Sex Differences in PTSD Risk Among Autistic Individuals: A Population-Based Matched Cohort Study

Objective: Autistic individuals may face elevated risk for PTSD, yet the degree to which this risk differs by sex remains unknown. We examined the association between autism and incident PTSD, characterized sex differences in risk, identified high-risk subgroups, and described post-diagnosis clinical trajectories. Method: We conducted a population-based matched cohort study using Swedish national registers. Individuals born 1990 through 2010 were followed from age 6 years through December 31, 2017. Autistic individuals (N=42,862) were matched 1:10 to controls (N=412,251) on sex and birth year. Cox proportional hazards regression estimated hazard ratios (HRs) for incident PTSD. Among those who developed PTSD, we compared care utilization, hospitalization rates, and persistence of care contacts. Results: During mean follow-up of 5.1 years, 401 autistic individuals (0.9%) and 903 controls (0.2%) developed PTSD (incidence rates: 18.3 vs 4.2 per 10,000 person-years). Autism was associated with 4.4-fold increased PTSD risk (HR=4.37; 95% CI, 3.93-4.86). Risk was higher among females (HR=4.79) than males (HR=3.39; P interaction=.006). Among autistic individuals, comorbid ADHD conferred additional risk (HR=1.38; 95% CI, 1.14-1.68). Ten-year cumulative incidence reached 6.0% among autistic females with ADHD. Autistic individuals with PTSD had higher care utilization (mean visits: 5.0 vs 3.9; P<.001), more psychiatric hospitalizations (27.9% vs 19.8%; P=.002), and more persistent courses (24.8% vs 12.3% with contacts in all 3 post-diagnosis years; P=.001). Conclusion: Autism is associated with substantially elevated PTSD risk, particularly among females with comorbid ADHD. When PTSD occurs, autistic individuals experience more severe and persistent clinical courses, supporting targeted screening and sustained follow-up.