Is Masking Correlated to Suicide Risk in Autistic Girls?

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Anyone familiar with autism might also be familiar with the term “masking.” Sometimes called social camouflaging, this term describes intentionally or unintentionally hiding aspects of oneself to avoid scrutiny or harm.

Here's how it works: Someone with autism, for instance, might mimic other’s social actions to seem conforming to societal expectations. Or a gay person living in an unaccepting region may force themselves to act otherwise to not gain negative attention. Clearly, masking, while it could ostensibly sound adaptive, hinders people’s ability to be authentic, lending itself to existential and emotional disturbances.

Perhaps the best summary of autism masking is by researchers Hull et al (2020):

Motivations for camouflaging in this study comprised the desire to fit in with others, to avoid bullying or other negative treatment; and wanting to form connections with others which the autistic person felt was not possible when they presented as their authentic self. Camouflaging behaviours involved masking of autistic characteristics by presenting more socially acceptable personas; and compensating for differences in social presentation, such as forcing oneself to make eye contact. Consequences of camouflaging included physical and emotional exhaustion, often requiring time alone to recover; issues around identity and authenticity which led some participants to “lose track of who I really am” …

A great summary for the dangers of masking is by researchers Bradley et al. (2021):

First, “dangers of camouflaging” described how the amount of time spent camouflaging led to exhaustion, isolation, poor mental and physical health, loss of identity and acceptance of self, others' unreal perceptions and expectations, and delayed diagnosis.

The mask-suicide correlation

Not surprisingly, this experience is correlated to suicidality in autistic people. In 2021, researchers South et al. reported that suicide attempts and deaths among autistic people were three times higher than in others, beginning at age 10. Further, Kolves et al (2021) reported that rates of suicide attempts and completions were much higher in autistic females, who seem savvier at masking, compared with males.

It seems this is correlated to autistic females flying under the detection radar, because of their masking mastery.

Have girls mastered masking?

Available information indicates that girls are underrepresented in estimates of the autism population because they present differently, or at least more subtly to observers. This could well be due to autistic girls' uncanny ability to chameleonize to neurotypical norms. Hull et al (2020) and others have considered that females have a phenotype generally different from males, which makes them blend in better overall.

It is noted in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 TR) that girls are diagnosed later, perhaps due to more subtle presentations. There often are no telltale repetitious movements, fixations seem to be on generally more socially-normative things, like, say, horses instead of pieces or parts of things, and they appear to socially reciprocate better.

Or is that last item masking/camouflaging?

In 2014, concerns about the possibility of gender misrepresentation in autism burgeoned. All of a sudden, from NPR stories to research in the Journal of the American Academy of Child and Adolescent Psychiatry, the discussion on gender inequality in autism took root. Across the board, the common thread cited as a major reason for missing autism in girls was a quirk in the social deficit component of the diagnostic criteria: masking. Basically, girls' social deficits might not be glaringly obvious.

Girls seem better at masking and providers can be unaware of it. In other words, if a girl didn’t present with “social awkwardness,” a very popular representative symptom of autism, they might be entirely missed.

Until the jury is in on a different criteria set for females, it will still be important to pay attention to the current framework, keeping in mind symptoms could be more subtle. Regardless or male or female, "social awkwardness" is not the be all/end all.

It is not uncommon for people, clinical and otherwise, to think of social awkwardness as a foremost diagnostic criterion for ASD and forget about the rest. Social deficits are only one element and, as Emil Kraepalin, the father of modern diagnostic framework, said over 100 years ago, "A single symptom, however characteristic it may be, never justifies a diagnosis by itself" (Spitzer et al., 2002).

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Remember, a diagnosis is a pattern, and along with social deficits, some, or all, of the following need to be present for ASD:

• Adherence to schedules and routines and low frustration tolerance for lack of normal routine
• Repetitive, seemingly meaningless behaviors (stereotypies). These might be self-soothing in nature, like rocking or playing with hair.
• Obsessions with pieces and parts of things or intense focus on a particular interest.
• Sensory-integrative complications.
• Developmental delays.
• Intelligence deficits and verbal incapability in some
• Catatonic states in severe cases.

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The refined masking of girls

According to researchers like Lundin et al. (2020), it seems that girls with ASD are more socially motivated. Thus, to outside observers they can appear to have positive interactions with peers because they keep close to the group and will talk and move about among the group. However, upon closer observation there are noticeable deficits in the within-group activity (e.g. Gould, 2017). Upon closer examination, interestingly, researchers Morris et al. (2017) noted there are even pragmatic language markers that can be noticed:

Pragmatic language markers distinguish girls and boys with ASD, mirroring sex differences in the general population. One implication of this finding is that typical-sounding disfluency patterns (i.e., reduced relative UH production leading to higher UM ratios) may normalize the way girls with ASD sound relative to other children, serving as “linguistic camouflage” for a naïve listener and distinguishing them from boys with ASD.

Girls have also been discovered to try harder to fit in and therefore suppress their desire for repetitive behaviors, whereas boys, perhaps being naturally more hyperactive, have a harder time controlling these. Lastly, the materials girls fixate attention on tend to be things that their neurotypical peers also enjoy (e.g. Bourson & Prevost, 2022), like popular-culture topics. Alternatively, boys tend to focus on more obscure things like coins or something overly scientific for their age, like the life habits of dinosaurs. I recall one boy I evaluated who fixated on newspaper flyer ads for tools.

Clinical implications

All of this considered, knowing the high correlation of suicide to autism, especially in girls, awareness of the possibility of masking is a key to prevention. Should a child present with some stereotyped activity and intense interests but seem socially typical there may be more than meets the eye. The following tips can be helpful in assessing for ASD:

• Remember that apparent social deficits alone are not evidence of ASD. They can be accounted for by anxiety, developing personality conditions such as schizoid and avoidant personalities, or other neurodevelopmental complications.
• Take a perinatal health history. Risk factors include maternal substance use, including cigarettes/vaping nicotine, and gestational diabetes and preeclampsia.
• Get an early developmental history, as kids with ASD tend to have developmental delays.
• ASD should not be diagnosed based on one encounter of history taking and observation. Obtain other data points such as administering an Autism Diagnostic Observation Schedule (ADOS)/neuropsychological testing. If the provider isn't qualified to administer these, referring to a psychological testing professional is a must. If the child is in school and they've not had psychoeducational testing, collaborating with the school system for an evaluation can also help assess for objective ASD data. This is especially important if a state's department of developmental disabilities is to become involved, as they require objective evidence prior to the age of 18.

Disclaimer: The material provided in this post is for informational purposes only and is not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care or intervention from an individual's provider or formal supervision if you're a practitioner or student.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.