No.1 Autism Expert: How To Spot Autism In High-Masking Autistic Women

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0:29Gina Rippon:If you're female adolescent and autistic, going to secondary school, hitting adolescence, I call it the perfect storm. You're not just somebody's child or in somebody's classroom. You're supposed to be somebody who's heading towards your own individual identity. What is the difference between an autistic person who has an insight into their differences and intentionally tries to change they are to fit in and someone who doesn't? The person who feels they have to camouflage, they might say, well, that's what I've done all my life. And so they kind of feel the difficulties they have might be worth the struggles they have.

1:01If a woman does have ADHD and also autism, but she doesn't know that, could the ADHD make her too talkative, spontaneous, impulsive, to the point where she doesn't fit the stereotype of autism and therefore she gets missed?

1:14Gina Rippon:Talking to women who have both, they will say... Can I have just a second of your time? If this podcast has helped you understand your brain or made you feel less alone, can you do me one favour? Can you hit the follow button? And I'll repay the favour by continuing to book the best and most exclusive conversations on this topic. Please enjoy the episode and always remember, you're not broken, just different and you have always been enough.

1:43Gina Rippon:Professor Gina Rippon, welcome back. Thank you very much for having me back. We're going to jump straight in. how can a autistic woman become so good at hiding their autism that even they can't see it well i think bearing in mind that the evidence suggests that camouflaging um or masking or accommodating different ways of disguising your autism starts very early so but actually is a practice effectively um and if you talk to quite young girls they will i talked to one girl once we were sitting looking at a playground through the window and she was pointing to the group of popular girls and pointing out um how they laughed you know they should be watching how which ones threw their heads back um and whether one one of them touched the other one and so very very socially astute um at a surface level and the idea being that somehow if i can learn to behave like that they won't notice that i'm different they won't call me weird or other or whatever so years of experience um and very often even things like watching television programs or reading books writing scripts um that you then literally practice in front of the mirror um And it becomes quite all-encompassing.

3:10And then, of course, to not have those scripts with you,

3:13Gina Rippon:but to have to play them out is very exhausting. Yes. Gosh, it sounds totally tiresome. Yes. But also, as you said, how they don't even know they're doing it, because, of course, it's not something you talk about. So some people are really surprised. Doesn't everybody do that? and and so it's quite a revelation when it becomes clear that they're masking the difficulties they've had somebody needs to ask them the right questions in order to find out what they're doing I think this is where it gets really interesting because I think there's many people going to be listening who relate to that but they might be wondering is that me how does someone tell the difference or no if they are someone who intuitively intellectually understands socializing versus them just being a brilliant performer well i think the difference between intuitively and intellectually is interesting because intuitively implies that there is some kind of automatic process which allows our brains to understand other people i mean there's a lot of that in the autism world, talking about mind reading and inverted commas, for example.

4:29Gina Rippon:So not only understanding how you feel about a situation, but how the other person you're talking to, the other people you're working with feel, even to the extent that you don't ask them, but you work out from what you know about them, perhaps, or what you know they believe, or their own experiences, or their facial expressions. So you come to understand other people but it is automatic um people who don't have that innate if it is skill then work on it intellectually um and it is literally decoding uh the the sort of physical events in the world looking at people's expressions i mean it's kind of characterized a bit with autistic children who find it very difficult to understand emotions and how to respond including their own and there's it may be anecdotal but you know there's evidence that if you teach a child who's finding it difficult to understand other people um you you know if the corners of their mouth are going up that's a smile and that means they're happy right and you have to teach them that and they have to remember that yes how young does masking start what does a high masking autistic girl look like uh young girl the the work that's coming out quite recently is suggesting that this camouflaging or masking starts very early five six perhaps when you first go to primary school in your in a sort of um compulsorily social situation um so i think that's how early it starts.

6:14Gina Rippon:And of course, it's much more simple at that stage, but it comes much more sophisticated as they get older. And if there is an autistic girl, maybe she has plenty of friends, maybe she gets good grades, maybe she is perfectly behaved. Can these manifestations, can these appearances, can that be a reason why she is missed? Because she doesn't perhaps fit some kind of stereotypical image that society has absolutely i mean and one of the realizations once people started actually asking questions about so why so few autistic girls and women were diagnosed um i mean there's all sorts of suggestions maybe they got a biological protective effect and then somebody said well let's have a look at the diagnosis um and they realized first of all the kind of behaviors that were part of the observational schedules all the questions that parents carers were asked etc um were based very much on boys um because that was that was the cohort that they've been developed on and so they realized they needed to ask different questions um and that was you know more than the yes no has she got friends yes then you need to ask a deeper question do you think she finds it difficult to make friends what what are the friendships like Are they very intense from her point of view?

7:35Gina Rippon:Does she have one special friend that she's quite demanding of? And then eventually because of that, the friendship breaks down. So you need to ask deeper questions. If you just ask, has she got friends? The answer could be yes, but there's more to it than that. And what happens when that girl reaches adolescence? I mean, does social complications make this more murky? Absolutely. Absolutely. I mean, I call it the perfect storm if you're female, adolescent and autistic. Going to secondary school, hitting adolescence, hitting puberty, it's just a triple whammy. In primary school, particularly the structure of primary school, things are quite predictable.

8:21Gina Rippon:The social rules are quite well established. You're in the same class with the same people, with the same teacher. you can build up a sort of scaffolding which allows you to keep disguising or your invisibility cloak, if you like, allows you to disguise the fact that you're really struggling. When you get to secondary school, all bets are off effectively. And that's very distressing because if you have been the child in primary school with friends and who does well, and there's a caveat to that, which I will come back to. And then you go to secondary school and all of a sudden there's these little friendship groups which form and then disperse, possibly within the space of a week.

9:07There's all sorts of individual identities.

9:11Gina Rippon:You're not just somebody's child or in somebody's classroom. You're supposed to be somebody who's heading towards your own individual identity. And if part of your identity has been hiding it, then that's quite challenging. and the whole business of adolescence and peer group approval, et cetera. I was going to say something about the child who behaves perfectly and always does well. Very often the story is that that's at school, in primary school, in public, and when they go home, that's when they have a complete meltdown, absolutely exhausted. But they've reached somewhere where hopefully they feel safe.

9:54Gina Rippon:and parents often will say the struggles they have with saying, I think my daughter is struggling, that school will say, oh, no, she's fine, you know, she's very quiet, but she's got friends and really good homework, et cetera. And the parents say, you know, when she gets home, you know, screams, shouts, head banging, door slamming, shutting herself in a room, et cetera, and clearly very unhappy. And you can see the school thinking, well, she's all right at school. Yes. That contradiction, Gina, between perhaps how a girl or a woman is in one setting, perhaps at a school or later on in life, perhaps the office, compared to how she might be behind closed doors, perhaps in a safer environment.

10:36What complications could that cause in her personal relationship?

10:40Gina Rippon:Oh, a lot. Partly because if you're struggling in public and then you might need to withdraw, you know, at the end of the day from the workplace or wherever. You might just think, just let me get through that door. I just can't cope anymore. So you shut yourself off. If there's kind of evening socialization, for example, when you're older, you don't join in because you are just exhausted. um and in order to maintain this sort of surface competence which allows you to be missed it's hugely exhausting and and when you look at the statistics the correlation between high levels of camouflaging and high levels of um mental illness distress uh depression anxiety suicidal ideation, but also physical problems like this kind of complete freezing when, you know, women report that having coped to a certain point in their lives, they suddenly find they can't get out of bed.

11:47Gina Rippon:They cannot physically move, motivate themselves because the system is just shut down. The concept of camouflaging is fascinating. I suppose following on from that to camouflage means that there is some shame that you're trying to hide, you're trying to blend in. What do you think autistic girls are made to feel like they need to hide? What part of them? I think the issue very much is with socialization. Girls are expected to be not to make any trouble, to have friends, to blend in, not to, you know, kick over the traces etc so there's that additional pressure um to be good but as a whole the whole human race really wants to belong we we know neuroscience has demonstrated the power of social rejection for example that the changes in the brain the changes in behavior uh the changes in in psychological well-being which are associated with social rejection and something about autistic girls means that the effect of social rejection is much more powerful.

12:57Gina Rippon:So they've got this huge drive not to be noticed as different, not to be called other or weird, to fit in. And those are the people I call the chameleons. Whereas another type of autism, which I call cannas, the canna type, most of whom are male um don't seem to have the concern about belonging or needing to fit in so of course they then develop the the traditionally stereotypical autistic behavior the aloof loner doesn't make either contact not interested in other people has absorbing hobbies which completely exclude other people etc um so i think it affects girls differently because maybe because of a kind of more powerful biological drive to fit in which would fit in with some of the evolutionary stories which I don't necessarily agree with but in a way if it is the case that there is a more powerful drive in females on average and a more powerful drive is an autistic female that social rejection affects you more that's a really profound struggle for anybody.

14:15Is it hard to camouflage and put on a version, a character around the people that you feel safest around? Because in many ways, they know your real self and they could probably see through the camouflage.

14:32Gina Rippon:That's a great question. And quite a lot of the personal testimonies of late diagnosed autistic women address that very issue because a lot of the time, particularly with early stages of relationships, they hide their differences because they want the relationship to be successful. And then as it carries on, they find it more and more difficult because they would like to reveal their real self, but they feel the relationship is based on the self they've presented. And it can be very challenging to make a relationship feel safe enough. But very often, if you spend a lot of time with somebody, even if you've become very good at camouflaging, there are hints which sensitive people will pick up on.

15:28Gina Rippon:Your sensory sensitivity is quite hard to hide. your need for routine, if that's how it presents, your need for things to stay the same. If your relationship involves, for example, moving in with somebody, then that almost invariably, unless they're the same, which is quite interesting, the person will feel that they're seeing another side to the person. Is there a risk that the partner of the autistic woman could end up resenting them a little bit because they might think, well, you're lovely to everyone else, but then you come home and you snap at me. And let's just say there isn't an awareness of autism in the relationship.

16:13Is that a possibility that they could get frustrated and feel like they're having the cold treatment?

16:20Gina Rippon:Well, I think that's where possibly a good therapist might come in. Or, you know, if the autistic woman was brave enough to say to this individual, I'm really sorry, things have to be like this because this is how it affects me. So they feel safe enough to reveal themselves to that individual, which hopefully will work, but sometimes doesn't. And then, of course, the next time that female is in another relationship, she might feel less secure about revealing herself. Which, of course, is even more exhausting because if you can't be yourself in front of somebody you're in a relationship with, it's very tiring.

17:03Yeah. In a relationship where there is an autistic woman, what happens when perhaps her need for predictability meets a spontaneous partner or children or a chaotic family life? Right. Can that cause huge issues?

17:19Gina Rippon:It can cause huge issues. And it takes a lot of negotiation, a lot of understanding from both sides, actually. I think sometimes people can feel everything has to be like this because that's how I am. So at some point there needs to be some understanding about compromise, which if you are kind of rigid thinker is quite tricky. So that's something. Children and the unpredictability of children can be very challenging. But very often, particularly if the autistic woman is a single mother, she can impose her need for routine, etc. And children are very insightful, actually, with autistic adults. They have a kind of understanding at one level of why somebody's like that.

18:21Gina Rippon:which isn't always matched by adults, unfortunately. I just want to zoom out for a second, Gina, because this I find super interesting, because I've met lots of autistic women, and some, I think, have an insight and an understanding that they're different, and they put a conscious effort into, like we said, camouflaging and altering who they are and trying to fit in. And then there are other autistic women that I've met who, at least from my point of view, don't have an internal desire to change who they are. They're just proudly themselves. They're authentic. What is the difference between an autistic person who has an insight into their differences and intentionally tries to change who they are to fit in and someone who doesn't?

19:11Gina Rippon:Gosh, great question again. I mean, I think the aim of a lot of all the discussions I've had with late diagnosed women is having got a diagnosis is part of the, you know, then there's, you know, the joy at finding my tribe, the grief of which they'd known about that for longer. But then there is the beginning of quite a long journey towards what they call their authentic self. So there is a feeling with the autistic community that you've been hiding, camouflaging your authentic self all your life and look at what it's done to you. So for your own good and your own well-being, then be upfront about being autistic.

19:54Gina Rippon:And of course, in most cases, the understanding of autism, autism awareness, autism acceptance is a great help because it allows you to be your autistic self. It allows you to be brave enough to say, you know, if we're all planning to go to the cinema in a couple of weeks time, please don't change anything unless you really, really have to, because that would really upset me. Don't ring up and say, shall we go to the afternoon show instead, et cetera, and hope that people will accommodate that. So that would be the person who is tricky, but worth the effort, if you like, you know, worth the effort to make them part of the group.

20:39Gina Rippon:the person who feels they have to camouflage at some level they might say well that's what I've done all my life and it means I haven't had as bad a time as perhaps my younger sister or somebody that you know and so they kind of feel the difficulties they have might be worth the struggles they have and I think at some point And there's a lot of interest in late diagnosed women or the emergence of problematic in inverted commas behavior with perimenopause, for example, where women will say, I've coped so far and it's worked, but now I can't. And that's the beginning of another long journey. is there a point where somebody who genuinely believes that they are coping uh has a complete collapse and everything falls down the scaffolding falls away yes i i think there there are and interestingly that the the work that's now emerging about the perimenopause is very often involves women successful women um high-powered women women who perhaps have been unusual in what they've been able to cope with but but they have been able to cope and then they effectively the metaphor often is hit a wall and very often it's associated with the perimenopause it's a bit like the transition from primary school to secondary school so you've managed so far as an adult but then some additional factor the hormonal straw if you like that breaks the camel's back And that can be quite profound because you're looking at somebody who for 40 or 50 years has been camouflaging, hiding, coping, achieving.

22:30Gina Rippon:And then all of a sudden, for no visible reason, you know, it's not as if they've had some terrible illness, although that may be part of it. Just can't cope anymore. And it's difficult for people to explain why. So the understanding about the effects of perimenopause on the emergence of autism is providing very interesting insights. What do you think the long-term risks are of camouflaging too much? Because I suppose camouflaging is another way of just saying you put other people's opinions, other people's wants and needs ahead of your own. And if you do that for long enough, surely you ultimately have no idea about who you are.

23:16Your identity is in shatters.

23:17Gina Rippon:Identity is a big issue with late diagnosed women. Identity and masking, because masking is another way of blending in where you present a completely different persona. You're not trying to fit in with everybody else. You might be the class clown that everybody laughs at or the sporting superstar or something. So you hide who you are so that they respect you they still think of you as different but they respect you as an achiever so that's a different way of coping um but yes i mean ongoing camouflaging the particularly with late diagnosed women one of the things that emerges is they haven't had you know life hasn't been um a picnic um they've had all sorts of mental health issues perhaps physical issues eating disorders self-harm etc um and then all of a sudden somebody says do you think you might be autistic and then you start to realize what you've been doing all your life or what people haven't seen um and and that can be that can be very challenging so we know because we now have quite well psychometrically reliable and valid measures of camouflaging you can look at the correlation between how how profound somebody's camouflaging is how much they camouflage with instances of anxiety disorders breakdowns burnouts physical other physical conditions as well and it's clear that camouflaging is very costly so that's interesting how do you measure how much someone's camouflaging um it used to be because in a way if you're a good camouflage you can't spot it yes and it was clear particularly with respect to looking at the standard traditional ways of measuring the gold standard autism tests where concerned clinicians were saying but you know i did an assessment on this girl and she scored way below the clinical threshold on all of the observational schedules for example so how how can i put that right um it and it used to be that you could you'd get a lot of self-report so somebody would say you know can you relax do you have lots of friends and they would say yes and then you would have a look at some of the sort of red flag type measures in in the autism schedule that you measures that you take and there would be a disconnect yes i i i'm you know completely relaxed in social situations and then some of the questions they were answering or people were answering about them in social situations there was a mismatch so that was the early measures this kind of disconnect but people like will mandy um a psychologist working with him at um ucl kcl um would have eventually devised uh um a questionnaires so you would say to him I mean, you would specifically ask them how they behaved in social situations.

26:19Gina Rippon:You wouldn't just observe it and say, they seem quite relaxed. You would actually ask them how they experienced it. And if they were not trying to continue their camouflaging, they would be upfront and say, actually, I find it really hard and this is how I deal with it. So you now have a very good metric of camouflaging, which we're starting to use in neuroimaging, for example. so you can put somebody in a situation a social situation you can get a measure of how they're dealing with that situation differently so parts of the frontal areas of the brain are much more much more activated when somebody is doing a lot of self-referencing when they're looking at you know how am i managing this situation it could be a cognitive task how well am i doing but if it's a social task so you can then get a measure to show how much this person is constantly monitoring their own role in the play that you're getting them to look at.

27:16The self-referencing, is that in real time as the social encounter is happening or is that after the event?

27:23Gina Rippon:Both. But in the scanning situations, it's while it's happening. So you've devised some online task, which is, or you can get them to imagine what it's like, But obviously, ideally, you'd get them to be in a situation, which is the kind of situation that you might have assessed in advance they find challenging. So you could do it in real time. But after the effect is very often to do with the kind of rumination that autistic women who find social situations challenging go through. They will replay the situation in their minds. And they will, when they said that, did they really mean that? Or when I responded that, should I actually respond to that?

28:09Gina Rippon:There is a lot of that. And that's part of the kind of, you know, after the event exhaustion, you can't switch off because the situation you've just come from, you think, maybe you think, oh, that went well, I must make sure I do that again. But you might think, hmm, that was really hard work. So sorry to interrupt your hyperfocus, but I promise it's worth it. Our sponsor is Timo, the best organizational tool for neurodivergent people. Timo wasn't named iPhone App of the Year in 2025 by Apple for no reason. It's the ultimate planning partner gently helping you turn the chaos in your head into a day that actually feels doable.

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29:53Gina Rippon:Yes, absolutely. I mean, I think, you know, as we know, and as certainly I'm coming to confront large numbers of women who've been diagnosed with autism, particularly late, are also then thinking, I don't quite fit this picture, but I do, some of my characteristics are more like ADHD. And of course, until 2013, you couldn't have both. You could only have one or the other. great diagnostician decisions there. So now you can have both. There's quite a lot of people who have both. And there is an emerging movement about ADHD where people say, actually, and this is where sometimes it may reveal the problems with diagnosis or it may reveal the apparently rigid categories that autism and ADHD are in.

30:48Gina Rippon:People will say, I've got both. and then there should be a third category, ADHD. And it may be DSM-6 is being written as we speak. So it may be that ADHD becomes a category. Maybe autism, I don't think, will stay as a spectrum. um and ADHD may again not be so rigid in terms of how it's defined so there may be a blending um yeah if they do if autism you don't think will stay as a spectrum what do you think it will turn into in terms of the diagnostic criteria and the cutoff point for reaching an assess a diagnosis Yeah, well, I think they're sort of halfway house. I mean, I actually think there are big problems with the way we slap categories on hugely overlapping areas of behavior.