The European Journal of Contraception & Reproductive Health Care

ISSN: 1362-5187 (Print) 1473-0782 (Online) Journal homepage: https://www.tandfonline.com/loi/iejc20

Backgrounds of women applying for reconstruction, the effects of counselling on myths and misunderstandings about , and the results of hymen reconstruction

Bianca R. van Moorst, Rik H. W. van Lunsen, Dorenda K. E. van Dijken & Concetta M. Salvatore

To cite this article: Bianca R. van Moorst, Rik H. W. van Lunsen, Dorenda K. E. van Dijken & Concetta M. Salvatore (2012) Backgrounds of women applying for hymen reconstruction, the effects of counselling on myths and misunderstandings about virginity, and the results of hymen reconstruction, The European Journal of Contraception & Reproductive Health Care, 17:2, 93-105, DOI: 10.3109/13625187.2011.649866 To link to this article: https://doi.org/10.3109/13625187.2011.649866

Published online: 31 Jan 2012.

Submit your article to this journal

Article views: 630

Citing articles: 30 View citing articles

Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=iejc20 The European Journal of Contraception and Reproductive Health Care, April 2012; 17: 93–105

Backgrounds of women applying for hymen reconstruction, the effects of counselling on myths and misunderstandings about virginity, and the results of hymen reconstruction

Bianca R. van Moorst ∗ , Rik H. W. van Lunsen † , Dorenda K. E. van Dijken ∗ and Concetta M. Salvatore † ∗Department of Obstetrics and , St Lucas/Andreas Hospital, Amsterdam, the Netherlands, † Department of Sexology and Psychosomatic Ob/Gyn, Division of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands

......

ABSTRACT Objective To study the backgrounds of women requesting hymen ‘ repair ’ , to assess the effects of extensive counselling, and the effects of hymen reconstruction. Methods A two-centre qualitative study, consisting of a semi-structured interview, education, discussion of alternatives, and instructions for self-examination (fi rst visit), educa- tional examination (second visit), decision on operation or alternative (third visit), and follow-up (fourth visit). Results Eighty-two women were interviewed at fi rst visit. Sixty-eight women were fol- lowed until their decision to be operated upon or not. Forty-eight percent of all subjects reported a history of sexual violence, and 37% had had one or more abortions. Only 29% eventually decided to be operated. Seventeen of the 19 women who submitted to an oper- ation and attended the follow-up visit reported no blood loss at fi rst marital intercourse. Conclusions Most women requesting hymen reconstruction had a history complicated by critical life events related to their request. All women were afraid they would not bleed and/or would not be ‘ tight ’ enough during the wedding night. For 75% of the women empowerment by means of extensive counselling resulted in a decision against operation. Hymenoplasty alone does not help women because most operated women will not bleed and because they often also have to prove to be ‘ tight ’ enough.

KEYWORDS Culture ; Genital ; Hymen ; Hymen reconstruction ; Hymenorrhaphy ; Hymenoplasty ; Hymen repair ; Revirgination; Religion ; Virginity

......

Correspondence: Rik H. W. van Lunsen, MD, PhD, Department of Sexology & Psychosomatic Ob/Gyn, Division of Obstetrics & Gynaecology, Academic Medical Centre H4-205, University of Amsterdam, PO Box 22660, NL-1100 DD Amsterdam, The Netherlands. Tel: ϩ 31 20 566 4456. Fax: ϩ 31 20 696 3489. E-mail: [email protected]

© 2012 The European Society of Contraception and Reproductive Health DOI: 10.3109/13625187.2011.649866 Counselling of women applying for hymen reconstruction van Moorst et al.

INTRODUCTION anymore who fear the wedding night. Therefore, in many cultures women are secretly instructed by elderly Over the past 15 years gynaecologists and other health women on how to use deception in case of a lack of care professionals in the United States, Canada, and blood loss, for example by hiding a little sac fi lled with several European countries have reported growing animal blood or a needle in the wedding gown to give numbers of women requesting hymen reconstruction oneself a fi nger puncture, or by the use of a blood 1 – 3 or a ‘ certifi cate of virginity ’ . Most authors see this stained sheet that the elderly women in the family as a result of the increasing number of immigrants saved for the younger ones11 – 13 . A harsher method 1,3 – 5 from countries with an Islamic culture . consists in applying nettles or other herbs a few days In many religions, like Judaism, the various Christian before , to make the raw, dry and vul- faiths, Islam and Hinduism, virginity before marriage nerable. Women migrated to western countries are traditionally has been associated with the integrity of often cut off from this transgenerational information the hymen. Even though Buddhism is generally less on how to ensure nuptial bleeding or otherwise mimic strict where is concerned, in some virginity. mixed Buddhist populations, like in Japan, the hymen The faith in the myth that an intact hymen proves should be ‘ intact ’ as well. However, although premarital virginity is still so implicit, that in many countries sex is not acceptable in many cultures, religions and parents decide to have their daughters ‘ offi cially societies, the necessity of proving a woman’ s prenuptial certifi ed ’ as a virgin by a gynaecologist14 . When there chastity by blood loss at fi rst marital intercourse is is even the slightest suspicion that a girl might not restricted to cultures in the Islamic world, parts of Asia, be a virgin, she may be forced to undergo a vaginal and some isolated Christian and Jewish communities. examination by a lay person or a gynaecologist8,14 . In those cultures this blood loss is seen as the ultimate Numerous suicide reports have documented the fact proof of virginity, testifying to the honour of the that this experience was so embarrassing for these woman concerned and that of her family: in the girls that they chose death rather than being touched absence of this proof the whole family is disgraced and by a stranger in an invasive manner 8,14 . The mere loses respect. Women who have lost their virginity existence of ‘ virginity certifi cates’ and ‘ hymen exam- before marriage fear they will be expelled or even inations’ illustrates that there are health care profes- murdered in the name of family honour when they sionals who claim to be able to establish the virginity do not bleed during their fi rst marital intercourse 1 . of women by assessing the condition of their hymen. Although the Qur’ an requires that both wife and men In the scientifi c literature, however, there is a broad should marry as virgins, there is no mention of the consensus that ‘ the archaic assumption that virginity necessity of this blood loss during the wedding night. is diagnosable by external genital examination’ 8 is The Bible is the only religious book that – in Deu- yet another myth4,15 – 18 . For example, in one study it teronomy, Chapter 22 – actually refers to keeping was found that in 19% of sexually active female blood-stained sheets as legal proof of virginity. There- adolescents the hymen showed no tears, clefts or fore, the myth of theintact hymen is more likely to notches17 . And in another study it was demonstrated have a cultural or Christian origin than an Islamic that even thorough inspection of the hymen with one.6 The fact that men never have to prove their a colposcope could not demonstrate anatomical dif- premarital chastity should be regarded as a double ferences between 13– 19-year-old girls with or with- standard of patriarchal societies, where the sexual out coital experience: the presence of hymenal oppression of women and the violation of their sexual notches or clefts was no proof of past intercourse, nor rights are not the result of an oppressive view of sexual- did the absence of notches or clefts rule out previous ity based on Islam, but of a combination of historical, penile-vaginal penetration18 . socio-political, and economic factors7 – 9 . The hymen reconstruction, also called hymenorrhaphy Although there is evidence that 40– 50% of all or hymenoplasty , is supposed to restore the ability of women from different cultural backgrounds do not the hymen to bleed at intercourse, thus protecting the have any blood loss at fi rst coitus 10 , this does not seem woman from penalty should she fail to prove her vir- to alter the importance attached to staining the nuptial ginity on the wedding night by staining the linen of bed. Thus, it is not just women who are not virgins the nuptial bed. Although the assumption is that these

94 The European Journal of Contraception and Reproductive Health Care Counselling of women applying for hymen reconstruction van Moorst et al.

operations guarantee post-coital blood loss, there is no ing the procedure are bound by ethical guidelines on record in the literature of follow-up studies ascertain- appropriate medical referral, according to which they ing this claim19 . The fact that during ‘ hymen repair’ , ‘ must give priority to their patients’ lives, health and sometimes, a gelatine capsule containing a blood-like well-being25 . substance that is supposed to burst during intercourse Several authors have expressed more balanced points is sutured in the vaginal wall, may be seen as a lack of of view, acknowledging the dilemma of women who confi dence in the hymenoplasty 5 . are in despair because of a male dominated view on Doctors facing requests for hymen reconstruction the controllability of women’ s sexuality. To stop the are confronted with a moral dilemma, forcing them to spreading of myths about virginity and to end gender make a choice between preventing possible negative inequalities with regard to sexual behaviour, a shift in consequences for the woman and her family should mentality is imperative, requiring huge efforts of opin- surgery be refused or performing an unnecessary ion leaders within the cultures involved to change. surgical procedure that might contribute to the Until then there will still be women requesting vir- upholding of myths and sexist attitudes and practices2 . ginity certifi cates and hymen reconstruction, which, as The fi rst article discussing this dilemma, published in argued, theoretically scores low on malefi cence and 1996, addressed the question whether or not hymen high on benefi cence, as it is a safe procedure which reconstruction is an adequate response to problems may preserve the personal and physical integrity of the that are actually rooted in sexual and other social gen- woman requesting it2,21,22 . der inequalities1 . A recent Swedish study among health care providers In 1998 Logmans et al . reported on 20 hymen showed that requests for surgery to restore virginity are reconstructions, claiming that after surgery all 20 dealt with in different ways, varying from simply send- women and, at long-term follow-up, all ten women ing the woman away, referral to a social worker or who could be traced, were satisfi ed with the outcome offering possibilities for actually having the surgery, an of the procedure20 . However, neither ‘ success’ nor ‘ sat- approach that is probably common in many western isfactory outcome’ were defi ned by the authors, and societies27 . Not only in the western world are ethical no information was provided on how the outcome issues surrounding hymen reconstruction being dis- of the intervention was assessed. Furthermore, it is cussed. An extensive analysis of debates within the remarkable that, while the authors state that the Muslim world identifi ed three standpoints28 . According requests of the women were the result of partly adopt- to one position, examination of the integrity of the ing the permissive lifestyle of a western society, half of hymen is the perfect way to establish a woman’ s chastity. them said they lost their virginity as a result of sexual And because women committing the sin of engaging abuse. This publication initiated a debate on whether in premarital sex should be punished, hymen repair is hymen reconstruction is clinically indicated or ethi- unacceptable under all circumstances. Adherents of a cally justifi ed 2, 21 – 26 . Some authors have argued that second stance argue that the woman who has premari- hymen reconstructions should not be performed or tal sex must be seen as a victim. She trusts her partner’ s should even be prohibited, because there is no medical promise that he will marry her later, but when the justifi cation for them, they might result in medical relationship ends before marriage, she faces severe dif- complications, and only contribute to persisting gen- fi culties in fi nding another marriage partner due to der inequality and the upholding of myths about vir- her dilated hymen. It is considered unfair that this ginity and the hymen23 . These authors also argue that will bar her from leading a ‘ natural life’ , i.e., getting the existence of hymen reconstructions will only raise married and bearing children. Moreover, according to suspicion in men’ s minds and thus lead to increasing this position, the validity of an ‘ intact hymen’ as proof numbers of forced hymenal examinations23 . Others of virginity and an incomplete hymen as proof of coital have stated, that although there are many arguments activity is very questionable. Lastly, from the third per- against the operation, it might be the only way out for spective, hymenorrhaphy is exclusively permitted for women facing possible harm when they would not be rape victims and women who have ‘ lost ’ their hymen able to produce blood during the wedding night24,26 . through sport or accidents, but prohibited in cases of Some have argued that practitioners who, for instance consensual premarital sex, where the woman would still because of qualms about deception, object to perform- have to face the consequences of her sinful behaviour.

The European Journal of Contraception and Reproductive Health Care 95 Counselling of women applying for hymen reconstruction van Moorst et al.

Overviewing discussions in both western countries All women applying for hymenal repair at the and the Muslim community, one may conclude that participating hospitals between January 2007 and the issue of how to deliver the best care for women December 2009 were eligible for this study. Women who fi nd themselves confronted with the threats and who lacked fl uency in the Dutch, English, French or fears of being shamed and humiliated, instantly divorced German languages were excluded from the study. or even killed when they do not bleed at the wedding Potential participants were provided with detailed night ’ s intercourse continues to raise more questions information about the procedure and content of the than it provides answers. The guideline of the Dutch study, and asked to participate. If they agreed, they Society of Obstetrics and Gynaecology does allow were requested to sign the informed consent form. hymen reconstruction, but only after extensive coun- Women reluctant to participate in the study received selling of the woman, and with due respect for her the same care as those who agreed to participate. cultural background and autonomy. The woman concerned must be informed about all pros and cons Measure and materials of the procedure, and her reasons for the request, including questions about possible underlying sexual Our previous clinical experience with women request- traumatisation, must be thoroughly explored29 . In the ing hymenal ‘ reconstruction’ convinced us that they present study we implemented these guidelines in an required a non-judgemental approach based both extensive standardised protocol based both on the on the respect of their autonomy and the prevention principles of autonomy of women and on the wish to of possible harm. This approach should include explor- empower them to make their decisions, being well ing the reasons behind the request, taking into account informed and having carefully considered all possible the individual history and psycho-social circumstances behavioural alternatives. The aim of the study was to of the woman, addressing myths and misunderstand- answer three main questions: ings about the hymen and virginity, counselling on possible behavioural alternatives and, in close colla- • What are the motives of women applying for boration with the woman, deciding on the best hymen reconstruction? possible solution in her specifi c situation. This would • What choices do women make after extensive also mean that if a woman, after having considered counselling about myths and misunderstandings her situation from every possible angle, is still con- surrounding virginity? vinced that hymen (re)construction is necessary, her • Does hymenal (re)construction result in bleeding request for the surgery should be granted. Based on during the wedding night? these principles a protocol was designed for the coun- selling and guidance through the decision-making process of these women. Motivational interviewing is a client-centred, direc- METHODS tive method for facilitating change by exploring and 30 Setting and sampling procedure resolving ambivalence . A semi-structured interview is conducted with a fairly open framework which allows A multi-centre prospective qualitative study was for focused, conversational, two-way communication. conducted in two hospitals in Amsterdam, the New questions can be brought up during the interview Netherlands. Participating hospitals were the St. as a result of what the interviewee says31 . To assess the Lucas-Andreas Hospital, a teaching hospital in a study’ s research issues and questions a semi-structured neighbourhood of Amsterdam with more than 50% motivational interview was developed, including an immigrants from Northern Africa, Eurasia and the interview guide defi ning the topics and questions that Middle East (the majority originating from Morocco needed to be addressed by the interviewers. and Turkey); and the Academic Medical Centre of the University of Amsterdam, located in a part of the Procedure city where two thirds of the inhabitants are of non- Dutch origin. The study was approved by the Medical The study encompassed four visits. During the Ethics Committee of both participating centres. initial visit participants were interviewed using the

96 The European Journal of Contraception and Reproductive Health Care Counselling of women applying for hymen reconstruction van Moorst et al.

semi-structured motivational interview by one of the Addressing the fact that 40– 50% of all women, fi rst two authors, both trained as counsellors and irrespective of their cultural background, do not bleed therapists in sexual health and women’ s health care. at fi rst coitus, possible behavioural alternatives to pro- After stressing the autonomy of the woman with duce ‘ blood on the sheet’ were discussed. Participants regard to her fi nal decision on the hymenoplasty and were informed that many women prick their fi nger after collecting essential biographical data, the reasons tip with a needle hidden in the wedding gown or that behind the request were explored in depth; this included a little sac with some animal blood could be used; to a detailed history taking of the circumstances that had this end, a tube with their own heparinised blood led to her losing her virginity, her expectations on how could be handed over to the women. Other possibili- she would have to prove her virginal state and to whom, ties are a timed withdrawal bleeding elicited by, for possible anxieties related to non-disclosure of her past, instance, a combined oral contraceptive, or insertion and her expectations concerning the surgery. This was of a vaginal suppository with carmine red before the followed by exploring the woman’ s sources of sexual coitus. Women were informed that hymenoplasty is no health information, and knowledge of- and possible guarantee for blood loss and that, therefore, an alterna- misconceptions about the hymen. This exploration tive method to mimic blood loss might be necessary included the subject’ s opinions about virginity and anyhow. With women expressing fears about a possible premarital sex, her ideas about, and experiences with, ‘virginity examination’ they might be forced to undergo, sexuality as a possible source of (dis)satisfaction or pain, the possibility was raised to provide them with an offi cial her knowledge about sexual physiology and anatomy certifi cate stating that ‘ Miss X has been professionally (including experiences with self-examination and mas- examined. Nothing in this examination indicated that she turbation), and her sexual health history with emphasis is not a virgin’ 3 . This talk in a very natural way led to on contraceptive use, sexually transmitted infections planned discussions on doing nothing at all, and on the (STIs), and unwanted pregnancy. Using the technique pro’ s and cons of disclosure to their future spouse weighted of motivational interviewing (e.g., ‘ Did you ever see against the diffi culties of living with a hidden past. photographs of how of different women can During the second visit subjects met one of the look like? Did you ever look at yours?’ ) the participant two female gynaecologists involved in the study. was then extensively informed about the hymen as a A mirror-assisted educational gynaecological exami- ‘mythical structure’ by means of discussing pictures nation32 – 34 was carried out, that aimed at increasing showing diverse morphological varieties of the hymen, the patient’ s knowledge about her genital anatomy about the myth of blood loss in the nuptial bed (‘ How and answering any further questions. Pelvic fl oor do you think that almost half the women in your cul- awareness and the ability of voluntarily contracting ture who do not bleed at fi rst intercourse solve this and relaxing the pelvic fl oor were assessed and, if nec- problem?’ ), and about the prerequisites for painless and essary, additional instructions were given. To select the pleasurable intercourse (e.g., relaxation and arousal). In proper surgical technique should the woman decide to our previous clinical experience we had discovered that have the operation, the hymen was examined. With a many women seemed to be more concerned about clearly identifi able hymen, a simple hymenoplasty being not ‘tight enough ’ than about the possibility of according to the ‘ Paris method’ 35 would be the preferred not bleeding. Therefore, much information was pro- technique. In this procedure two incisions are made on vided about the role of the pelvic fl oor as a sexual each side of the largest hymenal cleft that can be dis- organ. The woman must be aware that she can relax cerned and both sides are joined by small sutures17 . the muscles around the vaginal opening or, on the con- When there are no clefts or notches suitable for this trary, achieve a sustained, voluntary contraction of the method a small posterior introital narrow- latter, in order to mimic ‘ tightness ’ . Women were taught ing the introitus would be performed. These two tech- how to consciously contract and relax the pelvic fl oor niques are comparable to those described as being very to improve awareness of this structure and its function, successful by Logmans et al .20 . The procedure should and to gain self-confi dence. They were advised to be done no sooner than about 14 days before the examine themselves so as to get acquainted with their wedding, in order to increase the chance of blood loss, genitals, to inspect their hymen, and to evaluate whether and not much later, to avoid that remnants of sutures they were able to constrict their vaginal introitus. be seen.

The European Journal of Contraception and Reproductive Health Care 97 Counselling of women applying for hymen reconstruction van Moorst et al.

At the third visit the woman met her counsellor for Table 1 Demographic characteristics of participants the second time. She could ask for any additional ( N ϭ 82). information she needed to make up her mind, and was questioned about her evaluation of the protocol up Demographic features n (%) until that moment, her decision, if any, concerning the Mean age: 23.5 years (range 17 – 40) 82 (100) operation, and/or whether assistance or a prescription Education: for mimicking blood loss was needed. University 3 (4) The fourth visit was scheduled several weeks after the Tertiary vocational 18 (22) wedding. In most cases this visit consisted of a face- Secondary (high school) 15 (18) to-face interview with her counsellor; sometimes, Vocational 42 (51) however, this follow-up contact was conducted by Unknown 4 (5) e-mail or telephone when the wedding took place Religion: abroad or when the woman feared exposure of her Islamic 75 (92) secret by visiting the hospital without permission of Christian 5 (6) Hindu 1 (1) her husband. In this follow-up interview the woman’ s Areligious 1 (1) experiences and feelings during the wedding night Country of origin∗ : were explored, including the actual occurrence of Morocco 46 (56) blood loss and the need for enacting (e.g., tightening Turkey 22 (27) of the pelvic fl oor) or for using an expedient (e.g., Iraq 3 (4) carmine red). Specifi c issues addressed were whether Afghanistan 3 (4) or not the woman’ s husband had believed that she was The Netherlands 2 (2) still a virgin; whether, on second thought, the woman Algeria 1 (1) had decided to reveal her (sexual) history; whether Egypt 1 (1) there had been any sexual problems during the wed- Sudan 1 (1) ding night and, in case there had been, if and how the Sri Lanka 1 (1) newlyweds had been able to solve these; and whether Pakistan 1 (1) the woman was satisfi ed with the chosen option. Surinam 1 (1) Finally, the woman was asked for her fi nal opinion Born in country of origin 39 (48) Born in the Netherlands 43 (52) about the centre’ s approach of her request for a hymen reconstruction. ∗ Country where the woman or at least one of her parents was born . Analysis

The answers of the participants on the semi-structured shows that their educational level was relatively high. interview questions were recorded in a SPSS fi le. Nine out of ten women (92%) were Muslims. Four Analysis of the data was restricted to using frequencies Christian women were engaged to Christian men, to identify relevant trends in the women’ s answers. and one to a Muslim. The only non-religious woman was a Dutch woman about to marry a Muslim. The women came from 11 different countries. More than RESULTS half (43, i.e., 52%) of the women were born in the Sample demographics Netherlands; the other 39 women were born in Morocco ( n ϭ 22), Turkey (n ϭ 6), Iraq ( n ϭ 3) or Ninety-two women from all parts of the Netherlands other countries ( n ϭ 8). On average, participants had applied on their own accord to one of the participat- been living in the Netherlands for 13.5 years and most ing centres with a request for hymen reconstruction. had received their secondary education in this country. Ten women were excluded from the study because of Forty of the 43 women born in the Netherlands had insuffi cient fl uency in Dutch, English, German or one (n ϭ 3) or two (n ϭ 37) parents who were immi- French. The remaining 82 women were aged between grants from one of the countries mentioned in Table 1; 17 and 40 years, with an average age of 23.5. Table 1 the vast majority came from Morocco or Turkey.

98 The European Journal of Contraception and Reproductive Health Care Counselling of women applying for hymen reconstruction van Moorst et al.

Psychosocial and sexual history of sexual abuse in the form of non-consensual forced intercourse. Almost two thirds of the perpetrators ϭ Table 2 shows that one third ( n 27) of the women were partners. After having been raped by her boy- had lost their virginity as a result of consensual sex friend one woman was told: ‘ Now you’ re mine, you with a partner. Some of them afterwards only regret- will never be able to marry someone else’ . Three ted that they had not lived up to their own standards women were abused by a lover boy, one woman was and convictions regarding premarital sex, but the raped by an unknown person, and the remaining ten majority of these women now feared the conse- women had been abused repeatedly by relatives. quences of a possible discovery of their previous sex- Compared to a life-time abortion risk of 10% for ϭ ual activities. Another third of the women ( n 27) Dutch women, the 37% abortion rate in this study felt that they had been ‘ talked into sex’ after marital was extremely high. Six women (7%) reported an promises of their partner, who in most cases aban- attempted suicide, as the only way out after ‘ losing ’ doned them soon afterwards. Three of these women their virginity. A Turkish girl who had had a (forbid- later found out that the man they had been trusting den) relationship with a Kurdish boy visited the clinic was already married in the country of origin. In one together with her mother and said: ‘ I couldn ’ t talk case the man in question was a religious leader (Imam) about it with anybody. In our community there is so who, without revealing that he already had a wife and much gossip. I do not trust anybody. I was so afraid children, had talked the woman into sex by using that my older brother would discover the relationship. authoritative arguments about premarital sex being I was sure that he would murder both of us. (Mother legitimate (‘ haram ’ ) when two people love each other confi rms: ‘ I ’ m sure about that too’ .) I felt that I could and are certain that they will marry. do nothing else but commit suicide. After my attempt ϭ Almost a third (n 25) of the women had lost their I was admitted to the hospital and, even then, I did virginity through unwanted sex, by force or threat. not dare to tell my story to the psychiatrist. I did Three women (4%) believed that they had ‘ torn ’ their not trust her either’ . Three women were forced to hymen by non-coital activity; two of them feared prostitute themselves after being seduced by a ‘ lover- that that might have been the result of extra-vaginal boy ’ . In most cases there was comorbidity of two or petting. One woman got pregnant following inter- more of these critical events. Thirty-eight of the crural coitus and said she had lost her virginity as participants (46%) had ever been tested, and seven had a result of the abortion that followed. Blood loss at been treated for a STI. During the study 35 women fi rst intercourse was reported by 54% of the women were tested for STIs; two women tested positive for requesting hymen reconstruction. Chlamydia trachomatis . At the time of the fi rst interview With respect to major life events, half of the women 14 women (17%) used any contraceptive method; had a history of severe psychosocial problems related 34 (41%) had used a contraceptive method before, to their request. Forty-eight percent reported a history mostly (30) a combined oral contraceptive. Three women had ever used postcoital contraception. Table 2 Sexual history and life events related to the requested hymen reconstruction (N ϭ 82) . Previous knowledge about hymen Circumstances which surrounded and own genitals the ‘ loss of virginity’ n (%) More than half of the participants (57%) were totally Consensual sex 27 (33) ignorant about female sexual anatomy and had mis- Broken marital promise 27 (33) conceptions about the hymen (e.g., it being a mem- Sexual abuse 25 (31) brane sealing off the vagina). Mothers, sisters, aunts Non-coital activity 3 (4) and female friends were the most important sources Related life events of information. Thirty-fi ve women (43%) knew that Sexual abuse 39 (48) at fi rst intercourse bleeding was not guaranteed. Some Forced prostitution 3 (4) were well informed about the myths surrounding the Abortion 30 (37) hymen and virginity, and had tried to touch upon Attempted suicide 6 (7) these issues with their future spouse by asking him,

The European Journal of Contraception and Reproductive Health Care 99 Counselling of women applying for hymen reconstruction van Moorst et al.

for instance, what he would think if a woman would can feel whether a woman is virgin or not’ . Seven not bleed. Without exception the man had answered women (9%) were told that before the actual marriage that he certainly would notice if someone was not they would be sent to a doctor to be examined or to a virgin and that he would not accept it: ‘ I was a local lay person in the country of origin to have a fl abbergasted. He is so modern and liberal in many ‘ ’ . One third of the women ( n ϭ 28) did ways, except when it comes to these issues’ . Thirty- not know what to expect and how and to whom they two women (39%) had ever tried to inspect their would have to prove their virginity; they were just , some of them only to assess the suspected dam- afraid. Forty women (49%) feared that, upon discov- age to their hymen. ery, they would be expelled from their family and that they would have to live as an outcast, with no Expectations of the effects and the prospect of ever having contact with friends and rela- results of a hymen reconstruction tives again. Of the 23 women (28%) who expected their marriage would be cancelled should they fail to Blood loss during the wedding night was the sole prove their virginity, some said that they might be objective of the requested surgery for 25 (31%) of the granted a second chance, but most expected the worst women; ten women (12%) stated that blood loss and ten (12%) said they were sure that an honour was not important, but that their goal was to ‘ feel killing would ensue. Only nine women (11%) were tight ’ to prevent their husband from suspecting that without fear and had only internal motives to seek they were no longer a virgin. Twenty-nine women hymen repair. (35%) considered both objectives – feeling tight and More than two thirds of the women with a sche- blood loss – equally important. For seven women (9%) d uled wedding day said they were marrying for a hymen reconstruction was sought to serve as a ritual (mutual) love; nine were ‘ arranged’ in the for helping them to overcome traumatic sexual expe- sense that both families had decided about the mar- riences, as a way to feel ‘ whole and pure’ again: most riage with the spouses’ consent, and seven marriages of these women requested hymenal repair even though were forced against the woman’ s will. In general they currently had no marriage plans. Finally, for women stating they were about to marry for love did 11 women (13%) the only reason for undergoing not express fewer fears about possible repercussions the operation was the expectation that it would after discovery than women facing an arranged or increase their self-confi dence and/or self-esteem. forced marriage.

Fears and anxieties about proving The decision-making process and virginity and possible repercussions results of the hymen reconstruction

Forty-seven women (57%) expected that they would Figures 1 and 2 show the fl ow of the participants have to prove their virginity to their husband, through the study phases. Eighty-two women were family and/or family in law. However, for 33 of these enrolled in the study. Nine (11%) dropped out after women there were no requirements with regard to the fi rst visit, four of whom decided to postpone their showing the stained nuptial sheet to the family, a decision after having been told that the participating practice that was rejected by almost all women as hospitals perform the operation preferably just before being outdated. To them virginity was not a concern marriage in order to increase the chance of blood loss involving the whole community, but a responsibility at fi rst marital intercourse. We do not know whether of spouses and an obligation to God. Thus, these the other fi ve women no longer saw the necessity 33 women indicated that it was only their future of an operation after the extensive education and husband who required that they produce proof of counselling which took place at the fi rst visit, or their virginity by showing blood and/or being tight. went to another clinic for a ‘ quick-fi x ’ . Twenty-four Many women expressed the fear of ‘ not being tight of the enrolled subjects (29%) ultimately decided they enough ’ , a worry that was kept alive by repeated would undergo the surgical procedure; 44 relied warnings of their mothers, sisters, friends and, above on an alternative (behavioural alternative or doing all, by their future spouses who claimed that ‘ a man ‘ nothing ’ ).

100 The European Journal of Contraception and Reproductive Health Care Counselling of women applying for hymen reconstruction van Moorst et al.

First visit 82

Second visit Drop-out Alternative* Nothing (educational 9 10 8 exam) (11%) (12%) (10%) 55 (67%)

Alternative* Surgery 26 24 (32%) (29%) *Individual tailor-made expedients

Figure 1 Summary of the results of the decision-making protocol 1.

Nineteen of the women who underwent surgery visit and decided to do ‘ nothing ’ because they had were seen at follow-up. The majority of them ( n ϭ 17) changed their mind about the cultural constraint to had not bled during the wedding night. Thus, prove their virginity. Quotes from these women are they were forced to resort to one of the alternatives illustrative of their increased self-confi dence and discussed with a view to stain the linen or they dealt autonomy: ‘ I don’ t want to be part of this masquerade otherwise with the situation. In spite of what she anymore ’ ; ‘ I don’ t want to marry a guy who doesn’ t had been told, one of these women was convinced that want me for who I am’ ; ‘ I never did anything to she would bleed. When she did not, she panicked be ashamed of’ ; ‘ I am going to tell him the truth’ . and told her husband that she had been raped by an After the fi rst visit another ten women opted for an uncle. The husband got angry, not because of what alternative to surgery. They were convinced that the had happened, but because, in his eyes, she had not operation was unnecessary: ‘ I don’ t want to have sur- trusted him enough to tell her story before. Eleven of gery or any other medical intervention. I know now the 44 women who decided not to be operated could how I can solve this’ . Most women (n ϭ 55) visited the be interviewed at follow-up. Most of them had gynaecologist for the educational gynaecological been so preoccupied with the virginity issue that they examination. Following this visit, 26 women (47%) had not been able to enjoy the wedding night. The decided against surgery, three of whom after the exam- majority experienced pain at fi rst marital intercourse. ination had revealed that, in spite of coital experience, None of them was accused of not being a virgin dur- they had an annular hymen without any clefts or ing the wedding night. The marriage abroad of one notches. Five women dropped out of the study after woman was cancelled, because a local witch doctor the visit to the gynaecologist. Telephone follow-up had declared that she was not a virgin. revealed that these women no longer pursued surgery In Figure 2 the decision-making process is described. because they were convinced now that there were Although initially fully convinced that hymen recon- alternative ways to cope with their problem. Ulti- struction was the only solution for their problem, mately, 24 women decided to undergo the surgery and sometimes after a lengthy search for hospitals that they had contemplated: 17 had a small introital vagi- would not immediately reject them, eight women noplasty, and the other seven, a simple hymenoplasty. withdrew their request for surgery following the fi rst For most of them the decision to have the operation

The European Journal of Contraception and Reproductive Health Care 101 Counselling of women applying for hymen reconstruction van Moorst et al.

Intention to treat 92

Excluded Included 10 82

Drop-out after first Decision: 18 (22%) Second visit: visit Nothing: 8 (10%) 55 (67%) 9 (11%) Alternative*: 10 (12%)

Drop-out Alternative* Surgery: 24 (29%) 5 (6%) 26 (32%) simple hymenoplasty 7 introital vaginoplasty 17

Follow-up Follow-up 11 19

* Individual tailor-made expedients Did bleed Alternative* 2 17

Figure 2 Summary of the results of the decision-making protocol 2.

was mainly emotional. They often expressed this by learned ability to voluntarily contract the pelvic fl oor saying: ‘ Now I know that it all is a myth, sheer non- at intromission to mimic ‘ tightness’ . sense; our men are ignorant and infl ict their stupidity on us, but… I have to live with it. It is our culture Patient satisfaction and, by having the operation, I feel stronger knowing I did everything that could be done’ . For the sake of At the end of the third visit, after arriving at a deci- safety, these women were also instructed how to use sion, and at follow-up, participants were asked to alternatives as it was impossible to guarantee bleeding. rate the different parts of our protocol on a 10-point Surprisingly, only two of the 19 women seen at Likert scale. Overall, they were extremely satisfi ed follow-up had bled during their wedding night. with all stages of the protocol. The fi rst visit was However, the majority of the women (44) did not awarded a 9.5, the most valued aspect being ‘ to be choose surgery but preferred a tailor-made behav- able to tell my story ’ . The second visit, consisting of ioural alternative, going from doing nothing at all to the educational examination, was rated 8.5, with most one of the means to simulate blood loss and/or con- appraisal for the mirror examination. This high tracting the pelvic fl oor. There was no marked prefer- appraisal rate for the mirror examination is congruent ence for any of these possibilities although a majority with the women ’s expressions of disbelief at the fi rst combined feigned blood loss with using their newly visit when they were shown pictures of the vulva and

102 The European Journal of Contraception and Reproductive Health Care Counselling of women applying for hymen reconstruction van Moorst et al.

hymen: ‘ Do I really look like that?’ ; ‘ Is it that tight?’ ; was not simply related to the wish to bleed during the ‘ Where is the opening?’ . Often, after a fi rst inspection wedding night, but more to the fear many women at home, the biggest surprise of the women during reported about men being able to feel that they were the educational examination was that they could actu- no longer virgins. These fears are highly infl uenced by ally control ‘ tightness ’ by means of the pelvic fl oor the attitude of men with regard to virginity and alleged contractions they had exercised at home. proofs thereof, such as blood loss and tightness of the All 30 women who took part in the follow-up were introitus. Many women were desperate because of the very satisfi ed with all stages of the protocol. This also possible discovery of their past. In order to have them applied to women who had a hymenoplasty but did ‘ confess’ , some women were confronted with rumours not bleed at all. Thirteen of the 19 operated women, leading to a crossfi re of questions, threats with ‘ virgin- including the two who had experienced blood ity tests’ , violence, and doctor-examinations. At the loss, stated that they would make the same decision time of the fi rst visit, all women participating in this again. Six women mentioned that, in retrospect, they study were convinced that surgery would be their sole would not have chosen to have surgery; two women salvation. In most cases it was possible to correct myths said that they would have disclosed their past to their and misconceptions surrounding the hymen and vir- husband, and four would have used a behavioural ginity. However, in spite of their new conviction that alternative. Be that as it may, none of these women the prevailing ideas about ‘ blood loss’ and ‘ tightness’ had any regret about the operation, because the whole were false – indeed, almost half of them had not bled procedure – both the counselling about alternatives at their fi rst coitus – many women held on to their and the operation itself – had enhanced their self- belief that ‘ because of their culture’ they still would be confi dence. Ten of the women who did not have expected to be tight and/or to bleed during their wed- surgery but instead resorted to an alternative stated ding night. Nevertheless, suggestions to ‘ solve ’ this that they would do so again, and one said she would problem by means of pelvic fl oor contractions and/or have told her husband. alternative ways to stain the sheet were welcomed. For most women increased knowledge and self-confi dence DISCUSSION acquired during the study meant that they could decide against surgery, even though at fi rst they con- To the best of our knowledge this is the fi rst study sidered it was the only solution to the problem they that assessed the psychosocial and sexual health status were facing. The minority of women who still felt that of women requesting hymen reconstruction, and the the operation was necessary, were all very glad that fi rst one with post-surgery follow-up. Its aim was they had it done, despite the fact that they often had threefold: (i) to explore the motives of women apply- to resort to some ‘ tricks’ to mimic virginity. ing for hymen repair; (ii) to investigate choices women After extensive counselling, 24 of the 82 women make with regard to surgery or alternative options after (29%) enrolled in the study decided to be operated extensive counselling about myths and misconceptions upon. Since our intention when designing the proto- surrounding virginity, and (iii) to determine whether col was to give women requesting a ‘ hymen repair’ the or not hymen (re)construction results in bleeding possibility to reconsider their wish after extensive non- during the wedding night. We opted for a qualitative judgemental education and counselling, we judge this approach, because the latter is invaluable for explor- is a successful outcome. The high satisfaction rates for ing and understanding people’ s personal experiences. all aspects of the protocol may refl ect the quality of Women often had a complicated history leading to the therapeutic relationship with the women resulting the request for hymen repair: only one third of them from our patient-centred protocol. This is also illus- had lost their virginity through consensual premarital trated by the fact that – in contrast with the experi- sexual encounters, and there were many cases of sexual ence of many gynaecologists who report that their abuse and abortions. The latter may be explained by patients never show up at a scheduled follow-up visit the infrequent use of contraceptives during sexual – 79% of the operated women did come back for contacts that are surrounded with secrecy, guilt and/ follow-up, most often because they wanted to share or coercion. In contrast to the sparse literature about their experiences in order to help other women facing the subject, the request for hymen repair in most cases the same dilemmas in the future.

The European Journal of Contraception and Reproductive Health Care 103 Counselling of women applying for hymen reconstruction van Moorst et al.

As far as we know, our study’ s sample is highly attitudes, ignorance and double standards of men. The representative for Dutch women who request a hymen spreading of information about the hymen and vir- repair and who mostly have roots in the Middle East, ginity by means of leafl ets and the internet, as is done Eurasia, and the Maghreb. However, as in every quali- in the Netherlands and in Sweden36,37 , may help tative study, our results may not be generalisable to changing the opinions of women, but not those of comparable groups in other countries. The study men. Educational tools are needed that will correct sample was not randomly chosen: it consisted of a the mythical beliefs men (and some doctors) entertain subgroup of several cultural populations. Thus, the about the hymen and virginity. attitudes towards virginity and the hymen in this In view of the participants’ great appreciation of our sample may not represent the common attitudes pre- approach and the surprising outcome of the decision- vailing among the populations these women belong making process among the counselled women, the to. More qualitative and quantitative studies assessing study protocol, with the addition of routine STI attitudes towards virginity and the hymen of represen- testing, will become the standard modus operandi tative populations of men and women with the same for all requests of hymen repair in the participating cultural background are needed. hospitals.

CONCLUSION ACKNOWLEDGEMENTS

A non-judgemental, stepped, client-centred counsel- We thank all women who participated in the study for ling and educational procedure can be successful in their willingness to tell their stories – often for the empowering women driven to despair by the loss of fi rst time – to the authors. Several of them expressed their virginity. Hymenoplasty does not suffi ce: most the intention to contribute to a change of mentality operated women will not bleed at their fi rst marital within their communities. We also wish to express our intercourse; moreover, blood loss is not the only proof gratitude to Mario ter Smitten who reviewed spelling, they have to deliver. grammar and semantics of the article. Virginity is not an anatomical feature whose exis- tence can be ascertained by a physical examination, Declaration of interest: The authors report no confl icts but a psychological issue. All women who participated of interest. The authors alone are responsible for the in this study felt that the main problems were the content and writing of the paper.

REFERENCES

1. Bekker MJ, Rademakers J, Mouthaan I, et al . Recon- Netherlands 2008. Accessed 13 August 2011 from: structing hymens or constructing sexual inequality? www.aidsactioneurope.org/uploads/tx_ Service provision to Islamic young women coping with windpublications/874-0.pdf the demand to be a virgin. J Community Appl Soc Psychol 7. Ilkkaracan P. Women, sexuality, and social change in the 1996;6:329– 34. Middle East and the Maghreb. Soc Res 2002;69:753– 79. 2. Amy JJ. Certifi cates of virginity and reconstruction of 8. Parla A. The ‘ honor ’ of the state: Virginity examinations the hymen. Eur J Contracept Reprod Health Care 2008; in Turkey. Feminist Stud 2001;27:65– 88. 13:111– 3. 9. E¸ s sizo gˇlu A, Yasan A, Yildirim AE, et al . Double standard 3. Helgesson G, Lynö e N. Should physicians fake diagnoses for traditional value of virginity and premarital sexuality to help their patients? J Med Ethics 2008;34:133– 6. in Turkey: A university student’ s case. Women Health 4. Bravender T, Emans SJ, Laufer MR, et al . Use caution 2011;51:136– 50. when determining “ virginal” vs “ nonvirginal” status. 10. Loeber O. Over het zwaard en de schede; bloedverlies Arch Pediatr Adolesc Med 1999;153:773– 4. en pijn bij de eerste coï tus; Een onderzoek bij vrouwen 5. Kandela P. Egypt ’ s trade in hymen repair. Lancet 1996; uit diverse culturen. [About the sword and the sheet; 347:1615. blood loss and pain at fi rst coitus. A study of women 6. Young people, sex and Islam; an investigation into Dutch with different cultural backgrounds.] Tijdschrift voor young people of Moroccan and Turkish descent. STI AIDS Seksuologie 2008;32:129– 37.

104 The European Journal of Contraception and Reproductive Health Care Counselling of women applying for hymen reconstruction van Moorst et al.

11. gomiddleeast.com. Afraid that you won’ t bleed on your 26. O ’ Connor M. Reconstructing the hymen: Mutilation wedding night? Accessed 13 August 2011 from: www. or restoration? J Law Med 2008;16:161– 75. gomiddleeast.com/tag/bleeding-on-wedding-night/ 27. Ess é n B, Blomkvist A, Helströ m L, Johnsdotter S. 12. Blank H. Virgin; the untouched history. New York: The experience and responses of Swedish health pro- Bloomsbury 2007: 89– 91. fessionals to patients requesting virginity restoration 13. islamicgarden.com.The myth of the hymen continues . (hymen repair). Reprod Health Matters 2010;18:38– 46. Accessed 13 August 2011 from: www.islamicgarden. 28. Eich T. A tiny membrane defending ‘ us ’ against ‘ them ’ : com/mythhymen.html Arabic Internet debate about hymenorraphy in Sunni 14. G ü rsoy E, Gü lsen Vural G. Nurses’ and midwives’ views Islamic law. Cult Health Sex 2010;12:755– 69. on approaches to hymen examination. Nurs Ethics 2003; 29. Feitsma AH, Kagie MJ. NVOG Standpunt hymenre- 10:485– 94. constructie. Nederlandse Vereniging Voor Obstetrie en Gynae- 15. Curtis E, Lazaro CS. Appearance of the hymen in ado- cologie, (Guideline hymen reconstruction. Dutch Society of lescents is not well documented. BMJ 1999;318:605. Obstetrics and Gynaecology ). Utrecht: NVOG 2004. 16. Rogers DJ, Stark M. The hymen is not necessarily torn 30. Miller WR, Rollnick S. Motivational interviewing: after . BMJ 1998;317:414. Preparing people for change, 2nd edn. New York: Guilford 17. Emans SJ, Woods ER, Allred EN, Grace E. Hymeneal Press 2002. fi ndings in adolescent women: the impact of tampon 31. Lindlof TR, Taylor BC. Qualitative communication use and consensual sexual activity. J Pediatr 1994;125: research methods , 2nd edn. Thousand Oaks, CA: Sage 153 – 60. Publications 2002: 195. 18. Adams JA, Botash AS, Kellogg N. Differences in hyme- 32. Miller, Grant D. The gynecological examination as a nal morphology between adolescent girls with and learning experience. J Am Coll Health Assoc 1974;23: without a history of consensual sexual intercourse. Arch 162 – 4. Pediatr Adolesc Med 2004;158:280– 5. 33. Latta W, Wiesmeier E. Effects of an educational gyneco- 19. Goodman MP. Female genital cosmetic and plastic sur- logical exam on women’ s attitudes. J Obstet Gynecol gery: a review. J Sex Med 2011; 8:1813–25 . Neonat Nurs 1982;11:242– 5. 20. Logmans A, Verhoeff A, Bol Raap R, et al . Ethical 34. Willard MD, Heaberg G, Pack JB. The educational pel- dilemma: Should doctors reconstruct the vaginal introi- vic examination – Women ’ s responses to a new approach. tus of adolescent girls to mimic the virginal state? BMJ J Obstet Gynecol Neonat Nurs 1986;15:135– 40. 1998;316:459– 60. 35. Lammes FB. Chirurgische mogelijkheden bij virgo- 21. Webb E. Cultural complexities should not be ignored. problematiek (Hymenal reconstruction; surgical possi- BMJ 1998;316:462. bilities). Ned Tijdschr Obstet Gynaecol 2003;116:9– 10. 22. Friedman Ross L. Surgery is not what it seems. BMJ 36. Facts and fi ction about the hymen . Utrecht: Rutgers Nisso 1998;316:462. Groep 2007. Accessed 13 August 2011 from: http:// 23. Usta I. Hymenorrhaphy: what happens behind the www.rutgersnissogroep.org/ourinternationalwork/ gynaecologist’ s closed door? J Med Ethics 2000;26: product-services/products/products-1/facts-and- 217 – 8. fi gures-about-the-hymen-pdf 24. Wild V, Poulin H, Biller-Andorno N. Rekonstruktion 37. Kn ö fel Magnuson A. Vaginal corona; myths surrounding des Hymens: Zur Ethik eine tabuisierten Eingriffs. virginity – Your questions answered . RSFU, 2009. Accessed Deutsches Ä rzteblatt 2009;106:340– 1. 13 August 2011 from: http://www.rfsu.se/Bildbank/ 25. Cook RJ, Dickens BM. Hymen reconstruction: Ethical Dokument/Praktikor/praktika-Vaginal_corona2009. and legal issues. Int J Gynecol Obstet 2009;107:266– 9. pdf?epslanguage ϭ sv

The European Journal of Contraception and Reproductive Health Care 105