Stigma, Situational Triggers, and Symptoms: How Providers Justify Borderline Personality Disorder Among Sexual and Gender Minority Individuals

Borderline personality disorder (BPD) is disproportionately diagnosed among sexual and gender minority (SGM) individuals relative to cisgender heterosexuals. However, research aimed at understanding the reasons for this disparity is scarce. The current study employed a mixed-methods design to understand how mental healthcare providers' justifications for the BPD diagnosis differ based on the SGM status of the patient described and their own professional backgrounds. Two hundred seventy-one providers who were randomly assigned to one of three identical vignette conditions, with SGM status manipulated, indicated their agreement with the BPD diagnosis and explained the reason for their agreement. Results from thematic content analyses illustrated that providers referenced three themes when explaining their agreement with the BPD diagnosis: (1) BPD as provisional, (2) BPD as certain, and (3) BPD criteria met. Providers referenced a greater variety of themes to explain their disagreement with the diagnosis: (1) situational factors, (2) insufficient time course, (3) diagnostic criteria unmet, (4) insufficient assessment information, (5) differential diagnosis, (6) developmental immaturity, and (7) stigma concerns. None of these justifications were differentially employed based on the SGM status of the vignette. However, differences were observed based on providers' backgrounds; psychologists more frequently cited concerns about time course, developmental immaturity, and having insufficient assessment information than psychiatrists, counselors, and social workers in disagreeing with the BPD diagnosis. Implications for reducing BPD diagnostic bias are discussed.