Signing in at the receptionist’s desk of my cool female OB-GYN, I noticed a flyer taped to the glass. “Get your groove back,” it said, and though I like to think I still have my groove, it could always be better, so I kept reading. In smaller letters, near the bottom, the flyer read, “What is vaginal rejuvenation?”

I smacked my pen down on the counter. Were we doing this now? I knew what vaginal rejuvenation was. A makeover for your south mouth. One of the fastest-growing procedures in plastic surgery. Yet another dubious trend we might find under an umbrella labeled “the influence of porn.” I slumped in the plastic scoop chair, crossing my arms in the jean jacket I wore to look younger, and that’s when I noticed the enormous cardboard poster across from me for the same vaginal rejuvenation device. It was the kind of life-size promotional cutout you find in movie theater lobbies, a woman holding hands with a man as she walked on a beach. “It’s about you, it’s about time!” the ad read, and I said out loud, in the empty waiting room, “No, it’s not.”

Plastic surgery had been closing in for a while. I’d spent my early 40s looking past pamphlets for fillers and injectables, wincing at the highway billboards for mommy makeovers, watching the proliferation of med spas and Botox bars and the way self-care was blurring into self-alteration. The whole spectacle created an alternating current of despair and envy, like this was wrong and shallow and vain, and also, maybe I should try it. I’d never stuck a needle in my forehead, but mostly for the same reason I’d never done cocaine. I was afraid I’d like it and then I couldn’t afford to keep doing it. The ad for vaginal rejuvenation was a new low, however. As if it weren’t enough to overhaul our faces, our bellies, our butts. Now they were coming for our pussies.

I wondered if this was a Dallas thing. I often wondered that, as I watched young women in Uptown with eyelashes as long as butterfly wings, as I struggled to fit an arsenal of Sephora products and hair care serums onto a dainty hotel shelf, as I felt the hard thump of a woman’s breast implant when I went to hug her. I could never sort out what portion of the constant cosmetic renovation around me lay at the manicured feet of my image-obsessed hometown.

I texted a friend, a mother who lives on the East Coast. “There’s an ad for vaginal rejuvenation in my OB-GYN’s waiting room. Is this happening in your city?”

“No!” she wrote back. “Get details!!”

saw my first facelift at the age of 10. It was a friend’s mother, older and fancier than my earthy therapist mom with her beige flats and L.L. Bean turtlenecks. This lady wore a mink coat, because it was the ’80s, and because we lived in the Park Cities, which was like living through the Reagan years with the volume on full blast. This futuristic procedure—a lifting of your actual face!—kept the woman’s head swaddled in bandages like a mummy, even when she was driving carpool. It was ghoulish. It was fascinating.

Texas had become a hotbed for the brave new world of cosmetic surgery. A confluence of medical centers, free-flowing money, and vanity made our state an ideal spot for technologies that would alter our relationship with our own bodies. Don’t like what you’re born with? Change it. Silicone implants were invented in Houston, but it was Dallas that nailed the aesthetic. The Cowboys Cheerleaders brought cleavage and jiggle to prime time, helping to fuel plastic surgery’s first breakout success, the boob job, and introducing a dazzling new chapter in the American rags-to-riches tale. Seventy-five miles outside Dallas, in a little town called Mexia, a pretty brunette named Vickie Lynn was shape-shifting into a blond sex goddess named Anna Nicole with heaving double Ds. By 1993, she was Playboy’s Playmate of the Year.

I was going the opposite direction. I’d spent much of my teen years hiding my knockers in baggy shirts and casual slouches, and since humans mostly want what we cannot have, and because fashions change, what I longed for in 1993 was a breast reduction. I clomped around the UT campus in Austin in men’s flannel and steel-toe Doc Martens, watching the hippie girls traipse around braless, the gumdrop of their nipples tenting loose tank tops. Why couldn’t that be me? I coveted halter tops and silky slip dresses, the waif look. A friend got a breast reduction, and she looked better. She looked thin. But my mom in her endless beige flats told me 19 was too young for plastic surgery, and, anyway, I was creeped out by the gore, the knife through flesh. I’d heard they removed your nipple, and I could never get past that image: the pale pink dome of my areola sitting on a table like a slice of prosciutto.

Plastic surgery went mainstream over the next decade and turned cartoonish. Duck lips, reality show nightmares, porn-star chic. Anna Nicole Smith went from the Marilyn Monroe of her day to the punching bag of late-night TV shows. Entire websites were devoted to snarking on actresses whose procedures went awry, cautionary tales about wanting too much, and I clicked through photos at the desktop computer where I spent afternoons. What has she done to herself? I thought, as I dribbled cheese enchiladas down my hoodie. Plastic surgery signified so much that was corrosive in American culture at the turn of the century—dippy celebutantes and Us Weekly and fame at any cost—that I assumed every reasonable human was against it.

So I was taken aback one night when a friend who’d recently had her second child told me she was getting a tummy tuck. I got a weird, panicked feeling, like she’d announced she was joining the Dark Side. But-but-but you can’t!

She stayed calm. Childbirth had ravaged her belly, she explained, and she was determined to be the kind of mother who could run around unencumbered on a beach in a bikini, not the kind who hid beneath caftans and flutter skirts. She had a daughter, and she wanted her little girl to see her strong and confident in her own body.

But-but-but! I paused my objections only to light another cigarette, sip my red wine. Wouldn’t it be better if she taught her daughter that a woman’s appearance wasn’t what mattered? Wouldn’t her daughter learn a more valuable lesson about confidence if her mother accepted the imperfections of her body instead of trying to fit an increasingly narrow concept of hotness through surgical alteration?

My friend conceded that, yeah, in an ideal world, that sounded right. In this one? A tummy tuck would be her choice.

It unsettled me deeply, which is odd, given that in the past I’d had friends get hush-hush procedures to fix this or that perceived defect, and I didn’t much care. But this one felt momentous, the train whistle announcing we were leaving early adulthood, with its smug certainty and trendy dishevelment, and entering a more complicated landscape. Motherhood. Manicures. SUVs. I had no children, and I wasn’t married, but I can tell you this: I had not felt unencumbered in a bikini since roughly the age of 8. My friend and I bonded back in middle school over the failures of our figures. Her wide belly, my wide thighs. Her flat chest, my overdeveloped one. I understood self-loathing as a woman’s inheritance, a curse we carry around discreetly like tampons, and the goal was to rise above this mental warp, not crater to market demands. You can’t buy confidence, I grumbled to myself. Never mind that I drank mine most nights. What my friend sought in the surgeon’s knife was exactly what I sought in a frosty pint or a sloshing martini or a balloon glass of Malbec. That feeling of freedom. We could argue about which of these approaches is safer, smarter, morally superior, but let’s be clear: when it came to feeling strong and confident, both of us were reaching for a quick fix.

That was 2005. A lot of things happened over the next 15 years: Kim Kardashian, the iPhone, the rise of social media, but also online feminism, creating a double helix of narcissism and activism, one strand of Instagram perfectionism and one strand of body acceptance. There was a moment after the recession when it looked like plastic surgery might go away, but, nope, it only leveled up. We entered the age of Botox and noninvasive body-shaping techniques and the plumping power of hyaluronic acid, the softer-gentler modifications that made plastic surgery seem less plastic, more akin to a new and better you. Something else happened: I got older. I watched the fading topography of my body, smooth skin turning to cracked desert. Women in white lab coats turned magnifying mirrors onto my face and suggested fixes for flaws I had not yet named. This can help those elevens between your brows. (“Elevens”?) This will clear up those gray circles under your eyes. (I had gray circles?) I’d quit drinking by then, probably the best makeover I could have given myself, but I felt like I’d finally made peace with my body, only to discover new deficiencies, a strain of insecurity that never died, only mutated.

By my late 30s, I was living again in Dallas, a city of reflective glass and tanning salons, a city comfortable with its own vanity. Plastic surgery tends to cluster in the coastal cities and the South, places known for hot weather and hot people, but I found Dallas women to be particularly open about their tinkering. Upkeep, darling. Friends copped to boob jobs and Botox appointments. One friend let me tag along to her lip injections, and I cringed as a tiny woman in a white lab coat made four or five efficient jabs with a needle to the pale, thin skin of her lips, but even I had to admit, this was no big deal. I’d spent earlier parts of my life in Austin and Brooklyn around women who expressed a fashionable disdain for plastic surgery, and now we had promise-not-to-tell conversations over dinner about this or that possible adjustment. Being against plastic surgery at 28 is like being against divorce when you’re single. What do you even know? As a journalist friend told me, “I think every negative story about plastic surgery is written by someone under the age of 35.”

There is a dance inside every woman: how far will you go? Where do you draw the line? What is the balance between looking good and not looking desperate? Nobody wants to be That Woman, who held on too long. Nobody wants to be That Woman, who gave up too soon. I turned 40, then 41, then 42—you get the idea—and I found myself lying on padded tables across North Texas, listening to the sounds of tinkling water sculptures or string-quartet versions of the Titanic theme song as a technician slathered my face in green goo, or zapped me with a laser, or ran an electric current in Nike swooshes under my eyes. (“But no Botox,” I brag, as though it earns special points.) I ask myself, Am I trying too hard? I ask myself, Am I not trying hard enough? I’m 45 now, and, bless my heart, I’m still single, and I will tell you this: a woman’s relationship to her own body can be the most complicated of her life.

was still ticked about that vaginal rejuvenation poster as I sat in the exam room, awaiting my inspection. Should I say something? Say nothing? I felt a dangerous spike of adrenaline, like if I wasn’t careful, whatever I said next could come out too strong by half. The nurse practitioner lowered the stirrups, and I slid my heels into the cradles of cold metal, took a deep breath, and peered at her through the mountains of my knees.

“I was surprised to see that ad in the waiting room,” I said. The tone of my voice remained neutral, like maybe this was a good thing, maybe it wasn’t.

She chuckled. “Well, some women like it for the aesthetics, but it has health benefits,” she said. Is that the line they’re using? I thought. The old “deviated septum” trick. Later I would google the device and scan a list of supposed benefits. Reduces vaginal dryness and urinary incontinence. More sensation during sex. The American College of Obstetricians and Gynecologists remains skeptical of these claims, saying the science isn’t there yet, but cold, hard facts have rarely gotten in the way of hope. My Google search also yielded stories of reality stars hyping the procedure. A handful of Real Housewives, the Kardashian sisters. Some woman from Love & Hip-Hop livestreamed her own surgery.

“I never had kids,” I said to the nurse practitioner, in that same neutral tone, like maybe this was a good thing, maybe it wasn’t. “So I don’t really understand the effects of childbirth.” I was staring at the ceiling now, tenting my fingers. “I think bladder control is a big issue,” and the nurse said mm-hmm, as I felt the chilly insertion of the speculum. I’d been enduring more than two decades of these bizarre clinical intrusions, but I never got over the full-blown intimacy of opening my legs to a stranger under fluorescents as she pulled up a stool. I bit back tears the first time I had an annual. I was just so scared. What if something was wrong with me? How would you ever know? It hurt my heart sometimes, how much we wanted to be beautiful, how we never quite knew if we were. We turned to strangers on the internet, evaluated the eyes of men and women as they surveyed us. Do you think I’m beautiful? What about you?

I guess I could see why someone would want that stupid surgery. I could rage about the warping effects of YouPorn, Hollywood, selfies, glossy magazines, advertisements—modern culture, in other words—but it was scary, worrying your body was deficient. Sex had always been a challenge for me, and I knew how the obsessive mind could latch onto one insecurity, refuse to let go. If you could fix that, why wouldn’t you? If some “magical vagina laser” gave you peace, what did I care? My Google searches turned up women who liked the results, so fine, it’s not my money. But I didn’t like the ad in a medical setting. I didn’t like the device being embraced by my cool OB-GYN, whom I’d chosen because she was warm, and forward thinking, and much recommended, and showed up for my first appointment wearing a sweatshirt and a backpack. I’d chosen her because she was unconventional, and now she’d gone and proven herself unconventional in a way I didn’t like.

“Your cervix is nice and pink,” the nurse said. “That’s good.”

The cervix is pink? How long had that been going on? The nurse told me most women don’t know this either, and it struck me as something I’d like to change about the world, how much we women agonized over our appearance, how little we knew about what was inside.

“The cervix can be blue,” she said. It was called Chadwick’s Sign, named for the man who discovered the phenomenon. The blue tint is a sign you’re pregnant. “It’s beautiful,” she said, dragging out the last word as she placed the swab in a glass on the counter.

I liked this nurse. She pushed out from the low stool, and I propped myself up on my elbows to look at her, as if for the first time. She had luminous skin, a fuzzy halo of gray around her temples. She told me she’d recently stopped dyeing her hair, and she felt good about the decision, but the gray was changing how people saw her, how she saw herself.

“Aging is a trip,” she said. “It’s the one choice we don’t get to make.” The nurse told me she used to work with senior citizens, how she loved those ladies, but she listened to them complain about aging, aging, aging, and she would say. “Be quiet, y’all are beautiful.” Now she was the one watching the sweep of the clock as it passed over her body, and it was like, Oh, this is what you were talking about.

I heard an older woman say she would never get plastic surgery, because she’d lost her mother at a young age, and she would not deny her daughter the joy of watching a woman grow old. I loved the wisdom of that statement, that we should not fight the gift of being alive, though most of us seemed to be going in the opposite direction. Nobody wanted to age anymore. A recent trend in plastic surgery was women getting Botox in their 20s as a preventive measure. Sometimes I scrolled through Instagram accounts of gorgeous social media influencers and marveled at their full lips and porcelain skin and blank stares, wondering if I was the only one who thought they looked like robots. (Maybe they were robots?) I felt that alternating current of despair and envy, like all of this was wrong and bad and soul sick, but also, maybe I should try it?

The fantasy of agelessness is that no grief and loss would come to us. The fantasy of beauty and perfection is: if I only looked that way, no pain would wash up to my shore. I would not be lonely anymore. I would fix the blasted hole inside me. I would finally be happy. But what I have seen in my own life is the more I cling to happiness, the less I have it. The more I need to be beautiful, the more sad and scared and ugly I feel.

It was quiet in the exam room after the nurse left, and I got dressed and tugged on my jean jacket, which reminded me of a jean jacket I’d worn back when I was 14, because I was trying to look older, more sophisticated. I wondered if I would ever learn the trick of being comfortable with whatever I had, or if it was simply a part of being human, or being a woman, or being a woman in Dallas—to want more.

Sarah Hepola is working on a memoir titled Unattached for Dial Press/Random House. Write to [email protected]