Why Middle-Aged Women Are Re-writing the Story of Neurodivergence

When Jenara Nerenberg writes that “the world will benefit significantly from talents such as empathy, sensitivity, and depth of thought” she is not indulging in sentimentality; she is issuing a corrective to a diagnostic tradition that largely forgot women existed.

For more than thirty years, autism and ADHD were framed by data drawn almost exclusively from white, elementary-aged boys. The ratio of diagnosed boys to girls hovered around 4:1; in studies that excluded intellectual disability it climbed to 10:1.   Today, large epidemiological datasets show that the chasm is closing—North Carolina’s adult registry dropped from 5.6:1 in 2000 to 3.1:1 in 2021, yet thousands of women are still arriving at mid-life carrying decades of misdiagnosis, burnout, and addiction.

Biology in a Register of Its Own

The reason so many slipped through is physiological as much as social. In women, the hypothalamic-pituitary-adrenal (HPA) axis, which choreographs our stress response, grows up alongside a second, equally dynamic conductor: the reproductive cycle. When early-life stressors—maternal inflammation, hypoxia at birth, environmental toxins tune the HPA axis to a higher (or flatter) pitch, every estradiol peak and progesterone dip is amplified. A 2022 meta-analysis of cortisol in autism found consistently elevated peripheral cortisol in autistic cohorts, a biochemical marker that scrambles mood, sleep, and immune regulation.

Layer those rhythms onto the estrogen roller-coaster of perimenopause and you create what Harvard psychiatrist Jill Goldstein once called “a perfect storm” for misread psychiatric symptoms: the afternoon cortisol spike masquerades as panic disorder; mid-luteal dopamine flat-lines are stamped major depressive episode.  New qualitative work from Sweden captures how many women with ADHD experience a monthly “double whammy” ADHD core traits plus estrogen withdrawal and why stimulants feel miraculous one week, inert the next.

The Clinician’s Blind Spot

Because standard diagnostic tools were normed on male presentations—externalizing behaviors, overt social awkwardness women learned to contort. Social psychologists call the performance camouflage; autistic writer-scholar Devon Price calls it “a defensive reaction against societal rejection.” That relentless masking extracts a physiologic tariff: neuroendocrine depletion. By forty, many women arrive in clinicians’ offices exhausted, angry, sometimes chemically dependent, wielding a stack of irrelevant psychiatric labels. A 2024 Frontiers study found that over 60 percent of autistic adults believed they had been given at least one erroneous psychiatric diagnosis before clinicians considered autism; women led that statistic.

Addiction often flowers in this clinical vacuum. Sex-hormone research shows estradiol accelerates dopaminergic reward learning; drop estrogen and the brain goes hunting for substitutes; nicotine, sugar, slot-machine scrolls. A 2023 narrative review in Pharmacology traced how fluctuating hormones modulate every phase of the addiction cycle, rendering women more vulnerable at key points in their cycle and during perimenopause.

The Body Keeps the (Mis)Score

These chemical negotiations do not stop at mood. Collagen formation, mast-cell signaling, and gut permeability answer to cortisol and estrogen. It is no coincidence that hypermobility syndromes and Mast Cell Activation Syndrome (MCAS) appear in autistic women at rates up to eight times the general population. Chronic rashes, tachycardia, “allergic” panic attacks symptoms physicians wave off as anxiety, are often neuroimmune distress calls.

The Turning Tide

The literature is finally catching up. In 2023 researchers showed that the proportion of females receiving an autism diagnosis has risen steadily for twenty years, reflecting better recognition of the “female phenotype.” EEG work from the University of Texas has begun mapping sex-specific neural signatures different 1/f power-law exponents in autistic women, which may explain subtler social-language profiles and guide future diagnostics. arxiv.org

Sarah Hendrickx, whose seminal handbook “Women and Girls with Autism Spectrum Disorder” became a lifeline for late-identified women, puts it plainly: “Girls and women with autism: you’re fine exactly as you are… Yes, you’re a bit weird, but that’s perfectly all right.”

Required Reading: Divergent Mind

If there is a single book I press into every client’s hands, it is Jenara Nerenberg’s “Divergent Mind: Thriving in a World That Wasn’t Designed for You.” Nerenberg weaves neuroscience, evolutionary biology, and memoir into a manifesto for sensitive minds. She argues that neurodivergent women are “the canaries in the coal mine of modern life,” sounding the alarm on sensory overload, misogynistic office hierarchies, and a health-care system that still treats female pain as anomalous data. The chapters on hormonal nuance and interoception read like secret diaries for anyone who has ever wondered why migraine, IBS, or insomnia flares arrive on a perfectly predictable lunar schedule. By the time you reach her galvanizing conclusion, that societal design flaws, not broken brains, are the problem you feel less like a patient and more like a pioneer. You can find the paperback (and audiobook read by the author) here on Amazon.

The science is sobering but not bleak. Interventions that respect hormone physiology—cyclical stimulant titration, cortisol mapping, progesterone-supported sleep protocols—are already transforming care in specialty clinics from Melbourne to Minneapolis. The larger revolution, though, is cultural. As Nerenberg reminds us, “the problem is not in our minds; it’s in society’s expectations.”  Listening to women’s bodies in all their rhythmic, fluctuating intelligence may be the most advanced medical technology we currently possess.

Author’s note: I recommend Nerenberg’s book to every woman I work with, not as a cure-all but as a mirror. If you suspect your lifelong anxiety, your mercurial energy, or your intimate truce with caffeine might have a neurological accent, know that you are not “too late” to understand yourself. You are right on time.