If I wanted to have a career touring the country as a feature dancer—or glorified stripper—I’d get implants. Not only would I make a fortune on the road, breast implants would take me to the next level of my film career, according to my agent (he said I’d never be in the upper echelon of porn stars otherwise). I briefly entertained the thought of implants and went so far as to get a consultation, but in the end wasn’t brave enough to go under the knife. I was too afraid of coming out lopsided; I imagined a future where one boob spontaneously burst during a rough sex scene or due to a minor car accident during L.A. rush-hour traffic. I didn’t have the courage to face that future; somehow my agent’s ridicule was more tolerable. Personal preference aside, my agent was right about one thing: big boobs sell themselves. Of course, at the time no one had heard the term “BII”—breast implant illness.

Suffering from migraines not even medication could dull, constant fatigue, hair loss, and a myriad of other symptoms, Karmen Karma has been in and out of doctor’s offices for the last year trying to reclaim her quality of life. All the tests came back normal. How she could be in her twenties, supposedly in the prime of her life, yet feel closer to 60 was a mystery until a couple of months ago, when a worldwide recall was issued for textured breast implants. “I had the same ones that were recalled but mine were smooth not textured, and I got worried,” says Karma. “I read about breast implant illnesses and it sounded like everything I had.”

It hadn’t always been that way.

In 2014, a year and a half into her career as an adult actress, Karma heeded the advice of her agent and industry colleagues and opted for a breast augmentation. It was an instant career boost. “I struggled with getting work in the beginning because of my tattoos. As soon as I got my implants, all these companies that weren’t shooting me before were suddenly interested,” recalls Karma. “I guess I’m happy I got them even after everything that’s happened because they made me so much money.”

Towards the end of last year, Karma had a second breast augmentation—this time to replace her old implants. With a post-baby body, her proportions had changed and it was either go bigger or get a lift. Karma went bigger. That’s when the problems began. Realizing her implants were having a negative effect on her health, Karma struggled with the decision to have explant surgery, concerned about how it could impact her career. “I just though, what’s more important, being an active part of my daughter’s life or continuing to live like this?” Karma opted to explant last week. Though she’s still recovering and in her first week post-surgery, she says she feels better now than she has in almost a year.

With the release of her first book, Overcome, a memoir chronicling her adult career and journey to sobriety, Karma gained a new sense of confidence in her ability to earn a living without implants. “Before, it was like what else would I do? I make so much money and it’s what I know how to do. I don’t have a degree, I have tattoos all over me, and I’ve done porn. I don’t know what else I’d do but now that I wrote the book, I feel like if no one wants to see me anymore I can take a different avenue,” says Karma. “It’s the first way I’ve made money without my body, not that I’m ashamed of porn or anything I’ve done.”

“ I was told by certain male overseers, agents, and directors, that if I got my boobs done I’d make a lot more money, so in my naiveté I jumped at the first doctor I could find to do the procedure. ” — Nicole Aniston

Many other women in the adult industry face similar circumstances, and feel forced into making decisions that pit their health against the only career they’ve known.

“I was told by certain male overseers, agents and directors, that if I got my boobs done I’d make a lot more money, so in my naiveté I jumped at the first doctor I could find to do the procedure,” recalls adult actress Nicole Aniston.

Excited and happy with her new look and the additional work it brought to her, it would be several years before Aniston had a second procedure and then later a third to correct the work that wasn’t done properly the first time around. “After I went smaller in November of last year, I couldn’t shake the feeling that something wasn’t right,” says Aniston, who’d begun to experience some unpleasant side effects.

Before considering implant removal, Aniston had to consider the impact it would have on her earnings. To do that she turned to social media, where she has over half a million followers to query. “I put it on social media for my fans so they could prepare for it,” says Aniston. “I know now that if I never shoot for another company again, the fans that are really interested in my life who follow me on OnlyFans and Snapchat are dedicated to seeing me as a woman and will continue to support me.”

With dedicated fan support, women in the industry have more power to choose their health over implants while maintaining a successful career—especially with the prevalence of webcam modeling.

Renowned webcam model Christy Foxx had always wanted breast implants; in fact, she’d been planning on it since the age of 16. “I did so much research on what kind, what size, what brand, high or low or teardrop, I focused so much on what kind of implant I wanted that I didn’t look into the risks of getting it,” says Foxx.

She wasn’t prepared for the side effects. “I struggled with the fear of taking them out and what they would look like even though I had all kinds of physical problems, breathing issues, severe memory loss. I was fatigued and tired all the time,” Foxx remembers. “I’d have to lift both of my boobs up just to take a deep breath. I had no idea what BII was. I’d never heard of it before and didn’t think anything of it until my friend had her implants removed.”

Several procedures later, Foxx is feeling better now with a different set of implants; she’s not ready to give up on them just yet but says if her quality of life begins to deteriorate again, she’ll choose her health.

Nonetheless, if she could give some advice to her younger self it would be this: “Don’t do it, don’t do implants. Not that BII happens to everyone but you don’t actually need them for the job. If I could go back in time I’d never have gotten them in the first place.”