Today is Women's Equality Day. There is nothing equal about how women experience ADHD or autism relative to men.
Exposing high levels of gendered violence and mental illness experienced by ADHD and autistic women and undiagnosed CPTSD (trigger warning)
Crisis support signposting
Trigger warning. This article discusses abuse, including sexual abuse and suicide, which some readers might find distressing.
More Human is not a crisis support service. Please call emergency services or go to A&E if you’re in urgent crisis. If you need mental health support, please contact your GP or the Samaritans at 116 123 (24 hrs).
Wikipedia provides a list of global suicide crisis lines
https://en.wikipedia.org/wiki/List_of_suicide_crisis_lines
Today is women's equality day
There is nothing equal about how women experience ADHD or autism relative to men.
Neurodivergent women experience significant barriers to diagnosis, physical healthcare, mental health support and medication. ADHD and autistic women are diagnosed later, missed and misdiagnosed more than men. Research suggests that 80% of autistic women have not been diagnosed by age 18 (McCrossin, 2022).
2x as many men are diagnosed with ADHD, and 3x as many men are diagnosed with autism (Loomes, 2017; Slobodin & Davidovitch, 2019). This rises to 10:1 for girls without an intellectual disability (Fombonne, 2009; Rivet & Matson, 2011). Four months ago, I recruited 176 neurodivergent humans to help co-design a solution to this problem.
Last week, I onboarded over 100 additional neurodivergent humans from across the world to participate in the second-stage validation testing of a new ADHD and autism self-screen service for adult women, non-binary and AFAB.
A highly diverse group - 133 participated in the second-stage validation testing. Around 1 in 10 did not identify as a woman. For the purpose of this article, I will abbreviate it to “Neurodivergent women.”
What did we learn about neurodivergent women's life experiences?
Our research uncovered troubling levels of relational trauma, subsequent mental illness, unemployment, homelessness and attempted suicide. Autistic women without an intellectual disability (i.e. gifted) are more likely to die by suicide than any other group. We suicide more than men (Hirvikoski et al., 2016, 2020; Kõlves et al., 2021; Kirby et al., 2019, 2024; Newell et al., 2023).
Research has shown high levels of autism and ADHD amongst women diagnosed with BPD
One study showed that 50% of BPD humans meet clinical cut-off for autism (Nanchen et al., 2016).
A meta-analysis found that up to 60% of BPD humans meet clinical cut-off for ADHD (Ditrich et al., 2021).
BPD is the #1 misdiagnosis for Complex PTSD (CPTSD) (Jowett et al., 2020). Not only did medical professionals miss 80% of autistic and ADHD women in childhood, but they also overlooked relational abuse and misdiagnosed victims with BPD.
Awareness of the link between female ADHD and autism, victimisation and relational trauma is growing. During an ADHD or autism assessment, a woman will be asked about relational difficulties.
From personal experience of diagnosis, verbalising historical trauma is deeply re-traumatising and can trigger a depressive episode or symptoms of CPTSD. My assessor continued to press me despite my reporting high levels of distress, leaving me barely able to talk or make eye contact. Ignoring a client’s distress is highly unethical and in breach of BPS guidelines. It led to a formal complaint.
I believe women should have more choice over whom and how they disclose their lived experiences. Our new self-screening service includes an optional relational trauma checklist and the ability to request a trauma-informed diagnosis process. This can help women disclose their trauma in writing, reducing the risk of re-traumatisation during assessment.
Abuse needs silence to thrive. Too often, neurodivergent women who are abused are blamed, dismissed, invalidated, silenced and left without any sense of justice.
I want to make the level of abuse autistic and ADHD women are experiencing a public problem. The article presents the confronting statistics gathered while testing the service prototype.
I want to express my gratitude to all those who bravely disclosed this information and granted me permission to share these statistics publicly.
What is the size of the problem we are trying to solve?
When you are designing a new service, it is important to quantify the size of the problem you are trying to solve. These statistics are sensitive and carry a trigger warning.
Relational trauma rates
Pictured relational trauma rates for Sample A and Sample B. For a Google Sheets version, click this link.
Mental illness rates
Pictured mental trauma rates for Sample A and Sample B. For a Google Sheets version, click this link.
Our findings support previous research that neurodivergent women experience high levels of relational trauma and mental illness throughout their lifetime.
Although I haven't conducted regression analysis on the data yet, at an individual level, rates of mental illness appear to be linked to levels of relational trauma. ADHD and autistic women are not born mentally ill; Society and our life experiences are making us mentally ill.
ADHD and autism have a high psychiatric comorbidity rate. Biological factors also increase vulnerability to mental illness. Conditions such as premenstrual dysphoric disorder (PMDD), schizophrenia, bipolar disorder, and OCD are highly heritable and are more likely to co-occur in women with ADHD or autism.
Notably, up to 29% of women reported premenstrual dysphoric disorder (PMDD) - a debilitating condition that causes severe physical PMS symptoms and dysphoric mood in the luteal phase of a woman’s cycle. This is likely to be underreported because of a lack of awareness about the disorder. Some evidence suggests PMDD is more likely to affect ADHD and autistic women - though results are mixed (Lever & Geurts, 2016; Obaydi & Puri, 2008).
ADHD and autistic women experience chronic anxiety and depression. Up to 9 in 10 reported anxiety, 8 in 10 depression and 8 in 10 burnout. We observed differences in the reported levels of reported levels of anxiety and depression with burnout between the two sample groups. Sample B reported lower levels of anxiety (76.6% vs 87.9 % vs ) and depression (58.6% vs 80.8%) and higher levels of autistic/ADHD burnout (80.5 % vs 68.7%) relative to sample A.
Lower reported levels of depression are likely because of differences in self-asessment of whether a person believes themselves to have burnout or depression. Neither ADHD/autistic burnout nor occupational burnout is a clinical diagnosis (Bianchi & Schonfeld, 2023). The definition of autistic burnout was adapted from the definition of occupational burnout, which is caused by chronic stress and insufficient resources to meet demands (Higgins et al., 2021; Raymaker et al., 2020).
Research has shown that 98% of individuals with autistic burnout meet the clinical cutoff for major depression; the same research showed 52% report suicidal ideation (Arnold et al., 2023). From this, we can infer with a fair amount of confidence that around 80% of neurodivergent women reporting burnout experienced major clinical depression.
I have recently come across social media posts claiming, “I took antidepressants, but they didn’t help me because I had autistic burnout” and “I was told I had depression when I have autism.” As untreated major depression is a risk factor for suicide, I think it is important not to dismiss the possibility of treatment-resistant depression.
This might be a hard pill to swallow. While reducing stressors and resting should be the first steps in burnout recovery, seeking treatment for underlying depression might provide additional relief.
It is important to recognise ADHD and autistic women experience high rates of treatment-resistant depression and hypersensitivity to medications and their side effects (Fabbri et al., 2020; Secci et al., 2023; White, 2019). This can make underlying depression more challenging to treat with psychiatric medications. For more discussion on alternative approaches, see Dr Amitta Shah's research.
Pictured Catatonia, Shutdown and Breakdown in Autism. Author Dr Amitta Shah.
Reducing mental illness and suicide rates
The updated relational trauma checklist helps service users to report if they have experienced suicidal ideation or attempted suicide without having to verbalise it. In writing:
4 in 10 reported having suicidal thoughts.
Alarmingly, 11% reported attempting suicide.
Sadly, 7% shared that they had lost a family member to suicide.
These numbers are notably higher than the general population, where only 1% of humans in England die by suicide each year (Office for National Statistics, 2023).
Autistic women suicide more than any other group. Research indicates that autistic women without an intellectual disability (i.e. gifted) are 13 times more likely to die by suicide than neurotypical women and suicide more than autistic men (Hirvikoski et al., 2019). Other research has shown that 1 in 4 women with ADHD has attempted suicide (Fuller et al., 2022).
These statistics are likely underestimated considering the high levels of suicide among women with anorexia, who are highly likely to be autistic, and women with BPD or CPTSD, who are highly likely to be autistic and/or ADHD.
Understanding what predicts suicidality and attempt
Previous research has shown that masking your difficulties, combined with insufficient support, predicts burnout and suicidality among autistic humans (Cassidy et al., 2018; 2020). As a survivor of attempted suicide, I believe the contributing factors are much darker and more complex.
Suicide is a delicate topic that needs to be explored with care. I believe that understanding the root cause of this issue requires first-hand insight and ethical research conducted by neurodivergent women with neurodivergent women. Rose Matthews, my long-term friend and former colleague, is now working alongside me with these women.
I trusted that the women in my research sample would disclose this information to increase our collective understanding and raise awareness of this issue. As a survivor, I feel very privileged to be entrusted with sharing this information. Thank you.
Although we had 133 participants in our research, which is a considerable number, it isn't large enough for us to run an accurate analysis to understand the mediators. Once the service is live, we can conduct regression analysis to better understand what factors that predict suicidality and suicide attempts among service users.
Approximately 500 individuals will participate in beta testing, including the 256 participants in our research group, who will receive guest passes to share with their neurodivergent friends and family members. If 11% or more individuals report a suicide attempt, it will provide us with sufficient data to conduct regression analysis and report our findings.
This knowledge will empower women to take control of this problem and collaborate to find solutions. How will we share this information?
Exposing the impact of abuse - Real-time relational trauma and mental illness statistics
Women told me they feel gaslighted by medical professionals and disbelieved. I want to expose the level of trauma that this group is experiencing and start a difficult public conversation about potential solutions.
My development partner, James Inman, and I have been discussing the possibility of publishing real-time statistics on relational trauma and mental illness collected from our service. These statistics would be publicly available 24 hours a day.
The intent is to conduct real-time research, elevate marginalised voices and report accurately on what women report. There will be no hiding our abuse. Abuse thrives in silence. I want neurodivergent women to feel empowered, heard and seen.
I firmly believe current levels of abuse and mental illness are preventable. These statistics represent a public mental health emergency that requires urgent attention. This information will be crucial in reducing the suicide rate among women with autism and ADHD.
Reducing misdiagnosis of BPD and increasing recognition of co-occurring CPTSD
Borderline personality disorder (BPD) is the #1 misdiagnosis instead of autism and/or ADHD in women and co-occurring Complex PTSD (CPTSD) (Dell'Osso & Carpita, 2023; Fusar et al., 2020; Gesi et al., 2021; Iversen et al., 2022; Jowett et al., 2020; Rinaldi, 2021)..
In my research, women have expressed strong negative feelings about historical BPD misdiagnosis and fear about clinicians misattributing their symptoms of ADHD, autism, or CPTSD to BPD. A goal of the service is to reduce misdiagnosis rates, improve the accuracy of ADHD and autism diagnosis, and recognition of co-occurring CPTSD.
Borderline personality disorder (BPD), alternatively known as emotionally unstable personality disorder (EUPD) is defined in the DSM-5 as
“A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following:
Frantic efforts to avoid real or imagined abandonment
A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
Identity disturbance: markedly and persistently unstable self-image or sense of self
Impulsivity in at least 2 areas that are potentially self-damaging, for example, spending, substance abuse, reckless driving, sex, or binge eating
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
Affective instability due to a marked reactivity of mood, for example, intense episodic dysphoria, anxiety, or irritability, usually lasting a few hours and rarely more than a few days
Chronic feelings of emptiness
Inappropriate, intense anger or difficulty controlling anger, for example, frequent displays of temper, constant anger, or recurrent physical fights
Transient, stress-related paranoid ideation or severe dissociative symptoms
(APA, 2013)
For neurodivergent women who have experienced enduring relational trauma, victim blaming, and scapegoat abuse, a BPD diagnosis is the ultimate insult after injury. While a BPD diagnosis attributes symptoms to the individual and a personality disorder, a CPTSD diagnosis acknowledges these symptoms are most often (but not always) caused by enduring relational trauma.
BPD is a gendered diagnosis. 3x as many women are diagnosed with BPD (Skodol et al., 2003); you are 4x more likely to be given the BPD label if you identify as trans (Rodriguez-Seijas et al., 2023). Half of BPD humans no longer meet the threshold for diagnosis within 5 years. I.e. many are experiencing a trauma response and not a fixed enduring personality disorder (Phyllis Zelkowitz, 2007).
Bessel van der Kolk (2005), a leading psychiatrist specialising in the embodiment of trauma and author of The Body Holds the Score, has argued that many women with BPD have been traumatised and do not have a personality disorder, suggesting that they should be re-diagnosed with CPTSD. I agree.
Pictured Why Women are blamed for everything. Author Dr Jessica Taylor explores why women who are victims of sexual assault and abuse are subject to victim blaming.
My personal opinion is that BPD is victim blaming, documented as a psychiatric diagnosis. These women are rightfully angry. These women are not paranoid - they are being targeted for victimisation and experiencing chronic relational abuse. These women become suicidal because, per the CPTSD diagnostic criteria, chronic abuse feels inescapable.
Complex PTSD (CPTSD)
CPTSD is a relatively new diagnosis. CPTSD was added to the ICD-11 in 2018. CPTSD is still not a formal diagnosis in the DSM-5 (Maercker, 2021). Many women remain misdiagnosed with BPD. Clinicians can diagnose a person with CPTSD using the ICD-11 or PTSD with dissociative features using the DSM-5.
The ICD-11 defines CPTSD as
“Complex post traumatic stress disorder (Complex PTSD) is a disorder that may develop following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (e.g. torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse). All diagnostic requirements for PTSD are met.
In addition, Complex PTSD is characterised by severe and persistent
1) problems in affect regulation;
2) beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event; and
3) difficulties in sustaining relationships and in feeling close to others.
These symptoms cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.”
(WHO, 2022)
What is rejection sensitivity dysphoria (RSD), and how does it relate to CPTSD?
Rejection sensitivity is experiencing overwhelming negative self-beliefs, emotions, or behaviour in reaction to perceived criticism, rejection, or abandonment. RSD is not a clinical diagnosis or part of the ADHD diagnostic criteria.
This screening service includes an optional 35-point RSD screening. When we tested the most recent iteration, 72% of items in the RSD 35 were endorsed by 80% of participants.
Pictured ADHD and autistic women are super sensitive to rejection - why?
This quote is from a recent article published by ADDitude magazine.
“Rejection sensitive dysphoria is not a formal diagnosis, but rather one of the most common and disruptive manifestations of emotional dysregulation — a common but under-researched and oft-misunderstood symptom of ADHD, particularly in adults. Rejection sensitive dysphoria is a brain-based symptom that is likely an innate feature of ADHD. Though the experience of rejection sensitive dysphoria can be painful and even traumatic, RSD is not thought to be caused by trauma.”
I want to challenge this. I disagree on so many levels.
Fundamental attribution error is a cognitive bias where people misattribute biological or personality factors and overlook the role of social and environmental factors. The author attributes rejection sensitivity to innate neurological differences and contends that RSD is a symptom of ADHD.
The author states that the onset of rejection sensitivity dysphoria (RSD) is in adulthood. ADHD is a neurodevelopmental and neurological condition present since birth.
Although I agree that differences in ADHDer biology are likely to increase affect dysregulation, especially in women, I disagree with the contention that ADHDers are born with neurological differences that make them more sensitive to rejection. I reject the assertion that RSD is an innate symptom of ADHD, and by inference, RSD is exclusively an ADHD-exclusive phenomenon.
Firstly, ADHD and autism are estimated to affect 5% and 1% of the population, respectively (Nice, 2024; National Autistic Society, 2024). Society is intolerant of difference. Minority groups are more likely to be socially excluded and rejected by the majority. A more plausible explanation is that we become sensitised to rejection through increased rejection experiences.
Secondly, difficulties with affect regulation in response to a trigger event and relational difficulties are core symptoms of complex post-traumatic stress disorder (CPTSD), which is a clinical diagnosis typically caused by relational trauma. Affect dysregulation is also a symptom of major depression, which I have already reported affects up to 80% of ADHD and autistic women.
Thirdly, the prevalence of 'RSD' is likely to be gendered because of sex differences in attachment style. Neurotypical women are more likely to have an anxious attachment style and crave security, while men are more likely to have an avoidant attachment style (Del Giudice, 2019).
Pictured Attached. Authors Dr Amir Levein and Rachel S.F. Heller explain why men and women have different attachment styles.
Fourthly, neurodivergent women are more likely to experience victimisation and higher levels of relational trauma. CPTSD, like BPD, is a gendered diagnosis affecting 2-2.5 times as many women (McGinty et al., 2021). The drama triangle is gendered - neurodivergent women are more likely to be victimised than men.
Fifthly, fundamental attribution error is gendered. Classroom studies by Dweck (2005) show that we are more likely to blame girls and women personally and overlook the role of extrinsic factors, such as trauma, when determining causation.
From our research with two samples of over 100+ participants, we know neurodivergent women are experiencing incredibly high levels of relational trauma beginning in childhood. This includes childhood bullying (experienced by around 3 in 4), childhood emotional abuse (1 in 2), childhood sexual abuse (1 in 4), childhood physical abuse (1 in 5), and childhood abandonment (1 in 5).
In both samples, around 4 in 10 reported suicidal ideation, the same number reported PTSD, and an additional 3 in 10 reported CPTSD. Recall criterion 5 for BPD is “Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.” Suicidal ideation and behaviour is a common symptom of major depression and CPTSD.
All 35 items in RSD35 satisfy criteria 1, 2 and 3 of the CPTSD diagnostic criteria. There must be a history of trauma. The criteria for PTSD must also be satisfied. Women self-reported significantly elevated rates of relational trauma. Women reported high levels of symptoms associated with PTSD, including sleep problems, dissociation, avoidance behaviour and hypervigilance.
Taken together, what we are likely seeing are high rates of undiagnosed CPTSD caused by elevated levels of relational trauma. The cause of rejection sensitivity is clear. Rejection sensitivity is internalised discrimination, exclusion, rejection, and response to relational trauma.
One item from the RSD 35 is especially worthy of discussion, “I have a deep fear of abandonment by friends, partners, or family members.” This was endorsed at rates of 89.8% in sample A and 75.9% in sample B. An intense fear of abandonment, while associated with BPD, appears to be felt by up to 90% of women with ADHD or autism.
I don’t think it’s helpful to replace a BPD misdiagnosis with another label (RSD) that continues to misattribute the individual and overlooks the causative role of relational trauma. Attributing innate rejection sensitivity dysphoria (RSD), which is not a clinical diagnosis or a symptom of ADHD, may create additional barriers for women who would benefit from the diagnosis and treatment of co-occurring CPTSD.
Who is abusing neurodivergent women, causing CPTSD?
Let's summarise what we know from this research.
This research shows that neurodivergent girls experience high rates of relational trauma, including high rates of childhood abuse, childhood sexual abuse, and abandonment. Neurodivergent women equally experience high levels of sexual assault, domestic abuse and subsequent mental illness (CPTSD). Additionally, we know that ADHD and autistic women are disproportionately affected by high rates of chronic physical illness; ADHD and autism have a high physical illness comorbidity rate.
Our research showed that neurodivergent women have an intense fear of abandonment. What kind of personality can abandon a little girl dependent on them for love, care, and safety? What kind of personality has difficulties with empathy and will abandon a woman when they are physically or mentally ill without remorse? What kind of personality feels entitled to a woman's body, violates boundaries, and is capable of sexual assault or abuse?
All good questions. This is a subject I would love to explore in a future article.
About the author
Hello, I am Leanne. I am a late-diagnosed neurodivergent (woman!), Positive Psychology Coach, and the founder of More Human. More Human is on a mission to close the gender gap in ADHD and autism recognition and diagnosis, widen access to good support, and create equal opportunity.
More Human are launching the first ADHD and autism self-screening service for ADHD and autism in adult women, non-binary and AFAB. Over the past 4 months, I have been working with what is now 256 neurodivergent women to conduct research into their lived experience, co-design, and test a breakthrough service. As a brave survivor diagnosed with CPTSD, I feel privileged to lead this work.
I need your help to keep going.
5 ways you can support my work and help me deliver this breakthrough service
Restack and reshare this post (it is free)
To support my research and writing, upgrade to become a paid subscriber (all proceeds support my research and writing and my Master's research fees. My hope is to return in October to conduct a peer-reviewed study with a neurotypical control to validate the screenings to gold standard (subject to ethics approval)
Book 1-1 positive psychology coaching with me - see my LinkedIn references. I’m awesome. (UK funding is available through Access to Work)
Enrol in flourishing with ADHD or autism - a 10-week group coaching and learning experience for neurodivergent women, non-binary and AFAB. You can read about the programme here. (UK funding is available through Access to Work.)
Buy early access passes to the service when we launch presales (all purchases are fully refundable if you change your mind - no questions asked)
Thank you for your support.
Crisis support signposting
More Human is not a crisis support service. Please call emergency services or go to A&E if you’re in urgent crisis. If you need mental health support, please contact your GP or the Samaritans at 116 123 (24 hrs).
Wikipedia provides a list of global suicide crisis lines
https://en.wikipedia.org/wiki/List_of_suicide_crisis_lines
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