Transgender and Gender Diverse Patients Are Diagnosed with Borderline Personality Disorder More Frequently Than Cisgender Patients Regardless of Personality Pathology

Purpose: Borderline personality disorder (BPD) is a severe form of psychopathology associated with a host of negative outcomes. Some literature suggests elevated prevalence among transgender and gender diverse (TGD) samples. Elevated BPD prevalence among TGD populations could be due to factors other than BPD-specific psychopathology. Studies of TGD samples typically omit assessment of BPD, making it difficult to understand elevated BPD diagnosis. The current study explored (1) differences in BPD diagnosis among TGD patients versus cisgender patients, (2) if differences were explained by BPD-specific pathology, and (3) if BPD diagnostic disparities existed based on assessment modality.

Methods: Data from TGD (n=74) and cisgender heterosexual (n=920) patients who presented for treatment at one partial hospitalization program from 2014 to 2019 were compared to investigate differences in the frequency of BPD diagnosis.

Results: A larger proportion of TGD patients were diagnosed with BPD than cisgender patients (odds ratio [OR]=4.05, p<0.001). The disparity in diagnosis persisted even after controlling for BPD-specific personality pathology (OR=2.98, p<0.001). BPD diagnostic disparity occurred when assessed using structured (OR=4.78, p<0.001) and unstructured (OR=3.61, p<0.001) interview methods. There was no disparity, however, when BPD was diagnosed using an algorithm based on BPD-specific personality pathology purported to underlie the diagnosis.

Conclusions: Clinical providers appear inclined to assign a BPD diagnosis to TGD patients that may not correspond with group differences in underlying personality pathology. That some BPD symptoms might be more likely in TGD samples, future research can examine criterion-level biases in BPD diagnosis among TGD individuals.