Response

Critchley and colleagues make a compelling and timely case for embedding neurodevelopmental formulation across psychiatric practice, describing the under-recognition of neurodivergence in psychiatry as the ‘elephant in the room’. ^{Reference Critchley, Minnis, Gajwani, Green, Dew and Dale1} We write to name two prior, and perhaps larger, ‘elephants’: the autistic psychiatrists already in the room, largely unrecognised – both by themselves and by the profession – and the shame that keeps them invisible.

Our qualitative study of autistic psychiatrists found that, before self-recognition, shared characteristics between clinician and patient acted as a confounder rather than an aid to diagnosis. ^{Reference Doherty, Chown, Martin and Shaw2} Participants reported missing autistic patients precisely because they assumed that their own experiences were universal. One participant captured this with precision: ‘If we don’t recognise ourselves as autistic how on earth can we diagnose patients accurately?’ Following self-recognition, all reported markedly improved recognition of autistic patients. ^{Reference Doherty, Chown, Martin and Shaw2}

Critchley et al call for neurodivergent voices to be included at all levels of service design and delivery, describing them as ‘a largely untapped resource’.¹ Nonetheless, their own declaration of interest notes only that ‘the authorship includes neurodivergent individuals’ – collective, anonymous, unattributable. This is not a criticism of the authors, who may have sound personal reasons for this approach. It illustrates the cultural conditions that the profession has created: even those arguing for neurodivergent inclusion find individual disclosure professionally unsafe.

We are not arguing that autistic psychiatrists have any obligation to disclose. Recognition of one’s neurotype is a private matter, and disclosure carries documented professional risk. ^{Reference Doherty, Johnson and Buckley3,Reference Shaw, Fossi, Carravallah, Rabenstein, Ross and Doherty4} The right to privacy is not in question. What warrants examination at a structural level is why disclosure remains so rare even among those best positioned to model it – and what that invisibility costs patients.

The costs of this invisibility extend into clinical training in a specific and underappreciated way. Autistic psychiatrists who teach about autism – without disclosing their own identity – risk transmitting their masked presentation as an implicit example of what autism does not look like. Learners observe their trainer’s mannerisms, speech patterns and communication style and, in the absence of disclosure, may code these as neurotypical. This confounder is thereby transmitted to the next generation of clinicians. The consequence is miscalibrated pattern recognition: patients presenting similarly to an unrecognised autistic trainer risk being missed. Disclosure, by contrast, provides learners with a correctly coded reference point – one that may, in a future clinical encounter, mean the difference between recognition and another missed diagnosis. For autistic people, late or missed diagnosis is not merely a clinical gap – it is a pathway to the psychiatric deterioration, crisis presentations and excess mortality that the editorial seeks to prevent. It precludes the primary prevention of mental ill health that timely, accurate recognition makes possible. ^{Reference Shaw, Doherty, McCowan and Eccles5}

Shame, our second ‘elephant’ appears to be the mechanism that sustains this invisibility. ^{Reference Davidoff6,Reference Doherty, Chown, Martin, Grosjean and Chaplin7} It operates pre-emptively, driving concealment and persists even when the individual intellectually rejects deficit framings of autism. ^{Reference Doherty8} Shame does not operate alone: the professional risks of disclosure – to reputation, to career, to collegial relationships – compound its effects, creating a multilayered structural disincentive to acknowledge an autistic identity. When autistic psychiatrists – particularly those in neurodevelopmental services – cannot safely be visible, they cannot disrupt the diagnostic stereotypes that cause patients to be missed. Shame among clinicians is a driver of the very cycle of late recognition and crisis-driven care that the editorial describes.

The perpetuation of stigma through professional silence warrants examination at a societal level. Goffman described those who learn late in life that they have always had a concealable stigma – a group he termed the discreditable – as facing a particular burden of self-disapproval, having internalised the norms of the group from which they are now separated. ^{Reference Goffman9} For autistic psychiatrists who recognise themselves late, as our participants did, this burden is compounded: the stigma they have absorbed is their own profession’s stigma, directed at an identity they have always embodied. Disclosure does not merely involve sharing information: it moves the individual from Goffman’s discreditable to the discredited group – from stigma concealed to stigma known – a threshold whose psychological cost should not be minimised. ^{Reference Goffman9} Nevertheless, the consequences of collective concealment extend beyond the individual. Goffman observed that those who conceal a stigma are motivated to suppress its visibility in others who share it, preferring a tacit agreement that it – in this case, autism – goes unacknowledged. ^{Reference Goffman9}

Applied to psychiatric training and practice, this dynamic takes on particular clinical significance: the autistic psychiatrist who is passing as not autistic is not a neutral presence in the room, but one with powerful incentives to keep autism invisible. One autistic psychiatrist described reluctance to give an autism diagnosis to a patient who reminded him of himself, asking ‘what did that say about me?’ ^{Reference Doherty, Chown, Martin and Shaw2} Clinicians and advocates who build careers arguing for neurodivergent acceptance, while remaining anonymously autistic themselves, do not simply exercise a right to privacy – they transmit, through their own concealment, the message that the stigma is real and the risk of naming autism is too great, even among the most professionally secure. The shame cycle is not merely sustained – it is actively performed by those best positioned to interrupt it. ^{Reference Doherty, Chown, Martin, Grosjean and Chaplin7}

This dynamic is legible in the language of the field itself. ‘Neurodivergent’ has become the term of choice in psychiatric discourse – including in the editorial to which we respond, and in its declaration of interest. ^{Reference Critchley, Minnis, Gajwani, Green, Dew and Dale1} We do not use it uncritically here. Within psychiatry, neurodivergence encompasses a hierarchy of stigma: attention-deficit hyperactivity disorder, dyslexia and dyspraxia can be named; autism frequently cannot. A clinician who discloses being ‘neurodivergent’ while knowing themselves to be autistic is not simply exercising privacy – they are engaging in proxy disclosure, revealing the less stigmatised while concealing the most. That the word ‘autistic’ remains professionally unspeakable in the specialty most responsible for its diagnosis is not incidental. It is the measure of the problem. This Commentary concerns autistic psychiatrists – and we have named it accordingly.

The editorial calls for mandatory training, integrated care pathways and the prevention of downstream mental health consequences through early recognition ^{Reference Critchley, Minnis, Gajwani, Green, Dew and Dale1} – all very necessary. However, these rest on a prior foundation: a cultural shift within psychiatry, one in which autistic clinicians are not navigating self-recognition in isolation, ^{Reference Doherty, Chown, Martin and Shaw2} using euphemism as protective distance, or confined to anonymous collective acknowledgement. The risks are not theoretical: they are borne now by trainees taught by autistic psychiatrists who do not know they are autistic or do not disclose, by autistic psychiatrists themselves, by their patients and by the autistic community. Institutions, Royal Colleges and training programmes must create conditions in which visibility becomes possible – not compelled, but genuinely safe. Until the profession addresses the elephant among its own ranks, the elephant in the clinical room will remain.