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"Putting on My Best Normal": Social Camouflaging in Adults with Autism Spectrum Conditions


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Camouflaging of autistic characteristics in social situations is hypothesised as a common social coping strategy for adults with autism spectrum conditions (ASC). Camouflaging may impact diagnosis, quality of life, and long-term outcomes, but little is known about it. This qualitative study examined camouflaging experiences in 92 adults with ASC, with questions focusing on the nature, motivations, and consequences of camouflaging. Thematic analysis was used to identify key elements of camouflaging, which informed development of a three-stage model of the camouflaging process. First, motivations for camouflaging included fitting in and increasing connections with others. Second, camouflaging itself comprised a combination of masking and compensation techniques. Third, short- and long-term consequences of camouflaging included exhaustion, challenging stereotypes, and threats to self-perception. Electronic supplementary material The online version of this article (doi:10.1007/s10803-017-3166-5) contains supplementary material, which is available to authorized users.
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J Autism Dev Disord (2017) 47:2519–2534
DOI 10.1007/s10803-017-3166-5
“Putting onMy Best Normal”: Social Camouflaging inAdults
withAutism Spectrum Conditions
LauraHull1,6 · K.V.Petrides2· CarrieAllison3· PaulaSmith3·
SimonBaron‑Cohen3· Meng‑ChuanLai3,4,5· WilliamMandy1
Published online: 19 May 2017
© The Author(s) 2017. This article is an open access publication
Second, camouflaging itself comprised a combination of
masking and compensation techniques. Third, short- and
long-term consequences of camouflaging included exhaus-
tion, challenging stereotypes, and threats to self-perception.
Keywords Autism· Camouflaging· Coping· Sex·
Gender· Social adapation
Autism Spectrum Conditions (ASC)1 are atypical devel-
opmental conditions characterised by impairments in
social interaction and communication, alongside unusu-
ally restricted/repetitive behaviours and interests, need
for sameness, and atypical sensory processing (APA
2013). ASC is generally viewed as dimensional, with
traits found amongst the general population and a speci-
fied cut-off point, when present with concurrent func-
tional impairments, used to identify the clinical diagno-
sis (Baron-Cohen et al. 2001; Constantino 2011). One
behaviour associated with ASC that has recently attracted
interest is the development of camouflaging or coping
strategies for use in social situations (Attwood 2007;
Gould and Ashton-Smith 2011; Kopp and Gillberg 2011;
Lai etal. 2011; Wing 1981). These strategies may include
hiding behaviours associated with their ASC, using
explicit techniques to appear socially competent, and
finding ways to prevent others from seeing their social
Abstract Camouflaging of autistic characteristics in
social situations is hypothesised as a common social cop-
ing strategy for adults with autism spectrum conditions
(ASC). Camouflaging may impact diagnosis, quality of life,
and long-term outcomes, but little is known about it. This
qualitative study examined camouflaging experiences in
92 adults with ASC, with questions focusing on the nature,
motivations, and consequences of camouflaging. Thematic
analysis was used to identify key elements of camouflaging,
which informed development of a three-stage model of the
camouflaging process. First, motivations for camouflaging
included fitting in and increasing connections with others.
Meng-Chuan Lai and William Mandy are joint senior authors for
this paper.
Electronic supplementary material The online version of this
article (doi:10.1007/s10803-017-3166-5) contains supplementary
material, which is available to authorized users.
* Laura Hull
1 Research Department ofClinical, Educational & Health
Psychology, University College London, London, UK
2 London Psychometric Laboratory, University College
London, London, UK
3 Autism Research Centre, Department ofPsychiatry,
University ofCambridge, Cambridge, UK
4 Child andYouth Mental Health Collaborative attheCentre
forAddiction andMental Health andThe Hospital forSick
Children, Department ofPsychiatry, University ofToronto,
Toronto, ON, Canada
5 Department ofPsychiatry, National Taiwan University
Hospital andCollege ofMedicine, Taipei, Taiwan
6 Department ofPsychology, University College London, 26
Bedford Way, LondonWC1H0AP, UK
1 We use the term ‘Autism Spectrum Condition’ (ASC) when refer-
ring to a diagnosis of Autism Spectrum Disorder, to be respectful
to those on the spectrum who feel that the term ‘disorder’ is stig-
matising, whereas ASC is compatible with the presence of both the
strengths and difficulties of people on the spectrum.
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2520 J Autism Dev Disord (2017) 47:2519–2534
1 3
difficulties. In this paper we will refer to these behaviours
as ‘camouflaging’.
While many neurotypical people, of all genders, man-
age the way others perceive them in social situations
(Izuma et al. 2011), research suggests that individuals
with ASC have a reduced ability to do so (Cage et al.
2013). However, the research in this area has focused on
the manipulation of typical social behaviours, rather than
how individuals with ASC may want and be able to adapt
their ASC-related characteristics. Camouflaging is likely
to exist on a spectrum (similar to autistic traits) in those
who have an ASC diagnosis and those who are subclini-
cal. However, self-reported evidence suggests possible
categorical differences between autistic and non-autistic
camouflaging. For instance, camouflaging by ASC indi-
viduals has been reported as extremely effortful and chal-
lenging to one’s identity (Bargiela et al. 2016), unlike
ordinary reputation management in typically developing
Camouflaging has also been proposed as an explana-
tion for the missed or late diagnosis of females with ASC,
as part of the female phenotype or behavioural presen-
tation (Gould and Ashton-Smith 2011; Kirkovski et al.
2013; Lai et al. 2015). Amongst clinical samples, male
to female gender ratios for ASC diagnosis are generally
around 4:1 (Fombonne 2009), but when active case ascer-
tainment is used within the general population, the ratio
lowers to around 3:1 (Sun etal. 2014). This discrepancy
suggests that there are biases that work against females
with ASC receiving accurate, timely diagnoses from clin-
ical services. Females are less likely to receive a diag-
nosis of ASC than males with similar levels of autistic
traits (Dworzynski etal. 2012; Russell et al. 2011), and
those who receive a diagnosis on average are more likely
than males receiving the same diagnosis to be older and
have more additional needs, including increased intel-
lectual disability (Shattuck etal. 2009) and behavioural-
emotional challenges (Duvekot et al. 2016). Clinical
experience suggests that females with ASC may be more
likely than males with ASC to have been previously mis-
diagnosed with other mental health conditions, such as
personality disorders or eating disorders (Lai and Baron-
Cohen 2015; Mandy and Tchanturia 2015).
In addition to camouflaging, there are other gender
differences in autistic characteristics which may contrib-
ute to late diagnosis or misdiagnosis of females. While
few significant quantitative sex differences in the core
symptoms have been found (Hull etal. 2016; Lai etal.
2015; Mandy et al. 2012; Van Wijngaarden-Cremers
et al. 2014), comparisons of associated characteristics
have shown differences between the female and male
presentations (Kreiser and White 2014; Rivet and Mat-
son 2011). For instance, males with ASC are more likely
to experience externalising difficulties such as hyperac-
tivity and conduct problems, whereas females with ASC
are more likely to experience internalising problems such
as anxiety and depression (May etal. 2012; Oswald etal.
These ‘qualitative’ differences between male and
female presentation, including camouflaging behaviours,
need to be included in measures used to assess ASC, as
sex differences at a nosological level are likely to have an
impact on diagnosis (Lai et al. 2015). Current diagnos-
tic practices focus on the core ASC characteristics that
have been historically established from the behavioural
presentation in males, and so do not necessarily reflect
the areas in which females with ASC may display differ-
ent behaviours to males. As a result, current assessments
of females with ASC are restricted to the areas in which
females are most similar to males, and those females who
do not meet the male-typical behavioural descriptions
are likely to be missed (Van Wijngaarden-Cremers etal.
2014). Diagnostic biases may lead to biased sampling in
studies of sex differences in ASC, such that only male-
typical ASC behaviours are expected, and therefore only
these behaviours are found when looked for. It has hence
been argued that diagnostic assessments of ASC should
include female-typical behaviours to more accurately
assess ASC prevalence and characteristics across genders
(Kreiser and White 2014).
Camouflaging in certain settings may lead to the percep-
tion that individuals function well and do not experience
any problems, even though those individuals still experi-
ence difficulties as a result of the interaction of their ASC
and the context. For example, it is suggested that girls with
ASC may mimic other socially successful individuals to
give the impression that they too are socially successful,
but when placed in unknown environments they are not
prepared for, they struggle to socialise (Attwood 2006).
This may reflect both a stronger motivation to mimic, and
itself be the result of a stronger motivation to ‘systemize
social behaviour, than is seen in males with ASC. Teach-
ers or clinicians may therefore be unaware of the difficulties
being faced by girls and women with ASC, whereas family
members may see their loved one in a range of situations
and so realise the extent of their difficulties. Alternatively,
women who receive an ASC diagnosis later on in life may
have spent years feeling different and attempting to mini-
mise this difference, until their children receive a diagnosis
and they recognise the symptoms within themselves (Hol-
liday Willey 2015).
There is a variety of anecdotal evidence of camouflaging
amongst women with ASC. For instance, Liane Holliday
Willey describes how she spent her life pre-diagnosis ‘pre-
tending to be normal’, yet knowing that something was dif-
ferent about her (Holliday Willey 2015). In case studies of
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2521J Autism Dev Disord (2017) 47:2519–2534
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girls with ASC, researchers have suggested that the use of
social imitation strategies may lead to missed, late, or ques-
tioned diagnoses (Kopp and Gillberg 1992). Essentially,
social imitation may be a form of acting, whereby girls
with undiagnosed ASC may be coping without receiving
a diagnosis or even needing a diagnosis because their act-
ing is relatively successful. Success here may be defined as
simply not having overt functional impairments or raising
concerns of teachers or other professionals, even though
under the surface or behind maintaining such appearances,
females may report high levels of subjective stress, anxiety
and exhaustion, and a need to withdraw from social inter-
action to ‘re-set’. These observations have not yet been
systematically tested, despite extensive interest in gender
differences in ASC and the female phenotype (Gould and
Ashton-Smith 2011; Kopp and Gillberg 1992; Lai et al.
2015; Robinson etal. 2013).
Individuals with ASC also display significant variation
in their outcomes across the lifespan, especially concern-
ing their social functioning. Some adults with ASC form
friendships and relationships, and have fulfilling careers
that enable them to remain independent (Farley etal. 2009;
Strunz etal. 2016). Others, however, struggle to maintain
social relationships and may remain unemployed, despite
having the motivations and capabilities to work (Baldwin
and Costley 2015; Shattuck et al. 2012). While some of
this variation is due to individual differences in cognitive
abilities, language ability, and personal preference (Howlin
et al. 2000; Shattuck et al. 2012; Van Bourgondien et al.
1997), it is possible that an individual’s ability to cam-
ouflage their ASC contributes to them achieving socially
desirable outcomes. Individuals who are better able to cam-
ouflage their ASC characteristics might feel more able to
make friends, improve their social support, and perform
better in job interviews.
However, many individuals with ASC also report exten-
sive anxiety and depression, especially those with average-
to-high levels of IQ and language abilities (Lugnegård etal.
2011). Anecdotal evidence suggests that an individual’s
camouflaging can impact their mental health (Holliday-
Willey 2015). Where camouflaging is unsuccessful, stren-
uous, or if the person feels forced to camouflage, it may
be associated with high stress level, low mood and low
self-esteem. In addition, the pressure to maintain success-
ful camouflaging may lead to anxiety for individuals with
ASC. Camouflaging is not necessarily a beneficial behav-
iour, and should not be regularly expected or encouraged
for individuals with ASC, as this may risk increasing men-
tal health problems. It is therefore important to study cam-
ouflaging in order to better understand the individual dif-
ferences predicting long-term wellbeing and outcomes for
individuals on the autism spectrum.
A small number of studies have recently emerged which
directly examine social camouflaging behaviours in indi-
viduals with ASC. Tierney, Burns, and Kilbey (2016)
interviewed ten adolescent girls with ASC about their
experiences of camouflaging, and revealed some com-
mon themes including the uncertain, exhausting nature of
the social environment; the desire to make friends which
motivated camouflaging attempts; and using explicit tech-
niques to mask ASC-related difficulties. Similar themes
were also found during qualitative interviews with late-
diagnosed women with ASC (Bargiela etal. 2016). In par-
ticular, the idea of pretending to be normal, which could
be achieved through both learned and automatic strategies,
and the extensive costs of such strategies, were identified.
Recently, some empirical operationalisation of camouflag-
ing behaviours in both children and adults with ASC has
also been developed. Behavioural observations suggest
that girls camouflage their social difficulties (e.g. by stay-
ing in close proximity to peers and weaving in and out of
activities) to a greater extent on the playground than boys,
and therefore are less likely to be identified as struggling
socially (Dean etal. 2016). Camouflaging, operationalised
as the discrepancy between (a) interpersonal behavioural
presentation and (b) self-reported autistic traits and objec-
tively measured social cognitive abilities, was found to be
on-average higher in women with ASC than in men with
ASC, although was associated with more symptoms of
depression in men (Lai etal. 2016). These important initial
studies suggest that camouflaging is a real and meaningful
experience in the lives of people with ASC, and directly
impacts on their social functioning and mental wellbeing.
Despite these encouraging first steps, key questions
about camouflaging still need to be answered, such as
how common camouflaging is within the ASC population,
whether it varies across the lifetime, and whether individ-
ual differences in camouflaging are related to long-term
outcomes in functioning, achievement and quality of life. In
addition, the majority of those diagnosed with ASC iden-
tify as male, and a significant number of ASC individu-
als experience non-binary gender identities (Glidden etal.
2016; Kim etal. 2011). It is therefore important to examine
camouflaging behaviours across all genders, as research so
far has focused on female experiences.
Most importantly, studies of camouflaging in ASC can-
not progress until a conceptual model of camouflaging has
been produced, so that subsequent research has strong theo-
retical grounding. Such a model is best developed from a
qualitative analysis of the camouflaging experiences of
individuals with ASC. This will ensure that the construct of
camouflaging reflects the real-life experiences of individu-
als with ASC rather than the preconceptions of research-
ers or clinicians, and that our understanding of camouflag-
ing is representative of a broad range of individuals with
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2522 J Autism Dev Disord (2017) 47:2519–2534
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ASC. Inductive (i.e. data-driven) research resulting in a
comprehensive model of the camouflaging process will
enable hypothesis generation and form the basis of meas-
urement development to further explore camouflaging
The present qualitative study examined camouflaging in
a large sample of adults of all self-identified genders who
had been diagnosed with ASC, using internet-based survey
and thematic analysis. Emphasis was placed on the moti-
vations for camouflaging, techniques used, the impact that
camouflaging has for the individual, and their overall atti-
tudes to camouflaging. The aim of the study was to derive
a conceptual model of camouflaging to inform future
The following research questions were addressed:
1. What is camouflaging?
2. What are the techniques used and what do people with
ASC think camouflaging is?
3. Why do people camouflage their ASC?
4. What are the consequences of camouflaging?
Participants were 92 adults of 15 different nationalities
(55% British). They were eligible to take part in the study
if they were over the age of 16 years and had received a
DSM-IV or DSM-V diagnosis from a psychiatrist or clini-
cal psychologist in a recognized specialist clinic of an
ASC, including Autism/Autistic Disorder, Asperger Syn-
drome/Asperger’s Disorder, Autism Spectrum Disorder,
Atypical Autism, and Pervasive Development Disorder
Not Otherwise Specified. Participants were recruited via
the Cambridge Autism Research Database (CARD) and
through adverts placed on social media. Whilst it was not
possible for this study to independently verify the diagnos-
tic status of participants, several measures were taken to
check diagnostic status and establish the generalisability of
findings from this sample. Participants were asked to report
whether they had received an ASC diagnosis (and if so, at
what age and from which type of healthcare professional)
or whether they were self-diagnosed. Those who reported
self-diagnosis, or who reported receiving an ASC diagnosis
from someone other than a medical professional, clinical
psychologist, or healthcare team, were excluded from cur-
rent analysis (n = 3). Demographic characteristics of par-
ticipants are included in Table1. Participants were asked to
identify their gender as ‘female’, ‘male’ or ‘other’, and give
more details if they wished.
A newly designed questionnaire of camouflaging was
developed by the researchers, in consultation with other
experts in ASC, including clinicians, researchers, and
adults with ASC. The questionnaire included 23 closed and
20 open questions, and examined participants’ motivations
for camouflaging, the characteristics of their camouflag-
ing experiences, the consequences of camouflaging (posi-
tive and negative), and their attitudes towards camouflaging
(see online Appendix1). Closed questions were developed
from predicted behaviours and observations raised during
the development process, although participants were able
to give additional detail to their answers if they wished.
Open questions were designed to elicit new insights from
participants and identify experiences not anticipated by the
Demographic information about the participants, includ-
ing details of their ASC diagnosis, was also obtained. Other
measures, including those of quality of life, social anxiety,
Table 1 Demographic
characteristics of participants
and whether they reported
Three male participants reported their natal sex as female. All participants who identified their gender as
‘Other’ reported their natal sex as female
Female Male Other gender
N 55 30 7
Age (mean years) 40.71 (SD 14.14) 48.03 (SD 16.62) 40.71 (SD 14.29)
Age (range) 18–68 22–79 27–69
Age at diagnosis (mean years) 36.98 (SD 14.21) 41.03 (SD 18.08) 32.67 (SD 9.25)
Camouflage? (yes/no) 51/4 28/2 7/0
British 30 17 4
North American 12 3 1
Western European 7 6 2
Other 6 4 0
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2523J Autism Dev Disord (2017) 47:2519–2534
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and depressive symptoms, were administered, but not
included in the current analysis.
Participants were emailed an online link to ‘a study look-
ing at experiences of coping behaviours in social situations’
(which was hosted by Qualtrics) or followed a link posted
on social media. They were reminded that they could with-
draw at any point and were under no obligation to answer
any question. Participants completed the survey at their lei-
sure and were able to stop and start their responses as they
chose, to minimise stress or discomfort from completing
the survey.
Early in the questionnaire after demographic data had
been ascertained, participants were asked the following
question: “Have you ever had the experience of ‘camou-
flaging’ your autism? A reminder: in this survey we use
the term ‘camouflaging’ to refer to ‘coping skills, strate-
gies, and techniques that function to “mask” features of
ASC during social situations’.” Those who responded ‘no’
were directed to the end of the questionnaire, where they
could leave their thoughts on camouflaging if they wished.
These responses were included in the final analysis. Those
who responded ‘yes’ completed the full questionnaire. Four
females (7% of total number of females) and two males (6%
of total males) reported that they had never camouflaged
their ASC in social situations. All seven participants who
identified their gender as ‘Other’ reported camouflaging
their ASC. Responses were saved securely on the Qualtrics
server in anonymised format.
Ethical approval for this study was obtained from the
University of Cambridge Psychology Research Ethics
Committee, reference number Pre.2015.036. Informed con-
sent was obtained from all individual participants included
in the study.
Analysis followed the six phases of thematic analysis rec-
ommended by Braun and Clarke (2006) with the aim of
identifying patterns of information within the data which
answered the research questions. This inductive (i.e., data
driven) analytic approach was chosen because it does not
rely on a rigid theoretical framework for interpretation,
and so enables researchers to examine alternative perspec-
tives and identify new information within developing areas
of psychology (Willig 2013). Guidelines for good qualita-
tive research (Barker and Pistrang 2005; Elliott etal. 1999;
Ritchie etal. 2014) were followed to ensure that interpre-
tations were credible and could be generalised beyond the
existing sample. A consensus approach was taken with
data extracts read thoroughly by one author (LH) and
codes addressing the research questions identified. Initial
codes were audited by an independent researcher to con-
firm that interpretations reflected the data accurately. These
codes were then checked by the two senior authors (MCL
and WM), and the finalised set of codes was grouped into
themes and subthemes. All authors discussed and refined
themes until a consensus was reached. Member validation
was used as a further credibility check: themes and sub-
themes were sent to six participants (five female, one male)
who had expressed interest in the findings to ensure these
accurately reflected their experiences.
Seven themes, comprising 16 subthemes, were clustered
into three stages of the camouflaging process, as detailed
in Fig. 1. Motivations (Assimilation and “To know and
be known”) describe the reasons why respondents cam-
ouflaged their ASC, including the aims they hoped to
achieve as a result. What is Camouflaging? (Masking and
Compensation) describes the concept of camouflaging
itself, including the techniques used. Finally, the short- and
long-term consequences of camouflaging are described
through the themes “I fall to pieces”, “People have a stereo-
typed view”, and “I’m not my true self”. Names of themes
and subthemes are taken directly from quotations from
respondents. The number of participants who referenced
each theme at least once is displayed in Table2.
Motivations forCamouflaging
Assimilation: “Hide inPlain Sight”
Respondents described wanting to camouflage in order to
‘blend in with the normals’. Most respondents reported a
social expectation from the general population that indi-
viduals with ASC need to change in order to be accepted
by others. Respondents’ social and communication dif-
ficulties, and their unique behaviours and interests,
meant that they stood out from the crowd during social
situations. It was felt that the general population viewed
this as unacceptable, and so respondents felt a pressure
to change their behaviours in order to seem ‘normal
[I camouflage] to reduce the threat of feeling uncom-
fortable through being unable to measure up to social
expectations. (Male, 62)
I don’t want to draw attention to myself by appearing
to be different. (Female, 30)
However, a few respondents suggested that their moti-
vations to camouflage were similar to those of the general
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2524 J Autism Dev Disord (2017) 47:2519–2534
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population; camouflaging was simply seen as the way in
which everyone tries to fit in or hide less desirable aspects
of their personality:
Most neurotypicals are camouflaging nearly all the
time they are in public. (Male, 79)
A more pragmatic aspect of this motivation was the
desire to obtain jobs and qualifications, which respond-
ents felt were less accessible when they were more visibly
‘autistic’. Many respondents described how they would not
have achieved as much had they been more open about their
ASC characteristics. Camouflaging during these situations
was thought to improve employment opportunities, and so
enable them to become a ‘functioning member of society’.
I’m pretty sure no-one would ever hire me if I didn’t
camouflage in job interviews. (Other, 27)
Camouflaging helps to survive in school and college
and it is important for keeping jobs. (Female, 27)
The desire for assimilation was also prompted by con-
cerns for their own safety and wellbeing. Many described
being ostracised, verbally or emotionally attacked, and
some even reported physical assaults when they had not
camouflaged their ASC:
Fig. 1 Thematic map of the three stages (motivations, camouflaging, and consequences) of the camouflaging process. Themes are indicated by
rectangles; subthemes by ovals
Table 2 Number of participants
who referenced each theme Theme Number of participants
(n = 55)
(n = 30)
(n = 7)
Assimilation: “hide in plain sight” 49 20 7
“To know and be known” 42 24 5
Compensation: “to exceed what nature has given” 45 22 7
Masking: “I’m hiding behind what I want people to see” 38 18 7
“I fall to pieces” 44 21 7
“People have a stereotyped view” 32 6 4
“I’m not my true self” 31 15 3
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2525J Autism Dev Disord (2017) 47:2519–2534
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When I was younger and more obviously odd and
strange I was thought of as stupid and also badly
physically and mentally bullied. I also lost employ-
ment. I want to avoid the bullying mostly. I have even
been spat at in the street. (Female, 49)
Most attributed this to their perceived differences com-
pared to others, and used camouflaging techniques to mini-
mise these differences and hence reduce the threat. This
was particularly the case when describing their experiences
in childhood and adolescence; respondents often reported
that relations with others improved as they got older and
were better able to camouflage their ASC.
If I had known how to camouflage earlier, perhaps I
wouldn’t have been such an outcast as a child. (Other,
“I Want toKnow andBe Known”
The other key motivation for camouflaging was to increase
connections and relationships with others. Due to their
inherent social difficulties, many respondents reported
struggling to make friends and form romantic attachments,
despite this being a strong desire. Camouflaging was seen
as one way to overcome the initial obstacles to connection
and allow for future relationships to develop.
Many respondents wanted to be accepted by others and
be able to socialise, but recognised that they lacked the
skills needed to make small talk, interact comfortably with
strangers, and relax in social situations. This limited their
ability to get to know people better. As will be discussed
further in the theme ‘Compensation’, camouflaging offers
solutions to some of these issues. The payoffs in terms of
easier social interaction were a strong motivation for many
respondents to camouflage their ASC with others. How-
ever, several respondents felt camouflaging was only nec-
essary for the initial stages of a friendship or relationship;
once a connection was established, the respondent felt more
comfortable showing their ‘true’ ASC characteristics.
I know it is necessary when I am first getting to know
someone. After I have known them for a while and
they know I have Asperger’s and they are accepting
of my quirks, then I can let my guard down more.
Connections have to be made initially on neurotypical
terms. Then, hopefully, on my terms as well. (Female,
For some, the risk of failure and associated embarrass-
ment created severe anxiety during social interactions; by
camouflaging and using structured techniques, respondents
could reduce some of this uncertainty and so were more
confident in their ability to socialise. Respondents felt that
camouflaging would lead to success in a variety of social
situations, when compared to their default behaviours or
It enables me to be with other people in a way that
is relatively comfortable for me and for them. I avoid
looking like a socially clumsy idiot. It avoids the
embarrassment and awkwardness of getting things
wrong. (Female, 56)
What isCamouflaging?
Masking: “I’m Hiding Behind What I Want People toSee”
Masking encompasses the aspects of camouflaging that
focus on hiding one’s ASC characteristics and developing
different personas or characters to use during social situ-
ations. Both of these emphasise a distinction between the
respondent’s ‘true’ or ‘automatic’ behaviours, and what
they present to the rest of the world.
Camouflaging was partly performed through suppress-
ing, hiding, or otherwise controlling behaviours associated
with ASC that were seen as inappropriate in the situation.
The extent to which this happened could vary depending
on who the person was with; camouflaging tended to occur
less often with close friends and family members, although
some respondents described camouflaging at all times.
Respondents described attempting to minimise their
self-soothing or ‘stimming’ behaviours, and their responses
to sensory overstimulation, in order to make their condition
less obvious to others. These techniques included using
objects as ‘props’ to meet sensory needs in a subtle way,
and giving themselves regular excuses to leave overstimu-
lating environments and calm down.
I prevent myself from doing any particularly visible
or otherwise noticeable stims: I still find myself doing
things like shaking my leg repeatedly without notic-
ing, but don’t make any noises people would think are
weird, don’t full-body shake (like with the leg but…
all of me), or do any finger movements or tapping etc.
that would annoy people. (Female, 20)
Masking enabled respondents to present a different iden-
tity to the outside world, one that covered up those parts
of themselves they were not happy with. The combination
of controlled behaviour and appropriate conversation pro-
duced through camouflaging was often described as essen-
tial during social interactions, even though this meant con-
cealing one’s actual personality.
I don’t think I’ll ever completely stop wearing the
mask. It’s a defence mechanism really. It is easier
to have people you’re friendly with, than taking
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2526 J Autism Dev Disord (2017) 47:2519–2534
1 3
the mask of[f] and revealing the real broken you.
(Female, 18)
In some cases, this went as far as portraying an entirely
different character, and several respondents likened it to
acting or performing a role, complete with costumes. The
character or aspects of the role could change across differ-
ent situations:
I camouflage by putting on a character… I treat my
clothes rather like costumes, and certain items of
clothing help me to uphold certain personality char-
acteristics of which character I am on that occasion.
I have a repertoire of roles for: cafe work, bar work,
uni, various groups of friends, etc. They are all me at
the core, but they are edited versions of me, designed
to not stand out for the ‘wrong’ reasons. (Female, 22)
One way to easily identify the appropriate role to play
was to mimic the behaviours of others during a social inter-
action. Behaviours could be copied directly from the person
in front of them, or could be identified and learned from
observing others interacting, and even from watching tel-
evision and films. Some respondents went as far as to copy
clothing style, mannerisms, and even interests from others.
I try to copy socially successful people by trying to
imitate their speech and body language and trying to
understand their interests. (Male, 71)
Compensation: “To Exceed What Nature hasGiven”
The other aspects of camouflaging centre around develop-
ing explicit strategies to meet the social and communica-
tion gaps resulting from an individual’s ASC, which we
call compensation. These camouflaging techniques include
specific non-verbal communication strategies and guide-
lines for successful conversations with others. Respondents
often described these techniques as ‘rules’ or expectations
from others that had to be met, even if they themselves felt
these rules were not necessary.
Explicit, compensatory strategies were reported by many
respondents as a vital way to improve non-verbal communi-
cation with others. These strategies aimed to help the indi-
vidual perform behaviours used in typical social encoun-
ters, which they would not necessarily perform naturally.
Respondents described how these camouflaging techniques
required intensive monitoring of the way they presented
themselves, in order to ensure they were being performed
as correctly as possible.
Forcing and maintaining appropriate eye contact, or
attempting to look as close to another’s eyes as possible,
was a common compensatory technique reported. Respond-
ents also made an effort to display facial expressions of
emotion or interest, even if they didn’t feel this inside. Dif-
ferent expressions were identified as important for differ-
ent situations, and so many respondents described keeping
a mental list of how to behave depending where they were.
I look in people’s eyes when I first meet them/or in
formal/professional situations even though I wouldn’t
naturally, because I know you’re supposed to.
(Female, 26)
I try to look people in the eye and make faces that fit
the situation. (Other, 27)
Many respondents noted that their preferred levels of
emotional expression and body language did not match
those of others around them, and so over-emphasised these
behaviours in order to communicate better. This included
non-verbal and verbal signs of interest in the interaction,
which were also used to encourage others to continue
speaking and so take the pressure off the ASC individual to
respond appropriately.
My autistic lack of non-verbal signals are read as hos-
tility, arrogance or indifference by people, so I have to
act the good will that I genuinely feel. (Female, 45)
I’m not good at knowing when it’s my turn and I also
tend to just blurt out things or keep talking when I
should have stopped, so I prep myself always in social
situations to have a reminder or tag or internal buzzer
about not speaking too much and trying to do more
listening, nodding, agreeing. (Female, 49)
In addition to these non-verbal techniques, respond-
ents reported developing rules or guidelines to compen-
sate for some of the social difficulties they experienced
during conversations. These were more generalised and
so could be prepared ahead of time and applied to differ-
ent situations. These camouflaging strategies were used
to help the ASC individual get through ‘small talk’ or
more in-depth conversations with minimal stress, and to
make the chat more enjoyable for their social partners.
One rule was to ask questions of the other people.
Explanations for this varied between respondents, but
included minimising the amount of time they had to
speak, giving them more time to prepare things to say,
and ensuring the ASC individual did not take over the
conversation by talking about themselves or their own
I’ve recently tried to institute a rule about asking
more “you” questions - how did that make you feel,
what did you do next, what do you think about a given
thing - instead of “me” or “I” statements. (Male, 29)
My issue is talking too much or saying the wrong
things. I tend to think of one or two questions to
ask the person and most people are so happy just
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2527J Autism Dev Disord (2017) 47:2519–2534
1 3
to talk about themselves that it stops them shining
a spotlight on me. I find asking questions is the best
deflection and camouflage ever. (Female, 49)
Respondents were often aware that talking only about
themselves and their interests was not socially acceptable
and so developed strict rules to control their self-focused
talk. For some, camouflaging also involved not divulg-
ing personal details about themselves, whether to protect
themselves from being taken advantage of, or to maintain
I say as little about myself as possible as the more I
say, the more likely it is that I say something inap-
propriate OR give away too much information about
myself which can then be used against me. (Other,
I remain silent when I might otherwise have spoken,
knowing that I can’t always tell whether or not my
comments would be welcome. I make generic com-
ments rather than offering specific ones that might
reveal my more unusual traits. (Male, 29)
Respondents also described spending time before
an interaction to prepare topics of conversation, includ-
ing questions to ask, anecdotes to relate, and poten-
tial responses to others. These made them feel more in
control of the interaction, and reassured them that they
would have structured ‘scripts’ to follow rather than hav-
ing to spontaneously ‘chat’:
I usually also think up stories and how whole con-
versations might go before I have them so I have
responses practiced as well as potential things to
say if the conversation ‘dries up’. (Female, 20)
However, it is important to emphasise that not all
respondents developed such structured rules for conversa-
tion; some simply had the goal of speaking as little as pos-
sible in order to get out of the interaction quickly.
In these social situations, I do not talk about any-
thing of interest to me, I avoid talking much and just
pretend to be interested in what people are saying.
(Female, 42)
Consequences ofCamouflaging
“I Fall toPieces”
By far the most consistent consequence of camouflaging
described by respondents was exhaustion. Camouflaging
was frequently described as being mentally, physically, and
emotionally draining; requiring intensive concentration,
self-control, and management of discomfort. The longer
a camouflaging session continued, the harder it became
to maintain the intended level of camouflaging. Many
respondents reported needing time to recover after cam-
ouflaging, where they could be alone and release all of the
behaviours they had been suppressing.
It’s exhausting! I feel the need to seek solitude so I
can ‘be myself’ and not have to think about how I am
perceived by others. (Other, 30)
In addition to this exhaustion, after a camouflaging ses-
sion was over some respondents would experience extreme
anxiety and stress. Respondents felt significant pressure,
whether from themselves or others, to camouflage suc-
cessfully, but many were uncertain of how effective their
camouflaging strategies were. Twenty-one respondents (10
male, 11 female) reported being unsuccessful in their cam-
ouflaging attempts or reported that they had not achieved
the outcomes they intended.
I try to ask them about the things they like, question
after question, to keep conversation going but some-
times it doesn’t work and they leave me. (Female, 27)
Camouflaging therefore often involved a constant moni-
toring of the situation, as if training oneself in self-monitor-
ing, self-awareness, and monitoring others’ reactions, both
during and after the interaction occurred, which induced
stress and even greater anxiety.
My head will be racing as if I’m interpreting another
language. I will be incredibly anxious. It’s like study-
ing for an exam, constantly on edge trying to predict
what others will say and do. (Female, 49)
I hate it. I go over and over and over what they said
and what I said. Did I understand them correctly, did
I respond appropriately, did I make a gaffe? Have I
offended anyone? (Female, 45)
In contrast, a minority of respondents reported feel-
ing satisfied and relieved after camouflaging, particularly
if they felt as though it went well. For these individuals,
camouflaging was rewarding because it enabled them to
achieve what they wanted with minimal effort, whether that
was getting through a necessary social situation, or being
able to make a connection with someone. Interestingly,
60% of those who reported feeling positive or relieved after
camouflaging were male (n = 9, compared to six females),
in contrast to the majority female total sample.
Small sense of achievement and relief that it is over.
(Male, 69)
I am glad that the camouflaging enables me to survive
within myself and accomplish any necessary tasks.
(Male, 62)
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2528 J Autism Dev Disord (2017) 47:2519–2534
1 3
“People Have aStereotyped View”
Many respondents felt that, because their camouflag-
ing changed the way they presented themselves to others,
they did not meet the stereotype of ‘an autistic person
when they camouflaged. In many ways this was construed
as positive, since it allowed them to get on in life, succeed
in jobs and relationships, and achieve many of the aims
they wanted. Some also reported that this enabled them to
challenge commonly held views of autism, especially for
women. By demonstrating good social skills and educating
others about their conditions, respondents hoped to change
the public perception of autism and make others more
People don’t always realise that I have AS, more
likely to be socially accepted, more likely to get a job.
(Male, 28)
I feel that I’m showing the people I work with that
autistic people can have people skills and be good
role models (Female, 28)
Some female respondents (n = 7) suggested that others
were surprised that they had an ASC, since they differed so
much from the public perception of an ASC man with high
maths skills, poor eye contact, and uncommon interests.
So many people have a stereotyped view of what
ASC looks like. They think people with AS are all
geeky, and have little empathy and little insight. They
think people with ASC bore on and on about their pet
subject and make tactless remarks. They don’t realise
that women with ASC tend to internalise things much
more and do have empathy and insight, and are very
careful not to make hurtful remarks. (Female, 56)
However, there were also negative consequences to not
appearing autistic to others. The most striking was that
for some respondents their camouflaging, even if it was
involuntary, resulted in a delay or questioning of their
ASC diagnosis. Respondents reported that parents, teach-
ers, and even clinical professionals refused to believe
they could have an ASC, especially if they were female:
The amount of girls that aren’t diagnosed because
they are more likely to camouflage than boys is
really bad. I went for so long without being diag-
nosed because they didn’t know that I could pretend
to be normal! (Female, 20)
In addition to this, respondents described failing to
receive adequate support or allowances for their ASC
difficulties, because these difficulties were often hidden
behind the mask of camouflaging. Others would therefore
give them more responsibilities or expectations than the
respondent was comfortable with, because of a perceived
level of capability that did not always actually exist.
After beginning graduate school, a lot of issues
arose because I was camouflaging to the point that
my support needs weren’t being met. So, in that
instance, it was detrimental to camouflage. (Female,
I am an SEN teacher and my boss doesn’t know
when I am camouflaging. Currently highly stressed
because she keeps giving me more work and not
realising the stress it is causing. (Female, 44)
For some respondents, this reflected the idea that cam-
ouflaging was not a conscious choice; they described
wanting to control when and how they camouflage to a
greater degree, in order to access support when they
needed it:
People need to learn how to drop the camouflage
when in situations such as medical assessments or
dealing with support professionals otherwise they
may be under assessed for support as they appear to
be coping. (Female, 28)
For others, however, camouflaging was seen as a delib-
erate technique to avoid detection. Thus, increasing gen-
eral awareness of camouflaging strategies by the public,
and particularly by employers, was seen as ‘outing’ an
ASC individual without their consent. These respond-
ents feared that by giving others the tools to identify their
camouflaging, the negative consequences they were try-
ing to avoid would still happen.
If they [employers] can identify camouflaging, then
they will “find us out” and reject us. (Female, 68)
“I’m Not My True Self”
The final consequence reported by respondents was that
camouflaging affected their perception of themselves, in
particular how they represented themselves to the outside
world and their sense of authenticity. For many respond-
ents, by camouflaging their ‘true’ or natural behaviours
they were lying about who they were. This was often
regretted by the respondents, who wanted to be happy as
they were, but felt that the pressures of the typical social
world meant this was not possible.
I don’t care about being different, I like my differ-
ences (apart from things feeling really stressful and
no confidence) but I don’t want to deal with peo-
ples’ negative and sometimes evil reactions. I feel
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2529J Autism Dev Disord (2017) 47:2519–2534
1 3
like the weight of a black cloud is hanging on me
having to be this fake version of me. (Female, 48)
In an extension of this, for some respondents their
camouflaging behaviours contradicted the important role
they attributed to ASC in shaping their identity. Despite
feeling proud of their ASC diagnosis, and the community
they were a part of, they still deliberately camouflaged
the behaviours associated with this diagnosis. These indi-
viduals felt that by hiding their ASC characteristics, they
were betraying the ASC community as a whole.
It’s mentally exhausting constantly having to be
something else, literally never being able to be
myself, and kind of sad too I guess? I even stop
myself doing certain tics and things automatically
when I’m by myself and that kinda sucks, that I’m
not even me on my own. I guess I’m letting down
the side a bit by hiding my autism; I am very vocal
about stigmas and stereotypes with mental illness,
and do talk about my anxiety openly, so I don’t
know why autism is different. (Female, 20)
Some respondents felt that the relationships they
formed through camouflaging were based on deception,
and therefore the relationships themselves were false.
This reinforced experiences of loneliness and isolation,
as they felt no one truly knew them or understood them.
Some also felt bad for deceiving their friends and even
loved ones.
I feel sad because I feel like I haven’t really related
to the other people. It becomes very isolating
because even when I’m with other people I feel like
I’ve just been playing a part. (Female, 30)
I was married for 15 years and was camouflaging
in high gear during that time… My husband would
occasionally say to me that he wondered if I was
really who I was. I think he would get glimpses of
the real me. I didn’t even know who the real me
was… The marriage ended in divorce. (Female, 64)
The situations in which respondents camouflaged were
so extensive for some, they felt that they were losing sense
of who they truly were. Respondents often felt they were
playing so many different roles, it was hard to keep track of
their authentic sense of identity. This increased the anxiety
and stress associated with camouflaging, as individuals lost
a sense of grounding and security in who they were.
Sometimes, when I have had to do a lot of camou-
flaging in a high stress environment, I feel as though
I’ve lost track of who I really am, and that my actual
self is floating somewhere above me like a balloon.
(Female, 22)
This study identified key themes underlying the motiva-
tions, techniques, and consequences associated with social
camouflaging amongst adults with ASC. The vast major-
ity of participants (male, female, and of other genders)
reported camouflaging to some degree, although there
was significant variation in individual experiences of cam-
ouflaging. The results were combined into a model of the
camouflaging process, which we hope will contribute to
the generation of testable hypotheses and identification of
avenues for future research.
The themes revealed two key motivations for camouflag-
ing; assimilation and connection. This suggests that cam-
ouflaging behaviours come from multiple sources. They
may be internally driven by the individual to accomplish
specific goals such as friendships, but they may also be pro-
duced as a response to external demands placed on how a
person should behave in society. The differential influence
of each of these motivations varies between individuals,
but our findings suggest that people are strongly motivated
by wanting to avoid discrimination and negative responses
from others. This conclusion is supported by a recent study
demonstrating that non-autistic individuals judge autistic
people more negatively, and are less willing to interact with
them, even after only brief exposure to the autistic individ-
ual (Sasson etal. 2017). Several participants suggested that
improved education and acceptance of ASC amongst the
general public would improve their social experiences sig-
nificantly, and would allow them to both fit in and increase
their connections without the need to camouflage.
Respondents described a wide variety of techniques
used as part of their camouflaging behaviours, and further
research is needed to determine the extent to which specific
techniques can be generalised to all people who camou-
flage. The two main themes found here, masking and com-
pensation, appear to relate to the motivations of fitting in
and forming connections respectively; respondents used
techniques to mask their ASC in order to appear like other
people around them, and compensated for their social com-
munication difficulties in order to make better connections
with others. However, it remains to be seen whether these
two goals of camouflaging are entirely separate, or whether
the same techniques can be used to further both aims.
There was extensive variation in the consequences of
camouflaging reported, but one of the most striking find-
ings was that the vast majority of participants reported
some unpleasant and unwanted consequences of camou-
flaging. These included the exhaustion experienced during
and after camouflaging, which has been identified in pre-
vious research (Tierney etal. 2016). Our findings suggest
that, if people with ASC want to continue camouflaging
in the ways reported in our study, those supporting them
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2530 J Autism Dev Disord (2017) 47:2519–2534
1 3
should be aware of the associated strains. Time alone to
recover was identified as an important tool to help par-
ticipants continue camouflaging, and could be utilised by
employers and schools to make these environments more
accessible for ASC individuals.
In addition, a profound consequence of camouflaging
was a change in self-perceptions, as detailed by the theme
‘I’m not my true self’. Camouflaging appears to challenge
many participants’ views towards themselves, and produce
negative emotions and attitudes, such as being a ‘fake’ or
losing their identity. It may be that the rigidity of thinking
and scrupulous honesty that are present in many individuals
with ASC leads them to view any change in self-presenta-
tion as false (Chevallier etal. 2012). Regular camouflaging
would consequently increase the individual’s perception of
themselves as a ‘liar’ or inauthentic person, and could lead
to long-term negative impacts on self-esteem. This could
account for the finding that some participants viewed cam-
ouflaging as lying, in contrast to those who viewed it as a
We can only speculate whether differences in partici-
pants’ attitudes towards camouflaging, including the moti-
vations and techniques used, may lead to differences in
the consequences of camouflaging. Interestingly, positive
consequences were reported more frequently by males than
females or those of other genders. This could suggest that
camouflaging is more likely to be a satisfying process for
males with ASC given present gendered social-cultural
contexts; alternatively, it may reflect gender differences
in the actual camouflaging techniques used, which pro-
duce different consequences. However, some participants
reported that their camouflaging strategies were not always
performed successfully; a relatively large proportion of
these participants were male, in contrast to the gender
ratio of the overall sample. There may be a discrepancy
between desire to camouflage and ability to do so, and this
too should be investigated in different genders and across
the entire autism spectrum. The potential gender difference
corresponds well with a recent study showing on-aver-
age lower level of camouflaging and stronger association
between camouflaging and depressive symptoms (i.e. the
more camouflaging, the higher level of depression) in men
with ASC, compared to women with ASC (Lai etal. 2016).
It may be that females with ASC who camouflage tend to
do so more successfully than males.
Previous researchers have suggested that camouflaging
by females with ASC might account for the gender dispar-
ity in diagnosis (Gould and Ashton-Smith 2011; Kreiser
and White 2014; Lai etal. 2015). Our study is not designed
to directly test this idea, or to compare the extent of camou-
flaging between different groups. We found that relatively
equal numbers of males and females, and all individuals
of other genders, reported camouflaging, and no consistent
patterns of differences in camouflaging behaviours between
males and females were identified. However, some female
and other-gender participants argued that camouflaging was
a specific reason for their own or others’ late diagnosis, sug-
gesting that society places higher demands on social ability
and assimilation for people perceived as female. Indeed, a
recent study in elementary school children shows that the
gendered, female social landscape supports ASC girls for
camouflaging (e.g., staying in close proximity to peers) and
therefore if clinicians and teachers rely on a male landscape
to detect ASC characteristics (e.g., social isolation on the
playground), females will tend to be left unidentified (Dean
etal. 2016). Further examination of the impact of camou-
flaging behaviours in all genders is essential to understand
the difficulties in accessing support by those who do not
show a ‘typical’ ASC presentation.
One explanation for the similarities in camouflaging
between males and females found here is that our sample
was self-selecting, in response to a call for participants for
‘a study looking at experiences of coping behaviours in
social situations’. Although previous experience of camou-
flaging was not required to take part in the study, potential
participants might have interpreted the advertisement in
this way. It is therefore possible that our sample comprised
only those people who had experienced camouflaging,
which might include a substantial number of ASC females,
but a smaller proportion of ASC males. The majority of
those who did not take part, because they had never or only
rarely experienced camouflaging, may have more likely
been male. This would account for the high proportion of
female participants in our study, in contrast to previous
research into ASC. Further investigation of camouflaging
behaviours across the entire ASC population would shed
more light on this.
An alternative explanation is that camouflaging is
equally common in males and females with ASC. Previ-
ous research has either theorised that camouflaging is more
common in females (Lai etal. 2011; Wing 1981), has only
included female samples (Bargiela et al. 2016; Tierney
etal. 2016), or has observed on-average more evident cam-
ouflaging in females than males (Dean etal. 2016; Lai etal.
2016). If camouflaging does indeed lead to not receiving
the diagnosis, there may, in fact, be a significant number
of both males and females with ASC missing out on the
support they might need. Future research could test this
possibility by comparing camouflaging levels in males and
females with high ASC traits, but who have not received
an ASC diagnosis. However, this also leads to a point that
was raised by some of the participants who reported not
camouflaging—the concept that if people are camouflaging
so successfully that they are not diagnosed, they may not
need a diagnosis or related support. While this may seem
plausible to those who view camouflaging as a successful,
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2531J Autism Dev Disord (2017) 47:2519–2534
1 3
low-impact strategy, the significant difficulties and uncer-
tainty reported by our participants tell us that people who
camouflage still need to be able to access appropriate
This issue reflects a concern voiced by some partici-
pants, viz. that increasing the awareness of camouflaging in
the general public might actually lead to worse outcomes
for some individuals with ASC. Those participants who
used camouflaging to hide their ASC, especially at work,
often viewed their camouflaging as a defensive strategy
protecting them from discrimination. They worried that if
other people were able to identify camouflaging, the ASC
individual might lose this protection and be treated unfairly.
It remains to be seen how much camouflaging in ASC can
be identified by others. Many participants felt their cam-
ouflaging was at times unsuccessful, or reported occasions
where another person had commented on their techniques.
This concern suggests that research and public education
regarding camouflaging needs to be performed in consulta-
tion with a range of people from the ASC community to
ensure that increasing information helps rather than harms.
More crucially, this concern voiced by some participants
once again emphasises that the outcome of individuals with
ASC does not solely rely on personal characteristics—it
can more fundamentally rely on how the social contexts
treat them. A better person-environment fit is the key, and
this involves ‘treating the environment’ to reduce stigmati-
zation attached to autism and barriers to social life (Lai and
Baron-Cohen 2015).
Strengths andLimitations
One strength of this study was the high proportion of
females and those of non-binary gender, many of whom
were diagnosed later in life. This is an under-represented
population, and it is important to include their voices and
insights, which may be different to those of the majority
male, younger samples included in previous research. How-
ever, because of this our sample was not fully representa-
tive of the entire ASC community. Intellectual ability was
not measured, although it can be assumed that participants
should have had close to or average cognitive abilities in
order to be able to complete the online, text-based survey.
The cognitive and self-reflecting abilities required to com-
plete the survey may also mean that our sample were better
able to perform successful camouflaging behaviours than
others on the autism spectrum.
As a result, our findings cannot be said to represent the
views of those with ASC who also have intellectual disabil-
ity, or who cannot express themselves in written English.
Developing more accessible measures of camouflaging,
such as self-report questionnaires that can be orally or visu-
ally administered, or measures to identify camouflaging
behaviours, would improve our ability to understand cam-
ouflaging across the whole ASC community. This study
was not designed to measure camouflaging behaviours
across the ASC population, but to identify the component
parts of the construct of camouflaging. We hope that with
these results, future research can investigate the functional
and demographic characteristics of those individuals with
ASC who do or do not camouflage, including those with
non-binary gender identities and/or gender dysphoria, char-
acteristics that may also contribute to the need for camou-
flaging, and should be explored in their own right. Larger
and more varied samples of individuals from across the
autism spectrum should be included to further refine our
understanding of camouflaging in the future.
As previously mentioned, our sample only included
adults with a confirmed diagnosis of ASC; it is therefore
possible that those who are most likely to camouflage were
not included in our study as they would not have met the
diagnostic criteria. A typically developing comparison
group was not included in this study due to the difficulty of
operationalising camouflaging for individuals with limited
ASC-related characteristics. However, several participants
reported having camouflaged for years before receiving a
diagnosis later in life, suggesting that our findings have rel-
evance for undiagnosed ASC individuals. Using the behav-
iours and themes identified in this study, descriptions of
camouflaging suitable for the general population can now
be developed. Future research in individuals with high lev-
els of ASC traits, regardless of their diagnosis, may reveal
more about how camouflaging varies between those who
do and do not receive an ASC diagnosis. In addition, fur-
ther qualitative and quantitative research comparing the
camouflaging experiences of individuals from different age
groups may reveal more about how camouflaging develops
and changes across the lifespan.
The inductive nature of this study has resulted in novel
avenues for research, such as focusing on the impact of
camouflaging on identity, which may not have otherwise
been considered. In addition, although camouflaging has
previously been described as mainly a female expression
of ASC, we found that many males and individuals of
other genders also reported camouflaging. A recent study
operationalising camouflaging using existing ASC-related
measures also shows wide variability of the level of cam-
ouflaging in both men and women with ASC, indicating
that camouflaging is not a female-specific phenomenon
(Lai etal. 2016). In the present study, no statistically tested
gender differences in camouflaging behaviours or outcomes
were presented due to the qualitative nature of the data,
and no analysis of the subjective or objective success of
camouflaging attempts was made. However, our findings
have produced the first known conceptual model of camou-
flaging, with key themes and components as identified by
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2532 J Autism Dev Disord (2017) 47:2519–2534
1 3
individuals who camouflage. We hope that future research
in this area will use the themes identified here to develop
precise, testable hypotheses for qualitative or quantita-
tive research into camouflaging and the sex- and gender-
informed phenotypes of ASC.
The next stage of research requires the development of
measures of camouflaging behaviours, in order to stand-
ardise and compare camouflaging experiences between
autistic and non-autistic individuals and allow for follow-
up quantitative research. We hope that the model presented
in this paper, and in particular the behaviours described in
the ‘masking’ and ‘compensation’ themes, will provide a
framework for the development of such a measure. Fur-
thermore, studies delineating component psychological
constructs and interpersonal-contextual processes underly-
ing the themes identified here will deepen our understand-
ing of the mechanisms underlying camouflaging. Eventu-
ally this may lead to novel support strategies and advocacy
that maximise the positive consequences and minimise the
negative consequences of camouflaging—and to attain the
most appropriate person-environment fit for each individual
with ASC.
This study demonstrates that camouflaging of ASC-related
characteristics in social situations may be a common behav-
iour amongst adults with ASC. Camouflaging is motivated
by the desire to fit in with others and to make connections.
The behaviours themselves can be grouped into masking
and compensation strategies. In the short term, camouflag-
ing results in extreme exhaustion and anxiety; although
the aims of camouflaging are often achieved, in the long-
term there are also severe negative consequences affecting
individuals’ mental health, self-perception, and access to
support. Our findings demonstrate that camouflaging is an
important aspect in the lives of many individuals with ASC.
Future research is needed to quantitatively measure camou-
flaging and compare techniques in individuals with ASC of
all genders, to identify demographic and ASC characteris-
tics associated with individual variation in camouflaging
and its outcomes, to uncover underlying psychological and
interpersonal/contextual processes, and to devise strategies
that minimise negative impacts of camouflaging and facili-
tate the realization of maximal individual potential.
Acknowledgments The authors express their thanks to Holly
Walton for auditing the initial analyses. The authors would also like
to thank all those who took part in the study, especially those who
provided comments on the findings. During the period of the study
Meng-Chuan Lai was supported by the O’Brien Scholars Program
within the Child and Youth Mental Health Collaborative at the Centre
for Addiction and Mental Health and The Hospital for Sick Children,
Toronto, Canada; Simon Baron-Cohen was supported by the Autism
Research Trust, Autistica, the MRC and Wellcome Trust, and by
the National Institute for Health Research (NIHR) Collaboration for
Leadership in Applied Health Research and Care East of England at
Cambridgeshire and Peterborough NHS Foundation Trust. The views
expressed are those of the author(s) and not necessarily those of the
NHS, the NIHR or the Department of Health.
Author Contributions LH participated in the design and coordina-
tion of the study, interpreted the data and drafted the manuscript. KVP
participated in the interpretation, and revised the manuscript. CA and
PS conceived of the study, and participated in its design and coordina-
tion. SBC, MCL and WM conceived of the study, participated in its
design, coordination, and interpretation, and revised the manuscript.
All authors read and approved the final manuscript.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict
of interest.
Ethical Approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://, which permits unrestricted
use, distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
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Supplementary resource (1)

... This was also found by Bargiela et al. (2016) who spoke to 14 autistic women and found that these women, who had all received a diagnosis in late adolescence or adulthood, reported camouflaging their autistic behaviours, which was implicated in poor recognition of their need for help. Similar findings were reported by Hull et al. (2017), who interviewed 55 autistic females, 30 autistic males and 7 autistic people who identified as a different gender. Participants in this study commented that females often 'pretend to be normal' and therefore are often overlooked for autism diagnosis. ...
... In terms of possible motivations or predictors for camouflaging behaviour, research has shown both conventional (such as success in the workplace) and relational (such as fitting in with friends) factors may be the driving force (Cage & Troxell-Whitman, 2019). Similarly, Hull et al. (2017) found motivations for camouflaging reported by late-diagnosed autistic women included assimilation and a desire to build relationships. Sex differences have been observed in terms of the motivations for camouflaging, with females citing conventional factors more often than males. ...
... Cook et al., 2021). There is evidence to suggest that camouflaging behaviour is associated with increased self-reported stress and anxiety (Cage & Troxell-Whitman, 2019;Hull et al., 2017). Camouflaging behaviour has also been linked to increased exhaustion for those engaging in this often-effortful strategy (Bargiela et al., 2016). ...
Full-text available
Lay abstract: Many autistic people use strategies that help them adapt in social situations and hide behaviours that may seem different to non-autistic individuals - this is called camouflaging. Camouflaging may help autistic people fit in socially; however, it might also lead to poorer well-being. It has been suggested that autistic females camouflage more than autistic males. This article explored differences between males and females who have an autism diagnosis, have characteristics of autism but no diagnosis and those with few autistic characteristics. It is important to include these groups as camouflaging may make it more difficult to get an autism diagnosis and therefore make it less likely a person will receive support. We found that autistic women camouflaged more than all other groups. The group with few autistic characteristics (males and females) camouflaged the least. Loneliness was found to be a possible reason for camouflaging for the diagnosed autistic group only. In terms of outcomes related to camouflaging, it was found that those who camouflaged most had a lower quality of life; this was true of all groups. This tells us that there may be different reasons to camouflage, and different outcomes related to camouflaging for those with many characteristics of autism (including those with a diagnosis), and those with few. It is important that clinicians, teachers, parents and other stakeholders are aware of the negative outcomes associated with camouflaging so that more support can be provided for those who need it.
... Finally, despite dif culties in social awareness and understanding others' mental states, autistic adults often do experience subjective feelings of judgment and lack of social acceptance related to their symptoms and behaviors (Kapp et al., 2019a). Research investigating the phenomenon of "camou aging," in which autistic individuals mask, hide, or otherwise compensate for their autism features in social interactions, has clearly demonstrated their awareness of the need to change one's behavior to achieve various aims (Hull et al., 2017). ...
... Adults perceive stigma related to autism features and mental health problems, resulting in a heightened desire to "camou age" (Crane et al., 2019;Kapp et al., 2019a). However, these camou aging behaviors come at a high emotional cost, with reports of exhaustion, identity loss, depressive symptoms, and suicidality (Cage & Troxell-Whitman, 2019; Cassidy et al., 2018;Hull et al., 2017). Further, the construct of collective self-esteem, or one's beliefs about how autistic individuals as a group are viewed by society and by oneself, has been linked to personal selfesteem, anxiety, and depressive symptoms in autistic adults (Cooper et al., 2017), further compounding the potential negative effects of perceived stigma. ...
... Whilst this might resemble maladaptive behaviors presented in neurotypical groups, such as difficulties with social functioning precipitates a negative sense of self and disordered eating as proposed by the interpersonal model of binge eating (Wifley et al., 2000), CC serves as a "scaffold" for social behavior (socially adapted behaviors which are achieved through conscious CC strategies; Ullman and Pullman, 2015;Livingston and Happé, 2017). For example, autistic individuals may engage in masking/social camouflaging (suppressing AP behaviors) in an attempt to appear neurotypical (Lai et al., 2016;Hull et al., 2017). Although these strategies potentially facilitate social navigation, they are susceptible to rapid decline and/or maladaptation when faced with stressors (e.g., mental fatigue), and are inflexible to novel or ambiguous situations (Hull et al., 2017;Livingston and Happé, 2017). ...
... For example, autistic individuals may engage in masking/social camouflaging (suppressing AP behaviors) in an attempt to appear neurotypical (Lai et al., 2016;Hull et al., 2017). Although these strategies potentially facilitate social navigation, they are susceptible to rapid decline and/or maladaptation when faced with stressors (e.g., mental fatigue), and are inflexible to novel or ambiguous situations (Hull et al., 2017;Livingston and Happé, 2017). As a result, an individual may "mask" in way which adopts external, socio-cultural influences (e.g., copying anorexic values; Brede et al., 2020). ...
... Some of the participants reported being overwhelmed when presented with these scenarios, and still wanting to come across as 'polite'. Studies have suggested that many autistic adults 'camouflage' their autistic traits by trying to hide behaviour that might be viewed as socially undesirable to seem socially confident and is often motivated by a desire to make friends (Hull et al., 2017;Tierney et al., 2016). ...
Full-text available
Background: Many autistic young people use online devices for social connection and to share interests. However, there is limited research regarding autistic online safety behaviours. Compared with non-autistic children, parental surveys have indicated that autistic young people are less likely to block people and/or online sites. To date, no research has explored autistic young people’s perceptions of their online safety experiences. This qualitative research explored autistic young people’s experiences of communicating with others online, as well as their online safety experiences. Method: Semi-structured interviews were conducted with 14 autistic young people aged 11–17 years (M = 14.0, SD = 2.2), including 8 males (M = 13.9, SD = 2.1) and 6 females (M = 14.5, SD = 2.5). These were conducted face to face (n = 1), phone call (n = 2), or via Skype (n = 8) or live web chat (n = 3). Questions explored factors relating to autistic young people’s online safety experiences. Results: Interpretative Phenomenological Analysis was used to analyse the data. In line with previous studies, autistic young people reported being victims of cyberbullying. Young autistic females reported being subject to online sexual harassment. While participants’ online experi- ences varied, there were commonalities, including a desire for more support to block online comments and/or individuals. Conclusions: Our results support previous findings that autistic young people are subject to online harassment and are not confident blocking unwanted contact from others online. Future in- terventions will be more readily accepted and ecologically valid if they address the unique needs of autistic young people.
... 5 Background 'Masking' (sometimes called 'camouflaging') is an experience frequently reported for many autistic people within multiple different contexts. [1][2][3][4] Masking involves blending in with the neurotypical majority, using intentional or unintentional ways to get by in social situationssuch as developing scripts for conversations, suppressing stimming, or forcing oneself to make eye contact. 5,6 Due to ongoing conceptual discussions, 6,7 we use the term masking in this paper, to respect the term which the autistic community tends to use most often. ...
... These interests are less likely to be perceived as a fixation which increase the risk for under identification of females with ASD (Hiller et al., 2014(Hiller et al., , 2016Mandy et al., 2012;Sutherland et al., 2017). A related aspect is camouflaging (i.e. the use of coping strategies to fit in) which is reported to be more common in females without intellectual disability and has been proposed to contribute to the under identification of females with ASD (Hull et al., 2020;Hull et al., 2017;Lai et al., 2017). Furthermore, the choice of responders may influence the way sex differences are captured by a screening instrument. ...
Full-text available
Existing screening instruments for Autism Spectrum Disorder (ASD) might be prone to detect a male manifestation of ASD. Here, we examined the 17 items from the ASD domain in the Autism-Tics, ADHD and other Comorbidities inventory (A-TAC) for Differential Item Functioning (DIF). Data were obtained from the Child and Adolescent Twin Study in Sweden (CATSS) in which parents have responded to the A-TAC. Information regarding a registered diagnosis of ASD were retrieved from the National Patient Register. The cohort was divided into a developmental sample for evaluation of DIF, and a validation sample for examination of the diagnostic accuracy of the total ASD domain, and a novel male and female short form. Our main finding included the identification of DIF for six items, three favouring males and three favouring females. The full, 17 item, ASD domain and the male and female short form showed excellent ability to capture ASD diagnoses in both males and females up to the age of nine years. The full ASD domain in A-TAC is psychometrically largely equivalent across sex and the limited differences between males and females diminish the need for a sex-specific scoring when utilizing the 17 item total score.
... As such, his social impairments associated with ASD would not be apparent. In order to hide their impairments or difficulties, research has shown that some individuals with ASD may engage in social camouflaging, masking, or compensation (Cook et al., 2021;Hull et al., 2017;Lai et al., 2017;Perry et al., 2022). ...
Julian Assange is an Australian national and the founder of WikiLeaks, a nonprofit organization that publishes news leaks and classified information provided by anonymous whistle-blowers. In May 2019, a United States federal grand jury returned an 18-count criminal indictment against Assange. If convicted, Assange could face up to 10 years of incarceration for each Espionage Act (1917) charge and up to 5 years for conspiracy to access a government computer network. Due to Assange’s current physical location in the United Kingdom, the United States has requested extradition. However, to date, there has been limited scholarly discussion of the relationship between Assange’s autism spectrum disorder (ASD) diagnosis and his potential extradition and lengthy pretrial or postconviction imprisonment in the United States. This article explores the psychiatric submissions from Assange and the United States in light of available evidence on ASD and the risk of suicide among people who are imprisoned. The analysis will focus on common misperceptions about ASD, the particularly detrimental impacts of the prison environment on individuals with ASD, the varying opinions of Assange’s ASD diagnosis, and the importance of considering Assange’s risk of suicide in the context of ASD. From a human rights and individual fairness perspective, a complete understanding of the significance of these issues which does not minimize a diagnosis of ASD is paramount for Assange and any future case with similar elements.
... Future work should examine how a focus on social skills can be embedded within the screening and intervention process of a multi-tiered systems of support approach for autistic children. However, school-based professionals should ensure that any social skills support is driven by students' own social goals and are affirming of neurodiversity, authenticity, and self-determination (Bottema-Beutel et al., 2018;Cage & Troxell-Whitman, 2019) to avoid reinforcing stigma and ableism, inhibiting authenticity, or enforcing masking, which have negative mental health implications (Hull et al., 2017). ...
Autistic students often experience peer relationship difficulties. As peer acceptance and rejection may be malleable over time, we examined predictors of change in peer acceptance and peer rejection among early elementary‐age autistic students. We followed 166 autistic children (mean age: 6.1 years [range: 4–8], 82.5% boys, grades preK‐2nd) longitudinally across 2 school years. Social skills, internalizing problems, and externalizing behaviors were considered as predictors of change in teacher‐rated peer acceptance and rejection, covarying IQ and autism characteristics. Autistic children experienced high rejection and low acceptance; 51.9% of children were rejected by peers in one or both school years. Results revealed distinct predictors for peer acceptance versus rejection: social skills predicted change in peer acceptance across school years, whereas externalizing problems predicted change in peer rejection. Internalizing problems did not predict change in either construct. Findings can assist school professionals in supporting social acceptance and acceptance for young autistic students. The quality of autistic student's relationships with their peers fluctuates across time. With an understanding of the factors that uniquely influence peer acceptance and peer rejection, practitioners can identify targets for intervention to support autistic students development of positive peer relationships. An autistic student's externalizing problems play an important role in the rejection they experience from peers over time, such that autistic students with increasing externalizing behaviors are more likely to experience teasing and difficulty getting along with their peers. On the other hand, autistic students' social skills were the primary factor related to peer acceptance, suggesting that autistic students with improved social skills are better positioned to engage as an integrated, included member of the peer group. The quality of autistic student's relationships with their peers fluctuates across time. With an understanding of the factors that uniquely influence peer acceptance and peer rejection, practitioners can identify targets for intervention to support autistic students development of positive peer relationships. An autistic student's externalizing problems play an important role in the rejection they experience from peers over time, such that autistic students with increasing externalizing behaviors are more likely to experience teasing and difficulty getting along with their peers. On the other hand, autistic students' social skills were the primary factor related to peer acceptance, suggesting that autistic students with improved social skills are better positioned to engage as an integrated, included member of the peer group.
... It would seem that women are more able to use camouflage, even though the desire to do so can concern either gender. People with ASD have suggested that improving the general public's awareness and acceptance of their symptoms would improve their social experiences, their integration and relationships, without having to resort to camouflage to reach these objectives [44]. ...
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The existence of a female phenotype profile in autistic spectrum disorder is one of the current hypotheses to explain the diagnostic discrepancy between men and women. In this context, an international literature review was carried out to evidence and describe the characteristics of restricted interests found in girls with autistic spectrum disorder. A documentary search was conducted on PubMed and a systematic literature review was carried out based on the PRISMA methodology. We selected studies with a population of boys and girls diagnosed as autistic according to the DSM-IV or the DSM-5, in which quantitative and descriptive comparisons of restricted interests, according to gender were carried out. Nineteen studies were found to be relevant. Fifteen enabled a refining of the characteristics of restricted interests among females: fewer restricted interests were identified in comparison with boys, and the autistic girls’ interests seem to be closer to those of neurotypical girls than to those of autistic boys, which thus led to more complex screening. Age and Intelligence quotient seem to be two factors that trigger variations in restricted interests differently according to gender. Representations among professionals also have an impact on diagnoses among girls. For future research, one of the perspectives could be a comparison between girls with autism and neurotypical girls to limit gender bias. The present results contribute to potentially extending knowledge of a female phenotypical profile in autism and show the need to improve the general population’s awareness, to improve health professionals’ training and possibly to revise the diagnostic tools.
Social performances pervade human interactions. Some autistic people describe their social performances as ‘camouflaging’ and engage in these performances to mitigate social challenges and survive in the neurotypical world. Here, we reconsider autistic camouflaging under the unifying framework of impression management (IM) by examining overlapping and unique motivations, neurocognitive mechanisms, and consequences. Predictive coding and Bayesian principles are synthesized into a computational model of IM that applies to autistic and neurotypical people. Throughout, we emphasize the inherently transactional, context-dependent nature of IM, the distinct computational challenges faced by autistic people, and the psychological toll that compelled IM can take. Viewing camouflaging through this lens highlights the pressing needs to change societal attitudes, destigmatize autism, refine social skills-building programs for autistic individuals, and integrate these programs with environment-focused support.
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Individuals with autism spectrum disorder (ASD), including those who otherwise require less support, face severe difficulties in everyday social interactions. Research in this area has primarily focused on identifying the cognitive and neurological differences that contribute to these social impairments, but social interaction by definition involves more than one person and social difficulties may arise not just from people with ASD themselves, but also from the perceptions, judgments, and social decisions made by those around them. Here, across three studies, we find that first impressions of individuals with ASD made from thin slices of real-world social behavior by typically-developing observers are not only far less favorable across a range of trait judgments compared to controls, but also are associated with reduced intentions to pursue social interaction. These patterns are remarkably robust, occur within seconds, do not change with increased exposure, and persist across both child and adult age groups. However, these biases disappear when impressions are based on conversational content lacking audio-visual cues, suggesting that style, not substance, drives negative impressions of ASD. Collectively, these findings advocate for a broader perspective of social difficulties in ASD that considers both the individual’s impairments and the biases of potential social partners.
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Autobiographical descriptions and clinician observations suggest that some individuals with autism, particularly females, ‘camouflage’ their social communication difficulties, which may require considerable cognitive effort and lead to increased stress, anxiety and depression. Using data from 60 age- and IQ-matched men and women with autism (without intellectual disability), we operationalized camouflaging in adults with autism for the first time as the quantitative discrepancy between the person’s ‘external’ behavioural presentation in social–interpersonal contexts (measured by the Autism Diagnostic Observation Schedule) and the person’s ‘internal’ status (dispositional traits measured by the Autism Spectrum Quotient and social cognitive capability measured by the ‘Reading the Mind in the Eyes’ Test). We found that the operationalized camouflaging measure was not significantly correlated with age or IQ. On average, women with autism had higher camouflaging scores than men with autism (Cohen’s d = 0.98), with substantial variability in both groups. Greater camouflaging was associated with more depressive symptoms in men and better signal-detection sensitivity in women with autism. The neuroanatomical association with camouflaging score was largely sex/gender-dependent and significant only in women: from reverse inference, the most correlated cognitive terms were about emotion and memory. The underlying constructs, measurement, mechanisms, consequences and heterogeneity of camouflaging in autism warrant further investigation.
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Autobiographical descriptions and clinician observations suggest that some individuals with autism, particularly females, ‘camouflage’ their social-communication difficulties, which may require considerable cognitive effort and lead to increased stress, anxiety and depression. Using data from 60 age- and IQ-matched men and women with autism (without intellectual disability) we operationalized camouflaging in adults with autism for the first time, as the quantitative discrepancy between the person’s ‘external’ behavioural presentation in social-interpersonal contexts (measured by the Autism Diagnostic Observation Schedule) and the person’s ‘internal’ status (dispositional traits measured by the Autism Spectrum Quotient and social cognitive capability measured by the ‘Reading the Mind in the Eyes’ Test). We found that the operationalized camouflaging measure was not significantly correlated with age or IQ. On average, women with autism had higher camouflaging scores than men with autism (Cohen’s $\textit{d}$=0.98), with substantial variability in both groups. Greater camouflaging was associated with more depressive symptoms in men, and better signal-detection sensitivity in women with autism. The neuroanatomical association with camouflaging score was largely sex/gender-dependent and significant only in women: from reverse inference the most correlated cognitive terms were about emotion and memory. The underlying constructs, measurement, mechanisms, consequences, and heterogeneity of camouflaging in autism warrant further investigation.
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We used Framework Analysis to investigate the female autism phenotype and its impact upon the under-recognition of autism spectrum conditions (ASC) in girls and women. Fourteen women with ASC (aged 22–30 years) diagnosed in late adolescence or adulthood gave in-depth accounts of: ‘pretending to be normal’; of how their gender led various professionals to miss their ASC; and of conflicts between ASC and a traditional feminine identity. Experiences of sexual abuse were widespread in this sample, partially reflecting specific vulnerabilities from being a female with undiagnosed ASC. Training would improve teachers’ and clinicians’ recognition of ASC in females, so that timely identification can mitigate risks and promote wellbeing of girls and women on the autism spectrum.
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Objective: Individuals with autism spectrum disorder (ASD) often experience difficulties in maintaining romantic relationships. In this study high-functioning adults with ASD were examined concerning their romantic relationship interest and experience. Method: Participants, 31 recruited via an outpatient clinic and 198 via an online survey, were asked to answer a number of self-report questionnaires. The total sample comprised 229 high-functioning adults with ASD (40% males, average age: 35 years). Results: Of the total sample, 73% indicated romantic relationship experience and only 7% had no desire to be in a romantic relationship. ASD individuals whose partner was also on the autism spectrum were significantly more satisfied with their relationship than those with neurotypical partners. Severity of autism, schizoid symptoms, empathy skills, and need for social support were not correlated with relationship status. Conclusion: Our findings indicate that the vast majority of high-functioning adults with ASD are interested in romantic relationships.
Studies assessing sex/gender differences in autism spectrum conditions often fail to include typically developing control groups. It is, therefore, unclear whether observed sex/gender differences reflect those found in the general population or are particular to autism spectrum conditions. A systematic search identified articles comparing behavioural and cognitive characteristics in males and females with and without an autism spectrum condition diagnosis. A total of 13 studies were included in meta-analyses of sex/gender differences in core autism spectrum condition symptoms (social/communication impairments and restricted/repetitive behaviours and interests) and intelligence quotient. A total of 20 studies were included in a qualitative review of sex/gender differences in additional autism spectrum condition symptoms. For core traits and intelligence quotient, sex/gender differences were comparable in autism spectrum conditions and typical samples. Some additional autism spectrum condition symptoms displayed different patterns of sex/gender differences in autism spectrum conditions and typically developing groups, including measures of executive function, empathising and systemising traits, internalising and externalising problems and play behaviours. Individuals with autism spectrum conditions display typical sex/gender differences in core autism spectrum condition traits, suggesting that diagnostic criteria based on these symptoms should take into account typical sex/gender differences. However, awareness of associated autism spectrum condition symptoms should include the possibility of different male and female phenotypes, to ensure those who do not fit the ‘typical’ autism spectrum condition presentation are not missed.
In order to shed more light on why referred girls are less likely to be diagnosed with autism spectrum disorder than boys, this study examined whether behavioral characteristics influence the probability of an autism spectrum disorder diagnosis differently in girls versus boys derived from a multicenter sample of consecutively referred children aged 2.5–10 years. Based on information from the short version of the Developmental, Dimensional and Diagnostic Interview and the Autism Diagnostic Observation Schedule, 130 children (106 boys and 24 girls) received a diagnosis of autism spectrum disorder according to Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) criteria and 101 children (61 boys and 40 girls) did not. Higher overall levels of parent-reported repetitive and restricted behavior symptoms were less predictive of an autism spectrum disorder diagnosis in girls than in boys (odds ratio interaction = 0.41, 95% confidence interval = 0.18–0.92, p = 0.03). In contrast, higher overall levels of parent-reported emotional and behavioral problems increased the probability of an autism spectrum disorder diagnosis more in girls than in boys (odds ratio interaction = 2.44, 95% confidence interval = 1.13–5.29, p = 0.02). No differences were found between girls and boys in the prediction of an autism spectrum disorder diagnosis by overall autistic impairment, sensory symptoms, and cognitive functioning. These findings provide insight into possible explanations for the assumed underidentification of autism spectrum disorder in girls in the clinic.
This study examined the extent to which gender-related social behaviors help girls with autism spectrum disorder to seemingly mask their symptoms. Using concurrent mixed methods, we examined the social behaviors of 96 elementary school children during recess (autism spectrum disorder = 24 girls and 24 boys, typically developing = 24 girls and 24 boys). Children with autism spectrum disorder had average intelligence (IQ ⩾ 70), a confirmed diagnosis, and were educated in the general education classroom. Typically developing children were matched by sex, age, and city of residence to children with autism spectrum disorder. The results indicate that the female social landscape supports the camouflage hypothesis; girls with autism spectrum disorder used compensatory behaviors, such as staying in close proximately to peers and weaving in and out of activities, which appeared to mask their social challenges. Comparatively, the male landscape made it easier to detect the social challenges of boys with autism spectrum disorder. Typically developing boys tended to play organized games; boys with autism spectrum disorder tended to play alone. The results highlight a male bias in our perception of autism spectrum disorder. If practitioners look for social isolation on the playground when identifying children with social challenges, then our findings suggest that girls with autism spectrum disorder will continue to be left unidentified.