A literature review conducted by Meybodi and Jolfaei[1] discusses the prevalence of personality disorders among transgender individuals, suggesting transgender individuals have a higher risk of suffering from a personality disorder. Or perhaps more appropriately phrased: at higher risk of being diagnosed with a personality disorder. Yet the paper lacks reflection on the criticisms which delegitimise the personality disorder construct and the implications these discussions have for transgender people. In addition, the authors use medicalised, biased and microaggressive language, for example referring to “normal” as opposed to transgender individuals and describing transgender identities as “disease”. Pathologising transgender identities indicates a viewpoint that this is not a natural and beautiful experience, but a condition which could – and perhaps should – be cured.
In addition to having poor construct validity and reliability, personality disorders lack objective markers; they are diagnosed based on observations and reported experiences assessed against deviation from societal norms. The ‘symptoms’ of personality disorders are nebulous and value-laden; a behaviour considered maladaptive in one society may be ‘typical’ within another. Clinicians, who often lack understanding of transgender experiences, may assess self-involvement and preoccupation with appearance as pathological, but for a transgender individual navigating a hostile society, these traits are a survival instinct. Furthermore, experiences of gender dysphoria, oppression and discrimination are traumatising and can result in individuals self-harming or experiencing suicidal ideation, but this does not mean that a person has a ‘personality disorder’, or that such a diagnosis would have utility in understanding their distress.
Bias is observed in personality disorder diagnosis at a construct and assessment level towards marginalised communities whose pain mirrors back society’s inhumanity at it.[2] Criticism of research around the prevalence of personality disorder diagnosis amongst transgender populations highlights clinician bias, prejudice and misdiagnosis as influencing factors.[3] People diagnosed with personality disorders describe the devastation the diagnosis brings, being experienced not just as a form of character assassination but as confirmation the bad treatment one has experienced, whether developmentally or sociopolitically, was warranted.[4] Yet a personality disorder diagnosis is just as likely to deprive people of help than enable it, often producing contempt, neglect and disability denial in patients in need. Overlooking the inherent flaws and harms within the construct of personality disorders invalidates the conclusions made by the authors.
Meybodi and Jolfaei highlight a need to assess – perhaps routinely – transgender patients for personality disorders. However, they do not discuss the implications of this recommendation. A clinician may deny referral and access to gender-affirming treatment due to an individual’s mental health, resulting in transgender people avoiding seeking mental health treatment[5]; requiring routine personality disorder assessments would deepen this injustice. Meybodi and Atefeh call for further research considering personality disorder diagnosis in transgender people. However, those seeking to further research in this area must recognise the implications of research in upholding structures which are harmful to transgender communities, reflect on theirbiases, and prioritise transgender testimonies. Finally, future research must centre ambitions of supporting transgender people to thrive in a less inhospitable world.
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Conflicts of interest
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References
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