From disbelief in the existence of adult ADHD, underdiagnosis or misdiagnosis due to differing symptoms, to exhaustion, burnout, anxiety and shame, E&M Author Nisa Sherifi explores the particular hurdles faced by women with ADHD.
Depending on your social media algorithm, you might have come across memes and reels on what it feels like to have ADHD as an adult. While they are fun, and often depict quite well how this form of neuro”divergency” feels, the algorithm, I’d argue, is also quite good at suggesting life changing content to some relevant audiences. For instance, the algorithm can be quite good at orienting one towards content depicting what it might feel like to have undiagnosed ADHD as an adult woman.
While of course everyone needs to be very careful before going on a self-diagnosis tangent based on a few TikTok videos, why this speaks to so many people, especially women, actually speaks of a much more pervasive reality: women are often underdiagnosed when it comes to ADHD, even ending up misdiagnosed with other disorders, because of gender biases relating to ADHD among psychiatrists and other mental health professionals.
For those who have critically engaged with the history of psychiatry and its approaches, this probably comes as no shock, but since this is not a hobby for most, this article will try to look at the very tip of the iceberg when it comes to this issue.
A “boy’s” disorder, and a myriad of symptoms
When someone mentions ADHD, one of the first images many people have is that of a boy who cannot sit still, constantly disturbs his peers at school, and struggles academically. So, this already makes a few assumptions that completely exclude how ADHD might present in many others, like many women for instance.
For one, for many women hyperactivity is not their most noticeable symptom, while others have a more internal hyperactivity, especially since we are made aware of our physical behaviour far earlier, and are told that politeness and calmness are “womanly virtues”. Cutting others off and speaking a lot are also against what is often perceived as “acting womanly/féminine”, so many girls and women learn to mask such symptoms quite well, which comes at the price of exhaustion, burnout and heightened levels of anxiety and shame (according to conversations had with many women diagnosed with ADHD especially in adulthood, as well as a few psychiatrists and psychotherapists).
Then comes the idea that a child with ADHD will necessarily see their academic results and outcomes suffer. Except that, for many kids who are considered by others to be “bright”, or are very ambitious and motivated to succeed, their academic struggle, again, might be an internal one. While I cannot generalise for everyone, women in many countries, like France, perform better in school, especially in primary and high school.
From what I (in no way an expert or someone with credentials, but simply a person with experience and a particular hyperfixation on the topic), have been able to gather, when people with ADHD have to do a task, they need to motivate themselves differently from neurotypical people. When the task at hand is not one that sparks particular interest, or in other terms, makes our brain produce dopamine (the key “biological” element in ADHD), there needs to be another source of motivation. Simply “doing the task” is often not an option, as we enter a state of “ADHD paralysis”.
So, when the task is not exciting, new, or creative, it gets done by tapping into other thoughts and emotions that might push us to do it. Often, this motivation is negative. Namely, emotions such as shame, guilt, and anxiety take the lead and force us to start and finish the task.
“Why can’t I just sit and do this simple paperwork, like everyone else on the planet, why am I so lazy and ungrateful, what about all the sacrifices that have been made for me to fail this simple task” are thoughts familiar to many of us. And sure, the task gets done, but the central question is: at what cost? The cost, I find, is the further corrosion of an already fragile or non-existent self-esteem, cyclical burn out, and chronic stress and anxiety.
Add to that the fact women are expected to be caretakers, emotional supporters, the overall managerial backbone of families, and that their self-esteem is destroyed much more as they are undervalued, underappreciated, overworked, and made to feel like absolute trash about their appearance, and you have yourself a strong cocktail for feeling overwhelmed,exhausted, and just terrible.
Which brings me to another prominent symptom of ADHD that seems to be underemphasized: emotional dysregulation. People with ADHD struggle to regulate their emotions, often feeling them a lot more intensely, and having “disproportionate” reactions to what others consider “minor inconveniences”. In children, the prevalence of this dysregulation is 25-40%, while in adults it reaches up to 70%. The triggers of emotional dysregulation can be external or internal, meaning they can be caused by outside events, or thoughts inside our heads.
Rejection sensitive dysphoria, or extreme emotional sensitivity and reaction to being perceived as rejected or criticised by loved ones is also strongly linked to ADHD, and mimics mood disorders for those not familiar enough with this aspect of emotional dysregulation in ADHD. To people with ADHD, rejection feels like “a physical wound”, a “stab, or punch to the chest”.
And how does this aspect affect women in particular? Being a woman in our world, or at least in most of it, is an emotional minefield in itself. Constant criticism and policing of looks, behaviour, eating habits, sexuality, career choices, family and reproductive choices – is a daily occurrence, and it already really really sucks. Now add to that the fact that many ADHD symptoms, as explained earlier, are the very opposite of how most societies expect women to be like and behave, and you have yourself a group of women considered “too messy”, “too loud”, “too intense”, and “too disorganised” to be “good women”. (Also, there is a link between ADHD and higher risks of developing binge eating disorder and bulimia nervosa, so we can add “too greedy/too fat/too thin/too impulsive with food” to the list).
So, women with ADHD, other than gaslit to think that they don’t have ADHD in many cases, are waking up daily to repeated criticism from loved ones, acquaintances and society at large, while also experiencing rejection from the “proper/good women” club and told they are being “too dramatic” for the pain they experience and their reactions to it. Therefore, many of them mask, bottle up, spiral, explode, and struggle to just find peace.
The hurdles of getting diagnosed
So, after we’ve– minimally– looked at how some of the assumptions about ADHD are based on clear gender stereotypes and biases, and how they affect girls and especially adult women, then comes the journey of diagnosis.
Because so many adults miss the signs during childhood, many people realise in adulthood that they might have the disorder, and seek a diagnosis then. That is, if they are lucky enough to be in a context where such a realisation is possible. However, almost as if some higher power is shooting episodes for a ridiculous prank show, the journey to diagnosis is an absolute ADHD nightmare.
A key other symptom that we need to talk about, not mentioned above, which plays a major role in this celestial bad dream, is executive dysfunction. Executive dysfunction is “a term used to describe faults or weaknesses in the cognitive process that organises thoughts and activities, prioritises tasks, manages time efficiently, and makes decisions”.
Executive dysfunction makes graduating from college or holding down a job, especially a job you’re not super passionate about, very difficult – something most of us have experience with, in this late stage capitalist world. Logic should therefore have it that obtaining a diagnosis in the West, especially in countries with universal healthcare meant to help the population, should be a professional, yet quick and efficient process, right? Right.
But logic is not the problem, reality is. In the EU, ADHD in adults is underdiagnosed and undertreated, and obtaining a diagnosis can be very lengthy and energy consuming, very expensive, or both. Waiting time only to get a first appointment is months, and sometimes over a year long. And then, going forward, the process is rarely efficient, consistent enough, or welcoming.
I’ve had a friend be told by a psychiatrist working in the state hospital in Paris, that he simply “doesn’t believe in adult ADHD” after she had shown him the diagnosis she already had, and requested she try treatment for her symptoms. After asking the hospital to see someone else, as she obviously was no longer comfortable with this (excuse of a) psychiatrist, the hospital refused and advised her to find one herself outside the hospital, so a private practitioner.
Getting a diagnosis with a private practitioner on the other hand is a hefty few hundred euros, as a diagnosis cannot be given in the first sitting, and consultations are often not reimbursed or covered by health insurance. That is, if one manages to find a competent psychiatrist who is not overbooked, in a sea of incompetence and adult-ADHD-scepticism. ADHD criteria for diagnosis, which favour diagnosis in boys and men as opposed to girls and women, were developed by leading psychiatric experts – one can therefore imagine that many psychiatrists have internalised such sexist criteria and apply it in their work.
So, a person who is struggling to keep their job and make ends meet (impulsive spending and badc money management are also pretty cute symptoms of ADHD), keep relationships healthy, has to either just “figure it out” until the snail-like process in the public hospital *might* eventually lead them to a diagnosis, or find someone in the private sector who actually is good enough, and spend a bunch of money, which they are assumed to have.
And that is, in countries where this diagnosis is done and there are treatment options available, because in others even that isn’t very much the case. For instance, finding ADHD meds in a pharmacy in my home country Kosovo is more rare than finding a unicorn; you have to order them from Albania as they are quite simply not sold in our pharmacies, begging the question: how the f*** are people managing with no treatment, and often no diagnosis?! Personally, I have no idea. Power and patience to them, they really need it.
Photo by Andrea Piacquadio.