Queering the diagnostic trajectory of borderline personality disorder

Abstract

There is increasing evidence that LGBTQIA+ people are diagnosed with borderline personality disorder (BPD) at higher rates than cisgender and heterosexual populations. Despite this, limited qualitative research has critically examined the social, cultural, institutional, and diagnostic processes that shape these disparities. BPD is a highly stigmatised and contested psychiatric diagnosis, with a long history of debate across disciplines, including psychiatry. Critically unpacking these diagnostic trajectories is essential for understanding how gender and sexual diversity, and LGBTQIA+ people more broadly, are responded to within mental health and social care systems. Drawing on in-depth interviews with 13 LGBTQIA+ individuals who had received a BPD diagnosis, this study is informed by the sociology of diagnosis and queer theory. This framework enables a critical interrogation of how gender and sexual diversity intersect with dominant psychiatric discourses that continue to pathologise non-normative identities, emotional expression and relational practices. Findings are organised around three interrelated themes. First, participants described how limited understanding, validation, and access to LGBTQIA+ -affirming care contributed to experiences of distress that were subsequently interpreted through a diagnostic lens. Second, participants highlighted how BPD diagnostic criteria risk pathologising identity exploration and self-expression that diverge from cisnormative and heteronormative expectations. Third, clinical judgements were frequently shaped by superficial assumptions about appearance, gender expression and sexuality, compounded by limited queer-specific training among practitioners. Collectively, our findings suggest everyday clinical interactions, diagnostic practices and healthcare cultures contribute to the disproportionate application of BPD diagnoses among LGBTQIA+ people. The study underscores the need for further critical research, practitioner education and the resourcing of LGBTQIA+ -affirming mental health services.

Keywords

borderline personality disorder queer theory LGBTQIA+ lived experiences sociology of diagnosis critical mental health

Introduction

Psychiatry has a long history of pathologising LGBTQIA+¹ populations by framing non-normative sexed and gendered identities as inherently linked to psychic or bodily disturbance. In the early 20th and late 19th centuries, for example, Contrary Sexual Instincts, were viewed as states of degeneracy that were considered a combination of physical and psychic manifestations of decay and disturbance. States of degeneracy were highly sexed, classed, raced, and gendered, aligned to the regulation of those people, identities, and behaviours considered socially undesirable within the dividing practices of psychiatry and wider systems of colonial regulation and control (see Blackman and Walkerdine, 2001). Consider the views of one of the founding figures of biological psychiatry, Emile Kraeplin (1913), for example, who argued that ‘contrary sexual instincts’ were more common amongst male homosexuals, prevalent in certain employments, “such as among decorators, waiters, ladies’ tailors, also amongst theatrical people (p. 510). Showing the close relationship between the regulation of normative gendered and sexual categories and what was constituted as mental illness, he went on to say that employment was one route to explore supposed deviant sexualities, making an assumption that ‘women comedians are regularly homosexual’” (ibid).

We might look back now at these pronouncements and find them amusing or contrary to more modern categorisations, but psychiatry is full of controversial diagnostic categories with close links to normative gendering and sexing practices that build on the histories, legacies and controversies of these othering processes. Borderline personality disorder (BPD) is one such highly controversial psychiatric diagnosis that is increasingly contested and the subject of circuits of debate, argumentation and legitimation that surround some of the diagnostic practices of psychiatry. BPD carries some of these much longer and wider histories of attempts to posit links between different sexualities and genders and what is constituted as an expression of pathological disturbance.

The borderline category was first proposed in the 1930s to describe a group of patients for whom psychoanalytic methods were not effective (Opakten-Ringdal, 2022). The prominence of the diagnosis accelerated in 1980 when it was first included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) since then, the application and representation of BPD in clinical and popular culture has grown significantly (Jones, 2023). BPD is sometimes used interchangeably with Emotionally Unstable Personality Disorder (EUPD), particularly in the United Kingdom and Europe where the International Statistical Classification of Diseases (ICD) is often the system used in diagnostic practice. Indeed, BPD was removed from ICD-10 (1990) and replaced by EUPD. EUPD itself was then removed from ICD-11 in 2019 as the manual steered towards a dimensional approach to personality disorder that categorised according to ‘symptom’ severity (Jones, 2023). It has been suggested that the word ‘borderline’ can imply a sense of ambiguity, which can perpetuate misconceptions and negative stereotypes, while ‘emotionally unstable’ personality disorder places more emphasis on the core features of such a diagnosis, that is, emotional ‘instability’ (Sciriha Camilleri, 2024). However, the use of BPD remains extremely common and borderline even made a comeback in the ICD-11 with reference to a ‘Borderline Pattern’ that echoes how the DSM presents BPD (Newton-Howes et al., 2021). We will use the term BPD throughout the article as this is the most common terminology applied in Australia, which is the context for this study and participants’ experiences. BPD is depicted in psychiatric classification by nine criteria that have been constructed to cover extreme sensitivity to interpersonal conflicts, an unstable or absent sense of self, intense and volatile emotions, and impulsive emotions. Suicidal ideation and acts of self-injury are also part of the criteria (Chesney et al., 2014).

The criticism and controversy associated with BPD has emerged from a range of disciplines, including sociology, cultural studies, medical humanities and even psychiatry (Mulder and Tyrer, 2023). These controversies are reflected in broader discussions of ‘personality disorders’ (PD) and the associated classification, diagnosis, and treatment of these (Manning, 2000). A significant body of research has highlighted the stigma (Bonnington and Rose, 2014) and discrimination (Sulzer, 2015) people with a BPD diagnosis experience, particularly in the healthcare system (Ring and Lawn, 2019; Seal et al., 2025). There are a variety of stereotypes and misconceptions associated with BPD that generate and reinforce stigma in healthcare systems. These include that people are exaggerating their distress, being ‘manipulative’ to gain attention (Sulzer, 2015) and that people are difficult and challenging to work with (Klein et al., 2022). Further, common patterns associated with BPD, such as acts of self-injury and suicide attempts, can lead health practitioners to feel under-equipped or overwhelmed, contributing to their discomfort and consequently reinforcing stigma (Chandler, 2016). Ultimately, these rigid perceptions create the conditions in which people with a diagnosis of BPD experience poor and even harmful care practices.

Indeed, within the wider category of personality disorders, behaviours and relational patterns associated with psychopathy, narcissism and ASPD (antisocial personality disorder) are the least stigmatised. The social figure of the narcissist or psychopath, for example, has become an object of fascination within the context of media cultures and the explosion of films, television dramas and documentaries focussed on practices of coercion, con-artistry and deception, often aligned to the devious practices of a masculine perpetrator of domestic and intimate abuse, more congruous with social expectations across a range of professions and political contexts (see Blackman, 2025). However, it is the category of BPD that is seen as the most stigmatised and problematic (Bonnington and Rose, 2014), particularly in healthcare contexts (Klein et al., 2022). These perceptions help to drive the everyday experiences of stigma and discrimination that people with a BPD diagnosis commonly describe and encounter (Borovica et al., 2024; Seal et al., 2024).

An important strand of research has critically examined the social and cultural production of BPD and has aimed to situate our understanding of the diagnosis within specific social, cultural, historical and political milieux (Johnson, 2021; Pickersgill, 2024; Shaw and Proctor, 2005). A variety of themes drawing on these critical dimensions have been addressed including concerns about the nosological clarity of BPD (Jones, 2023; Lawn and McMahon, 2015), the influence and role of trauma given the high levels of early childhood, relational and sexual trauma experienced by people with a BPD diagnosis (Duff et al., 2020), and how BPD is inherently ‘gendered’ with research unpacking the social, cultural and political factors that have shaped higher rates of diagnosis amongst women compared to men (Ussher, 2013). Feminist scholars have argued that societal tropes often frame women as ‘hysterical’ or ‘overly emotional’ and consequently pathologise certain types and performances of femininity and experiences that are viewed as ‘unfeminine’ or ‘deviant’ (Blackman and Walkerdine, 2001; Shaw and Proctor, 2005; Showalter, 1985; Ussher, 2013; Wirth-Cauchon, 2000). There is also an increasing amount of work led by people with lived experience of mental distress, drawing on Mad Studies, crip theory and new materialisms, which contest current framings and understandings of the diagnosis and describe how ‘borderline’ knowledges might be reclaimed or reimagined (e.g. Johnson, 2021; Lewis, 2023; Redikopp, 2018; Tichenor, 2024).

Our article builds on these strands of critical inquiry, which share common sensibilities attuned to the interpretation of human distress through technologies of psychiatry and frameworks of diagnosis (Brinkmann, 2016). However, we attend to an expanding and concerning trajectory of BPD; the disparities in diagnosis between cisgender/heterosexual and LGBTQIA+ people (Rodriguez-Seijas et al., 2021; Zimmerman et al., 2022). While the overrepresentation of women has historically been interrogated, we suggest that the relatively recent emergence of this diagnostic culture requires close critical examination (Porter, 2023). While the relationship between LGBTQIA+ populations and the BPD diagnosis is likely complex and multifaceted, our article recognises the disproportionate rates of personality disorder diagnosis in LGBTQIA+ people as rooted within social, cultural and historical contexts.

Queering the ‘sociology of diagnosis’

Our work can be broadly located within the field of critical mental health studies and, more specifically, research that addresses the sociology of diagnosis, which is a field of study that has been surmised by both Brown (1990) and more recently Jutel (2009a). Work within the broad framing of diagnostic sociology focuses on ‘the engines of diagnosis’ (Jutel, 2009b: 21), which characterise the drivers of the creation and maintenance of specific diagnoses. As Pickersgill (2024) notes what diagnostic categories proliferate, what these categories might refer to, and the psychopathologies they are deemed to purport, vary markedly across time and space, as the opening paragraph of this article demonstrates. However, despite the historical and cultural variation, there is a certain intransigence in how the colonial legacies of normative concepts of reason and sanity work to order and contain difference through systems of exclusion, regulation, surveillance, and diagnosis of the supposed pathologies of non-normative bodies (see Blackman, 2021; Chen, 2012). Diagnosis is integral to the system of medicine and the way it creates social order, providing a cultural expression of what society is prepared to accept as ‘normal’, what it feels should be treated, and how it organises ‘illness’ (Bowker and Star, 2000; Jutel, 2009a, 2017), which Brinkmann (2016) refers to as a ‘diagnostic culture’ (p. 2). As Jutel (2009a) further asserts, ‘diagnosis is an important site of contest and compromise, because it is a relational process with different parties confronting illness with different explanations, understandings, values and beliefs’ (p. 279).

There are many different ‘engines’, drivers, or shapers, of psychiatric diagnosis that have been interrogated in the research literature to date. Such engines include how commercial and research funding gets organised and awarded (Jutel and Nettleton, 2011), the pharmaceutical industry and its interests (Jutel, 2009b; Pickersgill, 2024), and the biases and understandings of health professionals (Zimmerman et al., 2022). Further, in recent years, diagnostic cultures have manifested outside of psychiatry and psychology in everyday contexts such as schools, work places and homes, leading to a situation where people increasingly understand their distress in the light of psychiatric interpretations and diagnostic terminology (Brinkmann, 2016; Tiidenberg et al., 2021).

The LGBTQIA+ and BPD intersection

In this article we are interested in how diagnostic categories, in particular BPD, come to be assembled through sexuality and gendered norms and how these factors can affect the application or giving of a BPD diagnosis, alongside the lived experience of receiving such a diagnosis. Recent research has started to examine the complex relationship between a BPD diagnosis and sexuality and gender diversity, although there is very little which explores these issues within the context of the experiences of LGBTQIA+ populations living with a diagnosis of BPD. Previous research examining sexuality in people diagnosed with BPD reported a significant over-representation of sexual diversity (participants identifying within a sexual minority or reporting intimate relationships or sexual relationships with people of the same-sex) in comparison with people that are heteronormative or otherwise known population rates. The rates identified varied between men and women, and fluctuated across studies, but these ranged from between 29.8% and 57% of BPD-diagnosed men indicating they are sexually diverse (Reich and Zanarini, 2008), with rates of sexual diversity in women diagnosed with BPD estimated to range from 11% to 33% (Reich and Zanarini, 2008; Singh et al., 2011). Similar patterns have been observed in transgender and gender diverse people whereby these groups are diagnosed with BPD more frequently (Furlong and Janca, 2022; Rodriguez-Seijas et al., 2021; Zimmerman et al., 2022). Further, a particularly high prevalence of cluster B personality disorders (borderline, narcissistic, histrionic and antisocial personality disorders) in transgender communities has been identified. In particular, young people or adolescents (aged 15–19) who are LGBTIQA+ are more likely to receive a BPD diagnosis. (Reuter et al., 2016; Zanarini et al., 2021).

Collectively, this evidence indicates there is elevated BPD diagnosis amongst LGBTQIA+ people relative to heterosexual and cisgender people. Even though there is some emergent research in this area, there has been limited work that has critically addressed the factors that could lead to these disparities. The critical literature focussing on people’s lived experience of a BPD diagnosis has been expanding and developing (see Duff et al., 2020; Redikopp, 2018; Seal et al., 2024; Tichenor, 2024), however there is still relatively little work addressing the lived experience of people with a BPD diagnosis that are LGBTQIA+. The previous studies highlighted in this section are primarily statistically and prevalence based, opposed to what brings people to psychiatric attention and a psychiatric diagnosis of BPD. As Johnson (2021, p. 642) posits, we need to analyse ‘ the BPD diagnosis as one of the DSM’s back doors for heterosexual and cisgender supremacy’. Consequently, our research fills an important gap in current understandings by conducting a qualitative inquiry into LGBTQIA+ people’s experiences of receiving and living with a BPD diagnosis.

Theoretical framing

Our approach brings together conceptual frameworks that have explored the role of psychiatry and psychology as knowledge practices that play an intimate role in the production and regulation of sexualities, through social and diagnostic categories of insanity, unreason, disorder, and deviance (see Blackman and Walkerdine, 2001; Foucault, 1979). Some of this research draws directly from queer theory, with its foundational emphasis on the rejection of normative frameworks and the interrogation of those power structures which produce and reify distinctions between the normal and abnormal. This includes research which has explored the dominant societal and psychiatric discourses that can operate to pathologise non-conforming sexuality and gendered subjectivities (Pilling, 2022). Our research builds on longer genealogies of the role the psy disciplines have played in the regulation of mental health (Rose, 1990, 2009) and what is considered deviant or disordered, including the mental health of LGBTQIA+ populations (see, e.g. Czyzselska, 2022; Hodges, 2008). Queer theory challenges psychological models that position emotional intensity (i.e. certain criteria of BPD) or non-normative sexualities and gender expressions as problematic. Queer theory has played a significant role in reclaiming and resignifying emotions that have been historically pathologised, particularly those expressed by LGBTQIA+ communities. Emotions such as anger, grief, vulnerability and ‘non-normative’ desire, once labelled as excessive, unstable or abnormal, are reframed as socially and culturally meaningful responses to structural oppression and relational contexts. Cvetkovich’s work in ‘an archive of feelings’ (2003) illustrates how queer and feminist communities create spaces to recognise grief and trauma as collective, politically resonant experiences, rather than individual pathology. Similarly, Berlant (2011) reframes emotions that have historically been dismissed or pathologised, such as shame, disappointment, ambivalence and vulnerability, not as indicators of personal weakness or psychological dysfunction, but as socially and politically understandable responses to conditions of precarity and structural inequality. In this way emotions are meaningful and legitimate responses to external conditions. Work at the intersection of queer theory and affect studies does not just critique the pathologisation of emotion but actively transforms its interpretation, highlighting emotionality as productive and socio-culturally situated (Sedgwick, 1990). Such understandings of emotionality offer a critical lens for examining how psychiatric and psychological frameworks may misinterpret the emotional expressions of marginalised groups. It highlights the risk of pathologising these emotions and expressions, and healthcare practitioners misinterpreting or indeed judging these responses as ‘disordered’ in some way. A queer theory approach encourages a rethinking of people’s experiences in ways that affirm their validity and complexity to disrupt norms that collapse these same experiences into ‘sickness’ narratives within psychiatric discourse and dominant culture (Spurlin, 2019). Psychiatric processes spanning interpretations of emotional distress, the giving and management of diagnoses, interpersonal and relational dynamics, and the provision of associated services are ultimately intertwined with broader social, cultural, political and institutional structures that can impose rigid categories and expectations. These categories often marginalise non-normative experiences, in this case any experiences that fall outside of cisgendered and heterosexual frames of reference in the context of mental health. Queer theory is thus, ‘a lens that emphasises the slipperiness of meaning and the transgression of boundaries and categories’ (McCann and Monaghan, 2019: 2).

In particular, we are drawing on conceptual sensibilities in the work of Pilling (2022) and LeFrancois and Diamond (2014) who both apply queer theory approaches in the context of understanding mental ‘ill’ health. These scholars use this theoretical framing as a broad critique of the biomedical model while looking specifically at ‘how gender and sexual dissidence, and therefore LGBTQIA+ people are psychiatrised, which supports queer bodily autonomy and counters anti-queer practices of all kinds’ (Pilling, 2022: 10). To understand diagnosis through a queer theory lens is to question the mentally/sane dichotomy and to open up the potential for multiple interpretations of experience (LeFrancois and Diamond, 2014). In taking up a queer theory lens our interest does not lie in questions about what BPD ‘is’ or how we might infer more ‘accurate’ diagnosis for certain groups, instead we focus on asking what a BPD diagnosis does and how it is produced. In this way, we recognise the material realities of mental distress and mental health ‘categories’, but ‘contest the epistemic violences and hierarchies which foster their construction and pathologisation’ (Redikopp, 2018: 77). Therefore, the specific aims of this research are:

To explore the lived experiences of LGBTQIA+ individuals diagnosed with BPD focussing on their experiences of diagnosis and encounters in the healthcare system.

To identify social, cultural and systemic factors that may contribute to disparities in BPD diagnosis between LGBTQIA+ and cisgender/heterosexual people.

Method

Recruitment and participants

This article is based on an interdisciplinary qualitative study exploring the lived experiences of people living with a diagnosis of BPD. The research team comprised researchers from health sociology, critical mental health studies, and academic health practitioners, namely psychiatrists, and psychologists. The study was guided by an advisory group, including lived experience advisors, representatives from mental health non-government organisations (NGOs) and services and researchers with relevant content expertise. The research team, in collaboration with people with lived and living experience, developed the study design, research materials, and the analytical approach. Ethics approval was obtained through the Melbourne Health Human Research Ethics Committee (HREC) based in Victoria, Australia. Recruitment occurred via social media platforms including Twitter (now ‘X’) and Facebook, and the websites of relevant health service organisations. Participants were given details on the study, its aims, and confidentiality protocols, and all gave informed, written consent prior to taking part in an interview. Interviews were conducted with participants who had lived experience of a BPD diagnosis after receiving a diagnosis from a healthcare practitioner or by self-diagnosis.

The interviews took place between February and October 2022. An interview guide was developed in consultation with lived experience advisors and topics covered included, the experience of being given a diagnosis of BPD, everyday life, including socio-economic circumstances, wellbeing and practices of care, the quality of care and support received, experiences of work and/or study, and participants’ views and hopes about the future. Interviews were conducted via a digital meeting platform, audio-recorded and lasted between 60 and 120 minutes. The recordings were transcribed professionally, de-identified, and participants were sent their transcripts for review and approval. NVivo 12 software (Lumivero, 2017) was used to assist data management and analysis.

Overview of participants

Twenty-four interviews were conducted with participants who identified as having a BPD diagnosis. This article is based on the accounts of 13 participants that are LGBTQIA+

Participants were asked to self-describe their gender and sexuality identity and these are reported here in the terms used by the them. Three people indicated they were non-binary, one person described being gender fluid, and there were seven cisgender women and two cisgender men. In terms of sexuality, six participants were bisexual, one person described themselves as ‘queer’, four people were gay, and two participants self-described as lesbians. In terms of age, at the time of interview, 6 participants were aged between 20 and 29, 5 participants were aged between 30 and 39, and 2 participants were aged between 40 and 49. All participants in this sample had received a diagnosis of BPD in the mental healthcare system. All participants described themselves as being white, Australian apart from one participant who identified as being Aboriginal. We have assigned each participant a pseudonym to help retain their privacy and confidentiality. We recognise the lack of cultural and ethnic diversity with the predominantly white sample of participants and acknowledge this as a limitation of the current research in terms of being able to offer insights about other intersectional experiences. Future research could focus more specifically on this particular intersection with LGBTQIA+ status. We also acknowledge that, due to the number of participants in our sample, our analysis includes all participants collectively and does not disaggregate by gender or sexuality. While this approach allows us to explore common narrative dynamics, we recognise that gendered and sexualised social positions can produce distinct experiences. The qualitative, in-depth exploration of sexuality and gender diversity by various intersections is also an important potential future area of research.

Analysis

We conducted an iterative thematic analysis (Braun and Clarke, 2021), which occurred alongside data collection. Author one and author three read and reviewed the transcripts to map key themes and develop an initial coding framework. These themes and the coding framework were discussed and reviewed by co-authors and a lived experience advisory group that was part of the broader project. The framework was subsequently refined as more interviews were completed, which allowed for adjustment during fieldwork. The approach was collaborative and reflexive, focussing on identifying patterns, differences and singular cases. After data collection was complete and all transcripts had been analysed it became apparent that there were unique and intersecting experiences for people that were sexuality and/or gender diverse, hence the focus of this article is a smaller subset of participants (n = 13) that are LGBTQIA+.

The next stage of the analysis process involved the first author further developing the initial themes and patterns by conducting additional analysis. Author one read and reviewed the transcripts using a theoretical lens (queer theory as identified in the previous section) to understand participants’ accounts through this orientation. During this process the themes were mapped to broader social constructs to examine how heteronormative and cisnormative assumptions potentially influenced participants’ experiences of living with a BPD diagnosis and to interpret their historical experiences. This moved the analysis from a more descriptive understanding to critical interpretation. These resulting interpretations were reviewed by co-authors and further refined based on this collaborative process.

Positionality and reflexivity

We approached this study from critical and queer-informed perspectives, with professional and lived experience backgrounds in LGBTQIA+ health, critical mental health studies, mental health activism and cultural studies. These positions helped to shape the formation of research questions, our engagement with participants and the interpretive lens applied during analysis. We recognise that our readings of participants’ narratives are situated and partial, reflecting our feminist, queer and anti-pathologising commitments. To support reflexivity, we engaged in discussions about our assumptions and positionalities throughout coding and theme development, critically examining how our theoretical commitments, personal experiences and disciplinary backgrounds influenced how we interpreted participants’ narratives and which meanings we gravitated towards.

Results and discussion

The results are organised according to the following three broad themes connected with experiences of living with BPD and being LGBTQIA+, (1) mental distress generated from social, cultural, structural oppression, (2) practices of judgement, and (3) queerness and BPD ‘criteria’ conflation. These sections together and collectively highlight why LGBTQIA+ people are potentially more likely to receive a BPD diagnosis. In the first section, we outline why they are generally more at risk of experiencing mental distress in response to structural conditions in their lives and come into contact with psychiatric regimes. In the second section, we unpack how healthcare practitioners can lack competence and fail to understand the specific needs and struggles of LGBTQIA+ communities. Consequently, experiences of identity struggle or emotional impulsivity that are ordinary or ‘healthy’ forms of queer expression can be misinterpreted as BPD ‘symptomology’. The third and final section concentrates on the particularisms of the BPD diagnostic criteria and how aspects of the criteria overlap with often typical LGBTQIA+ experiences. We argue it is the way in which BPD is constructed and categorised, which creates thin definitions of ‘normalcy’ in relation to bodies, relationships and identity.

Mental distress generated from social, cultural, structural oppression

The experiences of LGBTQIA+ individuals, such as discrimination, stigma, stress, and identity struggles, can manifest in ways that may be misinterpreted as ‘symptoms’ or indicators of BPD. Oppression of all kinds, including homophobia, transphobia, ableism, sexism, classism and racism have negative effects on LGBTQIA+ people, which can contribute to mental distress (Pilling, 2022). There is now a strong body of evidence indicating the increased amount of mental distress that LGBTQIA+ people can experience, compared to cisgender and heterosexual people (Hatzenbuehler et al., 2024; Wilson and Cariola, 2020). In terms of gender and sexuality specifically, there were many examples across participants’ accounts of how these forms of subjectivity were invalidated and misunderstood. Quinn’s description of their relationship with their mum and the invalidation they experienced highlights this. Often when people are seeking nurturing support and affirmation, they can be confronted with parental questioning and self-blame, ‘where did we go wrong’?

“With my family I know that they’ll still love me and they’re not going to kick me out of the house. But it’s not something that they understand [being transgender] and I don’t think they will understand. My mum in particular has said things about, you know, we’ve spoken about my trans friends, or my non-binary friends, and she’s just been so confused and said that it’s not something she thinks she could deal with. I feel like a big part of it is that I don’t want to hurt my mum. She just hasn’t understood a lot of who I am. Sometimes even I’ll dress a certain way and she’s asked “what happened to you?” Or, “where did I go wrong?” The way that she feels around things that really aren’t that big of a deal has made me feel quite uncomfortable in telling her something that is very big (Quinn, aged 25).

Another example from participants’ accounts where they expressed not being able to be fully ‘themselves’ is apparent in Heidi’s experience. Heidi describes travelling interstate to meet up with friends so they could feel comfortable to express their gender in ways they needed to, rather than having to perform according to expectations aligned with their assigned gender’:

“The reason I went on a trip to [state name] was so that I could be myself, more myself instead of being at home and having to deal with my original gender or whatever. Because my family don’t accept it so there’s all that stigma around it and I can’t do it [express gender] around family but I can around friends. But that just makes it really hard if I was living outside then it would be better because I could just be full time, this person, whatever and then I don’t have to worry about it and stuff” (Heidi, aged 24).

These narratives help to demonstrate how a lack of understanding, validation and care can lead to experiences of emotional distress. The support and affirmation of family and friends, and indeed the wider community, is important for LGBTQIA+ people to feel acceptance and belonging (McDermott et al., 2021). That is not to affirm ‘minority stress models’ or arguments that LGBTQIA+ are more likely to have psychiatric ‘disorders’, but instead to recognise that the structural inequalities encountered make people likely to experience mental distress as a response. As argued by Pilling (2022) this is not the same as the claim made in much of the mainstream LGBTQIA+ literature that LGBTQIA+ people are more ‘vulnerable’ to mental health problems. The concept of vulnerability locates the problem within individual psychology and operates through a deficit model. It is limited in that it does not challenge the way in which normative concepts of mental illness are used uncritically to medicalise the social and historical basis of suffering and distress. As Daley and Ross (2018) cogently argue, ‘the minority stress model inspires the individualising and normalising of psychiatric discourses or rather psychocentri[sm]’ (p. 294). They go on to state, ‘the model invokes structural violence as a cause of queer and trans mental and emotional distress; yet, it remains firmly committed to the notion of individual pathology, and thus, continues the well-established pattern of psychiatrising queer and transgender people’ (p. 295). That is, in these conceptualisations the biomedical model prevails, the individual is positioned as the problem, and broader social constructs are obscured.

Practices of judgement

When working with LGBTQIA+ people, healthcare practitioners can lack competence and fail to understand their specific needs, struggles and challenges (see Czyzselska, 2022; Hodges, 2008). Participants often encountered healthcare practitioners who had little to no knowledge of LGBTQIA+ cultures, identities and ways of being and this was perceived as a significant challenge by participants. As Pilling (2022) asserts while this problem is not limited to approaches informed by the biomedical model, generally current forms of medical training are not inclusive, and do little to acknowledge or address this problem. This can lead to people’s experiences being interpreted through various diagnostic lenses, and as argued here, increasingly that of BPD. Ultimately, such practices contribute to marking as illegitimate aspects of queer sexuality and gender expression and marginalise non-normative experiences that fall outside of cisgendered and heterosexual frames of reference (LeFrancois and Diamond, 2014).

Historically, psychiatry has played a significant role in supporting the view that sexuality or gender diversity is a symptom of ‘mental illness’, rather than an integral aspect of an individual’s identity and sense of self. It plays out here in Quinn’s story, which highlights the creep of diagnostic practices that are judgemental, speculative and biased, exemplifying a lack of queer-centric knowledge(s):

“In the adult service, it’s not something [being LGBTQIA+] that I could talk about. I had to have somebody else that I was working with call them up and say, hey, you know, this person prefers this name and uses these pronouns because I didn’t feel comfortable saying that. Throughout I was still deadnamed and they didn’t use the right pronouns. I remember getting all my notes back after a freedom of information request. I could see that even after they knew [my pronouns] they would deadname me and write something like, ‘Quinn is a non-binary lesbian who blah, blah, blah, blah’. I’d never even said that I was a lesbian and I’m not a lesbian. So, they were assuming things, but in queer specific services they understood a lot better. It just feels very safe. I know that they’re not going to medicalise my queerness as well” (Quinn, aged 25)

In this account, Quinn describes how healthcare practitioners lacked understanding about their gender expression and sexuality, resulting in the assumption that they were a lesbian, they also refer to fears they had about their queerness being ‘medicalised’. Though many practitioners had no LGBTQIA+ specific knowledge, many still behaved like experts in this regard (Pilling, 2022). These acts of queer judgement on behalf of healthcare practitioners become generative diagnostic practices as the BPD criteria becomes overlaid in these spaces of misattunement and misunderstanding. The quote below also helps to illustrate these processes at play as Jonah describes how they felt their hair colouring and piercings were interpreted by a psychiatrist:

“I always felt with BPD umm it was the too hard basket and that people saw me as you know these risky behaviours and considered the way I present with coloured hair and piercings I felt like it was a judgement not based on my actual story, just based on the things I do and the way I look” (Jonah, aged 28).

Healthcare practitioners may reinforce biases, particularly by making assumptions based on superficial parts of a person’s appearance, such as hair colour, clothing choices, or other outward expressions of identity. These cues, often tied to cultural and ‘queer stereotypes’, can influence clinical judgements and perpetuate certain associations (Baker and Beazley, 2022; Klein et al., 2022). As demonstrated in Jonah’s case, a practitioner might interpret a person’s hair colour or appearance as a sign of emotional impulsivity, which are intertwined with current BPD diagnostic criteria. Such assumptions and assertions are often predicated on a narrow understanding of cisnormative and heteronormative performative ideals (LeFrancois and Diamond, 2014). These kinds of judgement, without considering a person’s individual story, can perpetuate harmful stereotypes, overlooking the role that historical experiences (such as trauma), societal marginalisation and identity struggles might play in shaping an individual’s emotional experiences. For example, Kate (aged 33) further adds, ‘I put in a freedom of information request for my medical records and could see I was given the [BPD] diagnosis in 2011, but when I was in that hospital they didn’t ask my any questions about my history or trauma or anything like that. They looked at the presentations and made a judgement’.

Implicit bias and judgement in psychiatric diagnosis among sexuality and gender minority groups has been previously documented (Garb, 2021; Merino et al., 2018; Rodriguez-Seijas et al., 2021). In the context of BPD, there appear to be certain judgemental practices associated with queerness that prevail as people’s lived experiences are often discarded and viewed through narrow lenses. In their queer reading of psychiatric chart documentation, Daley and Ross (2018) suggest that psychocentric discourses and the illegitimising of gender and sexuality diversity occurs through language use reflective of the heteronormative order and associated health practitioner judgements. As expressed by Jonah, Quinn and Kate they did not feel truly heard or listened to, which we argue can result in the diagnosis of a personality disorder driven by harmful biases and judgements. A persistent lack of training for clinicians on LGBTQIA+ experience contributes to misdiagnosis, as ordinary or ‘healthy’ forms of identity exploration may be misinterpreted as particular sets of ‘symptoms’ (Cruciani et al., 2024; Mizock and Lundquist, 2016). Quinn further describes how ‘snap’ judgements are made, leading to them feeling as though they were not properly understood, ‘I mean, people will make a snap judgement and say that I’m female or a girl and that’s just not something that I want. I still idealise masculine bodies, transbodies’.

The consequence of encountering these practices generated fear for participants, fear that sharing or telling their stories would lead to unknown results and reactions. The ‘small parts’ of people’s stories leave a haunting and enduring trace as they become part of the psychiatric apparatus and the hooks upon which diagnosis sticks. Such judgements can reinforce wider practices of shaming that contribute to historical processes of regulating sexuality and gender, forcing people to look towards themselves rather than the role of shaming environments (Liu, 2017). This led some participants to pursue LGBTQIA+ specific services and supports where they perceived the practices to be more understanding and inclusive:

“I think a big part of [seeking services] is feeling safe and feeling like I can talk about everything and not be judged. There are services that I won’t want to seek out unless I feel like they are you know safe and sensitive to queer people. I won’t see doctors that don’t have an understanding of queerness because there have been a lot of judgments in the past” (Blake, aged 31)

Seeking out LGBTQIA+ specific services or individual practitioners that overtly indicated an interest in working with LGBTQIA+ people was a protective mechanism enacted by participants and a way to access more supportive environments and practices. Heidi describes how they feel as though they might have received a different diagnosis, if they saw a practitioner with a varied set of set of understandings and more queer-centric knowledge, ‘I could see other people and they would give me a different diagnosis. It feels like it’s dependent on the individual person that you see at that time. In my situation seeing somebody while I was in crisis and having them talk to me for thirty minutes and ask certain questions, they’re going to get a very small part of my story’.

Queerness and BPD ‘criteria’ conflation

Borderline personality disorder, as a subset of personality disorders, operate to classify individual ‘symptoms’ that are considered in relation to understandings of ‘normalcy’ in the current socio-cultural milieux. The DSM, now in its fifth edition (DSM-V), is psychiatry’s central technology. It functions not only as a diagnostic manual but also as a system of knowledge that orders human experience, standardises diagnostic practice, and structures how mental health is understood, treated and researched (Pickersgill, 2024). Through its categories and criteria, it has shaped clinical research and policy landscapes for decades. A dominant narrative positions psychiatry as progressing towards ‘demedicalisation’ of queerness. This narrative points to the removal of ‘homosexuality’, classified in DSM-III (1973) as a ‘sociopathic personality disturbance’, and later, the replacement of ‘transsexualism’ and ‘gender identity disorder’ with ‘gender dysphoria’ in DSM-V (Jack, 2023). From this perspective, queerness is no longer a psychiatric subjectivity. Yet critiques have long unsettled this progressive account. Scholars argue, along the lines of our participant accounts, that even if queerness is no longer explicitly named, the pathologisation of LGBTQIA+ lives persists in less direct forms. For example, Serano (2013) contended that the move to replace ‘gender identity disorder’ with ‘gender dysphoria’ still frames transgender people’s internal experiences as the problem, rather than focussing on societal transphobia and lack of access to care that actually causes much of the distress, sustaining psychiatry’s hold (Pilling, 2022). Queerness becomes absorbed into other diagnostic categories, such as BPD, which recycle old pathologies under new terms (Cohen, 2016; Porter, 2023).

The diagnosis of BPD and associated diagnostic tools and tests have been developed in ways that do not account for intersectional experiences and differences between different social groups (Porter, 2023). This issue extends beyond the interactions between healthcare practitioners and individuals but is founded in the actual diagnostic criteria and how BPD is constructed in psychiatric classification systems. This creates a situation where emotionality and self-expression that deviate from gendered and sexuality norms and expectations are pathologised. That is the DSM-V does not account for how emotionality can vary across contexts, cultures and ethnic groups. Applying an intersectional lens is crucial in recognising that individuals’ experiences of living with a BPD diagnosis are not only shaped by gender and sexuality, but also by race, class, ethnicity and indigenity (De Genna and Feske, 2013; Gaztambide, 2019; Pilling, 2022).

Common acts of questioning and exploration around this are overlaid with, or mapped against, the BPD diagnostic criteria. Concepts such as ‘identity disturbance’ and ‘unstable relationships’ that are organised in DSM-V as BPD become indicative of ‘illness’ rather than a product of a person’s lifeworld. Consider the following account below where Quinn describes how they felt about their body in relation to BPD:

“Another big thing with BPD is because I was experiencing issues with body image and identity that was put down to BPD, opposed to the fact that body image issues and identity issues were because I didn’t feel like I fit into society or I fit into these boxes. Yeah because of that, I’ve really held back a lot of my story and experiences because I just didn’t feel comfortable being able to share that sort of stuff” (Quinn, aged 25)

We argue it is the way in which BPD is constructed and categorised, which creates thin definitions of ‘normalcy’ in relation to bodies, relationships and identity. Quinn’s narrative elucidates these issues as they describe how tensions and contestations around their body image were reduced to biomedical explanations, a ‘medicalising of queerness’, with a failure to consider that the driving forces could be attributable to limited and constraining societal categories or were in fact ‘healthy’ expressions of Quinn’s subjectivity (Porter, 2023). Tensions around gender are further highlighted in Blake’s narrative as they discuss how they viewed their body and gender and had historical struggles around this:

“There was a bit of body dysmorphic and gender stuff in there as well and my gender really started to come back into play again [when admitted to an inpatient mental health unit], which was really strange because when I came out at 19 I thought oh that’s it then. One of my nurses was a trans woman and I was so intrigued by this person and I started to talk to them and I said I don’t even know if I’m a boy or a girl I don’t know what I am and I started to cry. I kept referring back to this nurse and I wanted to talk to her because I was so mystified, I never met a transgender person before growing up in the country. There was something about it that really scared me, but made me feel good at the same time” (Blake, aged 31).

Talking openly to health practitioners about these challenges and subsequently receiving a diagnosis of BPD can lead to greater confusion at a time when people require authentic and validating support. Such confusion is palpable in Avery’s account as they describe how they felt when they received a BPD diagnosis on top of ongoing contestations around their sense of self:

“I think I still struggle with my identity and that has been something I have struggled with most of my life. I think that as a 22 year old I still don’t know really who I am and I think that is also to do with what I missed out on when I was younger or the experiences that a lot of kids at that age had. Throughout my life I have struggled with my gender and sexuality so what was something that impacted my life and I think that also has to do with having BPD with not knowing who I am, it’s just another identity” (Avery, aged 22).

Viewed in this way it is cisnormative and heteronormative expectations and assumptions that are problematic, not allowing for attention to the shifting practices through which people construct and live their identities. Riley’s (aged 31) account further highlights how these expectations can be troublesome, as they openly talk about their identity struggles as a consequence of not being accepted in relation to being queer, rather than struggling because of an innate, internal reason, ‘I struggle with identity. Just in terms that I don’t feel very accepted in terms of my queerness. I’ve been very invalidated in the past. I still partake in some risky behaviours, particularly around substance use. Partially to, I guess, get out of my head sometimes to feel something’. Rodriguez-Seijas et al. (2021) argue that the higher portion of people diagnosed with BPD who are sexuality diverse is partly due to bias in BPD symptoms, with BPD criteria overlapping with psychopathology commonly observed in sexuality diverse individuals (such as rejection sensitivity, uncertainty about one’s identity, impulsivity, and self-injurious practices). Diagnosis as a cultural expression of what society is prepared to accept as ‘normal’ and what it feels should be ‘treated’ helps to regenerate the heteronormative and cisnormative order of the psychiatric institution. LGBTQIA+ people may be assessed to meet the criteria for BPD, since it identifies anything beyond a narrow idea of ‘cisgender or heterosexual health’ as pathological (LeFrancois and Diamond, 2014). As Porter (2023) asserts, ‘with diagnosis at such uneven rates among marginalised groups, the diagnosis of personality disorders represents a tool to enforce compliance to gendered social expectations, raising questions around the appropriateness and ethicality of the diagnosis’ (p.143). There is a need to problematise naturalised discourses on sex, gender and sexuality to highlight how they work and operate in the context of diagnostic categories.

Conclusion

Our study qualitatively examined the disparity of BPD diagnoses amongst LGBTQIA+ people and the norms shaping this emergent socio-cultural expression of BPD. It is important to critically unpack what is shaping such diagnostic trajectories and care practices to look at how gender and sexual diversity, and therefore LGBTQIA+ people, are responded to and ‘treated’ within mental health and social care systems. Our research drew on the lived experiences of 13 people that are LGBTQIA+ and have received a diagnosis of BPD to unpack the social, cultural, and institutional factors that have shaped their experiences. We drew on the sociology of diagnosis and queer theory, which provided a critical framework for questioning the intersection of BPD and being LGBTQIA+ and the dominant societal and psychiatric discourses that can operate to pathologise (i.e. diagnose) non-conforming sexuality and gender subjectivities (Pilling, 2022).

There were three key strands to our findings. First, a lack of understanding, validation, and appropriate and safe care can lead to experiences of mental distress for LGBTQIA+ people

We seek to challenge and reject minority stress models that individualise distress. Instead, we emphasise that it is the structural inequalities LGBTQIA+ people encounter, not some form of inherent vulnerability, which generate conditions in which mental distress becomes an understandable and often inevitable response. Ultimately, limited access to LGBTQIA+ -specific and tailored support may heighten the likelihood that individuals are diagnosed with BPD, as their distress is more readily interpreted through a pathologising lens. Second, the diagnostic criteria of BPD is constructed in such a way whereby emotionality, self-expression, and identity questioning that deviates from gendered and sexuality norms and expressions has the potential to be pathologised. Common acts of questioning and exploration can be overlaid with, or mapped against, the BPD diagnostic criteria. Diagnosis as a cultural expression of what society is prepared to accept as ‘normal’ and what it feels should be ‘treated’ helps to regenerate the heteronormative and cisnormative order of the psychiatric institution.

Finally, the experiences of our participants demonstrate how superficial assumptions about appearance, gender expression and sexuality are often used to inform clinical judgements, leading to the pathologisation of individuals whose identities and everyday practices fall outside of cisnormative and heteronormative expectations. These practices, compounded by a lack of queer-specific training (Porter, 2023) not only perpetuate harmful assertions but also contribute to the medicalisation of queer experiences, treating them as symptoms of disorder. Collectively, we suggest that these everyday interactions, diagnostic practices and healthcare cultures formulate part of the engines of diagnosis that are shaping the increasing trajectory of a BPD diagnosis amongst LGBTQIA+ people and subsequent diagnostic expansionism (Cohen, 2016).

Based on our findings, there are several research and practice-based recommendations we would make. Currently, there is limited qualitative research that has attended to the intersection of LGBTQIA+ communities and a BPD diagnosis; more experiential research is required to add to our understanding and unpack what is shaping this complex relationship. Further, we would recommend specific education and training for healthcare practitioners to equip them to better understand the needs and lifeworld’s of people that are LGBTQIA+. Connectedly, it is important to fund and adequately resource mental health services that are explicitly affirming of LGBTQIA+ communities.

There is a need to challenge progress narratives; even though being gender or sexuality diverse is not explicitly named as a ‘mental disorder’, the pathologisation of LGBTQIA+ communities continues less directly by being bound up and recycled into different diagnoses, such as that of BPD. The BPD diagnostic disparity between cisgender/heterosexual and LGBTQIA+ people, especially young people, signals that psychiatry’s entanglement with sexuality and gender difference has not ended but rather taken new forms. These emergent socio-cultural expressions of BPD demand careful interrogation, not only to trace diagnostic bias but also to foreground the conditions through which LGBTQIA+ lives continue to be pathologised.

Footnotes

Acknowledgements

This research was funded by an Australian Research Council Linkage Project grant (LP190100247). We would also like to acknowledge the contribution to this project by wider members of the research team, research participants who generously shared their experiences with us, and project partners for their invaluable support.

ORCID iDs

Emma-Louise Seal

Tamara Borovica

Ethical considerations

Ethics approval was obtained through the Melbourne Health Human Research Ethics Committee (HREC) based in Victoria, Australia, approval number: HREC/65990/MH-2020.

Author contributions

Emma-Louise Seal: Conceptualisation (lead); methodology (lead); data curation (equal); investigation (equal); formal analysis (lead); writing – original draft (lead); writing – review and editing (equal). Renata Kokanovic: Supervision (lead); funding acquisition (lead); writing – review and editing (equal). Tamara Borovica: data curation (equal); investigation (equal); formal analysis (equal); writing – review and editing (equal). Lisa Blackman: writing – original draft (supporting), writing – review and editing (equal); funding acquisition (supporting).

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors disclosed receipt of the following financial support for the research and authorship of this article: This work was supported by the Australian Research Council Linkage Project (grant number LP190100247).

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Research data are not shared.

Notes

Author biographies

Emma Seal is a Research Fellow in the School of Health and Biomedical Sciences at RMIT University. Emma’s interdisciplinary research expertise intersects the cognate areas of sociology, medical humanities and critical public health. She has conducted applied research across a variety of areas in relation to health and critical mental health. Recent projects have focused on the lived experiences of long COVID, critical mental health studies, healthcare system experiences and organisational responses, and the use of arts-based and creative approaces to support wellbeing. Emma has a commitment to applied research that produces tangible outcomes for individuals and communities.

Renata Kokanović is an interdisciplinary scholar working at the intersection of critical mental health studies, social theory and medical humanities. Renata utilises qualitative research methods, with particular interest in narrative approaches to mental and emotional distress. She has published extensively in peer-reviewed journals, including in Social Science & Medicine, Sociology of Health & Illness and Subjectivity.

Tamara Borovica is a Vice Chancellor’s Postdoctoral Research Fellow in the School of Global, Urban and Social Studies at RMIT University. Her research focuses on psycho-social approaches to trauma, health and resilience and the intersection between creative practice, embodiment and individual and societal health. Her expertise is in embodied and arts-based methods for transformative research and human-centric design. She has taught in undergraduate and postgraduate Sociology and Education programs at University of Novi Sad (Serbia) and The University of Melbourne (Australia).

Lisa Blackman works at the intersection of body studies, media psychology, and media and cultural theory. Her research focuses upon the broad areas of affect, subjectivity, the body and embodiment. She has a keen interest in mental health research and activism and was one of the early pioneers of the Hearing Voices Movement. She has also made a substantive contribution to the fields of critical psychology and body studies. She has published six books across these areas and continues to work as an editor of the journal ‘Body & Society’ and a Co-Editor of the journal ‘Subjectivity’.

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