Diagnostic challenges of autism spectrum disorder in women without intellectual or language impairments: a narrative review.

Abstract

Autism Spectrum Disorder (ASD) in adult women without intellectual or language impairments is frequently under-recognized, due to subtler manifestations, greater use of compensatory social strategies, and reliance on diagnostic frameworks developed from male presentations. Diagnostic overshadowing, where autistic traits are misattributed to other psychiatric conditions, further delays accurate identification. This narrative review aims to critically evaluate recent evidence on the diagnostic challenges of ASD in adult women without intellectual or language impairments, assess the performance of widely used screening tools, and present recommendations for improving gender-sensitive diagnostic practices. A structured literature search was applied (PubMed, PsycINFO, Scopus; January 2010-July 2025; English language) targeting studies on females aged ≥18 years without intellectual or language impairment. Diagnostic accuracy, screening tools, camouflaging, misdiagnosis, and psychosocial outcomes were examined. Original research, meta-analyses, and systematic reviews were included, and a narrative synthesis approach was chosen due to study heterogeneity. Female-typical presentations often include subtle social-communication differences, context-specific restricted interests, and higher camouflage levels than males, which decrease the sensitivity of standard screening tools. Women are more likely to receive prior psychiatric diagnoses before ASD is recognized, contributing to mental health burdens and poorer functional outcomes. Current adult ASD screening tools have limited capacity to detect female phenotypes. Integrating camouflaging assessment, nuanced developmental histories, and updated, gender-inclusive screening instruments is essential to improving diagnostic equity.