I often see this when counselling midlife women who are venturing back into the dating minefield, whether hoping for a new relationship or just a one-night stand.
This patient was looking for the latter. Quick, clean, simple. Okay, maybe not as simple as she had remembered.
It seemed a fairly straightforward and undemanding sexual liaison (the man didn't live in the same city), but she was afraid -- of being pregnant.
This can be a real surprise for women who are in their latter 40s and recrafting themselves as sexual beings.
The random missed period without secure contraception (why bother at that age with so little action?) creates the spectre of an unwanted pregnancy. And believe me, being pregnant when your next major birthday starts with a "5" creates real panic.
Although a long shot, it can happen. The first time I encountered it in my practice involved a 48-year-old fashion designer. She was well past the midpoint in her pregnancy when she came in with what she assumed was a tumour growing at such a rapid rate that there wasn't anything that could be done about it.
Asked to explain, she betrayed a hint of sheer mental fatigue.
"I take it," I prompted, "you don't use condoms because he loses his erection."
Her sigh was a yes.
One of the best things about Viagra is that since being introduced in 1998, it has demonstrated that sexual dysfunction isn't just an issue for women, especially those who lose their desire during menopause. Six years later, the erectile-dysfunction drug market is a $2-billion bonanza, and television advertising has grown a lot more explicit.
Now pharma companies target middle-aged couples sitting side by side in outdoor tubs. Or sultry brunettes comment on how his getting it on is getting her more. Even the French call Cialis the "Weekender" because it can work for up to 36 hours.
Now, there is so much "recreational use" among younger men out to enhance their performance that doctors have to keep their samples under lock and key.
The bottom line: There appears to be a lot more sex happening out there in all age groups. Which brings me back to the issue of condoms.
Gail Sheehy, author of the seminal book on menopause, The Silent Passage, later wrote in Vanity Fair about male menopause, calling it less a function of age than of performance failure or the threat of it.
As hormones diminish in menopause, she explained, women have a drop in their libido. This, in turn, leads them away from seeing themselves as sexual beings, and hence the "take it or leave it" attitude so common among women I see.
Men, however, even with waning testosterone levels, are very capable of arousal well into their 70s and 80s. Indeed, for many men, ready alert is a constant state and thinking about sex occupies a lot of random thinking and fantasy time, if not much action.
So, for Gail Sheehy, the threat to men about losing their sexual capacity is functional and it can come at any age because it is tied to the first episode of performance failure. At that moment, she says, men fear they are goners.
Given that almost half of all men from 40 to 70 years old report sexual dysfunction and an increase of more than 300 per cent in the number of prescriptions for men 18 to 45 in the past two years, and a move in Britain to make Viagra available over the counter, we can assume there is a lot more getting it on going on.
So why does is it seem so tough to persuade that new lover to put on a condom?
For the record, my 20-year-old male patients don't share this anxiety. Perhaps it's because they grew up in the AIDS culture; perhaps it's just self-confidence. No matter what, my 48-year-old patient knows her man -- and he's not that secure.
Putting on a condom will cause him to lose his erection. This alone generates enough fear that the evening is ruined, even without the added baggage of booze and fatigue.
So she does what women usually do -- accommodate, take risks, hold their collective breath, coddle. That was what lay behind the blank stare -- how much did she dare tell me of her own critique of foolish behaviour, and play-acting.
What, in the end, did we make of pregnancy scare and exercise in unsafe sex?
It wasn't laughable, but we did laugh at the notion that a missed period at 48 sparked the same reaction as it did when, as teenagers, we assumed that thinking about being pregnant could make it happen.
We also assumed that any sex over 40, given how rare a commodity it was, was in all probability safe; that the randiest time in her whole life was right now and she was holding herself in check in order not to scare off her lover with the fierceness of her desire. So much for waning sexual needs in menopause.
We finally concluded that good corporate citizenship ought to dictate a whole new approach in advertising all those erectile-dysfunction drugs.
I propose that condoms be sold hand-in-hand with the little pills, along with the assurance that the pill is the chemical assist that will help keep it up even if it falls momentarily while the fiddling occurs.
That alone would go a long way toward managing the expectations of today's sexual encounters among the mature.