LGBTIQ+  body image and gender 

You may experience changes to your body image and how you feel about your gender through your breast cancer journey. 

Changes may relate to hair loss, mastectomy, flatness or reconstruction, fluid retention, skin marks, tattoos or scarring, ability, mobility, sexuality and intimacy. You may face decisions about your body, such as whether to go flat or have breast reconstruction. 

Studies indicate that LGBTIQ+ people’s responses to treatment-related bodily changes vary widely. There are a range of ways you can manage these impacts.  

Body image changes 

What bodily changes could I experience?

Your body may change through your cancer journey. These changes may affect how you feel about your body or gender. 

You may experience changes in your sexual feelings, the way you experience pleasure and your responses to intimacy. To find out more about this see Sexuality and intimacy for LGBTIQ+ people with breast cancer

Hair loss

Hair loss can be a distressing side effect of cancer treatment. For many people, hair is an important form of self-expression and identity. This may be more so for LGBTIQ+ people, as hair styling is a way of proudly demonstrating sexual orientation and gender. Your hair may be part of feeling sexually attractive. Hair loss may threaten your identity, your self-image or your confidence more broadly. 

You may find hair loss less distressing than expected or not important compared with other treatment-related side effects. For some people, hair loss or short hair after treatment can mean you are more visible as LGBTIQ+. 

How you manage hair loss is an individual choice. Some people wear wigs, scarves and hats, or undertake hair preservation measures such as scalp cooling to help prevent hair from falling out during chemotherapy. 

Others embrace hair loss by shaving their head prior to treatment. Some people find hair loss is celebrated by others in their LGBTIQ+ community and chosen family. What you do in response to hair loss is your choice - do not feel pressured by the expectations of others.  

Challenges to gender and gender affirmation

The side effects of breast cancer treatment may impact the way you feel about your gender, or the way you might ordinarily present to others. If you are trans and need to reduce or stop gender affirming therapy during treatment, this may present challenges for your self-image or wellbeing. The extent to which your gender is perceived by others may also change. Read more in Trans and gender diverse patients with breast cancer

You may find that breast cancer and the side effects of treatment have the opposite effect and affirm your gender - you may feel more empowered. Some people find their gender is unchanged by treatment. There’s no right or wrong way to experience your gender in relation to treatment. 

Decisions about lumpectomy, mastectomy and reconstruction 

What surgical treatment is right for me?

Your treating team may discuss lumpectomy (also called breast conserving surgery) or mastectomy surgery with you. You may be presented with decisions around what type of surgery is best for you and whether you want to have breast reconstruction. 

A lumpectomy is surgery to remove a breast cancer tumour and some of the normal tissue that surrounds it. 

A mastectomy is the removal of the whole breast, often leaving the underlying chest muscles intact. A bilateral mastectomy is the removal of both breasts. Mastectomies can be ‘nipple-sparing’ where the nipples are preserved at the time of mastectomy, reconstructed following mastectomy, or some people may have to have their nipples removed. 

Your feelings about your breasts may influence your decision about whether to have a lumpectomy or mastectomy. Some people don’t have a choice because of the size or type of cancer they have. 

It's important to be guided by your treating team about the treatments that are most likely to be effective for you. 

Reconstruction

You may find that surgery affects your body image or the way that you feel about your gender. Your decisions about reconstruction may be influenced by these feelings. 

Some people report reconstruction “restores” what was lost, the physical and emotional meaning of their breasts/chest tissue. Reconstruction can be a way of reflecting and affirming bodily pride, sexual identity and gender. 

For others, reconstruction is important for body shape, identity or maintaining sex and intimacy after cancer.  

There are different methods of reconstruction. Some people choose implants, and others choose reconstruction using tissue from another part of their body such as the belly (called a DIEP flap). This changes other parts of the body like the belly or hips. It can create curves in some areas and reduce them in others, impacting on a more masculine or feminine form.  

Many LGBTIQ+ people are satisfied living without breast reconstruction after mastectomy. You may choose not to reconstruct, called “staying flat”, “being flat” or “aesthetic flat closure”.  

Staying flat

Some people ‘go flat’ after cancer and find this affirms them as a LGBTIQ+ person. There are numerous ways to go flat, as there are many different methods of surgery. Going flat may be a part of gender affirmation, a matter of bodily comfort, or could simply feel like the right choice for you. Some people who are flat wear prosthetic chest or breasts pieces. Some queer, lesbian and bisexual women like the ease and comfort of living without breasts. Some people report mastectomy without reconstruction affirms their non-binary or trans identities. Having a mastectomy is different from top surgery, as there is generally more removal of tissue during a mastectomy. If you want to have more of a chest shape post mastectomy, you need to request a reconstruction with minor implants or tissue transfer. 

Explaining your desire to go flat, or to have breast reconstruction and your preferred breast size, to your treating team might feel difficult. You might feel they do not understand your decision. You may be concerned they expect you to make a certain decision, due to gender and sexuality norms in health care. You have a right to access cancer treatment that is free from discrimination just like any other patient. 

It is important to discuss your feelings about your desired post-mastectomy body shape with your treating team, and to work out the best options for you. Taking a support person with you can help with these discussions. 

Acknowledgements 

These materials were developed from the Out with Cancer Study, conducted at Western Sydney University, and funded by the Australian Research Council. Thanks are offered to the Out with Cancer study committee members with lived experience of cancer, BCNA LGBTIQ+ consumer representatives, ACON and LGBTIQ+ Health Australia who contributed their time and expertise. 

BCNA's LGBTIQ+ project was undertaken with support from Cancer Australia through the Supporting Women in Rural Areas Diagnosed with Breast Cancer program. 

Resources 

• The Cancer Council NSW has detailed  information on its website including a downloadable book that will help you understand how cancer and its treatment may affect LGBTQI+ people – lesbian, gay, bisexual, transgender, queer, and other diverse sexualities and genders, as well as people with intersex variations. 
• The Genders, Bodies and Relationships Passport is a tool to support clear communication between intersex, trans and gender diverse people, and health and social care services. The passport provides important information about a person’s gender/s, body, and relationships in a single location.
  The Passport is designed to help people to get quality care and help organisations to achieve inclusive practice. 
  For more information on how to access the Passport visit the website. 
• This deMilked blog post shows a series of photos of breast cancer survivors who decided to stay flat after surgery. The images are of 3 women headlining the LGBTQ support blog for women with double mastectomies. 
• This article by Claire Rudy Foster talks about the difference between Top Surgery and Mastectomy. It includes definitions of both terms, terminology, difference and overlap between the two. 
• Cancer's Margins in a Canadian LGBT2Q Arts-and Community based project that explored sexual and gender diversity, and experiences of cancer health, support and care. They developed a series of digital stories on a range of topics including: 
  • Healthcare Provider Communication 
  • Experiences of Breast Cancer 
  • Sexuality and cancer