Is Diagnosing ADHD Gender Bias? How Gender Can Impact ADHD Diagnoses and Symptoms

As with other neurodiverse disorders, attention-deficit/hyperactivity disorder (ADHD) presents itself differently in everyone it affects. But what are the commonalities and differences between how members of different genders experience ADHD? Do females and males experience ADHD the same way? And what about those who identify as a non-binary gender? How do they experience ADHD when it can be a disorder that presents itself differently in the cisgenders?

Why Do We Have to Talk About Gender When We Talk About ADHD?

Unfortunately, like in many other spheres, gender bias plays a huge role in the studying and diagnosing of ADHD.¹ As important as the evolution of studying and researching ADHD was and continues to be, it’s critical to remember that when ADHD was first studied, it was predominantly males who were observed and diagnosed.² This was because males are more likely to expresses the once hallmark ADHD symptoms, hyperactivity/impulsiveness and inattentiveness, which be disruptive and therefore easier to notice and diagnose.³ Since mostly males and their symptoms were originally studied, the diagnostic criteria on the disorder is tailored to how they experience ADHD, and it was assumed that the other genders experienced ADHD in these ways as well.⁴ Because of this, a majority of ADHD focused research that was conducted in past decades lacks a comprehensive understanding of how ADHD affects females and nonbinary individuals. Only in recent decades have researchers began to fully understand ADHD and the various ways it affects people.

The Gamut of ADHD Symptoms

One of the biggest differences between how males and females experience ADHD is that males’ symptoms are often external while females’ symptoms are often internal.⁵ An imagery tool to help understand the range of ADHD symptoms is the image of an iceberg; the external ADHD symptoms are seen as the tip of the iceberg whereas internal symptoms contribute to the hunk of ice hiding beneath the surface of the water.⁶ Even though only the tip is visible, that doesn’t mean the rest of the iceberg is any less there. The same can be said about ADHD symptoms.

External Symptoms

External symptoms are described as behaviors or characteristics that can be observed by others.⁷ They are categorized as inattentiveness and hyperactivity, which is often grouped with impulsivity.

Examples of inattentiveness:⁸

1. Difficulty paying attention
2. Poor time management and organization skills
3. Avoiding tasks that require a long period of concentration

Examples of hyperactivity:⁹

1. Difficulty sitting still, fidgeting
2. Interrupting others and completing others’ sentences
3. Often feeling restless

Internal Symptoms

Internal symptoms are defined as experiences that cannot be seen by others and occur in the body. Examples of internal symptoms:¹⁰

1. Executive dysfunction or being unable to plan ahead and organize
2. Frustration
3. Hypersensitivity or feeling emotions deeply and being sensitive to criticism
4. Decision paralysis
5. Difficulty with motivation

The internal symptoms of ADHD can be attributed to other mental health conditions like anxiety, depression, and bipolar disorder, further making it difficult to diagnose these symptoms as products of ADHD.¹¹ Even though external symptoms are easier to notice and attribute to ADHD, that doesn’t mean internal symptoms are any less valid or impactful to daily life.

ADHD in Males

With all of the progress made recently to better research and diagnose all affected individuals with ADHD, boys are still 13% more likely to be diagnosed with ADHD than girls who are diagnosed at about 6%.¹² As children, males with ADHD are usually diagnosed around the ages six to ten.¹³ Typical external symptoms that males experience are fidgeting, disruptive behavior, and engaging with high consequence behaviors.

Along with external symptoms, males are also likely to have “externalizing disorders” such as substance abuse and conduct disorders.¹⁴ Even though external symptoms are most commonly seen in males, they can also experience internal symptoms. The main internal symptoms males experience is rejection sensitivity dysphoria (RSD) which presents as men needing to be right or prove others wrong, anger, and apathy.¹⁵

ADHD in Females

In stark contrast to the average ages males are diagnosed, females are usually diagnosed in their twenties to their forties.¹⁶ ADHD diagnoses in women are often seen as an Ah-ha moment since many women were diagnosed with other mental health conditions like anxiety, depression, eating disorders, and low self-esteem earlier in their lives; yet these diagnoses never felt accurate.¹⁷ But why are the majority of females who have ADHD diagnosed so much later in life than males? The main reason is that females internalize their ADHD symptoms because from childhood girls are taught to be quiet, introspective, and to conceal their emotions, which doesn’t align with hyperactive and impulsive behaviors.¹⁸ Additionally, it common for females to, perhaps unknowingly, develop coping mechanisms that mask their ADHD symptoms, making it difficult for those symptoms to be attributed to the disorder.¹⁹ Looking at how ADHD affects females differently than males from a biological perspective, psychology professor Dr. Julia J. Rucklidge, once stated, “We can’t make assumptions that what applies to males will apply to females--females have different hormonal influences to start with that can greatly affect their behavior.”²⁰

Coping with troublesome ADHD symptoms and never feeling like you were being diagnosed and treated properly, has been recorded to cause more strife and difficulty in women who are living with undiagnosed ADHD. A study that researched this concluded:

…it is apparent that [for females] undiagnosed ADHD in childhood can have lasting negative consequences into adulthood. Missed or late diagnosis can be damaging for a woman’s self-esteem, mental health, and overall wellbeing, while accurate and timely diagnosis can profoundly change the lives of women and girls with ADHD, allowing them to stop blaming themselves and begin to lead more fulfilling and satisfying lives. Women and girls are too often suffering in silence, being left out of the ADHD narrative; it is imperative that these women are not forgotten.²¹

Diagnosed or not, the less noticeable ADHD symptoms that females experience are forgetfulness, frequently losing belongings, trouble listening, losing focus on tasks, and avoiding tasks that require long periods of sustained mental effort.²² Other internalizing symptoms can be experiencing emotional sensitivity and issues with self-esteem and self-image.²³ Women with undiagnosed ADHD are more likely to have depression, anxiety, and eating disorders because of the mental taxation that coping with undiagnosed ADHD causes.²⁴

ADHD in Nonbinary and Transgender Folks

Like with females, how ADHD affects the nonbinary and transgender communities has yet to be sufficiently researched. One study that looked at gender and ADHD found that people with ADHD and autism are 6.64 times more likely to “express gender variance,” indicating that neurodivergents may be more likely to question their gender.²⁵ An important distinction is that ADHD does not cause gender questioning, but rather:

People who have ADHD often experience social rejection, bullying, and criticism from both their peers and the authority figures in their lives. Because of this, many people with ADHD begin to perceive the world differently and come to realize that many of the expectations placed on them are arbitrary. They can tend to reject these rules in service of their own systems and behaviors that better support them and cater to their needs. For some people with ADHD, this includes the way they navigate and present their gender.²⁶

Similarly, it’s thought that for nonbinary and trans people with ADHD their childhood experience with the disorder was very different than how they experience ADHD as an adult.²⁷ Looking towards the future, more thorough research is needed to bridge the gaps between ADHD and understanding how it affects the non cisgenders.

But How Do I Cope with ADHD Symptoms?

While a majority of research shows patterns of specific ADHD symptoms occurring repeatedly in a specific gender, this doesn’t mean that another gender is unable to experience those symptoms as well. The way you experience ADHD can fluctuate throughout your life; no matter whether you experience external or internal symptoms of ADHD, or some of both, what’s most important is to seek helpful and healthy coping mechanisms to manage ADHD symptoms.

Luckily, there are a variety of tools and techniques to employ to help handle ADHD symptoms. One possible way to help understand your ADHD and find out how to best treat it is by speaking to a therapist who specializes in the disorder. In recent years, there has been a significant rise in the number of insurance plans than include psychologist and physiatrist therapists, making therapy more available and affordable.²⁸ Although, it’s also understandable if therapy is not a realistic option for everyone and there are plenty of other beneficial coping mechanisms to use to manage ADHD. Considering trying:²⁹

1. Learning how to bolster attention and focus habits

1. Thoroughly analyze a project before starting it and break it up into smaller tasks to help make it feel more doable
2. Eliminate distracting environments and noises when focusing
3. Utilize reminders and alarms to improve time management skills

2. Strengthening organization habits

1. Create a daily routine that you can realistically follow
2. Have a permanent place for important items to help keep track of them
3. Keep a calendar of meetings, appointments, reminders, etc.

3. Regulating overwhelm

1. Learn how to notice when you begin to feel overwhelmed and what techniques help you to begin processing the overwhelm
2. Practice deep breathing
3. Implement progressive muscle relaxation into your routine

How ADHD was originally diagnosed and studied could be viewed as gender biased since females and nonbinary genders with ADHD went unstudied. While there is still a generous amount of progress that needs to be made on fully understanding how ADHD affects people of all genders, it’s promising that in recent decades substantial progress has been initiated to minimize the amount of gender bias surrounding ADHD.

Citations

1. Ellen Littman, “The Gender Myths (Or ‘Only Boys Have ADHD’),” CHADD, last modified August 2021.
2. Ortal Slobodin and Michael Davidovitch, “Gender Differences in Objective and Subjective Measures of ADHD Among Clinic-Referred Children,” Front. Hum. Neurosci. 13, (2019).
3. Slobodin and Davidovitch, “Gender Differences in Objective and Subjective Measures of ADHD Among Clinic-Referred Children.”
4. Nicole Crawford, “ADHD: a women’s issue,” American Psychology Association 34, no. 2, (February 2003).
5. Slobodin and Davidovitch, “Gender Differences in Objective and Subjective Measures of ADHD Among Clinic-Referred Children.”
6. Sanjana Gupta, “What Does the ‘ADHD Iceberg’ Mean?” verywellmind, last modified 02 August 2023.
7. Gupta, “What Does the ‘ADHD Iceberg’ Mean?”
8. Gupta, “What Does the ‘ADHD Iceberg’ Mean?”
9. Gupta, “What Does the ‘ADHD Iceberg’ Mean?”
10. Gupta, “What Does the ‘ADHD Iceberg’ Mean?”
11. Morgan Mandriota, “What I Wish People Knew About Gender and ADHD,” Psych Central, last modified 31 January 2022.
12. “Data and Statistics About ADHD,” Centers for Disease Control and Prevention, last modified 16 October 2023.
13. Jillian Vogley, “Gender Differences in ADHD,” Honors Theses 35 no. 65, (2019).
14. Rachel Ann Tee-Melegrito, “How ADHD differs in Males and Females,” Medical News Today, last modified 31 October 2022.
15. Michael Hovde, “All About ADHD in Men,” PsychCentral, last modified 23 June 2022.
16. Vogely, “Gender Differences in ADHD.”
17. Heather Jones, “ADHD in Boys vs. Girls,” verywellhealth, last modified 9 February 2024.
18. Jones, “ADHD in Boys vs. Girls.”
19. Darby E. Attoe and Emma A. Climie, “Miss. Diagnosis: A Systematic Review of ADHD in Adult Women,” J Attend Discord. 27, no. 7, (May 2023).
20. Crawford, “ADHD: a women’s issue.”
21. Attoe and Climie, “Miss. Diagnosis: A Systematic Review of ADHD in Adult Women.”
22. Jones, “ADHD in Boys vs. Girls.”
23. Jones, “ADHD in Boys vs. Girls.”
24. Jones, “ADHD in Boys vs. Girls.”
25. Morgan Mandriota, “Are People with ADHD More Likely to Question Their Gender Identity?” Psych Central, 3 May 2022.
26. Mandriota, “Are People with ADHD More Likely to Question Their Gender Identity?”
27. Mandriota, “What I Wish People Knew About Gender and ADHD.”
28. Judith Graham, “Since 2008, Insurers Have Been Required by Law to Cover Mental Health- Why Many Still Don’t,” The Atlantic, last modified 11 March 2013.
29. Hope Gillette, “What are the Best Coping Skills for ADHD?” healthline, last modified 12 December 2023.