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Abstract
We present the case of a woman in her late 20s who consulted our gynaecology emergency department due to dyspareunia and vaginal penetration issues. She had undergone a ‘virginity reconstruction’ procedure 10 days before her wedding in Africa. Clinical examination revealed suture of the inferior part of inner labia (labia minora), narrowing of the vaginal introitus and abnormal vaginal discharge. We performed an inferior defibulation procedure and removed the sutures under general anaesthesia. Postoperative care included systemic metronidazole, counselling, vaginal dilators and topical estrogens for 1 month. There were no complications during the postoperative follow-up, and a month later, the woman confirmed a satisfactory outcome. The aim of this paper is to discuss the practice of so-called ‘virginity reconstruction’, currently classified among female cosmetic genital surgeries despite being very similar to what is defined as female genital mutilation, and the care that can be provided to women in such cases.
- Ethics
- Global Health
- Obstetrics and gynaecology
- Public health
- Migration and health
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Background
The concept of virginity is a cultural, religious and social construction that has no scientific basis.1 Its definition varies across different regions, cultures and time periods. Virginity is valued by different cultures and religions. It also provides, in some contexts, reassurance to men about the paternity of a child.2 Multiple beliefs about assessing and certifying virginity via clinical examination persist,3 as well as the myth that a woman will always bleed during her first sexual intercourse due to hymen tearing.4 In some cultures, it is customary for a woman to be certified as a virgin before marriage or to publicly display her vaginal bleeding the morning after her wedding.4 Additionally, virginity can provide economic advantages and guarantee a good marriage transaction.5
‘Integrity’ or ‘irregularities’ of the edge and the shape of the hymen are not unequivocal clinical signs of the absence or presence of past vaginal penetration. Thus, virginity cannot be certified by medical examination.6–11 Furthermore, the hymen can have several shapes and it changes over the course of a lifetime in keeping with hormonal changes (figure 1).2 3 12 13 However, ‘virginity tests’ such as ‘intact’ hymen and two-finger per vaginal examination are still performed in several countries around the world for varying purposes. Virginity tests have been reported in South Africa among preschool girls in an attempt to reduce HIV prevalence, in instances in India to determine sexual abuse, and on occasion in Indonesia as a requirement for certain state jobs.14–16 They have also been reported in the Netherlands, Sweden, Canada and Spain, in particular among migrant communities.4 17–19
Physiological variations of hymenal anatomy (upper line) and variations requiring investigations and treatment (lower line). Reproduced with permission from Moussaoui et al.2
These practices can be psychosocially and physically harmful and are therefore banned by the WHO.20
Some women request a ‘certificate of virginity’ or request hymenal repair (HR) before getting married, becoming mothers or putting a history of sexual assault behind them.21 These women may hope to fulfil their personal aspirations, meet sociocultural expectations or protect themselves. Women who cannot prove their virginity may risk being rejected by their family and society, or even murdered as an ‘honour killing’, with 5000 reported deaths of women worldwide in the year 2000.22 In this paper, we present the case of a woman who underwent HR in North Africa before her wedding to a man living in Europe.
Case presentation
A previously healthy, nulligravid woman in her late 20s presented to our gynaecology emergency department (ED) with a 2-day history of impossible penetration, dyspareunia and abnormal yellowish vaginal discharge.
Originally from North Africa, she married a man from her home country who was living in Europe, where she moved after her wedding.
Ten days prior to the wedding, she underwent hymenorrhaphy under general anaesthesia to ‘reconstruct a premarital virginity’. The patient did not report any intestinal or urinary symptoms.
The woman reported that complete digital and penile vaginal penetration had become impossible and extremely painful since undergoing the operation.
She had not previously suffered from these symptoms and had been able to engage in satisfying sexual intercourse.
Clinical examination showed inferior closure of the inner labia, of a length of 3 cm, starting from the posterior labial commissure and causing a narrowing of the vaginal introitus, reduced to approximately 1.5 cm (figure 2). The patient also presented with an odorous yellowish vaginal discharge, vulvar and anal erythema and palpable and painful vaginal knots on the posterior labial commissure. A complete vaginal examination was not possible due to the pain and discomfort presented by the patient.
Clinical examination at presentation.
After obtaining informed consent from the patient, inferior defibulation and removal of the hymenorrhaphy stitches (Vicryl 2-0) on the posterior labial commissure, as well as on the right and left vaginal walls, were performed as outpatient care the day after. The surgery was under general anaesthesia (figure 3).
Removal of hymenorraphy sutures.
Physiological anatomy was restored with the use of simple stitches of 2-0 Vicryl on the vaginal mucosa and 3-0 Vicryl stitches on the skin. The procedure resulted in a permeable and flexible vaginal orifice (figure 4). We palpated a 5 mm fibrous cord at the 7 o’clock position in the lower third of the left vaginal wall, suggesting a deep stitch which was not visible anymore.
Immediate postoperative status.
We prescribed oral metronidazole 500 mg two times per day for 1 week, the use of vaginal dilators for 30 min per day for a month, topical oestrogen cream once a day until complete healing occurred, and nine sessions of pelvic floor exercise therapy targeting the fibrous and potentially painful left vaginal area. Additionally, an oestrogen-progestogen pill was also provided for contraception. The patient requested full confidentiality but did not express any concern about the risk of danger in going back home and felt safe within her entourage. She was offered detailed information about her anatomy, the procedure she had undergone in her home country, and the inferior defibulation and follow-up. A confidential and safe setting has always been ensured since her initial visit to the ED. The operation and follow-up care were conducted by a gynaecologist trained in vulval disease and sexual health. Further psychosexual support was proposed but declined.
The postoperative follow-up was uneventful, and the woman resumed sexual intercourse with vaginal penetration and without pain within 1 month. During the healing process, she was sexually active but abstained from vaginal penetration, as recommended. The woman’s husband did not accompany her to any of her appointments. The woman had informed him that she needed to increase her vaginal opening through surgery.
Global health problem list
Hymenoplasty is not a standardised surgical technique and can have a negative health outcome.
Hymenoplasty is mostly requested by women from low-to-middle socioeconomic backgrounds.
Hymenoplasty, virginity tests and certificates are illegal in some countries and considered a form of sexual violence by the WHO.
There are controversial differences and similarities between what is defined as female genital cosmetic surgery (FGCS) and female genital mutilation (FGM).
Societies and communities exert pressure on women’s fears, decisions and consent.
Healthcare providers should support and help without causing any harm. Scientific societies and medical organisations can offer written guidance.
Global health problem analysis
Hymenoplasty is not a standardised surgical technique and can have a negative health outcome
Several techniques with confusing terminologies have been described but have yet to be standardised, taught to surgeons in academic curricula, or described in official textbooks.23 24 Some of these techniques include suture of the hymenal remnants or temporary hymen suture (THS), hymenoplasty, hymenorrhaphy and plastic surgery of the posterior labial commissure, among others.25 26 While these procedures are usually performed under local anaesthesia, general anaesthesia is considered because of the stress and pressure experienced by the patient.21
The aim is usually to narrow the vaginal orifice by modifying hymen shape in order to obtain bleeding on the first wedding night, or the sensation of a narrow vagina for the partner.4 25 27 It can be requested by a sexually active woman before her wedding without the knowledge of her partner or family; after non-consensual penetration to restore what ‘is lost’; or with a partner’s consent or as a gift.25 26 This surgery is performed worldwide and can cost between €1000 and €4000 in Europe.25 27
A recent Dutch study identified HR surgical techniques that are disappointing for the patient, as only 13 out of 17 (76%) women with THS and 6 out of 11 (55%) who underwent HR experienced bleeding on their wedding night.25 There is limited information on the financial costs and psychophysical health risks associated with these procedures, but severe complications may require expensive care due to the possibility of infections, haemorrhage, incontinence, fistulas and chronic vulvar or sexual pain.28 29
Hymenoplasty is mostly requested by women from low-to-middle socioeconomic backgrounds
A Tunisian study investigated the reasons why women seek hymenal surgery and physicians’ motivations to grant those requests.21 Hymenal surgery is mainly requested by women between the ages of 20 and 36 who come from low-to-middle socioeconomic backgrounds.21 The pressure to undergo this type of surgery originates from future in-laws and spousal desire to ensure their bride’s virginity before marriage.2 Women often choose to be accompanied by a friend or close family member.21 Physicians’ who agree to perform the surgery may be motivated by financial gain or the desire to do what they perceive to be the ‘right’ thing.21 Women have little knowledge of their anatomy and ask few questions about the procedure and the risks.21
Hymenoplasty, virginity tests and certificates are illegal in some countries and considered a form of sexual violence by WHO
Despite the demand for virginity certificates or HR, healthcare professionals face significant challenges as these procedures are considered a form of sexual violence, according to the WHO.20 They are considered harmful to individuals and societies as they promote discrimination and gender inequality and lead to violence against women.2 20 30 Article 124 of the Swiss Penal Code states that ‘any person who mutilates the genitals of a female person, impairs their natural function seriously and permanently, or damages them in some other way shall be liable to a custodial sentence or to a monetary penalty’.31 The Ordre National des Médecins (the French national medical association) has recently published a specific document for healthcare professionals stating that virginity cannot be scientifically or medically certified and advising against the issue of such certificates, which are comparable to false medical certificates.32 The Ordre National des Médecins insists that education, guidance, social support and when indicated, protection to women and families who may be subject to such practices is provided.32 This approach is likely to take a long time to bring about meaningful change in the society.
There are controversial differences and similarities between what is defined FGCS and FGM
HR is classified by several societies, such as the Royal College of Obstetricians and Gynecologists, the American College of Obstetricians and Gynecologists and the International Society for Vulvovaginal Disease as a form of FGCS.33–36 FGCS is defined as non-medically indicated cosmetic surgical procedures that change the structure and appearance of the healthy external genitalia of women, or internally in the case of vaginal tightening.33 Our patient underwent surgery of the female genital organ with no clinical indication. Surgery comprised narrowing of the vaginal orifice by apposition of inner labia, and suture of the vagina. This procedure is defined by WHO as FGM, type III (narrowing by apposition of the labia with or without excision of the clitoris) or IV (any non-therapeutic procedure on the female genitals not classified as types I, II or III).37 FGCS and FGM are often considered different practices based on the reasons why they are performed, the circumstances, the age of the woman/girl and their ability to consent, as well as possible physical and psychological consequences. However, there are similarities in the techniques, genital tissues affected, health professionals involved, and the circumstances and settings in which they are performed, as well as potential risks. These factors raise unresolved ethical, legal and medical controversies.36–38
Societies and communities exercise an important pressure on women’s fears, decisions and consent
In specific social contexts, women are expected to fulfil specific requirements in order to be socially accepted; thus, being a ‘virgin’ may be seen as a requirement for a woman to have value either as a wife or as a mother-to-be, or even to apply for certain jobs and public positions or to be part of her community.1 39 When taking a patient’s personal history, health professionals should always investigate the reasons behind the patient’s request and highlight any pressure or coercion by family members or the community. In such circumstances, as well as when facing danger or risking death, the validity of consent is debatable.39
Furthermore, women often lack knowledge about their sexual anatomy and physiology required to make informed decisions regarding such surgery. Women may seek out the support of health professionals during stressful situations, placing the professional in a difficult position too.19 40 Certificates of virginity or hymenal surgery reinforce discrimination against women and can be harmful to their health. If the healthcare provider simply refuses to fulfil the woman’s request, she may face rejection from her family, society, threats to her safety or even death.
Healthcare providers should support and assist but do no harm: scientific societies and medical organisations can offer written guidance
A surgical procedure that narrows the vaginal introitus and canal, performed in a stressful situation for the patient and potentially causing harm to the woman and the sexual health of the couple, cannot be considered a routine medical procedure. It cannot be simply classified as a form of FGCS. As for what is classified as FGM, already existing bans based on legal, medical, or ethical criteria may be appropriate. However, one might argue that a ban would increase the risks to women seeking hymenal reconstruction clandestinely (in unsafe/insanitary environments) at home or abroad. When it comes to what is currently classified as FGM, the WHO is clear: ‘The involvement of healthcare providers in the performance of FGM is likely to create a sense of legitimacy for the practice or make it seem like it is harmless. This can further contribute to the institutionalisation of the practice, rendering it a routine procedure and even leading to its spread into cultural groups that currently do not practice it. Furthermore, the medicalisation of FGM may lead to some healthcare providers developing a professional and financial interest in upholding the practice’.41
Healthcare professionals are obliged to promote the health of women and girls. This means to welcome, listen to and support them in accordance with scientific information and clinical expertise while offering psychological and social support and investigating the deeper reasons and context behind the patient’s request. Liaison with local support associations (especially community-based organisations) is important. Fake blood capsules and pelvic floor exercises have been reportedly used as potential alternatives to surgery.25 Patient confidentiality and safety are paramount. Every effort should be made to earn the trust of the patient and offer support that the patient can rely on.
A careful review of current classifications of the WHO and other scientific societies on ‘FGM’ and ‘FGCS’ would be helpful in establishing clear guidelines for clinicians and patients. Clear information may contribute to the abandonment of unsafe surgical procedures on female genitalia performed without clinical indication. Finally, efforts should be focused on providing accurate and comprehensive information and counselling for women and men on subjects such as the hymen, ‘virginity’, the absence of bleeding after first sexual intercourse, gender rights and agency, and sexual health.42 According to the literature, approximately 75% of women who initially requested hymen reconstruction eventually abandoned the request after receiving counselling.4 27
In conclusion, providing information about sexual and reproductive health to women and girls seeking virginity certificates or HR, and, in general, information, support and counselling to any individual, can contribute to sociocultural change and the abandonment of harmful practices, including HR.
Learning points
Virginity is a social and cultural construct with no medical basis and cannot be assessed and certified via a clinical examination.
Hymenal morphology varies greatly among individuals and changes during the stages of life (childhood, puberty and menopause). Only 50% of women will actually bleed during their first sexual intercourse.
Providing women and men with knowledge on vulvar anatomy, sexual and reproductive health can promote the abandonment of certain cultural beliefs and practices that are harmful to physical and mental health.
The need for psychological and psychosexual support, as well as social support and protection, should be assessed when confronted with a woman asking for hymenal repair or a virginity certificate.
The current classification and controversies regarding female genital mutilation and female genital cosmetic surgery warrant a multidisciplinary review and clear guidance for clinicians.
Ethics statements
Patient consent for publication
References
Footnotes
Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: MP, CB, CP and JA. The following authors gave final approval of the manuscript: MP, CB, CP and JA.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.