Authors: Alex and Luci, transgender people
Gender-diverse people have been prone to encountering issues with clinical bias in the field of mental health, being given pathologizing diagnoses, such as personality disorders, at a disproportionately higher rate than the cisgender population. It is thought to occur due to transphobia and a lack of trans-affirmative education.
Transgender individuals are diagnosed with Borderline Personality Disorder (BPD) at a rate nearly 2.5 times higher than their cisgender counterparts. It ranges from 15-50% among gender-diverse patients.
Research shows that, when given identical patient symptoms, with the only difference being their gender identities, practitioners were more likely to diagnose the trans-identified patient with BPD.
Personality disorders are not the only diagnoses that gender-diverse people are often mislabeled with.
Rara, a transgender woman, philosophy student, and illustrator, who is currently residing in Cluj, relates her story of getting diagnosed with Early-onset Schizophrenia (EOS), among others:
How did the mislabeling happen?
“It wasn’t really a one off moment. In my first years I went to a cognitive behavioral therapist, but I quickly understood how limited that approach was in regards to my suffering. After what I believe was 2 to 3 years, I ended up switching to a therapist with a psychoanalytical practice. I came to therapy for a few reasons, some of them being my depressive states, suicidal ideation (which first appeared when I was around 12 years old), an overall hyper anxious state, acute feelings of loneliness and meaningless, consistent struggles around socializing with my peers.”
Two biases that are especially important for understanding the misdiagnosing of gender-diverse individuals, are those of overpathologizing and confirmation. The overpathologizing bias is the tendency to interpret the unusual behaviours of members of marginalized groups as signs of psychopathology.
When data is collected and analyzed in a way that only supports a diagnosis, instead of taking into account all available information that could support or disprove it, it is known as confirmation bias.
“I must preamble by saying that I was lucky to have had both therapists be very well intentioned and supportive, but unaware of transgender mental health care practices, or incapable to identify, reason with and integrate into their understanding of my identity the very important aspect of gender, and my rapport to it. So we were stuck in a loop of treating the symptoms of a symptom, in the process confusing the common experiences of gender dysphoria (brought upon the transgender subject by a phallocentric, binary and rigid set of systems and institutions and available ways of life), with psychiatrical afflictions such as schizophrenia, bipolar disorder, borderline personality disorder, clinical depression, anxiety disorders and others.”
Systemic discrimination and gender dysphoria symptoms may often look like those of BPD. Some of these include, but are not limited to:
- chronic feelings of emptiness;
- recurrent suicidal behavior, gestures or self-mutilation;
- unstable self-image;
- fear of rejection or abandonment;
- unstable, intense relationships.
“By treating the symptoms of a symptom I mean to accentuate the fact that I believe it is a bit too reductive and too much in a tradition of trans medicalism for my comfort to see gender dysphoria simply as a diagnosis. It is often an imposed condition, the punishment for those daring to be in a relationship of transgression with the binary understanding and institutions of gender and sexuality.“
In the past, psychiatric literature has associated the transgender identity with the diagnosis of BPD. As a result, providers’ explanations for a BPD diagnosis may reinforce preexisting biases.
“While I credit therapy (and artistic expression) with saving my life and offering me help processing and coping with the day to day struggles of living as a trans feminine teen in denial in the Republic of Moldova, I also find it important to accept the simple fact that therapy didn’t do much to alleviate the main issue of gender dysphoria, neither did the medications.”
Although BPD is frequently associated with “difficult” behavior, the truth is far more complex. For queer and transgender people, who may already feel excluded from traditional therapy or care settings, stigma in mental health care can be particularly damaging. Health care providers may misdiagnose or treat patients inappropriately due to their lack of knowledge on the complexities of gender dysphoria or queer sexualities.
How did you realize it was gender dysphoria?
“By a slow process of learning to accept the possibility of me being trans feminine. Internalized transphobia is an unfortunate but understandable given for many of us especially in the early stages of acceptance and transitioning. Throughout the years I have come to the understanding that so much of my self-hatred was rooted in an acute and constant fear of the possibility that I did not identify with masculinity, and ultimately the fear that embracing my feminine would entail more violence than I could tolerate. Slowly I have started to warm up to the idea by getting to know and befriending other trans people, with whom I could discover what acceptance feels like and for me to ultimately reach the conclusion that I was non-binary. Only once I left Chișinău could I find the safety needed for me to start exploring and fully accepting my feminine side. In the process, I am finding so much joy and hope in a future in which I can finally live my life as the woman I desire to be.”
Research shows that, with appropriate gender-affirming care and social support, BPD-like symptoms begin to disappear.
“In Chișinău I was given anti-depressants and sleeping pills. In Cluj I was given antipsychotics. The antipsychotics didn’t really help over time. They made me numb and cold, feeling alone in a world in which I did not see myself having a fulfilling life. I felt like there could be no more obvious conclusion than the one that I am a woman, since it simply feels right. In the process of looking for help in tackling my depression, inadvertently I have been mislabeled and my condition has been misunderstood, which delayed the kind of help I needed the most. It took me a long time to accept the fear of having to live as a trans woman day by day, and I am still struggling with that. But the joy that comes with the experience has been extremely meaning-inducing in my life, and I am grateful to have the support and safety needed to go through my transition.”
Did you end up telling your therapist she was wrong?
“It’s been a long time since I talked with my ex-therapist, and who knows, maybe one day I’ll talk to them about the conclusions I have reached. Currently though, I choose to focus on my transition, and slowly getting better and more comfortable with life.”
As always, change begins with proper education. A good step forward would be integrating up-to-date scientific materials regarding gender identity and gender dysphoria into the academic programs for students pursuing degrees related to psychology/psychiatry.
With trans-identified individuals being at greater risk of dealing with mental health challenges due to the significant pressure and stigma they face in their daily lives, access to competent mental health services becomes crucial.
A lack of knowledge on gender identity and anti-transgender bias within the mental healthcare system can lead to improper diagnosis/treatment, resulting in further damage to one’s mental health.
The potential consequences are severe, such as crippling depression, anxiety, isolation, or even suicidal feelings. Alternatively, establishing safe and reliable therapy environments is a crucial factor in providing support and, potentially, saving lives.
Note from the author: While I was doing my research on this topic, I’ve come to realize I was also misdiagnosed with BPD. I had a major crisis after I finally moved out of my parents’ place at 18, facing harsh judgement from them, from the cis and heteronormative society and from my peers, I had very bad suicidal ideation and was on an emotional rollercoaster almost 24/7. The psychiatrist I was directed to diagnosed me with BPD, among other things, and gave me antidepressants. However, the BPD-like symptoms only began to diminish after I started HRT at 19.
