Borderline Personality Disorder (BPD) is often marked with a certain and greater stigma than other mental illnesses – represented both in clinician care and day-to-day life.1 The disorder is also more prevalent among lesbian, gay, and bisexual (LGB) individuals, an already marginalized and often stigmatized group. Research shows that bias toward diagnosis of BPD among LGB individuals is multifaceted, inclusive of:1-5

  • overestimation of behaviors that serve as the basis for criterion prescribed to a BPD diagnosis
  • higher rates of BPD being assigned to non-heterosexual individuals who present with the same vignettes as their heterosexual counterparts
  • the implicit assumption that LGB individuals are more prone to and more likely to have mental disorders than their heterosexual counterparts
  • a failing to recognize the ways in which societal pressures toward and among an LGB persons may manifest in behaviors easily attributable to, but not directly related to, a BPD diagnosis.

Researchers have sought to study the basis and implications of these clinical habits. Being cognizant of these  tendencies – whether conscious or unconscious – and having strategies to better engage with a non-heterosexual patient population can improve clinical practice and better serve the patient community at large.

Analyzing Provider Bias in Borderline Personality Disorder Diagnoses

Two recent papers published by Rodriguez-Seijas et al examine diagnostic practices in relation to BPD in LGB individuals. The first paper, Is There a Bias in the Diagnosis of Borderline Personality Disorder Among Lesbian, Gay, and Bisexual Patients, published in 2020, sought to understand whether clinicians may be predisposed to provide a BPD diagnosis to sexual minority patients, independent of their presenting psychopathology.2 To assess this, the researchers used an analytical sample of 1,099 cisgender participants from the Methods to Improve Diagnostic Assessment and Services (MIDSAS) Project. Just over 83% of this population self-reported as heterosexual and 16.4% self-reported being of a sexual minority (gay, lesbian, or bisexual).

To discern if clinicians provided a BPD diagnosis at a higher frequency to sexual minority patients (regardless of underlying psychopathology), the researchers compared clinician diagnoses with patients’ reports of elevated maladaptive personality domains. The clinician diagnoses were conducted either by unstandardized clinician assessment or by structured clinical interviews based on the Structured Interview for DSM-IV Personality Disorders. Maladaptive personality trait domains were assessed using the Personality Inventory for DSM-5 Brief Form (PID-5 BF). The diagnosing clinicians were given information about patient sexual orientation both before and during the assessment.

The results of this study showed that clinicians did indeed assign a BPD diagnosis to sexual minority individuals at a higher rate than their heterosexual counterparts. Across the entire sample of patients, BPD was diagnosed in 230 (21%) individuals. A greater proportion of sexual minority patients were diagnosed with BPD compared to heterosexual patients (35.0% compared to 18.2%.) However, when the diagnosis was based on patients’ reports of elevated maladaptive personality domains, fewer patients met the criteria for BPD diagnosis than when diagnosed via clinician assessment.

Lead author Craig Rodriguez-Seijas, PhD, an assistant professor of psychology at the University of Michigan Ann Arbor, tells Psycom Pro that, “The hard part is structural determinants of health. At the end of the day, the person coming in is experiencing some degree of distress and if the criteria for a BPD diagnosis are present, it may be an appropriate diagnosis, but there seems to be another layer at the level of clinician bias. When two patients present with the same clinical information and the person is gay, lesbian, or bisexual, they might get a diagnosis of BPD, whereas if the person is heterosexual, they might get an anxiety disorder, for example.”

Are There BPD Criterion-Level Biases among Clinicians?

The second study by Rodriguez-Seijas’ team, A Population-Based Examination of Criterion-Level Disparities in the Diagnosis of Borderline Personality Disorder Among Sexual Minority Adults, examined the degree to which bias exists in the assignment of BPD criteria among patients of minority sexual orientation status.3 This study, published in February 2021, used a population-based sample to compare:

  • differences in BPD diagnosis prevalence
  • differences in assignment of BPD diagnostic criteria based on sexual minority status
  • the extent to which differences in BPD criterion item assignment were explained by disparities in core transdiagnostic dimensions of psychopathology related to sexual minority status.

The researchers used data from the National Epidemiologic Survey on Alcohol and Related Conditions–III (NESARC-III) and included individuals meeting any of the nine criterion domains used for BPD diagnosis according to the DSM-5; these criteria were assessed using the 18 items in the NESARC-III.

Dr. Rodriguez-Seijas said he believes that provider bias can exist when a diagnosis is made without consideration of cultural and societal influences. He explains, “The criteria themselves seem to fit the diagnostic category, however, what meets the potential for that criterion needs to be accessed within the scope of each person’s sexual orientation and how that sexual orientation affects the expression of identity. Even beyond sexual orientation,” he noted, “the provider should consider how expectable and ‘normal’ a person’s behaviors are, based on their life and history. It’s about understanding what the criteria are meant to represent and if the exhibited behavior matches that representation.”

The Transdiagnostic Model: Disease Diagnosis Versus Underlying Cause

In their second study, Dr. Rodriguez-Seijas and colleagues were primarily interested in comparing traditional methods of diagnosis with the transdiagnostic methods. The traditional taxonomy of psychopathologies can be exemplified by comprehensive compendia of psychiatric diagnoses such as the DSM and the International Classification of Diseases (ICD). While these manuals are continuously updated to meet recent research and establish more accurate criteria for diagnoses, a growing consortium of behavioral and mental health professionals support the use of a “transdiagnostic approach” that puts a greater emphasis on the underlying causes of a “disease” rather than the diagnosis itself.4

“I don’t necessarily think of the transdiagnostic model itself as helping to combat against biases; I do think it could improve diagnostic outcomes,” explains Dr. Rodriquez-Seijas. “Rather than having all this variability in different disorders, the transdiagnostic model is asking, ‘What if we really understood what’s underneath them?’”

In their second study, his team first calculated the bivariate odds of a BPD diagnosis and endorsement of any criterion as a function of sexual minority status. Next, they repeated the same calculation, controlling for levels of transdiagnostic factors across groups by statistically modeling these transdiagnostic factors based on comorbidity patterns. They then controlled for those factors by ensuring that the groups were statistically equal. Finally, the team repeated the same analysis but used a more stringent estimation of BPD diagnosis and criterion item endorsement. This final analysis required that all criteria be associated with significant stress or impairment to be considered for diagnosis.

“We found that when the underlying transdiagnostic pieces were equal among LGB and heterosexual groups, homosexuals were diagnosed with BPD at higher rates,” says Dr. Rodriguez-Seijas. In brief, the results showed:

  • The majority of the diagnostic criteria do not show bias at the population level.
  • The reason for higher criterion endorsement seems to be from elevations in transdiagnostic psychopathology experienced by sexual minorities.
  • When significant stress or impairment was required to assign criteria, both BPD diagnoses and bias of diagnosis greatly decreased.

How Should the Mental Health Professional Proceed When Treating LGB Patients?

When assessing for borderline personality disorder in LGB patients, clinicians should “proceed with caution,” advises Dr. Rodriquez-Seijas. “Treatment [ie, behavioral approaches] for a person who is diagnosed with BPD versus the person who is not isn’t radically different, but it is a caution, because some clinicians may focus more on that biological piece. Helping an already marginalized individual understand that their behaviors don’t define them, but rather, developed as a function of challenging circumstances (such as homophobia) may be more helpful. Clinicians may want to focus more on this aspect of learned behavior.”

Although medications may be used to treat comorbidities such as anxiety or depression, there is no indicated pharmacological treatment for BPD.5 Dr. Rodriguez-Seijas notes, therefore, that addressing the underlying causes of behavioral maladjustments are often the best way to treat the patient and urges clinicians to view these behaviors in the context of the patient’s life.

As an example, he discusses the assignment of impulsivity criteria regarding condom use in gay men. “In my experience, it’s often a habitual way of not being assertive and it just shows up in this way. [A patient may state:] ‘I want to use a condom but I’m afraid of being rejected’ and in that situation, I would intervene differently than I would if it’s a case of impulsivity. This is an example that I’ve seen somewhat frequently and for me, falls more into a social anxiety bucket than an impulsivity and BPD diagnosis.”

Professional Takeaways

It’s no secret that psychiatric disorder diagnoses are a complicated and imperfect part of mental health care.

While a transdiagnostic approach may be the way of the future, Dr. Rodriguez-Seijas adds, “We are in the diagnostic system we are in right now; it’s used for insurance, it’s used for billing, so we more or less have to provide one. I’m hopeful that one day we will move to a system where the way we think about a diagnosis changes: we don’t have evidence that these diagnoses themselves have qualities, which make them as distinct as we think.”

For the diagnosing clinician, the best approach may be a dual understanding of care. It’s important not only to understand one’s own biases but also how an individual’s behavior is shaped by their navigation of societal biases and cultural demands. Particularly in relation to borderline personality disorder, the clinician should consider the significance of behaviors in the context of that individual’s unique set of life experiences.

Last Updated: May 7, 2021