The Cost of Passing: Autism, Masking, and the Gendered Disappearance from Diagnosis

Masking helps us survive—but it hides us from diagnosis, support, and even ourselves. This piece explores the paradox of autistic masking, misrecognition, and what it means to reclaim the self beyond acceptability.

Introduction

In 2022’s Autism and Place, I wrote about the conditional nature of belonging—how autistic people are allowed near others only when we manage to perform the version of ourselves that disturbs them least. It was a piece about proximity without welcome, about how masking becomes the price of entry to almost every space we’re meant to inhabit. But in revisiting that article now, with several years’ hindsight and painful clarity, I see that the patterns I described have only intensified. The predictions I made about diagnostic restriction—about how systems would continue narrowing the criteria in ways that disadvantage high-masking people—have, sadly, come true.

The shift in the DSM from “as manifested by the following” to “as manifested by all of the following” may seem semantic, but its impact is sharpest at the margins—especially for those of us socialised into silence. For autistic girls, women, and nonbinary people—particularly those raised in patriarchal, evangelical, or culturally conservative settings—the ability to mask is drilled in from the earliest age. We are taught to smile, submit, not take up space, not show distress. And we learn it well. Too well. So well, in fact, that when we finally come undone—burnt out, dissociated, confused—we are told we can’t be autistic, because we don’t look like the (male-coded) profile they expected. Our compliance disqualifies us. Our survival strategies mask us out of recognition.

And that is the paradox at the heart of this: the more we perform wellness, the more we are believed to be well. The more we mimic the acceptable, the more we disappear from view—not just socially, but diagnostically. It is not that we are missed by accident; we are erased by design. Because the system was built to detect those who fail to hide—not those who have spent a lifetime perfecting the disguise. And when autistic people finally come forward, in adulthood, asking to be seen, we are met with doubt. Accused of over-identifying. Of being too self-aware. Of reading too much. Of wanting the diagnosis for the wrong reasons.

It is a cruel fate: to live decades learning how to hide your needs, only to be told they never existed.

The Labour of Acceptability

Tien, I., Wolpe, S., Pearson, A., & Seers, K. (2025). “Creating a socially acceptable version of myself”: A qualitative thematic analysis of the female and nonbinary experience of navigating the autism diagnostic system. Neurodiversity, 3, 27546330241306380.

The Tien et al. (2025) study captures it with devastating accuracy: “creating a socially acceptable version of myself.” For so many of us—especially those raised as girls, or shaped by patriarchal and evangelical values—this isn’t a conscious strategy we adopted one day. It is the air we breathed. The only terms on which we were allowed to exist. We were not told we were autistic, or different, or even struggling. We were told to behave. To be nice. To not be difficult. And we learned—long before we had words for what we were doing—that the cost of authenticity was rejection. That safety lay in acceptability.

This labour of acceptability runs deep, so deep it embeds itself into our sense of self. It is not a mask we can take off at will; it becomes mistaken for who we are. Polite. Agreeable. Anxious, perhaps, but capable. High-achieving. “Sensitive.” “Empathetic.” “Gifted.” We become praised for the very traits that cost us the most to maintain. Over time, we internalise the message: your worth lies in your ability to accommodate others. You are only lovable, only safe, only welcome, when you are easy to be around.

And there is such a deep grief in realising this wasn’t inevitable. That it is not a universal human experience to have your natural way of being framed as a threat to others’ comfort. That this level of constant adjustment—this full-time, unpaid, soul-eroding job of making oneself palatable—is not some necessary rite of passage. It is a cruelty. And it is a cruelty we have come to expect as normal.

It should not be normal. It should not be required. It should not be the fate of half the human population to contort themselves into socially acceptable shapes just to avoid abandonment. And yet, here we are—decades into life, trying to unlearn what was never fair to ask of us in the first place. Trying to find out who we might have been, had we ever been allowed to simply be.

Diagnostic Systems Are Not Neutral

Craddock, E. (2024). Being a woman is 100% significant to my experiences of attention deficit hyperactivity disorder and Autism: exploring the gendered implications of an adulthood combined autism and attention deficit hyperactivity disorder diagnosis. Qualitative Health Research, 34(14), 1442-1455.

The systems we turn to for understanding—for answers, for recognition, for support—are not designed to see us. The DSM, the educational frameworks, the so-called objective assessment tools all depend on a visible, measurable disruption: an externalised “impairment.” But the reality of high-masking autistic life is that the most profound distress often has no outward marker. It lives inside the body—held in clenched jaws, stomach aches and digestion problems, internal monologues, tears blinked away in toilets and quiet bedrooms. It is not that we are without need. It is that we have been taught to make our needs invisible.

This is the systemic flaw, the great diagnostic blind spot: the tools are calibrated to detect those who fail to hide. If you meltdown in public, if you withdraw in class, if your behaviour disrupts others, you are flagged. But if your trauma has trained you to internalise every response, to mask through it, to excel in order to avoid scrutiny—you are overlooked. You are told you’re fine, even as the cost of being “fine” eats you alive.

Craddock (2024) speaks directly to this. Gendered expectations not only shape how distress is expressed, but whether it is recognised at all. The boy who refuses to sit still is labelled and assessed. The girl who quietly dissociates at her desk is praised for her maturity. The boy who shouts is a problem to be solved. The girl who cries in the bathroom and never asks for help is considered emotionally intelligent. By the time she breaks—because of course she will—it is treated as sudden, inexplicable. She is told she was coping fine, that things were going well. She is asked, bewilderingly, why she didn’t say anything sooner.

But how do you explain a distress no one ever taught you to name? How do you ask for help when your entire life has been spent performing the version of yourself that others wanted to see? This is not a matter of miscommunication. It is a design flaw. And it is a design that leaves so many autistic women, girls, and nonbinary people without a diagnosis, without support, and without a name for their pain—until it is too late.

The Role of Culture: Why Some of Us Disappear Entirely

There are some of us who disappear entirely—not because we are less autistic, but because we were raised in environments where silence was expected, gratitude was demanded, and strangeness was punished. In homes shaped by patriarchal values, evangelical morality, or conservative respectability, being acceptable wasn’t optional—it was survival. And for those of us who were autistic—especially girls, or those perceived as such—the need to hide our differences wasn’t a strategy. It was a condition of being allowed to stay.

I was adopted at an early age into a family from a culture that was not my own. From the start, I knew—though it was never said aloud—that my problems, whatever they were, were not my parents’ concern. I was meant to be grateful. To assimilate. To perform compliance, gratitude, normalcy. The house ran on the unspoken rule that children should be seen and not heard, though in my case, I was barely seen at all. I was an accessory. Tolerated, at best. There was no room for my questions, my sensitivities, my confusion. My distress wasn’t recognised as neurodivergence—it was moralised. Reframed as attitude, defiance, ungratefulness. And so, I learned to mask. Not as a choice, but as a reflex. An instinctive, embodied practice of staying safe.

That masking took on an entirely new dimension when I turned nine. By then, I was already head and shoulders above my peers—physically strong, visibly different. One day, my adoptive father took me to work with him at the warehouse, and I never really stopped going. I was put to work loading and unloading boxes from trailers—heavy industrial labour, shoulder to shoulder with grown men. I had to pass as older, had to match their pace, their silence, their stamina. At nine years old, I learned to mask as a teenage boy so that I wouldn’t be questioned. So that I wouldn’t get my father in trouble. So that I wouldn’t stand out any more than I already did.

In that context, masking was not about fitting in at school or avoiding bullying. It was about labour. About economic survival. About being believed as something I wasn’t, because the alternative—being seen as a child, as vulnerable, as different—was not an option. By the time I reached adolescence, the mask wasn’t something I put on. It was the only self I knew.

So when professionals later failed to see me as autistic, it wasn’t because I wasn’t in distress. It was because I had become so skilled at burying it. Diagnostic systems built to identify the unmasked were never going to catch someone like me—not someone raised to be grateful, to be useful, to be quiet, to be strong. I didn’t disrupt. I adapted. I didn’t present as broken. I presented as capable. And for a time, I was believed.

I was first diagnosed under DSM-IV: Asperger’s, along with documented issues in sensory processing—then called Sensory Integration Disorder—and marked difficulty with functional language. It wasn’t a perfect fit, but it was enough to get me seen, to anchor some form of recognition. Those labels would eventually be merged into Autism Spectrum Disorder under DSM-5, and I made the transition with them. But now, with the DSM-5-TR and its tightened criteria—requiring all traits to be “manifested across multiple settings”—that same diagnosis would be out of reach. My care team has already warned me: a reassessment would erase me. On paper, I no longer qualify. I am too fluent, too composed, too outwardly functional. I would lose my diagnosis for sure.

And so I live in this cruel double-bind: too autistic to live without support, but not autistic enough to be recognised by the system that defines support. This isn’t just a personal misfortune. It is a cultural failure—a systemic refusal to understand what masking really is, and who it protects. We have built a model that withholds care from those who succeed at surviving, and then calls it fairness. But there is nothing noble about forcing a child to survive by pretending to be someone else. There is only grief.

The Paradox of Functioning

Ante-Contreras, D. M. (2017). Autism as Metaphor: The Affective Regime of Neoliberal Masculinity. University of California, Riverside.

By the time I received my diagnosis, I had already learned what the world rewards: composure, fluency, usefulness. Masking wasn’t just a habit—it was how I stayed employed, how I kept housing, how I (mostly) avoided institutions. But that survival came at a cost. Because in this system—one built on neoliberal values of independence, self-regulation, and productivity—the very traits I cultivated to avoid harm now disqualifies me from care. I pass too well. And passing, in a society that equates “functioning” with wellness, is a trap.

This is the paradox of functioning. Under neoliberalism, you must perform normalcy to survive. But if you perform it too well—if you adapt, script, smile, comply—you’re deemed not in need. Those of us who mask to avoid punishment are then punished again by being excluded from support. As Craddock writes, support is allocated based on visible need—but those most in need have learned to become invisible. It’s not that the system can’t see us. It’s that it only looks for distress when it disrupts, never when it’s buried.

Tien et al. (2025) captures this with quiet devastation: the labour of creating a socially acceptable version of oneself isn’t just psychological—it’s economic. It’s what keeps people like me afloat. And yet, the moment we seek diagnosis or accommodation, that same labour is turned against us. We’re told we’re too articulate. Too emotionally aware. Too successful. The diagnostic model insists on impairment, but impairment in this framework is only valid if it performs itself in ways legible to professionals trained to see autism through a masculinised, externalised lens. As Ante-Contreras (2017) argues, autistic traits are treated as liabilities unless they are “overcome” through productivity—and once overcome, they are no longer seen as valid.

This paradox is especially cruel for those of us who were raised to perform a gender that never fit. I was raised male. And though I kept my queerness carefully hidden, I survived by constructing a kind of masculine cosplay—a patchwork of scripts borrowed from my father’s favourite war films. William Holden in Stalag 17, Karl Michael Vogler in Patton, Jack Watson in The Devil’s Brigade—these were my models. As a gestalt language processor, I could echo their cadence, their stoicism, their command. I wore them like armour. I learned early that whilst I could never be a man in the way the world expected, I could perform one—convincingly, and in ways none of my peers could trace. My scripts were vintage. My camouflage was cinematic. I masked not by blending in, but by playing a role older, colder, and more controlled than the chaos inside me.

In that performance, distress had no place. Vulnerability would have shattered the illusion. And so, I was never flagged. Not as autistic. Not as genderqueer. Not as someone in pain. I had done too good a job. And when the mask finally cracked, years later, there was no framework waiting to hold the truth. Just the stunned silence of systems that only know how to respond when people fall apart in predictable ways. That’s the tragedy of the paradox: if you fail to pass, you might get help. But if you pass too well, there’s nothing left for you when you finally collapse. Not because you’re fine—but because you were too convincing when you weren’t.

There is no grace in this system. Only performance, and the punishments for performing too well. If you shatter publicly—messily, recognisably—you might be offered support. But if you’ve spent a lifetime rehearsing strength, falling apart in silence, scripting every interaction with borrowed lines from men who were never real to begin with, then you’re on your own. The world sees the mask and assumes it is your face. And when you finally falter, they question your sincerity, not the strain you’ve been carrying. We are not overlooked because we fail to meet the criteria. We are excluded because the system demands we suffer on its terms—loudly, visibly, legibly. And if we don’t, it simply refuses to see us.

The Emotional Toll: Living as a Disbelieved Self

Tamilson, B., Eccles, J. A., & Shaw, S. C. (2025). The experiences of autistic adults who were previously diagnosed with borderline or emotionally unstable personality disorder: a phenomenological study. Autism, 29(2), 504-517.

Zack, D. S., Carroll, B., Magallanes, A., & Edgar, V. B. (2025). Take a Closer Look: Considerations for Autism Spectrum Disorder Assessment in Female Children and Adolescents. Journal of Pediatric Health Care, 39(1), 107-111.

There is a cost to being disbelieved. A cost to living in a body that knows something is wrong whilst being told, again and again, that everything looks fine from the outside. For those of us whose autism was hidden by necessity—camouflaged beneath scripts, silence, or service—the psychological toll builds slowly, then crashes hard. Burnout, identity confusion, emotional exhaustion—these are not occasional episodes. They are the long-term consequence of being unreadable to systems that only respond to crisis.

By the time I was diagnosed, the damage was already well underway. And yet, even with a diagnosis, the haunting question remained: Was it real? Was I just faking it too well? Years of masking had trained me to doubt my own perception. When care was finally offered, it came framed in suspicion. I knew how to articulate my needs—too well, it seemed. I was coherent, responsive, “insightful.” That ruled me out in the eyes of some. In fact, my original diagnosis of Asperger’s, and later ASD, came only after years of misdirection: I had been interpreted through lenses of childhood trauma, mood, and personality, but not neurology. That I could speak about my feelings at all was taken as proof I wasn’t autistic. No one considered that I had spent a lifetime borrowing language to describe experiences I was only just learning to feel.

The consequences of this misrecognition are not abstract. Tamilson, Eccles, and Shaw (2025) detail the lived experiences of autistic adults who were previously misdiagnosed with Borderline Personality Disorder. Their stories mirror mine: interventions focused on regulating behaviour and emotion, not understanding difference. Zack et al. (2025) make clear that even today, autistic girls and young women are frequently overlooked in assessments—not because they lack need, but because they don’t present in ways clinicians are trained to expect. The diagnostic tools remain calibrated for externalised, male-coded traits. Those of us who fracture inwardly, who perform normal until we can’t, are filtered out.

You don’t have to look far to see this playing out. Social media is full of AFAB creators telling the same story in slightly different scripts: first labelled with Borderline. Then with high-cycling Bipolar. Sometimes ADHD, sometimes trauma. Only years later—after therapy that didn’t help, medication that didn’t fit, and a mounting sense that something deeper was being missed—they come to discover they are, in fact, AuDHD. That their emotional intensity, relational difficulties, executive dysfunction, and sensory sensitivities were not signs of instability or disorder, but unrecognised neurodivergence.

These aren't rare anecdotes. They are a collective pattern. A generation of people misdiagnosed not because they were hard to see, but because the diagnostic lens was never built to find them. We are the evidence that the system is failing—not just in its criteria, but in its assumptions about what autism looks like, sounds like, and lives like.

And so we carry the weight of misrecognition—of lives lived under the wrong names, inside frameworks that never fit. We are medicated for anxiety we cannot explain, disciplined for behaviours that were actually distress signals, or pathologised with labels that never accounted for difference. We are told we are too intense, too sensitive, too much. Or else too calm, too competent, not struggling enough. We become case studies in contradiction.

The damage ripples outward. Relationships suffer, not because we are unwilling to connect, but because no one sees the person beneath the mask. Even in therapy—the one space meant to hold us—we find ourselves performing. We mask through the process of unmasking, narrating our pain in the language we believe will be understood. We script our disclosures. We self-edit. We look for evidence of our own legitimacy in the faces of professionals who hesitate, who doubt, who tell us we’re “very self-aware,” as if that cancels everything else out.

The result is a kind of split—not just in identity, but in belief. We begin to ask ourselves the same questions others have asked of us: Is this real? Am I making it up? Am I just very good at seeming like I belong? This isn’t just a clinical oversight. It’s an existential wound. Because to live as a disbelieved self is to be denied the most basic human need: to be recognised, not just as struggling, but as real. And without that—without the anchoring truth of being seen—we begin to drift. We vanish inward. We disappear from our own lives.

Reclaiming the Self Beyond Acceptability

And yet—somehow—we begin to find our way back. Or forward. Or inward. There comes a moment, often quietly, when the cost of maintaining the “socially acceptable version” of ourselves becomes too high to bear. When the mask no longer protects—it suffocates. And in that moment, the work of reclaiming begins. It is slow. Uneven. Sometimes terrifying. But it is also a return to something we never stopped being, only stopped believing we were allowed to be.

Recognition is where the unravelling starts—not just clinical recognition, though for many of us, a formal diagnosis is a necessary anchor. But perhaps more powerfully, it is the recognition that comes from others like us. From the shared language of neurodivergent space, where stimming is not strange, where silence is not judged, where eye contact is not required for truth. Where someone says, I see you, and means it—not as a diagnosis, but as a welcome.

The more we are seen, the more we begin to see ourselves—not as broken, but as misread. And in that seeing, we start to loosen the rules we once obeyed without question. We stop performing distress in ways that others will recognise, and instead begin expressing it in ways that make sense to us. We stop trying to justify our needs, and begin asserting them. We remember that we do not need to look unwell to deserve care. We do not need to fall apart to be worthy of support.

This is the truth that underpins everything I wrote in Autism and Place: that our belonging cannot be conditional. Our place is not something we earn through good behaviour, or soft speech, or tidy emotions. It is ours by right. And we claim it not by contorting ourselves to fit, but by arriving exactly as we are—unsmoothed, unfiltered, unmistakably real.

Somewhere Else

we were not hiding
you just called the wrong names
read the wrong signs
held the wrong image up to the light

we were always here—
beneath the scripted laughter
behind the clean lines
under the borrowed clothes

you said we were quiet
but we were speaking
just not in the language you taught us
not in the shape you expected

you searched for us in the noise
we bloomed in the hush
you wanted proof of struggle
we lived entire lives of it unseen

you didn’t lose us
you never looked in the right place

Final thoughts …

The system mistook our survival for success. It saw our composure and called it capacity. It saw our scripts and called them fluency. It saw our silence and called it consent. But it never asked what it cost us to appear that way. This is the failure at the heart of it all: a diagnostic model that reads masking as absence, rather than as the residue of trauma, adaptation, and fear. And it was never designed to see us. The gaze of the system has always followed value—reserved for white boys in affluent homes, tracked early, studied, invested in. The rest of us were not property worth maintaining. Certainly not girls. Not queers. Not adoptees. Not anyone whose pain wasn’t profitable. No one ever thought to check in on how the system’s invisible property was doing. Reform, if it’s to mean anything, must begin with lived experience—not just as evidence, but as truth. It must be grounded in cultural humility, and in the recognition that not all suffering is loud, and not all need announces itself. Masking is not a lack of impairment. It is the scar tissue of a life spent trying not to be cast out. We do not need to be broken in the right way to deserve care. We were always here—you just didn’t look in the right place.