A meta-ethnography of autistic people’s experiences of social camouflaging and its relationship with mental health

“Cohen’s kappa was 0.77, representing moderate agreement (McHugh, 2012).”

“The Minority Stress Model (Meyer, 2003) suggests that as an identity-based minority, autistic people are vulnerable to social stigma, rejection and victimisation, which can impact their health (Botha and Frost, 2018).”

“Camouflaging has also been considered to potentially overlap with impression management (Leary & Kowalski, 1990).”

“First-order constructs from participant accounts of their experiences and second-order concepts from researchers’ interpretations of accounts were extracted and compared across studies using the method described by Noblit and Hare (1988).”

“Across the reviewed studies, camou-flaging was framed as a ‘defence mechanism’ (Hull et al., 2017) used to adapt to the stressful context.”

“The review was conducted from an inductive critical real-ist position, which presumes that knowledge is filtered through the lens of human experience and may be more or less close to reality (Fletcher, 2017).”

“Although this has allowed a more comprehensive view of the evidence for the relationship between camouflaging and poor mental health, none of these reviews have added an additional interpretative layer in the way possible when synthesising qualitative data (Noblit & Hare, 1988; Walsh & Downe, 2005).”

“When interviewed about their experiences of autism diagnosis, many autistic women speak of ‘wearing a mask’ to fit in in social situations (Bargiela et al., 2016).”

“Furthermore, self-focussed attention is hypothesised to make it more difficult to engage with social situations, making it more likely for feared negative responses to occur (Clark & Wells, 1995; Hofmann, 2007).”

“Autistic people (1, 2, 3, 6, 7 and 9) described camouflaging to ‘protect [themselves] from violence, intimidation, bullying and harassment’ (Cage & Troxell-Whitman, 2019).”

“The Minority Stress Model (Meyer, 2003) suggests that as an identity-based minority, autistic people are vulnerable to social stigma, rejection and victimisation, which can impact their health (Botha and Frost, 2018).”

“As the available evidence suggests camouflaging and the mental health of autistic people is influenced by stigma (Botha & Frost, 2018; Pearson & Rose, 2021; Perry et al., 2022), it is important to consider how this may differ for autistic people who experience stigma that is intersectionally…”

“Studies without a significant theme relating to camouflaging were deemed to have insufficient data to synthesise qualitative research (e.g. Cage et al., 2018) where there was a single subtheme relating to camouflaging with only four participant quotes given.”

“The Camouflaging Autistic Traits Questionnaire (CAT-Q; Hull, Mandy, et al., 2019) has been used to research the association between self-reported engagement with cam-ouflaging and a variety of factors, including gender (Hull, Lai, et al., 2019) and personality (Robinson et al., 2020).”

“As a result, meta-ethnography is particularly suited for the generation of new theories (France et al., 2019; Sattar et al., 2021) and is therefore appropriate for exploring the relationship between social camouflaging and mental health.”

“Autism stigma has been theoretically linked with camouflaging (Turnock et al., 2022), and identified as a coping strategy for managing stigma by autistic people (Han et al., 2022).”

“These reflections echo previous reports of the experience of stigma by autistic adults and adolescents (Bachmann et al., 2019; Botha et al., 2022; Brownlow et al., 2021; Mantzalas et al., 2021).”

“However, it is noted that this relationship is complex, and it may be an individual’s self-perceived need to camouflage that impacts mental health more so than ability to camouflage (J. Cook, Hull, et al., 2021).”

“The Camouflaging Autistic Traits Questionnaire (CAT-Q; Hull, Mandy, et al., 2019) has been used to research the association between self-reported engagement with cam-ouflaging and a variety of factors, including gender (Hull, Lai, et al., 2019) and personality (Robinson et al., 2020).”

“Miller et al. (2021) particularly emphasised that camouflaging may be learnt during childhood.”

“A central feature of meta-ethnography is the presentation of the synthesis as a ‘line of argument’ composed of first, second-and third-order constructs (Hannes & Macaitis, 2012).”

“Further research has found an association between social camou-flaging and psychological distress (Beck et al., 2020), and suicidal thoughts and behaviours (Cassidy et al., 2020).”

“Although two studies (1 and 13) described autistic adolescents ‘develop[ing] strategies in order to establish friendships’ (Tierney et al., 2016), no studies described adolescents using camouflaging to obtain other opportunities such as to support success at school.”

“As a result, meta-ethnography is particularly suited for the generation of new theories (France et al., 2019; Sattar et al., 2021) and is therefore appropriate for exploring the relationship between social camouflaging and mental health.”

“Autistic children and adolescents are significantly more likely to be bullied than typically developing children and children with learning disabilities, with between 46.3% and 94% of autistic children experiencing bullying (Humphrey & Hebron, 2015).”

“Meta-ethnography is one of the most used methods of qualitative synthesis, with improvements in the transparency of the search criteria and critical appraisal of studies in meta-ethnographies over time (Dixon-Woods et al., 2007; Hannes & Macaitis, 2012).”

“Research into improving the mental health of autistic people, including the adaptation of psychological therapies, is a key priority for the autistic community (Benevides et al., 2020; Roche et al., 2021).”

“To not compensate would make life more unhappy for me’ (Livingston et al., 2019).”

“Social identity theory (SIT) (Tajfel & Turner, 1979) has also been used to understand social camouflaging in autism (Pearson & Rose, 2021; Perry et al., 2022).”

“Autism stigma has been theoretically linked with camouflaging (Turnock et al., 2022), and identified as a coping strategy for managing stigma by autistic people (Han et al., 2022).”

“Autistic people felt ‘you have no choice but to change’ and ‘it’s not possible to be “out” ... without incurring stigma and disapproval’ (Bradley et al., 2021).”

“Further research has found an association between social camou-flaging and psychological distress (Beck et al., 2020), and suicidal thoughts and behaviours (Cassidy et al., 2020).”

“These reflections echo previous reports of the experience of stigma by autistic adults and adolescents (Bachmann et al., 2019; Botha et al., 2022; Brownlow et al., 2021; Mantzalas et al., 2021).”

“Self-focussed attention is hypothesised to increase the salience of negative self-perceptions (Kashdan & Roberts, 2004), similar to how some autistic people in the reviewed studies appeared sensitised signs of camouflaging ‘failing’.”

“Subsequent research has investigated this experience further, referring to it as ‘masking’ (A. Cook et al., 2018) ‘compensatory strategies’ (Livingston et al., 2019) or ‘social camouflag-ing’ (Hull et al., 2017).”

“Autistic adults are also more likely to experience bullying than non-autistic adults (Weiss & Fardella, 2018), suggesting that autistic people experience genuinely high levels of rejection.”

“The existing systematic reviews have examined either quantitative studies alone (J. Cook, Hull, et al., 2021) or a combination of qualitative and quantitative literature (Alaghband-rad et al., 2023; Tubío-Fungueiriño et al., 2021).”

“However, it is recognised that the cognitive differences inherent to autism mean that there are unique features of camouflaging for autistic people in neurotypical contexts (Ai et al., 2022).”

“Schneid and Raz (2020) note that camouflaging to ‘pass as normal’ appears to increase autistic people’s ‘sense of alienation’.”

“Some researchers suggest an additive effect of belonging to multiple minorities on mental health, although this is not necessarily observed in the data (Hayes et al., 2011).”

“Camouflaging strategies include forcing eye contact, suppressing ‘autistic’ body movements and using conversational ‘scripts’ involving asking questions about others (J. Cook et al., 2022; Hull et al., 2017; Livingston et al., 2019).”

“Previous qualitative research has also recruited autistic advisors to ensure themes accurately reflect the autistic voice (Babb et al., 2021).”

“For example, some autistic people reported that ‘at home I can be myself’ (Halsall et al., 2021) (11).”

“Both Hull et al. (2017) and Bernardin et al. (2021) noted that positive feelings about camouflaging appeared more common in autistic males than in females.”

“J. Cook, Crane, et al. (2021) and J. Cook et al. (2022) instead described camouflaging as a range of diverse ‘idiosyn-cratic solutions’ to an individual’s social differences and suggested camouflaging strategies may exist on a ‘con-tinuum’.”

“The Camouflaging Autistic Traits Questionnaire (CAT-Q; Hull, Mandy, et al., 2019) has been used to research the association between self-reported engagement with cam-ouflaging and a variety of factors, including gender (Hull, Lai, et al., 2019) and personality (Robinson et al., 2020).”

“In autistic children and adolescents, camouflaging has been found to be a significant predictor of internalising symptoms such as anxiety and depression (Ross et al., 2023).”

“The CASP is a widely used tool for the evaluation of qualitative research (Dalton et al., 2017; Hannes & Macaitis, 2012) recommended by the Cochrane Qualitative and Implementation Methods Group (Noyes et al., 2019).”

“These reflections echo previous reports of the experience of stigma by autistic adults and adolescents (Bachmann et al., 2019; Botha et al., 2022; Brownlow et al., 2021; Mantzalas et al., 2021).”

“One participant in Ryan and Räisänen (2008) discussed their experiences of isolation: ... sometimes it feels that it is just happening all over there somewhere and I am living in a bubble or living on the other side of a plate glass window to everybody else ... it is kind of like really hard being…”

“This study followed previous meta-ethnographies in assigning studies a point for each criterion with a half point for each criterion that was partially fulfilled or unclear (Graham et al., 2020).”

“These reflections echo previous reports of the experience of stigma by autistic adults and adolescents (Bachmann et al., 2019; Botha et al., 2022; Brownlow et al., 2021; Mantzalas et al., 2021).”

“and lived experiences from autistic people suggest that camouflaging can trigger depression, anxiety, diminished self-esteem, felt inauthenticity, and burnout (Cook et al., 2021; Field et al., 2024).”

“This aligns with find - ings in the literature on autistic individuals (Field et al., 2024; Hull et al., 2021; Bradley et al., 2021), suggesting that social camouflaging serves similar psychological functions across these groups.”

“Because these social integration and stigma avoidance motives are pervasive across social settings, camouflaging may become habitual and employed automatically without conscious awareness (Field et al., 2024; W. B. Lawson, 2020).”

“Autistic people may internalize a sense of shame, threatening their mental health (Cumming et al., 2020; Field et al., 2024).”

“A meta-ethnography summarized the lived experiences that autistic people had of the relationship between camouflaging and mental health difficulties (Field et al., 2024).”

“Many autistic individuals also report social connections and friendships as primary goals of their camouflaging 4,7,8,50 .”

“Qualitative studies reveal the emotional toll of sustained camou-flaging (Bradley et al. 2021; Field et al. 2024).”

“These feelings are exacerbated by the pressure to appear neurotypical, or to ‘mask’ their autism, which can leave individuals feeling that their authentic selves are invisible, even in the presence of others (Field et al. 2024).”

“For example, when autistic people use social strategies, it may make them feel overlooked, under supported, burnt out, and inauthentic [3,4]; it may also develop a sense of low self-esteem and identity confusion [4], as well as exhaustion due to high cognitive demands [3,5], thus leading to…”

“Moreover, compensatory mechanisms are not always beneficial, and some may be linked to camouflaging, which can negatively affect mental health [38].”

“…masking helps neurodivergent women to experience belongingness and avoid judgments, it has been related to negative physical and mental health consequences like exhaustion, identity confusion, life dissatisfaction, anxiety, depression, and burnout (Field et al., 2024; Wicherkiewicz & Gambin, 2024).”

“Consistent with this interpretation, previous work had shown that camouflaging in autism is linked to poor mental health, involving heightened self-monitoring, cognitive exhaustion, and feelings of inauthenticity [89].”

“…operationalization efforts describe several facets of autistic camouflaging, such as the deliberate versus automatic use of social coping tactics, the intentions and efforts that sustain them, and self-efficacy (Field et al. 2024; Hannon et al. 2023; Livingston et al. 2019; Zhuang et al. 2023).”

“16,18 Although speculative and requiring further empirical validation, profiling social communication difficulties using the DISC ‐ 12 may serve as a valuable tool for psychological education in individuals with social communication deficits and for personalized treatment planning by clinicians.”

“This is consistent with existing research linking camouflaging with poorer mental health and greater cognitive burden [4, 5, 34]; such an alignment between findings of the context-discrep-ancy assessment and of prior CAT-Q-based research suggests construct convergence and lends support for task…”

“Field et al. [16] observed social hiding why the practice of autistic people covering their characteristics to seem more normal.”

“However, such adaptations do not always improve understanding and can add stress, emotional, and mental health burdens for autistic individuals (Crompton et al., 2020a; Field et al., 2024; Mandy, 2019; McQuaid et al., 2024).”