Three days before Christmas 2015, when I was 19, I had my breasts reduced in size. Sitting alone in my flat after the operation at Ross Hall hospital in Glasgow, I confronted my scars for the first time, and I cried.
It was not the first time that I had cried over my body, but these were not the tears of a miserable, frustrated teenager. I felt as if I had been through a battle and had emerged victorious. Holding those stitched-up breasts, a manageable 32E down from a 34GG, I was finally, gloriously me.
After Simona Halep was crowned the 2019 Wimbledon champion, I wondered if she had felt the same after her surgery 10 years ago. Halep, then a 17-year-old rising star, had felt that her chest was affecting her game, and opted to have her breasts reduced from a 34DD to a 34C. “It’s the weight that troubles me,” she said at the time. “My ability to react quickly – my breasts make me uncomfortable when I play.”
Although she told Sports Illustrated last year that her breast-reduction surgery had been her “biggest sacrifice” for the sport, Halep has said she has never regretted the decision. “I didn’t like them [her breasts] in my everyday life either. I would have gone for surgery even if I hadn’t been a sportswoman.”
Today, as a 23-year-old journalist, I still feel the magnitude of my decision, and its impact not just on my body, but on my mental health and every other aspect of my life. I no longer need to hide my body under layers of clothing or sleep in a particular position to avoid strain. I can sit up straight without attracting stares, or accusations of being attention-seeking. Most liberating of all, the operation freed me from chronic headaches, and back and neck pain that had led me to take painkillers every day.
Breast-reduction surgery is carried out under general anaesthetic, most often by cosmetic surgeons in private practice. The operation usually involves removing excess fat, glandular tissue and skin, and reshaping the remaining breast tissue. The nipple is moved, creating a scar that, for most women, runs vertically and across the breast crease in an anchor shape.
The operation can remove up to a kilogram from each breast, and takes between 90 minutes and four hours, depending on the extent of the reduction; a two-night hospital stay is recommended. It is also expensive: about £6,500, according to the NHS, excluding any consultations or follow-up care.
Despite all this, the number of people having the procedure is on the rise. In 2018, 4,409 women had their reductions paid for by NHS England, up from 4,354 in 2017, 4,188 in 2016 and 3,959 in 2015. The British Association of Aesthetic Plastic Surgeons’ annual audit in May found that it was the second-most-popular procedure for women (after breast augmentation), with 4,014 women in the UK having paid to have their breasts reduced in the past year, an increase of 7% between 2017 and 2018.
That so many women are prepared to shoulder the cost themselves is testament to the life-changing potential of the procedure. A 2010 study by Georgetown University Hospital found that many breast reduction patients reported an improvement in their chronic headaches and migraines following reduction surgery.
Patient satisfaction is high: in 2012, a 10-year retrospective analysis of 600 consecutive patients at a single institution in the US found that more than 95% of them would opt to have the surgery again. It concluded that there was a demonstrable improvement in the patient’s quality of life, regardless of their weight and size or how much breast tissue was removed.
“I don’t even consider a breast reduction to be a cosmetic procedure – it’s an incredibly beneficial operation,” says Chris Hall, a consultant plastic surgeon in Belfast and a member of the British Association of Plastic Reconstructive and Aesthetic Surgeons (Bapras). “The physical benefits, how patients feel psychologically afterwards and the improvement of their quality of life are all well-documented. Unfortunately, the eligibility criteria set, which has been increasingly tightened over the years, makes it almost impossible to get the procedure on the NHS.”
The NHS criteria are supported by the Academy of Medical Royal Colleges, which includes the Royal College of Surgeons and the independent assessors the National Institute for Health and Care Excellence. A patient must have had a steady BMI of less than 27; their breasts must be of “massive disproportion to body habitus”; they could or should have “intractable intertrigo” (inflammation caused by skin-to-skin friction), “asymmetry greater than one cup size” and “significant psychological distress”.
But many women who have sought to have their surgery covered have complained of inconsistencies and lack of transparency over how to qualify. Amy Hill, a 23-year-old personal trainer, was initially rejected for a breast reduction despite a bra size of 28KK. “I hated my breasts – they were a constant strain on me,” she says.
Getting a bra was impossible. When she went to Bravissimo, a specialist shop with the slogan “inspiring big-boobed girls to feel amazing”, they told her that they didn’t make them in her size. “I cried in the changing rooms.”
For the best part of a year, she wore a bikini top. “It was all that would fit me. I would always attract unwanted attention: people thought they were fake. You could always see them. They were enormous.”
When Hill was told that she did not meet the criteria for a reduction – “they told me they didn’t affect me mentally enough” – she blacked out, she says. “I was so desperate for it. For someone to turn around and tell me ‘no’ – it devastated me.”
But she kept pushing. “The whole process was so long and exhausting. I would wait three months for an appointment for them to then tell me something they could have told me on the phone. I was going to give up, but my mum had had [the operation] when she was my age, and told me that I needed to just keep trying. She said that it wasn’t as hard for her as it was for me.”
Hill eventually had a breast reduction on the NHS in 2016, when she was 21. In hospital, after her operation, a nurse didn’t believe that her breasts had previously been as large as she said. “She made me get out of the bed to measure them,” says Hill. “Everyone else in the ward was commenting that I couldn’t have possibly been the size I said I was; that it was impossible.
“I was so embarrassed, I cried. I felt a bit shamed by people for not appreciating my breasts, and wanting to get rid of them.”
But Hill has not regretted the operation for a moment. “Before, when I went to the gym, I had to wear three bras. Now, within a year of beginning training as a personal trainer, I’m opening a gym of my own. I was very lucky to get the procedure.”
The eligibility criteria differ in every sector of the NHS, meaning that women seeking the surgery are almost at the mercy of a postcode lottery, says Russell Bramhall, a consultant at the Canniesburn plastic surgery unit in Glasgow Royal Infirmary. “I cannot remember the last time I did a breast reduction on the NHS. Everything has got tighter and tighter; we work in a poorly funded state system.” The referral process and long waiting times can also be a barrier.
In my case, I was right to compare my journey to a battle. I campaigned for my operation to be performed by the NHS for four years. NHS Scotland recognises breast reductions under its exceptional referral protocol for procedures that are not treating an underlying disease process, and thereby only provides them on very rare occasions. Patients must be referred to a clinical psychologist after assessment and are subject to the decision of a clinical commissioning group.
I was expected to strip and stand at every consultation, poked and prodded by male doctors, student doctors and nurses. I felt I had no choice – it was as if by opting to have the surgery, I had given up my right to privacy.
At one appointment, a young GP printed off NHS advice on breast reductions after Googling it. At my psychiatric evaluation, a female clinical psychologist asked me: “When you say you think people are staring at you on the street – are you not staring at them first?”
After an exhausting, humiliating and intrusive fight with my GP and NHS Scotland, I ended up paying for the operation myself. The system effectively pushes women seeking breast reductions into the private sector, say Bramhall and Hall.
Ann (not her real name), a 22-year-old student living in Scotland, wants a reduction operation for her 36FF breasts, but can’t afford to go private. “I want to like the way my breasts look, but I really don’t, even though all my sexual partners love them. There have been times when I have felt so frustrated, I have imagined the psychological and physical relief of just chopping them straight off my body. They don’t make me feel more feminine, so I don’t think I’d feel less of a woman without them.”
Ann finds that clothes never fit properly, and bras cost much more than those in standard sizes. But most of all, she says, “my back hurts – but not enough for the NHS”.
Bramhall says that as well as the physical problems associated with large breasts – “back pain, shoulder pain, infections, bra straps cutting, impetigo-like thrush under the breast” – the impact on people’s mental health and quality of life is often not considered. “A common mental symptom in my patients is low self-esteem and poor body image. They lack confidence socially, and when they are out of their clothing with their partners. I get women all the time who describe not feeling comfortable in swimwear or summer clothing – the amount of pleasure they get in summer is lessened. People wear loose clothing all the time to camouflage their appearance. It’s not taken into account at all.”
Those who can’t afford private surgery may be tempted by cheaper options that are not always safe or well-regulated. Bapras members report seeing patients who had post-op complications after cosmetic procedures outside the UK, where eligibility criteria are often more lax or even nonexistent. In many cases, having unmanageably large breasts is associated with health complications such as obesity, due to the inability to exercise, and anxiety and depression, due to low self-esteem and self-image (which can morph into body dysmorphic disorders).
Hall says the NHS criteria can deny surgery to those who need it most. “A lot of the criteria are based on poor evidence: for example, it is very hard to maintain a BMI of below 27 for two years with large breasts. You can’t exercise. If you are slim, they look bigger. If you are a size M, your breasts can weigh the equivalent of 2lb of sugar on both sides.”
Both consultants acknowledge the pressure that the NHS is under, leading it to prioritise trauma and cancer cases. “The NHS doesn’t have a bottomless pit of money,” says Hall, “but what Bapras would like is transparency and uniformity. We would like the same eligibility criteria across the country so it is consistent, no matter where you live. If the NHS decides that no one is getting a reduction, then it should tell us that there is no money, and that it isn’t going to fund it.”
It speaks to a wider issue in women’s health issues not being taken seriously that every year, thousands of women are paying for a procedure that undoubtedly improves their health and quality of life. I had struggled with the decision to seek surgery, wondering if it was anti-feminist to want to change my body – but my reduction turned out to be the most empowering decision I had ever made. It was not just about making my breasts smaller – it was a path to a life of confidence, free from pain. I gained autonomy over my body, but I had to fight for it.