I am not exactly a shrinking violet. After all, I spent nearly all of my high school years dateless, in part due to my outspoken nature. Then there was my husband, who before we started dating told me that he thought I was smart, nice, and beautiful but “loud and obnoxious” (his diplomatic way of characterizing my outspoken nature), which at the time made me less than desirable romantic relationship material.

I used to love a good, passionate, intellectual debate. And sometimes the debates covered less than meaningful topics. And sometimes when I ran out of logic, I yelled. When I was working toward my Ph.D. in clinical psychology, one of my classmates remarked, “Elizabeth would argue with a fence post.” Now it’s not like I don’t argue any more but let’s just say that over the years, my thinking about complex issues has changed and my style of dealing with disagreement, has gotten calmer and not so loud. The downside of this is that my first response to a question is often “the psychologist answer”, which is, “It depends.” But also remember that the vast majority of psychologists have Ph.D., which are science degrees. So, we also use the scientific method. One of the things I miss most about being an active researcher is that a basic assumption in hypothesis testing is the possibility that the hypothesis is wrong. This is why so much research is done using inferential statistics, which are based on the laws of probability.  Logical reasoning is also strongly emphasized in research training. I might engage in a debate with a peer or in the blogisphere with something like, “I agree that points A and B follow the assumption I think is underlying your argument, but I don’t agree with the assumption.” Okay, I lied. I still very much enjoy an intellectual debate. I am just now less loud and more boring. As a psychologist, I know the importance of connecting on an emotional level with the people I work with. Our relationship is very special and extremely important. In other words, there are times I just need to listen and empathize rather than problem-solve. When I do need to provide education or lay out the logic of my recommendations, I need to do so with compassion as well as clear information. And finally, as a healthcare provider, I must respect that ultimate decisions about treatment are not mine to make.

In a nutshell, life is complicated.

I have been following a debate in the blogisphere about the negative ramifications of medicine’s use of the term “mastectomy” instead of the formerly used term, “breast amputation.” There have been two excellent posts on the Sarcastic Boob and Considering the Lilies. I encourage you to read the perspectives described there. I hesitate to speak for them but I will summarize my understanding of some of their points, as they provide context for this post. A theme in these posts is that the term “mastectomy” sanitizes the procedure that many of us undergo, now termed “mastectomy” and serves to trivialize the potential loss. Consequently, physicians are more likely to recommend the procedure and women are more likely to agree to it because it sounds less dire than “breast amputation.” A significant reason for this shift in language is a result of sexism by which women’s bodies and potential losses are devalued. Both posts also include a black and white video from 1930, “Radical Amputation of the Breast for Duct Carcinoma.”

My view of the “mastectomy” vs. “breast amputation debate”? You guessed it, my answer is, “It depends.” Although I agree with a lot of what has been posted on the subject and believe that the discussion is very important, I have a somewhat different perspective. The question reminded me of a meeting John and I had with Dr. Beatty, my breast surgeon last summer when we learned that my first lumpectomy had been unsuccessful because the margins of the excision were not clear of cancer. My husband asked if a mastectomy would be a good idea to be on the safe side. The question came from a good place (concern for a wife’s life) but it seemed extreme given that Dr. Beatty had already suggested that a second lumpectomy would be a reasonable option. Dr. Beatty’s response was, “It is easy for you or me to say that. But we can’t put a value on Elizabeth’s breast. She is the only one who knows the value of her own breast.” And then John started asking a bunch of questions about the potential psychological impact of a mastectomy, which resulted in the laugh riot I described in yesterday’s re-post.

I think this concept of self-appraisal of value, plays heavily into this debate as well as other factors such as how one deals with stress, including the prospect of one’s own mortality. For some women the experience will resonate with the word “amputation” whereas with others, the connotations of that word will not ring true. As a psychologist, I also wonder how these terms might impact different individuals likelihood of getting regular mammograms or when diagnosed with cancer, proceeding in a timely fashion with medical decisions. I can see either term encouraging or discouraging an individual from actively engaging in prevention and treatment depending on individual differences in factors such as personality and stress management. Finally, since having a serious illness involves a grief process, it is possible that even within the same person, assumptions, feelings, thoughts, and interpretations change over time.

As for myself, both terms seem true to me from an emotional standpoint though, “mastectomy” may be more technically accurate since amputation refers to the removal of an extremity, such as an arm or a leg. I suppose one might argue that a breast is like an extremity. Also, the term for the surgical removal of testes to treat testicular cancer is “inguinal orchietomy” rather than “amputation of the testes.” Obviously, this debate does not really relate to which term is correct from a medical terminology standpoint so much as it relates to connotations of the terms.  I am not purposely trying to miss the point. As a general rule, I tend to support people’s right to self-identify in the way that is true for them.

I also wonder whether posting of a 1930’s style mastectomy might unnecessarily sensationalize the issue since a radical mastectomy is no longer the standard procedure, based on my understanding of the history of breast cancer surgery. But it can also be argued that it got a lot of people thinking about and discussing the issue so maybe it was effective. I do think inclusion of a video of a contemporary procedure would have made a valuable addition to these posts.

I believe that sexism exists and further, that there is still a dominance hierarchy that exists in healthcare on which patients are too often on the bottom. I also believe that the loss of a breast can be devastating and for some it may mean a loss of femininity or perhaps for men with breast cancer, a loss of masculinity, since breast cancer is considered a “women’s disease.”

Finally, although there are parts of our experiences with breast cancer that are shared there are others that are not. But we can still be in this together.