Gender Bias in ADHD Diagnosis: The Intersection of Giftedness, Gender Identity and Late Diagnosis
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Introduction
The diagnosis of ADHD has historically been rife with bias, especially against women, nonbinary individuals, and transgender people. These biases stem from entrenched gender norms, cultural stereotypes, and a diagnostic paradigm originally calibrated to the “typical” hyperactive boy in mind. Over time, critical research and firsthand testimonies have illuminated how ADHD manifests differently across genders and intersecting identities.
Understanding Gender Bias in ADHD Diagnosis
Historical and Diagnostic Context
ADHD has long been studied in primarily male cohorts, leading to a classic diagnostic framework that emphasises externalising behaviours such as hyperactivity and impulsivity (Klefsjö et al., 2021; Kristensen et al., 2023). This focus tends to ignore more internal or subtle signs commonly observed in females, nonbinary individuals, and transgender populations. Such signs include inattentiveness, daydreaming, and internal distress—symptoms that may not disrupt classrooms or workplaces as overtly, thus evading the notice of educators and healthcare professionals.
Furthermore, societal expectations play a profound role in shaping the diagnostic landscape. Boys who exhibit disruptive behaviours are often flagged early for evaluation, while girls who quietly struggle with concentration may be dismissed as “shy” or “diligent.” Nonbinary and transgender individuals might face an even more complex path to diagnosis, due to less gender-conforming behaviours that further overshadow underlying ADHD traits. The result is a pattern of underdiagnosis, misdiagnosis, or delayed diagnosis for many gender-diverse individuals, depriving them of timely interventions and support.
Gender-Specific Presentation
Research consistently shows that ADHD symptoms present differently across genders. In boys, hyperactivity and impulsivity often trigger earlier referrals (Huynh et al., 2024). In contrast, girls—along with nonbinary and transgender individuals—are more prone to “masking,” or hiding the telltale signs of ADHD to meet societal expectations of calmness and compliance (van der Putten et al., 2024). This masking behaviour not only delays recognition but also contributes to a pronounced mental health burden over time, including heightened anxiety and depression.
The Complexities of Masking and Camouflaging
Masking (or camouflaging) encompasses deliberate efforts to minimise or conceal neurodivergent traits in order to align with social norms. While often discussed in the context of autism, emerging research confirms that ADHDers also engage in masking behaviours (van der Putten et al., 2024). For example, a student with ADHD might compensate for executive functioning challenges by spending excessive hours organising colour-coded planners to present as “highly organised,” or they might suppress restlessness during class by constantly fidgeting discreetly under a desk.
Masking is particularly prevalent among females, nonbinary individuals, and transgender people, who are often under societal pressures to appear docile and compliant. For many, the stakes feel especially high if their social circles or professional settings are already less inclusive of gender diversity. Consequently, the burden of maintaining a socially acceptable façade contributes to ongoing underdiagnosis, as standard clinical checklists may fail to account for how ADHD can be cloaked or manifest in subtle ways.
Intersectionality and Systemic Barriers
Cultural and Socioeconomic Factors
Intersectional research reveals that race, class, and ethnicity compound gender-related diagnostic disparities. African American youth, for instance, may be more frequently labelled with conduct disorders rather than ADHD, creating overlooked or misattributed ADHD symptoms (Tapia et al., 2024). In certain Asian cultures, including in Singapore, strict familial and educational expectations can lead caregivers and teachers to read inattentiveness as laziness or disinterest, particularly for girls (Lau et al., 2021). These systemic inequities underscore that gender bias in ADHD diagnosis does not exist in isolation; rather, it intersects with broader cultural biases.
Socioeconomic status further affects diagnosis and treatment access. Families with limited financial resources may struggle to afford private evaluations, comprehensive interventions, or even basic healthcare coverage. The resulting underdiagnosis in these communities perpetuates a cycle of diminished academic and professional opportunities, further entrenching economic and health disparities.
Healthcare Inequities in Marginalised Groups
For transgender and gender-diverse individuals, diagnostic barriers can be even more formidable. A lack of culturally competent providers, stigma related to gender identity, and limited access to affirming healthcare collectively restrict diagnosis and treatment options (Kristensen et al., 2023). Moreover, clinicians may too hastily attribute ADHD symptoms to the stress of gender dysphoria or hormonal treatment transitions. This misguided focus can obscure underlying neurodivergent needs, relegating these individuals to a prolonged journey of coping without adequate support.
My Lived Experience
Throughout my life, I’d carried an unspoken dissonance just beneath the surface—a feeling that I was both too much and not enough. On the outside, I seemed to have everything together, yet beneath that veneer of competence lay a perpetual undercurrent of chaos, where my attention ricocheted among countless thoughts, tasks, and worries. I clung to my planners to help get me through my day, though I never admitted how exhausting it truly was.
Much like many other female-presenting individuals, I had internalised my struggles and masked their outward expression, an unconscious adaptation born out of societal expectations. Growing up, I learned to blend in, to compensate, and to silence the parts of myself that didn’t fit the mould. This masking was so effective that not even I recognized the depth of my challenges. I attributed my struggles to personal flaws or inadequacies, constantly pushing myself harder to compensate. It wasn’t until my thirties, after years of navigating burnout, self-doubt, and a gnawing sense of incongruity, that anyone—including myself—considered the possibility that I might have ADHD.
Realising my neurodivergence was illuminating, but it simultaneously unearthed a cascade of new questions. What made this period particularly bewildering was the interplay between ADHD and giftedness. On one hand, I was celebrated for being diligent, insightful, and bright. On the other hand, I struggled with ADHD related challenges such as the inability to complete simple maths calculations in my mind due to my working memory. These incongruities left me feeling both capable and chaotic, as if I couldn’t reconcile the extremes of my abilities and challenges.
Learning I had ADHD was a revelation. For the first time, I felt permission to trust my own observations of my mind’s racing, nonlinear nature rather than constantly questioning it. It gave me a framework to understand why my thoughts sometimes felt like they were sprinting in every direction at once, often to exciting destinations but rarely on schedule. However, the relief of this clarity came with an undercurrent of regret. I couldn’t help but wonder: had I known earlier, could I have been spared years of relentless self-doubt, perfectionism, and the exhausting effort of masking my ADHD just to meet the world’s expectations? Could I have embraced my authentic self sooner, free from the fear of being “too much” or “not enough”?
This mix of emotions—relief, regret, curiosity—marked the beginning of a new chapter, one where I started to unravel the impact of late-diagnosed ADHD on my identity, relationships, and sense of self-worth. It wasn’t just about recognising what ADHD explained; it was also about relearning who I was, outside of the narratives shaped by misunderstanding and masking.
Learning about overexcitabilities profoundly expanded my understanding of ADHD, especially when viewed through a neurodivergent-affirming lens (Wells & Falk, 2021). It expanded my understanding of my heightened sensitivity and intensity across emotional, intellectual, sensory, imaginational, and psychomotor domains. Recognising these overexcitabilities within myself reframed many of my ADHD experiences—such as my intense emotional responses and near constant need for movement—not as deficits but as integral parts of my neurodivergence. This perspective validated my experiences in a way traditional ADHD narratives often fail to do, offering a strengths-based understanding that celebrates, rather than pathologises, these intensities. By viewing ADHD through the lens of overexcitabilities, I was able to see my traits as part of a rich and dynamic neurodivergent profile, helping me embrace my authenticity with greater self-compassion and pride.
Stepping into these discoveries hasn’t been a linear or easy path. There have been moments where my need to appear “on top of things” wars with my desire for authentic self-expression. Yet I’m learning to value all the complexity I bring to the table. My intense curiosity and propensity to hyperfocus have fuelled creative projects and deep dives into topics that fascinate me. Meanwhile, accepting my nonbinary identity has opened up a more expansive way of relating to myself and the world—one less tethered to rigid binaries or social expectations.
In letting go of old assumptions and the masks I once wore, I’m discovering spaces and communities where it’s not just accepted but genuinely celebrated to embrace my neurodivergence, to honour my truth as a nonbinary person, and to thrive in the beautifully complex middle ground where I belong. By sharing my journey, I hope to show that it’s not only possible but deeply liberating to hold multiple truths simultaneously. You can be both gifted and live with ADHD. You can project outward functionality while navigating unseen inner battles. Most importantly, these facets of yourself are not contradictions to be fixed but integral threads that weave together a dynamic, vibrant tapestry. True well-being and self-acceptance begin to flourish when we allow ourselves to embrace these complexities fully and unapologetically.
Moving Forward
Current diagnostic tools often emphasise overt hyperactivity, which can result in the under-assessment of internalising symptoms, masking behaviours, and unique stressors faced by marginalised genders. This oversight limits the accuracy of ADHD diagnoses, particularly for those whose symptoms don’t align with traditional expectations (van der Putten et al., 2024). To bridge this gap, researchers and clinicians must collaborate to develop or adapt diagnostic tools. Updated questionnaires, observational methods, and self-report scales should capture the full spectrum of ADHD presentations, ensuring that the nuances of different lived experiences are considered.
Ongoing education for healthcare providers is essential to address biases in recognising inattentive ADHD symptoms. Clinician training should emphasise how culture, gender, and socioeconomic factors shape symptom expression (Tapia et al., 2024). Reflexivity should be a cornerstone of this training, encouraging clinicians to critically examine how their own assumptions and biases may influence their diagnostic practices. By fostering a deeper understanding of diverse ADHD presentations, clinicians can provide more equitable care.
Diagnostic protocols must also be culturally responsive, as stigma, language barriers, and systemic mistrust often deter some communities from seeking mental health evaluations. Engaging with community leaders and incorporating cultural competence into clinical practices can mitigate these barriers.
Public policy interventions that address the intersection of race, gender, and socioeconomic status are critical for mitigating diagnostic inequities. Policies that mandate cultural competence training for healthcare providers and educators are a vital step forward (Bergey et al., 2022). Additionally, providing subsidies for comprehensive mental health evaluations in low-income communities can increase access to necessary care and reduce systemic disparities.
Conclusion
The prevailing biases in ADHD diagnosis are neither accidental nor unchangeable. They reflect systemic inequities that have shaped mental health care, educational systems, and broader cultural narratives. However, by adopting a neurodivergent-affirming perspective—one that emphasises inclusivity, compassion, and genuine curiosity about each individual’s experiences—we can move toward a more just future.
Achieving equity demands concerted efforts on multiple fronts: clinicians and researchers refining diagnostic criteria, policymakers implementing intersectional and culturally responsive policies, and communities fostering environments that recognise, rather than penalise, neurodivergent traits. Crucially, centring the voices of those with lived experience reveals how masking, misdiagnosis, and late interventions create profound and lasting harm.
Through collaboration, advocacy, and a reimagining of what ADHD “looks like,” we can break down the gendered expectations that obscure, trivialise, or penalise neurodivergent experiences. By celebrating each person’s strengths, we champion a future where all individuals—regardless of gender identity or socioeconomic background—have the opportunity to thrive with the support and recognition they deserve.
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References
Bergey, M., Chiri, G., Freeman, N. L. B., & Mackie, T. I. (2022). Mapping mental health inequalities: The intersecting effects of gender, race, class, and ethnicity on ADHD diagnosis. Sociology of Health & Illness, 44(3), 604–623. https://doi.org/10.1111/1467-9566.13443
Huynh, G., Masood, S., Mohsin, H., & Daniyan, A. (2024). The impact of late ADHD diagnosis on mental health outcomes in females. Social Sciences & Humanities Open, 10, 100977-. https://doi.org/10.1016/j.ssaho.2024.100977
Klefsjö, U., Kantzer, A. K., Gillberg, C., & Billstedt, E. (2021). The road to diagnosis and treatment in girls and boys with ADHD—gender differences in the diagnostic process. Nordic Journal of Psychiatry, 75(4), 301–305. https://doi.org/10.1080/08039488.2020.1850859
Kristensen, Z., Drinkwater, C., Johnson, R., & Menkes, D. B. (2023). Considerations in the assessment and management of ADHD within the TGDNB population. The New Zealand Medical Journal (Online), 136(1587), 46–51.
Lau, T. W. I., Lim, C. G., Acharryya, S., Lim-Ashworth, N., Tan, Y. R., & Fung, S. S. D. (2021). Gender differences in externalising and internalising problems in Singaporean children and adolescents with attention-deficit/hyperactivity disorder. Child and Adolescent Psychiatry and Mental Health, 15(1), 3–3. https://doi.org/10.1186/s13034-021-00356-8
Tapia, J. D., Sparber, A., Lopez, O., Martin, P., Graziano, P. A., Basu, H., Beaulieu, M. A., & Sibley, M. H. (2024). Racial and gender disparities in community mental health centre diagnoses of adolescent ADHD and comorbidities: A mixed methods investigation. Journal of Child and Family Studies, 33(11), 3472–3485. https://doi.org/10.1007/s10826-024-02857-4
van der Putten, W. J., Mol, A. J. J., Groenman, A. P., Radhoe, T. A., Torenvliet, C., van Rentergem, J. A. A., & Geurts, H. M. (2024). Is camouflaging unique for autism? A comparison of camouflaging between adults with autism and ADHD. Autism Research, 17(4), 812–823. https://doi.org/10.1002/aur.3099
Wells, C., & Falk, R. (2021). The origins and conceptual evolution of overexcitability. Educational Psychology. 62. 23-44. 10.5604/01.3001.0015.3816.