‘FLAT’ Tackles Heteronormativity in Breast Cancer Treatment

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Flat, by Catherine Guthrie, is a desperately needed narrative of one woman’s struggle living with breast cancer. It’s a memoir unlike anything on shelves now, because the dominant narrative of breast cancer being published centers “feminine” and heterosexual stories.

In Flat, we learn that at every step throughout the breast cancer treatment process, ridding the woman’s body of cancer seems to be of equal importance to making sure she doesn’t ‘lose’ her femininity, desirability, and status as a sexual object. That is why Flat, named for the choice to not pursue breast reconstruction, is so radical.

This book also shows us the ways the media has failed to give women the tools we need to fully understand our options for treatment and recovery. AfterEllen spoke with the author to learn more (this has been edited for length).

AfterEllen: You’re a journalist focused primarily on women’s health including breast cancer. An expert on ‘how to avoid breast cancer,’ were you ever anxious this would happen to you?

Catherine Guthrie: As someone who had written about breast cancer for 10 years at that point, I felt pretty confident or even cocky about sidestepping this disease. Naive, clearly.

At the time I thought: I’m in good shape, I don’t have a family history, I’m a vegetarian from my early college days, I’m a yoga instructor, so I’m pretty fit, I work pretty hard at managing my stress. All those things I’d written about for women’s magazines I put into use in my own life and naively thought I didn’t have to worry, especially in my 30s. But prevention, we don’t know that much about it scientifically.

AE: When you were young and living in San Francisco, you had learned to to love your body and accept yourself — not just your body, but also your sexuality, your mind/body/spirit integration — by going to a women’s spa and hanging out in spaces that were centering lesbian/bisexual women. Then going through cancer treatment you were also in women’s space in online support groups. Can you tell me more about the role of women’s spaces had in validating your mind/spirit/body?

CG: There were a lot of similarities and a lot of differences between those spaces. Between Asento (the spa) and medical spaces. Similarities clearly are that they are primarily women’s spaces. And I had interesting experiences with that in high school because I went to an all-girls Catholic high school.

But it really wasn’t until I got to San Francisco and was immersed in mid-90s dyke culture in the Mission that I found a new appreciation for women’s spaces; I found this judge-free zone in a lot of ways. It was so open and accepting of different sizes and colors and shapes of women. Asento being a lesbian-owned and operated space that welcomed all women’s bodies, it was the first time I had been surrounded by so much diversity and plurality, and it was so eye opening, and it allowed me to come into myself in a really profound way.

It was a clash of that, the embodiment of my own femininity and embrace of my own difference and my own shape and size, which clashed against the heteronormativity of breast cancer culture, that really gave rise to the book.

It was a clash of that, the embodiment of my own femininity and embrace of my own difference and my own shape and size, which clashed against the heteronormativity of breast cancer culture, that really gave rise to the book. I was coming from such a different place, a place of love and acceptance and thinking about my priorities, than the people who were suddenly tasked with saving my life. And to have that clash at this time when I was so scared about what was going to happen to me — it took me surprise, it made me feel so unseen and misunderstood, and yet I had to make a decision really fast. You know, these people were going to be cutting on my body.

It was the cognitive dissonance between these two worlds that really gave rise to the struggle that centers the book, and that made me realize that I want to write about this because I’m not seeing my experience reflected in the literature of the day.

Catherine Guthrie, photo by Adrianne Mathiowetz

AE: There was a chapter about shopping for surgeons and you had gone to a woman and found that her practice was pink washing and — what was the word you used — “bright-siding.” Later you found a female oncologist who had a very different approach than the male doctors you saw. So I wonder if your experience with the male doctors had broken your trust because their medicine came with the male gaze.

CG: Definitely my doctor [a female oncologist] now in Boston is the hero of my story in some ways. It’s tough. Medicine, on the whole, is historically and continues to be paternalistic. I think male doctors have a harder time untangling themselves from that paternalism. Not that they can’t or don’t, but that it’s a bigger challenge for ‘the mens.’

One of the plastic surgeons, well she’s a surgeon, outside Indianapolis, the only woman surgeon that I consulted — she had this pink washing thing happening in her office. You know, a lot of women like it. I don’t mean to ding her for doing that, I’m sure it makes some women feel comforted to walk in and have lots of pink. It wasn’t my experience, but I think, she’s doing her marketing, I’m sure she’s filling a niche for folks who do like that.

I’ve done some writing on this, ongoing, and in flat. I’ve done some research, and I interviewed a plastic surgeon who’s a woman — she does only breast reconstruction. She said the interesting thing, from a woman plastic surgeon’s perspective, ‘all of our training is by men, all the texts are written by men, so by the time we come out of med school and our plastic surgery residency even the women doctors have the male gaze.’

And I have heard from women who went to female surgeons hoping for a feminist perspective on the body and not gotten it and were disappointed. So, no one gender is going to be the answer in these moments. It’s more about having the conversation with the surgeon. Really listening. Are they resisting what you want to do? Are they supportive? Are they asking open-ended questions? Are they asking ‘what do you think about reconstruction?’ or are they asking ‘what kind of reconstruction do you want?’ These are important differences.

My Boston oncologist, she happens to be a doctor that specializes in breast cancer in young women and knows younger women’s issues and women’s relationships and job prospects and marriages, and she is thinking about these things in ways a lot of oncologists aren’t, not because they are lacking or bad people, but because it’s not on their radar screen as much. That’s kind of the magic of this person, as well as she’s just down to earth, very empathetic and very humble.  

She sat down with me and looked at me and was like, ‘This is a really tough case and I don’t know exactly what’s going on. Let’s talk about you and your quality of life and what you want your life to look like on a daily basis.’

AE: You chose not to go through with reconstruction. A lot of women who’ve never faced cancer don’t know the reality of what reconstruction actually means, and also a lot of us can’t imagine life without breasts. Even though femininity is a social construct, you may be disconnected from that and from ‘womanhood.’  I’m wondering if you can speak to that experience of choosing to be flat in a world that makes no room for that.

CG: Most of us don’t know anything about reconstruction, and that’s what surprised me so much. I had written about breast cancer for years, and I had no idea what reconstruction involved. And I thought that was a real disservice to women and women’s journalism. Media as a whole and women’s magazine culture — how can we not talk about this?

I think it’s really important for women to know that the average reconstruction takes 6-7 surgeries and is a 2-3 year long process. Every time you go into the operating room you risk serious complications such as infection. One of the biggest studies ever published about reconstruction after mastectomy came out this year and found that 30 percent of women have major complications. Women need good information to make good choices.

I’m not anti reconstruction; I’m pro information. And that information is not being given to women, and women need that information to make a well-informed choice. You have to go in with eyes wide open. You might make a different decision if you think about six surgeries vs one surgery. Two-three years of my life vs 2-3 months. Women need good information to make good choices.

I’m not anti reconstruction; I’m pro information. And that information is not being given to women, and women need that information to make a well-informed choice. You have to go in with eyes wide open. You might make a different decision if you think about six surgeries vs one surgery. Two-three years of my life vs 2-3 months. Women need good information to make good choices.

As you mentioned, femininity is a construct, and we’ve been taught through the male gaze that breasts are paramount to a woman’s femininity, so I would just encourage women to press back against that a little bit and question for themselves if their breasts make them feel sexy? Or is it something they would reconstruct because they’re afraid they wouldn’t be seen as desirable?

I have one friend who reconstructed, loves her new breasts, is in love with her body, and that’s phenomenal, but she did it for her, because it makes her feel her best.

So that’s the first question women need to check in with themselves. Check in with your gut. What do you want for your body? That’s often missing from these conversations.

If a woman does choose not to reconstruct what does femininity mean now? I’m still exploring that for myself for sure, there’s a big range of what people experience as femininity for themselves. For me, I found myself gravitating toward wearing a lot more dresses and skirts and jewelry and nail polish and those are all stereotypically feminine, and they are part of that construct as well, but you can pick and choose for yourself what makes you feel the way you want to feel. There’s a lot more latitude when you allow yourself to think about — when you have a body that presents as feminine and you don’t have to think about it in some ways or you only think about it in the context of the male gaze. But there’s such a possibility for self-expression and such a range of how to express yourself.


Guthrie’s evocative, beautifully written prose and keen sense of pacing made Flat hard to put down. I would recommend this book to anyone who loves a good story, even if you are not looking for a memoir or a story about breast cancer. Every woman should read this!

Follow Catherine Guthrie on Twitter.

Check out Catherine Guthrie’s journalism.

Buy Flat: Reclaiming My Body from Breast Cancer.

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