Gender Matters: Bias in Borderline Personality Disorder Diagnosis
How do you define promiscuity? How many partners does a man have to have to be considered promiscuous? How many partners does a woman have to have? Are the numbers different? Are women held to a higher standard of sexual purity than men? In psychiatry, this is not a theoretical exercise, but an integral part of diagnostic procedures, and bias in how behaviors are perceived based on gender can impact how diagnoses are made.
The Diagnostic and Statistical Manual of Mental Health Disorders, or DSM, is the defining text on psychiatric illnesses. According to the DSM, sexual impulsivity is one of several diagnostic criteria for Borderline Personality Disorder. Indeed, researchers have found that “those with borderline personality disorder are more likely to exhibit greater sexual preoccupation, have earlier sexual exposure, engage in casual sexual relationships, report a greater number of different sexual partners as well as promiscuity, and engage in homosexual experiences.”[1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3071095/] However, social tolerance for sexual behavior is different for men and women. Sexual preoccupation, for example, is often seen as a natural, normal, and even healthy state for men, whereas for women it is taken as a sign of underlying issues. A man going on Tinder looking for casual sex is just another Tuesday, whereas a woman doing the same must surely have some deep trauma in her past that is causing her to act out sexually. Conversely, same-sex experimentation is much more highly tolerated amongst women, giving social permission for engaging in homosexual experiences that is not enjoyed by men. Is it possible, then, that the threshold for pathologizing sexual experiences is lower for women than for men? And how does this impact diagnostic practice?
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Evidence of Bias
75% of people diagnosed with Borderline Personality Disorder are women. The reasons for this significant overrepresentation of women are unknown; there may be biological and psychosocial factors that predispose women to BPD. One possibility, for example, is higher rates of childhood sexual victimization among girls leading to the development of maladaptive personality formation. Women may also be socialized to express anger inward and participate in self-harm, while men are encouraged to outwardly direct their frustrations. However, there is compelling evidence that diagnostic gender bias may be a contributing factor in the striking disparity between male vs. female BPD diagnosis. A study published in Comprehensive Psychiatry provided clinical profiles that fit the criteria for a variety of personality disorders to 46 clinicians, and asked them to classify the presentation of the client. Although the client profiles were identical, those clinicians who were told the client was a woman were significantly more likely to provide a diagnosis of Borderline Personality Disorder.[2. http://www.ncbi.nlm.nih.gov/pubmed/2311380] A similar study published several years later in Professional Psychology: Research and Practice surveyed 1,080 clinicians and reached similar conclusions.[3. http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=1994-29756-001] Some research has also found that the gender of the clinician affects bias, and that female clinicians are more likely to identify women’s behavior as indicative of BPD.[4. http://www.researchgate.net/publication/263557753_Why_Are_Women_Diagnosed_Borderline_More_Than_Men_The_Fifteenth_Annual_New_York_State_Office_of_Mental_Health_Research_Conference]
The Importance of Accurate Diagnosis
Borderline Personality Disorder is a deeply disruptive mental health disorder that damages your ability to maintain healthy interpersonal relationships and leaves you feeling profoundly vulnerable. The pain caused by BPD can impact every area of your life and impair your ability to navigate through the world in a normal way. It is crucial that men who suffer from BPD are recognized, supported, and encouraged to access treatment to help restore function and quell emotional upheaval. Simultaneously, women’s normal emotional and behavioral experiences must not be pathologized; accurate diagnosis is essential to finding effective treatment–and if you receive a flawed diagnosis you will not have the tools you need to heal. Seeking out experienced clinicians with the expertise and progressive outlook that will allow them to provide an accurate diagnosis without dismissing your symptoms due to gender bias is the first step toward recovery. Only through true diagnostic clarity and a treatment plan that addresses the full scope of your distress can you move toward meaningful, lasting healing. Connecting with clinicians whose judgment you trust is vital to resolving your emotional suffering and establishing a trusting, productive therapeutic relationship in which you can gain the skills and insight to flourish.
Bridges to Recovery offers in-depth assessments to gain a complete picture of your symptoms and offer accurate diagnosis. Contact us to learn more about how our treatment program can help you heal from Borderline Personality Disorder or any other mental health disorder.