Sara Szal MD<\/span> <\/span><\/p>\n She was 39. She walked into board meetings and read the room before she opened her mouth: who held power, who was irritated or checked out, whose ego needed tending before a new idea could land. <\/span><\/p>\n She would edit sentences before she spoke them.<\/span><\/p>\n Then at night, she climbed into bed beside the person she loved and did it again. She sensed if he wanted sex or was disappointed, whether she should she ask for what she needed, or make it all easier for him instead. <\/span><\/p>\n Different settings but the same nervous system, fulfilling a similar job twice in one day.<\/span><\/p>\n I hear about this experience in women in one form or another every day in my medical practice. <\/span><\/p>\n It resonates because that was me before I learned that I am a highly sensitive person. I spent decades trying to manage it all\u2026 and not that successfully.<\/span><\/p>\n Maybe it resonates for you too.<\/span><\/p>\n For years I read every room I entered before I read my own body. I called it emotional intelligence, being a good leader and a good partner. I wondered why I was almost constantly burned out.<\/span><\/p>\n What I was taught, across years of medical and psychotherapy training: <\/span>sensitivity<\/span><\/em> is a personality trait, soft, easy to dismiss, and managing how you come across is simply professionalism. <\/span><\/p>\n What I now understand: a real part of what I was doing had a specific name the training never gave me: <\/span>masking.<\/span><\/em><\/p>\n Here\u2019s what I mean by both words, because I want to be precise before I build the case.<\/span><\/p>\n High sensitivity, or sensory processing sensitivity,<\/span><\/strong> is a well-documented temperament trait, first defined by Aron and Aron in 1997 and studied continuously since. <\/span>[1]<\/span><\/strong> It shows up in an estimated 20 to 30 percent of people: a nervous system that processes sensory and emotional information more deeply, notices more, and needs more time to recover afterward. <\/span>[1,2]<\/span><\/strong> It is a trait, not a diagnosis.<\/span><\/p>\n<\/li>\n Masking<\/span><\/strong> is what a woman does with that trait before she sees it. It\u2019s the daily practice of hiding overstimulation, smoothing emotional reactivity, and managing how she is perceived, so she can function in rooms that were not built for a nervous system like hers.<\/span><\/p>\n<\/li>\n<\/ul>\n Suppressing a genuine feeling has a documented cost in any nervous system; the emotion-regulation research has shown this for decades. <\/span>[3]<\/span><\/strong> <\/span><\/p>\n For highly sensitive women, I\u2019m proposing that the suppression starts earlier, goes deeper, and until recently, there were limited ways to fix it. That’s the main point of this post: not just the trait itself, but not knowing what was happening.<\/span><\/p>\n You may have read about HSPs before or taken the quiz to see if you are one. I knew about the concept but didn\u2019t <\/span>take the quiz<\/span> until 5 years ago. I am still shocked at how much it changed by day-to-day experience to know that I am HSP. <\/span><\/p>\n I have changed my work. I am careful about the rooms that I enter (and I sense that I\u2019m in the wrong room almost immediately). I got divorced. I track my overstimulation much sooner and design my environment to prevent it. I notice my emotional reactivity and use it as a tool instead of being at the effect of it. I care for my nervous system in a whole new way, and you can too.<\/span><\/p>\n There are lots of articles on HSPs, my purpose here is to frame the underlying physiology of not knowing what it is and masking in order to cope, and how that maps to a woman\u2019s work, home, and sex life.<\/span><\/p>\n Share<\/span><\/p>\n Almost every highly sensitive person, when interviewed, describes the same thing: a lifelong sense of being and feeling different, long before they ever hear the term. In one interview study of 38 self-identified HSPs, that sense of difference was nearly universal, and before people had language for it, it was experienced as something wrong with them rather than as a trait variation. <\/span>[4,5]<\/span><\/strong> <\/span><\/p>\n They describe ordinary environments, workplaces, commutes, parties, as places built for someone else\u2019s nervous system. I can relate. My constant question to myself was, \u201cWhy is this so hard? What is wrong with me? Others don\u2019t seem to struggle and suffer like I am.\u201d<\/span><\/p>\n This is the pre-recognition phase, and it is where masking gets built.<\/span><\/strong> <\/span><\/p>\n A girl notices she is more affected by tone of voice, more overwhelmed by noise, more attuned to the emotional temperature of a room than her peers seem to be. <\/span><\/em><\/p>\n<\/blockquote>\n She is met, more often than not, with some version of\u2026 you\u2019re too sensitive. So she learns, long before she has words for any of this, to hide the signs. She learns to look fine especially when she is not.<\/span><\/p>\n The mechanisms are remarkably consistent across the research. If you are an HSP, I wonder if this resonates?<\/span><\/p>\n Highly sensitive people who have not yet found adaptive tools tend to fall into what researchers call an <\/span>impression-management pattern<\/span><\/em>: regulating emotion not to feel better, but to control how they come across. In one large study, roughly 18 percent of highly sensitive people fit this profile, leaning on suppression and rumination rather than strategies that actually help. <\/span>[6]<\/span><\/strong> Some go further, deliberately dampening positive feelings or holding onto negative ones, as if their natural responses were too much and needed managing down. <\/span>[6]<\/span><\/strong><\/p>\n Some highly sensitive women describe a related paradox: feeling intensely while struggling to name what they are feeling. Researchers call this <\/span>alexithymia<\/span><\/em>, which simply means having a hard time identifying and describing your own emotions, even though you clearly feel them. [7] The feeling is real but the vocabulary for it just has not caught up yet for you.<\/span><\/p>\n In daily life, overstimulation shows up as ordinary-looking overwhelm. Experience-sampling research, tracking people\u2019s feelings in real time throughout the day, finds that highly sensitive people register more overstimulation specifically when something is unpleasant, when they are tired, or when their mood has already dipped. <\/span>[8]<\/span><\/strong> Those are exactly the moments a masking woman is least likely to let it show. <\/span><\/p>\n Overstimulation gets confused by many women as overwhelm.<\/span><\/em><\/p>\n<\/blockquote>\n Many cope by quietly engineering their own environment: leaving early, taking the stairs instead of the crowded elevator, building in recovery time nobody else seems to need. <\/span>[9]<\/span><\/strong> Used with awareness, this is wisdom. Used in secret, because no one has ever told her this is a trait and not a flaw, it looks to everyone around her like she is simply managing fine.<\/span><\/p>\n Leave a comment<\/span><\/p>\n Women carry more of this load than men do, and the research points to real, converging reasons.<\/span><\/p>\n Women score meaningfully higher on sensory processing sensitivity than men do, on average, which means there is simply more trait to manage in the first place. <\/span>[10]<\/span><\/strong> Sex differences in emotion-regulation circuitry show up even at the level of neural response, not only in self-report. <\/span>[11]<\/span><\/strong> And layered on top of the biology, women are socialized early toward being accommodating, socially fluent, and emotionally contained, which stacks real pressure on top of a trait already running the other direction. <\/span>[12,13]<\/span><\/strong><\/p>\n The perinatal period makes this especially visible. Highly sensitive women show a stronger link between stressful experience and depressive symptoms during pregnancy specifically, at precisely the moment the culture expects a woman to be endlessly calm, endlessly available, and endlessly composed for someone else. <\/span>[14,15]<\/span><\/strong><\/p>\n This is where the workplace version of masking lives, and it has its own literature. Workplace masking is a genuine, documented adaptive response, used to guard against negative social and professional consequences, and people whose processing runs differently from the majority report distinct, added pressure trying to pull it off. <\/span>[16]<\/span><\/strong><\/p>\n It is also expensive. Sensitivity itself predicts occupational burnout, and the dimension researchers call ease of excitation is linked to both exhaustion and disengagement from the work itself. <\/span>[10]<\/span><\/strong> Among speech-language pathologists, a field that is overwhelmingly female, 77 percent reported moderate or high burnout, and the most sensitive among them were the most vulnerable. <\/span>[17]<\/span><\/strong>During the early pandemic, sensory processing and perceived stress tracked burnout symptoms directly in a working population under sustained strain. <\/span>[18]<\/span><\/strong> The parallel research on autistic burnout describes something similar: a debilitating exhaustion that builds from living, day after day, in a world that was not built to accommodate how your nervous system actually works. <\/span>[19]<\/span><\/strong><\/p>\n A highly sensitive woman in leadership is often extraordinary at reading a room, and I want to name that plainly as a real skill, not a symptom. Discretion, tact, and social calibration are legitimate professional capacities, and a leader who cannot read a room is not automatically more effective for skipping that step. The cost here is not the skill. The cost is running on it for decades without ever being told there is a name for what she is drawing from, and no plan for how to refill it.<\/span><\/p>\n The same pattern follows a woman home, and the research on sensitivity and social pain helps explain why. Sensory processing sensitivity is linked to heightened sensitivity to social pain specifically: rejection, disappointing someone, being seen as too much, registers in the nervous system with unusual intensity. <\/span>[20]<\/span><\/strong> A highly sensitive woman in a relationship is often exquisitely good at reading her partner and quietly out of practice at being read herself.<\/span><\/p>\n There is a phrase from the research on women who camouflage related traits that I think about often: <\/span>looking good but feeling bad.<\/span><\/em> Women who hide their true processing style report real psychological distress, even while appearing entirely socially competent from the outside. <\/span>[21]<\/span><\/strong><\/p>\n Composure is not the same thing as connection. A woman can be fully fluent and fully alone in the same room. That used to be my experience.<\/span><\/p>\n Here is the part I think gets missed most often, and it is the part that made me want to write this post.<\/span><\/p>\n Masking is not only a habit. It is a nervous-system override, and that override runs on the same hormonal systems that regulate mood and threat response. Estrogen shapes serotonin, dopamine, and GABA signaling throughout a woman\u2019s life, and its decline across the menopause transition destabilizes all three systems at once. <\/span>[22]<\/span><\/strong>Progesterone\u2019s own metabolite, allopregnanolone, is a direct input into the GABA-A receptor, the brain\u2019s primary braking system for staying calm under load. As progesterone production falls through perimenopause, that braking system loses its most reliable fuel. <\/span>[23]<\/span><\/strong><\/p>\n I believe this is why so many highly sensitive women describe perimenopause as the moment the mask stopped fitting, not because they became more sensitive, but because the hormonal scaffolding that made decades of suppression effortful but possible began to withdraw, at the exact moment the culture asks women in midlife to hold even more.<\/span><\/p>\n My own capacity to perform composure changed inside that transition. I could feel the override becoming unavailable in real time, in rooms where it had always been available before. I did not decide to stop masking. My biology stopped cooperating with the performance.<\/span><\/p>\n Unrecognized, all of this shows up everywhere except where it belongs. Sensitivity independently predicts a meaningful share of physical symptoms, mediated by perceived stress: the effort of concealment becomes a body symptom before it ever becomes a named feeling. <\/span>[24]<\/span><\/strong> Sensory processing difficulties, more broadly, are now understood as a pattern that runs underneath anxiety, depression, and other diagnoses across the psychiatric literature, with strikingly large effect sizes. <\/span>[25]<\/span><\/strong> In network analyses of mental health symptoms, emotional and physiological reactivity sits at the very center, the hub everything else seems to run through. <\/span>[26]<\/span><\/strong><\/p>\n Every one of those findings describes a woman carrying a trait she was never educated about nor understood, and I\u2019m on a mission to change that.<\/span><\/p>\n Here\u2019s the good part: The same interview research that documented the pain of not knowing found something else, just as consistently: the moment a highly sensitive woman finds the concept and recognizes herself in it, the negative feeling of being different is replaced by relief, and then by real self-understanding. <\/span>[4]<\/span><\/strong> <\/span><\/p>\n Naming and understanding the trait does not only explain the past and why you feel overstimulated or fatigued or burned out, it changes what a woman does next.<\/span><\/p>\n Once she knows, she can stop treating her nervous system as a problem to manage and start treating it as a specification. She can build recovery time into her week instead of hiding that she needs it. She can ask an environment to work for her instead of spending her whole life quietly working around it. Highly sensitive people who understand their trait shift measurably toward strategies that actually help, including simple attention-awareness practices that strengthen the connection between noticing subtlety and tolerating difficult emotion. <\/span>[27]<\/span><\/strong> There is also real evidence that highly sensitive people respond more, not less, to good support once they receive it: the same trait that makes unsupportive environments harder also makes supportive ones pay off disproportionately. <\/span>[2]<\/span><\/strong><\/p>\n That\u2019s what I most want women to hear, that unmasking is not about becoming less sensitive. It is about building a life where the sensitivity is not spent managing everyone else\u2019s experience of you. <\/span><\/p>\n I believe that critical shift, of choosing which rooms get your real signal and which get your managed one, is a profound act of sovereignty inside of your own nervous system. <\/span><\/p>\n That\u2019s the win: not performing a sense of calm but rather living in your own skin most of the time, maybe all the time. Deep authenticity. Radical self-acceptance. Fortunately, it\u2019s a documented, researched outcome of how healthy it is to be told what you are working with, and finally being empowered to ask your environment to meet you.<\/span><\/p>\n Sensitivity is not a problem, though the years spent not knowing the language were a problem.<\/span><\/p>\n I want to keep going with this topic, and I want to build the next post around what you want and need. <\/span><\/p>\n Tell me in the comments: do you want the practical side, how to ask an environment to accommodate a highly sensitive nervous system, the deeper biology of perimenopause and emotional regulation, more on masking and unmasking sexually, or the screening questions I use in clinic to spot a woman who has been masking for years? <\/span><\/p>\n I read every comments, and it shapes what I write next.<\/p>\n I self-diagnosed my HSP trait 5 years ago, and as an enthusiast of the n-of-1 experiment, I have a long list of what has worked for me and what hasn\u2019t. Let me know if you want to open the kimono. <\/span><\/p>\n (My fellow HSPs will know already that the kimono is silk, a stunningly good color combination, and feels magnificent on the skin.)<\/span><\/p>\n xo Dr. Sara<\/span><\/p>\n\n
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