An Examination of Gender and Sexual Orientation Bias in Personality Pathology Diagnosis

Abstract

In addition to replicating examinations of gender bias in the diagnosis of all cluster B personality disorders (PDs), this is the first study to examine the extent to which patient sexual orientation biases the diagnosis of antisocial, histrionic, and narcissistic PDs as well as whether or not such sexual orientation bias differs by patient gender. Furthermore, this study is the first to examine how such gender and sexual orientation biases are moderated by (1) the model of personality pathology used (i.e., traditional DSM vs. dimensional Alternate Model of Personality Disorders [AMPD]) and (2) measurement specificity (i.e., global PD measurement vs. symptom-level measurement). To undertake these examinations, it utilized a vignette describing a patient whose gender identification (man or woman) and sexual orientation (heterosexual or gay/lesbian) were experimentally manipulated. Clinicians (N=435) were randomly assigned to examine one of the resultant four vignettes, after which they each completed three measures of personality pathology. Though there was evidence of gender bias, such bias was twice-to-four times as weak as gender bias found in past similar studies. There was no evidence of significant diagnostic bias based on patient sexual orientation and sexual orientation bias did not differ by patient gender. Broadly, neither gender nor sexual orientation bias was moderated by the model of personality pathology underlying the measures used, by the specificity with which the pathology was measured, or by clinician characteristics (i.e., age, gender, sexual orientation, licensure status, race). Results suggest a decrease in gender and sexual orientation bias within experimental contexts relative to that which was found by prior studies. Further examinations should elucidate the mechanisms moderating diagnostic bias.

Bias in the diagnosis of borderline personality disorder among sexual and gender minority persons: Results from a vignette-based experiment

“…Only two studies to date have examined bias in the diagnosis of BPD for SGM populations by experimentally controlling for clinical presentation, to equivocal ends (Assaad & Samuel, 2022;Eubanks-Carter & Goldfried, 2006). While Eubanks-Carter and Goldfried (2006) found that clinicians more frequently diagnosed BPD among vignettes reflecting a gay/bisexual man, Assaad and Samuel (2022) found no significant differences in BPD diagnosis based on sexual minority status. However, the nature of the vignettes used in these studies differed substantially.…”

“…Eubanks-Carter and Goldfried (2008) used a vignette that reflected typical behaviors and experiences that are common among both sexual minority and BPD populations including efforts to avoid abandonment, unstable and intense relationships, unstable self-image, impulsivity, suicidality, affective instability, feelings of emptiness, and difficulty controlling anger; however that vignette was not designed as a definitional depiction of BPD. In comparison, Assaad and Samuel (2022) adapted a standard vignette that depicts symptoms of cluster B personality disorders that was created to represent a patient with BPD. Thus, Assaad and Samuel used a vignette that definitionally describes a patient deserving of the BPD diagnosis whereas Eubanks-Carter and Goldfried described a case that was not created as a depiction of BPD per se but as a depiction of common psychosocial experiences SM individuals might face.…”