The art of camouflage and gender differences in autism–late diagnosis
This blog follows on from previous blogs I’ve published on autism that can be found here and here.
Many years ago I noticed that I was able to behave like a chameleon, I didn’t know if it was a particularly good or bad thing to do, I just knew I was astonishingly good at it. I could go from one situation to the next and just blend in, people would hardly notice I was there; I would spend a short time observing people so that I could work out what was needed in the new situation then I would do it.
This blog highlights the traits, usually seen in females, without cognitive impairment (IQ>70). What I’m about to explain may also be seen in males, this may lead to them receiving a late or no diagnosis, it’s just seen more often in females.
Until recently autism has been viewed as a male disorder and even, for a short period an “extreme male brain” theory was used to understand the disorder. However, as more understanding is developed, research is finding that autistic females tend to be able to camouflage their symptoms of autism and use compensatory behaviours that mask their social challenges.
Research has shown that there are a number of first impressions that people with ASD often present that can be negative. For example, atypical vocal prosody, unusual use of co-speech gestures, atypical facial expressivity, and general “awkwardness”. However, research has shown that to naïve individuals, during a short “get-to-known-you”, conversation, females with or without ASD gave a similar first impression where as males with ASD were not able to mask their symptoms. In this research the autistic females were matched to autistic males with similar ADOS-2 (Autism Diagnostic Observation Schedule) calibrated severity scores i.e. when assessed by expert clinicians their autism traits were reproducible.
As the autistic child grows up, even if they attempt to echo or mimic behaviours other people do, they lack the understanding to inform the social interactions. I remember doing my utmost to try to “blend in” and get it as right as I could, I just had a sense people would like me more if I was the same as them and so I just laughed and nodded along even when I didn’t understand…
Research shows that children in the playground tend to split into gender groups. Typically developing girls play socially together giving girls with autism opportunities to play on the periphery and they’re seen to weave in and out “practicing” masking their autism (even though this is unconscious at the time). Typically developing boys would play organised games, where as boys on the spectrum would spend time on their own.
In an assessment when asked “how do you manage eye contact?” A young lady answered:
Well, I look at them and then when they look away, I look away and wait a couple of seconds and then look back for a few seconds. You have to make sure you don’t look at them for too long, nor look away for too long and count a few seconds each time.
To most people, her social interaction when it came to eye contact would have looked “normal” but she had no idea that eye contact was meant to feel natural. She was treating it as though it was a mathematical puzzle to be figured out. She was managing all her social interactions as thought they were puzzles and she was exhausted!
I find eye contact horribly awkward but I worked out a long time ago that I can manage it more comfortably (i.e. it’s slightly less painful) when the other person is talking) so I tend to look away while I’m talking and look back when the other person is talking. That way, I’m doing some eye contact but I’m not forcing myself to do it all the time… a compromise I hope no one notices…!
…In fact, I don’t really understand why it’s considered normal to stare at someone’s eyeballs…
John Elder Robison
A prominent feature seen in some people with autism is an intense special interest. Firstly, this isn’t needed to meet the diagnostic criteria for autism (see here) so it may not be present at all. Secondly, females may have an intense, age appropriate feminine special interest that is overlooked, for example, if a teenage girl said she was into make-up, this could be seen as fairly standard. But if she’s categorised every brand of eye-shadow, foundation, blusher and bronzer by ingredients and has cross-referenced all the shades of her favourite brands in excel, I think you’d see this isn’t just a standard interest in make-up.
Females who spend time watching other females in order to mask their social awkwardness may be aware that they’re different but may find it very difficult to manage their differences all the time. I’ve always felt like I’m one step behind everyone else, desperately peddling to catch up but never quiet making it and I’ve never known why!
Due to the way society traditionally sees males and females—if a female has a shy, quiet, anxious nature and has a desire to stick to routine it’s more likely to be overlooked and accepted as their natural character. If a female struggles with loud sounds or bright lights, it’s accepted that they’re simply more sensitive. If a male has similar struggles, they are more likely to be pathologised. Females are more likely to be tolerated as quirky, there may be less pressure on them to perform academically. Of course, these are generalisations and don’t apply to everyone but small adjustments can traditionally enable females with ASD to “hide”.
Stimming is repetitive body movement or movement of objects (lining up cars/pencils). This is, again, not necessary for a diagnosis of autism (see here) so may not be present, but it may look different in females because it may be more subtle. Females are more likely to turn their behaviours inwards. Females may do small movements with their fingers or bite the inside of their cheeks rather than make large rocking movements that impact other people. For example, I have a compulsion to click pens but I know that would impact other people so I press the top so to the point of feeling the springy movement over and over but the sound doesn’t annoy the people around me. There’s scant research exploring these behaviours, they’re not just limited to autism.
All of these features added together, it’s not surprising females are growing up without a diagnosis. Females are even having to ask to be assessed by experts who understand that female autism presents differently. But the landscape is changing and I’m just trying to do my bit to spread understanding.
Blending in, masking, camouflaging, hiding our autistic traits comes at a price. Initially, it simply feels exhausting but as well as the late diagnosis, females with autism can also feel as though they don’t know who they are; if they’re covering up their traits, who would they be if they let loose?! Females can also pay with their mental health, it’s very common for undiagnosed females for be mis-diagnosed with personality disorders but also have co-morbid depression, anxiety and eating disorders.
However, with the relief of a diagnosis comes acceptance and liberation, a feeling that it’s ok to be different! A sense of belonging to a community of people who have the same struggles. I’m glad I’m able to blend in when I need to, it’s got my jobs and I’m able to socialise to some degree, I consider myself fortunate to have (to some extent!) these skills. I’m now enjoying having the freedom to be myself a little bit more, but I’m still able “to chameleon” if I need to!
