Plus, medical experts weigh in on the emotional effects of this life-saving surgery.
In an iconic scene in Judy Blume’s legendary young adult novel, Are You There God? It’s Me, Margaret, Margaret and her three best friends practice an exercise to make their boobs grow. The group thrust their arms in unison as they chant, “I must, I must, I must increase my bust.” The “hack” (which you may have tried alone in your room at age 13) is intended to push them into young adulthood faster so that they can begin all the typical rites of passage: Bras, boys, periods, and other facets of womanhood. As soon as their bust sizes miraculously grow, they expect their lives to begin.
Though most of us no longer mimic Judy Blume characters, we all — to some degree — equate boobs to femininity. So what does it mean to lose one’s breasts? When women decide to undergo mastectomies, not only are they tasked with facing breast cancer head-on, but they’ve also got to unpack how much of their femininity, sexuality, and self-esteem was stored in those bags of tissue.
To better understand how mastectomies impact femininity, sexuality, and body image, Katie Couric Media spoke to three women who’ve undergone different procedures to prevent or beat breast cancer. We also spoke to George Sledge, MD, chief medical officer for Caris Life Sciences, who provided his perspective as a medical oncologist. Monique C. James, MD, assistant clinical director in the Department of Psychiatry and Behavioral Sciences at Memorial Sloan Kettering Cancer Center, reflected upon her experiences counseling patients who have undergone mastectomies. Together, they explain the spectrum of physical and emotional experiences that can accompany this type of life-changing surgery.
“What have I done to myself?”
Melanie DiSalvo, 37, had atypical ductal hyperplasia — a precursor to breast cancer. “Basically, your cells are beginning to change. They’re not cancer yet, but they’re not normal.” A mastectomy suited her lifestyle better than a flurry of regular MRIs, mammograms, and even lumpectomies. “I was working full-time,” she says. “I have my own consultancy company…I’m all over the place. I couldn’t commit to having to come back every six months and do scans.”
She wasn’t required to have a mastectomy; in fact, no one technically is. According to Dr. Sledge, “A patient always has the right to choose.” He points out that there are “rare cases where mastectomy is the best option,” but that control over one’s body is key to feeling happy, whole, and confident. “A lot of patients’ comfort has to do with patient autonomy. If a woman chooses breast preservation or chooses a mastectomy, in general, most women are happy with the decision so long as they’re the one who gets to make [it]. The women who are least satisfied have been told by someone, ‘You have to do this.’”
So, in line with her own preferences, at age 35, DiSalvo opted for reconstruction; she chose to have bigger breasts — because why not? “If I’m going through all of this, why not do a little bit of an upgrade?” she points out.
That said, reconstruction isn’t the same thing as a boob job. “It’s not a purely cosmetic or plastic procedure. They have to take out tissue to either treat a tumor or to prevent a tumor, which makes it different,” says Dr. James.
And that difference can vary widely. In DiSalvo’s case, she struggled with a lack of necessary skin: “When you get a boob job, there’s [typically] stuff to hold that implant in place. When you have a mastectomy…in my case, I only had eight millimeters of skin [left], so they needed to build [the skin] up to hold the implant in place.”
As a result, DiSalvo chose reconstruction via expanders — “they’re deflated implants with a metal apparatus around them, and they’re sewn down to your chest. Every two weeks, you go to your doctor until you reach the size you want. There’s a port to fill them up a little bit more each time.” The visual effect isn’t exactly the stuff self-confidence is made of: “The expanders don’t come expanded; they come deflated. So your boobs are really saggy, dangly, and not nice to look at.” Looking in the mirror might be difficult for a long time — for DiSalvo, the expansion process took three months.
In terms of body image, DiSalvo says that her lowest point came directly after the mastectomy: “When I went to the bathroom, my robe fell off. I saw everything. You’ve got tubes coming out of you. The drains that are draining out the blood. And I thought, I’m a creature. What have I done to myself?”
This visceral reaction is common, according to Dr. James: “[Many patients feel] ‘I am a whole person with a whole bunch of body parts. And now you’re taking one away.’” That may sound simple — the point of a mastectomy is to remove parts of oneself — but that disassociation hits hard when you’re in it. “One thing that I was really taken with is how many of my patients said that they’ll be in the shower and they’ll wipe [their breasts] as fast as they can to get out of it.”
For DiSalvo, it specifically hurt that undergarments intended for mastectomy recovery were so frumpy and sexless: “For a mastectomy, you need a front closure bra with compression. And there are a lot of really ugly options out there.” When DiSalvo perused the so-called “cuter” options, she was disgusted: They looked like my first training bra from Limited Too: This is not feminine. This is for kids.”
Typically, when an adult woman buys underwear, she has the option to feel sexy and expressive. DiSalvo was being denied access to that experience: “I saw how society and the medical world viewed women with mastectomies. In my eyes, [it seemed like society was saying,] ‘You deserve these ugly things.’”
Anyone who’s purchased a bra knows the power of that piece of fabric: “Lingerie isn’t necessarily for other people; it’s for yourself. When you wear nice lingerie, you stand a little taller, you feel a little more confident. It’s something that you do for you.” Being forced to purchase drab bras diminished her confidence. When she realized her bra options would be severely limited, it made her wonder, “What else am I not realizing that I’m giving up?” Though she’d done extensive research on her decision, the moment triggered underlying emotional turmoil.
Post-recovery, DiSalvo started a line of post-mastectomy lingerie called nu:titty. Think breathable, front-closure bras made of sleek, eye-catching black lace. One detail was especially significant to her: “Having matching underwear was important because lingerie [is often offered] as a matching set. Whether you want it or not, that’s your business. But that’s traditionally how it’s purchased. I wanted to emulate that ‘normal’ experience.”DiSalvo feels the freedom to feel pretty or sexual can serve as a reminder of all that a person has survived and their hopes for the future.
“I felt like a shell of a human being.”
Simona Lazinsk, now 46, had grade three breast cancer — “a very highly aggressive form.” At first, she wasn’t exactly loud and proud about her diagnosis. “When I was going through it, I never told anyone. It was [during] Covid. There were so many people who didn’t see me lose my hair and didn’t see what I looked like.” Her friends and colleagues also didn’t see her process the decision to have a double mastectomy at age 41.
“It was a really scary decision,” Lazinsk recalls. “As a woman, our breasts are the thing that society has [said] is our femininity.” When she pictured that absence of femininity, a perfectly flat chest didn’t come to mind: “I grew up in an age where I saw old pictures of women who’d had mastectomies, and they had this hollow space in their chest. It looked caved in.”
Dr. Sledge explains that mastectomy technology has become more aesthetic over time, but confirms the photos Lazinsk saw were a harsh reality of decades past: “If one were to go back, say a half-century or so, when people spoke about mastectomy, they were talking about a radical mastectomy that involved not just breast surgery, but also removal of all of the lymph nodes, draining the breast, and removal of the pectoralis muscles on the chest wall. It was called a radical mastectomy for a reason. It was truly life-altering.”
“Over time, that’s changed,” he says. But those antiquated images made a significant impact on women like Lazinsk, who have formative memories of gravely unattractive surgery results.
And even contemporary technology can sometimes be a process. “Even though both the breast surgeon and the plastic surgeon usually work very well together to give the best aesthetic that we can,” says Dr. James, “…sometimes [they take] more tissue out. That can create a divot or a dimple. Sometimes, the impact is about, ‘I thought this would take two surgeries, now it’s taking four.’”
Despite her deep-seated fears of what the end product would look like, Lazinsk chose a mastectomy because she wanted to do everything possible to keep the disease at bay for good. After extensive research on plastic surgery, she opted for reconstruction: “During the procedure, they were able to remove all the breast tissue and put an implant in.”
You might think that immediately inserting an implant could counteract the experience of removing one’s breasts — waking up with new boobs is a dream to some. But Lazinsk says that the experience was a loss, too: “It felt like an amputation. I said [to my now husband], ‘How would you feel if someone were to remove your arms and give you prosthetics? It’s great because there’s plastic surgery, but it’s never the exact same as it was before.”
And life wasn’t the same. “Unfortunately, there was some shame that went with it,” Lazinsk says. “After I went through everything, things that we [group] femininity with — your hair, your breast — all these things, you lose [them] while you’re going through treatment. I felt like a shell of a human being. I lost my identity. I shouldn’t have felt that way, but I felt that society had put that stigma on me.” Plus, aside from looking different, she also physically felt unlike herself: “Plastic surgery is great today, but…I have no feeling in my breasts anymore.” (Aside from lack of sensation, Dr. Sledge clarifies that it’s also common to feel burning, itching, shocks, and other unusual sensations in one’s breasts or armpit after reconstruction.)
Since she no longer felt like herself, Lazinsk decided to reclaim her loss. Her method? Boldly veering toward the most hyper-feminine hobby she could find: “It motivated me to do pageants.” On the face of it, the idea of competing against a pack of conventionally gorgeous women for a crown doesn’t always inspire confidence. But Lazinsk discovered that dressing up and participating in a show affirmed her gender and femininity: “The more I did it, the more I said, ‘Hey, I can put on a dress, even with my double mastectomy, and be just as good as the girl next to me that didn’t have a double mastectomy.’ It didn’t make me less of a human being.”
Lazinsk’s body has changed, but she also won the Mrs. Florida International title in 2023 (complete with the perfect snapshot of her in a glittery gown and sash as a crown is placed atop her perfectly curled tresses). She wrote a book. She went through the process of buying a wedding dress that fit her new body. “I would tell my past self to not hold on to these stigmas that we put on ourselves,” she says.
“I never equated my breasts with being a woman.”
Years before her diagnosis, Mika Burns, now 55, watched a documentary called The What’s Underneath Project. “One of the interviews was with a woman named Gail Chovan, and she had had a double mastectomy without reconstruction.” Chovan explained that she didn’t want to revisit her trauma by dealing with implants, expanders, and a prolonged recovery. “And watching that, I said to myself, ‘If I’m ever put in that position, I’m going to make the same choice.’”
Unfortunately, Burns did end up in that position. After finding a lump in her breast at 49, she was told she had ductal carcinoma in situ — “pre-cancer, stage zero, nothing has really spread out of the ducts.” While it was early, a double mastectomy to aesthetic flat closure — which only rebuilds the shape of the chest wall — was the preventative measure she chose to eliminate the risk.
“I said I wanted a double mastectomy without reconstruction. My surgeon was quite resistant to taking both of my breasts…I knew that they had to honor my wishes. So I said, ‘I understand your point of view, but this is what I want.’ I was adamant about it. She wanted me to go see a plastic surgeon to be sure.”
Burns saw that consultation through but remained firm. “I felt a bit condescended to,” she explains. “There’s a pervasive feeling of, of course, you’re going to get reconstruction, of course, you want to have your breasts back.” (As Dr. Sledge said, telling a woman what to do with her body, unsurprisingly, doesn’t yield positive results.)
Only after her mastectomy did Burns find out she actually had aggressive breast cancer that had spread to her lymph nodes. Regardless of diagnosis, however, she was confident in her choice.
Breast cancer doesn’t discriminate; patients and survivors make up a diverse group. So, of course, the women who fight this disease aren’t a monolith. Some women simply won’t want treatment if they can’t keep their breasts. Dr. Sledge says, “I’ve had patients, for instance, who [have] said, ‘I can’t live if I have a mastectomy. My breasts are really important to me, and if I can’t have breast preservation, then I don’t want to have any therapy at all; I’d rather die.’”
Burns, however, lies on the other end of the spectrum. She didn’t process the mastectomy as a challenge to her gender or sexuality.
“There’s the mentality [that], to hold onto your womanhood and your femininity, you need to have breasts,” Burns says. “I never felt that way. That was never something that crossed my mind. I never equated my breasts with being a woman.”
It’s not as though Burns had some magical, mythical, stress-free experience. She underwent 16 rounds of chemo; her oncologist wouldn’t acknowledge or include Burns’ wife, which felt offensive; she lost friends to the disease. But she truly did not feel a loss of femininity or diminished sexuality when her breasts were removed.
“I think as a person of color,” Burns muses, “I’ve been othered my entire life. So being othered was not a concept that was foreign to me. It didn’t make me feel self-conscious because, to some extent, I’d lived my life like that. I was also a very small-breasted person, to begin with. My breasts were never the focus of attention. Losing them didn’t feel like it would be traumatic to me.”
That said, Burns says that the flat closure community isn’t some paradise where people have shed social stigma: “Even within the aesthetic flat closure community, there’s still an adherence to beauty standards. There’re still comparisons: ‘Oh, you got better results than me,’ or ‘You’re flatter than me,’ or ‘I’ve got…dog ears’ — which are extra tissue that’s often leftover after the initial surgery.”
“People in the flat community are all different shapes and sizes just due to anatomy,” she continues. “There’s a lot of stigma about that within the community, body image-wise. But also a lot of women get misgendered and are assumed to be male, and they find that very confronting and hurtful.” Breasts are no longer at stake, but old standards emerge in new ways.
By virtue of her body shape, Burns now fits this ideal of a thin person with a seamless, natural-looking, aesthetic flat closure: “It’s quite interesting to me because I’ve never actually felt like that my entire life. I never felt like I was ‘the pretty girl.’ I never felt like I stood out in that way. Now, to be in that position, it’s a little wild.”
Sexual solace
There’s no one way to emotionally recover from a mastectomy, just as there’s not one singular set of breasts. As Dr. James reminds us, though, there are many roads that will lead back to being comfortable in one’s body.
“The hope is that we can identify the things that are going to change after the surgery, like orgasm with nipple stimulation, for example, and give space to grieve. [Changes like that] need to be acknowledged.” Once they’ve addressed what they will lose, Dr. James can walk them through what they might gain. “Breast cancer survivors can get libido back [through exploration] and feel sexy again,” Dr. James says. “I actually have some patients who, in this exploration of different kinds of foreplay, actually find that their sexual intimacy experiences become more colored and dynamic in a way that they never experienced before.”
“You can have very beautiful, very good sexual experiences afterward, it will just be different,” she says. “I’ve seen it happen. Not all is lost.”
