Autistic masking

Autistic masking, also referred to as camouflaging, is the conscious or subconscious suppression of autistic behaviors and compensation of difficulties in social interaction by autistic people, with the goal of being perceived as neurotypical.^[1][2] Masking behavior is a learned coping strategy^[3][4] that can be successful from the perspective of some autistic people (e.g., in reducing the chances of being stigmatized^[5]), but can also lead to adverse mental health outcomes.^[1][6]

Autistic masking is the act of concealing autistic traits to come across as neurotypical, as if behind a mask.

Autistic people have cited social acceptance, the need to get a job, and the avoidance of ostracism or verbal or physical abuse as reasons for masking.^[7]

The process of consciously reducing masking tendencies or not masking in some contexts, which some autistic people see as a desirable goal, is referred to as unmasking.^[2][8][9] Motivations for unmasking include no longer hiding one's true identity and avoiding adverse mental health outcomes.^[2][10][8]

Terminology

There is no universally agreed-upon terminology for the concept.^{[1][6]: 16–17 [11]} While some use the terms masking and camouflaging synonymously,^{[1][2][6]: 16–17} others distinguish between masking (the suppression of behaviors) and compensation (of social difficulties) as the two main forms of camouflaging.^[1][3][12] Among autistic people, masking is the most commonly used umbrella term.^{[6]: 16 [10]} Autistic researcher Wenn Lawson has proposed that adaptive morphing is a more fitting term.^[13]

Forms

I camouflage by putting on a character… I treat my clothes rather like costumes, and certain items of clothing help me to uphold certain personality characteristics of which character I am on that occasion. I have a repertoire of roles for: cafe work, bar work, uni, various groups of friends, etc. They are all me at the core, but they are edited versions of me, designed to not stand out for the "wrong" reasons.

— (Female, 22), ^[3]

Typical examples of autistic masking include the suppression of stimming (in general or in public^[5]) and reactions to sensory overload.^[3] To compensate for difficulties in social interaction with neurotypical peers, autistic people might maintain eye contact despite discomfort^[14][15] or mirror the body language and tone of others.^{[1][2][3][16]}

Autistic people with conversational difficulties may also use more complex strategies, such as scripting a conversation outline, developing conscious "rules" for conversations, and carefully monitoring if these are being followed.^[3] Many autistic people learn conversational rules and social behaviors by watching television shows and other media and by observing and mimicking a character's behavior.^[16] Masking may also include refraining from talking about passionate interests.^[2][3]

Consequences

Masking requires an exceptional effort.^[5][3] It is linked with adverse mental health outcomes^[17][18][19] such as stress,^[20] anxiety, depression, and other psychological disorders,^[20] loss of identity,^[20] and suicidality.^[21][22][23] According to a recent meta analysis, the association between masking and depression, general anxiety, and social anxiety appear consistent across different age groups (children, adolescents, and adults).^[19] Some studies find that compensation strategies are seen as contributing to leading a successful life.^[5][1][12] Since many studies on masking focus on autistic adolescents or adults without cognitive impairments, the generalizability of such findings across the autism spectrum is uncertain.^[1]

Masking may conceal the person's need for support.^[7] It can complicate a diagnosis of autism spectrum disorder (ASD), for example, under-diagnosis for females, particularly past childhood, as relevant symptoms are suppressed or compensated for.^{[24][25]: 60–62} The diagnostic criteria for ASD in the DSM-5 published in 2013 explicitly state that while symptoms "must be present in the early developmental period", these "may be masked by learned strategies in later life", allowing for a diagnosis even if autistic behaviors and difficulties are successfully masked.^{[25]: 57 [26]} Addition of such a formulation was proposed to the workgroup drafting the criteria by representatives of the Autistic Self Advocacy Network including Ari Ne'eman and Steven Kapp.^[26] The diagnostic criteria for ASD in the ICD-11 (2022) contain a similar provision.^[27]

It has been hypothesized that masking may play an important role in explaining why autistic women and non-binary persons^[2] are significantly less often recognized and diagnosed as autistic compared to men.^[2][3][16] This hypothesis was put forward by Lorna Wing as early as 1981^{[6]: 20 [28]: 134} and is recognized in the DSM-5-TR published in 2022.^[25]: 65

Research

While masking was written about and discussed among autistic people, it has only become a focus of academic research since the 2010s.^[6]: 18 The Camouflaging Autistic Traits Questionnaire (CAT-Q), the first self-report measure for camouflaging, was published in 2018.^[29][30] Across 25 items, it measures the extent to which a person utilizes strategies to actively compensate for difficulties in social situations (Compensation, 9 items), uses strategies to hide autistic characteristics or portray a non-autistic persona (Masking, 8 items), and employs strategies to fit in with others in social situations (Assimilation, 8 items).^[29] Other researchers have criticized the use of self-report measures, arguing that self-report may exclude understudied groups within autism, such as individuals with linguistic disabilities.^[31]

In light of rising awareness of the adverse mental health outcomes of masking and insight into the double empathy problem, therapies and interventions with implicit or explicit targets of instilling neurotypical social behavior and suppressing autistic traits that can be adaptive in autistic people are controversial and often criticized by some researchers, neurodiversity proponents, and autistic self-advocates from the autism rights movement.^{[32][33][34][35][36]} Some autistic adults who experienced applied behavior analysis therapy as children describe being forced to behave like neurotypical peers with detrimental effects on their mental and overall well-being.^[37][38][39] In response to these concerns and accounts regarding risks of harm, some forms of ABA interventions have been reforming to mitigate risks of encouraging masking.^[34][40][41] Additionally, some researchers and/or practitioners have called for reforms in some other forms of interventions, such as social skills training, speech-language therapy, and occupational therapy to mitigate such risks, with some therapists implementing such reforms.^{[42][43][44][45][46][47]}

There are some research studies centered around the experiences of masking by comparing different groups of neurotypes. In 2021, researchers conducted an online survey comparing masking experiences between autistic, non-autistic neurodivergent, and neurotypical groups.^[5] They found that the behavior of masking is shared across all types of people, but some aspects of masking are more specific to autism, such as sensory suppression and suppression of stimming. Researchers also recreated this study in a workplace context and examined workplace masking experiences for autistic, non-autistic, and neurotypical adults in the UK. They reported large overlap amongst the three groups. Both neurodivergent and neurotypical people adopted masking strategies to achieve social goals, indicating that masking is a common experience, rather than one exclusive to autistic individuals.^[31]

There has also been qualitative research focused on the autistic experiences of masking. A study in 2022 conducted semi-structured interviews with twenty autistic teenagers and observed that masking is associated with mental health (but not necessarily in linear relationship) and how both of them are affected by social and environmental factors. Researchers stressed the need to approach masking, authenticity, and mental health through the context of people's identities and the environment, providing implications for diagnostic services and interventions.^[48] There have been comparisons between masking and passing.^[31]

In addition to masking, researchers investigated the "authenticity" autistic people feel while socializing and observed that supportive environments, such as being around people who accept and understand them, can lead to self-awareness and create more positive socializing experiences than camouflaging.^[49] However, this doesn't imply that autistic "masking" is equivalent to non-authenticity. Researchers proposed that the focus should not be encouraging masking but promoting autistic authenticity, creating a more positive self-image and better mental health.^[48]

Criticisms of methodologies

There are criticisms of the methodologies used in studies of autistic masking. It is argued that studies on self-reported experiences on the internet lack diagnostic rigor,^[50] and that comparisons between self-reported behavior and a diagnostic classification is not an accurate measure of masking due to a number of confounds. These confounds include the possibility of learning skills later than population average without being stressed by using the skills, especially since there is not any one single genetic mutation underlying all diagnoses of autism, making generalizations about the effects of learning social skills to etiologically different types of autism biologically unsound, that self-reporting is not an accurate measure of the degree of a condition that has difficulties in understanding problems with one’s behavior in its definition, and that a difference in the scores of two measures of one construct is not a validation of another construct.

The assumption that later development of an ability in early childhood necessarily entails lifelong lowering of the ability is argued to contradict the premise of different developmental trajectories,^[51] as brains that develop along different lines can and in some cases do display variations in which one variant develop an ability fast and early while another variant develops it slower but to a higher degree later on. The fact that many of the specific behaviours in neurotypical control samples differ between cultures is also cited as an argument against the claim that stress caused by the extent of use of these behaviors later in life can be linked to childhood delays of their acquisition associated with autism somehow making them "unnatural" to autistic people.

It is argued that the assumption that camouflaged autism in women must be the cause of lower rates of diagnosed autism in women than in men is circular reasoning, and that it skews research on camouflaged autism towards female samples^[52] which further confounds the applicability of research that appears to show harmful effects of learned social skills to male cases of autism. The construct of camouflaged autism is argued to follow a tradition of unfruitful constructs that made quantitative testing more difficult when similarly applied to depression and schizophrenia in the past, and that allegations of stress-related harmful effects of acquiring social skills may discourage both persons formally diagnosed with autism and formally undiagnosed persons who self-diagnose with autism from learning social skills or encouraging such people to exaggerate their symptoms, similar to allegations that learning social skills would destroy special abilities in past decades. It is also cited that studies that appear to show harmful effects of learned social skills in people with autism are qualitative, and that quantitative studies do not support the allegations of harmful effects.

See also

• Minority stress