Several years before the 1992 publication of Bastard Out of Carolina, Allison had already established herself as a writer outside of the mainstream; her 1988 collection Trash won the Lambda Literary award for best lesbian book. Bastard Out of Carolina was her first novel and considered to be her "crossover" book. It drew immediate attention from critics and readers. George Garrett wrote in his review for the New York Times, "When I finished reading Bastard Out of Carolina I wanted to blow a bugle to alert the reading public that a wonderful work of fiction by a major new talent has arrived on the scene." That year, as well, the book was selected as a finalist for the National Book Award.

Some reviewers saw Bastard Out of Carolina as a "southern" novel, rich in the gothic tradition of the grotesque and populated with a host of eccentric archetypes. Indeed, in Allison's novel are certain aspects strongly identified with the South, such as a tradition of oral storytelling, a marked interest in family history and lore, the power of evangelical religion, and the class system and social status.

Randall Kenan, however, noted that Allison "skates uncomfortably near the thin ice of stereotype, a feat at once worrisome and brave." Kenan described the southern stereotypes: "poor white trash; liquored-up, malevolent, unemployed, undereducated, country-music-listening, oversexed, foul-tempered men; and long-suffering, quickly aging, overly fertile, too-young-marrying, hardheaded women." Kenan found that "[W]hen Allison succeeds [in her characterization], she succeeds winningly." He particularly felt that Uncle Earle, Raylene, and Bone came across convincingly. Other characters—Anney, Glen, Reese, the cousins—hardly "ever come off as more than characters from a country music song." Garrett, however, would argue with this assertion; he found that the characters are "each distinct and memorable, each a recognizable physical presence."

Many critics also focused on the sexual aspect of the novel, which forms one of the major issues of Bone's young life. The character Bone had earlier appeared in Allison's short stories collected in Trash, in which the young sexually abused girl initiates particularly masochistic forms of masturbation. For Allison, writing is closely tied to her lesbian identity, feminism, and politics. She has stated, "It is only as the child of my class and my unique family background that I have been able to … regain a sense of why I believe in activism, why self-revelation is so important for lesbians." Deborah Horvitz, in an article published in Contemporary Literature, takes up this theme. She argues that the abused Bone needs to integrate the past traumas in order to move into the future. Horvitz discusses ways that Bone attempts to do this: "She attempts to transform her nightmare into narrative as a means of coping with what she considers to be her 'damaged' and 'ruined' body, but that proves impossible since her stories themselves, along with her desires, wishes, and passions, are entrenched in sadomasochism." Only when everyone surrounding Bone acknowledges the abuse can Bone take steps to heal. Writes Horvitz, "At the close of the novel, Ruth Anne, though far from happy, is finally safe. Anney 'wakes up' to the truth regarding Glen's cruelty and simultaneously confronts her own inability to leave him. Only then can she leave Bone safely within Raylene's protection."

Allison early on acknowledged the autobiographical element in the novel. She had been sexually abused by her stepfather from the ages of five to eleven. In an interview with Lynn Karpen in the New York Times Book Review, Allison revealed that many of the introductory details are largely autobiographical, and further, that "a lot of the novel is based on real experience, but not the entire thing. The characters are modeled on members of my family and on stories I heard when I was growing up." However, Vince Aletti, writing in the Voice Literary Supplement, pointed out that even "if [the novel] is rooted in autobiography, it never takes on the obsessive tone of a confessional or the crusading fervor of an expose." Horvitz maintained that "in order to appreciate the importance of Bone's 'remembering' her past, one must 'read' her story within the context of Allison's life as, in her other work, she encourages us to do.… Allison transforms actual and remembered trauma into art."

On many levels, whether personal, biographical, or narrative, Bastard Out of Carolina is a resounding success. Kenan applauded the work as "a singular and important act of art and courage." Amber Hollibaugh, writing in Women's Review of Books, took an even more personal approach: "This is a book I had dreamed of reading since I first discovered Allison's writing … in the late seventies.… She is right to say that her novel isn't easy to read, but neither are our lives. This is a book as consequential as our own stories: a novel that could save a life."