Rethinking Mastectomies
Viewing mastectomy as a loss or diminishment of health makes little sense when you consider the lifetime risk of breast cancer is a whopping 1 in 8.
by Emry Cohen, MD
Boobs. Am I right?
From Venus of Urbino to Phoebe Cates in 'Fast Times at Ridgemont High', we as a society have always been obsessed with breasts. However, over the past several years, some of the most virulent online discussions about breasts have been about the breasts that were surgically removed. Angelina Jolie made headlines in 2013 when she elected to undergo a double mastectomy after finding out that she carried the BRCA1 gene. More recently, Elliot Page infuriated transphobes by proudly showcasing his top surgery scars (and shredded, sexy physique). Gender affirming mastectomies in general have become an increasing source of outrage on twitter.
While conservatives will mourn the breasts of an almost-certainly happier trans person, it does bring up the question of why we place so much importance on breasts to begin with? Looking past the impact breasts have culturally on sexuality and attractiveness, they still have only one biological function, which is to produce and secrete milk for infants. Aside from breastfeeding, the only time we in the medical community really discuss breasts from a non-aesthetic perspective is when it comes to cancer.
About 1 in 8 cisgender women will develop breast cancer in their lifetime. (I use cisgender here because there is currently a lack of data on cancer rates for trans men and women) In cases of genetic predispositions, specifically BRCA1/2, that risk can increase to a whopping 70% lifetime risk of cancer. Breast cancer is the second leading cause of cancer death in women, per the American Cancer Society, and the chance that a woman will die from breast cancer is about 1 in 40 (about 2.5%). On a list of likely ways to die, this would place breast cancer higher than guns and motor vehicle accidents combined. So, if the risks are so high, why don’t we approve of someone removing their breasts, or at the very least view it as a net positive for a person’s health and longevity?
This is already the case for some patients. For those with BRCA1/2 mutations, the National Comprehensive Cancer Network recommends offering risk-reducing bilateral mastectomy. In several studies, risk-reducing or prophylactic bilateral mastectomy decreased the incidence of breast cancer by 90 percent or more in those at risk of hereditary breast cancer. Furthermore, in one study that included over 2400 patients with a known BRCA1/2 mutation, no patients developed breast cancer following mastectomy (0 of 247 women), whereas 98 of 1372 women (7 percent) who did not undergo surgery did.
For cancer patients without BRCA1/2 mutations, the decision to perform a bilateral mastectomy usually occurs after discovering unilateral breast cancer. While contralateral prophylactic mastectomies (CPMs) have not been shown to improve breast cancer-specific survival or overall survival when compared to breast-conserving therapy, it has been shown to improve mortality when compared to unilateral mastectomy alone. Additionally, personal satisfaction following a CPM has been high, with one survey of 583 patients finding that 83 percent of women were satisfied with the CPM 10 years after the operation, with 90% stating that they would undergo the procedure again. While these aren’t nearly as high as the rates of satisfaction following gender-affirming mastectomies, it’s certainly high enough to show that patients who choose to go forward with mastectomies generally feel they’ve made the right decision.
That being said, many cis women did report adverse changes in body image including reduced feelings of femininity, sexuality and sexual satisfaction, and self-esteem. In one study, 42% of participants stated that their sense of sexuality was worse than expected, and 31% felt that their self-consciousness about their appearance was also worse than expected. Cis women like having breasts, understandably.
So with all these studies out of the way, what does this all have to do with trans people and mastectomies? My answer is that we need to change the way we think about health and wellness when it comes to having breasts versus removing them. While there are always risks associated with surgery, we need to also understand that there are risks in not having surgery as well, including the risks of cancer or worsening gender dysphoria and depression. We need to stop associating mastectomies with losing, whether than is in regards to a ‘loss’ in the ‘battle’ against cancer or a ‘loss’ in the potential to breastfeed, and begin to look at them as a marker of resilience, strength, and survival. A healthy body is not synonymous with a cisgender body, and having breasts is not a marker of increased healthiness. But, most importantly, we need to let people make choices for their bodies and mind our own business.
Emry Cohen is a trans physician with a passion for transgender healthcare and patient advocacy. As a prior collegiate athlete and Navy veteran, they offer a unique perspective on many of the challenges facing the trans community.