The medical model is failing neurodivergent women.

For decades, conditions like autism and ADHD were understood primarily as matters of attention, executive function and social processing. Research was conducted almost exclusively on boys and men. Women were diagnosed late or not at all. Their presentations were dismissed as anxiety, depression, personality disorders, eating disorders or bipolar.

What is emerging now is a fundamentally different picture. And it has serious implications for every neurodivergent woman who has ever been failed by the system.

The medical profession accepted a biased view of the world and built its assessment and treatment models on flawed science. That is not a minor oversight. It is a systemic failure one that has left generations of women misunderstood, misdiagnosed, gaslighted and ineffectively supported.

A fundamental shift is required. I'm talking a wholesale reconceptualisation of neurodivergence in women, moving away from a purely cognitive or behavioural model toward understanding it as a whole-body condition. An approach that considers our nervous system, HPA axis and chronic inflammation as primary players.

We are not just a brain.

An autistic or ADHD woman is not simply someone whose brain works differently. Mind and Body are inseparable in human beings. Our nervous system, hormonal regulation and our immune system are in fact one complex system. Taking snapshots of this entire system and basing a diagnosis or treatment on this is unrealistic and certainly not scientific.

Neurodivergent women often have a nervous system, our body's threat surveillance system that has been in a state of chronic dysregulation for years. And because of this our hormonal regulation system, the body's stress response system is affected too. This can make us more sensitive to hormonal flux compared to non neurodivergent women. Our body carries the accumulated cost of systemtic dysregulation in the form of inflammation, immune activation and physiological exhaustion.

Evidence of this is clear. ADHD and autistic women. We are more likely to have co existing autoimmune conditions including endometriosis, fibromyagia, adenomyosis, pots, etc.

Understanding the body's stress response system

The hypothalamic-pituitary-adrenal axis, the HPA axis is the body's primary stress response system. When the brain perceives a threat via our nervous system, the HPA axis activates through a precise chain reaction. The hypothalamus releases a hormone that signals the pituitary gland, which in turn signals the adrenal glands to release cortisol. Once the threat has passed, rising cortisol levels feed back to the brain, switching the response off. The body returns to a non-threat mode.

In a well-regulated system this process is self-correcting. In neurodivergent women, it frequently is not.

Research suggests that HPA axis dysregulation in ADHD for example is linked to physiological under-arousal contributing to the chronic fatigue and difficult mornings so many women describe. In autistic women the pattern may look different with a higher baseline cortisol levels and exaggerated cortisol responses to stress. In both cases the alarm system struggles to find its rhythm. Ordinary life situations that for most people would register as neutral, for example, a busy supermarket, background noise, a crowd, register in the body as a threat.

And it is exhausting.

Sex hormones make a difference to neurodivergent symptoms

The HPA axis does not operate in isolation from the rest of the body. It is influenced by sex hormones. This is where the picture for women becomes significantly more complex. And has been ignored by researchers until very recently.

Testosterone generally inhibits the stress response, making the HPA axis more efficient at switching off after a stressor. Oestrogen tends to enhance and prolong the stress response making it harder for the system to return to baseline. Importantly progesterone offers some counterbalance, affecting anxiety-reducing GABA as it is metabolised into allopregnanolone. Progesterone does so much more than protect the womb lining at peri-menopause and yet this is the main reason for it's licence in the UK and prescribing progesterone at midlife.

The practical consequence of this hormonal landscape is that women, on average, have higher baseline cortisol levels and more prolonged stress responses than men. For neurodivergent women whose stress response systems are already dysregulated hormonal flux across the lifespan can be destabilising in ways that are still barely acknowledged by medicine.

Monthly and Life Cycles can affect neurodivergent symptoms

At puberty, rising hormones can trigger sudden onset or significant worsening of ADHD and autistic traits. Sensory sensitivity intensifies. Emotional regulation becomes harder. The young girl becomes aware that life is becoming more effortful but put's it down to the teenage brain.

Similarly during pregnancy and the postpartum period dramatic hormonal shifts can bring severe mood disruption. For some women high oestrogen offers a period of unexpected calm and focus; for others it disrupts dopamine sufficiently to cause profound changes in neurodivergent symptons. Traditionally this has been diagnosed as depression but it's probable that many of these cases were neurodivergence.

In perimenopause and menopause, falling testosterone, oestrogen and progesterone reduces the brain's capacity to manage neurodivergent traits. Long-held coping strategies and masking collapse as executive function deteriorates. Many women receive their first neurodivergent diagnosis at this stage because the hormonal scaffolding that helped them compensate has been removed.

What is also becomeing more clear is that throughout our monthly reproductive lcycle changes in sex hormones can intensify neurodivergent traits or lead to their abatement. What is clear is that sex hormones drive the severe emotional sensitivity, cognitive disruption and overwhelm that many women with ADHD and autism experience on a monthly basis. Lever & Geurts (2016) found 21% of autistic women experienced PMDD versus 3% of non-autistic women. Dorani et al. (2021) reported 46% of ADHD experience PMDD.

Not one of these documented hormonal effects on neurodivergent presentation in women has been incorporated into any standardised diagnostic assessment criteria.

Masking is a costly physiological adaptation

Neurodivergent women are significantly more likely than their male counterparts to develop masking strategies. Masking is the conscious or unconscious suppression of neurodivergent traits, behaviors, and needs to fit into a neurotypical culture. It a survival mechanism to avoid stigma, abuse, or discrimination. Women develop particularly sophistocated masking strategies that over time result in mental exhaustion, cycles of crash and burnout and a loss of identity. Late diagnosed women have suppressed their instinct for years, decades or a lifetime, performing social scripts. Metabolically and physiological costs are high keeping the nervous system and HPA axis in a state of chronic dysregulation. It's also likely that a woman who masks effectively is the woman most likely to be missed by the medical system completely. She is labelled as anxious, depressed or having some other type of personality disorder. The system usually hands her an antidepressant, SRII, SNRI or benzos. When she gives feedback that they have made no difference to her struggles, she is gaslighted, dismissed or ignored. I know because it happened to me, my friends and to many of the women I work.

Inflammation: downstream consequence or cause of neurodivergence?

Chronic HPA axis dysregulation does not stay contained within the stress response system. Over time it profoundly effects on the immune system and on inflammation throughout the body. Research has identified distinct inflammatory patterns in both ADHD and autism, disrupting neural signalling, impairing synaptic function, and altering cognition and emotional regulation. Chronic stress and prolonged cortisol elevation are associated with neuroinflammation and significantly with the shrinkage of the hippocampus (the region of the brain central to memory, learning and the regulation of the HPA axis itself). Hippocampus shrinkage under chronic dysregulation and sustained cortisol exposure affects the feedback loops that should return the stress response to baseline. The system loses its capacitty to self-correct. The woman lives is at the mercy of cortisol and a wide range of detrimental physical and mental health consequences including weight gain (particularly the face, upper back and torso), skin changes, metabolic dysfunction including type 2 diabetes, osteoporosis and slower healing.

Diagnostic failure

 As a former psychometritican I have concluded that there is currently no fully valid diagnostic assessment for neurodivergent women. This also decreases reliability of the diagnostic method.

Standard diagnostic tools for neurodivergence were developed primarily on male populations. This has produced criteria that emphasise externalised behaviours focussed on hyperactivity, aggression and inattention more typical of male presentations. The internalised symptoms more common in women such as anxiety, emotional dysregulation, exhaustion, masking are largely absent from these frameworks.

The gold-standard tools which include the ADOS-2 and the Autism-Spectrum Quotient are demonstrably less effective at detecting neurodivergence in women and girls.

In addition women face an average ten-year delay between first seeking help and receiving an autism diagnosis. They are routinely misdiagnosed with anxiety, depression, borderline personality disorder or eating disorders before anyone considers neurodivergence.

More gender-sensitive tools are emerging, the Girls Questionnaire for Autism Spectrum Condition, the Camouflaging Autistic Traits Questionnaire, the Screening for Autism in Females. Whilst this research is welcome, they are not yet standard practice.

The result is a wild west diagnostic landscape for women.

Private assessors are more likely to identify neurodivergence in women and NHS pathways significantly less so. Self-identification has become a valid starting point for many women because of system failures and increasing costs of private diagnoses and lack of dual care options available in the NHS.

What needs to change

Medicine needs to catch up with what research is already telling us.

Neurodivergence in women is not a milder or more subtle version of the male condition. It is a different presentation, shaped by different biology, different socialisation, different hormonal realities and different survival strategies.

Assessment criteria must incorporate hormonal influences on neurodivergent presentation. Clinical training must include female phenotypes and at the very least all diagnostic tools must be validated on female populations.

The physiological consequences of decades of undiagnosed neurodivergence - nervous system dysregulation, HPA axis disruption and dysregulation and chronic inflammation needs be taken seriously. They are medical realities.

Women who have been failed by this medical system deserved better.

References: this article draws on peer-reviewed research.

HPA axis dysregulation in ADHD - under-arousal, fatigue and delayed awakening

George, M.Y., et al. (2025). The cortisol axis and psychiatric disorders: an updated review. Pharmacological Reports. https://link.springer.com/article/10.1007/s43440-025-00782-x

Isaksson, J., et al. (2012). Cortisol levels in children with Attention-Deficit/Hyperactivity Disorder. Journal of Psychiatric Research, 46(11), 1398–1405. https://www.sciencedirect.com/science/article/abs/pii/S0022395612002543

Leffa, D.T., et al. (2021). Cortisol and inflammatory biomarker levels in youths with ADHD: evidence from a systematic review with meta-analysis. Translational Psychiatry, 11, 430. https://www.nature.com/articles/s41398-021-01550-0

HPA axis dysregulation in autism - elevated cortisol and exaggerated stress responses

Spratt, E.G., et al. (2012). Enhanced cortisol response to stress in children in autism. Journal of Autism and Developmental Disorders, 42(1), 75–81. https://pmc.ncbi.nlm.nih.gov/articles/PMC3245359/

Corbett, B.A., et al. (2022). Emotional stress, cortisol response, and cortisol rhythm in autism spectrum disorders: a systematic review. Autism Research, 15(11), 2023–2042. https://www.sciencedirect.com/science/article/pii/S175094672200126X

George, M.Y., et al. (2025). The cortisol axis and psychiatric disorders: an updated review. Pharmacological Reports. https://link.springer.com/article/10.1007/s43440-025-00782-x

Costs of masking

Aleksandar Sic ^1,2, Kiana Cvetkovic ¹, Eshanika Manchanda ¹, Nebojsa Nick Knezevic ^1,3,4,*

Editor: Neurobiological Implications of Chronic Stress and Metabolic Dysregulation in Inflammatory Bowel Diseases Arrigo Cicero PMCID: PMC11431196  PMID: 39329889

Cage, E., & Troxell-Whitman, Z. (2021). Experiences of autistic adults masking at work: a qualitative study. Autism in Adulthood, 3(4), 328–337. (Referenced via Hull et al., 2017, and Bargiela et al., 2016 — see below)

Hull, L., et al. (2017). "Putting on My Best Normal": Social camouflaging in adults with autism spectrum conditions. Journal of Autism and Developmental Disorders, 47(8), 2519–2534.

Nicholls, E., et al. (2026). How masking and boundary-setting challenges lead to burnout in neurodivergent women and AFAB individuals. True North Psychology. https://www.truenorth-psychology.com/post/how-masking-and-boundary-setting-challenges-lead-to-burnout-in-neurodivergent-women-and-afab-individ

Elemental Health & Nutrition. (2025). Neurodivergent masking fatigue: the biological cost of camouflaging. https://elementalhealthandnutrition.com.au/neurodivergent-masking-fatigue-the-biological-cost-of-camouflaging/

Hormonal influences on neurodivergent presentation across the lifespan

Lindenwood University. (2025). Premenopausal transition in neurodivergent women. Faculty Research Papers. https://digitalcommons.lindenwood.edu/cgi/viewcontent.cgi?article=1769&context=faculty-research-papers

George, M.Y., et al. (2025). The cortisol axis and psychiatric disorders: an updated review. Pharmacological Reports. https://link.springer.com/article/10.1007/s43440-025-00782-x

Diagnostic bias

Minutoli, R., et al. (2026). Female gender and autism: underdiagnosis and misdiagnosis — clinical and scientific urgency. Frontiers in Psychiatry, 16, 1704579. https://pmc.ncbi.nlm.nih.gov/articles/PMC12812640/

Gesi, C., et al. (2021). Gender differences in misdiagnosis and delayed diagnosis among adults with autism spectrum disorder. International Journal of Environmental Research and Public Health, 18(15), 7926. https://pmc.ncbi.nlm.nih.gov/articles/PMC8306851/

Sanchis-Sanchis, A., et al. (2021). Diagnostic tools for autism spectrum disorders by gender: analysis of current status and future lines. Frontiers in Psychology, 12, 626.https://pmc.ncbi.nlm.nih.gov/articles/PMC8066607/

Autism Research Institute. (2024). Women in autism. https://autism.org/women-in-autism/

Hippocampal atrophy under chronic cortisol exposure

Conrad, C.D. (2015). Stress effects on the hippocampus: a critical review. Frontiers in Neuroendocrinology, 38, 79–102. https://pmc.ncbi.nlm.nih.gov/articles/PMC4561403/

Bhatt, S., et al. (2025). Chronic stress-associated depressive disorders: the impact of HPA axis dysregulation and neuroinflammation on the hippocampus — a mini review. International Journal of Molecular Sciences, 26(7), 2940. https://www.mdpi.com/1422-0067/26/7/2940

Iordan, A.D., & Colesniuc, G. (2024). HPA axis: unveiling the potential mechanisms involved in stress-induced Alzheimer's disease and depression. PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC11416836/