What Role Does Gender Play in Relationship and Self Experiences of Individuals With Borderline Personality Disorder?

Scientific Background Studies have shown that people with BPD experience increased levels of stigma and that this has harmful effects on their mental health (e.g., Rüsch et al., 2006; Quenneville et al., 2020; Ring & Lawn, 2025; van Schie et al., 2024). The role of sex (biological or sex assigned at birth) and gender (socially and culturally constructed gender) aspects in the stigmatization experienced by individuals with BPD has been scarcely investigated to date. It has been hypothesized, however, that the heightened experience of stigmatization is partly related to the fact that the group of individuals with BPD studied predominantly belongs to the female sex assigned at birth (Quenneville et al., 2020). BPD is a severe mental illness characterized by, among other things, unstable emotions, relationships, and identity (APA, 2013). The prevalence ranges from 0.7% to 2.7% in the general population and from 6% to 22% in clinical samples (Leichsenring et al., 2024). In the latter, women are significantly overrepresented at over 70%, while interview-based epidemiological studies find comparable rates among men and women (Grant et al., 2008; Tomko et al., 2014). Feminist-oriented studies criticize psychiatric classification systems for reproducing patriarchal gender stereotypes: Thus, traits considered "too masculine for a woman" (e.g., the criterion of "inappropriate anger") as well as traits with "too feminine" connotations (e.g., the criterion of "mood instability") would be pathologized and thereby stigmatized (Cohen & Hartmann, 2021; Fellows, 2023).

The few studies that have examined the role of gender in people with BPD have focused on samples of people with sexual and gender diversity (SGD)-that is, samples comprising individuals with a sexual orientation other than heterosexuality or a gender identity other than cisgender (where gender identity aligns with the sex assigned at birth). These studies revealed associations between gender and homosexual or bisexual orientation and BPD symptoms; however, the authors emphasize the insufficient data and the need for further research (Shu et al., 2024; Denning et al., 2022). Recent experimental studies also point to gender-dependent differences in social stigmatization: For instance, male-coded BPD vignettes were rated with more anxiety and perceived danger, while female-coded ones were rated with more compassion by the general population (Masland & Null, 2022; Brown, 2024). Together with the knowledge that invalidating relationship experiences are considered central etiological factors in the development of BPD (e.g., Linehan, 1993; Porter et al., 2020; Bateman & Fonagy, 2010), these findings underscore the importance of conducting a differentiated examination of gender-specific relationship and stigmatization experiences in BPD.

Studies that focused on gender-related stigmatization and its impact on mental health also primarily examined SGD samples (Swann et al., 2024; Liu et al., 2025; Scandurra et al., 2020). Experiences of gender-related rejection among transgender and gender nonconforming (TGNC) adults were associated with poorer mental health via internalized trans-negativity-that is, internalized negative attitudes toward trans* individuals-but this effect was reduced with higher mentalization ability (Scandurra et al., 2020), suggesting that mentalization may serve a protective function in this context.

Mentalization describes the ability to explain one's own and others' behavior based on internal states, while maintaining an appropriately curious, open, and "correctable" attitude. Mentalization, as a kind of "psychological buffer" against the effects of aversive experiences on stress and mental health, has frequently been discussed as a resilience-promoting ability (Fonagy et al., 2019). Mentalization develops in early attachment relationships through "social biofeedback" (Gergely & Watson, 1996) as early as childhood, as the child receives feedback about their internal states (affective mirroring) from their immediate environment. Similarly, Koivisto et al. (2022) hypothesized that gender stereotypes might be relevant to the experience of stigmatization among patients with BPD: Rigid self-invalidations observed in a mentalization-based therapy (MBT) group could be associated with female gender stereotypes, which children exhibiting "feminine" behavior internalized as an "Alien Self" through feedback from their environment. In mentalization theory, the "Alien Self" refers to the internalization of a self-image that corresponds, for example, to destructive, incongruent "mirrorings" of one's own experience by the environment (Fonagy et al., 2018).

For example, a belief such as "I am manipulative" may become part of a person's self-concept due to frequent attribution by those around them, yet it may (unconsciously) feel foreign to them in their own experience and remain difficult to regulate effectively. Based on findings regarding the increased stigmatization of BPD vignettes coded as male (Masland & Null, 2022), it could be analogously assumed for individuals perceived as male that "male gender stereotypes" contribute to the formation of an Alien Self (e.g., "I am dangerous"). While MBT was developed specifically for the treatment of BPD and its core goal is to improve mentalization ability, including support in dealing with the Alien Self, it must also be noted here that gender has been neglected thus far.