Transgender and Gender Diverse Patients Are Diagnosed with Borderline Personality Disorder More Frequently Than Cisgender Patients Regardless of Personality Pathology

Potential Harm in the Psychological Treatment of Sexual and Gender Minority Youth

Sexual and gender minority (SGM) individuals show disproportionately high rates of mental distress relative to their cisgender, heterosexual peers resulting from minority stress, or unique identity-related stressors. The majority of research on minority stress and mental health in SGM individuals has focused on adults, a notable gap given that SGM youth face unique developmental factors that intersect with identity development and availability of support resources. SGM youth therefore represent a critical population for the mental health workforce to serve competently. Mental health providers risk significant harm to their SGM youth clients if they do not understand the mechanisms underlying mental health disparities in this population. This article will review treatment practices that carry the potential for harm with SGM youth, including harms that are more overt and attempt to change SGM identities (i.e., so-called "conversion therapies"), and others that are more covert, such as neglecting to consider SGM identity in conceptualization and treatment (e.g., eating disorders), pathologizing SGM identity and behaviors (e.g., personality disorders, social anxiety), and reinforcing stigma related to SGM identities (e.g., obsessive-compulsive disorder). Accordingly, this article reviews each of these potential harms in detail and provides alternative recommendations for affirming and justice-based treatment for SGM youth.

"I don't think I have been out of fight or flight. Ever." Transgender people's experiences in inpatient psychiatric treatment

BACKGROUND

Historically, marginalized groups have been deemed unwell and deserving of correction, resulting in disproportionate use of inpatient psychiatric institutionalization. Despite changes over the last hundred years, individuals from marginalized groups continue to experience poor treatment in inpatient psychiatric settings. Transgender people are marginalized in a society where it is assumed that all individuals exist solely as woman or man with predetermined roles influenced by innate biology based on their sex assigned at birth, i.e. gender essentialism. This contributes to mental health disparities (e.g., depression, anxiety, suicidal thoughts, and suicide attempts), which may result in higher acuity symptoms, leading to overrepresentation in inpatient psychiatric settings. Yet, little is known about transgender people's experiences during inpatient psychiatric treatment.

OBJECTIVE

To describe the experiences of transgender people in inpatient psychiatric treatment.

DESIGN

A qualitative descriptive study.

SETTING

Interviews were held in person or over Zoom.

PARTICIPANTS

Adults who self-identified as transgender and had been admitted to inpatient psychiatric treatment during the last five years were recruited to participate through community organizations, social media, and word of mouth.

METHODS

Semi-structured interviews were conducted between March 2019 and June 2022. Data were analyzed using thematic analysis.

RESULTS

Participants (N = 15) described experiences within inpatient psychiatric treatment. The first theme, gender essentialism causes stigmatizing experiences through structural and enacted power, was characterized by deliberate or accidental misgendering, gender treated as irrelevant to care, pathologized gender diversity, and withholding of gender-affirming needs. The second theme, psychological and emotional strain as the price paid for enforced gender essentialism, included examples of drained emotional resources, powerlessness, and worsening of gender dysphoria. Lastly, the theme actions in disruption of the structural gender essentialist power illustrated how the gender essentialist systems in place can be interrupted and resisted by transgender patients and healthcare professionals.

CONCLUSIONS

Power structures are embedded in psychiatric hospital policies and practices, as well as the physical layout of the hospital, operating under the assumption that all patients are either man or woman based on their sex assigned at birth. Healthcare professionals may unintentionally or deliberately reinforce these structures, further marginalizing transgender patients. Healthcare professionals have the opportunity to disrupt these harmful systems by advocating for and implementing changes that challenge gender essentialism. Creating care environments that incorporate gender diversity allows transgender individuals to focus on their mental health and recovery, rather than expending emotional resources navigating a system that overlooks or invalidates their identities.

SOCIAL MEDIA ABSTRACT

Inpatient psychiatric treatment reinforces gender essentialism, subjecting transgender patients to stigma and mistreatment. Participants described experiences of frequent misgendering, dismissal of gender-affirming needs, and emotional strain from navigating a system designed for non-transgender patients, leading to worse mental health symptoms, including gender dysphoria, and feelings of powerlessness. Healthcare professionals reinforce these harmful systems deliberately or unintentionally. However, instances of disruption by healthcare professionals and transgender participants were observed leading to the creation of affirming experiences despite the prevailing gender essentialism. Future opportunities to disrupt these structures include advocating for systemic change, engaging in patient-centered care, and developing inclusive policies. By creating inpatient psychiatric environments that accommodate gender diversity, healthcare providers could allow transgender patients to focus on their mental health and recovery, rather than combating stigma. Inclusive care can shift the focus from navigating systemic transphobia to healing.

Stigma, Situational Triggers, and Symptoms: How Providers Justify Borderline Personality Disorder Among Sexual and Gender Minority Individuals

Borderline personality disorder (BPD) is disproportionately diagnosed among sexual and gender minority (SGM) individuals relative to cisgender heterosexuals. However, research aimed at understanding the reasons for this disparity is scarce. The current study employed a mixed-methods design to understand how mental healthcare providers' justifications for the BPD diagnosis differ based on the SGM status of the patient described and their own professional backgrounds. Two hundred seventy-one providers who were randomly assigned to one of three identical vignette conditions, with SGM status manipulated, indicated their agreement with the BPD diagnosis and explained the reason for their agreement. Results from thematic content analyses illustrated that providers referenced three themes when explaining their agreement with the BPD diagnosis: (1) BPD as provisional, (2) BPD as certain, and (3) BPD criteria met. Providers referenced a greater variety of themes to explain their disagreement with the diagnosis: (1) situational factors, (2) insufficient time course, (3) diagnostic criteria unmet, (4) insufficient assessment information, (5) differential diagnosis, (6) developmental immaturity, and (7) stigma concerns. None of these justifications were differentially employed based on the SGM status of the vignette. However, differences were observed based on providers' backgrounds; psychologists more frequently cited concerns about time course, developmental immaturity, and having insufficient assessment information than psychiatrists, counselors, and social workers in disagreeing with the BPD diagnosis. Implications for reducing BPD diagnostic bias are discussed.

Prevalence of Personality Disorder Diagnoses in People Referred to Specialized Gender Identity Clinics in Finland

A higher prevalence of personality disorder diagnoses has been found among individuals with gender dysphoria. However, previous studies on this topic have been limited and methodologically inconsistent. The object of this research was to determine the prevalence of personality disorder diagnoses in individuals requesting medical gender reassignment. A registerbased follow-up study tracked individuals who contacted the nationally centralized gender identity services in Finland in 1996-2019 (n = 3,665) and 8:1 age- and sex-matched population controls (n = 29,292). All their specialist-level psychiatric treatment contacts in 1994-2022 were identified in the National Care Register for Health Care. ICD-10 diagnoses and dates of the contacts were extracted. Among the gender dysphoria group, 15.0% (551 out of 3,665) had received a diagnosis in the personality disorder group (F60-69 excluding F64.x), while among the control subjects, 2.1% (625 out of 29,292) had received such a diagnosis.

Examining Associations of Borderline Personality Disorder Symptoms and Eating Disorder Diagnoses: Results From a US Representative Sample

OBJECTIVES

Borderline personality disorder (BPD) and eating disorders (EDs) are common comorbid diagnoses. Given the various combinations of borderline personality disorder symptoms (BPDS) that can comprise a diagnosis, understanding whether specific BPDS are more likely to be associated with an ED (anorexia nervosa [AN], bulimia nervosa [BN], and binge eating disorder [BED]) is important for the conceptualization and treatment of BPD-ED comorbidity.

METHODS

This study used data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) study, a nationally representative dataset of US adults (N = 36,309). The association of BPDS with EDs, compared with psychiatric and healthy control groups, was examined in two binomial and two multinomial (i.e., with all ED diagnoses) models.

RESULTS

Compared with the healthy control group, affect instability, emptiness, impulsivity, self-injurious behaviors, and unstable relationships were positively associated with any ED diagnosis (AN, BN, or BED). Compared with the psychiatric control group, impulsivity was positively associated with any ED diagnosis. In the multinomial model with the healthy control group, impulsivity and self-injurious behaviors were positively associated with AN, BN, and BED, emptiness was positively associated with AN and BED, and unstable relationships and affect instability were positively associated with BED. In the multinomial model with the psychiatric control group, self-injurious behaviors were positively associated with AN, and impulsivity and affect instability were positively associated with BED.

DISCUSSION

Results suggest certain BPDS may be more common with certain EDs (AN, BN, and BED), even when controlling for other EDs and a psychiatric control group.