Comparison of two screening tools for borderline personality disorder (BSL-23 and MSI-BPD) among Indian gay, bisexual, and heterosexual men

Men are underrepresented among those diagnosed with borderline personality disorder (BPD). Paradoxically, gay and bisexual men are overrepresented among BPD-diagnosed individuals. This study compared McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) and Borderline Symptom List (BSL-23), two popular BPD screening tools, among Indian men, in the context of sexual orientation concealment (SOC) among gay and bisexual men, and dysfunctional behaviors (DBs) and the quality of overall personal state (QOPS) in general. The sample consisted of 45 gay, 43 bisexual and 28 heterosexual men (n = 116) without gender dysphoria aged between 21 and 45. Tools used to evaluate the participants included questions related to sociodemographic variables, MSI-BPD, BSL-23 and the Minority Stress Scale. MSI-BPD and BSL-23 were positively correlated with each other among all the three groups. MSI-BPD was not associated with age, years of education, sexual orientation, or SOC among any of the groups. BSL-23 was negatively correlated with age among gay men. Gay and bisexual men had higher median MSI-BPD scores than heterosexual men, whereas only gay men had a higher median BSL-23 score. Bisexual men had a higher level of SOC than gay men. Education and QOPS were not associated with SOC among gay and bisexual men. Age was positively correlated with SOC among bisexual men, and DBs were negatively correlated with SOC among gay men. There were no differences in DBs or QOPS among the three groups. MSI-BPD is a short and convenient tool to screen men for BPD regardless of their age, education, sexual orientation, or SOC in both clinical and research settings. BSL-23 can be used among men regardless of their sexual orientation as an initial BPD screening tool in clinical settings. Both the tools must be validated among larger samples in India, and translated into regional languages to ensure sociocultural suitability.

Borderline personality disorder; Sexual orientation concealment; Minority stress; Minority stressors; Sexual orientation; Homosexuality; Bisexuality; Gay; Bisexual

[1] Bohus M, Stoffers-Winterling J, Sharp C, Krause-Utz A, Schmahl C, Lieb K. Borderline personality disorder. The Lancet. 2021; 398: 1528–1540.

[2] Zanarini MC. Psychotherapy of borderline personality disorder. Acta Psychiatrica Scandinavica. 2009; 120: 373–377.

[3] Sansone RA, Sansone LA. Gender patterns in borderline personality disorder. Innovations in Clinical Neuroscience. 2011; 8:16–20.

[4] Rodriguez-Seijas C, Morgan TA, Zimmerman M. A population-based examination of criterion-level disparities in the diagnosis of borderline personality disorder among sexual minority adults. Assessment. 2021; 28: 1097–1109.

[5] Rodriguez-Seijas C, Morgan TA, Zimmerman M. Is there a bias in the diagnosis of borderline personality disorder among lesbian, gay, and bisexual patients? Assessment. 2021; 28: 724–738.

[6] Frost DM, Meyer IH. Minority stress theory: application, critique, and continued relevance. Current Opinion in Psychology. 2023; 51: 101579.

[7] Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychological Bulletin. 2003; 129: 674–697.

[8] Pachankis JE, Mahon CP, Jackson SD, Fetzner BK, Bränström R. Sexual orientation concealment and mental health: a conceptual and meta-analytic review. Psychological Bulletin. 2020; 146: 831–871.

[9] Hatzenbuehler ML, Nolen-Hoeksema S, Dovidio J. How does stigma “get under the skin”?: the mediating role of emotion regulation. Psychological Science. 2009; 20: 1282–1289.

[10] Fitzpatrick S, Dixon-Gordon KL, Turner CJ, Chen SX, Chapman A. Emotion dysregulation in personality disorders. Current Psychiatry Reports. 2023; 25: 223–231.

[11] Hendricks ML, Testa RJ. A conceptual framework for clinical work with transgender and gender nonconforming clients: an adaptation of the minority stress model. Professional Psychology: Research and Practice. 2012; 43: 460–467.

[12] Christian LM, Cole SW, McDade T, Pachankis JE, Morgan E, Strahm AM, et al. A biopsychosocial framework for understanding sexual and gender minority health: a call for action. Neuroscience & Biobehavioral Reviews. 2021; 129: 107–116.

[13] Weeks SN, Renshaw TL, Vinal SA. Minority stress as a multidimensional predictor of LGB+ adolescents’ mental health outcomes. Journal of Homosexuality. 2023; 70: 938–962.

[14] Lytle MC, Vaughan MD, Rodriguez EM, Shmerler DL. Working with LGBT individuals: incorporating positive psychology into training and practice. Psychology of Sexual Orientation and Gender Diversity. 2014; 1: 335–347.

[15] Fredriksen-Goldsen KI, Simoni JM, Kim HJ, Lehavot K, Walters KL, Yang J, et al. The health equity promotion model: Reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health disparities. The American Journal of Orthopsychiatry. 2014; 84: 653–663.

[16] Diamond LM, Alley J. Rethinking minority stress: a social safety perspective on the health effects of stigma in sexually-diverse and gender-diverse populations. Neuroscience and Biobehavioral Reviews. 2022; 138: 104720.

[17] Frost DM, Meyer IH, Lin A, Wilson BDM, Lightfoot M, Russell ST, et al. Social change and the health of sexual minority individuals: do the effects of minority stress and community connectedness vary by age cohort? Archives of Sexual Behavior. 2022; 51: 2299–2316.

[18] Michael Bailey J. The minority stress model deserves reconsideration, not just extension. Archives of Sexual Behavior. 2020; 49: 2265–2268.

[19] Zietsch BP, Verweij KJH, Heath AC, Madden PAF, Martin NG, Nelson EC, et al. Do shared etiological factors contribute to the relationship between sexual orientation and depression? Psychological Medicine. 2012; 42: 521–532.

[20] Meyer IH, Pachankis JE, Klein DN. Do genes explain sexual minority mental health disparities? Archives of Sexual Behavior. 2021; 50: 731–737.

[21] Drescher J, Fadus M. Issues arising in psychotherapy with lesbian, gay, bisexual, and transgender patients. Focus. 2020; 18: 262–267.

[22] Chang CJ, Kellerman JK, Fehling KB, Feinstein BA, Selby EA. The roles of discrimination and social support in the associations between outness and mental health outcomes among sexual minorities. The American Journal of Orthopsychiatry. 2021; 91: 607–616.

[23] Thepsourinthone J, Dune T, Liamputtong P, Arora A. The relationship between masculinity and internalized homophobia amongst australian gay men. International Journal of Environmental Research and Public Health. 2020; 17: 5475.

[24] Bostwick W, Hequembourg AL. Minding the noise: conducting health research among bisexual populations and beyond. Journal of Homosexuality. 2013; 60: 655–661.

[25] Herek GM, Norton AT, Allen TJ, Sims CL. Demographic, psychological, and social characteristics of self-identified lesbian, gay, and bisexual adults in a US probability sample. Sexuality Research & Social Policy. 2010; 7: 176–200.

[26] Schrimshaw EW, Downing MJ, Cohn DJ. Reasons for non-disclosure of sexual orientation among behaviorally bisexual men: non-disclosure as stigma management. Archives of Sexual Behavior. 2018; 47: 219–233.

[27] Tieu H, Spikes P, Patterson J, Bonner S, Egan JE, Goodman K, et al. Sociodemographic and risk behavior characteristics associated with unprotected sex with women among black men who have sex with men and women in New York City. AIDS Care. 2012; 24: 1111–1119.

[28] Leichsenring F, Fonagy P, Heim N, Kernberg OF, Leweke F, Luyten P, et al. Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies. World Psychiatry. 2024; 23: 4–25.

[29] Taylor PJ, Dhingra K, Dickson JM, McDermott E. Psychological correlates of self-harm within gay, lesbian and bisexual UK University students. Archives of Suicide Research. 2020; 24: 41–56.

[30] King M, Semlyen J, Tai SS, Killaspy H, Osborn D, Popelyuk D, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry. 2008; 8: 70.

[31] Videler AC, Hutsebaut J, Schulkens JEM, Sobczak S, van Alphen SPJ. A life span perspective on borderline personality disorder. Current Psychiatry Reports. 2019; 21: 51.

[32] Xu W, Zheng L, Liu Y, Zheng Y. Sexual sensation seeking, sexual compulsivity, and high-risk sexual behaviours among gay/bisexual men in Southwest China. AIDS Care. 2016; 28: 1138–1144.

[33] Grunewald W, Convertino AD, Safren SA, Mimiaga MJ, O’Cleirigh C, Mayer KH, et al. Appearance discrimination and binge eating among sexual minority men. Appetite. 2021; 156: 104819.

[34] Feldman MB, Meyer IH. Childhood abuse and eating disorders in gay and bisexual men. International Journal of Eating Disorders. 2007; 40: 418–423.

[35] Zhao Y, Guo Y, He X, Huo J, Wu Y, Yang X, et al. Assessing mental health signals among sexual and gender minorities using twitter data. 2018 IEEE International Conference on Healthcare Informatics Workshop (ICHI-W). 2018; 2018: 51–52.

[36] Sharma AJ, Subramanyam MA. Psychological wellbeing of middle-aged and older queer men in India: a mixed-methods approach. PLOS ONE. 2020; 15: e0229893.

[37] Wen G, Zheng L. The influence of internalized homophobia on health-related quality of life and life satisfaction among gay and bisexual men in China. American Journal of Men’s Health. 2019; 13: 1557988319864775.

[38] Oginni OA, Mapayi BM, Afolabi OT, Obiajunwa C, Oloniniyi IO. Internalized homophobia, coping, and quality of life among Nigerian gay and bisexual men. Journal of homosexuality. 2020; 67: 1447–1470.

[39] Bayes A, Parker G. Borderline personality disorder in men: a literature review and illustrative case vignettes. Psychiatry Research. 2017; 257: 197–202.

[40] Race K, Lea T, Murphy D, Pienaar K. The future of drugs: recreational drug use and sexual health among gay and other men who have sex with men. Sexual Health. 2017; 14: 42–50.

[41] Ekstam D. Change and continuity in attitudes toward homosexuality across the lifespan. Journal of Homosexuality. 2023; 70: 851–875.

[42] Reich DB, Zanarini MC. Sexual orientation and relationship choice in borderline personality disorder over ten years of prospective follow-up. Journal of Personality Disorders. 2008; 22: 564–572.

[43] Kleindienst N, Jungkunz M, Bohus M. A proposed severity classification of borderline symptoms using the borderline symptom list (BSL-23). Borderline Personality Disorder and Emotion Dysregulation. 2020; 7: 11.

[44] Zanarini MC, Vujanovic AA, Parachini EA, Boulanger JL, Frankenburg FR, Hennen J. A screening measure for BPD: the McLean screening instrument for borderline personality disorder (MSI-BPD). Journal of Personality Disorders. 2003; 17: 568–573.

[45] Zimmerman M, Balling C. Screening for borderline personality disorder with the McLean screening instrument: a review and critique of the literature. Journal of Personality Disorders. 2021; 35: 288–298.

[46] Gardner K, Qualter P. Reliability and validity of three screening measures of borderline personality disorder in a nonclinical population. Personality and Individual Differences. 2009; 46: 636–641.

[47] Dabaghi P, Mousavi Asl E, Taghva A. Screening borderline personality disorder: the psychometric properties of the Persian version of the McLean screening instrument for borderline personality disorder. Journal of Research in Medical Sciences. 2020; 25: 97.

[48] Melartin T, Häkkinen M, Koivisto M, Suominen K, Isometsä E. Screening of psychiatric outpatients for borderline personality disorder with the McLean screening instrument for borderline personality disorder (MSI-BPD). Nordic Journal of Psychiatry. 2009; 63: 475–479.

[49] Mirkovic B, Speranza M, Cailhol L, Guelfi J, Perez-Diaz F, Corcos M, et al. Validation of the French version of the McLean screening instrument for borderline personality disorder (MSI-BPD) in an adolescent sample. BMC Psychiatry. 2020; 20: 222.

[50] Munawar K, Aqeel M, Rehna T, Shuja KH, Bakrin FS, Choudhry FR. Validity and reliability of the Urdu version of the McLean screening instrument for borderline personality disorder. Frontiers in Psychology. 2021; 12: 533526.

[51] Soler J, Domínguez-Clavé E, García-Rizo C, Vega D, Elices M, Martín-Blanco A, et al. Validation of the Spanish version of the McLean screening instrument for borderline personality disorder. Spanish Journal of Psychiatry and Mental Health. 2016; 9: 195–202.

[52] Liu P, Wang X. Evaluation of reliability and validity of Chinese-version borderline personality features scale for children. Medical Science Monitor. 2019; 25: 3476–3484.

[53] Alghamdi FS. Borderline personality disorder in Saudi Arabia: the psychometric properties of the Arabic version of the Mclean screening instrument for borderline personality disorder (MSI-BPD). Journal of Research in Curriculum Instruction and Educational Technology. 2024; 10: 245–266.

[54] Verschuere B, Tibboel H. De Nederlandstaligeversie van de McLean screening instrument for borderline personality disorder (MSI-BPD).Psychologie&Gezondheid. 2011; 39: 243–248.

[55] Glenn CR, Weinberg A, Klonsky ED. Relationship of the borderline symptom list to DSM-IV borderline personality disorder criteria assessed by semi-structured interview. Psychopathology. 2009; 42: 394–398.

[56] Eubanks‐Carter C, Goldfried MR. The impact of client sexual orientation and gender on clinical judgments and diagnosis of borderline personality disorder. Journal of Clinical Psychology. 2006; 62: 751–770.

[57] Choudhary S, Gupta R. Culture and borderline personality disorder in India. Frontiers in Psychology. 2020; 11: 714.

[58] Pala AN, Dell’Amore F, Steca P, Clinton L, Sandfort T, Rael C. Validation of the minority stress scale among Italian gay and bisexual men.Psychology of Sexual Orientation and Gender Diversity. 2017; 4: 451–459.

[59] Stokes JP, Vanable P, McKirnan DJ. Comparing Gay and Bisexual Men on Sexual Behavior, Condom Use, and Psychosocial Variables Related to HIV/AIDS. Archives of Sexual Behavior. 1997; 26(4): 383–97.

[60] Balsam KF, Mohr JJ. Adaptation to sexual orientation stigma: a comparison of bisexual and lesbian/gay adults. Journal of Counseling Psychology. 2007; 54: 306–319.

[61] Bostwick WB, Boyd CJ, Hughes TL, McCabe SE. Dimensions of sexual orientation and the prevalence of mood and anxiety disorders in the United States. American Journal of Public Health. 2010; 100: 468–475.

[62] Choudhary S. Adaptation of psychometric tests for identifying borderline personality disorder patients in India. Journal of the Indian Academy of Applied Psychology. 2017; 43: 257–266.

[63] Skodol AE, Bender DS. Why are women diagnosed borderline more than men? Psychiatric Quarterly. 2003; 74: 349–360.

[64] Black DW, Gunter T, Allen J, Blum N, Arndt S, Wenman G, et al. Borderline personality disorder in male and female offenders newly committed to prison. Comprehensive Psychiatry. 2007; 48: 400–405.

[65] Dehlbom P, Wetterborg D, Lundqvist D, Maurex L, Dal H, Dalman C, et al. Gender differences in the treatment of patients with borderline personality disorder. Personality Disorders. 2022; 13: 277–287.

[66] Bjorklund P. No man’s land: gender bias and social constructivism in the diagnosis of borderline personality disorder. Issues in Mental Health Nursing. 2006; 27: 3–23.

[67] Choi-Kain LW, Murray GE, Jurist J, Ren B, Germine L. Online psychoeducation and digital assessments as a first step of treatment for borderline personality disorder: a protocol for a pilot randomized controlled trial. PLOS ONE. 2023; 18: e0294331.

[68] Dodge B, Banik S, Bowling J, Sivasubramanian M, Mengle S, Schick V, et al. Sexual relationships, behaviors, and experiences among bisexual men in Mumbai, India. International Journal of Sexual Health. 2016; 28: 70–84.

[69] Srinivasan S, Glover J, Tampi RR, Tampi DJ, Sewell DD. Sexuality and the older adult. Current Psychiatry Reports. 2019; 21: 97.

[70] Pachankis JE, Bränström R. Hidden from happiness: structural stigma, sexual orientation concealment, and life satisfaction across 28 countries. Journal of Consulting and Clinical Psychology. 2018; 86: 403–415.

[71] Sylva D, Rieger G, Linsenmeier JAW, Bailey JM. Concealment of sexual orientation. Archives of Sexual Behavior. 2010; 39: 141–152.

[72] Huang YT, Chan RCH. Effects of sexual orientation concealment on well-being among sexual minorities: how and when does concealment hurt. Journal of Counseling Psychology. 2022; 69: 630–641.

[73] Ronningstam EF, Keng S, Ridolfi ME, Arbabi M, Grenyer BFS. Cultural aspects in symptomatology, assessment, and treatment of personality disorders. Current Psychiatry Reports. 2018; 20: 22.

[74] Munson KA, Janney CA, Goodwin K, Nagalla M. Cultural representations of borderline personality disorder. Frontiers in Sociology. 2022; 7: 832497.

[75] Neacsiu AD, Eberle, Jeremy W, Keng SL, Fang CM, Rosenthal MZ. Understanding borderline personality disorder across sociocultural groups: findings, issues, and future directions. Current Psychiatry Reviews. 2017;13: 188–223.

[76] Dixit P. Navtej Singh Johar v Union of India: decriminalising India’s sodomy law. The International Journal of Human Rights. 2020; 24: 1011-–1030.

[77] Yadav S. India’s Supreme Court rules against marriage equality. 2023. Available at: https://www.npr.org/2023/10/22/1207863803/indias-supreme-court-rules-against-marriage-equality (Accessed: 01 February 2024).

[78] Gwalani P. ‘Shame forcing gay men to get married to straight women’. 2015. Available at: https://timesofindia.indiatimes.com/city/nagpur/shame-forcing-gay-men-to-get-married-to-straight-women/articleshow/48795234.cms (Accessed: 01 February 2024).

[79] Jones J. Gay affirmative therapy for the straight clinician: the essential guide. Journal of GLBT Family Studies. 2009; 5: 280–283.

[80] Debusmann Jr B. US immigration: why Indians are fleeing halfway around the world. 2022. Available at: https://www.bbc.com/news/world-us-canada-62893926 (Accessed: 01 February 2024).

[81] Nagaraj A. Bullied by peers, India’s LGBT+ children drop out of schools. 2019. Available at: https://www.reuters.com/article/idUSKCN1UD04T/ (Accessed: 01 February 2024).

[82] Alves MJH, Parente JS, Albuquerque GA. Homosexual orientation in childhood and adolescence: experiences of concealment and prejudice. Reprodução & Climatério. 2016; 31: 68–75.

[83] Card K, McGuire M, Bond-Gorr J, Nguyen T, Wells GA, Fulcher K, et al. Perceived difficulty of getting help to reduce or abstain from substances among sexual and gender minority men who have sex with men (SGMSM) and use methamphetamine during the early period of the COVID-19 pandemic. Substance Abuse Treatment, Prevention, and Policy. 2021; 16: 88.

[84] Bourne A, Reid D, Hickson F, Torres-Rueda S, Steinberg P, Weatherburn P. “Chemsex” and harm reduction need among gay men in South London. International Journal of Drug Policy. 2015; 26: 1171–1176.

[85] Lisboa C, Stuardo V, Folch C. Sexualized drug use among gay men and other men who have sex with men in Latin America: a description of the phenomenon based on the results of LAMIS-2018. PLOS ONE. 2023; 18: e0287683.

[86] Wang J, Zhao P, Xu W, Wang C. Sexual uses of drug and alcohol among men who have sex with men in China: implications for HIV prevention. Sexual uses of drug and alcohol among men who have sex with men in China: implications for HIV prevention. BMC Infectious Diseases. 2022; 22: 895.

[87] Zhao T, Chen G, Sun C, Gong X, Li H, Fu G. The epidemic of HIV and syphilis and the correlation with substance abuse among men who have sex with men in China: a systematic review and meta-analysis. Frontiers in Public Health. 2023; 11: 1082637.

[88] Hoertel N, Peyre H, Wall MM, Limosin F, Blanco C. Examining sex differences in DSM-IV borderline personality disorder symptom expression using item response theory (IRT). Journal of Psychiatric Research. 2014; 59: 213–219.

[89] van den Brink C, Harte JM, Denzel AD. Men and women with borderline personality disorder resident in Dutch special psychiatric units in prisons: a descriptive and comparative study. Criminal Behaviour and Mental Health. 2018; 28: 324–334.

[90] Goodman M, Patel U, Oakes A, Matho A, Triebwasser J. Developmental trajectories to male borderline personality disorder. Journal of Personality Disorders. 2013; 27: 764–782.

[91] Thomeer MB, Reczek C. Happiness and sexual minority status. Archives of Sexual Behavior. 2016; 45: 1745–1758.

[92] Salgó E, Szeghalmi L, Bajzát B, Berán E, Unoka Z. Emotion regulation, mindfulness, and self-compassion among patients with borderline personality disorder, compared to healthy control subjects. PLOS ONE. 2021; 16: e0248409.