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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. 2 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 5 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. 6 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. 7 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. 8 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. 9 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 Bibliography American Psychiatric Association (2000), Diagnostic and statistical manual of mental disorders (4th ed., text rev.), Washington, DC: Author. Addis, Michael E. and Mahalik, J.R. 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