Female autism: Grunya Sukhareva’s pioneering description reinterpreted in light of DSM-5-TR and the concept of camouflaging

The article explores the significant contributions of Grunya Sukhareva, a Russian child psychiatrist born in 1891, who provided an early description of autism in a well-regarded 1925 article, predating the more famous works by Kanner and Asperger. Although her work initially went unnoticed, it gained recognition through translations in 1966 and 2020. A scrutiny of the recently translated second part of Sukhareva’s article, which focuses on autism in females, reveals a notable alignment between her observations and the portrayal of the female autism spectrum in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). Additionally, we posit that certain characteristics described by Sukhareva may be understood in terms of the camouflaging strategies commonly exhibited by females with autism spectrum.

Article

Grunya Sukhareva was a renowned Russian child and adolescent psychiatrist, born in Kiev in 1891. She authored numerous articles, six monographs, and a three-volume work on child psychiatry, still studied in Russian universities today. Her writings are characterized by simplicity, clarity, coherence, and a systematic presentation of material ¹. Her clinical and research activities covered a wide range of mental disorders, but it was a particular article published in Russian in 1925 and partially translated into German in 1926 that brought Sukhareva to fame ². This article contains the first academic description of autism in young male and female patients, predating the more well-known descriptions by Kanner and Asperger by two decades ². As discussed in recent articles, Sukhareva’s contribution remained relatively overlooked outside of Russia for a long time ^1,2.

It was only in 1966 that the psychiatrist and neurologist Sula Wolff translated Sukhareva’s article “Die schizoiden Psychopathien im Kindesalter” into English, which appeared in European Child & Adolescent Psychiatry under the title “The first account of the syndrome Asperger described?” ³. However, Wolff’s translation exclusively covered the first part of Sukhareva’s original article, focusing on the description of cases of male children. The second part of the article, which contained clinical cases of female children with “schizoid psychopathy,” was only translated four years ago by C. Simmonds in 2020 ⁴. This highlighted to the international literature that Sukhareva’s work not only provided a clinical description of what we now recognize as autism before Kanner and Asperger, but also delved into the existence of gender differences in its clinical presentation. Simmonds’ translation aimed to provide an accurate English rendition of Sukhareva’s 1926 article on autism. This allowed professionals and those interested in the subject to access and benefit from Sukhareva’s insights ⁴. Through this translation, we were able to meticulously examine Sukhareva’s descriptions of five cases involving girls diagnosed with “schizoid psychopathy.” Our goal was to extract information that could contribute to and enhance the contemporary understanding of the female autism spectrum. The Diagnostic and Statistical Manual of Mental Disorders (DSM) officially addressed the female autism spectrum only in its latest revised version (DSM-5-TR) in 2022 ⁵, a topic that the authors of this article have long emphasized ^6-9. Recent literature has highlighted how the diagnostic criteria for autism spectrum disorder (ASD) may have been developed based on the typical male presentation of autism, overlooking a range of specific female characteristics ¹⁰. Below is a quote from the DSM-5-TR summarizing the characteristics attributed by scientific literature to the female phenotype of the autism spectrum: “girls without intellectual impairments or language delays may go unrecognized, perhaps because of subtler manifestation of social and communication difficulties. In comparison with males with ASD, female may have better reciprocal conversation, and be more likely to share interests, to integrate verbal and non verbal behavior, and to modify their behavior by situation, despite having similar social understanding difficulties as males. Attempting to hide or mask autistic behavior (e.g., by coping the dress, voice and manner of socially successful women) may also result in an under-diagnosis of ASD in some females. Repetitive behaviors may be somewhat less evident in females then in males, on average, and special interests may have a more social (e.s. a singer, an actor) or “normative” focus (e.g. horses), while remaining unusual in their intensity” ⁵. In summary, females within the autism spectrum are believed to exhibit better social skills, particularly through the use of a compensation mechanism based on imitation. This phenomenon is referred to as “social camouflaging,” a concept continually evolving and currently associated with the use of specific cognitive and behavioral strategies that individuals with autism employ to adapt to a predominantly neurotypical social world ^11-13. The conscious or unconscious imitation of behaviors and attitudes of those considered socially successful allows individuals to adopt a “non-autistic” lifestyle and/or mask the evidence of their social difficulties ¹¹. Gender-specific studies have found that individuals assigned female at birth, self-identifying as female, or non-binary individuals employ more frequent and pervasive social camouflaging strategies, extending across various life situations, compared to those employed by males ^14-16. These findings, corroborated by studies in adolescent and pediatric populations, could partially explain the traditionally observed higher prevalence of ASD in males ^17,18. The daily use of coping strategies comes at a cost in the life of an individual with ASD. Firstly, it represents a constant effort, a daily expenditure of mental resources in every social situation encountered. Nothing is relaxing; everything must be managed, controlled, and monitored in the smallest details to prevent the mask from slipping during a moment of distraction ¹⁹. Additionally, there is significant suffering arising from the dissonance between the perceived self, deemed unacceptable by others and thus concealed, and the presented self, experienced as inauthentic and alien ¹⁹. It is not surprising, therefore, that individuals employing such strategies exhibit higher levels of depression, suicidality, social phobia, generalized anxiety, and overall psychological distress ^20,21. We have delved into the description of camouflaging extensively because we believe that some features of the female autism spectrum, as outlined by Sukhareva, can be interpreted in light of this coping mechanism. According to the author, the main female characteristics of schizoid psychopathy, considered an equivalent to the contemporary autism spectrum, include greater emotional ambivalence, mood instability, and negativism, along with less pronounced motor deficits ⁴. Regarding emotional ambivalence and mood fluctuations, Sukhareva reports that, compared to males, females tend to alternate conflicting emotions, rapidly shifting between phases of mood stability with context-appropriate behaviors and moments of emotional dysregulation: “a picture of isolated sensitive spots against a backdrop of general emotional flatness” ⁴. Interestingly, as we can infer from the cases presented, this alternation tends to diminish with the subject’s growth, with girls becoming “gentler and calmer” over time ⁴. We could hypothesize that the observed emotional ambivalence in these girls reflects the gradual learning of camouflaging strategies. When implemented, these strategies might correspond to phases of increased behavioral composure and apparent mood stability. Over time, the girls described in the article may have become more proficient in employing these strategies, creating the impression of improved mood and emotional regulation.

It’s also interesting to note how the emotional dysregulation, mood swings, and negativism described by Sukhareva in girls with the autistic spectrum tend to resemble manifestations of borderline personality disorder. This is one of the diagnoses frequently given to patients with ASD or sub-threshold autistic traits, especially in the presence of a history of psychological trauma ²². Notably, such trauma is not uncommon in the family histories of the girls described by Sukhareva ⁴. In addition, the conclusions drawn by Sukhareva in 1926 align closely with those reached by the DSM-5 in 2022 and contemporary literature. Sukhareva’s description of better expressive movement abilities ⁴ could be assimilated into the DSM-5-TR’s mention of the integration of verbal and non-verbal behavior ⁵. Similarly, Sukhareva’s findings of lower tendencies toward abstraction, schematic thinking, and greater concreteness ⁴ are consistent with the DSM’s statements about the less obvious and more socially appropriate nature of female restricted interests compared to their male counterparts ⁵. The DSM’s remarks on the lesser “oddness” and greater social skills in females within the autistic spectrum could also be influenced by Sukhareva’s observations of less motor clumsiness and greater manual, physical, artistic, and linguistic abilities in her female patients compared to males ⁴. In conclusion, many of the findings put forward a century ago by Grunya Sukhareva regarding female “schizoid psychopathy” align with the contemporary description of the female autism spectrum phenotype and can be reinterpreted in the context of the modern concept of camouflaging. New insights could be derived from the analysis of the pioneering work of this author, who is still relatively unknown in international scientific literature.

Conflict of interest statement

The authors declare no conflict of interest.

Funding

This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.

Authors’ contributions

L.D.O.: conceptualization; G.A.: writing—original draft preparation; L.D.O., D.T., B.C.: writing—review and editing; L.D.O. and B.C supervision.