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Abstract
According to the Centers for Disease Control and Prevention (CDC), Autism spectrum disorder
(ASD) is a developmental disability caused by differences in the brain, and some people with
ASD have a known difference, such as a genetic condition. Other causes are not yet known.
People with ASD may behave, communicate, interact, and learn differently from most other non-
neurodivergent people. ASD is on the spectrum, with abilities ranging significantly, with some
individuals possessing advanced conversation skills and others nonverbal. The rate of diagnosing
autism in females is lower than in males, often resulting in misdiagnosis or a delayed diagnosis
aligning with the 4:1 male-female ratio specified in the Diagnostic and Statistical Manual of
Mental Disorders, fifth edition (DSM-V)(Lundström et al., 2019). Although the reason for the
higher prevalence of autism in males is not fully understood, evidence points to multiple factors.
The 'female protective effect' suggests that being female may reduce the likelihood of developing
autism. Still, evidence suggests that autism is often underdiagnosed in females, possibly because
their symptoms may not align with current diagnostic criteria (Hull et al., 2020). This paper
reviews the communication, behavior, and social skills presented by females diagnosed with
ASD. It explores the evidence for a female-typical autism presentation, also known as the
Female Autism Phenotype (FAP), and its characteristics. Understanding how ASD presents in
females is paramount to understanding social expectations and informing intervention efforts in
the minority population, improving their overall well-being, mental health, education,
employment, and independence.
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The Female Autism Phenotype and Camouflaging: a Narrative
Review
Communication
As there are currently no reliable biomarkers for ASD, the condition is diagnosed based on
observed behavior and described core characteristics that impact everyday functioning. One of
the core characteristics of ASD is language deficits. Although ASD is on the spectrum, with
abilities ranging significantly, some individuals possess advanced conversation skills, others are
nonverbal, have difficulties with pragmatic language and semantics, pedantic language, while
some have Echolalia (E Amanda Boutot, 2017).
It's important to note that while these communication characteristics can be present in
some individuals with ASD, they may be expressed differently, if at all, in females due to the
female autism phenotype (FAP) (Hull et al., 2020). For example, developing females
demonstrate an advantage in early language and communication skills (Ko et al., 2022) thus
making FAP is a behavioral expression of autism that shares similar underlying characteristics
outlined in the DSM-V. Additionally, FAP can include characteristics that are not part of the
autism diagnostic criteria (Hull et al., 2020).
A typical characteristic part of the FAP that affects communication is internalization.
Autistic females are more likely to experience internalizing problems, which means they tend to
express complex emotions inwardly, including anxiety, depression, self-harm, and disordered
eating (Hull et al., 2020). Research indicates that these internalizing disorders are more common
and severe in autistic females compared to males. On the other hand, autistic males are more
likely to exhibit externalizing disorders, such as behavioral problems and inattention (Hull et al.,
2020). This difference in how co-occurring conditions are expressed can make it more difficult
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for autistic females to have their autism recognized and increases their vulnerability to severe
mental health conditions.
Behavior
Typically autistic behavior comes with repetitive behaviors also known as self-
stimulatory such as rocking or hand flipping (E Amanda Boutot, 2017). However, these certain
characteristics associated with autism, such as strong systemizing abilities and challenges with
cognitive empathy and emotional expression tasks, are suggested to be linked to masculine traits
through the extreme male brain theory (EMB theory). The EMB theory suggests that individuals
with lower levels of androgens also demonstrate lower levels of these characteristics (Hull et al.,
2020).
Another behavioral characteristic that differs between autistic females and autistic males
is camouflaging. In 1981, the term "camouflaging hypothesis" was coined by Lorna Wig,
famously known for introducing the term Asperger syndrome. Camouflaging is described as a
behavior where an autistic female uses conscious or unconscious strategies that are either learned
or developed to mask the appearance of autistic characteristics in social settings. Examples
include mimicking the facial expressions of the person you are talking to, whether consciously or
not, or feeling the need to make eye contact and stop talking about an interest (Hull et al., 2020).
Compensation is another masking strategy. It involves using alternative cognitive
strategies to overcome specific socio-cognitive or behavioral difficulties in autism. For example,
an individual with autism may use executive function strategies to learn to recognize different
facial expressions, compensating for theory of mind difficulties.
The concept of varying adaptation to different environments, or variation in the person-
environment fit, has been proposed as a fundamental driver of camouflaging behaviors.
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Individuals who do not feel like they fit into a social situation, especially women who feel
significant pressure to fit in socially, may adjust their behavior in that situation in order to better
fit in. In less pressured situations, individuals do not feel the need to adapt their behaviors.
The way autism symptoms are expressed may vary depending on the environment, such
as at home, school, or during clinical assessments. This variation can result in differences in how
severe social communication difficulties experienced by someone with autism. It may also
explain why autistic characteristics may be perceived differently over time. As social situations
become more complex with age, individuals with autism may struggle more, even if they can
adapt to or compensate for more straightforward social interactions earlier in life.
Social Skills
Females with autism have unique socialization profiles and research suggests that autistic
females are likely to have fewer social impairments and higher social motivation than males (Ko
et al., 2022). Although, as discussed, this can be due to camouflaging, compensation, and other
masking behaviors through observation by others around them. However, autistic females may
struggle to maintain long-term friendships, unlike their male counterparts, due to difficulty in
coping compared to both autistic males and non-autistic females (Hull et al., 2020). Although
they can have positive relationships with others, autistic females are more likely to be unable to
maintain them long-term.
In the review, a study conducted in 2017 by Parish-Morris and colleagues found that
autistic females used more typical patterns of filling pauses in conversations than males with
similar levels of autistic traits. The research concluded that these typical-sounding disfluency
patterns might make autistic girls sound more typical to a casual listener, which could
differentiate them from boys with ASD. This underscores the importance and variation of
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camouflaging while highlighting the innovative potential of natural language in contributing to
objective behavioral imaging diagnostics for ASD.
Conclusion
This review examined the communication, behavior, and social skills of females with autism
by analyzing previous scholarly works. The review identified evidence for the proposed Female
Autism Phenotype (FAP). It emphasizes the concept of camouflaging as a part of it, suggesting a
standard part of the everyday experiences of autistic females. Additionally, it highlighted the
importance of considering sex and gender in understanding how autism spectrum disorder (ASD)
manifests in females. Such findings suggest that autistic females exhibit a unique presentation
and are, therefore, being differentially diagnosed, and research should focus on the experiences
of autistic females compared to non-autistic females to assess their social abilities accurately.
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References
CDC. (2024, May 14). About Autism Spectrum Disorder. Autism Spectrum Disorder (ASD).
https://www.cdc.gov/autism/about/index.html
E Amanda Boutot. (2017). Autism spectrum disorders : foundations, characteristics, and
effective strategies. Pearson.
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Hull, L., Petrides, K. V., & Mandy, W. (2020). The female autism phenotype and camouflaging:
A narrative review. Review Journal of Autism and Developmental Disorders, 7(4), 306–
317. https://doi.org/10.1007/s40489-020-00197-9
Ko, J. A., Schuck, R. K., Jimenez-Muñoz, M., Penner-Baiden, K. M., & Vernon, T. W. (2022).
Brief Report: Sex/Gender Differences in Adolescents with Autism: Socialization Profiles
and Response to Social Skills Intervention. Journal of Autism and Developmental
Disorders, 52(6). https://doi.org/10.1007/s10803-021-05127-0
Lundström, S., Mårland, C., Kuja-Halkola, R., Anckarsäter, H., Lichtenstein, P., Gillberg, C., &
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https://doi.org/10.1186/s13229-017-0164-6
