Splitting, rejection, and feeling 'wrong': Borderline personality and trans

My conversation with Lisa Duval

Elaine de Kooning, Juarez, 1958

Lisa, we know each other, of course, but could you please introduce yourself to readers who aren’t yet familiar with your work?

I’d be happy to. First, thanks for this chance to share ideas, Eliza. I so deeply appreciate your study of the impact of gender ideology and trans identity in today’s youth cultures. I’m a clinical psychologist and have been in practice for over 35 years. Because of the high level of psychopathology in my family of origin (In addition to sharing a generational history of alcoholism, depression, and eating disorders, my parents were both diagnosed with personality disorders, my father with Narcissistic Personality and my mother with Borderline Personality, well before these were commonly tossed around diagnoses), I have always gravitated towards long-term therapy with more deeply suffering and disordered individuals. I have compassion for those whose relationship styles often alienate others as well as a strong belief in people’s ability to heal from a pathological sense of self, under the right circumstances through long-term therapy. In terms of gender, the rapid-onset gender dysphoria phenomenon infiltrated my own personal world in 2016, and I have truly never before devoted as much thought to any one topic, especially because I have seen how gender ideology has increased people’s disturbances in their sense of self and ability to relate to others in a healthy way.

The topic of “Cluster B” personalities gets thrown around a lot when discussing the peculiar features of trans activism. What are “Cluster B” personality traits?

In general, personality disorders are characterized by long-term patterns of maladaptive behavior and beliefs that can affect the ways one thinks about oneself, experiences emotions, and relates to other people. These disorders are understood to evolve from a complex interplay of genetics, neurobiology, and early environmental factors, such as neglect, trauma, and sexual or physical abuse. Cluster B personality types—borderline, histrionic, antisocial (which does not mean introverted but rather refers to a long-term pattern of behavior that violates the rights and wellbeing of others), and narcissistic personality disorders—are manifested in dramatic, unpredictable, and intensely emotional behavior, leading to unstable relationships, emotional dysregulation, and impulsivity. People with Cluster B personality disorders act in extremely maladaptive ways to get what they desire, and what they desire is often extremely maladaptive.

Let’s set gender aside for a moment and focus on borderline personality. What characterizes borderline personality disorder? What have you observed in your clinical work with this population?

People with BPD have an intense fear of abandonment, an unstable and negative sense of self, the tendency to split others into extremes of all good or all bad, and a pattern of testing relationships—often through threats of self harm or suicide. The disorder was originally named ‘borderline’ because the distorted reactions to interpersonal dynamics often cross the border between rational and psychotic thinking. This could look like the common fear of a partner being unfaithful suddenly and out of nowhere escalating into absolute certainty of infidelity and then rage and the launching of a revengeful vendetta against the partner. In my clinical work, I have experienced patients’ extreme initial idealization and subsequent vilification of me that are hallmarks of borderline relationships. One of the reasons I tend to work long-term with this population is that I understand the pain at the core of the tempests and am comfortable not only sitting with the vilification, but eventually—gently, yet directly—challenging both the vilification as well as the equally unrealistic idealization from the beginning of the therapeutic relationship. This is the way to uncover the expectation of rejection that lies beneath most interactions for people with BPD, as the initial extreme positivity aims to deny any distance and difference between patient and therapist, and the eventual vilification seeks to blame the therapist for the inevitable rupture, in a desperate attempt to not be responsible for failure and abandonment.

Why might someone with borderline personality traits be drawn to identifying as trans?

I should have already said that another area of specialty of mine is working with adolescents. I mention this here because if you understand why a teenager could be seduced by the idea of becoming a completely different person and escaping from feeling absolutely wrong in mind, body, and soul, then you already have an inkling of why someone with BPD or borderline traits is even more susceptible to the allure of the identity. Personality disorders in general should not be diagnosed during adolescence because so many of the behaviors that go along with the developmentally appropriate search for identity, bonding with peers, and separating from parents and “old selves” can look narcissistic, antisocial, and borderline. But—when someone has the predisposition or environmental factors linked to BPD—with its self loathing, intense fear of rejection, and desperation to find immediate relief from discomfort, they are even more vulnerable to the idea that they were actually just “assigned wrong at birth,” say, and can change from caterpillar into butterfly or ugly duckling into swan with the help of interventions like “T” or “E” and “top” and “bottom” surgeries (pay attention to the euphemisms!). In addition, the prospect of joining an instant, all-accepting, all-loving (unless they desist or detransition) community and being heralded by the world as brave and persecuted and deserving of sanctuary states and glitter families is understandably alluring and offers escape from and solution to their sense of being wrong and unlovable.

You pointed out the widespread use of euphemisms for what can be drastic interventions. Is there more to say about this? Do euphemisms hold particular appeal to people with borderline traits who are already prone to idealization, since euphemisms put an idealized face on a potentially ugly or complicated reality?

Wow. That is such an interesting question. The euphemisms have always upset me because they attempt to turn something so gruesome and harmful into something cute and almost benign. When “supportive” adults use that language, it’s irresponsible to say the least, and when trans-identified individuals do, it might actually reveal more than just hip language they are copying from TikTok. I think you are onto something. Part of it is the idealization (which comes so naturally to the person with BPD) of the heralded metamorphosis, so you can’t look too carefully at what it actually entails, thus “top surgery” instead of double breast amputation or “bottom surgery” instead of castration. In addition, I think it’s a challenge to a duel, in a way: “Just how much are you actually paying attention to me?” There’s a process of “testing” that people with BPD enact, as they are always looking for proof to see how much you care. Parents recount the horror of their children’s cutting self-harm behavior being revealed to them almost blithely, like, “This isn’t such a big deal, calm down. It’s just skin.” But then when teens in extreme crisis or early manifestation of BPD traits don't feel that they are being taken seriously enough, they can become rageful and vilify their parents sometimes to the extent of referring them to Child Protective Services or accusing them of sexual or physical abuse. There’s a constant push-pull – the “Why are you making such a big deal out of everything?” but also “Why don’t you care enough?” This might be at play in the cutesy use of the “top surgery” language we’ve been unpacking versus the rage over being called one’s “dead name,” which is by contrast very morbid language. Parenting a teen in general and certainly a teen with BPD tendencies requires an impossible sixth sense of knowing when something has a hidden meaning and might be a cry for help. So, if you say, “Sure, let’s go get the top surgery next Tuesday,” like you’d say, “Sure let’s go to Sephora on Saturday for some new makeup,” you make her happy in the moment but fail a very important test.

At a recent conference, you explored some of the ways the core beliefs underlying trans activism can mimic, exacerbate, and even induce borderline traits in young people. What features of borderline personality do we see reflected in trans activism? How does exposure to these dynamics affect young people’s mental health and relationships?

First, I want to say that—although I inherently disagree with them—I think most people who support “trans rights” are fundamentally well-meaning. They truly believe they are advocating for the basic rights and protection of a supposedly marginalized group. But I actually call their perspective and ensuing actions “malevolent benevolence” because they are uninformed not only about the long-term effects of medicalization, but also about the underlying dynamics of trans identity in the first place and—here’s where I’ll get to your actual question—the harmful tactics of the loudest trans activists whose declarations they believe. Of course I can’t diagnose from afar, but any tactic that uses force or threats of social ostracism to silence disagreement, overdramatizes disagreement as leading to genocide, encourages young people especially to reject family members who express worry or disagreement, and irresponsibly insists that not giving young people what they want will lead them to kill themselves looks fairly “borderline” (if not actively antisocial!) to me. Do, but at the same time don’t, look up Jeffrey Marsh if you want a clear example of the kinds of dynamics I’m talking about.

In addition, I’ve witnessed how trans activism iatrogenically creates or intensifies borderline personality dynamics in vulnerable people. Iatrogenesis refers to the adverse and unintended outcome resulting from medical or psychological care. The trans activist narrative parallels, intensifies, and even creates borderline personality dynamics when it:

1. “Affirms” that someone is fundamentally wrong as they are and thus needs to change. This plays into the maladaptive belief that one is flawed to the core and that only dramatic, concrete transformation will make them OK;

2. Amplifies patterns of splitting by claiming that those who question or disagree with you are against you and should be rejected for not really loving you;

3. Puts the “trans individual” and their suffering at the heart of a social-justice movement and condones acts of “canceling” and threatening and/or harming those who express different views or don’t give you what you want (chosen pronouns, puberty blockers, hormones, surgery, access to the protected spaces of the sex you are claiming to be…);

4. Directly supports the suicide narrative that not being “accepted,” believed, supported, and allowed or helped to be your “true” self will lead you to kill yourself.

So, exposure to trans activism is harmful in myriad ways, most obviously in that it can lead to harmful medicalization while misdiagnosing, mistreating, or neglecting actual underlying psychological distress from trauma, internalized or societal/familial homophobia, porn exposure, social media-induced low self esteem, autism, eating disorders, etc., and more subtly because it amplifies or even creates features of BPD in concretizing the sense of a flawed self, encouraging splitting off from anyone who disagrees with you because they are seen as dangerously “against” you, and offering the manipulative tactic of saying you will kill yourself if you do not get what you say you need.

How can psychologists and psychotherapists connect with trans-identified young people who also present with borderline personality traits?

Your question actually contains the answer. Connect. At the heart of any good therapy is the experience of connecting, trusting, and being seen. This foundation is crucial yet sometimes near impossible to achieve with people suffering from personality disorders. Immediately affirming what someone says about themselves and then greenlighting medical intervention does the opposite of securing that foundation of connection and trust, and—in fact—only temporarily makes someone feel validated since, as I outlined above, blindly going along with a patient’s trans identification actually confirms that something is deeply, fundamentally wrong with them. The analogy to anorexia has been made over and over again, and yet still bears repeating. We don’t affirm a young woman’s sense of being overweight when she is emaciated and refer her to liposuction or dole out Ozempic. We explore, we empathize about how hard it is to grow up, to be female, to be sexualized, to feel sexual, to measure up… Often, the biggest thing “wrong” with people with BPD is their certainty that they are wrong and unlovable as they are. You have to start with validating their pain and exploring their sense of being wrong and understanding their desperation for immediate, concrete interventions. You have to explore what all of it actually means to them—not as some kind of “gotcha” of what does it actually mean to “feel” male/female when you were born the other—but asking questions like: What was going on for you when you first started to feel you were meant to be the other sex? What do you imagine will be better about living in this other role? By conveying a sense of true acceptance and positive regard, you as the therapist can build honest collateral and safety not only to question why patients don’t see themselves positively, but also to explore the ways they challenge, hurt, and alienate others in their lives.

What research do you hope to see in this area?

As much as I want there to be greater understanding of what has made so many vulnerable youth susceptible to gender ideology in order to inoculate them against or help them heal from it, I am almost equally curious about the traits of mental health clinicians who embraced and promoted “gender-affirming care” versus those who were skeptical and outspoken against it from the start. I would love to see someone study three groups of clinicians: those who have always and still do practice “affirmation only;” those who all along questioned gender ideology and the astronomical rise in trans-identified youth; and those who affirmed at first but eventually became gender critical.

What would a ‘healthier’ version of trans activism look like? What could help trans-identified young people shed the harmful beliefs and behaviors you’ve identified?

Not to be snarky, but a healthier version of trans activism looks pretty much like what all of us in the “gender critical” camp have been doing. Trans activists are considered for “trans” kids, and sex-realist/gender-critical activists are considered against “trans kids.” But I think it’s the opposite. When I see trans activists talk about “supporting trans kids,” I am devastated—and sometimes infuriated—because so many important words have been co-opted and sullied.

Support, affirmation, acceptance… these are loving words that have been stolen and tied to the very opposite of what they actually mean. Supporting people means keeping them from self-harm and lifelong medical intervention. Helping them love and accept themselves. Actually working to change the world around them to accept them in all their infinite variations and nonconformity to sex-role expectations instead of allowing and even encouraging them to change themselves through harmful medical interventions that can only create facsimiles of the opposite sex and leave the underlying sense of never being ‘right’ unexplored and unchallenged. No kid is in the wrong body. From my many years of working with teens and people with the distorted sense of self we see with personality disorders, it breaks my heart to see the regressive idea that anyone needs to change their external selves in an attempt to make their internal worlds more acceptable to themselves or others. When Stephen Levine explains that he prefers to speak of “temporarily identified trans people,” he implores us to understand that these young people can be helped to accept themselves using all the methods good therapists used to be trained in and which good parents instinctively know. We should aim to instill self acceptance—which at its fullest includes the ability to question and improve oneself—and increase tolerance for existential self doubt and loneliness, and instill an appreciation of the capacities and limits of the human body, instead of encouraging vulnerable young people to pin all their hopes for happiness on changing their bodies. That is true support.