My longtime patient Brenda let the top of her exam gown drop to her waist, stepped down off the exam table and turned to look at herself in the mirror. As I watched, she cupped her seventy-eight-year-old breasts in her palms and unceremoniously hoisted them up to where they’d probably resided when she was in her twenties.

“I’m thinking about having my boobs done,” she said. “My girlfriend had hers done, and she’s very happy with how they turned out. What do you think, doctor?”

As she spoke, her eyes remained on her reflection. Breasts held high, she made quarter turns to the right and left, then leaned back.

“I don’t like how they look now,” she said, appraising her reflection.

Seated maybe six feet from her, my pen poised over the chart where I’d been writing a note about her blood pressure, I watched her posing half-naked in front of the mirror, turning now this way, now that, adjusting a few stray hairs above one ear, imagining a new, surgically improved version of herself.

Prior cosmetic surgery had removed most of her facial wrinkles, I noted. If the forty-plus extra pounds she was carrying troubled her, she kept those thoughts to herself.

“My girlfriend went to a doctor in Beverly Hills. She liked him a lot. She showed me what he did, and I’ve got to tell you, she looks fabulous.” A quick lean in for a close-up of her lipstick, which, aided by a small pout, got a brief touch up from her pinky.

“My boyfriend thinks I’ll look great,” she said, her eyes still working the mirror.

Boyfriend? I didn’t ask Brenda about her husband of many years, who was older than she and confined to a wheelchair by Parkinson’s disease. She’d told me about their hilltop home above Hollywood, offering a commanding view of the entire Los Angeles basin from downtown all the way to the ocean. They’d done well.

“So what do you think?” she chirped, as if asking my advice about whether or not to buy a new sports car.

She finally turned to face me, but kept glancing over her shoulder to catch one more view of herself.

“Could I do it?” she asked.

Not, thank goodness, should I do it, I thought. I knew there was no right answer for the “should” question.

I assumed my best professional demeanor, trying to set aside the thoughts I was juggling about a woman who was nearing eighty wanting cosmetic surgery on her breasts to please a boyfriend while her wheelchair-bound husband sat in their home with the million-dollar view.

Does he know about her extracurricular activities? Do they have some kind of arrangement? After all, they live in Hollywood; people do strange things in Hollywood. People do strange things in lots of places. But even if I ask her, would her answers change the advice I’d give her?

“Well, you’re in generally good health. Could you have the surgery done without undue risk? Sure,” I said, motioning her to pull the gown back up.

“As for whether you should have it done, that’s a personal decision. You’ll need to make that choice yourself.”

“Oh, good!” She sounded pleased. Gown now in place, she settled onto the exam table. I turned back to my note about her well-controlled blood pressure.

“But that’s not actually what I wanted to ask you about,” Brenda said.

Again, I gave her my full attention. She’d pulled her ash-blond hair back into a ponytail.

“My boyfriend is ten years younger than me. He’s great-looking and very athletic. He used to be a professional ball player,” she said with a proud smile.

I smiled back.

“He wants to know if, while we’re doing it, he can put it in my rear.”

I took a beat to make sure I understood what she was asking.

“He says he really wants to.” Then she added, “He says he’s done it before with other women, and it didn’t hurt them.”

She offered this last as if it were a selling point.

“Would it … you know … hurt me?” she asked, looking straight at me.

Again, I went all professional. “You’re talking about anal intercourse, right? His penis in your rectum during sex, yes?”

“Yes.” She looked relieved that I understood, and that I’d matter-of-factly put it into clinical terms. “I’ve never done that before, but my boyfriend says he’ll be very careful.”

Time to take a moment to ponder what was going on:

I know this woman. There’s no dementia or psychosis here. She is fully compos mentis — competent to decide what she wants to do or not do. I don’t need to call Adult Protective Services. And on its face, her question isn’t unreasonable.

Still …

Good-looking man taking advantage of a vain, older, well-to-do woman? Is that what’s happening here? Sounds like maybe yes. Reportable crime? No. Just the stuff of too many romantic and not-so-romantic novels, usually with an unhappy ending.

No fool like an old fool, I concluded. Or not.

It was hard not to judge, not to speculate, not to feel there wasn’t some element of craziness here, some whiff of exploitation. But I told myself, Park it. Be professional, don’t openly react.

It took me all of four seconds to get to this place in my head. This wasn’t the first time I’d had to submerge my personal feelings beneath a professional demeanor.

“Do you understand what’s meant by ‘safe sex’?” I asked. “Is he always using a condom when you have sex?”

“Oh yes,” Brenda assured me.

I decided to believe her. I encouraged her to insist on that. Then, having never been asked about this before, I improvised what seemed to me some common sense advice about geriatric anal intercourse.

“Your partner has to understand that he must stop the moment you tell him you’re not comfortable with what’s happening,” I told her. We discussed lubrication. I also recommended that since she had a new partner, she’d need a vaccine for hepatitis B, a sexually transmitted infection.

As she nodded, I made a mental note to ask a proctologic colleague later on if I’d missed anything.

To sum up, I had a vain, aging, well-to-do married woman with drooping breasts and a disabled husband; she wanted cosmetic breast surgery to please a younger male lover who was pushing her to allow anal intercourse. Would that be OK, doctor?

Later, I shared this incident (leaving out any identifying details) separately with four female friends who ranged in age from their thirties to their fifties and included one professor of gender studies and sexual politics.

To my surprise, they all responded with some version of “You go, girl!” or “So what?” Not what I was expecting to hear.

Are my ageism and sexism showing? I worried.

Some years ago, I remembered, I’d published an essay describing how a naïve, Middle Eastern-raised medical student had admitted in a small group session on urogenital history-taking that he thought sex “is supposed to be painful for the woman.” His shocked classmates had to wait while I took a few minutes to explain the basics of female sexuality.

My essay’s take-home message was that patients aren’t the only ones who bring cultural biases and misconceptions into the exam room; we physicians bring our own as well. Now here I was, viewing this woman’s wishes and needs through my own flawed lens. Fortunately, I’d kept my opinions to myself.

I thanked my female friends for their feedback and for reminding me that every case is an opportunity to learn something — especially about ourselves.

Brenda went on to have uncomplicated breast surgery. As for whether or not she expanded her sexual repertoire, I have no idea. She never said another word to me about it.

And no, I never asked.

H. Lee Kagan is an internal medicine physician.  This piece was originally published in Pulse — voices from the heart of medicine. 

Image credit: Shutterstock.com