Dialectical Behavioral Therapy for adolescents (DBT-A) has many consistent characteristics no matter the individuals making up each unique DBT skills group. Core pillars of most DBT-A programs include five core modules (mindfulness, distress tolerance, walking the middle path, emotional regulation and interpersonal effectiveness), the therapeutic layout (crisis phone coaching, individual therapy, consultation group and multifamily skills group) as well as the expected commitment from both adolescent and their family (Rathus, et al 2015). What remains unpredictable is the unique and diverse range of people who enter into a DBT program, many who carry vastly different backgrounds, traumas and reasons behind their choice for starting DBT. While diagnosis, history and personality cause variety within DBT, one consistent trend is the predominant presence of female and LGBTQ+ DBT members, more than would be expected based on demographics of the general population. Reasons behind the overabundance of female and LGBTQ+ youth enrolling in DBT-A still need to be determined, however preliminary research has pinpointed several plausible explanations including mental health diagnosis, stressful and traumatic life events, and self-helping tendencies (Bozatello et al., 2024; Camp et al, 2023; Wendt & Shafer, 2016).
Marsha Linehan, creator of DBT, set out to help various clinical populations. However, when required by the American Psychological Association to only select one diagnosis to focus on, Borderline Personality Disorder (BPD) was the targeted population for her newly developing therapeutic approach. Over time researchers and clinicians have explored DBT’s effectiveness in treating other clinical populations, which we now know is an evidenced based treatment for numerous clinical diagnoses (Rathus, et al 2015). Gradually the number of diagnoses and population of people positively responding to DBT has increased exponentially (The Linehan Institute, n.d.). Today, DBT is not only utilized for treatment of the originally intended mental illness, BPD, but additionally disorders such as eating disorders, Major Depressive Disorder, anxiety disorders, and PTSD to name a few (The Linehan Institute, n.d.).
While diagnoses may range vastly from one DBT patient to another, BPD still remains to be one of the most common disorders treated within the program. Within the Diagnostic and Statistical Manual of Mental Health Disorders, Edition 5 (DSM-5) BPD is a personality disorder marked by prolonged patterns of emotional dysregulation and hardship maintaining relationships with others (APA, 2013; BPD Alliance, 2026). Other characteristics of BPD can include intense fear of abandonment, suicidal thoughts or self-harming behaviors, unstable or low self image, high impulsivity, difficulty with managing anger or other intense emotions (BPD Alliance, 2026). BPD individuals are strong candidates for DBT treatment, therefore understanding BPD, gender dictated symptom variation of BPD, and issues with present day diagnosing of BPD are important when attempting to understand the gender gap seen among DBT participants.
Historically the statistics have shown women to more frequently receive a BPD diagnosis (Bozatello et al., 2024). Recent research has begun contradicting this, alternatively proposing that the prevalence of BPD may be the same among women and men, but characteristics exhibited, type of accompanying diagnosis and history of the treatment tend to differ in significant ways (Sansone & Sansone, 2011). For example, within the variation of BPD symptoms associated with gender, BPD males were shown to exhibit more explosive temperaments and thrill seeking, impulsive behaviors than BPD females (Sansone & Sansone, 2011). The historical prevalence of BPD among women and transgender communities may have, over time, caused potential gender biases that favor diagnosing BPD within these populations (Bozatello et al., 2024; Sansone & Sansone, 2011). Meaning clinicians may have a greater tendency to diagnose individuals who present with more female dominant BPD symptoms (examples being chronic feelings of emptiness, affective instability, and suicidality/self-harm behaviors) than those who present with BPD symptoms more frequently associated with males (examples being intense and inappropriate anger and impulsivity) (Bozatello et al., 2024). This is one plausible explanation as to why we see more of a male absence among DBT group members.
Besides statistical history and symptomatology patterns, research has shown a link between stress and trauma experiences and a BPD diagnosis (Bozatello et al., 2024; Camp et al, 2023; Rodriguez-Seijas et al, 2024). Being gender minority groups, women and gender diverse individuals, have an increased risk of experiencing more trauma and stress, through forms of stigma, invalidating environments and societal oppression (Bozatello et al., 2024; Camp et al, 2023; Rodriguez-Seijas et al, 2024). Such experiences can produce stress responses and behavioral patterns largely overlapping with BPD symptomology (self-harming behavior, suicidality, high impulsivity, etc.) (Camp et al, 2023; Penta et al, 2022). The root cause of gender minority stress rather than BPD causing overlapping symptoms can result in a potentially inaccurate BPD diagnosis. Accurate or not this diagnosis then links these individuals directly to BPD therapeutic resources such as DBT. Here research has found another caveat of diagnosing BPD that could influence the gender gap among DBT members.
One final explanation could simply be a gender difference in help seeking tendencies. Both individual and societal expectations can produce stigma surrounding seeking treatment, which can be exasperated when gender roles come into play. The emphasis and societal favoritism for certain male characteristics, that are often viewed as contradictory to seeking help, creates further resistance surrounding treatment (Wendt & Shafer, 2016). Research has shown that compared to their female counterparts, men tend to stigmatize seeking mental health treatment more, are more likely to engage in avoidance of addressing mental health issues and overall are less likely to pursue treatment for their mental health issues (Wendt & Shafer, 2016). Additionally, research has indicated that when male BPD patients do seek treatment, treatment programs are more often addressing a multitude of diagnoses. For BPD males, many have additional diagnosis of substance abuse disorder and antisocial personality disorder which often leads to them pursuing other treatment programs suited for these disorders, like a substance abuse program, before seeking DBT treatment (Bozzatello et al., 2024; Sansone & Sansone, 2011).
Mental health diagnosis, clinical bias, experienced stress and trauma, and self-helping tendencies may each account for the gender disproportion observed across DBT groups (Bozatello et al., 2024; Camp et al, 2023; Wendt & Shafer, 2016). Potentially the gender gap is due to a combination of all of these factors. Researchers have noted that more studies further exploring each of these topics needs to be done. In the meantime, continuing to promote DBT treatment, reduce clinical bias, dismantle stereotypes and educate about the importance of utilizing mental health resources can help tip the scales and continue expanding DBT’s reach in accessing individuals that are most in need of its services.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Bozzatello, P., Blua, C., Brandellero, D., Baldassarri, L., Brasso, C., Rocca, P. & Bellino, S. (2024). Gender differences in borderline personality disorder: a narrative review. Frontiers in psychiatry, 15, 1320546. doi: 10.3389/fpsyt.2024.1320546.
Camp, J., Morris, A., Wilde, H., Smith, P. & Rimes, K.A. (2023). Gender- and Sexuality-Minoritised Adolescents in DBT: A Reflexive Thematic Analysis of Minority Specific Treatment Targets and Experience. Cognitive Behavior Therapist, 16. doi: 10.1017/S1754470X23000326.
National Education Alliance for Borderline Personality Disorder. (2026). What is BPD? BPD Alliance. https://bpdalliance.org/what-is-bpd-overview/
Penta, S., Correia, S., Schneider, M.A., Holshausen, K., Nicholson, A.A., Haefner, S.A., Mutschler, C., Ferdossifard, A., Boylan, K. & Hewitt, J. (2022). Sex and gender in treatment response to dialectical behavior therapy: current knowledge, gaps, and future directions. The Cognitive Behavior Therapist, 15(e30). doi:10.1017/S1754470X22000253.
Rathus, J. H., Miller, A. L., & Linehan, M. (2015). DBT-A Skills Manual for Adolescents. The Guilford Press.
Rodriguez-Seijas, C., Morgan, T.A. & Zimmerman, M. (2024). Transgender and Gender Diverse Patients Are Diagnosed with Borderline Personality Disorder More Frequently Than Cisgender Patients Regardless of Personality Pathology. Transgender Health, 9(6), 554-565. doi: 10.1089/trgh.2023.0062
Sansone, R.A. & Sansone, L.A. (2011). Gender patterns in borderline personality disorder. Innovations in clinical neuroscience, 8(5), 16-20.
The Linehan Institute. (2026). What are DBT & DBT Skills? www.linehaninstitute.org. What are DBT & DBT Skills? — Linehan Institute.
Wendt, D. & Shafer, K. (2015). Gender and Attitudes about Mental Health Help Seeking: Results from National Data. Health & Social Work, 41(1): e20-e28.
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