invertprivilege:

“I have a funny shape to me that makes people stare,” she says, her voicing trailing off.

According to Fitz, when she asked her surgeon what happened, he explained that he was worried she would change her mind and want to reconstruct later. “I’m told that I’m lucky to be alive—but this isn’t living,” Fitz says. But because she has an autoimmune disease, she’s decided she’ll have to live with the outcome. “Surgery is incredibly hard on my body,” she says. “I just can’t go through a revision.”

After reading stories like Fitz’s, Bowles was determined to make sure her doctor respected her wishes to go flat. She messaged women, listened to their experiences, and took their advice. They told her to clearly state her desire to go flat (she did), to put it in writing (she drafted a letter), to take a witness (she took her husband), and to provide photos of the smooth, flat chest she was hoping for (she provided six).

“When I met with my surgeon, I told him that I had seen other women left with skin to facilitate reconstruction and that I couldn’t live like that,” Bowles says. “I didn’t want to be reminded of what I’d lost. I told him I needed to be completely flat with no extra skin at all.”

She chuckles at the memory of her husband pulling her aside and telling her, Enough already. I think he gets it. But she stops laughing when she describes what happened next.

To state what should be obvious, you do not have to have boobs to be a woman. But experts say there are long-held beliefs around femininity and sexuality that are in direct conflict with the request to go flat. The surgical world is very paternalistic, says Clara Lee, M.D., an associate professor of plastic surgery at Ohio State University. “Many surgeons don’t know how to deal with a woman who’s deeply engaged in her own decision making.”

And they’re not always subtle about it either. Women who have stated their intention to go flat report that doctors can be pretty explicit in their anti-flat bias. In one case, a woman’s surgeon called her at home the night before her surgery begging her to change her mind, saying she was too young to live without breasts. Another said her doctor implied she’d never be able to get married if she didn’t opt for faux-boobs over going flat.

There’s a notion that “surgeons know best,” Sulik says. And many of those surgeons happen to be men. A report by the American College of Surgeons found that women make up only 15 percent of general surgeons and 13 percent of plastic surgeons.

But it’s not just misogyny bleeding into medicine: The majority of breast cancer surgery in the United States is done by general surgeons with no specialty training on how to handle breast disease, according to a study in the Journal of Clinical Oncology. The study pointed out that when breast cancer patients were treated by a surgeon that lacked specialization, they reported a lower level of satisfaction with their care compared to those who were tended to by a specialized surgeon.

“Breast cancer is still considered a true general surgery procedure,” says Julie Margenthaler, M.D. the director of breast surgical services at Washington University School of Medicine and a spokesperson for the American Society of Breast Surgeons. “But achieving a cosmetically pleasing outcome requires nuance that is hard to learn if you’re only doing a couple of mastectomies a month.”

These Cancer Patients Wanted to Get Rid of Their Breasts for Good. Their Doctors Had Other Ideas.