Friday, August 16, 2013

Gender Identity and Sexual Orientation in Women with Borderline Personality Disorder

I’m still searching for more research on developing a more solid personality when you have BPD (bus as of right now it does not look promising). However I did find this interesting piece on Gender Identity and Sexual Orientation in Women with BPD.

Gender Identity and Sexual Orientation in Women with Borderline Personality Disorder

Devita Singh MA1, Shelley McMain PhD2, Kenneth J. Zucker PhD1,*
Article first published online: 3 NOV 2010
The Journal of Sexual Medicine
Volume 8, Issue 2, pages 447–454, February 2011


Borderline personality disorder (BPD) is a complex psychiatric condition that has received an enormous amount of theoretical and empirical attention. In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, text revision (DSM-IV-TR), the polythetic diagnostic criteria for BPD consist of nine symptoms, of which five (or more) are required for a categorical diagnosis.

One diagnostic criterion for BPD pertains to a disturbance in “identity”. Indeed, Jørgensen has argued that identity disturbance, along with unstable relationships, are at the core of “borderline pathology.” In one study, 86% of BPD patients met the criterion for an identity disturbance at a baseline assessment . In DSM-III, identity disturbance was operationalized as an “uncertainty about several issues . . . such as self-image, gender identity, long-term goals or career choice, friendship patterns, values, and loyalties. . .” (p. 323). In DSM-III-R, it was described as an “uncertainty about at least two of the following: self-image, sexual orientation, long-term goals or career choice, type of friends desired, [or] preferred values” (p. 347). In DSM-IV-TR, it was simply characterized as a “markedly and persistently unstable self-image or sense of self” (p. 654).

Given that gender identity is such a core aspect of a person's sense of self, it is surprising that this aspect of identity formation has received relatively little attention in the empirical literature on BPD. Of note, the DSM-III explicitly mentioned gender identity as a potential site of identity disturbance in patients with BPD. Interestingly, however, reference to gender identity was removed from the possible examples of identity disturbance in DSM-III-R (perhaps replaced by uncertainty about sexual orientation), and there was no explicit reference to gender identity or uncertainty about sexual orientation in the DSM-IV-TR. However, in the text, there was reference to “sudden and dramatic shifts” in self-image that included “changes in. . . sexual identity.” Across these three editions of the DSM, the diagnostic criterion for a disturbance in “identity” has become more generic (with no specific examples), and the variation in text examples has not been formally explained or justified.

I imagine this is such a difficult issue to decide upon because this is something that many people struggle with even without personality disorders. It’s something that could be happening completely independently of personality disorder and it perhaps isn’t something that should be confused or occluded with these issues. On the other hand, if it’s not something that is inherent to a person’s personality and they are, perhaps simply being histrionic and acting out, then it may be indicative of a personality disorder trait….

Most of you will know by now that I am not heterosexual. I consider myself pansexual. I do not subscribe to the gender binary so I don’t consider myself bisexual. At times even my gender identification has been fluid from female to neutral (never male). However at no point have I ever, EVER, considered this a part of my personality disorder. I still don’t. I am not confused about this and this is something in particular, for me, that I do feel very strongly about. This is something that is actually a very stable, determined aspect of my personality.

To our knowledge, only one empirical study has examined for the possible presence of gender identity confusion or disorder in patients with BPD. Wilkinson-Ryan and Westen asked clinicians to provide ratings on a 1–7-point scale for 35 possible indicators of identity disturbance in 34 patients (82% female) with BPD, 20 patients (50% female) with another personality disorder (PD), and 41 patients (66% female) with no PD. For the item “Patient appears conflicted or unsure about own gender,” Wilkinson-Ryan and Westen reported that it had a factor loading of 0.54, one of 10 items that contributed to a factor labeled Role Absorption. Patients with BPD received higher ratings for this item (mean [M], 2.42; standard deviation [SD] = 1.73) than patients with another PD (M, 1.90; SD = 1.55) or no PD (M, 1.66; SD = 1.43), but only the contrast between the BPD patients and the patients with no PD was statistically significant. Of the 35 indicators in total, gender identity conflict had a relatively low severity ranking (32). This finding suggests that uncertainty about gender identity may not be a particularly salient aspect of identity disturbance in patients with BPD; however, because assessment of identity disturbance indicators was made by clinicians, it is not clear to what extent patients would have similar appraisals of their relative salience.

There is also a small literature regarding the sexual orientation of people with BPD. Several studies have reported an overrepresentation of either a bisexual or homosexual sexual orientation among men with BPD . However, the literature on women with BPD has been more variable: some studies have not found a significant overrepresentation of a bisexual or homosexual sexual orientation but others have.

I’ve actually talked about this quite a bit in the past. You can find some of those blogs articles here.

Reich and Zanarini ; B. Reich, personal communication, December 3, 2009) employed several metrics of sexual orientation (sexual identity self-labeling, interpersonal sexual experiences, and a fluctuation or change over time in these two parameters) in a sample of 290 inpatients (83% female) with a BPD diagnosis, and 72 inpatients (63.9% female) with some other type of PD. The percentage of both men and women who self-reported either a bisexual or a homosexual sexual orientation was about twice as common in the BPD patients compared with the patients with another PD (men, 29.8% vs. 11.5%; women, 26.6% vs. 15.2%). The percentage of BPD patients who had had a same-sex relationship was also substantially higher than that of the comparison group. In the BPD group (and, to a lesser extent, the PD group), the percentage who self-identified as either bisexual or homosexual was substantially higher than the rates reported on in epidemiological survey studies. In another recent study, Schulte-Herbrüggen et al. reported that 30.1% of 45 women with BPD, treated as inpatients, self-identified as bisexual or homosexual, compared with 20% of 30 healthy control women, a nonsignificant difference at P = 0.11.

**The aims of the present study were two-fold: (i) to assess the presence of gender identity confusion/gender dysphoria or frank gender identity disorder (GID) using dimensional measurement in a sample of female patients with BPD; and (ii) to assess self-reported sexual orientation. There are a couple of reasons why it is important to assess both of these psychosexual constructs in the same sample. First, the literature on gender identity in lesbians suggests that there may be a subgroup who manifest some signs of gender dysphoria or gender identity confusion, although they may not meet complete diagnostic criteria for GID. For example, Lee reported that there were both similarities and differences in gender-related phenomenology in “butch” lesbians and female-to-male transsexuals (see also Diamond and Butterworth ). Second, if a non-heterosexual sexual orientation is elevated among women with BPD, it is possible that signs of gender dysphoria may be more common among those women who are either lesbian or bisexual compared with those who are heterosexual.

In two previous studies that we have conducted, Deogracias et al.  and Singh et al. reported on the psychometric properties of a self-report, dimensional measure of gender identity/gender dysphoria, the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ).

In Deogracias et al. , the GIDYQ was administered to 73 adolescent or adult patients (51 male, 22 female) referred to one of two specialized gender identity clinics: one for children and adolescents and the other for adults. A comparison group consisted of 380 university students (143 male, 237 female), of whom 80% were classified as heterosexual and 20% as non-heterosexual. The GID patients reported, on average, significantly more gender dysphoria than both the heterosexual and non-heterosexual controls. In both studies, the GID patients reported, on average, significantly more gender dysphoria. In Study 1, specificity was 100% and sensitivity was 91.0%; in Study 2, specificity was 100.0% and sensitivity was 90.0%.
In the studies by Deogracias et al. and Singh et al., none of the non-heterosexual women met the criterion for GID caseness; however, in both studies, the non-heterosexual control women had significantly more self-reported gender dysphoria than the heterosexual control women did. If the rate of bisexuality or homosexuality among women with BPD is overrepresented, as suggested by some studies (op cit.), it would therefore be important to assess whether or not these women are also more likely to report gender dysphoria than heterosexual women with BPD.

So there’s a point that they should hopefully answer in the results; do bisexually reporting women with BPD report higher gender dysphoria as well.  



A total of 100 women referred consecutively to the Borderline Personality Disorder Clinic at the Centre for Addiction and Mental Health (CAMH) participated in the study. All of the patients met the DSM-IV-TR criteria for Borderline Personality Disorder.

Of these 100 women, 86 were diagnosed using the International Personality Disorder Examination BPD Section (IPDE) , a comprehensive semi-structured interview with good interrater reliability . The IPDE was administered to each patient by staff clinicians with extensive experience with structured diagnostic interviews. A time frame of the past 12 months was used. The remaining 14 patients were diagnosed using the DSM-IV-TR criteria for BPD.

The IPDE-BPD module consists of nine symptom domains, including one on identity disturbance (uncertainty about “what kind of person you are,” about what type of friends to have, about long-term goals or career choice, about ethics, values or morality, and about sexual orientation). Of the 86 patients administered with the IPDE, 17 (19.8%) were coded as “probable” and 53 (61.6%) were coded as “definite” for the identity disturbance criterion, consistent with the finding by Jørgensen et al..


Gender Identity/Gender Dysphoria

Participants completed the adult version of the GIDYQ . The GIDYQ was developed by the North American Task Force on Intersexuality Research Protocol Working Group, and was designed to index multiple indicators of gender identity and gender dysphoria, including subjective (n = 13 items), social (n = 9 items), somatic (n = 3 items), and sociolegal (n = 2 items) parameters. The GIDYQ has parallel versions for males and females. Principal axis factor analysis identified a one-factor solution that accounted for 61.3% of the variance. All factor loadings were ≥ 0.30 (median, 0.86; range, 0.34–0.96). Participants' total score was calculated by summing scores on the completed items and dividing by the number of marked responses (absolute range, 1–5). Lower scores indicate more gender dysphoria. For the present sample, Cronbach's alpha was 0.88.

Recalled Childhood Gender Identity and Gender Role Behavior

Participants also completed the Recalled Gender Identity/Gender Role Questionnaire-Revised (RCGI). The NATFI Research Protocol Work Group modified the original 23-item version of this questionnaire into a 19-item version by eliminating or replacing several items that did not discriminate between adult men and women or generated many missing responses, and by modifying and homogenizing the wording of others. Specifically, items that pertained to parent relations (closeness to mother and father) were eliminated, and those pertaining to cross-gender toy and play preferences were reworded. Individual items were rated on a 5-point scale, with lower scores indicating more recalled cross-gendered behavior. The RCGI has parallel versions for males and females. Deogracias administered this measure to 293 undergraduate students, unselected for gender identity and sexual orientation. Principal factor analysis identified a one-factor solution which accounted for 40.8% of the variance. All factor loadings were >0.30 (median, 0.64; range, 0.30–0.84). Preliminary information on discriminant validity was reported in Meyer-Bahlburg et al. . For the present study, the mean score was computed for each participant and Cronbach's alpha was 0.90.

I find this fascinating. Also exceptionally progressive that they would think to incorporate this. I was a tomboy when I was little. I started refusing to wear dresses and skirts when I was very young. I was very rough and tumble. I was angry and afraid when I hit puberty. I wanted to be a boy at times. I’m not sure I every quite wanted to be a girl. At least not a girly girl. (Btw, this is not the case now, I’m happy with the woman I am now, though I’m still not really a girly girl. Nerd girl represent.) So to bring up how you felt as a child and to compare it how you feel as an adult in relationship to how you know you were told to be…. Very interesting to me.

Sexual Orientation

Sexual orientation was measured in two ways. First, participants were asked to choose from one of five response options their self-labeled sexual identity: heterosexual/straight, bisexual, homosexual/lesbian, asexual, or unlabeled (dummy coded from 1–5). Second, participants were asked to identify their sexual attraction on a 7-point response scale, where 1 = exclusively to men and 7 = exclusively to women. Participants also had the option of selecting the descriptor “I don't feel attracted to either men or women.” For those participants who self-identified as heterosexual, bisexual, or homosexual (N = 94), the correlation with the continuous measure of sexual attraction (excluding those women who did not report attraction to either men or women) was 0.90 (N = 90), P < 0.001.

I like that they included asexual. It doesn’t quite include the proper discussion of gender fluidity and that there is more than a simple gender binary, but I think that may be a bit too complicated for this study.

On Monday we’ll get to the Results and Discussion. 

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