Flat: How One Woman Reclaimed Her Body From Breast Cancer
In 2009, at age 38, Catherine was diagnosed with breast cancer. Although the cancer was only in one breast, she opted for a double mastectomy and chose not to reconstruct. She was diagnosed with breast cancer a second time a year later in 2010. During her treatment, she searched for a memoir where the narrator grappled with the reality of the disease, where she unpacked questions about reconstruction, and challenged the tacit assumptions about what women want or need to feel whole after cancer. She couldn’t find a book that filled that niche, so she wrote one.
Listen to the podcast to hear Catherine discuss:
“the male gaze” and how it informs breast reconstruction, even if the surgeon is a woman
how her queerness affected her experience with breast cancer
how her experience with breast cancer has changed how she reports on the disease
her advice to women on things they can do to help ensure that their choices about reconstruction — or not — are respected by surgeons
Catherine Guthrie is a women’s health journalist with two decades of
experience in the magazine and publishing industry. She has written for Cosmopolitan; O, The Oprah Magazine; Slate; Time; and Better Homes and Gardens, among others. She is also the author of the queer, feminist memoir, FLAT: Reclaiming My Body From Breast Cancer.
— Last updated on July 31, 2022, 10:20 PM
Jamie DePolo: Hello, everyone. I’m Jamie DePolo, senior editor at Breastcancer.org. Welcome to our podcast. Our guest today is Catherine Guthrie, a woman’s health journalist with two decades of experience in the magazine publishing industry. She has written for Cosmopolitan; O, The Oprah Magazine; Slate; Time Magazine; and Better Homes and Gardens, among others.
In 2009 at age 38, Catherine was diagnosed with breast cancer. Although the cancer was only in one breast, she opted for a double mastectomy and chose not to reconstruct. She was diagnosed with breast cancer a second time a year later in 2010. During her treatment, Catherine searched for a memoir where the narrator grappled with the reality of the disease, where she unpacked questions about reconstruction and challenged the tacit assumptions about what women want or need to feel whole after cancer. She couldn’t find a book that filled that niche, so she wrote one. Catherine’s queer feminist memoir, FLAT: Reclaiming My Body from Breast Cancer, was published this fall. Catherine, welcome to our podcast.
Catherine Guthrie: Hello. Thank you so much for having me.
Jamie DePolo: I’m very excited to talk to you today because there has been quite a bit of discussion on our boards and in questions coming in to us about “going flat,” as most folks on the boards call it. And so now you called your book FLAT “a queer feminist breast cancer memoir,” and you’ve written about how breast reconstruction is informed by the male gaze even if the surgeon is a woman, so can you talk a little bit about what you mean by reconstruction and being informed by the male gaze? What are you talking about there?
Catherine Guthrie: So what I mean by using the phrase “the male gaze” when talking about reconstruction is that the plastic surgeons I’ve interviewed for journalistic pieces I’ve written on this topic talk about how textbooks and teachers they’ve had in medical school all were written or the classes taught by men, and for men the idea of a woman without breasts is the same as a woman disfigured, and my book is about kind of pulling apart that idea and kind of countering it.
From my perspective as a woman without breasts, I don’t feel disfigured. I feel whole. I feel feminine. And yet through a male gaze, which is kind of reflective of the patriarchal system that we live in, my body would be considered disfigured, so there’s that kind of tension between the male gaze — what a man might see when he looks at my body — versus how I feel in my body, which is whole and strong and beautiful, which is my gaze, right? There’s that tension between those two things that gave rise to the book that I wrote called “FLAT".
Jamie DePolo: Talk a little bit, too. So how did that idea, that sort of the male gaze and almost I guess what I would call kind of societal pressure, it kind of…you faced a lot of pressure to reconstruct from your surgeons and other doctors. So how did you kind of overcome that pressure and get what was right for you?
Catherine Guthrie: Right. There is so much pressure to reconstruct, and like you said in the introduction, there’s this tacit assumption about what women want and what we want for our bodies. So when I met with a plastic surgeon to talk about what was going to happen with my breast and my body, he immediately told me I was not a candidate for lumpectomy.
I didn’t realize that was even a thing, but it turns out 15 percent of breast cancer patients are not candidates for lumpectomy, which as we know is the least invasive option, so of course that’s always going to be something I would gravitate toward. So within 15 minutes of my appointment with this plastic surgeon, I found out not only that I was not a candidate for lumpectomy, but he immediately then jumped to, “But don’t worry,” with this kind of you know tone of, “Don’t worry, honey,” like a pat on the head. He’s like, “Here’s what we’re going to do, we’re going to give you a single mastectomy and because of the shape of your body, the only reconstruction you can have is called a LAP flap.”
“We’re going to sever a muscle from your back, wrap it around your front, and lay it over an implant.” And of course in my mind, I was completely unprepared for this. The way he described it, I’m seeing like a steak laid over a tennis ball, and I’m thinking that’s my back muscle, you know, like that has a greater purpose in my life I think at the time than creating a buffer for an implant. And the fact that he didn’t even pause, it was really his tone was like, of course this is what you’ll do, of course you’ll sacrifice your muscle to create a facsimile of a breast. It was that moment that really unhinged me in some way because of course, in that moment this person is a surgeon.
He’s standing in front of me as an authority figure and someone on the team of people who is going to save my life from this disease, so embedded in this lifesaving treatment is this push toward heteronormative femininity. And again, that’s another big phrase, but it just means a push toward you know “normal,” what women are supposed to look like, with no pause given to ask me what I wanted, if that suited me for who I am and who I present myself to be in the world. So it was really unnerving just to have that assumption made, that of course I would sacrifice one of the biggest muscles in my back to create a full breast.
Jamie DePolo: Did the surgeon tell you why you were not a good candidate for lumpectomy? It sounds like that’s what you wanted and had perhaps done research on and had kind of mentally prepared yourself for.
Catherine Guthrie: Exactly. So this, the plastic surgeon was the fourth surgeon I saw. I did some initial search and shopping as one does, especially when one is a women’s health journalist and has the luxury of excellent health insurance. I saw three breast surgeons, all of whom said a lumpectomy looked like a perfectly reasonable thing to do, and at that point I thought okay, I want the least invasive option.
My cancer was small. We caught it early. It was stage I at that point, so minimally invasive sounded good, but none of those surgeons were the ultimate authority on kind of how to preserve some sort of cosmetic outcome. So it wasn’t until I saw the plastic surgeon — the fourth surgeon — at the place where I had decided to have the surgery done that he took a look at my breast and said, “You know what, because of the location of your lump,” which was high on the breast, he’s like, “and the size of your breast,” which was small — I had an A-cup breast — he said “those two things are incompatible with lumpectomy, because once I take the lump out of…or once the breast surgeon removes the lump from your breast, it is going to decimate your breast.”
He said, “There will be no breast left after your lumpectomy,” so that was why I was not a candidate for a lumpectomy at all. And then I also happened to have just a petite frame, so I was not a candidate for other types of reconstruction either, like flap reconstruction where they take you know tissue transfer like from the belly, a deep flap, something that just took fat and tissue. That was not an option for me. I had to do a muscle flap, ideally from the back.
Jamie DePolo: I believe, if I’m remembering correctly, you did also meet with female surgeons who seemed to have the same viewpoint, and I know you talked a little bit about how all the instructors in medical schools for plastic surgery are males, the books are written by males, so even the women surgeons it sounds like are still sort of following the societal norm of what a woman should look like. Is that fair?
Catherine Guthrie: Absolutely. I mean, we are all you know…culture is something we swim in, so we’re all fish in the barrel, right? And the culture is the water, so men, women, anywhere on the gender you know fluidity scale, we’re all in it. We can’t rise above it or pull ourselves out of it unless we consciously choose to do so, and you know I’ve referred to this in other places as you know, surgeons getting woke, so surgeons need to be awakened or woke to their unconscious bias, where they do look at women’s bodies as disfigured if they don’t have breasts, and you know, that’s understandable.
We all get it. We all grew up, you know, being told and seeing in our culture and movies and television, everywhere, that breasts are the epitome of female sexuality and desirability, so we have to kind of wake up to like that’s a cultural construct. That’s not true, but it’s something that we all understand to be true, and that shift in thinking is really important when you’re trying to help someone make these decisions around their body so that you’re not putting your own kind of implicit bias onto them in the way that you ask questions or don’t ask questions, you know, and the way that you just move on to reconstruction without hitting the pause button and asking women, “So how do you feel about the idea of reconstruction?” That’s a great first question instead of, “What kind of reconstruction do you want?” And it’s subtle, but it’s so important to just reframe, and some doctors are getting there, but it’s a real minority still.
Jamie DePolo: How did you gather the strength and you know the — I guess it is strength — to kind of stand up for yourself and say, “No, I want this, and I’m sticking with it because we’re going to talk about this a little later”? But there have been many women who go, are put under anesthesia for surgery, and wake up with something that they did not want — explicitly did not want — and I know you know about this, so were you…were you frightened? How did you sort of steel yourself to get what you wanted?
Catherine Guthrie: What I had that a lot of women don’t have is an experience with a surgery that deeply shaped and informed my body. So when I was 13 — and I write about this in my book FLAT — I had surgery for scoliosis, where the surgeons fused my lower spine and ultimately you know as an adult, I found out that surgery was unnecessary.
At the time I was 13. I go in, and I trust. I hand my body over to surgeons. I mean my parents and I hand my body over to surgeons, and at 13 you can kind of decide for yourself how much agency I had in that conversation. And the surgeons were like, “It’s going to be great. We’re going to put this metal rod in your lower back. We’re going to put some screws in. It’s all going to just hold it together so you’re not going to have a curve in your spine anymore.” And I don’t even know like how to explain what happened next, but the pain was unimaginable.
The immobility was something they had not prepared me or my parents for, the long-term reality of living with this fused spine was something they never discussed with us, so having had that experience at 13 of seeing surgeons so excited to do something to my body that they thought was just going to fix it, and then doing a couple of follow-ups with me and then basically saying, ”You know what, that surgery was a success, because look how great you look now and your curve is gone, so bye-bye.” And I’ve had to live in that body for, you know, 30 years now.
And luckily I’m doing great, but I’ve learned a lot about maintaining my spine and my overall health through that experience. And so I was having déjà vu, right, when I’m sitting there listening to a surgeon say, “Honey, we know exactly how to fix this. Don’t worry, all we’re going to do is rearrange some things and then you’ll be good as new.” And of course, you know alarm bells are going off in my head, and I’m like, you know what? You’re going to have two or three follow-up appointments with me, you’re going to consider it a success, and you’re going to move on to the next patient down the road. And I’m going to be living in this body for the rest of my life without a key structural support for my back. That was just… yeah, that was…that was a real show stopper for me right there, and of course nothing gives you that sense of like confidence to stand up for yourself, nothing is greater than fear in that moment, right? I felt so much fear, my survival instincts kicked in, and I was just like, hell no, you’re not doing this. I will do anything to avoid this.
Jamie DePolo: How did your queerness affect your experience of breast cancer?
Catherine Guthrie: Yeah. I think that’s such an interesting question, and I think that’s one of the things that drove me to write the book, even though I think it’s a book that all audiences can relate to, but what’s interesting about having come out as queer a few years before I was diagnosed with breast cancer is that being a member of the queer community you are already outside of kind of what are considered the norms of you know, femininity or heterosexuality, so I had already kind of stepped off the tracks, you know what I mean?
And the other thing about being queer is it kind of is a provocation to think about things differently, to think about bodies differently, to think about your sexuality differently, to think about intimacy differently, because nothing is like the movies portray it to be, you know, that we all grew up watching the boy/girl stuff. And you know like that’s what it’s supposed to look like, and this is what sex looks like, and this is what bodies look like. And all of a sudden you’re like, wait, none of that makes sense. Let me just erase, erase, erase all of that, and then it’s like well, what does this all look like?
And at the time there wasn’t much visibility or representation in the media when I came out at age 22, so you just make it up as you go along. And so you know, I’ve been making it up as I went along for many years and the same with my partner. We’re both like, let’s just figure this out together. You know, what does this look like? What does this feel like?
And so when I was diagnosed with breast cancer and was thinking about like well, I wonder if I could just make this work without these breasts, you know, she was 100 percent supportive and she’s like you know what, honey, we’re going to figure it out because we’ve always been figuring it out, and you know I’m not going to make any assumptions about what you are or aren’t bringing to the bedroom or what you do or don’t need to be desirable to me, so it was so freeing because it was really a blank slate.
Jamie DePolo: That’s interesting too, because to me, thinking about it, most — not all, but most — I would say the majority of women diagnosed with breast cancer are older and heterosexual, and so you were kind of outside several boxes when you were diagnosed. You know, you’re a young queer woman, so was there any sort of support for you on any of those fronts? Like you know, you talk about support groups and things like that. Did those exist for you? I mean, were they helpful for you?
Catherine Guthrie: Yeah. No. You know, not only was I a young queer woman with breast cancer, but I was living in a small town in Indiana and I…and this was in 2009 and 2010. I was diagnosed twice with breast cancer, one year apart, and in small town Indiana at that point there was very little support and even less visibility. So I did not know a single person my age who had cancer, much less someone who had gone flat at my age.
I did have one neighbor who I write about extensively in the book. Lorraine is her name in the book, who had gone flat. She was about 20 years older than me, maybe 15, and she was a great role model, but I didn’t have anyone my age and that does matter. It did make it more difficult, and I struggled quite a bit to find support and representation and visibility, which is one of the other reasons why I wrote the book, just to kind of help flat women see themselves in a mainstream narrative.
Jamie DePolo: You have two decades of experience as a writer, specifically on women’s health, and you have said you did not know much about reconstruction. Why do you think that is? Is that because everybody kind of stops with cancer and figures, okay, if you have surgery to remove the cancer, you have treatments, we don’t need to talk about reconstruction? You know, why do you think that is?
Catherine Guthrie: Exactly. That’s a great question. I had written about women’s health for 20 years for primarily women’s magazines. I had written about breast cancer many times, but I never covered reconstruction or even hormone therapy or many of the realities of dealing with this disease, and I think that is because editors at women’s magazines, you know they are beholden to advertisers, and people want — editors and advertisers want — feel-good stories. They want stories with happy endings. They want rah-rah, you know, pink, happy breast cancer stories. And so without even realizing it, I as a journalist had been somewhat complicit in glossing over some of the darker and more difficult realities of this disease.
Jamie DePolo: I’m curious. In your history, have you written about metastatic disease, because that’s not a real rah-rah-happy-ending kind of story?
Catherine Guthrie: Exactly. No. I was never assigned a story about metastatic disease.
Jamie DePolo: You said you want to be pro-information, not anti-reconstruction, so what does that mean? How…is it shaping what kind of stories you decide to take? Are you pitching different stories?
Catherine Guthrie: Yes. I am absolutely pitching different stories now. I am looking for the nitty-gritty stories. I am looking for the stories that lurk in the shadows of breast cancer care that no one else is talking about, stories that shine the light on inequities or injustices or just truths that are there and yet glossed over by mainstream media. And these are truths that people with breast cancer are living with every single day, whether it’s the truth of metastatic disease and how deadly that is and how little research money is devoted to studying metastatic disease and how the number of women dying of metastatic breast cancer has not significantly decreased in more than 20 years.
There’s so much to say about that that’s not being written. There’s also a lot to say about stories like Kim Bowles, who I profiled in Cosmopolitan.com last month, who went in to go…asked her surgeon to make her flat. And right as she was being put under on the operating room table, heard her surgeon say to her, “I’m just going to leave a little extra skin in case you change your mind.”
So she woke up with skin pockets like a skin-sparing mastectomy, even though she had explicitly asked to go flat, so this paternalism and protectionism among surgeons that causes them to violate women’s bodies and go against women’s wishes is a really big problem. And that’s an important story that I’ve written recently that I wouldn’t have written, you know, before I was diagnosed.
Jamie DePolo: That reminds me, I just recently spoke to a woman and she’s a very petite woman, and she asked her reconstructive surgeon to make her a B cup. She decided to have reconstruction, and when she woke up from surgery she had D-cup breasts, and she was outraged. Not only were they D cup, they were not…one of them was way up by her collarbone.
It was not where it was supposed to be, and she had to go through — I don’t even know — at least, I think, 8 or 10 more surgeries to get the breasts that she wanted. So you know, and that’s just anecdotal, you know, what you said was anecdotal, but I have to imagine there’s a lot more of those types of cases out there, and I can’t…I can’t even imagine how that feels. I would be so full of rage that my wishes were completely dismissed.
Catherine Guthrie: Exactly. This goes back to that idea of the male gaze that we were talking about at the very beginning of the podcast, that often male surgeons — and I won’t put it all on male surgeons, and I don’t think male surgeons are bad or you know nefarious or anything — I think it is this unconsciousness of the male gaze, this bias that we aren’t really awoken to unless we look for it. So you can imagine a surgeon, you know, who’s unconsciously kind of projecting this male gaze and desirability on his patient and remembering maybe she asked for a B cup, but of course that bias is going to tell him like, you know what, I think a D cup would be even better.
This would fit. Why wouldn’t I put this in, because of course bigger is better. That’s the kind of mentality that you get when you’re just not kind of aware of your own bias, and it’s so easy to imagine this happening. And I’m so glad you brought it up, because when I was researching the Cosmopolitan piece and talking with breast surgeons about what happened to Kim, which is women wanting to go flat but being left with extra skin in case they change their minds, I had several of the surgeons say, you know what happens even more often is women get implanted with bigger breasts than they asked for. So exactly what you are tuning into, that’s on my list of stories to do next.
Jamie DePolo: This kind of leads me to when you hear surgeons talk, reconstructive surgeons, they talk about you know reconstructing a breast. It’s a way to make a woman feel whole or feminine after breast cancer, and my immediate reaction is well, I’m thinking that whole or feminine probably means something different to every woman. I’m sure it means something different to you than it does to me, so just to kind of help us get inside your head a little bit more, what does that mean to you to be whole after this cancer experience?
Catherine Guthrie: To me what it means to be whole after my cancer experience is to feel free in my body, to feel strong, to feel confident, to feel like I can do anything today that I would have been able to do before cancer. So being whole means being free to live my life to the fullest.
Jamie DePolo: And I notice nowhere in there did you say the word “breast,” and you can be all those things and do all those things without breasts.
Catherine Guthrie: Yes and you can…I also want you to know when I said I’m not anti-reconstruction I’m pro-information, what I meant by that is very much this idea that this was the right choice for me. I don’t think it’s the right choice for everyone, and what I want to advocate for is women having all of the choices in front of them.
I always say you can’t order something if it’s not on the menu, and I want to see flat be put on the menu along with the various types of reconstruction so that women have all of the information to make the best choice possible for them, for their bodies, for the rest of their lives. So I really want to advocate for just women being free to make a solid choice for them no matter what that choice is. I will be completely thrilled with women choosing reconstruction if they’re doing it knowing that they have other options as well. It’s just more information is the best.
Jamie DePolo: Breastcancer.org wholeheartedly agrees with that. Our position is that you know every woman is unique, every case of breast cancer is unique, and every treatment and subsequent reconstruction or not is going to be unique, and everybody has to make the choice that is best for them and their situation so we are in sync with that. So I’m also curious as you’ve researched the book and gone through these experiences yourself, is there any advice you would give to women to make sure that their choices are respected? Is there specific language that you might suggest a woman uses to talk to a surgeon?
Catherine Guthrie: Yeah, that’s a great question, and it’s so difficult to answer because of course you know I’ve spoken with women who have been very clear with their surgeons and their requests have still been violated. So, but what I can say are…you know, there’s some real basic parameters, which is make sure you are explicit with what you want, especially if you want to go flat, because it’s still seen as an anomaly. So be very clear, get it in writing that you want a smooth, flat result. Talk to your surgeon about this issue around like I’ve seen people being left with extra skin or I’ve seen kind of dog ears, which is the extra skin left under the armpits. Like how do we avoid that?
Let’s just talk about what are you going to do in my surgery to keep that from happening? Another great thing to do always, always regardless of what kind of surgery you’re going to have, take someone with you so you have a witness. Record it. We all have phones in our pockets that have recording capabilities.
Ask your surgeon if you can record the conversation — not as like a got you moment that you’re going to use later in court or something, but just as a document that you can review later to make sure you were clear and the surgeon was clear, but you also have that in case something goes wrong, and just you know, trust your gut.
I’ve heard from a lot of folks that maybe the surgeon gave them a lot of pushback or the surgeon needed a lot of convincing or the surgeon sent them for a psych consult once they found out that the patient wanted to go flat. Those are all red flags that your surgeon’s not woke, that your surgeon’s not able to hear you and respect your choice. If you’re getting those flags early, heed them and get a second opinion.
Jamie DePolo: To wrap up, I kind of want to make you look at the other side. If you could say one or two things to breast surgeons, what would you say?
Catherine Guthrie: Boy, this might take a while. You know, I would just encourage breast surgeons to hold themselves accountable for their bias, to do their best to peel off kind of those…those glasses that cause them to look at women through a male gaze, to see every breast cancer patient as an individual, exactly what you just said, not as a gender, not as a cookie cutter mold that oh, she’s going to lose a breast, we have to like figure out a way to fit one back on her so she’s “whole” again because we all know…everyone who’s had cancer knows you’re never the same as you were before regardless of what shape your body takes. So let’s stop pretending that’s true and treating as you said, patients as individuals, really listening, asking thought-provoking questions, not leading questions, open-ended questions, not questions entrenched in a tacit assumption about what you think your patient wants.
Jamie DePolo: That’s all good advice. Catherine, thank you so much for joining us today. It’s been very informative. I hope the book is doing well, and I’m wondering if you’re considering a sequel or a different type of book about breast cancer.
Catherine Guthrie: Oh, boy. Oh, boy! I don’t know. I think I’m going to have to get past the wave of this one first and have things settle and see what kind of comes out of it, but it’s been an amazing experience and I love talking about it. I love sharing information with people, so thank you so much for inviting me on and for asking me such great questions and just giving me the space to talk about something I really care about.