Autism Spectrum Conditions (ASC)1
are atypical developmental conditions characterised by impairments in social interaction and communication, alongside unusually 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 specified cut-off point, when present with concurrent functional impairments, used to identify the clinical diagnosis (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 difficulties. In this paper we will refer to these behaviours as ‘camouflaging’.
While many neurotypical people, of all genders, manage 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 subclinical. However, self-reported evidence suggests possible categorical differences between autistic and non-autistic camouflaging. For instance, camouflaging by ASC individuals has been reported as extremely effortful and challenging to one’s identity (Bargiela et al. 2016
), unlike ordinary reputation management in typically developing individuals.
Camouflaging has also been proposed as an explanation for the missed or late diagnosis of females with ASC, as part of the female phenotype or behavioural presentation (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 ascertainment 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 clinical services. Females are less likely to receive a diagnosis 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 intellectual 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 misdiagnosed 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 contribute 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 Matson 2011
). For instance, males with ASC are more likely to experience externalising difficulties such as hyperactivity 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. 2016
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 diagnostic 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 different 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 perception that individuals function well and do not experience any problems, even though those individuals still experience 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. Teachers 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 minimise this difference, until their children receive a diagnosis and they recognise the symptoms within themselves (Holliday 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 ‘pretending to be normal’, yet knowing that something was different about her (Holliday Willey 2015
). In case studies of girls with ASC, researchers have suggested that the use of social imitation strategies may lead to missed, late, or questioned 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 acting 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 interaction 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 concerning 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 camouflage their ASC contributes to them achieving socially desirable outcomes. Individuals who are better able to camouflage 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 extensive 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, strenuous, 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 successful camouflaging may lead to anxiety for individuals with ASC. Camouflaging is not necessarily a beneficial behaviour, and should not be regularly expected or encouraged for individuals with ASC, as this may risk increasing mental health problems. It is therefore important to study camouflaging in order to better understand the individual differences 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 individuals with ASC. Tierney, Burns, and Kilbey (2016
) interviewed ten adolescent girls with ASC about their experiences of camouflaging, and revealed some common themes including the uncertain, exhausting nature of the social environment; the desire to make friends which motivated camouflaging attempts; and using explicit techniques to mask ASC-related difficulties. Similar themes were also found during qualitative interviews with late-diagnosed women with ASC (Bargiela et al. 2016
). In particular, 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 camouflaging behaviours in both children and adults with ASC has also been developed. Behavioural observations suggest that girls camouflage their social difficulties (e.g. by staying 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 objectively 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 individual 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 identify as male, and a significant number of ASC individuals 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 cannot progress until a conceptual model of camouflaging has been produced, so that subsequent research has strong theoretical 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 individuals with ASC rather than the preconceptions of researchers or clinicians, and that our understanding of camouflaging is representative of a broad range of individuals with 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 measurement development to further explore camouflaging quantitatively.
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 motivations for camouflaging, techniques used, the impact that camouflaging has for the individual, and their overall attitudes to camouflaging. The aim of the study was to derive a conceptual model of camouflaging to inform future research.
The following research questions were addressed:
What are the techniques used and what do people with ASC think camouflaging is?
Why do people camouflage their ASC?
What are the consequences of camouflaging?
This study identified key themes underlying the motivations, techniques, and consequences associated with social camouflaging amongst adults with ASC. The vast majority of participants (male, female, and of other genders) reported camouflaging to some degree, although there was significant variation in individual experiences of camouflaging. 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 camouflaging; assimilation and connection. This suggests that camouflaging 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 produced 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 individual (Sasson et al. 2017
). Several participants suggested that improved education and acceptance of ASC amongst the general public would improve their social experiences significantly, 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 camouflage. The two main themes found here, masking and compensation, 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 communication 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 findings was that the vast majority of participants reported some unpleasant and unwanted consequences of camouflaging. These included the exhaustion experienced during and after camouflaging, which has been identified in previous 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 should be aware of the associated strains. Time alone to recover was identified as an important tool to help participants 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-presentation 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 camouflaging as lying, in contrast to those who viewed it as a performance.
We can only speculate whether differences in participants’ attitudes towards camouflaging, including the motivations 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 produce 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-average 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 disparity 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 camouflaging 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, suggesting 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 camouflaging 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 camouflaging 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. Previous 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 camouflaging 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, low-impact strategy, the significant difficulties and uncertainty reported by our participants tell us that people who camouflage still need to be able to access appropriate support.
This issue reflects a concern voiced by some participants, 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 camouflaging 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 consultation 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 stigmatization 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. However, because of this our sample was not fully representative 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 complete 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 disability, or who cannot express themselves in written English. Developing more accessible measures of camouflaging, such as self-report questionnaires that can be orally or visually administered, or measures to identify camouflaging behaviours, would improve our ability to understand camouflaging 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, characteristics that may also contribute to the need for camouflaging, 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 relevance for undiagnosed ASC individuals. Using the behaviours and themes identified in this study, descriptions of camouflaging suitable for the general population can now be developed. Future research in individuals with high levels 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, further 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 camouflaging 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 camouflaging, with key themes and components as identified by 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 quantitative 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 standardise 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. Furthermore, studies delineating component psychological constructs and interpersonal-contextual processes underlying the themes identified here will deepen our understanding of the mechanisms underlying camouflaging. Eventually 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.