Tekhnē of reconstruction: breast cancer, norms, and fleshy rearrangements

Abstract

This essay is an engagement with and a rejoinder to Audre Lorde's framing of prosthetics and breast reconstruction in her seminal The Cancer Journals. Given that, as Susan Merrill Squier has argued, human life is increasingly defined and understood in terms of discourses and possibilities for the “instrumental deployment of resources for bodily renewal,” this essay explores how the body/materiality might be understood in relation to the tekhneē (the technologies, techniques, and craft) of reconstruction three decades after Lorde's account.

Keywords:

• breast cancer
• reconstruction
• prosthetics
• norms
• flesh
• technology

Acknowledgements

This paper is dedicated to my mother, who passed away from breast cancer in 2003, and to Thomas Lam, James French, Rita Vingati-Orme, and all the wonderful people associated with the Breast Cancer Clinic at Westmead Hospital, Sydney, Australia. The author thanks Shiloh Krupar, for helping to conceive this project and work towards its conclusion.

Notes

1. This ethno-critical study of breast cancer and breast reconstruction web forums has been conducted over a three-year period. In this paper, the material I reference is drawn from one primary breast cancer forum that covers general topics. This site currently has 96,848 members on its discussion boards (as of May 2011), and 66 individual forums covering 73,744 topics. Information in this study is also gleaned from analysis of numerous sites that are dedicated to issues of breast reconstruction, although I focus here on the materials from one particular site that currently has nearly 2000 members. For anonymity purposes I have not named the sites or any of the participants in the forums. One of the very important points that I have not been able to address in this paper is the incredible disparity in who is offered or is able to access breast reconstruction. Such disparities are invariably predicated on race, ability to speak the dominant language, level of education, access to medical insurance, and socioeconomic status. For instance, the November 2008 issue of Archives of Surgery reported that black women in the United States are 47% less likely than other women to undergo breast reconstruction after having a mastectomy. Further, they will have fewer referrals to plastic surgeons, and if they do have a referral, they have a lower rate of going to those referrals. If these women do see a plastic surgeon, reconstruction seems to be offered with less frequency. See “Multilevel Analysis of the Impact of Community vs Patient Factors on Access to Immediate Breast Reconstruction Following Mastectomy in Maryland”: http://archsurg.ama-assn.org/cgi/content/short/143/11/1076 (accessed May 23, 2011).

2. BreastCancer.Org: http://www.breastcancer.org/symptoms/understand_bc/statistics.jsp (accessed May 23, 2011). Also see detailed information in The American Cancer Society “Breast Cancer Facts and Figures 2009–2010” document: http://www.cancer.org/acs/groups/content/@nho/documents/document/f861009final90809pdf.pdf (accessed May 23, 2011).

3. See Susan Sontag (1990), who examines the discourses surrounding cancer, particularly as they pertain to notions of silence and concealment.

4. For other analyses of breast reconstruction, see Hallowell (2000), and Wilkinson and Kitzinger (1994, 2003).

5. This is an idea that I return to in the last section of this paper.

6. This idea follows from Derrida's notion of différance: the understanding that no term has independent value or meaning but, rather, that “there is an overflowing and intermingling of categories, a mutual dependence that belies the traditional insistence on clear and distinct divisions. Moreover, nothing is fixed in essence or given in advance of its representation; on the contrary, insofar as it is constructed through a tissue of mobile differences, meaning is fully discursive” (Shildrick 2005, 6).

7. In Discipline and Punish, Foucault (1991) explains that this disciplinary form of power emerged in eighteenth-century Europe and eventually overlaid an earlier form of power premised on the rule of the sovereign. This earlier form of power, according to Foucault, was a vengeful power. It was punitive in nature and execution; it exerted itself directly on bodies through corporeal punishment and, through spectacle and ritual, confirmed the absolute power of the ruler and their right over life and death. Changing power relations within the social body and the increasing inefficiency of sovereign power, however, resulted in the emergence of disciplinary power. This modern form of power continues to target the body—the individual body—but through different means. Where sovereign power wielded direct force and control over the corporeal, discipline—or what Foucault alternatively calls the anatamo-politics of the body—works through coercion to modify and manipulate the body. This is “achieved” through various techniques and technologies that distribute individual bodies: they are surveyed, organized, separated, and hierarchized in developmental sequence according to a constructed norm. The techniques also operate to control the individual body so as to produce a docile and useful—a productive—subject.

8. Butler's account of power as a “regulatory regime” operates “not only as an external constraint or repression [ … ] but as the formative principle” (1992, 64).

9. Also see Ladelle McWhorter (2004, 155), who argues: “We cannot defy normalization insofar as it gives us ourselves entirely, but we can resist and gradually perhaps dismantle normalizing technologies and disciplines.” I address how this might be imagined in the latter part of this paper.

10. In Hermeneutics of the Subject, Foucault defines bios (life) as the object of techniques, as “the correlate of a tekhneē.” In this understanding, the life of the population and the individual body “became known, measured, and mastered thanks to a number of instruments and objectives which characterized the tekhneē” (Foucault 2005, 486).

11. As Judith Butler (1988, 521) has argued, for instance: “[T]he body is understood to be an active process of embodying certain cultural and historical possibilities, a complicated process of appropriation … [T]he possibilities that are embodied are not fundamentally exterior or antecedent to the process of embodying itself. As an intentionally organized materiality, the body is always an embodying of possibilities both conditioned and circumscribed by historical convention. In other words, the body is a historical situation … and is a manner of doing, dramatizing, and reproducing a historical situation.”

12. The individual is called on to regulate (and produce) themselves as particular kinds of subjects, in the name of “health” and through specific medico-juridical techniques. As Elizabeth Grosz notes, “subjects thus produced are not simply the imposed results of alien, coercive forces” (1990, 65). Rather, subjects participate in these techniques of regulation through their active engagement with medical protocols and norms: for, what medicine offers is “the possibility of vanquishing the sufferings of the flesh, or at least postponing them, through the instrumentalization of life by medical criteria and procedures” (Rose 1994, 68). The self is thus interpellated as an active agent, and medicine is generally constructed as enabling self-empowerment. On the instrumentality of medicine and the politics of life, see Nikolas Rose—specifically his recent book, The Politics of Life Itself: Biomedicine, Power, and Subjectivity in the Twenty-First Century (Rose 2007). As he has argued: “a new ontology of ourselves constituted by medicine appears to offer us a rational, secular and corporeal solution to the problem of how we should live our lives for the best; of how we might make the best of our life by adjusting it to our truth, by letting medicine enlighten our decisions as to how to live it” (Rose 1994, 69).

13. I am making a distinction here between discipline and the more traditional understanding of technology (which I am referring to as “hard” technologies).

14. In this vein, Zylinska has argued that “[t]he human is thus always already prosthetic, whereby relationality and dependence on ‘the outside’ are the condition of his emergence and existence in the world. [In this way, we can see] ‘technology as originary and inevitable enhancement’” (2010, 156). Also see Pugliese and Stryker (2009, 2), who further this point in reference to the term somatechnics: “At its most quotidian, somatechnics references the particular ensemble of embodiment practices operative at any given place at any given time, but it also gestures more grandiosely toward an ontological necessity, a general somatechnic imperative that governs the field of our collective being … we have never existed except in relation to the techné of symbolic manipulation, divisions of labor, means of shelter and sustenance, and so forth.”

15. On prosthesis as metaphor or trope, see Sobchack (2006) and Jain (1999).

16. These are so-called “gummy bear” implants: they are more cohesive silicone gel-filled breast implants made of a firmer silicone gel filler to help maintain the shape of the implant. See US Department of Health and Human Services: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm063719.htm#2 (accessed May 23, 2011). These implants are used as the standard for breast reconstruction in Europe, the United Kingdom, Australia, and Canada.

17. See the online site, “BreastReconstruction.org”: http://www.breastreconstruction.org/SecondaryProcedures/NippleAreolaReconstruction.html (accessed May 23, 2011).

18. See Vivian Sobchack (2009).

19. I use ethics here in a Foucauldian sense to denote the “relation the self has with itself as it crafts a life for itself, as it struggles with the terms of a meaningful life and, implicitly, a meaningful death” (Murray 2006, 209). Ethics, in this understanding, however, is not just about the self, but also about the pursuit of how one should best relate to others. Ethical activity, for Foucault, has to do with individual and collective actions and choices about how we wish to exist in the historically and culturally specific conditions we find ourselves within: it is about reflecting on how we are constituted as subjects and how we might live (and die) otherwise to normative conventions.

20. It is important to note that this biosociality does not just take any form. The group I refer to here is highly self-selecting and regulated: to become a member, one needs to prove that they are actually a breast cancer patient by posting a required number of times on another breast cancer discussion site, they must request permission to join the group, the administrator of the group will vet them, and they must post a particular number of times to assure other members that they are not just “lurking.”