Free breast alteration surgery in India’s Tamil Nadu: Is there a case for public funding?

Prioritising cosmetic surgery is debatable given the many critical unmet health needs among women

Lakshmi Narasimhan and Vandana Gopikumar

Recently, the state government of Tamil Nadu, India, announced that breast alteration surgery would now be free for women from low income backgrounds through the plastic surgery unit at Stanley hospital, a publicly funded tertiary care centre. The hospital, which had reportedly already been performing free reconstructive surgery for breast cancer survivors, will now extend the service to women “who want to increase or reduce their breast size,” although the BBC reports that women seeking augmentation will have to pay some money for implants.

Several countries, foremost among them Brazil, already have a culture of beauty as a right, with people from low socioeconomic backgrounds offered cosmetic procedures for free or at discounted rates. Proponents of the initiative in Tamil Nadu say that cosmetic procedures, including invasive ones, should be accessible to people from diverse socioeconomic backgrounds and that there are psychological benefits to be had from breast alteration surgery.

The idea of cosmetic surgery being available to all women could be argued to be progressive—a strike back against paternalistic attitudes that determine what poor women “deserve” to have access to. And, as the feminist and medical sociologist Kathy Davis has pointed out in her book Reshaping the Female Body, which looks at the first person narratives of many women, cosmetic procedures can be empowering for women who see it as a way to reclaim their body and sense of self.

However, the idea that women’s body image issues and the associated effects on self-esteem can in some way be “fixed” by a cosmetic procedure does not always stand on firm ground. While studies have demonstrated that many women report postoperative satisfaction, the effects of cosmetic surgery on long term psychological outcomes are mixed, with some studies finding a higher than expected rate of suicide among women who underwent breast augmentation. This association does not, of course, indicate causality—other factors may be at work, including the likelihood that women who undergo breast surgery may have had psychosocial risk factors before the procedure. Nevertheless, the current level of evidence suggests that we should be cautious in attributing psychological benefits to cosmetic surgery.

More importantly, the remit of women’s mental health goes far beyond body image issues. India performs poorly on indices of gender equality, with women facing considerable inequalities in terms of their health, education, and economic rights. Women are disproportionately affected by common mental disorders that are associated with socioeconomic deprivation, gynaecological morbidity, and gender based violence.

Poverty among women in India is often multidimensional: it manifests not only in income, but also in lower educational attainment, poor sanitation, low social rank, and pervasive gender disadvantages. These disadvantages manifest at the policy level too, with the representation and participation of women across various levels of government remaining low.

In Tamil Nadu, one of the few states in India with the reputation of having a better public health system, it’s been found that over half of women have anaemia, over three quarters were not paid in cash for work or did not own their own land/home, and three quarters of women in rural villages had no access to sanitation. Despite making strides in infant and maternal mortality rates in Tamil Nadu, women’s health still requires far more substantive investment than the INR 52 800 crores set aside for health at the national level—one of the lowest health spending among low middle income countries.

Our work at the Banyan, a not for profit organisation in Chennai, focuses on supporting homeless women with mental health problems. These women’s stories of descent into homelessness are often characterised by disruptions in dependency relationships against a background of extreme poverty. In such a context, can women from marginalised communities truly make the choice to have cosmetic procedures as autonomous subjects for their own desired ends? These seemingly choice based transactions become contentious in an imperfect world where women’s bodies are constantly scrutinised under the hegemonic male gaze. Prioritising cosmetic surgery is already debatable given the many critical unmet health needs among women, but especially so when you consider the gender politics of Indian society.

Breast alteration surgery may make many women feel more in tune with the look they want for themselves, and by all means the option to make such choices should not remain in the realm of the rich. However, in a society largely shaped by a patriarchal order, where women often lack agency, promoting such an initiative as a means of improving self esteem may end up perpetuating sexist notions of the ideal female body. With many women in Tamil Nadu facing serious and multifaceted poverty, their mental health needs may be better served by helping them identify and assert their agency beyond sexist narratives. Then women will truly be able to make choices.

Lakshmi Narasimhan, PhD scholar, Athena Institute, Vrije Universiteit, Amsterdam, leads the BALM-Sundram Fasteners Center for Research and Social Action in Mental Health, the Banyan, and the Banyan Academy of Leadership in Mental Health (BALM).

Vandana Gopikumar is co-founder of the Banyan and the Banyan Academy of Leadership in Mental Health (BALM), organisations based in India that focus on developing comprehensive mental health solutions for people with mental illness who are homeless or live in poverty. She is also professor, School of Social Work, Tata Institute of Social Sciences (TISS).

Competing interests: None