Citation
Lai, M.-C., Lombardo, M.V., Ruigrok, A.N.V., Chakrabarti, B., Auyeung, B., Szatmari, P., Happé, F. & Baron-Cohen, S., & MRC AIMS Consortium (2017). Quantifying and exploring camouflaging in men and women with autism. Autism, 21(6), 690–702. doi: 10.1177/1362361316671012
Key findings
- This was the first study to operationalise and quantify camouflaging in autism using a discrepancy method: camouflaging was measured as the gap between a person’s “internal” autistic status (self-reported traits via the Autism Spectrum Quotient plus mentalising ability via the Reading the Mind in the Eyes Test) and their “external” behavioural presentation (scored on the ADOS).
- Autistic women showed significantly higher camouflaging scores than autistic men, with a large effect size (Cohen’s d = 0.98). Despite similar self-reported autistic traits and similar mentalising scores, women appeared less autistic on the ADOS.
- Camouflaging scores were not correlated with age or IQ, suggesting that camouflaging is not simply a function of cognitive ability or life experience.
- Greater camouflaging was associated with more depressive symptoms in men with autism, and with better signal-detection sensitivity in women — suggesting that the correlates of camouflaging may differ by gender.
- Neuroanatomical analysis (exploratory) found that the neural correlates of camouflaging were largely sex/gender-dependent and significant only in women, with associated brain regions related to emotion processing and memory.
Method in brief
The study used data from 60 autistic adults (30 men, 30 women), matched for age and IQ, all diagnosed per DSM-IV/ICD-10 criteria, without intellectual disability. Camouflaging was calculated by standardising and comparing internal (AQ + RMET) and external (ADOS) measures. Mental health was assessed using the Beck Anxiety Inventory and Beck Depression Inventory. A subset also underwent structural MRI for exploratory neuroanatomical analyses.
Relevance
This paper is a landmark in camouflaging research for several reasons. It was the first to provide a quantitative measure of camouflaging, moving beyond qualitative description. It provided the first robust evidence that autistic women camouflage more than autistic men, a finding that has been replicated across multiple subsequent studies and has significant implications for diagnostic practice.
The finding that camouflaging is associated with depression in men is clinically important and often overlooked — the narrative around camouflaging has tended to focus on women, but men who camouflage may face distinct risks.
For diagnostic practice, the paper’s central implication is stark: the ADOS — the gold-standard diagnostic observation — may systematically underestimate autism in people who camouflage effectively, particularly women. This has direct consequences for diagnostic equity.
Limitations
- The sample was limited to autistic adults without intellectual disability, and findings cannot be generalised to the broader autistic population.
- The discrepancy method assumes that self-report (AQ) and cognitive testing (RMET) capture “internal” autistic status accurately, which is debatable — self-report is influenced by self-awareness, and the RMET has known ceiling effects.
- The study was cross-sectional, so causality cannot be inferred — it is unknown whether camouflaging causes depression or whether those with depressive tendencies are more likely to camouflage.
- The sample size (n = 60) was modest, particularly for the neuroanatomical analyses, which should be considered exploratory.
- The study used a binary male/female categorisation and did not include non-binary or gender-diverse participants, despite subsequent evidence that non-binary autistic people may also camouflage at high rates.