Hiding in Plain Sight: Eating Disorders,Autism,and Diagnostic Overshadowing in Women

Abstract

Background:

Autism and elevated autistic traits are increasingly identified in eating disorder (ED) populations, although less research has focused on ED rates and risk factors in individuals who already have an autism diagnosis. This study aimed to investigate the timing and sequence of autism and ED diagnoses in women and examined associations between autistic traits, autism diagnosis, and risk of EDs and other mental health difficulties.

Method:

In this cross-sectional study, we recruited 371 cisgender autistic women (M_age = 34.38 years, SD = 10.54) and 394 cisgender non-autistic women (M_age = 33.49 years, SD = 10.40). We used the Autism Spectrum Quotient to measure autistic traits, the Eating Attitudes Test to assess ED risk, and the Depression, Anxiety, Stress Scale for broader mental health concerns. We used chi-square tests to establish the rate of overlap between autistic traits, autism diagnosis, and mental health risks and linear regression models to assess the unique impact of autistic traits and autism diagnosis on mental health symptom severity.

Results:

We found that 58% of women with high autistic traits (with and without an autism diagnosis) were at high risk of an ED (N = 174). While autistic traits predicted elevated ED risk overall, the effect was substantially lower in women with a formal autism diagnosis [b = −8.34, t(718) = −5.84, p < 0.001], suggesting a potential protective factor. This finding was particularly notable, as approximately one-third (N = 106, 28.6%) of diagnosed autistic women reported a history of EDs. Critically, however, in 75% of these cases, an ED diagnosis preceded an average delay of 13.86 years (SD = 9.76) before they were identified as autistic. Higher autistic traits were also associated with increased depression, anxiety, and stress symptoms, with less severe depression levels again found in women with a formal autism diagnosis [b = −1.70, t(718) = −3.27, p = 0.001].

Discussion:

Our findings underscore the urgent need for clinicians to screen women presenting with an ED for autism, as a formal diagnosis may improve their mental health-related outcomes. While we found that most autistic women were initially diagnosed with an ED and faced substantial delays before their autism was recognized, those diagnosed with autism first were 17 years old on average, indicating that their diagnoses were also delayed. Future research should therefore investigate differences in mental health outcomes in a broader range of autistic people, including gender-diverse individuals and those diagnosed in both childhood and adulthood.

Community Brief

Why is this an important issue?

Studies in people with eating disorders often find that many have high levels of autistic traits, and some have undiagnosed autism. This is important, because research has shown that standard eating disorder treatments can be a poor fit for autistic people, particularly if they do not recognize their individual support needs.

What was the purpose of this study?

This study looked at a large group of women who already have an autism diagnosis, who may or may not have had a previous eating disorder. The goal was to identify how old they were when they received each diagnosis and to understand whether having higher autistic traits or an autism diagnosis influenced whether they were at risk of developing an eating disorder or another mental health condition.

What did the researchers do?

We surveyed 371 autistic women (meaning women with a formal diagnosis) and 394 non-autistic women (meaning women who do not have a diagnosis and do not self-identify as autistic). We measured levels of autistic traits using the Autism Spectrum Quotient, their risk of developing an eating disorder using the Eating Attitudes Test, and signs of other mental health issues using the Depression, Anxiety, Stress Scale. We used the scores from these surveys to identify relationships between autistic traits, having an autism diagnosis, and risk of developing an eating disorder or other mental health concerns.

What were the results of the study?

Our study found that 28% of autistic women had experienced an eating disorder in the past. However, for most of these women (75%), their eating disorder was diagnosed on average, 14-years before they received their autism diagnosis. We also found a strong connection between autistic traits and eating disorders. Among women with a history of eating disorders, 49% showed high levels of autistic traits. Similarly, for women currently at high risk of developing an eating disorder, 58% showed high levels of autistic traits. Importantly, our study found that having a formal autism diagnosis might reduce the risk of certain mental health challenges. Women with a formal autism diagnosis had a lower risk of developing an eating disorder, and had less severe depression symptoms compared to women with high autistic traits but no formal autism diagnosis.

What do these findings add to what was already known?

This study found a higher rate of eating disorders and eating disorder symptoms in autistic women and women with high autistic traits than previous research had found. It also highlights that mental health professionals should consider screening women with an eating disorder for autism, as the vast majority will be undiagnosed when they develop an eating disorder.

What are potential weaknesses in the study?

One limitation is that most of the autistic women in our sample were diagnosed in their late teens or adulthood. Additionally, our study focused on cisgender women only, so the results do not reflect the experiences of gender-diverse people or people who self-identify as autistic.

How will these findings help autistic adults now or in the future?

Our study builds on what is already known about autism and eating disorders in women, by showing that the connection is stronger than previously thought. This may prompt mental health professionals to consider and screen for autism in women with an eating disorder in a more timely way, which could offer some protection against severe eating disorder and depression symptoms, and help to reduce the number of missed autism diagnoses in women.