Invisible Twice: The Mental Health Toll of Camouflaging Autism and Gender

Autistic trans people often mask both their neurotype and gender to survive in a hostile world. This piece explores the mental health toll of “double masking” and calls for identity-affirming, systemic change—not assimilation.

Introduction

Autistic people are significantly more likely to experience anxiety, depression, and suicidal ideation than their non-autistic peers—a fact long confirmed by research, yet rarely met with genuine concern or effective support. The mental health crisis affecting autistic individuals is not caused by autism itself but by the relentless demands to suppress it. Stigma, exclusion, and the constant pressure to conform to neurotypical norms create a hostile environment in which merely existing becomes a psychological burden. For those of us who are also transgender or gender-diverse, the weight intensifies. Many live with the need to mask not only our neurotype but also our gender identity, engaging in what researchers now call “double masking”—a sustained effort to camouflage core aspects of selfhood in order to navigate a world that punishes difference.

This double bind is particularly acute for those diagnosed in adulthood, after years or even decades of trying to perform neurotypicality and cisnormativity simultaneously. The emotional toll is staggering. Studies have shown that non-straight autistic adults report significantly higher levels of masking than their straight peers, with this masking closely linked to poorer mental health outcomes—especially when individuals are unable to disclose their identities safely (Evans et al., 2024). Other research has highlighted that trans and gender-diverse autistic adults score higher on compensation strategies—subtle social adaptations intended to pass as neurotypical—further contributing to exhaustion and misdiagnosis (McQuaid et al., 2021). These findings are more than statistics; they are reflections of lived reality for those of us forced to shrink ourselves in two directions at once.

It’s April—Autism Awareness Month—and once again, the same stories circulate. Well-meaning campaigns repeat last year’s slogans, awareness is confused for understanding, and the voices at the margins of the autistic community remain ignored. Rarely does anyone look beyond the surface to ask why so many autistic people are in crisis, or what it means to live at the intersection of multiple identities. This piece steps into that silence. It explores the phenomenon of double masking as both a psychological survival strategy and a systemic failure. Drawing on recent research, lived experience, and critical frameworks, it examines the mechanisms and consequences of camouflaging both neurotype and gender identity. It interrogates the role of mental health and educational systems in perpetuating harm, and calls for a shift toward truly affirming spaces—spaces that recognise and honour the full, complex humanity of autistic trans people.

What Is Masking?

Masking—also referred to as camouflaging or compensating—is the conscious or unconscious withholding of natural behavioural responses. It involves hiding, minimising, modifying, or tightly controlling the behaviours typically associated with the autism neurotype. In my book No Place for Autism?, I describe masking as akin to improvisational acting—an adaptive performance shaped by environments not built for us. It is most commonly deployed in social and workplace settings, where autistic people must navigate the expectations of the neuro-majority to avoid negative consequences. But whilst this may appear on the surface as a set of social strategies, it is, more truthfully, a survival response.

This act of camouflaging doesn’t exist in a vacuum—it is deeply rooted in power dynamics and social threat. Using the Power Threat Meaning Framework (PTMF), we can understand masking not as a set of “maladaptive” behaviours to be corrected, but as a response to living under systems that pathologise difference and enforce conformity. Masking is what many autistic people have to do when the threat of exclusion, punishment, or harm looms large. For those of us who are also transgender or gender-diverse, this burden is magnified. Gender masking—the suppression of one’s authentic gender presentation or identity to meet cisnormative expectations—often overlaps with autistic masking, creating a complex and exhausting performance of safety.

What may be perceived as shyness, quiet competence, or even success is frequently the outcome of chronic hypervigilance. For many, masking is not about fitting in or making friends—it’s about avoiding bullying, institutional violence, job loss, or worse. Camouflaging, in this light, is a trauma-adapted behaviour. It is shaped by power, fuelled by threat, and imbued with meaning—specifically, the message that our authentic selves are not welcome here.

The Science: What the Research Tells Us

The research is clear: masking takes a measurable toll, and that toll is heaviest for those of us living at the intersection of multiple marginalised identities. Autistic people who are not straight or cisgender report significantly higher levels of camouflaging, and this additional burden is closely associated with poorer mental health outcomes. Rather than being an incidental feature of autistic life, masking among LGBTQIA+ autistic individuals often reflects a chronic response to environmental hostility and social risk—a strategy shaped more by survival than by social aspiration.

This burden is particularly acute for those diagnosed in adulthood. McQuaid et al. (2021) found that trans and gender-diverse autistic adults, especially those who received their diagnosis later in life, are significantly more likely to engage in compensation strategies designed to present as neurotypical. These include rehearsing conversations, mirroring neurotypical behaviours, or suppressing natural responses to sensory overwhelm. These tactics are exhausting, often invisible to others, and rarely understood for what they are: trauma-adapted attempts to avoid harm.

One of the more intimate forms of masking involves the suppression of repetitive movements (RMs), commonly referred to as stimming. Wiskerke et al. (2018) documented how many autistic women and trans adults consciously inhibit these movements in public settings, despite their self-regulatory function. This is not because stimming is undesirable, but because the social consequences of being visibly autistic remain dangerous. Avoiding stigma often means silencing the body itself.

Perry et al. (2021) confirm that masking is overwhelmingly motivated by a desire to avoid rejection or punishment. The camouflaging of both neurodivergent and gender-diverse traits is not random—it is a rational, adaptive response to a society that routinely punishes difference. And yet, what protects us socially in the short term often destroys us emotionally in the long run.

Rivera and Bennetto (2023) highlight the mental health consequences of this sustained performance. Autistic trans and gender-diverse individuals face disproportionately high rates of anxiety, depression, and suicidal ideation. The ongoing pressure to hide core parts of oneself—to be invisible in order to be safe—creates a sense of disconnection so profound that it can become unbearable. It is not autism, nor gender diversity, that leads to crisis—it is the persistent message that we must not be seen.

Beyond the Research: What It Feels Like

For those of us who live this reality, masking isn’t just a behaviour—it’s a kind of disappearance. It’s the gradual erosion of self in service of survival. From an early age, often before we have words for it, we learn that parts of us must be hidden: our stims, our way of speaking, our truth. We begin to edit ourselves to fit the expectations of others—smoothing out the parts of us that don’t quite align with the script. Over time, the performance becomes habitual, and what remains visible is a carefully managed version of ourselves. The rest is concealed—because being known has never been safe.

This constant internal surveillance is exhausting. It fractures our sense of self, leaving us dissociated from our own interior world. As I wrote in The Uncharted Self, masking can feel like standing next to your life instead of inside it. You become fluent in the language of performance, but alien to the language of your own needs. And when you are both autistic and trans, this fragmentation deepens. The body itself becomes a site of negotiation—how to walk, how to speak, how to dress, how to be—each choice filtered through questions of legibility, threat, and erasure.

There are no models for us. No socially legible way to be autistic and trans and whole. In systems that reward conformity, those of us who do not fit are often read as problems to be solved rather than people to be understood. Clinicians overlook us, educators misread us, and institutions expect us to simplify ourselves so we can be more easily categorised. As I explored in The Complexities of Identity, this illegibility is not accidental—it’s systemic. The world was not built to hold us, and so it chooses to pretend we’re not there.

And yet, we are. Even when invisible, even when splintered by the weight of constant masking, we persist. But persistence is not the same as thriving. The cost of being unseen—of having no safe place to exist without performance—builds slowly until it spills over as burnout, depression, anxiety, or collapse. And still, too often, we are told that the problem is within us. Not in the systems that refuse to see us. Not in the world that demands our erasure as the price of acceptance.

Double masking is not about deception. It’s about survival. But it is also a quiet kind of grief—the mourning of a self we have never been allowed to fully become.

The Failure of Traditional Mental Health Systems

Traditional mental health systems were not built for people like us. For many autistic individuals—especially those of us who are also trans or gender-diverse—seeking support often means entering systems that view our distress as pathology and our identities as problems to be fixed. Therapy, when rooted in behavioural compliance or gender normativity, can become yet another site of erasure. Rather than affirming our experience, many therapeutic models focus on suppressing visible difference. As Buchholz (2023) notes, traditional autism interventions often prioritise behavioural conformity over authenticity, reinforcing masking and undermining our ability to express ourselves safely.

The result is not healing, but further fragmentation. Clinicians unfamiliar with the realities of double masking frequently misread the outward signs of distress—emotional overwhelm, social withdrawal, identity uncertainty—and diagnose what they can see, rather than what lies beneath. Many of us are misdiagnosed with borderline personality disorder or bipolar disorder, diagnoses that may feel more socially legible to professionals than autism, especially in adults assigned female at birth or those who are high-masking. These misdiagnoses can lead to treatment plans that not only miss the mark but actively deepen harm. Fletcher et al. (2014) and Skokauskas & Frodl (2015) both highlight how traits like emotional dysregulation and shifting identity presentation—common in autistic people under stress—are easily mistaken for other psychiatric conditions when clinicians fail to account for neurodivergence or minority stress. For children, subclinical manic traits in autism are also routinely mistaken for bipolar disorder, as shown in Okada et al. (2016), further complicating the diagnostic landscape.

Late diagnosis compounds this harm. Many of us go decades without knowing why we feel so alien in the world. Instead of receiving support, we internalise shame. Pearson and Rose (2020) write of the isolation and self-doubt experienced by those who mask heavily and remain undiagnosed or misdiagnosed. When the systems around us fail to name our neurotype accurately, or worse—name us wrongly—we are left to navigate a distorted version of ourselves, one shaped by other people’s misunderstandings. This is not simply a personal tragedy; it is a systemic failure. And for those with co-occurring diagnoses, such as autism and bipolar disorder, the complexity of care needed is rarely provided. Borue et al. (2016) show that youth with both conditions often face more severe impairment, yet their experiences remain poorly understood.

What emerges is a pattern: a system designed to pathologise difference rather than support it. Therapy becomes another performance, another mask we wear to be believed, to be helped, to be allowed to exist. But healing is not found in pretending to be someone else. It begins only when we are recognised in our full complexity—and allowed to stop hiding.

What Needs to Change?

If double masking is a survival response, then any path toward healing must begin by removing the conditions that make survival feel like the only option. Traditional mental health systems often respond to our distress by urging us to adapt better, cope harder, or conform more convincingly. They offer “support” that centres assimilation—into cis-normativity, into neurotypical norms, into capitalist systems of productivity. But what we need is not to be better at pretending. We need systems of care that affirm who we are, that recognise our distress as meaningful, and that refuse to pathologise our difference.

This means rejecting assimilation-driven approaches and building identity-affirming systems rooted in collective liberation. As I argued in The Master's Tools and the Therapist’s Office, the therapeutic establishment often functions more as an agent of social control than as a site of healing. By framing our suffering as individual dysfunction rather than a response to hostile environments, it gaslights us into believing that our struggle is our own fault. The result is that therapy becomes yet another mask we must wear, another role we must perform, another way we are told to be someone else in order to be helped.

This is not accidental. As explored in Capitalism’s Gaslighting, the very structure of our society relies on this misdirection. Under capitalism, suffering is always framed as personal failure. The system dispossesses, alienates, and exploits—and then sells us wellness products and bootstraps ideologies to cope with the damage. Mental health, in this context, is rarely about liberation. It is about returning people to productivity. It is about making the alienated functional, not whole.

So what must change?

First, we need spaces led by our people—spaces where our ways of knowing and being are not just accepted, but foundational. No one is better equipped to understand the nuances of double masking than those who live it. Community care, peer-led support, and collective models of healing can interrupt the isolating logic of the clinic and replace it with relational belonging.

Second, therapy must shift from behaviour correction to co-regulation. Neurodiversity-affirming, trauma-informed, and gender-expansive therapeutic models already exist—they just need to be resourced, protected, and centred. Clinicians must be trained not only to recognise gestalt language processing, alexithymia, or masking, but to interpret these not as deficits, but as meaningful adaptations to environments built against us.

Third, we must abolish the idea that “passing” should ever be a prerequisite for safety or care. Systems that reward those of us who can hide well are systems that abandon the most visibly vulnerable. This harms us all. Affirmation must not be conditional. Protection must not depend on our ability to disappear.

Finally, the lens must shift—from “what’s wrong with you” to what has happened to you, how did you survive, and what does that say about your strength? This is the promise of the PTMF. It offers a way to honour the logic in our distress, to see our responses not as disorders, but as resistance. It insists that pain is intelligible—and that healing requires listening to what it is telling us.

We do not need more tools for surviving unjust systems. We need to dismantle the systems that require our survival strategies in the first place. We need not adaptation, but revolution—rooted in solidarity, grounded in care, and led by those who have always been told we do not belong. Because we do. And we always have.

Final thoughts …

So much of what circulates during Autism Awareness Month is surface-level—soft-focus platitudes, recycled slogans, and vague calls for “understanding.” These narratives often centre comfort over truth, awareness over action, and visibility only when it’s neat and non-threatening. My writing does something else. It dives deep. It names the things that aren’t supposed to be named. It lives in the liminal spaces—where many of us have always existed—and insists that our experiences are worth recording, worth researching, worth being taken seriously.

This piece, like all my others, is part of that effort. I know it doesn’t always resonate with mainstream audiences or fit neatly into corporate toolkits. That’s never been the point. This is where I store the things I didn’t have words for growing up. It’s my digital delayed echolalia—a place to loop back, make sense, and speak the truths I once had to swallow. It’s not polished for mass consumption. It’s real. It’s what I needed to read when I was young and invisible.

Because the problem was never that I was autistic. Or trans. Or too much. The problem has always been the demand to hide—to contort, to conform, to survive by erasing myself. For many of us, the performance of safety has come at the cost of authenticity, health, and even life. And yet we are still here. Still writing. Still reaching for one another.

Visibility, in this context, is not exposure—it’s liberation. It’s not about being seen for applause or acceptance. It’s about being seen so we no longer have to vanish to stay alive. True safety comes not from learning to mask more effectively, but from building a world where masking is no longer necessary. That requires more than coping strategies. It requires solidarity. It requires systems that affirm rather than erase. And it requires us—those on the outside—to keep telling the truth, even when it isn’t welcomed.

I write because I know what it is to be misread. And I write so others like me might be recognised before they are erased.