The Quadruple Empathy Problem

Hello and welcome to Divergent Menopause with Sam Galloway.

Today I'm going to read to you the quadruple empathy problem.

Autism, ADHD, menopause, and why we are still the ones expected to adapt.

Empathy.

According to the Cambridge Dictionary,

the definition of empathy is the ability to share someone else's feelings or

experiences by imagining what it would be like to be in that person's situation.

Empathy

the ability to share someone else’s feelings or experiences by imagining what it would be like to be in that person’s situation

Source: Cambridge Dictionary

This Elder Millennial vividly recalls standing in front of the bathroom mirror in my locked family bathroom, aged 7 or 8 or so. Forcing tears to stream from my eyes, my crying voice rasping, feeling the hot slime from my sinuses dripping down the back of my throat, I didn’t feel sadness. Perhaps we can grow out of alexithymia, but the act of crying on cue did not prompt emotion. Reflected back to me in the mirror was a girl who cried, smiled, and laughed at all the wrong times. Many hours were spent alone learning to morph my face to look how it was expected of me.

“Too much”, “not enough”, “too sensitive” and “insensitive”, were some of the labels attached to me whenever my childhood response was perceived to be misaligned with the social expectation. Learning the rules of emotional expression was arduous and exhausting. Watching the neurotypical girls whisper about me, then trick me into thinking they were my friends before not long later calling me fat, ugly and ginger, was my daytime schooling.

Where was their empathy for me?

Burnout regularly ensued.

Life was endlessly confusing. For reasons still unclear to me, as a girl screaming and crying in pain when I was injured and hurting was deemed over the top. Yet silently sobbing myself to sleep was apparently fine. I learnt that as long as I could hide my emotions from others, I was safe. The agonising intensity of my emotions was not for public consumption, and my pain and anguish was supposed to be kept private.

Crying into the mirror, was an instinctual exercise in social masking. Self-set homework was studied only by the special girls like me, in secret, whilst everyone else got on at home with learning more traditionally academic subjects, and playing with easily found and kept friends. My social skills learning was autodidactic in my early years, but would pay off in time when I took it upon myself to achieve an upper second-class honours degree Bachelor of Science in Psychology.

The classic Psychology undergrad degree A.K.A. the neurodivergent thinking woman’s endeavour to cognitively grasp concepts behind individual and collective human thoughts, motivations, neurology and behaviours. Including (neurotypical) empathy. Using our strengths of curiosity, pattern recognition and intellect, we endeavour to compensate for the neurodevelopmental lagging skills that made too many of our childhoods a misery.

The unrelenting stereotype of neurodivergent people is that we cannot comprehend the emotions of others, never mind be able to empathise with them. It would still be two decades before my autism and ADHD were identified.

Despite our extreme efforts to performatively show our emotions in a dignified, standardised and socially acceptable manner, many female and AFABs pre-diagnosed autistic, ADHD and AuDHD can also gaslight ourselves into thinking that we can’t be neurodivergent. How can we be neurodivergent when we show too much emotion, rather than none at all? Our emotional dysregulation can trigger us to weep, and seeing such intense public displays of empathy can make other people uncomfortable.

Neurodivergent empathy looks different.

But our late identification has prompted family members and society at large to think that we are just jumping on the “latest trend” of autism and ADHD.

For those of us who are exquisitely high masking and often with co-occuring giftedness, the assumption is that we can empathise in a neurotypical way, but we choose not to. Too often, we are regarded as arrogant, manipulative, and over- or under- performative.

When we eventually receive a diagnosis, having fought a lifelong battle to fit in with the people who love us the most yet understand and accept us the least, it becomes clear that neurotypicals also have difficulty showing us empathy.

Our emotions look different.

Our empathy looks different.

Many late diagnosed neurodivergent women and AFABs, consider ourselves to be deep empaths. For decades, we have masked our emotional intensity, and yet we are often the first to donate to worthy causes and to cry at distressing world news stories. The challenge for us isn’t whether or not we can respond emotionally to others. The challenge for us is self-regulating our emotional responses. When the intensity of our emotional responses is socially unacceptable, we are labelled “too much” and/or “not enough”.

Sobbing in work meetings.

Melting down during minor disagreements.

Shutting down when newly bereaved.

Our emotional intensity sets us apart from the majority. To me, this is an advantage to being neurodivergent. But we hide it, moderate our emotional responses, and stop our faces from giving us away, in order to avoid rejection.

When the societal norm is to visibly empathise swiftly then move on, our deep empathy is feared and misunderstood. Public crying is deemed shameful, and being told to “grow up” as kids really meant “keep it to yourself”. Hiding our pain doesn’t stop us from feeling it.

We made it our mission to pass for normal, and we were picked apart regardless.

Our natural response as neurodivergents is pathologised as emotional dysregulation, and we are medicated, therapised and/or shunned to obscure our differences from the world.

Many of us learn to shield ourselves from our emotional triggers, for example, by actively avoiding live footage broadcasts of global catastrophes, and the effects of their aftermath.

Other neurodivergents may enter politics, education and other influential institutions to try and change systems from the inside in a bid to improve life chances for all, reverse the climate crisis and drive other social justice causes that they empathise with deeply.

By midlife, we have learnt to mask and moderate our neurodivergent empathy and emotional responses. Repeated rejections, perceived “failings” on our part and collapsed relationships have taught us to hold it all inside whatever the cost. Lived experience tells us that we are not safe acting as ourselves in the world at this time. It can be hard to know where the line is between who we inherently are, and who we are pretending to be.

We may know when we are okay to be around other people, scheduling our social engagements around our menstrual cycle. Some days and weeks we can’t be trusted to people.

As highly sensitive people, we respond to our hormones with the entirety of our minds and bodies, and so we may avoid certain people and activities when hormonal volatility is predicted.

Hormonal flux becomes unpredictable as we approach the menopause transition. We no longer possess the self-regulatory capacity to moderate our every word, action and facial response. Regressions in functioning occur, and our second nature skills of masking are lost. It can be terrifying to go into meltdowns from triggers that you have coped with masked for decades.

In perimenopause, this can trigger the sense of intense loss of self.

But there is light at the end of the tunnel. In the later stages of neurodivergent perimenopause and beyond, fewer f***s are given. Literally and metaphorically.

We can come back to ourselves, find our neurotribe, and settle into a lifestyle that lends itself to managing our energy expenditure. We align the generous gift that is our empathy where it is validated, wanted and most needed.

Neurodivergent-driven research on the topic of empathy in the menopasue transition is developing, and what follows is a selection of the work on empathy so far.

The Double Empathy Problem

Many of us late diagnosed neurodivergent adults will have come across the theory of the double empathy problem whilst trying to figure out why we have felt so misunderstood for much of our lives. Often attributed as an issue for autistic people when communicating (or trying to) with neurotypicals, the double empathy problem originates from a much wider concept.

First coined “the double empathy problem” by autistic researcher and sociologist Dr. Damian Milton in 2012, Milton drew on the notion that people of different cultures may often struggle to find some common ground, and experience communication breakdowns in the process.

‘Simply put, the theory of the double empathy problem suggests that when people with very different experiences of the world interact with one another, they will struggle to empathise with each other. This is likely to be exacerbated through differences in language use and comprehension.’

UK National Autistic Society: The double empathy problem

Misunderstandings in mixed neurotype relationship dynamics have for too long been considered the fault of the neurodivergent partner. And this goes for all types of neurodivergence, despite the strong link the autistic community has with the double empathy problem. It is just as likely to be an issue for a stereotypically enthusiastic and energetic ADHDer or AuDHDer to be brushed off as “annoying” and “too much”.

The double empathy problem theory provides reassurance that we are not the problem. Our supposed social deficits and communication differences are only apparent and obstructive when we are communicating with people who do not share our neurotype.

This is why finding our neurotribe is invaluable to adults who self-identify as or are diagnosed neurodivergent. “I don’t understand you” is too frequently said to neurodivergents by their neurotypical partners, as though they are just not trying hard enough to make themselves understood. There is often very little flexibility from the neurotypical to try to understand their partner, who may already be struggling and exhausted from every single interaction, every single day.

The time it takes for this awareness to occur can cost us our self-compassion, self-esteem and even our sense of self. Not wanting to face rejection after rejection, we learn from every social exchange with neurotypicals, and tweak our responses accordingly. It is not uncommon for later in life self-identified and diagnosed neurodivergents to have adopted another persona entirely.

Masters of mimicry, and driven by a biological human instinct to be accepted, too many of us spent our formative years studying (and failing) how to appear acceptable, on the social periphery studying peers in the playground, obsessive book character analysis, copying soap opera stars’ mannerisms and so on.

Hopefully our younger neurokin no longer need to do this because surely all the teachers, SENCOs, practitioners and parents are clued up about the double empathy problem by now..?

The Triple Empathy Problem

Have you ever visited a healthcare practitioner and felt like you have not been understood, validated and treated appropriately?

Unfortunately, this has been the norm for neurodivergent patients for all too long. Sometimes complicating factors make us seem too hard for the average doctor to want to work collaboratively with us. Finding healthcare providers who are willing to learn about nuances in health profiles, such as differing cultural and ethnic groups, co-occuring chronic health conditions, mental health conditions and increased likelihood of gender dysphoria and/or being trans can make medical visits feel harder than they need to be.

On average, autistics and ADHDers have shorter life expectancy than neurotypicals. This may be because we do not experience pain and report symptoms in the manner medical professionals are used to. Sensory overload in clinical settings may reduce our capacity to engage. Executive functioning challenges make it a struggle to book and attend appointments, collect prescriptions, and remember to take our meds. There is a myriad of reasons why our life expectancy is shorter due to our neurodivergence, but it is unacceptable and shouldn’t be our burden to carry alone.

Why is this not widely known, and managed as a systemic health crisis?

In 2023, Shaw et al. took the double empathy problem theory, situated it within the medical context, and coined the term the triple empathy problem.

‘Patients struggle to see their doctor’s perspective, and doctors can also struggle to see their patients’ perspectives. For example, when doctors are patients themselves, they experience healthcare with their own medical knowledge. The difficulty is seeing the perspective of a patient without any medical knowledge. Similarly, autistic people struggle to see non-autistic people’s perspectives and vice versa. So, it proves even harder for autistic patients to see their (non-autistic) doctor’s perspective, and even harder for (non-autistic) doctors to see autistic patients’ perspectives… This triple empathy problem may also be at play when autistic people interact with other professions and services, such as education, social care or the justice system.’

Barriers to healthcare and a ‘triple empathy problem’ may lead to adverse outcomes for autistic adults: A qualitative study by Shaw et al. (2023)

In my experience, working collaboratively on my medical issues has been best achieved when my healthcare providers are neurodivergent themselves. Unfortunately, it is not always safe for doctors and health practitioners to disclose their own neurodivergence in the workplace. Proactively seeking neuro-affirming medical staff throughout our lifespan to support us could be most effective, giving us the best possible health outcomes. Yet self-advocacy can still be extremely challenging, especially when we are already feeling depleted and sick.

Training is essential for this travesty to be corrected, and there are recommendations for healthcare practitioners to adopt in order for our neurodivergent cultural differences in social communication, pain response and identification plus other variations to be best accommodated.

Building on Shaw et al’s findings, Doherty et al. (2023) developed Autistic SPACE: a novel framework for meeting the needs of autistic people in healthcare settings.

‘This (the Autistic SPACE framework) encompasses five core autistic needs: Sensory needs, Predictability, Acceptance, Communication and Empathy. Three additional domains are represented by physical space, processing space and emotional space. This simple yet memorable framework encompasses commonalities shared by autistic people.’

Autistic SPACE: a novel framework for meeting the needs of autistic people in healthcare settings by Doherty et al. (2023)

The Doherty et al. paper is packed full of great information on neurodivergent inclusivity that should be compulsory reading for all patients, medical staff, therapists, holistic practitioners and health boards. I strongly encourage you to take a look at the table of Recommendations for supporting Autistic SPACE in practice, because I think you will feel totally validated. (Screenshots of the table are below, with credit to Doherty et al., 2023).

Sensory processing disorder is a form of neurodivergence that co-occurs extremely highly with autism and ADHD, and we all have differing sensory sensitivities and tolerance levels. Hormonal fluctuations during perimenopause and beyond exacerbate these differences, and can make day to day life feel torturous. Temperature dysregulation can worsen, joint pain may feel agonising, and menstrual cramps can combine, putting us into a sedentary lifestyle.

Shutdowns, meltdowns and periods of inertia may increase, forcing our functioning to plummet to a debilitating extent.

Spiralling hormones drive our mood, cognition and energy levels to spiral too. Just when we have the least capacity to understand what is going on for ourselves and self-advocate, we need to do so more than ever before.

The Quadruple Empathy Problem

Widespread symptoms of the menopause transition may affect neurodivergent people to the extreme. The mind and body effects of fluctuating oestrogen, progesterone and testosterone production can lead to regressions and an inability to function. This was certainly the case for me, but I hope you are faring better!

Midlife burnout for neurodivergent women and AFABs is often misattributed to factors other than hormonal flux, and therefore we are prone to being misdiagnosed and medical gaslit, resulting in inappropriate treatment.

In their 2024 study “A perfect storm”: Autistic experiences of menopause and midlife, Brady et al. identified menopause as the fourth dimension of the empathy problem.

Shaw et al. (2023) described a triple empathy problem where autistic people struggle to make themselves understood and understand those of other neurotypes in the context of medical settings.

We found an added dimension where communication challenges were even more profound for some autistic participants transitioning through menopause, combined with what we would characterize as medical misogyny; this could be seen as creating a quadruple empathy problem.

Some participants indicated that menopause was reminiscent of former experiences of hormonal transition like puberty and menarche, transitions in which they had also struggled with communication…

… A key takeaway is the importance of person-centred, autism-informed healthcare that considers intersectionality and accessibility needs. We encourage healthcare professionals to recognize autistic communication styles and the various symptoms of menopause, including those that are less widely discussed, and to be receptive to the fact that menopause may start earlier than is commonly expected.

Brady et al. (2024) “A perfect storm”: Autistic experiences of menopause and midlife

Medical gaslighting of neurodivergent menopause is still prevalent, with women and AFABs being told we are too young to be experiencing symptoms. When neither the practitioner nor the patient are well informed about menopause and/or neurodivergence, the chances of appropriately treating her symptoms are extremely unlikely.

There is also some emerging research into ADHD and menopause, such as the academic paper ADHD in females: Survey findings on symptoms across hormonal life stages by Osianlis et al. (2026). Their results showed that 97.5% of participants perceived a worsening of ADHD symptoms during menopause, but as it was self-reported data, there are limitations in extrapolating these findings. However it does suggest that more research is needed in this area.

As an AuDHDer, I find it concerning that research continues to polarise women and AFABs by their neurodevelopmental conditions. Surely we don’t need to continue studying ADHD and autism separately when both co-occur so strongly. I cannot separate the effects of menopause on my ADHD versus my autism as they are equally integral to my human experience.

If widely applied in medical settings, the Autistic SPACE framework shared above could transform our interactions within the healthcare system, and improve our life chances.

With so many multipliers to the empathy problem, neurotypical people need to take equal responsibility in understanding how neurodivergents perceive and cope in this world which rarely has our best interests at heart. Children should be accepted as they are, without having to waste their childhoods fawning “normal”, regardless of their neurotype.

By the time the younger generation growing up today reach midlife, this all needs to be understood and standard practice within all healthcare institutions. Neurodivergent friendly medical settings and neuro-affirming practitioners will enhance our life chances, whilst providing the validation and supports we have lacked for so long.

I would love to hear from you in the comments!

* Do you relate more to the double, triple or quadruple empathy problem?

* Do you feel the biggest empathy breakdowns happen in your relationships, healthcare, workplace or family?

* Has your menopause transition affected your experience of giving and receiving empathy?

Cheers,

P.S. Please excuse typos and general nonsensical grammar. This essay taken me hours and hours and hours to write, edit, review, rewrite, edit, record the audio voiceover and upload to publish. Whilst I can report an astonishing improvement in my quality of life now that I am in surgical menopause, the lingering effects of the heavy sedation and general anaesthetic from August 2025 are still with me. 😵‍💫

If this resonated, you are not alone — and you deserve spaces where your empathy isn’t pathologised. Paid subscribers help sustain this work and gain access to deeper dives, research breakdowns, and a community that empathises with you.