Unmasking Autism: Role of Bio-psycho-social Perspective on Camouflaging Behavior and Gender Disparity in Autism Diagnosis

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by persistent challenges in social communication and restricted, repetitive patterns of behavior. In the Indian context, the prevalence of ASD remains relatively low in community estimates, with diagnosis heavily reliant on the Indian Scale for Assessment of Autism (ISAA). However, diagnostic efficacy is complicated by the lack of universal screening tools and the significant role of cognition, which impacts the manifestation of symptoms. This discussion adopts a bio-psycho-social model to examine how cognitive, socio-cultural, and biological factors influence camouflaging behavior, a conscious or unconscious effort by individuals to mask natural characteristics to fit the social mold. While camouflaging facilitates social integration, it often leads to emotional exhaustion and delays diagnosis, particularly contributing to the significant gender disparity in ASD diagnoses, currently estimated at a 4:1 male-to-female ratio. The phenotype hypothesis suggests that this disparity is rooted in historical gender biases in nosological criteria and instrument construction, which have largely excluded female representations. Research indicates that higher cognitive abilities and cognitive flexibility enable females to successfully camouflage traits, whereas those with intellectual disabilities are diagnosed at rates similar to males. Furthermore, theoretical frameworks such as the “male brain theory” and the “female protective hypothesis,” which posit biological and genetic liabilities, are increasingly scrutinized for lacking specific genetic mechanisms and failing to account for epistemological flaws in sampling. Consequently, it is imperative to move beyond traditional, culturally biased assessments such as the theory of mind and investigate how cognitive factors specifically drive camouflaging behavior, thereby obscuring diagnosis, and perpetuating gender inequality in the ASD cohort.