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. 

Thursday, August 15, 2013

Thoughts from the Borderline

For a moment I was concerned. Panicked even. Then I remembered that regardless of what others think, or say, I like who I am, I like who I’m becoming, and that’s the only thing that matters.

You have no power over me.

Wednesday, August 14, 2013

The Last Psychiatrist: Borderline & Narcissism Identity

I found an interesting article on Borderline and Narcissism and potential for Borderline to become Narcissism. I don’t necessarily agree with everything the article says, but on the other hand it makes some interesting point.  Take a look.

January 5, 2007

Narcissism- what I believe to be the primary disease of our times-- is one side of a coin.  The other side-- the narcissist's enabler-- is the borderline.

If the analogy for narcissism is "being the main character in their own movie," then the analogy for borderline is being an actress.

Note the difference: the narcissist is a character: an invented but well scripted, complete with backstory, identity.  The narcissist is trying to be something-- which already has a model.  Perhaps he thinks himself an artist type, or a tough guy, or the type interested in spiritualism, or like the guy in the Matrix.  Types, characters.  The borderline is no one: the borderline waits for the script to define her.

Her?  Yes.  Narcissists are mostly hes, and borderlines hers.  (Not always, sure.) 

The classic description includes: intense, unstable relationships; emotional lability; fear of abandonment.  The borderline has no true sense of self.

Ironically, the borderline is a borderline only in relationship to other people.  The borderline has a problem with identity only because other people in the world have stronger identities.  Your Dad wants you to be one way, so you do it.  Your boyfriend wants a different woman; so you do it.  Your husband wants something else; so you do it.  Who the hell are you, really?  You have no idea, because you are always molding yourself based on the dominant personality in your life.

I don’t necessarily believe that it’s because others have stronger identities. I've always had a very strong personality, even a strong identity at times, especially when alone, even when I’m with people in relationships, which is why things become so volatile… however my need to not risk abandonment and my desire to make the loved ones in my life happy, to please them, so they’ll stay, not leave, not reject me, so that I take more of an interest in their needs often takes more of a precedence… then when those things eventually clash for tooooooo long and some resentment at having neglected my strong will has gone on, that’s when sparks often start to fly.

This is done mostly out of fear of abandonment: if you don't "be" the person they want, then they'll leave you, and then what?  (Borderlines don't end relationships-- they end relationships for another relationship.)

The narcissist creates an identity, then tries to force everyone else to buy into it.  The borderline waits to meet someone, and then constructs a personality suitable to that person.

If a borderline is dating a guy who loves the Dallas Cowboys, then for sure, she will love the Dallas Cowboys.  If, however, she breaks up with him, and then dates a guy who loves the Giants, then she'll love the Giants.  But here's what makes her a borderline:  she will actually believe the Giants are better.  She's not lying, and she's not doing it for him; she actually thinks she thinks it's true.  (Note: This I totally agree with.) Everyone else on the outside sees that it is obviously a function of whom she's dating, but she is sure she came up with it on her own. And she's not play acting: at that moment that she believes, with every fiber of her being, that the Giants are better.

Here's the ironic part: if a borderline was shipwrecked on a desert island with no one around, she'd develop a real identity, of her own, not a reaction to other people.  Sorry, that's not the ironic part, this is: she'd become a narcissist.

I’m not sure I agree with this at all part that says just because she finds herself she's now a narcissist? How so? This doesn’t make sense to me. I think she just develops her own identity free from the influence of others. However when others are reintroduced into the equation she will probably begin to notice problems again. This is still where I struggle.

The borderline has external markings of identity: tattoos, changing hair colors, clothes.  You may recall I said almost the same thing about the narcissist: the difference is, of course, the borderline changes her image as she changes her identity-- in other words, as she changes the dominant personality in her life; but the narcissist crafts a look, an identity, which he then defends at all costs:  "I would sooner eat fire ants than shave my mustache."  Of course. Of course.

All those silly movies about a woman moving away, or to the big city, and she "finds herself:" that's a borderline becoming a narcissist. 

Is it though? I guess if she goes to the city and BAM, there she is a whole new person without any whole process of self discovery and work and self-awareness. Otherwise, no.

If you look back on past long term relationships you've had, and are completely perplexed as to what on earth you ever saw in each of those people that kept you with them for a year; well, there you go. 

This is why narcissists marry borderlines, and not other narcissists.  Two narcissists simply can't get along: who is the main character?  Meanwhile, two borderlines can't be with each other-- who supplies the identity?  The narcissist thrives with the borderline because she provides for him the validation that he is, in fact, the lead; the borderline thrives with the narcissist because he defines her.  And, as she will tell you every single time, without fail: "you don't know him like I do." Everyone else judges his behavior; but the borderline is judging his version of himself that she has accepted.  

Go back to my white high heel shoes example.  The narcissist demands his woman wear white high heel pumps not because hem ay like them himself-- he might or might not-- but because he is the type of man that would be with the type of woman who wears white pumps.  He thinks he's the sophisticated, masculine man of the 1980s, so she damn well better be Kim Bassinger from 9 1/2 Weeks.  Blonde hair, white pumps.  She could weight 400lbs, that's not the point (though it will become one later.)  So she wears the shoes, and starts to believe she likes them, starts to believe that she isthat woman.  He reinforces this with certain behaviors or language towards her (he'll open the door for her, push her chair in, etc.  You say, "well, what's wrong with that?  Nothing, except that he ALSO beats her when she doesn't wear the shoes.)

It's almost battered-wife syndrome: what keeps her with tat maniac is that when he's not beating her, it seems like he is actually being kind to her, so great is the difference between being beaten and simply not being beaten.  Meanwhile everything he does wrong has an external explanation: it was the alcohol, he's under stress, etc.  And she's doing this rationalizing for herself, not for him, because it is vital to her own psychological survival that he actually be who he says he is, that he actually have a stable identity that things happen to, because her identity depends on his being a foundation.

I found myself rationalizing a lot with my Evil-Ex, who btw, was a classic malevolent Narcissist.

That's why the therapist has to maintain such neutrality, consistency in the sessions.  It's not just to avoid conflicts; by being the most dominant (read: consistent) personality, the borderline can begin to construct one for herself using the blueprints of yours as a guide.

Oddly I don’t feel like I have much of an identity at all when I see my Therapist. 

If the borderline sounds like a 15 year old girl, that's because that's what she is.  The difference, of course, is the actual 15 year old girl is supposed to be flaky, testing identities and philosophies and looks until she finally lands on the one that's "her."  But if you're 30 and doing that, well...


(BTW, if you want to understand the mystery of women's addiction to shoes, here's my take: shoes are the article of clothing that represent possibility.  Each shoe is a different look, a different character, and she can select "who" she wants to be that day.  You might not notice the difference, but she feels it.  This is not borderline-- it's normal, but it's normal because the shoe changes and the rest of her doesn't.) 

I think the one thing this article completely misses is that it’s discussing organic identity discovery from nothing to narcissism in an unhealthy way. That’s how to go from BPD to NPD. My Therapist would never in a million years tell you I’m going from Borderline to Narcissist even though my sense of identity is becoming more firm, because I’m doing it in a healthy way. I’m discovering things that I like and maintaining those things and incorporating those things in my life in a consistent way. I’m not just DECLAIRING that something is me, and making it so. True self-discovery takes time and listening to yourself to ensure that it’s really something that is right for you. 

Tuesday, August 13, 2013

Developing a LESS flexible Sense of Self in Borderline Personality Disorder

Currently I’m looking for researched journals and something more scientific to share with you. So in the meantime I’m going to share with you what I’ve been working on. These aren’t things that my Therapist has necessarily told me, but things I’ve noticed.

When I say less flexible, I don’t mean you should be rigid. Oaks in a storm are the first to break, after all. However, you don’t want to be so flexible that you are whoever the latest person that walks by wants you to be. Ultimately the only person you really need to be, is you. For someone with Borderline Personality Disorder, this is a much more complicated revelation than you would think. It’s not so simple as stopping a certain behavior, or no longer worrying about what people think. Often it’s about overcoming a lifetime of deeply ingrained fears of abandonment and rejection and the adaptations we’ve developed to acquire people’s attention and relationships.  Many of which we may not even be completely aware of.  So how do you even begin? Well we’ve already talked about everything you need to start.

Mindfulness and Self-Awareness

Before you can improve anything, you have to realize what needs to be improved. This takes time and paying attention to how we behave in different circumstances with difference people, and how we feel in those instances. When do we feel good? When do we feel wrong? When do we feel like we’re only acting for others? When do we feel like something is actually sitting right with us?

Go back and read what I’ve written on Mirroring and Projecting. Pay attention to those. When you do those things, that’s typically for other people. Spend some time on your own. Pay attention to the things that you actually like and the things you only do for attention or for other people, or because other people like them.

*** Understanding the scope of this, all the ingrained areas that this has crept into, can take a very long time.

The thing here that I’ve really taken away from my Therapist is that you can develop a caring, trusting relationship with someone that accepts you for you, even when they know your flaws and foibles… and they won’t judge you and they won’t leave you or reject you.  This has helped me develop confidence in my other relationships.  It’s helped me believe that I can open up more to the people that are close to me (that deserve my trust!!!!) and be more of my authentic self and not just who I think they want me to be.

Develop Consistency

This comes with time and is something of a Part 2 to that Mindfulness and Self-Awareness. Once you’ve had time to become aware of the things you’re doing that are less for you and more for others you can begin to put an end to that. Learn to say ‘no’ to those behaviors. Learn to say ‘yes’ to those behaviors that actually make you feel happy and fulfilled because they resonate with you, not simply because you know they will make others happy. And do it consistently.

Learn to Trust Yourself

This is something I’ve struggled with the most. When we have such volatile and conflicting emotions that change constantly, it’s hard to know what to believe, especially when those signals are coming from your own brain. My inner monologue is often of two minds: my logical half and my emotional half. Too often my emotional half (at least in matters of relationships) would win out even though I KNOW my logical mind was the smarter decision maker (which would just frustrate me further). Emotions and gut feelings are hard to ignore, but it’s important to remember, especially in the heat of the moment, that we need to respond appropriately, not simply react emotionally. Easier said than done, but it can be, we just need to learn to trust our minds over our emotions.

It’s actually incredibly scary to start doing things for yourself, when you’ve been accustomed to doing so much for others, or to keep others around, for so long. That fear of rejection, that anticipation of abandonment has deep roots that go to our very core. It takes small steps, safe environment/relationships in which to try this to really allow to this to take hold. Part of why it’s so hard for many of us to make these changes is that we don’t often have safe spaces, which is why therapy is such a great thing if it’s available to you. However it’s not a necessity and you can definitely accomplish a lot without it.  The trick however, is finding people that you can actually heal and grow with… not simply someone(s) you wish/want to.  You’ll find it’s also much more fulfilling, for you and the people around you, when you learn to be authentic to you, you can also be truer to those around you as well.

Truer and happier for everyone involved.

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