Masking, burnout, and suicidality
Masking, sometimes called camouflaging, is the conscious or unconscious adjustment and suppression of natural tendencies to “fit in” with social and cultural expectations. Techniques used for masking include forcing oneself to make eye contact, imitating social movements, scripting conversations, suppressing traits, and more (Pearson & Rose. 2021; Sedgewick et al., 2021). This and other forms of identity management frequently result from stigma and prejudice avoidance, a required part of daily functioning for many autistic individuals across their lifetime (Belcher et al., 2022a; Hull et al., 2017). Consequences of masking can include exhaustion, threats to self-perception, increased mental health difficulties, self-injurious behavior, autistic burnout, and suicidality (Hull et al., 2017; Cassidy et al., 2018; Miller et al., 2021).
“I used to sit next to a person or with a group of people for hours and be so uncomfortable, and everything was wrong, but I wouldn’t want them to know [and] I didn’t want to be difficult [or] cause a problem. So I would just sit there and just suck it up. And I realized that 90% of my life was sucking it up. And I’m like other people don’t do this! Other people will say ‘Hey, I don’t like the way I’m sitting, I’m gonna move.’ I would just sit there and be so uncomfortable. I was always afraid about being misunderstood.”
Chris Nicholson (Interview, 21/02/23)
Autistic burnout (AB) is a “highly debilitating condition” characterized by withdrawal, exhaustion, executive function problems, and increased manifestation of autistic traits. AB results from the cumulative load of stressors and barriers experienced by many autistic individuals and is significantly associated with high rates of masking and increased suicidality (Arnold et al., 2023a; Raymayker et al., 2020; Hedley et al., 2018; Kirby et al., 2019; Kõlves et al., 2021). Researchers posit that much of the pressure to mask stems from a widespread lack of autism awareness and understanding due to classical descriptions and stigmas like the “deficit narrative”(Bradley et al., 2021; Raymaker et al., 2020; Dinishak, 2016). Such narratives have historically shaped autism descriptions within research literature and the broader culture, creating a lack of acceptance and empathy from non-autistic people. Uninformed social expectations and a general lack of empathy inflate the need for autistic people to mask and subsequently increase the risk of autistic burnout and suicidality (Mantzalas et al., 2022; Pearson & Rose, 2021).
Research shows that autistic women and female-presenting people are at more than eight times the risk of suicidality compared to non-autistic women, whereas autistic men are at less than twice the risk (Kirby et al., 2019; Kõlves et al., 2021). Another study found that autistic women and female-presenting individuals (without intellectual disabilities) are at higher risk for suicidal behaviors than autistic men and male-presenting people (Hirvikoski et al., 2020). As previously discussed, masking is a significant risk factor for mental health difficulties and suicidality in autistic people (without intellectual disabilities) regardless of gender (Hull et al., 2021). However, recent studies reveal an association between the length of time spent masking and adverse mental health outcomes. Contrastingly, social acceptance and receiving a diagnosis are reasons autistic adults feel they do not need to mask (Bradley et al., 2021; Cage et al., 2017).
You can learn more in our article on Autism and Depression and our webinar on Stress and Anxiety Reduction presented by Dr. Amy Keefer
When we consider the cycle of late and missed/diagnosis alongside the obligation of autistic masking, the rate of suicidality and poor mental health in autistic females is no surprise. Given such data, healthcare providers and clinical practitioners are investigating and adapting assessment tools and treatments to bolster support and increase quality of life for autistic women and female-presenting people (Raymaker et al., 2020; Hull et al., 2021). Contemporary studies have identified specific levels of masking associated with a higher risk of mental health problems, and treatment strategies focused on intentional masking and authenticity are being explored (Hull et al., 2021; Beck et al., 2020). However, to ensure increased support and care, shifts in societal autism understandings must occur alongside advances in diagnosis and treatment.
“We need to minimize and move the onus of fitting in from autistic people masking toward non-autistic people learning to accept autistic people as they are. Consequences are severe if this is not the case… masking natural behaviors and traits denies expression of our true selves and identity.”
Dr. Hannah Belcher (ARI presentation, 2022)