(BOSTON, MA) — Put yourself in Bob’s shoes. He’s a 43-year-old man who lives in Milton, works in investment management and has had HIV for six years. He asked that his real name not be printed.
Bob is a savvy, health-conscious guy, a gay man who takes his body and his physical appearance seriously.

”No one wants to age, especially gay men,” he confided. ”It’s the Peter Pan syndrome: We never grow up. Gay men tend to be vain.” Besides, he said, he has to look good to be successful and ”the people I work with don’t know I have AIDS.”

But last year, the AIDS drugs he had been taking (Epivir, Ziagen and Viramune — among the safest of the AIDS ”cocktails”) began causing lipo-atrophy — loss of fat tissue in the face that leads to sunken cheeks and a gaunt appearance. So, Bob stopped taking the drugs.

”I gambled,” he said. ”I didn’t like the facial changes.”

Is Bob crazy to put looks ahead of controlling a potentially fatal disease? Not in my book.

It may sound — and sometimes be — foolish to sacrifice health for beauty, especially if the decrease in beauty (like losing hair because of cancer chemotherapy) is temporary and the potential gains in health are substantial and long term.

But the fact is taking some calculated risks with health to enhance attractiveness is as old as humanity.

”People all over the world modify their bodies in ways that are painful and sometimes dangerous, to enhance their beauty,” said Sally Engle Merry, a Wellesley College anthropologist.

Scarification is common in many cultures, even though the cutting of the skin and insertion of coloring agents can be painful. Some women in Burma wear increasing numbers of brass rings around their necks, even though this makes the neck so unstable the rings can never be removed. In China, girls’ feet used to be painfully bound because small, misshapen feet were considered more erotic.

In modern America, the trade-offs may be more subtle but no less real.

Millions of women routinely endure foot pain from pointy, high-heeled shoes. In fact, 72 percent of women persist in wearing high heels at least sometimes, according to the American Podiatric Medical Association, even though bad shoes contribute to foot pain.

The booming plastic-surgery business is another obvious indicator of how much we value looking good and how much we’re willing to pay for it — in money, pain and some medical risk. Last year, 6.5 million Americans had cosmetic surgery — 5.6 million women, and nearly 1 million men, according to the American Society of Plastic Surgeons. For the privilege of acquiring more fashionable noses, perkier eyelids and skinnier stomachs and thighs, Americans spent a whopping $7 billion.

And that’s the easy stuff. The real rub, psychologically and ethically, comes with more complicated decisions like Bob’s that involve weighing the value of attractiveness against the medical risks of using, or not using, powerful drugs.

Take steroids, for instance, and many Americans do, often to damp down overactive immune systems in diseases such as asthma and rheumatoid arthritis. Steroids like prednisone clearly work, but they cause disturbing side effects as well, including the puffy look dubbed ”moon face.”

Some people with arthritis get so upset with the way they look that they taper off steroids too quickly, said Dr. Paul Romain, a rheumatologist at Cambridge Hospital.

It’s a delicate dilemma for both patients and doctors: ”When you lose control over your appearance, you lose control over your own privacy,” he said. ”You may want to keep your illness to yourself, but when your appearance changes, you are forced to interact with other people about it.” An altered appearance can also be a constant reminder to the patient of his or her own vulnerability.

Weight gain is another all-too-visible side effect of many drugs, including those used to treat psychiatric diseases. Some antischizophrenia drugs like Clozaril and Zyprexa trigger an average weight gain of 15 pounds and sometimes 100 pounds or more, said Dr. Donald Goff, a psychiatrist who heads the schizophrenia program at Massachusetts General Hospital.

Not surprisingly, ”a lot of patients don’t want to take these medications,” he said, adding that weight gain ”is not just a matter of vanity; it’s a serious threat to a person’s general health.” Fortunately, several newer drugs, including Geodon and the recently approved Abilify, do not trigger weight gain.

Drugs that cause weight gain pose an especially wrenching dilemma for young women with anorexia and bulimia who are already terrified of looking fat, yet need psychiatric medication, said Dr. David Herzog, president of the Harvard Medical School Eating Disorders Center at MGH. Other patients often hesitate to take antidepressants, which sometimes cause weight gain, and some people with manic-depression (bipolar disorder) fear lithium for the same reason.

Cancer patients on chemotherapy often face the same dilemma, said Barrie Cassileth, chief of the Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center in New York. Now that there are good drugs to control nausea and vomiting, weight gain is actually viewed as an increasingly common problem, she said. ”I don’t know that people actually stop chemotherapy because of the weight gain, but it is devastating.”

As for Bob, his physician, Dr. Cal Cohen, research director for Community Research Initiative/New England, is supportive of the delicate balancing act between appearance and health.

The advent of better AIDS drugs in recent years has certainly been a plus, Cohen said, but ”there are disfiguring toxicities from some of the drugs, which make people look sick. . . . Nobody wants to be with you if you look sick.”

Which brings us back to Bob. He’s been having monthly injections of a substance believed to boost collagen in the face. He’s also decided to go back on his AIDS drugs for three months to ”tromp the virus down,” then take another year off.

No one knows yet how his gamble will play out. But, for the record, I can’t help but admire his clarity about his own values and his willingness to live by them.

Judy Foreman is a freelance columnist who can be contacted at [email protected].

Check out all Judy’s works here.