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Autism

Masking and Mental Health in Women with Autism

Why anxiety, depression, and suicidality can be linked to autistic camouflaging.

Key points

  • Women with autism "camouflage"—hiding symptoms or behaviors seen by others as problematic—more than men with autism or people without autism.
  • Autistic camouflaging has been shown to be linked to a heightened risk of depression, anxiety, and suicidality in women with autism.
  • Making a conscious decision to mask when necessary—for example, at work—while being more authentic with loved ones can bolster mental health.

The vast majority of women with autism have a history of “masking,” or camouflaging, their symptoms. They do this in order to make and maintain friendships, fit in at school and higher education, and pass as “normal” in a variety of social contexts, including the workplace.

Camouflaging behaviours often employed by women with autism include forcing themselves to make eye contact, using memory techniques to remember suitable conversation topics, suppressing autistic tendencies, and/ or trying to engage in “normal” social behaviours.1 Autistic women aren’t alone in camouflaging, but research suggests they are more likely to camouflage than neurotypicals or autistic men.2

Camouflaging isn’t all bad. My client Mandy, for example, recognises a need to mask in the workplace and describes it as a conscious decision. “People have told me in the past that I don’t listen, that I talk too much, that I’m too opinionated… if I wasn’t aware enough to tone down quite a lot of that stuff, it would certainly affect my employability”.

However, as much as making oneself more like other people seems like a common-sense response to a genuine issue faced by women with autism, it comes at a cost—and the cost can be quite high.

Several research studies have shown a link between camouflaging in autistic women and a range of mental health issues. These include low self-esteem, stress, exhaustion, anxiety and depression,3 and suicidality.4 Rather than being related to the severity of autistic traits, mental health issues appeared to be most strongly related to the degree to which a woman masks.5

My clients’ experiences back up what we know from the research: Camouflaging is an inherently negative experience that can affect one’s mental health.

Ade told me, “I learned to mask early on. My mother reminded me daily how weird I was and I learned to hide myself. The biggest impact of that for me was the constant worry that I’d done something wrong—that I’d revealed too much of myself by mistake. I’d ruminate for hours about whether I’d let the mask slip.”

Diane’s experience of masking led to a loss of identity. “I’m so good at masking I feel like no one knows the real me. But now I don’t feel like I know the real me either. I feel very depressed and lost a lot of the time." Diane had also attempted suicide in the past.

“It’s very depressing to believe that there’s something fundamentally wrong about you and that you can’t be honest with other people in case they discover this hidden fact. I’ve spent my whole life being too scared to be who I really am—and I’ve experienced severe loneliness and depression because of that,” Martha, another client, told me.

Many women with autism become so skilled at masking they don’t know they’re doing it. One study showed that it may not be until later in life that women’s social difficulties become too great for them to manage with their usual camouflaging strategies.6

Given the link with mental health issues, it seems that, ideally, women with autism would remove the masks and reveal their authentic selves. But as some of my clients have clearly pointed out, to do so places them in a vulnerable position. The workplace, in particular, is one arena where camouflaging can help, especially when it comes to career advancement and long-term progression. Even neurotypical people tend to have a “professional” versus “private” persona.

But what about camouflaging in front of friends and family? Given the impact it has, it's important for autistic women to ask themselves if they want to keep masking themselves around the people closest to them.

Another client, Alana, felt there was a strong—and practical—need to mask at work. But she decided to experiment with revealing more of her true self around friends and family. “As a child, I was quite blunt and I’ve always held strong opinions," she explained to me. "Because I was criticised a couple of times, I went the opposite way and wouldn’t open my mouth to express an opinion. I’ve now decided that, although I might not be everyone’s cup of tea, there are people out there who I can be open and honest with.”

Fiona described the moment she realised that constantly masking was too much. “My anxiety levels hit a peak. I’d become dizzy and confused because I was too scared about mucking up when I spoke. It was upsetting, too, to have to put on a sort of an act literally all the time. I’ve started, very slowly, to bring more of myself—even if some people think I’m weird—and not to worry so much about what others think of me.”

citalliance, 123rf
Source: citalliance, 123rf

“It wasn’t until I realised the cost that camouflaging was having on my health, physical and mental, that I decided to stop," client Jan told me. "Alcohol allowed me to appear as the most sociable person in the room and was my way of masking the social anxiety and burnout I had. When I developed an alcohol-related illness, it was a huge wake-up call. People can take me as I am or not at all.”

Dropping the mask isn’t always easy for women with autism, as wearing it has become a part of them. But if there’s a way to safely and gradually reduce their camouflaging, they may well experience an improvement in their mental health—along with a huge sense of relief.

In my new book, I talk about how to move beyond masking towards self-acceptance.

References

1. Hull, L, Mandy, W, Lai, M-C, Baron-Cohen, S, Allison, C, Smith, P, Petrides, KV (2019) Development and validation of the Camouflaging Autistic Traits Questionnaire (CAT-Q). Journal of Autism and Developmental Disorders, 49(3), 819-833

2. Cassidy, S, Bradley, L, Shaw, R, Baron-Cohen, S (2018) Risk markers for suicidality in autistic adults. Molecular Autism, 9(1), Article 42

3. Cage, E, Troxell-Whitman, Z (2019) Understanding the reasons, contexts and costs of camouflaging for autistic adults. Journal of Autism and Developmental Disorders, 49(5), 1899-1911

4. Beck, JS, Lundwall, RZ, Gabrielsen, T, Cox, JC, South, M (2020) Looking good but feeling bad: “Camouflaging” behaviours and mental health in women with autistic traits, Autism, 24, 4, 809-821

5. Beck, JS, Lundwall, RZ, Gabrielsen, T, Cox, JC, South, M (2020) Looking good but feeling bad: “Camouflaging” behaviours and mental health in women with autistic traits, Autism, 24, 4, 809-821

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