Gender and diagnosis: why current models fail many people

Many people still believe autism and ADHD look a certain way. This is because most research, diagnostic tools, and examples are based on white boys and men. As a result, people of other genders are often missed, misunderstood, or diagnosed later in life. This post explains how gender affects the experience and recognition of autism and ADHD, and how current models fail to represent everyone.

Why diagnostic models are based on men and boys

Autism and ADHD were first described and researched mainly in boys. Early studies used male-only samples, and assessment tools were created to reflect those patterns. For example, traits such as fidgeting, impulsivity, or social disinterest were treated as typical signs, while quieter or internalised differences were not.

This means that diagnostic systems, from questionnaires to observation scales, are based on a male norm. Girls, women, and people of other genders may still show strong signs of autism or ADHD, but because they do not fit those patterns, they are less likely to meet diagnostic thresholds. When they do receive a diagnosis, it is often after years of misunderstanding.

Guidance from the National Institute for Health and Care Excellence (NICE) acknowledges that ADHD can look different in adults and that presentation varies by gender. Similarly, NICE’s autism guidance for adults encourages clinicians to consider how gender and culture influence behaviour. Despite this, most tools remain normed on male populations.

Gendered expectations and moral judgement

Society expects women and girls to manage emotional and household responsibilities. They are often expected to hold the mental load — keeping track of dates, relationships, and tasks. When ADHD or autism make these things difficult, people may be judged as lazy, careless, or disorganised rather than recognised as neurodivergent.

Instead of being seen as “hyperactive”, women and girls may appear anxious, daydreamy, or withdrawn. Their energy and distress turn inward, becoming self-blame, perfectionism, or exhaustion. This internalising pattern leads many to develop anxiety, depression, or burnout before ever being assessed.

These same social pressures mean that when women or gender-diverse people struggle with executive function or overwhelm, it is framed as a moral failure rather than a disability. The social narrative of responsibility still defaults to women, which hides how much structural bias is built into diagnostic norms.

Research from the British Psychological Society (BPS) and UK universities has highlighted that diagnostic tools often reflect gender stereotypes and fail to recognise how women and gender-diverse people mask or compensate in social settings.

Masking and social learning

Masking describes how autistic or ADHD people hide or compensate for their differences. Research shows that women and gender-diverse people are often better at masking because of social conditioning. From an early age, many are taught to observe, imitate, and smooth over awkwardness. They may become skilled at smiling, nodding, and guessing what is expected. This can delay recognition and increase exhaustion.

A 2020 review in the British Journal of Psychiatry found that diagnostic criteria under-identify autism in women and that masking plays a major role in under-recognition. Masking is often praised as “good behaviour”, but it comes at a cost. Constant performance can make people feel unseen or fragmented. It is not a sign of lesser support needs — it is a sign of adaptation under pressure.

Gender, sex, and assessment tools

Some assessment tools are still written and normed by binary sex models rather than gender. They ask for “male” or “female” and adjust scoring based on that binary. This approach excludes intersex people and disregards non-binary or gender-diverse identities. It assumes that gender expression matches sex assigned at birth, which is not always the case.

This is particularly harmful for trans people. Anecdotally, transgender clients have shared that their earlier assessments were normed on gender expectations that did not fit their lived identity. When later reassessed under the appropriate gender norms, they met diagnostic criteria clearly. The mismatch between biological sex categories and social gender experience creates gaps in accuracy and fairness.

The Gender Identity Research and Education Society (GIRES) and Stonewall both emphasise that diagnostic and mental health tools must recognise gender diversity and avoid binary-only measures. Tools used in assessment should reflect lived diversity, not erase it.

Intersectionality and double masking

Gender never exists in isolation. People’s experiences of neurodivergence are also shaped by race, class, sexuality, and disability. A Black woman or non-binary person with ADHD, for example, may face stereotypes about behaviour that make diagnosis harder. A person already used to code-switching or adjusting their behaviour for safety may have developed masking skills that hide symptoms completely.

The concept of intersectionality, first described by Kimberlé Crenshaw, helps explain how these layers of identity interact. Systems that rely on one-size-fits-all models fail to recognise the impact of social context on both diagnosis and support.

Acknowledging bias and responsibility

As assessors, it is vital to recognise the bias built into existing systems. The frameworks and psychometric tools we use were not designed with full gender or racial diversity in mind. They reflect the populations they were created from — mainly white, male, and Western.

Our responsibility is to question those tools, talk openly about their limits, and keep learning. We can only provide ethical, trauma-informed care if we remain aware of how these systems have excluded people in the past.

Moving forward with equity

Making diagnosis fairer requires action at several levels:

• Updating screening tools to include non-binary, trans, and intersex experiences
• Training clinicians in gender-inclusive and culturally competent practice
• Recognising that masking, emotional labour, and social performance hide support needs
• Listening to lived experience rather than relying only on standardised scores

Diagnosis should never depend on how closely someone matches an outdated picture of a white, middle-class boy. It should reflect the diversity of real people and the environments they live in.