Ep 31: Neurodivergent Experience - Male/Female Vs Internalising/Externalising Presentations & Late Diagnosis

Send us Fan Mail🎙️ Episode 31: Neurodivergent Experience - Male/Female Vs Internalising/Externalising Presentations & Late Diagnosis"When we talk about male and female presentations, we're really talking about internalising and externalising presentations."Summary:In this episode of The AuDHD Psych Podcast, clinical psychologist and AuDHDer Aaron Howearth asks why more boys and men are diagnosed with autism and ADHD than girls and women. He argues that what we call male and female presentations is better described as internalising and externalising. An internalising presentation suppresses the impulse and works hard to fit the social rules, while an externalising presentation acts on it and is visible to everyone in the room. He links that split to how we still raise sons and daughters differently, and to how diagnostic criteria are built from what clinicians and researchers could observe. Because externalising presentations are the observable ones, they are the ones encoded in slow-moving manuals like the DSM and ICD, while quieter internalising presentations are less likely to be noticed or referred on.He then traces the cost of being missed. Internalising presentations more commonly come with anxiety, depression, self-harm and suicidality, difficulties with self-esteem and self-concept, and a greater likelihood of a personality disorder diagnosis. Externalising presentations more often attract conduct diagnoses, defiance and aggression, but they also tend to bring earlier recognition and the relief of seeing yourself reflected in peers with the same label. Without that recognition, "I'm different" quietly becomes "I'm not enough". He closes on late diagnosis: masking eventually meets a threshold it cannot hold, and for many neurodivergent women that arrives at perimenopause, when falling oestrogen affects GABA, serotonin and dopamine and brain fog, inattention and sensory gating become harder to hide.Key Themes & TakeawaysInternalising vs Externalising – What we often call male and female presentations may be better described as suppressing the impulse versus acting on it.Culture May Contribute to Teaching Us Our Presentation – "Boys will be boys" permits externalising, while girls are taught to be pro-social, so masking is learned earlier.How Criteria Get Built – Manuals encode what clinicians could observe, so externalising is captured and quieter presentations are missed.Masks, Scripts And Stress – An internal compendium of social rules, with a script for each situation, works but can be a costly constant effort.Patterns of Difficulties Differ – Internalisers more often meet criteria for anxiety, depression and personality disorders; externalisers for conduct and aggression.Self-Concept Is A Deeper Injury – Without a name for what you are, self-understanding drifts from who you actually are.Community Repairs The Picture – Seeing your strengths and struggles in others replaces being a bad person with being a different one.Perimenopause And Late Diagnosis – A real Female-Male difference may be the reduced effects of oestrogen on GABA, serotonin and dopamine, amplifying brain fog, inattention and sensory gating.The Double Mask – People approaching burnout often mask the burnout too, which can push diagnosis even later and burnout deeper.Referenced ConceptsInternalising and externalising presentations of autism and ADHDHow diagnostic criteria are constructed in the DSM and ICDPersonality disorder diagnoses in internalising presentationsSelf-concept and identity after late diagnosisPerimenopause, oestrogen, GABA, serotonin and dopamineSensory gating, attention and autistic burnoutSee Eps 10, 20 & 24 for related diagnosis/late diagnosis content.If this episode raises difficult feelings, support is available in Australia: Lifeline 13 11 14, 13YARN 13 92 76, or Beyond Blue 1300 22 4636.We are different, not defective.🎙️ Follow @AuDHDPsychPodcast on Instagram for content reels from each episode.📩 Send us your questions via fan mail — links in the episode player.Support the showKeywords: AuDHD podcast, autism and ADHD, neurodivergent psychologist, neurodiversity affirming, Howearth Psychology, queer psychologist, autism diagnosis, ADHD awareness, lived experience, neurodivergent mental health, clinical psychology podcast