Extending the Minority Stress Model of Autism: Internalized Stigma and Loneliness as Predictors of Stress and Life Satisfaction

Abstract

Autistic people’s minority status makes them more vulnerable to minority stressors, such as stigmatization and victimization, which are linked to greater stress and lower life satisfaction. The Psychological Mediation Framework (PMF) proposes that cognitive, affective, and social-psychological processes help explain the relationships between these stressors and adverse outcomes. This cross-sectional study tested the PMF in autistic adults by examining how two of its key processes, internalized stigma and loneliness, are associated with stress and life satisfaction. Using self-report survey data from 831 autistic participants enrolled in the Netherlands Autism Register (NAR), aged 18–87 years (M_age = 47.5; SD = 12.5; 408 women, 309 men, and 114 gender-diverse individuals), multiple regression analyses showed that internalized autism-related stigma, emotional loneliness, and social loneliness were each positively associated with stress and negatively associated with life satisfaction. Mediation analyses indicated that both types of loneliness partially mediated the relationship between internalized autism-related stigma and these outcomes. Supporting the PMF, the findings suggest that autism-related stigmas may become internalized and be associated with loneliness, which is linked to greater stress and lower life satisfaction. Future studies should build upon the PMF and explore strategies to mitigate underlying minority stressors.

Lay Abstract

Understanding stress and life satisfaction in autistic adults with the psychological mediation framework

Why was this study done?

Autistic adults often experience higher levels of stress and lower life satisfaction than non-autistic adults. Recently, research has suggested that these experiences are linked to them being part of a minority group—autistic people. Minorities often experience extra stress from experiences like stigma, sometimes called minority stressors. A theoretical model, the Psychological Mediation Framework (PMF), describes how minority stressors are linked to differences in people’s thoughts, emotions, and feelings. This study examined whether the PMF can also help explain the stress and life satisfaction of autistic adults. We did this by testing whether two important parts of the PMF, internalized autism-related stigma (negative beliefs about being autistic) and loneliness, were linked to their stress and life satisfaction (how content people feel with their lives overall).

What did we do?

We analyzed data from 831 autistic adults who filled out a survey. In our statistical models (mathematical analyses that test how variables are related), we took into account other factors that are more commonly used to examine which factors were statistically associated with stress and life satisfaction in autistic adults, such as the level of characteristics related to autism and education level. By doing this, we increased the chance that any relationships we found could be attributed to minority stressors.

What did we find?

Autistic adults who experienced more internalized autism-related stigma, emotional loneliness (feeling disconnected from close relationships), and social loneliness (lacking a broader social network) reported higher stress levels and lower life satisfaction. We also found that autistic adults with more internalized stigma felt lonelier, and this loneliness was linked to higher stress and lower life satisfaction.

What do the findings mean?

The results suggest that autistic adults may internalize autism-related stigmas, which are linked to greater loneliness, higher stress, and lower life satisfaction. As these findings align with the PMF, we believe future studies should continue using this model. Also, we recommend that researchers should study ways to reduce minority stressors and improve the mental health of autistic adults.

Keywords

autism minority stress psychological mediation framework internalized stigma loneliness stress life satisfaction

Introduction

Perceived stress, henceforth stress, describes experiences in which individuals feel that the demands of the environment exceed their ability to cope effectively (Cohen et al., 2016). Such excessive or overwhelming demands—known as stressors (Epel et al., 2018)—activate various neurobiological mechanisms, including immune, cardiovascular, and metabolic systems, which help the body adapt, solve problems, and restore homeostasis (Greenberg, 2002; Slavich, 2020). However, the cumulative effect of long-term stress may disrupt homeostasis and be negatively associated with physical and mental health (Fava et al., 2019). Indeed, heightened stress is consistently associated with lowered life satisfaction (McQuaid et al., 2022; Ribeiro et al., 2018), defined as the subjective evaluation of one’s quality of life (Diener et al., 1985). Understanding the precise nature and mechanisms of stressors, as well as their consequences, is essential for developing effective interventions to support populations with heightened stress, such as autistic adults (Moseley et al., 2021). To our knowledge, this study is among the first to test the Psychological Mediation Framework (PMF; Hatzenbuehler, 2009) in autism. We examined two key psychological processes within this framework, internalized autism-related stigma and loneliness, and their associations with stress and life satisfaction in a large sample of autistic adults (N = 831). To provide a more nuanced understanding, we also distinguished between emotional and social loneliness to examine their respective associations with these outcomes.

Autism is a form of neurodivergence that shapes how people experience themselves and their environments (Autistic Self Advocacy Network, n.d.). While there is no singular way to be autistic (Masi et al., 2017), common autistic traits include variations in sensory processing, communicating, thinking, socializing, and movement (Autistic Self Advocacy Network, n.d.). Although classified as a disorder in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013), many autistic adults increasingly view their traits as natural variations of human psychology, recognizing them as central to a minority identity, similar to those based on gender, sexuality, and ethnicity (Anderson-Chavarria, 2021; McVey et al., 2023). Despite this shift away from a pathological model of autism, autistic adults generally experience more stress and lower life satisfaction than their allistic (non-autistic) counterparts (McQuaid et al., 2022; Moseley et al., 2021; Van der Linden et al., 2022). In response, autistic adults advocate for research that addresses these outcomes (Cage et al., 2024; Putnam et al., 2023).

Nevertheless, it has proven challenging to comprehensively explain heightened stress and lower life satisfaction in autistic adults, hindering the development of effective interventions (Moseley et al., 2021). Research on this topic has traditionally focused on internal causes, such as genetic vulnerabilities (Tye et al., 2019) and compromised coping skills (Griffiths et al., 2019; Hollocks et al., 2021). However, one novel perspective, including environmental components, is offered by the minority stress model (Meyer, 2003). This model suggests that minority groups, such as autistic people, are more likely to encounter harmful social experiences, minority stressors, that are associated with elevated stress levels. Indeed, autistic individuals are at higher risk of experiencing stressors such as bullying (Hoover & Kaufman, 2018), maltreatment (Fisher et al., 2019), stigma (Alkhaldi et al., 2021; Jones et al., 2021), and exclusion (Rowley et al., 2012) than their allistic peers. These stressors likely arise from stigma related to diagnostic labeling and from negative social reactions to autistic communication styles, needs, preferences, and behavioral expressions (Botha et al., 2020; Sasson et al., 2017; Wood & Freeth, 2016). Autism-related stigmatization has been identified as a strong predictor of their life satisfaction (Caron et al., 2021), while another study found that minority stress explained up to 72% of the variance in their stress levels (Botha & Frost, 2018). Together, these findings suggest the relevance of the minority stress model in explaining elevated stress and reduced life satisfaction in autistic adults.

While the minority stress model primarily links minority stressors directly to these outcomes, several psychological processes may also contribute (Hatzenbuehler, 2009; Hoy-Ellis, 2021). To address this limitation, several extensions have been proposed (Frost & Meyer, 2023), most notably the PMF (Hatzenbuehler, 2009). According to this model, minority stressors are linked to cognitive (e.g., rumination), affective (e.g., emotion dysregulation), and social-psychological (e.g., feelings of alienation) mechanisms that help explain the relationship between these stressors and adverse outcomes. Since its introduction, the PMF has gained extensive empirical support within minority groups (Frost & Meyer, 2023; Hoy-Ellis, 2021). For instance, one longitudinal study in sexual and gender minority individuals found that experiencing minority stressors led to increased rumination, which, in turn, heightened depressive symptoms (Sarno et al., 2020). Thus, the PMF may provide a more nuanced understanding of how minority stressors are related to mental health.

To our knowledge, the PMF has not yet been examined in autistic adults. However, two repeatedly identified psychological processes, internalized stigma and loneliness, are also prevalent within this population (Brewster et al., 2013; Chan & Tsui, 2023; Drapalski et al., 2023; Garro et al., 2022). Overt experiences of stigmatization are often accompanied by anticipated stigma—the expectation of further stigmatization—which is associated with internalized stigma, the incorporation of these public stigmas into one’s self-concept (Park et al., 2013; Quinn et al., 2015). Research indicates that moderate-to-severe internalized autism-related stigma affects between 15.4% and 45.5% of autistic adults (Bachmann et al., 2019; Dubreucq et al., 2020; Huang et al., 2023; Riebel et al., 2025), and this experience has been linked to both increased stress (Botha & Frost, 2018) and reduced life satisfaction (Huang et al., 2023). Loneliness is a negative emotional state that results from a perceived discrepancy between desired and actual social relationships (Peplau & Perlman, 1982). This construct has traditionally been divided into two dimensions: emotional loneliness, which is the lack of close, intimate relationships; and social loneliness, which concerns the lack of a social network to share common activities and interests (Van Tilburg, 2021; Weiss, 1973). These factors therefore capture the depth and breadth of perceived social relationships, respectively. Altogether, loneliness is highly prevalent in autistic adults, with a meta-analysis finding a strong association (Hedges’ g = .89) between being autistic and this experience (Hymas et al., 2022). Thus, the widespread presence of internalized stigma and loneliness suggests that the PMF may be relevant to autistic adults as well.

Furthermore, the two factors of loneliness may help explain the link between internalized autism-related stigma and stress and life satisfaction (Grace et al., 2022; Moseley et al., 2021). Autism-related stigmas may become internalized, and this internalization has been associated with feelings such as depression and (social) anxiety, pressure to mask stigmatized traits (social masking), and expectations of rejection (Han et al., 2021; Marion et al., 2023). Such experiences are further associated with greater difficulty connecting with others, heightened loneliness, and reduced access to social support that helps buffer against stress (Cacioppo & Hawkley, 2009; Lin et al., 2025). Prior research has supported the potential mediating role of loneliness in the relationship between internalized stigma and stress and life satisfaction. For example, studies have shown that having an autism diagnosis or heightened autistic traits was associated with greater loneliness, which was also linked to various adverse outcomes, including greater depression and anxiety (Camus et al., 2025; Moseley et al., 2021; Schiltz et al., 2020; Stice & Lavner, 2018), accelerated aging (Mason, 2023), and lower life satisfaction (Reed et al., 2016). However, it remains untested whether these relationships can be attributed to internalized autism-related stigma or other factors unrelated to minority stressors, such as daily functioning challenges. Therefore, it remains unclear to what extent these findings can be understood through the lens of the PMF.

To better understand the adverse outcomes in autistic adults and given the potential relevance of the PMF, this study examined two key psychological processes frequently identified in both PMF and autism research—internalized autism-related stigma and loneliness—in relation to autistic adults’ stress and life satisfaction. Furthermore, we differentiated between emotional and social loneliness to better understand their respective contributions. In line with the PMF, we hypothesized that internalized autism-related stigma and emotional and social loneliness would each be positively associated with autistic adults’ stress and negatively associated with their life satisfaction. In addition, we predicted that both types of loneliness would mediate the relationship between internalized autism-related stigma and these outcomes.

Method

Design

This cross-sectional questionnaire study was led by an autistic researcher and utilized retrospective data from the Netherlands Autism Register (NAR), a database established in 2013 by the Dutch Autism Association (NvA) in collaboration with the Vrije Universiteit Amsterdam (VU). The NAR contains annual online survey data from a large number of autistic adults, with questionnaires selected in close collaboration with autistic employees. Participants are recruited through multiple channels, including social media, newsletters, magazines, and collaborations with partner universities and mental health organizations. Informed consent is provided online upon registration. More information on the NAR and its surveys can be found on https://nar.vu.nl/. The study was preregistered on https://osf.io/p6xw8, and ethical approval was obtained from the ethics committee of the VU (approval number 2013/45).

Participants

For this study, data were drawn from all 1,307 autistic individuals aged 16 years and older who had completed the 2022 annual NAR questionnaire. Participants aged 16 or 17 years were excluded to focus on adults only. Notably, all individuals in this age group (n = 8) had missing demographic data required for the main analyses and were therefore already excluded as part of the missing data procedure. After excluding all other cases with these missing data, the final sample consisted of 831 participants aged 18–87 years (M_age = 47.5; SD = 12.5). These respondents all stated that they had received a diagnosis of autism spectrum disorder according to either the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) or DSM-5 (American Psychiatric Association, 2013) by a qualified mental health professional. More details on the study sample can be found in Table 1.

Table 1.

Participant Demographics (N = 831).

Demographic	n	%
Age of autism diagnosis
< 18 years	84	10.1
⩾ 18 years	696	83.8
Unknown	51	6.1
Intelligence quotient (self-reported)
⩽85	84	10.1
86-115	153	18.4
>115	565	68.0
Unknown	29	3.5
Gender
Male	309	37.2
Female	408	49.1
Other	114	13.7
Ethnic background
Dutch	791	95.2
Dutch + other group(s)	24	2.9
Other group(s) only	16	1.9
Education Level
Low	151	18.2
Middle	177	21.3
High	503	60.5
Co-occurring conditions
Yes ^a	366	44.0
No	420	50.5
Unknown	45	5.4

The most reported co-occurring conditions were mood disorders (n = 180), attention-deficit/hyperactivity disorder (n = 118), post-traumatic stress disorder (n = 100), and anxiety disorders (n = 85).

Measures

Main Variables

Internalized Autism-Related Stigma

The Dutch version of the 10-item Internalized Stigma of Mental Illness Inventory (ISMI-10; Boyd Ritsher et al., 2003; Van Beukering et al., 2022) was used to assess internalized autism-related stigma. In order to measure autism-specific internalized stigma, we replaced all references of ‘mental illness’ by ‘autism’. An example statement is ‘People ignore me or take me less seriously just because I have autism’. Items are scored on a four-point Likert-type scale, ranging from 1 = strongly disagree to 4 = strongly agree. Mean scores are computed, with higher scores indicating greater internalized autism-related stigma. The ISMI has been previously used in a study involving autistic adults, showing acceptable to good internal consistency (Bachmann et al., 2019; Riebel et al., 2025). Internal consistency for the current sample was acceptable (Cronbach’s α = .77).

Emotional and Social Loneliness

Emotional and social loneliness were assessed using a six-item version of the De Jong Gierveld and Van Tilburg’s (2006) Loneliness Scale, which measures both emotional and social dimensions of loneliness. The three emotional loneliness items are negatively formulated (e.g., ‘I often feel rejected’), while the three social loneliness statements are formulated positively (e.g., ‘There are plenty of people I can rely on when I have problems’). Each item has five answer options: ‘Yes!’, ‘Yes’, ‘More or less’, ‘No’, and ‘No!’. In the case of emotional loneliness, confirming answers (Yes!, Yes, and More or less) all receive one point, while with social loneliness, this applies to all negative answers (More or less, No, and No!). Total scores vary from 0 to 3 per subscale, with higher scores indicating more loneliness of the respective type. A combined score (range = 0–6) can also be calculated to reflect total loneliness. The scale was selected to provide a brief assessment of both traditional loneliness dimensions because it has demonstrated good to very good internal consistency in autistic populations (Scheeren et al., 2022). In this study, the internal consistency of both the emotional and social loneliness subscales was acceptable, with Cronbach’s α = .70 and .79, respectively.

Stress

Stress scores were obtained with the 10-item Dutch version of the Perceived Stress Scale (PSS-10; Cohen et al., 1983; Van Eck et al., 1996), which measures perceived levels of stress during the past 4 weeks. An example question is, ‘How often did you feel stressed and nervous?’. Items are scored on a five-point Likert-type scale, which ranges from 0 = never to 4 = very often. The higher the sum score (range = 0–40), the more stress a person perceives. We chose this scale because it is a validated and widely used measure of stress with good internal consistency in autism research (Thoen et al., 2021). It also demonstrated good internal consistency in our study (Cronbach’s α = .88).

Life Satisfaction

Life satisfaction was assessed using a one-item Cantril ladder (Cantril, 1965). Participants were asked to rate their life on an 11-point scale, ranging from 0 (worst possible life) to 10 (best possible life). While single-item, continuous Cantril ladders may not capture the full dimensionality of life satisfaction, they are efficient given the length of the annual NAR questionnaire and have been extensively used as valid and reliable measures in studies involving autistic adults (e.g., Grant et al., 2022; Grove et al., 2018).

Confounding Variables

Gender

Gender was measured with the question, ‘Some people do not feel (entirely) at home with the gender assigned to them at birth. Based on your feelings you are . . .’. Participants could choose from three answer options: Male, Female, and Other.

Ethnic Background

Ethnic background was measured by asking, ‘Which ethnic identity or identities do you consider yourself to be part of? Multiple answers are possible’. Responses were then coded into three overarching categories: Dutch, Dutch + other group(s) (when participants selected both Dutch and another ethnic background) and Other group(s) only. Non-native Dutch groups were collapsed due to small sample sizes to ensure statistical stability. We did not explicitly specify whether ethnic background referred to ancestry, nationality, cultural identity, or (migration) background, allowing participants to interpret and report this aspect of identity in a self-defined manner.

Education Level

Education level was assessed using the question ‘What is your highest level of education?’. Answers were coded into three categories, based on the International Standard Classification of Education (ISCED; UNESCO, 2012): Low (ISCED Levels 0–3; up to upper secondary education), Middle (ISCED Level 4; post-secondary non-tertiary education), and High (ISCED Levels 5–8; short-cycle tertiary to doctoral education).

Autistic Traits

Autistic traits were measured using the Dutch version of the Autism Quotient-Short (AQ-Short; Hoekstra et al., 2010). An example item of this 28-item scale is ‘I find it hard to make new friends’. Participants answer these statements on a four-point Likert-type scale ranging from 1 = ‘Definitely agree’ to 4 = ‘Definitely disagree’. The higher the sum score (range = 28–112), the more autistic traits a person attributes to themselves. Internal consistency of the scale in the current sample was good (Cronbach’s α = .83), similar to previous research (e.g., Hoekstra et al., 2010).

Data Analysis

Data were analyzed using JASP (https://jasp-stats.org/), version 0.19.1. Prior to the main analyses, assumption checks (linearity, absence of multicollinearity, homoscedasticity, normality of residuals, and independence of errors) were conducted. To test the study hypotheses, we performed two separate multiple regression analyses to predict respectively stress and life satisfaction (dependent variables) based on internalized autism-related stigma and emotional and social loneliness (independent variables). To isolate the unique role of internalized stigma and loneliness as minority stress-related processes, we controlled for five demographic and individual characteristics previously associated with adverse outcomes in autistic adults: age (Braden et al., 2021; McGillivray & Evert, 2014), gender (McGillivray & Evert, 2014; McQuaid et al., 2022), ethnic background (Ames et al., 2022), education level (Shattuck et al., 2012), and autistic traits (García-Villamisar & Rojahn, 2013; Muniandy et al., 2023). Because gender, ethnic background, and education level were three-category variables, effect coding was applied, in which each regression coefficient represents the difference between one category and the average of the remaining categories. To align with the study’s minority stress framework, we specifically assessed gender and ethnic background using self-identification measures. Subsequently, we conducted two mediation analyses using the SEM package, controlling for the same confounders. In these models, internalized autism-related stigma was the independent variable, and emotional and social loneliness served as the mediators, with stress as the dependent variable in one model and life satisfaction in the other. Associations were statistically significant when the p-value was lower than .05.

Results

Descriptive Statistics and Missing Data Handling

Of all 1,307 participants, 476 (36.4%) had missing demographic data used in our main analyses. The most frequently omitted demographic included the highest education level (n = 203), because many respondents had not yet finished their current educational program and were therefore not prompted to disclose it. We conducted chi-square and independent t-tests on key variables (age, gender, ethnic background, autistic traits, stress, and life satisfaction) and found only trivial to small effect sizes for differences between cases with missing and complete data in autistic traits, M_missing = 81.8, SD = 11.0; M_complete = 83.3, SD = 10.8; t(1280) = −2.31, Cohen’s d = −0.14, p = .02, and age, M_missing = 44.1, SD = 16.0; M_complete = 47.5, SD = 12.5; t(1302) = −4.30, Cohen’s d = −0.25, p < .001. Furthermore, excluding education level as a covariate in our main analyses did not significantly change the results. Given these minimal differences and the remaining large sample size, we excluded all cases with missing demographic data, resulting in a final sample of 831 participants. Descriptive statistics for these respondents are presented in Table 2. Notably, average internalized autism-related stigma (M = 1.83; SD = 0.42) was minimal to none (1–2; Lysaker et al., 2007), and average stress (M = 29.86; SD = 6.96) was high (27–40; Gambetta-Tessini et al., 2018).

Table 2.

Participant Characteristics (N = 831).

Characteristic (range)	N (%)	M (SD)
Autistic traits (28–112)		83.30 (10.81)
Internalized autism-related stigma (1–4)^a		1.83 (0.42)
Minimal to none	595 (71.6)
Mild	199 (23.9)
Moderate	32 (3.9)
Severe	5 (0.6)
Loneliness (0–6)^b		3.11 (2.08)
None	338 (40.7)
Moderate	232 (27.9)
Severe	261 (31.4)
Emotional loneliness (0–3)		1.41 (1.17)
Social loneliness (0–3)		1.69 (1.24)
Stress (0–40)^c		29.86 (6.96)
Low	7 (0.8)
Moderate	259 (31.2)
High	565 (68.0)
Life satisfaction (0–10)		6.18 (1.72)

M = mean; SD = standard deviation.

Minimal to none = 1–2, mild = 2.01–2.5, moderate = 2.51–3, and severe = >3 (Lysaker et al., 2007).

None = 0–2, moderate = 3–4, and severe = 5–6 (De Jong Gierveld & Van Tilburg, 2006). No reference scores for the emotional and social subscales are available.

Low = 0–13, moderate = 14–26, and high = 27–40 (Gambetta-Tessini et al., 2018).

Assumption Checks and Bivariate Analysis

All statistical assumption checks were met, except for the Shapiro–Wilk test on the residuals of the multiple regression model with life satisfaction as the outcome. This test revealed a significant deviation from normality, W(831) = .98, p < .001. However, visual inspection of Q-Q plots and histograms suggested only slight skewness. Therefore, we attributed this violation of normally distributed residuals to a high statistical sensitivity stemming from the large sample size and proceeded without conducting transformations. Bivariate correlations of the covariates and main variables are presented in Table 3, indicating no problematic multicollinearity (|r| < 0.7; Dormann et al., 2012). Variance inflation factor (VIF) and tolerance values from the multiple regression models were also acceptable (all VIFs < 2.5, all tolerances > .40).

Table 3.

Bivariate Correlations of Covariates and Main Variables (N = 831).

Variable	1	2	3	4	5	6	7	8	9	10
1. Age	−
2. Gender^a	−.24***	−
3. Ethnic background^b	.002	.07*	−
4. Education level^c	.06	.04	.03	−
5. Autistic traits	.17***	.06	.10**	−.08*	−
6. Internalized autism-related stigma	.05	.06	.08*	−.15***	.22***	−
7. Emotional loneliness	−.01	.03	.05	−.07*	.01	.41***	−
8. Social loneliness	.17***	.01	.07*	−.04	.15***	.38***	.49***	−
9. Stress	−.07*	.21***	.02	−.08*	.19***	.50***	.44***	.33***	−
10. Life satisfaction	.04	−.12***	−.08*	.11**	−.14***	−.49***	−.47***	−.38***	−.58***	−

Correlation coefficient = Pearson’s r.

1 = male, 2 = female, and 3 = other.

1 = Dutch, 2 = Dutch + other group(s), 3 = other group(s) only.

1 = low, 2 = middle, 3 = high.

p < .05; **p < .01; ***p < .001.

Main Analysis

Multiple Regression Analyses

Full results of the multiple regression analyses are presented in Table 4. For the model with stress as the outcome variable, when only including covariates (age, gender, ethnic background, education level, and autistic traits), the model explained adjusted R² = .08 of the variance. After including internalized autism-related stigma and emotional and social loneliness as predictors, the explained variance increased to adjusted R² = .37. In the full model, lower age and higher autistic traits were associated with more stress. In addition, gender-diverse participants and those identifying as Dutch reported stress levels above the overall sample mean, and education level was not significantly associated. For the main predictors, higher internalized autism-related stigma (B = 5.75, 95% CI = [4.70, 6.79], p < .001), emotional loneliness (B = 1.56, 95% CI = [1.17, 1.94], p < .001), and social loneliness (B = 0.38, 95% CI = [0.01, 0.74], p = .04) were each associated with greater stress.

Table 4.

Multiple Regression Analysis With Age, Gender, Ethnic Background, Education Level, and Autistic Traits as Covariates; Internalized Autism-Related Stigma and Emotional and Social Loneliness as Independent Variables; and Stress and Life Satisfaction as Dependent Variables.

Variable	Stress							Life satisfaction
						95% CI							95% CI
	B	SE	β	t	p	LL	UL	B	SE	β	t	p	LL	UL
Covariates only (adjusted R² = .08 with stress and .05 with life satisfaction)
Age	−0.03	0.02	−0.06	−1.67	.10	−0.07	0.01	0.01	0.01	0.04	1.14	.26	−0.004	0.02
Gender (ref: male)^a	3.68	0.76	0.25	4.85	<.001***	2.19	5.17	−0.62	0.19	−0.17	−3.24	.001**	−0.99	−0.24
Gender (ref: female)^b	1.68	0.72	0.12	2.33	.02**	0.26	3.10	−0.47	0.18	−0.14	−2.59	.01*	−0.83	−0.11
Ethnic background (ref: Dutch)^c	−1.26	1.41	−0.04	−0.89	.37	−4.03	1.51	−0.33	0.36	−0.04	−0.92	.36	−1.03	0.37
Ethnic background (ref: Dutch + other)^d	13.17	6.60	0.09	2.00	.05*	0.21	26.13	−1.91	1.66	−0.05	−1.15	.25	−5.17	1.35
Education level (ref: low)^e	−1.41	0.63	−0.08	−2.23	.03*	−2.65	−0.17	0.49	0.16	0.11	3.10	.002**	0.18	0.81
Education level (ref: middle)^f	0.11	0.59	0.01	0.19	.85	−1.06	1.28	−0.02	0.15	−0.00	−0.11	.92	−0.31	0.28
Autistic traits	0.12	0.02	0.19	5.55	<.001***	0.08	0.17	−0.02	0.01	−0.12	−3.51	<.001***	−0.03	−0.01
Full Model (adjusted R² = .37 with stress and .35 with life satisfaction)
Age	−0.05	0.02	−0.08	−2.78	.01*	−0.08	−0.01	0.01	0.00	0.07	2.45	.01*	0.002	0.02
Gender (ref: male)^a	3.05	0.63	0.21	4.84	<.001***	1.82	4.29	−0.47	0.16	−0.13	−2.96	.003**	−0.78	−0.16
Gender (ref: female)^b	1.26	0.60	0.09	2.09	.04*	0.08	2.44	−0.38	0.15	−0.11	−2.52	.01*	−0.68	−0.08
Ethnic background (ref: Dutch)^c	−2.31	1.17	−0.07	−1.97	.05*	−4.61	−0.01	−0.05	0.29	−0.01	−0.17	.87	−0.63	0.53
Ethnic background (ref: Dutch + other)^d	10.68	5.48	0.07	1.95	.05	−0.07	21.44	−1.28	1.37	−0.03	−0.93	.35	−3.97	1.42
Education level (ref: low)^e	−0.28	0.53	−0.02	−0.54	.59	−1.32	0.75	0.23	0.13	0.05	1.70	.09	−0.04	0.48
Education level (ref: middle)^f	0.97	0.50	0.06	1.96	.05	−0.00	1.94	−0.22	0.12	−0.05	−1.81	.07	−0.47	0.02
Autistic traits	0.07	0.02	0.12	3.94	<.001***	0.04	0.11	−0.01	0.01	−0.05	−1.57	.12	−0.02	0.00
Internalized autism-related stigma	5.75	0.53	0.35	10.77	<.001***	4.70	6.79	−1.26	0.13	−0.31	−9.46	<.001***	−1.53	−1.00
Emotional loneliness	1.56	0.20	0.26	7.86	<.001***	1.17	1.94	−0.40	0.05	−0.27	−7.98	<.001***	−0.49	−0.30
Social loneliness	0.38	0.19	0.07	2.03	.04*	0.01	0.74	−0.19	0.05	−0.13	−3.99	<.001***	−0.28	−0.10

Method = Enter. CI = confidence interval; LL = lower limit; UL = upper limit.

−0.66 = male, 0.33 = female and other.

−0.66 = female, 0.33 = male and other.

−0.66 = Dutch, 0.33 = Dutch + other group(s) and other group(s) only.

−0.66 = Dutch + other group(s), 0.33 = Dutch and other group(s) only.

−0.66 = low, 0.33 = middle and high.

−0.66 = middle, 0.33 = low and high.

p < .05; **p < .01; ***p < .001.

For the model predicting life satisfaction, the covariate-only model explained adjusted R² = .08 of the variance, increasing to adjusted R² = .35 when adding internalized autism-related stigma and emotional and social loneliness. In the full model, higher age was associated with greater life satisfaction, and gender-diverse participants reported life satisfaction levels below the overall sample mean. Education level, ethnic background, and autistic traits were not significantly associated. For the main predictors, higher internalized autism-related stigma (B = −1.26, 95% CI = [−1.53, −1.00], p < .001), emotional loneliness (B = −0.39, 95% CI = [−0.49, −0.30], p < .001), and social loneliness (B = −0.19, 95% CI = [−0.28, −0.10], p < .001) were each associated with lower life satisfaction (see Table 4).

Mediation Analyses

After covariates were added, a direct positive relationship between internalized stigma and stress, b = 5.75, 95% CI = [4.71, 6.78], p < .001, was partially mediated by both elevated emotional loneliness, b = 1.89, 95% CI = [1.32, 2.40], p < .001, and social loneliness, b = 0.41, 95% CI = [0.01, 0.80], p = .04. Similarly, a direct negative association between internalized stigma and life satisfaction, b = −1.26, 95% CI = [−1.52, −1.00], p < .001, was partially mediated by both elevated emotional loneliness, b = −0.47, 95% CI = [−0.61, −0.34], p < .001, and social loneliness, b = −0.20, 95% CI = [−0.30, −0.10], p = .04. Path coefficients of both mediation models are shown in Figure 1. The indirect pathways through emotional and social loneliness explained respectively 23.2% and 5.1% of the total association of internalized autism-related stigma with stress and 24.4% and 10.4% with life satisfaction.

Discussion

The purpose of this study was to examine whether internalized autism-related stigma was positively associated with stress and negatively associated with life satisfaction in autistic adults and whether these associations were mediated by emotional and social loneliness. Our analyses supported all hypotheses. Most notably, including internalized autism-related stigma and both types of loneliness in our statistical models markedly improved the model’s ability to explain individual differences in stress and life satisfaction, over and above characteristics such as autistic traits and education level. Therefore, our findings underscore the relevance of the PMF, and more specifically, internalized stigma and loneliness, in understanding adverse outcomes within this population.

First, consistent with the PMF, internalized autism-related stigma was associated with both stress and life satisfaction. These findings align with previous studies suggesting that autism stigma is pervasive, affecting both the autism label (Butler & Gillis, 2010; Matthews et al., 2014) and autistic behaviors (Sasson et al., 2017; Wood & Freeth, 2016). For instance, Sasson et al. (2017) reported that negative evaluations by allistic peers arise within seconds of observing autistic people. Given these findings, it is reasonable to assume that autism-related stigmas may become internalized and be negatively associated with mental health (Botha & Frost, 2018). Notably, the observed bivariate correlations between internalized stigma and our outcomes (r = .50 with stress and−.49 with life satisfaction) are consistent with prior autism studies (e.g., r = −.42 with life satisfaction; Huang et al., 2023), but stronger than those observed in other minority groups, such as r = .31 with stress in various stigmatized identities (mental illness, substance abuse, experience of domestic violence, experience of sexual assault, and experience of childhood abuse; Quinn et al., 2014) and r = −.34 with life satisfaction in sexual minorities (Gómez et al., 2021). In contrast, these relationships align more closely with a meta-analysis reporting a link of r = −.47 between internalized mental illness stigma and life satisfaction (Del Rosal et al., 2021), suggesting an additional burden faced by autistic adults due to autism being pathologized.

Further supporting the relevance of the PMF in autistic adults, we observed associations between loneliness with stress (r = .44 for emotional loneliness and .33 for social loneliness) and life satisfaction (r = −.47 for emotional loneliness and −.38 for social loneliness). These correlations were comparable to those reported in other minority groups (e.g., r = −.49 for general loneliness on stress among lesbian, gay, bisexual, and transgender (LGBT) individuals; Blankenau et al., 2022, and −.47 on life satisfaction across various stigmatized populations, such as sexual minorities and immigrants; Park et al., 2020). Collectively, our findings challenge persistent stigmas that autistic adults lack social interest (Chevallier et al., 2012; Huws & Jones, 2010; Jaswal & Akhtar, 2018), suggesting instead that they seek meaningful social connections. Notably, to our knowledge, this is only the second study to explore associations between multiple types of loneliness in autism. Schiltz et al. (2020) reported that the relationship between autistic traits and various mental health outcomes in autistic young adults was partially mediated by both social and family loneliness, but not by romantic loneliness. Taken together, these findings align with qualitative evidence. For instance, a recent review suggested that, while some autistic individuals may find fulfillment in romantic relationships alone (Strunz et al., 2016), they primarily benefit from broader experiences of ‘acceptance, understanding, acknowledgement, emotional support, empathy and inclusion’ (Lisboa White et al., 2024, p. 5).

In addition, emotional loneliness was more strongly associated than social loneliness with both stress and life satisfaction in the multiple regression model, and it also emerged as the stronger mediator between internalized autism-related stigma and these outcomes. This pattern is consistent with findings in allistic populations (e.g., Salimi, 2011; Tan et al., 2020; Wolters et al., 2023) and may reflect that emotional loneliness signals a lack of attachment figures who can buffer against threats to emotional well-being (Wolters et al., 2023) or the belief that emotionally meaningful connections are harder to form than surface-level friendships that alleviate social loneliness, making their absence more distressing (Salimi, 2011). Altogether, we recommend continuing to differentiate between types of loneliness in autism research to better understand their respective contributions to mental health outcomes.

Moreover, we found that both emotional and social loneliness mediated the relationship between internalized stigma and stress and life satisfaction. These patterns align with other research reporting mediations of loneliness on the link between internalized stigma and various outcomes in sexual and gender minorities (e.g., Garro et al., 2022; Lin et al., 2025), older adults (Pedroso-Chaparro et al., 2023), adults with HIV (e.g., Yoo-Jeong et al., 2022), and adults with psychotic disorders (Świtaj et al., 2013). However, the magnitude of our reported indirect pathways for emotional (23.2%–24.4%) and social loneliness (5.1%–10.4%) was relatively small compared to those in some of the aforementioned studies, which were generally stronger and, in two instances, represented full mediations (Lin et al., 2025; Świtaj et al., 2013). As the contributions of psychological processes within the PMF can vary between minority groups (Chan et al., 2020), other processes may provide more robust pathways in autistic adults. For instance, the only other study to examine a mediator between internalized autism-related stigma and an outcome, depression, found that this positive association was mediated for 36.7% by feelings of shame (Riebel et al., 2025). Given its known adverse effects on stress in autism (Scheeren et al., 2025), another potentially stronger pathway may be through increased social masking. Notably, however, Perry et al. (2021) found that social masking did not mediate the negative relationship between the awareness of autism stigmas and autistic adults’ life satisfaction, highlighting the need for further research.

More broadly, our findings contribute to a growing body of evidence suggesting that adverse outcomes in autistic individuals may be shaped less by inherent traits but more by ill-fitting environments and societal responses to their neurodivergence (Dwyer, 2022; Woods, 2017). Consistent with our results, prior research has shown that the degree of autistic traits has limited predictive value in explaining autistic adults’ stress (García-Villamisar & Rojahn, 2013; Muniandy et al., 2023) and life satisfaction (Muniandy et al., 2023; Pickles et al., 2020), challenging pathological models that frame these traits as a continuum of impairment. Based on a literature review, Kapp (2018) attributed these findings to different yet similarly distressing challenges within autistic individuals. For instance, while those with more pronounced traits may encounter greater challenges with daily living, those with fewer traits may be more likely to experience reduced access to services, higher societal demands, and increased stigma awareness, often resulting in increased pressure to mask their traits. Importantly, as autism is considered a spectrum and subscales of autistic trait measures tend to be only weakly interrelated (English et al., 2019), it must be noted that our modeling of autistic traits as a single overall score may have obscured constellations of traits that are more strongly linked to stress and life satisfaction. The AQ total score should therefore be interpreted as a pragmatic control for general levels of autistic traits rather than as a unidimensional construct. Therefore, while it remains important to investigate the role of distinct autistic traits in shaping mental health outcomes, our findings support further exploration of social models of adverse outcomes in autism, which advocate the need to adapt societal structures and support systems to better accommodate the needs of autistic individuals (Woods, 2017).

Strengths and Limitations

The study had three notable strengths. First, it was guided by a well-established framework in research involving minority groups (Hoy-Ellis, 2021). Second, the large sample size enhanced the statistical power of the analyses, enabling the detection of small but meaningful effects. Third, the study was led by an autistic researcher and aligned with the desire of autistic adults for more research on improving their life satisfaction (Cage et al., 2024; Putnam et al., 2023). This positioning likely enhanced the study’s sensitivity to community priorities and the practical relevance of the work.

Nevertheless, the study also had five notable limitations. First, we did not directly assess minority stressors. While the PMF suggests that internalized autism-related stigma and loneliness arise from these stressors (Hatzenbuehler, 2009), this causal pathway was inferred in our study rather than measured. Second, although we controlled for various characteristics unrelated to autistic minority stress, other unmeasured factors (e.g., breakups, serious illness) may also have contributed to participants’ stress and life satisfaction (Botha & Frost, 2018), potentially confounding our outcomes. These potential confounders include additional marginalized identities based on co-occurring conditions (e.g., neurodevelopmental or physical disabilities), which were common in our sample (44%). Third, the cross-sectional design prevents inferences about the causation and directionality of the observed relationships. For instance, it is plausible that heightened stress also contributes to increased feelings of loneliness over time (Laustsen et al., 2023; Li et al., 2023).

Fourth, the generalizability of the findings to the broader autistic population and to other cultural contexts may be limited. The sample was predominantly female, highly educated, native Dutch, and without intellectual disability. Furthermore, because participation in the NAR is voluntary and requires online registration, self-selection and digital access biases cannot be fully ruled out. In addition, the use of nationalities (e.g., Dutch) within the ethnic background response options may have conflated nationality and ethnicity and may in practice have functioned as a proxy for majority group membership rather than a strictly defined ethnic identity. Combined with the collapse of both gender and ethnicity into an ‘other’ category, these methodological decisions may have obscured important within-group differences and reduced the visibility of gender- and culturally diverse experiences. In addition, we had to exclude participants with missing data, especially those currently enrolled in education, which may have further affected representativeness. This is likely reflected in the age difference between included participants and those with missing data, as younger adults were more often still in education, thereby reducing their representation in the analyses.

Of particular interest, only 4.5% of participants reported moderate or higher levels of internalized stigma, significantly lower than those reported in other autism studies (15.4%–45.5%; Bachmann et al., 2019; Dubreucq et al., 2020; Huang et al., 2023; Riebel et al., 2025). While this warrants further caution in generalizing, these differences may also reflect cultural variations in autism stigmatization or differences in sample characteristics. Bachmann et al. (2019) and Dubreucq et al. (2020) studied participants receiving treatment, and Huang et al. (2023) and Riebel et al. (2025) used purposeful sampling through autism communities, meaning their participants may have had greater concern about autism-related stigma.

Fifth, it should be noted that the main questionnaires were not specifically designed for autistic populations, potentially compromising their validity. For example, the ISMI was developed for people with later-onset mental health conditions rather than lifelong neurodivergence (Boyd Ritsher et al., 2003). This is evident in an item asking participants whether they have fewer social contacts than before due to their autism making them look or act ‘weird’. Similarly, loneliness may be a qualitatively different experience in autistic compared to allistic people (Lisboa White et al., 2024). For instance, based on qualitative interviews, Berns (2016) suggested that reports of loneliness in autistic individuals may be less intrinsic and more driven by social norms. Likewise, Lisboa White et al. (2024) reported that autistic young people frequently alleviated these feelings by connecting with objects and animals, indicating that our loneliness scale, which primarily assessed a lack of human connections, may not have accurately captured their experience of loneliness. Future research should therefore employ measures that more accurately capture autistic experiences.

Implications for Research and Clinical Practice

Future studies should employ a longitudinal design to replicate this study’s findings with a more representative sample. Including measures of minority stressors and additional psychological processes proposed by the PMF, such as social masking (Scheeren et al., 2025) and rejection sensitivity (Feinstein, 2019), could further enrich our understanding of this framework. Moreover, incorporating potential moderators, such as autism community connectedness (Botha et al., 2020), self-understanding (Huang et al., 2023), and self-compassion (Riebel et al., 2025), could reveal which factors buffer or exacerbate the impact of minority stressors and inform tailored interventions. Finally, we recommend examining the role of intersectionality to better understand how having multiple minority identities influences experiences of minority stress in autistic adults.

Regarding interventions targeting internalized autism-related stigma and loneliness, we suggest a shift in focus may be needed. Existing interventions for these challenges have primarily focused on coping strategies, such as compassion-focused therapy for internalized autism-related stigma (Riebel et al., 2024) and peer support groups for loneliness (Bourdeau, 2019; Hillier et al., 2017). However, these approaches do not address the minority stressors that may underlie these experiences (Cleary et al., 2023). While such interventions can be beneficial at the individual level, we emphasize the need to evaluate macro-level strategies that can reshape societal attitudes. Promoting neurodiversity by researching and advocating for the PMF, rather than a pathological model, may offer a pathway to achieving this (Pellicano & den Houting, 2021; Walker, 2021, 2023).

Footnotes

ORCID iDs

Alvin van Asselt

Yvette Roke

Sander Begeer

Anke M Scheeren

Ethical Considerations

Ethical approval was obtained from the ethics committee of the Vrije Universiteit Amsterdam (approval number 2013/45).

Consent to Participate

If participants consented digitally before completing surveys.

Author Contributions

Alvin van Asselt: Conceptualization; Formal analysis; Methodology; Project administration; Writing—original draft.

Yvette Roke: Conceptualization; Methodology; Writing—review & editing.

Sander Begeer: Conceptualization; Methodology; Writing—review & editing.

Anke M Scheeren: Conceptualization, Methodology; Writing—review & editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data used in this study can be requested from info@nederlandsautismeregister.nl, subject to reasonable request and approval.

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