Abstract

Breast cancer surgery will always be necessary as it is a solid tumor. Due to the local advancement of the disease, some cases may require a mastectomy, i.e., the complete removal of the breast. To mitigate the bodily changes, breast reconstruction offers a possibility for local repair and an alternative to what is socially considered as a +reestablished body. This essay is based on a brief search in scientific databases linking breast reconstruction and social representations. We found a possible gap in the problematization of what a normal, repaired, reconstructed body would be and what the subjective forces would be that interfere in a woman’s decision to resort to what are known as reparative surgeries. By questioning the different views on what constitutes a healthy body, we draw on Foucault, Butler, and Le Breton for a broader understanding of the concepts of corporeality.

Keywords:
Breast Cancer; Breast Reconstruction; Corporeality; Social Representations

Initial considerations

Breast cancer is the most common malignant disease in women in Brazil and worldwide, excluding non-melanoma tumors (Inca, 2022INCA - Instituto Nacional do Câncer (INCA). Dados e números sobre câncer de mama: Relatório anual. Rio de Janeiro: Ministério da Saúde (MS), 2022.). Although it is very common for lay people to believe that cancer only occurs when there are cases of the disease in the family, this rule does not apply to the female mammary gland. Approximately nine out of 10 cases of breast cancer are considered accidental, that is, they do not involve genetic mutations inherited from the family that would justify the disease. This means that the onset of breast cancer in a woman is predominantly related to factors acquired throughout life. When we look at breast cancer in terms of gender, 99% of its incidence will be female, highlighting “being a woman” as one of the main risk factors. The main justification for cancer being so recurrent among women is, in addition to the development of the gland through hormonal stimulation, the exposure of the breasts to hormonal variations in menstrual cycles throughout reproductive life.

Given the general overview of the disease, it is understandable that we focus our efforts on adapting breast cancer treatment and rehabilitation for women, since they will be more impacted by the physical changes brought about by both the disease and the stages of the therapeutic process.

An important point, which should not be neglected, is the difference between a reconstructed breast and a repaired body. Breast reconstruction, by the very definition of the term, will encompass various surgical techniques, more or less complex, involving silicone implants and dorsal or abdominal myocutaneous flaps, with the aim of restoring the volume of the breast that was removed due to the disease. Regardless of the surgical technique, more or less invasive, the result will be a “neobreast.” A repaired body, in turn, broadens the understanding of the subjective needs of each subject. A woman with mastectomy scars can have a repaired body even without reconstruction, if she feels comfortable in doing so. Clarifying these terms that can generate semantic similarity strengthens us in the more judgment-free debate about what is or is not normal in someone’s life.

Among the phases that a woman with breast cancer will have to go through, surgery is still a moment that brings anguish to a significant portion of patients with regard to identity and possible stigmas. Losing a breast is a physical threat that dialogues with social issues, because, besides aspects related to femininity and sexual activity, the absence of the gland can cause feelings of worthlessness, shame, and loneliness.

Pereira, Gomes and Oliveira (2017PEREIRA, G. B.; GOMES, A. M. S. M.; OLIVEIRA, R. R. Impacto do tratamento do câncer de mama na autoimagem e nos relacionamentos afetivos de mulheres mastectomizadas. Life Style, [s. l.], v. 4, n. 1, p. 99-119, 2017. Disponível em: Disponível em: https://www.researchgate.net/publication/327950263_IMPACTO_DO_TRATAMENTO_DO_CANCER_DE_MAMA_NA_AUTOIMAGEM_E_NOS_RELACIONAMENTOS_AFETIVOS_DE_MULHERES_MASTECTOMIZADAS . Acesso em: 5 fev. 2023.
https://www.researchgate.net/publication... ) show us that the absence of a breast can break the unity of a woman’s body, which can lead to dissatisfaction with self-image, given that in these cases the perception of incompleteness of the body is common. Losing a breast affects a woman’s identity, as the image is linked to the construction of the ego in the face of a unified body (Lacan, as cited in Santos; Siviero; Pietrafesa, 2020SANTOS, C. B. O.; SIVIERO, I. M. P. S.; PIETRAFESA, G. A. B. A sexualidade da mulher acometida com o câncer de mama. Revista Interdisciplinar em Ciências da Saúde e Biológicas, Santo Ângelo, v. 4, n. 2, p. 15-25, 2020. DOI: 10.31512/ricsb.v4i2.97
https://doi.org/10.31512/ricsb.v4i2.97... ). Since the breast is closely related to femininity, Gonçalves, Arrais and Fernandes (2007GONÇALVES, S. R. O. S.; ARRAIS, F. M. A.; FERNANDES, A. F. C. As implicações da mastectomia no cotidiano de um grupo de mulheres. Revista da Rede de Enfermagem do Nordeste, [s. l.], v. 8, n. 2, p. 9-17, 2007. ) note that a woman who has undergone a mastectomy may come to terms with the absence of a breast, but may remain dissatisfied due to social demands for the female body perfection.

Medicine offers solutions to mitigate the absence of this part of the body through breast reconstructive plastic surgery. It is possible to reconstruct a breast with silicone implants below the pectoral muscles, with muscle and skin flaps from the back (latissimus dorsi muscle) and the lower abdomen (rectus abdominis muscle). These techniques, some more or less morbid, aim to restore the previously breast-like volume to the chest.

Although the reconstructed breast does not replace the natural one, reconstruction in women who have lost this organ is a possibility that impacts quality of life (Archangelo et al., 2017ARCHANGELO, S. C. V.; SABINO NETO, M.; VEIGA, D. F. et al. Sexuality, depression, and body image after breast reconstruction. Clinics, São Paulo, v. 74, e883, 2017. DOI: https://doi.org/10.6061/clinics/2019/e883
https://doi.org/10.6061/clinics/2019/e88... ). Breast reconstruction can have positive impacts on femininity and strengthen self-esteem through the reconstruction of body image. In view of this, quality of life can be restored, given a better acceptance of one’s own body. Finally, it is possible to observe a reduction in anxiety and depression after mastectomy (Matthews et al., 2017MATTHEWS, H.; CARROLL, N.; RENSHAW, D. et al. Predictors of satisfaction and quality of life following post - mastectomy breast reconstruction. Psychooncology, Chichester, v. 26, n. 11, p. 1860-1865, 2017. DOI: 10.1002/pon.4397
https://doi.org/10.1002/pon.4397... ). Satisfaction with aesthetic appearance can reduce psychological trauma resulting from mastectomy (Pittermann; Radtke, 2019PITTERMANN A.; RADTKE C. Psychological aspects of breast reconstruction after breast cancer. Breast Care, Basel, v. 14, n. 5, p. 298-301. DOI:10.1159/000503024, 2019.
https://doi.org/10.1159/000503024... ).

None of the reconstructive techniques are capable of recreating an organ that has been removed: there is no lactational function nor erogenous sensation in the mammary papilla (nipple). A neobreast is an area visually similar to the female breast, but without tactile sensitivity and without physiological function.

Edmonds (2010EDMONDS, A. Pretty Modern: beauty, sex, and plastic surgery in Brazil. Durham: Duke University Press, 2010.) explores the topic of plastic surgery in aspects that are more distant from the biomedical view of the procedures. In an ethnography of surgery clinics and websites, the author produced an analysis of how women show their life stories based on body modifications. In addition, Edmonds discusses the predominant models of beauty in Brazil. The author shows the relationships between culture and beauty and how the extension of market forces into human experience is formed. The culture of beauty shows changes in sexuality, which are guided by those who consume culture, psychology, and medicine. In the assumptions of the relationship between culture and the female body, it is possible to see how a woman who consumes Brazilian culture can feel worthless in the event of a mastectomy.

From the perspective of Le Breton (2003LE BRETON, D. Adeus ao corpo: antropologia e sociedade. Campinas: Papirus, 2003.), breast reconstruction can be seen as an incorporation of technoscience in which the body is repaired or rearranged in the service of ideologies that can either restore or imprison body standards. In this sense, along with the idea that reconstruction can restore the self-esteem of women who have lost their breasts, one cannot ignore the fact that, in certain cultural universes, this reconstruction meets the demands of certain aesthetics that designate the female body.

Interested in the symbolic dimension of breast reconstruction, we conducted a quick survey on the Virtual Health Library (BVS) database. In this survey, we observed that most of the publications involving breast reconstruction are in the biomedical field: surgical techniques, aesthetic results, and other graft possibilities. When searching using the descriptor “breast reconstruction,” 21,574 articles were found. When we cross-referenced this datum with descriptors that dialogue with the subjectivity of the act of reconstruction, we came across a possible theoretical gap: “breast reconstruction” and “symbolism” - 2 articles; “breast reconstruction” and “cultural approach” or “cultural aspects” or “cultural representations” or “social representations” - no articles. When searching for “breast reconstruction” and “stigma,” we found 12 articles and, when we cross-referenced it with “ethnography,” six articles have been found. The survey did not limit the year of publication, and one selected articles, theses and dissertations in the Portuguese, English and Spanish languages. We excluded duplicates and articles that did not address the subjectivity of breast reconstruction as a central theme, reaching the amount of six articles of greatest interest among the 20 found. In this small group of publications, we have chosen two to begin our discussion. The first refers to the analysis developed by Ucok (2007UCOK, O. The fashioned survivor: Institutionalized representations of women with breast cancer. Communication & Medicine, Berlim, v. 4, n. 1, p. 67-78, 2007. DOI: 10.1515/CAM.2007.008
https://doi.org/10.1515/CAM.2007.008... ), which is based on a broader ethnographic study on the transformations of the self among women, transformations that result in changes in body appearance after cancer treatment and/or surgery. This study highlights a serious challenge to a person’s identity and the suffering due to the loss of control over body appearance and self-presentation, which can be debilitating for some women. Ucok notes that, for a woman, breast reconstruction may mean the reconstruction of the self, rather than her breasts only.

The second study refers to the research carried out by Webb, Jacox and Temple-Oberle (2018WEBB, C.; JACOX, N.; TEMPLE-OBERLE, C. The Making of breasts: navigating the symbolism of breasts in women facing cancer. Plastic Surgery, Oakville, v. 27, n. 1, p. 1-5, 2018. DOI: 10.1177/2292550318800500
https://doi.org/10.1177/2292550318800500... ), who analyze tensions and ambivalence that involve breast reconstruction, indicating the need for surgeons working in the area of breast reconstruction to be aware of the cultural history that shapes the understanding of breasts. Thus, for these authors, whether a woman chooses to undergo breast reconstruction or not, the decision is not merely personal, but is deeply rooted in her culture.

Based on these studies, we intend to problematize breast reconstruction, which can involve complex decisions related to this procedure. Women undergoing the different phases of treatment may have time to process bodily losses, such as breast loss, and decide not to undergo further consultations and hospitalizations with the plastic surgery team. Farnsworth (2019FARNSWORTH L. Rejecting Stigma - embracing ‘living flat’: motivations for resisting breast reconstruction and prosthetic breasts after mastectomy. Tese (Mestrado em Ciências Sociais) - Departamento de Sociologia e Antropologia, Concordia University, Montreal,, 2019.) addresses the term “going flat” after a mastectomy. This option has become emerging in culture in the 21^st century. “Going flat” is the informal term used when a woman does not want to undergo breast reconstruction, or has her reconstruction reversed for various reasons. It has become a trend on social media in the Western world. This motivates the actions and behaviors of women who are part of this growing culture of conventional breast practices. By resisting surgeries and the use of prostheses, they reject the notion of Goffman (1981GOFFMAN E. Estigma: notas sobre a manipulação da identidade deteriorada. São Paulo: LTC, 1981.) of modified identity stigma, which could decolonize the medical industry. The female body that is not colonized, thus normalizing “flat housing” as a respected post-mastectomy option. On the other hand, some women may be eager to begin this process so that they can recognize themselves as complete subjects who have fully recovered from something.

In our research, we found an excerpt from Détrez that gave meaning to the questions that this study intends to discuss:

In order to fill gaps and/or deepen the debate related to the subject in question, our discussion aims to problematize the symbolic dimension that involves breast reconstruction. Anchored in specific literature, we will follow the path of an essay, which can be understood as an exploratory exercise on a theme or object of discussion, seeking a new way of looking at the subject (Tobar; Yalour, 2002TOBAR, F.; YALOUR, M. R. Como fazer teses em saúde pública: conselhos e ideias para formular projetos e redigir teses e informes de pesquisas. Rio de Janeiro: Fiocruz, 2002.). In this path, we adopted the strategy of formulating the following questions: (1) What does breast reconstruction present itself? (2) Who is interested in reconstructing breasts after breast cancer intervention? and (3) What theoretical bases help us understand corporealities in the context of bodily losses and their possible reparations, in breast cancer?

The presentation of breast reconstruction

Although there are social advantages in deciding to reconstruct a breast that was removed due to breast cancer, some women may not understand what this process involves at first. It is also important to note that, on the more avant-garde, upper-middle-class side, it is possible to value the “natural” appearance. In this case, mastectomy scars can be “sexy,” and baldness, something to celebrate (Ehrenreich, 2001EHRENREICH, B. Welcome to cancerland. Harper’s Magazine, Nova York, nov. 2001. Disponível em: Disponível em: https://harpers.org/archive/2001/11/welcome-to-cancerland/ . Acesso em: 22 jul. 2024.
https://harpers.org/archive/2001/11/welc... ). Comparing it to a building that can be demolished with a few seconds of well-placed dynamite explosion, anyone can understand that constructing a building is much more complex than imploding it. With due respect to extreme comparisons, the breast reconstruction process involves, on average, two to three surgeries, depending on the technique and what can be saved from the patient’s chest. In the absence of the mammary gland, one immediately imagines that a silicone implant could take its place, in a mechanism similar to that of cosmetic plastic surgery for breast augmentation. However, skin without a mammary gland is not capable of supporting an implant, thus requiring the displacement of the pectoral or back muscles-latissimus dorsi muscle-to perform this function. Another technique in reconstruction processes is using the lower part of the abdomen, in which skin and subcutaneous fat tissue are displaced to the thorax, simulating a breast without silicone, but with enormous surgical morbidity, since it also causes abdominal wall fragility and the need to use synthetic meshes to prevent hernias in the inguinal region.

Although it is not the objective of this article to describe the numerous ways to reconstruct a breast removed due to cancer, summarizing how this process is not simple will help us guide the debate about the fact that, eventually, women who are not prepared or simply do not want such interventions embark on a journey of surgeries, consultations, exams, and physical and financial expenses for body repair. Mitigating mastectomy with breast reconstruction can restore self-esteem through surgical techniques, but we must also consider the level of discomfort that the culture of beauty can impose on a woman with the absence of a breast and, therefore, she will seek reconstruction as a way to repair her subjective perceptions.

In the literature, we find texts that discuss techniques, advantages and ways to physically repair a woman who feels mutilated by mastectomy. Offering breast reconstruction is understood by the medical community as a standard of excellence in the treatment of breast cancer, and is supported by Law No. 9,656, of June 3, 1998, and by Law No. 9,797/1999, which states that women who suffer total or partial breast mutilation resulting from using a cancer treatment technique, have the right to reconstructive plastic surgery, whether immediate, when possible, or delayed, within the Brazilian Unified Health System (SUS).

Cosmetic surgery, by reconstructing the breasts, can be the answer to the desire for a new birth, as Le Breton (2003LE BRETON, D. Adeus ao corpo: antropologia e sociedade. Campinas: Papirus, 2003.) observes, which arises from the possibility of discarding an unloved body by someone who feels incomplete. In this sense, this surgery can serve the desires of people who are not sick but want to change their appearance. On the other hand, cosmetic surgery can fulfill a social role of constructing the body (submitted to the permanent design of medicine), tailored to make it more visible (Le Breton, 2003LE BRETON, D. Adeus ao corpo: antropologia e sociedade. Campinas: Papirus, 2003.).

A woman who undergoes breast reconstruction may not be fully aware that choosing this modality can impact her life in other spheres besides the physical one. Although defining “woman with breast cancer” is a broad task, we must take into account the social profile of women affected by the vulnerabilities of the labor market, such as those who do not have a formal employment relationship. In addition, women treated by the SUS need to overcome more barriers to access treatment, which can lead to more advanced locally advanced diseases and a greater need for treatments, such as mastectomy. When starting the reconstruction process, a woman who has already been absent from her social and work life due to breast cancer treatment will have to go through other periods of seclusion for new rehabilitation. Volkmer et al. (2019Volkmer, C.; Santos, E. K. A.; Erdmann, A. L. et al. Reconstrução mamária sob a ótica de mulheres submetidas à mastectomia: uma metaetnografia. Texto & Contexto Enfermagem, Florianópolis, v. 28, 2019. DOI: 10.1590/1980-265X-TCE-2016-0442
https://doi.org/10.1590/1980-265X-TCE-20... , p. 11), in their meta-ethnography, refer to “the existence” of an ambivalence of feelings regarding the expectations and results of breast reconstruction and the complexity of the process of “bouncing back.” In addition, women who had their breasts reconstructed with prostheses said they did not know how long and uncomfortable the entire process would be.

The profile of breast cancer survivors is reduced to a white, heterosexual, middle-class, thin patient with balanced torso (Carter, 2003CARTER, T. Body count: autobiographies by women living with breast cancer. Journal of Popular Culture, [s. l.], v. 36, n. 4, p. 653-668, 2003. DOI: 10.1111/1540-5931.00039
https://doi.org/10.1111/1540-5931.00039... ). In other words, it is understandable that access to medical technologies that will result in reconstruction will meet the social structures that privilege the same type of woman. This access can be seen as a certain aesthetic sense, expressing a sense of distinction (Bourdieu, 2011BOURDIEU, P. A distinção: crítica social do julgamento. Porto Alegre: Zouk, 2011.). In other words, breast reconstruction can be seen as a distinction of social class, with certain conditions of existence that differentiate it from another class.

Among the possible reasons for accessing or not new surgeries and treatments, a woman with breast cancer must have a support network to take time off work, take care of her children (which does not reaffirm that this care should be exclusively maternal) and of her own health. Chauí (2020CHAUÍ, M. O totalitarismo neoliberal. Anacronismo e Irrupción, Ciudad Autonoma de Buenos Aires, v. 10, n. 18, p. 307-328, 2020. DOI: 10.62174/aei.5434
https://doi.org/10.62174/aei.5434... ) describes the abandonment of social welfare with the advancement of neoliberal policies and the work precariousness in Brazil. Understanding the social fragility of a woman with breast cancer in the context of breast reconstruction, that is, no longer physically ill, can contribute to the refusal to undergo the procedure without a deeper reflection on the subject.

Who is interested in reconstruction?

Breast reconstruction surgery, like any other surgical procedure on the external part of the body, such as the breast, establishes a new relationship of identification with the treated area. Women who need to remove their breast completely and wish to have reconstruction, whether immediate-during cancer treatment-or delayed-after living without the organ-are informed by the health team about the risks and benefits of such decision. The aim is not to focus on mastectomy scars as exclusive symbols of a disease, since they also represent the treated area, but to discuss the expectations of a reconstruction that may be merely social if the person is unable to subjectivize the neobreast. Although the aim is to reduce the aesthetic damage caused by these techniques, it is possible that women maintain the perception of the absence of the breast and/or have a false breast. This text does not intend to deny the benefit of breast reconstruction for the self-esteem of a range of women who sought and obtained this procedure. nevertheless, when faced with a neobreast, which usually requires more than two surgeries to be completely restored, some women do not achieve this goal and may not feel restored even with cosmetic surgery.

Understanding the various social vectors that permeate the bodily losses caused by breast cancer and the desire for breast reconstruction, for whom is the presence of a breast prosthesis in body control technologies useful? How can the mechanisms of alterity interfere with a woman’s desire for reconstructive surgeries that are often more morbid than the cancer treatment itself? Questions that are apparently difficult to answer in a simple way bring the social representations and sociocultural aspects of breast reconstruction to the focus of our discussion. In other words, how can the sociocultural dimension contribute to the perception of breast reconstruction?

Last century occidental culture shows us the female breast as a symbol of beauty, motherhood, and vitality. In the scenario of a mastectomy, multiple discourses can converge in favor or against reconstruction in a process full of tension and ambivalence. A woman who accepts and wants to undergo this procedure may be motivated by the cultural representations of having breasts and what shapes her understanding of them within her social context. Given the cultural discourses regarding breasts, a woman’s choice of having breast reconstruction or not may not be a merely personal decision, but a contextualized one. Messages that communicate what can be “normal,” feminine and healthy would dialogue with the consciousness and unconsciousness of decisions (Webb; Jacox; Temple-Oberle, 2018WEBB, C.; JACOX, N.; TEMPLE-OBERLE, C. The Making of breasts: navigating the symbolism of breasts in women facing cancer. Plastic Surgery, Oakville, v. 27, n. 1, p. 1-5, 2018. DOI: 10.1177/2292550318800500
https://doi.org/10.1177/2292550318800500... ).

But, what would be considered “normal” when we talk about bodies that do not maintain the conventional standard, that is, two breasts? Canguilhem (2009CANGUILHEM, G. O normal e o patológico. 6. ed. rev. Rio de Janeiro: Forense Universitária, 2009., p. 145) shows us that what is pathological would not be the absence of a norm, but “that it tolerates no deviation from the conditions in which it is valid, incapable as it is of changing itself into another norm.” In this sense, health ceases to be limited to the absence of disease and becomes something difficult to make judgments. The author puts health and disease, normal and pathological, into perspective, making us comfortable in also admitting that a woman without breasts can be healthy within the limits in which she finds herself.

Culture in discourses promotes notions of appearance of what is “acceptable,” “desirable” and “beautiful,” even when a person is no longer sick. From this point on, Ucok (2007UCOK, O. The fashioned survivor: Institutionalized representations of women with breast cancer. Communication & Medicine, Berlim, v. 4, n. 1, p. 67-78, 2007. DOI: 10.1515/CAM.2007.008
https://doi.org/10.1515/CAM.2007.008... ) brought visual materials from women treated for breast cancer to debate the understanding of the cultural meanings of the disease. Visual models for a renewed femininity during and after cancer treatment were provided with the aim of discussing existing definitions of beauty, femininity, and gender appearances. With an emphasis on the normalization of appearance change, described as “problematic,” the images worked to restrict women’s meanings and choices as to their bodies, as well as the ways in which they can manage their bodily appearance.

A woman’s decisions in the face of bodily losses resulting from breast cancer and whether or not she needs breast reconstruction refer us to the debate by Le Breton (2007LE BRETON, D. A sociologia do corpo. Petrópolis: Vozes , 2007., p. 12) on the body: “a body that increasingly deserves the passionate attention of the social domain.” By delving deeper into the understanding of corporeality as a cultural and social phenomenon, the author advances the theme of the sociology of the body and its propagated cultural logic. In the context of breast cancer and decisions about who would benefit from reconstruction, since it departs from the concept of a normal or repaired body, we come closer to the author when we state that designating a body (when possible) immediately translates a fact of the social imaginary and we can understand the different types of societal structures.

Western culture, especially Brazilian culture, which is one that presents the higher number of consumers of aesthetic procedures, suggests that social relations may be more exclusionary for women with bodies that do not meet the standardization of having breasts. When Le Breton (2007LE BRETON, D. A sociologia do corpo. Petrópolis: Vozes , 2007., p. 7) writes that “the body is the semantic vector through which the evidence of the relationship to the world is constructed” and that “existence is first corporeal,” he elaborates the idea that existence is only possible when we have a body.

In this sense, breast reconstruction can also fulfill a social role. Plastic surgery can restore any social losses caused by mastectomy, which alters the body shape and, possibly, for some, causes the redefinition of the female body. Nevertheless, we are interested here in discussing the point at which, in the face of culture, a woman can feel repaired exclusively if she undergoes breast reconstruction. When Le Breton (2007LE BRETON, D. A sociologia do corpo. Petrópolis: Vozes , 2007.) relates social practice, body, and culture, we come closer to the hypotheses constructed previously: “At the foundation of all social practices as a privileged mediator and pivot of human presence, the body is at the intersection of all instances of culture, the point of imputation par excellence of the symbolic field” (2007, p. 31).

Broadening the debate on body repair and reconstruction, it is necessary to reflect on how biomedical discourse is deeply linked to power relations by linking breast reconstruction to the reestablishment of what would be understood as “normal.” By creating a social demand, whose assumptions of normality are symmetrical bodies, the notion of replacing something that needs to be missing for being sick emerges. This discourse reduces the space for debate about what it means to be normal, repaired, or what it means to feel incomplete or not. It involves reducing the entire health-disease process within subjectivity to a surgical procedure.

Analyzing breast cancer, mastectomy, and breast reconstruction solely within the biomedical discourse of physical reparation can reinforce the cultural oppression that impact the female body and impose subordination on women in both the public (work) and private (affective) spheres.

The understanding of the body occurs through a market relationship, in which the expectation is that it will correspond to the imperatives of social efficiency, that is, that it will be part of the productive force (Le Breton, 2011LE BRETON, D. Antropologia do corpo e modernidade. Petrópolis: Editora Vozes, 2011.). The biomedical perspective seeks the efficiency and productivity of the body, whether it is an instrument that perishes or not. Therefore, it must be submitted to medical instrumentation for repair. This context creates an understanding of the prevention of suffering and death. The body ceases to be just a physical object that performs its functions and becomes something that also carries cultural meaning.

There is no value judgment about whether or not to want breast reconstruction in the context of cancer. The debate about what it means to be normal, or rather, the lack of debate about whether it is normal to eventually not have a breast, is what presents itself as a gap within the subjectivity of the disease.

Corporeality in the context of bodily losses

Corporeality, according to Le Breton (2007LE BRETON, D. A sociologia do corpo. Petrópolis: Vozes , 2007., p. 7), is seen as a “social and cultural phenomenon, symbol matter, object of representations and imagination.” In this sense, everyday life, in many instances, is mediated by corporeality, serving as an anchor for what is seen, tasted, felt, touched, besides being the basis for meanings created by people in the world surrounding them.

In order to discuss the subjectivity of breast reconstruction in breast cancer, it is necessary to talk about the body. The breast, as a structure, in addition to being an organ, evokes the subjective dialogue of the physical changes brought about by the surgical treatment of breast cancer. This debate must go beyond biomedical issues. In this session, we intend to discuss how the literature on corporeality can help understand the changes in these women’s self and social images.

Although it is not said literally, Western society, especially Latin society, understands as a prototype of a successful woman the following: a woman with fair skin, large breasts, a curvy body, long hair, sensuality, and preserved reproductive capacity. The standardization of the female body has undergone some variations over the last few centuries.

In Europe, which was experiencing rapid economic growth and industrialization at the end of the 18^th century, it was up to institutions, through science and punitive mechanisms, to standardize bodies. In the case of health, it was up to medicine to determine what sanitation is, hospitalization for childbirth, what is or is not a healthy attitude, and how people should take care of their own bodies. Michel Foucault describes these control technologies as devices (Foucault, 1987FOUCAULT, M. Vigiar e punir: nascimento da prisão. Tradução Raquel Ramalhete. Petrópolis: Vozes, 1987.). In the case of the female body, the device of sexuality is what most affects and brings women closer to the suffering related to the stigmas of breast cancer.

A body controlled to be useful, docile and consistent with economic production cannot be mutilated, deformed, or made sick. Understanding health as a mechanism of social control attributes obligations to the female body that are incompatible with human vulnerabilities. From a cultural perspective, there is also the demand to maintain youthfulness, the absence of wrinkles, and permanent thinness.

By moving away from the Foucauldian concept and perspective on the control of bodies by a higher power, in the case of this reflection, we propose a debate closer to interpersonal relationships, in which the vectors of interference between subjects will occur in interaction, that is, in materiality. The debate on materiality is the key that takes us from Foucault to the literature of Judith Butler: there is nothing above the subconscious and the social situation. In this way, no subjectivity occurs without the materiality of the interaction provoked by interpellation (Butler, 2017BUTLER, J. A vida psíquica do poder: teorias da sujeição. Belo Horizonte: Autêntica, 2017.).

The study of the body from a Butlerian perspective can be delimited in the field of otherness. When a person looks at the other and observes themselves in their individuality, they are able to recognize themselves in this interaction. It is only possible to know who we are when we observe the other, who is different from us. This is where studies on ontology reside, which would lead us to understand the frustrations over the bodily changes caused by breast cancer.

The cultural assumption that a woman with breast cancer is a weakened, inactive, and economically unproductive subject, as she is exclusively dedicated to treating her illness, contributes to the process of ontologization (Prins; Meijer, 2022PRINS, B.; MEIJER, I. C. Como os corpos se tornam matéria: entrevista com Judith Butler. Revista Estudos Feministas, Florianópolis, v. 10, n. 1, p. 155-167, 2002. DOI: 10.1590/S0104-026X2002000100009
https://doi.org/10.1590/S0104-026X200200... ). Socially, she will be treated as someone who deserves care, less capable of fulfilling goals and duties, and also someone to whom affection may not be taken into consideration. After all, who, during cancer treatment, is going to think about emotional or sexual health? This segregation of what is expected of the behavior of a person with cancer can be expressed through the bodily changes that are exposed by the disease and treatment. When dealing with a woman without breast volume under her clothes, society projects feelings that she should have and prevents her from making possible choices and desires.

When discussing gender, Butler (1999BUTLER, J. Problemas de gênero. Feminismo e a subversão da identidade. Nova York: Routledge , 1999.) dedicates herself to thinking about the topic based on an identity that is pre-discursive and prior to social relationships. In the context of breast oncology, this context is also affected when feminine attributes are not recognized in women who have undergone mastectomy. It is not appropriate to say that this is a gender affectation, but rather a bodily affectation, that of intelligibility, which will evoke the assumptions of how we should dialogue with a sick person.

The intelligibility of bodies, from Butler’s perspective, is the coherence of gender, biological sex, and desire (Butler, 1993BUTLER, J. Bodies that matter. Nova York: Routledge, 1993.). A body that dialogues with “coherence” within these limits is socially understood as a body within normality, and which deserves affection. When discussing intelligibility in gender, the author wants to approach especially the transsexual population, more specifically the feeling of abjection that this segment receives.

The bodily intelligibility of a woman with breast cancer can be broken when she no longer presents characteristics that socially identify her as a “normal woman.” A woman usually declares that the physical attributes that characterize her as a female are not necessarily genitals, but breasts, hair, eyebrows, and body posture. It is at this point that the woman with her body modified by the disease may feel the need for some form of breast reconstruction, thus meeting the social assumptions of the “repaired body.” This social scenario can refer us to a form of body adaptation. Some women resort to breast reconstructions and others opt for different relationships, socially intelligible or not, with their bodies. Social relationships through the body will not necessarily depend on reconstruction, but we have to consider that some women, faced with the absence of a breast, may feel restored by surgery.

Le Breton (2003LE BRETON, D. Adeus ao corpo: antropologia e sociedade. Campinas: Papirus, 2003.) also reflects on personal and social relationships with bodies. The author proposes a trinomial body-subject-society, in which especially scientific practices will affect this balance. Examples such as tattoos, cosmetic plastic surgery, and surgical gender modification shift the age-old dialogue between body and soul to the shape of the body and the individual. The freedom and greater ease of manipulating the shape of the body are translated as the subject’s alter ego, which is there to satisfy their desires.

Displaced from the desires for modification or body adaptation, Le Breton’s thought emerges as a starting point for understanding part of the frustrations of women whose feminine appearance is affected by mastectomy in the treatment of breast cancer. In the modern and Western time discussed by him, the regression of bodily losses in the recognition of the subject who is socially inserted may not fit. Not only does the interaction and questioning of Butler’s thoughts seem necessary, but a personal relationship that will also be exposed socially. The altered body generates conflict in the individual and, consequently, disruption of social relations.

Final considerations

The female body is a body historically marked by surveillance, observation, medicalization, and social punishment. Observing that Brazil is the second largest country in the world regarding consumers of cosmetic plastic surgeries (Sociedade Internacional de Cirurgia Plástica, 2023SOCIEDADE INTERNACIONAL DE CIRURGIA PLÁSTICA E ESTÉTICA. A mais recente pesquisa global da ISAPS demonstra aumento significativo em cirurgias estéticas em todo o mundo. ISAPS, Mount Royal, 2023. Disponível em: Disponível em: https://www.isaps.org/media/hdmi0del/2021-global-survey-press-release-portuguese-latam.pdf . Acesso em: 22 jul. 2024.
https://www.isaps.org/media/hdmi0del/202... ), behind only the United States, opens up an opportunity for debate about how a woman is socially viewed. When this group of women is affected by the bodily changes caused by breast cancer, we can infer a greater difficulty in understanding the possible perspectives of what is-or should be-normal for each individual.

When elevating the debate on corporeality and breast cancer to medical discourse, we cite, in another work, Marilena Chauí (2014CHAUÍ, M. A ideologia da competência. São Paulo: Fundação Perseu Abramo, 2014.), who discusses the myth of the “ideology of competence.” In her book of the same name, the author problematizes the use of competence to the detriment of economic exploitation, political domination and cultural exclusion of one part of society by another. In the example of our debate, stating that any woman can benefit from breast reconstruction as a shortcut to completeness seems to us to disregard what it means to be complete. Using medical discourse to generalize losses, pains or body shapes may not be a way of fully welcoming.

By problematizing how the principles of otherness, through interpellation, create ontologized subjects through the bodily modifications due to breast cancer, we allow some women to choose to question what a satisfactory body is, in the public sphere or not, in order to move on with their own lives. The interface of studies on gender and the intelligibility of bodies, although not contextualized in breast cancer in its origin, allows the analysis of different bodies, no longer sick, as matter that still needs correction so as not to be left on the social margins. Bodies that would need to be repaired in order to adapt and feel normal. The vector that brings the demand, external to personal desire, suggesting that someone needs repair, was theorized in different ways and moments: Foucault, through the devices of control and sexuality; Butler, through the interpellation and construction of discourse; and Le Breton, through social analyses of corporeality.

Choosing to reconstruct the breast touches on subjectivity that affect the person’s intimacy, but it also dialogue with the demands of culture and society, which may not be comfortable with individual decisions. The mechanisms of otherness that can affect the decision-making power of a woman without a breast regarding her own body have to be taking into account, considering the fact that every individual is relativized within society, culture, and their personal desires. Thus, we keep the debate on body and culture broader, especially for women who want reconstruction, without denying that it is possible to remain comfortable with just the scars from the mastectomy.

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