Understanding camouflaging, stigma, and mental health for autistic people in Japan

doi:10.21203/rs.3.rs-2614748/v2

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Research Article

Understanding camouflaging, stigma, and mental health for autistic people in Japan

https://doi.org/10.21203/rs.3.rs-2614748/v2

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Background: Camouflaging refers to behaviors in which autistic individuals hide their autistic characteristics and “pass” as non-autistic people. It is postulated that camouflaging is a response to stigma, and preliminary evidence supports this hypothesis. However, there has been limited research on this topic outside of Western countries. This study sought to replicate and extend previous work examining the relationships between camouflaging, stigma, and mental health in Japanese autistic people.

Methods: Two hundred eighty seven autistic people living in Japan completed an online survey on camouflaging, perceived stigma, individualistic and collective strategies, mental wellbeing, anxiety, social anxiety, and depression. We used multiple regression analysis, mediation analyses, and two-sample t-tests to analyze the collected data.

Results: We found that higher camouflaging was predicted by higher perceived stigma and more individualistic and collective strategy use. Camouflaging mediates the association of stigma with depression, anxiety, and social anxiety (but not wellbeing). Furthermore, autistic people in Japan reported lower perceived stigma, camouflaging, wellbeing, and collective strategy use but more individualistic strategies than those in a Western sample.

Conclusion: Our findings support the hypothesis that camouflaging is a response to stigma and can influence the impact of stigma on mental health. There are also cross-cultural differences worth attending to, and more work around supporting positive autistic identity in Japan would be beneficial.

Psychology

Autism

Camouflaging

Stigma

Social Identity Theory

Mental health

Japan

Why is this an important issue?

Social camouflaging is a behavior in which autistic individuals hide their autistic characteristics and “pass” as non-autistic people. While camouflaging can help autistic individuals adapt to non-autistic society, it also causes extreme fatigue, depression, and anxiety. To reduce these negative effects, we must identify the reasons why autistic people camouflage. In 2021, Perry et al. surveyed Western autistic people and showed that camouflaging might be a strategy to avoid autism-related stigma. However, it is unclear whether their findings apply to autistic people worldwide.

What was the purpose of this study?

This study examines whether Perry et al.’s results also apply to autistic people in Japan and whether perceived stigma, camouflaging, mental health, and coping strategies in the West differs from those in Japan.

What did the researchers do?

The researchers surveyed 287 autistic adults residing in Japan about perceived stigma, camouflaging, mental health, and their coping strategies. Then, the researchers examined whether perceived stigma affects the extent to which autistic people camouflage. They also investigated the role camouflaging plays in how stigma affects autistic people’s mental health. Finally, they compared perceived stigma, camouflaging, mental health, and coping strategies in the West with that in Japan.

What were the results of the study?

This study found the following:

(1) The higher the perceived stigma, the higher the extent of camouflaging.

(2) Autistic people who try to distance from the autistic community are more likely to camouflage. Those with stronger autistic identity and stronger pride in the autistic community are also likely to camouflage.

(3) By encouraging camouflaging, stigma causes depression, anxiety, and social anxiety. It also impairs autistic individuals’ mental wellbeing, but camouflaging has no role in it.

(4) Autistic people in Japan perceive lower stigma, camouflage less, and have poorer mental wellbeing than those in the West. While responding to stigma, autistic people in Japan tend to dissociate from the autistic community rather than advocating for it.

What do these findings add to what was already known?

Autistic people in Japan camouflage to avoid autism-related stigma, just like those in the West. However, autistic people in the West and Japan differ in all other aspects, that is, perceived stigma, camouflaging, wellbeing, and coping strategies.

What are potential weaknesses in the study?

This study surveyed autistic people only once. Therefore, it could not prove that stigma directly triggers camouflaging. How will these findings help autistic adults now or in the future?

These findings show that it is importance to reduce autism-related stigma and create an environment in which autistic people can openly reveal their identity.

Autistic people have specific styles of social communication and interaction and focused and repetitive patterns of behavior, interests, or activities.¹ They often experience mental health problems,² with the lifetime prevalence of mental health conditions being 79%, much higher than that in non-autistic people (41%).^3,4 Over the past few years, several studies have asserted social camouflaging as a risk factor for the mental health of autistic people.^5–9 Social camouflaging refers to behaviors in which autistic people conceal their social differences to get by in a majorly neurotypical world,^8,10 but such behaviors are not restricted to autistic people only.^11,12 For autistic people, camouflaging includes several types of behaviors, such as masking autistic behaviors like repetitive hand movements, learning social cues from TV programs, movies, and books, and assimilating with non-autistic people by forcing interaction.^13,14

On the surface, camouflaging may help autistic people adapt to non-autistic society.^5,8,15 However, this comes at considerable cost.¹⁶ Qualitative studies have described how camouflaging leads to fatigue, burnout, a sense of falsifying their identity, and feelings of “false relationships” with others.^5,8 Quantitative studies have shown associations between camouflaging and depression, generalized anxiety, social anxiety, and suicidality.^6,7 Additionally, camouflaging makes autistic traits harder to recognize and may prevent autistic people from receiving a timely diagnosis.^17,18

Autistic people have described that they camouflage to maintain friendships, obtain jobs or qualifications, and avoid embarrassment or awkwardness.^8,19 In other words, camouflaging might be a strategy to avoid autism-related stigma. Autistic people have long been socially stigmatized, being labeled as “dangerous and unstable,” “unloved,” or “introverted and withdrawn.”^20–22 Further, non-autistic people have more negative first impressions of autistic people and show attitudes of dehumanization.^23,24 Autistic people might therefore camouflage to avoid these stigmas and negative evaluations.

Several studies have asserted that social camouflaging is a response to stigma,^24,25 but it has rarely been examined quantitatively. Perry et al.⁹ quantitatively investigated the relationship between autism-related stigma and camouflaging using social identity theory (SIT).²⁶ Social identity is one’s perception of the social group one belongs to. SIT proposes that people are motivated to create, maintain, and protect the positivity of their social identity to maintain positive self-esteem.²⁷ When a group is stigmatized, and the self-esteem of in-group members is threatened, they may adopt two different coping strategies.

Those who use “collective strategies” seek to restore the positive social identity, redefining the stigmatized group as valuable and centrally defining aspects of identity.²⁸ They resist social norms and values underpinning stigma²⁹ and try to improve the in-group’s status by restructuring oppressive cultural and structural systems (e.g., by participating in social movements).³⁰ In contrast, those who use “individualistic strategies” try to hide, minimize, or overcome stigmatized characteristics and move from stigmatized in-group to a higher status out-group.²⁸

Of the two strategies, using individualistic strategies seems similar to camouflaging. If camouflaging is highly related to using individualistic strategies (a response to stigma), one can infer that perceived stigma facilitates camouflaging. Perry et al.⁹ examined the relationship between stigma, individualistic strategies, collective strategies, and camouflaging. Further, they proposed that camouflaging mediates the relationship between stigma and autistic people’s mental wellbeing, considering the idea that camouflaging is a response to stigma. This hypothesis was based on Botha and Frost’s³¹ proposition that stigma severely impacts autistic individuals’ mental wellbeing and is associated with lower quality of life and lower self-esteem.^31,32 Botha and Frost³¹ interpreted these negative effects of stigma within the framework of the minority stress model. The model proposes that people with minority identities are exposed to higher stress burdens, such as stigma or lack of social support, resulting in greater physical and mental health problems.³³ While the minority stress model posits a direct negative impact of stigma, Perry et al.’s⁹ hypothesis suggests that indirect pathways exist that affect autistic people’s mental wellbeing.

Perry et al.⁹ conducted an online survey of 223 autistic adults. Multiple regressions showed that perceived stigma positively predicts camouflaging, supporting the hypothesis that camouflaging is a response to stigma. As for strategy use, individualistic strategy use positively predicted camouflaging, suggesting that the two are highly related. However, collective strategy use, which may seem to be the opposite of individualistic strategies, also positively predicted camouflaging. Contrary to the hypothesis, camouflaging did not mediate the relationship between stigma and mental wellbeing. The mediation of camouflaging between stigma and mental health warrants further investigation by considering other aspects of mental health, including depression, generalized anxiety, and social anxiety, which have been shown to relate to camouflaging.⁷

While Perry et al.’s⁹ study is meaningful as the first study to interpret camouflaging in the framework of SIT, it has some limitations. One of these is the regional, racial, and ethnic bias of the participants. Most were Caucasians living in the UK or North America, almost none living in Asian countries. Since social-cultural factors differ between Asia and the West, the style in which autistic people react to stigma may also differ. In East Asia, people emphasize “inter-dependence”; they respect cooperation with others and avoid rejection by not disturbing the harmony of the group.^34,35 In such environments, people try to find their faults that do not conform to others’ expectations and correct them to achieve self-fulfillment.³⁶ In Western countries, “independence” is respected, where the self is considered a unique reality separate from others.³⁵ Under such a self-view, people find attributes to be proud of in themselves and try to gain self-esteem by expressing them outwardly.³⁶

Although there are certain criticisms of perceiving national characteristics in this way,^37,38 it is possible that the response to stigma may differ between Asian and Western countries. Indeed, autism-related stigma varies by region, with autistic people in Asian countries more stigmatized than those in Western countries.^39–41 Therefore, it is meaningful to verify whether Perry et al.’s⁹ results are replicated in Japan, where the experience and response to stigma could differ, and whether the level of stigma, camouflaging, and coping strategies used by autistic people are different.

Thus, this study is a quasi-replication of Perry et al.⁹ that verifies whether their results are replicated in Japan. We also re-examined the mediation of camouflaging, adding several different mental health questionnaires to the one they used. Lastly, we examined differences between Japan and the UK in the perception of stigma, camouflaging, mental wellbeing, and individualistic or collective strategies used by autistic people. We hypothesized that: (1) perceived stigma positively relates to camouflaging, (2) both individualistic and collective strategy use positively relate to camouflaging, (3) camouflaging mediates the impact of stigma on autistic people’s mental health (mental wellbeing, depression, generalized anxiety, and social anxiety), and (4) perceived stigma, camouflaging, strategy use, and mental wellbeing differ significantly between Japan and Perry et al.’s⁹ Western sample.

Participants

Individuals who had been diagnosed as autistic by psychiatrists according to the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) were eligible to participate. Those who had received the diagnosis from someone other than a psychiatrist or had self-diagnosed were excluded. We also excluded participants who scored below the cut-off on the Japanese version of the Autism-Spectrum Quotient 10-item short version (AQ-J-10; n = 163 excluded).⁴² Resultingly, there were 287 participants.

To recruit participants, we sent one email newsletter to individuals who belonged to a private firm’s research panel and another to individuals registered with a support facility that helped autistic people find employment. We recruited participants and collected data between January and March 2022. Informed consent was obtained from all participants, and this study was approved by the Research Ethics Committee at Chiba University (Reference No: M10319).

Of the participants, 146, 120, and 14 identified as men, women, and non-binary, respectively. Five participants used other terminologies to describe their gender, and two preferred not to disclose. Participants’ ages ranged between 20 and 63 (Mean(M) = 37.5, Standard Deviation(SD) = 9.8), and their age at diagnosis ranged from 0 to 48 years (M = 12.2, SD = 9.8). Most participants (280) reported being Asian, followed by those who reported being White (4), Hispanic (1), mixed race (1), and other ethnicities (1). Regarding the highest level of education, most participants had a bachelor’s degree from a four-year college (136), followed by those who had a middle or high school diploma (73), a technical or junior college degree (38), other educational backgrounds (28), and a master's degree or doctorate (12). All participants resided in Japan, and 177 were employed at the time of participation.

Materials And Procedure

Potential participants accessed the research website and were screened if they were eligible for the study. The questionnaires were presented in the order mentioned below. Those who scored below the cut-off on the AQ-J-10 did not complete the questionnaires after that point. When scales had to be translated, the Japanese version was back-translated and verified by native English speakers.

Demographic Information

Participants first provided their demographic information, including their age, age at diagnosis, gender, ethnicity, residency, highest level of education, and employment status.

Autism-spectrum Quotient 10-item Short Version (Aq-j-10)

The AQ-J-10 is a short version of the Autism Quotient, which quantifies autistic traits.^42,43 Participants rated 10 items, such as “I prefer to do things with others rather than on my own,” on a 4-point Likert scale. The total score could range between 0 and 10, and higher scores indicated higher autistic traits. We could not calculate Cronbach’s α in this study because participants with total scores below the cutoff were excluded.

Patient Health Questionnaire-9 - Japanese Version

The Patient Health Questionnaire-9 (PHQ-9)⁴⁴ is a 9-item, self-administered measure to assess depressive symptoms in the past two weeks. Participants rated each item (e.g., “Little interest or pleasure in doing things”) on a Likert scale of 0 (Not at all) to 3 (Nearly every day). The total score could range from 0 to 27, with higher scores suggesting more depressive symptoms. Ten is the threshold for the presence of major depressive disorder.⁴⁴ We used the PHQ-9 Japanese version Muramatsu et al.⁴⁵ developed. We had good internal consistency (α = 0.867).

Generalized Anxiety Disorder-7 - Japanese Version

The General Anxiety Disorder-7 (GAD-7)⁴⁶ comprises seven items related to generalized anxiety symptoms. Participants rated items such as “Feeling nervous, anxious, or on edge” on the same Likert scale as the PHQ-9. Total scores could range from 0 to 21, with 10 as the cutoff for the presence of generalized anxiety disorder. We used the Japanese version of the GAD-7⁴⁷. We had good internal consistency (α = 0.899).

Liebowitz Social Anxiety Scale - Japanese Version

The Liebowitz Social Anxiety Scale (LSAS)⁴⁸ is a self-reported measure of social anxiety symptoms over the past week. It comprises 24 items related to the fear/anxiety and avoidance of various social situations. The items are scored on a 4-point Likert scale. The total scores could range between 0 and 144, and higher scores suggested more social anxiety. Asakura et al.⁴⁹ developed and validated the Japanese version. We had excellent internal consistency (α = 0.972).

Camouflaging Autistic Traits Questionnaire - Japanese Version

This 25-item measure was designed to quantify camouflaging for autistic people.¹⁴ Items were rated on a 7-point scale (strongly disagree to strongly agree). An example item was “While interacting socially, I use behaviors that I have learned from watching other people interact.” The total scores could range from 25 to 175. Those with higher scores camouflaged more. Hongo et al.’s⁵⁰ Japanese version was reliable and valid, and we had good internal consistency (α = 0.888).

Warwick-edinburgh Mental Wellbeing Scale - Japanese Version

Participants’ mental wellbeing was assessed using the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), which has 14 items.⁵¹ Participants rated items such as “I've been feeling relaxed” on a 5-point Likert scale ranging from “none of the time” to “all of the time.” The total scores could be between 14 and 70, with higher scores suggesting more positive mental wellbeing. We used the WEMWBS’s Japanese version that Suganuma et al.⁵² developed and had excellent internal consistency (α = 0.905).

Stigma Consciousness Scale

The stigma consciousness scale comprised five items related to perceived stigma⁵³ adapted by Perry et al.⁹ for autistic people. Participants rated items including “Stereotypes about autistic people have not affected me personally” (reversed item) and “Most people do not judge someone based on their being autistic”(reversed) on a Likert scale of 0 (strongly disagree) to 3 (strongly agree). The total score could be between 0 to 15, and higher scores indicated a stronger consciousness of social stigma. Since there was no Japanese version of this scale, we translated it into Japanese and had moderate internal consistency (α = 0.606).

Individualistic Strategy Use

We translated the 13-item scale of individualistic strategy use²⁸ adapted for autistic people.⁹ Participants reported the extent to which they agreed with each item on a 7-point Likert scale. Example items included “I try to hide my autistic traits from others in certain situations” and “I don’t think of myself as an autistic person.” The total score could be between 13 and 91, and those with higher scores used individualistic strategies more frequently. We had poor internal consistency (α = 0.598).

Collective Strategy Use

We modified and translated the collective strategy use scale²⁸ into Japanese.⁹ The scale comprised 13 items related to pride in the autistic community, “I have a lot of pride in the autistic community,” or social change activism, “I am an autistic rights activist.” Each item was rated on a 7-point agreement scale, with total scores ranging from 13 to 91. Those who scored high used collective strategies more frequently. We had excellent internal consistency (α = 0.905).

Design And Data Analysis

Being a quasi-replication of Perry et al.’s⁹ study, this study has a cross-sectional correlational design. We performed all statistical analyses using SPSS statistics version 28.0 and mediation analyses using PROCESS add-on version 3.3.⁵⁴ For multiple regressions, we created two dummy codes for gender: “male versus female” and “male versus non-binary.” We set male as the reference category and coded it as zero because most participants identified as male.

To test hypothesis one, we performed a multiple regression analysis with camouflaging as the dependent variable and stigma and demographic variables (gender, age, age at diagnosis, and autistic traits) as independent variables. We controlled demographic variables that have been known to be related to camouflaging.⁵⁵ We tested hypothesis two by performing a multiple regression analysis with camouflaging as the dependent variable. We entered demographic variables as above and individualistic and collective strategy use as independent variables. To test hypothesis three, we used four mediation models. In all models, stigma was the independent variable, and camouflaging was the mediating variable. The dependent variables were mental wellbeing (Model 1), depression (Model 2), generalized anxiety (Model 3), and social anxiety (Model 4). To test hypothesis four, we used two-sample t-tests for summary data and compared each measure’s mean total score in our study with that in Perry et al.’s⁹ study. However, we could not directly compare these because Perry et al.⁹ assessed autistic traits using different scales. Moreover, Perry et al.⁹ did not assess depression, generalized anxiety, and social anxiety; thus, comparisons could not be made.

We considered two-tailed p values of 0.05 as significant and 95% confidence intervals (CI) as appropriate. Using G*power and referring to the effect size in Perry et al.’s⁹ study, the adequate sample size for multiple regression analyses (f^༒=0.06, α = 0.05, 1-β = 0.80) was 234. The VIF was between 1.05 and 3.61 for multiple regressions, indicating no multicollinearity. All variables used in the analysis were normally distributed with skewness and kurtosis in the range of -2 to 2.⁵⁶ The results of Leven’s tests showed that all the variables were homogenous. For mediation analyses also, variables were normally distributed and homoscedastic. Furthermore, no missing values existed.

The average, SD, range, kurtosis, and skewness of all variables are presented below (Table 1). The correlation matrix is also presented (Supplementary Table 1).

Table 1

Mean, standard deviation, range, kurtosis, and skewness of all variables
	Mean (SD)	Range	Skewness	Kurtosis
Age	37.52(9.81)	20–63	-0.49	0.63
Age at diagnosis	31.80 (12.19)	1–60	-0.13	-0.48
WEMWBS	34.71 (10.10)	14–62	0.26	-0.23
PHQ-9	14.42 (6.54)	0–27	-0.05	-0.74
GAD-7	10.70(7.57)	0–21	-0.02	-1.03
LSAS	80.48 (34.43)	0-144	-0.41	-0.44
AQ-J-10	8.47 (1.05)	7–10	0.10	-1.17
Collective strategy use	39.70 (15.31)	13–83	0.25	-0.37
Individualistic strategy use	50.17 (9.10)	19–74	-0.49	0.63
Stigma consciousness scale	8.48 (2.68)	0–15	-0.43	0.46
CATQ	110.86 (22.36)	47–173	-0.28	0.09
SD: standard deviation; WEMWBS: Warwick-Edinburgh Mental Wellbeing Scale; PHQ-9: Patient Health Questionnaire-9 GAD-7: Generalized Anxiety Disorder-7; LSAS: Liebowitz Social Anxiety Scale AQ-J-10: Autism-Spectrum Quotient 10-item short version; CATQ: Camouflaging Autistic Traits Questionnaire

[Insert Table 1 here]

Stigma And Camouflaging

The results of multiple regression analysis are presented below (Table 2). Stigma was a significant predictor of camouflaging; greater stigma scores suggested greater camouflaging. Moreover, identifying as female or non-binary, age, and age at diagnosis significantly predicted camouflaging.

Table 2

Regression model testing the relationship between stigma and camouflaging
Variable	B	B Cl	SE B	β	p
Age	-0.59	[-1.05, -0.12]	0.24	-0.26	0.014
Age at diagnosis	0.39	[0.02, 0.76]	0.19	0.21	0.038
Male versus female	11.28	[6.31, 16.22]	2.52	0.25	< 0.001
Male versus non-binary	14.23	[2.71, 16.22]	5.85	0.14	0.016
Autistic characteristics	0.32	[-2.03, 2.67]	1.19	0.02	0.787
Stigma	2.43	[1.51, 3.35]	0.47	0.29	< 0.001
B: unstandardized partial regression coefficient; B Cl: two-sided 95% confidence intervals; SE B: standard error β: standardized partial regression coefficient; F = 9.6; df (6,280); p < 0.001; R² = 0.172

[Insert Table 2]

Camouflaging And Strategy Use

The results of multiple regression analysis are presented below (Table 3). Greater individual and collective strategy use and identifying female or non-binary were significant predictors of more camouflaging.

Table 3

Regression model testing the relationship between individualistic strategy use, collective strategy use and camouflaging
Variable	B	B Cl	SE B	β	p
Age	-0.40	[-0.89, 0.06]	0.23	-0.18	0.087
Age at diagnosis	0.359	[-0.003, 0.73]	0.19	0.20	0.052
Male versus female	10.533	[5.17, 15.02]	2.50	0.22	< 0.001
Male versus non-binary	17.386	[6.73, 29.65]	5.82	0.18	0.002
Autistic characteristics	2.247	[-0.07, 4.58]	1.18	0.11	0.058
Individualistic strategies	0.841	[0.55, 1.10]	0.14	0.34	< 0.001
Collective strategies	0.189	[0.04, 0.36]	0.08	0.14	0.017
B: unstandardized partial regression coefficient; B Cl: two-sided 95% confidence intervals; SE B: standard error β: standardized partial regression coefficient; F = 9.6; df (7,279); p < 0.001; R² = 0.173

[Insert Table 3]

Camouflaging, Stigma, And The Mental Health Of Autistic People

Regarding Model 1 (stigma, camouflaging, and mental wellbeing), the total effect was significant (b=-1.08, t (285) = 23.0, p < 0.001). The path between stigma and camouflaging was significant (b = 2.35, t(285) = 4.95, p < 0.001), but the path between camouflaging and wellbeing was not (b= -0.001, t(284)=-0.05 p = 0.96). The direct effect was significant(b=-1.08, t(284)= -4.81, p < 0.001, but there was no significant indirect effect, with 95% CI including zero (0.67 to -0.13). Thus, stigma affected autistic people’s mental wellbeing directly, and camouflaging did not mediate this relationship. Furthermore, camouflaging did not affect mental wellbeing significantly.

Regarding Model 2 (stigma, camouflaging, and depression), the total effect was significant (b = 0.46, t(285) = 3.20, p < 0.001). The direct effect was not significant(b = 0.28, t(284) = 1.96, p = 0.05), while the indirect effect was significant with 95% CI of 0.06–0.07. Thus, camouflaging mediated the relationship between stigma and depression completely.

Regarding Model 3 (stigma, camouflaging, and generalized anxiety), mediation analyses showed a significant total effect (b = 0.54, t(285) = 4.36, p < 0.001). The direct effect was also significant(b = 0.35, t(284) = 2.89, p = 0.004). The indirect effect was significant with 95% CI of 0.05 to 0.09. Thus, camouflaging partially mediated the relationship between stigma and generalized anxiety.

Regarding Model 4 (stigma, camouflaging, and social anxiety), the total effect was significant (b = 3.72, t(285) = 5.10, p < 0.001). The direct effect was also significant(b = 2.89, t(284) = 3.90, p < 0.01). The indirect effect was significant with 95% CI of 0.29–0.32. Thus, camouflaging partially mediated the effect of stigma on social anxiety.

Supplementary Figs. 1A–1D present the mediation diagram of each model.

Comparisons Between Japan And The Uk

The results of two sample t-tests of summary data are presented below (Table 4). All variables differed significantly between the Japanese and Western sample. Participants in our study perceived less stigma, camouflaged less, had more negative mental wellbeing and used more individualistic strategies but fewer collective strategies than Western participants.⁹

Table 4

Differences in means of each score between the Japanese and Western sample
	Japan^*		UK^**
	(n = 287)		(n = 223)								95% CI
	M	SD	M	SD	t-value	Df	P	Mean difference	SE difference	d	Lower	Upper
WEMWBS	34.71	10.10	39.07	9.56	-4.95	508.00	< 0.001	-4.36	0.88	0.44	-6.09	-2.63
Collective strategy use	39.70	15.31	64.96	13.40	-18.74	508.00	< 0.001	-24.26	1.30	1.74	-27.80	-22.72
Individualistic strategy use	50.17	9.10	44.74	10.77	6.17	508.00	< 0.001	5.43	0.88	0.55	3.70	7.16
Stigma consciousness scale	8.48	2.68	10.61	2.48	-9.21	508.00	< 0.001	-2.13	0.23	0.82	-2.58	-1.68
CATQ	110.86	22.36	126.65	21.79	-8.00	508.00	< 0.001	-15.79	1.97	0.71	-19.66	-11.92
Japan: participants in this study; * UK: participants in Perry et al.’s (2021) study M: Mean; SD: Standard deviation; df: Degrees of freedom; SE: Standard error; d: Cohen’s d; CI: confidence intervals WEMWBS: Warwick-Edinburgh Mental Wellbeing Scale; CATQ: Camouflaging Autistic Traits Questionnaire

[Insert Table 4 here]

This study examined the relationship between stigma, camouflaging, and the mental health of Japanese autistic people using the framework of SIT. Replicating Perry et al.’s⁹ study, we found that higher perceived stigma contributed to more camouflaging, and both individualistic and collective strategy use positively predicted greater camouflaging. Camouflaging did not mediate the relationship between stigma and mental wellbeing, but it mediated the relationships between stigma and depression, generalized anxiety, and social anxiety. Compared with a Western sample, autistic people in Japan perceived less stigma, had lower levels of camouflaging and mental wellbeing, and were more likely to use individualistic strategies but less likely to use collective strategies.

Our findings further support the hypothesis that camouflaging is a response to stigma. In perceiving stigma, autistic people are motivated to camouflage and avoid bullying, abuse, or rejection by others.^5,15,57 This finding aligns with Perry et al.’s⁹ study and previous discussions.^24,25 The fact that stigma facilitates camouflaging is of great importance. Often, support available for autistic individuals is based on the biomedical model and focuses on reducing "maladaptive behaviors” by intervening with being autistic.^58,59 On the contrary, the findings of this study support the view of the social model, which considers the difficulties of people with disability to be due to mismatches between their characteristics and the environment.⁶⁰ To reduce the negative effects of camouflaging, it is essential to create societies where autistic people are accepted as they are and not forced to become “less autistic.”

We also found that individualistic strategy use was a positive predictor of camouflaging, supporting the hypothesis that camouflaging is highly related to individualistic strategies and a response to stigma.

Further, collective strategy use, a concept that theoretically opposes individualistic strategy use, also positively predicted camouflaging. In other words, people with a strong and positive autistic identity were more likely to use camouflaging. This finding aligned with Perry et al.’s⁹ finding, although partial regression coefficient in our sample (0.14) was relatively smaller than that in the Western sample (0.25). Further study is required to determine why collective strategy use positively predicted camouflaging, but one possibility is the “double bind” in which autistic people are caught. For example, using mediation analysis, Cage & Troxell-Whitman⁶¹ showed that higher autistic identity contributed to less camouflaging via autistic individuals disclosing their diagnosis. However, when disclosure was controlled for, higher autistic identity directly increased camouflaging. This competitive mediation suggests that people with higher autistic identity have a dilemma; they want to disclose their diagnosis and stop camouflaging, but it is hard to do so. Cage and Troxell-Whitman⁶¹ cited fear of stigma as a reason they cannot stop camouflaging.

Disclosure of autistic status may lead to further stigma³¹ and negative labeling.²² In an environment where it is not safe to disclose an autistic diagnosis, autistic people may have no choice but to continue to camouflage, even if they are proud of being autistic.

In this study, perceived stigma was significantly and negatively related to mental wellbeing, depression, generalized anxiety, and social anxiety for autistic people. Moreover, camouflaging mediated the relationship of stigma with depression, generalized anxiety, and social anxiety completely and partially. This suggests that an indirect pathway exists in which stigma impairs autistic people’s mental health, although stigma also directly affects generalized anxiety and social anxiety. These findings offer a new perspective on interpreting mental health problems in autistic individuals, supporting the minority stress model.³¹

On the contrary, as in Perry et al.’s⁹ study, we found that camouflaging did not mediate the relationship between stigma and mental wellbeing. Moreover, camouflaging did not affect mental wellbeing significantly in our analyses. This may be because wellbeing is a broader and more general concept that includes positive feelings, life satisfaction, autonomy, good relationships with others, and positive self-esteem.^62,63 Qualitative studies have suggested that camouflaging links to a sense of career accomplishment, good relationships with colleagues and friends, and pride in masking skills^5,15,56 while contributing to depression and exhaustion,^5,7 thus undermining any perceived “successful camouflaging” and off-setting any possible benefits of masking.¹⁶ Additionally, we used a standardized measure of wellbeing which may not fully capture autistic-specific aspects of wellbeing, which may differ to neuro-normative conceptualizations.⁶⁴ Therefore, the relationship between subjective wellbeing and camouflaging is likely complex and requires further investigation.

Finally, comparing scores on each scale in the Japanese and Western sample, we found that autistic people in Japan perceived less stigma than those in Western countries. This finding contradicts previous research showing that Asians have higher stigma toward autistic people than Westerners.^39,40,41 However, it should be noted that we did not study the level of public stigma, but rather autistic people’s perception of being stigmatized by others.⁶⁵ In a previous study on stigma against mental illness, Australians showed less personal stigma toward people with mental illness than Japanese people but higher perceived stigma.⁶⁶ In other words, levels of public and perceived stigma can differ. Griffiths et al.⁶⁶ speculated that people were more aware of the problem of discrimination against mental illness in Australia, where a large-scale anti-stigma campaign⁶⁷ had been conducted. Similarly, among Perry et al.’s⁹ sample of people in the UK and North America, there may be more awareness regarding neurodiversity, neurominorities, and autistic advocacy.⁶⁸ Therefore, autistic people there might be more sensitive to stigma than Japanese autistic people, which may explain the higher stigma consciousness.

Next, autistic people in Japan reported less camouflaging than those in Perry et al.’s⁹ sample. Considering the hypothesis that perceived stigma facilitates camouflaging, it is understandable that Japanese participants with less perceived stigma had lower scores of camouflaging. However, it could also be that Japanese autistic people might camouflage in a different style. Most of the research on camouflaging has been conducted in Western countries, and the CAT-Q was also developed in the UK.¹⁴ Autistic people in Japan might have shown lower scores because of specific styles of camouflaging, such as “over adaptation,” which the CAT-Q does not evaluate well.

Over adaptation is an attitude in which an individual attempts to conform to the demands and expectations of the environment in a near-perfect manner, suppressing their personal demands.⁶⁹ It is a widely known concept in Japan. There are several reports that Japanese autistic individuals are prone to over adaptation,^70,71 and others have shown the similarity between camouflaging and over adaptation.^72,73 Over adaptation includes concepts similar to compensation and assimilation, such as “biting off more than one can chew so as not to be looked down upon” and “suppressing oneself so as not to be left out.” It also includes unique concepts, such as greater desire for evaluation (e.g., feeling uncomfortable unless an individual receives a higher evaluation than others), compulsiveness (e.g., putting work first at the expense of something else), and hesitation in seeking help (e.g., trying to do everything on their own without support).⁷⁴ Japanese autistic people might attempt to avoid negative evaluations from society by obtaining positive evaluations such as “good grades” or “always doing a job carefully.”⁷⁰ Further research is needed on whether to include these concepts in the concept of camouflaging.

Third, autistic people in Japan tended to adopt fewer collective strategies and more individualistic strategies than those in Western countries.⁹ Several studies have shown that, generally, in-group members with strong group identity (a sense of belonging or pride in a group) are more committed to the group and less likely to “seek asylum” in other.^28,75 Group identity is fostered by interactions with other members of the in-group,⁷⁶ and the same is true for autistic people; online and offline interactions with other autistic individuals promote a sense of belonging.^63,77,78 In Japan, autistic people have few opportunities to interact with each other, and autistic-led communities, like Autscape, have only just begun to emerge. Thus, this could explain the use of fewer collective strategies in our sample. Notably, collective strategy use was associated with more positive mental wellbeing and lower levels of depression, generalized anxiety, and social anxiety, while individualistic strategy use was correlated with poorer mental health. Therefore, it is important to ensure that Japanese autistic people have opportunities to interact with each other and consider being autistic a positive part of their identity.

Finally, autistic people in Japan have poorer mental wellbeing and lower level of perceived stigma than those in the UK.⁹ It is possible that differences in response to stigma had some influence on the differences in wellbeing; autistic people in Japan are less likely to adopt collective strategies which contribute to protecting mental wellbeing. However, as mentioned earlier, various factors influence wellbeing, and different cultures emphasize different aspects of wellbeing.^79,80

Limitations

This study had several limitations. First, it had a cross-sectional design, and we could not clarify causal relationships between variables. There are criticisms that most studies on camouflaging are cross-sectional,^81–84 and some studies suggest reverse causality between some variables (e.g. pre-existing anxiety may promote camouflaging; camouflaging reaffirms the stigma that autistic characteristics must be hidden).^83,85 To resolve this limitation of cross-sectional studies, longitudinal studies assessing perceived stigma, camouflaging, and mental health of autistic individuals are needed.

Second, the participants in our study differed from those in Perry et al.’s⁹ study in terms of age, age at diagnosis, gender, and educational background. Age, age at diagnosis, and gender have been known to be associated with camouflaging.^8,18,86,87 Moreover, gender⁸⁸ or life stage⁸⁹ affects the sense of wellbeing . In our sample, most participants identified as men, and participants were slightly older and diagnosed later than those in Perry et al.’s⁹ sample. Therefore, these differing factors may have confounded some of our results when comparing the two samples, although we did control for gender, age, and age at diagnosis in our multiple regression analyses.

Third, several questionnaires we used (stigma consciousness scale, individualistic strategy use, and collective strategy use) had not been validated and standardized in Japan. Although several native speakers had confirmed the translation’s accuracy, these questionnaires may not correctly assess Japanese people’s perceived stigma and levels of strategy use. Particularly, terms such as “Autistic community” or “Autistic culture” in the Collective Strategy Use scale are less familiar to Japanese people and may have been difficult to understand. We hope these questionnaires are translated into Japanese in the future and questionnaires unique to Japanese autistic people developed.

Finally, examining the impact of camouflaging on mental health, we focused on camouflaging behavior itself and did not consider how autistic individuals perceive camouflaging. Some autistic individuals might consider camouflaging simply a skill for survival, and camouflage consciously. They might camouflage only in certain situations, such as job interviews, and be themselves around people who accept their autistic characteristics. In that case, negative effects of camouflaging would be relatively mild. However, for those who believe that they must be “normal” and camouflage unknowingly, camouflaging would have significant impacts. They might mask their characteristics at every turn, even with their families. Researchers have just began studying how perceived camouflaging influences the impact of camouflaging,⁵⁶ and further quantitative research is needed.

This study replicated Perry et al.’s⁹ findings. It showed that camouflaging is a response to stigma among Japanese autistic adults. Beyond replication, it also showed that camouflaging mediates the association of stigma with depression, generalized anxiety, and social anxiety. Furthermore, the level of stigma consciousness and camouflaging and the strategies autistic people employ in dealing with stigma are different in Japan. These findings show how stigma is deeply problematic for autistic people worldwide and highlight the importance of focusing on the social environment to reduce the negative effects of camouflaging.

Acknowledgments

We would like to thank Editage (www.editage.com) for English language editing.

Author contribution statement

Masaki Tamura: Conceptualization (equal); Methodology (lead); Resources (lead); Investigation (lead); Formal analysis (lead); Writing–original draft (lead). Eilidh Cage: Conceptualization (equal); Methodology (equal); Writing-Review and Editing (equal). Ella Perry: Conceptualization (lead); Methodology (equal); Resource (supporting); Writing-Review and Editing (equal). Minako Hongo: Writing-Review and Editing (equal). Mikuko Seto: Resource (equal). Toru Takahashi: Formal analysis (equal). Eiji Shimizu: Writing-Review and Editing (supporting). Fumiyo Oshima: Funding acquisition (lead); Methodology (equal); Project administration (lead); Writing-Review and Editing (lead).

Competing interests: The authors declare none.

Funding: This research was funded by External Fund Acquisition Promotion Program of Chiba University for Fumiyo Oshima (Reference No: 430A11).

Ethics Approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Research Ethics Committee of Chiba University (Reference No: M10319).

Consent: All participants provided informed consent.

Data Availability: The data used in this study is available from the corresponding author upon reasonable request.

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Understanding camouflaging, stigma, and mental health for autistic people in Japan

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Abstract

Community Brief

Introduction

Methods

Participants

Materials And Procedure

Demographic Information

Autism-spectrum Quotient 10-item Short Version (Aq-j-10)

Patient Health Questionnaire-9 - Japanese Version

Generalized Anxiety Disorder-7 - Japanese Version

Liebowitz Social Anxiety Scale - Japanese Version

Camouflaging Autistic Traits Questionnaire - Japanese Version

Warwick-edinburgh Mental Wellbeing Scale - Japanese Version

Stigma Consciousness Scale

Individualistic Strategy Use

Collective Strategy Use

Design And Data Analysis

Results

Stigma And Camouflaging

Camouflaging And Strategy Use

Camouflaging, Stigma, And The Mental Health Of Autistic People

Comparisons Between Japan And The Uk

Discussion

Conclusion

Declarations

References

Supplementary Files

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