Gray Atherton, Ph.D., details the socialization of the female gender experience and how that plays into autism gender biases. The speaker discusses the experiences of autistic women, highlighting that gender is a critical barrier to diagnosis and care. Atherton details recent investigations into implicit gender biases in autism and their impact on medical care and autism understanding. She evidences contemporary shifts in the zeitgeist of gender and autism and provides suggestions for future research. The presenter offers sources and acknowledgments before the Q&A, where she discusses masking, minorities and misdiagnosis, videogaming and autism, and much more. 

In this webinar:

1:00 – Agenda and introduction
4:40 – Gendered development & autism descriptions
8:00 – Female protective effect
10:00 – Male brain theory
12:35 – Gender and autism
16:20 – Masking
18:50 – Study 1: Age of diagnosis and quality of life
26:10 – Effects of late diagnosis
30:00 – Gender biases and a new ratio
35:12 – Study 2: Implicit gender biases against female autism
40:11 – Findings
42:40 – Study 3: The zeitgeist of gender and autism
44:50 – Summary and future research
48:08 – Q&A

Female gender experiences

Atherton discusses the construction and socialization of the female gender experience, underscoring observed differences in toys, colors, expectations, and language used with female versus male children (2:15). She explains that females show more relational aggression (indirect) compared to males by age four (4:40) and tend to consider hierarchies and reputation in social interactions and communication from a very young age (6:15). These differences, the speaker continues, result, in part, from contrasting developmental pressures and environments between females and males. 

Gender and autism

Historical descriptions of autism are skewed toward the male presentation due to classic gender biases (6:40). Atherton outlines two prominent hypotheses that aim to explain observed gender differences in autism: the Female Protective Effect (8:00) and the Male Brain Theory (10:10). While these theories have been widely investigated, contemporary understandings of gender and autism reveal them to be limited in scope and understanding. 

Atherton cites research showing higher rates of gender diversity in autism, where transgender and gender-diverse people are three to four times more likely to be autistic than cisgender people (12:35). She discusses masking (16:20), or the process of copying other people and learning how to socialize, and how repetitive behaviors and other signs of autism can be easily mistaken for the expected “nice” “quiet” or “organized” qualities of girls and women (13:35). 

Age of diagnosis and quality of life

The speaker details a recent investigation into the effect that age at autism diagnosis has on an individual’s quality of life (QoL) (18:50). The study found that women are significantly more likely to be diagnosed in adulthood compared to men and that women actually reported higher thresholds of autistic traits, but were still missed by practitioners (21:13). QoL scores were negatively associated with age of diagnosis and masking. In a subsequent interpretive phenomenological analysis of lived autistic experiences, participants reported that their gender kept them from receiving a diagnosis – that they would have received a diagnosis much younger if they were male (22:16). These findings suggest that women do have autism at least as frequently as men and that women are primarily underdiagnosed in adolescence, which leads to lower overall QoL (25:05).

A study by Rodgaard et al., 2021 found that women who received a late diagnosis were misdiagnosed at least once with depression, anxiety, sleep issues, etc. (28:35). Atherton underscores that without early diagnosis and proper medical care, individuals are more likely to develop co-occurring conditions. In fact, 26% of late-diagnosed women have co-occurring conditions compared to 13% of late-diagnosed males and 3% of the general population (26:10). 

Implicit gender biases

The presenter outlines a study by Burrow et al., 2022 where researchers conducted direct assessments of autism symptoms at six to nine (6-9), twelve to fifteen (12-15), twenty-four (24), and thirty-six to sixty months (36-60) (30:00). Data revealed a 1:1 gender ratio of male/female children with “high concern” for autism – a stark contrast to the historically accepted 4:1 ratio. Clinician notes often referenced ‘monitoring’ girls over time but not needing a diagnosis in the same way as the boys did (33:00). These findings, Atherton asserts, suggest that although there is no biological bias, there seems to be different symptoms in females, perhaps as a result of female socialization, and subsequent bias in autism understandings and diagnosis.

 To determine whether there are implicit biases held against female autism, Atherton and her team paired vignettes of autistic descriptors with male and female names and asked participants to say how autistic each vignette seemed (35:12). She explains that implicit biases may never be cognizantly acted upon, but that they still affect the way we understand and respond to information (38:15). Results from the study showed that participants were slower to respond and made more mistakes when autistic descriptors were paired with female names compared to male names. Item-by-item differences were also recorded, where words that were explicitly autistic were viewed as male, and those that were the opposite of autistic were considered female (40:11). The speaker asserts these findings show implicit biases associated with females being autistic. 

Conceptualizing autism

To properly care for autistic individuals, it is critical to understand the zeitgeist or cultural climate around autism and gender. To test this, the speaker collected photos that represented autism from 163 people. Many participants sent pictures of females and wrote about the struggles that autistic women face. Many participants also noted that we need to reimagine autism in accordance with gender (42:40). 

The speaker summarizes her presentation, highlighting the difficulties in diagnosis and care faced by autistic females, that women have the same amount or more autistic traits compared to men, that there are implicit biases against autism as a female experience, and that the cultural zeitgeist of autism and gender is changing according to the unique struggles and voices of autistic females (44:50). Atherton provides signup information for individuals interested in participating in future research projects about female autism trait presentation, gender diversity in autism, and adult experiences of neurodiverse people, specific to improving QoL (45:50). She provides references and thanks before the Q&A session (48:08). 

Dr. Gray Atherton, Ph.D., explores the connection between autism and anthropomorphism. She provides a brief historical and social context for anthropomorphism in our daily lives before diving into the prevalence and advantages of anthropomorphism in autism. The speaker details recent studies that challenge prevalent theories about socialization, Theory of Mind, and anthropomorphism in autism. Atherton asserts that many autistic people use anthropomorphism prolifically in everyday life and often outperform their non-autistic peers in this aspect of Theory of Mind. The presenter highlights anthropomorphism as a strength for many autistic individuals and suggests using it to support learning and interventions for autism. 

Handouts are online (.pdf) HERE

In this webinar:

1:58 – What is anthropomorphism?
5:00 – Importance of anthropomorphism
8:05 – Autism and anthropomorphism
10:00 – Social Motivation Theory of Autism
14:00 – Study 1: Theory of mind processes in autistic adolescents
18:50 – Study 2: Review of studies with anthropomorphic stimuli
23:45 – Study 3: Reading the Mind in the Eyes Test – anthropomorphized
29:00 – Study 4: Intellectual disability and emotion recognition
32:25 – Study 5: Verbal anthropomorphism and theory of mind
35:30 – Study 6: Pets and anthropomorphism in everyday life
39:50 – Recap
41:30 – Flip the narrative
46:00 – Applications and interventions
48:20 – Q & A session

History and importance of anthropomorphism

Atherton defines anthropomorphism as the attribution of human-like qualities, emotions, or behaviors to non-human entities, such as animals or objects (1:58). Examples of anthropomorphism are seen throughout history in our deities and legends, who often assume human characteristics. The speaker explains the importance of anthropomorphism in religion, connection, and socialization. She explains that wanting to understand something that isn’t human drives us to anthropomorphize and highlights that anthropomorphism is frequently related to loneliness (5:00). Atherton touches on the presence of anthropomorphism in childhood media and notes its increasing use in contemporary care work and technology (6:25). 

Autism and Anthropomorphism

The presenter discusses the Social Motivation Theory of Autism and outlines publications supporting the claim that autistic people are less socially motivated than their peers (9:00). Theory of Mind (ToM), or the capacity to ascribe emotions to other people based on facial expressions and personal characteristics, is closely related to anthropomorphism. Atherton outlines a study that tested ToM in relation to a video of moving shapes. Results showed that non-autistic respondents used human-like adjectives to describe the shape interactions, while autistic participants used more concrete descriptives and less mental state language (10:56). Given the contrast in responses, researchers concluded that autistic people have lower ToM and are less likely to anthropomorphize or use human-like descriptors. Atherton describes her own professional experiences with autistic individuals as totally contrary to these assumptions and asserts the need for further exploration into ToM and autism (12:10). 

Study 1: Theory of Mind processes in autistic adolescents 

To explore the Theory of Mind experiences of autistic adolescents, the speaker conducted an open-response interview and interpretive phenomenological analysis (14:00). The study revealed four overarching themes concerning how autistic people engage with ToM processes: honesty, humor, visualization, and anthropomorphism (15:00). Atherton presents sub-themes and quotes from participants that reflect their prolific use of anthropomorphism in daily life. She asserts that these findings challenge accepted notions that autistic people have low ToM and social motivation (17:23). 

Study 2: Review of investigations with anthropomorphic stimuli

Although anthropomorphism isn’t often explicitly studied, many investigations use anthropomorphic stimuli as a control in comparative studies (18:50). In reviewing such studies, the speaker found that autistic individuals perform significantly better on ToM tests when the stimuli are non-human instead of human (20:00). She outlines three publications that revealed:

1. Autistic people prefer anthropomorphized images over human ones.
2. Autistic people actually have an advantage in this area of ToM compared to their non-autistic peers.
3. This advantage may have to do with the expertise or familiarity that autistic people have with non-human social agents (22:30). 

Study 3: Reading the Mind in the Eyes test – anthropomorphized

Reading the Mind in the Eyes test (RME) is a classic ToM exercise where participants determine emotions based on photos of a person’s eyes. Atherton and colleagues created a cartoon (anthropomorphic) version of the RME and compared autistic and non-autistic group responses for both versions (23:45). Results showed that the non-autistic group had higher success on the human RME test but that the autistic participants outperformed their counterparts on the cartoon test (27:00). These results, the presenter posits, suggest that anthropomorphism may be a strength for autistic individuals, further challenging the preconceived notions that autistic people have low ToM and emotion recognition capabilities.

Study 4: Intellectual disability and emotion recognition

Around 40% of autistic individuals also have some co-occurring intellectual disability, and many are non-verbal. Atherton explains how communication barriers often exclude this part of the autistic community from research participation (28:00). She outlines a recent study that took these differences into account and assessed whether the prolific use of anthropomorphism revealed in previous studies defines the entire autism spectrum (29:00). Researchers used a combination of human faces and animal face filters to test ToM. They found a significant increase in correct answers for the photos with animal filters on them, suggesting participants better understand anthropomorphized stimuli compared to human faces (31:20). The presenter discusses study limitations, noting the aspect of visual salience. 

Study 5: Verbal anthropomorphism and theory of mind

To see if anthropomorphism extends beyond visual context, Atherton and colleagues used a verbal ToM Faux Pas test (32:25). They tested participants’ ability to determine whether someone said something awkward in both human and anthropomorphized stories provided in text. Similar results to previous studies were found: autistic people struggled with human-based wording but performed at the same level as, if not better than, the non-autistic group with anthropomorphized stories (34:00). Atherton asserts that these findings suggest anthropomorphism may play a critical role in how autistic people engage in perspective-taking and conceptualize ToM. 

Study 6: Pets and anthropomorphism in everyday life

As human beings, we often anthropomorphize our pets to relate to them and create connections. Atherton describes a study on differences between autistic and non-autistic groups in their anthropomorphism of pets. Results showed that the autistic group was equally attached to their pets and used similar amounts of anthropomorphism as their non-autistic counterparts. Interestingly, the presenter states, Autism Quotient scores correlated with anthropomorphism and autistic people were more likely to substitute pets for people (mediated by social avoidance) (35:30). Interpretive phenomenological analysis of 16 interviews with autistic pet owners showed that pets can often act as a social alternative and/or a social lubricant. Participants frequently noted that with animals, “you don’t have to wear a mask – they don’t know what social rules you may be breaking” (37:15). 

Atherton states that these real-life examples show how autistic individuals intentionally create anthropomorphic connections to compensate for social deficits or avoidance. These intentional connections manifest in various ways, from donating to animal charities to becoming a cat behaviorist. The speaker asserts that we need to understand anthropomorphism as a strength and something that autistic people may be particularly good at. Perhaps, she continues, they are engaging with and becoming experts in anthropomorphism because it’s a way to have connections that don’t feel judgmental or forced (39:00). 

The big picture

The speaker summarizes the presentation, highlighting that evidence suggests autistic people anthropomorphize at least to the same degree as their non-autistic peers and that anthropomorphism may play a role in the way autistic people conceptualize or engage in ToM and perspective-taking (39:50). She presents a diagram of the Social Motivation Theory and suggests that we flip the narrative. Instead of saying autistic people have decreased human/social motivation or recognition, we can say they have increased non-human attention to faces and understand non-humans much more (41:30). 

The presenter notes that anthropomorphism may vary across developmental stages and cites a multi-age study where anthropomorphism decreased with age (44:15). She suggests leveraging anthropomorphic stimuli, like cartoons, in educational and therapeutic settings with autistic individuals. For example, a pilot study using Hololens glasses is underway, which could allow for more meaningful interactions using anthropomorphism and digital projections (46:00). Atherton invites viewers to share their real-life experiences with anthropomorphism and provides her contact information (47:15) before beginning the Q & A session (48:20)

Dr. Tami Bar-shalita, Merry Kalingal Levi, and Dr. Yelena Granovsky explore the intricate connections between pain, sensory perception, and autism. They discuss quantitative and qualitative research findings that shed light on the relationship between sensory modulation and pain perception, identify potential neurophysiological descriptors for sensory modulation in autism, and reveal critical factors about the everyday pain experiences of autistic individuals. The presenters summarize their findings and highlight the need for vigorous investigation into the complex relationship between pain and autism.

Handouts are online HERE

A video shared by The National Autistic Society, demonstrating sensory experiences, is referenced in the talk; the video is available to view online HERE

In this webinar: 

4:00 – Introduction
7:00 – Sensory modulation dysfunction and pain perception by Dr. Tami Bar-Shalita
7:58 – Video: SOR experience
9:30 – What is pain?
10:20 – Study 1: Pain Perception in individuals with SOR
11:15 – Findings
12:50 – Published studies on SOR
13:25 – SMDolor Model – Based on E/I imbalance theory
15:08 – Historical context of autism and pain
17:00 – Study 2: Pain ratings of suprathreshold stimuli
18:20 – Findings
20:48 – Qualitative Exploration of Pain Experience by Merry Kalingal Levi
21:35 – Study 3: Qualitative exploration of pain experiences in autism
22:40 – Findings
25:30 – Lived experiences and accessibility suggestions
27:45 – Neurophysiology of pain in autism by Dr. Yelena Granovsky
28:30 – Study 4: EEG activity in autism
29:45 – Results
34:00 – Study 5: Pain-evoked potentials
37:00 – Findings
38:36 – Study 6: Heart Rate Variability (HRV)
40:00 – Findings
44:00 – Summary and conclusions
46:00 – Q&A

Introduction

Multisensory integration, or the simultaneous use of different sensory modalities, is a crucial aspect of our daily lives and ability to interpret and react to the world. This multisensory perception enhances our efficiency in responding to environmental stimuli (4:23). For example, the olfactory system can detect the smell of smoke, but you also need to hear burning sounds and see a light to locate its source (5:30). Understanding how sensory perception influences pain, behaviors, and ability to function is critical in ensuring the best possible care for autistic individuals. 

Sensory Modulation Dysfunction and Pain Perception, by Dr. Tami Bar-Shalita

When our reactions to stimuli hinder our general ability to function, this may indicate Sensory Modulation Dysfunction (SMD) (7:16). Sensory over-responsiveness (SOR), a type of SMD, occurs when the responses to ordinary, non-painful stimuli are amplified and cause suffering and pain, thereby reducing one’s ability to function efficiently (7:40). Bar-Shalita defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.” She explains the pathological nature of chronic pain and asserts the need to study pain within the lens of SMD (9:30).

Study 1: Pain Perception and Brain Activity in Individuals with Sensory Over-Responsiveness

Bar-Shalita and her colleagues tested pain perception (in a controlled lab setting) in neurotypical individuals with SOR. Participants reported higher pain intensity and significantly less pain reduction over time than those without SOR (10:20). These differences in perception also manifest as imbalances in excitatory and inhibitory (E/I) responses in the brain. Bar-Shalita outlines the SMDolor Model and notes that hypersensitivity to pain could be a predisposing factor in chronic pain development (13:00). 

Historical context of autism and pain 

Historically, autistic people were thought to be hypo-sensitive (indifferent) to pain based on the frequent presentation of self-injurious behaviors (SIB) (14:30). Bar-Shalita discusses research that shows reduced pain sensitivity in autistic children and a high prevalence of autism in chronic pain clinics (15:20). This evidence, the speaker asserts, suggests an ongoing misdiagnosis of chronic pain in autism and vice versa. She underscores that when left undiagnosed in autism, chronic pain can lead to compromised health care and pain treatment neglect (16:30). 

Study 2: Pain ratings of suprathreshold stimuli

Using heat pain stimuli in the lab, Bar-Shalita and her team conducted the most extensive pain study in autism to date. They found that autistic individuals with SOR tend to be hypersensitive to pain and do not show the same pain reduction over time compared to the neurotypical group (17:00). The study also found that autistic individuals who take psychiatric medication displayed higher scores on the Sensory Responsiveness Questionnaire (18:20). Autistic participants with SOR reported higher anxiety and ranked higher on the Autism Quotient and the World Disability Schedule. Bar-Shalita concludes that the symptoms severity of autistic people with SOR is higher compared to those without SOR” (20:00). 

Qualitative Exploration of Pain Experience, by Merry Kalingal Levi

Study 3: Qualitative exploration of pain experiences in autism

Per the multidimensional nature of pain experiences, Kalingal Levi and her team conducted a qualitative study to compare with the quantitative findings (21:00). They employed a phenomenological approach to explore the experiential aspects of pain perception in everyday lived experiences (21:35). Four main themes arose: pain sensitivity, pain awareness, pain communication, and pain awareness solutions (22:30). Although there was heterogeneity in the type of pain processing (hypo- vs. hypo-), identifying the existence (23:25), nature (23:45), and severity (24:10) of pain were common issues across the study group (23:20). 

Kalingal Levi explains that difficulties with pain awareness often hinder effective communication or expression of pain experiences for autistic individuals (24:40). Participants recounted situations where they or their physicians did not comprehend the seriousness of pain and, therefore, were not given proper treatment (25:00). Participants in the study suggested creative aids, such as booklets with tags and pictures, to help them recognize and convey their pain experiences. They also emphasize the need for doctors to be willing to explore what pain is and how it’s perceived individually (25:30). The research findings underline that difficulties in pain awareness are a fundamental aspect of pain experience in autistic individuals. The speaker restates the need for intensive investigation into this new area of study and urges the medical community to adopt the changes in communication and care environments cited in their research (27:00). 

Neurophysiology of Pain in Autism, by Dr. Yelena Granovsky

Study 4: EEG activity in autism

Granovsky outlines her team’s recent study on spontaneous electroencephalogram (EEG) activity in autistic individuals (28:30). Results showed that autistic individuals have enhanced activity in EEG bands responsible for physiological regulatory mechanisms and limbic system activity (29:45). Specifically, young autistic children exhibited enhanced activity in both slow Delta and Theta EEG bands, a departure from the U-shaped curve seen in typical children (30:00). The speaker discusses underlying mechanisms for these differences and notes that similar central neuronal abnormalities are relevant for chronic pain (31:00). Autistic participants also exhibited higher power at slow Delta and Theta and fast Beta bands (32:36). Enhanced Delta oscillations in autistic individuals were associated with lower pain sensitivity, indicating a correlation between specific EEG activity and pain perception in autism (33:30). 

Study 5: Pain-evoked potentials

The speaker defines evoked potential (EP) as “the change in cortical activity that occurs in response to an event of some kind (34:20). She outlines the basics of EP detection, highlighting the influence of stimulation intensity and perceived pain on EEG amplitude (35:40). To date, only two studies (all male) on pain EPs in autism have been published (37:00). Granovsky’s findings suggest a discrepancy between pain reports and the responses from pain detecting areas in autism and highlight the sex-related nature of responses in the cortical pain-detecting regions (38:15). 

Study 6: Heart Rate Variability (HRV)

Heart Rate Variability (HRV) reflects the autonomic regulation of the cardiovascular system, which is regulated by the sympathetic and parasympathetic nervous systems (38:30). Granovsky and her team conducted one of the first studies on HRV and pain in autism. They found that autistic participants had higher pain thresholds and lower pain perception than neurotypical groups (40:00). They concluded that higher parasympathetic (PS) activity is associated with lower pain perception, suggesting the PS system plays a protective role in pain sensitivity. This relationship between HRV and pain sensitivity in autism suggests that HRV may help gauge the severity of autism symptoms and day-to-day difficulties (42:30). Granovsky asserts that future investigation should aim to evaluate the role of sex in autism pain neurobiology and to develop mechanism-based precision therapy approaches for pain and SOR in autism (43:00). 

Conclusion

The research discussed in this presentation highlights the intricate relationship between sensory processing, pain perception, and autism. Through a combination of quantitative and qualitative investigation, the presenters established a link between SMD and heightened pain sensitivity in autism, revealed distinct patterns in EEG and HRV activity related to pain in autism, and shed light on the physical and communication challenges related to pain experienced by autistic people every day (44:00). Bar-Shalita emphasizes the gap in awareness and communication around pain experiences in autism and reminds that common autistic behaviors may be a form of communicating pain (44:45). She provides thanks and acknowledgments (45:15) before the Q&A session (46:00).