Why Are Men With Borderline Personality Disorder Still in the Shadows?

A note about gender: There isn’t scope here to address the rich and overlooked area of gender diversity and its intersections with BPD but it’s an area for further research and writing, which includes this article. 

Just before I turned 38, I finally received a diagnosis for borderline personality disorder (BPD). I began dialectical behavior therapy (DBT) with a bunch of beautifully brave and deeply empathetic women. For the whole year of the therapy, I was the only guy in a group of up to eight, and at the end of each module, I would ask my facilitators with a hopeful, childlike upward inflection if there were any men in the next intake. And every time, there wasn’t. Something in me felt like a limb was missing, and I realized that men were not getting the treatment they so desperately needed. 

For men living with BPD, there is often a sense of being alone in the shadows. This was amplified by an initial misunderstanding that the disorder was predominantly female (by 3-to-1, according to the DSM-IV), despite recent studies showing a more equal distribution. How could there be just as many of us and yet I’m the only guy in my DBT group for a year? 

These questions are really life-and-death-level important given that, according to an Australian meta-review of suicide and mental disorders, the risk of suicide in BPD is 45 times higher than the general population. I imagine that those men who, unlike me, are not being treated or can’t accept their diagnosis are in urgent mortal danger. As a man with this often-brutal illness, which nevertheless has high recovery and remission rates, my heart breaks for my BPD brothers. I long for a way to get them help in a safe space which allows them to move towards acceptance and change. I may be very different from the stigmatizing stereotype of the antisocial, substance-abusing, angry BPD man, but I imagine that our acute core feeling of abandonment accompanied by overwhelming, rapidly changing emotions are similar among other shared symptoms. Maybe I can articulate my pain better but that doesn’t seem fair that only I get to be better.

In a quest for some answers to why many of my BPD brothers are still in the shadows, I read some recent research papers on male BPD. Almost all the studies reported in the findings to their clinical trials that “BPD is equally prevalent among men and women.”

As to the reason why the traditional assumption about gender and BPD is so female-lopsided, another study put this down to clinical bias: “… as a consequence of greater prevalence of females in clinical settings, males are underrepresented in BPD research.” “Studies with sufficient numbers of male BPD subjects are needed for sufficient power to detect gender differences.” 

Academic articles show fascinating similarities on how BPD manifests in different genders. However, research also highlights numerous differences both among genders and within the same gender group. I personally feel I was underdiagnosed with depression for so long because I didn’t fit the assumed male BPD, stereotype. Really, this gendered reading of BPD doesn’t help anyone and allows all genders to be under or misdiagnosed and not able to access the right treatment they so desperately need. 

Silberschmidt, Lee, Zanarini and Schultz summarize it best:

“While the literature is full of investigators theorizing that women with BPD ‘internalize’ while men ‘externalize’ BPD pathology, our data suggest that the gender-related differences in BPD are small and often not as great as the differences in the general population… Rather than (exclusively) asking how women and men with BPD are different, perhaps it is time to begin to ask, “Why aren’t they?”

If the gender differential was largely because of sampling bias and other studies add a clinician bias too, it seems that is also because fewer men present to clinical or treatment settings generally. Maybe this has got to do with some men having a stigma about seeking psychological help, having lower emotional awareness, being less communicative in general and being less open to any treatment. If such a man gets as far as a diagnosis, then it could also be that he doesn’t accept it and prefers to stay in the thinking and behaviors that so entrap him.

Now to strike a more hopeful note, I want to share with you a story about men with BPD who do accept their diagnosis, who do seek treatment and who do find each other.

A Personal Story of Male BPD Friendship

I have a male friend with BPD who lives on the other side of the world. Our friendship has had a profound impact on both of us. We came into each other’s lives when he read one of my stories on the Mighty last year and sent me a message. Since then, we have regularly chatted and had video calls. We immediately found we have many things in common even though we are far away from each other, and our virtual friendship is still very strong.  Chiefly, we both don’t fit the stereotype of the male BPD mentioned above.

It is impossible to say who helps whom the most, but rather than continue to describe our 10-month friendship, let me show it to you, with my friend’s permission. It reveals a way to bring men with BPD out of the shadows.

My friend is labeled as J, and I am A.

August 6, 2020

J: Hey man, found your writing on The Mighty about BPD. Struggling with that myself. Good to hear a male perspective on it because I’m a male in my early 20s with the same thing. Keep up the good writing/blogging! Having a difficult time finding people who understand it/get it.

A: Hey J., thank you so much for your message. I greatly appreciate it. And sorry for your struggle. It is a marathon not a sprint but also gives us great gifts I think. I wish I was diagnosed in my young 20s like you and didn’t have to wait til I was 37. God bless x

A: You’re a young man. So, how did a diagnosis come about?

J: I got to university at age 18, and very soon started having issues/struggles, but I didn’t even think of them as psychological. These issues were like not knowing at all who I am, how to be around others, what my thoughts and feelings are about anything, feeling emptiness inside… I presume you know that feeling of having no self-identity. Also was having extreme rapid mood swings, and inability to maintain any motivation/concentration. After about a year and a half of this going on, I realized my issues weren’t external but internal… then started researching and read up on borderline personality disorder, and it was the first time I ever felt accurately described. Thanks for letting me tell my story man… That always feels good, especially since I rarely do it!

A: Thank you J. You’re a brave young man. You’re doing so well on your own. Hope you can get some support. We really need it… Getting my diagnosis saved my life.

J: Can relate to the diagnosis saving my life. You said, “I don’t show anger or (negative) emotion. I push it all inside.” I do the same thing myself. In some ways it kinda sucks, ‘cause if I was more rowdy and verbal about my pain, I probably would have gotten help sooner…

A: Oh J, so much to say. You are a smart guy and also sound empathetic. We will get on well… I am not some violent, abusive, hysterical bastard. Definitely. But that’s the stigma! But there was nothing quiet inside my head or heart when I was at my worst.

August 27, 2020

J: Today had ups and downs, but have at least gotten better sleep past couple nights. So “crazy,” how in a given day though I can have such different perspectives on life, according to my mood fluctuations. Often one week can feel like an entire year of living, simply because of how emotionally intense our experience is. And I really think that’s the case for us, like most people don’t have as much emotionally intense experience in a whole decade of life as we do in a week. I know I’m writing to someone who knows what emotional intensity is, maybe it’s a little different once on medication, but I wonder if you feel like a week passing feels like a whole year? Sometimes I just look at how ridiculous it is and am able to just laugh at it, obviously though, much pain a lot of the time. Letting my thoughts flow, so thanks for reading…

A: That is really beautifully put. When can I read something you write/publish? Articulate, eloquent even. Big fan… And yes, everything you’ve described I’ve experienced, I think.

September 27, 2020

J: So happy I stumbled upon your writing and reached out. Your words lift me up. Relating with people has always been tough, so it says a lot about you to be able to hold space for me to express myself freely. A lot ahead my friend!

A: I think you still underestimate yourself here. You have many gifts and are worthy of great love. Further, our illness constantly lies to us both xx

J: Yeah haha, you’re right about that. You and I both have tremendous and unique gifts that we just sometimes don’t realize we possess on our own.

November 11, 2020

J: Life’s been a shitstorm this past year for me. I mean, I know you’ve had it pretty intense in the past. But I’ve been too late to get medication and stuff, which has really made it shitty. I’m not good at taking care of myself. But getting better of course.

A: It’s never too late while you still have breath. You are a very young man. You are fighting. That’s the commendable thing xx

J: I mostly look to others and see that they’ve made a livable life for themselves even after multiple hospitalizations and stuff and that inspires me!

A: It really is possible. It probably seems the furthest from your possibility in your mind. But your mind is wrong x

J: Yes, my mind can be so wrong sometimes.

A: And remember that, according to the latest research I did for my article on BPD recovery and remission, all the studies argue the same thing: that six to 10-year rates of remission or recovery are very high for BPD, up to 70 to 80% in longitudinal studies. Far off maybe but just remember it when you are at your lowest.

J: Thank you for taking time to give me reassurance.

January 5, 2021

A: Oh I know what to do when I’m at my worst. Well, I should, by now.

J: Yeah for sure. People don’t realize that with mental illness, you eventually become a ninja at mindfulness stuff and controlling your impulses. Imagine if we had all that skill but in a healthy person’s body/brain!

February 16, 2021

J: How are you?

A: I’m OK. Not easy without a job. And lost my confidence with writing but I’m gonna do it anyway.

J: Pulling for you man. Every article you put out reaches many that you probably don’t even know of. Just remember that was my first encounter with you. So keep it up for sure.

A: Thanks J. I’m pulling for you too. You deserve better health. You have so many gifts and gold. And deserve your place in this world xx I pray for a soon breakthrough, my man xx

J: Yes, indeed, for both of us!

April 20, 2021

J: Lovely to hear about your relationship. I’m over here freaking out about the fact that I’ve never had a girlfriend or even really had a friend who was a female my whole life. Definitely something I wanna change.

A: I know J. I was 42. I know what the drought is like. You so would make a good friend to the ladies. You have depth. You have intelligence. You have loyalty. You have emotional intelligence and empathy and big rich emotions.

J: That feels good to be reassured. Thank you a lot. I feel like female friends could also relate to me more on the sensitivity level…

We both have exciting relationship journeys ahead of us I hope!