A transgender woman with intellectual disability and borderline personality disorder

William J Newman, Amy V. Barnhorst, Jacqueline S. Landess

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


What diagnostic criterion is noted to be a central feature for each of the diagnoses of intellectual disability, borderline personality disorder, and gender dysphoria? A. Functional impairment. B. Emotional instability. C. Cognitive dysfunction. D. Neurotic traits. "Ms. A" is a 23-year-old transgender woman (assigned male at birth) with a history of fetal alcohol syndrome, mild intellectual disability (a full-scale IQ of 60), and borderline personality disorder. She received primary care and support through a regional intellectual disability agency but was also well known to psychiatric services for frequent violent outbursts and recurrent self-harm gestures. Ms. A's interactions with the mental health system began before age 5. She was adopted at birth into a home with other special-needs siblings. Early records reflect her difficulty with impulse control and anger management. By age 8, she was frequently wearing makeup or girls' clothing. By age 16, she consistently identified as female, wearing articles of women's clothing at school and soliciting her sisters' boyfriends. She made frequent self-harm gestures, such as cutting herself in the school hallway as well as threatening suicide, and she occasionally responded with violence toward peers or siblings who taunted her. During adolescence, Ms. A used social networking sites to find potential dates, often meeting older men in dangerous situations. Her high-risk behaviors continued; she often threatened "to turn myself into a girl" with knives, and she asked a man to "rape and kill me." By age 23, she had more than 15 referrals to mental health crisis units for behavioral issues, typically leading to inpatient hospitalizations. Despite support in her gender identity by her adoptive mother, she was unable to find services that provided hormone or surgical transition services for transgender youths and therefore had not received either intervention. Her main social service provider for intellectual disability also did not provide resources for transgender youths. Police last brought Ms. A to our facility after she threatened herself with scissors when a peer referred to her as a boy. She appeared tall and thin, looked younger than her age, and had a speech impediment with a significant lisp. She also exhibited dysmorphic facial features consistent with fetal alcohol syndrome, shoulder-length blonde hair, and faint beard growth. She frequently hunched over, hiding her face in her hands or behind her hair. She moved awkwardly and frequently missed social cues, unintentionally provoking anger from peers on the inpatient unit. On admission, Ms. A wore pink pajama pants and a loose-fitting T-shirt. She commonly wore pink T-shirts with adolescent slogans during her stay. She usually engaged readily and eagerly with staff and peers, but she was often childish in her mannerisms, consistent with intellectual disability Throughout her stay, she displayed limited frustration tolerance and frequently responded to misidentification of her gender with dramatic displays of emotion. Staff was unsure how to address Ms. A. Some were outwardly hostile. On one occasion, a staff member was overheard saying, "I'm not going to call that a she." Documentation from Ms. A's previous contacts with service agencies revealed unfamiliarity with transgender terminology and frequent dismissal of her transgender status. Of 15 intake notes, only two referred to her gender with correct pronouns; others documented male pronouns; some used both male and female pronouns; one avoided mentioning gender altogether. One writer noted, "He is trying to be transgender." Others frequently put the transgender modifier in quotation marks. Ms. As treatment team made several attempts to change her recorded gender on her hospital identification to prevent misidentification on subsequent admissions. Although gender misidentification was a trigger for many of her admissions, this was rarely included as part of her treatment plan. Most inpatient treatment focused on bolstering coping mechanisms before discharging her to the care of her service agency. The issue of her transgender status was often unaddressed, sometimes even actively avoided. Ms. A was unable to be discharged back to her adoptive mother's house. She and her mother sought a group home placement through the intellectual disability regional services. However, the local group homes were gender segregated, and the homes for females would not accept Ms. A, who often looked like a young man. Meetings between the family, the mental health team, and intellectual disability regional services revealed no known housing resources in the area that would meet her gender, intellectual, and mental health needs.

Original languageEnglish (US)
Pages (from-to)1061-1063
Number of pages3
JournalAmerican Journal of Psychiatry
Issue number11
StatePublished - Nov 1 2018
Externally publishedYes

ASJC Scopus subject areas

  • Psychiatry and Mental health


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