Breast Reconstruction in Lesbians and Bisexual Women

Attitudes towards breast cancer have changed dramatically over the last 40 years. Once a disease to be hidden in secrecy and shame, breast cancer has now taken center stage in the media. However, as people have felt more empowered to speak about their experience with breast cancer, certain new expectations have emerged. There is a growing idea that breast cancer should be a ‘transformative’ experience, from which women are supposed to derive great meaning, and – crucially – emerge looking and feeling at least as beautiful and healthy as they were before. This is not always the case. Research on lesbian breast cancer survivors reveals that they experience higher stress and lower satisfaction with their care, in addition to more problems with chemotherapy side effects than their heterosexual counterparts.

In addition to the pressure on breast cancer patients to embrace a positive (and pink) survivor’s stance, they are confronted with society’s unexamined politics on breasts, gender, sexuality, beauty, and reconstructive surgery. These assumptions have not been sufficiently challenged.

A 2014 study found that just over half (56%) of women had some form of breast reconstruction after their mastectomy, although White women are more likely to choose reconstruction than Women of Color. Some feminist theorists have spoken out against the idea, prevalent among many medical professionals, that breast reconstruction, or some degree of replacement (either via surgery or prosthetics), is an essential part of recovering from breast cancer, despite the fact that it involves more surgery and, therefore, longer healing and more opportunities for complications. Reconstructive surgery also comes with its share of risks. Within five years of reconstruction, almost one third of the women need revision operations, due to issues like asymmetry or hardness and/or pain. Recent research found that many women complain of numbness in their reconstructed breasts and were not informed in advance that this could be so. Of course, for many women, the opportunity to have their breasts reconstructed is welcome. But, too often, mastectomy without reconstruction is not offered as a viable, healthy and attractive option.

Many lesbian and bisexual women have resisted the pressure they received from cultural norms and/or their healthcare providers to have reconstruction following mastectomies, rejecting the notion that the female body is only ‘functional’ or acceptable when it looks a certain way. As the authors of a recent article put it, “breast loss is typically viewed through a male-identified lens”, which positions the major issue with breast loss as the loss of something men like to look at. In one study, lesbian and bisexual women reported that their body image was shaped instead by their sexual minority identity. Some refuse reconstruction because they place a higher value on strength and functionality than on appearance. The women in that study who chose reconstruction experienced difficulties and regrets, whereas the women without reconstruction adjusted well after time. In the same study, their partners were as satisfied or as dissatisfied with the results as the patients themselves.

In another large study of lesbian breast cancer survivors, five themes emerged about their attitudes to breast reconstruction.

(1) They rejected being defined by their body image

(2) They prioritized sensation over appearance

(3) They believed that being breastless was protective against further cancer

(4) They perceived social support within their community for nonreconstruction

(5) They felt pressured by mainstream social norms to undergo reconstructive surgery

Indeed, a small movement has begun to develop of proud lesbians and bisexual women who have not had reconstruction. Some call themselves Flattoppers, or flatties and bare their bodies proudly to their partners and, sometimes, the camera. They remind us all that one does not need breasts to be a woman (and not all people with breasts are women).

Some lesbians and bisexual women choose to have reconstruction. There is not one reason that explains all choices. Age is often a factor in the decision, with younger women being more likely to choose reconstruction. Also, those who have had only one breast removed may opt for reconstruction for a sense of physical “balance”. Some find that reconstruction boosts their self-esteem. Relationship status may also play a part in decision-making.

Breast cancer holds up a mirror to society’s views of breasts and beauty. However, individual choices about reconstructive surgery following breast cancer are entirely one’s own to make. There is no ‘right’ answer. If you are a lesbian or bisexual breast cancer patient, be aware that the options offered to you will often have been framed through a hetero-normative lens. It is well worth making your own decisions on the topic of reconstructive surgery, based on YOUR life, YOUR body, and YOUR values. Do what is right for you. There are an infinite number of ways to be beautiful, sexy, and female.

by Helen Fleming and liz margolies, LCSW