Hidden in Plain Sight: Autism, Masking, Medical Harm

Authored by: Mia Bakota

Art by: Vanessa Chen Hsieh

Autism Spectrum Disorder (ASD) is a heterogeneous neurodevelopmental condition. However, clinical recognition and diagnosis remain significantly skewed toward externally observable traits, leading to an invisibility problem in high-masking populations. This article reviews the evidence demonstrating that autistic masking creates a detrimental healthcare gap, resulting in profound and interconnected psychological burnout and physiological health risks due to chronic misdiagnosis and overlooked stress.

For many high-functioning autistic individuals, life becomes a game of hiding what others can’t see—a deliberate effort to put on an allistic (non-autistic) mask. Masking is the conscious or unconscious suppression of autistic traits to appear neurotypical, an adaptive strategy that allows for safety and belonging but at a personal cost. From mimicking social cues and forcing eye contact to disguising sensory distress, it serves as social camouflage in a world that misunderstands difference. “Camouflaging consists of complicated copying behaviors and/or masking certain personality features with an adaptive role that aids changes to different situational demands” [1]. While masking may help individuals appear high functioning, it also contributes to burnout, anxiety, depression, suicidality, and heightened physical-health risks due to chronic stress and delayed diagnosis [2,3]. In healthcare, this invisibility game is especially dangerous because patients who mask effectively are often the least likely to be identified as autistic, consequently not receiving the care they need (e.g., CBT, DBT).

The psychological toll of masking cannot be overstated. Autism in Adulthood reports that adults who frequently mask experience emotional exhaustion, self-doubt, and a disconnection from identity [4]. Masking may begin as a form of protection from ridicule, misunderstanding, or discrimination, but over time, it erodes the boundary between authentic self and social performance. What is often praised as “resilience” is, for many autistic people, a sign of distress. The paradox is clear: the more someone conceals their autism, the less likely they are to receive understanding or support.

Part of this lack of support lies in how autism is defined and diagnosed. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and related models have historically emphasized the behaviors more typical of young, cisgender boys, such as social difficulties, repetitive actions, and limited interests. “Males are diagnosed with ASD three to four times more often than females” [4]. “Females are diagnosed with autism at a later age than boys, reducing their possibilities of obtaining care” [1]. The commentary DSM-5 and Challenges to Female Autism Identification argues that this bias distorts how clinicians recognize autism across populations. Individuals who present differently, from individuals who mask or gender-diverse people, often fall outside of the rigid diagnostic frameworks [5]. Similarly, Underdiagnosed and Misunderstood further highlights how diagnostic frameworks fail to capture the full spectrum that encompasses autistic expression and calls for intersectional models that acknowledge cultural, gendered, and behavioral diversity [5]. Until such models are implemented, countless autistic individuals will remain undiagnosed, not because their traits are absent, but because they are misunderstood.

When masked autistic individuals seek help, healthcare professionals often overlook what they see. In the Journal of Clinical Medicine, Attwood and Garner describe how inadequate clinician education perpetuates the cycle of misdiagnosis. Traits such as strong verbal skills, social imitation, or eye contact are frequently interpreted as evidence that an individual cannot be autistic, while underlying exhaustion, sensory overload, and emotional dysregulation are misattributed to anxiety or personality disorders [3]. Consequently, patients may receive partial or inappropriate treatment for symptoms rather than an acknowledgement of a neurodevelopmental condition. This fragmentation of care erodes trust and delays access to interventions that could improve quality of life.

The psychological strain of long-term masking does not remain confined to the mind; rather, the sustained stress activates physiological pathways that compromise immune and metabolic health. A study in Autism research identified significantly higher rates of chronic illness, including autoimmune, cardiovascular, and gastrointestinal disorders, among autistic adults compared to the general population [3]. These disparities cannot be separated from the constant effort of masking. A mediation analysis further demonstrates the bidirectional relationship between mental and physical health: prolonged psychological distress contributes to inflammation, fatigue, and an overall weakened immune response, while physical illness exacerbates emotional strain [6]. For many autistic individuals, years of masking and delayed diagnosis lead to both psychological burnout and physiological decline.

​ Together, these findings expose a systemic blind spot within healthcare. Because medicine traditionally relies on observable signs, clinicians may equate invisibility with wellness. Masking allows individuals to pass undetected through diagnostic systems built upon external behaviors (presented in young, usually white, males), leading to a chronic underdiagnosis and misrepresentation in research of people with high-functioning autism. Healthcare professionals mistake quiet suffering for stability; this illusion of normalcy conceals a population at elevated risk for comorbid and physical disorders.

Addressing this issue requires more than incremental updates to diagnostic criteria; it demands a shift in perspective. Autism cannot be assessed in an environment that prioritizes visibility over experience. Clinicians must learn to recognize the effort required to appear “typical” and to interpret social fluency as a possible indicator of masking rather than proof of wellness. Training programs should integrate neurodiversity affirming frameworks that emphasize curiosity over correction.

Healthcare must move beyond visibility as its measure of legitimacy and begin valuing the lived realities that remain unseen. Only then can medicine fulfill its purpose: to recognize and aid those in need. Recognizing masking as a legitimate health determinant reframes autism not as hidden, but as systematically overlooked.

References 

1. Alaghband-Rad, J., Hajikarim-Hamedani, A., & Motamed, M. (2023). Camouflage and masking behavior in adult autism. Frontiers in Psychiatry, 14, 1108110. Frontiers | Camouflage and masking behavior in adult autism

2. Cage, E., & Troxell-Whitman, Z. (2019). Autistic adults’ experiences of camouflaging and its perceived impact on mental health. Autism in Adulthood, 1(2), 130–139. Autistic Adults' Experiences of Camouflaging and Its Perceived Impact on Mental Health | Autism in Adulthood

3. Bishop-Fitzpatrick, L., Movaghar, A., Greenberg, J. S., Page, D., DaWalt, L. S., Brilliant, M. H., & Mailick, M. R. (2018). Using machine learning to identify patterns of lifetime health problems in decedents with autism spectrum disorder. Autism Research, 11(8), 1120–1128. Using machine learning to identify patterns of lifetime health problems in decedents with autism spectrum disorder - Bishop‐Fitzpatrick - 2018 - Autism Research - Wiley Online Library

4. Loomes, R., Hull, L., & Mandy, W. (2020). DSM-5 and challenges to female autism identification. Journal of Autism and Developmental Disorders, 50(6), 2249–2250. DSM-5 and Challenges to Female Autism Identification | Journal of Autism and Developmental Disorders

5.  Attwood, T., & Garnett, M. (2021). Underdiagnosed and misunderstood: Clinical challenges and educational needs of healthcare professionals in identifying autism spectrum disorder in women. Journal of Clinical Medicine, 10(21), 4953. Underdiagnosed and Misunderstood: Clinical Challenges and Educational Needs of Healthcare Professionals in Identifying Autism Spectrum Disorder in Women

6. Dewa, C. S., McDaid, D., & Ettner, S. L. (2018). The relationship between physical and mental health: A mediation analysis. Social Science & Medicine, 198, 85–92. Retrieved from The relationship between physical and mental health: A mediation analysis - ScienceDirect