Autism, Discrimination and Masking: Disrupting a Recipe for Trauma

Abstract Outcomes of discrimination for autistic people include masking, social isolation and exclusion, trauma, and mental health problems. This discursive paper discusses the discrimination experienced by autistic people in health, education, employment, and media settings; and considers how to reduce the impact of discrimination. Addressing the impact of discrimination requires an improved understanding of the lived experience of the autistic person, the embedding of inclusive practices in communities, developing the person’s life skills and supports, and enabling the person to work through their psychological trauma. Further research can aid in minimizing and preventing discrimination against people with autism.

Most people are neurotypical and consider the neurotypical interaction style as the norm (Lawson, 2020).Autistic people are in the minority, so their interaction style is perceived as different and less socially acceptable (Alkhaldi et al., 2019;Grossman et al., 2019).Consequently, many autistic people seek to achieve neurotypical standards and acceptance (Ai et al., 2022).Achieving such standards can also reduce the power imbalance against autism, a result of its minority status; and decrease the social stigma, self-stigma, and discrimination often associated with autism (Sasson et al., 2017).
People with autism may encounter various experiences of discrimination.For example, tertiary students with autism who, after disclosing their diagnosis, report being refused practical placements because of an unwillingness to accommodate autism or other disabilities in practice-based settings (Sullivan, 2021).Autistic people may be unable to attain employment because autistic traits, such as a lack of eye contact, can be viewed as a poor cultural fit in job interviews (Gonzales, 2022).Once employed, people with autism may experience bullying, including the weaponizing of autistic traits by colleagues (e.g.deliberate use of loud noises by colleagues to upset the autistic person) (Praslova, 2021).
Both the experiences and outcomes of discriminatory behaviors and practices for autistic people are challenging.For example, many autistic people attempt to reduce the risk of social isolation, bullying, or discrimination through masking or camouflaging, which carry negative effects, including lack of self-acceptance and feelings of disassociation (Hull et al., 2017).Psychological trauma is another outcome of discrimination and bullying, which may contribute to the higher incidence of mental health disorders in autistic people when compared to non-autistic people (Chapman, 2020;Cleary et al., 2023).
This discursive paper brings together various facets of autism to the social discrimination experienced by autistic people and the impact of this discrimination, including psychological trauma.The paper aims to support practitioners, including mental health nurses, to develop a deeper understanding of the issues faced by people with autism, and to consider how to identify, minimize and prevent social discrimination and the associated psychological trauma.Practical suggestions to achieve change are provided, together with recommendations for the future, with a view to better supporting the person with autism to live their life to the fullest.

The experience of discrimination
Discrimination is the unfair, unequal, or unfavorable treatment of people who are disadvantaged by those who are advantaged; thus, it disproportionately affects minority groups (Gaston & Jackson, 2022).Discrimination can be either through direct and intentional acts, such as denying rights under the law; or indirect and often unintentional acts, including a lack of accessibility to buildings or events (Australian Institute of Health & Welfare, 2022).Discrimination feeds into inequities across various social and physiological areas, such as health outcomes, poor sleep, poor diet, and cardiovascular disease (Duran & Pérez-Stable, 2019;Panza et al., 2019;Slopen et al., 2016).Discrimination can also lead to lower self-esteem, feelings of powerlessness, anger, or sadness (Bhui, 2016), and poor mental health (Wallace et al., 2016).
While autistic traits can be a catalyst for discrimination, the experience only becomes discriminatory when a lack of societal acceptance of these traits fuels exclusion and creates disadvantage (Chapman, 2020).Negative attitudes toward autistic people, which are the precursor for discrimination, are quick and widespread, with neurotypical people taking as little as 10 seconds of exposure to an autistic person's social behavior to decide the person is not neuro-normative and therefore 'different' (Sasson et al., 2017).Of concern are findings of a 2018 study of 111 autistic adults, which found that only 7% believed society accepted them, and 43% reporting they were not accepted (Cage et al., 2018).
Discrimination and discriminatory practices do not stand in isolation.They are often coupled with experiences of bullying (Maïano et al., 2016), physical or verbal violence (Jeanneret et al., 2022), social exclusion, and even threatening behavior and sexual harassment and assault (Cooperative Institutional Research Program at the Higher Education Research Institute at UCLA, 2019).Moreover, discrimination is strongly linked to the concept of stigma.
While social discrimination is generally understood as an action of one person against another, stigma can be viewed as the attitudes or feelings that are created through or driving these actions.Stigma was once considered an individualized discrediting attribute that reduced a person from the usual to the discounted (Goffman, 1963).However, modern interpretations pay greater heed to the social forces that shape and drive stigma, including power imbalances between the stigmatizer and the stigmatized (Link & Phelan, 2001).Those with social power create the association between a label (e.g.'autism') and a negative stereotype, resulting in a status loss for the stigmatized (Han et al., 2022).This feeling of stigma can become so pervasive and ingrained that it is internalized by the stigmatized person, becoming a 'self-stigma' that prevents them from overcoming discrimination.
Discrimination and stigma can be found in all areas of social interaction between autistic people and the neurotypical majority, including health care, education, employment, and recruitment.Discrimination and stigma are further exacerbated or minimized by influences such as the language used in media and societal or organizational responses to this language.

Discrimination in healthcare
There are often-high levels of interaction between autistic people and the health system, largely due to their increased rates of physiological and psychological comorbidities.Even so, discrimination can be found in the processes that support autistic people to access health care, and the responses of health professionals.A 2022 report from the World Health Organization (WHO) noted that in low and middle-income countries, four to 15% of people with a disability live in institutional settings, often against the wishes of the individual or family.The experiences of autistic people in these settings can be intolerable (WHO, 2022).Recent data from Australia found that of all people over 15 years with a disability, 29% experienced problems accessing hospitals and other health services (Australian Institute of Health & Welfare, 2022).The consequence of direct or indirect forms of health care discrimination can be an avoidance of these services and facilities by the autistic person, with 25% of people 15-64 years who experienced disability discrimination by health professionals going on to avoid medical facilities (Australian Institute of Health & Welfare, 2022).Another consequence of discrimination in health care and/or health inequalities is earlier death (WHO, 2022), with autistic people dying on average 12 years earlier than the general population (Christou et al., 2016).
Discrimination by the health system and staff is often the result of a lack of knowledge and skills relating to various disabilities, including autism (WHO, 2022).A survey in the United States found that only 41.8% of doctors felt very confident about their capacity to provide quality care to people with a disability (Iezzoni et al., 2021).Negative attitudes and beliefs about people with autism are another common underlying cause of discrimination, with a recent global evidence synthesis finding health professionals knowingly or subconsciously carry societal beliefs into their practice (Rotenberg et al., 2022).This lack of confidence or negative attitudes can lead to communication barriers that impede the person from expressing their needs or discriminatory practices, ranging from negative assumptions (Pearson et al., 2022) to refusal of service (Lagu et al., 2022).

Discrimination in education
Research has consistently found discrimination across all levels of education.Discrimination can take the form of refusal of enrolment, expulsion from the school, removal from the class setting to another location, suspension from school, exclusion from educational activities, or refusal to make reasonable adjustments to accommodate an autistic person's needs (WHO, 2022).At its worst, there have been instances of autistic students being locked inside a small room by teachers to provide 'time out' (9News, 2015) and, in one instance, even being locked inside a cage during times the autistic student exhibited extreme distress (McLaughlin & Grant, 2016).
As children, autistic students are more likely to encounter stigmatization, resulting in higher levels of social exclusion, reduced social interactions and less time spent in collaborative activities with their peers, as found in a recent systematic review (Morris et al., 2021).This, in turn, leads to fewer quality friendships.Post-school, autistic students are less than half as likely to proceed to further education (Australian Bureau of Statistics, 2018).
Likewise, another systematic review reported that for college and/or university students, experiences of discrimination, bullying and harassment impact the college/university experience, including retention (Anderson et al., 2019).This is even more pronounced when autistic people straddle multiple minority identities-for example, gender, ethnicity, or sexual orientation (Hillier et al., 2020).However, while social rejection is one experience of discrimination for autistic people (Jackson et al., 2018), a recent nationwide survey in the USA has counterintuitively pointed to more participation in campus-facilitated events as increasing experiences of discrimination (Kim et al., 2022), as the number of social interactions increases the opportunity for discrimination.
Where education overlaps with employment preparation, particularly through practical placements for tertiary students in areas such as teaching or nursing, autistic students can encounter corporate ableism.This attitude describes the treatment of people with disabilities by organizations or corporations based on the belief that neurotypical people make better employees.Qualitative research across undergraduate degrees (e.g.policing, teaching, journalism, social work, psychology) identified a number of autistic students being refused placements after disclosure of their diagnosis, early termination of placements when the diagnosis was noted, and negative stereotyping of the level of ability and supervisory needs of autistic students (Sullivan, 2021).Such scenarios can be exacerbated by a seeming lack of collaboration between the university and the organization providing the placement, leading to missed opportunities to discuss, understand, and prepare for the students' specific needs and abilities in advance.Even more concerning was the discussion of deliberate strategies used by organizations to justify their decision to refuse a placement without opening themselves up to an allegation of discrimination (e.g. as citing timeframe impediments) (Sullivan, 2021).

Discrimination in employment
Participation in employment amongst autistic people is consistently at lower levels than neurotypical counterparts.In Australia for example, the participation rate was 38% for autistic people of working age and 84.1% for those with no disability; in contrast, the unemployment rate for autistic people was eight times those with no disability (Australian Bureau of Statistics, 2018).The participation rate was even lower in places like the United Kingdom (UK) at 29% for autistic people compared to 81.6% for working-age non-disabled people (Office of National Statistics, 2022).
Recruitment exists as a crucial barrier between autistic people and employment.A survey in the UK in 2020 found that 50% of respondents would not employ someone who was neurodiverse in any way (Fair Play Talks, 2020).This attitude was evident despite research suggesting autistic people make fewer errors in their employment and are 90 to 140% more productive than neurotypical employees (Waldmeir, 2020).Case studies highlight autistic people applying for 'hundreds' of jobs and participating in 'dozens' of interviews only to be stymied by a recruitment process that heavily favors the neurotypical personality (Praslova, 2021).The findings of a broad-scale survey in the United Kingdom indicate that employers display preferences for employing non-autistic candidates over autistic candidates (Davies et al., 2023).Rather than a process that assesses the fit between the role and an applicant's skill, interviewers may be concerned by an absence of eye contact, unusual vocal intonation, stimming behaviors, or difficulty identifying social cues, which may have very little to do with job performance (Gonzales, 2022).
When autistic people successfully move into employment, there can be impediments to disclosing their autism diagnosis.For example, autistic employees who participated in a phenomenological study expressed anxiety that the workplace reflects an overarching intolerance of difference (Sullivan, 2021).The stereotyping of autistic people persists, with one survey-based study finding perceptions that they are low-functioning, unempathetic, and problematic, complicating the process of disclosure (Atherton et al., 2022).Where disclosure does occur, a recent social media study has found autistic people are moved on or have their conditions altered to make it difficult for them to continue working, leading to their resignation (Mantzalas et al., 2022).To avoid recognition and subsequent stigma, autistic people indicated in a social media study that they may avoid stimming behaviors in the workplace, which can create adverse outcomes for those who use this strategy as a self-soothing mechanism (Radulski, 2022).

Discrimination in the media
The media are highly influential in shaping opinions, and promoting or dispelling stereotypes.Choice of language and veracity of information are two ways the media can help or hinder the reception and acceptance of autistic people across the multiple spheres previously discussed.With one cross-sectional survey pointing to media organizations as the most utilized sources of information on autism (Jacoby et al., 2019), it is necessary to ensure that the language used and information circulated is credible, accurate, and conducive to positive outcomes.Yet a recent analysis of over 1350 news articles published in Australia over a three-year period found a medium-to-high level of negative depictions of autism in 36% of the articles, compared to only 26% having medium to high positive portrayals (Baroutsis et al., 2023).
Negative depictions of autism in the media are numerous.A recent news content analysis found these depictions to include: high costs to taxpayers to fund interventions for autistic people; referring to autistic people as 'helpless' , 'victims' , or 'naïve'; removing autistic children from mainstream education; autism being used as a defence against criminal behavior; violence perpetrated by autistic offenders; and linking autism to aggression and violence (Baroutsis et al., 2023).Alternatively, when autism was represented positively, and autistic people were involved in content creation or used celebrity disclosure, the results were increased anti-stigma (Akhtar et al., 2022;Calhoun & Gold, 2020;Hoffner & Cohen, 2018).

Masking
Avoiding discrimination is a primary concern for many autistic people.The negative effects of social exclusion and the need for belonging can be critical drivers of such avoidance.One avoidance strategy used by people with autism that is extensively covered in research is camouflaging or masking.Masking involves the autistic person making deliberate efforts to disguise their visible autistic traits and simultaneously augmenting traits acceptable in a neuro-normative society (Ai et al., 2022;Goffman, 1959).Masking can also be adopted and deployed unconsciously, meaning the authentic self is suppressed without insight (Chapman, 2020).Pearson and Rose (2021), through a conceptual analysis of autistic masking, move beyond the definition of masking as a strategy of avoidance by suggesting it is a trauma response from the lived experience of stigma, while others consider masking a response to oppressive societal attitudes (Ai et al., 2022), born from a desire for survival (Lawson, 2020).In addition to avoiding discrimination and social exclusion, the other motivators for masking can come from a need to feel safe, a feeling of shame, and the need for social acceptance and connection (Chapman, 2020).
While autistic people often use masking to minimize the negative impact of discrimination, the masking itself can have serious consequences.For example, autistic burnout, which can result from the effort required to maintain masking for extended periods, is detrimental to mental health, quality of life (Cage et al., 2018;Mantzalas et al., 2022), and self-worth (Lilley et al., 2022).Other consequences of masking can include depression, anxiety, social disconnectedness, and suicidality (Chapman, 2020).Masking in the workplace increases feelings of inauthenticity and emotional exhaustion (Bernardin et al., 2021), and its use in social media is linked to depression, stress, and anxiety (Mun & Kim, 2021).Persistent masking leads to reduced physical stamina and executive functioning in people who already carry the burden of limited self-regulatory resources (Higgins et al., 2021;Raymaker et al., 2020).
Masking can also produce internalized stigma, sometimes known as self-stigma (Botha & Frost, 2020); a sense of having betrayed the autistic community (Hull et al., 2017); and a reduced ability to maintain appropriate boundaries (Evans, 2022).A lack of appropriate boundaries creates further vulnerability and a possible self-perpetuating cycle of trauma, begetting masking, begetting trauma.Another concern is that many autistic people did not positively influence first impressions by masking, despite their beliefs to the contrary, which suggests their masking was ineffective and/or they lacked insight into this lack of effectiveness (Belcher et al., 2022).Yet, removing the act of masking is complex and can contribute to burnout through sudden exposure to any or increased levels of resultant discrimination and stigma (Mantzalas et al., 2022;Miller et al., 2021;Pearson & Rose, 2021).

The experience of psychological trauma
The experience of social discrimination, with or without masking, can leave the person vulnerable to traumatization.Psychological trauma can occur when a person experiences an event or incident perceived as threatening, resulting in immediate, delayed or even longer-term impacts on their functioning (Kerns et al., 2015).The experience and symptoms of trauma are subjective (Peterson et al., 2019), meaning one person might be minimally affected by an action or event while another person with the same experience can become traumatized.
The psychological trauma experienced by an autistic person can be a different experience from that of the neurotypical population.For example, the experience of social discrimination for an autistic person can be solitary.While people who share a minority trait with their families or communities (e.g.racial minorities) can find identity and build resilience within their group, the autistic person may be the only one in their family or friendship circle (Botha & Gillespie-Lynch, 2022).Moreover, as an outcome of their autism, they may feel unable to join a support group.Of concern are findings from a cross-sectional online survey of autistic people found over 51% of respondents had high rates of psychological distress; with some reporting family member were negative and/or harmful; or work colleagues were similarly negative and/or harmful (Jeanneret et al., 2022).
People with autism are already more susceptible than the general population to trauma due to a heightened risk of bullying (Rai et al., 2018), victimization, and sexual abuse (Sevlever et al., 2013).Other susceptibilities include the difficulties experienced by some autistic people with language, processing information, emotional regulation, social isolation (Brenner et al., 2018;Kerns et al., 2015), and correctly interpreting non-verbal cues (Peterson et al., 2019).There is also the heightened risk of trauma resulting from adverse childhood events-experiencing trauma early in life can impact neurodevelopment and increase the risk of mental health disorders at a later life stage (Gruhn & Compas, 2020).
In a review of extant findings, autistic people were found to be at an increased risk of experiencing adverse childhood events (Hoover & Kaufman, 2018).These adverse childhood events can manifest into intrusive thoughts, distressing memories, lethargy, and loss of interest more profound than those who may have autism but no history of such trauma (Brenner et al., 2018).Conversely, some people are not diagnosed with autism until later in life, when they are dealing with trauma that has not been acknowledged or understood in the context of a diagnosis (Atherton et al., 2022).Such circumstances may further traumatize the person, who will be faced with the challenge of processing their diagnosis and what it means for them, in addition to processing the trauma they have experienced as a result of delayed treatment.

How can we address the issues?
There is a need to understand the issues and effects of discrimination, masking, and trauma to enable positive change for autistic people.Strategies to minimize or prevent risks and harms can be achieved at any point along the continuum between discriminatory actions and long-term trauma.These strategies include changing attitudes and language, boosting inclusivity, building skills, providing support, and promoting balance.

Changing attitudes and language
Changing societal attitudes to reduce the likelihood of social discrimination and psychological trauma experienced by people with autism requires broad-scale strategies.One of the most effective ways to achieve increases in the contact between the neurotypical and the neurodivergent is to promote open communication and improve understanding of autism and its lived experience (Cleary et al., 2022;2023).
The essence of what it means to be autistic has undergone a transformation in recent times.Autism advocates have reframed the social discourse on autism from one informed by notions of disorder to one shaped by social identity (Kapp, 2020).This transformation suggests that the notion of autism is evolving to generate an understanding that the condition is less an impairment that requires a cure and more an experience of some people when interacting socially (Botha & Gillespie-Lynch, 2022).Neurodiversity is promoted as an invaluable part of societal progress (Bailin, 2019).
In the past, many autistic people have been told by health professionals, educators, and even parents that they must try to appear neurotypical (Chapman, 2020;Ghanouni & Quirke, 2023).Attitudinal change can support autistic people to be themselves and thereby achieve positive results for all.Acceptance of neurodiversity requires society to relinquish the firmly held mindset that difference or otherness is undesirable (Ghanouni & Quirke, 2023).
A key strategy to assist attitudinal change is using awareness campaigns and language.Campaigns such as the #TakeTheMaskOff movement challenge the medical view of autism and instead promote awareness of the negative impacts of masking (Radulski, 2022).The Time to Change program in the UK is another example of awareness raising that aims to reduce stigma by changing how autism is represented in the media (Rhydderch et al., 2016;Thornicroft et al., 2022).Reductions in the use of language that infantilises autistic people or portrayals of the autistic person as unemotional have been achieved (Praslova, 2021).

Inclusivity
The simple concept of feeling included has been shown to act as a buffer against the adverse effects of social discrimination against minority groups (Hurtado et al., 2015).This concept can reasonably be extrapolated to include autistic people (Kim et al., 2022).Genuine inclusivity involves acceptance, the opportunity to participate in quality experiences, achievement or progress in skills, and the prevention of segregation (Morris et al., 2021).The potential of inclusivity to positively impact autistic people highlights the need to adopt programs and interventions that extend beyond the autistic population to apply across workplaces, campuses, and communities (Kim et al., 2022;Morris et al., 2021).Where a workplace or campus culture promotes and sustains inclusivity, research has shown colleagues, peers, and teachers to be supportive, inclusive, and desirous of learning more about autism and an autistic person's support needs (Kim et al., 2022;Sullivan, 2021).

Building skills
Building skills to protect against discrimination and subsequent trauma can assist the autistic population, and shape the environment where discrimination occurs.For example, teaching autistic children how to respond positively to subjective and objective experiences of social isolation can be achieved by challenging the maladaptive social cognition of the autistic person (Ma et al., 2020).Likewise, it is important to improve social skills through involvement in friendship or family psychoeducational programs, enhancing social support through peer support programmes, and increasing opportunities for autistic people to have social contact with neurotypical peers (Masi et al., 2011).
In educational settings, the concept of 'habit of mind' is particularly protective for autistic students against the likelihood of harassment (a more severe form of discrimination) (Kim et al., 2022) and can be an effective tool for preparing autistic people for educational readiness.Developing a good habit of mind involves thinking through the situation when facing a problem or engaging in behavioral habits that support effective learning (Costa & Kallick, 2008).Additionally, a good habit of mind can be achieved through problem-solving, analyzing multiple sources of information, accepting mistakes as a part of the learning process and can lead to increased educational outcomes (Costa & Kallick, 2008); and improving social skills and addressing challenging behaviors (Burgess, 2012).
Skills are equally crucial to those interacting with autistic people.Teachers and faculty staff have indicated a lack of preparedness for working with autistic students and knowledge to effectively support them (Zeedyk et al., 2019).Likewise, health professionals have expressed a lack of training and knowledge to deal with the needs of autistic patients, often resulting in inadequate service provision (Camm-Crosbie et al., 2019;Crane et al., 2019;Maddox et al., 2020).Health professionals can acquire knowledge of autism through clinical experience and on-the-job training; access to experienced colleagues and good-quality autism research are also as necessary sources to improve the knowledge and skills needed to support autistic people (Urbanowicz et al., 2020).With better access to targeted autism training and skills development for teachers, clinicians, and hiring managers, knowledge and support can follow, thereby minimizing discriminatory practices.

Support
Support of autistic people by other autistic people, employers, educators, mentors, health professionals, service providers, and friends can all positively impact an autistic person.This positive impact can buffer against the effects of discrimination and resulting trauma.Research has recommended strategies, including providing autistic employees with job coaching to improve employment opportunities (Gonzales, 2022); consulting others before determining appropriate methods of feedback (Sullivan, 2021); providing support services to newly diagnosed adults on the possible effects of masking (Atherton et al., 2022); and advising on how to manage traumatic events (Kimhi & Eshel, 2015).
Also necessary the support provided by health professionals.For example, autistic people with psychological trauma are best supported with trauma-informed care adapted to meet their specific needs (Benevides et al., 2020;Faccini & Allely, 2021).Such needs include understanding the role of bullying and discrimination in developing psychological trauma and how the health professional can support the autistic person to feel safe (Allely & Faccini, 2020).

Balance
Two studies discussed the need for many autistic people to balance their authentic selves and their masked self (Mantzalas et al., 2022;Radulski, 2022).Masking may still be necessary for autistic people to achieve goals and protect themselves against stigma.However, some autistic people learn the importance of dropping the mask when surrounded by those they trust in environments safe to do so.This simple strategy alleviates the pervasive nature of masking.It allows that person to reduce the subsequent risk of autistic burnout and greater susceptibility to traumatization.The #TakeTheMaskOff campaign (Hancock, 2020) was premised on this notion and allowed autistic people to support one another by building an online community.

Implications for health professionals and mental health nurses
Autistic people, like neurotypical people, will become unwell and seek health care.With higher risk factors for developing mental illness, autistic people will likely present to mental health services for help.In light of the stigma, social discrimination, and psychological trauma experienced by many autistic people in health care and other institutional settings, there is a need for health professionals, including mental health nurses, to critically reflect on the issues involved.Such consideration may focus on how to adapt practice to improve the support they provide to people with autism.Questions to guide the critical reflection must include: • What practical steps can health professionals take to reduce the traumatic experiences of people with autism in health settings?What is the role of trauma-informed care when supporting autistic people?How can trauma-informed care be adapted to meet the needs of people with autism, and their families?• How can health professionals develop a greater understanding and acceptance of people with autism, including the traumatic incidents or events they may have experienced, such as bullying, discrimination, and the role of masking?• What skills development does the health professional need to enable the autistic person to manage their symptoms and achieve recovery?
Such critical reflection will enable health professionals, including mental health nurses, to reduce the adverse outcomes of masking and discrimination against autistic people, including social isolation and exclusion, psychological trauma, and mental health problems.

Strengths and limitations of review
This paper discusses the need for and benefits in responding positively to the interrelated issues of autism, discrimination, and masking.The paper also provides a range of strategies and solutions to support autistic people to achieve the best possible outcomes, but is not without limitations.
The first limitation is the acknowledgement that not all studies and reviews included in this discussion are equal in terms of their veracity and comprehensiveness.A range of papers, including systematic reviews, social media analyses and primary research studies, were integrated to provide a broad understanding of current thought in the focus area.The knowledge drawn from the papers must be considered in the context of the methodology, sampling, and rigor of the paper.
A second limitation is the limited scope of the discussion.Many issues that are relevant to autism, discrimination, and masking could not be included for brevity's sake.For example, masking is not unique to neurodiverse people, with neurotypical populations also masking a range of behaviors in social situations.Comparisons between the characteristics of masking between neurotypical and neurodiverse people would require its own paper.
Nevertheless, when discussing ways to improve the balance between autism, discrimination, and masking to minimize their harmful impacts, this paper identifies a range of high-level strategies and thoughts.Building upon these strategies to make them specific to and implementable by mental health nurses would benefit autistic people further and is highly recommended as a consideration for future research.
Another strength of the paper is the use of language that reflects the preferences of neurodiverse people.The recent Guidelines for respectful and accurate reporting on autism and autistic people by autism advocacy group Amaze (n.d.) outlined the way in which language can be used when describing the experiences of autistic people.Their preference for the use of identity-first language (autistic person) has been respected and used throughout the paper, thus empowering autistic people to control the discourse around their diagnoses and experiences.

Conclusion and future directions
The analysis of the experience of social discrimination by autistic people in this paper demonstrates connections between stigma, social discrimination, masking, and psychological trauma.Addressing these issues would help to address adverse outcomes of the experience of social discrimination for autistic people, and give rise to positive change.Recommendations for change to support autistic people at the practice-based level in the education, employment, and health care sectors are important.Nevertheless, there remains a lack of a comprehensive, over-arching strategy to protect autistic people from broader discriminatory practices and the psychological trauma these broader can engender.
Changing the attitude of society at large to reduce stigma and promote autism as a social identity and an equally valid way of being, can remove the problematic mindsets and assumptions that support overt and even subconscious acts of discrimination.Removing these mindsets would provide a flow-on effect whereby masking is not considered necessary, discrimination is not readily experienced, and autistic people are less traumatized.
More work is required to achieve these outcomes.Further research can aid in designing and implementing over-arching strategies aimed at removing and preventing discrimination.This research is needed in several key areas, including the experience of disclosure of their diagnosis by autistic people and how masking is affected by disclosure.Providing autistic people, employers, and other stakeholders with a framework around how to safely disclose an autism diagnosis and how to respond to and support people following this disclosure is a first step toward removing a potential trigger for stigma, discrimination, and trauma.Another reason research is needed is to deepen understanding of masking and how the behavior can impact mental health.Such research would aim to enable the development of strategies to remove the need for masking, raise awareness about the potential harms of masking, and reduce the likelihood of autistic burnout.
Further along the harm reduction continuum lies the need for ongoing research into the autistic person's experience of trauma, including the clinical manifestations of trauma in autistic people and differences with the neurotypical population.Such research would allow for the implementation of more autistic-specific, trauma-informed interventions and the development of valid and reliable self-reporting measures to evaluate the experience of trauma.Current interventions to treat the consequences of trauma can often be unsuitable for autistic populations.However, many of interventions could be adapted to autism-specific requirements, including trauma-informed cognitive behavioral therapy, and symptom management (Peterson et al., 2019).
Research in these areas could fill knowledge gaps and contribute to the design of many connected and overlapping strategies to reduce discrimination and stigma.Additionally, the ultimate goal of removing a key source of psychological trauma for autistic people may be achieved.This outcome could reduce a significant burden for those faced with lifelong adversity and help to build a culture of greater understanding, acceptance, and inclusivity to support people with autism.