Virginity Testing: Recommendations for Primary Care Physicians in Europe and North America

Practice BMJ Glob Health: first published as 10.1136/bmjgh-2019-002057 on 20 January 2020. Downloaded from Virginity testing: recommendations for primary care physicians in Europe and North America 1,2 1 3 4 Sondra S Crosby , Nicolette Oleng, Muriel M Volpellier, Ranit Mishori To cite: Crosby SS, Oleng N, ABSTRACT Summary box Volpellier MM, et al. Virginity Virginity testing is a complex, culturally mediated practice testing: recommendations that is poorly understood by Western clinicians. While ► An examination of the hymen cannot accurate- for primary care physicians advocating for global elimination of the practice of virginity in Europe and North ly or reliably tell you whether a woman has had testing as a human rights violation, clinical practice is America. BMJ Global Health intercourse. often more complicated and ethically nuanced, and the 2020;5:e002057. doi:10.1136/ ► ”Virginity testing” is a complex, culturally mediat- clinician must act in the best interest of her patient. bmjgh-2019-002057 ed practice that is poorly understood by Western Upholding human rights does not have to be incompatible clinicians. with providing a needed service to a patient, which should Handling editor Seye Abimbola ► While advocating for global elimination of the prac- never include an invasive exam if not medically necessary, tice of “virginity testing” as a human rights violation, Received 7 October 2019 but should include education and safety assessments. clinical practice is often more complicated and ethi- Revised 24 November 2019 cally nuanced, and the clinician must act in the best Accepted 30 November 2019 interest of her patient. ► Refusal of care may be counterproductive, and a missed opportunity for education about the lack of INTRODUCTION science behind ‘virginity testing’, and about female "Virginity” testing refers to the practice of anatomy and sexuality. evaluating—through a physical examina- ► Clinicians should not perform an invasive two-finger tion of the hymen—whether a woman or examination for the purpose of ‘virginity testing’. girl has ever engaged in vaginal sexual intercourse (with or without consent). “Virginity” testing is practiced in countries from multiple and especially in the shape and appearance regions of the world, but appears to be most 1 of the hymen. http://gh.bmj.com/ established in Asia and the Middle East and In some cultures, virginity is considered an 1 countries in northern and southern Africa. important social norm that links sexual purity This practice is controversial and broadly with the honour of an individual woman, considered to be unethical and ill- advised. As her family and community, and ultimately part of the global call to eliminate violence the State.3 Virginity is celebrated as a virtue, against women and girls everywhere, on 17 and women are expected to be ‘virgins’ prior on October 2, 2021 by guest. Protected copyright. © Author(s) (or their October 2018, The UN Human Rights Office, to marriage. ‘Virginity’ examinations have employer(s)) 2020. Re- use UN Women and WHO issued a statement been conducted forcibly by official repre- permitted under CC BY-NC. No stressing that ‘virginity” testing was unscien- sentatives of the State in cases where women commercial re- use. See rights tific and a violation of human rights and that and permissions. Published by are suspected of adultery or prostitution, or BMJ. ‘this medically unnecessary, and often times during detention. It is also not uncommon 1Medicine, Boston University, painful, humiliating and traumatic practice for law enforcement or adjudicators to 2 Boston, Massachusetts, USA must end.’ request an examination of the hymen in cases 2Schools of Medicine and “Virginity” testing usually involves visual of alleged vaginal sexual assault, despite the Public Health, Boston University, inspection of the hymenal membrane by a fact that a hymen examination has a very low Boston, MA, USA medical professional (physician, nurse or 4 3St Marys Hospital London, predictive value in such circumstances, and London, UK, London, UK midwife). In some cases, the examination that best-practice dictates a full body examina- 4Department of Family Medicine, includes a ‘two- finger’ test to assess the size tion including a thorough ano-genital exam- Georgetown University, of the vaginal opening. The purpose is to ination. In 2016, a parliament member in Washington, DC, USA ‘determine if a woman is a virgin’ though it Egypt called for “virginity” tests for university Correspondence to is based on an incorrect and false assumption entrants with the stated reason to discourage 5 Dr Sondra S Crosby; that penile penetration results in predictable premarital sex. A “virginity” test is required scrosby@ bu. edu observable changes in the vaginal introitus, in some countries such as Indonesia when Crosby SS, et al. BMJ Global Health 2020;5:e002057. doi:10.1136/bmjgh-2019-002057 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-002057 on 20 January 2020. Downloaded from an unmarried women applies for a job in the military.6 and the low predictive value of a hymen examination to Although officially banned in Afghanistan, it has been determine ‘virginity’,17 little practical guidance has been reported that the practice of “virginity” testing remains published for clinicians who may encounter requests for widespread, both officially by the State, and unofficially “virginity” testing in the clinical setting. at the request of families. An Afghani woman told a The ethical conflict for clinicians in this case is one of reporter ‘If your hymen is broken, it is finished—you fall respecting traditional cultural practices versus practicing into hell.’7 according to western values of gender equality and sexual There are few articles in the medical literature rights. We are taught that upholding human rights always discussing ‘virginity” testing from the perspective of clini- supersedes respect for cultural traditions. However, cians from countries where ‘virginity’ testing is practiced. upholding human rights does not have to be incompat- Robatjazi et al examined the perceptions and experiences ible with providing a needed service to a patient, even of 16 physicians and midwives who perform ‘virginity’ if the practice does not fit into our social norm. For tests in Iran.8 The authors report that ‘virginity’ testing example, we would argue that the physician may comply is conventionally requested because of cultural factors with the request for a ‘virginity’ test under certain condi- and social pressures. Examples of reasons for patients’ tions, and with the understanding that he or she is not requesting ‘virginity’ testing included fear of not being a assessing ‘virginity’, but rather performing a compre- virgin, certifying ‘virginity’ before marriage and requests hensive sexual evaluation and providing documentation. for determination if their hymen was ‘dilatable’, so they These conditions include when the patient provides a could engage in premarital sex without damaging the compelling argument that she wants the evaluation, and hymen. Legal reasons for ‘virginity’ testing included has given informed consent; a ‘virginity certificate’ may assessment of sexual assault and assessing accusations of be necessary for her marriage, and failure to acquire not being a virgin in the absence of bleeding on one’s such a certificate may create problems for her or even wedding night. In this small study, the clinicians admitted affect her safety. A western ethical framework is outlined that the test was unreliable in determining ‘virginity’. below,10 16 but a deeper exploration into the woman’s Most of the clinicians in this study reported discomfort beliefs, values and realities of her life and social structure with performing the test at all, and agreed that education is required to fully comprehend the situation and begin on virginity testing and guidance for clinicians as well as the complex decision- making process. to the public is necessary. More research is needed on the attitudes and practice of clinicians from countries where ‘virginity’ testing is practiced. ETHICS PRINCIPLES ‘Standard’ medical ethics analysis limits itself to the VIRGINITY TESTING IN EUROPE AND NORTH AMERica ‘Georgetown mantra’ of autonomy, non-maleficence and The current unprecedented refugee crisis and global justice. We adopt these frames, but add to them to take 9 account of beneficence (attempting to do good under migration increases the likelihood that clinicians in http://gh.bmj.com/ host countries will encounter the issue of ‘virginity” the circumstances) and pragmatism (doing the best you can for your patient under difficult, real life, circum- testing. Although no precise statistics are available, there 18 are reports of increasing requests for ‘virginity’ tests in stances ). Canada and Europe.10 In the USA it has also been anecdo- tally reported in non-immigrant populations, such as the Non-maleficence Orthodox Jewish community and among certain Chris- Virginity is not a medical condition requiring diagnosis on October 2, 2021 by guest. Protected copyright. tian fundamentalist groups.11 Most recently ‘virginity’ and treatment. ‘Virginity’ tests do not provide any clin- testing has been catapulted into the news by rapper T.I.’s ical benefit to a patient, and have several harms asso- admission12 that he requires his daughter to undergo ciated with them. These include the risks of physical these exams, and by media reports13 that ‘premarital discomfort and pain,

Load more