Sex/Gender Phenotypes and the Diagnosis and Treatment of Autism Spectrum Disorder: Implications for Applied Behavior Analysts

Blair et al. (2020) wrote a position paper. They looked at how sex and gender change the way autism shows up. They warned that most tools were built for boys, so girls get missed or labeled late.

The authors asked behavior analysts to open their eyes. They want us to change how we test and teach so we do not leave girls behind.

The paper does not give new data. It says girls often hide signs by copying peers. This masking leads to late diagnosis and wrong goals in treatment plans.

They also note that restricted or repetitive behaviors look different in girls. Clinicians who expect boy-type rocking or lining up toys may score girls as "typical" when they are not.

Beggiato et al. (2017) backs the warning. They showed that the ADI-R misses girls because its cut scores favor male patterns. Blair et al. (2020) builds on that work and asks us to adjust our tools.

Emerson et al. (2023) adds a twist. Their big review finds that intellectual disability flips the pattern: girls with ID show more severe social and repetitive problems than boys with ID. So sex differences are not fixed; they change when ID is present.

Souza et al. (2023) widen the lens. They report girls with ASD have higher rates of epilepsy and ID, while boys have more repetitive behaviors. Together these reviews say: always check for ID and medical traits before you decide a girl is "mild" or "not autistic."

If you test a girl using boy norms, you risk sending her home without services. Blair’s team wants you to add girl-friendly questions: ask about social exhaustion, camouflaging, and intense interests in people, not just objects. When you write goals, target the skills she needs, not the ones the manual wrote for boys. A quick fix: keep two profiles in mind—one for girls with ID and one for girls without—and pick assessment tools that let you score both.