A Population-Based Examination of Criterion-Level Disparities in the Diagnosis of Borderline Personality Disorder Among Sexual Minority Adults

Abstract

Sexual minority individuals are diagnosed with borderline personality disorder (BPD) at higher proportions than heterosexual individuals regardless of presenting psychopathology. It is unclear if such bias is reflective of diagnostician idiosyncrasies or population-based diagnostic/criterion bias. Data from the National Epidemiologic Survey on Alcohol and Related Conditions–III were utilized to examine if differences in BPD endorsement were related to/independent of transdiagnostic factor differences between sexual minority and heterosexual individuals. BPD diagnosis/criterion endorsement was higher among sexual minority compared with heterosexual individuals (odds ratios = 1.47-3.82). Furthermore, when dysfunction/impairment associated with criterion endorsement was ignored, endorsement disparities were magnified. Diagnostic/criterion differences were mostly explained by transdiagnostic factor differences associated with sexual minority status, with some notable exceptions. These results suggest that the predilection toward BPD diagnosis among sexual minority individuals does not appear reflective of criterion-related bias. They further highlight the importance of understanding group-specific forms of psychiatric malaise and reinforce the importance of cultural humility for equitable assessment. These results further raise questions pertaining to the conceptualization and epistemology of BPD as it relates to sexual minority individuals.

The roles of discrimination and social support in the associations between outness and mental health outcomes among sexual minorities.

“…The high proportion of our sample that met the cutoff for a possible BPD diagnosis may have been due to the high proportion of our sample that identified as bisexual/pansexual. Previous research has found that bisexual/pansexual individuals report more severe psychopathology (Matsuno et al, 2020) and greater rates of BPD compared to other sexual minority individuals (Rodriguez-Seijas et al, 2021b), and this result likely is not a simple measurement issue due to items such as identity disturbance. Consistent with these findings, the bisexual/pansexual participants in our sample were more likely to meet the cutoff for possible BPD than were the other sexual minority participants in our sample.…”

“…These symptoms may be particularly impactful for sexual minority groups, as chronic experiences of marginalization may result in psychosocial challenges as well as the maladaptive coping strategies that are implicated in BPD. Researchers have suggested that these behaviors, which overlap with BPD symptoms, may be forms of emotion dysregulation in response to minority stress rather than a function of BPD per se (Rodriguez-Seijas et al, 2021b). Sexual orientation also remains significantly associated with BPD features, even after controlling for depression and anxiety (Reuter et al, 2016).…”

Sociocultural Context and the DSM-5 Alternative Model of Personality Disorder: Comment on Widiger & Hines

“…My clinical training lies in the provision of evidence-based, affirming care to sexual and gender (SGM) populations (e.g., Rodriguez-Seijas, Burton, et al, 2019) and in training graduate students in conceptualizing psychopathology with an eye to sociocultural context. Most recently, my research has broadened into the personality disorder realm, focusing on issues related to assessment and diagnosis of borderline personality disorder among SGM populations (e.g., Rodriguez-Seijas et al, 2021a, 2021b. On a personal level, I possess several minoritized identities including sexual and racial/ethnic minority, and immigrant statuses.…”

“…For instance, borderline personality disorder is Running Head: Sociocultural Context & AMPD 8 identified as reflecting the core of personality pathology and overlaps with the LPF in several ways. We've previously suggested that sociocultural context might explain several borderline personality disorder criteria among SM populations (Rodriguez-Seijas et al, 2021a. 2021b.…”

Traumatic invalidation as a pathway to emotional dysregulation in sexual and gender minorities—For some: Comment on Cardona, Madigan, and Sauer-Zavala (2022).

“…However, extrapolating the argument to conclude that SGM individuals may be “hardwired” to heightened sensitivity would risk perpetuating essentialist and stigmatizing stereotypes. The literature suggesting that sexual minority individuals are diagnosed with BPD more than heterosexual individuals also points to potential bias and cultural insensitivity in the diagnostic process, and that bisexual individuals, in particular, are more often diagnosed with BPD (Rodriguez-Seijas et al, 2021a, 2021b). Eubanks-Carter and Goldfried (2006) found, in an analogue study, that clinician’s diagnosed BPD when case descriptions presented the individual endorsing criterion symptoms as gay male more than when the “client” was presented as a woman or not a sexual minority.…”