Cancer Log 40: “Don’t you want to be normal?”
I admit it; I was shocked that those words actually came out of the surgeon’s mouth. I think I must live in a more liberal / radical bubble than I realize – I honestly couldn’t believe that she’d just said that. What doctor says that?? Wait, let me back up. You need context. I was talking to a surgeon (not my current surgeon) about my surgical options. She’d gone through the same things the oncologist had already told me – that’d they’d be recommending what’s chemotherapy before surgery, to hopefully shrink the tumor. If it shrunk a lot, they might be able to do a lumpectomy, rather than a mastectomy. (Maybe on one side, maybe both.) If not, not – but she didn’t want me to worry, because whatever they did, they’d send me to a plastic surgeon afterwards, and I could have breasts again. That’s when I said, “Well, I might not bother.” That’s when she started to…freak out, is the only way I can think to describe it. She was visibly startled, and became a little agitated. “Don’t worry – insurance will cover it.” No, I understand that. I’m just thinking that breasts have been a nuisance for much of my life, and I might be ready to be done with them. That’s when she broke out the line, “Don’t you want to be normal?” And I honestly didn’t know what to say for a moment, because what doctor says something like that? We talked about it a little more – argued, really. I found myself angry, and after a bit, a little tearful, though I fought it back and tried to sound as calm and rational as I could. But underneath, I was simmering. I had enough to worry about with the cancer, didn’t I? Did I really have to argue with my doctor, and a female doctor at that, about whether or not I’d have the option of not reconstructing my breasts? If mastectomy were the decision, then essentially, I’d be getting a boob job afterwards, having inserts put in, to bring my breasts up to a C cup. It would be added months of surgical recovery, more somewhat painful procedures. Surely that last should be optional? Up to the patient’s discretion? I’d already had this argument once before. I grew up with large breasts – a 5’0” girl who developed DD cups at age 9. Yes, pity me. Seriously. They were pretty horribly annoying in a variety of ways until I finally started really dating in college. Then I discovered that breasts had their good points, and that was fine, although I still would’ve preferred them smaller. I would’ve had a reduction then, but I wanted children, and I wanted to breast feed, so fine – I held out until age 38. Finally, I’d had my kids, I was done nursing (which had caused my breasts to balloon up a few more sizes, joy), and I went in to get a reduction – and the (male) surgeon wouldn’t let me go down to a B cup. He said that it was because it’d be removing too much tissue, that it was less safe, and I didn’t know enough to argue with him. In retrospect, I’m pretty sure that aesthetic considerations were a major factor for him – when you read up on the topic online, you’ll see a lot of conversation among plastic surgeons about creating an ideal and balanced form, which mostly seems to translate to a C cup. Ideal for whom? Various athletes ask online whether reduction to an A is possible, and in general, the surgeons were very dismissive of the possibility. Psych evalautions were often mentioned. In the room, in that moment, I was afraid that if I pushed too hard, my surgeon might decide I wasn’t a good candidate for reduction surgery after all; all the power was in his hands. So I went along with him, and agreed to go down to just a C cup, and while it wasn’t everything I’d wanted (I still had to wear a bra much of the time, especially while exercising), the smaller size was such a vast improvement that I was mostly content. So here I was, facing breast surgery again, and the only good side was that maybe I could be rid of these, if I wanted. I didn’t actually want to get rid of my nipples – they’d been good to me for many years. But if they had to go, then I wasn’t sure I had any interest in fake breasts. I already knew, from the reduction surgery, that skin sensation was greatly reduced in the areas of the surgery – the area under my breasts is somewhat numb, years after the reduction, by comparison to the rest of my skin. Did I really want two numb objects attached to my chest? For what? (I do think Kevin and Jed would miss my breasts, but I am lucky in my men, and I am quite sure that after a period of adjustment, they would be just fine with the lack of them. They’d adapt, and we’d still have great sex. I know not every woman is so lucky.) So we argued, and I made my case, somewhat incoherently. Then she said, “But you’re a professor; you’ll be standing in front of a classroom, and you’ll want to look pretty.” I didn’t know what to say to that either. By that point, I mostly wanted to just get out of the room, so I said something appeasing about how maybe I’d just go down to a B. And she still looked confused, but said that yes, B was probably an option, if that’s what I really wanted. And we wrapped up, and she let me go. And listen – I do understand where her assumptions were coming from. For one thing, in this society, a woman’s worth is often wrapped up in how well she conforms to conventional aesthetics. It’s probably true that if I went breastless, there would be some social consequences, maybe even career consequences. I might have a harder time finding dresses cut to fit me, I imagine. And it would likely be a handicap on the dating scene, were I to launch myself out there again. A bigger problem is internal self-esteem. Insurance covers breast reconstruction after mastectomies, which is interesting, because it is, certainly, cosmetic surgery in some sense. Insurance doesn’t generally cover regular boob jobs. But there’s a strong political argument to be made that for many women, most women, possibly even for me, having breasts is a huge part of our self image, and that without them, we might well find ourselves horribly depressed, feel less female, etc. I’m not arguing against the reconstruction, for those who want them, and that probably is most women. It might even be me. (An exercise for the reader: apply all of this, including the insurance aspect, to transgender people.) I didn’t really mind her assumptions. But the fact that the doctor would actually argue with me about it – that made me furious. I called a doctor friend and ranted at her in the car on the way home, and I am not normally a ranting type. More than anything, this is a plea to any medical professionals who might be listening. Please, advise us of our options. Make your recommendations, and if you happen to know that 99.9% of women who have gone through breast cancer and mastectomies feel much more emotionally stable if they choose to do reconstruction, then that is absolutely a valuable piece of information for your patients to have, and do bring it to the table. But listen to your patient, let their needs and desires guide your advice and advocacy. Try, as best you can, not to let current social prejudices inform your practice of medicine. First, do no harm. And for the love of all the gods and little fishes, PLEASE do not ever ask a patient, “But don’t you want to be normal?”
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