Constructions of “female autism” in professional practices: A Foucauldian discourse analysis

Ethical approval was obtained from the University of Leicester’s Psychology Research Ethics Committee. The Ethics Committee agreed professionals providing data should not be regarded as participants, as they were supplying existing descriptions and resources as opposed to being interviewed for their views. Nevertheless, respondents were given information sheets that explained the purposes of the study and the reason texts on female autism were being requested. The design of the study followed recommendations from the British Psychological Society’s Ethics Guidelines for Internet Mediated Research (BPS, 2021).

Data were provided directly via 10 professionals (seven psychologists, two nurses, one speech and language therapist), with some respondents collating resources from other colleagues in their networks. We also identified resources from professionals’ recommendations on online forums. Recruitment was limited to UK-based respondents because although there might be broad shared ways of thinking about autism internationally, differing sociopolitical and service contexts will shape its social construction (O’Dell et al., 2016). All data were English language, many were created by UK-based authors/organisations, with some from other English-speaking countries. See Table 1 for a summary of the data collected.

Texts judged closest to those generated by professionals in clinical practice (i.e., text used in clinical reports), or which represented common currency in professional discourses (judged by the number of recommendations by respondents, or the degree to which the content of the text appeared across different sources), were prioritised for analysis.

The analysis, informed by Parker (1992) and Willig (2013), was underpinned by social constructionist epistemological assumptions, meaning categories such as female autism were not regarded as describing “objective realities” (Georgaca, 2013). Rather, we viewed the construction and application of categories as being situated within the knowledge politics of the psy-disciplines, shaped by broader social and power structures (O’Reilly & Lester, 2017). Our analysis sought to take seriously Hook's (2001) critique that discourse analysis approaches often neglect historical contextualisation and the role of materiality both “in and outside” of the text.

Foucault himself did not develop FDA, but a central feature of his work was on how power “ebbs and flows” in “disciplinary societies” as a form of governmentality (Foucault, 1977). Here, the psy-disciplines function as a technology of domination, the “expert gaze” determining the “normal” from the “pathological.” Foucault was also concerned with “technologies of self,” whereby subjects transform their own bodies, minds, and lifestyle in accordance with dominant discourse (Foucault, 1988). Our analysis looked for the operation of both technologies and how they function within texts on female autism, shaping practice and the construction of femininity, difference, and distress.

We first coded the data to identify and group into themes the different ways in which female autism as a discursive object was constructed across texts. Extracts representing themes were then analysed by connecting constructions of female autism to wider discourses, attending to congruence and tensions between discourses, identifying the functions of the constructions in specific discursive contexts, examining what opportunities for speech or action were made possible or legitimate, and considering implications for subjectivity and power relations.

This theme is about the ways in which the identification and investigation of female autism as a distinct diagnostic profile is framed as progress: an improved professional knowledge, benefiting a previously neglected group. A number of discourses are at play in these constructions. The first is a discourse of medical–scientific advancement. Female autism is constructed as signifying both continuity and change within the history of autism.

Extract 2 (original author unknown; provided by two contributors from separate organisations who utilised the text in clinical reports):Connecting female autism “today” (Extract 1, Line 3) with the foundational case studies of Asperger (Extract 1, Line 1) gives a history and heritage to female autism and its underrecognition. Placing female autism in autism's origin story adds legitimacy to the concept. Labelling autism as a “historically … predominantly male condition” (Extract 2, Line 1) marks the male-centric understanding as outdated. “Growing awareness” (Extract 2, Line 2) invokes a positivist narrative of the history of science as a linear accumulation of knowledge (Niiniluoto, 2019). Distinction between past and present, out-of-date and up-to-date, establishes binary positions for professionals: at the forefront of developing knowledge, or stuck in the past. “More subtly” (Extract 2, Line 3) reinforces this, suggesting that the “aware” clinicians are more skilled, for they can identify subtle differences. Connecting the discounting of “an ASC explanation” with professionals having stereotypes (Extract 1, Line 5) draws on discourses about “good” science being free from bias. Referring to “the stereotype” protects the category of autism itself from critique, locating the problem instead with its application by the unskilled/biased professional.

A second discourse around gender equality is drawn on to support the idea of female autism as progress.Female autism is constructed as underdiagnosed due to a “boy bias” in diagnostic practices (Extract 3, Line 2). This rests on a binary understanding of gender, articulated in common sense terms: “we all know” boys and girls are “very different” (Extract 3, Lines 3–4). Evoking feminist–empiricist critiques of medicine as male-normed (Gergen, 2001; Wigginton & Lafrance, 2019), an activist position is created for professionals advocating the recognition of female autism. In Extract 4, the moral argument for female autism as a gender equality issue reaches its apotheosis as a matter of human rights (Line 8).

This morally loaded human rights discourse enters at a point where the promise of scientific advancement seems fragile, the evidence base “inconclusive” (Extract 4, Line 3). Yet describing the evidence as “currently sparse” (Extract 4, Line 3) suggests more confirmatory evidence will complete the picture. Scepticism about the validity of female autism is discouraged by a morally charged call for “consensus” (Extract 4, Line 5) in the interests of the girls and women who “need to be recognised” (Extract 4, Line 6). Implicit in these constructions is an argument for the involvement of educational, health, or social care services, to ensure that women and girls with autism, positioned as potential service users, are “recognised” by the expert gaze and then “enabled and effectively equipped” (Extract 4, Lines 6–7).Extract 5, written by the headteacher of a specialist school, draws on individualistic positive psychology discourses in constructing happiness as a matter of “understanding, regulating and managing” emotions (Extract 5, Line 1), of shaping the self in accordance with expert advice. Under this disciplinary gaze, the subject can understand herself (Extract 5, Line 1), be “contained” and “emotionally functioning” (Extract 5, Line 4); yet unrecognised as autistic, anxious, and bedroom-bound (Extract 5, Lines 4–5), she cannot be “happy,” or access “opportunities” (Extract 5, Lines 2–3). Positive psychology discourses about personal flourishing tie into a wider neoliberal economic context of competitively accessed opportunities, in which an individual's worth is measured by their potential to contribute economically, and in which educational, health, and social care services are tasked with “equipping” individuals to meet these expectations (Clegg & Lansdall-Welfare, 2020).

Mallett and Runswick-Cole (2016) have written of the commodification of autism. The narrative of female autism as progress talks the language of feminist empiricism, scientific neutrality, and human rights, whilst opening new markets: for researchers, expert diagnosticians, training providers, and specialised services catering to the needs of this newly recognised cohort of hitherto overlooked girls and women. Our second theme is about how this market expansion is underpinned by the ways in which female autism extends the reach of autism. Through constructions of female autism, the expert gaze identifies women and girls who, on the surface, may seem similar to female peers, and differ from stereotypes of autism.In this vivid imagery, autism is unseen until the clinician “shines” the light of knowledge (Extract 6, Lines 3–5), a special, revelatory power. This knowledge-power is the preserve of the “appropriately trained” (Extract 6, Line 3), and so requires an infrastructure of professionals and institutions to invest in, develop, and disseminate training.The identification of female autism is presented as a highly skilled activity: from the vantage point of “very experienced clinicians,” it is possible to see “beyond” the diagnostic criteria (Extract 7, Lines 1–2), to detect female autism where the presentation looks different to existing classification systems. Opposing positions are again formed: the skilled professional, experienced, able to see versus the inexperienced professional, constrained by the criteria. Framing this as a question of experience and skill delegitimises the voice asking, “If we are going beyond the criteria for ‘autism,’ are we still talking about ‘autism’?” Even if one were to see autism as something other than a biomedically valid diagnostic category—a social kind, or a serial collective (e.g., Chapman, 2020)—arguably, the continued expansion of autism's boundaries presents challenges to its utility as a descriptor: the risk that diagnostic inflation devalues the currency.“Thomas the Tank Engine,” “eye contact” … these stereotypes are jettisoned as not applicable to girls with autism (Extract 8, Lines 1–4): the rules have changed. A distinction is created between what autism “is” and what “society” thinks autism is (Extract 8, Lines 5–6); a parallel distinction between the expert's insight and others’ stereotyped assumptions. To “redefine” autism to better capture women and girls (Extract 8, Line 5) means redrawing the boundary, expanding autism.Female autism as a “copied” way of being invokes gendered tropes of femininity as masque and artifice (King, 2004). The construction of “masking” as characteristic of female autism requires separating “normal” social learning from the “copying” perceived as symptomatic of female autism: the differentiation between “intellect” and “intuition” (Extract 9, Line 3) creates distinct autistic and nonautistic processes underpinning behaviour which may look on the surface very similar. How does one distinguish between intellect-based and intuition-based behaviour? The tools of expertise.

One such tool is the Camouflaging Autistic Traits Questionnaire (CAT-Q; Hull et al., 2019). Extract 10 is a sample of items from its “masking” and “assimilation” components.The CAT-Q is interesting for several reasons. The very concept of camouflaging suggests “otherness”—a disguise to blend into the environment—in military parlance, a means of hiding from “the other side.” This otherness is in tune with representations of autism as alien (Hacking, 2009), of autistic Women From Another Planet (Kearns Miller, 2003), and indeed, of woman as “other” (King, 2004). In line with medical–scientific discourse, the administration of the questionnaire reveals the “truth.”

The CAT-Q is freely available under a Creative Commons license and can be reproduced and altered. In the article on its development and validation (Hull et al., 2019), the 7-point Likert scale is described as ranging from “strongly disagree” to “strongly agree.” In the version of the CAT-Q provided by a contributing clinician, the poles of the scale had been altered to “never” and “always,” with a midpoint of “about half the time,” implying camouflaging can be quantified based on the proportion of time someone might mask or assimilate. If it became accepted that someone might be “pretending to be normal” (Bargiela et al., 2016, p. 3281) some of the time, then the threshold for diagnosis drops. Indeed, Hayes et al. (2021) noted the explaining away of contradictory evidence by recourse to the concept of masking in diagnostic decision-making in autism assessment teams—particularly when diagnosing women and girls. Numerical scoring allows expert measures to sustain an “illusion of objectivity,” as has been highlighted in relation to the Autism Diagnostic Observation Schedule (ADOS) (Timimi et al., 2019). Yet what the responses signify is highly subjective, necessitating a number of value judgements: whether a “normal” way of being is to never (or always) behave in a certain way, whether it is an issue if someone camouflages only half the time, what consideration is given to context, or motivation.

Items presented as signs of masking (Extract 10, Lines 1–3) might, in some contexts, be cultivated as interpersonal skills (therapists are trained to be aware of and consciously adapt their nonverbal communication). Yet the language of monitoring and adjusting (Extract 10, Lines 1–2) evokes mechanistic discourses, tapping into tropes of autism as robotic (Lilley, 2011), implying that monitoring and adjusting should be intuitive, below the level of conscious awareness. “Being oneself” (Extract 10, Line 5) is positioned as the optimal, “natural” way to be. This connects to the fetishisation of “authenticity” and the expression of “true self” in late capitalist individualistic society (Whitmer, 2019). The implication is that nonautistic people can be their authentic selves without the “need to put on an act” (Extract 10, Line 4). The camouflage hypothesis, integral to the narrative that women and girls with autism are “missed” by professionals (Allely, 2019), creates a catch-all, whereby if a woman or girl acts in a way which does not appear autistic on the surface, this in itself may signify autism, if reframed as compensatory camouflaging.

King (2004, p. 33) has written of the paradox of femininity: “regarded as the most ‘natural’ of the genders … it also requires the most artifice to be considered successful, whilst those that are unsuccessful or refuse to take part in it are regarded as ‘unnatural.’” Perhaps the most successful mask is that which conceals its artifice to appear “natural”: the social performance equivalent of a “no make-up” make-up look. This speaks to the double binds and multiple standards women are meant to live up to (Hirji, 2021), and raises questions about how female autism might serve the policing of these standards. Seers and Hogg (2023, p. 7) describe the exhaustion resulting from masking as an “existential depletion … incurred through the act of rigid self-management, whereby the need to manage the self, and the social expectations of others … may serve as a latent reminder of ‘defectiveness.’” In this respect, female autism seems an exemplification of the contradictory pressures of contemporary femininity (Alexandersson & Kalonaityte, 2021; Bordo, 2008; Gunby et al., 2020).

Within the progress narrative, the development of female autism as a concept is constructed, in a feminist empiricist framing, as advancing gender equality. However, from a feminist social constructionist position, implications of female autism are concerning. This third theme deconstructs the ways in which female autism acts to reinforce hegemonic gender.

In some respects, female autism is constructed as departing from stereotypical femininity:In Extract 11, autistic women buck the societal expectation that women should be socially amenable (Line 1). If disliking “chit-chat” (Extract 11, Line 2) or other stereotypical gendered expectations is a sign of female autism, women's resistance to gendered norms risks being pathologised (Russell, 2021): through punishing the pariah feminine, hegemonic femininity is reinforced (Schippers, 2007).

Yet in other respects, fundamental to the construction of female autism is its characterisation as distinctly female, asserting a binary, essentialist conceptualisation of gender. Gendered tropes fuse with “disorder” discourses, shaping the ways autistic women and girls are constructed. This was seen in the way in which the camouflage hypothesis constructs autistic women and girls as “copying” and “performing” rather than behaving “naturally” (the trope of female artifice meets the trope of autism as robotic). A similar fusing happens in relation to emotionality.Constructing female autism as being highly sensitive to others’ mental states (Extract 12, Lines 1–2) is in striking contrast to dominant framings of autistic people as rational subjects, with difficulties understanding, let alone adopting, others’ emotions. Although arguably more consistent with double empathy theory's challenge to dominant theory of mind deficit understandings of autism (Milton, 2012), as well as writing on the intensity of neuroqueer subjective experience (Walker, 2021), we note how the departure from traditionally understood (male) autism may be given credibility by the invocation of gendered discourses in which orientation to relationships (Mahalik et al., 2005) and emotionality (King, 2004) are coded female. It is implied in Extract 13 that females with autism may be oversensitive to emotion. This echoes the trope of female hysteria, which has a long lineage in medicine (Showalter, 1993) and connects to patriarchal constructions of women as impressionable and weak (Prentice & Carranza, 2002), constructions which also underlie the “female autistic vulnerability” narrative.Rates of abuse of autistic women are high (Dike et al., 2023). However, positioning autistic women as vulnerable to abuse naturalises patriarchal and ableist narratives: female as the “weaker” sex combined with gendered associations between disability and physical or psychological weakness (Hirschmann, 2013). Reproduced in different forms across accounts of female autism, the vulnerability discourse is problematic for the ways in which it locates causes of abuse or victimisation within the “vulnerable” autistic girl/woman (their attempts to “fit into society” [Extract 13, Lines 2–3], their lack of consideration of “risk” [Extract 13, Line 4]), shifting blame from perpetrators and the wider societal factors (misogyny, rape culture) which endanger all women's safety, and placing responsibility for averting victimisation on women (Moore et al., 2022; Warner, 2009). The operation of oppression and victim-blaming is simultaneously reinforced and shielded from scrutiny (Boyle, 2003).

Drawing upon hegemonic gender discourses, constructions of female autism act to regulate gender by presenting female autism as characteristically female while narrowly defining what is characteristically female, in ways which reproduce gendered stereotypes.The quietness of female autism (Extract 14, Line 7) matches gendered constructions of femininity as passive rather than active. This then functions as an explanation in the narrative as to why autism in women and girls is missed: an explanation set in their femininity. Female autism is constructed as differing from typical male presentations in sociability and interest in other people (Extract 14, Line 1; Extract 15, Line 3). The construction of the “special friend” (Extract 14, Line 3) acts to resolve the tension between gendered discourses of female sociability and dominant understandings of autism, in which difficulties with sociability are a core characteristic: friendship is problematised as “intense” and “dependent” (Extract 14, Line 4), rebranded as akin to a “special interest” symptom of female autism.

Indeed, the positions available for autistic girls in Extracts 14 and 15 are defined by the subordinate loci of hegemonic femininity (Schippers, 2007): “dependent” (Extract 14, Line 4), “led” by others (Extract 14, Line 2), “compliant” (Extract 14, Line 7), “passive” (Extract 15, Line 3), with interests which reproduce gender stereotypes (Extract 15, Line 6). The male traits described (Extract 15, Lines 1–2) are consistent with hegemonic masculinity (Schippers, 2007) and the theory of the “male brain” as systematising, “technical,” and rational (Baron-Cohen, 2002).

When female autism is flexible (“subtle”) enough that symptoms are present in both behaviours that fit gendered expectations and those that do not, there is little escape from the diagnostic gaze, as any form of gendered behaviour, normative or non-normative, potentially becomes a symptom: if someone is not stereotypically feminine, perhaps she has an autistic male brain; if someone appears similar to female peers, perhaps she is too similar, trying too hard, masking.