Masking and camouflaging in autism

Summary

Masking and camouflaging refer to the strategies autistic people use to conceal their autistic characteristics, compensate for social difficulties, and present a more neurotypical-appearing persona. This is not a minor or peripheral phenomenon. Research consistently shows that camouflaging is widespread among autistic people, is associated with significant mental health costs, and is a major reason why many autistic people — particularly women, non-binary people, and those without intellectual disability — are diagnosed late or not at all.

Understanding camouflaging is essential for anyone working in autism assessment, support, or sensory processing. A person who appears to be coping may be doing so at enormous hidden cost.

What masking and camouflaging are

The terminology in this field is not yet fully standardised, but the following distinctions are commonly made:

Camouflaging is the umbrella term for the overall phenomenon of hiding or modifying autistic characteristics during social interactions. Hull et al. (2017), in their foundational qualitative study, identified two core components:

• Masking: hiding or suppressing autistic traits, such as forcing oneself not to stim, controlling facial expressions, or concealing sensory distress.
• Compensation: actively developing and deploying strategies to navigate social situations, such as learning conversation scripts, studying facial expressions from media, rehearsing social scenarios in advance, or mimicking the body language of others.

Livingston and Happé (2017) proposed a related but distinct framework centred on compensation, which they define as the processes by which an individual’s behavioural presentation appears improved despite persisting underlying cognitive differences. Their framework distinguishes between:

• Shallow compensation: relatively simple strategies like suppressing behaviours or copying others.
• Deep compensation: more cognitively demanding strategies like using explicit logical rules to infer others’ mental states in the absence of intuitive social cognition.

Hull et al. (2019) added a third component to their model when developing the Camouflaging Autistic Traits Questionnaire (CAT-Q):

• Assimilation: efforts to fit in with others in social settings, including forcing oneself to endure uncomfortable situations or avoiding interactions entirely to prevent “exposure.”

How it is measured

The Camouflaging Autistic Traits Questionnaire (CAT-Q) (Hull et al., 2019) is the most widely used self-report measure. It is a 25-item questionnaire with three subscales (Compensation, Masking, Assimilation), scored on a 7-point Likert scale. It has good internal consistency (Cronbach’s α = 0.94 for the total scale) and acceptable test-retest reliability. A 9-item short form (CATQ-SF) was validated by Hull et al. in 2024.

An alternative measurement approach uses discrepancy methods (Lai et al., 2017): camouflaging is operationalised as the gap between a person’s “internal” autistic status (self-reported traits and cognitive test performance) and their “external” behavioural presentation (as observed on the ADOS or similar instrument). This approach captures the outcome of camouflaging rather than the strategies themselves.

Both approaches have limitations. The CAT-Q may inadvertently capture social anxiety rather than camouflaging per se (explored in recent construct validity studies). Discrepancy methods depend on the sensitivity of the observation instrument and may miss unsuccessful camouflaging attempts.

What the evidence shows

Prevalence and gender patterns

Camouflaging is not unique to autistic women, but it is more prevalent and more pronounced in autistic women and non-binary people than in autistic men. Lai et al. (2017) found that autistic women showed substantially higher camouflaging scores than autistic men (Cohen’s d = 0.98) when camouflaging was measured as a discrepancy between self-reported traits and observed behaviour. Hull et al. (2020) confirmed this gender difference using the CAT-Q, while also noting that camouflaging was present across all genders in both autistic and non-autistic groups, though the autistic-non-autistic difference was largest in women.

This gender pattern has significant implications for diagnosis. The male-to-female ratio in autism diagnosis (historically around 4:1) is increasingly understood to reflect, at least in part, diagnostic bias — not a true difference in prevalence. If autistic girls and women camouflage more effectively, they are less likely to be identified by assessments designed around a male-typical presentation.

Mental health costs

The most clinically significant finding in this field is the consistent association between camouflaging and poor mental health. Studies have linked higher camouflaging to:

• Depression: Lai et al. (2017) found that greater camouflaging was associated with more depressive symptoms in autistic men. Hull et al. (2017) identified exhaustion, stress, and depression as consequences of sustained camouflaging.
• Anxiety: Though the relationship is complex — some studies find a direct association, others do not (Lai et al., 2017; Schuck et al., 2019) — qualitative research consistently describes camouflaging as anxiety-provoking.
• Autistic burnout: The concept of autistic burnout — a state of chronic exhaustion, loss of function, and reduced capacity to mask — is closely linked to sustained camouflaging (Raymaker et al., 2020).
• Suicidal ideation: Cassidy et al. (2018) found that lifetime experience of camouflaging was associated with suicidality in autistic adults, even after controlling for depression and anxiety.
• Identity confusion: Qualitative studies (Hull et al., 2017; Bargiela et al., 2016) describe a loss of sense of self — the feeling that one has performed a role for so long that the “real” person underneath has become inaccessible.

The survival-strategy tension

Camouflaging is not simply pathological. For many autistic people, it is a survival strategy developed in response to real social consequences — bullying, exclusion, discrimination, being denied employment or housing. The decision to mask is often rational, even when it is costly.

This creates a tension that practitioners and researchers must sit with. Camouflaging can be:

• Adaptive: it enables social connection, employment, and the avoidance of stigma.
• Harmful: it depletes energy, damages mental health, delays diagnosis, and erodes identity.
• Both at once: many autistic people describe camouflaging as simultaneously necessary and destructive.

Telling an autistic person to “just stop masking” without addressing the social context that makes masking necessary is unhelpful and potentially harmful. The goal should be to create environments where masking is less necessary, while supporting individuals to make informed choices about when and how they present.

Implications for diagnosis

Camouflaging is now recognised as a significant barrier to accurate autism diagnosis. The ICD-11, published in 2019, explicitly notes that clinicians should be aware of masking or coping behaviours when assessing autism. However, most diagnostic instruments — including the ADOS-2 — were developed and validated using samples that skewed male and younger, and may not be sensitive to the presentation of autistic people who camouflage effectively.

Late diagnosis is associated with its own harms, including years of misdiagnosis (often with personality disorders, anxiety disorders, or depression), inappropriate treatment, and the psychological burden of knowing something is different but not having a framework to understand it.

Open questions

• Is camouflaging a single construct or a collection of related but distinct processes? Recent factor-analytic work suggests the CAT-Q may be capturing multiple overlapping phenomena, including social anxiety.
• What is the developmental trajectory of camouflaging? Most research has been with adults; very little is known about when and how camouflaging develops in childhood.
• How does camouflaging interact with sensory processing? If an autistic person is masking sensory distress (suppressing reactions to noise, light, or touch), what is the cumulative physiological cost?
• Can we develop assessments that can detect autism even in people who camouflage effectively? This is a priority for reducing diagnostic bias.
• What role does the social environment play in driving or reducing camouflaging? Preliminary evidence suggests that camouflaging decreases in autistic-majority spaces and in contexts perceived as accepting.

Implications for practice

• Assume camouflaging is happening. When assessing or supporting an autistic person, do not take outward presentation at face value. A person who “seems fine” may be masking at significant cost.
• Ask about it directly. Use the CAT-Q or ask open-ended questions about social strategies, effort, and exhaustion after social interactions.
• Recognise the gender dimension. Be particularly alert to camouflaging in autistic women, non-binary people, and girls, who are at highest risk of late or missed diagnosis.
• Don’t pathologise masking without offering alternatives. If a person is masking, the first question should be “what in your environment makes masking necessary?” — not “how do we get you to stop?”
• Create lower-demand environments. Sensory-friendly spaces, clear communication, reduced social performance expectations, and explicit acceptance of autistic behaviours all reduce the pressure to camouflage.
• Monitor for burnout. If an autistic person’s functioning suddenly deteriorates after a period of apparent coping, consider whether burnout from sustained camouflaging may be a factor.

Key sources

• 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, 2519–2534. doi: 10.1007/s10803-017-3166-5
• Hull, L., Mandy, W., Lai, M.-C., Baron-Cohen, S., Allison, C., Smith, P. & Petrides, K.V. (2019). Development and validation of the Camouflaging Autistic Traits Questionnaire (CAT-Q). Journal of Autism and Developmental Disorders, 49, 819–833. doi: 10.1007/s10803-018-3792-6
• Hull, L., Lai, M.-C., Baron-Cohen, S., Allison, C., Smith, P., Petrides, K.V. & Mandy, W. (2020). Gender differences in self-reported camouflaging in autistic and non-autistic adults. Autism, 24(2), 352–363. doi: 10.1177/1362361319864804
• Lai, M.-C., Lombardo, M.V., Ruigrok, A.N.V., Chakrabarti, B., Auyeung, B., Szatmari, P., Happé, F. & Baron-Cohen, S. (2017). Quantifying and exploring camouflaging in men and women with autism. Autism, 21(6), 690–702. doi: 10.1177/1362361316671012
• Livingston, L.A. & Happé, F. (2017). Conceptualising compensation in neurodevelopmental disorders: reflections from autism spectrum disorder. Neuroscience & Biobehavioral Reviews, 80, 729–742. doi: 10.1016/j.neubiorev.2017.06.005
• Livingston, L.A., Shah, P. & Happé, F. (2019). Compensatory strategies below the behavioural surface in autism: a qualitative study. The Lancet Psychiatry, 6(9), 766–777. doi: 10.1016/S2215-0366(19)30224-X
• Livingston, L.A., Colvert, E., Social Relationships Study Team, Bolton, P. & Happé, F. (2019). Good social skills despite poor theory of mind: exploring compensation in autism spectrum disorder. Journal of Child Psychology and Psychiatry, 60, 102–110. doi: 10.1111/jcpp.12886
• Bargiela, S., Steward, R. & Mandy, W. (2016). The experiences of late-diagnosed women with autism spectrum conditions: an investigation of the female autism phenotype. Journal of Autism and Developmental Disorders, 46, 3281–3294.
• Cassidy, S., Bradley, L., Shaw, R. & Baron-Cohen, S. (2018). Risk markers for suicidality in autistic adults. Molecular Autism, 9, 42. doi: 10.1186/s13229-018-0226-4
• Raymaker, D.M. et al. (2020). “Having all of your internal resources exhausted beyond measure and being left with no clean-up crew”: defining autistic burnout. Autism in Adulthood, 2(2), 132–143. doi: 10.1089/aut.2019.0079
• Cage, E. & Troxell-Whitman, Z. (2019). Understanding the reasons, contexts and costs of camouflaging for autistic adults. Journal of Autism and Developmental Disorders, 49, 1899–1911. doi: 10.1007/s10803-018-03878-x

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