“Are you interested in a story about eight amazing breast cancer survivors who saw a serious need in the community for ‘flat education’ and started a organization to fill the gap?” So began an email from Catherine Guthrie. Knowing who she is, my answer was, of course, yes. Guthrie is the author of Flat: Reclaiming My Body from Breast Cancer, about her decision to decline breast reconstruction after a double mastectomy, which Cancer Health excerpted in an essay titled “Why I Went Flat” in the winter 2018 issue. 

Now she’s back, with the soon-to-be-officially-a-nonprofit organization Flat Closure NOW, which aims to give women more information about this choice. The organization’s website provides information, links to photo galleries of “body-positive pics of flat folks” and a searchable list of flat-friendly surgeons that was compiled in conjunction with the nonprofit group Bullshit Breastcancer.

“You can’t order something if it’s not on the menu,” Guthrie explained on the phone. “I’m not anti-reconstruction—I’m pro-information. For some women, reconstruction is where it’s at, and I applaud that. But other women don’t know [going flat is an option]. Information is being withheld.”

Other excellent resources, she says, include the website I Don’t Need Two and the Facebook pages Flat & Fabulous and Flatties Unite. “Now, you can get your phone out, and tell your surgeon, ‘I want my chest to look like this.’”

Achieving an optimal flat result requires surgical training, skill and experience—plus a willingness to offer no reconstruction as an option in the first place. “Breast cancer care is often a cookie-cutter situation, an assembly line,” Guthrie says. “After a mastectomy, you’re sent to a plastic surgeon or a breast surgeon. There’s an implicit bias, an assumption that women want to reconstruct at all costs.

“Plastic surgeons don’t give women full information that with implants and reconstruction, there’s a 30% chance of a significant complication that will send them back to the OR,” she continues. “One told me, ‘I just want to be the happy doctor.’ They think that women are already dealing with cancer so they don’t want to upset them with things like complications of reconstruction. They think, We’ll just get them through it.”

But that attitude represents “an infantilizing of women that is just mind-blowing,” says Guthrie. “There’s so much sexism baked into medicine. It’s inherently patriarchal and protective of women, and that creates a lot of suffering.” In an article Guthrie wrote for Cosmopolitan last year, she documented several cases of women who specifically requested post-mastectomy flat surgery but woke up after anesthesia to find that the surgeon had left a flap of skin—in case the women “changed” their minds.  “We see stories like this on a daily basis,” says Guthrie. “We’ve got our work cut out for us.” 

Still, she has seen great progress. There’s an awful lot more information out now than there was in 2009 when she made her own choice. “I’m a health writer, so when I was diagnosed with breast cancer, I started interviewing surgeons,” she says. “All four surgeons told me I needed to reconstruct. I didn’t even know that going flat was a possibility.” When she was told that the surgeon would cut a muscle from her back, wrap it in front and lay it over an implant, she asked whether that muscle was doing anything where it was. Most women never miss it, her surgeon told her, “they just want to look good in clothes.” Then he asked, “You’re not an athlete, are you?”

But Guthrie was a yoga instructor, and she was concerned about surgery that could limit her mobility. “One of my favorite things were handstands—they gave me a great sense of power in my body, in a world in which women were told we weren’t supposed to be strong.”

She was never asked whether reconstruction was something that she wanted. Fortunately, she had a neighbor who was 25 years older than her who had gone without reconstruction.” Still, it was a lonely decision. “It was an information desert. I felt like a freak.”

That’s changing, in part, of course, because of her. “Social media has brought women’s voices to the center of everyone’s phone. You can see pictures on Instagram; you can search Facebook. We are finding each other and giving visibility. It’s creating a sea change for going flat.”


For Guthrie, one reason she didn’t get even more pushback at the time, she believes, is that her partner was (and still is) a woman. “I have friends who are married to men, and their surgeons said, ‘What will your husband say? Have you gotten permission?’ Some were even sent to get psych evaluations.” She and Mary weren’t married at the time because it wasn’t legal in Indiana, where they lived. In 2013, after the Supreme Court struck down the Defense of Marriage Act and same-sex marriage became legal throughout the United States, they tied the knot. Guthrie concludes her book with a description of that wedding ceremony. It’s a beautiful book: part personal memoir, part investigation of medical malfeasance, part love story.

But while being gay may have made it easier to have her wishes carried out, she is emphatic that it didn’t make her decision easy. “Sometimes in the queer community, people think that women don’t want their breasts because they want to be more like men,” she says. But while that may be true for certain women, it decidedly wasn’t so for her. “I identify as a femme queer. I loved having breasts. I was as connected to them as my hetero women friends were to theirs. For me, being part of a relationship with a woman is about being attracted to a woman’s body.” In her book, and often in talks that she gives, she recalls the moment driving back from the doctor when she asked Mary whether she was going to miss her breasts. Mary stopped the car, looked at her and reassured her, “Honey, I’m more of an ass man.”

At the end of the day, says Guthrie, a woman’s decision after a mastectomy is deeply personal.

“It’s about the individual, how you feel about your body, sexual pleasure and presentation.” For women who are considering going flat, her message is, there is no reason to be ashamed. “We hide cancer from one another, which makes it scarier,” she says. She wants to help women who choose to go flat to transcend both fear and shame. “You are still you. You are still a woman.”