Camouflaging in Autism - A Systematic Review - Accepted Manuscript

Running Head: CAMOUFLAGING IN AUTISM 1
Camouflaging in autism: A systematic review
Julia Cook1, Laura Hull1, Laura Crane2 and William Mandy1
1 Research Department of Clinical, Educational, & Health Psychology, University College London, UK
2 Centre for Research in Autism and Education (CRAE), UCL Institute of Education, University College
London, UK
DOI: https://doi.org/10.1016/j.cpr.2021.102080
© 2021. This accepted manuscript version is made available under the CC-BY-NC-ND 4.0
license https://creativecommons.org/licenses/by-nc-nd/4.0/
Author Note
Julia Cook https://orcid.org/0000-0002-8984-6656
Laura Crane https://orcid.org/0000-0002-4161-3490
Laura Hull https://orcid.org/0000-0002-8289-2158
William Mandy https://orcid.org/0000-0002-3564-5808
Correspondence concerning this article should be addressed to Julia Cook, Research Department of
Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place London
WCIE 6BT, UK. Email: [email protected]

Highlights
 Current approaches to measuring camouflaging appear to measure ‘camouflaging intent’ and
‘camouflaging efficacy’.
 Adults with more self-reported autistic traits report greater engagement in camouflaging.
 Sex and gender differences exist in camouflaging.
 Higher self-reported camouflaging is associated with worse mental health outcomes.
 Study designs are limited by poor participant characterisation and representativeness.

Abstract
Some autistic people employ strategies and behaviours to cope with the everyday social
world, thereby ‘camouflaging’ their autistic differences and difficulties. This review aimed to
systematically appraise and synthesise the current evidence base pertaining to autistic
camouflaging. Following a systematic search of eight databases, 29 studies quantifying
camouflaging in children and adults with autism diagnoses or high levels of autistic traits were
reviewed. The multiple methods used to measure camouflaging broadly fell under two different
approaches: internal-external discrepancy or self-report. These approaches appear to relate to
two distinct but potentially connected elements of camouflaging: observable behavioural
presentations and self-perceived camouflaging efforts. While significant variation was noted
across individual study findings, much of the existing literature supported three preliminary
findings about the nature of autistic camouflaging: (1) adults with more self-reported autistic
traits report greater engagement in camouflaging; (2) sex and gender differences exist in
camouflaging; and (3) higher self-reported camouflaging is associated with worse mental health
outcomes. However, the research base was limited regarding participant characterisation and
representativeness, which suggests that conclusions cannot be applied to the autistic
community as a whole. We propose priorities for future research in refining the current
understanding of camouflaging and improving measurement methods.
Keywords: Autism, Camouflage, Camouflaging, Social Behaviour, Gender, Mental Health

Camouflaging in autism: A systematic review
Autism Spectrum Disorder (henceforth ‘autism’) is a neurodevelopmental condition diagnosed
on the basis of early onset social communication and social interaction difficulties as well as restricted
and repetitive interests, activities and behaviours (American Psychiatric Association, 2013). Some
autistic people1 employ strategies and behaviours to adapt to, and cope within, the everyday social
world, thereby ‘camouflaging’ their autistic differences and difficulties (Attwood, 2007). Camouflaging in
autism is the focus of a rapidly growing body of research; much of which aims to quantify camouflaging
in children and adults as well as test associations between camouflaging and various other constructs
including gender, age, autistic traits, anxious/depressive symptoms, and cognitive abilities. Currently, a
lack of consensus exists regarding many of these associations. Recent discussions and commentaries
highlight potential problems within the field including variations in operationalisations and
measurement approaches, under-established validity and reliability across measures, and a lack of
representativeness within study samples (Fombonne, 2020; Lai et al., 2020; Williams, 2021). The
current systematic review provides a comprehensive and critical evaluation of the current camouflaging
research base; identifying consistencies in the current evidence as well as issues that require further
research.
Although definitions of camouflaging are still evolving, here we define camouflaging (also
variously referred to in the literature as compensation, masking and adaptive morphing) as the
employment of specific behavioural and cognitive strategies by autistic people to adapt to or cope
within the predominately non-autistic social world (Cook, Crane, Hull et al., 2021; Hull et al., 2017; Lai et
al., 2011; Lawson, 2020; Livingston & Happé, 2017; Pearson & Rose, 2021). Camouflaging may enable an
1
We used identity first language (e.g., autistic person) in this paper given that it is the preference of most autistic
people (Kenny et al., 2016), is less associated with stigma (Gernsbacher, 2017) and is less discriminatory towards
disabled people (Bottema-Beutel et al., 2021).
individual to, consciously or unconsciously, present a non-autistic social style, hide autistic
characteristics, and/or minimise the visibility of social difficulties (Hull et al., 2017; Lawson, 2020). Such
strategies can involve masking autistic behaviours and/or employing compensatory strategies to
overcome social difficulties (Hull et al., 2019; Livingston, Shah, & Happé, 2019). Common examples of
camouflaging strategies include supressing repetitive hand movements, forcing eye contact, using
conversational scripts, and using learned rules to respond to others’ non-verbal behaviour. A related
concept that evolved concurrently with camouflaging is that of compensation (Livingston & Happé,
2017). Compensation has a more specific focus on cognition and refers to the use of alternative
cognitive routes to demonstrate a less autistic behavioural presentation despite persisting autism-
related difficulties or differences in cognition (e.g., in social reasoning). Within the literature,
compensation is generally (but not always) theorised to fall under the broader phenomena of
camouflaging (Hull, Petrides, & Mandy, 2020; Livingston, Shah, & Happé, 2019). For clarity, in this review
we use the term camouflaging to refer to compensation, masking, and adaptive morphing, since this
term is most commonly used in the included research. However, we acknowledge that some autistic
people prefer other terms (Lawson, 2020; Pearson & Rose, 2021) and support calls for researchers in the
field to consult with the autistic community regarding terminology moving forward (Lai et al., 2020).
Descriptions of camouflaging first appeared in clinical and autobiographical writings; usually to
describe and explain the presentation of autistic girls and women, as well as the often-under-recognised
diagnostic and support needs of this group. Autistic girls and women (and some boys and men) were
described as using social strategies to adapt to the demands of their social environment, thereby
camouflaging their social difficulties and differences (Attwood, 2007). Initially, these strategies were
thought to predominately involve the effortful performance of non-autistic social behaviour, learnt over
time through careful observation and imitation (Attwood, 2007; Gould & Ashton-Smith, 2011; Kopp and
Gillberg, 1992; Holliday Willey, 1999). However, this often exhausting and stressful camouflaging was
seen as masking rather than resolving underlying social difficulties.
These clinical and autobiographical writings stimulated qualitative research aimed at
conceptualising camouflaging by exploring the lived experiences of autistic girls and women (e.g.,
Cridland et al., 2014; Bargiela et al., 2016; Tierney et al., 2016), but also boys, men, and non-binary
people (e.g., Hull et al., 2017; Livingston, Shah, & Happé 2019). Across this research, autistic people
provided rich and detailed accounts of camouflaging, significantly advancing the field. Importantly,
findings suggested that many autistic people of all genders use a diverse range of camouflaging
behaviours and strategies in navigating the predominately non-autistic world, often at great personal
cost.
A burgeoning body of cross-sectional quantitative work has now emerged, designed to test
important hypotheses generated by the qualitative camouflaging literature. In seeking to operationalise
and measure camouflaging, several novel measurement methods developed in parallel. These methods
broadly fall under two categories: internal-external discrepancy and self-report approaches (Hull et al.,
2019). Internal-external discrepancy approaches focus on quantifying the degree to which an
individual’s autistic social difficulties or differences are camouflaged during an interaction; that is,
quantifying the difference between an individual’s ‘true’ autistic state and their observable behavioural
presentation (e.g., Lai et al., 2017, 2019). In contrast, self-report approaches focus on quantifying an
individual’s use of specific camouflaging strategies or behaviour via self-reflection (e.g., Hull et al., 2019,
Livingston et al., 2020). Using both internal-external discrepancy and self-report approaches,
quantitative research has focused on the following questions, which form the basis of the present
systematic review.
Is camouflaging associated with having high autistic traits or an autism diagnosis?
In conceptualising camouflaging, it is important to understand the extent to which camouflaging
is specific to autism (Lai et al., 2020). Autistic people report camouflaging to gain employment and
education, develop and maintain friendships and romantic relationships, and avoid bullying and
ostracism (Cage & Troxell-Whitman, 2019; Hull et al., 2017). Non-autistic people similarly use social
behaviour to create desirable social impressions and facilitate positive outcomes in interactions with
others (i.e., impression management or self-presentation behaviours; Goffman 1959; Leary, 1995).
However, compared to most non-autistic people, autistic people are more likely to experience a
mismatch between their natural way of being and the demands of the social environment; the
consequence of which may be stigmatisation and discrimination (Botha & Frost, 2020; Lai & Baron-
Cohen, 2015; Mandy, 2019; Perry et al., 2021). Aspects of camouflaging may be unique to autism since
camouflaging represents an attempt to manage this mismatch between a person’s autistic way of being
and the non-autistic social environment. Thus, in further refining the construct of camouflaging, it is
important to investigate the degree to which camouflaging likely varies as a function of autism
diagnosis. Additionally, autism is increasingly viewed as a dimensional condition, representing one end
of a continuum of traits that extend throughout the general population (Robinson et al., 2016). On this
basis, related to the question of whether autism is specific to those with an autism diagnosis, it is also
useful to investigate whether camouflaging likely varies in those without an autism diagnoses, in line
with variability in autistic traits (Hull et al., 2017).
Are there sex or gender differences in camouflaging behaviours?
The role sex and gender play in camouflaging is increasingly debated (Fombonne, 2020; Lai et
al., 2020; Pearson & Rose, 2021). Nonetheless, camouflaging is often discussed in relation to female
sex/gender and offered as partial explanation for increased rates of missed or late diagnosis found
amongst this group (e.g., Duvekot et al., 2017; Dworzynski et al., 2012; Head et al., 2014; Kirkovosi et al.,
2013; Lai & Baron-Cohen, 2015; Lehnhardt et al., 2016; Shattuck et al., 2009; Whitlock et al., 2020). To
date, much of this discussion has focused on male-female sex/gender differences without consideration
of non-binary genders. One possibility is that due to sex-related differences in cognitive profiles, autistic
females may have an enhanced ability to camouflage compared to autistic males (Lehnhardt et al.,
2016). Alternatively, compared to autistic boys/men, autistic girls/women may feel more pressure to fit
in socially via camouflaging, because of gender-based societal expectations and socialisation experiences
(Kreiser & White, 2014; Pearson & Rose, 2021). A further possibility is that autistic individuals of all sexes
and genders, including those outside the gender binary, may engage in similar levels of camouflaging
due to a mismatch in person-environment fit and related stigma and discrimination. In moving the field
forward, it is important to establish a consensus regarding the role of sex and gender in camouflaging.
Are particular cognitive abilities or processes associated with camouflaging?
A considerable degree of heterogeneity exists amongst autistic people regarding general
cognitive ability as well as specific cognitive strengths and weakness (Charman, 2011). Relevant to
conceptualising camouflaging is the need to investigate cognitive abilities associated with camouflaging.
IQ and executive functioning, in particular, have been hypothesised as supporting camouflaging via the
facilitation of compensatory cognitive strategies (e.g., using learned social rules or scripts; Livingston,
Colvert, et al., 2019). It is therefore useful to explore if individual differences in such cognitive abilities
account for variability in camouflaging amongst autistic people.
Is camouflaging related to current age or age at diagnosis?
In conceptualising camouflaging, it is important to understand changes in camouflaging across
the lifespan. Qualitative research suggests that children, adolescents, and adults engage in
camouflaging, although perhaps to varying degrees (e.g., Dean et al., 2017; Halsall et al., 2021; Hull et
al., 2017). Age-related fluctuations in camouflaging may relate to, for example, changes in cognitive
development, social demands and experiences, and mental health; all of which likely occur throughout
development and into adulthood (Hull, Petrides, & Mandy, 2021). Moreover, age-related changes in
constructs that may be related to camouflaging (e.g., impression management) are known to occur in
non-autistic people (e.g., Pledger, 1992). Thus, in further characterising camouflaging, it is important to
investigate the degree to which camouflaging varies with age. Additionally, a later age at diagnosis may
be associated with a greater tendency to adapt to social demands and camouflage social difficulties (Lai
& Baron-Cohen, 2015). Alternatively, having had additional time to form a strong autistic social identity,
those diagnosed younger in life may feel less pressure to conform to non-autistic social standards via
camouflaging (Cage & Troxell-Whitman, 2020). To better understanding fluctuations in camouflaging
across the lifespan, it is important to consider the role of age at diagnosis.
What is the relationship between camouflaging and mental health or wellbeing outcomes?
Consistently high rates of mental health problems are found amongst autistic people across the
lifespan (Lever & Geurts, 2016; Simonoff et al., 2008), which are associated with lower social and
adaptive functioning (Moss et al., 2015), employment and educational difficulties (Keen et al., 2016;
Lounds Taylor et al., 2015), and poorer quality of life (Adam et al., 2019). In the qualitative camouflaging
literature, autistic people consistently describe camouflaging as being exhausting and associated with
feelings of anxiety, stress, sadness, and identity confusion (Bargiela et al., 2016; Hull et al., 2017; Tierney
et al., 2016). Camouflaging may be one factor that makes autistic people more vulnerable to mental
health problems. Thus, investigating links between camouflaging and mental health is important in
improving the well-being and life opportunities of autistic people.
Previous Reviews
Given the early nature of camouflaging research, a lack of consensus remains regarding many of
the aforementioned questions. Previous reviews, focused on camouflaging in autistic females, provide
partial insights. In an early examination of the field, Alley (2019) reviewed eight studies to identify and
explore camouflaging in autistic females. More recently, a systematic review of 13 studies was
conducted by Tubío-Fungueriño (2021). This latter review examined camouflaging in autistic females
with a focus on the camouflaging process, as well as camouflaging causes and consequences. Finally,
Hull, Petrides, & Mandy (2020) completed a narrative review of research examining the female autism
phenotype and camouflaging. Across these three reviews, preliminary evidence suggested that for
autistic females: camouflaging abilities may be associated with self-control, empathy, and/or feedback
abilities; motivators of camouflaging may include societal expectations and feelings of loneliness or
isolation; and consequences of camouflaging may include late findings cannot be generalised to
individuals of all sexes and genders.
Moreover, recent discussions and commentaries (Fombonne, 2020; Lai et al., 2020; Williams
2021) have highlighted several potential problems within camouflaging literature that have not been
addressed in the above reviews. First, significant variations in the operationalisation and measurement
of camouflaging may mean that making comparisons between, and drawing conclusion across, studies is
difficult. Second, advancement of the field requires the establishment of valid and reliable measures of
camouflaging; yet, at the time of earlier reviews, much of this work was still ongoing. Third, a lack of
representativeness in study samples may limit the extent to which findings can be generalised to the
wide range of people on the autism spectrum. To date, no review has systematically identified and
described methods of measuring camouflaging, nor has it systematically examined the measurement
properties of these methods. Further, no review has systematically examined and described the
characteristics of participants included in camouflaging studies. Thus, a critical evaluation of
camouflaging research related to all sexes and genders is now needed to identify consistencies in the
current evidence as well as gaps that require further research.
The Present Review

The present systematic review aims to: systematically review studies quantitatively examining
camouflaging in children and adults of all sexes and genders who have an autism diagnosis or high
autistic traits; report detailed summary information on the characteristics of study participants;
summarise measurement methods, including measurement properties; and assess the quality of
studies. In addition, to identify consistencies within the current evidence base as well as avenues for
future research, we examine and summarise study findings based on the five aforementioned research
questions.
Review Methods
Search Strategy and Selection Criteria
This review protocol was registered online with PROSPERO, the international prospective
register of systematic reviews (registration number: CRD42019141410). Our review proceeded as
planned except that one research question (“Is camouflaging associated with having high autistic traits
or an autism diagnosis?”) was added after the search, in response to multiple studies presenting data on
camouflaging, autistic traits, and diagnostic status. The most current version of the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for conducting systematic reviews
was followed throughout the review process (Page et al., 2021). In consultation with a bioscience and
psychology subject librarian, the following databases were searched from inception to October 2020 for
publications on autism and camouflaging: Medline (Ovid), Embase (Ovid), APAPsycINFO (Ovid), Web of
Science and Scopus. The search strategy involved a combination of keywords and controlled vocabulary
terms and was modified for use with each database (see Appendix A for search strategies). No filters,
restrictions, or limits were applied at this stage. To identify additional unpublished and emerging
research, a targeted search of the following grey literature databases was conducted using keywords in
October 2020: ProQuest Dissertations and Theses Global, Google Scholar, and PsyArXiv. Experts in the
field and authors of relevant theses, conference abstracts/proceedings, and preprint articles were then
contacted to identify any full text articles accepted (but not yet published) in peer reviewed academic
journals. An updated search employing the same initial search methods was then conducted on 13th
May 2021. Reference lists of included studies and relevant past systematic reviews were manually
checked for additional relevant research. References were managed using Endnote and Rayyan (Ouzzani
et al., 2016). Duplicates were removed iteratively using Endnote’s duplication identification strategy,
and then manually.
JC initially screened the titles and abstracts of all identified articles using broad
inclusion/exclusion criteria to ensure any potentially relevant publications were retained for further
evaluation. Publications included at this stage discussed any aspect of camouflaging in any population.
No publication or language restrictions were applied. After exclusion of research according to these
broad criteria, the full texts of remaining publications were evaluated for inclusion independently by JC
and LH. Studies adhering to the inclusion criteria in Table 1 were included in the review. Discrepancies
regarding the eligibility of studies were reconciled between JC and LH, with WM and LC.
[insert table 1 here]
Data Extraction
Using a standardised form developed for this study, data on study information, participant
characteristics, methods of measuring camouflaging, and study results were extracted for studies
meeting the inclusion criteria. Each author independently extracted data for ≈25% of included studies.
Each author then cross-checked data for a separate ≈25% of included studies. Discrepancies were
discussed and resolved via consensus. Missing data were requested from study authors.
Quality Assessment
Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT; Hong et al., 2018).
The MMAT is designed for use in mixed studies reviews and is suitable for use with qualitative research,
randomized controlled trials, non-randomized studies, quantitative descriptive studies and mixed
methods studies. The five quality criteria applied to studies using the MMAT vary according to study
design. Outcomes for each criterion are defined as ‘yes’ meets criteria, ‘no’ does not meet criteria, or
‘can’t tell’ where appropriate information was not reported. In line with current literature suggesting
that summed quality scores do not provide a meaningful index of study quality (e.g., Herbison et al.,
2006), the authors of the MMAT discourage the calculation of an overall quality score for each study and
instead suggest that a more detailed description of the criterion ratings are presented. Each study was
independently rated by two reviewers (i.e., either JC and LC or WM and LH). Reviewers did not assess
studies for which they were also authors, with the exception of one study (Cook, Crane, Bourne et al.,
2021) on which all four reviewers were authors. To ensure consistency, pairs of reviewers met
separately and then as a whole group to discuss their interpretation and application of each of the
MMAT criteria regarding the included studies. Discrepancies in ratings were discussed and resolved by
consensus.
Results
Overview of Included Studies
As can be seen in Figure 1, after removal of duplicates, 2160 unique citations were screened for
eligibility, of which 104 full-text articles were reviewed and 29 studies were identified as eligible for
inclusion in the systematic review. Where additional analyses of study data were presented across
multiple articles, all articles were included. Six of the studies included in the two previous systematic
reviews (Allely, 2019; Tubío-Fungueiriño et al., 2021) did not quantitatively measure camouflaging and
thus were not included in the current review (see Appendix B for further details).
[insert Figure 1 here]
Details of included studies are provided in Tables 2, 3, 4, and 5. Eighteen of the included studies
examined camouflaging in adults, and 11 examined camouflaging in children and adolescents. Studies
were either open to individuals worldwide to participate (but conducted in English; n=9) or were
restricted to individuals located in the UK (n=10), USA (n=8), Australia (n=1), or Poland (n=1). The
majority of studies (n = 23) involved solely quantitative methodologies and a further three used mixed
methods designs (Cage et al., 2018; Jedrzejewska & Dewey, 2021; Livingston et al., 2020). Three studies
involving chiefly qualitative design were included because each included a quantitative measure of
camouflaging (Cook, Crane, Bourne et al., 2021; Hull et al., 2017; Livingston, Shah, & Happé et al., 2019).
Quality Assessment
Results of the quality assessment using the MMAT are detailed in full in Appendix C. Although
the overall quality of included studies was sound, several specific methodological issues were common
across the quantitative and mixed-methods studies. Most studies failed to gain a representative sample
of autistic participants (n = 23) and/or did not provide a description of participant flow (e.g., an
indication of the number of people who started, but failed to finish, an online questionnaire; n = 17).
Less common methodological issues included: failing to consider or account for any potential between-
group differences in demographic variables, in design or analysis (n=10); failing to control for autistic
traits in analyses between autistic and non-autistic groups (n=2); using measures not designed for
autistic people/a specific age group of autistic people and failing to provide information regarding the
suitability of these measures and/or failing to provide reliability data for these measures with the study
sample (n=4); and using an ad hoc method of quantifying camouflaging or compensation, that is,
providing participants with camouflaging or compensation scores based on text responses to open
ended questions (n=2).
Participant Characteristics
Table 2 provides an overview of participant characteristics for participants with autism
diagnoses or high autistic traits. There were four sets of studies in which samples were partially or fully
duplicated (Hull et al., 2019; Hull, Lai, et al., 2020; Hull, Levy, et al., 2021; Jorgenson et al., 2020;
Bernardin et al., 2021; Lai et al., 2017, 2019; Livingston, Shah, & Happé, 2019; Livingston et al., 2020). In
these instances, only information from one study (the study with the largest N) was counted when
calculating aggregated participant characteristics. In total, 2254 autistic adults (clinically diagnosed or
self-identifying) and adults with high levels of autistic traits were included across all studies (sample
sizes ranged from N=17 to N=354). Adults ranged in age from 16 to 82 with a mean age of 36.47 years.
The majority of participants reported female sex or identified as women2 (60.1%) and were formally
diagnosed with autism (95.9%). Further characterisation of adult participants was generally poor. Most
participants in the eight studies reporting ethnic group/race were white (86.1%). General anxiety
(54.8%) and depression (53.1%) were common amongst participants in the five studies reporting co-
occurring mental health conditions. Participants were typically diagnosed in adulthood (M=32.98 years)
across the seven studies reporting mean age at diagnosis. Only four studies measured IQ and
participants in these studies were of average to above average intelligence (Full Scale IQ, M=112.35).
Most studies recruited adult participants via advertisements distributed through social media, autism
charities and support groups, and/or research databases.
Child and adolescent samples ranged from N=33 to N=236 with a total of 1077 children and
adolescents with an autism diagnosis or high levels of autistic traits included across all studies.
Child/adolescent participants ranged in age from 5 to 18 years with a mean age of 11.90 years. Most
participants were of male sex or identified as boys3 (62.9%) and were formally diagnosed with autism
(94.7%). Mean Full Scale IQ was in the average range (99.93). Further characterisation of
child/adolescent participants was frequently lacking. Most participants in the two studies reporting
ethnic group/race were white (75.8%). Almost half of the participants in the one study reporting
2
In describing sex and gender of participants, adult studies reported: gender only (n = 8); sex and gender (n = 3);
sex only (n = 2). In the remaining two studies it was unclear if the measurement of sex/gender reported referred to
sex or gender.
3
In describing sex and gender or participants, child studies reported sex only (n = 6); what was termed sex/gender
by authors (n = 2); and gender only (n = 2). In one study it was unclear if measurement of sex/gender reported
referred to sex or gender.
comorbidities had co-occurring diagnoses (40.7%). Studies recruited child and adolescent participants
via a variety of means including via autism and mental health clinics, research centres and databases,
schools, birth records, a social skills trial, social media, and word of mouth. Specific participant
characteristics reported in each included study are in Appendix D.
[insert Table 2 here]
Camouflaging Measures
Included studies quantified camouflaging using two different measurement approaches:
internal-external discrepancy approaches, or self-report approaches. A range of terms (i.e., masking,
camouflaging, and compensation) were used to describe measures. Throughout this review, we used
the term camouflaging to refer to the related concepts of camouflaging, compensation, and masking.
However, to ensure accuracy when describing specific study measures, we use the terminology used by
the relevant study authors in this section.
Internal-External Discrepancy Approaches
As can be seen in Table 3, three adult studies and six child/adolescent studies used internal-external
discrepancy approaches. Internal-external discrepancy approaches aim to measure camouflaging by
quantifying differences between internal (‘true’) autistic states and observable behavioural
presentations (Lai et al., 2017, 2020). Across studies, various self- or parent-report measures of autistic
traits and/or performance-based measures of social cognition were used as proxy measures of ‘true’
autistic status while observer/computer rated measures of social behaviour were used to assess
external behavioural presentation. Two studies calculated individual camouflaging scores by quantifying
the difference between individuals’ scores on a self-report measure of autistic traits/a performance-
based measure of Theory of Mind (ToM) and an observer rated measure of social behaviour (Lai et al.,
2017, 2019). One study calculated individual camouflaging scores by quantifying the difference between
individuals’ scores on a self-report measure of autistic traits and an observer-rated measure of social
behaviour (Schuck et al., 2019). Three studies classified participants into distinct compensation or
‘compensatory camouflaging’ ability groups (e.g., high, low, deep, or unknown) based on scores on
performance-based measures of ToM (splitting participants based on the median or mean score of the
sample or the median score of a non-autistic reference group) and observer rated measures of social
behaviour or reciprocity (splitting participants on median or mean scores of the sample; Corbett et al.,
2020; Livingston, Colvert, et al., 2019; Wood-Downie et al., 2020). Four studies compared differences
between groups hypothesized to differ in camouflaging ability (i.e., boys and girls) in parent-rated social
communication skills/autism characteristics and observer rated social behaviour/s or reciprocity (Parish-
Morris et al., 2017; Ratto et al., 2018; Rynkiewcz et al., 2016; Wood-Downie et al., 2020). Two of these
studies further explored camouflaging-related differences in the quality of social behaviour exhibited by
autistic girls and boys by comparing differences in social behaviour between autistic and non-autistic
girls and autistic and non-autistic boys (Parish-Morris et al., 2017; Wood-Downie et al., 2020).
Self-Report
As can be seen in Table 4, 19 studies used self-report measures of camouflaging. Self-report approaches
aim to measure camouflaging by quantifying individuals’ self-perceived engagement in camouflaging.
One additional study used a parent-report measure of masking. The precise nature of these self-report
and parent-report methodologies and instruments varied significantly between studies.
Nine adult studies and four child/adolescent studies used the Camouflaging Autistic Traits
Questionnaire (CAT-Q; Hull et al., 2019). The CAT-Q is a 25-item self-report questionnaire designed to
measure camouflaging strategies and behaviours (e.g., “I adjust my body language or facial expressions
so I appear relaxed”) across three subscales (compensation, masking, and assimilation) with higher
scores indicating greater levels of camouflaging. Items on the CAT-Q were developed based on a
qualitative study exploring the camouflaging experiences of autistic adults. The CAT-Q was validated in a
sample of 832 autistic and non-autistic adults (Hull et al., 2019). Test-retest reliability reported in the
validation study was good (r=0.77). Internal consistencies for the Total CAT-Q and subscale scores in
included studies ranged from α =0.79 to α =0.94. Whilst yet to be validated for use with autistic
adolescents, four studies using the CAT-Q involved adolescent samples (Bernadin et al. 2021; Hull,
Petrides, & Mandy, 2021; Jedrzejewska & Dewey, 2021; Jorgenson et al., 2020). Internal consistency for
the total CAT-Q and subscale scores ranged from α = 0.81 to α = 0.91 across these four studies. One
study also included a modified version of the CAT-Q measuring camouflaging strategies and behaviours
used in the social media environment (Jedrzejewska & Dewey, 2021).
Two studies used modified versions of the Girls Questionnaire for Autism Spectrum Conditions
(GQ-ASC; Attwood et al., 2011). One study used the Questionnaire for Autism Spectrum Conditions (Q-
ASC) - a version of the GQ-ASC modified for use with males and females (Ormond et al., 2018). The
Masking subscale on Q-ASC measures a parent’s perception of their child’s masking behaviours via five
items (e.g., “Does s/he have a facial ‘mask’ that hides his/her social confusion?”). Internal consistency
for the Social Masking scale was α =.61. Another study used a version of the GQ-ASC modified for use
with women (Brown et al., 2020). The camouflaging scale on this version of the GQ-ASC includes four
items measuring self-reported engagement in camouflaging behaviours (e.g., “I adopt a different
persona in different situations”). The structure of this version of the GQ-ASC was investigated using
principal components analysis in a sample of 672 autistic and non-autistic women. Internal consistency
for the Camouflaging subscale was 𝜔= 0.67.
Livingston et al. (2020) used the Compensation Checklist, a list of 31 strategies (e.g., “Mimic
phrases, gestures, facial expressions, tone of voice picked up from other people and/or TV/film/book
characters”) divided in to four categories (masking, shallow compensation, deep compensation, and
accommodation) created based on a qualitative study of compensatory strategies (reported in
Livingston, Shah, & Happé, 2019). Individuals in the same dataset (reported in Livingston et al., 2020)
were then given compensation scores based on the number of times they referenced specific
compensation strategies and behaviours in their text responses with greater compensation scores
indicating a higher number of strategies and behaviours referenced. The greatest lower bound
reliability for the Total Compensation Score was glb = 0.82.
Authors in three studies created a single question or short sets of questions to measure
camouflaging. Cassidy et al. (2018) created a set of four questions measuring engagement in
camouflaging (yes/no), camouflaging areas (e.g., work, educational settings, social gatherings, etc.),
camouflaging frequency (i.e., percentage of social situations a person is camouflaging in), and
camouflaging amount (i.e., amount of the day spent camouflaging). Scores were summed for
camouflaging areas, frequency, and amount; with higher total scores indicating more camouflaging.
Reported internal consistency for the questions was α=.75. Cage and Troxell-Whitman (2019) measured
the frequency with which participants engaged in two overarching camouflaging contexts (formal and
interpersonal contexts) identified from an initial set of 22 camouflaging contexts. Participants were then
classified into three groups: consistently low camouflagers (camouflaging low in both contexts);
switchers (camouflaging high in one context but low in the other); and consistently high camouflagers
(camouflaging high in both contexts). Internal consistency for the set of camouflaging contexts was
α=0.95. Hull et al. (2017) included a single item quantitatively measuring engagement (yes/no) in
camouflaging.
Two studies provided quantitative data measuring camouflaging generated from qualitative
data sets. One study provided quantitative data regarding the number of participants who
spontaneously reported camouflaging in text responses to questions about autism acceptance and
mental health (Cage et al., 2018). Another study provided quantitative data regarding the total number
of participants who endorsed themes, three of which were types of compensation behaviours or
strategies (i.e., shallow compensation, deep compensation, and behavioural masking) in text responses
to open ended questions about compensation (Livingston, Shah, & Happé, 2019).
Study Findings
An overview of the camouflaging evidence base is shown in Table 5. Results regarding specific study
findings are described and discussed further below, based on the five identified research questions.
Again, to ensure accuracy when describing specific study measures, we use the camouflaging
terminology used by the relevant study authors in this section.
Is Camouflaging Associated with having High Autistic Traits or an Autism Diagnosis?
Adults. Four studies examined associations between camouflaging, diagnostic status, and/or autistic
traits in adults using self-report measures. Overall, results suggested that higher levels of self-reported
camouflaging are associated with having an autism diagnosis or higher autistic traits in adult samples.
In a large sample of adults, formally diagnosed autistic individuals scored higher than non-
autistic individuals on the CAT-Q Total and subscale scores (Hull et al., 2019). Associations between CAT-
Q subscale scores and autistic trait severity varied somewhat in this sample. However, higher overall
scores on the CAT-Q were associated with higher autistic traits for both formally diagnosed and non-
autistic individuals. Autistic (formally diagnosed and self-identifying) and non-autistic adults similarly
described either deep compensation, shallow compensation, or behavioural masking strategies at least
once in text responses to open ended questions (Livingston, Shah, & Happé, 2019). However, formally
diagnosed autistic individuals described a greater total number of compensation strategies compared to
non-autistic individuals (Livingston et al., 2020). This association was not maintained after accounting for
autistic traits and education, suggesting that the relationship between camouflaging and autism
diagnosis may be driven by autistic traits. Finally, in a large sample of cisgender and transgender
women, formally diagnosed autistic women scored higher than non-autistic women on the
Camouflaging subscale of the modified GQ-ASC (Brown et al., 2020). However, higher scores on the
Camouflaging subscale were only associated with higher autistic traits for non-autistic women.
A further three studies examined associations between self-reported camouflaging and social
concepts related to diagnosis: autistic identity, experiences of autism acceptance, disclosure, and
stigma. Across these studies, evidence suggested that experiences of stigma and not feeling accepted by
others was associated with increased camouflaging (Cage et al., 2018; Perry et al., 2021) whilst high
autistic identification and open disclosure of one’s diagnosis may be associated with reduced
camouflaging (Cage & Troxell-Whitman, 2020).
Children and Adolescents. In child and adolescent samples, two studies used self-report
measures to compare camouflaging between autistic and non-autistic adolescents. Results across these
two studies were inconsistent. Jorgenson et al. (2020) found that while autistic and non-autistic
adolescents displayed some variation regarding CAT-Q subscales, autistic adolescents did not score
more highly overall on the CAT-Q than non-autistic adolescents. In contrast, Jedrzewska & Dewey
(2021) reported that autistic adolescents demonstrated significantly higher Total CAT-Q scores than
non-autistic adolescents in offline (but not online) settings.
Are there sex or gender differences in camouflaging behaviours?
Adults. Nine of the included studies using adult samples reported data relating to sex or gender
differences in camouflaging using internal-external discrepancy or self-report approaches. Five of these
studies examined gender differences, two examined sex differences, and two examined what they
termed sex/gender differences. To ensure accuracy, when describing study results, we use the sex or
gender terms used by the relevant study authors. Results across these studies varied, but evidence from
five of the nine studies suggested that those reporting male sex or identifying as men camouflaged less
than those reporting female sex or identifying as women. Additionally, results from one study suggested
that those reporting non-binary genders camouflaged more than those identifying as men (Perry et al.,
2021).
Results of three exploratory studies using predominately qualitative methodologies were not
suggestive of sex or gender differences in camouflaging (Cage et al., 2018; Hull et al., 2017; Livingston et
al. 2020). However, results of four studies using psychometrically rigorous methods of quantification
(i.e., continuous rating scales) generally supported sex or gender differences. When examining sex
differences in camouflaging frequency and pervasiveness, compared to autistic males, autistic females
reported camouflaging across more situations, more frequently and for more of the time (Cassidy et al.,
2018). Regarding gender, Hull, Lai, et al. (2020) found that autistic women demonstrated higher Total
CAT-Q scores than autistic men after accounting for age and autistic-like traits. Gender differences in
self-reported camouflaging between men, women, and non-binary people were not found, however, the
sample was underpowered for non-binary people. Perry et al. (2021) also reported that gender was a
suggestive predictor of camouflaging such that identifying as female or non-binary predicted higher
Total CAT-Q scores. However, Cage and Troxel-Whitman (2019) found no gender differences on the
Total CAT-Q score between autistic men or women.
The two studies investigating what they termed sex/gender differences using the internal-
external discrepancy approach found that autistic women demonstrated higher camouflaging scores
than autistic men (Lai et al., 2017; Schuck, et al., 2019).
Children and Adolescents. Nine of the included studies reported data related to sex or gender
differences in camouflaging in autistic children and adolescents. Five studies reported sex differences;
two reported gender differences; and two studies reported what the authors termed sex/gender
differences. Again, findings were mixed, but evidence from seven of the nine studies suggested that
through childhood and adolescence, those reporting female sex or identifying as girls camouflage more
than those reporting male sex or identifying as boys.

Across five internal-external discrepancy studies investigating sex or sex/gender differences,
autistic females with high autistic traits and/or autism diagnoses demonstrated less autistic social
behaviour than males with autistic traits and/or autism diagnoses, despite having equivalent (or poorer)
social communication skills, autistic traits, and ToM abilities (Corbett et al., 2020; Parish-Morris et al.,
2017; Ratto et al., 2018; Rynkiewcz et al., 2016; Wood-Downie et al., 2020). In contrast, Livingston,
Colvert, et al. (2019) found no gender differences between compensation groups, although the sample
was underpowered for females.
More variation existed across the three studies using self/parent-report methodologies.
Regarding sex, autistic females engaged in more parent-reported masking behaviours than autistic
males on the Masking subscale of the Q-ASC (Ormond et al. 2018). Similarly, autistic and non-autistic
adolescents identifying as female gender reported engaging in more camouflaging online (using the
CATO-Q) than those who identified as male gender (Jedrzejewska & Dewey, 2021). However, no sex or
gender differences were found for autistic adolescents using the CAT-Q in offline contexts (Jorgenson et
al., 2020; Jedrzejewska & Dewey, 2021).
Are particular cognitive abilities or processes associated with camouflaging?
Adults. The two small-scale studies exploring associations between camouflaging and cognitive
abilities in autistic adults via internal-external discrepancy measurement approaches yielded
inconsistent results.The sole adult study reporting data on camouflaging and IQ found no association
between camouflaging and Full-Scale IQ, Verbal IQ, or Performance IQ (Lai et al., 2017). With regard to
executive functioning abilities, Schuck et al. (2019) found no relationship between camouflaging and
executive functioning, while Lai et al. (2017) suggested that higher camouflaging scores may be
associated with better executive functioning abilities for autistic women but not autistic men.
Children and Adolescents. Four included studies examined relationships between cognitive
abilities and camouflaging in children and adolescents using internal-external discrepancy and self-
report measurement approaches. Results regarding associations between camouflaging and IQ were
inconsistent. However, there was some evidence to suggest that higher camouflaging was associated
with better executive functioning abilities.
Three studies used internal-external discrepancy approaches to stratify children/adolescents
into compensation ability groups. Livingston, Colvert, et al. (2019) found high compensators
demonstrated significantly higher Full Scale IQ and Verbal IQ (but not Non-Verbal IQ) scores than low
compensators. Similarly, using a smaller sample, Wood-Downie et al. (2020) reported a non-significant
trend towards high ‘compensatory camouflagers’ demonstrating higher Full Scale IQ scores compared to
low ‘compensatory compensators’. However, Corbett et al. (2020) found no differences between high
and low camouflagers on Verbal IQ or Performance IQ. The one study using a self-report methodology
with adolescents found no relationship between self-reported camouflaging on the CAT-Q and Full-Scale
IQ (Hull, Petrides, & Mandy, 2021), although it should be acknowledged that this study was only
powered to detect large effects.
Regarding executive functioning, Livingston, Colvert, et al. (2019) reported that high
compensators demonstrated better executive functioning abilities than low compensators. Hull,
Petrides and Mandy (2021) found that fewer executive functioning difficulties predicted greater total
self-report camouflaging on the CAT-Q.
Is camouflaging related to current age or age at diagnosis?
Adults. Five studies examined relationships between age and camouflaging in autistic adults.
Four of these studies found no relationship between camouflaging and age, or age at diagnosis, using
either internal-external discrepancy (Lai et al. 2017) or self-report measures (Cage & Troxell-Whitman,
2019, Cassidy et al., 2018; Livingston et al. 2020). However, the one self-report study using a validated
measure of camouflaging found that age, and age at diagnosis, may be associated with camouflaging
such that older age suggestively predicted lower total CAT-Q scores while older age at diagnosis
suggestively predicted higher total CAT-Q scores (Perry et al., 2021).
Children and Adolescents. A further four articles presented data on age and camouflaging in
children and adolescents. No evidence was found to support a relationship between camouflaging or
compensation and age in autistic adolescents using either internal-external discrepancy approaches
(Livingston, Colvert, et al., 2019) or self-report measures (Hull, Petrides, & Mandy, 2021; Jorgenson et
al., 2020). However, the one study comparing masking across different developmental stages suggested
that autistic adolescents (13-19 years) displayed higher parent-reported levels of masking than autistic
children (5-12 years; Ormond et al., 2018).
What is the relationship between camouflaging and mental health and wellbeing outcomes?
Adults. Ten of the identified studies explored associations between camouflaging and well-being
and/or mental health in adults using internal-external discrepancy and self-report approaches. Overall,
significant evidence from eight of these ten studies supported a relationship between increased self-
reported camouflaging and poorer mental health.
Initial studies, employing a variety of self-report methodologies, provided mixed support for an
association between camouflaging and mental health. Spontaneously reported camouflaging (in text
responses to questions about autism acceptance and mental health) was associated with higher
depression, but not anxiety or stress scores (Cage et al., 2018). Self-reported camouflaging on a set of
four items predicted suicidality after controlling for a range of additional factors, but it was not
associated with a self-reported diagnosis of depression or an anxiety disorder (Cassidy et al., 2018).
Camouflaging in more environments or contexts was also associated with increased anxiety and stress,
but not depressive symptoms (Cage & Troxell-Whitman, 2019).
Later studies quantifying both camouflaging and mental health constructs using validated
measures have provided more consistent evidence suggesting that greater self-reported camouflaging
(i.e., higher Total CAT-Q scores) is associated with increased neuroticism (Robinson et al., 2020);
increased social anxiety, general anxiety, and depressive symptoms (Hull et al., 2019; Hull, Levy, et al.,
2021); greater psychological distress (Beck et al., 2020); and decreased well-being (Hull et al., 2019;
although see Perry et al., 2021). However, there was no evidence that the relationship between self-
reported camouflaging and mental health outcomes was moderated by gender (Hull, Levy, et al., 2021).
Two small-scale studies employing internal-external discrepancy approaches examined
associations between camouflaging and mental health outcomes separately for autistic men and
women. Lai et al. (2017) found that higher camouflaging scores were associated with greater depressive
symptoms in men but not women, while camouflaging was not associated with anxiety symptoms in
either sex/gender. Similarly, Schuck et al. (2019) found no relationship between camouflaging scores
and social anxiety symptoms for either sex/gender.
Children and Adolescents. Three studies using internal-external discrepancy and self-report
approaches yielded some preliminary evidence supporting an association between camouflaging and
poorer mental health in children and adolescents. Two studies examined associations between
camouflaging and anxiety in children and adolescents using internal-external discrepancy methods.
Livingston, Colvert, et al. (2019) reported that high compensators demonstrated high self-report (but
not parent-report) anxiety compared to low compensators. Corbett et al. (2020) found no differences
between high and low compensators in terms of self-report trait or state anxiety. However, low
compensators demonstrated higher levels of observer-rated anxiety compared to high compensators.
The sole study using a self-report approach found that greater self-reported camouflaging was
associated with higher levels of anxiety and depression in both autistic and non-autistic adolescents
(Bernardin et al., 2020).

Discussion
Camouflaging refers to the conscious or unconscious employment of specific behavioural and
cognitive strategies used by autistic people to adapt to, or cope within, the predominately non-autistic
social world (Cook, Crane, Hull, et al., 2021; Hull et al., 2019; Lai et al., 2017; Lawson, 2020).
Camouflaging may enable autistic people to (consciously or unconsciously) present a non-autistic social
style, hide autistic characteristics, and/or minimise the visibility of social difficulties. The current
systematic review aimed to critically evaluate existing quantitative camouflaging research to identify
consistencies in the current evidence base, as well as gaps that require further research. We identified
29 studies quantifying camouflaging in children/adolescents and adults with autism diagnoses or high
levels of autistic traits. Next, we provide an overview of current measurement approaches as well key
findings, before discussing limitations in the current literature and providing suggestions for future
research.
Research into Camouflaging and Autism: Current Measurement Approaches
The multiple methods used to measure camouflaging in included studies broadly fell under two
different approaches: internal-external discrepancy and self-report approaches. The internal-external
discrepancy approach aimed to measure camouflaging by quantifying differences between internal
(‘true’) autistic status and observable behavioural presentation (Lai et al., 2017, 2020). Following this
approach, high camouflaging was conceptualised as either fewer social-communication difficulties or
more ‘typical’ social behaviour despite high autistic traits/poor social cognition abilities. Across studies,
various self- or parent-report measures of autistic traits and/or performance-based measures of social
cognition were used as proxy measures of ‘true’ autistic status, while an observer rated assessment of
autistic behaviour (i.e., ADOS) was typically used as a measure of external behavioural presentation
(however, see Parish-Morris et al., 2017; Rynkiewcz et al., 2016; Wood-Downie et al., 2020). Adult
studies calculated individual camouflaging scores for participants, while child/adolescent studies
stratified children/adolescents into camouflaging ability groups and/or described group level differences
between boys and girls. Such methods highlight an important issue related to camouflaging and
diagnosis: certain autistic individuals show strengths in performance on observer-rated assessments of
social communication, relative to performance on measures of social cognition and scores on measures
of overall autistic traits.
However, several important criticisms have been raised questioning the underlying assumptions
of the internal-external discrepancy approach (e.g., Fombonne, 2020; Pearson & Rose, 2021; Williams,
2021). First, given the multiple behavioural, cognitive, and sensory domains implicated in autism,
performance on a measure of social cognition alone is arguably a poor proxy for ‘true’ autistic status (Lai
et al., 2017). Second, recent evidence suggests that lab-based measures of social cognition may not
ordinarily predict observable social behaviour in either autistic or non-autistic people (Morrison et al.,
2020; Williams, 2021). Third, given that the ADOS was developed using predominately white, male
samples, scores on this measure may reflect, at least in part, the degree to which an individual’s
behavioural presentation ordinarily deviates from the stereotypically male autistic presentation, rather
than the degree to which an individual’s behavioural presentation is changed via camouflaging (Pearson
& Rose, 2021). Fourth, the relationship between greater self-report levels of autistic traits and improved
performance on measures of social communication may be driven by social insight or reasoning as
opposed to camouflaging (Livingston et al., 2020).
In contrast to the internal-external discrepancy approach, self-report approaches measure self-
perceived engagement in camouflaging independent of observable behavioural presentation (Hull et al.,
2019). For this reason, self-report methodologies could be conceptualised as measuring camouflaging
attempts, efforts, or intentions (e.g., Beck et al., 2020; Hull, Petrides, & Mandy, 2021; Livingston et al.,
2020). Operationalisation of camouflaging varied significantly across studies from spontaneous
descriptions of camouflaging in response to open-ended questions, to reported time spent camouflaging

across various settings, to endorsement of specific camouflaging behaviours and strategies. Some
promising self-report camouflaging measures are yet to demonstrate reliability and validity, so require
further formal testing (Williams, 2021). However, 13 of the 19 self-report studies used the CAT-Q; a
camouflaging measure validated in a large sample of autistic and non-autistic adults (Hull et al., 2019;
Williams, 2021). In this regard, the CAT-Q showed potential as measure of self-perceived camouflaging,
demonstrating sound internal consistency and test-retest reliability and performing generally as
expected when tested in relation to gender, autistic traits, and mental health and wellbeing (Hull et al.,
2019; although see Fombonne, 2020).
However, it is important to note that camouflaging likely involves both the conscious and
unconscious employment of behavioural and cognitive strategies. In this regard, self-report measures
are limited in measuring unconscious engagement in camouflaging (Lawson, 2020). Moreover, several
behaviours and strategies included on self-report measures appear to overlap with behaviours
associated with more established constructs such as social anxiety/safety behaviours, impression
management, and passing (Fombonne et al., 2020; Lai et al., 2020; Williams, 2021). Thus, the degree to
which camouflaging behaviours and strategies, as measured in current self-report measures, represent a
theoretically distinct phenomena, remains unclear.
It is likely that internal-external discrepancy and self-report approaches measure distinct but
potentially converging elements of camouflaging (Lai et al., 2020). Self-report methodologies may
measure the extent to which individuals consciously employ camouflaging behaviours and strategies,
and we label this ‘camouflaging intent’. By contrast, internal-external discrepancy methods may capture
the extent to which these behaviours and strategies (as well as behaviours and strategies operating
outside of conscious awareness) translate into observable social behaviour, and we label this
‘camouflaging efficacy’. We note here that, as previously described, camouflaging may not be a desired
but rather a necessary coping strategy for autistic people, and so ‘efficacy’ refers to meeting intended
aims rather than optimal outcomes. It is important to acknowledge that given the nascent stage of
empirical research examining camouflaging, methods for measuring the phenomena are in their infancy.
Currently, there is a dearth of research investigating relationships between either internal-external
discrepancy or self-report measures of camouflaging and measures of more established, theoretically
related constructs (e.g., impression management, social anxiety, passing; Lai et al., 2017, 2020).
Similarly, self-report and internal-external discrepancy methods have not been directly compared, to
determine the extent to which these show concurrent validity in measuring the same underlying
construct (Fombonne, 2020). It is also important to note that, in the current systematic review, we were
not able to aggregate data across studies via meta-analytic techniques, owing to differences both
between and within measurement approaches.
Research into Camouflaging in Autism: Current Findings
The literature we reviewed suggests the following three preliminary findings about the nature of
autistic camouflaging. First, emerging evidence suggests that adults with higher self-reported autistic
traits report greater camouflaging efforts (Brown et al., 2020; Hull et al., 2019; Livingston et al., 2020).
Having an autism diagnosis similarly appears to be associated with greater camouflaging efforts, and
there is some evidence to suggest this relationship is driven by autistic traits rather than the presence of
diagnostic label per se (Livingston et al., 2020). Such findings suggest that regardless of diagnosis, adults
with higher self-reported autistic traits feel a greater need to modify their social behaviour via the use of
camouflaging strategies. The underlying mechanisms contributing to increased camouflaging amongst
those with higher autistic traits are not yet clear. However, preliminary findings from two included
studies suggest that experiences of stigma and not feeling accepted play a role (Cage et al., 2018; Perry
et al., 2021).
The second key finding from this review is that, across the lifespan, the majority of included
studies found that autistic females and girls/women demonstrate higher levels of camouflaging than
autistic males and boys/men (Cassidy et al., 2018; Corbett et al., 2021; Hull, Lai, et al., 2020;
Jedrzejewskar & Dewey, 2021; Lai et al., 2017; Ormond et al., 2018; Parish-Morris et al., 2017; Perry et
al., 2021; Ratto et al., 2018; Rynkiewcz et al., 2016; Schuck, et al., 2019; Wood-Downie et al., 2020). The
remaining included studies found null results and no study found the converse effect of higher
camouflaging in males or boys/men. Sex and gender differences were demonstrated using both self-
report and internal-external discrepancy measurement approaches. While no study directly compared
camouflaging efforts and observable social behaviours, these findings provide preliminary evidence that
compared to autistic males and boys/men, autistic females and girls/women appear to consciously
engage in more camouflaging, with more noticeable effects. Thus, the current evidence base appears to
support suggestions that camouflaging is more associated with the experiences of autistic females and
girls/ women, and may partially explain increased rates of missed or late diagnosis found amongst them
(Duvekot et al., 2017; Dworzynski et al., 2012; Head et al., 2014; Kirkovosi et al., 2013; Lai & Baron-
Cohen, 2015; Lehnhardt et al., 2016; Shattuck et al., 2009; Whitlock et al., 2020). Yet, the consistent
documentation of camouflaging in autistic males and boys/men also shows that camouflaging is not
specific to females and girls/women (Lai et al., 2017; Hull, Lai, et al., 2020). Indeed, given the effect sizes
were often small-to-moderate for sex and gender differences, the real-life camouflaging experiences of
these groups may be broadly similar.
Unfortunately, owing to a lack of research involving adequately powered samples of non-binary
people, drawing conclusions about differences in camouflaging between binary and non-binary genders
was not possible. It is, however, important to acknowledge that one study found non-binary autistic
people to engage in similar levels of camouflaging to autistic women (Perry et al., 2021). It should be
added that a more nuanced understanding of sex and gender differences in camouflaging is currently
lacking, owing in part to included studies largely failing to provide a comprehensive characterisation of
participants’ gender identity via the description of the multiple components of sex and gender.
The third key finding was that, for autistic adults, higher self-reported camouflaging appeared to
be associated with increased symptoms of mental ill health (Beck et al., 2020; Cage et al., 2018; Cage &
Troxell-Whitman, 2019; Cassidy et al., 2018; Hull et al., 2019, 2021; Lai et al., 2017; Robinson et al.,
2020). As such, the current evidence base suggests that autistic individuals who feel a greater need to
modify their social behaviours via camouflaging experience more mental health difficulties. At the same
time, an association between observable camouflaging efficacy, measured via internal-external
discrepancy approaches, and mental health difficulties was not consistently found for either autistic
adults or children. Thus, the relationship between camouflaging and mental health difficulties may be
more related to an individuals’ belief that they need to camouflage their autism rather than their ability
to do so. However, to date, no studies have explored interactions between mental health difficulties,
camouflaging intention and camouflaging efficacy. Moreover, it is important to note that due to the
cross-sectional nature of the current research base, a causal relationship between camouflaging and
mental health difficulties cannot be inferred. Nonetheless, any association between psychological
distress and camouflaging is of significant concern, given the high rates of co-occurring mental health
difficulties found amongst autistic adults (Lever & Geurst, 2016).
Research into Camouflaging in Autism: Current Limitations
As is often the case in autism research (e.g., West et al., 2016; Russell et al., 2019), most of the
included studies were limited regarding their characterisation of participants. Many studies failed to
provide information regarding participants’ IQ, educational attainment, social economic status, and
race/ethnicity. Similarly, as previously mentioned, the description of the multiple components of sex
and gender was largely absent in included studies. Given the heterogeneity of the autistic community,
adequately described samples are key in determining the generalisability of research findings. Equally,
comprehensive descriptions of race/ethnicity, gender identity, sexual orientation, and social economic
status are especially necessary in camouflaging research owing to the likely role of marginalisation in the
development and perseverance of camouflaging (Botha & Frost, 2020; Lai et al., 2020; Perry et al.,
2021).
Notwithstanding, available data suggested that adult participants in camouflaging research were
mostly white, university educated females and/or women diagnosed in adulthood with a mean IQ in the
“high average” range. By contrast, child and adolescent participants were mostly white males and/or
boys diagnosed in childhood with a mean IQ in the “average” range. Current evidence of camouflaging
across the lifespan therefore involves samples differing on the key demographics of sex and gender, IQ,
and age of diagnosis, which makes it difficult to draw inferences about the progression of camouflaging
across different developmental stages. Moreover, given these sample demographics, the current
camouflaging evidence base cannot be applied to the autistic community as a whole. Adult-focused
research particularly is limited in generalisability regarding males and men, people of non-white ethnic
groups or races, those diagnosed in childhood, those with lower educational attainment, and those with
intellectual disabilities.
In seeking to design camouflaging research that is more representative of the broader autistic
community, it is important to understand why current camouflaging research involves such a specific
minority of the larger population of autistic adults. A subset of included studies purposely recruited
females or women or those without intellectual disability, to examine specific research questions (Beck
et al., 2020; Brown et al., 2020; Lai et al., 2017, 2019; Schuck et al., 2019). However, in the remaining
online questionnaire-based studies, individuals largely self-selected to participate by responding to
adverts distributed via social media, autism organisations, or research databases. The homogenous
nature of these self-selecting samples across studies may indicate that camouflaging is particularly
central to the experience of late-diagnosed autistic females and women, a notion that may be supported
by the current evidence base. However, the lower rates of males and men in self-report studies may
have also resulted in the under identification of camouflaging behaviours and strategies specifically used
by these groups (Fombonne, 2020). Additionally, the substantial reliance on online questionnaires
within camouflaging research likely means members of the autistic community who are less active
online or for whom questionnaire-based methods present a barrier to participation (e.g., those with
certain intellectual or language difficulties) have been systematically excluded (Hull, Lai, et al., 2020; Lai
et al., 2020; Livingston et al., 2020).
Camouflaging in Autism: Future Directions
Conceptualisation and Measurement of Camouflaging
Advancement in our understanding of camouflaging is reliant upon valid and reliable
camouflaging measures. Given that our current understanding of camouflaging is still emerging, ongoing
work is required in refining not only camouflaging measures but also the construct itself (Lai et al.,
2020). Current self-report and internal-external discrepancy measurement approaches may capture two
distinct but potentially related elements of camouflaging: self-perceived engagement in camouflaging
(‘camouflaging intent’) and observable behavioural presentation (‘camouflaging efficacy’). Future
research directly comparing self-report and observer rated methods is now required to test this notion
and determine the extent to which these elements show concurrent validity in measuring separate
aspects of the same underlying construct. Equally, direct comparison of self-report and observer-rated
measures is needed to determine the role of conscious awareness in changed social presentation.
It should also be noted however, that across included studies, self-perceived engagement in
camouflaging was differentially operationalised as: motivation to engage in camouflaging; specific
behaviours and strategies used in camouflaging; and the frequency or pervasiveness of camouflaging in
various social contexts. Further research is needed to clearly differentiate these related but separate
aspects of camouflaging, and qualitative research may be particularly useful in this regard. Subsequent
examination of each of these distinct aspects of camouflaging, related to both self-perceived
engagement and observable behaviour change, is required in both autistic and non-autistic samples.
Specific efforts should be made to include non-autistic samples who similarly experience social
challenges (i.e., social anxiety) or stigma, to further the current conceptualisation of camouflaging and
help in distinguishing autism specific elements of camouflaging (Lai et al., 2017, 2020).
Longitudinal and Experimental Research
Although a cross-sectional association between camouflaging and mental health difficulties was
identified from the current research base, longitudinal research is now required to investigate the
direction of this relationship and causality. Equally, questions regarding causality may be investigated by
experimental designs, for example a randomised control trial of an intervention to reduce camouflaging
with mental health outcomes as secondary outcomes. Longitudinal research will also be helpful in
establishing the developmental trajectory of camouflaging through childhood to adulthood, as well as
sex and gender differences in camouflaging across different developmental stages.
Adequately Described, Representative Samples
Future research should focus on groups currently underrepresented in camouflaging research,
including adult males and men, people of non-white ethnic groups and races, those with intellectual
disabilities, and adults diagnosed in childhood. Such samples will also facilitate further exploration of the
impact of having multiple-minority identities on camouflaging effects (Botha & Frost, 2020).
Diversification in terms of measures and recruitment practices is likely required to reach such
individuals.
Limitation of the current systematic review
As is the case with any systematic review, our search may not have been exhaustive.
Additionally, as authors who have previously published camouflaging research, including research
featured in this review, we acknowledge that we are embedded within the camouflaging field and that
this may have had an impact on the review. Whilst our familiarity with the topic likely improved our
ability to draw conclusions about and identify limitations within the evidence base, it may have
increased the risk of bias. Finally, the review did not involve participatory design and thus is limited by a
lack of autistic input.
Conclusions
This is the first review to systematically appraise and synthesise the current evidence base
pertaining to autistic camouflaging in children and adults of all sexes and genders. Three preliminary
conclusions about the nature of autistic camouflaging emerged: (1) adults with more self-reported
autistic traits report greater engagement in camouflaging; (2) autistic females and girls/women appear
to demonstrate more camouflaging than autistic males and boys/men; and (3) higher self-reported
camouflaging is associated with increased mental health difficulties. However, the evidence base was
limited regarding participant characterisation and representativeness, suggesting that conclusions
cannot be applied to the autistic community as a whole. Given the nascent stage of camouflaging
research, future research is required to refine both the construct of camouflaging as well as current
measurement approaches (Lai et al., 2020).

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Note. * = included in systematic review

Table 1
Study Inclusion and Exclusion Criteria.
Inclusion Criteria Exclusion Criteria

Design Reported quantitative data Reported purely qualitative
measuring camouflaging (i.e. data.
numerical data quantifying
camouflaging strategies or
behaviour within an individual
or group).
Population Participants were autistic Studies only involving general
individuals (either those with a population samples.
clinical diagnosis of autism or
those who self-identified4 as
autistic) or individuals with high
levels of autistic traits (as
defined by study authors).
Publication Studies published (or accepted Articles not reporting peer-
for publication) in peer reviewed, original empirical
reviewed academic journals. findings such as opinion pieces,
conceptual pieces, thesis, and
conference abstracts.
Language Written in English.
4
Some members of real-world autistic communities are self-identified or self-diagnosed (Sarrett, 2016). Such
autistic individuals who recognise autistic traits within themselves but do not meet or are yet to meet criteria for a
clinical diagnosis, may be particularly adept at camouflaging their autistic traits (e.g., Lai et al., 2017; Livingston,
Shah, et al., 2019).
Figure 1
PRISMA Flow Diagram Showing Study Selection

Table 2
Aggregated Participant Characteristics
% Mean Mean Mean % Clinical % Race/ethnic % Educational attainment % Co-morbid mental health
Gender age age of FSIQ autism groupa diagnosisa
diagnosis diagnosis
N adult studies 14 13 7 4 14 8 6 5
used in calculations
Adult studies (n= 60.1 F; 36.47 32.98 112.35 95.9 86.1 White; 4.1 4.9 No qualifications; 25.1 53.1 Depression; 54.8
18) 29.0 M; Mixed; 1.4 Asian; 0.5 High school or equivalent; General anxiety; 6.5 Social
8.3 O; Hispanic/Latino/a; 30.0 Undergraduate anxiety; 0.4 Specific phobia;
2.6 0.2 Black; 1.2 Other; degree; 24.0 Post- 11.0 OCD; 5.5 PTSD; 4.3
n.r. 6.9 n.r. graduate degree; 12.3 Bipolar disorder; 3.7
Other; 3.7 n.r. Personality disorder; 0.9
Schizophrenia; 2.4 Eating
disorder
N child studies used 10 8 7 10 2 1
in calculations
Child studies (n= 36.9 F; 11.90 99.93 94.7 75.8 White; 5.5 40.7 Co-morbid diagnosis
11) 62.9 M; Black; 4.1
0.3 O Hispanic/Latino/a;
3.4 Asian; 7.8
Other/Unknown; 3.4
n.r
Note. F = female; M = male; O = other (study authors reported a range of genders included as ‘other’ such as non-binary, genderfluid,
transgender male and transgender female); n.r. = not reported. Percentage may not sum to 100 due to rounding.
a
Percentages will not sum to 100 due to categories not being mutually exclusive.
Table 3
Overview of Internal-External Discrepancy Measurement Methods
Author Operationalisation of Autistic Social cognitive Measure of Type of outcome

(Year) camouflaging traits/social ability measure; behavioural
communication Social cognitive presentation
skill measure ability
Adult Studies
Lai et al. Discrepancy between self- AQ REMT; ToM ADOS Individual camouflaging
(2017) reported autistic scores
traits/performance based socio-
cognitive ability and observer
rated social behaviour
Lai et al. Discrepancy between self- AQ REMT; ToM ADOS Individual camouflaging
(2019) reported autistic scores
traits/performance based socio-
cognitive ability and observer
rated social behaviour
Schuck et al. Discrepancy between self- AQ - ADOS Individual camouflaging
(2019) reported autistic traits and scores
observer rated social behaviour
Child/Adolescent Studies
Rynkiewcz et Discrepancy between parent- AQ, SCQ - Computerized data Group level differences
al. (2016) reported autistic traits/social on gestures
communication skills and occurring during two
“Gesture Index” sections of the
ADOS-2
Parish- Discrepancy between parent- SCQ, Vineland-II - Pragmatic language Group level differences
Morris et al. reported autistic traits/social markers occurring
(2017) communication skills and during a section of
pragmatic language markers the ADOS-2
Ratto et al. Discrepancy between parent ADI-R, SRS, SRS-2, - ADOS/ADOS-2 Group level differences
(2018) reported autistic traits/social Vineland-II
communication skills and
performance on gold-standard
diagnostic measures
Livingston, Discrepancy between - Frith-Happé ADOS Four compensation
Colvert, et performance based socio- Animations; ability groups (low
al. (2019) cognitive ability and observer ToM compensators, high
rated social behaviour compensators, deep
compensators, and
unknown)
Corbett et al. Discrepancy between - NEPSY-II (theory ADOS-2 Four compensation ability
(2020) performance based socio- of mind groups (low
cognitive ability and observer subscale); ToM compensation, high
rated social behaviour compensation, deep
compensation, and
unknown)
Wood- Discrepancy between parent SCDC REMT; ToM IDT 1. Two compensatory
Downie et al. reported autistic camouflaging ability
(2020) traits/performance based socio- groups (low
cognitive ability and compensation and high
performance-based social compensation)
reciprocity 2. Group level differences
Note. AQ = Autism Quotient; REMT = Reading the Mind in the Eyes Test; ToM = Theory of Mind; ADOS= Autism Diagnostic Observation Scale ;
SCQ = Social Communication Questionnaire; ADOS-2 = Autism Diagnostic Observation Scale, Second Edition; Vineland II = Vineland Adaptive
Behaviour Scales, Second Edition; ADI-R = Autism Diagnostic Interview- Revised; SRS = Social Responsiveness Scale; SRS-2 = Social
Responsiveness Scale 2; NEPSY-II = NEuroPSYschological Assessment Second Edition; SCDC = Social and Communication Disorders Checklist; IDT
= Interactive Drawing Test
Table 4
Overview of Self-Report Measures
Author (Year) Operationalisation of Measure/s Evidence of Validity and Reliability

camouflaging
Adult Studies
Hull et al. Self-reported experience of Single item measuring Questionnaire was developed in consultation with expert
(2017) camouflaging presence or absence of clinicians, researchers, and autistic adults.
camouflaging
Cage et al. Spontaneous reporting of Mixed methods n.r.
(2018) masking or camouflaging in text questionnaire examining
response to questions the relationship between
autism acceptance and
mental health.
Cassidy et al. Self-reported tendency to Set of four items Items were developed in consultation with autistic adults.
(2018) camouflage measuring engagement in Internal consistency for the total score was α=.75.
camouflaging.
Cage and 1 Self-reported use of 1. CAT-Q 1. In this sample, internal consistency for the total CAT-Q
Troxell- camouflaging strategies or score was α = 0.89.
Whitman behaviours
(2019)
2. Self-reported camouflaging 2. Set of 22 items 2. Camouflaging context items were developed in
contexts measuring camouflaging consultation with autistic adults. Internal consistency for
contexts the total score was α=0.95. Switchers and high
camouflagers demonstrated equivalent CAT-Q scores.
Hull et al. Self-reported use of CAT-Q Items on questionnaire developed based on qualitative
(2019) camouflaging strategies or study of autistic adults’ experiences of camouflaging.
behaviours Questionnaire validated in a sample of 832 autistic and
non-autistic adults. Internal consistency for the total CAT-Q
score (with combined autistic and non-autistic samples)
was α=0.94. Internal consistencies for subscales were:
Compensation (α=0.92), Masking (α=0.86), and
Assimilation (α=0.93). Test-rest reliability (r = 0.77) was

good in a subsample of autistic participants.
Livingston, References to social Qualitative questionnaire n.r.
Shah, & Happé compensatory strategies in text exploring social
(2019) responses to questions compensatory strategies
Beck et al. Self-reported use of CAT-Q n.r. using study sample
(2020) camouflaging strategies or
behaviours
Brown et al. Self-reported engagement in the Camouflaging subscale on Internal consistency for Camouflaging subscale was 𝜔=
(2020) active process of developing and a modified version of GQ- 0.67.
displaying strategies that ASC
minimize the impact of social
challenges
Cage and Self-reported use of CAT-Q In this sample, internal consistency for the total CAT-Q
Troxell- camouflaging strategies or score was α=0.89.
Whitman behaviours
(2020)
Hull, Lai, et al. Self-reported use of CAT-Q In this sample internal consistency for the total CAT-Q
(2020) camouflaging strategies or score was α=0.94.
behaviours
Livingston et al. References to social Compensation Checklist Items on the checklist were developed based on
(2020) compensatory strategies in text qualitative study of autistic and non-autistic adults’
responses to questions experiences of compensation. Greatest lower bound
reliability was glb=0.82.
Robsinson et al. Self-reported use of CAT-Q In this sample, internal consistency for the total CAT-Q
(2020) camouflaging strategies or score was α=0.94. Internal consistencies for the subscales
behaviours were: Compensation (α=0.94), Masking (α=0.80), and
Assimilation (α=0.90).
Cook, Crane, Self-reported use of CAT-Q In this sample, internal consistency for the Total CAT-Q
Bourne et al. camouflaging strategies or score was α=0.84.
(2021) behaviours
Hull, Levey, et Self-reported use of CAT-Q In this sample, internal consistency for the Total CAT-Q
al. (2021) camouflaging strategies or was α=0.79.
behaviours
Perry et al. Self-reported use of CAT-Q In this sample, internal consistency for the Total CAT-Q
(2021) camouflaging strategies or was α=0.90.
behaviours
Ormond et al. Parent-reported level of masking Social Masking subscale Internal consistency for the Social Masking subscale was α
(2018) emotional responses and on the Q-ASC. =.61.
expressions during social
interactions
Hull, Petrides, Self-reported use of CAT-Q In this sample, internal consistency for the total CAT-Q
& Mandy camouflaging strategies or score was α= 0.91. Internal consistencies for subscales
(2021) behaviours were: Compensation (α=0.89), Masking (α = 0.81), and
Assimilation (α=0.87).
Jorgenson et al. Self-reported use of CAT-Q In this sample, internal consistency for the total CAT-Q
behaviours
Bernardin et al. Self-reported use of CAT-Q In this sample, internal consistency for the Total CAT-Q
behaviours
Jedrzejewska & Self-reported use of 1. CAT-Q 1. n.r. in study sample
Dewey (2021) camouflaging strategies or
behaviours 2. CATO-Q 2. n.r.
Note: n.r. = None reported; CAT-Q = Camouflaging Autistic Traits Questionnaire; GQ-ASC = Girls Questionnaire for Autism Spectrum Conditions;
Q-ASC = Questionnaire for Autism Spectrum Conditions; CATO-Q = Camouflaging Autistic Traits Online Questionnaire
Table 5
Summary of Evidence Presented in Included Studies Grouped by Research Question.
Author (year) Q1: Is Q2: Are Q3: Are Q4: Is Q5: What is the
Camouflaging there sex or particular camouflaging relationship
associated gender cognitive related to between
with having differences abilities or current age or camouflaging
high autistic in processes age at and mental
traits or an camouflaging associated diagnosis? health and
autism behaviours? with wellbeing
diagnosis? camouflaging? outcomes?
Internal-external discrepancy adult studies
Lai et al. (2017)    
Schuck et al. (2019)    
Self-report adult studies
Hull et al. (2017)   
Cage et al. (2018) a  
Cassidy et al. (2018)   
Cage and Troxell-   
Whitman (2019)
Hull et al. (2019)  
Livingston, Shah, & 
Happé (2019)
Beck et al. (2020) 
Brown et al. (2020) 
Cage and Troxell- b
Whitman (2020)
Hull, Lai, et al. (2020) 
Livingston et al. (2020)   
Robinson et al. (2020) 
Hull, Levy, et al. (2021) 
Perry et al. (2021) c   
Internal-external discrepancy child/adolescent studies
Rynkiewcz et al. (2016) 
Parish-Morris et al. 
(2017)
Ratto et al. (2018) 
Livingston, Colvert, et    
al. (2019)
Corbett et al. (2021)   
Wood-Downie (2020)  
Self/parent report child/adolescent studies
Ormond et al (2018)  
Hull, Petrides, &  
Mandy (2021)
Jorgenson et al. (2020)   
Bernardin et al. (2021) 
Jedrzejewska & Dewey  
(2021)
Note: = indicated significant findings with respect to at least one variable;  = indicates the research question
was investigated but no significant finding was identified
a
experiences of autism acceptance
b
autistic identity
c
stigma
Appendix A
Database Search Strategy
Database: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and
Daily from 1946
Search Strategy:
1 exp child development disorders, pervasive/ or autism spectrum disorder/ or asperger
syndrome/ or autistic disorder/
2 autis*.mp.
3 asperger*.mp.
4 (pervasiv* adj2 development* adj2 disorder*).mp. [mp=title, abstract, original title, name of
substance word, subject heading word, floating sub-heading word, keyword heading word,
organism supplementary concept word, protocol supplementary concept word, rare disease
supplementary concept word, unique identifier, synonyms]
5 ASD.mp.
6 1 or 2 or 3 or 4 or 5
7 Social Conformity/
8 (peer imitation or social imitation).mp. [mp=title, abstract, original title, name of substance
word, subject heading word, floating sub-heading word, keyword heading word, organism
supplementary concept word, protocol supplementary concept word, rare disease
supplementary concept word, unique identifier, synonyms]
9 camouflag*.mp. [mp=title, abstract, original title, name of substance word, subject heading
word, floating sub-heading word, keyword heading word, organism supplementary concept
word, protocol supplementary concept word, rare disease supplementary concept word, unique
identifier, synonyms]
10 (compensat* adj20 (autis* or asperger* or ASD or social or behav* or mask* or camouflag* or
strategies)).mp. [mp=title, abstract, original title, name of substance word, subject heading
11 (pass adj20 (autis* or asperger* or ASD or social or behav* or mask* or camouflag* or
12 (passing adj20 (autis* or asperger* or ASD or social or behav* or mask* or camouflag* or
13 (mask* adj20 (autis* or asperger* or ASD or social or behav* or pass or passing or camouflag*
or strategies)).mp. [mp=title, abstract, original title, name of substance word, subject heading
14 7 or 8 or 9 or 10 or 11 or 12 or 13
15 6 and 14
Database: Embase from 1980
Search Strategy:
1 autism/ or asperger syndrome/ or "pervasive developmental disorder not otherwise specified"/
2 autis*.mp.
3 asperger*.mp.
4 (pervasiv* adj2 development* adj2 disorder*).mp. [mp=title, abstract, heading word, drug trade
name, original title, device manufacturer, drug manufacturer, device trade name, keyword,
floating subheading word, candidate term word]
5 ASD.mp.
6 1 or 2 or 3 or 4 or 5
7 compensation/
8 masking/
9 (peer imitation or social imitation).mp. [mp=title, abstract, heading word, drug trade name,
original title, device manufacturer, drug manufacturer, device trade name, keyword, floating
subheading word, candidate term word]
10 camouflag*.mp. [mp=title, abstract, heading word, drug trade name, original title, device
manufacturer, drug manufacturer, device trade name, keyword, floating subheading word,
candidate term word]
strategies)).mp. [mp=title, abstract, heading word, drug trade name, original title, device

14 (mask* adj20 (autis* or asperger* or ASD or social or behav* or pass or passing or camouflag* or
15 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14
16 6 and 15
Database: APA Psych Info (Ovid) from 1806
Search Strategy:
1 autism spectrum disorders/ or neurodevelopmental disorders/ or autistic traits/
2 autis*.mp.
3 asperger*.mp.
4 (pervasiv* adj2 development* adj2 disorder*).mp. [mp=title, abstract, heading word, table of
contents, key concepts, original title, tests & measures, mesh]
5 ASD.mp.
6 1 or 2 or 3 or 4 or 5
7 "compensation (defense mechanism)"/
8 (peer imitation or social imitation).mp. [mp=title, abstract, heading word, table of contents, key
concepts, original title, tests & measures, mesh]
9 camouflag*.mp. [mp=title, abstract, heading word, table of contents, key concepts, original title,
tests & measures, mesh]

strategies)).mp. [mp=title, abstract, heading word, table of contents, key concepts, original title,
13 (mask* adj20 (autis* or asperger* or ASD or social or behav* or pass or passing or camouflag* or
14 7 or 8 or 9 or 10 or 11 or 12 or 13
15 6 and 14
Database: Scopus
Search Strategy:
( TITLE-ABS-KEY ( autis* OR asperger* OR asd OR ( pervasive AND development* AND disorder* ) ) )
AND ( ( TITLE-ABS-KEY ( camouflag* ) ) OR ( TITLE-ABS-KEY ( ( peer AND imitation ) OR ( social AND
imitation ) ) ) OR ( TITLE-ABS-KEY ( compensat* W/20 ( autis* OR asperger* OR asd OR social OR
behav* OR mask* OR camouflag* OR strategies ) ) ) OR ( TITLE-ABS-KEY ( pass W/20 ( autis* OR
asperger* OR asd OR social OR behav* OR mask* OR camouflag* OR strategies ) ) ) OR ( TITLE-
ABS-KEY ( passing W/20 ( autis* OR asperger* OR asd OR social OR behav* OR mask* OR
camouflag* OR strategies ) ) ) OR ( TITLE-ABS-KEY ( mask W/20 ( autis* OR asperger* OR asd OR

social OR behav* OR mask* OR camouflag* OR strategies ) ) ) OR ( TITLE-ABS-KEY ( masking W/20
( autis* OR asperger* OR asd OR social OR behav* OR mask* OR camouflag* OR strategies ) ) ) )
Database: Web of Science Core Collection from 1900
Search Strategy:
3 1 and 2
2 TS=(camouflag*) OR TS=("peer imitation" or "social imitation") OR TS=((compensat* near/20 (auti
s* or asperger* or ASD or social or behav* or mask* or camouflag* or
strategies) )) OR TS=((pass near/20 (autis* or asperger* or ASD or social or behav* or mask* or
camouflag* or strategies) )) OR TS=((passing near/20 (autis* or asperger* or ASD or social or
behav* or mask* or camouflag* or strategies) )) OR TS=((mask* near/20 (autis* or asperger* or
ASD or social or behav* or pass or passing or camouflag* or strategies) ))
1 TOPIC: (autis*) OR TOPIC: (asperger*) OR TOPIC: (((pervasiv* near/1
development*) AND disorder*)) OR TOPIC: (ASD)
Database: ProQuest Dissertations and Theses
Search Strategy:
(ti(autis* OR asperger* OR ASD) AND ti(camouflag* OR "compensatory strategies")) OR (ab(autis* OR
asperger* OR ASD) AND ab(camouflag* OR "compensatory strategies"))
Database: Google Scholar
Search Strategy:
1 allintitle: Autism camouflaging OR camouflage OR "peer imitation" OR "social imitation" OR
passing OR masking OR "compensatory strategies"
2 allintitle: Autistic camouflaging OR camouflage OR "peer imitation" OR "social imitation" OR
passing OR masking OR "compensatory strategies"
Database: PsyARXIV
Search Strategy:
autis* AND ( camouflag* OR compensat* OR passing OR masking OR "peer imitation" OR "social
imitation")
Appendix B
Table 6
Overview of Exclusion Reasons for Articles Previously Included in Allely (2019) and Tubío-Fungueiriño et
al. (2020).
Author and Year Reason for Exclusion

Bargiela et al. (2016) Presented only qualitative data regarding camouflaging in late diagnosed
women.
Cook et al. (2018) Presented only qualitative data regarding masking in autistic girls and
their mothers.
Dean et al. (2017) This study quantitatively compared playground activities (type of activity
and time spent in activity) between autistic and non-autistic boys and
girls. Qualitive data was provided describing camouflaging behaviours.
Thus, this study did not present quantitative data measuring
camouflaging.
Head et al. (2014) The authors compared autistic and non-autistic children’s scores on a
self-report measure of friendship quality, understanding, and empathy.
Thus, this study did not report quantitative data measuring
camouflaging.
Lehnhardt et al. (2016) The authors compared differences in cognitive, executive functioning,
and mentalising abilities between late diagnosed autistic men and
women. The authors discussed these abilities as potentially enabling
camouflaging. Thus, this study presented data on abilities that may be
associated with camouflaging rather than camouflaging per se.
Tierney et al., (2016) Presented only qualitative data regarding camouflaging in autistic girls.
Appendix C
Table 7
Results of Quality Assessment using MMAT.
Quality Criteria N studies Reasons studies did not meet criteria (i.e. received a “no” or “can’t tell”
meeting Criteria rating)
Quantitative/mixed Are participants 3  Target population was autistic people, however those with ID were
methods studies (n representative of the excluded/not invited to participate (n=10)
= 26) target population?  Target population was autistic adults, however, online format is a
barrier to participation for those with certain intellectual or
language difficulties (n =11)
 Sample was predominately female (not including studies with
gender related hypothesis; n = 5)
 Sample was predominately diagnosed in adulthood (n = 4)
 Data come from larger data set and no information provided
regarding differences between participants included and large
number of participants excluded (n=1)
 Target population was autistic people, however reported IQ range
does not include IQ < 70 (n=1)
Are measurements 18  Measure/s not designed for use with autistic people and no
appropriate (e.g., information provided regarding the suitability of these measures
justified, appropriate, for use with autistic population/no reliability data provided for
validated, and current sample (n =3 )
reliability tested)?  Measure/s not designed for specific age group of autistic people
and no information provided regarding the suitability of measure/s
for use with this age group/no reliability data provided for current
sample (n = 1)
 Ad hoc method of quantifying camouflaging or compensation
scores based on text responses to open ended question (n = 2)
 Measured main variable of gender using single question where the
only response options were male and female (n = 1)
 Measured main variable of interest using single item, thereby
limiting individual variation that could be captured (n = 1)
Is outcome data 6  >20% of data missing on a main variable (n =2 )

complete?  Flow of participants not provided (n = 17)
 Amount of missing data unclear (n = 1)
Are confounders 14  Main analysis involved between group comparison, however, no

considered and statistics were provided regarding potential between group
accounted for in the differences on demographic variables (n = 10)
design and analysis?  Autistic and non-autistic group compared, however, autistic traits
were not controlled for (n = 2 )
Qualitative studies Qualitative approach is 3
(n = 3) appropriate for the
research question
Adequate data 3
collection methods
Findings derived from 3

the data
Interpretation of 3
results sufficiently
substantiated by data
Coherence between 3
qualitative data
sources, collection,
analysis and
interpretation
Note. Reasons studies did not meet criteria are not mutually exclusive.
Appendix D
Table 8
Overview of Participant Characteristics for Included Studies
Author N (n= Mean age, % Clinical Mean age at Mean FSIQ % Ethnic group % Educational % Comorbidities Location;
(year) sex/gender); (SD), range diagnosis diagnosis (SD); or race attainment Recruitment
measurement of autism (SD) measure methods
Hull et al. 92 ASD (n = F: 40.71 100 F: 36.98 n.r. n.r. n.r. n.r. Worldwide;
(2017) 55 F, 30 M, 7 (14.14), 18- (14.21); Recruitment via
O); gender 68; M: 41.03 CARD and adverts
M: 48.03 (18.08); placed on social
(n= 65 F, 27 (16.62), 22- O: 32.67 media.
M); sex 79; (9.25)
O: 40.71
(14.29), 27-
69
Lai et al. 60 ASD (n = F: 27.8 (7.6), 100 n.r. F: 114.9 n.r. n.r. n.r. UK; Recruitment via
(2017) 30 F, 30 M); 18-49a; (13.8); CARD, referral from
sex/gender M: 27.2 (7.3) M: 115.4 diagnostic clinics for
(14.1); adults with autism
WASI or Asperger’s
Syndrome and
advertisements
placed with
national and local
autism support
organisations and
support groups.
Cage et al. 111 ASD (n = 36.4 (12.0), 90 31.4 (14.0) n.r. 70 White 4 No 51.4 Depression; UK; Advertisements
(2018) 62 F, 28 M, 12 18-72 British; 18 qualifications; 9 55.9 Anxiety; 31.5 distributed via
O, 1 TG, 1 Other white 1-4 GCSEs or Social anxiety; social media and
N.R.); gender background; 4 equivalent 9; 7 16.2 Attention autism
Mixed 5+ GCSEs or deficit organisations and
ethnicity; 1 equivalent; 1 hyperactivity groups.
Asian; 4 Other; Apprenticeship; disorder; 16.2
3 Prefer not to 11 2+ A-levels or Obsessive
say equivalent; 31 compulsive
Undergraduate disorder; 8.1
degree; 24 Post-traumatic
Masters degree; stress disorder;
3 Doctoral 6.3 Bi-polar; 3.6
degree; 8 Other Tourette's
qualifications; 4 syndrome
Prefer not to
say
Cassidy et 164 ASD (n = F: 38.89, 100 F: 35.06 n.r. n.r. n.r. 79.9 Depression; Worldwide;
al. (2018) 99 F, 65 M); (10.47), 20- (11.83); 71.3 Anxiety; Recruitment via
sex 60b; M: 34.55 14.6 Obsessive CARD and adverts
M: 41.52, (14.75) compulsive placed online.
(11.73) disorder; 7.3
Bipolar disorder;
14 Personality
disorder; 3.7
Schizophrenia;
5.5 Anorexia; 1.2
Bulimia; 7.9
Myalgic
encephalopathy;
2.4 Tourettes; 3
Epilepsy; 18.9
Other
169 TD (n = F:41.48,
115 F, 54 M); (11.18), n.r.;
sex M: 39.11,
(10.09), n.r.
Cage and 262 ASD 33.62, 100 21.2% Under n.r. 85.5 White; 8.4 n.r. 51.9 Anxiety; 14.5 UKc; Direct contact
Troxell- (n = 135 F, (11.52), n.r. 18; 42.8% Mixed/multi- ADHD; 3.1 via autism charities
Whitman 111 M, O 12, 18–34; 36% ethnic; 2.7 Bipolar; 50.8 and organisations
(2019) 4 n.r.); gender 35–64 Asian; 1.9 Depression; 7.6 and advertisements
Other; 1.1 Obsessive placed on social
Prefer not to compulsive media.
say disorder; 9.5
Post-traumatic
stress disorder;
23.7 Social
anxiety disorder;
1.9 Tourette’s
syndrome; 18.7
Other diagnosis
Hull et al. 354 ASD (n = 41.93, 100 34.2 (n.r.) n.r. n.r. n.r. n.r. UKc; Recruitment
(2019) 179 F, 108 M, (13.55), 16- via CARD and word
17 O, 50 n.r.); 82b of mouth.
gender
478 TD (n = 30.24 (13.72)

255 F, 192 M,
29 O); gender
Lai et al. 57 ASD (n = F: 28.19, 100 n.r. F: 114.46 98 Caucasian; 2 n.r. n.r.; Adults with UK; Recruited via
(2019) 28 F, 29 M); (7.23), 18-45; (13.56); Mixed history or current CARD, referrals
sex M:26.59, M: 114.14 Caucasian and psychotic from diagnostic
(7.04), 18-41 (16.42); other ethnic disorders and clinics for adults
(n = 28 F, 29 WASI background substance use with autism or
M); gender disorder Asperger’s
excluded. Syndrome, and
advertisements
placed with
national and local
autism support
organisations and
support groups.
62 TD (n = 29 F: 27.63, n.r. 98 Caucasian; 2 n.r. n.r.

F, 33 M) (6.40), 18-45; Mixed
M: 27.94, Caucasian and
(6.08), 18-42 other ethnic
background
Livingston, 77 ASD (n = D: 35.8, 75.3 30.1 (13.8) n.r. n.r. D: 4.7 (2.1); S.I.: 13 Worldwide;
Shah & 46 F, 21 M, 10 (11.5), 18-70; 4.8 (1.9)d Developmental Advertisements
Happé O); gender S.I.: 40.2, disorders; 39 distributed via
(2019) (11.1), 25-64 Anxiety disorders; social media and
6.5 Obsessive- the UK National
compulsive; 23.4 Autistic Society.
Depressive
disorders; 1.3
Bipolar disorder;
1.3 Eating
disorder; 3.9
Trauma/stress
disorder; 5.2
Other
59 TD (n = 51 33.9, (14.8), 4.7 (1.8)d 3.4
F, 8 M); 18-77 Developmental
gender Disorder; 30.5
Anxiety disorder;
3.4
Obsessive-
Compulsive; 20.3
Depressive
disorder; 1.7
Bipolar disorder;
0 Eating disorder;
3.4
Personality
disorder; 1.7
Trauma/stress
disorder; 0
Schizophrenic
disorder; 0 Other
Schuck et 28 ASD (n = F: 33, (9.72), 100 n.r. F: 101 75 White; 7 n.r. n.r. USA; Referral from
al. (2019) 11 F, 17 M); n.r.; (16.01); Asian; 4 the Autism and
gender sex/gender M: 23, (4.09), M: 102 Hispanic; 14 Developmental
n.r. (16.77); Unknown Disabilities Clinic at
Standford- Stanford Children’s
Binet Health and flyers
Intelligence placed at colleges.
Scales, 5th
Ed.
34 TD (n = 15 F: 28, (8.03), 11.8 White;

F, 19 M) n.r. 41.2 Asian; 5.9
M: 26, (7.35), Hispanic; 11.8
n.r. Black; 29.4
Unknown
Beck et al. 58 ASD/ASD 25.2, (6.17), 31 55.6% F: 114.6 94.8 White; 1.7 3.4 Some high 39.7 Generalized USA;
(2020) traits (n = 58 n.r. childhood; (11.27); Black or African school; 6.9 High anxiety disorder; Advertisements
F); n.r. 22.2% WASI-II America; 1.7 school diploma 31.0 distributed via
adolescence; Asian; 1.7 More or GED; 8.6 Major depressive mental health
22.2% than one race; Associates disorder; 17.2 clinics and social
adulthood 6.9 Hispanic or degree; 46.6 ADHD; 15.5 media.
Latino College student; Social anxiety
25.9 Bachelor's disorder; 12.1
degree; 8.6 Obsessive-
Graduate degree compulsive
disorder; 6.9
Eating disorder;
5.2 Learning
disorder; 5.2
Specific phobia;
3.4 Personality
disorder; 1.7
Bipolar disorder;
1.7
Trichotillomania
Brown et 350 ASD (n = 36.21, 100 n.r. n.r. 80.9 Caucasian n.r. n.r. USA;
al. (2020) 280 F, 3 M, 66 (10.10), 18- Advertisements
O); gender 72 placed on social
media, online
(n = 345 F, 4 women's autism
M, 1 O); sex community and
support groups.
322 TD (n = 34.83, (9.93), 84.5 Caucasian

309 F, 1 M, 11 18-72
O); gender
(n = 322 F);
sex
Cage and 180 ASD (n = 33.89, 87.8 n.r. n.r. 58.9 White- 6.1 No n.r. Worldwide;
Troxell- 93 F, 76 M, 9 (11.21), n.r. British; 26.7 qualifications; Advertisements
Whitman O, 2 n.r.); White other 10.0 Other distributed via
(2020) gender background; qualifications; social media,
8.3 Mixed or 23.4 High school autism charities and
multi-ethnic; qualifications; organisations, and
3.3 Asian or 32.8 contacts via the
British-Asian; Undergraduate university disability
1.7 Other degree; 23.9 service.
ethnicities; 1.1 Postgraduate
Prefer not to degree; 3.9
disclose Preferred not to
say
Hull, Lai et 306 ASD (n = F: 39.91, 100 F: 34.07 n.r. n.r. F: 36 Secondary n.r. Worldwide;
al. (2020) 182 F, 108 M, (12.75), n.r.; (13.13); school; 30 Recruited via CARD,
16 NB); M: 46.68, M: 37.92 Undergrad; 33 advertisements
gender (13.98), n.r.; (15.99); Postgrad; 1 Not placed on social
O: 33.50, O: 23.76 specified media, and word of
(11.74), n.r. (13.08) M: 35 Secondary; mouth.
28 Undergrad; 35
Postgrad; 2 Not
specified
Non-Binary = 66
Secondary; 17
Undergrad; 17
Postgrad; 0 Not
specified
472 TD (n = F: 29.86, F: 47 Secondary
252 F, 193 M, (13.40), n.r. school; 28
27 O) M: 30.94, Undergrad; 25
(14.78), n.r.; Postgrad; 0 Not
O: 26.52, specified;
(10.74), n.r. M: 47 Secondary
school; 30
Undergrad; 23
Postgrad; 0 Not
specified
N.B.: = 86
Secondary
school; 7
Undergrad; 7; 7
Postgrad
Livingston 58 ASD (n = 35.85, 100 30.14 (13.84) n.r. n.r. 4.66 (2.08)d n.r. Worldwide; Adverts
et al. 44 F, 14 M); (11.53), 18- placed on social
(2020) sex 70 media and with the
UK National Autistic
Society.
59 TD (social 33.88, 4.68 (1.78)d
difficulties not (14.83), 18-
diagnosed) (n 77
= 51 F, 8M)
Robinson 278 ASD (n = 36.8, (15.4), 100 n.r. n.r. n.r. n.r. n.r. Worldwide; Online
et al. 163 F, 104 M, n.r.e recruitment system
(2020) 11 O); n.r. at University
College London, via
social media, and
CARD.
230 TD (n =
187 F, 40 M, 3
O)
Cook et al. 17 ASD (n = 8 44.53 100 41.71 (12.18) 112.47 88.2 White; 5.9 5.8 A-levels; 44 n.r. UK; Recruited via
(2021) F, 6 M, 3 AG); (12.03), 25- (4.65); Mixed; 5.9 Bachelor's adverts
gender 64 TOPF Hispanic degree; 41.2 disseminated on
Master's social media and
through autism
degree; 5.8 PhD
support groups.
Hull et al. 305 ASD (n = 41.90 (CI: 100 n.r. n.r. n.r. n.r. 56.7 Generalised Worldwide;
(2021) 181 F, 104 M, 40.37,43.43)f, anxiety disorder; Recruited via CARD
18 NB); 18-75 54.4 Depression and adverts placed
gender disorder; 2.3 on social media and
Social anxiety with relevant UK
(n = 283 disorder/social based autism
cisgender) phobia diagnosis charities.
Perry et al. 223 ASD (n = 34.19 (11), 100 28.67 (13.31) n.r. 92.8 White; 3.1 3.6 None; 11.7 n.r. Worldwide;
(2021) 130 F; 53 M; 18-65 Mixed; 1.3 High school; 22.4 Recruited via
39 NB/O; 1 Other; 0.4 College/sixth adverts shared on
Prefer not to Black; 2.2 form; 4.9 researcher's social
say); gender prefer not to Trade/vocational; media accounts,
say 28.7 emails to UK-based
Undergraduate autism community
degree; 17 groups, charities,
Masters degree; and word of mouth.
6.7 Doctorate;
2.2 Other; 2.7
preferred not say
Rynkiewcz 33 ASD (n = F: 8.06, 100 n.r. F (n = 13): n.r. n.r. Poland; Recruited
et al. 16 F, 17 M); (1.57), n.r.; 109.58 via child and
(2016) sex/gender M: 8.23, (11.70); adolescent mental
(2.05), n.r. M (n = 16): health services and
112.31 autism clinics.
(13.10);
medical
records
Parish- 65 ASD (n = F: 10.66, 100 n.r. F: 104 85 White n.r. USA; Recruitment
Morris et 16 F, 49 M); (1.55), n.r.; (13); M: via the Centre for
al. (2017) sex M: 9.73, 106 (14); Autism Research at
(2.16), n.r. DAS-II the Children's
Hospital of
Philadelphia.
17 TD 11.32, 104 (15); n.r.
(2.21), n.r. DAS-II
Ormond et 236 ASD (n = n.r., (n.r.), 5- 100 n.r. n.r. n.r. F: 42.9 co-occurring Australia; Clinic-
al (2018) 98 F, 138 M); 19 diagnosis based sample via
sex M: 39.1 co-occurring specialist autism
diagnosis clinic.
Ratto et al. 228 ASD (n = F: 10.11, 100 n.r. F: 101.16 73 White; 7 n.r. USA; Clinic-based
(2018) 114 F, 114 (2.19), n.r.; (19.14); Black; 4 Asian; 5 and research-
M); sex M: 10.12, M: Latino/a; 10 recruited samples
(2.15), n.r. 101.03 Other/unknown via the Centre for
(18.67) Autism Spectrum
WASI; Disorders at
WASI-II; Children’s National,
WISC-IV; the National
WISC-V; Institute of Mental
WAIS-IV; Health Laboratory of
WPPSI-IV; Brain and Cognition,
DAS-II the Centre for
Autism Research at
Children’s Hospital
of Philadelphia, and
research and clinical
programs at Virginia
Tech, including the
Centre for Autism
Research.
Livingston, 136 ASD (n = 13.28, 74.3 n.r. low n.r. n.r. UK; Post-hoc
Colvert, et 24 F, 112 M); (0.93), 10-15 comp: analysis of data.
al. (2019) gender 85.54 Participants were
(20.60); originally recruited
high for the Twins Early
comp: Development Study
94.6 and identified via
(17.58) birth records.
deep
comp:
101.88
(14.75);
unknown:
97.11
(16.08);
WASI
67 TD
Corbett et 161 ASD (n = F: 12.93, 100 n.r. F: 97.48 n.r. n.r. USA; Post-hoc
al. (2020) 46 F, 115 M); (1.80), 10:0- (17.3); analysis of data.
sex 16:11;a M: 98.98 Data originally
M: 12.78, (18.5); collected as part of a
(2.03) WASI-II multisite
randomized clinical
trial targeting social
skills. No further
recruitment details
reported.
Hull, 58 ASD (n = 14.48, 100 n.r. 100.85 n.r. n.r. UK; Recruited via
Petrides & 29 F, 29 M); (1.74), 13-18 (15.98); local National Health
Mandy n.r. WASI-II Service services,
(2020) advertisements
placed on social
media, and word of
mouth.
Jorgenson 78 ASD (n = 15.03 (1.67); 100 n.r. n.r. n.r. n.r. USA; Recruited via
et al. 23 F, 55 M); 13-18b specialty clinic for
(2020) sex autism and
neurodevelopmental
disorders; SPARK
database;
advertisements
placed on social
media and local
university email
announcement.
62 TD (n = 35 15.31 (1.65)
F, 27 M); sex
Wood- 40 ASD/ASD F: 10.12, 45 n.r. F: 99.00 n.r. n.r. UK; Recruited via
Downie et traits (n = 18 (1.43), 7.92- (15.68); Special Educational
al. (2020) F, 22 M); 13.42 M: 99.55 Needs Coordinators
sex/gender M: 10.08, (17.58); and/or Head
(1.75), 8.08- WASI-II Teachers from 16
13.92 mainstream primary
schools and three
mainstream
secondary schools in
the South of
England.
44 TD (n = 22 F: 9.62, F: 101.41
F, 22 M); (1.01), 8.08- (14.18) n;
sex/gender 11.5 M:
M: 10.50, 107.59
(1.40), 8.58- (12.36)
14.42
Bernardin 78 ASD (23 F, 15.03 (1.68), 100 n.r. n.r. n.r. n.r. USA; Recruited via
et al. 55 M); sex 13-18b specialty clinic for
(2021) autism and
neurodevelopmental
disorders; SPARK
database;
advertisements
placed on social
media and local
university email
announcement.
62 TD (35 F, 15.31 (1.65)
27 M); sex
Jedrzewska 42 ASD (13 F, 14.1g (n.r.), 100 n.r. n.r. n.r. n.r. UK; Recruited from 5
& Dewey 26 M, 3 O); 13-19b schools in London.
(2021) gender
158 TD (41 F,
110 M, 7 O);
gender
Note: n.r. = not reported; F = female; M = male; TG = transgender; NB = non-binary; AG = agender/gender neutral; O = other genders (study
authors reported a range of genders included as ‘other’ such as non-binary, genderfluid, transgender male, and transgender female); D= formally
diagnosed; S.I. = self-identifying; Low Comp = low compensation group; High Comp = high compensation group; Deep Comp = deep
compensation group; Unknown= unknown group; WASI = Wechsler Abbreviated Scales of Intelligence; WASI-II = Wechsler Abbreviated Scales of
Intelligence Second Edition; WISC-IV: = Wechsler Intelligence Scale for Children Fourth Edition; WISC-V = Wechsler Intelligence Scale for Children
Fifth Edition; WPPSI-IV = Wechsler Preschool and Primary Scale of Intelligence Fourth Edition; DAS-II = Differential Ability Scales, Second Edition;
ToPF = Test of Premorbid Functioning; CARD = Cambridge Autism Research Database; SPARK = Simons Foundation Powering Autism Research for
Knowledge
a
age range for total ASD sample.
b
age range for total ASD and TD sample combined.
c
location based on first authors institution if location of study participants not specified in the article.
d
mean and (SD) for International Standard Classification of Education.
e
mean and (SD) calculated based on ASD and TD sample combined.
f
95% confidence interval.
g
based on ASD and TD sample combined.

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Running Head: CAMOUFLAGING IN AUTISM 1

Camouflaging in autism: A systematic review

Julia Cook1, Laura Hull1, Laura Crane2 and William Mandy1

Julia Cook https://orcid.org/0000-0002-8984-6656

Laura Crane https://orcid.org/0000-0002-4161-3490

Laura Hull https://orcid.org/0000-0002-8289-2158

William Mandy https://orcid.org/0000-0002-3564-5808

WCIE 6BT, UK. Email: [email protected]

 Current approaches to measuring camouflaging appear to measure ‘camouflaging intent’ and

 Sex and gender differences exist in camouflaging.

 Higher self-reported camouflaging is associated with worse mental health outcomes.

 Study designs are limited by poor participant characterisation and representativeness.

camouflaging. Following a systematic search of eight databases, 29 studies quantifying

approaches: internal-external discrepancy or self-report. These approaches appear to relate to

two distinct but potentially connected elements of camouflaging: observable behavioural

representativeness, which suggests that conclusions cannot be applied to the autistic

understanding of camouflaging and improving measurement methods.

Keywords: Autism, Camouflage, Camouflaging, Social Behaviour, Gender, Mental Health

Camouflaging in autism: A systematic review

Autism Spectrum Disorder (henceforth ‘autism’) is a neurodevelopmental condition diagnosed

Descriptions of camouflaging first appeared in clinical and autobiographical writings; usually to

seen as masking rather than resolving underlying social difficulties.

These clinical and autobiographical writings stimulated qualitative research aimed at

important hypotheses generated by the qualitative camouflaging literature. In seeking to operationalise

2019). Internal-external discrepancy approaches focus on quantifying the degree to which an

Is camouflaging associated with having high autistic traits or an autism diagnosis?

In conceptualising camouflaging, it is important to understand the extent to which camouflaging

with variability in autistic traits (Hull et al., 2017).

Are there sex or gender differences in camouflaging behaviours?

Are particular cognitive abilities or processes associated with camouflaging?

A considerable degree of heterogeneity exists amongst autistic people regarding general

account for variability in camouflaging amongst autistic people.

Is camouflaging related to current age or age at diagnosis?

In conceptualising camouflaging, it is important to understand changes in camouflaging across

camouflaging (Cage & Troxell-Whitman, 2020). To better understanding fluctuations in camouflaging

across the lifespan, it is important to consider the role of age at diagnosis.

improving the well-being and life opportunities of autistic people.

individuals of all sexes and genders.

characteristics of participants included in camouflaging studies. Thus, a critical evaluation of

current evidence as well as gaps that require further research.

The Present Review

Search Strategy and Selection Criteria

register of systematic reviews (registration number: CRD42019141410). Our review proceeded as

and then manually.

[insert table 1 here]

[insert Figure 1 here]

ended questions (n=2).

Table 2 provides an overview of participant characteristics for participants with autism

charities and support groups, and/or research databases.

characteristics reported in each included study are in Appendix D.

[insert Table 2 here]

Included studies quantified camouflaging using two different measurement approaches:

internal-external discrepancy approaches, or self-report approaches. A range of terms (i.e., masking,

the relevant study authors in this section.

Internal-External Discrepancy Approaches

discrepancy approaches. Internal-external discrepancy approaches aim to measure camouflaging by

[insert Table 3 here]

aim to measure camouflaging by quantifying individuals’ self-perceived engagement in camouflaging.

and parent-report methodologies and instruments varied significantly between studies.