Download Conclusion and discussion

Lost in translation: how a gendered analysis of Borderline Personality
Disorder through the lens of masculinity can help explain the current
gender disparity in the diagnosis of BPD
Naam: Sander ‘t Sas
Studentnummer: 3401103
Studie: Taal en cultuurstudies (TCS)
Docente: Marielle Smith
Studiejaar: 2015-2016
Blok: 4
Datum van inlevering: 24 juni, 2016
Abstract: Ever since its inclusion in the DSM-III in 1980, Borderline Personality Disorder has elicited vivid
discussions and controversy, especially surrounding the 3:1 female to male diagnostic ratio. Several
theories have been proposed on why there is such a gender disparity in BPD, ranging from a
neurobiological perspective, especially in the psychiatric field, to a socio-cultural perspective, mainly
championed by feminist researchers. None of the proposed theories and their answers have been
conclusive. This thesis proposes that this is because there has never been an attempt to integrate
theories of masculinity in the existing analyses of BPD. This thesis attempts to bridge this theoretical gap
by setting out why it is important to incorporate theories of masculinity in the current discussion
surrounding BPD and how this would benefit both males and females diagnosed with this disorder. I
have done this by reviewing and analyzing the most significant feminist and psychological arguments
and offsetting those with masculinity theory.
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Table of contents
Introduction .................................................................................................................................................. 4
Method and caveats ..................................................................................................................................... 5
1.
BPD: genuine illness, instrument of oppression or mode of resistance? ............................................. 6
2.
Boys don’t cry: why men are not equated with BPD symptomatology .............................................. 12
3.
On femmes fatales and killers: the myths surrounding BPD .............................................................. 15
4.
How integrating masculinity will help the treatment of both men and women with BPD ................ 19
Conclusion and discussion .......................................................................................................................... 21
Bibliography ................................................................................................................................................ 24
3
Introduction
In 2012 I have been diagnosed with a Borderline Personality Disorder (BPD). When I first got confronted
with this diagnosis my initial reaction was to dismiss it. I had heard of BPD before, and from what little
information I had gathered through the media and personal discussions, only women and homosexuals
could be diagnosed as borderline. I am neither a woman nor a homosexual. But the diagnosis stood, and
determined to know everything there was to know about this disorder I set out on finding as much
information as I could, especially on borderline males.
To my surprise I found that as a white heterosexual young male from the upper middle class, my
diagnosis made me part of a group of patients whom researchers acknowledged existed, but were only
mentioned as an afterthought in research articles and books. There was some information, but nothing
substantial. This state of affairs baffled me, especially considering the substantial amount of information
available on women with BPD.
As chance would have it, during that time I started my Major in Gender studies. This choice
opened up new avenues of thought that I found incredibly helpful in making sense of my diagnosis. I had
always suspected that personality disorders were more than just a medical diagnosis and that the
neurobiological framework in which they were placed did not constitute the entirety of the picture.
Feminist theory not only validated that suspicion but gave me the tools to look for answers. It was
empowering not only on an intellectual level, but on a deeply personal level as well. But while feminist
thinkers provided important and a much needed analysis on the socio-cultural dimensions of BPD, they
too only focused on women with BPD while within psychiatry, researchers increasingly focused on
neurobiological explanations. Both fields of study agreed that the gender disparity in BPD was
problematic but took mostly opposing stances when it came to formulating a satisfactory explanation.
In her book Borderline Personality Disorder: Women and their stories (2001), which is a feminist
analysis of BPD, Janet Wirth-Cauchon devoted a few pages to the discussion of two of the known case
studies of male borderlines. She noted that these men enacted their symptoms differently than women,
reminiscent of ‘hegemonic masculinity’. Intrigued, I started searching for the term and discovered that
4
there was a whole field of study devoted to men within gender studies: masculinity studies. This
provided me with gendered analyses of mental health issues such as depression or suicidality through
the lens of masculinity. If such an analysis were made of BPD, could it shed some light on this gender
disparity? Why has such an analysis never been attempted? And if such an analysis were provided, what
would that mean for the diagnosis and treatment of BPD?
To the best of my knowledge, a gendered analysis of BPD through the lens of masculinity has
never been proposed before. It is beyond the scope of this thesis to perform such an analysis. Rather I
want to lay the groundwork for further research on this topic by attempting to bridge the theoretical
gap between feminism, masculinity studies and psychiatry when it comes to BPD. In order to do that I
have formulated the following research question: In what way can a gendered analysis through the lens
of masculinity explain and address gender disparity in the diagnosis of Borderline Personality Disorder?
To be able to answer this question, the following questions must be answered first: In what way has the
feminization of the narrative surrounding BPD contributed to the current gender disparity in BPD?; What
are the potential consequences of the current feminized framework in which BPD is viewed on both
male and female patients?; How can a gender-sensitive analysis of BPD benefit both male and female
patients?
In order for me to answer these questions, I will first position myself in the current debate on
gender and BPD by giving an overview of the current feminist viewpoints. From there I will build up my
argument for the inclusion of masculinity theory by analyzing the current findings on BPD and
connecting these to research done on other mental disorders from a masculine perspective. Finally, I
will show that incorporating masculinity in the current discussion on BPD will not only benefit men, but
women as well, as it will provide extra avenues of research to develop gender-sensitive therapies and
provide leverage to the idea that the way BPD has been presented up until now is indeed heavily biased
against women.
Method and caveats
The aim of this thesis is to make the case for why it is important to incorporate a gendered analysis of
BPD through the lens of masculinity. I will do this by giving an overview of the most important literature
about gender disparity in BPD, and point out the gaps in the research because of the hypothesized
absence of masculinity theory. By combining existing studies I will try to bridge the gap between
disciplines of psychology and gender studies. The psychological articles have been chosen because they
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represent the dominant lines of inquiry on gender and BPD, which makes them suitably comprehensive
for the scope of this thesis. I will base my analysis of BPD from a feminist perspective, primarily on the
work of Wirth-Cauchon (2001). Her feminist study of BPD is the most detailed and thorough analysis to
date. I will draw on masculinity theory primarily from a mental health perspective, also to fit the scope
of this paper.
A caveat is that I will not be able to go into extreme detail when it comes to the biological roots
of BPD, as that is beyond the scope of this paper to do so. Also, I will extend my analysis of masculinity
and BPD from previous studies on depression and masculinity, as this paper is the first attempt to
introduce masculinity studies in BPD. Still, this will not hamper the goal of this paper which is to connect
the fields of masculinity studies, feminism and clinical psychology.
I focus on BPD as it has been described in the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision (2000) or DSM-IV-TR for short. In 2013, the DSM-IV-TR has been
supplanted by the newest edition: the DSM-5, which includes changes in the naming of BPD, now called
Emotion Regulation Disorder (ERD) as well as changes in the way diagnostic criteria are outlined. How
these changes will affect gender disparity in disorders such as BPD remains to be seen as it is still too
early to tell if there will be any effect. This then does not put into question the validity of research on
BPD done before and after 2013, which still uses BPD as it is described in the DSM-IV-TR.
1. BPD: genuine illness, instrument of oppression or mode of
resistance?
Borderline Personality Disorder is defined as:
“a personality disorder characterized by fears of abandonment, relationships where others are
alternately idealized or demonized, an unstable sense of self, impulsivity, suicidal behavior,
mood swings, feelings of emptiness, overwhelming anger, and stress-related paranoia or
dissociative symptoms”1.
1
Rebecca J Lester, « Lessons from the borderline : Anthropology, psychiatry, and the risks of being human, »
Feminism & Psychology 23(1) (2013) :71.
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BPD was first described by Adolph Stern in 1938 as being on the border between neurosis and
psychosis. Yet it was not until 1980 that BPD got accepted in the classification of mental health
disorders, the Diagnostic and Statistical Manual Third Edition, or DSM-III, after which research on the
subject of BPD began in earnest2. BPD has always elicited vivid discussions, especially on the subject of
gender disparity within the borderline population. 75% to 80% of patients diagnosed with BPD are
female3. Up until this day researchers disagree on why that is, even though it has now been shown
conclusively that prevalence of BPD is equal among both males and females4. There is also more overlap
than previously thought in Axis I and II comorbidity as well as in overall symptoms between the genders,
which in some cases even attenuates gender differences5. Since 1980, a system of five different axes has
been used to differentiate between disorders. Axis I disorders are clinical disorders such as major
depression and panic disorders. Axis II includes the personality disorders such as BPD and Antisocial
Personality Disorder (ASPD). There is a high level of comorbidity between the axes, comorbidity meaning
that someone has several different diagnoses at the same time6. BPD has an especially significant
association with comorbidity7.
2
Joel Paris, “A History of research on Borderline Personality Disorder in Childhood and Adolescence,” C. Sharp and
J.L. Tackett (eds.), Handbook of Borderline Personality Disorder in Children and Adolescents, DOI 10.1007/978-14939-0591-1_2, Springer Science+Business Media New York (2014): 9.
3
Joel Paris, “Gender Differences in Personality Traits and Disorders,” Current Psychiatry Reports 6 (2004): 72; Amy
Silberschmidt, S.Lee, M. Zanarini, S. Charles Schulz, “Gender differences in Borderline Personality Disorder: results
from a multinational clinical trial sample,” Journal of Personality Disorders 28. The Guilford Press (2014):1.
4
Silberschmidt et al, Gender differences, 2.
5
Ibid, 9-10.
6
Espen Roysamb, K. Tambs, R. E. Orstavik, Svenn Torgersen, K. S. Kendler, M. C. Neale, S. H. Aggen, T. ReichbornKjennerud, “The joint structure of DSM-IV Axis I and II disorders,” Journal of Abnormal Psychology 120(1)
(2011):198-209.
7
Dawn M. Johnson, M. Tracie Shea, S. Yen, C. L. Battle, C. Zlotnick, C. A. Sanislow, C. M. Grilo, A. E. Skodol, D. S.
Bender, T. H. McGlashan, J. G. Gunderson, M. C. Zanarini, “Gender differences in Borderline Personality Disorder:
findings from the Collaborative Longitudinal Personality Disorders Study, Comprehensive Psychiatry vol.44, no. 4
(2003):284.
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If the prevalence and presentation of symptoms in BPD, as well as comorbidity, cuts through
perceived gender differences, how can the disparaging approximation of a 3:1 female to male ratio8
within the BPD population be explained? Throughout its history, the narrative surrounding BPD has
been feminized, especially after its inclusion in the DSM-III. This feminization has led to an
overwhelming focus on female patients and their symptoms. Not only within clinical psychology, which
increasingly focused on a neurobiological explanation, but also within such fields as feminism, who,
while making valuable contributions to the discussion on BPD, also inadvertently contributed to the
reinforcement of a one-sided view of gender and BPD by almost solely focusing on women. This has led
to the marginalization of borderline men, who are frequently either misdiagnosed or not diagnosed at
all.
Ever since BPD was first included in the DSM-III in 1980, it has elicited heated discussions and
controversy9. It is not the function of this chapter to rehash what has already been written on the
inherent gender bias in BPD and how this gender bias led to the feminization of this disorder. Still, a
quick overview of the most important arguments regarding gender bias in BPD is important in order to
be able to extrapolate towards how masculinity and mental health intersect and how this relates to BPD.
In her seminal article “A woman’s view of DSM-III” which appeared in the July 1983 edition of
the American Psychologist, Marcie Kaplan posited that the way that many mental disorders were being
described were unfairly balanced against women. According to Kaplan, the DSM-III represented the
codification of masculine-based assumptions on what should be considered healthy and unhealthy
female behavior. Kaplan especially questioned the underlying meaning of phrases like “impairment in
social or occupational functioning”10 and the DSM’s definition of social deviance11. Could for example a
woman who was unemployed other than being a housewife be considered impaired in occupational
functioning? Or when could somebody be considered socially deviant? What was social deviance
exactly? The vagueness of this term made it extremely difficult at best, if not impossible, to distinguish
8
Andrew E. Skodol and D. S. Bender, “Why are women diagnosed borderline more than men?” Psychiatric
Quarterly, vol.74, no.4 (2003): 350.
9
Rebecca J. Lester, “Brokering authenticity: Borderline Personality Disorder and the ethics of care in an American
eating disorder clinic,” Current Anthropology vol. 50, no.3 (2009):285.
10
Marcie Kaplan, “A woman’s view of DSM-III,” American Psychologist (July 1983):788.
11
Ibid, 789.
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social deviance brought on by mental illness and social deviance brought on by an individual’s subjective
distress due to a conflict with an unjust society12. These vague codifications in their turn influenced
patterns in diagnosis and treatment rates13. These patterns would show that exponentially more women
than men would be diagnosed and treated lending renewed credence to the perceived objectivity of the
way mental disorders and their symptoms were codified, a codification that was flawed in the first
place. Indeed it was striking how male to female sex-ratios could differ so widely in certain disorders, as
critics had noted for many years already and Kaplan’s article only served to underline. But what Kaplan
did was clearly state that one of the reasons that many disorders were mainly prevalent in one gender
or the other (like for example anorexia in women and Antisocial Personality Disorder (ASPD) in men)
was because the codification of these disorders was not based on objective facts, but on stereotyped
assumptions, heavily influenced by a patriarchal mode of thought that pathologized certain aspects of
femininity.
While Kaplan did not discuss BPD in her article, borderline soon did become the focus of
research on gender bias in psychiatry. Having been a heavily contested and under-researched topic prior
to its inclusion in the DSM-III, research on borderline as well as its rate of diagnosis sky-rocketed after
1980. Within a few years, BPD became the most often diagnosed disorder, primarily in young women14.
Feminists pointed out that the nine criteria for BPD, of which a patient must exhibit five in order to
become eligible for diagnosis15, were couched in such vague and biased terms that they could
encompass literally any female, healthy or not. For example, one of the defining criteria of BPD is a
marked impulsivity in at least two major areas of life such as sex, drug use or reckless spending. But
when can a woman be considered impulsive when it comes to sex? Could a woman who has more than
one sexual partner for example be considered impulsive? As Kaplan already showed, the definitions
used were so all-encompassing that whether or not an individual with nontraditional views or lifestyle
would be considered mentally ill would be decided by the subjective views of the clinician performing
12
Ibid.
13
Ibid:786.
14
Janet Wirth-Cauchon, Women and Borderline Personality Disorder: Symptoms and Stories, Rutgers University
Press USA, 2001.
15
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th edition, text rev.),
Author, 2000.
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the diagnosis16. Most importantly, for feminist thinkers, BPD became a symbol for the position women
had historically taken up in Western society. Being neither fully integrated within society nor totally
outcast, women occupy the cracks and corners, and function primarily as a symbol of what masculinity is
not17. Women traditionally live on the borderlands of a patriarchal society, just like borderline women
live on the borderlands between sanity and insanity, borderline thus becoming a representation of the
place men had relegated women to18. But borderline also came to represent female resistance against
this state of being, a resistance that showed in the violence of the symptoms that make up BPD19. BPD
showed the inherent madness of society in general and provided a mirror for it.
This line of thought provided a much needed critique of the way BPD was codified and women
with BPD were diagnosed and treated in psychiatric settings, but in practice it did not necessarily help to
challenge and change the gender bias in BPD, a bias that had been shown to exist20. One of the reasons
for this was that feminism politicized BPD by focusing entirely on the sociocultural and historical factors
that are partly inherent to the description and diagnosis of any mental disorder, and foregoing any other
explanation, especially neurobiological ones. In doing so, feminist thinkers in effect negated the lived
experiences of female BPD sufferers, by turning their plight into a politicized mode of resistance against
a male dominated society. This left women with BPD in something between a rock and a hard place as
the stigmatization and abuse highlighted by feminism was very real. Ironically, this left them with
nowhere to go, as feminism simply switched one mode of thinking with the other without considering
the practical implications of what it meant for women to live with BPD and its devastating symptoms21.
In short, feminism erased the fact that while the way BPD might have been constructed was biased
16
Kaplan, Woman’s View, 789.
17
Ibid.
18
Wirth-Cauchon, Symptoms and Stories, 81-86.
19
Dana Becker, Through the looking glass: Women and Borderline Personality Disorder, Westview Press USA, 1997;
Wirth-Cauchon, Symptoms and Stories.
20
Skodol and Bender,Why Are Women Diagnosed.
21
Lester, Lessons From The Borderline, 73; Elizabeth J. Donaldson, “The corpus of the Madwoman: toward a
Feminist Disability Studies theory of embodiment and mental illness,” NWSA Journal vol.14, no.3, Feminist
Disability Studies (Autumn 2002):99-119; Marta Caminero-Santangelo, The Madwoman can’t speak: or why
insanity isn’t subversive, Cornell University Press, 1998.
10
against women, for those very same women, their symptoms and everyday struggles are very real, no
matter the label and its origins.
Another important consequence of the way BPD was being discussed within feminism and
psychiatry is that there was less and less room to theorize about BPD in males from a social perspective.
Within psychiatry, the discussion on gender differences in BPD was firmly in the hands of
neurobiological researchers, who looked towards heredity and biological predispositions to explain why
women were over-represented in the BPD population22. Feminism in the meantime had politicized BPD
as an unconscious feminine rebellion against patriarchy to such an extent that to focus on men would
have hurt the feminist endeavor to critique and change gender biased aspects of the psychiatric field.
Feminists, who had fought long and hard to gain a voice and a certain status, especially in academia,
were naturally loathe to give up the advantages they had finally gained within a system that was run by
men and for men. Logically, within gender studies, men were being marginalized in favor of research on
women23. Consequently there has been relatively little attention for men with mental health problems24
and it is but rarely that the male experience when it comes to (mental) health is deconstructed using a
gendered analysis25.
The result of this negation of the male experience when it comes to mental health issues hurts
both males and females with mental health problems, and BPD is a prime example of that. Feminists set
out to challenge the negative bias against women that exists in psychiatry as a whole, and used BPD as a
prime example, as the gender disparity in the diagnosis of this disorder is so glaring. But in only focusing
on a gendered analysis of BPD through a feminist lens, feminists arguably shot themselves in the foot as
their focus on women only served to strengthen the already existing perceived link between femininity
and BPD, instead of debunking the myth that only women can be diagnosed borderline. Yet gender
22
Paris, History Of Research.
23
Nikki Wedgwood, “Connell’s theory of masculinity – its origins and influences on the study of gender,” Journal of
Gender Studies vol.18, no.4, (December 2009):337.
24
Carol Emslie, D. Ridge, Sue Ziebland, K. Hunt, “Men’s accounts of depression: reconstructing or resisting
hegemonic masculinity?” Social Science and Medicine vol.62, no.9, (May 2006): 3.
25
Joan Evans, B. Frank, J.L. Oliffe, D. Gregory, Health, Illness, “Men and Masculinities (HIMM): a theoretical
framework for understanding men and their health,” JMH vol.8, no.1, (March 2011): 7.
11
overall is an interplay between the male and female side, with the male gender only properly
understood when studied in tandem with the female gender and vice versa26.
2. Boys don’t cry: why men are not equated with BPD
symptomatology
In the previous chapter I have outlined the main threads of the discussion surrounding BPD as a
disorder. In this chapter I will detail in what way the feminization of the narrative surrounding BPD has
contributed to the current gender disparity in BPD.
Gender is “the complex of social relations and practices attached to biological sex”27. In other
words, what makes a man or a woman is not defined in its totality by one’s biological makeup. Feminism
has long showed that this holds true for women as “one is not born, but rather becomes a woman”28. As
this holds true for women, so this should hold true for men. Yet “men have not been treated as
‘engendered and engendering persons’”29, rather masculinity is usually viewed as a fixed and
homogenous entity. Thus when it comes to mental health men have been under-researched in terms of
how their gender affects their well-being30 even though it has been shown conclusively that gender “is
one of the most important socio-cultural factors in health and health-related behavior”31. In short, how
men position themselves in relation to their mental health is informed by the way society constructs the
notion of masculinity, of what it means ‘to be a man’.
In the study of men and masculinities, the Australian sociologist Raewyn32 Connell’s theory of
masculinity, which she first set out in the first edition of her book Masculinities (1995), is the most
26
Raewyn W. Connell, Masculinities, Polity Press UK, 1995.
27
Evans et al, HIMM, 7.
28
Simone de Beauvoir, Second Sex, translated by: Constance Borde and Sheilla Malovany-Chevallier, Vintage
Books, Random House USA, 1949.
29
Emslie et al, Accounts Of Depression, 3.
30
Ibid.
31
Evans et al, HIMM, 7
32
In 1995, Raewyn Connell was still known as Robert Connell. Since coming out as transgender, she has specifically
requested that she be quoted using her new name instead of Robert, even for publications prior to her coming
out.
12
influential33. What is crucial in Connell’s theory of masculinity is that it overcomes the social
determinism of sex-role theory by providing a critical feminist analysis of historically specific
masculinities while acknowledging the wide variation of degrees in which individual men reproduce
dominant forms of masculinity34. Masculinity is actively performed and in constant flux, subject to
changes in the social and geographical settings in which each individual man finds himself throughout
his life35. Masculinity is not a fixed entity, rather one should speak in the plural –masculinities– which are
not embedded in individual personality traits or the body but are “configurations of practice”36. Thus,
Connell identified hegemonic masculinity as the ideal type of masculinity that men should strive to
achieve, as well as subordinate masculinity, complicit masculinity and marginalized masculinity37.
Central to this notion is the concept of hegemonic masculinity. Hegemonic masculinity is best
defined as a set of practices and beliefs that constitute the norm on what masculinity should entail. This
does not mean that it is a type of masculinity that is consequently applicable to all male behavior, rather
it forms a creed, a set of traits, beliefs and behaviors that men should aspire to and work towards
achieving38. Originating as an explanation for male dominance over women, hegemonic masculinity is
usually associated with notions like insensitivity, physical violence, rigidity and control. This is too
narrow a definition as it also encompasses notions as a man’s duty to bring home a wage, act as a
protector, and to fulfill a leadership role. The term “hegemonic” does not imply that all men submit to
this notion. Rather what is considered hegemonic masculinity is under constant attack, and subject to
change, throughout time and within males as a group, but also in the individual life of each man39.
Another important concept is that masculinity is primarily defined by what it is not: feminine40.
Masculinity is thus constructed in relational terms to femininity and this implies a hierarchy of
33
Wedgwood, Theory Of Masculinity.
34
Ibid, 330.
35
Connell, Masculinities.
36
Raewyn W. Connell and J.W. Messerschmidt, “Hegemonic Masculinity: rethinking the concept,” Gender and
Society vol.19, no.6 (Dec. 2005): 836.
37
Wedgwood, Theory Of Masculinity, 335.
38
Connell and Messerschmidt, Hegemonic Masculinity, 832.
39
Ibid, 835.
40
Emslie et al, Accounts Of Depression, 2.
13
masculinities, with hegemonic masculinity as the ideal. But this also means that many men, who for one
reason or another cannot live up to the masculine ideal, feel stigmatized and experience subordination.
In general men are more constrained than women by gender ideology, as their status as a man is under
constant scrutiny and attack, and can be lost at any moment if they exhibit practices that are perceived
as un-masculine and feminine41. Gay men for example are typically often seen as half a man or not men
at all, due to their sexual orientation and the way they might or might not exhibit this. The reverse is
also true. By the accomplishment of what is considered typically masculine behavior a man can gain
more status and thus climb higher in the masculine hierarchy42. Men who experience a sense of
stigmatization and subordination have been identified as being specifically at risk for certain types of
behavior that can jeopardize their health such as excessive risk-taking or showing imperviousness to
pain or discomfort, which are meant to stave off the risk of being associated with what is considered
typical feminine behavior such as vulnerability, dependence and loss of control. Hence the reason why
many men will typically avoid to see a doctor as illness in general and mental illness specifically is
associated with femininity43. This then could go a long way in explaining why there is so little known
about men with borderline as the way this disorder presents itself in the literature is quintessentially
feminine. BPD is all about loss of control, extreme vulnerability and dependence, and it has been shown
that men as well as women will enact certain representations of symptoms if these are believed to
correlate better with their gender44.
Yet the results of a multinational clinical trial published in 2014 show that there is much more
overlap in symptomatology between the genders than previously thought. While the prevalence of
certain symptoms and comorbid disorders like Bulimia Nervosa have been found to be on par with the
general population, certain results differ from previous conclusion in important ways that are specific to
the BPD population. Borderline men do not exhibit a greater propensity for substance dependence and
abuse then borderline women, a finding that differs greatly from rates among the general population. It
41
Joseph A. Vandello and J. K. Bosson, “ Hard won and easily lost: a review and synthesis of theory and research on
precarious manhood” Psychology of Men & Masculinity vol.14, no.2 (2013):101-113.
42
Evans et al, HIMM, 8.
43
Ibid., 9; Michael E. Addis and J.R. Mahalik, “Men, masculinity, and the contexts of help seeking” American
Psychologist vol.58, no.1, (January 2003):6.
44
Lester, Brokering Authenticity, 298-299.
14
has also been found that there is an unexpected convergence between the genders in levels of
aggressiveness as well as suicidality; aggressiveness being considered a typical masculine symptom and
suicidality a typical feminine symptom. Expected gender gaps in panic disorder and obsessive
compulsive disorder, as well as posttraumatic stress disorder, are either not apparent or attenuated45. In
the report of their findings, the researchers end with positing that in view of these results, it might be
time to not wonder what the differences are between men and women with BPD, but to ask instead the
question of why they actually are not that different. Using masculinity theory to analyze BPD would
greatly help in giving an answer to this question.
3. On femmes fatales and killers: the myths surrounding BPD
By its very nature, BPD is an interesting disorder to analyze, because of its many facets, and the myriad
of ways that it presents itself. The more researchers learn about this disorder, it seems as if what they
learn only yields more questions. But in what way do the discussions surrounding BPD impact reality in
the field? What are the potential consequences of the current feminized framework in which BPD is
viewed for both male and female patients?
While negative stereotyping and stigmatization is rife across the whole of the spectrum of
different mental disorders, many of those disorders also carry certain ‘positives’. Depression has for
example been linked to greater empathy and a greater sense of realism, Posttraumatic Stress Disorder
(PTSD) with greater resilience and Bipolar Disorder with creativity46. This is not so in the case of BPD.
Ever since BPD gained prominence as a disorder, in the public imagination borderline has gained
an aura of dark unpredictability, chaos, hyper-sexuality, violence and death. If for example one searches
on Google using the search phrase ‘movies about borderline personality disorder’, one of the first pages
a searcher can click on is a list from the Internet Movie Database (IMDb)47. This list includes such films
as FATAL ATTRACTION (1987), BASIC INSTINCT (1992), MULHOLLAND DRIVE (2001) and MY SUPER EX-GIRLFRIEND
45
Silberschmidt et al, Gender Differences, 8-10.
46
Juan Francisco Galvez Florez, S. Thommi, and N. Ghaemi, “Positive aspects of mental illness: a review in bipolar
disorder” Journal of Affective Disorders 128 (2011):185-190.
47
For a full list see: http://www.imdb.com/search/title?keywords=borderline-personalitydisorder&title_type=feature,tv_movie,documentary
15
(2006) among many others. Not all of these films explicitly use BPD as a theme but they have come to
equate and represent this disorder48 as they share such over-arching themes as hyper-sexuality, extreme
impulsiveness, extreme psychological and physical abuse, extreme obsession with loved ones, extreme
neediness and violent manipulation. All of these are hallmarks of BPD and in most of these movies it is
the women who display such traits. This extremely negative view on the part of Hollywood has partly
been echoed in popular literature, especially in pop-psychology. Most of these are self-help books such
as Stop walking on eggshells: taking your life back when someone you care about has Borderline
Personality Disorder (1998) by Randi Kreger and Paul Mason or I hate you - Don’t leave me:
understanding the borderline personality (2010) by Jerold Kreisman and Hal Straus are international
bestsellers. These books claim to try and demystify BPD and to give concrete handholds and tips to
sufferers of BPD and their loved ones. This is a worthy cause in itself, but these books primarily focus on
BPD as being destructive in the extreme, with the sufferer bent on extreme manipulation, selfdestruction, obsession and dangerous behavior. They portray BPD as a disorder that leaves a path of
destruction in its wake, and which sucks everything and everyone into a black hole. Since the advent of
the Internet, this stereotyping has only grown worse, with numerous blogs, vlogs and articles warning
about people with BPD and the danger that they pose, especially to those around them.
In psychiatry, borderlines are considered the most difficult patients to work with, emotionally
draining, needy and unpredictable. In interviews, therapists have used the Dementors in the Harry
Potter books (creatures who survive by sucking the life out of their surroundings) to describe how
draining borderline patients can be49. Others talk about the ‘meat grinder sensation’ meaning that if a
patient makes a therapist feel as if their insides are slowly turning to mush, then that patient is most
probably borderline50. In many cases, there is feeling of contempt in the way borderline patients are
viewed by therapists51. The vagueness of the symptoms that compose BPD allow clinicians to easily
diagnose as borderline “anyone that doctors find inscrutable, provocative, or even merely annoying”52.
48
Joseph Nowinsky, Hard to love: understanding and overcoming male borderline personality disorder, Central
Recovery Press USA, (2014): xiii.
49
Lester, Brokering Authenticity, 285.
50
Ibid.
51
Lester, Lessons From The Borderline, 70.
52
Potter in Lester, Lessons From The Borderline, 71.
16
BPD is one of the few medical conditions that one can be diagnosed with based primarily on how a
patient makes a psychiatrist feel53.
Thus, women with BPD suffer under the stigma that comes with the misogynist cultural fantasy
that has been created around them54. They are presented as the ultimate ‘femme fatale’, who will go to
any length to manipulate those around them (usually men) to get what they want, leaving a path of
destruction in their wake. It could be argued that the use of BPD symptoms like uncontrollable rage or
self-destruction by feminist thinkers as a metaphor for the position that women are put in within
patriarchal culture has impacted the plight of borderline patients negatively in the sense that they have
lost their right to be ill. By overtly focusing on the sociocultural aspects of the way BPD symptomatology
presents itself, borderline patients have become accountable for their illness, as it is cast by feminist
thinkers as a way to protest feminine subjugation. This then means that those women with BPD can be
seen as willingly presenting these symptoms by clinicians and the general public, thus adding to the
stigma of the borderline woman as an inauthentic manipulator.
In the case of men with BPD, the picture is just as bleak. Films like FALLING DOWN (1993) and
AMERICAN PSYCHO (2000), depict borderline males as violent and bloodthirsty in the extreme. The big
difference between the way borderline males and their female counterparts are presented is that
borderline men are thought to be more externally violent, and physically aggressive, while women are
thought to use more psychological manipulation and will be quicker in turning violent against
themselves. Where borderline women suffer from the image of a femme fatale or a sex-bomb, BPD
traits in males are typically represented in the popular mind by the out-of-control killer, as in AMERICAN
PSYCHO or the cold and calculating tyrant or dictator. It has been theorized that dictators and warcriminals like Adolf Hitler, Josef Stalin or Saddam Hussein, as well as Muammar Ghaddafi could have had
BPD due to the way they presented themselves55. While of course this is possible, such analyses as have
been made are partially based on speculation due to the nature of the topic. This speculation can take
on a life of its own, right up to the point where the nuances of what BPD really is are lost and the only
53
Lester, Brokering Authenticity, 298-299.
54
Wirth-Cauchon, Symptoms And Stories, 171.
55
Betty Glad, “Why tyrants go too far: malignant narcissism and absolute power” Political Psychology Vol.23, No.1,
(March 2002): 1-37.
17
image that remains is that BPD in males results in the likes of Adolf Hitler. For obvious reasons this is not
an image that anybody wants to identify with.
The biggest practical problem that BPD males face, is that there is so little known about them.
This means that they are either undiagnosed or misdiagnosed. In both cases this state of affairs can have
far reaching and even deadly consequences. BPD has one of the highest suicide rates of all personality
disorders, with about 10% of all patients successfully completing suicide, and at least three quarters
attempting suicide at some point during their illness. Rates of suicide among the BPD population is
higher than among the general population56. But in the general population, those most at risk of
successfully completing suicide are young men57. Studies on suicidal behavior among men show that a
feeling of loss of control over one’s life, the risk of having to disclose emotional pain, the inability of men
who generally subscribe to the hegemonic masculine paradigm to acknowledge their feelings and a
general fear to deviate from the masculine norm, and thus to be seen as ‘feminine’, can drive men to
suicide much quicker than women as they see no other way out of their problems58. Even more
dangerous is that not successfully completing suicide can be seen as a feminine act in and of itself as this
would show a ‘lack of courage’ needed to complete the deed59. Gender differences in rates of suicidality
within the BPD population are still not fully understood60, but it could be argued that because as a
disorder BPD carries such a high risk of suicidality, it could very well be that the current figure of 10%
when it comes to successful suicides linked to BPD is distorted due to the fact that there is so little
known about borderline men. If it is indeed so difficult for many men to take the step to actually seek
help for their mental problems, and if, when they finally do, the root of their problems is not recognized
as being BPD due to the prevailing gender bias, the conclusion can be drawn that these men will be even
quicker in contemplating and even successfully completing suicide.
56
Maurizio Pompili, P. Girardi, A. Ruberto, R. Tatarelli, “Suicide In Borderline Personality Disorder: a meta-analysis”
Nordic Journal of Psychiatry Vol.59, no.5, (February 2005):319-324; Donald W. Black, N. Blum, B. Pfohl, N. Hale,
“Suicidal behavior in Borderline Personality Disorder: prevalence, risk factors, prediction, and prevention” Journal
of Personality Disorders, Vol.18, no.3, (2004):226-239.
57
Anne Cleary, “Suicidal action, emotional expression, and the performance of masculinities,” Social Science and
Medicine (2011):1.
58
Ibid, 7
59
Emslie et al, Accounts Of Depression, 19.
60
Pompili et al, Suicide In Borderline Personality Disorder, 323.
18
The label of BPD carries a great deal of stigma and is often misrepresented. Women with
borderline suffer because they are viewed as either hypersexual and manipulative deviants who use
their symptoms to get what they want. Borderline men suffer because they are equated with extreme
violence and tyranny. For men with BPD the problem is compounded by the fact that there is so little
known about them, due to the focus on women with BPD and the way they present their symptoms
which means that male borderlines go unrecognized in a majority of cases, if they dare to take the step
to go to a psychiatrist at all. It has to be noted though that for some time now, a less destructive
counter-narrative about BPD has been gaining more credence. Due to the high correlation between
trauma and BPD, sufferers of BPD have increasingly been cast as survivors who have developed their
borderline symptomatology in order to be able to handle their traumatic experiences61. This is a
welcome and more constructive narrative, as indeed most borderline patients are survivors of
harrowing experiences, especially child sexual abuse, rape, and other forms of violence. They are
survivors, who fight every day for their lives, and it is a good thing that this aspect of BPD gains more
prominence. Incorporating men in the BPD narrative will go a long way in strengthening positive
counter-narratives as it will help to break down the prevailing and misleading idea that borderline is a
‘female malady’ and that women with BPD are nothing but destructive and manipulating deviants.
4. How integrating masculinity will help the treatment of both men
and women with BPD
From the onset, BPD has had the reputation of being incurable and a lifelong condition. Even though this
idea has remained generally persistent, in recent decades it has been proven that this not the case62. A
series of studies have shown that BPD not only has a much more benign course than is generally thought
to be the case, but recent decades have also shown the emergence of specific treatment courses such as
Mentalization Based Therapy (MBT) that have dramatically altered the prospects of recovery for
patients with BPD. In six years, 75% of patients showing such severity of symptoms that they require
hospitalization achieve remission. Most importantly, recurrence of symptoms is rare, standing at only
61
Lester, Lessons From The Borderline.
62
Lester, Brokering Authenticity, 291.
19
10% over a period of six years, contrasting quite strongly with other disorders where recurrence is much
more common63. This is an achievement that makes for a hopeful future, especially considering the level
of overall impairment and the mortality rate among patients with BPD. Due to the level of suicidal
tendencies and propensity to auto-mutilate, along with how common this disorder is, borderline
patients are among the most care-intensive patients in the mental health care system. It is therefore
important that existing regimens of treatment are being built upon to better serve the needs of this
particular group of patients64.
Therapies like Mentalization Based Therapy work from the concept that the problems borderline
patients experience with attachment on an interpersonal level and affect regulation stem from “a failure
to develop a robust mentalizing capacity”65. Bateman and Fonagy define mentalizing as “the process by
which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states
and mental processes. It is a profoundly social construct in the sense that we are attentive to the mental
states of those we are with, physically or psychologically”66. By practicing MBT and other, similar,
therapies, patients deconstruct and reconstruct their personality, their selves. It is important here to
realize that this is what therapy essentially is: seeing the self in a new light. But deconstructing and
reconstructing the self is inexorably linked to gender67. When it comes to BPD this understanding takes
on a new importance as BPD is defined as a disorder of the self, a fragmentation of the self. As the sense
of self and performances of masculinity are so bound together in men, the better the interplay between
gender and BPD is understood, the better patients with BPD can be helped.
A very promising avenue of research could be a more widespread use of life history and
narrative identity. Connell’s research into masculinities has been very much grounded in the use of life
history case studies, informed by psychoanalysis68. Connell argued that the tools of psychoanalysis can
63
Peter Fonagy and A. Bateman, “Progress in the treatment of Borderline Personality Disorder,” British Journal of
Psychiatry Vol.188, (2006):1.
64
Anthony Bateman and P. Fonagy, “Mentalization Based Treatment for Borderline Personality Disorder” World
Psychiatry Vol.9, (2010):11-15.
65
Ibid, 12.
66
Bateman and Fonagy, Mentalization Based Treatment, 11.
67
Emslie et al, Accounts Of Depression, 9.
68
Wedgwood, Theories of Masculinity, 333.
20
be used to show how pressures to conform to society forms the adult personality. In this she has been
influenced by Freud, who hypothesized that adult sexuality and gender are not fixed, natural attributes
but rather constructed over the course of a lifetime in a long process that is steeped in conflict69. It is not
an individualistic approach but rather places a person, the mind and the body in broader concepts like
gender and class without losing sight of the individual. This enabled Connell to solve the problem of
theories being “based either on sociological or biological determinism or an unsatisfactory combination
of the two”70. In psychology, a new sub-discipline called ‘narrative identity research’ has emerged which
is informed by the same view as Connell had, that personality is continually in flux as “Biological and
social changes, role demands of particular life stages, historical and cohort influences all conspire to
make any individual’s narrative a fluid and evolving work in progress”71. While still a sub-discipline,
narrative identity research has steadily been gaining ground in the field of psychology, as it provides a
more holistic and fluid way to interpret and approach a patient’s problems. In the case of the life study
method, its use has not been as widespread as it could have been, mainly because it is a very timeconsuming method. This is a pity as it is a very powerful method of unraveling the different complexities
and contradictions inherent in masculinities72.
Widening the scope of inquiry to encompass a gendered-analysis through the lens of masculinity
will benefit women with BPD as well. Men and women differ in the reasons for embracing or rejecting
culturally dominant gender forms when it comes to their mental health (Emslie et al 2006:18). Mapping
out these differences will enable therapists to devise gender-sensitive therapies that focus on femininity
as well as masculinity, breaking the ‘one-size-fits-all approach’ that foregoes the nuances of difference
that exists between the genders when it comes to so many facets of therapeutic intervention.
Conclusion and discussion
69
Ibid, 334.
70
Ibid, 334.
71
Jefferson A. Singer, “Narrative identity and meaning making across the adult lifespan: an introduction,” Journal
of Personality Vol.72, no.3 (June 2004):445.
72
Wedgwood, Theories Of Masculinity, 335.
21
Ever since its inclusion in the DSM-III, BPD has elicited much controversy, especially because of the
gender disparity within the diagnosed borderline population, of which approximately 75% to 80% are
women. The explanations for this disparity vary and depend on the lens through which researchers view
this disorder. Within the psychiatric field, BPD has become more and more the focus of neurobiological
research, which mainly foregoes the socio-cultural factors that infuse personality disorders as a whole
and BPD in particular, even though these factors are acknowledged. Within gender studies, feminism
theorized BPD as the new female malady, akin to hysteria. Feminist thinkers have focused on the vague
terms in which BPD has been codified and on the subjectivity that fuels the diagnostic criteria of BPD,
resulting in an inherent gender bias against women. While the feminist focus has brought important
viewpoints on BPD, feminism has overtly politicized this disorder, the result of which is that the fact that
BPD is first and foremost a debilitating illness is more often than not overlooked. Most importantly, the
feminist focus on women with BPD, while logical, has had as an unexpected result that it has helped to
strengthen the idea that BPD is indeed a feminine illness, instead of debunking this myth as men and
masculinity theory has never been integrated in the feminist analyses of BPD. Nevertheless, the tone
and focus of the discussion on gender disparity in the diagnosis of BPD has slowly been changing.
Recent, multinational, studies have definitively proven that BPD cuts through gender lines. In light of
this, the question has been posed why men and women with BPD are actually so alike instead of so
different, as previously thought.
The reason why up until now explanations for the existing gender disparity in the diagnosis of
BPD have been unsatisfactory is because a gendered analysis of BPD from a masculinities perspective
has never been made and integrated in the discussion. When it comes to mental health in general, men
have never been seen as gendered or engendering persons. Masculinity is mostly seen as a fixed entity,
a natural state of being. But masculinity is not fixed at all. Rather it is in constant flux, its meaning
constantly contested and changing throughout time as well as within individual lives. Masculinity is a
hierarchized notion, with at the top hegemonic masculinity, which is not so much what most men
represent, but more a state of being they need to strive for. Most importantly, masculinity is defined by
what it is not: feminine. And as mental health has very feminine connotations, men usually get
overlooked in this field. Men are not pushed to be open about mental health problems, least of all those
disorders that carry strong feminine connotations, even though they suffer them at least as much as
women do.
22
A gendered analysis of BPD through the lens of masculinity will bring men with BPD to the
foreground, putting the spotlight a group of patients of which practically nothing is known. This would
not only benefit men suffering with BPD, but their female counterparts as well as it would help counter
the gender bias inherent in BPD. In this way, BPD will finally lose its label of quintessentially female
illness. A more gender-sensitive approach will also help refine the different treatments for BPD, to the
benefit of both men and women with BPD. A more holistic and integrative approach to how and why an
individual presents with a certain set of symptoms heightens the chances for the individual’s recovery.
Integrating the masculine experience in BPD will open up new paths of research into what BPD
exactly is. This thesis is a first attempt to bridge the current theoretical gap between feminism,
psychiatry and masculinity studies and is an attempt to lay the groundwork for further research. It
would for example be interesting to research whether BPD carries the same stigma in The Netherlands
as it does in the United States. It also opens up new avenues of research when it comes to comorbidity.
In the borderline population, certain gender differences are attenuated. Why is that? Finally, BPD has
been reassessed and recodified in the latest edition of the DSM. Masculinity theory will help to provide
a big part of the answers to these questions.
23
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