Wood-Downie, H; Wong, B; Kovshoff, H; Mandy, W; Hull, L; Hadwin, JA; (2020) Sex/Gender Differences in Camouflaging in Children and Adolescents with Autism. Journal of Autism and Developmental Disorders 10.1007/s10803-020-04615-z.

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Abstract

This study investigated sex/gender differences in camouflaging with children and adolescents (N = 84) with and without an autism diagnosis/increased levels of autistic traits using two conceptualisations/operationalisations of camouflaging. A significant group-by-gender interaction using ANCOVA, with the covariate of verbal IQ, reflected similar levels of social reciprocity in autistic and neurotypical females, whereas autistic males had lower reciprocity than neurotypical males. Autistic females also had higher reciprocity than autistic males, despite similar levels of autistic traits (behavioural camouflaging). Additionally, autistic males and females had similar theory of mind skills, despite females having increased reciprocity (compensatory camouflaging). These findings provide evidence of increased camouflaging in autistic females, which may contribute to delay in the recognition of difficulties and provision of support. Autism is a neurodevelopmental condition characterised by difficulties with social interaction and communication, as well as restricted and repetitive patterns of behaviour, activities and interests (American Psychiatric Association 2013). Autism is diagnosed in approximately 1% of the population and this diagnosis is made more frequently and earlier in development in males than females, with a reported approximate ratio of four males to every female (Fombonne 2009). Relatively recent large-scale population studies have, however, reported a ratio of approximately three males to every female (e.g., Baxter et al. 2015; Loomes et al. 2017; Zablotsky et al. 2015). This shift in recognition of autism in females fits with a growing body of research which reflects an increased clinical awareness of the female autism phenotype (Lai et al. 2016). This research suggests that autism may manifest differently between sexes/gendersFootnote1, and has led some researchers to suggest there may be a female-specific phenotype of autism (e.g., Lai et al. 2015). Research studies have increasingly aimed to explore the possibility that there may be a differential phenotypic profile in autism between males and females (e.g., Hull et al. 2019a; Lai et al. 2016; van Ommeren et al. 2017). Camouflaging, defined as strategies used to appear less autistic in social interactions (Hull et al. 2017), is argued to be a key feature of the female autisticFootnote2 phenotype (Hull et al. 2019a; reviews by Hull et al. 2020; Wood and Wong 2017). This sex/gender difference may increase challenges to identify females with autism and contribute to the later diagnosis for this group (e.g., Begeer et al. 2013; Giarelli et al. 2010). Late diagnosis in general, and camouflaging in particular, have been associated with increased mental health difficulties (e.g., Hull et al. 2019b; Lai and Baron-Cohen 2015) and a risk marker for suicidality (Cassidy et al. 2018). It is therefore important to investigate sex/gender differences in camouflaging to facilitate earlier identification and planning of specialised support for females (Lai et al. 2016). Several qualitative studies have explored the experiences of females diagnosed with autism and these have resulted in rich and detailed accounts of camouflaging (e.g., Bargiela et al. 2016; Cridland et al. 2014; Hull et al. 2017; Tierney et al. 2016). For example, Tierney et al. (2016) interviewed ten female adolescents with autism to explore their experiences of social relationships. All participants described using ‘masking’ strategies to appear more socially competent, which were often motivated by a desire for friendship. However, adolescents further indicated that the use of these cognitively demanding strategies resulted in adverse psychological consequences. For example, one adolescent described an ‘identity crisis’, attributed to ‘pretending to be the same as everyone else’ (Tierney et al. 2016, p. 79). In a further study, Cridland et al. (2014) interviewed three autistic female adolescents, their mothers, and two other mothers who also had autistic daughters. All the autistic females reported experiencing difficulties developing and maintaining friendships. In addition, maternal reports suggested that these challenges resulted, to some extent, from a reliance on imitation during childhood in an attempt to mask underlying social difficulties (Cridland et al. 2014). Similar themes were found in a study that involved interviewing 14 autistic women diagnosed in late adolescence or adulthood (Bargiela et al. 2016). Detailed accounts of ‘pretending to be normal’ (p. 3287) were given in which young adults reported using explicit strategies to fit in with peers. These included using learnt phrases and facial expressions from TV, books and magazines, social imitation, and masking autistic traits. In addition, eight women indicated that when they were teenagers, their peers were noticeably more advanced in their social abilities, leading to difficulties forming friendships and feelings of rejection. Many women also reported having experienced a mental health condition, with depression, anxiety and eating disorders being the most common. Hull et al. (2017) interviewed 92 autistic adults of all genders about camouflaging, which often was motivated by a similar desire to fit in and connect with others. In addition, adults reported that camouflaging resulted in both negative (e.g. exhaustion, loss of identity) and, for a minority of participants, positive (e.g., connecting with others) consequences (Hull et al. 2017). In this research, camouflaging was reported in a similar number of males and females, as well as participants who identified as non-binary. However, it did highlight sex/gender differences in the techniques used for, and the consequences of, camouflaging.

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