Understanding and recognising the female phenotype of autism spectrum disorder and the “camouflage” hypothesis : a systematic PRISMA review

Purpose: Females with ASD may display superficial social skills which may mask their autism spectrum disorder (ASD) symptomology impacting on the identification of the disorder – known as the “camouflage” hypothesis. Compared to males with ASD, it is increasingly recognised that females with ASD have a stronger ability to imitate behaviour which is socially acceptable, particularly those females who have higher cognitive abilities (i.e., intelligence considered to be within the normal range) (Ehlers & Gillberg, 1993). Design/methodology/approach: This present paper will explore the literature on camouflaging or masking behaviour in females with ASD. A systematic PRISMA review was conducted. Findings: The capacity to ‘camouflage’ social difficulties in social situations is considered to be one of the main features of the female phenotype of ASD (e.g., Kenyon 2014). Social imitation or camouflaging enables some level of success and coping which results in some females never receiving a diagnosis of ASD. They typically may not exhibit any observable functional impairments. However, under the surface of the camouflage, females may experience high levels of subjective stress, anxiety and exhaustion and a need to re-charge or recuperate by withdrawing from any social interaction. Practical implications: There is a need for the development of a camouflaging measure. Research limitations/implications: There is a relatively little understanding and knowledge of the female phenotype of ASD. This lack of understanding and knowledge impacts significantly on the ability to identify females with ASD (Lai et al., 2015; Bargiela et al., 2016) which can have a number of negative consequence (Adamou et al., 2018; NICE, 2012). Originality/value: There is a real need for further research exploring the positive and negative impact of the phenomenon of ‘camouflaging’, or ‘pretending to be normal’ in females with ASD