Abstract
Autism, typically described as a spectrum neurodevelopmental disorder characterized by impairments in verbal ability and social reciprocity as well as obsessive or repetitious behaviours, is currently thought to markedly affect more males than females. Not surprisingly, this encourages a gendered understanding of the Autism Spectrum. Simon Baron-Cohen, a prominent authority in the field of autism research, characterizes the male brain type as biased toward systemizing. In contrast, the female brain type is understood to be biased toward empathizing. Since persons with autism are characterized as hyper-systemizers and hypo-empathizers, Baron-Cohen suggests that, whether they are male or female, most possess an “extreme male brain profile.” We argue that Baron-Cohen is misled by an unpersuasive gendering of certain capacities or aptitudes in the human population. Moreover, we suggest that this may inadvertently favour boys in diagnosing children with Autism Spectrum Disorders. If this is correct, it could also have rather serious consequences for treatment and services for girls (and women) on the Autism Spectrum.
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Notes
London has pointed out that the triad of basic symptoms defining autism do not associate highly, “thus leaving undetermined the validity of studying autism in its currently defined triad of symptoms” (London 2007, 408). This is to say, with recent population-based studies, although the three areas of autistic-like behaviours have been found to occur at above-chance rates, in the vast majority of cases they do not reliably occur together. Happé and colleagues have therefore contended that the triad of (so-called) “impairments” of autism should be studied separately rather than explained collectively as they have been for the past half-century, since Kanner originally proposed the co-occurrence of the three symptoms as indicative of a unifying syndrome (Happé, Ronald, and Plomin 2006; London 2007, 409).
Though we do not have the space for counterpoints to all of what is implied in this kind of claim, Harvard cognitive psychologist Elizabeth Spelke points out that “[r]esearch on the cognitive abilities of males and females, from birth to maturity, does not support the claim that men have greater intrinsic aptitude for mathematics and science. … [T]he wealth of research on cognition and cognitive development, conducted over 40 years, provides no reason to believe that the gender imbalances on science faculties, or among physics majors, stem from sex differences in intrinsic aptitude” (2005, 956).
For trenchant theoretical as well as detailed methodological critiques of those studies through which the Baron-Cohen team would try to vindicate the “hardwiring” of essential sex differences across brains, see Fine (2010a, especially chapters 2, 9, and 10), Fine (2010b), Jordan-Young (2010, especially chapters 4 and 8), and Nash and Grossi (2007).
Neil Levy makes the astute observations that “[i]t is worth remarking that Baron-Cohen’s conception of innateness is far from perspicuous. The notion with which he works is essentially negative: a trait is ‘biological’ (as he says) just insofar as it is the [sic] not the result of socialization (see, for instance, Connellan et al. 2000, pp. 113–118). But since what evolves is not phenotypic traits as such, but phenotypic plasticity—i.e., a range of traits is generally selected for—the relative strength of a disposition in a neonate is not evidence for the ‘biological’ origin of a trait. Socialization is not a pattern of interferences, which obscures the underlying design of the infant: it is an essential part of the process whereby the phenotype is completed” (Levy 2004, 323, note 5).
We decided to use “gender representation” here rather than “sex representation” because of the use of gender stereotypes in the evidence Baron-Cohen cites in favor of his view.
Some investigations have revealed a noteworthy number of cases of undiagnosed Autism Spectrum amongst adolescent and adult females with previous diagnoses of (1) anorexia nervosa (Gillberg and Rastam 1992; Nilsson et al. 1999; North 2009), (2) anxiety disorders and selective mutism (Kopp and Gillberg 1997), (3) paranoid disorders or mild paranoid problems, and (4) obsessive compulsive disorders (Kopp and Gillberg 1992; North 2009; cf. also Wolff and Mcguire 1995).
Admittedly, the risks of either under- or misdiagnosis are not one-sided for girls or boys. To explain, according to Smith, “the diagnostic criteria for autism emphasize, among other things, language deficits and extreme reactions such as tantrums and aggression in response to changes in routine” (2002, section 4). It stands to reason that girls who manifest these signs or behaviours may be all the more conspicuous, judged as “non-normal” (in certain cultures), and therefore considered deserving of clinical attention, whereas relevant boys who manifest these signs or behaviours may be comparatively less conspicuous, judged as quite “normal” (in certain cultures), and for this reason escape early clinical notice. Be that as it may, we should be cautious in presuming that reasons for under-diagnosis of ASD in girls (the focus of this paper) necessarily imply over-diagnosis for boys: i.e., that the reasons to explain the former are the same as those to explain the latter. Sorting this out is beyond the scope of this paper. Our point here is to simply underscore that a theory of autism that bootstraps itself upon a theory of gender expectations is at risk of being insufficiently or improperly discriminating as a diagnostic tool in its practical application.
References
Abbeduto, L., and A. McDuffie. 2007. Language learning and use as embedded social activities: Evidence from autism and fragile X syndrome. In Language disorders from a developmental perspective: Essays in honor of Robin S. Chapman, ed. R. Paul and R.S. Chapman, 195–214. Mahwah: Lawrence Erlbaum Associates.
American Psychiatric Association and Task Force on DSM-IV. 2000. Diagnostic and statistical manual of mental disorders, DSM-IV-TR. Washington, DC: American Psychiatric Association.
Anonymous. 2005. Girls’ autism “under-diagnosed.” BBC News. http://news.bbc.co.uk/go/pr/fr/-/1/hi/health/4630705.stm. Accessed August 18, 2010.
Baron-Cohen, S. 1995. Mindblindness: An essay on autism and theory of mind. Cambridge: MIT Press.
Baron-Cohen, S. 2002. The extreme male brain theory of autism. Trends in Cognitive Sciences 6(6): 248–254.
Baron-Cohen, S. 2003. The essential difference: Men, women and the extreme male brain. London: Penguin.
Baron-Cohen, S. 2005a. Autism—“Autos”: Literally, a total focus on the self? In The lost self: Pathologies of the brain and identity, ed. T.E. Feinberg and J.P. Keenan, 166–180. Oxford: Oxford University Press.
Baron-Cohen, S. 2005b. The empathizing system: A revision of the 1994 model of the mindreading system. In Origins of the social mind: Evolutionary psychology and child development, ed. B.J. Ellis and D.F. Bjorklund, 468–492. New York: Guilford Press.
Baron-Cohen, S. 2005c. The male condition. The New York Times. http://www.nytimes.com/2005/08/08/opinion/08baron-cohen.html. Accessed August 15, 2010.
Baron-Cohen, S. 2009. Coevolution of language and theory of mind. Do sex differences in empathy account for sex differences in language acquisition? Interdisciplines—European Science Foundation. http://www.interdisciplines.org/coevolution/papers/7/4. Accessed August 18, 2010.
Baron-Cohen, S., H. Tager-Flusberg, and D.J. Cohen. 1993. Understanding other minds: Perspectives from autism. Oxford: Oxford University Press.
Brasic, J. R. 2011. Autism. Medscape Reference. http://emedicine.medscape.com/article/912781-overview. Accessed August 13, 2011.
Bryson, S.E., S.J. Rogers, and E. Fombonne. 2003. Autism Spectrum Disorders: Early detection, intervention, education, and psychopharmacological management. The Canadian Journal of Psychiatry 48(8): 506–516.
Burman, D.D., T. Bitan, and J.R. Booth. 2008. Sex differences in neural processing of language among children. Neuropsychologia 46(5): 1349–1362.
Caplan, P.J., and J.B. Caplan. 1999. Thinking critically about research on sex and gender. New York: Addison-Wesley Longman.
Carmen, E., N.F. Russo, and J.B. Miller. 1981. Inequality and women’s mental health: An overview. The American Journal of Psychiatry 138(10): 1319–1330.
Connellan, J., S. Baron-Cohen, S. Wheelwright, A. Batki, and J. Ahluwalia. 2000. Sex differences in human neonatal social perception. Infant Behavior and Development 23(1): 113–118.
Cowley, G. 2003. Girls, boys and autism. Newsweek. http://www.newsweek.com/id/59999/output/print. Accessed August 18, 2010.
Davidson, J. 2007. “In a world of her own …”: Re-presenting alienation and emotion in the lives and writings of women with autism. Gender, Place and Culture 14(6): 659–677.
de Villiers, J. 2000. Language and theory of mind: What are the developmental relationships. In Understanding other minds: Perspectives from developmental cognitive neuroscience, ed. S. Baron-Cohen, H. Tager-Flusberg, and D.J. Cohen, 83–123. Oxford: Oxford University Press.
Donvan, J. 2008. “Underdiagnosed” girls with autism struggle to fit in. ABC News. http://abcnews.go.com/print?id=4177353. Accessed August 18, 2010.
Downs, E. 2008. Girls’ autism signs miss early diagnosis. The Journal Gazette. http://www.journalgazette.net/apps/pbcs.dll/article?AID=/20081214/FEAT/812140310. Accessed August 18, 2010.
Dyck, M.J., K. Ferguson, and I.M. Shochet. 2001. Do autism spectrum disorders differ from each other and from non-spectrum disorders on emotion recognition tests? European Child and Adolescent Psychiatry 10(2): 105–116.
Ellefsen, A., H. Kampmann, E. Billstedt, I.C. Gillberg, and C. Gillberg. 2007. Autism in the Faroe Islands. An epidemiological study. Journal of Autism and Developmental Disorders 37(3): 437–444.
Faherty, C. 2002. Asperger’s syndrome in women: A different set of challenges? Autism Today. http://www.autismtoday.com/articles/Aspergers_in_Women.htm. Accessed August 18, 2010.
Farrant, B.M., J. Fletcher, and M.T. Maybery. 2006. Specific language impairment, theory of mind, and visual perspective taking: Evidence for simulation theory and the developmental role of language. Child Development 77(6): 1842–1853.
Fausto-Sterling, A. 1985. Myths of gender: Biological theories about women and men. New York: Basic Books.
Fausto-Sterling, A. 2000. Sexing the body: Gender politics and the construction of sexuality. New York: Basic Books.
Fenson, L., P. Dale, J. Reznick, E. Bates, D. Thal, and S. Pethick. 1994. Variability in early communicative development. Monographs of the Society for Research in Child Development 59(5): 1–173. discussion 174–185. Chicago: Chicago Press.
Fine, C. 2010a. Delusions of gender: How our minds, society, and neurosexism create difference. New York: W.W. Norton.
Fine, C. 2010b. Response to Simon Baron-Cohen. CordeliaFine.com. http://www.cordeliafine.com/Fine_Response_Psychologist_December_2010.pdf. Accessed August 10, 2011.
Fisch, G.S. 2005. Syndromes and epistemology I: Autistic Spectrum Disorders. American Journal of Medical Genetics Part A 135(2): 117–119.
Flora, C. 2006. An Aspie in the city. Psychology Today, November/December. http://www.psychologytoday.com/articles/index.php?term=pto-20061103-000002&print=1. Accessed August 18, 2010.
Fombonne, E. 2005. Epidemiology of autistic disorder and other pervasive developmental disorders. The Journal of Clinical Psychiatry 66(Supplement 10): 3–8.
Frith, U. 1989. Autism and “theory of mind”. In Diagnosis and treatment of autism, ed. C. Gillberg, 29–52. New York: Plenum Press.
Frith, U., and F. Happé. 1999. Theory of mind and self-consciousness: What is it like to be autistic? Mind and Language 14(1): 1–22.
Gillberg, C. 1991. Outcome in autism and autistic-like conditions. Journal of the American Academy of Child and Adolescent Psychiatry 30(3): 375–382.
Gillberg, C., M. Cederlund, K. Lamberg, and L. Zeijlon. 2006. Brief report: “The autism epidemic”. The registered prevalence of autism in a Swedish urban area. Journal of Autism and Developmental Disorders 36(3): 429–435.
Gillberg, C., and M. Coleman. 2000. The biology of the autistic syndromes. London: Mac Keith.
Gillberg, C., and M. Rastam. 1992. Do some cases of anorexia nervosa reflect underlying autistic-like conditions? Behavioural Neurology 5(1): 27–32.
Ginn, J., S. Arber, J. Brannen, et al. 1996. Feminist fallacies: A reply to Hakim on women’s employment. British Journal of Sociology 47(1): 167–174.
Hale, C.M., and H. Tager-Flusberg. 2003. The influence of language on theory of mind: A training study. Developmental Science 6(3): 346–359.
Happé, F. 1999. Autism: Cognitive deficit or cognitive style? Trends in Cognitive Sciences 3(6): 216–222.
Happé, F.G.E. 1995. The role of age and verbal ability in the theory of mind task performance of subjects with autism. Child Development 66(3): 843–855.
Happé, F., A. Ronald, and R. Plomin. 2006. Time to give up on a single explanation for autism. Nature Neuroscience 9(10): 1218–1220.
Hill, A. 2009. Doctors are “failing to spot Asperger's in girls.” The Guardian—The Observer. http://www.guardian.co.uk/lifeandstyle/2009/apr/12/autism-aspergers-girls. Accessed August 18, 2010.
Howlin, P., L. Mawhood, and M. Rutter. 2000. Autism and developmental receptive language disorder—a follow-up comparison in early adult life. II: Social, behavioural, and psychiatric outcomes. Journal of Child Psychology and Psychiatry and Allied Disciplines 41(5): 561–578.
Jordan-Young, R.M. 2010. Brain storm: The flaws in the science of sex differences. Cambridge: Harvard University Press.
Karrass, J., J.M. Braungart-Rieker, J. Mullins, and J.B. Lefever. 2002. Processes in language acquisition: The roles of gender, attention, and maternal encouragement of attention over time. Journal of Child Language 29(3): 519–543.
Kindlon, D.J., M. Thompson, and T. Barker. 1999. Raising Cain: Protecting the emotional life of boys. New York: Ballantine Books.
Kitayama, S., and D. Cohen. 2010. Handbook of cultural psychology. New York: Guilford.
Kopp, S., K.K. Berg, and C. Gillberg. 2010. Girls with social and/or attention deficits: A descriptive study of 100 clinic attenders. Journal of Attention Disorders 14(2): 167–181.
Kopp, S., and C. Gillberg. 1992. Girls with social deficits and learning problems: Autism, atypical Asperger syndrome or a variant of these conditions. European Child and Adolescent Psychiatry 1(2): 89–99.
Kopp, S., and C. Gillberg. 1997. Selective mutism: A population-based study: A research note. Journal of Child Psychology and Psychiatry and Allied Disciplines 38(2): 257–262.
Kraemer, S. 2000. The fragile male. British Medical Journal 321(7276): 1609–1612.
Levy, N. 2004. Understanding blindness. Review of The essential difference: Men, women and the extreme male brain by S. Baron-Cohen. Phenomenology and the Cognitive Sciences 3(3): 315–324.
Liss, M., B. Harel, D. Fein, et al. 2001. Predictors and correlates of adaptive functioning in children with developmental disorders. Journal of Autism and Developmental Disorders 31(2): 219–230.
Lloyd, G. 1984. The man of reason: “Male” and “female” in Western philosophy. London: Methuen.
London, E. 2007. The role of the neurobiologist in redefining the diagnosis of autism. Brain Pathology 17(4): 408–411.
McLennan, J.D., C. Lord, and E. Schopler. 1993. Sex-differences in higher functioning people with autism. Journal of Autism and Developmental Disorders 23(2): 217–227.
Miller, C.A. 2001. False belief understanding in children with specific language impairment. Journal of Communication Disorders 34(1–2): 73–86.
Minshew, N.J., and G. Goldstein. 1998. Autism as a disorder of complex information processing. Mental Retardation and Developmental Disabilities Research Reviews 4(2): 129–136.
Minshew, N.J., and J.A. Meyer. 2006. Autism and related conditions. In Patient-based approaches to cognitive neuroscience, ed. M.J. Farah and T.E. Feinberg, 419–431. Cambridge: MIT Press.
Minter, M., R.P. Hobson, and M. Bishop. 1998. Congenital visual impairment and “theory of mind”. British Journal of Developmental Psychology 16(2): 183–196.
Mwachofi, A.K. 2009. Gender difference in access and intervention outcomes: The case for women with disabilities. Disability and Rehabilitation 31(9): 693–700.
Nash, A., and G. Grossi. 2007. Picking Barbie’s brain: Inherent sex differences in scientific ability? Journal of Interdisciplinary Feminist Thought 2(1): 1–23.
Nicholas, J.S., J.M. Charles, L.A. Carpenter, L.B. King, W. Jenner, and E.G. Spratt. 2008. Prevalence and characteristics of children with autism-spectrum disorders. Annals of Epidemiology 18(2): 130–136.
Nilsson, E.W., C. Gillberg, I.C. Gillberg, and M. Rastam. 1999. Ten-year follow-up of adolescent-onset anorexia nervosa: Personality disorders. Journal of the American Academy of Child and Adolescent Psychiatry 38(11): 1389–1395.
North, A. 2009. Asperger’s underdiagnosed in girls, says expert. Jezebel. http://jezebel.com/5210227/aspergers-underdiagnosed-in-girls-says-expert. Accessed September 3, 2011.
Nyden, A., E. Hjelmquist, and C. Gillberg. 2000. Autism Spectrum and attention-deficit disorders in girls. Some neuropsychological aspects. European Child and Adolescent Psychiatry 9(3): 180–185.
Paechter, C.F. 2007. Being boys, being girls: Learning masculinities and femininities. Maidenhead: Open University Press.
Pâerez Pereira, M., and G. Conti-Ramsden. 1999. Language development and social interaction in blind children. Hove: Psychology Press.
Petersen, A.R. 2004. Engendering emotions. Houndmills: Palgrave Macmillan.
Peterson, C.C., and M. Siegal. 1995. Deafness, conversation and theory of mind. The Journal of Child Psychology and Psychiatry 36(3): 459–474.
Peterson, C.C., and M. Siegal. 2002. Representing inner worlds: Theory of mind in autistic, deaf and normal hearing children. Psychological Science 10(2): 126–129.
Powers, M., and R.R. Faden. 2006. Social justice: The moral foundations of public health and health policy. Oxford: Oxford University Press.
Reddy, W.M. 2001. The navigation of feeling: A framework for the history of emotions. Cambridge: Cambridge University Press.
Rogers, L.J. 2010. Sexing the brain: The science and pseudoscience of sex differences. Kaohsiung Journal of Medical Sciences 26(6): S4–S9.
Rooney, P. 1994. Recent work in feminist discussions of reason. American Philosophical Quarterly 31(1): 1–21.
Schick, B., J. de Villiers, P. de Villiers, and B. Hoffmeister. 2002. Theory of mind: Language and cognition in deaf children. The ASHA Leader, December 3. http://www.asha.org/Publications/leader/2002/021203/f021203.htm. Accessed August 18, 2010.
Sherwin, S. 1992. No longer patient: Feminist ethics and health care. Philadelphia: Temple University Press.
Skuse, D.H., W. Mandy, C. Steer, et al. 2009. Social communication competence and functional adaptation in a general population of children: Preliminary evidence for sex-by-verbal IQ differential risk. Journal of the American Academy of Child and Adolescent Psychiatry 48(2): 128–137.
Smith, T. 2002. Sexual differences in Pervasive Developmental Disorders. Medscape Psychiatry & Mental Health eJournal. http://www.medscape.com/viewarticle/431135. Accessed August 18, 2010.
Smith, T., and O.I. Lovaas. 1998. Sex and bias: Reply to Boyd. Journal of Autism and Developmental Disorders 28(4): 343–344.
Spelke, E.S. 2005. Sex differences in intrinsic aptitude for mathematics and science? A critical review. American Psychologist 60(9): 950–958.
Steele, S., R.M. Joseph, and H. Tager-Flusberg. 2003. Brief report: Developmental change in theory of mind abilities in children with autism. Journal of Autism and Developmental Disorders 33(4): 461–467.
Stobbe, M. 2007. Autism “epidemic” may be all in the label—behaviors were as common years ago, but definition, diagnosis have shifted. MSNBC.com. http://www.msnbc.msn.com/id/21600784/. Accessed August 18, 2010.
Tager-Flusberg, H. 1993. What language reveals about the understanding of minds in children with autism. In Understanding other minds: Perspectives from autism, ed. S. Baron-Cohen, H. Tager-Flusberg, and D. Cohen, 138–157. Oxford: Oxford University Press.
Tager-Flusberg, H. 2007. Evaluating the theory-of-mind hypothesis of autism. Current Directions in Psychological Science 16(6): 311–315.
Tavris, C. 1998. The science and politics of gender research: The meanings of difference. In Gender and motivation, ed. D. Bernstein, 1–24. Lincoln and London: University of Nebraska Press.
Thompson, T., M. Caruso, and K. Ellerbeck. 2003. Sex matters in autism and other developmental disabilities. Journal of Learning Disabilities 7(4): 345–362.
Traustadóttir, R., and K. Johnson. 2000. Women with intellectual disabilities: Finding a place in the world. London: Jessica Kingsley Publishers.
Venter, A., C. Lord, and E. Schopler. 1992. A follow-up study of high-functioning autistic children. Journal of Child Psychology and Psychiatry and Allied Disciplines 33(3): 489–507.
Volkmar, F.R., P. Szatmari, and S.S. Sparrow. 1993. Sex differences in pervasive developmental disorders. Journal of Autism and Developmental Disorders 23(4): 579–591.
Wallentin, M. 2009. Putative sex differences in verbal abilities and language cortex: A critical review. Brain and Language 108(3): 175–183.
Walsh, P.N., and T. Heller. 2002. Health of women with intellectual disabilities. Oxford: Blackwell Science.
Wolff, S., and R.J. Mcguire. 1995. Schizoid personality in girls—a follow-up-study: What are the links with Asperger’s syndrome? Journal of Child Psychology and Psychiatry and Allied Disciplines 36(5): 793–817.
World Health Organization. 2009. Women and health: Today's evidence tomorrow’s agenda. WHO. http://www.who.int/gender/documents/9789241563857/en/index.html. Accessed September 23, 2011.
Yoder, J.D., and A.S. Kahn. 2003. Making gender comparisons more meaningful: A call for more attention to social context. Psychology of Women Quarterly 27(4): 281–290.
Zahn-Waxler, C. 2006. The origins and development psychopathology in females and males. In Developmental psychopathology—vol. 1: Theory and method, ed. D. Cicchetti and D.J. Cohen, 76–138. Hoboken: Wiley.
Zahn-Waxler, C., E.A. Shirtcliff, and K. Marceau. 2008. Disorders of childhood and adolescence: Gender and psychopathology. Annual Review of Clinical Psychology 4: 275–303.
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Thanks to Susan Sherwin and the Novel Tech Ethics research team for feedback on previous drafts of this paper as well as audience members who attended an oral conference presentation on the topic at the American Society for Bioethics and Humanities annual conference in 2009. Funding for this project was provided by the Canadian Institutes of Health Research, NNF 80045, States of Mind: Emerging Issues in Neuroethics.
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Krahn, T.M., Fenton, A. The Extreme Male Brain Theory of Autism and the Potential Adverse Effects for Boys and Girls with Autism. Bioethical Inquiry 9, 93–103 (2012). https://doi.org/10.1007/s11673-011-9350-y
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DOI: https://doi.org/10.1007/s11673-011-9350-y