The Hidden Cost of Blending In: Autistic Masking Linked to Anxiety, Depression and Suicide Risk in Women

For many autistic women, the daily effort of hiding who they are comes at a devastating price. A new systematic review published in the Journal of Autism and Developmental Disorders has pulled together a decade of evidence showing that autistic masking—the behavioral and cognitive work of concealing or compensating for autistic traits to fit into neurotypical social environments—is consistently and independently linked to anxiety, depression, and suicidality in autistic adult women. The findings, drawn from nine studies published between 2018 and 2025 and covering more than 1,500 women across seven countries, suggest that masking is not merely a social inconvenience but a significant psychosocial risk factor for mental health deterioration.

The review, conducted by E. Cuni and M. Cantero-García at the Universidad a Distancia de Madrid in Spain, followed PRISMA 2020 guidelines and was prospectively registered in PROSPERO. The researchers searched five major databases—PubMed, Web of Science Core Collection, Scopus, APA PsycINFO, and ProQuest One Psychology—for publications from January 2015 to December 2025. To be included, studies had to involve formally diagnosed autistic adult women aged 18 or older, explicitly measure masking, and report at least one of four specified mental health outcomes: anxiety, depression, autistic burnout, or suicidality. Methodological quality was assessed using the Newcastle-Ottawa Scale and the Critical Appraisal Skills Programme checklist.

What emerged from the synthesis is a strikingly consistent pattern. Masking showed a robust association with anxiety, with standardized coefficients ranging from 0.21 to 0.22 and a large effect size of d = 0.93. The relationship with depression was also substantial, with Hedges’ g = 0.56, and structured lifetime diagnostic interviews revealed that masking explained a notable proportion of variance in depressive outcomes, with a Nagelkerke R² of 0.358. In other words, the more intensely autistic women masked, the more likely they were to experience clinically significant anxiety and depressive symptoms.

Perhaps most alarming is the connection to suicidality. Masking emerged as an independent predictor of suicidal outcomes, with a standardized coefficient of 0.198 and an odds ratio of 5.04 when compared against the general population. The review identified the assimilation subscale of the Camouflaging Autistic Traits Questionnaire (CAT-Q)—which measures the effort to blend in with neurotypical peers—as the specific predictor of suicidal ideation in women, with anxiety serving as a mediating pathway. This finding aligns with the Interpersonal Psychological Theory of Suicide, which posits that feeling like a burden and experiencing social alienation are key drivers of suicidal thinking.

The mechanism behind these associations is likely multifaceted. Masking demands continuous self-monitoring, suppression of natural behaviors, and constant vigilance to social cues that may not come intuitively. This sustained cognitive load can deplete psychological resources over time, a phenomenon closely related to autistic burnout—a state of chronic exhaustion, loss of skills, and reduced tolerance to stimuli described in qualitative research by Raymaker and colleagues in 2020. Notably, however, the review found that no study in the included literature had assessed autistic burnout using validated instruments, highlighting a significant gap in the field.

The disproportionate impact on women is a recurring theme in autism research. Autistic women are more likely to be underdiagnosed or misdiagnosed, often receiving labels such as borderline personality disorder, anxiety disorders, or eating disorders before autism is recognized. Masking may contribute to this diagnostic delay by making autistic traits less visible to clinicians, while simultaneously worsening the very mental health problems that bring these women to clinical attention in the first place. The result is a vicious cycle in which the effort to appear neurotypical both hides the underlying condition and intensifies its psychological consequences.

The minority stress model, extended to the autistic population by Botha and Frost in 2020, offers a useful framework for understanding these findings. According to this model, masking is not simply an individual choice but a response to a hostile or unaccommodating social environment. The chronic stress of navigating a world designed for neurotypical minds—combined with the internalized pressure to conceal one’s authentic self—accumulates over time and manifests as anxiety, depression, and suicidal thinking. From this perspective, the mental health crisis among autistic women is not an inevitable feature of autism itself but a consequence of the mismatch between autistic individuals and the societies they inhabit.

The clinical implications of this review are direct and urgent. The authors recommend that systematic assessment of masking using validated instruments such as the CAT-Q should be integrated into mental health and suicide risk evaluation protocols for autistic women. Clinicians who work with this population should recognize that a patient who presents with anxiety or depression may be expending enormous effort to mask autistic traits, and that this effort is itself a driver of the symptoms they report. Screening for masking could help identify women at elevated risk before crisis points are reached.

There are important limitations to acknowledge. The review included only nine studies, and the evidence base for autistic burnout remains entirely qualitative or unmeasured with validated tools. Most included studies were cross-sectional, which limits causal inference—while the associations are consistent and robust, the direction of the relationship between masking and mental health deterioration cannot be definitively established from correlational data alone. It is plausible that women who experience worse mental health may also mask more, or that the relationship is bidirectional. Longitudinal research is needed to disentangle these possibilities.

Nevertheless, the consistency of the findings across different countries, research groups, and measurement approaches lends considerable weight to the conclusion that masking constitutes a genuine and independent psychosocial risk factor. As diagnostic rates of autistic females continue to rise globally, and as awareness of underdiagnosis grows, the need to understand and address the mental health consequences of masking becomes ever more pressing. For the more than 1,500 women whose data underpin this review, and for the countless others who navigate the world behind a carefully constructed neurotypical facade, the message is clear: the cost of blending in is measured not just in daily exhaustion but in long-term psychological harm, and that cost deserves systematic clinical attention.

Subject of Research: Autistic Masking and Mental Health Outcomes in Autistic Women: A Systematic Review (2015–2025)

Article Title: Autistic Masking and Mental Health Outcomes in Autistic Women: A Systematic Review (2015–2025)

Article References: Cuni, E., & Cantero-García, M. (2026). Autistic Masking and Mental Health Outcomes in Autistic Women: A Systematic Review (2015–2025). Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-026-07557-0

Image Credits: AI Generated

DOI: 10.1007/s10803-026-07557-0

Keywords: Autistic, Masking, Mental, Health, Outcomes, Women, Systematic, Review, scientific research