ADHD in Women Is Different and Often Undiagnosed

As a child at church, Faith Skeen said she was the "least favorite person in any given room" because of her inability to sit still and stay silent. It was much the same at school, where she struggled to pay attention or was hyperfixated, unable to redirect her focus. Her mother seemed exasperated; her teacher reprimanded her.

As she got older, Skeen learned to conceal her inner tempest but continued to struggle.

"It was definitely a contributing factor in my dropping out and getting a GED at 15," said Skeen, a resident of Midland, Texas.

At the time, Skeen—who has since graduated college and started her own business—was unaware she had attention-deficit/hyperactivity disorder (ADHD). Though common, the condition is most often diagnosed during childhood in people assigned male at birth (AMAB). People assigned female at birth (AFAB) frequently fly under the radar for years or—as in Skeen's case—decades before receiving a diagnosis and treatment.

Some studies indicate males are up to 16 times more likely to be diagnosed with ADHD than females. According to the Centers for Disease Control and Prevention (CDC), boys are about twice as likely as girls to receive a diagnosis. In adults, the ratio is closer to even.

Some researchers theorize the condition more frequently persists in people AFAB, while dissipating with age for people AMAB. Others suggest the discrepancy is caused by delayed diagnoses for people AFAB.

According to a 2018 study, between 2003 and 2015, the number of privately insured females ages 15 to 44 in the United States who filled a prescription for ADHD medication increased by 344 percent. However, some research suggests up to 75 percent of girls with ADHD may be undiagnosed.

The repercussions of a missed or delayed diagnosis can have profound effects. People with ADHD—similar to other neurodivergent folks—have to live in a world that wasn't designed with them in mind. Everything from household chores to dating can present distinct challenges.

Without understanding the root of their problem, people's struggles with stress, anxiety, depression and self-castigation can arise.

How ADHD affects the sexes

Most people AFAB don't fit the ADHD mold in more ways than one, according to Zoe Martinez, M.D., a psychiatrist in San Francisco and the clinical leader at Done, a digital health company.

She explained children AMAB are more likely to have the hyperactive/impulsive type of ADHD, characterized by conspicuous—and stereotypical—behaviors, such as fidgeting, overactivity, physical aggressiveness and nonstop talking. In adulthood, people AMAB often have combined type ADHD, consisting of hyperactivity/impulsivity and inattentiveness. But for people AFAB, hyperactivity and impulsivity aren't prominent.

"Girls and women are more likely to have the inattentive type of ADHD, which often goes unnoticed because they are more likely to be quietly distracted rather than seeking attention or exhibiting hyperactive or impulsive behavior that at a minimum may irritate others," Martinez explained.

Symptoms of inattentive ADHD include challenges with executive function, forgetfulness, difficulty concentrating, trouble listening, disorganization, anxiety and low self-esteem.

The age of onset may be different based on sex as well. Most people AMAB are diagnosed in elementary school and experience less severe symptoms during and after puberty. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Psychiatric Association's diagnostic tool, states ADHD symptoms appear by age 7. An updated version of the DSM is expected to change that age to 12, but many people AFAB don't exhibit significant symptoms until their late teens.

Experts believe estrogen may play a part, as can the loss of structure and stability that comes with high school graduation.

Societal and cultural biases and expectations reinforce gender discrepancies in ADHD research and diagnosis, according to Martinez. In general, she said, people AFAB are encouraged to internalize their emotions and maintain a composed façade irrespective of any inner turmoil. By contrast, it is more acceptable for people AMAB to be slightly hyperactive, impulsive or aggressive.

Iman Gatti, an author, a speaker and a certified grief recovery specialist in Edmonton, Alberta, agreed. Gatti was initially diagnosed at age 7 but had no knowledge of this until she was rediagnosed at age 39. The reason she wasn't told sooner is unclear, she said, but it seems her guardians in the foster care system thought it was in her best interest. She heartily disagreed.

"I think that patriarchal influence teaches people AMAB to take up space and vocalize frustration, whereas people AFAB are encouraged to be quiet and nurturing and not to be disruptive," Gatti said. "We end up with boys showing their anxiety by releasing it physically through defiance and hyperactivity. They get diagnosed earlier because it's more socially acceptable for them to show their symptoms. Girls and women tend to keep everything inside, and that same frustration and anxiety stay in our heads. Women learn to mask better, which leads to later diagnosis."

How ADHD affects sex and relationships

Priscilla Gregório Hertz, M.Sc.-Psych., a psychologist associated with the department of psychiatry and psychotherapy at the University Medical Center in Mainz, Germany, has extensively studied the effects of ADHD on sexual health and development.

According to her, research doesn't show any correlation between ADHD and delays or disturbances in sexual maturation. However, ADHD and comorbidities can influence the shaping of a person's sexual identity and lifelong sexual health.

"Because of ADHD-specific symptoms/characteristics, such as emotional dysregulation, impulsivity, sensation seeking and executive dysfunctions, it's no surprise that ADHD goes along with peculiarities in sexual functioning and sexual well-being," she explained, adding that hormonal changes during puberty can underline these effects.

The average age at which people had intercourse for the first time was similar for people AFAB with and without ADHD, according to her research. However, those with childhood ADHD engaged in oral sex much earlier and had about twice as many oral sex partners than people without ADHD. Research has shown ADHD is associated with a higher rate of unprotected sex and sex while intoxicated. Additionally, people with ADHD are more likely to be teen parents.

The condition's impact on sexual health can persist into adulthood. According to Ari Tuckman, Psy.D., a psychologist in West Chester, Pennsylvania, who specializes in ADHD treatment, people with ADHD generally have a stronger desire for sex.

Tuckman's findings also indicate women with ADHD are more likely to rate themselves as kinkier and to explore consensual nonmonogamy. Yet, according to Gregório Hertz, research suggests a 39 percent prevalence rate of sexual dysfunction among males with ADHD and a 43 percent prevalence rate among females with ADHD. About 13 percent of sexually active males and 18 percent of females who reported sexual dysfunctions said they caused marked distress.

Gregório Hertz noted that although many people with ADHD report hypersexuality, some experience the opposite, often as a result of co-occurring anxiety or depression or antidepressant medications.

"In a recent study, adult women with ADHD reported significantly more problems in all sexual function domains, such as desire, arousal, orgasm, satisfaction, pain and lubrication," she added. "Women with ADHD usually have difficulties in reaching orgasm. Some women report at times not being able to reach orgasm even with prolonged stimulation, while at other times, they are able to have many orgasms very quickly. For someone with ADHD, sex can be just as challenging as other activities. Concentration problems during sex can occur and lead to distraction and following, and loss of interest in what they are doing."

While ADHD's effects on sexual health apply to both sexes, societal and cultural expectations can intensify the impact on those AFAB, according to Lisa Lawless, Ph.D., a psychotherapist in Bend, Oregon, and CEO of Holistic Wisdom.

Women tend to bear a heavier mental and emotional load than men, she pointed out. They also tend to have to focus more to achieve orgasm. For people with ADHD, these factors, combined with intrusive thoughts and other ADHD symptoms, can significantly interfere with sex and orgasms.

"Gendered conditioning in our society has led to many double standards of what is acceptable. In terms of sexual behavior, it is often quite different for men and women," Lawless said. "Men are often encouraged to be assertive with their sexuality and pursue multiple partners. In contrast, women are typically rewarded for being more reserved with their sexuality, which is often seen in derogatory terms. Thus, it's essential to understand that these biases play a part in gender differences regarding sexuality with or without ADHD."

ADHD can interfere with other aspects of dating and relationships as well. Generally, Gregório Hertz noted, people with significant ADHD symptoms tend to have less stability and quality in their romantic relationships, display more maladaptive coping strategies and report less relationship satisfaction.

However, she emphasized ADHD has its advantages, which can be a boon for individuals and couples alike. These include personal features such as cognitive dynamism, energy, divergent thinking, nonconformism, hyperfocus, adventurousness, self-acceptance and sublimation.

"There are several positives and strengths related to ADHD," Gregório Hertz explained. "People with ADHD are generally more open to trying new things. We could say people with ADHD are more creative and experimental regarding sex, so they are more open to trying new sex positions, extraordinary locations, and new and unusual techniques; anything that might help keep things exciting in bed and avoid boredom in the relationship. Moreover, divergent thinking marked in ADHD can be a superpower when deconstructing outdated societal beliefs, such as the typical roles women are still assigned regarding sexual behaviors and expectations."

The effects of a missed diagnosis

ADHD can substantially impact multiple facets of life, and a missed diagnosis and subsequent lack of treatment can have significant effects that may last a lifetime. For example, Martinez noted that untreated ADHD can hinder school learning, work performance and interpersonal relationships. The lack of a diagnosis can exacerbate stress, anxiety and self-esteem issues because symptoms can be misconstrued as laziness, lack of motivation or other personal shortcomings.

"I think it contributed to my low self-esteem," Gatti said. "Life felt especially hard for me. The trauma and abuse I endured were already quite taxing, and my undiagnosed neurodivergence just made things that much more difficult. Looking back, I think it made me not want to try because I was always so embarrassed, and I could see that people were bothered by me taking so long, so I just got quiet and faked my way through things."

Research shows a correlation between ADHD and other psychiatric conditions as well. One study of 40,000 adults indicated women with ADHD were more likely to have depression, bipolar disorder or personality disorder compared with the average population. Indeed, many women who are diagnosed with ADHD later in life have experienced mental health challenges for years. A study published in the Journal of Consulting and Clinical Psychology indicated girls with ADHD were more likely to exhibit self-harm or suicidal behaviors during adolescence.

Substance use disorder is also more prevalent among people with ADHD. The reason is uncertain, but such conditions can compound ADHD symptoms, creating a circumstance that may feel insurmountable. Lawless noted binge eating disorder (BED), which predominantly affects females, is widespread among the ADHD community as well. She said this is partly because of the pressure on women to conform to societal expectations, and because eating food can provide a dopamine rush and a sense of stimulation, comfort and pleasure.

"When people with ADHD cannot regulate themselves emotionally, they often seek something to soothe them," she explained. "Because it is more socially acceptable to eat than for women to participate in risky behaviors, such as unprotected sex with strangers or substance use, food can be a more socially acceptable option to cope with emotional dysregulation. Eating can become a food addiction because it can become more about providing emotional comfort by releasing pleasurable dopamine in the brain. Food can also become a self-stimulation 'stim' exercise because it is a controllable, pleasurable stimulus that can quickly become more about the food's taste, texture and smell rather than satiating hunger. This may lead to eating in binge episodes far beyond physiological hunger."

Why seek a diagnosis now?

Silvia Sarmiento, a trauma program nurse consultant in Ontario, California, and patient at Done who was diagnosed at 33, said a diagnosis—however late—can be "life-changing." Commonly, she said, women with ADHD are deemed forgetful and disorganized or the opposite: rigid and particular.

An official diagnosis doesn't obligate a person to try medication or any specific treatment, she said, but it can provide a better understanding of a person's well-being and sense of self. It also provides the foundational knowledge needed to make lifestyle adjustments or request support that could be helpful.

"You might have a reason as to why sometimes things feel like they are constantly overwhelming," Sarmiento explained.

Gatti agreed, noting she never recognized her symptoms as ADHD until a friend disclosed her diagnosis, prompting Gatti to research the disorder and seek an assessment. Since receiving her own diagnosis, Gatti said she often wonders how her life would have been different had she known earlier.

"I think the more you know yourself, the better chance you have at making powerful choices in your life," she said. "I would have probably had more compassion for myself and I would like to think I would have been kinder to myself. Life would have been so much easier with support, compassion and the right tools to guide me."

Gatti, Skeen, Sarmiento and Martinez each recommended that anyone who thinks they may have ADHD seek professional care as soon as possible—and to get a second or third opinion if an initial visit isn't fruitful. If that doesn't seem feasible at the current time, Gatti suggested researching and taking online tests, as even a self-diagnosis can be empowering.

"I may have missed out on a lot by being diagnosed later, but it's never too late to prioritize your health and meet your own needs," Gatti said.