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So to start off with, Borderline Personality Disorder is frequently thought to be a trauma reaction; the result of continuing childhood trauma that extends beyond more condensed episodic trauma, that forces the child to develop a series of strategies for coping/surviving the ongoing situation…
If you’ve seen me in chat a lot, you’ve probably seen me at some point say something along the lines of “I have borderline traits.”
What traits?
· Identity disturbance: markedly and persistently unstable self-image or sense of self.
· Affective instability due to a marked reactivity of mood.
· Chronic feelings of emptiness.
· Inappropriate anger or difficulty controlling anger.
· Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms.
Uh oh! 5 or more means Borderline, right? Wrong.
Before you can meet the criteria for BPD, you must first meet the general criteria for Personality Disorders.
Which ones of those DON’T I meet?
Well, frankly, most of them, BUT, the biggest would be that the symptoms must not be explained by another diagnosis.
And therein lays the whole damned point of this post.
By the way, if you’re struggling to follow, or suspicious, I have never been diagnosed nor had the diagnosis of BPD suggested for me. This isn’t about me trying to rationalize my way out of a dx I don’t like, or anything of the sort.
In fact, I wouldn’t particularly mind the dx of BPD, were it accurate.
A year or two of DBT would be a shit-ton easier than what I’m facing to fix the root cause of my borderline traits.
So what the fuck is the root cause of meeting FIVE criteria [six if you count the fact that for about oh… 6 months as a kid I half-heartedly cut myself, mostly to piss my mom off, partially because I wanted/needed attention that I wasn’t getting] of BPD?
Another disorder. Gender Identity Disorder.
Why are the correlations between GID and BPD never talked about?
Well, I think the biggest reason is, it terrifies the trans community. The majority of incorrect GID diagnoses [and subsequent horrible “OMG, I had a SRS and now I realize I wasn’t trans!!!”] were in Borderline patients.
Why? Because in borderlines, the lack of self-image can be so pervasive as to interfere with one’s sense of gender. Most often these mistakes are made by very bad doctors who cannot differentiate [and oftentimes, don’t care to differentiate] between GID and BPD.
So I think, on a whole, the trans community gets a little touchy when the subject of BPD comes up.
Frankly, most of us get touchy about the fact that GID is in the DSM at all.
My ultimate feeling on that is, is Intersex in the DSM? Then neither should GID be.
But, I digress, because that actually seems contradictory to the points I’m trying to make.
Returning to my first point, BPD is the result of ongoing trauma in childhood.
That ongoing trauma results in coping skills/survival mechanisms that are arguably counter-productive and even self-destructive. However, what’s a kid with no scope or insight, to do, right? On top of all that, the self-image is horribly deformed by this ongoing trauma, because development of a healthy identity is hindered by circumstance.
GID does the same damned thing.
Living in the wrong body, is an ongoing trauma. How can you form a sense of self, when every day, the mirror doesn’t match what you feel? How can you form an identity when the world tells you that something is very, very wrong? You feel male, but you are told you are female. Your coping mechanisms become horrifically stunted. Every time you try to picture your future self, you either draw a blank, or more frighteningly, you see yourself as male, when the mirror continues to remind you that you are female.
Speaking about these feelings only garners disgust, outrage and punishment from caretakers.
Every day, well-meaning adults make comments that further the humiliation, trauma and hopelessness of your situation: “Do you want to be a mommy when you grow up?”, “You’re such a pretty little girl”, “Little girls don’t play like that”, “Eat all your vegetables so you can grow up to be a beautiful woman”, on and on, never knowing that they’re eroding the self-image that the child with GID is frantically trying to build each day.
[yes, I realize that these examples are entirely transman-centric, but hey, I'm a transman. I'm only speaking for myself here.]
Transpeople come from diverse backgrounds.
As opposed to Borderlines, no common threads of abuse, neglect or family disruption have been identified in the Trans community. Granted, some of us do come from broken, disordered homes and posses lengthy trauma histories. Overwhelmingly, however [and as evidenced by some of the most outspoken Trans Activists], Transpeople come from two-parent homes, with no evidence of childhood abuse or neglect. In short, Transpeople come from a diverse set of circumstances, and there is no evidence that our histories play a part in the development of our transsexualism.
I think the distinguishing factors between trans and borderline are onset and symptom range.
I, and most Transpeople, when we look back on our childhoods with any degree of self-honestly, can identify feelings of gender conflict as early as three or four years old; essentially, our earliest memories include feelings of gender incongruence.
These feelings are consistent throughout our lives, and while they may not exist in the forefront of our minds in each developmental period, we are aware of them to some degree, on a consistent, unremitting basis.
This is in contrast with BPD where feelings of gender conflict are transient and related to periods of crisis, typically beginning in early adolescence.
Additionally, in a transsexual, our struggle with self-identity/self-image is centered SOLELY around our gender conflict. The gender conflict is not caused by other crises, it causes other crises. Sort of the inverse of borderline, really.
Typically, the interpersonal conflicts that transsexuals experience are cenetered not around issues of attachment, but issues of gender role, intimacy and low self-image. The interpersonal conflicts that transpeople do have are markedly different from the crises caused by the "i love you, i hate you attitude" shifts that borderlines experience. Rather than frantically adoring and later demonizing partners when the relationship encounters difficulty, unable to identify personal accountability; transpeople generally place the responsibility for relationship troubles on a perceived failure of his/herself to live up to the correct gender role. "I'm too sensitive a man", "I'm not masculine enough", etc.
Finally, BPD's natural course indicates that it improves, with or without intervention, over time.
This is in direct contrast with the course of GID, which has been shown to worsen as a transsexual ages, mitigated only by transition, to the extent that recently a 70+ year old transwoman completed her transition.
Why is any of this important, anyway?
It struck me, when reading about BPD, the strong similarities between symptoms of borderline and GID. Which of course drove me to question, even if the causes are different, if the symptoms are similar, would established treatments of BPD work to mitigate symptoms of GID to the degree that the period prior to transition can be made more bearable for the sufferer?
In other words, can DBT skills keep me from killing myself for the next 4.5 years while I wait for my career to end so I can transition?
Thus far, the answer has been a resounding, yes.
MANY of the DBT principles have eased my gender dysphoria to a manageable level.
Radical acceptance; accepting that for now, my body is female, that’s just the way it is. It is neither good nor bad. It just is. It’s a healthy, functional body that allows me to enjoy my world. I’ll change it when the time comes that I have that option, but for now, this is the way things are.
Emotional Regulation and Distress Tolerance have also become critical skills.
No, they don’t cure GID or gender dysphoria, but they do provide tools to cope.
Ultimately, until the biological cause of transsexualism is identified and can be treated, the only cure for transsexuals will remain transition.
But just as achieving adulthood and moving away from the source of childhood trauma doesn’t cure the emotional and cognitive damage borderlines experience as a result of their upbringing, transition doesn’t fix the decades of damage that the ongoing trauma of being trans has created.
Many transsexuals [and Kate Bornstein has been startlingly honest about this in hir books and public speaking tours] find themsevles depressed after transition, when they feel they are unable to perform the gender roles of their transitioned gender properly. My personal feeling is that this is largely related to the extreme black and white thinking and other cognitive distortions... the "borderline traits" that transsexuals so often suffer. The GID itself is, arguably, cured. The body and the mind, match [I'll touch on the problems inherent in that statement in a moment] and yet, the symptoms of GID remain. Why is the dysphoria still present in the post-transitioned transman or transwoman?
I think both the medical community and the mental health community are guilty of abject failure to care for the transsexual population by providing both adequate surgical options for transition [for transmen, this includes appalling genital surgical options; for transwomen this includes lack of access to facial feminization surgery and electrolysis] and mental health support services that extend beyond the currently prescribed practice of one-year’s worth of monitoring performed by a mental health professional prior to undergoing SRS.
The few mental health services available to Transpeople focus largely on the acquisition of an accurate diagnosis of Gender identity Disorder to facilitate Hormone Replacement Therapy, and the supervisory role during the mandated one-year “Real Life Experience” required prior to undergoing SRS. Mental Health support services beyond that are stark, and typically focused on crisis-intervention.
I would like to see a lengthy clinical trial conducted to measure the effectiveness of DBT to reduce suicide rates in pre-transition transsexuals, as well as its effectiveness at improving quality of life and mitigation or cessation of gender dysphoria in post-transition transsexuals.
I think the largest barrier to this sort of study is the fear within the transcommunity that introducing non-surgical treatment options will lead the erroneous assumption that GID can be cured through therapy rather than transition [it can’t], and that transsexuals will be seen as mentally ill, rather than suffering from a legitimate gender incongruence stemming from a biological cause that is present at birth, and unrelated to external stimuli.
Second to that, is the fear that success treating the damage caused by GID using DBT will lead to a GID simply being called a variant of BPD or a similar form of Personality Disorder, and not a biological mismatch between brain and body.
I think it is important to note in closing that unlike BPD, which shows response to psycho-pharmacological intervention, GID shows no such response at any dose.
Only one study has ever produced results demonstrating that GID responds to treatment with psycho-pharmaceuticals, and it has since been shown to have been scientifically flawed, and the author distinctly biased.
One specific substance has proven to be the only effective chemical treatment for GID:
Gender-appropriate hormones.
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