Studie; de mulige psykologiske konsekvenser af en mastektomi-operation (Og et par andre links)

Jeg vil gerne dele nogle sider, der går i dybden med, hvad man kan risikere i forbindelse med at få foretaget et mastektomi. Det er ikke nemt at vænne sig til sin nye krop, og det kan måske hjælpe at læse lidt om andre, og om, at det er naturligt, det man går igennem, selvom det ikke er nem læsning.


Psychological Problems Derived from Mastectomy: A Qualitative Study


Research Article
Psychological Problems Derived from Mastectomy: A Qualitative Study
José Manuel García Arroyo1 and María Luisa Domínguez López2

1Department of Psychiatry, Faculty of Medicine, University of Seville, 41004 Seville, Spain
2Mental Health Center, 21700 La Palma del Condado, Huelva, Spain

Received 29 September 2010; Revised 20 January 2011; Accepted 8 March 2011

Academic Editor: C. H. Yip

Copyright © 2011 José Manuel García Arroyo and María Luisa Domínguez López. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Advances in treatment of breast cancer have not avoided using mastectomy in all cases, and when this happens, we are dealing with a woman who is suffering from psychological problems. In order to study this issue we have carried out a research with the collaboration of The Andalusian Association of Women with Mastectomies (AMAMA) in Seville, which provided us with a sample of 46 mastectomized women. The objective of this study is to analyze in depth the psychological reaction of women to mastectomy through its different stages from diagnosis to surgical treatment. We chose a cualitative method so as to explore the subjective components of psicologycal respons. As a result, we found in studied women: (a) The “fracture” of the “corporal imaginary” related to the disappearance of a valuable organ, linked to the feeling of loss of personal attractiveness, low self-esteem and avoidance of social relationships. (b) The problem with “femininity” has been linked to the issue of “desirability”, something innate in the “feminine position”. (c) Many of them keep in mind the idea of mutilation, as a “hole” which is impossible to integrate. (d) Finally, we demonstrate how certain features of personality made them especially vulnerable to the explained phenomena.
1. Introduction

Breast cancer is the most common malignant tumour in women, but nowadays there has been a great progress in its early detection and treatment, improving the diagnosis of the disease [1]. In this sense, the practice of the conservative surgery tends to be done, and it contradicts the defending ideas which asserted that “we had to remove as much as we could.” Consequently, there has been a reduction in the amount of these traumatic operations which took place with the only purpose of saving lives.

Despite these technical advances, mastectomy continues to be practiced, and several authors assert [2] that there is 40% of breast cancer cases in which it is still done. This is due to various reasons (size or position of the tumour, anticipating a bad cosmetic result, small breast, multifocal tumour, a woman’s request, etc.). Although this operation may be done, sometimes an immediate reconstructive surgery of the breast is performed. This technique, becoming more and more popular in recent years [2, 3], tries to preserve the breast with its natural appearance in affected women. In order to achieve that, some resources and coordination in medical teams are necessary, what unfortunately is not always the case.

We sometimes witness situations in which these favourable conditions are not given, and we are in the presence of a woman with a lack of her breast who shows psychological disorders that can be noticeable [4–11]. Barcia [12] stated that “mastectomy causes more trauma than the cancer illness itself,” hence the need to deal in depth with this issue in order to promote a reasonable psychotherapeutic treatment for this women [13].

In this study, we intend to analyze the psychological issues affecting a mastectomised woman, particularly those due to the lack of her breast and how the subjectivity of this woman assimilates this event, involving various aspects (aesthetic, related to femininity, relational, etc.), since the breast is not just a gland that receives hormonal influences, but an area that has caught a lot of attention in our culture for being part of the “female body image” and has an indisputable erogenous value to both the affected person and her couple.

We next lay out the difficulties of the current study.(a)It seems frivolous to deal with this issue in the presence of such a serious disease, where the most important thing is to save a life. Hitherto, this has been the only concern of the doctors, who have shown little interest in the matter of the feelings of women.(b)Such study should include several psychological components somehow uncomfortable to talk about, such as the eroticism in women, femininity, the mechanisms of male-female attraction, and autoeroticism.(c)New conceptual tools are needed because psychology and traditional psychopathology focus mainly on the conscious aspects (or cognitive), and they lack elements to approach this kind of experiences.

Here we also develop a previous research in which we coined the term “Sexualised Body Schema” (SBS) [14, 15] in 1991, in an intend to give an account of a series of strictly feminine reactions.
2. Material and Methods

The data of the research comes from a sample of 46 mastectomised women belonging to Andalusian Association of Mastectomised Women (AMAMA). Ethics approval was obtained from the institution, and they participated voluntarily. They were middle-aged, middle class, and both working and nonworking women. The researchers performance took place in the doctor’s office at the Department of Psychiatry of the Faculty of Medicine in Seville. Interviewers were all doctors.

The method consists in a series of scheduled interviews in which the role of the interviewer is to facilitate the free speech in women making possible the unrestricted communication of their illness experience at its different stages. To achieve this aim the researchers have to listen and write down carefully whatever the woman says, and anything that may disturb or misunderstand the compilation of these statements must be put aside (psychological or psychiatric theories, personal beliefs, worries, allusions to the body, value judgments, etc.). By doing so, we get a spontaneous verbal material not influenced by the observer, and, as a result, the recorded sentences come to be isomorphic with what happens in woman’s “inner” when they express the experienced distress regarding their breast operation.

The analysis we propose is complex because of the multiple psychological components of these experiences in which each woman discovers a particular vision of the problem. So we must take into account the following special feature of this verbal material.(a)This verbal material consists in expressions which do not normally occur in the context of these women’s daily lives, because of a clear censorship on these issues for many reasons (avoid worrying the family, maintain an image of strength, avoid being rejected, etc.). Since the interviews were set up in a noncritical context, away from “social censorship,” these contents were revealed.(b)The most interesting statements that give an account of the suffering of these women and the affective aspects of their experience did not appear when expected, for example, when asking them a direct question on some issue, cause of a defense mechanisms that led them to leave those experiences behind and go away from those in which they had felt vulnerable. But in the course of free speech, these experiences were reported when the defense vanished, what justified our method. We will quote some of them here textually.(c)While the investigation progressed, both the women and the researchers benefited from the verbal material in two ways: first the analysis of women experiences became more and more concise and detailed since the verbal expressions helped them to name, put in order, and clarify their experiences which were initially confused enough to overwhelm them. Miller [16] describes this phenomenon as “significantization” and letting the women felt relaxed and less stressed. Second, the interviewer was able to obtain a much higher quality speech in describing women feelings.(d)The interviewed women were able to bring to mind circumstances that had been apparently forgotten but showed by the emotional vivacity deployed in the interviews. The verbalization of many of these facts was accompanied by honest emotional expressions, making the doctor’s office a suitable context for the emotional relief (catharsis).

As we stated in a previous work, you must consider classifying the patients speech into “useful statements” and “useless statements” [17]. The latter are generally related to stereotypes (to make a good impression, avoid giving an image of weakness, repeat sentences heard before in a social context, etc.). For this reason we had to make specific tactical interviews in which women were reminded that they were not going to be judged or criticised at no time and that they could express themselves openly and unrestrictedly, making sincere verbalizations that had a greater interest for us.

We are not using quantitative methods to deal with these patients (scales, surveys, questionnaires, etc.). We do not think it is appropriate for the following reasons: (1st) questionnaire works as a distraction, since it forces the person to focus on it instead of her own particular feelings losing both the time and the verbal material that give an account of the problems, (2nd) the experiences to be reported do have a qualitative rather than quantitative value [18, 19], and (3rd) what you get from clinical scales (anxiety, depression, obsessions, etc.) is often what is expected without reaching a new knowledge (e.g., it is obvious that women with breast cancer may suffer from anxiety, what is easily demonstrable with high score in anxiety scale). Therefore, we consider that the use of these methods is a difficulty more than a help, in this type of research [17].
3. Results

In the early stages of the disease acute emotional reactions are produced due to the women’s attempt to adapt themselves to the new situation [20]. Later, when the surgical wounds heal and acute experiences are relieved, specific attitudes of the mastectomised women emerge, being more organised and having firm positions. These are developed in a gradual way and are related to the experiences of the body which has been altered by the ablation. On the following paragraphs we will give an account of these assertions.
3.1. The Fracture of the “Imaginary Body”

The breast is part of the female “body image,” being appreciated from the erogenous (alo-/autoerotic) point of view, which is often the expression of her own worth and power. Such limits may be seen in the interviews, in whose space many different retrospective attitudes about the image of this anatomic area (she is proud of her breast, she hides or disguises it, wants to show them in order to receive a praise, makes her feel confident, it is related to shame, etc.) are recorded. Hence, we have included it in the Sexual Body Schema (SBS) (14.15) not just for producing erotic sensations but for the value the woman gives it and, eventually, gives to herself because of its possession.

Mastectomy, as a breast removal, involves the loss of this worthy image, which provokes the fracture of the “corporal imaginary” (a discontinuity in the SBS), which is not observed in the surgical treatment of other female tumours. Therefore, after surgery, there is a fall in value (or erotic value) in two ways.

(a)   In relation to herself, the loss of the breast is experienced by women as an attack to the body image worrying about aesthetic features from that moment, which provokes that she does not feel beautiful: “When I see myself, I do not feel I have any charm, and this is a huge problem for me. I try to accept it, but I cannot.” Then it is not strange that she avoids looking at the mirror, which is a reference to the personal charm that no longer exists: “My appearance was like a circus clown, I felt sorry for myself,” and also avoids all those situations where she has to expose her body to the gaze of others (beaches, pools, gyms, etc.), in a way to hide herself, what we take as a “nonexhibitionist” attitude: “I used to walk naked around the house, but when I was operated I did not do it anymore”; “I enjoyed going to the nudist colony, I took pleasure in the feeling of getting into the water and swim naked, now I’m ashamed of that and I’ve stopped doing it.” The latter is understood as a way of not wanting to face a “mirror” in other people, fearing to receive a negative image from them.

At the same time, the loss of courage related to a single part of the “body image” is transmitted to the complete self-image and also to the whole personality, showing then a characteristic chain of thought: “my breast is not worthy” → “my body is not worthy” → “I’m not worthy.” The following sentences of patients testify this: “I used to see positive things on me, but not now, it seems I’m discovering more and more imperfections in my body”; “I’m no longer worthy as a person, I consider myself a complete failure”; “The truth is that I’m no longer good for anything, I’m a wreck.” We identify a generalization here which expands to the “whole” person, having internal connections established between different groups of representations in the same organization of the ego [21].

This leads to a fall in the self-esteem (“non-self-esteemed” feelings) that drive the woman not to like herself or even to reject herself, leading her to an attitude of introversion, inward-looking, shyness, insecurity, confinement, and/or social inhibition, which did not exist before the problem or at least were not so emphasised. We can even talk about feelings of inferiority: “I hate the way I am, because I do not feel like the other women, I’m not complete,” “I feel I’m not worthy and I do not know how to explain it,” “When I’m with my friends I become a shy person since I feel I’m inferior”; “I do not understand how this can make such an influence on me, since it not only stop me in intimacy with my sentimental couple, but also with the visitors who come home and I’m speechless when I’m with them, as though I had no words and could not express myself. This had not happened to me before.” Such feelings can be compensated by developing activities that previously were lack of interest, studying, working, reading, embellishing, and so forth: “I’ve started to study and I feel better now. I did not think I could do it, but here I am, the disease has brought me something good.” Many of these women find in these reactions a way to evade themselves and avoid thinking about their problems. More disturbing was those patients who had “reaction formations” which brought them to appear egoist and arrogant: “I’ve faced all this with a lot of integrity and I have proved to myself many times that I can deal with any problem;” in these circumstances having a subsequent collapse is not uncommon [22].

(b)   In relation to others, what happens to the woman herself is reflected in her surrounding environment; that is, her body appearance may now be described through the manifestations, statements, or opinions from those around her, especially her couple, family, or friends, so she is more sensitive to any sign of rejection or disdain, perceiving any verbal or gestural expression of others as an affront. This makes her vigilant and show, quite often, a little bit dysphoric or irritating reactions.

These women try to hide the loss of a breast, having to deal with filling a bra or prosthesis since they are afraid others may discover their physical absence and also they see any glance as an attack to a zealously guarded privacy. They feel uncomfortable with people’s curiosity about their physical condition and, especially, if they look insistently at the lost breast, feeling easily intimidated. Exaggerated interpretations abound here, and it is not easy to determine what is true and what is a figment of her imagination when they perceive rejection in place of esteem in gestures of others.

It is not uncommon in this context, the presence of phobic symptoms associated with social contact [23, 24]. Then they experience an extreme fear to rejection, which may lead them to refuse to return to their jobs after the period of recovery. Some of them kept in secret both the disease and surgery, and it was difficult for them to show their feelings: “I have not told anyone what happened to me. My husband, my mother and my daughters were the only ones who knew about my problem.” In such a case, the living circumstances are a matter of shame and women show a tendency to stay at home, having no desire to go to organizations or support groups, due to the fact that others can find out about what happens: “I suffer from low self-esteem and I spend more time at home.” Isolation and inactivity contribute to the problem, as they have more time to think about the situation of disability and the problems with people around them, what increased false interpretations of simple comments.

In some cases we recorded non-delusional self-references when they went out with the thought that they were being observed or they thought others saw them as an “oddball.” It is as if the other (magically) could detect the missing breast with his eyes despite having the body covered: “When I went out I felt everyone was looking at me, I felt naked in front of a people’s jury,” “It seemed like my prosthesis moved constantly and everybody was waiting for the next move.”

For the mastectomised woman, the relationship with her partner is essential. In fact the latter is involved in her own thoughts, so that if she does not value herself neither does her partner: “If I hate myself, how do you think I’ll be likeable to my husband?” Hence, they are quite sensitive in the relationship, and their partners do not know how to treat them and are afraid to do something to disturb, damage, or influence them in some way. These women are alert over the behaviour of men and are afraid of being rejected; this happens even after leaving the hospital: “I was afraid of not being able to attract him and that complicated everything. Then, he reacted very well and he did not give importance to it at all, as if nothing had changed”; “The fact of not having a breast made me lose spontaneity when I was with my husband.” They can even interpret as a sign of rejection or disdain the fact that he does not take the lead in the physical contacts.

For these reasons, it is reasonable that these women have a loss of sexual desire, often suffering a deterioration in their relationships; this can be related to the fact that they are ashamed of their damaged body image: “Seeing myself like that, ugly! I spent a long time without having sexual relationships.” Most women were reluctant to show their partner the surgical wound: “I had sex with my husband wearing a shirt and a bra. I could not allow him to see me so. I did not like me.”

In case of single women they were afraid of meeting a man and the idea of telling him about their problem specially at the moment of facing her naked body: “If I met someone else, how could I say I’ve lost a breast? How and when could I be undressed in front of him? It’s a problem.”

The “corporal imaginary” can also be broken by other changes which take place after the surgery and which are related to the absence of the breast, such as the following: the swelling of the arm caused by the lymphedema, which provokes brachial asymmetry: “it was a living hell for me to look at myself in the mirror and see my swollen arm and the lack of my breast,” and the alopecia that follows the chemotherapy, may be even more feared than the removal of the breast because it is impossible to hide. However, we found women who are shaved and did not mind showing bald pates or they faced the problem with more serenity after thinking about it for a while. The capillary prosthesis gives no ideal solution because it also caused problem in their relationship with frequent self-references: “People looked at me when I went down the street, I could not stand it and came back to my home quickly”; “I felt people had changed their perception of me”; “I thought they had realised that I was wearing a wig, because when I was talking they did not look into my eyes, but to my forehead.” In addition, wigs cause a special fear at the prospect of flying away or moving, the binomial intervening concealment/unveiling (to the gaze of others). The loss of eyebrows and eyelashes make the problem more difficult because they think her face is losing its definition.

(c) Increase in weight and the swelling as a result of the inactivity due to the fatigue and fluid retention as an after-effect of medicines, also produces a rejection of the new image.
3.2. The Problem of “Femininity” in the Mastectomised Woman

We have witnessed how the patients associate the lack of the breast with a loss of “femininity” without knowing what is going on exactly. We verified how their discursive approaches to the problem were clearly expressive of discomfort: “I looked at my breast and I thought: you’re not such a woman”; “It takes your femininity away. People say: The important thing is you overcome the disease, but I said to the doctor “please, do not remove my breast””; “I stopped feeling like a woman, something had disappeared. I needed to have something in that part.”

There is a constant loss of desire in these women, often attributed to the treatments (e.g., hormonal), but we detected in the interviews that there were numerous aspects which had to do with their “femininity” so after recognize this issue her desire improved on.

We determined that this decrease in the libido is related to the fact that the woman does not feel themselves to be attractive once the breast is removed (being bald, with no eyebrows, with no eyelashes, and more weight). She is defaced, she has stopped being beautiful, and she does not feel enough capacity for seducing: “How can you think we may have a relationship when I’m such a frump?”

We refer here to something which is essential for women as a part of the “femininity”: the issue of “desirability,” meaning the fact of whether she is desired or not. The desire does not work in the same way in the “female position” and the “male” one because in case of a woman the basic principle of being desired/desirable is needed: “if I’m desirable, then I’ll feel desire” or “I desire him because he desires me.”

These psychological events are altered in the mastectomised woman because, if she does not think her body is attractive, it will be difficult for her to be able to provoke the desire in a man: “I do not think I look pretty anymore and that’s why I have no desire to be with him”; “Something was missing on me, I had lost all my sensuality”; “I always felt very proud of my breast, I used to go out without a bra. It was horrible when I had my breast removed. At first I could not believe it and then I did not feel pretty, I thought it was impossible any man liked to be with me, not even my own partner”; “The breast is very important for men, I do not know if it has to do with culture or education. When men meet a woman they use to look at her breast.”

They may even feel, in association with the other gender, that they are in a position of deception or fake: “I was walking down the street and several men were looking at my breast, I thought I was wearing the prosthesis. A man looks at two boobs as it’s feminine”; “They look at you but you know they’re looking something inexistent; it’s a lie and you feel bad.”

Despite that their sentimental partners do not often show a lack of desire for them and still consider them attractive, the machinery seems to be broken: “I know perfectly well that he supports me and he says his feelings has not changed, but I cannot believe it, really.”

Therefore, “being female” means to many women paying a special attention to their body (to take care of themselves, to dress themselves up, to get themselves ready, etc.) to make it desirable, and also involving a man in all that process to make him “a prey of their many charms.” In this sense, it is thought that to lose a breast is the equivalent to lose a part of their “femininity,” and, what is more, some of them feel like they lose their own identity: “I said, I’m not the same anymore”; “With this, doctors steal your own personality.”

We must add that they also have to change their clothes so as to be able to hide the lack of their breast or the prosthesis, so they cannot use freely low-cut neck clothes, tight or transparent: “I had to find another type of clothing that was very different from my previous style. It’s very hard”, “I did not feel feminine because I had to wear a bra which looked like my grandmother’s. Mastectomy limits yourself when wearing your underwear.”

This change of clothing prevents them from seducing by showing their body shapes, including the cleavage or the intermammary sulcus, both of them being a powerful incentive to attract the gaze (and the desire) of a man: “I feel I’m a less flirtatious woman because I have always loved to wear low-cut neck clothes and miniskirts.”

Interestingly when the breast reconstruction has been successful and they were satisfied with the results, they started to feel feminine again: “Now I have that shape, I know that’s not my breast, but I can already dress as a female and I do not have to wear an orthopaedic bra”; “I have an expander and it has provoked a turn of the screw in my life.” “I have more desire to wear a low-cut neck shirt or to crouch at any time. Before the reconstruction when I crouched I saw a hole. I am much happier.” As a matter of fact, many authors have agreed in asserting that one of the reasons to have a breast reconstruction is to have the freedom to use different types of clothes [25–31].
3.3. Mutilation or “the Real” of the Body

Although the operation took place some time ago, many patients still had in their minds the issue of mutilation. This one belongs not to the “body image” (already discussed) but to a psychological dimension which Lacan [32] called “the Real” of the body to refer to a hole impossible to be integrated into the psyche. Indeed, any organic disease or corporal disorder must be integrated into the psyche through a process of symbolization or “significantization” [16] to keep mental stability.

The phenomena related to this dimension are shown from the early stages of the operation, although they can decrease, they never disappear completely. In the early stages we observed the fear of the patients when they looked at the mirror or when they touched that part of their body, especially when they were cleaning them up, doing it in a special way (with their eyes closed, in the dark, etc.) since they could not face the postoperation modifications. This is a way of refusing to be aware of the mutilation which is considerd as a defense from “the Real.”

What we have here is the horror or the fear of the impressive presence of a deformed body, on which it is impossible to articulate a word, which makes the woman feel speechless. That is the reason why the modern medicine tries to avoid, by all means, this terrible event, by developing ways to reconstruct the breast so that its absence is not exposed: “It was a great relief for me when I checked my breasts were still in their place after the operation. I thanked God because that awful situation had already gone.”

Some women may avoid this confrontation during a long time and when they finally face it they receive a strong impact: “I was not prepared to perceive the scar in the mirror until several weeks after the surgery. Although my doctor had explained to me what he had done during the operation and, when I did it, I was paralyzed by shock. There was a missing part on me”; “The image I found out in the mirror caused me a great disappointment, I could not see it. I thought life was very hard for women,” “I looked at myself in the mirror and started to cry”; “It took me six months to look at myself in the mirror, although I saw many images on the Internet. At the end I was able do it and I cannot explain how I felt.”

It is not uncommon to display depersonalization experiences: “I did not know who I was, I did not recognize myself,” “I thought I’d never be the same anymore. I felt weird,” “it was an enigma to me where I was or who I was.”

All these experiences often turn into sexual refuse, “asexuality,” or “aversion to sex.”

We must not ignore that some secondary effects of the treatments may also be unacceptable beyond the mere aesthetics (e.g., The swelling of the arm can cause many limitations, chemotherapy causes nausea and fatigue, etc.)
3.4. Particularly Problematic Cases

The psychological elaboration of mastectomised woman is not always performed favourably, and we have already mentioned that her personality is essential concerning this matter [20]. Therefore, those who have more difficulties and who may be more affected by the disease are those who dedicate too much time and energy to take care of their body in order to preserve their physical appearance. They are also people who avoid enlightening other longer-lasting qualities than the physical ones. An intense dedication to the body care takes away a valuable time which could be used for other activities, thereby losing the opportunity to acquire representational material from other sources.

We refer to women who (a) take all their self-esteem from corporal values as well as physical attractiveness, while they seek and live looking for the attention of those who live around them, (b) describe their breast as a very important factor of the sexual desire (desirability), and, above all, (c) have too high expectation of ideal body. It seems clear that an uncompleted body image is produced in mastectomy and a woman with these (hysteriform) characteristics is unable to assimilate since it differs dramatically from what we might call the “ideal sexualised body schema” (ISBS).
4. Argument and Conclusion

In the preceding pages we have strived to study the women affected by breast cancer, a field in which advances are becoming larger and larger every day, so that the early detection, the change in treatment guidelines, and the possibility of reconstruction have changed the outline of this medical issue. But the particular circumstances of each case provoke that not all the affected women can benefit from breast reconstruction techniques keeping a normal body appearance. Many of them lose the breast, what leads them to psychological problems [8, 10, 11, 33, 34]. So they should be supported by a mental health professional skilled in these matters.

Once the mastectomy has been produced, the woman suffers too much due to the physical change she has experienced, although this psychological pain can sometimes be hidden behind another such as the fear of disease and its possible reappearance, but this does not mean it is not present. Halsted, the founder of breast surgery, focused on the issue of saving the lives of the patients, leaving aside the “body image.” In this sense he wrote the following: “The disability is irrelevant in comparison to the life of the patient. In addition, these patients are old, they have an average of nearly 55 years.” These claims are now meaningless.

At first, the mastectomised woman shows a fracture in the “corporal imaginary,” that is, in the mental image of the body that everyone has, which is directly linked to intersubjectivity. Then, the self-image depends on how the others perceive it and vice versa. These interactions were already suspected by Sartre [35] and developed by Schilder [36] and Lacan [37], being the latter who related them to narcissism. As a consequence, the “body image” is inextricably linked to the self-appraisal.

The breast, in this situation, constitutes itself an essential erotic part that gives value to the woman. It is understandable that the removal of such a worthy part for her leads to the idea of stopping be desirable. This is something that affects, in a greater or lesser extent, all the women who pass through this situation. They avoid, from that moment, any situation which reveals its “imaginary incompleteness,” hiding it from other people and also from themselves. The lack of value of a body part, representationally, is widespread to the rest of the person. It is then that the fall of self-esteem takes place leading to introversion and social inhibition. The feeling of inferiority has a rather unique development here, since it breaks with the particular competition which leads them to think “I’m better than you”; now, by contrast, that cannot be said anymore. In that moment we witness the Adlerian compensations, which need not be considered pathological but an excess of the opposite may occur, in which case the woman may show her arrogance and immoderation: “I can deal with everything,” “nothing can stop me,” and so forth.

This broken “corporal imaginary” is given, mostly, in the emotional-sexual field, as it is in privacy, where they are fully examined. The possibility of rejection here is felt in depth. Hence, they become very sensitive to the behaviour of their couples. But these, taking our experience as an example, tend to be careful and keep on behaving as they used to do despite the change. They declare frequently that they do not mind the consequences the operation has had on their bodies. It is not weird that some surgeons, presuming the magnitude of the problem, recommend their patients to have sex as soon as possible.

It is not strange that mastectomy discusses the matter of “femininity” and it should be treated adequately, as almost all the interviewed women understand the removal as an attack to their femininity. In order to understand the problem, it is necessary to get into the field of “masculinity-femininity” and “the games of attraction between men and women.” We discovered then that the “femininity” or “the female position” is associated with the disposition of the body of the woman based on the attractiveness it has for a man. Its function is to become attractive as well as awaken the desire of him, an aspect which we have named “desirability” in this paper. This phenomenon does not occur when there is a missing breast and she feels disfigured, and the femininity weakens. The comfort that comes when they see their couples, tireless and faithful, do not seem to have lost the desire, while they are expecting to detect any kind of reluctance on them.

Obviously, a series of behaviours are intended to praise and enhance the physical through the mending and clothing in order to get the “desirability.” Logically thinking, the clothing worn by the mastectomised woman does not necessarily tie with such behaviour, by altering the position of the women. The interviewed women complain that doctors “do not put in the shoes of the women” and that may be true in some cases, since it is advisable to scrutinize the experiences we have described to do it.

The quality of the previous sentimental relationship clearly influences the existing communication, particularly, this entire journey, so that, if it is a good relationship, we will consider it a positive case. We have seen that, in the frequent periods of high emotion, if the communication leaves a lot to be desired, any act or omission is received with much more power and impact.

One aspect that we do not want to leave out, perhaps one of the most dramatic, is the one that has to do with the problem of mutilation, which lies in “the Real” of the body [32]. It is something impossible to integrate into the psychic life and that occurs in the hospital in many ways, being the most common is to avoid a direct conflict with the mirror or any other situation which shows them that “body fracture.” It is common that, in later times, a part of the phenomenon still remains (e.g., feeling disgust, repulsion, or shivers).

For all the explained reasons, not only the woman has to make a physical effort to recover from a sick body, which often leaves her exhausted, but also she must make an extra mental work to prepare herself to all the adverse events described above. These are not always easy to assume, especially in the cases where the patient depends too much on her body, uses her image in her job, has a lack of independency since she only exists when other people look and/or admire her, and she is at the beck and call of powerful “physical ideals” that make her think in achieving a “perfect body” impossible to reach.

Therefore, the patient has to try to fight herself as Baudrillard insists in one of his famous texts that “The body has become the most beautiful object of consumption,” to develop new personal skills that lead the woman to another state with which she can feel less disconcerted.



Keeping Your Self-Esteem After a Mastectomy


Keeping Your Self-Esteem After a Mastectomy

Breast cancer surgery can do damage to your self-esteem. Here are some ways to feel better about yourself and your body following a mastectomy.

Even though it’s an important weapon in the fight against breast cancer, a mastectomy can take a serious emotional toll on a woman and even affect the way she looks at herself.

The loss of a woman’s breasts to cancer can affect her self-esteem, her sex drive, and just how she feels about herself as a woman.

But although it may take some getting used to and a lot of communication with her partner, a woman battling breast cancer can learn to love her post-mastectomy body and feel just as womanly and sexy as she did before breast cancer treatment.

After Mastectomy: How Many Women Feel

Women should understand early on that a mastectomy will affect them mentally almost as much as it will physically and that they should begin exploring therapies to help them cope with the emotional effects of a mastectomy even before their breast cancer surgery.

“A mastectomy can lead to a distorted self image, pain, and lymphedema [swelling due to fluid build-up after lymph node removal],” says Virginia Kaklamani, MD, an oncologist at Northwestern Memorial Hospital in Chicago and an assistant professor of medicine at the Feinberg School of Medicine at Northwestern University. “Consultations with plastic surgeons can definitely help, as well as seeing a psychologist prior to the surgery.”

Even if a woman knows it’s the right thing, agreeing to a mastectomy as part of breast cancer treatment can be a difficult choice to make.

“When I had to make up my mind about getting a mastectomy, it was hard,” says Carol Knizek, a two-time breast cancer survivor who was first diagnosed in 2004. “I was the only one that could make the hard choice. It was either a mastectomy or partial mastectomy on my right breast.”

Knizek opted for a full mastectomy. “When I had my surgery, I wanted my doctor to do the mastectomy and put in my expander on the same day,” she explains. An expander is used to prepare the breast area for reconstruction by slowly stretching the area and making room for an implant. “I did not want to face myself with only one breast,” Knizek says. “Today, I am happy with the decision that I made.”

How to Cope After a Mastectomy

Keep a positive attitude. To help deal with the loss of your breast or breasts, it’s important to focus on the positive.

“I coped pretty well with the loss of my right breast,” Knizek says. “To keep myself sane, I thought of the bright side of the picture: I was going to get a perky breast, what I always wanted. The loss of my breast has not affected my self-image; actually, it has made it better.”

Talk with your partner. Many women may worry about their sexual relationships after a mastectomy — and may wonder if others will still find them attractive. Women also may miss the sensitivity and pleasure derived from touching their nipples and breasts. Talk with your partner and share your concerns and fears. You will probably discover that there are many characteristics beyond your breasts that make you attractive and womanly to your partner.

A mastectomy for breast cancer will not change a woman’s ability to enjoy sex physically, but it can make her feel a little self-conscious. A woman who is shy about intimacy after a mastectomy may prefer to have sex in a position that doesn’t require her partner to be on top — where her missing breasts are more obvious. Once again, communication with your partner can be very helpful in maintaining a healthy, happy sex life after breast cancer.

Consider breast reconstruction or a breast prosthesis. To help feel more like themselves and improve self-esteem, many women — like Knizek — opt for plastic surgery to reconstruct their breasts after mastectomy. A woman’s own breast tissue, implants, or breast expanders, or a combination of these, can be used to surgically enhance the appearance of breasts. Some women may choose to use a prosthetic breast, an artificial breast that can be worn under a bra to give the appearance of a natural breast.

Do things that make you feel healthy and good about yourself. Figure out what helps you feel good about yourself, and stick to that regimen.

“I use food as my medicine to stay healthy,” Knizek says. “I became a partial vegetarian. I do not consume sugar, preservatives, or chemicals anymore. I watch everything that I put in my mouth.”

She adds: “I stay physically healthy by exercising and doing tai chi to calm my nerves. Of course I stay very positive about everything! Actually, at 42 years old, I look better now than when I was in my twenties. I enjoy life more and try new things.”

Bottom line: Although a mastectomy can change your feelings about yourself and your body, it’s important to remember that you’re worthy of love and attention — both from yourself and others. By staying positive and surrounding yourself with a good support system, you can undergo a mastectomy with your self-esteem intact.


Impact of Breast Cancer Surgery on the Self-esteem and Sexual Life of Female Patients

(Den her kan jeg ikke skrive ind her, så klik på link 🙂 )


Improving Your Self-Esteem after Mastectomy


Improving Your Self-Esteem after Mastectomy

breast reconstructionA mastectomy affects you not only physically, but also mentally and emotionally. Many women feel like a vital part of them has been taken away, and their self-esteem suffers as a result. If these feelings aren’t resolved, they can lead to depression and other issues. It’s important that if they surface, you recognize them and know you can find help.

Focus on the positive.

While the surgery itself may not be a positive thing, focusing on being optimistic helps your self-esteem. You may decide on breast reconstruction and feel excited about having new breasts, or you may be heartened by the fact that you’re now a breast cancer survivor and can move forward with your life. Often, mastectomy patients find that the smallest things, such as a drive in the mountains or a sunrise, bring them joy.

Allow yourself to grieve.

You’ve had a loss, and it’s likely to provoke the same feelings of grief as losing a loved one. You may feel denial or anger, which is perfectly normal. Allow yourself to experience those feelings instead of minimizing them or holding them inside. If you feel the need for a grief counselor, ask your doctor or religious professional for a referral. A hospice bereavement counselor may also be a good choice.

Talk it out before, during, and after.

Whether you feel relief that the cancer is gone, grief over losing a part of your body, or hesitation in allowing your partner to see you right after your mastectomy, talk it out with someone you trust. Many women confide in their partners first, while others may turn to a family member, fellow breast cancer survivor, or therapist.

Find someone you feel comfortable with, and don’t be afraid to express yourself. The more you bring out in the open, the better you’ll feel.

Consider breast reconstruction as soon as possible.

Many patients look at natural breast reconstruction as their chance to finally have the breasts they’ve always wanted. They become very involved in learning what the surgery entails and what their options are. In fact, reconstruction often improves our patients’ self-esteem because their new breasts signal a new beginning, which is exciting and empowering.

In fact, our happiest patients are those who choose to have reconstruction at the same time as mastectomy, which reduces self-esteem issues.

Treat yourself.

This is the time to celebrate the amazing, unique woman you are. Be kind to yourself, and treat yourself to what you desire as often as you can. Travel, go shopping, and pursue those dreams.

If you’re a survivor, what advice can you give?


God aften derude 🙂


Flat Chested – The Movie

Ved et tilfælde faldt jeg over denne film.

Jeg kender den ikke i forvejen – den er en smule speciel (men, det er jo heller ikke et “nemt emne at behandle”)  Men giv den en chance – den bliver bedre halvvejs ind i filmen. De kunne sagtens have “gået dybere”, men der er ikke mange film på området, så jeg siger ja tak med kyshånd til enhver.

Jeg vil i hvert fald gerne dele den.


Her er dokumentaren bag, den kan måske være god at se først, sådan lidt baggrundsviden:






Og her er filmen så:




Lidt inspireret af filmen deler jeg et par links jeg også har fundet. Jeg tænkte ikke selv på det med at “sige farvel” til mine bryster inden jeg fik foretaget dobbelt mastektomi operationen, men det giver god mening, synes jeg. Jeg har selv tænkt på at skrive et brev til dem bagefter – selv til min livmoder og æggestokke. Men det er stadig undervejs. Måske det kunne hjælpe andre. Synes idéen fra filmen er virkelig sød også; At få lavet en afstøbning af brysterne.


Her er listen fra filmen ligeså:

1.Name Your Breasts

2. Get a Breast Facial

3. Buy a Farewell Outfit

4. Photograph Your Breasts

5. Make and Paint a Plaster Cast(Mold) of Breasts

6. Visit a BRCA Support Group

7. Write Them A Letter

8. Let The World Say Goodbye


Og et par links:


3 Ways to Say Goodbye to Your Breasts Before a Mastectomy


3 Ways to Say Goodbye to Your Breasts Before a Mastectomy

Perhaps there is nothing more emotionally trying for a woman than learning that the cost of the breast cancer she has will cost her her breasts. Knowing that this distinctive and defining part of her body will be removed forever can be completely overwhelming. Many women have shared that the emotions they feel when facing mastectomy range from depression and sadness to joy and a sense of freedom knowing that this is a step in ridding her body of cancer.

Related: What Are My Breast Reconstruction Options in Phoenix 

Because there is so much feeling and emotion that accompanies a mastectomy, some women have found that finding a way to say goodbye to their breasts helps them cope with the situation better. Here are a few ideas of how to say goodbye to your breasts:

1. Throw a Party

As weird as it might seem to celebrate just before a moment of significant loss, some women have found it very empowering to have a send off party for their breasts. Rather than dwelling on the negative aspect of losing your breasts, this can be a defining moment that allows you to feel strength and courage for taking the future of your health into your own hands. A party for your breasts really turns into a celebration of you as a person, your life and your determination to defeat cancer.

2. Write a Letter

Another way of saying goodbye to your breasts is to write them a letter. This allows you to document and record the many feelings you may be having. It’s incredible how emotionally liberating it can be to write your thoughts and feelings down. Write down memories you have your breasts, from the development stage to the first time you used them to feed your child. Experts in psychiatry say that being able to write a goodbye letter to breasts has an overall positive impact on your ability to handle the emotions of losing them to a mastectomy.

Here is a sample goodbye letter if you need some ideas:

3. Boudoir Photo Shoot

A sexy photo shoot of you showing off your breasts and body is a great way to celebrate yourself while capturing a final memory with your breasts. Many women find that a boudoir photo shoot is something every woman should do regardless of their breast cancer gene. It helps to instill confidence and self-esteem in a moment of despair.

Once your mastectomy is complete, talk to Dr. Richard J. Brown about the breast reconstruction services he offers and has helped so many other women with. Reconstruction can restore a sense of wholeness and helps patients continue on with their lives. Call 480-947-2455 to set up your initial consultation.





Og her et slags “farvel-brev”, lidt som jeg selv havde i tankerne:

A Goodbye Letter To My Boobs

A Goodbye Letter To My Boobs

by Eden on April 6, 2014

In a few hours, I will be getting a preventative double mastectomy as I carry a gene that puts me at an 87% chance of developing cancer. A mastectomy would reduce my chances to less than 5%.

Here’s my farewell letter to my boobs.

Dear boobs,


But before we part, I would like to thank you.

Thanks for growing in (even if it was a little late).

Thank you for making me feel sexy and attractive.

Thank you for scoring me free drinks.

Thank you for distracting guys and sparing me awkward eye-contact with them.

Thank you for being squishy and providing a pillow for pets and past boyfriends.

Thank you nipples, for telling me when it’s cold. You guys are the more reliable than any weather app.

Thank you cleavage, for catching stray snacks. I’ll never forget that one time I dropped an M&M and you caught it so perfectly.

However, dear boobs, we must part.

I know this may sound shocking to you, as you haven’t tried to kill me yet, but I know you’re planning on it.

Like the boobs of all the women in my family, you are beautiful, but deadly. Breast cancer has taken away my mother and grandmother.

I can’t let it take me.

I need to live a long and healthy life, because my parents didn’t get that chance.

I will not fall into the pattern of my family. I will be the pioneer, I will dodge that breast cancer bullet.

You will be replaced by two implants that I hope I’ll learn to love just as much as I’ve loved you.

Actually come to think of it….this isn’t really a goodbye, more like a swap.

I will continue using my cleavage to get free stuff.

I will still be feminine and hopefully still feel sexy.

I thought saying goodbye would be a lot harder

I’ll even try not to call my new boobs “fake” because children that are adopted aren’t called “fake children”.

I guess I’m just saying goodbye to the boobs I was born with.

We’ve had a good run, but I’ve got a life to live and no room for cancer in it.

Peace out,




Jeg har linket denne artikel før, men her er den igen, for jeg finder den virkelig rørende:


An Open Letter to My Patient on the Day of Her Mastectomy

An Open Letter to My Patient on the Day of Her Mastectomy

October 16, 2013

Hello, Dear.

Today is the day. I am a member of the surgical team who will take care of you — the team that will remove your breast to treat the cancer that has tried to make a home in your body. We all have our role today, and the world would see yours to be the “patient.” I see it as something more: a powerful gift to us.

Because you remind us why we do what we do.

Today will feel sterile and scary. And I am sorry for that.

I wish there were a better way. Today we will ask you to take all your clothes off and put in their place a gown. Women before you have worn it. Women after you will wear it. Be sure to ask for warm blankets, because we always have plenty. We will ask of you your blood type, your medical history, your allergies. We will ask you to lie down in a bed that’s foreign to you. We will have to poke you so that we can start an IV.

You will meet many nurses, doctors, and hospital employees. We will write down important things for you to know. Your surgeon will see you soon. He will have to mark the breast we are having to remove today.

We will take you into the Operating Room — a room only few have seen. There will be bright lights, lots of metal, instruments that you’ve never seen, and we will be dressed in gowns, gloves, and masks. Over our masks, we hope you can see our eyes reassuring you as you go off to sleep.

Today is the day you will have to say goodbye to a part of your body, a part of yourself.

Your breast has felt the warmth of a lover’s caress, has fed your child with life-sustaining milk and connection. You have many memories stored in your breast, stories none of us today know about. Somehow I wish I knew them.

And yet. Here we are. We must do our rituals. We must scrub our arms and hands with alcohol so that we can fight off infection before we start. We don our gowns, our gloves, our masks. We must drape your body in blue.

You are exposed. And unconscious. And it must be difficult to trust. I honor you, Dear One.

My job is to help your surgeon take away the cancer. I get a bird’s eye view of the process. The surgery begins and I feel your warm skin through my gloves. I wonder what stories you already have and the ones that are yet to come.

We carefully remove your breast. It never gets easy to see or to do. You must know this. It never feels natural, it never feels cavalier. It feels sacred to me. Every. Single. Time.

I look down and see your pectoralis major — the big muscle behind your breast. A source of strength. It is beautiful and shiny. Sometimes it contracts a little bit while we work. Sometimes the muscle is bright red and young. Sometimes the muscle is faded a little. But it is always strong. I like to gently touch it withmy fingers. Because I feel your strength there.

We must send your breast away now. It officially leaves your body. I always feel an ache in my gut in that moment. There is no way for you to fully prepare for this day, Dear One.

I like to think that your body is already healing, as we close the incision we had to make.

Sewing your skin back together feels like I’m helping a little. But I know it’s actually all you doing the work. Even as you sleep, Dear One.

We will put a bandage on your incision. We will wake you up. We will tell you everything went well. But the road is just beginning for you.

I saw you today.

You are beautiful.

You are strong.

Thank you for entrusting me and my colleagues with your most intimate moments. I am honored to be a witness to this phase of your life.

Because now the healing begins. Now the grief is in full force. Now your breast is gone and in its place is a memory.

I watch you as you wake up. And I want to make it all go away. I can’t. Today your body underwent a transformation. And today our team took care of your body. I hope we took care of your heart, too.

There is nothing we can say or do to make it go away. But please know that I care. We care. Behind our masks and gowns are heavy hearts and sometimes tears.

Yours are a gift today. Because you remind us of human resilience. You remind us of strength. You remind us of trust.

I saw you today.

You are beautiful.

You are strong.

I will not forget.

—Niki, your Nurse Practitioner First Assistant on the Surgical Team



Jeg afslutter aftenens post med et citat fra filmen:


“You´re doing the smart thing.”


“If it´s so smart, shouldn´t I feel good?”


“No. Smart things usually hurts the worst”