Autistic Camouflaging and its Relationship with Mental Health: Systematic Review

Camouflaging (also known as masking) refers to strategies used by autistic individuals to mask or hide their autistic characteristics in social situations to fit in or avoid negative reactions from others.

Examples include forced eye contact, mimicking others’ social behaviors, and suppressing repetitive movements.

While camouflaging may help autistic people navigate social situations, it often comes at a cost to their mental health and sense of authenticity.

Camouflaging is thought to be more common in autistic females and may contribute to missed or late diagnosis.

Understanding camouflaging is important for improving recognition and support for autistic individuals’ needs.

Zhuang, S., Tan, D. W., Reddrop, S., Dean, L., Maybery, M., & Magiati, I. (2023). Psychosocial factors associated with camouflaging in autistic people and its relationship with mental health and well-being: A mixed methods systematic review. Clinical Psychology Review, 105, 1–16. https://doi.org/10.1016/j.cpr.2023.102335

Key Points

This mixed methods systematic review synthesized qualitative and quantitative research on psychosocial factors associated with camouflaging and its relationship with mental well-being in autistic and non-autistic people.

Seven main themes were identified relating to psychosocial correlates and consequences of camouflaging:

1. Social norms and pressures drive camouflaging
2. Camouflaging is used to gain social acceptance and avoid rejection
3. Self-esteem and identity influence camouflaging
4. Camouflaging has some practical benefits for functioning
5. Camouflaging leads to difficulties being overlooked
6. Camouflaging negatively impacts relationships
7. Camouflaging causes identity confusion and low self-esteem

More research with diverse participants is needed to better understand psychosocial influences on camouflaging. The findings call for a whole society approach to increase acceptance of autistic people.

Rationale

Camouflaging involves autistic individuals hiding their autistic characteristics in social situations, often to fit in and avoid stigma (Hull et al., 2017).

While a rapidly growing area of research, most studies have focused on the experiences of a narrow demographic – White, female, late-diagnosed autistic adults with average to above average abilities (Cook et al., 2021; Libsack et al., 2021).

Though camouflaging enables some to achieve social and functional goals (Hull et al., 2017; Livingston et al., 2019), it has been consistently associated with poorer mental health (Beck et al., 2020; Cassidy et al., 2018).

Qualitative accounts suggest various psychosocial factors may motivate camouflaging and explain its mental health impact, such as societal stigma and the desire for belonging (Cage & Troxell-Whitman, 2019; Cook et al., 2021). However, no review has systematically examined psychosocial influences on camouflaging and well-being.

This mixed-methods systematic review aimed to critically synthesize qualitative and quantitative research on psychosocial factors associated with camouflaging and its relationship with mental well-being in autistic and non-autistic people.

Understanding psychosocial motivations for camouflaging could inform support to promote more adaptive camouflaging and authentic self-expression, contributing to better mental health for autistic people.

Method

Procedure

This meta-synthesis followed PRISMA guidelines. Six databases were searched, and backward citation searching and expert consultations were conducted.

A thematic synthesis was conducted, where data were categorized and pooled together based on similar meanings.

Quantitative data were first transformed into themes and textual descriptions to allow integration with qualitative data. Then, line-by-line coding of findings was completed, codes were organized into descriptive themes, and analytical themes were developed.

Codes and themes were iteratively discussed among the research team, which included academics and two autistic advisors who provided input on the data synthesis and interpretation.

The first author conducted coding using NVivo software. A sample of 30 data extracts was independently coded by the last author using the finalized thematic map, demonstrating very good (80%) inter-rater agreement.

Sample

58 studies (40 qualitative, 13 quantitative, 5 mixed methods) were included, encompassing 4808 autistic and 1780 non-autistic participants.

Participants were predominantly White (85.9%), female (61.8%), and late-diagnosed (mean age of diagnosis 30.47 years) autistic adults with likely average to above average intellectual/verbal abilities.

Results

Seven themes relating to psychosocial correlates and consequences of camouflaging were identified:

1. Social norms and pressures drive camouflaging. Participants faced expectations to conform to neurotypical norms and experienced stigma for autistic differences.
2. Camouflaging is used to gain social acceptance and avoid rejection. Camouflaging was a protective response to bullying. The desire for belonging was a key motivation.
3. Self-esteem and identity influence camouflaging. Internalized stigma motivated camouflaging, while self-acceptance reduced the perceived need to camouflage.
4. Camouflaging has some practical benefits for functioning. It enabled everyday functioning and impression management.
5. Camouflaging leads to difficulties being overlooked. Camouflaging resulted in participants’ needs being unmet, delayed diagnosis, and autistic burnout.
6. Camouflaging negatively impacts relationships. While camouflaging facilitated social connections, relationships felt inauthentic.
7. Camouflaging causes identity confusion and low self-esteem. Extensive camouflaging eroded participants’ sense of self.

The themes highlight the bidirectional influences between the individual and environment in camouflaging.

Camouflaging emerged as a largely socially-motivated yet self-reinforcing response that comes with serious costs to authenticity and mental well-being.

Insight

This review provides a novel and comprehensive synthesis of psychosocial factors implicated in camouflaging.

The findings indicate that camouflaging arises from the dynamic interplay between the individual and their social environment, challenging purely individual-focused explanations.

Autistic individuals’ camouflaging efforts were driven by societal pressures, stigma, and the need for acceptance. Over time, repeated exposure to adverse social experiences led them to anticipate rejection and develop camouflaging as a learned response.

Furthermore, internalizing stigmatizing narratives motivated individuals to mask their differences.

However, camouflaging often had the unintended effect of leaving stigma unchallenged while increasing internalized stigma. It also resulted in autistic people’s needs being overlooked and unmet.

Additionally, while the desire for social connections drove camouflaging, participants felt that the relationships formed through it were inauthentic. These “double binds” made it difficult for individuals to break out of the camouflaging cycle.

The findings call for a shift from changing the individual to fostering more inclusive environments.

A whole-society approach is needed to increase understanding and acceptance of autism, thus reducing pressures on autistic people to camouflage.

Encouragingly, participants described reducing their camouflaging when experiencing self-acceptance, often facilitated by their autism diagnosis and connections with the autistic community.

This review extends previous research by providing an in-depth examination of psychosocial influences on camouflaging.

Future studies should empirically test the conceptual model presented and prioritize diverse participant representation.

Additionally, research examining the influence of everyday psychosocial experiences on camouflaging can provide insight into how autistic individuals navigate camouflaging in daily life.

Strengths

This study had several methodological strengths, including:

• Rigorous mixed methods approach enabled a rich, comprehensive understanding of psychosocial factors in camouflaging
• Utilized participatory methods by involving two autistic advisors who provided input on data synthesis and interpretation
• Developed a novel conceptual model of psychosocial correlates and consequences of camouflaging that can guide future research
• Highlighted critical gaps in current research, such as the lack of diverse participant representation

Limitations

Despite its strengths, there are several limitations of this study, including:

• Overrepresentation of White, female, late-diagnosed autistic adults with average to above average cognitive abilities limits the generalizability of findings
• Restricted to English-language articles and participants mainly from Western societies introduces potential language and cultural bias
• Inadequate reporting of key demographics (e.g. race/ethnicity, education) in most included studies further limits generalizability
• As a systematic review, cannot determine causal relationships between variables

Implications

The findings have important implications for increasing awareness, acceptance, and support for autistic people:

• Highlights the need for anti-stigma interventions and a shift towards accommodating rather than pathologizing autistic differences
• Professionals and educators should have a greater understanding of camouflaging to improve recognition of autistic people’s needs
• Diagnostic processes should account for camouflaging behaviors, especially for females and late-diagnosed individuals
• Psychosocial supports focused on strengthening autistic identity and community connections may enhance authenticity and well-being

However, as most included studies involved a narrow participant demographic, more research is needed to understand the relevance of findings for underrepresented groups, including racial/ethnic minorities, males, gender diverse individuals, those with intellectual disability, and people from non-Western cultures.

Additionally, prospective studies are required to establish directional relationships.

References

Primary reference

Zhuang, S., Tan, D. W., Reddrop, S., Dean, L., Maybery, M., & Magiati, I. (2023). Psychosocial factors associated with camouflaging in autistic people and its relationship with mental health and well-being: A mixed methods systematic review. Clinical Psychology Review, 105, 1–16. https://doi.org/10.1016/j.cpr.2023.102335

Other references

Beck, J. S., Lundwall, R. A., Gabrielsen, T., Cox, J. C., & South, M. (2020). Looking good but feeling bad: “Camouflaging” behaviors and mental health in women with autistic traits. Autism, 24(4), 809–821. https://doi.org/10.1177/1362361320912147

Cage, E., & Troxell-Whitman, Z. (2019). Understanding the reasons, contexts and costs of camouflaging for autistic adults. Journal of Autism and Developmental Disorders, 49(5), 1899–1911. . https://doi.org/10.1007/s10803-018-03878-x

Cassidy, S., Bradley, L., Shaw, R., & Baron-Cohen, S. (2018). Risk markers for suicidality in autistic adults. Molecular Autism, 9(1), 42. https://doi.org/10.1186/s13229-018-0226-4

Cook, J., Crane, L., Bourne, L., Hull, L., & Mandy, W. (2021). Camouflaging in an everyday social context: An interpersonal recall study. Autism, 25(5), 1444–1456. https://doi.org/10.1177/1362361321992641

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

Libsack, E. J., Keenan, E. G., Freden, C. E., Mirmina, J., Iskhakov, N., Krishnathasan, D., & Lerner, M. D. (2021). A systematic review of passing as non-autistic in autism spectrum disorder. Clinical Child and Family Psychology Review, 24(4), 783–812. https://doi.org/10.1007/s10567-021-00365-1

Livingston, L. A., Shah, P., & Happé, F. (2019). Compensatory strategies below the behavioral surface in autism: A qualitative study. The Lancet Psychiatry, 6(9), 766–777. https://doi.org/10.1016/s2215-0366(19)30224-x

Keep Learning

Here are some reflective questions related to this study that could prompt further discussion:

• How might the social environment be changed to reduce pressures on autistic people to camouflage?
• What kinds of supports would be most helpful for autistic individuals in managing decisions around camouflaging versus authentic self-expression?
• How can mental health professionals, educators, and workplaces create environments where autistic people feel psychologically safe to unmask?
• What are respectful ways for non-autistic people to respond when an autistic person discloses their diagnosis?
• How might camouflaging present differently across cultures? What unique challenges might autistic people with multiple marginalized identities face?