Doherty et al ^{Reference Doherty, Rebowska, Grosjean, Kinnear, Dakin and Porter1} invoke a serious clinical call to action by Critchley et al, ^{Reference Critchley, Minnis, Gajwani, Green, Dew and Dale2} developed with a panel of clinical and research experts, advocating a fundamental shift in how psychiatrists identify, assess and treat neurodevelopmental disorders within psychiatric services. Against this important backdrop, however, the commentary by Doherty et al risks presenting two complex personal, psychological and professional issues experienced by autistic psychiatrists as more generalisable than the available evidence permits.

This distinction is particularly important because 7 of the 13 authors of the commentary are autistic psychiatrists and may also have been represented within the sample underpinning some of its conclusions. The cited qualitative study ^{Reference Doherty, Chown, Martin and Shaw3} interviewed eight autistic psychiatrists and analysed their accounts using interpretative phenomenological analysis. This methodology is well suited to exploring individual lived experience and the meanings that participants attribute to those experiences. However, as with all research methodologies, it has important epistemological and methodological boundaries. Interpretative phenomenological analysis is deliberately idiographic and concerned with depth rather than statistical representativeness. Its findings therefore provide valuable insight into individual experiences and contexts but should not, without further evidence, be interpreted as representative of autistic psychiatrists as a wider professional population. Moreover, interpretation necessarily involves the interaction between participants’ accounts and researchers’ analytic perspectives, making reflexivity an important consideration when drawing broader conclusions. ^{Reference Lee, Tiu, Low, Cheng, Yau and Akingbade4–Reference Rodger and Smith6}

These methodological considerations become particularly relevant to the authors’ proposition that there is a ‘confounding effect’ arising from shared characteristics between an autistic psychiatrist and an autistic patient before the psychiatrist recognises their own autism. The terminology warrants careful examination. In epidemiological terms, confounding refers to a situation in which a third variable is associated with both an exposure and an outcome and thereby distorts the estimated relationship between them. ^{Reference Varkevisser, Indra, Brownlee, Varkevisser, Indra and Brownlee7} It is therefore not immediately apparent how the shared experience of autism, as described by Doherty et al, fulfils this definition. The proposed relationship between an unrecognised autistic identity in the psychiatrist and the subsequent ability to recognise autism in patients appears to require a different conceptual framework from statistical confounding.

More importantly, the commentary moves from accounts provided by eight individuals to broader claims concerning autistic psychiatrists as a professional group. Among these claims are that self-recognition markedly improves psychiatrists’ recognition of autistic patients, that the consequences of ‘invisibility’ are transmitted into clinical training and that autistic psychiatrists actively reproduce a ‘shame cycle’ that they are particularly well positioned to interrupt. These are potentially important hypotheses. However, the distinction between a hypothesis generated by qualitative research, or even cross-sectional samples, and an empirically established conclusion is essential. The available evidence, as presented, does not appear sufficient to establish the prevalence, magnitude or causal mechanisms implied by these claims.

A similar concern arises in relation to professional disclosure. The decision of an individual psychiatrist not to disclose an autistic identity may reflect numerous factors, including personal preference, privacy, previous experiences, professional context, perceived or actual discrimination, or simply a decision not to regard disclosure as clinically or professionally relevant. Interpreting non-disclosure primarily as a consequence of a psychiatric culture that makes disclosure professionally unsafe risks imposing a particular explanation on heterogeneous individual experiences. This is precisely where caution against generalisation is warranted.

I do not question the importance of examining stigma, disclosure and the experiences of autistic psychiatrists. On the contrary, these issues merit rigorous investigation. My concern is that the strength of the conclusions should remain proportionate to the strength and scope of the evidence. Qualitative and cross-sectional accounts can identify important phenomena, generate hypotheses, challenge assumptions and illuminate experiences that may otherwise remain invisible. They cannot by themselves establish that those experiences are shared across a professional population or establish the causal mechanisms proposed.

The use of ‘shame’ as a central explanatory concept similarly deserves careful consideration. Doherty et al argue that shame contributes to autistic psychiatrists’ rejection of deficit-based framings of autism and to reluctance to disclose because of perceived professional risks. These may be important experiences for some individuals. However, presenting them as a characteristic of autistic psychiatrists collectively risks reproducing the very problem that the commentary seeks to address, allowing a particular interpretation of autistic experience to stand in for the diversity of autistic experiences.

There are also conceptual limitations to relying predominantly on Goffman’s framework to explain these phenomena. As has been argued in the broader stigma and disability literature, an interactional model centred on impression management can place disproportionate emphasis on individual adaptation while giving insufficient attention to structural and institutional determinants. It can also risk treating ‘the stigmatised’ and ‘normals’ as relatively discrete categories, even though individuals occupy multiple, intersecting social positions and may simultaneously experience privilege and marginalisation. ^{Reference Link and Phelan8–Reference Fine and Asch10} These limitations are relevant when applying such a framework to autistic psychiatrists working within contemporary medical institutions.

There is nevertheless reason for optimism. Society, professional organisations and royal colleges in the UK are increasingly recognising the contributions of autistic people, including within medicine. At the same time, a more accurate understanding of the impairments and barriers associated with autism remains essential if appropriate adaptations are to be implemented and if autistic people are to participate in professional and social environments without unnecessary masking.

Cultural change should undoubtedly be accelerated. However, for that change to be credible and sustainable, it should be accompanied by an appropriately rigorous evidence base. My own experience of disclosing that I am autistic to colleagues, employers, doctors and patients has not been one of professional unsafety; rather, I have experienced increased regard, credibility and respect. I recognise fully that this is an individual experience and should not be generalised to autistic psychiatrists as a group. Conversely, individual experiences of stigma or professional risk should not be generalised to the profession as a whole without supporting evidence.

The central issue, therefore, is not whether the individual experiences and individualistic analytical framework described by Doherty et al are real or worthy of attention. They clearly warrant attention. The issue is whether the available evidence supports the breadth and strength of the conclusions drawn from them. If autistic psychiatrists are to be described as collectively sustaining shame, transmitting invisibility through training or contributing to missed or delayed diagnoses because of unrecognised autism, these propositions require empirical investigation beyond what has been made available to us.

Respect for autistic psychiatrists should include respect for the heterogeneity of their experiences – and, equally, for the methodological standards by which claims about those experiences are evaluated. In this context, even when I disagree with the concept used of ‘neurodivergent’, I remain with Critchley’s ‘elephant in the room’.