Summary: National survey data show that borderline personality disorder (BPD) is diagnosed nearly twice as often in sexual minority adults as in heterosexual adults. Researchers suggest this disparity may reflect clinician bias and a failure to account for the stressful, stigmatizing environments many lesbian, gay and bisexual people face.
Source: University of Michigan
Health care providers may unintentionally let biases about sexual orientation influence their diagnosis of borderline personality disorder, according to a University of Michigan researcher.
Borderline personality disorder (BPD) is a persistent mental health condition characterized by emotional instability, impulsive actions, confusion about identity and difficulty maintaining relationships. Craig Rodriguez-Seijas, an assistant professor of psychology at the University of Michigan, reports that diagnostic bias appears more pronounced for lesbian, gay and bisexual (LGB) individuals than for heterosexual people.
“LGB individuals are more likely to be labeled with BPD particularly when clinicians do not carefully assess whether the observed behaviors produce marked distress or impairment,” Rodriguez-Seijas says. He is the lead author of a study published in the journal Assessment.
The research team analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a large population survey completed in 2012–2013. The dataset includes responses from more than 36,000 adults aged 18 to 90. About 1,100 respondents (approximately 3%) identified as lesbian, gay or bisexual; the remainder identified as heterosexual.
Across the full sample, 11% met criteria for BPD when criteria were applied without careful differentiation of impairment. The prevalence was nearly double among sexual minority respondents (20%) compared with heterosexual respondents (11%). However, when diagnoses explicitly required evidence that symptoms caused significant distress or functional impairment, the prevalence was similar: around 2% for sexual minorities versus 1% for heterosexuals.
The researchers propose several explanations. Clinicians may overlook the environmental stressors—such as discrimination, harassment, rejection or threats to safety—that disproportionately affect LGB people. Behaviors that can resemble BPD symptoms, like shifting how one presents or withdrawing from social situations, may be adaptive responses to prejudice and risk. Without careful, culturally informed assessment, these protective or pragmatic strategies can be mistaken for pathological identity disturbance or dysfunction.
For example, Rodriguez-Seijas notes that changing one’s appearance or concealing aspects of identity in different social contexts is a common and adaptive way for sexual minority people to reduce exposure to harm. If clinicians do not ask targeted questions to distinguish between coping strategies and clinically impairing identity problems, they risk misdiagnosis.
The study also found higher reported rates among sexual minority participants for certain behaviors often associated with BPD, including non-suicidal self-injury and impulsive sexual or financial behaviors. The authors emphasize that these differences do not necessarily indicate a true, intrinsic higher prevalence of BPD among LGB people; instead, some differences reflect broader patterns of stress, minority stress, and co-occurring psychiatric factors.
These findings have clinical implications. Evidence-based treatments for BPD can be effective, but some therapeutic approaches that emphasize biological or genetic explanations may inadvertently reinforce stigma if they overlook how social context shapes behavior. Clinicians should balance evidence-based interventions with cultural humility and an awareness of the social challenges that influence symptoms and coping strategies in sexual minority populations.
This study follows earlier work by Rodriguez-Seijas and colleagues demonstrating that, in some clinical settings, mental health professionals diagnosed BPD more frequently in LGB patients than in heterosexual patients even when objective measures of BPD pathology did not differ by sexual orientation.
Co-authors on the paper include Theresa Morgan, clinical assistant professor of psychiatry and human behavior at Butler Hospital, and Mark Zimmerman, professor of psychiatry and human behavior at Rhode Island Hospital; both are faculty at the Warren Alpert Medical School of Brown University.
About this psychology research news
Source: University of Michigan
Contact: Jared Wadley – University of Michigan
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Original Research: Closed access.
“A Population-Based Examination of Criterion-Level Disparities in the Diagnosis of Borderline Personality Disorder Among Sexual Minority Adults” by Craig Rodriguez-Seijas et al. Assessment. DOI: 10.1177/1073191121991922
Abstract
A Population-Based Examination of Criterion-Level Disparities in the Diagnosis of Borderline Personality Disorder Among Sexual Minority Adults
Previous research has shown that sexual minority individuals are diagnosed with borderline personality disorder at higher rates than heterosexual individuals, regardless of their presenting symptoms. Using data from the National Epidemiologic Survey on Alcohol and Related Conditions–III, the authors examined whether differences in endorsement of BPD criteria between sexual minority and heterosexual groups could be explained by broader, transdiagnostic factors. Results showed higher BPD diagnosis and criterion endorsement among sexual minority individuals (odds ratios ranging from 1.47 to 3.82). When clinicians or diagnostic procedures did not account for associated dysfunction or impairment, disparities in endorsement increased. Much of the observed diagnostic difference was attributable to transdiagnostic factors linked to sexual minority status, though some criterion-level differences remained. These findings suggest that the tendency to diagnose BPD more often in sexual minority individuals is not fully explained by criterion-related bias and highlight the importance of culturally informed assessment, attention to group-specific stressors, and clinical humility when evaluating symptoms in sexual minority populations.