Shy, Anxious, or Autistic? Rethinking Quietness, OCD, and Women’s Hormonal Masking Across the Lifespan
For generations, the word shy has acted as a soft explanation.
A quiet little girl who prefers reading to playground chaos? Shy.
A teenager who avoids sleepovers? Shy.
A woman who finds networking events draining? Shy.
It sounds benign. Even affectionate.
But as awareness of autism has increased — particularly in women — many are re-examining those early descriptions. Some are asking:
Was it really shyness?
Or was it autism that went unnoticed?
And when childhood shyness later evolves into anxiety or OCD, the question deepens:
How will we ever know the difference?
Layer onto this the complex role of female hormones — particularly oestrogen and progesterone — and the picture becomes even more nuanced. Many women appear socially competent for years, sometimes decades, only to find that during puberty or perimenopause, their coping strategies unravel.
This blog explores that complexity: the overlap between shyness, anxiety, OCD, and autism — and the often under-discussed influence of women’s hormonal changes across the lifespan.
The Historical Gender Gap in Autism Recognition
For decades, autism was primarily identified in boys. Early research samples were overwhelmingly male, shaping diagnostic criteria around male-presenting traits.
Simon Baron-Cohen (2002) proposed the “extreme male brain” theory of autism, which influenced how clinicians conceptualised autistic traits for years.¹ This framing inadvertently contributed to the under-recognition of female presentations.
The publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition broadened autism into a spectrum condition, recognising greater heterogeneity in presentation. However, even with this change, many women remained undiagnosed.
Lai et al. (2015) noted that autistic females often show “less overt restricted and repetitive behaviours and greater social motivation,” which may contribute to delayed diagnosis.²
Girls frequently:
Observe before participating
Imitate peers to blend in
Develop intense but socially acceptable interests
Internalise distress rather than externalise it
From the outside, this can look like shyness.
Internally, it may involve intense cognitive effort.
Shyness vs Autism: Surface Similarity, Different Roots
Jerome Kagan’s work on behavioural inhibition describes shyness as a temperamental trait linked to heightened sensitivity to novelty and potential threat (Kagan, 1989).³
A shy child:
Understands social rules
Feels anxious about evaluation
Warms up gradually
Autism, however, involves neurodevelopmental differences in social cognition and communication. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, core features include:
Persistent differences in social communication
Restricted or repetitive patterns of behaviour
Symptoms present from early development
An autistic child may not intuitively grasp unwritten social rules and may need to consciously learn them.
Two children may both sit quietly.
Only one is anxious about being judged.
The other may be processing the social world differently.
When Anxiety and OCD Develop Later
Anxiety disorders commonly emerge in adolescence. The World Health Organization reports that anxiety disorders are among the most prevalent mental health conditions globally.⁴
OCD often appears in adolescence or early adulthood. It is characterised by:
Intrusive, unwanted thoughts
Compulsions aimed at neutralising anxiety
Significant distress
Stein et al. (2019) describe OCD as involving “recurrent and persistent thoughts, urges or images that are experienced as intrusive and unwanted.”⁵
OCD is anxiety-driven. Autism is neurodevelopmental.
However, co-occurrence is common. van Steensel et al. (2011) found anxiety disorders occur at significantly higher rates in autistic youth compared to neurotypical peers.⁶
The presence of anxiety or OCD does not confirm autism — nor does it exclude it.
The Hormonal Dimension: A Critical Missing Piece
Women’s brains are profoundly influenced by hormonal cycles across:
Puberty
Menstrual cycles
Pregnancy
Perimenopause
Oestrogen plays a central role in:
Serotonin regulation
Dopamine pathways
Emotional processing
Verbal fluency
McCarthy & Arnold (2011) note that sex hormones shape brain development and behaviour in complex ways throughout life.⁷
Higher oestrogen levels are associated with:
Improved verbal communication
Enhanced emotional recognition
Greater social attunement
This may help explain why some autistic girls appear more socially competent than boys.
Hull et al. (2017) describe “social camouflaging” as the process of masking autistic traits to fit in socially.⁸ They found this behaviour is more common in autistic females.
Hormones may enhance the cognitive flexibility required to mask.
In simple terms:
Oestrogen can help buffer social differences — until it fluctuates.
Puberty: The First Major Shift
Puberty introduces hormonal volatility and increased social complexity.
Rutter et al. (2003) highlight adolescence as a critical developmental window for the emergence of internalising disorders.⁹
For some girls:
Anxiety spikes
OCD emerges
Sensory sensitivity intensifies
Social exhaustion increases
This does not automatically indicate autism. But puberty can expose vulnerabilities that were previously manageable.
Masking and Burnout
Masking involves:
Rehearsing conversations
Suppressing stimming
Copying peers
Forcing eye contact
Hull et al. (2017) found camouflaging is associated with increased mental health difficulties.⁸
Sustained masking may contribute to:
Burnout
Depression
Anxiety
Identity confusion
Many late-diagnosed women describe decades of appearing “fine” while feeling chronically exhausted.
Perimenopause: The Unmasking Phase
Perimenopause involves fluctuating oestrogen and progesterone levels.
Freeman et al. (2014) found increased risk of mood disorders during perimenopause, linked to hormonal instability.¹⁰
Oestrogen influences serotonin systems — central to mood and OCD regulation.
As oestrogen declines:
Mood regulation may destabilise
Anxiety may increase
Sensory tolerance may reduce
Cognitive flexibility may decrease
Some women report:
Sudden social intolerance
Heightened overwhelm
Intensified OCD symptoms
Emotional volatility
For some, this leads to a late autism assessment. Not because autism appeared at 45 or 50 — but because hormonal buffering diminished.
Anxiety vs Autism in Women
Clinicians often differentiate by asking:
Were there lifelong sensory sensitivities?
Was imaginative play typical?
Did social exhaustion exist even in positive interactions?
Are routines grounding or driven by fear?
If anxiety treatment reduces fear and restores ease, anxiety may be primary.
If anxiety reduces but social processing differences remain, neurodevelopmental differences may be present.
The Risk of Over-Correction
Increased awareness is valuable — but over-pathologising normal temperament is a risk.
Introversion is not pathology.
Sensitivity is not pathology.
Shyness is not pathology.
As Kagan (1989) reminds us, behavioural inhibition is a normal variation in temperament.³
The question is not whether someone is quiet.
The question is whether there is:
Persistent impairment
Significant distress
Lifelong developmental patterns
So How Will We Ever Know the Difference?
We look for patterns across time.
We assess developmental history.
We explore internal experience.
We evaluate response to treatment.
We consider hormonal transitions.
Diagnosis is pattern-based, not trend-based.
A Compassionate Conclusion
We are shifting from labelling behaviour
to understanding internal experience.
Shyness is descriptive.
Anxiety is emotional.
OCD is compulsive and intrusive.
Autism is neurodevelopmental.
Hormones modulate them all.
Human beings — especially women — cannot be understood without considering biology, development, and environment together.
Instead of asking,
“Is this autism or just shyness?”
We might ask:
What is happening in this nervous system?
What role are hormones playing?
What has this person done to cope?
What support reduces suffering?
When curiosity replaces assumption, clarity follows.
References
Baron-Cohen, S. (2002). The extreme male brain theory of autism. Trends in Cognitive Sciences.
Lai, M.-C., et al. (2015). Sex/gender differences and autism. Journal of the American Academy of Child & Adolescent Psychiatry.
Kagan, J. (1989). Temperamental contributions to social behavior.
World Health Organization (2022). Anxiety disorders fact sheet.
Stein, D. J., et al. (2019). Obsessive-compulsive disorder. The Lancet.
van Steensel, F. J. A., et al. (2011). Anxiety disorders in children with autism spectrum disorders. Clinical Child and Family Psychology Review.
McCarthy, M. M., & Arnold, A. P. (2011). Reframing sexual differentiation of the brain. Nature Neuroscience.
Hull, L., et al. (2017). Social camouflaging in autism. Journal of Autism and Developmental Disorders.
Rutter, M., et al. (2003). Developmental psychopathology and adolescence.
Freeman, E. W., et al. (2014). Risk for major depressive disorder during perimenopause. Archives of General Psychiatry.