary explanation for a pain that for decades had no name.

Late diagnosis acts, above all, as a tool for reconciliation. According to Hervás, the goal is not to “fix” anyone, but to offer 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.