Recentering Environmental Context in the Conceptualization of Borderline Personality Disorder among Sexual and Gender Minority Individuals

Borderline personality disorder (BPD) prevalence is higher among sexual and gender minority (SGM) individuals compared with cisgender heterosexuals; SGM individuals are additionally diagnosed with BPD more frequently in clinical settings. There appears to be a small effect of clinician bias—particularly for gender minority individuals. However, it does not fully explain this observed psychiatric disparity. In the current article, we review the historical origins of the borderline personality disorder diagnosis as well as present-day conceptualization of the disorder. The theory, research, and treatment of BPD overwhelmingly reinforces an intra-individual deficit framing of the etiology and maintenance of the disorder. However, predominant conceptualizations of the disorder fail to adequately contend with the pernicious, inflexible, and stable impacts of minority stress processes that SGM individuals face, rooted in societal heterosexism and cisnormativity. The sources of oppression SGM individuals face are ostensibly different from the individual-level invalidation that is most typically discussed in relation to BPD. We review each of the nine BPD diagnostic criteria, demonstrating their close associations with SGM-relevant minority stress processes. We also briefly discuss dimensional models of BPD and how they too confound adaptations to minority stress processes with assumptions about intra-individual developmental deficits in the normal developmental process. We posit that societal heterosexism and cisnormativity create strong social forces and pressures, the adaptations to which engender behaviors that overlap with the BPD phenotype. We end discussing clinical implications of the limited utility of the BPD diagnosis when working with SGM individuals and directions for future research.