Sexual Behavior in Borderline Personality

Abstract

According to the Diagnostic and Statistical Manual of Mental Disorders, various forms of impulsivity are associated with borderline personality disorder, including sexual impulsivity. The existing empirical literature indicates that patients with borderline personality disorder appear to differ from patients without this personality disorder in a number of relevant ways. Specifically, those with borderline personality disorder are more likely to exhibit greater sexual preoccupation, have earlier sexual exposure, engage in casual sexual relationships, report a greater number of different sexual partners as well as promiscuity, and engage in homosexual experiences. In addition, patients with borderline personality disorder appear to be characterized by a greater number of high-risk sexual behaviors; a higher likelihood of having been coerced to have sex, experiencing date rape, or being raped by a stranger; and the contraction of more sexually transmitted diseases. Overall, the psychological themes relating to sexual behavior in borderline personality disorder appear to be characterized by impulsivity and victimization. We discuss the potential implications of these findings for clinicians in mental health and primary care settings.

This ongoing column is dedicated to the challenging clinical interface between psychiatry and primary care—two fields that are inexorably linked.

Introduction

Borderline personality disorder (BPD) is an Axis II phenomenon that is characterized by intrinsic impulsivity. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, impulsivity may manifest in a variety of life areas, including sexual behavior, spending behavior, substance usage, driving, and eating.¹ In this edition of The Interface, we review the literature with regard to sexual behavior in BPD to gain a broader sense of the sexual patterns that might be encountered in these types of patients. We then discuss the potential implications of these findings in terms of psychiatric and primary care settings.

The Literature on Sexual Behavior in BPD

There are a number of reports in the literature that describe sexual behavior in individuals with BPD. These reports consist of clinical impressions, case reports, and empirical investigations.

Clinical impressions. In the early literature, Hoch and Polatin² described a group of patients who would likely be diagnosed with BPD according to contemporary approaches. With regard to this cohort, these authors emphasized the phenomenon of “pan-sexuality” (i.e., all-embracing sexuality), which encompassed promiscuity, “polymorphous perverse sexual practices,” and heterosexual/homosexual vacillation.

In discussing impressions of his clinical practice, Stone,³ another authority in the field of BPD, indicated that more than 25 percent of his outpatients with this Axis II disorder exhibited promiscuity. In contrast, Stone reported that promiscuity was uncommon among his non-BPD clientele.

In discussing the issue of sexual relationships between the therapist and the patient, Gutheil⁴ commented that patients with BPD are particularly prone to evoke boundary violations. As an example, he underscored sexual acting out.

Case reports. In addition to authoritative clinical impressions, there are several case reports in the literature on the sexual behavior of patients with BPD. For example, Pelsser described a female BPD patient in her 20s who suffered from promiscuity.⁵ Likewise, O'Boyle described the collective sexual experiences of four patients with BPD and portrayed their self-reported promiscuity as a means of coping.⁶

Empirical studies. In addition to authoritative impressions and case reports, there are a number of empirical studies on sexual behavior in BPD. For example, in an empirical endeavor that was designed to explore sexual attitudes, Hurlbert, Apt, and White⁷ compared 32 women with BPD to 32 women without personality disorders. In this study, the authors found that women with BPD evidenced greater sexual assertiveness, erotophilic attitudes, sexual esteem, sexual preoccupation, and sexual dissatisfaction.

Miller et al⁸ compared 52 substance-using individuals with BPD to 40 non-substance-using individuals with BPD. In addition to poor academic performance and unemployment, the substance-using group was significantly highlighted by promiscuity.

Hull et al⁹ examined 71 hospitalized female patients who were diagnosed with BPD. These investigators found that 46 percent of the participants in this study impulsively entered into sexual relationships with partners that they did not know very well (i.e., they engaged in casual sexual relationships).

In a dissertation thesis, Allan¹⁰ examined 71 medical patients with regard to various sexual behaviors. In preparation for analyses, she divided participants into two groups according to their history of sexual risk—high-risk versus low-risk. Participants in the high-risk subsample differed from those in the low-risk subsample in having a greater prevalence of BPD.

Lavan and Johnson¹¹ explored relationships between personality pathology and high-risk sexual behaviors among 403 teens. In this sample, the authors asked participants about the number of sexual partners during the past year and their lifetime, as well as the use (or not) of condoms. Condom non-usage was defined as “high-risk sexual behavior.” In this study, after controlling for co-occurring psychiatric disorders and overall levels of personality disorder symptoms, BPD symptoms were independently associated with high-risk sexual behavior.

Chen et al¹² compared women with BPD both with and without substance abuse with regard to the prevalence of sexually transmitted diseases. In this study, participants with substance abuse reported significantly more sexually transmitted diseases, particularly gonorrhea, trichomonas, and human papillomavirus (HPV). This finding was, in part, mediated by recent unprotected sex with two or more partners and more than 20 lifetime sexual partners.

Finally, in a literature review that was based upon six empirical studies, Neeleman¹³ concluded that patients with BPD exhibit heightened sexual impulsivity as well as a vulnerability to homosexual experiences. Further details of this analysis are unavailable because the original article is written in Dutch.

Collectively, these preceding studies indicate that individuals with BPD may harbor greater sexual preoccupation, engage in more high-risk sexual behaviors, experience more casual sexual relationships and more sexual partners, contract more sexually transmitted diseases, and be more likely to experiment with homosexual activities. The overall theme among patients with BPD is greater sexual impulsivity.

Empirical studies by Sansone et al. We have also studied the relationship between BPD and various sexual behaviors. In a 2008 study, we examined 76 women outpatients in an internal medicine clinic regarding their sexual histories (e.g., age of first intercourse, number of different lifetime sexual partners, homosexual experiences, history of rape).¹⁴ Using self-report measures for BPD, we found two statistically significant relationships in this study—individuals with BPD reported earlier sexual experiences as well as a greater likelihood of date rape.

In a 2009 study, we analyzed a compilation of 12 of our previous databases (N= 972) of both psychiatric and nonpsychiatric patients who were diagnosed with or without BPD according to a self-report measure.¹⁵ We examined these databases with regard to two sexual variables: 1) casual sexual relationships (e.g., “I have done things on impulse that can get me into trouble…[such as] having sex with people I hardly know”) and 2) promiscuity (e.g., “Have you ever intentionally, or on purpose,…been promiscuous [i.e., had many sexual partners]?”). In this study, we found that participants with BPD were twice as likely to endorse casual sexual relationships as well as promiscuity, regardless of clinical setting.

In a third study, we examined a consecutive sample of 354 internal medicine outpatients.¹⁶ Using either of two self-report measures for BPD, participants with this Axis II disorder reported approximately twice the number of different sexual partners compared to those without BPD.

In a final study on the relationship between BPD and sexual behavior, using two self-report measures for BPD, we examined a cohort of 126 psychiatric inpatients.¹⁷ Compared to those without BPD (i.e., participants who did not score above the cut-off on two measures of BPD), those with BPD (i.e., participants who scored above the cut-off on both measures of BPD) were significantly more likely to report a greater number of sexual partners, having been raped by a stranger, and having been coerced to have sex. There were no between-group differences with regard to age at menarche, age of first intercourse, total number of times treated for a sexually transmitted disease, having experienced date rape or rape by a partner, or having had homosexual experiences.

The preceding empirical findings are summarized in Table 1. Note that most, if not all, of the behaviors that are empirically identified as more frequent in BPD fall into the psychological categories of impulsivity and/or victimization. Generally, impulsivity appears to be represented by greater sexual preoccupation, earlier sexual exposure, more casual sexual relationships, a greater number of different sexual partners, promiscuity, and homosexual experiences, whereas victimization appears to be represented by a greater number of high-risk sexual behaviors; a greater likelihood of being coerced to have sex, date rape, and/or rape by a stranger; and a higher number of sexually transmitted diseases.

Table 1.

Empirical studies of sexual behavior in individuals with borderline personality disorder

FIRST AUTHOR	YEAR	DIFFERENTIATING FINDING IN BPD
Hurlbert7	1992	Greater sexual assertiveness, erotophilic attitudes, sexual esteem, sexual preoccupation, sexual dissatisfaction
Miller8	1993	With substance abuse, greater promiscuity
Hull9	1993	More casual sexual relationships
Allan10	1998	More frequent high-risk sexual behaviors
Lavan11	2002	More frequent high-risk sexual behavior (non-use of condoms)
Chen12	2007	With substance abuse, higher prevalence of sexually transmitted diseases
Neeleman13	2007	Greater sexual impulsivity, more homosexual experiences
Sansone14	2008	Earlier sexual experiences, greater likelihood of date rape
Sansone15	2009	More casual sexual relationships, greater promiscuity
Sansone16	In press	Twice the number of sexual partners
Sansone17	2010	Greater number of sexual partners, greater likelihood of having been raped by a stranger and/or having been coerced to have sex

Empirical studies that may refute current findings. Only two studies seemingly counter the trends reported in the preceding empirical data. In the first, Zanarini et al¹⁸ examined 290 patients with BPD regarding their sexual behavior. In this study, 41 percent of participants reported the avoidance of sexual activity. In addition, 34 percent of participants reported becoming symptomatic after sexual activity, suggesting a possible relationship between these two findings. In a second study, Lloyd et al¹⁹ examined the medical records of 85 patients who were diagnosed with compulsive sexual behavior. In this retrospective study, only one patient met the criteria for BPD.

Implications of Findings: Mental Health and Primary Care Settings

Given the greater possibility of various sexual behaviors characterized by impulsivity and/or victimization, there are potential treatment implications for clinicians in various settings. In mental health settings, clinicians need to be alert to undertaking queries in the area of sexuality, not only in the service of the psychotherapy treatment (i.e., processing the dynamics of self-regulation, impulsivity, victimization) but also to identify those patients with high-risk sexual behaviors and refer them for medical evaluation. Likewise, in primary care settings, clinicians need to be aware that patients with BPD may have histories of sexual impulsivity, which require careful review for sexually transmitted diseases as well as ongoing planning around contraception and prophylaxis against such diseases. Conversely, those patients in primary care settings who present with promiscuity warrant an assessment for BPD, and if positive, probable referral to a mental health professional.

Conclusion

The majority of the literature in this area suggests that in comparison with individuals without BPD, those with BPD evidence greater sexual impulsivity as indicated by higher levels of sexual preoccupation, earlier sexual exposure, more casual sexual relationships, a greater number of different sexual partners, promiscuity, and homosexual experiences. In addition, these patients evidence greater victimization as indicated by a higher number of high-risk sexual behaviors; greater likelihood of being coerced to have sex, date rape, or rape by a stranger; and more sexually transmitted diseases. Note that both of these themes, impulsivity and victimization, characterize the psychological themes encountered in a number of other common behaviors in BPD (e.g., alcohol and substance misuse/abuse, eating pathology, difficulty regulating money). From a psychiatric perspective, these findings suggest that sexual impulsivity and victimization are practical clinical concerns in patients with BPD, both in terms of relevant psychological themes as well as health risks. From a primary care perspective, findings suggest that clinicians in these settings need to maintain a high index of suspicion about the possibility of multiple sexual partners, sexual traumatization, and sexually transmitted diseases in these patients as well as the need to address contraception and prophylaxis against sexually transmitted diseases. Likewise, patients who present with promiscuity in primary care settings may need to be evaluated for BPD and possibly referred for treatment to a mental health professional.

In summary, the psychodynamic theme of impulsivity, as described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, appears to be a legitimate sub-criterion in many patients with BPD. What seems to be missing in the current descriptors is the undertone of victimization that also characterizes the sexual behavior of these patients.