What You Are Hiding Could Be Hurting You: Autistic Masking in Relation to Mental Health, Interpersonal Trauma, Authenticity, and Self-Esteem

Abstract

Background:

Autistic masking refers to some autistic individuals' tendency to hide, suppress, or camouflage their autistic traits, autistic identity, or autism diagnosis. Autistic masking also may include unconscious or conscious attempts to mimic the behavioral, cognitive, or sensory styles of nonautistic neurotypical people and to suppress natural forms of autistic behavior, cognition, and reactions to sensory experiences. Since autistic people are a stigmatized minority in many neurotypical dominated societies, passing as nonautistic through autistic masking may be an attempt to avoid autism stigma and a reaction to previous interpersonal trauma. Increased autistic masking behaviors are associated with reports of increased depression, anxiety, burnout, and exhaustion in autistic people, and thus, exploring the roots and impact of autistic masking is an important mental health topic.

Methods:

This study investigated the relationships between autistic masking and depression, anxiety, gender identity, sexual orientation, interpersonal trauma, self-esteem, authenticity, and autistic community involvement. Participants were autistic adults (n = 342) recruited through autistic social media groups.

Results:

This study found that higher self-reported autistic masking behaviors were associated with higher reports of past interpersonal trauma, greater anxiety and depression symptoms, lower self-esteem, lower authenticity, and lower participation within the autistic community. Autistic masking was not associated with gender identity or sexual orientation.

Conclusions:

The results of this study highlight the relationship between autistic masking and past interpersonal trauma, finding that autistic masking behavior is associated with mental health, self-esteem, and authenticity risks for autistic adults. We call into question the teaching of autistic masking strategies in therapies and education programs for autistic people based on the negative associations with autistic masking presented in this study and other research in this field.

Community brief

Why is this an important issue?

Autistic masking refers to autistic people suppressing their natural autistic traits, responses, and behaviors, in an attempt, consciously or unconsciously, to hide or reduce the visibility of their autistic traits, autistic identity, or autism diagnosis. High levels of autistic masking are associated with negative mental health, authenticity challenges, and burnout for autistic people. Interpersonal pressuring, past traumatic social experiences, and autism stigma potentially fuel autistic masking.

What is the purpose of this study?

This study aimed to investigate relationship between autistic masking and depression, anxiety, interpersonal trauma, self-esteem, authenticity, autistic community involvement, gender identity, and sexual orientation.

What did the researchers do?

We recruited 342 autistic adult participants through autistic social media groups on Facebook to complete a 30-minute anonymous survey online comprising validated scales to measure autistic masking, depression, anxiety, interpersonal trauma, self-esteem, and authenticity. Additional questions were asked about demographic factors, such as gender identity and sexual orientation, and we asked open-ended questions about past social trauma and intersectional issues.

What were the results of the study?

We found that higher self-reported autistic masking behaviors were associated with higher reports of past interpersonal trauma, specifically being shamed and teased about autistic traits, and broader experiences of emotional and physical abuse. Masking was also associated with greater anxiety and more depression symptoms, lower self-esteem, lower authentic living, greater accepting of external influence, higher self-alienation, and lower participation within the autistic community. Autistic masking was not found to be associated with gender identity or sexual orientation. Participants who reported involvement in previous applied behavior analysis therapy reported higher past interpersonal trauma than participants involved in some other forms of therapy such as cognitive behavior therapy.

What do the findings add to what was already known?

This study supports previous research associating autistic masking with depression and anxiety symptoms, and lower reported authenticity, such as autistic people feeling they were not being true to themselves, or revealing their genuine selves to others. This study is the first to quantitatively investigate relationships between autistic masking and past interpersonal traumas, self-esteem, authenticity, and autistic community involvement.

What are potential weaknesses in the study?

Our sample is not representative of the U.S. population when it comes to race, educational level, gender, and sexual orientation. It was very White, highly educated, had few cisgender men, and sixty three percent were members of sexual minority groups. The majority of participants reported late diagnosis of autism. This sample potentially contained an overrepresentation of people with high levels of autistic masking or who more recently realized they were autistic masking in comparison with the general autistic population. We did not analyze differences between early-diagnosed and late-diagnosed cohorts.

How will these findings help autistic adults now or in the future?

This research calls into question the teaching of autistic masking strategies in parenting, education, and therapy programs for autistic people based on the negative associations of autistic masking. Our findings should be utilized as a strong call to action to push back against practices that encourage autistic masking and autistic trait shaming. Instead we advocate for promoting forms of parenting, education, and therapy that respect autistic people's traits, communication styles, sensory needs, and autistic identity.

Introduction

Autistic masking refers to conscious or unconscious strategies utilized by autistic individuals to hide, camouflage, or compensate for their autistic traits in social interactions.¹ In the autistic community, these cognitive, sensory, and behavioral masking experiences are often referred to as autistic masking, whereas within the academic literature, the terms autistic camouflaging and masking are both utilized.² In this article, autistic masking and camouflaging refer to the same construct. Examples of masking include suppressing repetitive body movements utilized by some autistic people for self-calming (autistic stims) or forcing oneself to engage in eye contact, or to remain in certain sensory environments, even when they are unnatural, uncomfortable, or painful.³ Not all autistic people report engaging in masking behaviors, and some people describe not consistently masking their autistic traits across social settings and relationships.^1,4

The study of autistic people hiding aspects of their identity is important because concealing significant aspects of one's authentic self has implications for the mental health of autistic individuals. Some autistic individuals have expressed that attempting to hide their autism came at a high cost, because they felt their masking behaviors created cognitive dissonance; they shared feeling socially compelled to mask their autism in certain environments, while also simultaneously feeling psychologically and physically uncomfortable with the practice and exhausted from the demands of masking behaviors.^4,5

Some autistic adults have reported that autistic masking caused them stress, anxiety, sadness, depression, and loss of authentic self, and masking has been associated with emotional and psychological distress and mental health issues in some autistic adults.^6–11 There has been a tendency for research to show positive associations between masking and anxiety symptoms^7,11 and depression symptoms.^7,8,10,11 However, some research has not supported these links for depression⁹ or anxiety.^2,8,12 Many studies have found evidence of masking being associated with more mental health difficulties and higher neuroticism and psychological distress.^2,6–11,13 However, some researchers posit that there may be gender differences in the degree of distress experienced from masking. For example, Hull et al. found that more autistic men than women reported that they saw benefit in masking, yet that study only included 30 men,⁴ and thus, its results many not be generalizable to broader autistic populations.

Most masking research has found that autistic women mask more than autistic men.^2,12,14–19 McQuaid et al. surveyed 502 autistic adults ages 18–49 years and found that autistic women scored higher in all the Camouflaging Autistic Traits Questionnaire (CAT-Q) subscales than autistic men.¹⁸ However, some studies did not find sex differences in masking behaviors.^4,20 Those studies that did not find sex differences in autistic masking had smaller sample sizes of certain gender cohorts, such as Hull et al.⁴ In comparison, larger studies such as Hull et al. have found sex differences between autistic women and men, suggesting that autistic women mask more.¹⁵ However, in that study, there were no gender differences in masking between nonbinary and cisgender cohorts, and a very small sample of only 16 autistic nonbinary adults making that cell too small to draw statistical conclusions about.¹⁵

Previous research with a nonbinary cohort showed mixed results, such as greater masking in nonbinary autistic people than in autistic cisgender people,¹⁸ no masking differences between nonbinary people and other genders,¹⁵ and cisgender women and nonbinary people masking at a greater frequency than cisgender men.²¹ Due to these mixed results and the small sample sizes of nonbinary people studied in previous research, further exploration of this topic in nonbinary autistic people is needed.

Typically most studies in this area asked gender as an identity question, and not as sex assigned at birth, and thus, it remains unclear how gender roles, gender identity, and sex assignment at birth impact autistic masking behavior. Some researchers posit female gender roles are less congruent with externalizing autistic traits, and thus, autistic girls and women may be subjected to increased social pressure and face more stigma when revealing their autistic traits than boys and men because autistic traits are seen to violate female gender role expectations.¹ Furthermore, autistic people of any gender may experience a more internalized presentation of autism.¹

When living in neurotypical dominated environments in which autistic traits are stigmatized, some autistic adults reported masking their autistic traits because they felt pressured to, or felt it was an expectation of the social environments and relationships they navigated; thus, Pearson and Rose posit autistic masking is not truly a choice,²² but a requirement in some people's lives within certain social relationships, situations, and environments, such as school, work, or while dating.

In line with the minority stress model,²³ autistic people and the autistic community have a stigmatized minority identity; and thus, they are subjected to greater stress as a marginalized minority because of stigmatization, prejudice, and discrimination, and autistic mental health is negatively impacted by minority stress and stigmatization.^24,25 Due to autism's stigma as a mental disorder, autistic people may mask to try to hide their autism as an attempt to pass as neurotypical to try to avoid the stigma of being labeled with a mental disorder.^21,24 Autistic masking may also be an interpersonal trauma response in autistic people who have been shamed, criticized, or bullied regarding their autistic traits.^21,26 Pearson et al. found high rates of past interpersonal victimization in the life narratives of autistic people, and that many of their participants were qualitatively reporting links between their victimization in some social contexts and their autistic traits and autistic identity.²⁶

Autistic people have self-reported masking in an attempt to avoid autism discrimination, social exclusion, and bullying.^4,20,27–29 Botha and Frost²⁴ and Perry et al.²¹ showed that autistic masking was associated with negative views of autism and more past exposure to environments with autism discrimination. Some autistic people describe feeling placed in a double-bind situation with regard to masking or not, feeling either option comes with potential negative consequences.³⁰ Botha et al. posit that autistic people will be othered by neurotypical people, seen as different or “weird” whether they disclose being autistic or not.³⁰

Furthermore, some autistic people are explicitly or implicitly taught autistic masking by their caregivers, therapists, or educational programs, and this autistic masking instruction may have a stigmatizing, shaming, and interpersonally traumatizing impact on their psychological development.^31,32 For example, Kupferstein found increased reports of post-traumatic stress disorder (PTSD) symptoms in autistic people exposed to previous applied behavioral analysis (ABA) therapy in a survey of 460 participants who were either autistic themselves or caregivers of autistic people reporting about autistic people's symptoms.³³ Kupferstein's study was the first to quantitatively demonstrate a potential link between ABA and PTSD. Kupferstein's research fueled discussion about how autism and autistic traits may be stigmatized in certain forms of autism therapy, social skills training, and education programs, which may create a form of interpersonal trauma for autistic people in those environments.

Social identity theory³⁴ posits that when a group is stigmatized, group members seek to regain positive identity utilizing both individualistic and collective strategies. Autistic masking is an example of an individualistic strategy in response to autism stigmatization. Lawson proposes autistic masking as a coping strategy to survive stigma, and that masking is an adaptive morphing technique to camouflage autistic traits and utilize neurotypical behavior styles as a way to cope with social threat and survive in environments that stigmatize autism and autistic traits.³⁵

Applying social identity theory, individualistic strategies such as masking a stigmatized group identity involve dissociating from the stigmatized in-group (e.g., the autistic community) and instead attempting to “pass” into higher status unstigmatized or less stigmatized out-groups (e.g., nonautistic communities). In contrast, collective strategies improve in-group status because they positively reframe an in-group in comparison with an out-group.²¹ Examples of collective strategies include the autism pride movement, the neurodiversity movement, and online autistic social networks. People may experience more or less autism stigma based on the social environments and cultures they navigate.

The present study aimed to quantitatively explore participants' perceptions of autism stigma in relation to their past interpersonal trauma experiences, and participants previous experiences of past trauma in social interactions more broadly. We have operationalized interpersonal and social trauma within this study to include all forms of trauma occuring within social interactions. Past interpersonal trauma exposure within our study includes self-reports of being the target of social rejection, teasing, shaming, bullying, unwanted physical contact with another person, and all forms of verbal, physical, or sexual assault. We also aimed to assess participation in the autistic community as a possible collective strategy protective factor for offering interpersonal support, disability advocacy, and a safe-space environment to disclose autistic traits and unmask.

The objectives of the present study were to explore associations between self-reported autism masking behaviors, mental health, past interpersonal trauma, authenticity, self-esteem, sexual orientation, and gender identity. We also explored participation within the autistic community as a possible protective factor.

Primary hypotheses

• 1.We hypothesized that autistic masking would be associated with more depression and anxiety symptoms.
• 2.We hypothesized autistic cisgender women and nonbinary individuals would show greater evidence of anxiety symptoms, depression symptoms, and autistic masking than cisgender men.
• 3.We hypothesized sexual orientation minorities would report more masking, and more anxiety and depression symptoms than their straight counterparts.
• 4.We hypothesized masking would be associated with more past interpersonal trauma, such as histories of being shamed and teased about autism and autistic traits, therapy trauma, and emotional and physical trauma in participants' personal histories.
• 5.We hypothesized masking would be associated with self-alienation, a higher likelihood of accepting external influence, and lower authentic living.
• 6.We hypothesized masking would be associated with lower self-esteem and less community involvement in the autistic community.

Methods

Participants

To qualify for this study, participants had to self-report a formal diagnosis or self-diagnosis or self-identification of autism spectrum disorder or Asperger's disorder and be 18 years of age or older. No other exclusions applied. We originally recuited participants through posts placed on autistic social media groups on Facebook, and snowball sampling following these posts. The study was open for participation from September 12, 2022, to October 7, 2022. There were no incentives offered for study participation. An a priori power analysis showed that 195 participants were necessary to have 0.80 power to detect a medium-sized effect with a 0.05 criterion of significance for 5 groups, and this requirement was met.

The final sample was composed of 342 people. There was a study completion rate of 82.75%, and only one person was deleted list-wise due to excessive missing data. Participants with missing data were retained for any analysis for which they had provided full data.

There were a number of sexual and gender identities reported among the sample, displayed in Table 1. Gender was organized into five groups for data analysis purposes. Participants who did not list their gender were removed from gender analysis. The sample also contained a sizeable number of participants who reported sexual minority group identities (n = 192), which represented 63% of participants. Due to the low cohort sizes of sexual minority groups such as gay, lesbian, and fluid, all sexual minorities were combined into one group for data analysis.

Table 1.

Characteristics of the Sample

Gender	N	%
Cisgender Man	24	7.92
Cisgender Woman	184	60.72
Nonbinary	71	23.43
Not Listed Here	13	4.29
Transgender Man	9	2.97
Prefer not to answer	2	0.66

Sexuality	N	%
Asexual	29	9.57
Bisexual	35	11.55
Demisexual	18	5.94
Fluid	4	1.32
Gay	5	1.65
Lesbian	10	3.30
Pansexual	28	9.24
Queer	32	10.56
Questioning or Unsure	22	7.26
Straight	109	35.97
Non-straight not listed	9	2.97
Prefer not to answer	2	0.66

Race	N	%
Asian	14	4.1
Black	7	2.6
Hispanic or Latinx	20	5.8
Indigenous American	12	3.8
Multiracial	13	3.8
Pacific Islander or Hawaiian	1	0.3
White	283	84.5

Highest educational attainment	N	%
No formal education	2	0.60
Middle school graduate	2	0.60
High school graduate	69	22.10
Undergraduate university graduate	139	45.0
Advanced university graduate	100	31.6

Current employment	N	%
Caregiver	30	9.6
Employed by company	130	41.7
Self-employed	37	11.9
Not working for pay and not looking for paid work	34	10.9
Not working for pay and looking for paid work	26	8.3
Retired	16	5.1
Student	39	12.5

Autism diagnosis	N	%
Formal	193	57.0
Self-diagnosed	146	43.0

Average age of formal autism diagnosis		Age
Cisgender men		26.36
Cisgender woman		33.55
All other gender options		32.55

Barriers to autism diagnosis	N	%
Adults/caregivers not consent	20	6.3
Adults/caregivers did not realize was autistic	190	59.7
Did not know how to get autism assessment	93	29.2
Difficulty obtaining assessment in region lived	66	20.8
Long waitlist for assessment	57	17.9
Cost of autism diagnosis expensive	112	35.2
Felt uncomfortable asking for autism assessment	73	23.0
Encountered racism	4	1.3
Encountered sexism	49	15.4
Encountered heterosexism	27	8.5
Encountered homo predjudice/negativity	7	2.2
Encountered trans predjudice	6	1.9
Did not realize was autistic earlier	217	68.2
Masked autism to look like something else	224	70.4
Encountered misdiagnosis/mislabeled	74	23.3
Do not know what barriers were faced	32	10.1
Other reasons	46	14.5

Co-occurring psychiatric conditions	N	%
Anxiety disorder	196	59.6
ADHD	119	36.2
Bipolar	27	8.2
Depression	179	54.4
Eating disorder	42	12.8
Neurodevelopment disorder	19	5.8
Personality disorder	14	4.3
Schizophrenia	3	0.9
Substance abuse	9	2.7
Trauma or stressor related disorder	106	32.2
Not listed here	35	10.7

History of therapy	N	%
Cognitive behavior therapy	183	56.5
Couples therapy	46	14.0
Psychoanalysis	40	12.4
Occupational therapy	29	12.1
Speech therapy	28	8.3
Exposure therapy	27	8.3
Humanistic therapy	22	6.7
Applied behavioral analysis	20	6.0
Subtance abuse therapy	12	4.1

Psychiatric medication use	N	%
Yes	156	49.1
No	162	50.9

Participants ranged in ages from 18 to 80 (M = 38.46, SD = 11.41). The self-reported racial composition of participants in this study is displayed in Table 1. The majority of participants reported graduating high school, and as their highest form of educational attainment 45.0% reported an undergraduate university degree, and 31.6% reported an advanced university degree. Students comprised 12.5% of the sample and 54.1% of the sample reported being employed.

A formal autism diagnosis was reported by 57.0% of participants and 43.0% of participants reported being self-diagnosed as autistic. The average age of formal autism diagnosis can be viewed in Table 1. Some participants reported that they faced barriers to autism diagnosis, displayed in Table 1. We decided to include self-identified autistic people without a formal autism diagnosis in this study due to potential systemic sexism, classism, and racism in the autism diagnosis process, because we hoped for a representative sample of the autistic population.¹

Many participants reported co-occurring psychiatric conditions. The percentage of participants reporting a psychiatric diagnosis in addition to autism was 82.2%. All additional diagnostic information is displayed in Table 1. In addition, 83.3% of participants reported a history of therapy, with some participants having experience with multiple modalities, as displayed in Table 1.

Measures

Authenticity scale

We used the authenticity scale (AS)³⁶ to measure participants' authentic living (feeling internally inauthentic), acceptance of external influence (conformity), and self-alienation (externally living one's life in an authentic way publicly). The test–retest reliability (r = 0.78 to r = 0.91) and internal consistency (α = 0.82 to α = 0.92) were sufficient in previous research.³⁶ An example of an item exploring self-alienation is “I feel out of touch with the real me.” An item example of accepting external influence is “I am strongly influenced by the opinions of others,” and an example of authentic living is “I live in accordance with my values and beliefs.”³⁶

Beck Depression Inventory II

To measure a participant's depression symptoms, we gave participants the Beck Depression Inventory II (BDI II).³⁷ The BDI II is a widely utilized 21-item, self-report measure of clinical depression. Each item had a range of answer choices from a score of 0 for not reporting a specific depression symptom (e.g., “I do not feel sad”) to a score of 3 for reporting a severe amount of the symptom (e.g., “I am so sad and unhappy that I can't stand it”). The test–retest reliability (r = 0.93) and internal consistency (α = 0.92) have been high in previous research.³⁸

Camouflaging Autistic Traits Questionnaire

To assess autistic camouflaging (masking) behavior and frequency in participants, we utilized the CAT-Q full scale.¹¹ The CAT-Q is a 25-item questionnaire with a 7-point Likert scale ranging from strongly agree to strongly disagree. The CAT-Q has demonstrated high internal consistency (α = 0.94), and acceptable test–retest reliability (r = 0.77) and has been found to be reliable and valid in autistic populations as a self-report measure of masking behavior.¹¹ A sample item is “I have spent time learning social skills from television shows and films, and try to use these in my interactions.”¹¹

Generalized Anxiety Disorder 7-Item Scale

To measure participants' anxiety symptoms, we used the Generalized Anxiety Disorder 7-Item Scale (GAD-7).³⁹ The items ask participants about anxiety symptoms such as having trouble relaxing and being easily irritable or annoyed during the last 2 weeks. Participants rated each item based on their feelings during the last 2 weeks, with one of four qualifiers, which are: (0) not at all, (1) several days, (2) more than half the days, and (3) nearly every day. A sample item is “Not being able to control or stop worrying.” In previous research, the Cronbach's alpha for the GAD-7 was α = 0.88 and convergent validity with other anxiety measures has been shown to be strong.⁴⁰ Correlations for anxiety disorders and the GAD-7 range from r = 0.70 for anxiety disorders to r = 0.62 for related anxiety constructs.⁴⁰

Perception of Teasing Scale-Autism Version

We adapted the Perception of Teasing Scale (POTS),⁴¹ a measure of weight-based teasing, to assess past interpersonal trauma from teasing, criticism, and shaming about autistic traits and autism. The POTS has previously been tested and found to have both sufficient reliability and validity for assessing weight-based teasing.⁴² In previous research, Cronbach's alpha for the POTS ranged from α = 0.76 to α = 0.86, and test–retest reliability was sufficient (r = 0.85).⁴² In addition, we also found sufficient convergent validity [F(1,70) = 21.16, r = 0.48, p < 0.001, R² = 0.23] between the Perception of Teasing Scale-Autism Version (POTS-AV) and the Forms of Bullying Scale Victimization Version⁴³ in a pilot validation study of the POTS-AV with 72 autistic adult participant responses by using simple correlational and linear regression analyses.

We developed the modified POTS-AV by replacing weight-based language in the POTS with autism-based language to assess being teased about autistic traits and autism. A sample item is “People mocked or criticized your autistic traits.” Participants rated each item on a 5-point scale from (1) never to (5) very often. For each endorsed item, participants were asked how much it upset them from (1) not upset to (5) very upset.

Social trauma

Social trauma items were developed for the current research to assess broader forms of interpersonal trauma, such as interpersonal therapy trauma (2 items), bullying victimization (3 items), and interpersonal assault (3 items). These questions contained the same 5-point scale as the POTS-AV.

Rosenberg Self-Esteem Scale

To measure participants' self-esteem, we administered the 10-item Rosenberg Self-Esteem Scale (RSES). Participants rated their opinions on a 4-point Likert scale ranging from strongly disagree to strongly agree about statements regarding their sense of personal worthiness, with some negative statements scored in reverse.⁴⁴ In previous research, Cronbach's alpha from samples were typically in the ranges of 0.77 to 0.88, and test–retest correlations typically were in the 0.82 to 0.88 range.⁴⁵ A sample item is “I feel that I have a number of good qualities.”⁴⁴

Procedure

This study received approval from the Pepperdine University Institutional Review Board. Participants were recruited from September 12, 2022, to October 7, 2022, via posts in Facebook social media groups popular with autistic people. Participants signed an informed consent form before starting the online survey. The survey was completed in the following order: (1) general questions about a participant's autism diagnosis, demographic characteristics, and mental health status and therapy history; (2) CAT-Q; (3) RSES; (4) questions assessing participants' involvement in the autistic community; (5) GAD-7; (6) POTS-AV; and additional questions assessing past social trauma experiences; (7) AS; (8) a question set about intersectionality masking issues to explore other identities and aspects of one's authentic self the participant might be masking; and (9) BDI II.

We selected that presentation order to administer the less triggering aspects of the survey before question sets involving potentially distressing disclosures about interpersonal trauma and depression. We administered the BDI II last because it has a suicidality item, and we wanted to offer support resources directly after that section. At the conclusion of the study, each participant was given a debriefing statement with links to mental health resources.

Results

Preliminary analyses

Statistical results for preliminary analyses are presented in Table 2. Descriptive statistics and correlations between all measures are presented in Table 3.

Table 2.

Independent Samples t-Test

Variable name	Formally diagnosed (n = 173)	Self-identified (n = 130)	Levine's F	p-Value for Levine's F	t	df	p-Value (two sided)	d
GAD7	12.04 ± 0.42	10.94 ± 0.52	2.01	.16	1.67	297	.099	0.20
BDI	39.62 ± 0.79	41.25 ± 0.97	0.17	.69	−1.31	283	.192	0.16
CATQ	133.79 ± 1.53	132.68 ± 1.91	0.03	.85	0.45	301	.654	0.05
POTSAV	69.65 ± 1.62	67.05 ± 1.81	0.26	.61	1.07	293	.284	0.13
Social trauma	18.44 ± 0.47	18.44 ± 0.56	0.02	.89	0.00	291	.99	0.00
Authentic living	21.37 ± 0.38	21.30 ± 0.42	0.59	.44	0.12	288	.902	0.02
Accepting external influence	14.89 ± 0.51	15.84 ± 0.64	1.83	.18	−1.17	288	.249	0.14
Self-alienation	15.94 ± 0.59	15.92 ± 0.70	0.16	.69	0.02	288	.981	0.003
Rosenberg	24.25 ± 0.50	24.91 ± 0.47	8.31	.01	−0.96	297.86	.337	0.11
Community involvement	11.29 ± 0.44	9.15 ± 0.46	0.30	.58	3.33	297	<.001	0.39

All measures are expressed as mean ± standard error of the mean unless stated otherwise.

Table 3.

Descriptive Statistics and Correlations for Study Variables

Variable	Number of items	α	N	M	SD	1	2	3	4	5	6	7	8	9	10	11
1. CAT-Q	25	.90	303	133.31	20.87	—
2. GAD-7	7	.90	299	11.57	5.64	.37*	—
3. POTS-AV	11	.94	295	68.55	20.74	.31*	.28*	—
4. Social trauma	8	.74	293	18.44	6.13	.26*	.31*	.57*	—
5. Authentic living	4	.75	290	21.34	4.84	−.16*	−.15*	−.00	−.06	—
6. Accepting external influence	4	.88	290	15.29	6.85	.33*	.24*	.15*	.06	−.39*	—
7. Self-alienation	4	.91	290	15.93	7.67	.26*	.28*	.15*	.06	−.35*	.45*	—
8. Intersectionality	14	.75	289	24.18	3.98	.40*	.25*	.31*	.33*	−.15*	.21*	.33*	—
9. BDI	21	.89	285	40.32	10.37	.31*	.62*	.33*	.36*	−.22*	.27*	.47*	.43*	—
10. Autistic community involvement	10	.76	299	10.37	5.61	−.19*	−.06	.07	.11	.24*	−.16*	−.23*	−.18*	−.21*	—
11. Rosenberg self-esteem	10	.91	302	24.54	6.08	−.25*	−.56*	−.36*	−.30*	38*	−.35*	−.46*	−.33*	−.71*	.21*	—

^* p ≤ .012. 1 = CAT-Q; 2 = GAD-7; 3 = POTS-AV; 4 = social trauma; 5 = authentic living; 6 = accepting external influence; 7 = self-alienation; 8 = intersectionality; 9 = BDI; 10 = autistic community involvement; 11 = rosenberg self-esteem.

We used t-tests to establish that the formally diagnosed and self-diagnosed autistic respondents in our sample did not differ from one another in most of our variables of interest, including anxiety, p = 0.10, 95% confidence interval (CI) of the Difference = [−0.20 to 2.39], depression, p = 0.19, 95% CI of the Difference = [−4.08 to 0.81], masking, p = 0.65, 95% CI of the Difference = [−3.72 to 5.93], social trauma, p = 0.99, 95% CI of the Difference = [−1.42 to 1.43], past teasing of autistic traits, p = 0.28, 95% CI of the Difference = [−2.20 to 7.41], authentic living, p = 0.90, 95% CI of the Difference = [−1.06 to 1.20], accepting external influence, p = 0.24, 95% CI of the Difference = [−2.55 to 0.65], self-alienation, p = 0.98, 95% CI of the Difference = [−1.77 to 1.82], and self-esteem, p = 0.34, 95% CI of the Difference = [−2.01 to 0.69].

These results are consistent with previous research.⁴⁶ Formally diagnosed autistic respondents and self-diagnosed autistic respondents did differ in autistic community involvement, p < 0.001, 95% CI of the Difference = [0.88 to 3.41]. Given the similarity between formally diagnosed and self-diagnosed autistic respondents in most of our variables of interest, we analyzed formally diagnosed and self-diagnosed respondents together in our primary analyses.

Primary analyses

Linear regressions were used to assess whether autistic masking predicts depression and anxiety. We used a Bonferroni correction to keep family-wise error at 0.05, so the regressions have a critical p of 0.025. Autistic masking predicted both more depression, F(1,283) = 30.50, p < 0.001, R² = 0.10, standard error of the estimate (SEE) = 9.87, B = 0.15, standard error (S.E.) = 0.03, 95% CI for B = [0.10 to 0.21], β = 0.31, and more anxiety, F(1,297) = 45.73, p < 0.001, R² = 0.13, SEE = 5.26, B = 0.10, S.E. = 0.02, 95% CI for B = [0.07 to 0.13], β = 0.37.

One-way analysis of variances was used to assess gender differences in masking, depression, and anxiety. The models were significant for anxiety, F(4,292) = 2.61, p = 0.04, η² = 0.04, depression, F(4,279) = 2.43, p = 0.048, η² = 0.03, and masking, F(4,296) = 2.79, p = 0.03, η² = 0.04. However, post hoc Games–Howell multiple comparisons only showed significant gender group differences for depression. Cisgender women (M = 41.31, SD = 9.97) reported more depression than participants who said their gender identity was not listed among the survey options (M = 32.85, SD = 7.55).

We used t-tests to assess whether sexual minorities (n = 192) differed from straight individuals (n = 108) in their levels of anxiety, depression, and masking. We used a Bonferroni correction to keep family-wise error at 0.05, and thus, the three t-tests have a critical p of 0.017. Sexual minorities (M = 11.98, SD = 5.76, Range = 21) reported more anxiety, Levene's F = 1.43, p = 0.29, t = −1.69, df = 297, p = 0.046, d = 0.20, 95% CI of the Difference = [−2.23 to −0.02], than straight individuals (M = 10.83, SD = 5.38, Range = 20).

In addition, sexual minorities (M = 41.26, SD = 10.79, Range = 53) reported more depression than straight individuals (M = 38.62, SD = 9.40, Range = 42), Levene's F = 1.14, p = 0.23, t = −2.08, df = 283, p = 0.02, d = 0.26, 95% CI of the Difference = [−4.76 to −0.54]. Sexual minorities did not differ significantly in their levels of masking (Levene's F = 0.325, p = 0.57, t = −1.02, df = 301, p = 0.31, d = 0.12).

Linear regressions were used to assess whether past interpersonal trauma predicts autistic masking. We used a Bonferroni correction to keep family-wise error at 0.05, so the regressions have a critical p of 0.025. Past interpersonal trauma predicted more autistic masking, F(1,291) = 21.53, p < 0.001, R² = 0.07, SEE = 20.31, B = 0.89, S.E. = 0.14, 95% CI for B = [0.52 to 1.28], β = 0.27. In addition, past teasing of autistic traits predicted more autistic masking, F(1,293) = 31.88, p < 0.001, R² = 0.10, SEE = 19.92, B = 0.32, S.E. = 0.06, 95% CI for B = [0.21 to 0.43], β = 0.31.

Linear regressions were used to assess whether autistic masking predicts authentic living, accepting external influence, and self-alienation. We used a Bonferroni correction to keep family-wise error at 0.05, and so, the regressions have a critical p of 0.017. Autistic masking predicted less authentic living, F(1,288) = 7.88, p = 0.005, R² = 0.03, SEE = 4.79, B = −0.03, S.E. = 0.01, 95% CI for B = [−0.06 to −0.01], β = −0.16. Autistic masking predicted greater acceptance of external influence, F(1,288) = 35.18, p < 0.001, R² = 0.11, SEE = 6.48, B = 0.11, S.E. = 0.02, 95% CI for B = [0.07 to 0.14], β = 0.33. Autistic masking predicted more self-alienation, F(1,288) = 20.95, p < 0.001, R² = 0.07, SEE = 7.42, B = 0.10, S.E. = 0.02, 95% CI for B = [0.05 to 0.14], β = 0.26.

Linear regressions were used to assess whether autistic masking predicts self-esteem and autistic community involvement. We used a Bonferroni correction to keep family-wise error at 0.05, and so, the regressions have a critical p of 0.025. Autistic masking predicted lower self-esteem, F(1,300) = 19.66, p < 0.001, R² = 0.06, SEE = 5.90, B = −0.07, S.E. = 0.02, 95% CI for B = [−0.10 to −0.04], β = −0.25, and less involvement in the autistic community, F(1,297) = 11.37, p < 0.001, R² = 0.04, SEE = 5.51, B = −0.05, S.E. = 0.02, 95% CI for B = [−0.08 to −0.02], β = −0.19.

Exploratory analyses

We also conducted exploratory analyses to examine differences in our variables of interest on the basis of whether participants had ever undergone ABA. This is of interest because ABA potentially teaches and reinforces autistic masking behavior and the long-term effects of ABA on autistic clients are still a matter of debate.⁴⁷

Participants who reported past ABA therapy reported higher levels of social trauma (Levene's F = 7.46, p = 0.007, equal variances not assumed, t = −2.03, df = 15.74, p = 0.03, d = −0.76, 95% CI of the Difference = [−8.59 to −0.65]) and accepting of external influence (Levene's F = 0.13, p = 0.91, t = −2.55, df = 288, p = 0.01, d = −0.66, 95% CI of the Difference = [−7.89 to −1.02]).

They did not report statistically significant differences for anxiety (Levene's F = 0.005, p = 0.941, t = −0.46, df = 297, p = 0.65, d = −0.12), depression (Levene's F = 7.74, p = 0.006, equal variances not assumed, t = 0.185, df = 14.64, p = 0.86, d = 0.07), masking (Levene's F = 2.72, p = 0.10, t = 0.47, df = 301, p = 0.64, d = 0.12), self-esteem (Levene's F = 6.87, p = 0.009, equal variances not assumed, t = 1.24, df = 16.86, p = 0.23, d = 0.44), authentic living (Levene's F = 0.41, p = 0.52, t = 0.13, df = 288, p = 0.90, d = 0.03), or self-alienation (Levene's F = 5.92, p = 0.02, equal variances not assumed, t = −0.13, df = 15.94, p = 0.86, d = −0.04).

Discussion

Through social identity theory,³⁴ autistic masking is viewed as an example of an individualistic strategy in response to autism stigmatization involving potentially trying to acquire a nonstigmatized group identity or greater social status by dissociating from the stigmatized autistic group and attempting to pass into higher status unstigmatized or less stigmatized out-groups. Pearson and Rose posit that autistic masking may be a response to interpersonal trauma, and it can be viewed as a protective attempt to limit exposure to autism stigma.²²

Some people may that assume passing for less stigmatized group identities through autistic masking could reduce the negative psychological impact of being a member of a stigmatized group. However, our findings suggest autistic masking is associated with higher depression and anxiety symptoms, lower self-esteem, and less personal authenticity. Although causal links cannot be established through our methodology, autistic masking may come at a high psychological cost for some autistic people.

These findings support previous research that has found autistic masking to be associated with more depression symptoms^2,7,8,10,11 and anxiety symptoms.^7,11 In addition, finding a quantitative relationship between higher masking and lower personal authenticity concurs with previous qualitative research reporting some autistic people felt masking caused them to feel like they were not being their authentic selves with others.⁴ Demonstrating a relationship between higher autistic masking and lower self-esteem in autistic people also adds to the literature in this field because that explicit relationship had not been explored before quantitatively.

For the most part, we did not find gender differences, which may have been the result of small cohorts of certain gender identities in our sample. Only 22 cisgender men participated, and thus, there were not enough cisgender men to draw statistically relevant conclusions. There were 69 nonbinary people who participated, but they did not show gender differences from the cisgender women or cisgender men cohorts. Only cisgender women and those people who said that their self-identified gender was not listed in the survey options showed any gender differences. Future research would benefit from samples with more balanced gender representation. Lack of gender differences agrees with some previous research that did not find gender differences in autistic masking.^4,20

Anxiety and depression scores were also higher in the sexual minority cohort compared with heterosexual autistic individuals. This finding is consistent with previous research showing that sexual minorities in the general population report more anxiety and depression symptoms than their straight counterparts.⁴⁸ Autistic masking did not differ based on participants' sexual orientation, suggesting that autistic masking was not an underlying reason for increased anxiety or depressive symptoms among sexual minority autistic individuals.

The minority stress theory posits that minority groups are subjected to greater stress as a marginalized minority because of prejudice, stigmatization, and discrimination impacting the stress levels and mental health of minority group members.^21,24 Autistic people have self-reported masking in an attempt to avoid autism discrimination, social exclusion, and bullying.^4,20,26–29 Similarly, we found a predictive relationship between participants social trauma histories and autistic masking.

Our results support Perry et al.,²¹ Pearson and Rose,²² and Pearson et al.'s²⁶ theory that autistic masking may be a trauma response in autistic people linked to interpersonal trauma and autistic stigma. Autistic people through experiences of past interpersonal trauma, in which they felt their autistic traits were associated with being targeted for victimization, may feel physically, socially, and emotionally unsafe unmasking in neurotypical dominated environments or around neurotypical people.²² Our research focused on operationalizing social and interpersonal trauma as victimization through being targeted by bullying, teasing, criticism, and interpersonal forms of assault. Future research would benefit from incorporating a focus on social exclusion and refining the exploration of the association of autistic masking with specific forms of interpersonal trauma in a more detailed manner.

Future research is also needed to specifically examine the effects of ABA therapy and other therapies that may promote autistic masking. We found that participants who reported past ABA therapy reported higher levels of past interpersonal trauma and greater acceptance of external influence. The goal of many ABA programs is to reduce autistic behavior patterns (such as autistic stims) and replace them with other forms of behavior more closely approximating neurotypical behavior norms.^31,32 Autistic people within ABA programs are rewarded for suppressing their autistic stims and developing neurotypical styles of communication and behavior.⁴⁹

These procedures should be examined carefully given the current findings that autistic masking is associated with symptoms of anxiety and depression. While the number of participants who reported past ABA therapy was small (n = 20), making it difficult to evaluate outcomes associated with ABA in this study, these analyses are exploratory, and point to directions for further research.

We found participants who disclosed past cognitive behavior therapy (CBT) reported less past social trauma in their lives than those who had histories of ABA. However, it is important to note that aspects of behaviorism, and perhaps encouragement of masking, are present in many non-ABA therapies and education programs, including CBT, and some applications of special education teaching, speech and occupational therapy, and social skills classes. More directly exploring various forms of therapies and education programs as perpetuators of social trauma is warranted so that autistic people can be informed about safe forms of education and therapy.

Our results suggest having a safe social space to be one's authentic self and unmask is a protective factor. We found that higher participation in the autistic community was associated with lower masking scores, higher self-esteem, and higher authenticity. Consistent with social identity theory, these findings suggest autistic community spaces and affiliation activities provided a protective factor that supports people in developing a positive autistic identity, which may facilitate unmasking. Autistic community participation may provide a buffer for the stress and stigma experienced by autistic people in neurotypical dominated spaces.

Participants who were formally diagnosed as autistic did not statistically differ from participants who were self-identified without diagnosis. This finding suggests that self-diagnosed autistic people and formally diagnosed autistic people are relatively similar clinically and this confirms the utility of studying self-identified autistic adults along with the formally diagnosed to research a broader cross section of the autistic community, especially in light of the barriers to diagnosis that some autistic people face.¹

Most participants in this study had a very late diagnosis or self-identification of being autistic. It is possible that aspect of our participant pool biased our results toward individuals who were already engaged in high levels of masking, which potentially made their autism diagnosis more challenging, and contributed to delaying it. It is unknown if the results of our study would apply as readily to autistic people who may autistic mask less due to their autistic traits being less camouflageable and more visible. More research needs to be conducted on masking in nonspeaking autistic populations and other potential autistic cohorts, which may be more visibly identified as autistic. We did not ask participants if they were minimally speaking or nonspeaking, and it is unknown how that variable would have impacted our results.

Another limitation of this study is that most of our participants were recruited in autistic social media groups. Literacy and fluency in English were required to read and respond to written survey questions. The sample had high educational attainment, which may have influenced results. Access to the internet may also have influenced who responded to our call for participants.

It is also possible given the growing popularity of the neurodiversity and autism pride movements in many autistic social media groups that this research was impacted by some participants having greater access to social groups with favorable views about autism and unmasked autistic community role models. Autistic people who seek out autism affirming social media groups may be more likely to seek out other autism affirming social communities and might be more likely to be part of pro autism workplaces and school settings. More research is needed on specific environments that support unmasking and authentic living for autistic people.

Unfortunately the sample lacked racial diversity. It was predominately White. Intersectional pressures may impact the relationships between the variables. For example, autistic people of color in racist cultures may experience a multipronged hit from racism, ableism, and social trauma that makes it crucial for further research in this area to explore the masking experiences of autistic people of color in more detail, in addition to the narratives around unmasking and safety in multiply marginalized groups.

While this study lacked racial diversity, it had a high degree of sexual orientation diversity. Sixty-three percent of the sample were members of sexual orientation minorities. While this high representation of sexual minorities agrees with the finding of Weir et al.,⁵⁰ which found autistic people were more likely to be members of sexual minorities than the general population, it is unknown if our sample was proportionately representative of the degree of sexual orientation diversity in the autistic community more broadly. Further research is needed across a wider cross section of the global autistic population to examine if the current findings replicate.

Although correlational in nature, the findings of this study raise questions about autistic masking having many negative associations in the lives of autistic people. Botha posits autistic people describe feeling placed in a double-bind situation with regard to debating if they should mask or not, feeling either choice comes with potential negative consequences.²⁴ Our research findings also highlight the relationship between autistic masking and histories of past interpersonal trauma. This tendency suggests that bullying, teasing, and social and societal messaging that stigmatizes autistic traits and autism may create an environment for many autistic people in which hiding a key part of themselves becomes a learned response.

However, autistic masking may not truly have the social benefits some people assume. Belcher et al. found that autistic masking intentions by autistic people did not predict the social impression they made on nonautistic people.⁵¹ In addition, Sasson and Morrison found that nonautistic people rate autistic people less favorably in situations in which those autistic people do not disclose autism; yet, when autistic individuals disclose autism they are rated more favorably than undisclosed autistic people.⁵² In addition, disclosing being autistic may help with greater access to better autism understanding and accommodations in work and school settings. While there may be some environments where some autistic people still feel unsafe unmasking, there is growing awareness and respect for neurodiversity in many schools and workplaces,⁵³ and even an emerging wave of autistic self-help books, such as those by Price⁵⁴ and Belcher⁵⁵ supporting autistic people in unmasking and reclaiming their authentic selves.

There is growing awareness about the potential harm of autistic masking in discourse in the autistic community and among some academics, but this message still has not widely disseminated outside of the autistic community. We hope our research will inspire further study and discussion on this topic area, and a critical look at therapies, parenting, social skills, and education programs for autistic people that teach autistic masking.

The implications of our study are important for professionals working with autistic children, autistic adults, and their extended families, who may be engaging in, or explicitly or implicitly teaching and reinforcing, autistic masking behavior. The current findings suggest these individuals should be more reflective about the potential long-term risks of such behavioral strategies on the self-esteem, personal authenticity, and mental health of autistic people. Therapeutic approaches that are neurodiversity affirming and that nurture clients toward having more pride in their autistic neurotype and promote healing of internalized ableism are likely to benefit autistic individuals. Examples of therapy qualities that are neurodiversity affirming are approaches that respect and value neurodivergent traits, behavioral patterns, communication, sensory perceptions, and the client's natural ways of being. Designing new forms of therapy and educational programs that respect neurodiversity and that do not teach masking is vital.

This research also offers support for advocacy and education to destigmatize autism in the general public, reframe autism more positively, and to embrace neurodiversity. If neurodivergent traits such as autistic traits become less stigmatized in neurotypical dominated spaces and cultures, autistic masking and the interpersonal trauma that fuels it could become a relic of the past.

Conclusion

Our study results show support for the previous theory that autistic masking may be a trauma response in autistic people linked to interpersonal trauma and autistic stigma.^21,22,26 Our results also indicate that autistic masking is associated with mental health, self-esteem, and authenticity risks for autistic adults. Based on these findings and other research associating autistic masking with poorer mental health and psychological distress for autistic people,^2,6–11,13 we call into question the teaching of autistic masking strategies in parenting, therapy, and education programs for autistic people.

Our findings should be utilized as a strong call to action to combat practices that encourage autistic trait shaming and autistic masking. To prevent or alleviate potential future trauma to autistic populations, we advocate that parenting, therapy, and education for autistic people be neurodiversity affirming with clear respect for autistic traits and autistic identity, and that practices that shame autistic people for their autistic traits and identity be halted.

Authorship Confirmation Statement

J.A.E. contributed to this research by writing the research proposal for this study, operationalizing some of the study's concepts, developing some of the survey questions, leading participant recruitment, designing the online questionnaires, extracting and analyzing the data, writing the initial draft of this article, and rewriting and editing the subsequent revisions of the article. J.A.E. and S.V.R. conducted a validation study of the POTS-AV together. S.V.R. and E.J.K. provided feedback on study conceptualization and data analysis, and they were involved in all the critical revisions of the article. All coauthors have reviewed and approved this article for submission. This article has solely been submitted to this journal. It has not been published previously or submitted elsewhere for publication.

Autistic Community Participation

This research study was primarily designed, written, and implemented by an autistic person, and many of the core theoretical hypotheses we were testing were from the works of other autistic researchers. All our participants were autistic, and fellow autistic people helped us to recruit participants for this study. Thus, our research project is participatory grassroots autism research by autistic adults.

Author Disclosure Statement

We have no known conflicts of interest to disclose.

Funding Information

This research was not funded.