The triple bind meets Barbie

Soaring mental health risks for girls.

Stephen P. Hinshaw

October 12, 2023

This summer the blockbuster film Barbie portrayed the embodiment of the iconic doll with physically impossible—if scaled to human size—breast-waist-hip measurements. Along with Playboy centerfolds, Barbie has epitomized ideal female sexual attributes for over sixty years. Fascinatingly, however, 2023’s flat-footed and cellulite-ridden Barbie plays out, at least in part, a feminist agenda as she thrives.

Yet the dark reality of female mental health is nothing short of devastating, particularly for teens and young adults. Well past the COVID-19 pandemic periods of lockdown, catastrophic statistics continue to emerge. 

To be specific: Serious depression and anxiety are soaring in teen girls. Rates of cutting and burning (so-called non-suicidal self-injury) are reaching epidemic proportions—and the average age of onset for such destructive acts is dipping into the preteen years, ages eleven and twelve. (Try to imagine girls aged seven and eight cutting themselves…too many do.) Rates of emergency room visits for self-injury are far higher than they were a decade ago, particularly for girls and young women. In the United States, suicide is currently the second leading cause of death for girls and young women aged 10 to 24. 

 The Centers for Disease Control and Prevention, the surgeon general (who earlier this year described “devastating effects” of the teen mental health crisis), and youth advocacy groups have put out a full alarm, decrying an epidemic of anxiety, depression, and substance use among females across all ethnic, racial, and socioeconomic segments of the population.

Although continuing to rise, these trends did not appear out of nowhere. Rates have been surging for several decades. The 2009 book The Triple Bind: Saving Our Teenage Girls from Today’s Pressures and Conflicting Expectations, which I wrote with the assistance of Rachel Kranz, highlighted that despite moderately-sized genetic risk for issues such as depression, self-injury, and binge eating, their rapid ascent among girls since the 1970s and their ever-earlier onset can only result from societal and cultural forces. At an evolutionary level, any changes in predisposing genes could not be transmitted via natural selection nearly that fast—but social forces can and do push the envelope. 

The crucial question: What has changed in our culture over the last few decades? The key premise of The Triple Bind is as follows: Girls increasingly face an impossible set of expectations, with potentially disastrous consequences when they blame themselves for failing to meet these unattainable goals. Allow me to lay out the argument.

First, societies continue to hold the time-honored expectation that girls must be empathic and nurturing, mainly in preparation for their ultimate role as mothers. Sure, there’s been movement toward gender parity in this regard, but boys are rarely held to the same “empathy standard” as girls.

Second, following the social upheavals and consciousness-raising of the 1960s, girls became expected to excel academically and athletically. Consider Title IX, the early-seventies amendment to the Civil Rights Act that equalized access to athletics for males and females, with other equity-enhancing provisions. Higher education used to be male-dominated, but the scales have tipped. At present, 60 percent of US college students are women. In short, it’s become expected that girls are academically not only equivalent to boys, but superior. 

How can a girl show true compassion when climbing to the top? Leading a sprint to the finish line, the almost-victorious girl who assists her stumbling competitor in the next lane will fall short of breaking the tape, losing out on the blue ribbon or gold medal. 

Now add the insidious third prong of this bind: Girls must be both ultra-nurturing and ultra-competitive, and with an effortlessly “hot” look. Physical attractiveness matters hugely in our overly sexualized world. Indeed, the Barbie doll has become a lasting symbol of sexual objectification. 

Who can be ultra-compassionate, ultra-competitive, and ultra-sexualized at the same moment? But that physical and psychological impossibility is the clear ideal! When “failure” inevitably ensues, self-blame is highly likely (“It must be my fault—and just look at all those perfect examples of other girls I see all the time on Instagram”). Rumination—the constant replay of such “failure”—lies close behind, reinforcing a sense of personal flaw. And then, learned helplessness—the phenomenon uncovered half a century ago by psychologist Martin Seligman—is a common result. Dogs in psychological experiments, first unable to avoid punishing shock when they try to move away but later removed from their shackles, typically remain in place, unable to comprehend that there is a way out. These dogs’ learned helplessness is a metaphor for the triple-bind-related tendency for girls and young women to simply stop trying.

Let’s get back to the third prong, the pressure to be sexual all the time. Overfocus on physical appearance erodes girls’ schoolwork, given their intense concentration on body image at the expense of engaging core mental resources for the task at hand. Sexual objectification and obsession with looks even inhibit girls’ engagement in social action. 

Another consequence of the attempt to meet impossible expectations, and the resultant pressure to do the impossible, is a lack of sleep. Poor sleep impairs not just general memory but also the ability to recall and experience positive emotions, as my University of California, Berkeley, colleague Matt Walker has convincingly shown. 

Families may play an inadvertent role here. With college competition at an all-time high, parents may come to value their daughters as academic commodities rather than loving yet struggling individuals. And sound research reveals that shared mealtimes, conversations about real-life struggles, and promotion of prosocial values are vital for mental health. But families focused on success at all costs often sacrifice these practices. An especially pernicious result is that too many girls believe that they must live up to the ideals of a false self, based on the impossible messages of societal expectations. How can anyone attain a true self without an outward focus on what’s going on in the world and without the trial and error of discovering one’s true calling? 

All girls are not created equal as the teen years emerge. If a girl attains adolescence with risk factors such as early ADHD or learning problems, or with a genetic predisposition to depression and anxiety, the risk for despair and self-destruction rises ever higher. My own long-term study of girls with ADHD, following up into adulthood, reveals alarmingly high rates of such outcomes, which also include high risks for unplanned pregnancy and being victimized by sexual assault.

When initially elaborated fourteen years ago, information about the triple bind was grounded in science, analysis of cultural trends, and testimony of focus groups. The predictions were dire. Yet in retrospect, I had no idea just how dire. The current situation has transcended my worst fears. 

Without a crystal ball, I couldn’t have foreseen the lasting consequences of the economic downturn of 2008 and 2009 or of the political upheavals of the following decade, including Occupy Wall Street, Black Lives Matter protests in 2014 and 2020, and responses to climate change. Likewise, I didn’t predict the COVID-19 pandemic, during which youth rates of academic achievement and mental wellness plummeted. Even as we emerge from mandated lockdowns into the current uncertain landscape, these trends have not let up.

From another angle: Adult rates of mental health issues, which rose precipitously during the initial year of the COVID-19 pandemic, had receded back to “baseline” by 2022 and 2023. But youth rates, particularly for girls, have shown no signs of lowering.     

Above all, I didn’t fully anticipate the past decade’s oncoming and continuing social-media explosion, which has spread like a firestorm. This is a poignant analogy given today’s uncontrolled, lethal blazes, but I choose this term in full awareness.  

In the world of psychology, core debates still rage: Does social media use serve as a cause of or trigger for mental health issues? Or do those teens with preexisting anxiety, depression, and perceived social rejection gravitate toward overuse? Is it some combination?

Finally, clarity is emerging. The review by Jean Twenge, Jonathan Haidt, and colleagues provides a clear—and devastating—conclusion. Even with adjustment for prior levels of psychological concerns, the ill effects of social media on mental health outcomes are negligible for boys but substantial for girls. 

At just the time—prepuberty, puberty and the start of middle school—when girls need real-life guidance and role models to form lasting values, the pull of social media is subjugating far too many to cyberbullying, “ghosting,” unrealistic social comparisons with supposedly “perfect” peers, and frank falsehoods. Social media use can be helpful, but mainly for those girls and young women who already have a viable in-person social network. For those without such contacts, reliance on social media too often leads straight down a rabbit hole. 

Don’t get me wrong: Boys certainly don’t have it easy. Many commentators decry the difficulties of forming a viable male identity these days. And far more remains to be learned about the effects of discrimination and societal rejection on youth who hold non-conforming gender identities. Yet we ignore the current—and soaring—female mental health crisis at our peril. 

There is some good news. Stigma toward depression has finally turned a corner in the United States. The main driver of such enhanced social acceptance is people under thirty. Young people place high value on authenticity, shifting American values. In addition, disclosures by celebrities and athletes regarding stress and mental health struggles have become mainstream. 

But access to evidence-based mental health treatment for teens is abysmal, virtually absent in rural areas and with huge waitlists in urban centers. I hasten to point out that stigma toward psychotic conditions and substance use has worsened over the last decade. At best, progress is uneven. 

Beyond the availability of services, we need to think about prevention, by examining our personal and societal values, school systems, and plans for the kinds of lives we want our daughters to lead. Clearly, social media will not disappear, but we cannot allow the next generation of women to live exclusively in the fantasy (or horror) world of vicious self-judgment, transitory “friends,” and insidious lies.

Back to Barbie: I wonder whether her newly advanced agendas and values would have earned over one billion dollars at the box office this past summer were she a “plain Jane”? I highly doubt it. 

In short, the triple bind lives on, with physical looks remaining high atop the list of “qualifications” for a female voice or a female success story.  

To lift girls out of the current mental health abyss, it will take the massive effort of removing the suffocating, sexualizing, and impossible expectations that remain all too present. Instead, let’s teach critical thinking, let’s not have every high-school and college course require a letter grade, let’s encourage exploration (meaning that you don’t have to be perfect at everything you do!), and let’s promote real social engagement rather than the dark mirror of obsessive screen time. The future of half our population—in fact, the future for all of us—depends on it.

Stephen P. Hinshaw is Distinguished Professor of Psychology at the University of California, Berkeley, and Professor of Psychiatry and Behavioral Sciences at the University of California, San Francisco. His work focuses on developmental psychopathology, clinical interventions with children and adolescents (particularly mechanisms underlying therapeutic change), and mental illness stigma.