Women and girls with autism are masking their conditions to such a degree that they risk late or missed diagnosis. Masking symptoms of autism may help socially and professionally but may also harm the individuals in the process.
What is masking? Masking or camouflaging is artificially ‘perform’ social behavior that is deemed to be more ‘neurotypical’ or hiding behavior that might be viewed as socially unacceptable (1). The motivations for masking symptoms of autism includes fitting in and increasing connections with others. Masking itself is comprised of a combination of camouflaging and compensation techniques where the individual is able to control impulses, act ‘neurotypical’, rehearse answers to questions or conversations and mimic others. The short- and long-term consequences of masking includes “exhaustion, challenging stereotypes, and threats to self-perception” (2).
Over the years, the reported male to female ratio of who have received an autism spectrum condition (ASC) diagnosis has been 1 female to every 4-5 males (3). This imbalance of ASC diagnosis between the sexes can be due to different parameters. One of which, may be due to biological gender differences but another, strongly supported reason, may be due to under- or misrecognition of autism in females. Studies of autism have predominantly been done with male subjects, thus making the behavior and characteristic of autism gender stereotypical with a male-based behavioural characterization of autism. Females with ASC have a higher likelihood of subtler and different behavioral presentation that their male counterparts. “Behavioural observations suggest that girls camouflage their social difficulties (e.g. by staying in close proximity to peers and weaving in and out of activities) to a greater extent on the playground than boys, and therefore are less likely to be identified as struggling socially” (2). Thus, women or girls with autism tends to be underdiagnosed as they many may ‘fly under the radar’ due to the insufficient knowledge of the female behavioral characteristic of autism.
Females with autism may, as mentioned, be better at ‘camouflaging’ or ‘masking’ their symptoms while displaying subtler behavioral presentation than males (1). Anecdotal clinical and autobiographical observations suggest that females with ASC show more social interest, heightened emotion or affective empathy, increased imagination, better masking of social difficulties, different contents of narrow interests and more friendships than males with ASC (3).
The motivation for masking is foremost of the desire to fit in and create connections with others. Masking can contribute to achieving socially desirable outcomes such as making friends, improving social status and perform better in job interviews (2). Camouflaging or using social imitation strategies include imitations like “making eye contact during conversation, using learned phrases or pre-prepared jokes in conversation, mimicking other’s social behaviour, imitating facial expressions or gestures, and learning and following social scripts” (1). These masking or compensation strategies are often very exhausting for the individual to perform and comes at a cost. Masking requires a substantial cognitive effort, which can be exhausting and may lead to “increased stress responses, meltdown due to social overload, anxiety and depression, and even a negative impact on the development of one’s identity” (1).
Females with ASC are more likely to experience internalising problems, like anxiety and depression, than the more likely male dominant external difficulties such as hyperactivity and conduct problems. Additionally, studies indicate that females with ASC are more likely than males to receive a misdiagnose of other mental health conditions, such as personality disorders or eating disorders.
Hence, the use of masking or social imitation strategies may lead to either missed or late diagnoses (2).
Late-diagnosed individuals tend to suffer from concurrent mental health challenges, potentially related to long-term stress due to social overload in adaptation to daily life in society (1).
Autobiographical observations and interviews with women, who have been diagnosed later in life, indicates that the women have compensated for their ASC and spent their whole life feeling different until their children have received a diagnosis with symptoms of which the can recognize themselves in (2).
With the new ICD-11, the measures used to assess ASC have been changed and sectioned into six distinctive expressions that now ables specialists to assess challenges and behavior individually. Late diagnostic practices focused on the core ASC characteristics that have been historically established from the behavioural presentation in males and may not reflect upon the female behavioural presentation which resulted in the overlook of females who did not meet the male-typical behavioural presentation (2).
Masking is not necessarily a beneficial behavior and scientist suggest that it should not be expected or encourage for individuals with ASC, as masking may oppose a risk for their mental health. In addition, although masking has predominantly been described generally as a female expression of ASC, studies have reported that many males and other genders also camouflage, hereby indicating that camouflaging is not a female-specific phenomenon. However, we still need more studies and research on the behavior of masking in order to better understand the long-term impact of the consequences and wellbeing of individuals with ASC (2).