Autism in women and the masking that wears you out

The front door closes behind her and the first thing she does is switch off the light. Not because work wore her out — work went smoothly today. She has just come back from her sister’s birthday party. For three hours she laughed at the right moments, asked the questions people ask, made sure to look people in the eye, but not for too long, and smiled at her uncle’s joke instead of explaining why it didn’t hold up. Nobody noticed a thing. “You were so relaxed today,” her sister said as they said goodbye.

Now she is sitting on the hallway floor, coat still on, unable to say a single word more. Tomorrow she will need the whole day to come back to herself.

What she was doing for those three hours is what researchers call masking, or camouflaging. When we talk about autism in women, it may be the single most important word to know. It explains why so many autistic women went unnoticed for decades — and why the price of going unnoticed is so high. I wrote about what a late recognition can bring an adult in Autism in adults: a late diagnosis and how much it explains. Here I focus on what happens before: the years when someone tries so successfully to be “normal” that they convince everyone except themselves.

What masking is

Masking (also called camouflaging) is an umbrella term for the ways an autistic person — consciously or not — hides or compensates for whatever those around them would recognise as different. In 2017 Laura Hull, William Mandy and colleagues published one of the first studies to ask adults directly how they experience it. They took the title from a phrase people use themselves: “Putting on my best normal”.

Participants described conversation rules learned by heart, sentences prepared in advance, watching others and copying their gestures, holding back the movements that soothe them, and constantly monitoring their own face. As reasons, they named wanting to fit in, to have friends, not to be teased, to get or keep a job. As consequences, almost all of them mentioned the same things: exhaustion, anxiety, and the question of who they actually are once the mask comes off.

It is important to understand that masking is not lying and it is not acting. Most people who mask started very early, when it was the only way to be accepted in class or to stop adults correcting them all the time. Over time it becomes so automatic that a person no longer recognises it as something they are doing. It just feels like who they are — only more tired than everyone else.

Why autistic women went unnoticed for so long

For a long time autism was thought to be about four times more common in boys than in girls. In a 2017 meta-analysis, Rachel Loomes, Laura Hull and William Mandy looked specifically at studies that actively searched for autism in the population, rather than simply counting children who already had a diagnosis. There, the ratio was closer to three to one. The authors concluded that girls who meet the criteria are disproportionately likely to go without clinical recognition.

There are several reasons, and they are intertwined. For a long time, diagnostic criteria and questionnaires were developed mainly by observing boys. In girls, intense interests are often less socially unusual — animals, books, a particular band, the psychology of people — and nobody notices that they carry the same depth and persistence that, in a boy who knows every train timetable by heart, would prompt a question. A quiet girl watching a game from the sidelines is “shy”, not different. And girls are expected from early on to adapt, to read the mood of a room and not to cause trouble — which is exactly what an autistic girl learns to do with enormous effort.

In 2016 Sarah Bargiela, Robyn Steward and William Mandy held in-depth conversations with women who were only diagnosed in adulthood. Almost all of them described long years of pretending to be “normal”, and many had already sought help before — but had been treated for other difficulties. Nobody had thought of autism, because they did not fit the picture professionals had in mind.

A similar pattern of being overlooked is known in ADHD too — more on that in ADHD in women: why it goes unnoticed until adulthood. In both cases the point is not that women have a “milder form”, but that their difficulties show up where people are not used to looking for them.

The three faces of masking

When researchers later developed a questionnaire to measure masking (the CAT-Q), they found that one name covers three quite different activities. It helps to tell them apart, because each one drains energy in its own way.

• Compensation — actively making up for what does not come naturally. Conversation rules learned from observation or even from books. Ready-made answers to “how are you?”. A mental list of topics that are safe for lunch with colleagues.
• Masking — constantly monitoring yourself so that nothing shows. Forced eye contact. Holding back movements that soothe, such as rocking or turning a ring. Suppressing your reaction to noise, light or smells that are unbearable.
• Assimilation — the sense of playing a part in order to blend in. Joining conversations that don’t interest you. Laughing when others laugh. Going to an event because “that’s just what you do”.

Most people use all three, but to different degrees. Some are masters of compensation and come across as even more skilled than average in conversation, because they have studied it more closely than others. For others, masking is in the foreground — and because it means constantly holding back, it is often the most tiring, even though nothing at all shows on the outside.

What others see and what happens inside

Masking creates a gap that is hard for those close to you to understand. At a party, someone seems talkative, warm, even funny. At home, she doesn’t answer messages for two days. At work she is seen as a reliable, precise colleague who never causes problems. In the evening she cries in the car before she can gather the strength to go into the flat. People only see the first half, and are understandably puzzled by the second.

This is how a conversation between two friends might go (composed, not a real person):

“I don’t get it. You’re not autistic — you’re so good at talking to people.”
“I am. For three hours. Then for two days I can’t face anyone.”
“But everyone’s tired after a party.”
“Yes. Only at a party I’m constantly calculating when to laugh, where to look and when it’s my turn to say something.”
A pause. “I didn’t know that.”
“That was the idea.”

That last line is the heart of it all. Masking works precisely because it cannot be seen. And because it cannot be seen, the people around cannot take it into account — not with adjustments, not with understanding, not with permission to go home early. Often the person herself doesn’t know she has spent the whole evening doing something very demanding. She only knows she is exhausted and can’t explain why.

This is also why the sentence “but you don’t look autistic” hurts so much. It is meant as reassurance, but it sounds like proof that the mask worked — and so that nobody will ever see what it costs.

The cost: a tiredness a weekend won’t fix

In a 2020 study designed together with autistic researchers, Dora Raymaker and colleagues described a phenomenon autistic adults have long called autistic burnout. It involves long-lasting exhaustion, the loss of skills that used to work (someone may suddenly no longer manage a phone call or a trip to the shop), and reduced tolerance to stimuli. Participants attributed it to the build-up of everyday demands that exceed their capacity for a long time without adequate support — and they often named masking as one of the main sources of that load.

Autistic burnout is not the same as occupational burnout, even though from the outside the two can look very similar. If you recognise the signs described in Burnout is not laziness: signs your nervous system is asking for a break, it is worth looking at how much everyday socialising costs you too, not just work. For some people a holiday doesn’t help, because a holiday is full of new people, places and noise.

There is a more serious side as well. In 2018 Sarah Cassidy and colleagues found that among autistic adults, self-reported camouflaging was associated with a higher risk of suicidal thoughts and behaviour. This doesn’t mean that masking in itself causes suicidality, but it does mean that hiding yourself for years is worth taking seriously. If you are having thoughts that it would be better if you weren’t here, reach out to someone straight away: in Slovenia, the mental distress helpline Klic v duševni stiski on 01 520 99 00 (every day from 7 pm to 7 am), the Samarijan helpline on 116 123 (24 hours), or in an emergency 112.

The wrong door: when help is sought for something else

Many women who only recognised their autism in adulthood had sought help before — for anxiety, depression, exhaustion or relationship difficulties. Those difficulties were real and treatment often made sense. But because nobody looked at what lay beneath them, the pattern kept repeating: a few months better, then another collapse at the next change, the next job or the next move.

Anxiety is particularly interesting here. For many autistic women it isn’t “too much worry for no reason”, but a perfectly understandable response to a life in which you constantly have to guess the unwritten rules and never know for certain whether you have guessed right. From the outside this can look like what I described in High-functioning anxiety: in control on the outside, an alarm ringing inside — and sometimes it is. The difference lies in where the alarm is coming from.

The point is not for one diagnosis to replace another, or for the “right” explanation to be whichever comes last. A diagnosis is a tool for understanding, not a final verdict on a person — more on that in A diagnosis is a map, not a name for you: what the ICD says and what it does not. What matters is that the map matches the terrain; otherwise someone walks the wrong path for years and wonders why they never get anywhere.

Masking is not a free choice

When people first hear about masking, they sometimes ask: so why not just stop? The answer is simple and uncomfortable. Masking develops as a response to an environment that punishes difference — with teasing, exclusion, looks, correction, a lower score at a job interview. Someone who has experienced that for years didn’t “decide” to hide themselves. They learned that it was safer.

The British researcher Damian Milton, himself autistic, described in 2012 what he called the double empathy problem. When an autistic and a non-autistic person misunderstand each other, the problem is not only the autistic person who supposedly “can’t read others”. Misunderstanding runs both ways — non-autistic people are also poor at reading autistic people. But because they are the majority, the minority is expected to adapt. Masking is the price of that one-sided adaptation.

Something important follows from this. The answer is not only for an individual woman to “learn to mask less”, but also for her surroundings — family, partner, workplace — to become places where the mask isn’t necessary. A concept that captures this well is neurodivergence: the idea that brains differ from one another and that working differently is not in itself a fault to be fixed.

And one more thing: years of masking also leave a mark on how a person sees themselves. When you spend years trying to make sure nobody sees what you are like, a belief settles in that there is something wrong with what you are like. That belief has a name — I described it in Shame: the emotion that whispers “There is something wrong with me”.

Exercise: a map of the mask

This exercise is not a test for autism and won’t tell you whether you are autistic. It simply helps you notice where in everyday life you spend energy on adapting — which is useful whatever the answer to the bigger question turns out to be. Give yourself twenty minutes and a sheet of paper.

1. Choose an ordinary day from the past week and divide it into five or six parts: morning at home, the journey, the morning at work, lunch, the afternoon, the evening.
2. Next to each part, write down what you didn’t have to control and what you did. Did you hold back a movement? Rehearse a sentence in your head? Laugh when nothing was funny? Put up with light or noise without saying so?
3. Give each part an effort score from 0 to 10 — not by how it looked from the outside, but by how it felt from the inside.
4. Find the part with the lowest score and write down what was different about it: who was there, what the space was like, whether you knew what was going to happen.
5. Choose one small thing for next week that would bring one demanding part closer to that easiest one: headphones on the way to work, lunch alone twice a week, a message to a friend that you’ll leave the party at nine.

If the exercise shows that the effort is high almost all day and has been for a long time, that is worth taking seriously — not as proof of anything, but as a reason to talk to a professional about it.

Where this explanation doesn’t hold

Because so much has been written about masking in recent years, it is only fair to say what it doesn’t tell us.

We all adapt. Social adjustment is part of human life. Non-autistic people also control their faces in job interviews and laugh at the boss’s jokes. Research on masking has been done mainly with autistic people and doesn’t mean that every bit of tiredness after socialising is a sign of autism. Introversion, social anxiety, the after-effects of trauma or simply a long week can produce a very similar feeling.

Recognising yourself in an article is not a diagnosis. Online tests and videos in which someone recognises themselves can be a valuable first step — but an autism diagnosis is made by a psychiatrist or clinical psychologist after a thorough assessment that also includes developmental history. I explained who may do what in Who may diagnose, who may prescribe, and who leads the process. As a therapist in training under supervision in marriage and family therapy, I do not make diagnoses myself.

Masking is not only a women’s issue. Research suggests that women on average report more masking, but men and people of other genders do it too. Writing about women makes sense because they were overlooked for longest, not because the phenomenon belongs to them alone.

Taking off the mask isn’t always the right goal. In some settings the mask is still protection. It isn’t a woman’s task to reveal herself everywhere, but to have some places and relationships where she doesn’t need to wear it — and for the choice of where she wears it to gradually become more her own.

What therapy can offer

Psychotherapy doesn’t “treat” autism and shouldn’t try to. But it can be a place where, for the first time in their life, a person isn’t trying to be different from who they are. That alone is an unusual experience for many: being able to look away during a conversation because it helps them think, being allowed to say “I don’t understand what you mean” without it being awkward, or asking for the light to be dimmed a little.

In relational family therapy, in which I am training, we look at a person within the relationships that shaped them. With masking this makes particular sense. Who was the first to correct you? When did you learn it was better if it didn’t show? What role did your “good” adapting play in the family? These questions aren’t looking for someone to blame. They help you understand why the mask took exactly the shape it did — and where it is still needed today.

Therapy can also be support for a partner or family. When those close to you understand why you shut yourself in your room after visiting relatives, they stop taking it personally. Instead of “why are you being so strange again”, an agreement can emerge: two hours at the visit, then silence in the car, no questions asked.

And finally, therapy is a place where you can build what masking eroded most: a sense of who you are beneath the mask. It isn’t a quick process. It often involves grief for the years you spent trying without understanding, and tenderness towards the girl who learned to survive in the only way she knew. Self-compassion helps here too — not as a reward at the end, but as a way of approaching all of it. I also work with English-speaking clients, in person in Ljubljana.

What to remember

• Masking means hiding or compensating for autistic traits in order to fit in — often automatic and learned very early.
• Autism in women was overlooked for a long time: studies that actively look for it suggest a sex ratio closer to three to one than four to one.
• The cost of masking is exhaustion, anxiety, losing a sense of who you are — and it can also include autistic burnout.
• Masking is not a free choice but a response to surroundings that punish difference, so part of the answer lies in those surroundings too.
• Recognising yourself is not a diagnosis — assessment is done by a psychiatrist or clinical psychologist, while therapy can be a place where you don’t have to wear the mask.