Stop Calling Trauma “Borderline”

A Call to Awareness and Restorative Action

This essay is written by a licensed psychologist and is intended for educational and reflective purposes only. It does not constitute clinical advice, diagnosis, or treatment. The views expressed are those of the author in his capacity as a writer and advocate for trauma-informed, restorative approaches to care. Readers seeking personal mental-health guidance should consult a qualified professional within their own jurisdiction.

When humiliation looks like a diagnosis

There is a pattern many of us have witnessed. A queer person, starved for belonging, constructs a persona—the only version of self the culture will allow to cross the threshold. The persona becomes a bridge. People respond, sometimes through coercion, sometimes through the ugly gravity of power dynamics that pass for acceptance. Then the persona is exposed. What follows is public humiliation, mass rejection, and exile from community life. The queer person decompensates and experiences panic, shame, sleeplessness, bargaining, collapse, and even suicidality. A clinician, often meeting the queer person only at the apex of crisis, writes three letters in the queer person’s medical chart: BPD.

That is not a personality.
That is what social injury looks like in a nervous system built for connection.

This essay makes a simple claim: in queer and trans contexts, “Borderline Personality Disorder” (BPD) is too often a trash-can label. It is a proxy for countertransference, risk management, and structural stigma applied to the state dysregulation of acute rejection and exile, and then misread as a trait structure that allegedly defines the person across time and situations (Aviram, Brodsky, & Stanley, 2006; Linehan, 1993). The result is ethically consequential. A label that should be exceedingly rare and carefully established becomes a gatekeeping device. It translates out-group stigma from the wider culture into the subculture of medical care, where the same person is further overlooked and dismissed by the very systems that claim to help.

What clinicians are actually seeing

If we slow down at the moment of crisis—before we reach for a trait label—we notice a familiar psychophysiology: the body in threat. There is sympathetic alarm (fight/flight), shame collapse (freeze/fawn), frantic attempts to reattach after social expulsion, identity lability under spotlight, and self-harm or suicidal ideation as last-ditch affect regulation when interpersonal refuge disappears (Herman, 1992; Linehan, 1993).

In other words: a human doing exactly what humans do when belonging is ripped away.

This is state dysregulation under conditions of acute social threat, not necessarily evidence of a trait personality organization. As Linehan’s biosocial model emphasizes, what we call “emotion dysregulation” emerges at the intersection of biological sensitivity and invalidating environments—contexts that chronically deny or punish inner experience (Linehan, 1993; Crowell, Beauchaine, & Linehan, 2009).

In queer lives, invalidation is not theoretical.
It is chronic, layered, and often lethal.

Why queer and trans folks “look borderline” in hostile settings

Minority stress research has documented, for decades, how prejudice, rejection, and stigma-vigilance increase baseline arousal, erode coping, and worsen mental health across lesbian, gay, and bisexual populations (Meyer, 2003). Later work shows how stigma gets “under the skin,” altering stress physiology and shaping emotion, cognition, and behavior under hostile social conditions (Hatzenbuehler, 2009). For many queer and trans people, the “persona” is not deceit so much as armor: a performance forged by an unsafe world that makes authenticity expensive.

When that armor fails, especially in public, what follows is not a personality unmasked so much as a nervous system unprotected. The resulting picture can mimic the behavioral surface of BPD: frantic reassurance seeking, swings in self-representation, relational volatility, even self-harm. But the engine is often trauma plus stigma, not a fixed constitutional organization (Herman, 1992; Meyer, 2003; Crowell et al., 2009).

How “borderline” became a culture-bound label

Historically, “borderline” evolved as a placeholder category in psychoanalysis at the boundary of neurosis and psychosis. Over time, it accumulated a clinical folklore: difficult, manipulative, and treatment-resistant. These are labels that said as much about the clinician’s countertransference (i.e. personal reactions to a patient) as about the patient’s inner life (Aviram et al., 2006; Gunderson, 2011). In practice, “borderline” became shorthand for how a patient makes clinicians feel: emotionally flooded, helpless, angry, over-involved, or even scared.

The DSM’s structure compounds this drift. By prioritizing symptom checklists over etiology, it incentivizes a focus on how behavior looks rather than why behavior exists (American Psychiatric Association, 2022). In humiliation and exile, nearly anyone will appear “unstable in relationships,” show “identity disturbance,” demonstrate “impulsivity,” or exhibit “affective instability”—especially when the criteria are scored without careful attention to chronicity, cross-situational consistency, and developmental history.

Put simply, we end up diagnosing injury as identity.

The iatrogenic loop: when diagnosis extends the exile

Stigma is not just a public phenomenon. Stigma is a system of social processes that sort, separate, and sanction (Link & Phelan, 2001). When clinicians use “borderline” as a pejorative (e.g. “they’re so borderline”), we effectively recreate the out-group dynamics of the broader culture inside care. The person who has already been exiled by community is exiled again by treatment: triaged to the margins, offered fewer warm handoffs, framed as liability, and subtly taught that humility will not restore dignity because the chart has already spoken (Aviram et al., 2006; Livingston & Boyd, 2010).

This is the cruelest irony. A diagnosis leveraged to control perceived risk often increases risk by narrowing access, eroding trust, and reinforcing the very invalidation that intensifies dysregulation (Crowell et al., 2009; Linehan, 1993). In short, we treat the culture’s injury to the person by injuring the person as culture.

A better formulation

Clinically, the first obligation is not to locate the person in a diagnosis but to understand the function of behavior. What is this act achieving or preventing? What threat is it answering?

In humiliation/exile arcs, the functions are plain: to stop intolerable shame; to reestablish contact; to command attention when abandonment feels fatal; to anesthetize unbearable arousal; to regain any control in a story told by others.

A responsible differential must center timeline and context. Were the so-called “borderline” features present before the exposure and exile, across multiple settings and relationships, from early developmental epochs? Did they intensify after public humiliation? Do they abate in validating, safe, smaller relational fields? Are there confounds (substance use, sleep loss, concussion, autistic masking, dissociation) that better account for the apparent volatility? A careful answer to those questions is worth more than a lifetime of labels.

Where the picture resolves toward complex trauma and attachment injury—a common finding in queer lives—interventions should privilege:

1. Safety and stabilization first. Skills for arousal modulation and practical containment should be prioritized. Approaches such as Seeking Safety can help.

2. Shame literacy and compassion practices directed at the self who survived by performance (Herman, 1992).

3. Relational repair in micro-communities that can hold imperfection without banishment (Linehan, 1993).

4. Clear, non-punitive boundaries that prevent harm while preserving hope of repair. The individual should face consequences without annihilation (Crowell et al., 2009).

None of this denies that some people genuinely meet criteria for borderline personality disorder as a stable pattern. That reality deserves sophisticated, long-term care. It does insist, however, that overuse and misuse of the BPD label in trauma-saturated queer lives is common, consequential, and avoidable (Aviram et al., 2006; Gunderson, 2011).

The culture we keep diagnosing

It bears saying plainly: the problem is not the person. The problem is a culture that renders belonging conditional, then calls the survivor “borderline” when their nervous system shows the cost. Minority stress theory predicted these outcomes long before the DSM caught up: stigma erodes health by chronic activation of vigilance and shame (Meyer, 2003). Structural stigma embeds that harm in schools, workplaces, media, and even mental health systems (Hatzenbuehler, 2009). When humiliation becomes entertainment, collapse becomes ordinary. Charts should not make collapse a character.

This is especially urgent in an era that confuses “accountability” with cancel culture and public annihilation. Humiliation is not justice. Humiliation is a theater of control. In that theater, clinicians are not neutral. We can either translate the culture’s contempt into treatment by hardening it with a diagnosis, or we can interrupt it with formulation, boundaries that protect without banishing, and clinical language that keeps people human.

Boundaries keep people safe.
Love keeps people human.
We need both.

What clinicians can do tomorrow

The first task is to formulate before labeling a human being in distress. Every behavior has a context and a function. Understanding why an act makes sense to the person is far more clinically useful than describing how it looks from the outside. Writing formulation statements that trace meaning, sequence, and environmental contingencies brings the person’s humanity back into view and guards against the shorthand of personality labeling.

Clinicians must also interrogate their own countertransference. Feelings of being manipulated, flooded, angry, or compelled to rescue are inevitable in trauma-saturated work. What matters is where those feelings are processed. They belong in supervision and consultation, not in the chart. When we record frustration as diagnosis, we move from care to control and from empathy to distance (Aviram, Brodsky, & Stanley, 2006).

Next, it is essential to score diagnostic criteria honestly. The DSM calls for evidence of chronicity, cross-situational stability, and developmental onset. Those requirements exist precisely to prevent the misclassification of crisis states as enduring personality patterns. Careful attention to whether symptoms existed across the lifespan is an act of clinical integrity and ethics, no matter how onerous or resource intensive.

We must also name stigma as a clinical factor rather than treating it as background noise. Minority stress theory has shown repeatedly that stigma, rejection, and chronic vigilance shape both physiology and affect regulation in queer and trans lives (Meyer, 2003; Hatzenbuehler, 2009). When we fail to include those forces in our formulations, we end up pathologizing adaptive survival responses to oppression.

After relational ruptures, clinicians should offer repair pathways, not just rules. Boundary-setting is vital for safety, but it should never be confused with banishment. Clients who test connection after betrayal are asking whether relationship is still possible. A plan for reengagement—one that names conditions for safety while affirming worth—models precisely the kind of accountability that builds lasting change (Linehan, 1993).

Finally, and perhaps most urgently, we must stop using “borderline” as a slur. Language shapes care. The phrase “they’re so borderline” is not diagnostic. It is defensive and vile. It often translates to “I feel overwhelmed and unsure how to help.” Naming that truth directly, without weaponizing the label, is clinically truer and infinitely kinder (Aviram et al., 2006; Livingston & Boyd, 2010).

You can make a difference now

If humiliation and exile can make almost anyone “look borderline,” then the first group we should treat is the culture that confuses control with care. In queer and trans lives, the difference between pathology and physiology often comes down to whether a room will still make space for a human who feels they have failed in some way. When we write “BPD” where “betrayed and terrified” belongs, we don’t increase precision. We close doors to care and repair. And we carry forward, in miniature, the same out-group contempt that sent the person to a clinician in the first place.

We can do better than that clinically, ethically, and humanly.

The nervous system is built for connection.
Let’s practice a psychology and culture that is, too.

⸻

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing.

Aviram, R. B., Brodsky, B. S., & Stanley, B. (2006). Borderline personality disorder, stigma, and treatment implications. Harvard Review of Psychiatry, 14(5), 249–256. https://doi.org/10.1080/10673220600975121

Crowell, S. E., Beauchaine, T. P., & Linehan, M. M. (2009). A biosocial developmental model of borderline personality: Elaborating and extending Linehan’s theory. Psychological Bulletin, 135(3), 495–510. https://doi.org/10.1037/a0015616

Gunderson, J. G. (2011). Borderline personality disorder. The New England Journal of Medicine, 364(21), 2037–2042. https://doi.org/10.1056/NEJMcp1007358

Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135(5), 707–730. https://doi.org/10.1037/a0016441

Herman, J. L. (1992). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. Basic Books.

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.

Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363–385. https://doi.org/10.1146/annurev.soc.27.1.363

Livingston, J. D., & Boyd, J. E. (2010). Correlates and consequences of internalized stigma for people living with mental illness: A systematic review and meta-analysis. Social Science & Medicine, 71(12), 2150–2161. https://doi.org/10.1016/j.socscimed.2010.09.030

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674

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