The sexuality of patients with BPO often reflects the deeper features of their inner world. In this domain, key difficulties characteristic of BPO frequently emerge:

• identity diffusion,
• instability in relationships,
• intense affects,
• oscillation between idealization and devaluation of the other.

Sexual relationships for patients with BPO may become both a source of intimacy and a space in which aggression, fear of rejection, and struggles for control unfold. For this reason, the sexual life of such patients often demonstrates significant variability: it may fluctuate from an almost complete absence of sexual desire to intense, yet unstable and dramatic relationships.

This is related to the fact that, in their experience, love and sexuality do not always coincide. Sexuality combines libidinal and aggressive elements and, to a certain extent, represents a crossroads between them.

The development of a mature and intimate sexual life is a goal of Transference-Focused Psychotherapy (TFP), especially in cases where the patient’s sexual life has been stunted or overwhelmingly infiltrated with aggression. We examine issues relating to the sexual history and adjustment of the patient and aspects of sexuality as they arise in treatment.

Human sexuality includes core gender identity, gender role identity, object choice, and intensity of sexual desire (Kernberg 1995). The latter two constructs, object choice and intensity of sexual desire, are most relevant in discussing patients with BPO. The object choice of the patient with BPO may, as a consequence of identity diffusion, involve confusion in object choice and chaotic bisexuality on the behavioral level. Intensity of desire may vary widely, with some patients with severe BPO having little desire.

Patients with BPO generally begin treatment within a defined range of pathology in their sexual adjustments, but within that range there is substantial variation (Table 9–2). The patient’s level of sexual capacity and adjustment at the beginning of treatment will define areas of potential improvement. Patients with more severe BPO may present with an absence of the capacity for the central pleasures of normal sexuality. These patients may find no pleasure in any sexual outlet, including masturbation, and no sexual desire linked to any individual. A history of severe traumatic experiences and physical or sexual abuse and the absence of any attachment to a loving parental object often dominate their history. With these patients, the goals of treatment in the sexual realm may be limited.

Treatment may first help patients to access a capacity for idealization of another and to express their longing for an idealized relationship. With further treatment and integration of the idealized and persecutory images, the patient may be able to establish a committed attachment that involves affection, but this type of patient may show no capacity for passionate love.

Patients with borderline personality organization with a narcissistic personality structure tend to have a capacity for sexual excitement without the capacity for a deep investment in an intimate partner. Many of these individuals have never been in love. The notable sexual promiscuity of these individuals is often linked with sexual desire and excitement for a person who is considered by others to be attractive or valuable. With this type of attachment, sexual fulfillment may gratify the need for conquest but may also trigger the unconscious process of needing to feel superior and to devalue the other, resulting in a disappearance of both sexual excitement and interest in the other person.

Patients at the higher end of BPO may begin treatment with the capacity for sexual excitement and erotic desires. These patients may have the full capacity for genital excitement and orgasm linked with a passionate commitment to another. They are able to integrate aggression with love and sexuality, and they have a capacity for a primitive kind of falling in love that is characterized by an idealization of the love object. In fact, intense sexual experiences and intense love affairs with an idealized other may obscure the underlying incapacity to tolerate ambivalence. 

However, with the splitting mechanisms of BPO, their interpersonal and intimate relationships are fragile and always at risk of being contaminated by split-off, all-bad aspects that may change the idealized relationship into a persecutory one. In the midphase of therapy the question of sex may intertwine with manifestations of the idealized transference and, at times, with the persecutory one.

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(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy

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