Reconfiguring Breast Reconstruction in the Post-Cancer Life in Vietnam

ABSTRACT

In the context of breast cancer, women who refuse reconstruction are often portrayed as having limited agency or control over their bodies and treatment. Here we assess these assumptions by paying attention to how the local contexts and inter-relational dynamics influence women’s decision-making about their mastectomized body in Central Vietnam. We situate the reconstructive decision within an under-funded public health system, but also show how the widespread perception of the surgery as merely an aesthetic practice dissuades women from seeking reconstruction. Women are shown both conform to existing gendered norms while simultaneously challenging and defying them.

RESUMEN

Những người phụ nữ lựa chọn không tái tạo vú sau phẫu thuật đoạn nhũ thường bị coi là thiếu chủ động hoặc bị hạn chế khả năng kiểm soát đối với cơ thể và các phương pháp điều trị. Trong bài báo này chúng tôi xem xét lại những giả thiết trên dựa vào kết quả nghiên cứu về trải nghiệm của bệnh nhân ung thư vú tại miền Trung Việt Nam. Nhóm nghiên cứu quan tâm tới tình hình địa phương và sự tác động qua lại của các mối quan hệ xã hội có ảnh hưởng như thế nào tới việc đưa ra quyết định sau phẫu thuật đoạn nhũ. Chúng tôi xem xét liệu họ có hay không thực hiện tái tạo vú trong bối cảnh một nền y tế công còn nhiều hạn chế về nguồn lực. Ngoài ra, những đánh giá về mặt đạo đức cho rằng tái tạo vú chỉ đơn thuần là phẫu thuật thẩm mỹ liệu có ngăn cản họ trong việc ra quyết định? Nghiên cứu này chỉ ra rằng thông qua quyết định của mình, một mặt phụ nữ vẫn tuân thủ nhưng đồng thời thách thức và phản đối lại những chuẩn mực truyền thống về giới tính và vai trò của phụ nữ trong xã hội Việt Nam.

KEYWORDS:

• Vietnam
• breast cancer
• breast reconstruction
• cancer survivorship
• women’s bodies
• mastectomy

Statistics from across the world suggest that breast reconstruction post-mastectomy is increasingly popular within the context of breast cancer. For instance, it is estimated that the overall rates of reconstruction (immediate plus delayed reconstruction) among women undergoing mastectomy are nearly 35% in France (Nègre et al. 2020) and over 60% in the United States (Jagsi et al. 2014). In Asian countries such as South Korea where data are available, the proportion of women with breast cancer who opted for breast reconstruction following mastectomy have increased sharply from 19.4% in 2015 to 53.4% in 2018 (Song et al. 2020). This is, however, not the situation we observed in Vietnam. Throughout our ethnographic research on the lived experience of breast cancer in Central Vietnam, we often found ourselves immersed in conversations with our informants about sharing a room with a peer patient with a “pretty, round, firm breast but without a nipple.” Nevertheless, we rarely met a patient from the Central region coming to the hospital where we conducted our research to have their breasts reconstructed. This absence was despite the hospital’s prestige for having successfully performed reconstructive surgeries for patients nationwide for nearly 20 years and frequently hosting national and international workshops on these techniques. Only 2 of 33 patients from the Central region participating in our research had an immediate reconstruction, 3 had breast-conserving surgery, and the rest had radical mastectomy without any form of reconstruction.¹

In this article, we focus on women’s practices in relation to reconstruction post-mastectomy and provide contextualized explanations of their decision-making. Our work contributes to cross-cultural theorizing on embodiment, and femininity and medicine, and questions the assumptions about the agency of breast cancer survivors. Given the symbolic role of women’s breasts in the notions of beauty, femininity, and womanhood across different social and cultural contexts, attention has been placed on the overlap of beautification practices and oncological procedures to explore breast reconstruction (Greco 2016). Research such as the account written by the American feminist Lorde (1997) considers the surgery as a form of social control over women that reinforces the social pressures on women to conform to normative beauty standards. Recent anthropological research has also questioned reconstruction as a panacea to restoring body-self alignment, with accounts revealing breast reconstruction is an illusion that is unable to recreate the experience of pre-cancer body wholeness (e.g Manderson 2016).

Further, in this work we position women’s subjectivity as inseparable from its social and political environment (e.g Biehl and Locke 2017). From medical professionals’ viewpoints, reconstruction is viewed as vital to remedying postsurgical asymmetry and enhancing a woman’s psychological well-being and quality of life; therefore, it is fundamental to breast cancer patients’ normalizing process and the ultimate goal for women with mastectomized bodies (Crompvoets 2006; Fang et al. 2013). Breast reconstruction is seen by medical providers as a “gain” or “improvement” for the patients (Greco 2016:312). In providing more nuanced understandings of this post-cancer surgery, we utilize the case studies presented here to refute the assumptions made by medical professionals that reconstruction is surgically optimal and all women would desire reconstruction post-mastectomy.

While the literature examining reconstructive decision-making mostly focuses on women in Western societies, there is a growing body of anthropological and sociological scholarship attending to people’s engagement with cosmetic surgery in non-Western contexts. A key theme in this body of research is the culturally-nuanced tension between aesthetic and therapeutic understandings of cosmetic surgery, which provides important conceptual base and empirical considerations for our research to explore and understand women’s decisions with their post-mastectomy bodies. Works by Edmonds (2010), Jarrín (2015), Leem (2017), or Luo (2013), for instance, have offered rich accounts documenting the cross-cultural acceptability of cosmetic surgery and illuminating how the local contexts have played in explaining its growth in Asia and South America. Moral judgment against those who seek surgical beautification is present in societies such as China where cosmetic surgery is perceived to be against the naturalistic fallacy² and, therefore, a practice that violates the culturally ingrained valuing of the intact body as a mark of filial relations with one’s parents (Tam et al. 2012). In South Korea, the cosmetic surgery industry has long attracted governmental endorsement and the public are more amenable to body modification (Holliday and Elfving-Hwang 2012). Even so, only surgery that emulates the natural body is most valued, echoing the naturalism associated with cosmetic surgery in China.

Anthropological literature has described how aesthetic surgery is sought by women to remedy the body that deviates from the local ideals of femininity. For instance, in Brazil, where ugliness is pathologized as not only an individual but also a societal illness, plastic surgery has become necessary for people to fit into the national beauty standards centered on whiteness (Jarrín 2015). In Europe, O’Neill et al. (2022) have described how the decision to seek clitoral reconstructive surgery among African migrant communities from Senegal and Guinea was driven by the desire to align their mutilated body with the social ideals of sexuality and femininity prevailing in Western contexts. Amidst the boom in Gangnam-style plastic surgery in South Korea, Leem’s ethnography (2017) has revealed the increasing popularity of pre-surgery visualization practices during clinical consultations when the surgeon loaded a graphic representation of the clients’ face on computer screens and subsequently adjusted the image to emulate the appearance of local celebrities considered ideally beautiful.

Many scholars have drawn on earlier feminist viewpoints to consider how women pursuing cosmetic surgery are victims of a patriarchal culture or passive, irrational objects of the beauty industry (e.g, Bordo 1997; Coy and Garner 2010). More recently, this view has been contested by scholars who have unfolded the more complex meanings attached to cosmetic surgery, paying attention to women’s agency, choice, and self-determination (see Taylor 2012). Beauty is accordingly conceptualized as a form of biopower and surgical beautification is considered as a technology that empowers its consumers, offering opportunities for self-improvement, the benefits of late-modern health care and social mobility (Edmonds 2010; Jarrín 2015; Luo 2013).

Despite these critiques and compared to the literature reflecting the experiences of women choosing reconstruction or engaging in cosmetic surgery, there remains limited scholarship on the decision to not pursue reconstructive surgery. Indeed, biomedical literature portrays non-reconstructed bodies as incomplete, physically deformed or pathological (Greco 2016), and women who refuse reconstruction as socioeconomically underprivileged or with limited control over their treatment (Crompvoets 2006; Fang et al. 2013). These women might even face negative responses from their medical teams (Holland et al. 2016) or the risk of being categorized as desexualized (Rubin and Tanenbaum 2011). These absences and emphases in the literature tend to reinforce the assumption that women who forgo breast reconstruction lack bodily agency. In this way, the habits of science help constitute the lack of agency of some women. But as we shall see in this article, the lives of women who choose not to have breast reconstruction are comprised of agential practices that are so far poorly understood and theorized.

Recent studies in the social sciences have demonstrated women who decide not to restore their breasts are active agents of their choice to challenge the simple classification of reconstruction opt-out as a non-choice and lack of control (Holland et al. 2016; Porroche-Escudero 2012; Rubin et al. 2013). Those women carefully research different surgical options, consult their peers, and in consideration of pro-reconstruction information delivered to them by their medical providers, make choices based on their assessments of the prospective pain and complications of reconstruction. The process of decision-making against reconstruction is in fact not less complex than that which leads to surgery. It is a long process of navigating and accepting the changed bodies (Archer et al. 2018). For some, perceiving the breastless body is difficult but it serves as a positive reminder of their strength and struggle with cancer (Rubin et al. 2013). Such decisions might even change over the course of the cancer treatment. For instance, the women in southern Arizona (in the United States) studied by Armin’s (2019), first planned to have the surgery, but eventually had prophylactic mastectomies in lieu of reconstruction due to the anticipated stress on their bodies, which included the year-long limited mobility they could potentially suffer post-surgery.

Based in Vietnam, our study explores the nuanced logics applied to women’s reconstructive decision-making as they navigate through the post-cancer life and grapple with the mastectomized body. We have found that the existing research surrounding reconstruction from non-Western contexts mostly departs from biomedical assumptions and, therefore, has a tendency to concentrate greater attention on the physical attributes of the procedure and positions breast cancer as a personal, cosmetically-oriented crisis (Gibson et al. 2014). As we show in our analysis, such focus downplays the survival concerns of cancer sufferers and overlooks the social experiences of living with this life-threatening condition.

The Vietnamese context

The analysis in this article is drawn from a larger ethnographic study of the lived experience of breast cancer undertaken in Central Vietnam. For the Việt people (Kinh ethnic) – the major ethnic group accounting for around 86% of the total population in Vietnam and the whole sample of our study – their beliefs and everyday practices are heavily influenced by Confucianism, especially its emphasis on familial relationships and gender roles (see Jamieson 1995; Taylor 2007). Accordingly, throughout her life course, a woman should conform to “tam tòng” (three obediences). These are to obey: her father during childhood; her husband after getting married; and her son during widowhood. She should also maintain “tứ đức” (four virtues) which consist of: Công (Labor); Dung (Appearance); Ngôn (Speech); and Hạnh (Behavior). The introduction of the 1986 Đổi Mới (Renovation) – Vietnam’s transition from a subsidized to a socialist-oriented market economy³– provided women with unprecedented opportunities for educational, political, and economic advancement. However, Confucian-inspired discourses still dominate public discussion surrounding the modern image of womanhood in the post-socialist state (Hoang 2020; Khuat et al. 2010). As Hoang (2020) has noted in her analysis on the role of the Women’s Union – a mass organization tasked by the Vietnamese Communist Party to represent women – the individuality and autonomy of women has been rejected by the socialist state, despite their increasing participation in the economic and political arenas. Vietnamese women have been (re)socialized into traditional roles within the domestic sphere whereby the virtues of “endurance” – the ability to live with and accept pain and hardships, and “sacrifice” – putting others’ well-being above one’s own – continue to be socially expected of “good women” or worthy citizens in the socialist gender regime (Gammeltoft 2021; Leshkowich 2014). For instance, in her ethnography on women’s experiences of distress in Northern Vietnam, Gammeltoft (2021) has described how women concealed their negative emotions or stayed in troubled marriages rather than seek divorce, as part of their everyday practice of serving Confucian-inspired kinship. As we see later in our analysis, these ideals of endurance and kinship profoundly impact the perception of women’s consumption behaviors and their practices of seeking breast reconstruction.

Viet Nam’s government-owned health system (public health care) comprises four administrative levels: national; provincial; district; and commune. At the national level, general hospitals, universities and colleges, and national research and institutes under the management of the Ministry of Health, are the highest points of referral in the health system. Since Đổi Mới, the government restructured the system by permitting greater hospital autonomy and legalizing private hospitals (London 2013; Stalford 2019). The simultaneous commodification of health care has prompted increases in medication and treatment costs, resulting in growing stratification of the public-private mix reflected in increased health access inequity across different population groups and regions (see Lincoln 2014). In oncology care, disparate diagnostic and treatment capability prevails across regions and between national- and lower-level health facilities. Patients can only access the latest technology and treatment services at a small number of comprehensive cancer centers which mostly concentrate in urban cities like Hanoi and Ho Chi Minh City. This situation renders extensive and costly travel to obtain oncology treatment inevitable for the least advantaged patients residing in rural areas or small urban cities and often leading to the overcrowding of urban public hospitals (Stalford 2019).

In addition, breast cancer has become the most frequent cancer among women in Vietnam, accounting for 25.8% of all new cancer cases detected among Vietnamese women and claiming 9,345 deaths nationwide in 2020 (GLOBOCAN 2020). As we describe in this article, similarly to the way laypeople explain the occurrence of breast cancer through the historical experience of warfare, the inequalities of a new rapacious market economy, poverty, and Confucian configurations of gender roles (Do and Whittaker 2020), the decisions to undergo breast reconstruction are mediated through the biosocial and political settings. According to the latest regulations, breast reconstruction when performed as a delayed procedure is not covered by universal health insurance⁴. Therefore, patients must pay for the surgery out-of-pocket, with costs ranging from 30,000,000 VND to 60,000,000 VND (~US $1290 to US $2580), excluding the costs of reconstructing the nipple or additional revisional operations of the remaining breast to achieve symmetry. In a lower middle-income country like Vietnam which has GDP per capita slightly above the surgery’s cost, estimated at US $2587 at the time of our fieldwork (GSO 2018), one might surmise that economic constraints explain women’s decision to opt out of breast reconstruction. While financial cost greatly influences the decision-making in the context of illness management, what we show in our article argues for a more expansive understanding of costs to consider not only the immediate cost of the surgical procedure, but also all the hidden, social, and long-term costs it incurs on the patients and their families, and other issues they factor into their decision-making.

The ethnography of breast cancer treatment and care in Central Vietnam

Ethnographic fieldwork was conducted by the first author in Thua Thien Hue province in Central Vietnam from April to December 2019. The Central region stretches from the Northern Central zone to the Coastal Central zone and comprises 14 provinces. Hue City is the municipal city of Thua Thien Hue province and Vietnam’s former capital during the Nguyen dynasty⁵ with an estimated population of 358,754 (as of 2018) (Hue Government n.d.). The hospital where the ethnography was based is located in Hue City and is the largest public hospital serving the whole Central region and one of Vietnam’s three largest general hospitals. The hospital is also one of the first hospitals in Vietnam to perform breast reconstruction, including implants and autologous (flap) methods. Alongside our fieldwork in the hospital and to build up a picture of breast cancer treatment in Vietnam, we included focus groups with laypeople in a rural district which lies to the north-west of Thua Thien Hue province and is home to around 4,500 people.

Our ethnography involved observation, focus groups, and in-depth interviews, all of which were conducted in Vietnamese (Do and Whittaker 2020). We recruited patient informants via the hospital and the Hue-branch of a breast cancer peer support network that operates in over 20 provinces. The 33 women patients we interviewed came from 10 provinces in the Central region. Nineteen came from rural provinces. Patients ranged in age from 26 to 62 years (median = 46) and included women diagnosed at stage I (n = 7), stage II (n = 15), stage II (n = 3), stage IV (n = 1) breast cancer. Seven did not know about their cancer stage when first diagnosed. Our sample was quite diverse in terms of the informants’ educational attainment, marital status, and the duration of living with breast cancer (ranging from a couple of months to over eight years by the time of our fieldwork). For the focus groups, our recruitment was based on convenience sampling via the local mass organizations. Twenty-one community members participated in 3 focus groups, including 15 women and 6 men aged between 18 to 65 years.

Our study excluded women who had just received their cancer diagnosis and were awaiting their first bodily treatment interventions because we were concerned about their psychological distress. The interpretation of our data should consider this exclusion due to the possibility that this group may differ in their views toward breast reconstruction than the women captured in our research. For example, some women could still opt to have immediate reconstruction at the same time with mastectomy rather than as an additional procedure.

Observation took place in both hospital and community settings. The first author observed patients and health care providers at the Consulting, Diagnostic (mammography, ultrasound room) and In-patient divisions of the hospital, in the patients’ home settings, as well as participating in monthly gatherings and activities of the peer support network. Interviews with the women patients were guided by opened-ended questions which inquired into their experiences of breast cancer. As our interviews progressed, depending on their responses, we asked the patients about the meanings they gave to breast reconstruction, their access to reconstructive information/services, and the decision-making for/against reconstruction. Patients were interviewed over the course of 1 to 5 appointments and each interview lasted from 45 to 120 minutes. In our focus groups, we asked participants to respond to several vignettes based on real stories we collected during our fieldwork by imagining themselves as family members, friends, or relatives of the patients in order to provide their views. Each focus group took place for approximately two hours. Informed consent was sought from all participants prior to any interview or discussion. We digitally recorded all focus groups and most interviews, or wrote down extensive notes in case an informant preferred not to use a recorder. All names used in this article are pseudonyms.

Given the lack of knowledge regarding breast reconstruction in Vietnam and countries with similar cultural settings or level of socioeconomic development, we used a grounded theory approach (Charmaz 2014) to build a nuanced analysis of the qualitative materials and generate new insights for theory and practice. In the following sections, we unpack women’s interpretations of breast reconstruction surgery’s potential harms and then illustrate how an opt-out decision is one of conformity and defiance that the women proactively strive to make.

“Will the flesh stay alive or become rotten?” Fears of additional surgery and its accompanying risks

Since most of the women participating in our research had undergone a mastectomy without an option of an immediate reconstruction, having their breast restored would require them to be re-hospitalized and experience additional procedures. Our informants were wary of the surgery due to the complex technicalities of the reconstructive process which led to their skepticism about the reconstruction’s success and concerns over its post-operative repercussions, most notably, cancer recurrence or metastasis. A common belief found in many of our interviews and focus groups was related to the importance of completely removing the cancerous breasts irrespective of the cancer stage. In their opinions, this can only be realized by radical mastectomy. Retaining a breast, either by conservation or reconstruction, interfered with their concept of cancer curability since it created a breeding ground for “cancer roots,” thereby accelerating the growth of cancerous cells to other parts of the body and prompting relapse or metastasis. For these women the “uncertain presence” of cancer remained as long as any part of the breast remained (Greco 2021).

With that in mind, many women opted for a radical mastectomy even when they were eligible for conservative surgery at their first diagnosis. The story of 47-year-old Hay, who was diagnosed with stage II cancer when her tumor size was not large, exemplifies the decision for radical mastectomy. Despite her doctor’s suggestion for reconstruction, Hay was worried about the invasiveness of the flap surgical methods and insisted on having a mastectomy right at the beginning. Hay explained: “When you do it [reconstruction], they cut your stomach and take out the flesh and sew it onto your upper part. Will the flesh stay alive or become rotten?” She additionally articulated her fears of taking antibiotics post-surgery, if the surgery was unsuccessful, or if complications arose in case the newly constructed breast became incompatible with her body. The former kindergarten teacher believed that such a procedure would exacerbate her health status and prompt cancer to return. Her belief can be understood against the Vietnamese popular knowledge whereby antibiotics as Western medicine are widely perceived as “hot” and harmful and, therefore, people should restrict their use or take small doses, in contrast with traditional Vietnamese herbal medicine which is believed to be benign and nutritious (Craig 2002).

Doubts over the success of reconstructive surgery were not only expressed in Hay’s case. During our fieldwork, many women narrated the stories of other patients sharing an inpatient room or via the peer support network who had experienced surgical failures with serious wounds or infections or who needed multiple operations to “fix their new breasts.” Those experiences led some women who had wanted reconstruction at the time of mastectomy to change their mind, finally settling on an opt-out decision. Their fears over the surgery’s failure do not only seem to suggest uncertainty about the procedure, but may also indicate how our informants were concerned over medical expertise at Vietnamese hospitals where public distrust of the quality of health care services and health professionals has long been noted (for example, Vu 2014).

The notion of the body as vulnerable to external forces, be they invasive surgery like breast reconstruction or antibiotic use, was common even among the informants who had lived cancer-free for over five years by the time of our ethnography. The way that those women perceived the vulnerability of their bodies reminds us of Nguyen’s recent ethnographic account (2021) of Vietnamese women engaged in body work to revitalize their “weak” skin. The lingering and pervasive effects of chemical warfare from the Vietnam War, along with greater exposure to industrial toxins and declining air and water quality resulting from the country’s new industrialization era, have prompted the women’s fears of having weak skin and bodily deterioration. To protect their bodies, the women that Nguyen followed in her research in Ho Chi Minh City sought to engage in noninvasive enhancement efforts such as massage, cosmeceuticals, herbal medicine combined with spiritual beliefs and folk knowledge. For the women patients in our study, the notion of a vulnerable body took shape after a prolonged period of radical treatment following their primary diagnosis, which involved exposure to various types of medical examinations, invasive surgery, chemicals, and radiation. Therefore, when primary treatment had concluded and cancer had been put under control, these women still considered themselves to occupy a sick role: they were still physically too vulnerable to undertake additional procedures that could potentially aggravate their existing vulnerability.

The hidden costs of hospitalization

Medical risks associated with reconstruction were not the sole explanation for women’s decisions against the procedure. For many, the idea of having further surgery revived their accounts of the physical pain and psychosocial distress associated with their mastectomy, including the traumatic period of hospitalization during the treatment journey. Long, a 35-year-old resident of an urban town in the Central Highlands, asserted that she rejected reconstructing her breast, because for her any operation was a reminder of her past hospital experiences: “After mastectomy I felt almost dead. If I had another one [surgery], I would never be able to endure it.” Long continued our conversation by recalling her hospitalization after her stage II cancer diagnosis in 2011 at the age of 27. Long’s cancer trajectory resembled those experienced by the other women who lived far from a hospital with oncology services and, consequently, had to bypass the lower-level facilities to obtain cancer screening and treatment at a national tertiary hospital. These accounts echo those of the cancer patients “from the provinces” described in Stalford’s ethnography (2019) in Southern Vietnam. These patients strongly resisted ever returning for follow-up care to avoid the anxiety associated with the agonizing bus trips they had previously endured when traveling to major cities for oncology care.

During the primary treatment period, Long and her husband first traveled to an oncology hospital in Ho Chi Minh City where she was kept waiting indefinitely for a surgery and then relocated to Hue City. There while undergoing a mastectomy followed by 8 cycles of chemotherapy and 25 sessions of radiotherapy, Long and her husband rented a room for over six months in a guesthouse close to the hospital because they could not return to their place of residence which is around 700 kilometers or a 14-hour bus ride from Hue City. During the day, Long’s husband would look after her in the inpatient room and outside visiting hours he came back to their rented room and prepared meals for them both. In the first two weeks after her mastectomy, at night Long’s husband slept on a foldable bed in the post-op room that Long was sharing with typically more than ten other patients along with their caregivers. On some Fridays, Long’s husband would take her home on his motorbike to see their daughter who was staying with Long’s parents, returning late Sunday in time for the next round of treatment.

Long dreaded another surgery as she knew it would again cause her severe physical pain, but also force her to undergo the plight of a prolonged period of hospitalization in an overcrowded cancer ward. Also, the arduous stay associated with the reconstruction would inevitably disrupt her husband’s business because he would have to accompany her during her hospitalization. The surgery would also burden Long’s extended family with the care of her only daughter while she was away. Long’s opt-out decision, despite her insecurity about the mastectomized body, was also made in light of the limited sick leave she was entitled to in her part-time job at a beauty salon. Another consideration was the trouble dealing with hospital bureaucracy including a bribe to expedite her treatment which she had usually paid during previous hospital visits.

All of these financial and logistical intricacies added to the hidden costs of having reconstruction. The women’s non-reconstructive practice was therefore a rational decision to prioritize survival and avoid an imagined future loaded with uncertainties. It was also a decision taken to not risk their moral standing as good Vietnamese citizens by engaging in a practice that was susceptible to others’ disapproval, as we analyze in the following section.

Like “elevating one’s nose”: Breast reconstruction as a cosmetic practice

We had met Mai at two monthly events of the peer support network in Hue before we visited her at home in a newly developed residence zone in the northeast of the city. Contrary to her usual silence at the group gathering, Mai was chatty from the beginning of our visit. She spoke to us about her previous teaching career in Dong Ha (Quang Tri province) and her decision to retire in Hue where she was born and grew up. In 2011 when she was diagnosed with breast cancer, her doctor advised her about an immediate reconstruction. She recalled: “I myself had no idea what it meant but he told me it was possible, so I just went with it. Because at that time I was still working as a teacher in Vietnamese Literature and had to wear áo dài⁶ (traditional long dress) to class very often, I did not want to look asymmetric.” Mai was content with her post-surgical body and commented that even without a nipple, it still looked “authentic and full.” She joked with us that when she was home with her husband, sons and daughters-in-law, she did not need to wear a bra and everyone hardly noticed her reconstructed breast. However, she often concealed her contentment from other peers by responding: “I only did what the doctor told me to do” whenever she was asked about the surgery, and only a few fellow patients knew that Mai “still had two breasts.” (Fieldnote, 2019)

Sixty-year-old Mai was among the very few women we met during our fieldwork who had undergone breast reconstruction. What struck us from the conversations with Mai and other women who had their breast reconstructed post-mastectomy was their attempts to conceal their reconstructive status, either by not speaking about it or adopting a blame-averting strategy. Like Mai, when we talked privately, Duong often told us that she felt “lucky” for retaining her breast since the 47-year-old woman had with quite large breasts and without one she would certainly experience a lot of dressing-related inconvenience. However, at the peer network’s gatherings Duong was strongly vocal against reconstruction, claiming the practice was too costly and harmful to one’s health. She repeatedly asserted that she “had no idea” about the procedure and often referred to herself and other peers who had undergone any form of breast reconstruction as “chuột bạch” (a doctor’s “lab rat”). Shifting the decision-making responsibility onto the doctor and using a metaphor that their surgery was medical experimentation suggested the patients’ skepticism about the procedure’s uncertainties and may signify a lack of trust with health care providers and the health system at large. It could also act to help them avoid the moral judgment attached to reconstructive surgery.

Throughout our fieldwork, breast reconstruction was widely referred to as “làm thẩm mỹ” (doing aesthetics). Our participants believed that it could merely improve the aesthetic aspects of a patient’s appearance, rather than comprising a necessary treatment with medical, psychological, and other practical benefits. This view was partly attributable to the fact that for most women, reconstruction was rarely considered at the same time as their mastectomy, which was a procedure vital to one’s survival. For them the surgery was a cosmetic practice akin to enhancing the face, which was exemplified in one woman’s remark: “[I]t’s using the knife to cut, like people going for a cosmetic [surgery], like you know, elevating one’s nose, I read about this in the Internet, it is terrifying.”

Such beliefs affected perceptions of the appropriateness of the surgery in relation to a patient’s age. Accordingly, many patients cited their old age among the important reasons that discouraged them from seeking reconstruction, believing that an older woman’s beauty was no longer under public scrutiny. It followed that there was a pervasive perception regarding cosmetic practices, including breast reconstruction, as suitable for young women as they needed to “stay pretty” for successful social relationships, be they marriage- or work- related purposes. This age-related notion of reconstruction as cosmetic recalls the gendered standards in patriarchal societies which often emphasize the significance of physical appearance and a woman’s employability or marriageability. In Korea, for example, the growing popularity of aesthetic surgery among young women has been explained in terms of “body capital” improvements that help women boost their competitiveness in the areas of relationships and employment (Holliday and Elfving-Hwang 2012). Our participants’ position that cosmetic practices only have relevance for young age groups can also be understood with reference to the dominance of young women in Vietnamese visual culture, especially cosmetics and fashion advertisements. Additionally, in the post-Đổi Mới decades, women’s magazines and state-run campaigns have long emphasized women as modern subjects who were taught to purchase cosmetics and clothes to stay beautiful and young in order to maintain a “happy family,” but also fulfil their responsibilities as proper citizens in the modernization era (Nguyen 2021).

Notably, in viewing reconstruction as a purely aesthetic practice, many participants viewed this surgery through a moral lens. For instance, when requested to comment on a vignette of a middle-aged patient who was considering breast reconstruction, the women villagers participating in our focus groups strongly opposed a woman’s decision to undergo reconstructive surgery: “She should not do it, rather put that money aside for her children and grandchildren.” They considered it an unacceptable behavior for a virtuous woman, despite the illness context of cancer: “If you do aesthetic surgery and something bad happens to you, they hate you more. They will tell you it [the failure] serves you right.”

In many of our interviews, it was often emphasized that women opting for breast reconstruction deviated from the majority approach. For example, Mong (aged 53) recalled meeting a patient who came to have her breast reconstructed at the same time as her hospitalization:

Interviewer: You told me that you heard from others that it cost 20 million?

Mong: 20 million per breast.

Interviewer: How about you? Will you consider doing it later?

Mong: No. Many patients are much younger than I am, but they have not done it. So why do I? I know that woman coming from Hanoi. She had been treated overseas, in Singapore. And then she came here to do reconstruction. She had bought two [silicone] breasts from overseas, or maybe in Hanoi, I’m not very sure. But she had the surgery here for a week or so. And then she left by plane back home.

Obvious in the description of our research participants was the labeling of reconstructive surgery as a special commodity and a notional class differentiation between someone with reconstructed breasts and someone without. The former was usually described as coming from a privileged background: they resided in big cities with higher status of economic development and could afford luxurious consumption (e.g, “people who are extremely rich will do aesthetics”). Those statements evoked the past socialist public morality of Vietnam, which regarded consumer products as utilitarian benefits that should be rationed (Vann 2012). Under early socialism, Vietnamese communist leaders problematized consumerism and the pursuit of a consumerist lifestyle was judged as an immoral practice. It was to be eradicated and its association with capitalism contradicted socialism and threatened the interests of the state and the society (Bélanger et al. 2012; Marr 1981). As more recent scholarship on Vietnamese socialism has showed, the reform-era following market decentralization and liberalization has seen the rapid expansion of Vietnam’s urban middle class, along with changing patterns of consumer practices, such as increased consumption of luxurious, foreign-brand goods, including vehicles, household appliances, and cosmetics (Hansen 2017; Vann 2012). While a shift away from a centrally planned economy has brought about enormous opportunities in terms of purchasing power and wealth accumulation, it is believed that only a fraction of the population can enjoy the biggest economic gains. They include a large number of high-ranking government officials and those with close ties to the state whose sources of income are often under suspicion (Hansen 2017; To 2012). Considering this post-socialism context, the widespread moral condemnation of luxuries such as cosmetic surgery as revealed among our informants, many of whom are either from rural areas or lower-income households, may be an expression of their position in the social and economic inequities that are increasingly felt across the country.

The morality attached to women’s consumption of reconstructive surgery manifested in our research corroborates previous studies which show that in Vietnam, women’s moral standing is not merely an individual matter. Rather, it is linked with collective ideologies of gendered behaviors. Such social disapproval, then, takes shape within a historical context of the state’s long intervention in women’s consumption practices. In the post-Đổi Mới decades, women were targeted as the subjects of state-run modernizing campaigns whereby they were encouraged to embrace new economic opportunities by buying the right clothes and aesthetic products (Nguyen 2021). However, state movements and campaigns simultaneously emphasized women’s role in retaining traditional values in the new market conditions, expecting them as modern women citizens to behave selflessly and sacrifice for their family (Hoang 2020; Shohet 2021). As captured elsewhere in other post-socialist states, women’s success beyond the domestic domains provoked anxieties over the traditional gendered order, which led to systemic attempts to re-essentialize femininity surrounding maternal roles and criticize excessive women’s consumption (see Leshkowich 2011). In context of Vietnam, the moral condemnation that was explicitly expressed by our participants toward those who consumed a luxury like reconstructive surgery could be seen as their endorsement of the virtue regarding women endurance, placing societal expectations on their ability to carefully ration the limited resources for survival and the family economy, but not for their own cosmetic sake. This key moral ideal strongly shapes the way people perceive women’s consumption behaviors, but also impacts how women who have opted for the surgery speak about their decision in order not to be regarded as socially deviant.

Negotiating predominant discourses of female beauty, femininity, and womanhood

Scholarship on reconstructive and aesthetic decision-making has shown that in considering the procedure, women invariably confront debates about agency and complicity with sexist social values (Manderson 2016) and reigning standards of sexual and physical attractiveness (Wegenstein 2012). This is especially evident where predominant discourses tend to place greater emphasis on the value of breast wholeness for a woman’s femininity and sexuality. For example, when deciding about having her remaining breast removed in lieu of a reconstruction, the American anthropologist Jain (2013:75) once argued that “breasts had forced me to live in a sort of social drag” and brought different expectations for a woman’s behaviors. In Vietnam, women’s bodies have been constantly placed under suppression by Confucian-dominated virtues that expect them to be physically attractive only to the husband (Marr 1981), but also by state discourses targeting the bodies as a dangerous object that needed to be concealed during wartime, or controlled by the national population-planning interventions post-Đổi Mới (Khuat et al. 2010).

Regarding the local ideals of women’s beauty and breasts, people from the Central regions whom we encountered primarily discussed the maternal role of the women’s breasts when asked about the meanings they attached to this body part. In their opinions, the most important role of a woman’s breasts was to produce milk and nurse their children. Standards for beautiful breasts were usually shaped around this nurturing role. For instance, people recalled that a mother of grown-up sons preferred having daughters-in-law with “bụ nở nang” (round, blooming breasts) and large buttocks with a belief that they could give birth easily and produce abundant breast milk. Considering this, the shape and look of one’s breasts could affect a woman’s marriageability: those who had small, flat, deflated (“xẹp lép”) breasts were undesirable due to a belief that they lacked the ability to provide sufficient or good-quality milk to her infants. Aesthetically, our participants stated firm breasts were highly desired and having medium-sized breasts was more ideal than large or flat breasts, but symmetry was always given prominence when judging the beauty of one’s breasts.

In contemporary times visual media has played an important role in sexualizing women’s breasts, making them a visible site of sexuality or eroticism. While in the past women were taught to conceal this intimate part of their body by not wearing breast-revealing clothes in order to stay modest and virtuous, there has been a growing trend in media coverage featuring young, urban women wearing cosmetics and fashionable outfits that expose their cleavage or a significant part of their breasts, conveying the idealized version of modern female beauty. Television and print media are also full of advertisements of breast-enhancing products that are promised to make women more sexually attractive to men (see Drummond 2004 and Earl 2013 for the discussion on the portrayal of women in Vietnamese media post-Đổi Mới).

These normative beauty standards were reaffirmed by the men we met throughout our fieldwork who articulated the significance of breast wholeness to womanhood. A male oncologist we interviewed assumed that post-mastectomy women “no longer feel like a normal person, no longer women.” Likewise, when asked to provide their advice to some woman after a radical mastectomy, the men participating in our focus groups argued for the necessity to retain both of her breasts. Those participants equated a missing breast to a bodily disability by describing a woman without a breast as “a physically handicapped person” and contrasted her situation with men whose status in the society could not be damaged with a physical impairment. For those men, similarly to the women participating in our research, breast reconstruction within a cancer context was widely conceived as an aesthetic practice. However, they did not consider undergoing reconstruction a luxury; rather, they disregarded the economic aspect of the surgery and maintained their support of reconstruction as a technology that was essential to restore a woman’s traits of femininity and make her socially acceptable. Such responses may also point to how having the economic ability to afford reconstruction and an attractive partner also reflects the social standing of men and fits Vietnamese heteronormative masculine ideals as good providers and men’s aesthetic ideals of partners.

Not oblivious to the dominant discourses featuring strong preferences for breast wholeness to femininity, many women patients in our study framed their opt-out by referring to those aesthetic values when describing the husband’s role in their decision-making, for example, in looking for a famous reconstructive surgeon or information related to the surgery. However, speaking of their spouses’ preferences was a means through which our patient informants implicitly challenged and resisted the pressures to conform to the culturally and socially acceptable version of an ideal female body, thereby asserting their sense of control. For instance, 45-year-old Khiem, a senior nurse at a large public hospital, explained her opposition to her husband’s preference for a wholly-breasted state and described it as a rational decision to protect the economic well-being of her whole family, but also sustain her independent status:

My husband wanted me to do the reconstruction because you know men all like beauty. (…). But I do not want to endure another surgery. (…). In my family I am the main income earner. He gives me his salary, but it is only symbolic, cannot even cover the kids’ tuition fees. So I told him I need to survive to keep managing everything.

Reconstructive surgery may offer Khiem the opportunity to repair her mastectomized body and regain a version of femininity that her husband and society expected. However, in her opinion, the security of her future was not subject to the presence of both breasts; rather, it lay with her ability to maintain economic self-sufficiency. Khiem was not an exceptional case among our sample, many of whom made significant contributions to the economy of their households. The post-Đổi Mới era has witnessed women’s rising engagement with the labor market, working in salaried jobs or running household business in response to the opportunities emerging from market liberalization reforms (Leshkowich 2014; Nguyen 2021). Such changes in employment status have led to increased economic independence for women, transforming the class regime of the late socialist state, but also liberating women from patriarchy, as observed in Leshkowich’s ethnography (2014) conducted with petty traders in the south of Vietnam. Our study has further exemplified the changing gender dynamics that occur within the domestic sphere. Women have claimed some agency in relation to their husband when it comes to decision-making about their body as they now possess increased financial independence. The women patients’ accounts documented throughout our fieldwork have suggested how they made the decision to forgo reconstruction as autonomous, rational individuals, and despite their partners. Those women were unwilling to subject their bodies to pleasing their husband’s expectations for wholeness and acted to protect themselves from enduring further surgical interventions or accepting a foreign object (a new breast) implanted into their bodies.

In making the decision to disengage themselves from the practice that promises to align their body with the local ideals of femininity, the women also seek to reconstruct the conceptions of self-identity and womanhood away from the traditional standards that largely focus on a woman’s physical appearance. Thirty-six-year-old Tuyen, whose husband was supportive of and financially prepared for the surgery, resisted his suggestion though she was very young (34 years old) when she had her right breast removed following a stage I cancer diagnosis. Tuyen explained her decision: “If it was my breast loss that made my husband no longer love me, he deserved my abandonment.” Tuyen went on to tell us that, she felt a loss of self-confidence in her sexual life and body image in the first months following mastectomy;⁷ however, she had learnt to cope with the absent breast. An urban resident working as a chief accountant for a private company and with a wide social network, Tuyen claimed that the mastectomized body did not deter her from appearing in public wearing curve-accentuating outfits deemed only appropriate for women with symmetrical bodies, such as swimsuits and áo dài. Using the simple technique of self-tailoring her own prosthesis by sewing additional cushions onto her bras or wearing those specially made for the mastectomized breast, a noninvasive dressing practice exercised by many other women, Tuyen could still opt for the fashionable clothes she had favored in the pre-cancer life. Like her peers in the support network, Tuyen did not hesitate to publish pictures of herself in those outfits on social media and by doing so, claimed that her feminine identity was not located in the breasts and positioned the non-reconstructed body as strong, healthy, and independent rather than weak or “handicapped.” For women like Khiem and Tuyen, their asymmetric single-breasted body has become a site to exercise one’s agency and reinstate ownership over the body and sense of self.

Conclusion: Reconfiguring the decisions against reconstruction

In this article we challenge the assumption that women who decide against breast reconstruction are passive actors who lack agency and control over their bodily experiences. We have revealed how opt-out is indeed a practice made with intention and women are active, reflexive agents of this choice. We have identified the various competing, but intersecting logics that explain women’s decisions to forgo reconstruction post-mastectomy. The persistent moral judgment against breast reconstruction as an excessive cosmetic practice and women patients’ resistance to the procedure in our study might vary markedly with the growing normalization of body modification across East Asian and South-East Asian countries. However, as our analysis has highlighted, opting-out should be located within the broader social and historial context. This includes patients’ previous negative hospital experiences throughout their primary cancer treatment in a context where public distrust with the quality of health care services and professionals is commonplace. Such decisions occur within a system where universal health coverage is absent for certain forms of breast reconstruction, leaving the responsibility for bearing the surgical costs entirely with the women who want to have their breast restored as a delayed procedure. Considering this, we argue that the exclusion of breast reconstruction from public health insurance reinforces the moral judgment that surgery is merely related to enhancing one’s appearance and exacerbates the financial burden on women with breast cancer. The women’s reconstruction decision-making also takes shape within a socialist gender regime where women’s political and economic independence is rising whereas dominant discourses upheld by government policies and the media continue to discipline their compliance with traditional domestic values. As such, through the decision not to have their breasts reconstructed, women both conform to existing social gendered norms within a patriarchal culture while simultaneously challenging and defying them. In paying attention to how women’s decision-making is situated within the local contexts and inter-relational dynamics, we emphasize the significance of having nuanced, contextualized understandings of breast reconstruction choices. Women’s (dis)engagement with normalizing body projects therefore should not be understood merely as missing out on newfound consumerism, a lifestyle choice, or other individual motivations, but as a reflexive negotiation of collective identity of breast cancer survivorship.

Ethics approval

This study was approved by Monash University Human Research Ethics Committee (Project 14130) and the Internal Review Board in Human Subject Research of the Institute for Social Development Studies (Vietnam).

Acknowledgments

We would like to thank all participants for generously sharing their time and stories. Our fieldwork would not have been possible without the facilitation of the Club of Courageous Women (Câu lạc bộ Phụ nữ Kiên cường) and many doctors and nurses at three oncology hospitals in Hanoi and Hue. We dedicate this work to the loving memory of Lượt and Khanh.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The study is conducted within the first author’s PhD program at Monash University for which she received Monash Graduate Scholarship and Monash International Tuition Scholarship. The first author also benefited from Barbara Rosenblum Scholarship for the Study of Women and Cancer by the Sociologists for Women in Society and the Postgraduate Publication Award by Monash University during the preparation of this manuscript.

Notes on contributors

Trang Thu Do

Trang Thu Do has worked at the Faculty of Arts, Monash University as a Research Officer after completing her PhD. Her research focuses on women’s health, chronic conditions, gender and social inequalities. She has recently started her postdoctoral position at the Murdoch Children’s Research Institute in Melbourne where she is working on implementation of genomics into clinical care.

Andrea Whittaker

Andrea Whittaker PhD, FASSA is Professor of Anthropology at the School of Social Sciences, Monash University, Melbourne, Australia. As a medical anthropologist, she specialises in the fields of reproductive health and biotechnologies.

Mark Davis

Mark Davis is Associate Professor of medical sociology in the School of Social Sciences at Monash University. His books include Selling Immunity: Self, Culture and Economy in Healthcare and Medicine (Routledge) and Pandemics, Publics and Narrative (Oxford University Press) written with Davina Lohm.

Notes

1. Our observation resonates with the few data that are available on breast reconstruction in Vietnam. A recent study based on 202 responses from women with breast cancer across Vietnam estimates that only 10% of the surveyed woman underwent the surgery (Tran et al. 2022). Unpublished reports from the oncology ward of the hospital where we conducted our ethnography reveal that in 2018 they performed reconstructive surgery for 23 women as compared to 255 mastectomies.

2. According to this belief, a woman’s beauty is considered acceptable only when it is achieved naturally or look natural.

3. The pre-Đổi Mới (Renovation) era was characterized by Vietnam’s political and economic isolation from the West following the end of the Vietnam War (1975), and the authoritative role of the Communist Party in managing and distributing goods and services. This so-called state subsidy period came to an end in 1986 when reforms were officially announced in the wake of a political and fiscal crisis throughout the 1980s. The Đổi Mới era has seen the de-collectivization of agriculture, the expansion of the private economy, trade liberalization, and the removal of state subsidies, even though the Communist Party remains the ruling party (see Beresford 2008; Gainsborough 2010).

4. See Ministry of Health’s Decree 39/2018/TT-BYT and Decree 13/2020/TT-BYT.

5. Nguyen Dynasty was the last imperial monarch ruling Vietnam from early 1800s to 1945. The Nguyen replicated the Chinese Qing monarch whereby Confucian ideologies were highly emphasized and promoted (McLeod et al. 2001). Due to this historical context, Confucian ideologies still greatly influence the culture and everyday life in Thua Thien Hue province, which might explain the more conservative attitudes held by the people we met during our fieldwork toward reconstructive surgery and women’s consumption behaviors.

6. Áo dài is the traditional costume usually worn at formal occasions, such as Lunar New Year or wedding, as a uniform at certain schools and political organizations, and a compulsory garment at every beauty pageant. Although in the past it was worn by both sexes, now Áo dài’s meanings are associated with the Vietnamese traditional concept of beauty and femininity. Because it is often made with transparent fabrics and requires custom tailoring to make it a form-fitting dress, it accentuates the shape of the wearer’s body and all natural curves (Lieu 2000), despite its being a long flowing dress, covering almost every part of the whole body.

7. Tuyen shared with us that breast cancer negatively affected her sex life, especially in the first year of primary treatment when she rarely had sex with her husband. Tuyen, like many women we interviewed during our ethnography, reported feeling insecure about their body after the mastectomy. Many told us the story of wearing a shirt or a bralette while having sex. For most of the women patients, the frequency of sex declined as compared to the pre-cancer period. However, they mostly attributed changes in their sex life to the side effects of hormonal therapy they had been undergoing which caused vaginal dryness and lessened their sex drive and pleasure, rather than a consequence of a breast loss.