“My breasts have always made me feel like I look older than I am,” Thembelihle Mkhwanazi (26) says. She is a candidate on the waiting list for a breast reduction surgery at Durban’s Inkosi Albert Luthuli Hospital (IALH). She had initially been scheduled for surgery in 2020 but due to the COVID-19 pandemic, that had to be put on hold. Now it seems 2022 may be the year she finally gets her new start.

Thembelihle has macromastia (enlarged breasts) and is one of many South African women who suffer from this condition. Macromastia causes symptoms such as back, neck, and shoulder pain, which is not alleviated by medication or physiotherapy. For some women, it may go as far as causing scoliosis (bent spine). Other symptoms of enlarged breasts are rashes, called intertrigo, within skin folds and ulcers because of lack of blood supply to the skin— Thembelihle who is currently a G cup, experiences all of these symptoms.

Apart from the physical symptoms, women with enlarged breasts also have emotional and mental struggles. Being hyper-sexualised, often from as young as 12; struggling to find bras that fit and are appealing; having to dress modestly to avoid attracting ‘too much’ attention to themselves; and not being able to participate in everyday physical activity. All these things often hinder a woman’s self-esteem and Thembelihle says she felt like she lost a lot of her childhood and confidence because of this. A breast reduction can help alleviate these physical, emotional and mental symptoms and can allow a woman more freedom to lead a more active lifestyle.

Patients seeking a breast reduction in South Africa have two options; they can either go to private practitioners or to a state hospital. The procedure costs anything between R62 000 to R80 000 (US$3875-5000) at a private hospital and most South African women cannot afford that so their next best option is a state hospital. The South African Department of Health offers subsidized or free breast reduction surgeries at selected hospitals around the country. Each year, IALH in Durban earmarks 1 week in March to perform reduction procedures and as a result, the waiting lists are long and the process of qualifying for a free surgery is a lengthy one. A candidate who wants a breast reduction must first visit a local clinic where they are assessed and transferred to a regional hospital. MRI scans are done and a physiotherapist does evaluations at the regional hospital to see whether the breasts are a real issue and if it is really difficult for the patient to lead a normal life. After these assessments, the patient is transferred to a specialist hospital (IALH in Thembelihle’s case) where plastic and reconstructive surgeons will see them, and their names enter a long waiting list.

Private medical schemes in South Africa do not consider breast reductions as medical procedures, even when doctors make motivations for their patients. Dr. Isabel do Vale, a cosmetic surgeon and member of the Association of Plastic and Reconstructive Surgeon of Southern Africa (APRASSA) wrote: “Women who request breast reduction usually have excessively large breasts that are out of proportion with the rest of their body. This puts additional strain on the neck and upper back, causing unbearable physical symptoms including neck, back, shoulder pain, and headaches.” Even with that information private medical schemes still do not cover breast reductions. They claim it is difficult to draw a conclusive link between the size of breasts and musco-skeletal pain. APRASSA has lobbied medical aids for years to make the criteria a bit more reasonable and inclusive of a wider range of patients to no avail.
Discovery Health, one of SA’s largest medical aid schemes, says they cover breast reduction for members on higher plans who have specific clinical needs for these procedures. This obviously leaves a majority of women, who are either unemployed or earn lower incomes to depend on the overburdened state hospital programmes or just live with the physical, emotional, and mental burden of having large breasts. Momentum, another medical aid scheme, said they would take a look at their policies after “Good Luck” lead singer Juliet Harding’s claim was rejected by the medical aid and she took to Facebook to talk about it. Overall SA medical schemes consider all cosmetic surgery a General Scheme Exclusion.

In a patriarchal society, women with large breasts are objectified and ridiculed for wanting smaller breasts. You only have to go through the comments made by men in the social media posts of women who have had or are seeking breast reductions to see that men believe women’s breasts are for their viewing pleasure. Add to that that we live in Africa where cosmetic surgery is still a taboo and you have a cocktail of ridicule and manipulation by society toward women who want breast reductions. Thembelihle experiences this from community members who say there is no need for her to change her ‘God given gifts’ and ask her what her husband will lean on if she has small breasts or how she will breast feed her children. As Twitter user @oldladypants wrote after her procedure on Medium after her reduction procedure: “F U patriarchy” 

The surgery is considered to be a high-risk procedure and as a result candidates are required to have a BMI of less than 30 and to have no other co-morbidities. During the procedure excess breast tissue, fat, and skin is removed and the nipples and areolas are repositioned; and the breast is reshaped. Recovery takes anything from six to 12 weeks and there are risks of complications such as sepsis or losing the nipples. After having the risks thoroughly explained to her by her surgeon, Thembelihle is still very keen on getting the reduction done. She is also very grateful for the support she has received from her family and friends. And though some people still think she shouldn’t get the procedure done she is adamant that she should do it for her health and peace of mind.

With a long, strenuous, and painful journey hopefully finally coming to an end Thembelihle says: “I look forward to no longer having back pain; to no longer getting rashes under my breast. I’m looking forward to finding bras easier and I am especially looking forward to having no bra days where I can just let them hang loose! But more than anything I’m looking forward to being a healthier and happier me.”