When I think of the word “masking”, I immediately remember the 1994 film The Mask starring the one and only Jim Carrey. While the movie promises a good time and pure comedy; its synopsis actually has some parallels with the act of “masking” among people on the autism spectrum. The character behind The Mask is a man who is constantly ridiculed in his everyday life. He eventually discovers a mask that, when worn, turns him into a green-skinned superhero with powers that he wouldn’t have without it.
Although the movie is really just for fun, one could say the character has similarities with many individuals with autism, especially girls, who mimic neurotypical behaviors to hide autistic traits. Just like The Mask, some children with autism modify their behavior by creating a front or persona that enables them to conform to customs of non-autistic social behavior.
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What Are the Signs of Autism in Girls – Is Asperger’s in Girls Overlooked?
This article looks deeper into what masking, also known as camouflaging, is and its prevalence among girls/women in comparison to boys/men on the autism spectrum. I hope that, through reading this piece, parents of children with autism will learn more about masking, and will also be given hope to keep pushing for a diagnosis for their children who could possibly be on the spectrum.
The three characteristics of autism
Before we dive into the topic of camouflaging or masking, let’s discuss some definitions of autism.
According to the DSM-5, autism spectrum disorder (ASD) is characterized by difficulty in social communication, difficulty in social interaction, and the occurrence of repetitive behaviors and interests or activities.
Because ASD is a spectrum, every individual with autism differs from another. People with autism do not all share the same mix of traits. People can be anywhere on the spectrum, sharing some traits and not others, but most people with autism are labelled as either high-functioning or low-functioning.
Low-functioning vs high-functioning autism
Low-functioning autistic people are often non-verbal or have incoherent echoic prompts—repeating words or phrases they may have heard without context. A person who is low functioning tends to have severe communication delays and behavioral challenges. Additionally, he/she can experience more severe sensory difficulties, lack of eye contact, excessive special interest, and lack social interaction.
In contrast, some high-functioning autistic people almost resemble “neurotypical” individuals. Typically, someone who is high-functioning does not show signs of intellectual disability but still has some level of difficulty in communication, understanding social cues, reading facial expressions, possible fixation on certain objects or topics, and some resistance to change, to name a few. Someone who is considered high-functioning is more likely to “mask” their autism traits and mimic neurotypical people in a social setting.
Of course, these two descriptions are very generic, and many people will have a mix of ASD traits. Some individuals are also not easily categorized by society as either high-functioning or low-functioning.
Masking/camouflaging—let’s take a look
What is masking?
So, let’s take a closer look at masking. Masking occurs most often among high-functioning autistic people.
The act of masking takes on various forms and masking strategies are very diverse. Some camouflaging techniques include making a decision to make eye contact during a conversation among non-autistic people, and being constantly aware of stimming behaviors and able to hide them.
While both men and women are known to camouflage their autism traits, it is particularly common in girls and women on the spectrum and is thought to be one of the reasons females are less likely to receive a diagnosis.
The late psychiatrist and autism researcher Lorna Wing brought into focus the concept of the “autism spectrum”; she was among the first pioneers who described autism as a dimension in the 1980s. In 1981, Lorna Wing hypothesized that some autistic females who don’t show any intellectual disability are often missed during diagnosis because they appear to have better social communication skills than males. Masking could be the reason for their better communication—girls tend to mimic their friends and copy how others interact with each other.
Masking has been documented by many autistic people, one of whom is Liane Holliday Willey, EdD. Lianne wrote the best-selling memoir Pretending to be Normal in 1999, centered on her experience of growing into adulthood as an undiagnosed girl with autism/asperger’s. The book was released long before her autism diagnosis.
From these women and others, we can understand that, while autism camouflaging has existed for a very long time, it is only recently that research studies have caught onto it.
Is masking mostly linked to autism in women?
Autism is more often diagnosed in boys than girls. In clinical samples, the ratio of males to females who receive timely autism diagnosis is 4:1. Regardless of how similar the presentation of autism is to a girl in comparison to a boy, a girl on the spectrum is likely to receive her diagnosis later on in her life partly due to masking her traits.
Masking can be both conscious and unconscious; it is a way for individuals to hide their autism traits in the “neurotypical” world. It is believed there are two reasons for under diagnosis of autism in girls—firstly, the “female protective effect” which some believe is an inherent trait that reduces the likelihood of developing autism. The female protective effect also indicates inherent genetic gender differences in relation to ASD. Secondly, the ability of girls to camouflage their autistic traits. Many girls with autism study the behaviors of “typical” girls and, eventually, adopt those same attitudes, gestures and facial expressions to adopt a more “normal” or non-autistic persona during social situations.
Girls can also mask by choosing more “socially acceptable” topics as their special interests. For example, a girl might become obsessed with make-up, boys, or celebrities—topics which many neurotypical girls will also show an interest in. In contrast, a boy might become very interested in something specific like trains or bridges, and will not be so concerned about whether that makes him “different” from his peers.
Some women with autism have expressed having suffered mental health difficulties as well as the feeling of living a double life as they approached adulthood without an understanding of why they felt different to others. Surveys of adults with autism have stated that the act of camouflaging is a protective shield against the judgement of others and the need to feel like they’re accepted.
Although masking is more common in girls than boys, this does not mean that boys do not camouflage. One study did a qualitative analysis of masking among adults with ASD and, although the majority of responses were from females, there were a few from males. However, it seems masking has a more internalizing effect among girls; with many stating their experience of masking has been emotionally taxing and that they feel they embody a persona outside of themselves. In contrast, masking has an externalizing effect on boys, with many saying they feel hyperreactive, and believe they have social conduct problems.
Unfortunately, despite evidence of autistic traits from personal accounts and research studies, quite often, girls receive misdiagnosis of mental health problems such as personality disorders or eating disorders rather than autism. Diagnostic criteria have not been adapted to consider the female expression of autism and, as a result, clinicians still under diagnose girls on the spectrum until later in life—often in their adulthood.
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What are the signs of autism among individuals who mask?
To the naked eye, an autistic person who is masking his/her traits can appear neurotypical; they are engaged in conversations, and can respond to social cues without problem. Without an educated awareness of the phenotype of camouflaging and the distinction of autistic behaviors in comparison to neurotypical behavior, it is easy for some men and women on the spectrum to fit into the crowd.
In an event where a person with ASD is masking and has not been diagnosed; here are some subtle signs that one can look for to spot ASD traits:
Difficulty socializing in unfamiliar environments
- In comfortable settings, a person masking will appear to be at ease in communication, make eye contact during conversation, and lack stim behavior. However, when brought to an unfamiliar environment, socially, he/she tends to be less successful because they have not fully learned the etiquettes of that environment. Look for small signs of him/her not being completely at ease such as not joining in much with the conversation, laughing along with what is being said, and repeating the points/comments of others
- Pretending to be someone you are not is mentally exhausting. Often, when a child who has been masking returns from school, he/she might have meltdown or shutdown behaviors; this a method he/she might use to release their suppressed anxiety and return to equilibrium
- Meltdowns typically take the form of being tearful, upset, angry, distressed, having what could be misinterpreted as “tantrums”, or aggressive repetitive stimming
- Shutdown takes the form of someone excluding him/herself from any form of social interaction; i.e. just being alone and quiet
Lack of communication flow
- For someone who is masking, many of the conversations that he/she participates in are scripted to some extent. He/she might rehearse their responses or rehearse questions to ask to form a conversation. If your child is doing this, it could be a sign he/she is on the spectrum
Sensitivity to sensory input
- Your child might be be hyperreactive or hypo-reactive to sensory input
- When a person with autism is hyperreactive, he/she is very sensitive to sensory input such as sound, touch, taste, and smell
- When a person with autism is hypo-reactive, he/she seeks sensory input or high arousal to regulate their sensory needs
Noticing these dynamics can help parents gage whether their children, or child, are in need of support and whether a diagnosis should be sought. Journaling observations of the child and taking notes along when consulting with a clinician could help guide doctors when considering an autism diagnosis.
What are the social implications and consequences of masking?
Some studies have documented the reason why girls with autism mask; results suggest that it is motivated by the need to avoid being bullied, the feeling that it is an obligation to mask, and the fear of being ostracized for being autistic. This highlights the impact of an imbalance between the environment in relation to the person; as described by the person-environment fit model. The model highlights the degree to which the environment and the individual influence each other.
The balance between the two describes a person’s overall motivation, behavior, mental, and physical health. If the fit is balanced, the individual functions optimally and, if it is not adequately supported, the person can experience maladaptation. Taking this into account, we can understand the environment’s influence on an autistic person possesses a lot of power over how he/she adapts in social circumstances.
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What Are the Signs of Autism in Girls – Is Asperger’s in Girls Overlooked?
When there’s pressure to change oneself to fit into an environment, and the change causes significant physiological stress, the environment might become toxic and harmful to the person with autism. For example, according to Mandy, W, masking in the social context can cause mental health challenges—some girls with autism believe masking has resulted in them suffering from anxiety and depression. Other findings indicate camouflaging or masking may lead to stress, exhaustion, identity confusion, and a high risk of suicidality.
Other implications of masking include:
- Difficulties in getting a diagnosis of autism due to the person’s ability to reflect non-autistic traits
- Many autistic individuals who camouflage are able to get a job, and can maintain relationships. However, these responsibilities can increase the feelings of needing to mask, and keeping up “the act” could come at the cost of one’s mental health
- Pretending not to be autistic can impact a person’s sense of identity and in turn lead to his/her needs being misunderstood or overlooked
Consider this extract from Hull, et al: “I feel sad because I feel like I haven’t really related to the other people. It becomes very isolating because even when I’m with other people I feel like I’ve just been playing a part.” (Female, 30).
It is unimaginable how emotionally taxing masking must be for individuals with autism. The pressure of wanting to “fit-in” is more pronounced in girls than in boys, and it doesn’t help that diagnostic criteria overlooks masking as a characteristic of autism. It is saddening to realize many individuals who camouflage do so in order to avoid rejection and feeling like an outcast for being different.
The prevalence of masking in girls means they are so often missed for diagnosis due to the diagnostic criteria being based on the male phenotype of autism, which does not consider masking. Imagine living your whole life believing you are different, when an early diagnosis could have reassured you: “you’re autistic and your symptoms are normal.”
I think saying “it isn’t fair” is an understatement—we need to do better! As parents, being aware of your child’s habits is important and, through observing your child’s behaviors, you can become your child’s expert. So pay attention, do your research, journal your observations, and be vocal—your child just needs an advocate like you who understands him/her.
Holmbeck, G. N., Jandasek, B., Sparks, C., Zukerman, J., & Zurenda, L. (2008). Chapter 2 – Theoretical Foundations of Developmental-Behavioral Pediatrics. In M. L. Wolraich, D. D. Drotar, P. H. Dworkin, & E. C. Perrin (Eds.), Developmental-Behavioral Pediatrics (pp. 13-45). Mosby. https://doi.org/10.1016/B978-0-323-04025-9.50005-2
Hull, L., Petrides, K. V., Allison, C., Smith, P., Baron-Cohen, S., Lai, M. C., & Mandy, W. (2017). “Putting on My Best Normal”: Social Camouflaging in Adults with Autism Spectrum Conditions. Journal of autism and developmental disorders, 47(8), 2519–2534. https://doi.org/10.1007/s10803-017-3166-5
Hull, L., Petrides, K.V. & Mandy, W. (2020). The Female Autism Phenotype and Camouflaging: a Narrative Review. Review Journal of Autism and Developmental Disorders, 7, 306–317. https://doi.org/10.1007/s40489-020-00197-9
Mandy, W. (2019). Social camouflaging in autism: Is it time to lose the mask? Autism, 23(8), 1879–1881. https://doi.org/10.1177/1362361319878559
Milner, V., McIntosh, H., Colvert, E., & Happé, F. (2019). A Qualitative Exploration of the Female Experience of Autism Spectrum Disorder (ASD). Journal of autism and developmental disorders, 49(6), 2389–2402. https://doi.org/10.1007/s10803-019-03906-4
This article was featured in issue 123 – Autism in girls
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