Underdiagnosed and Overstressed

By: Yamini Srikanth

Where the absolute fuck were the car keys? 

I had turned the house upside down, gone through every room and corner. The traffic would be getting worse by the minute, and I had already forked over a considerable sum for a doctor who was only available once in three months. Panicking, I remembered some advice from a previous therapist, who said ice cold water could reboot the nervous system.

I ran into the kitchen and there, on the second shelf of the fridge, lit up like a treasure chest in a video game: my keys! 

After the appointment, I sat in the car holding my prescription. Knuckles white. Heartbeat in my ears. Scrawled across the top in loopy, illegible doctor’s handwriting: “Provisional Diagnosis: ADHD + Anxiety”. 

For seven years, that second diagnosis ruled my life. Anxiety. It’s “just” anxiety. The school counselor, my parents, and two therapists, had all  decided it was anxiety. My symptoms eventually abated, but not because of anything my mental health support did for me. I graduated from school. I found something I love doing so deeply that it never bores me.

It took seven years for someone to dig a little further, and diagnose me with ADHD as well as anxiety. While the symptoms of anxiety were very apparent, the root causes were my struggles with academic work and managing my life which stemmed from ADHD. I was prescribed antidepressants and anti-anxiety medications. CBT helped fix thought patterns that stemmed from feelings of worthlessness, but not the academic missteps that led to these feelings. By treating the symptoms and not their cause, most of the suggested avenues ended up failing. 

Why did it take so long for trained mental health practitioners to get me the help I needed? 

Gender plays a huge role in the diagnosis and support of neurodevelopmental disorders such as autism and ADHD. People who are assigned male at birth (AMAB) are socialized differently than those who are assigned female at birth (AFAB). Here, I’d like to highlight that sex refers to that which is assigned at birth, while gender is a much broader social idea. During formative childhood and teenage years, most individuals are socialized in a manner that is congruent with what is assigned at birth, regardless of what their true gender identity is. A trans man might experience similar issues with diagnosis and treatment as a cis woman due to this socialization process. 

Current research suggests that the prevalence of ADHD in young AMAB individuals is 2–2.5 times higher than its prevalence in young AFAB individuals. The easy assumption made from this data is that people who are AMAB are more likely to have ADHD than   people who are AFAB. This obscures the layers of gendered bias inherent in the diagnosis and treatment of ADHD. 

Calvin from Calvin and Hobbes: the poster child for ADHD, with all its associated stereotypes.

Image via Flickr

Mental health research has suffered from non-representative samples. Studies on depression and eating disorders almost always overrepresent AFAB individuals, with people who are AMAB making up less than 50% of the study. In contrast, research into ADHD has been dominated by AMAB samples, with people who are AFAB making up a vanishingly small proportion. This means we have a poorer understanding of all the possibilities of what ADHD looks like, and our diagnostic criteria are probably far more limiting than they should be. 

Additionally, symptoms present differently between people who are AFAB versus AMAB. Impulsivity for AMAB people might mean an inability to sit still, but for AFAB people it might mean excessive talking. AFAB people also show an inattentive subtype far more frequently than the hyperactive subtype. 

The same emotion on a man versus a woman can be interpreted very differently depending on the biases of the viewer.

Image by Katrien de Blauwer via WikiArt

People socialized as women are also taught to suppress “undesirable” behavior to a greater degree. The bounds for what is acceptable is so much narrower for girls. Unspoken norms repress hyperactivity, forcing people socialized as women to internalize their symptoms. As someone who was socialized as a girl,  I’ve often sat quietly in classes, but my head has been in another world entirely. This process, termed masking, can often remove any trace of symptoms from childhood onwards. Since ADHD is characterized as a “neurodevelopmental disorder”, a diagnostic criteria is that symptoms need to be present from childhood. If societal expectations cause these symptoms to vanish, then it seems like that person doesn’t have ADHD. 

It’s a vicious cycle - because AFAB individuals are underrepresented in studies, we have a poorer understanding of the whole range of symptoms that ADHD presents as. Then, since their symptoms might differ from cis-men, they’re underdiagnosed.  AFAB individuals are also socialized to suppress their symptoms. The perception that fewer people AFAB have ADHD than people AMAB then leads researchers to believe they don’t need a representative sample at all. 

ADHD is a disorder that affects every aspect of life. It leads to difficulty in professional lives. Our tendency to lose things or miss appointments means additional financial strain, leading to a phenomenon some people have termed as “ADHD tax”. We struggle to maintain interpersonal relationships because our forgetfulness is perceived as a lack of care. If ADHD goes undiagnosed and we don’t get support for all of these challenges, it’s not surprising that we develop anxiety and depression. One study found that rates of antisocial, mood, anxiety, developmental, addictive, and eating disorders were higher in people AFAB who hadn’t been diagnosed in childhood than those who were. 

A missing diagnosis of ADHD can lead to profound feelings of isolation and loneliness.

Painting by Edward Hopper via WikiArt

Then comes the real kicker. Anxiety and depression is better studied in AFAB individuals. Mental health professionals are taught exactly how anxiety and depression present in AFAB individuals, and subconsciously perceive it to be more common. If an AFAB person does overcome other barriers and seek mental health support, the knee-jerk reaction is a diagnosis of anxiety or depression. Young AFAB individuals who come to clinics for emotional problems are treated with non-ADHD medication far more frequently than young AMAB individuals, where an ADHD diagnosis is assumed. Once that diagnosis is received, nobody thinks to question it until something goes seriously wrong. All avenues for depression and anxiety have to be attempted before a practitioner wonders if maybe the problem isn’t really anxiety or depression at all. 

Depression and anxiety are diagnosed far more in women than men

Image by Cindy Sherman via WikiArt

When I sat there holding that paper, thinking for the very first time in my life that I might have ADHD, I felt a sense of profound grief. I grieved for the little girl who taught herself that she played tag for too long. I grieved for the little girl whose aunt told her she was a blabbermouth who just couldn’t shut up. I grieved for the college student who thought something was wrong because she just couldn’t get it right like everyone else seemed to, effortlessly. 

So how do we begin to fix this wicked problem?

Institutions need to do better in representing all genders in their research. Diagnosticians need to be educated on “subtler” forms of ADHD. All mental health practitioners need to reflect, examine their biases, and understand the consequences of their biases. 

If any of this sounds familiar to you, I urge you to read more about underdiagnosis of ADHD in AFAB individuals and proposed diagnostic criteria for us. Unfortunately, biases against AFAB people persist in medicine, and we’re forced to be advocates for ourselves in a way that people AMAB just aren’t. If your healthcare provider isn’t listening to your concerns, challenge them. If they refuse to budge, find someone else. It’s expensive and it sucks, but there isn’t much of a way around it.

Between 2008 and 2014, the number of adult AFAB individuals diagnosed by ADHD has increased by 85%. The recognition of underdiagnosis is reflected in the number of research publications calling out this issue. Things are getting better, and advocacy and research ensures it continues to do so. 

Yamini is an ecologist whose other interests include science communication, writing and trying to build a better world. When not languishing in front of a laptop, she can be found outside poking at any insect, bird or plant.


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