Commentary - Borderline personality disorder and sexual abuse: A systematic review

Lucas Fortaleza de Aquino Ferreira

Hospital de Saúde Mental Professor Frota Pinto, Fortaleza, Brazil

Although sexual abuse (SA) is known to be frequent among borderline personality disorder (BPD) patients, few reviews or meta-analysis examining that topic have been published. The aim of our study1 was to investigate SA history (including adulthood) as a predictor of BPD diagnosis, clinical presentation and prognosis. I will comment on our most relevant results.

We analyzed 40 papers. Eligibility criteria were described in the manuscript. Overall, SA played a major role in BPD, particularly in women. Childhood sexual abuse (CSA) was a relevant risk factor. To our knowledge, this is the first systematic review that showed higher rates of adult sexual abuse (ASA) in BPD compared with other personality disorders (PDs). Our review is also the first one to demonstrate the negative impact of CSA and ASA on BPD clinical presentation and prognosis.

Two longitudinal studies with sexually abused children presented mixed outcomes. WIDOM et al.2 described possible explanations for the absence of significant association between CSA and BPD in their article: court cases may differ from CSA reported by BPD patients (usually minor or single incidents), women who seek treatment may have more CSA, and the relatively lower proportion of SA victims compared to other trauma may have led to limited power. CUTAJAR et al.3 found statistical significance only in the female sex, which represented 80.1% of the sample and was 7.62 times more likely to develop BPD than healthy controls. On the other hand, BIERER et al.4, in their cross-sectional paper, reported a statistical trend between BPD and CSA only in males, which represented 64.9% of the sample.

Analyzing the relationship between BPD and type of CSA, MERZA et al.5 concluded that genital fondling and penetration were strong predictors of BPD, but not oral sex or anal penetration. This finding resembles that of the meta-analysis of FOSSATI et al.6, in which BPD was associated with genital fondling and penetration, but not with oral sex. One possible explanation for these findings is that our sexuality is culturally linked to the genitalia, so acts involving oral or anal regions are less likely to be interpreted by the children as sexual abuse and causes less impact on mental health.

By relating BPD to the age of occurrence of CSA and the profile of the abuser, articles showed divergent results. ZANARINI et al.7 compared BPD with other PDs and found an association between BPD and CSA by non-caregiver, but not between BPD and CSA by the caregiver. On the other hand, LAPORTE and GUTTMAN8, when comparing BPD, anorexia nervosa and healthy controls, revealed a correlation between BPD and CSA at an earlier age and BPD and intrafamilial CSA, but not between BPD and extrafamilial CSA. These findings differ from those of the meta-analysis of FOSSATI et al.6, who reported a statistically more significant relationship between BPD and adolescence/extrafamilial SA than between BPD and childhood/intrafamilial SA.

Among clinical presentation or prognosis variables, suicidality was the most studied. BPD patients with CSA had a 10-fold increased risk of a history of suicide attempt than BPD patients without CSA9,10. Several papers have described statistical significance between suicide ideation or attempts and CSA in BPD10,11,12,13,14,15,16. Many researchers have found the correlation between CSA and suicidal behavior in adulthood17,18,19,20.

Some results from the included articles suggest a dose-response relationship between CSA and clinical presentation of BPD. The severity of CSA or the co-occurrence of physical and SA in childhood were related to self-mutilation episodes14,15 and suicide attempts10,13,14,15. Other authors have already revealed a dose-response effect of childhood trauma on self-injurious or suicidal behaviors in adulthood21,22.

Previous studies reporting lower CSA rates in samples with less BPD traits or milder symptoms raise the hypothesis that there may also be a directly proportional relationship between BPD severity and positive history of CSA23,24. Another paper demonstrated a directly proportional relationship between the number of types of childhood trauma and the number of BPD symptoms25.

Although CSA has been consistently associated with BPD, CSA rates in individuals with BPD may be overestimated, possibly because false memories and misinterpretations are more common in this population26. The scientific literature lacks more prospective articles about the prevalence and course and management effect for documented or corroborated SA cohorts. Future research also needs to further study prognosis variables and ASA, and include more men and milder BPD patients. It is also essential to clarify the clinical repercussions of CSA in the various presentations (e.g., intrafamilial versus extrafamilial) and age groups (childhood, latency, adolescence), as well as to investigate whether differences in CSA management (e.g., validate versus invalidate victim report) influence the association with BPD. The impact of other traumatic experiences, such as emotional abuse, should also be systematically reviewed.

  1. de Aquino Ferreira LF, Queiroz Pereira FH, Neri Benevides AML, et al. Borderline personality disorder and sexual abuse: A systematic review. Psychiatry Res. 2018 Feb; 243(3): 255–62.
  2. Widom CS, Czaja SJ, Paris J. A prospective investigation of borderline personality disorder in abused and neglected children followed up into adulthood. J Pers Disord. 2009; 23(5): 433–46.
  3. Cutajar MC, Mullen PE, Ogloff JRP, et al. Psychopathology in a large cohort of sexually abused children followed up to 43 years. Child Abuse Negl. Elsevier Ltd; 2010; 34(11): 813–22.
  4. Bierer LM, Yehuda R, Schmeidler J, et al. Abuse and neglect in childhood: relationship to personality disorder diagnoses. CNS Spectr. 2003; 8(10): 737–54.
  5. Merza K, Gábor P, Ildikó Kuritárné S. The role of childhood traumatization in the development of borderline personality disorder in Hungary. Eur J Psychiatry. 2015; 29(2): 105–18.
  6. Fossati A, Madeddu F, Maffei C. Borderline personality disorder and childhood sexual abuse: A meta-analytic study. J Pers Disord. 1999; 13(3): 268–80.
  7. Zanarini MC, Williams AA, Lewis RE, et al. Reported pathological childhood experiences associated with the development of borderline personality disorder. Am J Psychiatry. 1997; 154(8): 1101–6.
  8. Laporte L, Guttman H. Abusive relationships in families of women with borderline personality disorder, anorexia nervosa and a control group. J Nerv Ment Dis. 2001; 189(8): 522–31.
  9. Ferraz L, Portella MJ, Vállez M, et al. Hostility and childhood sexual abuse as predictors of suicidal behaviour in borderline personality disorder. Psychiatry Res. Elsevier; 2013; 210(3): 980–5.
  10. Soloff PH, Lynch KG, Kelly TM. Childhood abuse as a risk factor for suicidal behavior in borderline personality disorder. J Pers Disord. 2002; 16(3): 201–14.
  11. Horesh N, Nachshoni T, Wolmer L, et al. A comparison of life events in suicidal and nonsuicidal adolescents and young adults with major depression and borderline personality disorder. Compr Psychiatry. Elsevier Inc.; 2009; 50(6): 496–502.
  12. Dubo ED, Zanarini MC, Lewis RE, et al. Childhood antecedents of self-destructivenes in borderline personality disorder. Can J Psychiatry. 1997; 42(1): 63–9.
  13. Links PS, Kolla NJ, Guimond T, et al. Prospective risk factors for suicide attempts in a treated sample of patients with borderline personality disorder. Can J Psychiatry. 2013; 58(2): 99–106.
  14. Zanarini MC, Yong L, Frankenburg FR, et al. Severity of reported childhood sexual abuse and its relationship to severity of borderline psychopathology and psychosocial. J Nerv Ment Dis. 2002; 190(6): 381–7.
  15. Kaplan C, Tarlow N, Stewart JG, Aguirre B, Galen G, Auerbach RP. Borderline personality disorder in youth: The prospective impact of child abuse on non-suicidal self-injury and suicidality. Compr Psychiatry. Elsevier Inc.; 2016;71:86–94.
  16. Menon P, Chaudhari B, Saldanha D, et al. Childhood sexual abuse in adult patients with borderline personality disorder. Ind Psychiatry J. 2016; 25(1): 101–6.
  17. Afifi TO, Enns MW, Cox BJ, et al. Population attributable fractions of psychiatric disorders and suicide ideation and attempts associated with adverse childhood experiences. Am J Public Health. 2008; 98(5): 946–52.
  18. Molnar BE, Berkman LF, Buka SL. Psychopathology, childhood sexual abuse and other childhood adversities: Relative links to subsequent suicidal behaviour in the US. Psychol Med. 2001 Aug 31; 31(6): 965–77.
  19. Chen LP, Hassan Murad M, Paras ML, et al. Sexual abuse and lifetime diagnosis of psychiatric disorders sexual abuse and lifetime diagnosis of psychiatric disorders: Systematic review and meta-analysis. Mayo Clin Proc. 2010; 85(7): 618–29.
  20. Turner S, Taillieu T, Cheung K, et al. The relationship between childhood sexual abuse and mental health outcomes among males: Results from a nationally representative United States sample. Child Abuse Negl. 2017 Apr; 66: 64–72.
  21. Afifi TO, MacMillan HL, Boyle M, et al. Child abuse and mental disorders in Canada. Can Med Assoc J. 2014 Jun 10; 186(9): E324–32.
  22. Steine IM, Winje D, Krystal JH, et al. Cumulative childhood maltreatment and its dose-response relation with adult symptomatology: Findings in a sample of adult survivors of sexual abuse. Child Abuse Negl. 2017 Mar; 65: 99–111.
  23. Herman JL, Perry JC, Kolk BA van der. Childhood trauma in borderline personality disorder. Am J Psychiatry. 1989; 146(4): 1989.
  24. Salzman JP, Salzman C, Wolfson AN, et al. Association between borderline personality structure and history of childhood abuse in adult volunteers. Compr Psychiatry. 1993; 34(4): 254–7.
  25. Sansone RA, Songer DA, Miller KA. Childhood abuse, mental healthcare utilization, self-harm behavior, and multiple psychiatric diagnoses among inpatients with and without a borderline diagnosis. Compr Psychiatry. 2005 Mar; 46(2): 117–20.
  26. Frías Á, Palma C, Farriols N, et al. Sexuality-related issues in borderline personality disorder: A comprehensive review. Personal Ment Health. 2016 Aug; 10(3): 216-31.

Article Info

Article Notes

  • Published on: April 03, 2018


  • Borderline personality disorder

  • Sexual abuse
  • Personality disorders


Dr. Lucas Fortaleza de Aquino Ferreira
Hospital de Saúde Mental Professor Frota Pinto, Fortaleza, Brazil
Fax: 215 573-5566