The Hymen As Proof of Virginity

Faculteit Letteren & Wijsbegeerte

Bio-ethische vraagstukken rond maagdenvliesherstel

Alain Vande Putte

Masterproef voorgedragen tot het behalen van de graad van Master in de Wijsbegeerte

2015

Chapter 1: Problem and Context ...... 6

Introduction ...... 6

Terminology ...... 8 Hymenoplasty ...... 8 Virginity ...... 9 “Prove” and “proof” ...... 9 Female genital cutting (FGC) ...... 9

The virginity rule ...... 10 A predominantly Muslim demographic ...... 10 Premarital virginity is important in many cultures ...... 11 A cultural rather than a religious rule ...... 11 Dealing with the problem at hand ...... 11

Social background of migrant Muslims ...... 12 Gender inequality in the enforcement of the virginity rule ...... 12 Anthropological basis of the virginity rule ...... 13 A shame culture ...... 13 Social control ...... 14 Inter-cultural stress ...... 14 Arranged and forced marriages ...... 15 Male privileges ...... 15 Female guilt ...... 15

Lack of Sexual Knowledge ...... 16 The development of healthy adolescent sexuality ...... 16 Lack of sexual education ...... 17 Lack of knowledge regarding virginity and the hymen ...... 18 Contextual certainties ...... 19 Lack of knowledge regarding possible solutions ...... 19

Consequences of loss of virginity ...... 20

Other reasons for requesting HP ...... 21 “Feeling tight” ...... 21 Overcoming trauma and self-loathing ...... 22 Safeguarding the family ...... 22 Social mobility ...... 22

Circumstances leading to the request ...... 23

Ethical Problems for Western Doctors ...... 24

Caveats ...... 24 Representativeness of the population ...... 24 Difficulties surrounding follow-up evaluation ...... 25 Absence of reliable cost-benefit data ...... 25 Absence of reliable prevalence data ...... 26

Chapter 2: The Hymen as Proof of Virginity ...... 27

Myths and misconceptions ...... 27 An intact hymen does not constitute proof of virginity ...... 27 A ruptured hymen does not prove sexual intercourse ...... 28 A physical examination cannot tell an intact from a ruptured hymen ...... 28 Blood loss during sexual intercourse does not prove virginity ...... 29 Absence of blood loss does not prove previous sexual intercourse ...... 29 The hymen does not have the function of signalling virginity ...... 29 The hymen does not have a pre-ordained function ...... 30 Conclusion ...... 31

The limits of educational means ...... 31

Chapter 3: Analogical Procedures ...... 33

Introduction ...... 33

Analogical reasoning ...... 33

Medicalised female genital cutting ...... 35 Delineating the analogy ...... 35 Why mFGC? ...... 36

Labiaplasty ...... 37 Delineating the analogy ...... 37 Why cLP? ...... 38

Chapter 4: Consequentialist Objections to HP ...... 39

HP may cause medical complications ...... 39 Medical complications of mFGC ...... 40 Medical complications of cLP ...... 42 Conclusion regarding medical complications ...... 43

HP may have psychological consequences ...... 45 Psychological consequences of FGC ...... 46 Psychological consequences of cLP ...... 47 Conclusion regarding psychological consequences ...... 48

HP may fail to achieve its intended effect ...... 49 HP does not guarantee blood loss ...... 50 A lack of “tightness” may cause doubt in spite of blood loss ...... 51 Public knowledge of HP may cast doubt on the blood loss ...... 52 Preliminary conclusion regarding HP and its intended effect ...... 53 mFGC and its intended effect ...... 53 cLP and its intended effect ...... 53 Conclusion regarding intended effect ...... 54

Conclusions consequentialist objections ...... 54

Chapter 5: Deontological Objections to HP ...... 56

HP is Medically Unnecessary ...... 56 Medical necessity and mFGC ...... 58 Medical necessity and cLP ...... 59 Conclusion regarding medical necessity ...... 60

HP constitutes deceit ...... 60 Preliminary conclusion regarding HP and deceit ...... 63 mFGC and deceit ...... 63 cLP and deceit ...... 63 Conclusion regarding deceit ...... 64

HP perpetuates gender inequality ...... 64 The case against the virginity rule ...... 65 The political economy of the virginity rule ...... 67 The cultural defence ...... 69 HP versus the virginity rule ...... 71

HP violates the right to freedom from discrimination ...... 72 HP is not discriminatory in itself ...... 72 HP does not perpetuate discriminatory practices ...... 73 The consequences of not bleeding outweigh any discriminatory aspects of HP ...... 74 Preliminary conclusion: HP and the right to freedom from discrimination ...... 75 Is mFGC discriminatory in itself? ...... 76 Does mFGC perpetuate discriminatory practices? ...... 77 The consequences of refusing mFGC versus its discriminatory aspects ...... 78 The right to freedom from discrimination and cLP ...... 78 Conclusion regarding the right to freedom from discrimination ...... 78

HP and the right to bodily integrity ...... 79 mFGC and the right to bodily integrity ...... 81 cLP and the right to bodily integrity ...... 82 Conclusion regarding the right to bodily integrity ...... 83

HP and the right to autonomy and self-determination ...... 83 HP is not the only option ...... 84 HP may enhance rather than diminish autonomy and self-determination ...... 85 HP can be an expression of autonomy and self-determination ...... 85 The dichotomy between free choice and coercion is problematic ...... 87 Preliminary conclusion: HP and the right to autonomy and self-determination ...... 88 mFGC and the right to autonomy and self-determination ...... 88 cLP and the right to autonomy and self-determination ...... 89 Conclusion regarding the right to autonomy and self-determination ...... 91

Right to protection of human rights by the state ...... 92 mFGC and the right to protection of human rights by the state ...... 93 cLP and the right to protection of human rights by the state ...... 94 Conclusion regarding the right to protection of human rights by the state ...... 95

Conclusions deontological objections ...... 95

Chapter 6: Recommendations ...... 98

Introduction ...... 98

Objections against HP are culturally situated ...... 98

Avoiding passive acceptance of the virginity rule ...... 100

Multidisciplinary approaches ...... 101 Counselling ...... 101 Information ...... 102 Examination ...... 105 Multiple visits ...... 106 Results ...... 107 Conclusion regarding multi-disciplinary approaches ...... 110

Chapter 7: Conclusion ...... 111

Addendum ...... 112

Anatomy of the Hymen ...... 112 Female Genital Anatomy ...... 112 Hymen Shape ...... 113 Hymen Size ...... 113 Histological Structure ...... 113 Development ...... 113 Abnormalities of the Hymen ...... 114 Imperforate Hymen ...... 115 Age-related Changes ...... 115 Function ...... 115 Ruptured Hymen ...... 116

Hymenoplasty Techniques ...... 116 General Technique ...... 116 Temporary Hymen Suture (THS) versus Hymen Restoration (HR) ...... 117 The Cerclage Method ...... 118 Alternative methods ...... 119

Female genital cutting techniques ...... 119

Labiaplasty Techniques ...... 120

Bibliography ...... 121

Chapter 1: Problem and Context

Introduction

During the last few decades, health care professionals in Western Europe have increasingly faced requests from girls and young women, mostly from a Muslim migrant background (Bekker et al 1996; Helgesson & Lynöe 2008; Amy 2008), to perform hymenoplasty (HP). HP is an operation during which the hymen is surgically altered in order to guarantee vaginal blood loss at the next sexual intercourse, thereby allowing girls and young women to “prove” their virginity to their future husbands and/or extended families on their wedding night. The girls and young women requesting HP are mostly adolescents or young adults living at home and about to get married. Most have had previous sexual intercourse and want their hymen, which they presume is now ruptured, to be repaired. Some are virgins, but fear they will not bleed on their wedding night and request HP to make sure they will (Cindoglu 1997; Essén et al 2010).

In many cultures, girls and young women are expected to refrain from having premarital sex (Bhugra 1998), and it is considered a matter of great shame for a family if its daughters do not remain virgins until their wedding day (Helgesson & Lynöe 2008). In such cultures, the hymen has taken on a great symbolic value (Essén et al 2010): an intact hymen is seen as proof of virginity, and guarantees that a woman will be a good mother and a faithful wife (Eich 2010), whilst a torn hymen is seen as proof of premarital sex (Frank et al 1999) and is taken to mean that a woman “is bad, and will stay like that for the rest of her life” (Eich 2010). Sometimes the future husband or his family will request a virginity certificate, and some girls are sent to their country of origin to undergo a virginity examination (van Moorst et al 2012a). In many Muslim countries such examinations, in which the intactness of the hymen is physically probed, are routinely carried out (Helgesson & Lynöe 2008), both by medical doctors (Bekker et al 1996) and by laymen (van Moorst et al 2012a). And on the wedding day, the newlyweds may have to present the bloodied sheet from the wedding bed to the extended family as “proof” of the girl’s virginity (Bekker et al 1996; Logmans et al 1998a; Cook & Dickens 2009). In Muslim migrant communities in the West this custom is largely rejected as old-fashioned (van Moorst et al 2012a). Instead, the girl or young woman has to “prove” her virginity on the wedding night to her husband only, by means of blood

loss and being “tight” upon penetration. (Essén et al 2010; van Moorst et al 2012a). The consequences of not being able to ‘prove’ virginity have included expulsion from the family and/or community, divorce or annulment of the marriage, lack of marital prospects, violent reprisals, and even “honour killings” in which a girl or young woman is murdered by a family member in order to “reclaim the family honour” (Bekker et al 1996; Logmans et al 1998a; van Moorst et al 2012a). As many women don’t experience blood loss at first coitus (Bekker et al 1996; Paterson-Brown 1998; Loeber 2008), all girls and young women who are required to “prove” their virginity are at risk, even if they are in fact virgins (Bekker et al 1996).

As HP may offer protection against these potentially severe consequences (Bekker et al 1996; van Moorst et al 2012a), and the operation is said to score low on maleficence and high on beneficence (O'Connor 2008), many health care professionals agree to carry out the surgery and “reconstruct” the hymen of girls and young women at risk (Logmans et al 1998a). However, many of those health care professionals have voiced concerns regarding the ethical soundness of the operation, as they feel that it may cause medical and psychological complications (Usta 2000; Cook & Dickens 2009; Tschudin et al 2013); may not achieve its intended effect (Essén et al 2010; van Moorst et al 2012a; Tschudin et al 2013); may be medically unnecessary (Bekker et al 1996; Saharso 2003a; Cook & Dickens 2009); may make them complicit in the deceit of the girls and young women’s future husbands and families (Raphael 1998; Cook & Dickens 2009); and may perpetuate sexual inequality (Bekker et al 1996; Cook & Dickens 2009; van Moorst et al 2012a). Additionally, because the patients need the intervention to remain confidential for it to have the desired result, records are usually destroyed (Logmans et al 1998a), follow-up is often difficult or impossible (Essén et al 2010; Tschudin et al 2013; Loeber 2014a), and there is little reliable information regarding HP’s long-term costs and benefits (Essén et al 2010; Cain et al 2013).

In the remainder of chapter one, I will elaborate on my methodological choices regarding terminology, on the virginity rule and the social context in which it takes place, on the consequences girls and young women may face if they can’t “prove” their virginity, and on the ethical problems Western doctors have raised regarding HP. In chapter two, I will discuss the myths and misconceptions surrounding the virginity rule, and the limitations of educational attempts as a means of dispelling them. In chapter three, I will introduce two analogical procedures that I will use to test the strength of my conclusions regarding HP. In chapter four, I will discuss the consequentialist objections health care professionals have

raised against HP. In chapter five, I will discuss the deontological objections they have raised. In chapter six, I will elaborate on a multi-disciplinary intake model that incorporates multiple visits, and informs, educates and counsels girls and young women requesting HP in order to help them make an independent and informed choice regarding the operation. And in chapter seven, I will formulate my final conclusions regarding the bio-ethical problems surrounding HP.

Terminology

Hymenoplasty

I have chosen to use the term ‘hymenoplasty’ over several other terms used for the operation, as I feel it is the most neutral and scientifically correct one. First, ‘hymen restoration’ seems incorrect, for as we will see below, the hymen has no standard shape and size it can be “restored” to. Second, ’hymen repair’ seems equally incorrect, for as one author pointed out, ‘repair’ refers generally to a “thing or product which is broken” (Cindoglu 1997). As the intended outcome of the operation is blood loss on the wedding night, this would imply that it is the function of the hymen to provide this blood loss, a view which as we will see below is untenable. Third, ‘hymenorraphy’, which translates literally as “suturing in place of the hymen” (The Free Dictionary, retrieved 5 February 2015) also seems incorrect, for if no hymenal remnants are present, or if they prove to be of insufficient size or shape to perform the operation, a narrow strip of posterior vaginal wall is dissected from which a “hymen” is newly constructed (Logmans et al 1998a). In contrast, the term ‘hymenoplasty’, which translates literally as “moulding or forming”, seems to capture the idea that the surgery bestows a shape, size, and function on the hymen that it doesn’t possess of itself. As one author puts it, “something is being created that didn’t exist before” (Verhaar 1999, my translation). I will therefore use ‘hymenoplasty’ in what follows as a general term for the various surgical techniques that seek to alter or create a hymen in such a way that it will cause blood loss during the next sexual intercourse.

Virginity

Most migrant Muslim girls and young women consider ‘virginity’ to be synonymous with an intact hymen, rather than “an immaterial state or feeling”. Virginity is regarded as “a verifiable physical status” (Cinthio 2014): a “proof” to be produced externally rather than a state of chastity (Bartels 1993). Consequently, the taboos surrounding the virginity rule seem to relate more to the physical state of virginity than to “the virtue of chastity” (Hegazy & Al- Rukban 2012; Awwad et al 2013), and many migrant Muslim adolescents perform sexual acts that avoid vaginal penetration and/or rupture of the hymen. However, as we will see below, both an intact and a ruptured hymen fail as proof of, respectively, virginity and sexual intercourse, and a physical examination cannot adequately distinguish one from the other. In what follows I will therefore use the terms ‘virgin’ and ‘virginity’ to indicate that a girl or young women has not yet had sexual intercourse, regardless of whether or not her hymen has been ruptured.

“Prove” and “proof”

As we will see below, there is no reliable way to determine whether a young girl or a woman is a virgin or not, and the practices of virginity examinations and the “bloodied sheet” are based on myth rather than fact. I will therefore parenthesise “proof” and “prove” when referring to the various means by which girls and young women’s virginity is believed to be evidenced. It may be considered tendentious to mark these terms as ambiguous in this way, but the findings that lead to the conclusion that there is no reliable proof of virginity are based in scientific fact, and it would seem less than precise to use these terms without indicating the ambiguity of their use in this context.

Female genital cutting (FGC)

The World Health Organisation considers “all procedures that involve partial or total removal of the female external genitalia and/or injury to the female genital organs for cultural or any other non-therapeutic reasons” to constitute female genital mutilation (World Health Organization 2011). As the cultural practices they refer to irreversibly alter the female body and are said to compromise its healthy sexual and reproductive functioning, they consider the term ’female genital mutilation’ more accurate than ‘female genital cutting’ (FGC). However,

it has been suggested that ‘female genital mutilation’ is “not a neutral description, but a means of condemnatory advocacy” (Cook et al 2002), and there may be sufficient reasons to use the term ‘female genital cutting’ instead. First, it has been pointed out that many women who subscribe to the practice of FGC “positively evaluate its consequences for their psychological, social, spiritual and physical well-being”, and “feel empowered by the initiation ceremony” (Shweder 2002). Second, the motivation of parents submitting their daughters to FGC may stem from love and concern for their daughters’ future, which may be severely compromised by being “uncut”. Using the term ‘mutilation’ may therefore be unfair and may risk “alienating and offending them ” (Tostan, retrieved 28 April 2015). Third, the term ‘FGC’ may stigmatise girls who have been subjected to the practice, as not all of them may want to be labelled as ‘mutilated’. Fourth, ‘female genital cutting’ is less judgmental and value-laden than ‘female genital mutilation’, and may make it easier for groups who are trying to give up the practice to engage members in a dialog regarding the practice (Tostan, retrieved 28 April 2015). Finally, it may be hard for communities to fully understand the medical consequences of FGC, and they may be more open to and more trusting of information from sources outside the community if those sources are not perceived to be judgmental. Therefore, it may be more accurate and/or more helpful to use the term ‘female genital cutting’.

The virginity rule

A predominantly Muslim demographic

Although there is little reliable data regarding the prevalence of HP, most studies suggest that the number of girls and young women in Western Europe who request the operation is rising (Bekker et al 1996; Helgesson & Lynöe 2008; Amy 2008). Many authors attribute this to the growing Muslim population: there are more Islamic girls and young women in Western Europe than before (Bekker et al 1996; Kandela 1996; Rademakers et al 2005; Helgesson & Lynöe 2008), and more of them seem to engage in premarital sex than before (Bekker et al 1996). At the same time, female premarital virginity remains very important in Islamic communities: a girl must remain a virgin until marriage, and if she fails to do so, she dishonours the whole family and faces potentially severe sanctions. Because of this, nearly all the request for HP received by Western European health care professionals are from girls and

young women from a Muslim migrant background (O'Connor 2008; Saharso 2003a; Tschudin et al 2013).

Premarital virginity is important in many cultures

However, HP requests are not limited to Muslim communities only. Several studies have shown that the virginity of girls and young women at marriage is an important factor in maintaining the family honour in many cultures (Cindoglu 1997; Verhaar 1999; Tschudin et al 2013). Up until 50 years ago, the virginity of the bride at the time of her wedding remained an important moral prescript in Western societies as well. And although today, in Western Europe, the virginity rule is no longer upheld in all but the most conservative Christian households (Loeber 2014b), there have been HP requests in conservative Christian milieus in the USA (Eich 2010). Additionally, HP has recently been requested as a form of “lifestyle surgery”, by Western women “who want to experience defloration once again” (Eich 2010).

A cultural rather than a religious rule

Congruently, many authors have pointed out that the virginity rule may have a cultural (Kyrillou et al 2009; Solberg 2009; Awwad et al 2013) origin rather than a religious one (van Moorst et al 2012a). The double standard according to which women have to prove their virginity and men don’t may be a recurrent element of patriarchal societies (Cindoglu 1997; Gürsoy & Vural 2003) rather than a religious commandment, and “the sexual oppression of women and the violation of their sexual rights” may be due to historical, socio-political, and economic factors rather than “an oppressive view of sexuality based on Islam” (van Moorst et al 2012a). Furthermore, as there is significant disagreement within those Muslim communities regarding these issues, it would be unhelpful to suggest that the virginity rule is an inseparable element of the Islamic religion.

Dealing with the problem at hand

Additionally, some authors feel that the focus on Islamic culture as the predominant source of the problems surrounding premarital virginity, erects unnecessary barriers between Muslims and non-Muslims (Bartels 2000). Furthermore, such a unilateral focus may seem unfair, as many Muslim families do not expel their daughters if they lose their virginity

before marriage, and instead look for solutions within their own group (Bartels 2000). Nevertheless, in the first two chapters of this text, I cannot help but focus on HP requests made by girls and young women from a Muslim migrant background. First, because HP requests in Western Europe are predominantly made by girls and young women from migrant Muslim communities (Saharso 2003a; Eich 2010; Tschudin et al 2013). And second, because the ethical objections raised by Western health care professionals seem to flow directly or indirectly from concerns regarding Muslim cultural practices they deem discriminatory. However, in chapter three, four and five I will draw analogies between HP and other discretionary surgical interventions, and show that although a strong case can be made against the cultural practices that motivate HP requests, there are commonly accepted operations that are motivated by Western practices which may suffer from the same ethical ambiguities.

Social background of migrant Muslims

Gender inequality in the enforcement of the virginity rule

Although the Qur’an requires that both men and women marry as virgins, and prescribes neither the requirement of proof nor the necessity of sanctions (van Moorst et al 2012a), in practice the virginity rule and its consequences are enforced on girls and young women only, and not on boys and young men (Bekker et al 1996; Saharso 2003b). Whereas promiscuity is generally accepted for boys, and may even gain them prestige (Bhugra 1998; Gürsoy & Vural 2003), girls are scorned and and/or punished if they engage in the same sort of behaviour. Women are considered to possess a dangerous, “omnipotent sexual energy” (Cindoglu 1997) that must be kept under control by their husbands, their families and the community as a whole (Cindoglu 1997). Girls and young women must ‘prove’ their virginity: some are subjected to “virginity examinations”; others must produce the bloody sheet to be shown to the extended family (Logmans et al 1998a; Paterson-Brown 1998; Cook & Dickens 2009); and all are expected to bleed on their wedding night.

Anthropological basis of the virginity rule

Throughout history, marriage has been a cornerstone of societal structure, and as some have pointed out, the romantic notion of marriage for love is “a late-modern and still quite marginal phenomenon” (Cinthio 2014). In ancient Muslim culture, marriage served to secure goals such as “proliferation of the clan, power over assets, control over individuals, conflict resolution, and alliance building (Cinthio 2014), and even today, the hymen may continue to serve as a political mechanism that preserves group cohesion. Premarital sex is often seen as something Western that “should not exist” in Islamic societies (Eich 2010). Both in Muslim countries and Muslim migrant communities, female chastity may become a way of “differentiating the self from the other”, and controlling the sexual behaviour of women may turn into “an act of national self-defence” (Peteet 2002; Eich 2010) by which “Islam or the nation (or both) are defended” (Eich 2010).

A shame culture

What emerges is a self-protective “shame culture” (Loeber 2014b), in which unmarried girls living at home are the responsibility of their father and their brothers, and married women are the responsibility of their husbands (Loeber 2014b). If fathers and brothers cannot give untainted daughters and sisters in marriage it is a severe blemish on their status and worth (Cook & Dickens 2009), and in the absence of proof of virginity, the whole family “is disgraced and loses respect” (van Moorst et al 2012a)”. Women themselves often contribute to the enforcement of the virginity rule: mothers want their daughters’ hymen intact and the sheets bloodied on the wedding night, and mother-in-laws want worthy virgins as brides for their sons (Cook & Dickens 2009). And though premarital sexual activity amongst young Muslim girls and young women is increasing, Muslim men and boys still want a virgin bride (Verhaar 1999). Perhaps more surprisingly, there is no wholesale rejection of the virginity rule amongst the younger generation of women either: whilst some Muslim girls see it as a form of sexual inequality, others consider it a virtue (Bekker et al 1996) and a sign of their loyalty to their family (Cindoglu 1997).

Social control

Girls living at home are generally restricted in their freedom, and conduct that deviates from the social norms may have serious repercussions. Islamic culture is far less individualistic than Western culture. Family is of the utmost importance and the home is considered a “warm nest” (Loeber 2014b), where people take care of each other. On the other hand there is also “intense social control, with a lot of gossip” (Loeber 2014b). Girls often have to go about their lives under intense scrutiny and may feel like they are constantly being watched (Bekker et al 1996). They are not allowed to be “too close” physically to a boy or young man, and a discourse of “respect” for one’s parents is constructed to enforce such restrictions (Cinthio 2014). If a girl is suspected to have lost her virginity, she may be confronted with “a crossfire of questions” and threats (van Moorst et al 2012a). In this kind of environment, girls who feel they need more freedom often resort to living a double life (Loeber 2014b). As a consequence, these girls “may have no confidants and feel isolated in their dilemmas “(Bhugra 1998).

Inter-cultural stress

For second- and third generation girls from a migrant background, the discrepancies between the traditional culture experienced at home, and the more permissive Western culture experienced at school or in the work place, may lead to serious inner conflict (Bhugra 1998; Logmans et al 1998a; Essén et al 2010). Girls who belong to fiercely patriarchal communities are particularly at risk (Webb 1998), as they live their lives at the intersection of two cultures with widely different norms. In Western culture, it is generally acceptable to have sexual intercourse before marriage, and young people more often than not have several serious and intimate relationships before they settle down with “the one”, whereas in Muslim culture, marriages are sometimes “arranged” or ‘forced”(Bekker et al 1996) by the girls’ parents and premarital sex can compromise their future life “as adults in their own communities” (Webb 1998). Many young Islamic women may feel and act similarly to their Western European peers, but when they get closer to marrying age, three quarters of sexually active migrant Muslim girls and young women are said to develop problems regarding sexuality and virginity (Mouthaan et al 1997) and to experience a dilemma “between the traditional Islamic norms and values regarding sexuality, and the more permissive (Western European) norms and values” (Rademakers et al 2005).

Arranged and forced marriages

A marriage can be “arranged” by the parents with the girl’s consent (Bekker et al 1996; Kopelman 2014), or “forced” upon her (Bekker et al 1996; van Moorst et al 2012a). Some parents assess potential husbands through other persons acting as “brokers” (Cinthio 2014), arrange their daughter’s wedding without her consent or involvement, and merely inform her of the wedding date (Bekker et al 1996). If a girl facing an arranged or forced marriage is no longer a virgin, she may be desperate for a solution that can save her from the consequences of being found out (Bekker et al 1996).

Male privileges

Boys and young men who grow up in such a patriarchal system internalise the beliefs and the behaviours that form part of it (Gürsoy & Vural 2003; Loeber 2014b). Men and women are considered to be fundamentally “different creatures” (Smerecnik et al 2010) and are therefore subject to different rights and obligations. A man has the uncontrollable urge - and hence the right - to seduce a woman (Hendrickx et al 2002; Loeber 2014b). Moreover, a man has to prove he is a “real man” (Hendrickx et al 2002), and is allowed to boast about his conquests, whereas mere gossip can stop a woman from being considered a serious marital prospect. Men have a right to demand proof of their future bride’s virginity, all women are believed to bleed the first time they have sex, and claims to the contrary are to be mistrusted (Loeber 2014b). And although the virginity rule may sometimes put pressure on boys and young men as well, as we will see below, they do not suffer equally severe consequences as do girls and young women.

Female guilt

Women, in contrast, are held responsible for male sexuality (Cindoglu 1997): a woman must resist a man’s advances, and if she does not, she loses status - even to her seducer (Loeber 2014b). Like men, women have internalised these views, and they may refer to other girls as “sluts or whores acting dirty and shameful”, and feel righteous whilst at the same time experiencing shame and self-contempt over feelings they have or over transgressions they have committed themselves (Cinthio 2014). Some girls are repulsed by their own sexual desire, and consider themselves to be “guilty” and “dirty” for having touched themselves or

for having “made out” with a boy (Cinthio 2014). Furthermore, many of these girls and young women see female sexuality as a gift for their future husbands to enjoy, rather than something that exists in its own right, for the women themselves to enjoy. Consequently, many migrant Muslim girls and young women feel that, for women, sex causes problems rather than pleasure (Cinthio 2014).

Lack of Sexual Knowledge

The development of healthy adolescent sexuality

The cultural practices surrounding the virginity rule may adversely affect the healthy sexual development of migrant Muslim girls and young women. From a medical standpoint, sexuality is a normal and potentially positive part of human life, which develops “from the moment of conception onward through all life stages” and is “intrinsically interwoven with (…) family and social systems” (Chilman 1990). In this view,

“ (…) Adolescent sexual health is based on esteem and respect for the self and other people in both sexes. It embraces the view that both males and females are essentially equal, though not necessarily the same. Sexually healthy adolescents take pleasure and pride in their own developing bodies. As they mature they have an increasing ability to communicate honestly and openly with persons of both sexes with whom they have a close relationship. They accept their sexual desires as natural but to be acted upon with limited freedom within the constraints of reality considerations, including their own values and goals and those of “significant others” ” (Chilman 1990).

Although this may allow for personal and cultural interpretation, and acknowledges that sexual freedom needs to be delineated by certain constraints, it does not advocate premarital virginity, as “total abstention from sexual activity” and too much control of sexual knowledge, feelings and behaviour “can create problems for adolescents in terms of repression, denial, and isolation from social interaction” (Chilman 1990). Some of the problems that may result are low self-esteem, guilt, anxiety, difficulties in impulse control, problems with body image and self-acceptance, a lack of understanding “of their own developing sexuality and that of the other sex”, and value conflicts between adolescents and

their peers, and adolescents and their parents (Chilman 1990). In Western European countries, sex education is therefore generally considered beneficial (Rademakers et al 2005; Chilman 1990).

Lack of sexual education

However, due to the perception amongst Muslim migrant communities that knowledge about sexuality leads to promiscuous sexual behaviour (Orgocka 2004), immigrant girls may not receive adequate sex education (Paterson-Brown 1998), and as a consequence may be less well informed about sexuality than their indigenous Western European counterparts (Smerecnik et al 2010). First, because of an increased need for group coherence, immigrant communities are often more conservative and exert more social control than is common in their countries of origin (Hendrickx et al 2002). Second, talking about sex and sexuality in the family is generally taboo (Hendrickx et al 2002) and the little communication that does occur between mothers and daughters on the subject is “confined primarily to the risks premarital sexual relationships (pose) to the social order” (Orgocka 2004). Third, sex education in primary and secondary schools goes against the wishes and beliefs of many migrant Muslim parents (Rademakers et al 2005), and some of them may try to exclude their children from sexual education classes (McGown 1999), to have the boys separated from the girls (Smerecnik et al 2010), or to counter the information taught at school by means of “educating activities at home” (Orgocka 2004). Fourth, mothers’ attempts to educate their daughters may be hampered by embarrassment and/or by their own lack of knowledge regarding the subject (Orgocka 2004). Fifth, culture-sensitive sex education, which informs migrant Muslim adolescents about the scientific facts regarding the hymen and virginity without rejecting the virginity rule, may fail to correct the false beliefs instilled in them by their conservative upbringing: in one study, liberal Imams who contradicted these beliefs were denounced by the participants as having “gone astray” (Smerecnik et al 2010). Finally, in at least one study, migrant Muslim adolescents and young adults have been found to have an incomplete or incorrect knowledge of contraceptives as well as of HIV and other STD’s (Hendrickx et al 2002). Therefore, it seems reasonable to conclude that migrant Muslim adolescents and young adults are less well informed about sexuality than their indigenous Western European counterparts.

Lack of knowledge regarding virginity and the hymen

Various studies have tried to gauge the level of knowledge amongst migrant Muslim adolescents of the facts regarding the hymen, virginity, and “defloration”. In one study, 57% of the girls and young women requesting HP “were totally ignorant about female sexual anatomy and had misconceptions about the hymen”, and only 37% had ever inspected their own vulva (van Moorst et al 2012a). Another study, based on questions received via a sexual health website, reveals the lack of knowledge amongst some migrant Muslim adolescents regarding these matters (Loeber 2014b). Some girls worry that their hymen may be torn by masturbation, or by the insertion of foreign objects such as tampons or masturbatory aids. Many mistakenly believe the hymen is membrane that closes off the vagina completely (Bekker et al 1996), and is guaranteed to rupture and produce bleeding during first sexual intercourse (Cinthio 2014). Some try to examine themselves, hoping to visibly ascertain the state of their hymen, and think there is a certain way “a vagina looks like when you are deflowered”. Some want to know how much HP would cost, and if it can be done without their parents finding out. Some have been told by men that they can feel it if a woman is no longer a virgin (Loeber 2014a). One girl wanted her vagina “sewn up tight” so that her husband would have a lot of trouble inserting his penis, and she would have “a lot of pain” and would “have to cry out”. Many have been told by men that they “just know” if a woman is no longer a virgin (Cinthio 2014).

Even when girls and young women are well informed, they may not be able to make use of their knowledge if their partners are not equally well informed. In one study, some girls were aware of the myths surrounding virginity and the hymen, but when they had tried to talk to their future husbands about this, they had invariably been told that “he certainly would notice if someone was not a virgin and that he would not accept it” (van Moorst et al 2012a). Questions posted on sexual health websites reveal that boys and young men worry that their future wives may deceive them about being a virgin, and that many of them are ignorant about the facts regarding female anatomy and virginity. One boy probed his girlfriend’s vagina with his finger and expected there to be blood loss. Some boys believe gossip regarding their girlfriend’s virginal status and neither her claims to the contrary, nor the presence of blood loss can convince them (Loeber 2014b). Some suspect that they are being deceived by means of a blood capsule sewn into the vagina (Loeber 2014b). Some worry about their own performance. Some want to know more details regarding the “defloration”,

such as how much blood there will be, and worry that it will be messy, chaotic and scary (Cinthio 2014). Some future husbands, who know that their future bride has had sexual intercourse at some time in the past, expect her to “be a virgin again” after a period of abstinence (Loeber 2014a). It seems reasonable to conclude from all this that there is a general lack of knowledge amongst young people from a migrant Muslim background of the facts regarding the hymen, virginity, and “defloration”.

Contextual certainties

Unfortunately, evidence-based information may not dispel the myths regarding the hymen, virginity, and “defloration”. Migrant Muslim adolescents who are given information on female anatomy and on “virginity as a social construct” (Cinthio 2014) may develop a deep and complex understanding about these issues, which is apparent when they talk about scientific fact. However, when talking about marriage and family, these facts do not seem to matter, and they often “relapse into a simplified and symbolically charged understanding of virginity” (Cinthio 2014). These different sets of knowledge may constitute contextual certainties (Batens 1992): adolescents are aware of both the traditional beliefs surrounding the virginity rule and the scientific facts of the matter, but use only one set of knowledge at any one time, depending on the problem at hand. Whilst dealing with the traditional expectations surrounding the virginity rule, the scientific facts are not rejected, but are simply of no use in that problem-solving context, and vice versa. For these adolescents and young adults, “critical and scientifically based reasoning around virginity is simply not relevant in situations where the surrounding players do not have that same understanding” (Cinthio 2014).

Lack of knowledge regarding possible solutions

Additionally, there may be a lack of knowledge regarding the solutions that are available to a girl or young woman who has lost her virginity before marriage. First, she may not be able to talk about it to anybody she feels close to (Bekker et al 1996). Second, it may be very difficult for her to contact a health care provider without being found out: the house phone may offer no privacy and her cell phone and/or its detailed invoices may be scrutinised; written communication may be discovered by her parents or her siblings; she may not be able to explain her whereabouts during personal consultations or the operation itself, and she may

run the risk of being seen upon entering or leaving the gynaecological practice or the hospital. Consequently, girls who have lost their virginity before marriage may not receive all the information, the support and the treatment they may need to enable them to deal with their problem.

Consequences of loss of virginity

In one study, almost a third of girls and young women requesting HP did not know what the possible consequences might be if their loss of virginity became known (van Moorst et al 2012a). For others, however, the potential consequences of failing to “prove” their virginity are all too real. First, if a girl or young woman can’t produce “proof” of virginity on her wedding night, she may be stigmatised, and bring scorn and disgrace on herself and her family (Cook & Dickens 2009). Second, she may be expelled from her family and/or community (Logmans et al 1998a; Cook & Dickens 2009). In one study, nearly half of the girls and young women requesting HP “feared that (…) they would have to live as an outcast, with no prospect of ever having contact with friends and relatives again” (van Moorst et al 2012a). Third, some men who ‘find out’ on the wedding night that their new bride was not a virgin file for divorce (Paterson-Brown 1998; Cook & Dickens 2009) or try to have the marriage annulled (Bekker et al 1996). In one controversial case in France, a court granted the annulment of a marriage because the bride was no longer a virgin at the time of the wedding (de Lora 2014). Fourth, girls and young women who tell their boyfriend about past sexual relationships may find that he no longer wants to marry them. In general, if a girl or young woman is known to have lost her virginity, she is no longer considered a possible marital partner (Logmans et al 1998a; Cook & Dickens 2009; Loeber 2014a). In some cases, parents may try to solve the lack of marital prospects by marrying their daughter off to an “inferior” match (Bekker et al 1996). Fifth, girls and young women who lose their virginity before marriage and are expelled from their families and their communities may not have many options open to them and may be “driven into prostitution” (Saharso 2003b). A double standard that “restricts the female while giving the male freedom”, combined with a lack of opportunities for girls and young women to work and live independently of male support within their community, is generally correlated with a greater prevalence of prostitution (Bullough & Bullough 1987). Sixth, girls and young women who are suspected of having lost their virginity before marriage may be forced to undergo a vaginal examination carried out by

a gynaecologist, or worse, by a lay person (van Moorst et al 2012a). Such an examination can be very traumatic for girls who have grown up in a sexually repressed community, and some girls commit suicide (Cindoglu 1997), rather than suffer the embarrassment of “being touched by a stranger in an invasive manner” (van Moorst et al 2012a). Seventh, some women who don’t succeed in “proving” their virginity may become the target of physical violence (Logmans et al 1998a; Cook & Dickens 2009; Hegazy & Al-Rukban 2012). Even mere suspicion or gossip regarding the non-virginity of a girl or young woman may lead her father, brothers, or (future) husband to subject her to violent reprisals, as they may feel “bound to perform some spectacular act by which to reply to people’s gossip” (Lindisfarne 1994). Finally, if a girl is perceived to bring shame upon her family by losing her virginity before marriage, a family member may even try to reclaim the family honour by murdering the girl in what has perversely been called an “honour killing” (Paterson-Brown 1998; van Moorst et al 2012a). Although the number of “honour killings” in Western countries is said to be rather low (Saharso 2003b), migrant girls and young women may be sent abroad to get married, and statistics of “honour killings” in Western Europe may not include girls that are killed in their countries of origin. That this perceived as a realistic threat is shown by at least one study, in which as much as 12% of the girls and young women requesting HP said that they were sure that they would be killed if their non-virginity was discovered.

Other reasons for requesting HP

“Feeling tight”

Although blood loss is generally thought to be the sole purpose of HP, it is not the only reason why girls and young women request the operation. Some hope that the operation will make them “feel tight”, so their future husband won’t suspect that they aren’t virgins anymore. In one study, 12% of the applicants stated that “feeling tight” was their only reason for requesting the operation, whilst 35% considered both blood loss and “feeling tight” equally important. Only 31% stated that blood loss was their only reason for requesting HP (van Moorst et al 2012a).

Overcoming trauma and self-loathing

For some girls and young women HP may “serve as a ritual for helping them to overcome traumatic sexual experiences”. Many of them request HP even though they have no current marriage plans, and hope the operation can make them feel “whole and pure” again. For others, who not have experienced traumatic sexual experiences, but nevertheless experience psychological problems related to their loss of virginity, the goal of the operation is to “increase their self-confidence and/or self-esteem” (van Moorst et al 2012a). Some of them have been talked into sex by means of a false promise, or have had consensual sex and regretted it afterward. Some of them subscribe to the ideal of keeping their virginity for the man they marry (Hendrickx et al 2002), and may feel that by undergoing HP they can recapture it. Others may want to appear to be virgins at their wedding simply because “that is what is expected from a decent and good girl” (Verhaar 1999).

Safeguarding the family

Some migrant Muslim girls and young women may want to explore their sexuality, without endangering their “warm family relationships” (Loeber 2014b). Some may want to safeguard their parents from the shame the family would be subjected to socially if it became known that their daughter was no longer a virgin at marriage (Verhaar 1999; Bartels 2000). Some may want to protect their mother specifically, as she may be accused of not having raised her daughter properly (Verhaar 1999). Some may be eager to fulfil their future husband’s and his family’s expectations (Cindoglu 1997). Consequently, they may be willing to “do all that is needed” to ensure that they bleed on their wedding night (Loeber 2014b).

Social mobility

As we will see below, boys and young men may suffer negative consequences of the virginity rule too. If a boy or young man doesn’t succeed in producing the bloodied sheet on the wedding night, he may be considered “feminine” and “weak” by other men, and may suffer diminished access to social resources, status and power. On the other hand, if a girl or young woman can demonstrate her husband’s “virility” and successfully “prove” her virginity, she may help her husband move up in the world and thereby gain his support. Therefore, both partners have a vested interest in covering up a possible failure to “deflower”

his wife on the groom’s part and/or a failure to “prove” her virginity on the bride’s part, and “power couples” may conspire to fake the blood on the sheets in order to protect their social mobility (Lindisfarne 1994). However, a girl or young woman who fears or suspects that her husband-to-be may not be open to such an arrangement, may request HP in order to secure her husband’s - and by extension her own - privileged access to social resources, status and power.

Circumstances leading to the request

Some may feel that the girls and young women who request HP have brought their problems upon themselves, and that the consequences they may suffer are therefore justified. At least one author has suggested that “Muslim (…) women who have had voluntary sexual intercourse, have simply given up that aspect of (their) culture” (de Lora 2014). However, there are a number of reasons why this argument is not tenable. First, some of the girls and young women requesting HP are virgins who are afraid they won’t bleed at first intercourse (van Moorst et al 2012a). Second, some of them may have ruptured their hymen during non- sexual activity (Frank et al 1999). Third, some may have accidentally lost their virginity during sexual activity that did not or was not meant to include full intromission (Bekker et al 1996). Fourth, some may have had consensual sex and may not have been fully aware of the consequences (Logmans et al 1998a). Fifth, some may have been talked into sex with promises of marriage and subsequently abandoned by their partner (van Moorst et al 2012a; Cinthio 2014). Sixth, some may have lost their virginity through forced sexual intercourse (Logmans et al 1998a; Brown et al 2009; van Moorst et al 2012a). Finally, girls and young women should be entitled to live as freely chosen lives as they can, with equal human dignity (Okin 1999) as is granted to boys and young men. Therefore, it seems reasonable to conclude that the argument that girls and women who request HP have brought their problems upon themselves and that the consequences they may suffer are therefore justified, is not tenable.

Ethical Problems for Western Doctors

Many health care professionals have raised objections against HP surgery. First, as the secrecy that often surrounds these operations makes long-term follow-up extremely difficult, and as there are no clinical studies available regarding its long-term benefits and costs, some are concerned that HP may cause medical complications (O'Connor 2008; van Moorst et al 2012a; Tschudin et al 2013). Second, for the same reasons, some are concerned that HP may have psychological consequences, ranging from anxiety caused by having to keep the operation secret (Bekker et al 1996; Raphael 1998), to guilt, (Raveenthiran 2009), loss of self-esteem (Helgesson & Lynöe 2008), and even post-traumatic stress disorder (Bhugra 1998). Third, as so little is known about the long-term costs and benefits, and as the few studies that exist suggest that HP does not seem to guarantee blood loss on the wedding night (Essén et al 2010; van Moorst et al 2012a), some are concerned that HP may not have the desired effect. Fourth, as a ruptured hymen is not an illness needing treatment, some feel that HP constitutes unnecessary surgery (Bartels 2000; Saharso 2003a; Cook & Dickens 2009). Fifth, as the goal of the operation is to simulate virginity, some feel that HP constitutes deceit of the woman’s future husband and extended family (Verhaar 1999; Kyrillou et al 2009; Kopelman 2014). Sixth, as the virginity norm is only enforced upon women, some feel HP perpetuates gender inequality and social injustice (Lindisfarne 1994; Chambers 2004; Loeber 2014b) and/or that it may hamper the public debate that “may end the virginity rule” (Saharso 2003a).

Caveats

Representativeness of the population

In the above discussion, no differentiation has been made between migrant Muslim communities coming from different countries of origin, which may lead to unfair generalisations. Furthermore, in many studies the sample population was not randomly chosen. Instead, it consists solely of girls and young women requesting HP. Consequently, their attitudes towards virginity and the hymen may not even be a fair representation of the general attitudes prevalent within their specific community (van Moorst et al 2012a). First, the girls and young women who are under pressure to remain virgins until marriage and who

will have to “prove” their virginity may only represent a subgroup of the population. Second, girls and young women who find in-group solutions may not request HP (Bartels 2000). Therefore, research must differentiate between the different Muslim migrant communities, and include girls who do not request HP. Only then can it be possible to gauge the extent of the problem, and to find out whether other solutions are available

Difficulties surrounding follow-up evaluation

Many authors mention the difficulties surrounding follow-up evaluation (Loeber 2014a). As the purpose of the operation is to prevent a girl or young woman’s family and/or future husband from finding out she has had previous sexual intercourse, confidentiality is of the utmost importance. If it becomes known that she has undergone the operation, the consequences are potentially very high, and unsurprisingly, this complicates attempts to gather qualitative and complete follow-up data. Most girls and young women requesting HP, when given the option to have the procedure removed from their medical records, choose to do so (Logmans et al 1998a).

Furthermore, even when women do agree to be contacted, this has proven difficult in practice. Some women are given a cell phone with a new number by their husbands (Loeber 2014a). Some women move abroad and find themselves with no means of communication (Loeber 2014a). Some may have means of communication but may simply want to forget about the fear and the hardship they went through (Loeber 2014a).

Absence of reliable cost-benefit data

As a consequence, the little data that has been gathered so far has generally been incomplete, and there is hardly any evidence available regarding the effect of the operation on blood loss at the next intercourse, the possible medical complications, or the possible psychological consequences of the operation. As we will see below, the studies that do offer data regarding the success or failure rate of the operations are at times vague, and often contradict each other. And apart from one intake and treatment model developed by a Dutch university team (van Moorst et al 2012a), there are no standard guidelines on how health care professionals should deal with HP requests (Loeber 2014a).

Absence of reliable prevalence data

Due to these problems, the prevalence of the operation is difficult to gauge. Nevertheless, studies attempting to do so generally note a rise in HP requests. In two separate studies, more than half of the health care professionals who responded to the enquiry had received requests to carry out the operation (Essén et al 2010; Tschudin et al 2013). However, there may be some bias, as the studies had been carried out by means of written questionnaires, and “the motivation to answer a questionnaire is normally higher when the respondent is familiar with the subject” (Essén et al 2010).

Chapter 2: The Hymen as Proof of Virginity

In what follows, I will discuss the myths and misconceptions surrounding the hymen and its perceived function of signalling virginity. Further details on the anatomy of the hymen and on the hymenoplasty procedure can be found in the addendum.

Myths and misconceptions

An intact hymen does not constitute proof of virginity

First, as the hymen becomes thick and redundant at puberty; as its elasticity increases during adolescence; as it does not become thin and brittle again until oestrogen deprivation sets in at menopause (Hegazy & Al-Rukban 2012); and as this period coincides with the fertile period in a woman’s lifetime, during which challenges to her virginity are most likely to take place; it seems justified to say that in “the majority of cases” the hymen of girls and young women who are subject to such challenges is “elastic and stretchy” (Knöfel Magnusson 2009). As a consequence of this elasticity, penetration may not result in visible tissue damage (Finkel 1989; Loeber 2014a). Second, if acute injuries do occur, there is a possibility that they heal completely (Finkel 1989). Finally, empirical studies into the state of the hymen of sexually active adolescent girls have shown that the absence of tears, notches, clefts, or other signs of penetrating trauma does not rule out previous penile-vaginal penetration (Emans et al 1994; Adams et al 2004; Kellogg et al 2004). One study found the hymen to be intact in 52% of sexually active girls (Adams et al 2004). In one case, even a microperforate hymen had persisted after decades of sexual intercourse (Di Donato et al 2008). In another case, an imperforate hymen had formed spontaneously during pregnancy, possibly due to exposure to higher oestrogen levels (Onan et al 2005). Even when raped, a girl’s hymen only rarely “indicates past intercourse” (Essén et al 2010). Therefore, an intact hymen does not constitute proof of virginity.

A ruptured hymen does not prove sexual intercourse

Conversely, a ruptured hymen cannot reasonably be seen as proof of sexual intercourse, as the hymen may tear due to non-sexual activities such as the use of tampons; engaging in sports such as horseback riding, gymnastics and bicycling; and gynaecological examinations and surgery (Emans et al 1994; Goodyear-Smith & Laidlaw 1998; Cook & Dickens 2009). In one study, only 57% of virgins were found to have an intact hymen (Underhill & Dewhurst 1978). Consequently, in traditional Islamic culture, girls and young women are generally forbidden from using tampons and instructed to avoid certain sports (Bekker et al 1996). However, such precautions cannot effectively rule out the possibility of the hymen being ruptured by non-sexual activity ”(Abder-Rahman 2009). Furthermore, notches in the hymen can appear spontaneously (Rogers & Stark 1998). Therefore, a ruptured hymen does not constitute proof of sexual intercourse.

A physical examination cannot tell an intact from a ruptured hymen

Not only does the hymen fail as proof of both virginity and previous sexual intercourse, an intact hymen cannot be adequately distinguished from a ruptured one. First, the shape and size of the hymen vary greatly between women due to congenital differences (Knöfel Magnusson 2009; Hegazy & Al-Rukban 2012; Fahmy 2015). Second, the shape and size of the hymen are also influenced by fluctuations in oestrogen levels, which vary greatly in the course of a woman’s lifetime (Pokorny 1987; Hegazy & Al-Rukban 2012). Third, the hymen has already suffered a rupture during the perinatal period (Schöni-Affolter et al., retrieved 8 December 2014). Fourth, the observed shape and size of the hymen may be influenced by the method and circumstances of the examination, and the level of relaxation and cooperation of the patient, (Hegazy & Al-Rukban 2012). Finally, the hymen may display abnormalities such as polyps, tags, ridges, bands and notches, which may lead to “over-interpreting small anatomic findings that (…) lie within the range of normal variations” (Hegazy & Al-Rukban 2012). Therefore, it seems reasonable to conclude that a physical examination cannot adequately determine the difference between an intact and a ruptured hymen (van Moorst et al 2012a).

Blood loss during sexual intercourse does not prove virginity

First, as we have seen above, the hymen may remain intact even after repeated sexual intercourse, and may not rupture and/or bleed until the wedding night, thereby producing false “proof” of virginity. Second, the likelihood of bleeding during intercourse is increased by, and can be solely caused by violent penetration damaging the vaginal wall (Raveenthiran 2009), forced sexual relations, lack of arousal or lubrication, vaginal infection, genital malformation (e.g. imperforate hymen), generalised bleeding disorder, and/or psychological factors such as fear (Bekker et al 1996; Essén et al 2010). Finally, hymenal bleeding can be faked in a variety of ways, some of which pre-date HP operations and are traditionally passed on inter-generationally (Tschudin et al 2013), such as pricking the finger tip with a needle hidden in the wedding gown, or using a small sachet filled with animal blood (van Moorst et al 2012a). Therefore, blood loss during sexual intercourse does not constitute proof of virginity.

Absence of blood loss does not prove previous sexual intercourse

First, in adolescent girls and young adult women the hymen is elastic, and if penetration occurs into the orifice of the hymen, it often simply stretches (Loeber 2008), which usually does not cause any blood loss (Adams et al 2004; Kellogg et al 2004). Second, the hymen is a relatively bloodless membrane, and as a consequence, is unlikely to bleed significantly even if torn (Raveenthiran 2009; Kyrillou et al 2009; Hegazy & Al-Rukban 2012), and if there is any bleeding it often stops soon after the hymen is torn (Kyrillou et al 2009). Third, the hymen may already have been ruptured due to non-sexual causes and may therefore not produce any bleeding (O'Connor 2008; Cook & Dickens 2009; Kyrillou et al 2009). Fourth, several studies confirm that a significant percentage of women do not bleed during first intercourse, with figures ranging between 40% and 80% (Bekker et al 1996; Loeber 2008; van Moorst et al 2012a). Therefore, absence of visible blood loss during sexual intercourse does not constitute proof of previous sexual intercourse.

The hymen does not have the function of signalling virginity

As neither a physical examination nor the presence or absence of bleeding during intercourse can offer conclusive proof of virginity, it is unlikely that the hymen has the

function of signalling virginity. Furthermore, this conclusion seems to be congruent with medical findings regarding the development of the hymen. As the top layer of the hymen is derived from the bottom wall of the utero-vaginal canal, and the bottom layer of the hymen is derived from the back wall of the urogenital sinus, and as these two structures, before the formation of the hymen, are separate and distinct, I would argue that the hymen may be nothing more than an intermediate stage in their merger. Some authors have suggested that, in the early life of a child, the newly perforated hymen may play a role in the protection of the vaginal mucosa from contamination by external agents (Fahmy 2015). I would argue that during foetal development, the hymen may remain imperforate beyond the time of the merger of the utero-vaginal canal and the urogenital sinus for precisely that reason. However, as a perforated hymen is bound to offer less protection against external agents than an imperforate one, and as there seems to be no reason why the hymen would have to be perforated until puberty, when menses need to be expelled, the protection it offers during foetal life may be its main function, exapted from the merger of the utero-vaginal canal and the urogenital sinus. And as its rupture after birth has no medical consequences (Cook & Dickens 2009; Hegazy & Al-Rukban 2012), this function might be completed when perforation occurs during the perinatal period, and any partial protection it offers after birth may be incidental. If this is true, it seems reasonable to conclude that the hymen is a remnant of foetal development (Raveenthiran 2009; Knöfel Magnusson 2009; Hegazy & Al-Rukban 2012) and that it has no significant biological function after birth (Cook & Dickens 2009; Knöfel Magnusson 2009; Kyrillou et al 2009; Hegazy & Al-Rukban 2012; Fahmy 2015).

The hymen does not have a pre-ordained function

Nevertheless, in traditional Islamic culture, some have argued that the hymen serves a “God-given purpose”(Eich 2010). As the Qur’an states that God has “created man in the best of molds” (Dawood 2003), and God doesn’t create anything in vain, the hymen must have a function. And as the hymen doesn’t have a biological function, its function must be social: to provide proof of virginity and thereby allow the control of female sexuality (Eich 2010). Leaving aside questions regarding the existence of a supernatural creator and/or the authenticity of the Qu’ran, there remains an important objection we can raise against this argument. If God has created human beings in “the best of molds” (Dawood 2003), and the purpose of the hymen was to deliver proof of virginity, then it seems reasonable to assume that this proof would be clear and infallible. However, as the medical findings above have

shown, it is neither: the hymen’s ability to deliver proof of virginity is, at the very least, severely flawed, if not non-existent. Therefore, the idea that the hymen was created by God in order to provide such proof seems incongruent with the nature of the divine, which is deemed to be perfect.

Conclusion

Taking all these factors into account, it seems we must come to the following conclusion: as both an intact and a ruptured hymen fail as proof of, respectively, virginity and previous sexual intercourse; as a physical examination cannot adequately distinguish one from the other; as both the presence and the absence of blood loss fail as proof of, respectively, virginity and sexual intercourse; as medical findings regarding the development of the hymen suggest that the hymen is a developmental remnant that has no biological function after birth; and as religious arguments claiming that the hymen has the social function of signalling virginity are incongruent with the nature of the divine; it follows that there is no reliable, evolved or pre-ordained way to determine whether a girl or young woman is a virgin or not.

The limits of educational means

Some authors feel that, as false beliefs regarding virginity, the hymen and blood loss remain widely held in migrant Muslim communities, the problems surrounding the virginity rule need to be addressed by educational means (Loeber 2014a). Some of them have therefore called for educational tools to “correct the mythical beliefs” migrant Muslim adolescents entertain about the hymen and virginity” (van Moorst et al 2012a). Some feel that families need to be educated about their adherence to the “bloody sheet theory” (Paterson-Brown 1998), and that efforts must be made to raise public awareness regarding the facts of the matter.

However, there are several problems that suggest that the implementation and the effectiveness of such educational attempts may not constitute a complete solution to the problems surrounding the virginity rule. First, as we have seen above, there is strong resistance in the Muslim migrant community, both amongst parent and adolescents, against sexual education in general and the scientific facts that contradict religious dogma in

particular (Rademakers et al 2005; Smerecnik et al 2010; Cinthio 2014). Second, as we have also seen above, migrant Muslim adolescents and young adults may retain a culturally determined understanding of virginity and may oscillate between this view and scientific fact according to the context in which they find themselves (Cinthio 2014). Third, information such as the prevalence of virgins who do not bleed upon first intercourse may have an adverse effect and cause additional anxiety, as even girls and young women who remain virgins may become afraid that they will not able to “prove” their virginity on their wedding night. Finally, the false beliefs and the customs surrounding virginity form part of a social complex in which individuals and families “invest collective value and meaning” and may serve emotional, social, economic and political purposes such as controlling adolescents’ sexual behaviour, gaining and/ §or maintaining social status and wealth, and protecting group coherence. And “as with any belief” that serves such purposes, scientific fact may not succeed in convincing people to give up these “multiple functions of the myth” (Cinthio 2014). Therefore, it seems reasonable to conclude that the implementation and the effectiveness of such educational attempts may not constitute a complete solution to the problems surrounding the virginity rule. As one author puts it,

“ (…) Intellectual, factual knowledge is not necessarily relevant when dealing with emotionally and culturally charged beliefs, and (…) the ideologically driven agenda of “the truth shall set you free” is not fully in touch with the complex reality of those who are subjected to chastity ideals. Attacking misconceptions around the hymen does not necessarily recognise the principal dilemma of the collective asserting power over the individual in matters concerning relationships and sexuality” (Cinthio 2014).

Chapter 3: Analogical Procedures

Introduction

In what follows, I will make a distinction between consequentialist objections and deontological objections. Consequentialist objections are discussed in chapter four, and include the claims that HP may cause medical complications, that it may have psychological consequences, and that it may fail to achieve its intended effect. Deontological objections are discussed in chapter five, and include the claims that HP is medically unnecessary, that it constitutes deceit, and that it perpetuates gender inequality. I will break this latter claim down into four interconnected concerns: that HP may violate girls and young women’s right to freedom from discrimination, their right to bodily integrity, to autonomy and self- determination, and to protection of their human rights by the state. I will analyse each of these objections separately, and discuss whether or not they are successful with regards to HP. In the remainder of this chapter, I will introduce two analogical procedures that I will use to test the strength of these conclusions.

Analogical reasoning

Analogical reasoning is a valuable tool in bio-ethical questions such as these, as there are always new medical procedures being developed that are in need of moral evaluation. In theory, if enough morally relevant similarities can be found between a procedure for which the ethical questions are already answered (the source) and an ethically undecided procedure (the target), then it may be possible to transfer the moral judgement from the source procedure to the target procedure. However, it has been pointed out that, in practice, there are always dissimilarities present, and that analogies are often chosen because of the dissimilarities, rather than in spite of them (Mertes & Pennings 2011). Mertes and Pennings identify three different types of analogies: similar analogies, dissimilar undermining analogies and dissimilar reinforcing analogies. Similar analogies emphasise the similarities between source and target, and accept a transfer of moral judgement: they show that the target is equally morally (un)acceptable as the source. Dissimilar undermining analogies emphasise the differences between source and target, and reject a transfer of moral

judgement: they show that the target is less morally (un)acceptable than the source. However, they do not justify an opposite conclusion: the dissimilarities between murder and theft may make the latter less morally unacceptable, but that doesn’t warrant the conclusion that it is morally acceptable. Dissimilar reinforcing analogies also emphasise the difference between source and target, but nevertheless aim at a similar moral judgment: they indicate that the target is even more morally (un)acceptable than the source. The best way to visualise the difference between these three types of analogies is by placing the source and target procedures on a continuum between morally acceptable and morally unacceptable procedures:

(Mertes & Pennings 2011)

As this schema illustrates, a similar analogy places the target procedure on the same level of moral (un)acceptability as the source procedure. A dissimilar undermining analogy pulls the target procedure towards the middle of the continuum, leaving it undecided. It is therefore the weakest of the three types of analogies, but can nevertheless possess “a strong rhetorical power to invalidate a classic analogy made by an opponent in an ethical discussion” (Mertes & Pennings 2011). A dissimilar reinforcing analogy pulls the target procedure further towards the pole that the source procedure leans towards, thereby supporting an even stronger conclusion. It is therefore the most effective of the three types of analogies (Mertes & Pennings 2011). In what follows, I will consider the objections health care professionals have voiced against HP, and I will construct analogies between medicalised female genital cutting and HP, and between labiaplasty and HP, in order to examine to what extent ethical conclusions can be transferred between these different procedures

Medicalised female genital cutting

‘Female genital cutting’ (FGC) refers to the non-Western cultural practice of surgically altering the female genitalia, and may include removal of the labia and the clitoris, and/or the sewing up of the vaginal opening. FCGt is a social convention associated with gender, sexuality and life-event rituals. It is associated with gender, because the clitoris is often perceived as a masculine organ “that needs to be removed to ensure pure femininity” (World Health Organization 2011). It is associated with sexuality, because the clitoris is generally seen as the cause of female sexual desire, and is removed to reduce a woman’s libido. This is thought to safeguard premarital virginity, marital fidelity and sexual modesty (World Health Organization 2011), as well as to protect the social order from women’s “dangerous” sexuality (Cook et al 2002). It is associated with life-event rituals, because the procedure is often perceived as a coming-of-age ritual marking a girl’s transition to womanhood. In many communities FGC is believed to be prescribed by “the locally common religion, which includes Islam, Christianity and traditional faith systems” (World Health Organization 2011). However, FGC is a cultural rather than a religious prescript, and the decision to have a girl or young woman undergo the procedure is mostly made by “multiple family members, including mothers, fathers, grandparents and aunts” (World Health Organization 2011). And as FGC is a strong social convention, the reasons families and/or girls and young women submit to it may include “social acceptance, peer pressure, the fear of not having access to resources and opportunities as a young woman, and to secure prospects of marriage” (World Health Organization 2011). It has been pointed out that the social consequences of being an “uncut woman” may be so severe that a family who decide to have their daughter cut may be acting in her best interest, and that the dominant emotion involved in FGC may be parental love (Tostan, retrieved 28 April 2015).

Delineating the analogy

In order to construct an analogy between FGC and HP, it is necessary to make a distinction between medicalised female genital cutting (mFGC) and traditional female genital cutting (tFGC). As efforts to eradicate FGC have so far met with little success, proponents of mFGC advocate a medicalised version of the operation in order to protect women from some of the negative consequences of tFGC. The reason why it may be morally justified to carry

out mFGC is analogous to the reason why it may be morally justified to carry out HP: because it may protect girls and young women from some of the harmful effects imposed by cultural practices. I will therefore limit the analogy with HP to mFGC. Additionally, as the girls and young women who undergo HP request the operation themselves, I will limit the analogy to instances of mFGC in which the operation is freely chosen by mature girls or adult women. As we go along, I will provide the necessary facts and figures to draw this analogy. Further information on female genital cutting can be found in the addendum.

Why mFGC?

Some have claimed that HP is a form of “ritualistic surgery” (Logmans et al 1998a). However, a possible analogy between HP and female genital cutting, one of the most widespread “ritualistic surgeries”, is rejected by most authors (Raphael 1998; Webb 1998). Some go as far as to say that drawing analogies between HP and female genital cutting is “absurd” (Webb 1998), as female genital cutting is “so dangerous, mutilating and painful that there is no doubt of the appropriateness of its prohibition”, whereas HP is thought to be “a safe procedure which may preserve the personal and physical integrity of the woman requesting it” (Webb 1998). However, the wholesale rejection of a possible analogy between the two procedures may be due to the association of the term ‘female genital cutting’ with its traditional and most severe forms. There are various forms of female genital cutting, and efforts have been made to restrict the negative consequences of tFGC by offering women living in communities where female genital cutting is practiced the possibility to undergo mFGC instead. If the latter is carried out by health care professionals in sterile and controlled environments, mFGC may carry a significantly smaller health risk than tFGC. Consequently, the above objections to a possible analogy, which are based on an extreme dissimilarity between tFGC and HP regarding the safety and the personal and physical integrity of the patient, may lose some of their force with regards to mFGC. Nevertheless, mFGC remains a controversial issue, and it may seem contentious to argue in its favour. However, my main interest in mFGC is what it can tell us about HP. What I hope to show, minimally, is that mFGC cannot be rejected offhand, and that if the arguments in favour of mFGC are strong enough to make us doubt the validity of some of the objections against so controversial an operation as mFGC, then they must make us doubt the validity of those objections even more in the case of HP.

Labiaplasty

‘Labiaplasty’ (LP) refers to the Western cultural practice of surgically altering the size and the shape of the female genitalia, and more specifically the labia. The majority of women who request LP do so for aesthetic reasons (Renganathan et al 2009) and some of them feel their vulva is abnormal in appearance (Rogers 2014). However, there are wide variations in “labial size, symmetry and coloration” (Lloyd et al 2005), and the prevalence of labia “measurably outside the norm” is said to be small (Goodman et al 2007). In adult women, the labia are seldom completely symmetrical, and often the labia minora protrude outside the labia majora (Rogers 2014). Like other forms of female genital cosmetic surgery, LP may constitute “surgery performed on a woman within a normal range of variation of female anatomy, including childbearing changes and changes associated with aging” (Cain et al 2013). After undergoing LP, the newly created labia are symmetrical, small, and hidden by the labia majora, characteristics that are said to be “shared with prepubescent girls” (Rogers 2014). However, most adult women describe these atypical characteristics as “normal” (Pauls 2014). Anatomical differences in female genitalia can also cause functional problems such as discomfort in clothing, discomfort during sport and exercise, and problems with intercourse (Goodman et al 2010). Some women suffer from dyspareunia, caused by invagination of the excess labial tissue during penetration (Goodman et al 2007). Often women request LP for a combination of aesthetic and functional reasons. Women who feel their labia are abnormal may avoid wearing tight-fitting clothing or bathing suits, may feel too embarrassed about their body to engage in sexual activity, and may experience pain whilst walking, exercising and during sexual intercourse (Veale et al 2014). This may result in a “low body image and feelings of self-consciousness”, which may impact on their “quality of life and mental wellbeing, as well as lead to sexual dysfunction” (Pauls 2014). Some may request LP because they hope the operation will enhance their sex life and/or improve their relationships (Lloyd et al 2005).

Delineating the analogy

In order to construct an analogy between HP and labiaplasty, it is necessary to make a distinction between cosmetically motivated labiaplasty (cLP), and medically motivated labiaplasty (mLP). As we will see below, there are no medical motivations to perform HP, and I will therefore limit the analogy with HP to cLP.

Why cLP?

Some may claim that the distinction between cLP and mLP is purely theoretical, as there are many different reasons why women request labiaplasty. However, I would argue that the distinction is legitimate, as using labiaplasty as a source procedure without making the distinction between the various reasons why women request the procedure may lead to a biased analogy. First, there are “legitimate medical indications” for labiaplasty, such as “unusually large or long labia” leading to “discomfort with normal physical activity and intercourse” (Pauls 2007), and there are no analogous medical indications for HP. Consequently, an analogy between HP and labiaplasty that incorporates these medical indications may unfairly favour the ethical acceptability of labiaplasty over that of HP. Second, as HP is inspired by non-Western cultural practices, it may be subject to cultural bias when analysed from a Western perspective. And as mFGC is also inspired by non-Western cultural practices, it is unlikely that the analogy between HP and mFGC can help reduce this cultural bias. Labiaplasty, in contrast, finds its origin in Western culture. As it has been argued that cosmetic surgery and HP are ethically comparable, as both “allow women to fulfil physical ideals of their respective cultures” (Logmans et al 1998b), and as the majority of women who undergo labiaplasty do so partially or wholly for cosmetic reasons (Renganathan et al 2009), an analogy between HP and labiaplasty that concentrates primarily on those cosmetic reasons may expose and thus help limit this cultural bias. Therefore, it seems reasonable to conclude that limiting the analogy with HP to cLP is methodologically justified, even if the distinction between cLP and mLP is difficult to make in practice. As we go along, I will provide the necessary facts and figures to draw this analogy. Further information on labiaplasty can be found in the addendum.

Chapter 4: Consequentialist Objections to HP

HP may cause medical complications

The first consequentialist objection I will consider is the claim that HP may cause medical complications. Several authors have hinted at this possibility, and there may be sound reasons to be cautious regarding the safety of the operation. First, an operation, even under professionally skilled and sterile management is never zero risk (Cook & Dickens 2009). Second, HP is not generally included in standard gynaecological training (Tschudin et al 2013). Third, there are no clinical studies available regarding HP (Essén et al 2010). Fourth, there is no adequate evidence base concerning its long-term benefits and harms (Cain et al 2013). Finally, attempts to gather data are hampered by measures taken to guarantee the confidentiality of the operation (Essén et al 2010; Tschudin et al 2013). Therefore, it could be argued that we may need to err on the side of caution and not understate the medical risks associated with the operation (Cook & Dickens 2009).

On the other hand, most authors agree that few complications occur when HP “is performed under adequate standards of care” (Tschudin et al 2013). Reports to the contrary may be predominantly associated with unskilled or inexperienced practitioners: the predominant reference regarding possible medical complications of HP, which recurs in several academic papers (Cook & Dickens 2009; Eich 2010; Tschudin et al 2013; Vermeirsch et al 2013), seems to lead back to a single study on the consequences of back-street operations in Guatemala (Roberts 2006). If HP is carried out in hospitals, under sterile conditions, under anaesthetic and by skilled practitioners, there may be equally sound reasons to not overstate the risks involved. First, HP is a small intervention, which can be carried out on an outpatient basis. Second, the operation is unlikely to challenge the skills of experienced gynaecological surgeons. Third, there are no great foreseeable risks involved. Finally, the alteration can easily be reversed (Verhaar 1999). Therefore, it seems reasonable to conclude that HP is unlikely to cause medical complications.

In fact, prohibiting HP may well lead to more medical complications, as it may drive the practice underground (Frank et al 1999). In most Arab countries, where HP is illegal (Prakash

2009), the operation is carried out in secret (Paterson-Brown 1998). Specialists in this procedure advertise on the Internet, and perform as many as five or six procedures per week (Paterson-Brown 1998). In Thailand and the US, HP is heavily advertised on the Internet and in other mass media, and there are concerns that this may lead to an increase in medical tourism (Kyrillou et al 2009). Medical tourism packages are indeed available to countries such as Tunisia, where the operation is offered for a lower price tag (Sciolino & Mekhennet 2008). At the very least, these findings suggests that prohibiting an operation that many girls and young women see as their only way out of a threatening situation may not have the desired effect. Instead of preventing them from having HP performed, it may lead them to have the operation carried out in less than ideal circumstances, by unauthorised practitioners (Prakash 2009). In the worst-case scenario, it may even lead them to have the operation carried out in highly dangerous circumstances, by untrained and unqualified persons. The previously mentioned study carried out in Guatemala, where HP is illegal, found that gynaecologists are frequently faced with women who have had HP carried out in a back- street operating theatre, and who subsequently suffer from numerous health problems, including “infections, haemorrhaging, incontinence, fistulas, and extreme pain during sexual intercourse” (Roberts 2006).

Medical complications of mFGC

Although it has been said that HP and FGC are similar, in that they both may be aimed at “(making) women marriageable within their communities” (Cook & Dickens 2009), it is perhaps their differences that are most instructive regarding the question of medical complications. First, whereas HP procedures are generally conducted in hospitals, under sterile conditions, under anaesthetic and by skilled practitioners, FGC is often performed with crude instruments, in unsterile conditions, without anaesthetic and by traditional, unskilled practitioners (Cook et al 2002; Cook & Dickens 2009). Second, whilst reports of medical complications as a consequence of HP are scant, the reported medical complications of FGC are considerable, and include short-term consequences, long-term consequences, and complications surrounding childbirth. Finally, whereas the alterations that are made to the hymen by HP are undone upon “defloration”, the alterations done to the clitoris by FGC cannot ever be reversed (Verhaar 1999). Therefore, it may seem reasonable to conclude that the risks of “physical, psychological and sexual complications” are higher in the case of FGC than in the case of HP (Logmans et al 1998a).

Certainly, there seem to be many potentially severe medical complications linked to FGC. First, short-term consequences of FGC can include severe pain, haemorrhage, detention of urine and faeces because of swelling and inflammation around the wound, keloid scars, local and systemic infections, shock from blood loss, and potentially death (Shell-Duncan 2001; Cook et al 2002; World Health Organization 2011). Second, long-term consequences can include dermoid cysts and abscesses, repeated urinary tract infections and chronic pelvic infections (World Health Organization 2011), “which may cause irreparable damage to the reproductive organs and result in infertility” (Cook et al 2002), and “may ascend to the bladder and the kidneys, potentially resulting in renal failure, septicemia, and death” (Shell- Duncan 2001). Third, complications surrounding childbirth can include bleeding from tearing and de-infibulations (the reopening of a sewn-up vagina), prolonged or obstructed labour, and obstetric fistulae (holes or tunnels between the bladder and the vagina and/or between the rectum and the vagina) (Cook et al 2002). Vulval scarring can lead to postpartum haemorrhage and stillbirths, the risk of which increases with more than 50% in girls and young women who have undergone Type 3 FGC, which includes infibulation (World Health Organization 2011). Vulval scarring from all types of FGC has also been reported “as a contributing or causal factor in maternal death” (Cook et al 2002). For many who have undergone Type 3 FGC, sexual intercourse is painful in the weeks following sexual initiation as “the infibulation must be opened either surgically or through penetrative sex” (World Health Organization 2011). Further surgery may not only be needed “when infibulations must be opened to enable sexual intercourse” but also at childbirth, and as in some communities this is followed by re-infibulation, this can be a recurrent process. (World Health Organization 2011). Therefore, it may be reasonable to conclude that the medical complications surrounding FGC are not only higher than those surrounding HP, but are in fact prohibitive.

However, it has been claimed that possible medical complications may be grounds to make the practice safe rather than oppose it (Shweder 2002). As we have seen above, FGC has become increasingly medicalised, and an estimated 18% of all women who have undergone FGC, have had the procedure carried out by health care professionals. Parents choosing this option may be motivated by “an increased awareness of the health risks associated with the practice” (World Health Organization 2011). Proponents of mFGC claim the operation may reduce the medical complications of tFGC, and support policies and campaigns that promote the medicalization of female genital cutting.

In contrast, the World Health Organisation has issued a global strategy to stop medicalization of FGC, as it holds the view that health care professionals performing mFGC do not necessarily reduce harm: although mFGC may reduce some of the short-term complications of tFGC, it may not reduce the long-term consequences and the complications surrounding childbirth (World Health Organization 2011), and studies show that mFGC is not systematically less extensive than tFGC(World Health Organization 2011).

However, it could be argued that this does not justify the prohibition of mFGC. First, as we have seen above, the potential short-term complications that mFGC may prevent are severe and lead to the death of the girls or women subjected to tFGC. Second, as these potential short-term complications can occur in all forms of tFGC, the harm that mFGC may reduce is not limited to less severe forms of cutting only. Third, bringing FGC into the medical realm may open the door for long-term follow-up by health care professionals, which may prevent most or all of the long-term consequences and of the complications surrounding childbirth that are associated with more severe forms of cutting. Fourth, although mFGC may not be systematically less extensive at first, it may form an intermediate step that ultimately leads to the acceptance of a symbolic intervention such as the pricking of the clitoris, or perhaps, in time, to the abandonment of the practice. Finally, attempts to eradicate the FGC outright have so far met with little or no success. Therefore, it could be argued that the objection that mFGC causes medical complications, although not without merit, fails to provide sufficient grounds for health care professionals to refuse to perform the operation.

Medical complications of cLP

As far as LP is concerned, patient satisfaction rates “typically range from 90% to 100%” (Braun 2010), and the complication rate of LP is said to be lower than that of many widely accepted procedures and to consist of mainly minor complications. (Pauls 2014). One study reports a risk factor ranging from 2% to 6%, whereas breast augmentation has a risk factor of 18,2 %, of which 1,9% relates to major complications (Gulcelik et al 2011). Generally the reported complication rate of LP tends to be lower than 5%, and predominantly consists of ruptures along the surgical suture followed by pain (Braun 2010). However there may be several reasons to adopt a cautious approach with regards to possible medical complications of LP. First, though the low complication rate is repeated in many studies, the list of possible

complications remains extensive: LP can lead to post-operative infection, hematoma, asymmetry, poor wound healing, wound separation, over-zealous resection, urinary retention, skin retraction, delayed local pain, and painful sexual intercourse (Iglesia et al 2013). Second, the labia are innervated and have an erectile core (Pauls 2014), and it has been suggested that surgery may damage the nerve supply and cause impaired sensitivity and impaired sexual function (Liao et al 2010). Third, there are no reliable data regarding the costs and benefits of the operation, as “follow-up (is) not carried out for most studies” (Liao et al 2010), and in those studies where it is, often only consists of a limited and short-term personal follow-up of a small percentage of the patients treated combined with written questionnaires (Alter 2008). Fourth, many studies regarding the medical consequences of LP are carried out by clinics offering the operation commercially, and it has been pointed out that ideally, “assessment should not be conducted by those with fiscal interest in the outcome” (Braun 2010), as such studies may show bias towards success rate and consumer satisfaction. Finally, although overall satisfaction following LP interventions is said to be very high (Pauls 2014), “consumer satisfaction should not be confused with clinical effectiveness” (Liao et al 2010), as “satisfaction and absence of regret can be accounted for by cognitive dissonance” (Liao et al 2010): patients may rationalise their irreversible choice after the fact in order to reduce tension created by doubts over whether they have made the right decision. Therefore it seems reasonable to conclude that, until more conclusive data regarding the costs and benefits of the operation can be gathered, a cautious approach may need to be taken.

Conclusion regarding medical complications

It has been claimed that HP may cause medical complications, and there may indeed be reasons to exercise caution: no operation is without risk, surgeons are not specifically trained for HP, there is no conclusive data regarding its costs and benefits, and the confidentiality surrounding it makes it difficult to gather such data. On the other hand, HP is a small intervention that is unlikely to challenge skilled gynaecological surgeons, there are no foreseen risks, it is easily reversed, and refusing it may drive it underground and cause potentially severe complications. It therefore seems reasonable to conclude that, in the absence of evidence to the contrary, the objection that HP may cause medical complications is without merit and surgeons should not refuse the operation on such grounds.

It could be argued that, although the objection regarding medical complications of mFGC also fails to provide sufficient grounds for surgeons to refuse the operation, it does so for different reasons, and these reasons are instructive with regards to the analogy between HP and mFGC. First, tFGC is non-reversible, is often carried out by unskilled practitioners in medically unsound circumstances, and regularly causes severe medical complications, which sometimes result in death. Second, efforts to convince communities practicing FGC to abandon the custom have met with little success. Third, mFGC may prevent the short-term consequences of tFGC, may open the door for medical follow-up and reduce some of the long-term consequences and the complications surround childbirth, and may be an intermediate step towards the acceptance of purely symbolic cutting or even abandonment of the practice. Therefore, the objection that mFGC causes medical complications, though not without merit, may fail to provide sufficient grounds for surgeons to refuse the operation. However, as mFGC cannot eliminate all the medical complications of FGC, and as some of these complications are potentially severe, it seems reasonable to conclude that the analogy between mFGC and HP, with regards to their possible medical complications, is a dissimilar reinforcing one: if the argument that the operation may cause medical complications does not justify a refusal to perform it in the case of mFGC, it does so even less in the case of HP.

I would argue further that, although the risk of medical complications caused by LP is low, it too constitutes a dissimilar reinforcing analogy when compared to HP. Both operations share the absence of conclusive data and a cautious approach may therefore be warranted. However, whereas the known potential medical complications of HP are limited to the risks that attach to every operation, LP can cause additional complications that are particular to the operation, such as asymmetry, over-zealous resection, urinary retention, skin retraction, delayed local pain, and impaired sensitivity and sexual function. It therefore seems reasonable to conclude that the analogy between LP and HP, with regards to possible medical complications, is also a dissimilar reinforcing one: if the argument that the operation may cause medical complications does not deter surgeons from performing LP, than it should do so even less in the case of HP.

HP may have psychological consequences

A second consequentialist objection that has been raised against HP is that it may negatively affect girls or young women’s psychological health (Cook & Dickens 2009). First, they may experience guilt for having deceived their husbands (Raveenthiran 2009; Cook & Dickens 2009). Second, they may experience fear of being found out (Raphael 1998; Raveenthiran 2009). Third, if they have a history of sexual abuse, the surgery itself may be “traumatic and associated with fear, panic and depression” (Bekker et al 1996). Finally, in cases of abuse, HP may medicalise the problem and leave the woman to deal with the consequences of the abuse herself (Bekker et al 1996). Therefore, it may seem reasonable to conclude that HP may negatively affect the girls or young woman’s mental or psychological health.

However, there are good reasons to assume that many of the potential psychological consequences of HP can be successfully addressed, and that any psychological consequences that may remain are outweighed by the severity of the psychological consequences they may suffer if they do not have the operation. First, as we will see further down, multi-disciplinary intake models which include counselling, information about the medical facts regarding virginity, and self-examination may help girls and young women requesting HP to deal with feelings of guilt and/or fear. Second, the fear girls and young women may experience of the HP operation being discovered, may be outweighed by the fear of not being able to “prove” their virginity, may not extend beyond the wedding night, and may be diminished by being informed of medical confidentiality and the willingness of health care professional to destroy the records of the operation. Third, the concern that the HP operation itself may be traumatic and associated with fear, panic and depression if girls or young women have a history of sexual abuse may be addressed by counselling, and may be mitigated by the feeling of being “whole and pure” again (van Moorst et al 2012a). And as we have seen above, many girls and young women request HP precisely to “overcome traumatic sexual experiences” (van Moorst et al 2012a; Loeber 2014a). Fourth, intake processes that include counselling can address sexual abuse and its psychological consequences, and may thereby avoid that the consequences of abuse are left untreated. Fifth, the virginity rule that leads girls and young women to request HP may itself have psychological consequences which may include not only guilt and fear but also insecurity, loneliness, social isolation, identity problems, a

distorted body image, conflicts with their parents, depression, despair, and suicidal feelings (Bekker et al 1996; Gürsoy & Vural 2003; Essén et al 2010). If HP can address these consequences, the psychological benefits of the operation may outweigh any of its remaining psychological consequences. Finally, as we have seen above, the consequences of not being able to “prove” her virginity are potentially severe, and if HP can prevent these consequences, the benefits of the operation to the girl or young woman’s overall health and wellbeing may outweigh any remaining psychological consequences. Therefore, it seems reasonable to conclude that most if not all of the potential psychological consequences of HP can be successfully addressed, and that any psychological consequences that may remain are outweighed by the severity of the (psychological and non-psychological) consequences they may suffer if they do not have the operation. If this is true, the objection that HP may have psychological consequences fails to provide sufficient grounds for health care professionals to refuse the operation.

Psychological consequences of FGC

The potential psychological consequences of FGC include post-traumatic stress disorder, anxiety, depression, psychosexual problems, somatisation, phobia and low self-esteem (World Health Organization 2011). On the basis of this, it may seem reasonable to conclude that health care professionals should not perform mFGC. However, it could be argued that the potential psychological consequences that remain if the operation is medicalised do not form sufficient grounds for health care professionals to refuse to perform mFGC. First, as we have seen above, girls and women living in traditional communities may receive psychological benefits from undergoing FGC, as they may consider “genital modification and the bravery and self-control displayed during the operation as constitutive experiences of (…) personhood” (Kratz 1993). Second, in such communities, girls and women may suffer considerable psychological consequences from not undergoing FGC, as they may be ridiculed and shunned, and lose all access to social privileges, marriage and motherhood. Third, mFGC may prevent some of the most acute psychological consequences of FGC such as post- traumatic stress disorder and anxiety. Fourth, mFGC may open the door for medical follow- up, which may allow health care professionals to address some or all of the other psychological consequences of the practice. Fifth, mFGC may form an intermediate step towards less severe forms of cutting or even purely symbolic FGC, which may further reduce or even eliminate any remaining psychological consequences of the practice. Finally, efforts

to eradicate the tradition have met with little success and mFGC may be the only way to reduce the psychological consequences of the tradition. Therefore, it could be argued that the potential psychological consequences of mFGC do not form sufficient grounds for health care professionals to refuse to perform mFGC.

Psychological consequences of cLP

It has been pointed out that the decision to undergo cosmetic genital surgery “invariably has a strong psychological basis” (Renganathan et al 2009). Some women who request cLP believe their labia to be abnormal (Pauls 2014), and many authors therefore recommend that women should be educated about female genitalia’s “wonderfully varied array of sizes, shapes and colours” (Lloyd et al 2005; Goodman et al 2007; Cain et al 2013). However, some women who are informed about the wide variety in size, shape and colour of the labia, and have been counselled regarding the appearance of their own labia, may still experience “psychological distress, loss of self-esteem (…) and diminished libido (Braun 2010). The high patient satisfaction rates of the operation suggest that cLP may indeed “relieve a pre- existing distress” and improve a woman’s “self-esteem and sex life.” The psychological benefits women may receive from cLP are thus considerable. (Braun 2010). Furthermore, there is no mention in the available literature of any psychological costs that may attach to it. Therefore, it seems reasonable to conclude that, in normal circumstances, health care professionals should not refuse to perform cLP on the grounds of psychological consequences.

However, the paucity of the research regarding the long-term costs and benefits suggests that some caution may still be necessary. The prevalence of depression and suicide is significantly higher in people choosing cosmetic surgical enhancements. Understanding the reasons why a woman wants to have the operation is therefore essential (Pauls 2014). Health care professionals should not perform cLP if patients suffer from depression or from a mental impairment (Goodman et al 2007). Some women may request female genital cosmetic surgery because they suffer from body dysmorphic disorder (Pauls 2014). Body dysmorphic disorder is an extreme “preoccupation with an imagined or slight defect in appearance”, which causes “notable distress and impairment in functioning, and is associated with markedly poor quality of life” (Phillips & Crino 2001). Women who suffer from body dysmorphic disorder may need “disinterested counselling or psychiatric care” Cosmetic

surgery, such as cLP, will not solve their problem (Cain et al 2013). Therefore, it seems reasonable to conclude that, although cLP may relieve some women’s distress and improve their self-esteem and sex life, intake procedures may need to involve education and counselling to determine who may benefit from the procedure, who can be helped in other ways, and who may be harmed by it.

Conclusion regarding psychological consequences

I have argued that many of the potential psychological consequences of HP can be successfully addressed, and that any psychological consequences that remain are outweighed by the severity of the (psychological and non-psychological) consequences girls and young women may suffer if they do not have the operation. If this is true, the objection that HP may have psychological consequences fails to provide sufficient grounds for health care professionals to refuse the operation.

It could be argued that mFGC can address at least some of the psychological consequences of tFGC by the medicalization of the practice, and that as efforts to eradicate FGC outright have so far met with little or no success, any psychological consequences that remain may be outweighed by the psychological consequences girls and women may suffer if they don’t have the operation. If this is true, the objection that mFGC has psychological consequences may fail to provide sufficient grounds for health care professionals to refuse the operation.

However, this doesn’t mean HP and mFGC are perfectly aligned. First, whereas HP may resolve most if not all of the psychological consequences that attach to the virginity rule, mFGC may resolve only some of those that attach to FGC. This is because the extent to which mFGC may resolve the psychological consequences that attach to tFGC is correlated with the extent of the cutting. Although mFGC makes the operation safer, and may thereby address a number of the psychological consequences that attach to all forms of tFGC such as post-traumatic stress disorder and anxiety, other psychological consequences such as psychosexual problems may only be addressed by less extensive cutting. And as we have seen above, mFGC is not systematically less extensive than tFGC (World Health Organization 2011). Second, the psychological consequences that may remain in the case of HP seem to be of a less severe nature than those that may remain in the case of mFGC.

Whereas HP may in some cases fail to fully alleviate the guilt over the deceit, and the fear of being found out that girls and young women may suffer, the psychological consequences tFGC may fail to address are more numerous and include depression, psychosexual problems, somatisation, phobia and low self-esteem. Therefore, it seems reasonable to conclude that the analogy between mFGC and HP, with regards to their possible psychological consequences, is a dissimilar reinforcing one: if the argument that the operation may have psychological consequences does not justify a refusal to perform it in the case mFGC, it does so even less in the case of HP.

Regarding cLP, I have argued that the psychological benefits women may receive from cLP are considerable, that in normal circumstances the operation does not have any psychological consequences, and that therefore health care professionals should not refuse to perform cLP on the grounds of psychological consequences. At first glance, it may seem that this makes the analogy between cLP and HP a dissimilar undermining one: as cLP has no psychological consequences, whereas HP does, HP would seem to be less justified. However, I would argue that the psychological problems that HP offers girls and young women protection from are more numerous, acute and urgent than those that lead women to request cLP, that they outweigh any psychological consequences that may attach HP, and that consequently HP is more beneficent than cLP. Therefore, it seems reasonable to conclude that the analogy between cLP and HP is also a dissimilar reinforcing one: if the psychological benefits of the operation provide sufficient grounds to make it available in the case of cLP, than they do so even more in the case of HP.

HP may fail to achieve its intended effect

A final consequentialist objection that has been raised against HP is that it may fail to achieve its intended effect. First, HP does not guarantee blood loss on the wedding night (Essén et al 2010; van Moorst et al 2012a; Tschudin et al 2013). Second, if the husband does not perceive his bride as being ‘tight’ during intercourse, he may doubt her virginity in spite of blood loss (van Moorst et al 2012a). Third, if the availability of HP operations becomes public knowledge, he may doubt the authenticity of the blood loss (Helgesson & Lynöe 2008).

HP does not guarantee blood loss

There are good reasons to assume that HP does not guarantee blood loss in every case. First, although there is a paucity of precise data and wide-scale follow-up studies (van Moorst et al 2012a), the reports that are available suggest that HP does not always cause blood loss. In one study, only 2 out of 19 women who had undergone the operation subsequently experienced blood loss (van Moorst et al 2012a). Another cites a success rate of 76% (Loeber 2014a). Yet another study claims all patients reported a satisfactory outcome (Logmans et al 1998a), but fails to specify whether that means they experienced blood loss or not. This omission may be important, as all 19 women from the first study mentioned above expressed satisfaction with the overall process, even though only two of them actually experienced blood loss. Although vague and contradictory results such as these do not give us a clear picture of the success rate of the operation, they suggest that HP does not always cause blood loss. Second, as we have seen above, as an intact hymen does not guarantee blood loss upon “defloration”, and 40% to 80% of women with an intact hymen do not bleed during first intercourse, (Bekker et al 1996; Loeber 2008; van Moorst et al 2012a), it seems reasonable to assume that, all else being equal, women with a restored hymen will not exceed these figures. Finally, the use of a gelatine capsule of fake blood sutured in the vaginal wall (Paterson- Brown 1998; Renganathan et al 2009) suggests “a lack of confidence in the HP procedure” amongst health care professionals (van Moorst et al 2012a). Therefore, it seems reasonable to assume that HP does not guarantee blood loss in every case.

However, I would argue that the failure of HP to guarantee blood loss in every case does not in itself justify the claim that it fails to achieve its intended effect. First, it is an inherent risk of any discretionary (and other) operation that it fails to deliver the benefits that the patient expects of it (Cook & Dickens 2009), and many operations with a less than optimal success rate are carried out routinely. Second, HP may not guarantee blood loss, but as we have seen, neither does being a virgin, and it could be argued that the operation successfully restores the hymen, and merely fails at enhancing the frequency at which it produces blood loss upon “defloration”. Third, the above results indicate that HP causes blood loss at “defloration” in at least some of the cases, and as the potential consequences girls and young women may suffer if they can’t “prove” their virginity are severe even a low success rate may be sufficient to justify the operation. Fourth, HP may have psychological benefits that mitigate the failure to guarantee blood loss. Although only 2 out of 13 women in the study

mentioned above experienced blood loss, all 13 women stated they were satisfied with the overall process and would “make the same decision again” (van Moorst et al 2012a), suggesting that the operation has other effects which may not be so easy to gauge as the presence or absence of blood loss. Finally, although the proximate goal of the operation is blood loss, the ultimate goal is to protect girls and young women from the consequences of not being able to prove their virginity. By having HP performed, women may feel they did “everything that could be done” (van Moorst et al 2012a), and may be sufficiently empowered to avoid these consequences even if the operation doesn’t cause blood loss. Therefore, it seems reasonable to conclude that the failure of HP to guarantee blood loss in every case does not in itself justify the claim that it fails to achieve its intended effect.

A lack of “tightness” may cause doubt in spite of blood loss

Some authors have pointed out that HP alone may not solve these young women’s problems, as a perceived lack of “tightness” during intercourse may cause their future husbands to doubt their virginity in spite of the presence of blood loss (van Moorst et al 2012a). The false belief that it is possible to tell whether a woman has had previous sexual intercourse by how “tight” her vagina feels is perpetuated by “repeated warning (by) their mothers, sisters, friends and, above all, by their future spouses who (claim) that a man can feel whether a woman is a virgin or not” (van Moorst et al 2012a). As a consequence, some girls and young women are more concerned about not being “tight” enough than about “the possibility of not bleeding” (van Moorst et al 2012a).

However, as at least one study has shown, this concern can be alleviated by providing girls and young women requesting HP with pelvic floor training. This consists of teaching them about the “role of the pelvic floor as a sexual organ” and making them aware that they can “achieve a sustained, voluntary contraction” of the muscles around the vaginal opening in order to cause a sensation of “tightness” (van Moorst et al 2012a). As not feeling “tight” worries some girls and young women more than not bleeding, the capacity to contract their vaginal muscles to mimic “tightness”, together with the knowledge that their hymen is “restored” - even if it isn’t guaranteed to cause blood loss - may empower them sufficiently to confidently deny any accusations or doubts regarding their virginal status. Therefore, it seems reasonable to conclude that HP combined with pelvic floor training can help girls and young women avoid any doubt regarding their virginity due to a perceived lack of “tightness”.

Public knowledge of HP may cast doubt on the blood loss

Some health care professionals have voiced the concern that public knowledge of HP may cause men to doubt the authenticity of a their bride’s blood loss and may significantly undermine the capacity of the operation to achieve its intended effect (Bartels 2000; Helgesson & Lynöe 2008). That this is no idle claim, is shown by questions posed by a boy from a migrant background on a Dutch sexual health website, who wants to know if there is any way he can tell the difference between an “original hymen” or one that is “recovered (through) surgery”. Additionally, his concern regarding the blood that “looked (…) orange and left no stain after cleaning, while blood stains” suggests an awareness of the use of fake blood to simulate blood loss (Loeber 2014b). If knowledge of the operation becomes widespread, it may cast doubt on the authenticity of the blood loss on the wedding night.

However, I would argue that this is unlikely to significantly undermine the capacity of the operation to achieve its intended effect. First, although public knowledge of HP may make men more suspicious regarding the nature of their bride’s blood loss, they have no way of knowing whether or not this blood loss is the consequence of an HP operation. Second, as the idea of blood loss as “proof” of virginity is deeply embedded in migrant Muslim culture, and all women are expected to bleed upon “defloration”, unconfirmed suspicions regarding the nature of a bride’s blood loss may be easier to deny than the “proof” of non-virginity constituted by an the absence of blood loss. Third, combining HP with other methods such as mimicking “tightness” may help to alleviate such suspicions. Fourth, it seems reasonable to assume that public knowledge of HP is unlikely to make every man suspicious regarding the authenticity of his bride’s blood loss, and there may be more instances in which HP can help girls and young women successfully convince their husbands of their virginity than instances in which public knowledge of HP causes their husbands to doubt the nature of their blood loss. Fifth, concern for the hypothetical effects of public knowledge of HP on the credibility of the blood loss of future girls and young women doesn’t help girls who face the consequences of not being able to “prove” their virginity now. Sixth, as the questions posed on the Dutch sexual health website show, the genie may already be out of the bottle, and refusing to perform HP may not undo the level of public knowledge which already exists. Seventh, public knowledge of HP may erode the importance of blood loss as “proof” of virginity. Finally, as I will argue below, public knowledge may subvert the virginity rule

rather than perpetuate it. Therefore, it seems reasonable to conclude that although the concern that public knowledge of HP may lead some men to doubt the authenticity of their bride’s blood loss, this is unlikely to significantly undermine the capacity of the operation to achieve its intended effect.

Preliminary conclusion regarding HP and its intended effect

First, although there are good reasons to conclude that HP does not always achieve its proximate goal of producing blood loss on “defloration”, the operation may nevertheless achieve its core goal of helping the girls and young women requesting it to avoid the consequences that may befall them if they can’t “prove” their virginity. Second, HP can be combined with other methods such as pelvic floor training, which may enhance its “evidentiary power” and empower girls and young women sufficiently to successfully deny any accusations or doubts levelled at them. Third, though public knowledge of HP may lead some men to doubt the authenticity of their bride’s blood loss, this is unlikely to significantly undermine the capacity of the operation to achieve its intended effect. Therefore, it seems reasonable to conclude that the objection that HP may fail to achieve its intended effect fails to provide sufficient grounds for health care professionals to refuse the operation.

mFGC and its intended effect

The question we must answer in order to decide whether mFGC achieves its intended effect is whether it reduces the harm girls and women may suffer as a consequence of tFGC. As this is the only justification for the medicalization of FGC, the failure of the operation to achieve that effect would be prohibitive. However, it could be argued that mFGC reduces significant harm now, and may open the door to long-term medical follow-up and thereby reduce most or all of the harm caused by tFGC. Therefore, the objection that mFGC fails to achieve its intended effect may be without merit.

cLP and its intended effect

As the patient satisfaction rates regarding LP “typically range from 90% to 100%” (Braun 2010), it seems reasonable to assume that cLP generally achieves its purely physical goal of altering the appearance of the labia and bringing it more in line with what has been termed a

“designer vagina” (Braun 2010). And although there are some concerns that unrealistic expectations regarding the operation’s psychological and social effects may cause some women to be dissatisfied with its results (Renganathan et al 2009; Braun 2010; Ostrzenski 2013), the high satisfaction rate of the operation suggests that these cases are the exception rather than the rule, and that the psychological screening and counselling that generally forms part of the intake process of cLP tends to be successful at limiting their occurrence. Therefore, it seems reasonable to conclude that the objection that cLP fails to achieve its intended effect is without merit.

Conclusion regarding intended effect

Although HP may not always achieve its physical goal of producing blood loss, it may nevertheless achieve its core goal of preventing the consequences that may befall girls and young women if they can’t “prove” their virginity on their wedding night. Therefore, the objection that HP fails to achieve its intended effect does not provide sufficient grounds for health care professionals to refuse to perform the operation. Nevertheless, as the objection is not entirely without merit, we must admit that both the analogies between HP and mFGC, and HP and cLP are of a dissimilar undermining nature: although the objection is unsuccessful regarding all three of these interventions, it is less so regarding HP, and we may need to take this into account when we make the final balance of the ethical problems surrounding the operation.

Conclusions consequentialist objections

Having examined all the consequentialist objections raised against HP, and tested their strength by drawing analogies between HP and mFGC, and HP and cLP, it seems reasonable to conclude that these objections fail to provide sufficient grounds for health care professionals to refuse the operation. First, HP is a low-risk, reversible intervention and is unlikely to cause any operation-specific medical complications. Additionally, refusal to perform the operation may drive the practice underground, in which case the risks of medical complications increase exponentially. In contrast, mFGC may reduce some of the medical complications associated with tFGC, but not necessarily eliminate them. If the objection that the operation may cause medical complications does not justify a refusal to perform it in the

case of mFGC, it does so even less in the case of HP. The same may be true for cLP: whereas the potential medical complications of HP are limited to the risks that attach to every operation, cLP can cause a variety of additional complications, and if the objection that the operation may cause medical complications does not stop surgeons from performing cLP, then it should stop them even less in the case of HP. Thus, the objection that HP may cause medical complications fails. Second, HP is unlikely to cause psychological consequences that cannot be prevented by counselling. Furthermore, HP may prevent most if not all of the psychological consequences girls and young woman may suffer due to the virginity rule. In contrast, mFGC may only resolve a few of the psychological consequences that attach to tFGC. If the argument that the operation may have psychological consequences does not justify a refusal to perform it in the case of mFGC, it does so even less in the case of HP. Additionally, HP addresses psychological problems that are more numerous, acute and urgent that those that lead women to request cLP, and if the psychological benefits women may reap from cLP provide sufficient grounds to make the operation available, then the psychological benefits of performing HP do so even more, Thus, the objection that HP may have psychological consequences fails. Finally, although HP may not in every instance achieve its physical goal of producing blood loss, it may nevertheless achieve its core goal of harm reduction, and it can be combined with pelvic floor exercises to empower girls and young women to confidently deny accusations regarding their virginity. The objection that HP fails to achieve its intended effect is therefore largely without merit. And although it is entirely without merit regarding mFGC and cLP, this dissimilarity fails to provide sufficient ground for health care professionals to refuse to perform HP.

In summary, HP does not cause significant medical complications, and prevents more psychological consequences than it causes. And although HP may not always achieve its physical goal of producing blood loss, it achieves its core goal of preventing the potentially severe consequences of the virginity rule. Therefore, health care professionals are not justified in refusing to perform HP on the basis of these consequentialist objections.

Chapter 5: Deontological Objections to HP

HP is Medically Unnecessary

The first deontological objection I will discuss is the concern that HP may constitute unnecessary surgery (Bartels 2000; Saharso 2003a; Cook & Dickens 2009). Generally, the term ‘medical necessity’ is used to determine which health services should be offered in a particular circumstance to a particular person. However, its concrete meaning and its implementation vary greatly across different health care professionals, health insurers and legal systems (Glassman et al 1997). One attempt to define what constitutes medical necessity lists:

“…services or supplies which are required for treatment of illness, injury, diseased condition, or impairment, and are consistent with the patient’s diagnosis or symptoms“ (Bergthold 1995).

Some argue that lately the term is used primarily as a tool to control scarce resources (Bergthold 1995), and congruent with this claim, many of the papers on the subject consist of efforts to defend particular medical practices against economic restrictions (Brougher et al 1986; Kerrigan et al 2002; Brown et al 2009). However, ethical concerns regarding the appropriateness of a medical intervention are not limited to economic concerns only: if the possible costs to the patient, in terms of health and well-being, are greater than the possible benefits, then a treatment may be judged unethical. It is primarily in this vein that we must interpret the objection made by some health care professionals that HP is medically unnecessary (Bekker et al 1996; Bartels 2000; Saharso 2003a; Raveenthiran 2009; Cook & Dickens 2009; Kopelman 2014).

Certainly, such a cost-benefit analysis of HP, using the above definition as a guide, seems to support the claim that the operation constitutes unnecessary surgery. First, if the hymen fulfils no biological function after birth, as I have argued above, then a ruptured hymen does not constitute a physical impairment. Second, as the rupture of the hymen is of no medical consequence (Hegazy & Al-Rukban 2012), a ruptured hymen does not constitute an illness or a diseased condition. Third, as the trauma involved in the rupture of the hymen causes no

lasting pain, heals rapidly, and without significant scarring (McCann et al 2007), it does not constitute an injury that requires medical attention. Therefore, it seems justified to say that HP is a “surgical intervention without medical necessity” (Bekker et al 1996).

The question remains whether health care professionals should therefore refuse to perform the operation. To limit the medical interventions we consider ethical to operations that are medically necessary may commit us to a narrow conception of optimal health, that restricts itself to the optimal functioning of the physical body, and does so in a psychological, social and cultural vacuum. I would argue that on a broader conception of optimal health, which takes into account the psychological, social and cultural wellbeing of the patient and her right to autonomy and self-determination, surgeons may be justified in granting the operation when requested. First, HP may be an ethically acceptable form of discretionary surgery. As the criteria listed above suggest, ‘necessary surgery’ refers predominantly to operations for physical dysfunctions that need to be seen to with a degree of urgency. ‘Elective surgery’ refers to operations for physical dysfunctions that “pose no immediate threat to life or health and can, therefore, be scheduled at a time of convenience”. Both types of surgery are predominantly aimed at restoring the optimal functioning of the physical body. ‘Discretionary surgery’, on the other hand, refers to operations “that do not affect physical function but are desired by the patient to improve his or her sense of well-being” (Leape 1989). This more inclusive conception of health is congruent with the World Health Organisation’s definition of ‘health’ as a state of not only physical but also “mental and social wellbeing”. And as we shall see below, there are similar operations of this kind that are performed routinely. Second, in accordance with the right to autonomy and self- determination, the ultimate cost-benefit analysis of any kind of operation must be made by the patients themselves, based on their own values, and how these values inform the way they weigh the possible costs and benefits of the surgery against each other:

“… (Their) tolerance of risk, fear of surgery, tolerance of pain or disability, preferred lifestyle, requirements for peace of mind, and how (they) envisages living the rest of (their lives)” (Leape 1989).

As these considerations are highly subjective, it has been claimed that the medical profession “cannot generate the necessary conceptual apparatus or information” to produce a sound judgement in this regard. In this view, an operation is “necessary if it improves well-being

and unnecessary if it makes the individual worse off”, and only the individual can make that judgement (Pauly 1979). Therefore, on a broad conception of optimal health, which takes into account psychological, social and cultural wellbeing of the patient, and respects their right to autonomy and self-determination, surgeons may be justified in performing the operation when requested.

However, this doesn’t mean surgeons are obliged to perform the operation and become mere tools in the hands of their patients. Although the ultimate decision whether or not to go ahead with a particular operation may lie with the patient, there may be valid reasons for the surgeon to pre-empt that choice by not making the intervention available in the first place. Furthermore, some surgeons may not wish to perform the operation because of their personal ethical and/or religious convictions, in which case they may refuse to perform the operation, provided they abide by the International Federation of Gynaecology and Obstetrics (FIGO) guidelines on appropriate referral. However, if they cannot provide appropriate referral, they “must give priority to their patients’ lives, health and well-being” (FIGO Committee for the Ethical Aspects of Human and Women's Health 2006).

Medical necessity and mFGC

There is no doubt that, according to the above definition, mFGC constitutes unnecessary surgery: the procedure is carried out on healthy female bodies and there is no impairment, illness or injury requiring medical attention. But does this entail that it is unethical for surgeons to carry out the operation? It has been pointed out that most women in communities that uphold FGC consider the procedure essential for their “psychological, social, spiritual, and physical well-being”. Many women believe that the genital alterations produced by FGC make them “more beautiful, more feminine, more civilised and more honourable”. More beautiful, because female genitals are considered unappealing in their “natural state” and are made “smooth, cleansed, and refined” by the procedure. More feminine because the clitoris is seen as “an unwelcome vestige of the male organ” and its removal is associated with “the attainment of full female identity, induction into a social network and support group of powerful adult women and ultimately marriage and motherhood”. More civilised, because the procedure is a symbolic act by which one values self-control over sexual pleasure. And more honourable, because it announces “one’s commitment to perpetuate the lineage”. As a consequence, girls and women who are uncut may be ridiculed, be shunned, and lose all

access to social privileges, marriage and motherhood (Shweder 2002). Consequently, the psychological, social and ultimately physical wellbeing of women living in communities that uphold FGC may be severely compromised if they are denied the mFGC procedure. Furthermore, to restrict a woman’s access to the procedure may be in breach of her right to autonomy and self-determination. Therefore, it could be argued that on a broad conception of optimal health, surgeons may be justified in performing mFGC when requested.

However, similarly to HP, this doesn’t mean surgeons are obliged to perform the operation when requested, and there may be other reasons for surgeons to not to make the intervention available. Furthermore, as we have seen above, surgeons may also refuse to perform the operation because of their personal ethical and/or religious objection, providing they comply with appropriate referral guidelines.

Medical necessity and cLP

In contrast to HP and mFGC, there may be cases in which LP is necessary rather than discretionary surgery. If a woman experiences loss of physical and psychosexual function because her genitalia cause her physical pain and discomfort, her condition may be considered “pathologic” (Cain et al 2013), and surgeons may perform the operation “for treatment of illness, injury, diseased condition or impairment” (Bergthold 1995). However, this doesn’t mean that LP is always necessary surgery, and the majority of women who request LP are said to do so for cosmetic reasons (Renganathan et al 2009). Nevertheless, on a broad conception of optimal health which takes into account psychological, social and cultural wellbeing of the patient and respects their right to autonomy and self-determination, cLP can be classed as discretionary surgery, and surgeons may be justified in performing cLP in spite of its lack of medical necessity.

Again, this doesn’t mean surgeons are obliged to perform cLP, as there may be other reasons to make the operation unavailable, and surgeons may refuse on personal grounds if they provide adequate referral. However, in the case of cLP, there is an additional reason why surgeons may refuse to perform the operation: there has been concern that some cLP requests may be due to pathological factors such as body dysmorphic disorder, which may undermine the capacity of the patient to give informed consent (Renganathan et al 2009; Goodman 2009;

Cain et al 2013). In such cases the conditions for the surgery to qualify as discretionary are not fulfilled, and surgeons must not perform the operation.

Conclusion regarding medical necessity

Although HP is medically unnecessary surgeons may nevertheless be justified in performing the operation when requested, on the basis of the desire of the patient to have the operation to improve her sense of physical, psychological and social wellbeing, and her right to autonomy and self-determination. If HP fulfils these requirements, it may classify as discretionary surgery, and there are many forms of discretionary surgery that are carried out routinely and are not considered unethical:

“The claim that the procedure is unnecessary on medical grounds (…) aligns it with many other medical interventions, including considerably more invasive and risk-bearing cosmetic interventions, that professionals conscientiously undertake, without censure” (Cook & Dickens 2009).

Indeed, as we have seen above, HP’s lack of medical necessity aligns it with cLP, which is carried out on a discretionary basis and is generally considered ethically acceptable. However, it also aligns it with FGC, a highly controversial operation, which many feel is highly unethical and in violation of a woman’s human rights whether it is performed medically or not (Cook et al 2002). It therefore seems reasonable to assume that the lack of medical necessity is not a decisive factor in the existing moral judgements regarding these operations, and cannot form the basis for a transfer of any moral conclusions between them. This doesn’t mean that medical necessity is morally irrelevant regarding HP: if other objections that health care professionals have raised against the operations are found to be valid, the lack of medical necessity may lend them more moral weight.

HP constitutes deceit

The second deontological objection I will consider is the claim that HP constitutes deceit: health care professionals could be accused of colluding with patients to deceive their future husbands and their extended families (Raphael 1998; Cook & Dickens 2009; Kopelman 2014). However, it may be untenable to hold that health care professionals who perform HP

are necessarily complicit in any deceit. First, due to the need for secrecy surrounding the operation, it is unlikely that health care professionals will be directly requested to divulge medical information to the husbands and the extended families of girls and young women requesting HP, in which case they do not directly deceive anyone themselves. Second, health care professionals may intend to protect girls and young women requesting HP from harm and merely foresee the potential deceit this may entail, and thereby act in accordance with the doctrine of the double effect. Third, some girls and young women request HP to feel “whole and pure” again (van Moorst et al 2012a), and have no current wedding plans, in which case no immediate deceit takes place. Fourth, some may never get married, in which case no deceit takes place. Fifth, some girls and young women who do have wedding plans may decide to confess their loss of virginity to their future husbands and/or extended families, in which case no deceit takes place. Finally, some girls may, like their Western counterparts, request HP for symbolic and/or recreational purposes, and with full disclosure to their husbands, in which case no deceit takes place. Therefore, it seems untenable to hold that health care professionals who perform HP are necessarily complicit in any deceit.

However, while it may be true that health care professionals are not necessarily complicit in deceit, it could be argued that in many if not most cases they are. Most girls and young women requesting HP do so with the explicit purpose of hiding their previous loss of virginity from their future husband on their wedding night. And as the health care professionals performing these operations are generally aware of this, it may be unhelpful to claim that they intend to protect their patients from harm and merely foresee the deceit this may entail. After all, it is by facilitating this deceit that they mean to protect the girls and young women requesting HP, and should the operation fail to further this goal, then surely they would not deem it successful. Therefore, we may need to concur that in many if not most cases health care professionals are complicit in the deceit that girls and young women requesting HP intend to perpetrate on their husbands and/or extended families.

On the other hand, it could be argued that health care professionals are neither required nor permitted to divulge information to the husbands and the extended families of girls and young women requesting HP. Although at least one author has claimed that it would “not be proper” to say that health care professionals have a duty to the patient alone and have no responsibility “for the morality of the patient’s relationship with her husband” as HP is “intimately concerned with that relationship”(Raphael 1998), I would argue that health care

professionals are bound by the principle of confidentiality regarding their patient, and not regarding her future husband and/or family (Paterson-Brown 1998; Cook & Dickens 2009; Loeber 2014b). First, the principle of confidentiality dictates that health care professionals may not divulge any information regarding their patients to anyone, no matter how close his or her relationship with the patient, unless the patient specifically allows it. Second, any intervention by health care professionals in the “morality” of a patient’s relationships with third parties would seem to be a serious violation of the right to privacy. Finally, showing respect for the autonomy and bodily integrity of their patient, and “removing irrelevant obstacles to (her) free choice”(Helgesson & Lynöe 2008) may be a positive duty of health care professionals seeking informed consent, and may override considerations of truthfulness towards third parties interested in controlling these aspects of the patient’s life. Therefore, it seems reasonable to conclude that health care professionals are neither required nor permitted to divulge information to the husbands and the extended families of girls and young women requesting HP.

Furthermore, we may need to qualify the severity of any potential deceit perpetrated by girls and young women undergoing HP against their future husbands and/or extended families. I would argue that in some cases, this deceit may be less morally objectionable than in others. First, a girl or young woman’s hymen may have ruptured before marriage due to sexual intercourse with the future husband (Cook & Dickens 2009), in which case the deceit only affects her extended family. Second, a girl or young woman’s hymen may have ruptured due to non-sexual causes, such as sporting activities or the use of tampons. Finally, a girl or young woman’s hymen may have ruptured due to rape, in which case:

“according to the ethic of justice, women should not forfeit their reputations for good moral character through the misfortune of being subjected to rape. Hymen reconstruction as part of rape rehabilitation disguises lost virginity, but can be consistent with victims' maintenance of personal virtue” (Cook & Dickens 2009).

As in none of these cases the girl or young woman has previously had consensual sexual intercourse with a man other than her future husband, it seems reasonable to conclude that in such cases the deceit is less morally objectionable than in cases where she has. If this is true, the potentially severe consequences the girl or young woman may suffer if it becomes known that she is no longer a virgin may be disproportionate to the moral objectionability of this

deceit. And once we allow that these consequences are disproportionate to the gravity of the deceit in cases in which the girl or young woman has not had previous consensual sexual intercourse with a man other than her future husband, it becomes untenable to claim that they are not equally disproportionate in cases in which she has. Therefore, the moral injustices that may befall girls and young women if they can’t “prove” their virginity outweigh the moral injustice of a deceit which is, in essence, a mere lie about their personal sexual history.

Preliminary conclusion regarding HP and deceit

It seems reasonable to conclude that the objection that HP is deceit does not constitute sufficient grounds for health care professionals to refuse to perform the operation. Although it could be argued that in many if not most cases health care professionals are complicit in the deceit patients intend to perpetrate on their future husbands and extended families, the principle of privacy prohibits health care professionals from divulging any information regarding their patients without their explicit permission, and the moral injustices that may befall girls and young women if they can’t “prove” their virginity outweigh the moral injustice of this deceit.

mFGC and deceit

As the physical alterations made by mFGC do not artificially simulate a naturally occurring state, and are more often than not carried out with the full knowledge and/or at the request of the woman’s future husband or extended family, mFGC cannot be said to constitute deceit.

cLP and deceit

Regarding cLP things may not be so clear-cut. On the one hand, it is untenable to hold that health care professionals performing cLP are complicit in any deceit women may perpetrate on third parties. HP aims to simulate virginity, which relates to a girl or young woman’s sexual history, and cannot be equated with a physical state. The operation mimics the physical consequences of the rupture of an intact hymen at first intercourse. However, this does not make the girl or young woman a virgin. No real alteration from non-virgin to virgin takes place. In contrast, cLP aims to alter the shape of a woman’s labia. This shape may

change over the course of time, but it is nevertheless a purely physical state. During the operation, a real alteration from one shape to another takes place. It could be argued that this new shape is not the original shape of the woman’s labia, but human bodies are constantly changing, and if this new shape is not used to lend credence a lie, imposing a surgical change does not in itself constitute deceit. And if a woman who has undergone cLP does afterwards use the new shape of her labia to lend credence to a lie and, for example, pretends to be younger than she is, it is untenable to hold that the surgeon who has performed the operation is complicit in this deceit.

Conclusion regarding deceit

Regarding HP, I have argued that although the operation may involve an element of complicity in deceit, this is outweighed by the principle of privacy and the moral injustice that may befall girls and young women if they are refused the operation. And I have concluded that therefore the objection that HP constitutes deceit fails to provide sufficient grounds for health care professionals to refuse the operation. However, as I have subsequently argued that mFGC and cLP do not involve any deceit at all, it seems reasonable to conclude that the analogies between HP and mFGC, and HP and cLP are dissimilar undermining ones: although the objection that the operation involves deceit is ungrounded with regards to mFGC and cLP, it is less so with regards to HP. And although this element of deceit that attaches to HP may not constitute sufficient grounds to refuse the operation, it may lend more weight to other arguments against HP, should these prove to be successful.

HP perpetuates gender inequality

Perhaps the most fundamental objection against HP is that, by helping girls and young women to conform to the virginity rule, which is actively enforced upon females but not upon males (Saharso 2003a; Kyrillou et al 2009), health care professionals who perform HP may perpetuate gender inequality (Lindisfarne 1994; Usta 2000; van Moorst et al 2012a). First, I will discuss the ethical viability of the virginity rule and to what extent it can be equated with HP. Subsequently, I will discuss the four interconnected concerns into which the claim that HP perpetuates gender inequality can be broken down. First, HP may violate girls and young women’s right to freedom from discrimination. Second, HP may violate their right to bodily

integrity. Third, HP may violate their right to autonomy and self-determination. And finally, HP may violate their right to protection of human rights by the state. If these claims are true, health care professionals may be justified in refusing to perform HP on the grounds that it perpetuates gender inequality.

The case against the virginity rule

There are many reasons to conclude that the virginity rule is ethically untenable. First, the unilateral enforcement of the virginity rule on one gender and not the other is discriminatory (Cindoglu 1997; Frank et al 1999), as it subjects girls and young women to rules and sanctions prohibiting the same kind of behaviour that it actively encourages in boys and young men. Second, the interference in the sexuality of adolescent girls and young women constitutes a severe breach of their privacy, personal autonomy and freedom (Frank et al 1999; Gürsoy & Vural 2003). Third, the virginity rule may be difficult to adhere to, and may put unfair pressure on girls and young women who grow up in the midst of a more permissive Western culture (Rademakers et al 2005), who generally get married at a later age than before (Eich 2010), who consequently may experience sexual longing or need long before the permitted context of marriage, and who, unlike boys, are not permitted to act upon this “irresistible passion” (Hendrickx et al 2002). Fourth, the virginity rule may lie at the root of the taboos prohibiting the discussion of sexuality in the family and of parents’ opposition against sex education in the school. This may cause migrant Muslim adolescents and young adults to be less well informed about sexuality than their indigenous Western European counterparts (Smerecnik et al 2010), and to possess an incomplete or incorrect knowledge of contraceptives, and HIV and other STD’s (Hendrickx et al 2002). Fifth, additionally, the virginity rule makes it virtually impossible for girls and young women to plan and/or buy contraceptives, leading to a higher prevalence of unwanted pregnancies and STD’s amongst migrant Muslim girls and women than amongst their indigenous Western-European counterparts. Sixth, the taboos prohibiting the discussion of sexuality in the family, and parents’ opposition against sex education in the school, combined with the virginity rule that prohibits girls and young women from exploring and developing their sexuality in a free and open manner, may cause psychological harm and have a long lasting effect on the way they deal with their own bodies and their sexuality. Seventh, in Western-European culture, sex before marriage is generally considered normal, and allows partners to get to know and trust each other and to find out whether they are sexually and emotionally compatible. Going into

a marriage without that knowledge may lead to sexual frustration, trust and intimacy issues, and in the worst case, divorce (Smerecnik et al 2010). Eighth, the rise of HP requests in both Western European migrant Muslim communities and in their countries of origin, and the higher prevalence of unwanted pregnancies and STD’s amongst migrant Muslim girls and young women than amongst their indigenous Western-European counterparts, suggest that the virginity rule does not succeed in preventing premarital sex. Ninth, practices such as virginity examinations and “defloration” affirm male superiority (Lindisfarne 1994) and perpetuate patriarchal control over women’s bodies (Cindoglu 1997; Verhaar 1999). Tenth, the virginity rule objectifies and commodifies girls and young women and their virginity (Frank et al 1999), and makes their hymen into a “capital good” which is “ranked and valued along with other commodities” (Lindisfarne 1994). Eleventh, the virginity rule reduces girls and young women’s moral worth to their virginal status, and takes no account of their general behaviour and character (Eich 2010). Twelfth, the rationale behind the virginity rule, which construct women’s sexuality as dangerous and omnipotent (Cindoglu 1997), may lead to the justification of sexual violence as a girl is considered “far more responsible for rape than a boy” (BBC News - Delhi rapist says victim shouldn't have fought back, retrieved 4 March 2015). Thirteenth, fear of breaking the hymen during a medical intervention may delay necessary treatment for illness (Gürsoy & Vural 2003). Fourteenth, the practices to which girls and young women are subjected in order to ascertain their virginal status constitute a severe breach of bodily integrity (Frank et al 1999; Gürsoy & Vural 2003). Fifteenth, as we have seen above, there is no reliable, evolved or pre-ordained way to determine whether a girl or a young woman is a virgin or not, and the practices of virginity examinations and the “bloodied sheet” are therefore based on myth rather than fact. Sixteenth, as a consequence, girls and young women are at risk of being accused of having lost their virginity even if they are, in fact, still virgins. Seventeenth, the fear of being subjected to virginity examinations and having to expose themselves and be probed in their most intimate parts, of not being able to “prove” their virginity, and of the possible consequences if they can’t, may all lead to psychological consequences, including guilt, insecurity, loneliness, social isolation, identity problems, a distorted body image, conflicts with their parents, depression, despair, suicidal feelings (Bekker et al 1996; Gürsoy & Vural 2003). Eighteenth, unjustified belief in the possibility of deducing previous sexual intercourse from the state of the hymen perpetuates the use of virginity examinations to establish sexual assault trauma, a task for which their effectiveness has been disproved (Frank et al 1999). Nineteenth, the consequences brought to bear upon girls and young women if they fail to “prove” their virginity have included

expulsion from the family and/or the community, divorce or annulment of the marriage, lack of marital prospects, violent reprisals and even “honour killings” (Bekker et al 1996; Logmans et al 1998a; van Moorst et al 2012a) . Twentieth, the social pressure on the man to “perforate” the hymen, and on the girl or young woman to “prove” her virginity through vaginal bleeding, may turn their wedding night into a traumatic life event (Bekker et al 1996; van Moorst et al 2012a). Twenty-first, the virginity rule may put unfair pressure on Western girls and young women, as they may become the target for migrant Muslim boys and young men wanting to “learn and take advantage of them”, whilst at the same time looking down “on those girls who have sex and are not a virgin” (Hendrickx et al 2002). Finally, the use of the virginity rule as a means to maintain the coherence of the minority group may be discriminatory to members of other minority groups and/or the majority group. Therefore, it seems reasonable to conclude that the virginity rule is ethically untenable.

The political economy of the virginity rule

As some authors have illustrated, boys and young men may suffer negative consequences of the virginity rule too. Honour systems in general, and the virginity rule in particular, are said to aim at the control of women’s sexuality by men. However, it has been pointed out that both men and women can be empowered as well as disempowered by the customs surrounding the virginity rule, and that “the notions of honour and shame are not separate from the political economy” that governs differential access to social resources, status and power (Lindisfarne 1994). In honour and shame societies, men are expected to be physically and morally strong, and such men must be able to control the sexual behaviour of their “own” women. If they don’t, they are “preyed upon” by other men and “feminised” as “soft” or “weak”. A woman’s sexuality is “treated as an index of a man’s success or failure”, and a man’s dishonour is not just measured by her actions, but also by “those of men who (challenge) his authority as a surrogate father, brother and neighbour and (render) him socially impotent”. A man who is thus put under pressure to penetrate his virgin bride and “perforate” her hymen, sometimes whilst his friends and family wait downstairs for the “proof” of his manliness (Lindisfarne 1994), may suffer “fear, distress and erection problems” (Bekker et al 1996). If he fails to deflower his bride, he may need to be “helped by a friend or a proxy, a midwife, (his) mother and sometimes even (his) mother-in-law” (Lindisfarne 1994). Such failure may cast him in the role of a subordinate male, and obstruct his social mobility. On the other hand, a man who can demonstrate his “capacity for

penetrative sex with his virgin bride” may be cast in the role of a hegemonic male, with privileged access to social resources, status and power (Lindisfarne 1994). Women too, can be empowered as well as disempowered by the practice of defloration. If a women can demonstrate her husband’s “virility” and successfully “prove” her virginity, she is likely to gain her husband’s support, and privileged access to social resources, status and power. Both the man and the woman therefore have a vested interest in covering up a failure to deflower on the man’s part and/or a previous loss of virginity on the woman’s part (Lindisfarne 1994), and such “power couples” may conspire to fake the blood on the sheets in order to protect their social mobility.

However, I would argue that this does not mitigate the moral objectionability of the virginity rule. First, it seems unjust and cruel to base the social mobility of a newly wedded couple on their ability to produce blood loss on the wedding night, as it has been shown that this bleeding is sometimes solely caused by violent penetration damaging the vaginal wall (Raveenthiran 2009), forced sexual relations, lack of arousal or lubrication, (Essén et al 2010) and/or psychological factors such as fear (Bekker et al 1996). Second, it seems unjust to exert pressure on men to produce public proof of their capacity to penetrate their brides and deflower them, and to expose them to the scorn and ridicule, and the diminished access to social resources, status and power that befall subordinate males if they fail. Third, it seems unjust that women can be disempowered and have less access to social resources, status and power than other women, based solely on whether or not they (have been made to) bleed on their wedding night. Fourth, the common interest men and women may have in producing blood loss on the wedding night does not place women on an equal footing with men, as the potential consequences girls and young women may suffer if the blood loss can’t be produced arew more severe and last longer. Fifth, as boys and young men may not face equally severe and long lasting consequences, they may not be willing to conspire with their brides in covering up a failure to deflower or a previous loss of virginity. Finally, aside from the consequences they may suffer if they can’t produce blood loss, girls and young women may also be made to suffer the consequences of “inadvertently witnessing their husbands’ impotence”, which may be equally severe and have at times included murder (Lindisfarne 1994). Therefore, it seems reasonable to conclude that the fact that both men and women can be empowered as well as disempowered by the customs surrounding the virginity rule does not mitigate the moral objectionability of the virginity rule.

The cultural defence

Some may feel that aside from values such as gender equality, bodily integrity, autonomy and self-determination, the ethical discussion surrounding the virginity rule should also take values such as “cultural autonomy” into account (Verhaar 1999). In this view the custom may have to be respected, even if the “defloration-ritual” is “harsh and cruel”, as even rituals that are a challenge and an ordeal to the person undergoing them are said to command “respect for culture” (Verhaar 1999, my translation). Some may feel that in Western European countries the “white ethnic majority can have little insight into the cultural complexity” of migrant girls and young women’s lives (Webb 1998), and that non-Muslims “should keep out of the virginity discussion” (Bartels 2000). Though such claims may sound rather militant and exclusive, some may argue that the virginity rule is a cultural custom in which a liberal and tolerant society cannot intervene (Verhaar 1999). First, minority groups have the right to recognition and accommodation of their cultural identities (Okin 1999), and the virginity rule may represent a way for the migrant Muslim community to differentiate “the self from the other” (Peteet 2002; Eich 2010) and thereby retain its cultural identity (Bartels 2000). Second, the former expectation that minority groups integrate has come to be regarded as oppressive (Okin 1999), and the virginity rule may represent a way for the migrant Muslim community to resist integration and protect its internal cohesion and homogeneity. Finally, cultural groups may need to be protected from extinction, as they may form the fundamental context within which individuals can develop their sense of self-worth and make meaningful choices (Okin 1999), and the virginity rule may represent a way for the migrant Muslim community to protect their cultural group from extinction. Therefore, some may consider the virginity rule to be a cultural custom in which a liberal and tolerant society cannot intervene. And as individual rights may not suffice to protect the migrant Muslim community from social policies that may be perceived to interfere with the virginity rule, such as sexual education, public awareness campaigns, child protection services and others, a liberal state may need to officially assign group rights to allow members of this community to opt out of such policies.

However, there is no doubt that the virginity rule often comes at a great personal cost to the girls and young women upon whom it is enforced. The question then arises whether group rights can be invoked to accommodate cultural traditions like the virginity rule and inhibit any form of intervention by the majority group, even if these traditions violate the rights of

the girls and young women who are subjected to them (Saharso 2003b). I would argue that they cannot. First, group rights may be incompatible with liberal ideals (de Lora 2014), as these ideals consider the individual to be the basic moral unit and the bearer of individual rights and freedoms (Saharso 2003a). Second, group rights may conflict with other, more inclusive rights. UNESCO states in its Universal Declaration On Bioethics And Human Rights that “cultural diversity and pluralism should be given due regard” but should not be invoked to “to infringe upon human dignity, human rights, and fundamental freedoms” (Unesco, retrieved 10 March 2015). Third, group rights may also conflict with concerns regarding the safety and well-being of minors, and associations such as American Academy of Pediatrics have endorsed policies that rank the duty to protect minors higher than the duty to honour their parent’s religious or cultural views (Kopelman 2014). Fourth, groups need to guarantee internal liberalism in order to qualify for group rights, as the very reason for wanting to safeguard cultural membership by means of these rights is “that it allows for meaningful individual choice” (Kymlicka 1989). Consequently, “individual group members must be free to choose whether or not to follow tradition” (Saharso 2003b). Fifth, group rights may ignore internal differences within the group such as the fact that groups are gendered, and may attribute rights to boys and men that discriminate against girls and women, inhibiting them from living as freely chosen lives as they can, with equal human dignity (Okin 1999). Group rights must take such inequalities within the groups into account, and must adequately represent the “less powerful members of such groups” (Okin 1999). Sixth, group rights may ignore the private sphere, where “persons’ senses of themselves and their capacities are first formed”, where “culture is first transmitted”, where girls and young women spend more time, and where discrimination can “severely constrain their choices” and “seriously threaten their well-being and even their lives” (Okin 1999). Finally, group rights may thus result in subcultures of oppression, facilitated by the state, in which girls and young women may be “inhibited from questioning their inherited social roles”, and condemned to “unsatisfying, even oppressive lives” (Kymlicka 1995). Therefore, a liberal and tolerant society cannot extend group rights to accommodate the virginity rule and protect it from all intervention, as it fulfils none of the conditions and avoids none of the pitfalls listed above. So it seems that, at least as far as group rights is concerned, the cultural defence fails:

“In the case of a more patriarchal minority culture in the context of a less patriarchal majority culture, no argument can be made on the basis of self-respect or freedom that the female members of the culture have a clear interest in its

preservation. Indeed, they might be much better off if the culture into which they were born were either to become extinct (so that its members would become integrated into the less sexist surrounding culture) or, preferably, to be encouraged to alter itself so as to reinforce the equality of women - at least to the degree to which this value is upheld in the majority culture” (Okin 1999).

HP versus the virginity rule

As we have seen above that the virginity rule is ethically untenable, that possible (dis)empowerment of men as well as women does not mitigate its moral objectionability, and that a cultural defence that invokes group rights to defend the practice fails, it may seems reasonable to conclude that Western health care professionals should not perform the directly related HP operation. However, no matter how intimately entwined they may be, HP is a subject which is quite distinct from the virginity rule. And although the virginity rule may cause a conflict with health care professionals’ own values regarding “women, self- determination and sexuality” (Mouthaan et al 1997), by performing HP they are not condoning the virginity rule and the gender inequality that it entails (Verhaar 1999). First, most health care professionals who perform HP do so because of pragmatic considerations: to safeguard the girls and young women requesting the operation from the severe consequences they may suffer if they can’t “prove” their virginity (Verhaar 1999). Second, by performing HP, they may offer these girls and young women the possibility of partially circumventing the virginity rule, and of exploring and developing their sexuality with a degree of impunity. Third, HP may impart a degree of independence and confidence on these girls and young women that may in time influence their freedom of choice and their status in relation to their future husbands, their families and their communities. Fourth, HP is generally disapproved of by migrant Muslim communities upholding the virginity rule and forbidden in their countries of origin (Bartels 2000). Finally, HP may challenge and subvert the virginity norm (Saharso 2003a; Cook & Dickens 2009), rather than perpetuate it. Therefore, it seems reasonable to conclude that HP is a subject which is quite distinct from the virginity rule, and that by performing the operation, health care professionals are not condoning the virginity rule and the gender inequality that it entails. In what follows I will therefore focus on HP rather than on the virginity rule, and discuss whether or not it perpetuates gender inequality. That is, after all, the objection that is raised.

HP violates the right to freedom from discrimination

Many health care professionals have voiced the concern that HP may be a violation of girls and young women’s human rights, particularly the right to freedom from discrimination as stipulated by the Women’s Convention, and some feel that therefore they may have to refuse to perform the operation (Saharso 2003a; Cook & Dickens 2009; Kyrillou et al 2009). The UN Convention on the Elimination of All Forms of Discrimination against Women (‘the Women’s Convention’) defines discrimination as:

“… any distinction, exclusion or restriction made on the basis of sex which has the effect or purpose of impairing or nullifying the recognition, enjoyment or exercise by women, irrespective of their marital status, on a basis of equality of men and women, of human rights and fundamental freedoms”(Assembly 1979).

Following this definition, the one-sided virginity rule and the severe consequences that may befall a girl or young woman if she fails to meet it are clearly discriminatory. However, regarding HP, concerns regarding sexual inequality may lead to two opposite positions. On the one hand, health care professionals may refuse to carry out the operation, because they feel HP is discriminatory in itself and/or perpetuates the discriminatory practices surrounding the virginity rule. On the other hand, they may agree to carry out the operation because they feel that their concerns regarding sexual inequality are outweighed by the severity of the consequences girls and young women may suffer if they are refused the operation (Verhaar 1999). I will argue below that HP does not violate girls and young women’s human rights, and that health care professionals should not refuse to carry out the operation on those grounds. First, HP is not discriminatory in itself. Second, it is not clear whether HP will perpetuate the discriminatory practices surrounding the virginity rule, subvert them, or indeed affect them at all. Third, the consequences girls and young women may suffer if they can’t “prove” their virginity outweigh any remaining concerns regarding possible discriminatory aspects of HP.

HP is not discriminatory in itself

I would argue that the idea that HP is discriminatory is untenable. Although only girls and young women and not boys and young men are subjected to surgery in order to comply with

the virginity rule, this discriminatory aspect does not attach to the operation itself. First, health care professionals carry out the operation on the explicit request of the girls and young women themselves. Second, by providing a fall-back solution for unmarried girls and young women who want to enjoy, explore and develop their sexuality, but do not want to give up their place within their community, the availability of the operation may at least partially reduce gender discrimination. Third, similarly, by providing a way out for unmarried girls and young women who have already lost their virginity, and helping them to avoid the consequences that may befall them, the operation may at least partially reduce gender discrimination. Therefore, it seems reasonable to conclude that HP is not discriminatory in itself, and may instead protect girls and young women requesting the operation against at least some of the discriminatory practices surrounding the virginity rule. Instead, the discriminatory aspects of HP needs to be traced back to the communities that enforce the virginity rule on girls and young women only and thereby cause them to request the operation.

HP does not perpetuate discriminatory practices

I would argue further that the idea that HP perpetuates discrimination against women is also untenable, as it is not clear which if any effect HP may have on the virginity rule. First, the claim that HP may perpetuate discriminatory practices is based on the idea that the availability of the operation would lead to an increase in the number of girls and young women who bleed on their wedding night, and would thereby falsely affirm the reliability of blood loss as proof of virginity. However, it is unlikely that HP would in fact lead to such an increase, because as we have seen above, the operation is often unsuccessful in producing blood loss, and studies seldom report a ratio of success that is higher than the ratio of virgins that bleed naturally on their wedding night. Second, it is equally unlikely that the refusal to perform HP would prevent an increase in the number of girls and young women who bleed on their wedding night, as they may turn to alternative - and perhaps more successful - methods of mimicking blood loss. Third, the refusal to perform HP is based on the idea that making the operation unavailable would lead to a decrease in number of girls and young women who bleed on their wedding night, thereby subvert the reliability of blood loss as proof of virginity, and ultimately lead to the abandonment of the virginity rule. However, despite the absence of reliable data regarding the prevalence of HP, it seems reasonable to assume that only a small subgroup of migrant Muslim girls and young women have it

performed, and as only a subgroup of this subgroup may bleed as a result of the operation, any decrease in the total number of brides who bleed on their wedding night caused by making the operation unavailable is bound to be small. Fifth, the virginity rule may remain unaffected even if the refusal to perform HP did lead to a noticeable decrease in the number of girls and young women who bleed on their wedding night, as this may fail to subvert the reliability of blood loss as proof of virginity: the mistaken idea that all virgins bleed on the wedding night has survived for hundreds of years despite blood loss at first intercourse occurring naturally in only about half of the female population. Fifth, the virginity rule may remain unaffected even if the refusal to perform HP did lead to a noticeable decrease in the number of girls and young women who bleed on their wedding night, and this did cast doubt on the reliability of blood loss as proof of virginity, as there are other factors such as “tightness” which may replace the means by which girls and young women are expected to “prove” their virginity. Sixth, the virginity rule may be subverted rather than perpetuated by HP, as public knowledge of the availability of HP may cast more doubt on the reliability of blood loss as proof of virginity than a possible decrease in the number of girls and young women who bleed on their wedding night. Seventh, public knowledge of HP may intensify the discriminatory effects of the virginity rule, as increased doubt regarding the reliability of blood loss as proof of virginity may lead to increased fervour in the policing and sanctioning of girls and young women, and an even greater violation of their right to freedom from discrimination. Finally, HP may diminish the discriminatory effects of the virginity rule, as it may offer girls and young women a means of partially reducing the consequences of discrimination and - to a degree - making their life choices more freely and equally. This may allow them to develop more confident and strong personalities, which may lead to a change in their relationships with their partners and families. In time, this may lead to a change in their community’s moral stance regarding sexuality in general, and premarital virginity specifically. Therefore, it seems reasonable to conclude that the claim that health care professionals, by performing HP, perpetuate discrimination against women is untenable, as it is not clear whether HP will perpetuate the discriminatory virginity rule, subvert it, or have any long-term effect on it at all.

The consequences of not bleeding outweigh any discriminatory aspects of HP

I would argue further that preventing the consequences that girls and young women may suffer if they can’t “prove” their virginity does indeed outweigh any remaining concerns

regarding possible discriminatory aspects of HP. First, some of these consequences represent a severe and immediate threat to the health and well-being of the girls and young women requesting HP, whereas the operation itself does not, as we have seen above. Second, HP in fact offers immediate protection against this threat, whereas the hypothesis that refusing the operation may eventually eliminate it by subverting the virginity rule does not. Third, protecting the health and wellbeing of actual girls and young women in the present outweighs protecting the health and wellbeing of hypothetical girls and young women in the future (Saharso 2003a). Fourth, health care professionals have an ethical duty towards their individual patients, rather than to the “abstract group of ‘women’ “ (Verhaar 1999, my translation), and should not fight an ideological battle at the expense of actual suffering. Finally, as most girls and young women who request HP do so to avoid the possibly severe consequences of not being able to “prove” their virginity, and as these consequences are themselves discriminatory, it seems reasonable to assume that they themselves feel that any possible discriminatory aspects that attach to HP are outweighed by the discriminatory aspects that attach to the virginity rule. Therefore, it seems reasonable to conclude that preventing the consequences girls and young women may suffer if they can’t “prove” their virginity does indeed outweigh remaining concerns regarding possible discriminatory aspects of HP.

Preliminary conclusion: HP and the right to freedom from discrimination

First, HP is not discriminatory in itself, and may instead protect girls and young women against many of the discriminatory practices surrounding the virginity rule. Second, the idea that health care professionals, by performing HP, perpetuate discrimination against women is untenable, as it is not clear which, if any effect HP may have on the virginity rule. Third, protecting girls and young women requesting HP from the consequences they may suffer if they can’t “prove” their virginity outweighs any remaining concerns regarding possible discriminatory aspects of HP. Therefore, it seems reasonable to conclude that HP is not a violation of girls and young women’s right to freedom from discrimination, and that health care professionals should not refuse to perform the operation on those grounds.

Is mFGC discriminatory in itself?

There are several factors that support the objection that FGC is a violation of women’s right to freedom from discrimination. First, FGC is an invasive and at times violent procedure; it imposes irreversible changes on girls and women’s bodies; it has possibly severe “physical, psychological and sexual complications” (Logmans et al 1998a); and boys and men are generally not subjected to genital cutting, and those who are may be subjected to a less severe form of cutting such as male circumcision. Second, the subjection of girls and women to this practice, which prepares them for “the use, pleasure and/or proprietary control of a man” (Cook & Dickens 2009), may confirm a lack of equality and a subordination to men. Finally, the sexual consequences of the practice may deny them the right to enjoy sexual satisfaction. If these claims are true, it seems reasonable to conclude that FGC is a violation of women’s right to freedom from discrimination.

On the other hand, it could be argued that not all forms of FGC violate this right. First, some have claimed that “genital alteration is a rather poor example of gender inequality” (Shweder 2002). The invasiveness and potential violence of the procedure may depend on the extent of the cutting and the circumstances in which it occurs; the bodily alterations may be considered an essential part of their personhood by the girls and women themselves; the “physical, psychological and sexual complications” (Logmans et al 1998a) may be less severe and wide-spread as is generally assumed and may need to be offset against the consequences of not having the procedure; and “very few cultures, if any” perform genital alterations on girls but not on boys, and some of these alterations of boys’ genitals involve major modifications such as splitting of the penis along the line of the urethra (Shweder 2002). Second, some have claimed that FGC may also be “a rather poor example of patriarchal domination”, as there is great variation between the different communities that uphold FGC, and whilst some are patriarchal, others are not. Furthermore, female genital alterations are said to be “almost always controlled, performed, and most strongly upheld by women” who are “not particularly inclined to give up their powers or share their secrets” (Shweder 2002). Finally, as we have seen above, some studies claim that FGC is not incompatible with sexual enjoyment (Obermeyer 1999) and that women who have undergone the procedure “continue to be orgasmic” (Edgerton & Mau 1989), and there is no solid evidence to support the claim that FGC denies women the right to enjoy sexual satisfaction. If

these claims are true, it could be argued that there may be some forms of FGC that don’t violate women’s right to freedom from discrimination. At the very least, these opposing views suggest that the claim that FGC is a violation of women’s right to freedom from discrimination may need to be qualified: although it may be justified in some cases, it may not be in others, depending on the type of FGC, the circumstances in which it is performed, and the cultural background of the women on whom it is performed. Unfortunately, it is unclear where on this scale mFGC is situated. On the one hand, mFGC may guarantee that the operation is painless, prevent at least some of the physical, psychological and sexual complications of tFGC, and allow women to conform to the prescripts of their culture on their own terms. On the other hand, mFGC remains an invasive procedure, may not prevent all of the physical, psychological and sexual complications of tFGC, and may still function as a means by which girls are prepared for a subordinate role under the control of men. Therefore, it seems reasonable to conclude that the claim that mFGC violates women’s right to freedom from discrimination is not without merit, and that proponents who support the medicalization of mFGC do so in spite of this ambiguity.

Does mFGC perpetuate discriminatory practices?

On the one hand, proponents of mFGC claim that the medicalization of FGC reduces harm now, and may ultimately lead to its abandonment (Shell-Duncan 2001). There has been at least one claim, by a local female activist, that mFGC may help end the practice of tFGC in a matter of years (Tenoi 2014). On the other hand, the World Health Organisation argues that there is no evidence supporting this claim, and that quite to the contrary, mFGC may perpetuate FGC (World Health Organization 2011). Opponents of mFGC have argued that medicalization may be seen as legitimising FGC (Pearce & Bewley 2014), and some suggest that local women may not have the power to convince other community members to abandon the practice (Shell-Duncan 2001). As these views are diametrically opposed; as there is no reliable data available that can help decide the issue one way or the other; and as it is unclear to what extent mFGC violates women’s right to freedom from discrimination; it could be argued that, in the absence of empirical evidence, the claim that mFGC perpetuates discriminatory practices is untenable. It is not clear whether mFGC will perpetuate the practices associated with FGC, subvert them, or have any long-term effect on them at all.

The consequences of refusing mFGC versus its discriminatory aspects

That said, it could be argued that the consequences of not performing mFGC are less desirable than its possible discriminatory aspects. First, as we have seen above, the medical complications and psychological consequences of tFGC are potentially severe, and many of them may be prevented by offering mFGC as a safer alternative. Second, as mFGC may guarantee that the operation is painless, may prevent at least some of the physical, psychological and sexual complications of tFGC, and may allow women to conform to the prescripts of their culture on their own terms, the medicalised operation is likely to be less discriminatory than its traditional counterpart. Finally, it is unclear whether mFGC will perpetuate the discriminatory practices associated with FGC or subvert them, or have any long-term effect on them at all, and preventing real harm now outweighs the unsupported claim that refusing to perform mFGC will prevent potential harm in the future. Therefore, it could be argued that the consequences of not performing mFGC outweigh its possible discriminatory aspects.

The right to freedom from discrimination and cLP

Some may argue that the way women are portrayed in the advertising and the porn industries is discriminatory, and may be partially to blame for the rise in cLP request. However, I would argue that it doesn’t follow that cLP is discriminatory towards women. First, as women freely choose to have cLP, the operation is not unilaterally forced upon them. Second, it seems implausible to hold that refusing cLP will stop or diminish the publication of discriminatory images in the advertising and porn industries, and consequently the operation cannot be said to perpetuate discriminatory practices. Finally, it has been pointed out that analogous operations for men, such as penis enlargements, are being advertised and carried out without censure (Cook & Dickens 2009). Therefore, cLP does not violate women’s right to freedom from discrimination

Conclusion regarding the right to freedom from discrimination

As cLP does not violate women’s right to freedom from discrimination, this objection cannot form the basis for a transfer of any moral conclusions from cLP to HP. In contrast, there may be reasons to conclude that an analogy between mFGC and HP, using the right to

freedom of discrimination as its sole relevant moral element, is a dissimilar reinforcing one. In both cases, it is unclear whether the operation will perpetuate the discriminatory aspects that may attach to the practice that it addresses. And in both cases, the consequences of not performing the operation may outweigh the risk that performing it may perpetuate that practice. However, whereas the objection that the operation may itself violate women’s right to freedom from discrimination is not without merit with regards to mFGC, it is untenable with regards to HP. Therefore, if this objection fails to provide sufficient grounds for health care professionals to refuse the operation in the case of mFGC, it fails to do so even more in the case of HP.

HP and the right to bodily integrity

A second concern regarding gender inequality is that HP may be a violation of girls and young women’s right to bodily integrity. The living human body is generally thought to have a higher moral value than that of non-living, vegetative or animal tissue, and “the extent to which it is morally acceptable to violate the integrity of one’s own body or that of some other person is fundamental to the practice and theory of medicine and health care” (Dekkers et al 2005). Health care professionals may feel that by performing HP, they are preparing a girl or young woman for “the use, pleasure and/or proprietary control of a man” (Cook & Dickens 2009), making them complicit in a violation of bodily integrity by proxy. Furthermore, they may feel that performing an invasive procedure upon the most intimate part of a woman’s body is itself a violation of her bodily integrity. To see whether these objections have any merit, we need to find out what the right to bodily integrity entails. In her paper Human Rights and Human Capabilities, Martha Nussbaum considers the pertinent goal of human rights to be “to make people able to function in a variety of areas of central importance” (Nussbaum 2007). She goes on to list ten “central human capabilities”, one of which is the right to bodily integrity, which she defines as follows:

“Being able to move freely from place to place; to be secure against violent assault, including sexual assault and domestic violence; having opportunities for sexual satisfaction and for choice in matters of reproduction” (Nussbaum 2007).

Following this definition, there may be ample reasons to conclude that the virginity rule violates girls and young women’s bodily integrity. First, girls and young women who are subjected to it are not able to move freely from place to place, as they are generally under intense scrutiny and social control. Second, they are not secure against violent assault, as they are more vulnerable to sexual abuse than their indigenous Western European counterparts, and are in danger of violent assault if they can’t “prove” their virginity. Third, their opportunities for sexual satisfaction and for choice in matters of reproduction are controlled and restricted by others. Finally, the right to bodily integrity includes the right to “self-control over the body” (Dekkers et al 2005), and the virginity rule, which requires women to refrain from premarital sex, intensive sports and tampon use, and demands that she bleed vaginally on her wedding night, seems to gravely violate that right. Therefore, it may be reasonable to conclude that the virginity rule violates girls and young women’s bodily integrity.

However, whereas the virginity rule may violate girls and young women’s bodily integrity, there may be ample reasons to conclude that HP does not. First, by helping girls and young women to avoid the consequences of not being able to “prove” their virginity on their wedding night, HP may enable them “to move freely from place to place; to be secure against violent assault, including sexual assault and domestic violence; (and to have) opportunities for sexual satisfaction and for choice in matters of reproduction”, thus restoring their “central human capabilities” (Nussbaum 2007) entailed by the right to bodily integrity rather than removing them. Second, the right to bodily integrity may include the right to anatomical and functional wholeness (Dekkers et al 2005), and as the purpose of HP is to restore the hymen so it can cause blood loss on the wedding night, the operation may restore this wholeness. Third, the right to bodily integrity may include the right to a subjective feeling of wholeness (Dekkers et al 2005), and some girls and young women request HP precisely in order to feel “whole and pure” again (van Moorst et al 2012a). Fourth, some health care professionals have claimed that by performing the operation, they support a women’s right to have control over her own body (Loeber 2014b). Fifth, although health care professionals would violate a woman’s right to bodily integrity if they performed HP at the request of third parties, such as her future husband or her family, they cannot be accused of violating this right if they perform HP at the request of the woman herself. Sixth, a breach of bodily integrity is permissible if it is done with the informed consent of the patient (Verhaar 1999). As the girls and young women requesting HP are generally young adult women or mature minors, this informed consent rule can in theory be met (Cook & Dickens 2009): if health care

professionals performing HP provide the necessary information and counselling in their intake process, the operation does not constitute an impermissible breach of bodily integrity. Finally, some women may have a pragmatic take on HP, and see it as a practical solution that allows them the freedom to explore their sexuality. If some girls and young women have premarital sex, knowing and accepting that this will mean their expulsion from the community (Verhaar 1999), then it seems reasonable to assume that others may look upon HP as an equally known and accepted, and perhaps less prohibitive consequence of premarital sex. Therefore it seems reasonable to conclude that HP does not violate a girl or young woman’s right to bodily integrity, and that health care professionals should not refuse to carry out the operation on those grounds.

mFGC and the right to bodily integrity

There are several reasons to conclude that tFGC is a violation of women’s bodily integrity. First, as the practice itself is often performed without consent; as it is often carried out with crude instruments, in unsterile conditions, without anaesthetic and by traditional, unskilled practitioners; and as it has a high risk of “physical, psychological and sexual complications” (Logmans et al 1998a); tFGC may tick all the necessary boxes to be classified as violent assault. Second, as the main motivation for tFGC is the social control of women’s sexuality (Cook et al 2002; World Health Organization 2011); as its concrete purpose is to reduce women’s desire in sexual intercourse; and as one of its consequences is a greater likelihood of diminished or absent sexual satisfaction and pain during intercourse (World Health Organization 2011); it follows that tFGC may permanently deny women opportunities for sexual satisfaction. Third, as tFGC may cause severe obstetric complications later on in life (Cook et al 2002; World Health Organization 2011); it follows that tFGC may deny women opportunities for choice in matters of reproduction. Fourth, the right to bodily integrity may include the right to anatomical and functional wholeness (Dekkers et al 2005), and as both the anatomical and functional wholeness of a women’s bodies may be compromised by tFGC; it follows that tFGC may deny women that right. Finally, as most of the girls undergoing tFGC are aged between four and ten; as they generally do not have access to adequate information and/or the capacity to understand that information; and as they are generally not given any choice in the matter; it follows that there is no informed consent. Therefore, it seems reasonable to conclude that tFGC violates women’s bodily integrity.

Regarding mFGC, we must allow that, although some of the problems listed above are partially or wholly addressed by the medicalization of the operation, the objections that it violates women’s bodily integrity is not without merit. First, although mFGC may prevent some of the potential physical, psychological and sexual complications, it may not prevent all of them. Second, mFGC may prevent some of the problems that may deny women opportunities for sexual satisfaction, such as pain during intercourse. However, it may not prevent all of them, as mFGC in most cases does not preclude removal of the clitoris, and clitoral stimulation is considered a key factor in female sexual satisfaction. Third, unless the extent of the cutting is purely symbolic, mFGC continues to deny women the right to anatomical and functional wholeness. Finally, for the purpose of the analogy I wish to draw with HP, I have delineated mFGC in such a way that it only includes operations freely chosen by mature girls or adult women, which presumes informed consent. However, there may be problems with the quality of this consent, and I will discuss these problems in the next section, when I discuss the right to autonomy and self-determination. Therefore, it seems reasonable to conclude that, although some of the problems listed above are partially or wholly addressed by the medicalization of the operation, the objections that it violates women’s bodily integrity is not without merit.

cLP and the right to bodily integrity

In contrast, there are several reasons to conclude that cLP does not constitute a violation of women’s bodily integrity. First, as the operation is carried out at the request of the patient, by skilled health care professionals, in sterile conditions, with anaesthetics, and with little risk, cLP cannot possibly be classified as assault. Second, it does not deny women opportunities for sexual satisfaction, and may in some cases, quite to the contrary, enhance them. Third, it does not deny women opportunities for choice in matters of reproduction. Fourth, although the operation may remove part of a woman’s labia, it doesn’t remove them completely. Rather than an alteration of the genitalia to an anatomical state that does not occur naturally, as is the case with removal of the clitoris or infibulation as part of FGC, cLP attempts to restore a more adolescent appearance to the labia. To claim that this constitutes a lack of wholeness would be unhelpful: we would not say that a person who has had a cosmetic operation reducing the size of their nose is no longer anatomically whole. Furthermore, cLP does not compromise women’s functional wholeness, and may in some cases even improve it. Finally, health care professionals performing the operation generally

go to great lengths to ensure informed consent and adequate counselling prior to surgery. And although it could be argued that there may be external factors contributing to a woman’s decision to undergo cLP, these factors are not of a coercive nature, as I will argue below. Therefore, it seems reasonable to conclude that cLP does not constitute a violation of women’s bodily integrity.

Conclusion regarding the right to bodily integrity

As cLP does not violate women’s right to bodily integrity, this objection cannot form the basis for a transfer of any moral conclusions from cLP to HP. In contrast, there may be reasons to conclude that an analogy between mFGC and HP, using the right to bodily integrity as its sole relevant moral element, is a dissimilar reinforcing one. As mFGC may cause some physical, psychological and sexual complications; as it may compromise women’s opportunities for sexual satisfaction; as it may deny women anatomical and functional wholeness; and as there may be problems with the quality of the consent; it follows that the objection that mFGC violates women’s right to bodily integrity is not without merit. If proponents of mFGC consider this violation to constitute insufficient grounds to refuse the operation, they do so because it reduces harm: women who live in communities that uphold the FGC tradition, and who are refused access to mFGC, are likely to undergo tFGC, and the violation of bodily integrity that attaches to that procedure is significantly more severe. Therefore it seems reasonable to conclude that the analogy between mFGC and HP, using the right to bodily integrity as its sole relevant moral element, is a dissimilar reinforcing one. Although both mFGC and HP reduce the violation of bodily integrity caused by respectively tFGC and the virginity rule, mFGC may itself violate bodily integrity whereas HP does not, and if the objection that the operation violates women’s right to bodily integrity fails to provide sufficient grounds for health care professionals to refuse it in the case of mFGC, it fails to do so even more in the case of HP.

HP and the right to autonomy and self-determination

A third concern regarding sexual inequality is that HP may be a violation of girls and young women’s right to autonomy and self-determination. Article 12(1) of the Women’s Convention states that women should enjoy “on a basis of equality of men and women,

access to health care service” (Assembly 1979), and the right to autonomy and self- determination suggests that decisions that competent women, adolescent females and mature minors make regarding their own bodies and medical treatment should be respected, “even when others, including women, disagree” (Cook & Dickens 2009). However, some may argue that girls and young women who grow up and live in deeply patriarchal “shame” cultures are limited in their autonomy and would not request HP voluntarily (Verhaar 1999; Saharso 2003b). In this view, HP is a “forced choice” made by “brainwashed” victims of cultural traditions (Saharso 2003b). I would argue that HP does not violate girls and young women’s right to autonomy and self-determination, and that health care professionals should not refuse to carry out the operation on those grounds. First, girls and young women requesting HP may have other options available to them. Second, HP may enhance rather than diminish their autonomy and self-determination. Third, HP may in some cases be an expression of autonomy and self-determination. Finally, the dichotomy between free choice and coercion may be problematic.

HP is not the only option

As girls and young women independently contact health care professionals to request HP, and take great care to hide this from their future husbands, their families and their community in general, it seems reasonable to conclude that they have made an independent choice to do so. The implication of the claim that HP violates their right to autonomy and self- determination must therefore be that the virginity rule, and the consequences they may face if they fail to live up to it, are so prohibitive and severe that they have no other choice than to request HP (Verhaar 1999). I would argue that several other options may in fact be available to them. First, girls and young women requesting HP can resort to an alternative, less invasive method to fake blood loss, as we will see below. Second, some girls and young women may be able to persuade their family to accept that they are not virgins, and look for a solution within their community, such as marrying an “inferior” match (Bekker et al 1996). Third, some women may be able to persuade their future husbands to accept that they are not virgins, and secure their complicity in hiding that fact from their families. Fourth, some girls and young women may be able to get their families to accept that they marry non-Muslim husbands for whom virginity is not an issue. Finally, girls and young women who can’t find a solution within their community can choose to break with their community, a solution which may be difficult and undesirable, but which in Western-European countries is nevertheless

possible (Verhaar 1999). Therefore, it seems reasonable to conclude that, even though some of these options may not be very desirable, girls and young women requesting HP may in fact have several other options available to them.

HP may enhance rather than diminish autonomy and self-determination

In a just society, individual freedom cannot be absolute, as it must be delineated by the right of others to enjoy the same freedom. Autonomy is therefore necessarily a matter of degree, and individuals enjoy more autonomy if more options are available to them. By offering girls and young women subjected to the virginity requirement a different and perhaps more desirable option than the ones listed above, HP may enhance rather than diminish their autonomy and self-determination. First, HP may give them more confidence than alternative methods for faking blood loss. Second, it may prevent them from damaging their relationships with their families and their future husbands. Third, it may prevent them from having to choose future husbands in function of their lost virginity. Fourth, it may allow them to stay within their community. Finally, it may allow girls and young women to explore their sexuality, which may increase their self-confidence and their self-awareness and leave them better equipped to make autonomous choices. Therefore, it seems reasonable to conclude that the availability of HP enhances rather than diminishes autonomy and self- determination.

HP can be an expression of autonomy and self-determination

A stronger interpretation of the objection that HP violates girls and young women’s right to autonomy and self-determination may be that although it allows girls and young women subjected to the virginity rule some degree of freedom, it ultimately situates female sexuality firmly “within the limits of patriarchal expectations” (Cindoglu 1997). In this view, proponents of the operation may implicitly accept the lack of autonomy and self- determination that women suffer within patriarchal communities. For example, one of the arguments in favour of HP suggests that some women have been “talked into sex” by the promise of marriage, only to be abandoned shortly after, and thus shouldn’t be made to suffer the consequences (van Moorst et al 2012a). The underlying assumptions of this view paint the woman as a victim: a woman who has premarital sex is believed to do so for love, not to satisfy lust; she gives a man her virginity and in return expects him to marry her; if he doesn’t

she has been cheated and is considered a passive victim of an unfair exchange; therefore she must be allowed to have HP. This argument may be an adequate description of the concrete situation that some of the girls and young women that request HP find themselves in, but I would agree that it “implicitly accepts differential access to social power”. Although it endows women with a certain amount of agency, “this agency is constructed within a patriarchal framework in which men have power over women and their bodies” (Eich 2010). However, I would argue that within such a framework, HP may represent a valid social strategy, and we may need to regard girls or young women’s requests for HP as “the manifestation of women’s demand for control over their own bodies” (Cindoglu 1997). It has been pointed out that the objections that Western health care professionals raise against HP may result from a “limited imagination” regarding the choices that women from other cultures make with respect to “cultural or religious customs” (Verhaar 1999, my translation). If we allow for these cultural and/or religious differences, there may be good reasons why an HP request can, at least in some cases, constitute an expression of autonomy and self- determination. First, though some Muslim girls and young women may reject the virginity rule, some attach importance to it themselves (Verhaar 1999). Second, though the virginity rule is said to perpetuate gender inequality, migrant Muslim girls and young women may have different views regarding what constitutes equality or inequality between men and women (Verhaar 1999). Third, even if these girls and young women consider the virginity rule to be a double standard themselves, it does not necessarily follow that they reject it as a moral requirement (Verhaar 1999). Fourth, “incomprehensible beliefs” and “bad choices” that we don’t consider to be in the interest of the person making them, and that to us seem discriminatory towards women (Verhaar 1999, my translation) do not allow us to conclude that the person holding these beliefs and making these choices does not do so autonomously. Fifth, Muslim girls and young women may differ greatly amongst themselves in the meaning and value they attach to the virginity rule and “defloration”. I would argue that, as has been noted in the context of the headscarf debate, these customs “can take on many meanings”. One such interpretation may be “gender inequality” (Saharso 2003b), however, other interpretations may include empowerment. Some have argued that by “restoring” her virginity, a girl or young woman living in a patriarchal community “re-establishes her assets” (Cindoglu 1997), gains “privileges and social precedence” (Lindisfarne 1994), and demonstrates “increased agency and authorship (Cinthio 2014). Sixth, as we have seen, girls and young women requesting HP often do so to regain control of themselves and their lives after traumatic events, suggesting that at least for some, requesting HP represents a

reaffirmation of autonomy rather than a loss of it. Finally, migrant Muslim girls and young women have a right to their own cultural values and opinions (Verhaar 1999), and can’t reasonably be excluded from society’s moral reasoning (Saharso 2003b). Therefore, it seems reasonable to conclude that an HP request can, at least in some cases, constitute an expression of autonomy and self-determination.

The dichotomy between free choice and coercion is problematic

An even stronger interpretation of the objection that HP violates girls and young women’s right to autonomy and self-determination may be that migrant Muslim girls and young women request HP due to oppressive socialisation and that consequently, this must be regarded as a coerced choice . In this view, Muslim girls and young women have internalised the ideas forced upon them by a patriarchal society, and had they not been indoctrinated in this way, they would not request HP voluntarily. However, this objection may itself be incumbent on human rights that, though thought to be universal in theory, may be subject to different interpretations in their practical application. People’s assumptions and convictions, their thoughts and ideas, their likes and dislikes, and the choices they make on the basis of those preferences, are at least partially shaped by their interaction with their social environment. And it is clear from the existence of many different cultures around the world that this social environment, when it comes to moral customs and convictions, comes in many shapes and forms. Consequently, the right to autonomy and self-determination may itself be subject to different interpretations (Alvarez 2009), and it may follow that the dichotomy between free choice, commonly associated with Western-European women, and coercion, commonly associated with migrant Muslim women, is problematic (Saharso 2003b). First, the free choice / coercion dichotomy assumes that Western-European women are fully autonomous (Saharso 2003b), and ignores the social constraints that may be present in Western-European society. Second, it neglects the complexity of women’s agency in oppressive cultures (Saharso 2003b), which may include developing different strategies to negotiate the patriarchal constraints that are imposed upon them (Cindoglu 1997). Third, it fails to take into account that Western-European and migrant Muslim women’s conditions for autonomy and self-determination may differ greatly, and that the right to autonomy and self- determination must endow both with the freedom “to make the choices they feel are in agreement with their culture” (Saharso 2003a). Fourth, individuals are at least partially “constituted by the family and community relationships in which they participate” (Saharso

2003b), and migrant Muslim girls and young women participate in the more permissive Western European culture as well as in the migrant Muslim community’s culture. As a consequence, the trajectory of premarital sex and hymen repair may reflect an autonomous choice made by girls and young women who have access to the possibilities afforded by both cultures, and choose which aspect of each culture they wish to accept, and which aspect they wish to reject. Finally, it has been pointed out that a lack of right to autonomy is not the same as a lack of capacity for autonomy (Saharso 2003b), a claim which is corroborated by the very fact that migrant Muslim girls and young woman request HP even though the practice is widely condemned within their culture and illegal in their countries of origin (Cindoglu 1997; Prakash 2009). Therefore, it seems reasonable to conclude that, in spite of oppressive socialisation, we need to regard the request to undergo HP made by migrant Muslim girls and young women as a free choice rather than a coerced one.

Preliminary conclusion: HP and the right to autonomy and self-determination

Although the virginity rule clearly violates girls and young women’s right to autonomy and self-determination, there are good reasons to conclude that HP does not. First, although some of the alternative choices may not be very desirable, HP is not the only choice available to girls and young women trying to solve the problems arising from their loss of virginity. Second, as HP may offer them yet another and perhaps more desirable option, it enhances rather than diminishes girls and young women’s autonomy and self-determination. Third, in spite of seeming to situate female sexuality within the limits of patriarchal expectations, the choice to have HP can, at least in some cases, be an expression of autonomy and self- determination. Fourth, in spite of oppressive socialisation, we need to regard migrant Muslim girls and young women’s request to have HP as a free choice rather than a coerced choice. Therefore, it seems reasonable to conclude that performing HP does not violate girls and young women’s right to autonomy, and that health care professionals should not refuse to perform the operation on these grounds (Saharso 2003b).

mFGC and the right to autonomy and self-determination

It has been argued that mFGC should be granted to adult women when it concerns a “genuinely voluntary” demand, made by an adult female, “based on deeply held moral beliefs” (Parekh 2002). In this view, the right to autonomy and self-determination implies

that women must be allowed to “make the choices they feel are in agreement with their culture (Saharso 2003a), and a refusal to grant their request for mFGC violates that right.

However, there may be good reasons to conclude that whereas HP does not violate women’s right to autonomy and self-determination, things may not be so clear-cut with regards to mFGC. First, the alternative options open to women living in communities that practice FGC may be fewer, and may be limited to remaining in the community as a virtual outcast, or stepping out of the community. Second, adding mFGC to the available options may not enhance women’s autonomy, as the choice of how to be cut and to what extent is likely to remain dependent on the prescripts of the community. Third, whereas it could be argued that HP allows girls and young women to secretly circumvent some of the prescripts of their community that violate their right to autonomy and self-determination, mFGC does not, and can thus not be regarded as an expression of autonomy and self-determination. Therefore, it may be reasonable to conclude that, although it could be argued that the right to autonomy and self-determination dictates that mFGC should be granted to adult women who give informed consent, the objection that mFGC violates women’s right to autonomy and self-determination is not without merit.

cLP and the right to autonomy and self-determination

Whereas HP and mFGC are operations that have been created to reduce the potential harm caused by non-Western cultural practices, cLP is just one item on a long list of Western life-style operations that have been designed to allow women to escape the randomness of nature and the ravages of time, and choose what they want their bodies to look like. It may therefore seem strange to suggest that the cLP may violate women’s right to autonomy and self-determination. There are many life-style options open to a Western woman, including the option not to have cosmetic surgery. The availability of cLP adds another option to her list, and the choice to have the operation performed can be an expression of autonomy and self- determination whether she means to enhance her natural appearance or to restore her lost youth. And as there is generally no coercion involved in a woman’s choice to have cLP, it seems reasonable to conclude that the operation does not violate her right to autonomy and self-determination.

However, it may be necessary to qualify this conclusion. At first glance, it may seem that a Western woman’s choice to have cosmetic surgery is more truly free than a non-Western girl or young woman’s choice to have HP or mFGC . However, some have claimed that this is due to a “double standard” (Essén & Johnsdotter 2004), as any cultural belief system “can change perceptions about normal anatomy and acceptability” (Cain et al 2013), and it could be argued that the cultural practices of Western societies that lead some women to request cLP may be just as influential as those that lead non-Western women to request HP or mFGC:

“Media-driven representation of sexually desirable traits (e.g. adolescent vulva) that do not represent the full range of normal anatomic variation is arguably just as coercive for vulnerable women seeking to be desirable to their present or future partners. Who defines ‘normal’ and how it is defined in terms of both anatomy and sexual function are important, and a responsibility that all health care professionals carry to ensure that women’s health rights are fully respected” (Cain et al 2013)

It has been pointed out that the “increased visibility of the vulva” (Rogers 2014), generally presented in “highly selective images” (Lloyd et al 2005) as “lacking any imperfection” (Renganathan et al 2009), has led to “skewing of societal perceptions” of what constitutes “normal” female genitalia (Cain et al 2013). In Western culture, the idealised image of the vulva seems to be “light skinned with a small clitoris, no hair, with a non-gaping introitus, characteristics which are said to be “shared with prepubescent girls” (Rogers 2014). Some have pointed out that the marketing of an “ideal” labial appearance may be “just another form of exploiting the social vulnerability of women” (Rogers 2014). If these claims are true, we may have to admit that Western women are also subject to socialisation, and that this socialisation may play a part in some women’s decision to have cLP.

Nevertheless, I would argue that this does not put the autonomy of a Western woman’s choice to have cLP on the same footing as a non-Western woman’s choice to have HP or mFGC. First, whereas women requesting cLP may be conforming to an idealised image, women requesting HP or mFGC are conforming to a social rule. Second, as a consequence the socialisation that may occur due to idealised images of adolescent-looking vulva in the media is less up close and personal than the socialisation that occurs with regards to the virginity rule and FGC. Finally, whereas Western women are generally not coerced into

requesting cLP, the consequences that may befall girls and young women growing up in communities that uphold the virginity rule or FGC are potentially severe and may indirectly coerce them into requesting HP or mFGC. Therefore, it seems reasonable to conclude that, although Western women requesting cLP may also be subject to socialisation, this socialisation is of a less compelling nature than it is in the cases of HP and mFGC.

Conclusion regarding the right to autonomy and self-determination

Regarding mFGC, it could be argued that the right to autonomy and self-determination dictates that a genuinely voluntary request by and adult woman to undergo the operation should be granted, and that refusing to perform the operation may constitute a violation of that right. However, as there may be fewer other options open to women requesting mFGC than to girls and young women requesting HP, it seems reasonable to conclude that the objection that mFGC violates women’s right to autonomy and self-determination is not entirely without merit, and that the analogy between mFGC and HP with the right to autonomy and self-determination as its sole relevant moral element is a dissimilar reinforcing one. If the objection that the operation violates the right to autonomy and self-determination fails to provide sufficient grounds to refuse the operation in the case of mFGC, then it fails to do so even more in the case of HP.

Regarding cLP, I have argued that the operation does not violate women’s right to autonomy and self-determination. This aligns cLP with HP, which unlike the virginity rule is congruent with this right. However, I have also argued that, although Western women requesting cLP may be subject to socialisation, this socialisation is of a less compelling nature than it is in the case of HP. Consequently, we may have to allow that the analogy between cLP and HP with the right to autonomy and self-determination as its sole relevant moral element, is a dissimilar undermining one. Although the socialisation that may attach to women’s requests fails to provide sufficient grounds for health care professionals to refuse the operation in both cases, it is even less problematic in the case of cLP.

Right to protection of human rights by the state

If human rights conventions are to be of any real value it seems reasonable to expect that the countries that commit to them actively protect these rights. Following Article 2(e) of the Convention on the Elimination of All Forms of Discrimination Against Women, these countries are required to “take all appropriate measures to eliminate discrimination against women by any person, organisation or enterprise” (Assembly 1979), and governmental health authorities and medical associations should collaborate to “discourage procedures seen as discriminatory” (Cook & Dickens 2009). As all European countries have ratified or acceded to the Women’s Convention (List of parties to the Convention on the Elimination of All Forms of Discrimination Against Women - Wikipedia, retrieved 6 February 2015), they should “undertake to put into place domestic measures and legislation compatible with their treaty obligations and duties” (retrieved 6 February 2015). As some authors have claimed that the availability of HP could hamper the public debate that “may end the virginity rule” (Saharso 2003a), and as the virginity rule discriminates against women, it could be argued that by making the operation legal and available, both the states that allows it and the health care professionals who perform it fail to protect the human rights of girls and young women who are subjected to the virginity rule and its possible consequences.

However, I would argue that prohibiting HP and/or denying girls and young women’s request to have the operation may not protect them against the human rights violations that surround the virginity rule. First, It is not clear that public debate regarding HP would in fact “end the virginity rule” (Verhaar 1999; Saharso 2003a). Although in Turkey, public debate regarding “virginity examinations” has led to their prohibition, this has not hindered them taking place illegally, nor has it had any impact on the continued importance of the virginity rule (Verhaar 1999). And as migrant communities often cling even more strongly to traditions in order to avoid alienation and maintain group coherence (Bekker et al 1996), it seems reasonable to assume that, similarly, public debate regarding HP may not necessarily lead to the disappearance of the virginity rule. Second, although some Muslim girls and young women reject the virginity rule, others embrace it. Many of them say they feel emotionally attached to their virginity, partially for moral and/or religious reasons, and partially because they want to please their parents. Even in more liberal Muslim communities, many girls still consider being a virgin on their wedding day valuable, lending further support to the idea that

public debate regarding HP may not necessarily lead to the disappearance of the virginity rule. Third, taking into account the strong embedment of the virginity rule in Muslim culture, there would need to occur a significant shift in public opinion in order to eradicate the potentially severe consequences that accompany it. Such a shift in public opinion may take a long time to accomplish, and HP is a relatively safe procedure that can prevent trauma and protect girls and young women’s mental and physical integrity in the meantime (Helgesson & Lynöe 2008; O'Connor 2008; van Moorst et al 2012a). Fourth, even if the refusal to perform HP could ultimately effect a societal change, it is hard to see how the state and/or health care professionals could justify making the girls and young women requesting HP “sacrificial instruments of eventual cultural reform”(Cook & Dickens 2009, my emphasis) whilst not solving the actual suffering of non-virgins now (Verhaar 1999). In doing so, they might be “fighting an ideological battle” in the interest of “future generations”, whilst ignoring the suffering of “real individuals” (Saharso 2003a). Finally, health care professionals are ethically and legally bound to act in the best interest of their patients. These patients are conceived of as individuals, and their rights are incumbent on that conception. The duty of a health care professional is therefore to each one of his patients as an individual, and not to the abstract category of “women” (Saharso 2003a). Therefore, it seems reasonable to conclude that prohibiting HP and/or denying girls and young women’s request to have the operation does not protect them against the human rights violations that surround the virginity rule. In fact, depriving the girls and young women of the possibility to have HP may increase their vulnerability to such violations.

mFGC and the right to protection of human rights by the state

Based on the evidence and experience of over three decades of work aimed at ending FGC, the World Health Organisation states that broad-based long-term commitment is needed if the human rights of potential victims of FGC are to be protected. Interventions need to support successful behaviour change and address core values and enforcement mechanisms that perpetuate the practice. Efforts must be made to encourage communities practicing FGC to lead and define programs and solutions themselves. Successful programs have been non- judgmental and non-coercive and have focussed “on a collective choice to abandon FGC” (World Health Organization 2011). Continued submission to FGC may often be due to social pressure rather than personal choice, and some projects have successfully drawn on “silent opposition” within groups by “encouraging opponents to speak out and engage their

communities in a debate on the subject” (World Health Organization 2011). At a national level, activities should “promote a process of social change that leads to a shared decision to end FGC”, and must include “traditional, religious and government leaders” (World Health Organization 2011).

Taking these findings into account, it could be argued that prohibiting mFGC and/or denying women’s request to have the operation may not protect them against the human rights violations that surround FGC. First, the WHO warns that the effectiveness of any law depends on “the extent to which it is linked to the broader process of social change” (World Health Organization 2011). Second, attempts to affect such a social change may remain unsuccessful or may take a long time before they come to fruition:

(FGC) is often connected with complex and dynamic meanings that might include reproduction, sexuality, personhood, power, religious identity and marriageability, and it is well recognised that efforts toward change must take into account the broader social meanings, and may take decades to take hold” (Shell- Duncan 2001).

Third, in the absence of a social change regarding FGC, prohibition of mFGC may drive the practice underground and cause women to be subjected to tFGC. Fourth, although the claim that mFGC is a violation of women’s human rights in not without merit, it is a lesser violation of those rights than tFGC. Fifth, neither the state nor health care professionals can reasonably justify choosing a more severe violation of human rights over a lesser one in order to affect a social change. Sixth, it is unclear whether prohibiting and/or refusing mFGC would eventually lead to a social change regarding FGC. Finally, as I have argued above, health care professional are ethically bound to serve the best interests of their patients, rather than those of the abstract category of “women” (Saharso 2003a). Therefore, it could be argued that prohibiting mFGC and/or denying women’s request to have the operation does not protect them against the human rights violations that surround FGC.

cLP and the right to protection of human rights by the state

I have argued above that cLP does not violate women’s right to freedom from discrimination, their right to bodily integrity, or their right to autonomy and self-

determination. Therefore, cLP does not violate women’s human rights, and cLP must not be prohibited or refused on the basis of that objection.

Conclusion regarding the right to protection of human rights by the state

It could be argued, regarding both mFGC and HP, that prohibiting and or denying women’s request to have the operation does not protect them against the human rights violations that attach to, respectively, tFGC and the virginity rule. However, there remain significant differences between the two operations. Although the wrongs of mFGC may be outweighed by the wrongs tFGC, mFGC remains a violation of women’s human rights in itself. HP, in contrast, is not. Therefore, it seems reasonable to conclude that the analogy between mFGC and HP, with the right to protection of human rights by the state as its sole relevant moral element, is a dissimilar reinforcing one. If the objection that the operation violates the right to protection of human rights by the state fails to provide sufficient grounds to refuse the operation in the case of mFGC, then it fails to do so even more in the case of HP.

Conclusions deontological objections

Having examined all the deontological objections raised against HP, and having tested the strength of my conclusions by drawing analogies between HP and mFGC, and HP and cLP, it seems reasonable to conclude that these objections fail to provide sufficient grounds for health care professionals to refuse the operation. First, HP can be classified as discretionary surgery, requested by girls and young women to improve their physical, psychological and social wellbeing. Other medically unnecessary operations, such as cLP, are carried out routinely on this basis, and all other things being equal, surgeons must heed their patients’ right to autonomy and self-determination in the case of HP as well. Consequently, the objection that HP is medically unnecessary fails to provide sufficient grounds for health care professionals to refuse the operation. Second, although HP may involve an element of deceit, this is outweighed by other considerations such as the principle of privacy and the moral injustice that may befall girls and young women if they are refused the operation. The objection that HP constitutes deceit is therefore largely without merit, and although it is entirely without merit regarding mFGC and cLP, this dissimilarity fails to provide sufficient

grounds for health care professionals to refuse to perform HP. Third, HP is not discriminatory in itself, it is unclear whether HP will perpetuate the virginity rule, subvert is, or have any effect on it at all, and any remaining concerns about possible discriminatory elements are outweighed by the consequences girls and young women may suffer if the operation is made unavailable to them. This may align HP with mFGC, as any discriminatory effects that may result from mFGC may be similarly outweighed by the discriminatory effects that may result from refusing to perform it. However, unlike HP, mFGC is discriminatory in itself. If the objection that the operation violates girls and young women’s right to freedom from discrimination does not justify a refusal to perform it in the case of mFGC, it does so even less in the case of HP. Fourth, HP does not violate girls and young women’s right to bodily integrity, whereas mFGC does. However, as mFGC may violate that right to a lesser extent than tFGC, and in doing so may reduce harm, the objection that the operation violates the right to bodily integrity may fail to provide sufficient grounds for health care professionals to refuse to perform it. And if it does not justify a refusal in the case of mFGC, it does so even less in the case of HP. Fifth, HP does not violate girls and young women’s right to autonomy and self-determination. And although mFGC does, it could be argued that it does so to a lesser extent than tFGC, and that refusing mFGC may itself be a breach of that right. If this is true, and the objection that the operation violates girls and young women’s right to autonomy and self-determination does not justify a refusal to perform it in the case of mFGC, it does so even less in the case of HP. In contrast, as there may be an element of socialisation that attaches to cLP, but no coercion, this objection does not justify a refusal to perform the operation. As there is an element of social coercion that attaches to HP, we may need to allow that whereas the objection is largely without merit regarding HP, it is entirely without merit regarding cLP. However, this dissimilarity fails to provide sufficient grounds for health care professionals to refuse to perform HP. Finally, prohibiting HP does not protect girls and young women against the human rights violations that attach to the virginity rule. It could be argued that, similarly, prohibiting mFGC does not constitute protection against tFGC. However, mFGC remains a violation of women’s human rights in itself. If the objection that the operation violates girls and young women’s right to protection of human rights by the state does not justify a refusal to perform it in the case of mFGC, it does so even less in the case of HP.

In summary, although HP is medically unnecessary and may involve an element of deceit, these objections fail to provide sufficient grounds for health care professionals to refuse the

operation. Furthermore, HP does not violate girls and young women’s right to freedom from discrimination, to bodily integrity, to autonomy and self-determination, or to protection of human rights by the state. The only real uncertainty that attaches to HP with regards to these objections is whether the availability of the operation will perpetuate the virginity rule, subvert is, or have no effect at all on it. However, there is no way of deciding this issue, and as any remaining concerns about possible discriminatory effects of HP are outweighed by the discriminatory consequences girls and young women may suffer if they are refused the operation, this objection does not offer sufficient grounds to refuse the operation. Furthermore, the analogies I have drawn between mFGC and HP, and cLP and HP in all cases but one add more weight to these conclusions. Therefore it seems reasonable to conclude that the deontological objections that have been levied at HP fail, and health care professionals are not justified in refusing to perform HP on the basis of these objections.

Chapter 6: Recommendations

Introduction

I have argued above that both the consequentialist and the deontological objections against HP fail to provide sufficient grounds to refuse the operation. In what follows, I will argue that these objections may be culturally situated; that rejecting them does not need to entail passive acceptance the virginity rule; and that a multi-disciplinary intake model for HP may empower girls and young women to address that rule in an informed and autonomous way, whilst leaving the ultimate decision whether or not to go ahead with the operation fully in their hands.

Objections against HP are culturally situated

An overall problem which may lead Western health care professionals to raise these objections is that they may be culturally situated and not have the necessary insight into the true nature of the problem. Some have pointed out that virginity has been at issue during most of Western history and that the current moral yardstick that is being levied by Western health care professionals has only recently become the norm (Loeber 2014b). Although this is true, as we have seen above, it cannot in itself refute any justified moral objections. Health care professionals need to base their ethical judgments regarding what constitutes good medical practice on current scientific and moral knowledge rather than on historical moral prescripts, and if that knowledge leads them to conclude that performing HP is not in the best interest of their patient, they must refuse to operate. However, various authors have argued that the “white ethnic majority” can have “little insight into the cultural complexities” (Webb 1998) of young migrant girls’ lives, and that “young women living in traditional patriarchal families where family honour depends on their chastity (form) a hidden group”. Because of this, health care professionals “might not be meeting their needs” (Essén et al 2010) and the objections they raise against HP may be culturally situated (Verhaar 1999; Bartels 2000). First, health care professionals may not take into account that both the future husband and the family of the woman requesting HP may prefer a “white lie”, which can prevent loss of honour, to a direct confrontation, which necessitates a reaction that can be witnessed by the

social environment (Loeber 2014b). It has been reported that “parents sometimes request a certificate of virginity in spite of the girl having a boyfriend and having intercourse with him” (Essén et al 2010), and some authors have commented that “it is no secret that when some marriages are consummated, the virginity of the bride is artificial” (Mernissi 1975). Second, the moral concerns that health care professionals have regarding HP may not be shared by the girls and young women requesting it. Several studies have shown that many of them look upon the operation pragmatically and instrumentally: ’virginity’ is a “proof” to be produced externally rather than a state of chastity (Bartels 1993), and their primary problem, to which HP offers them a solution, is not being able to produce that “proof” come the wedding night. (Verhaar 1999). Third, if the girls and young women do have a moral issue regarding HP, it is more likely to be the guilt they feel towards their husband for letting him believe he has married a virgin (Verhaar 1999; Raveenthiran 2009; Cook & Dickens 2009), and although many health care professionals are aware of this problem, they may not fully understand why girls and young women requesting HP consider the moral injustice of deceiving their husband to be worse than the moral injustices surrounding the virginity rule. Fourth, as we have seen before, Muslim culture is generally less individualistic than Western culture (Loeber 2014b): family members may be more closely involved in each other’s lives, creating the feeling of a “warm nest”, and the moral narrative surrounding the family can be especially strong. Because of this, Western health care professionals may not fully understand why girls and young women requesting HP rate the moral imperative to protect the family higher than their own feelings regarding the operation. Fifth, although some girls and young women reject the virginity rule, others value virginity themselves, and feel no need to distance themselves from Islamic morals (Verhaar 1999). As we have seen above, the reasons girls request HP and the circumstances in which some of them have lost their virginity are extremely varied: a girl or young woman may have had premarital sexual intercourse and still consider her “virginity” at marriage “a substantial part of her sexual identity” (Verhaar 1999, my translation). Western health care professionals may not have the necessary insight in the way Muslim girls and young women experience, manage and conceptualise their sexuality, and may feel that by having consensual sex they have “given up that aspect of their culture” (de Lora 2014). Sixth, even if some girls and young women requesting HP are fully informed about the facts surrounding virginity and the hymen, and consider the one-sided virginity rule an unfair and nonsensical imperative forced upon them by male ignorance and hypocrisy (Verhaar 1999; Eich 2010; van Moorst et al 2012a), they may still be resigned to the dictates of the culture and feel they have to live with it and do “everything that (can) be done” (van Moorst et al

2012a). Seventh, although many authors have pointed out that the virginity rule is a cultural rather than a religious phenomenon, one of the reasons why virginity remains important in Muslim culture, is because remaining a virgin until marriage is the way women can reach the purity expected of devoted Muslims (Verhaar 1999). Some Muslim girls and young women who have lost their virginity before marriage may feel remorse, and HP may be the only way they feel they can redeem themselves and be that “whole and pure” (van Moorst et al 2012a) again. Eight, as we have seen above, men may experience negative consequences of the virginity rule too: they may suffer “fear, distress and erection problems” (Bekker et al 1996), and failure to deflower his bride may cast a man in the role of a subordinate male, and diminish his access to social resources, status and power (Lindisfarne 1994). Finally, women can “prove” both their husband’s “virility” and their own virginity by the blood on the sheet may gain privileged access to social resources, status and power, and some Muslim girls and young women may consider HP to be a valuable tool in the navigation of this social hierarchy, rather than a consequence of gender inequality. Therefore, the moral objections health care professionals have against HP may indeed be culturally situated, and at least partially inspired by a lack of knowledge regarding the culture of their patients. To understand the needs of these patients, their requests may need to be approached “pragmatically and sensitively”, and may need to be handled by health care professionals who are trained in multicultural practice (Webb 1998). Multidisciplinary models such as the ones described below “would allow doctors to work with colleagues in other disciplines who do have these skills” (Webb 1998), and may lead to a better, less culturally situated approach to the problem.

Avoiding passive acceptance of the virginity rule

A further advantage of multi-disciplinary models, is that they allow health care professionals to avoid passive acceptance of the virginity rule. As I have argued above, HP is not discriminatory in itself, and may help girls and young women to avoid some or all of the discriminatory effects that attach to the virginity rule. In contrast, the virginity rule is discriminatory in itself, as are the consequences that may befall girls and young women who fall foul of it. Because of this, health care professionals may be faced with a moral dilemma. To sit back and leave these girls and young women to suffer these consequences is ethically unacceptable. However, to passively accept the virginity rule may be equally ethically

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unacceptable. I would argue that the multi-disciplinary models that I will discuss below may offer a way out of this dilemma. If health care professionals can offer girls and young women an intake process that informs, educates and empowers them, and places the ultimate decision whether or not to go ahead with the operation more firmly in their patients’ hands, they may thereby avoid passive acceptance of the virginity rule.

Multidisciplinary approaches

In recent years, some hospitals have been attempting to establish best-practice guidelines, incorporating skills from various disciplines into the intake and treatment process of patients requesting HP. Various multidisciplinary models have been implemented by health care professionals such as Logmans, Van Moorst and others (Logmans et al 1998a; van Moorst et al 2012a; Loeber 2014a). One of these models, developed by Van Moorst et al, merits special attention, as it incorporates counselling, education on female anatomy and the hymen, instructions for self-examination, educational medical examination, discussion of alternatives and follow up. This approach has been particularly successful at empowering girls and young women to decide against the operation, with as much as 75% of them deciding not to go ahead with it (van Moorst et al 2012a). That said, the authors also stipulate that, if a girl or young woman, “after having considered her situation from every angle, is still convinced that (HP) is necessary, her request for surgery should be granted” (van Moorst et al 2012a). Ultimately, the goal is not so much to dissuade women from undergoing the operation, as to give them all the necessary tools to make an informed and autonomous decision.

Counselling

Gathering information regarding the circumstances the patient finds herself in, and the proximate and ultimate goals that prompt her to request HP may be an invaluable tool in order to help her to arrive at the best available solution (Loeber 2014a). Many authors suggest that an individual interview should be part of the intake procedure (Saharso 2003b; van Moorst et al 2012a), and in some institutions this is indeed common practice (Saharso 2003b). The guideline of the Dutch Society of Obstetrics and Gynaecology prescribes extensive counselling, in which the girl or young woman’s reasons for the request, “including questions about possible underlying sexual traumatisation” must be explored (van Moorst et

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al 2012a). However, the girl or young woman may have never talked about her problem to anyone before, and taking the step to seek advice and help, and thereby exposing her secrets to a third party, may put her in a vulnerable position. Counselling should therefore be culturally sensitive and respectful (Loeber 2014a). Van Moorst et all (van Moorst et al 2012a) have designed an intake procedure consisting of three visits before the operation can take place, with an additional fourth visit for follow-up. Three of these visits consist of meetings with counsellors trained in sexual health and women’s health care. During the initial visit the counsellors conduct an interview aimed at finding out the girl or young woman’s biographical data; the reasons for her request, including how she lost her virginity, and how and to whom she would have to “prove” her virginity; and her knowledge and possible misconceptions about virginity, female anatomy, and sexual health in general. In the course of this interview, they supply the girl or young woman with information designed to allow her to evaluate the options open to her, and to make an informed and autonomous choice.

Information

In order to give girls and young women a better chance at evaluating these options, it seems imperative for health care professionals to clarify the myths surrounding virginity and the hymen. First, some girls and young women are unaware of the precise location of the hymen, of the great variety in shapes and sizes it comes in (Bekker et al 1996), and of the unreliability of blood loss at first intercourse. Second, some are unaware that HP entails certain risks and does not guarantee blood loss on the wedding night. Third, some are unaware that there are alternative ways to deal with their problem, which include not only other methods to mimic blood loss, but also the option of doing nothing at all (van Moorst et al 2012a). Fourth, some are unaware that “feeling tight” is predominantly caused by either lack of lubrication or contraction of the muscles of the pelvic floor (Loeber 2014a), and that the latter can be produced voluntarily (van Moorst et al 2012a).

1) Information about female anatomy and blood loss at first intercourse

Van Moorst et al (van Moorst et al 2012a), have implemented a technique called motivational interviewing, using questions such as “Did you ever see photographs of how hymens of different women can look like?” and “How do you think that almost half the

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women in your culture who do not bleed at first intercourse solve this problem?” and so on, to inform girls and young women that the hymen, conceived of as a membrane guarding virginity, is a “mythical structure” and that guaranteed blood loss at first intercourse is a modern day fable.

2) Information about the HP operation itself

In addition, women must be informed about the pros and the cons of the operation (van Moorst et al 2012a). And as HP does not guarantee blood loss, they are informed that an alternative way to deal with their problem may be necessary.

3) Information about alternative ways to deal with the virginity rule

They then discuss alternative ways to deal with the problem at hand.

a) Inserting a small sponge soaked with anti-coagulated blood

The sponge can be inserted into the vagina before the coitus and removed the next day. This is said to be a good solution if the family needs to see proof of the blood loss, as the discolouration of the stain will be identical to stains caused by actual blood loss. However, the blood cannot be kept at room temperature for a long period of time (Loeber 2014a).

b) Inserting a capsule with food colouring

The capsule needs to be inserted about 30 minutes before the coitus, and will produce a red stain. However, this stain will not show any discolouration over time, the way blood does, nor will the ‘Artificial Hymen Kit’ that can be ordered over the internet, and which contains a folded gelatine package with a blood-like paste (Loeber 2014a).

c) Timing menstrual blood loss via oral contraceptives

The girls or young woman can stop taking oral contraceptives ahead of time, thereby triggering menstrual blood loss (van Moorst et al 2012a; Loeber 2014a).

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d) Other methods of mimicking blood loss

If all else fails, there are time-honoured and trans-generationally passed-down back-up methods such as pricking the finger with a hidden needle to produce a few drops of blood (van Moorst et al 2012a; Loeber 2014a), or using a little sac filled with animal blood(van Moorst et al 2012a). Alternatively, an updated version could consist in providing the patient with a tube with her own heparinised blood (van Moorst et al 2012a).

e) Virginity certificates

Some women have requested a medical document from the health care professional, that states that she is still a virgin. Some authors have suggested providing the patient with a document declaring that there are no visible signs of previous intercourse (van Moorst et al 2012a), a statement which is technically true (Helgesson & Lynöe 2008; Loeber 2014a), as there is no reliable way to deduce previous intercourse from the state of the hymen. However, by providing the certificate, the physician could be said to knowingly and purposefully mislead the third party for whom the document is intended, and this may still constitute deceit. Nevertheless, there could be good reasons for health care professionals to adopt the practice of providing virginity certificates. First, as in some cultures the old traditions regarding proof of virginity have evolved into “purely formal social convention”, the truthfulness of the certificate may not be at issue (Helgesson & Lynöe 2008). Second, if the intended recipient of the certificate believes its authenticity, it may save the girl or young woman from the severe consequences that may befall her if she cannot ‘prove’ her virginity. Third, as the certificate, if worded carefully, does not state a medical falsehood, the responsibility regarding the way in which it is used and whether that use constitutes deceit may ultimately lie with the patient. Therefore, a virginity certificate may be an ethically acceptable “pragmatic emergency solution” (Helgesson & Lynöe 2008) and may form part of the tool box with which health care professionals can help their patients in the absence of social reform. On the other hand, such a certificate may not have the desired result, and it may be advisable to try to find out during counselling sessions whether a virginity certificate is likely to improve or exacerbate the particular situation the patient finds herself in.

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f) Doing nothing at all

Van Moorst et al (van Moorst et al 2012a) have noted that, in the course of the first counselling session, whilst discussing the alternative ways to deal with the virginity rule, “this talk in a very natural way led to planned discussions on doing nothing at all, and on the pros and cons of disclosure to their future spouses weighted against the difficulties of living with a hidden past” (van Moorst et al 2012a).

4) Information about the role of the pelvic floor as a sexual organ

In order to avoid not “feeling tight”, which some men falsely believe to be a proof of previous intercourse, women can exercise their levator ani muscle (Loeber 2014a) in order to contract the vaginal introitus and mimic this feeling of tightness. Some clinics, predominantly in the Netherlands, have started showing women how to exercise this muscle. In the model developed by Van Moorst et all (van Moorst et al 2012a),

“… women were taught how to consciously contract and relax the pelvic floor to improve awareness of this structure and its function, and to gain self-confidence. They were advised to examine themselves so as to get acquainted with their genitals, to inspect their hymen, and to evaluate whether they were able to constrict their vaginal introitus “(van Moorst et al 2012a).

Examination

In addition to being counselled and receiving information, girls and young women requesting HP need to undergo an examination before the operation can proceed. In addition to the examination needed to determine the right surgical technique, Van Moorst et al (van Moorst et al 2012a) have developed a self-examination model that can help to further clarify the myths regarding the hymen and the virginity rule.

1) Examination of the hymen by gynaecologists

Some clinics examine the hymen beforehand to select the right surgical technique (van Moorst et al 2012a): if there are clear hymenal remnants, then the regular restorations

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techniques above can be used; if there are no suitable remnants, then strips of vaginal skin must be dissected to construct a “hymen”. Some clinics may also examine the hymen to determine whether HP might be able to produce the required blood loss, taking into account “the number of clefts or notches in the hymen, the thickness of its remnants and the diameter of the vaginal opening” (Loeber 2014a). If there are too many notches or the hymenal rim is folded and supple, HP is not expected to lead to visible blood loss (Loeber 2014a). An additional reason to carry out an examination of the hymen may be to find out if the woman in question is able to relax enough to undergo HP under local anaesthetic (Loeber 2014a).

2) Mirror-assisted educational gynaecological examination

In the model developed by Van Moorst et al (van Moorst et al 2012a), the girls and young women requesting HP don’t undergo a physical examination until the second visit, when they meet with two female gynaecologists. Apart from the above mentioned examination of the hymen in order to select the right surgical technique, a mirror-assisted educational gynaecological examination is carried out, aimed at “increasing the patient’s knowledge about her genital anatomy” and at answering any questions that may have remained after the first visit. Additionally, “pelvic floor awareness and the ability of voluntarily contracting and relaxing the pelvic floor” are assessed, and further instructions are given if necessary (van Moorst et al 2012a).

Multiple visits

As most if not all of the girls and young women requesting HP need to keep the situation they find themselves in secret from their future husband, their extended family and their community in general, it may be very difficult to ensure that their requests constitute informed consent. They may be very nervous and afraid of the consequences of being found out, and they may feel uncomfortable discussing matters relating to their sexuality and being touched, examined and operated upon in the most intimate place of their bodies. As a consequence, they may find it difficult to discuss their problem calmly and openly. For the same reasons, it may be hard for them to remember all the necessary information that is given to them in one session. They may need time to think through the various options that are open to them, and may not remember all that was said by the health care professionals. Although

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written information is often offered, most refuse to take this home (Loeber 2014a), as this may lead to discovery. They may feel under pressure to decide on a solution to their problem as quickly as possible. In such a stressful situation, health care professionals must make extra efforts to make sure that the consent girls and young women give is truly informed.

The multiple-visits model developed by Van Moorst et al (van Moorst et al 2012a) may address this concern. First, having multiple meetings with counsellors lending a sympathetic ear, rather than the physicians who may ultimately need to carry out an invasive examination, may reduce embarrassment and enhance trust, thereby allowing the girl or young woman to speak more openly. Second, for the same reason, it may be easier for her to process and retain the information that is given to her and to reflect upon her options. Third, the multiple visits allow her to ask any questions that arise between sessions and to go back to points she may have forgotten or had not fully understood. Fourth, they also allow her to revisit written documentation available at the hospital. Fifth, they may force her to slow down and take the time to decide which solution is best for her. In this model, at the third visit, after having undergone the mirror-assisted educational genital examination, the girl or young women meets with her counsellor for the second time. At this time, she can obtain additional information, and inform her counsellor of her decision if she has made one. She can also ask for further assistance, or for a prescription for mimicking blood if that is the option she decides to take (van Moorst et al 2012a).

Results

Obtaining feedback regarding the results of the multidisciplinary models and the alternative methods offered to girls and young women requesting HP is severely hindered by the patients’ need for secrecy. Once the wedding day is over, many girls and young women would rather forget the whole thing and/or can no longer make contact or be contacted safely (Loeber 2014a). Because of this, the little feedback that has been gathered so far has mostly been vague and unspecific. One approach that has managed to realise more complete follow- up results has been Van Moorst’s intake and treatment model, possibly due to the trust engendered by multiple visits with counsellors as well as physicians.

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Counselling

Findings from a number of studies, predominantly in the Netherlands, suggest that counselling and informing the women requesting HP is an indispensable part of the search for a long-term solution to the problems surrounding virginity. In one study providing these services, less than half of the women requesting HP ultimately opted for surgery (Loeber 2014a). In the model developed by Van Moorst et al, this number is even lower: only 29% of the applicants decided in the end to go through with the operation (van Moorst et al 2012a). Furthermore, the majority of girls and young women in this study were extremely satisfied with the counselling sessions, especially with the aspect of being able to tell their story (van Moorst et al 2012a).

Information

Providing the girls and young women with information regarding female anatomy and the likelihood of blood loss at first intercourse is imperative in order to help them make an informed and autonomous decision. However, as we have seen above, being aware of the myths surrounding virginity and the hymen does not necessarily lead to a rejection of the virginity rule. As one woman put it:

“Now I know that it all is a myth, sheer nonsense; our men are ignorant and inflict their stupidity on us, but... I have to live with it. It is our culture and, by having the operation, I feel stronger knowing I did everything that could be done (van Moorst et al 2012a)”.

Nevertheless, I would argue that imparting unbiased scientific information is a necessary part of the intake and treatment program of girls and young women requesting HP, as it may not only help them make an informed and autonomous decision regarding the operation itself: having more knowledge at their disposal may also better equip them to stand up to the “crossfire of questions” (van Moorst et al 2012a) and threats that may ensue if they are suspected to have lost their virginity, and empower them to choose different courses of action and/or take control of the situation on their own terms.

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Examination

The mirror-assisted gynaecological examination introduced by Van Moorst et al (van Moorst et al 2012a), seems one of the most inspired and most appreciated additions to the HP intake and treatment model. For girls and young women growing up in a sexually restrictive society this experience may be revelatory and allow them to put the myths regarding virginity and the hymen, which may have taken on larger-than-life proportions, into perspective. Furthermore, it allows them to confirm visually that they can control the (lack of) “tightness” that they have been warned about, by contracting their pelvic floor muscles (van Moorst et al 2012a).

Alternative options

As HP cannot guarantee blood loss on the wedding night, it may be advisable that all women are instructed in how to use alternative methods to produce blood on the sheet (van Moorst et al 2012a), so they can resort to a back-up method if necessary (Loeber 2014a). However, several studies have reported that there is no marked preference amongst the girls and young women for a particular method(van Moorst et al 2012a), and no data regarding which methods are most successful (Loeber 2014a). In the multi-disciplinary model of Van Moorst et al (van Moorst et al 2012a), the majority of girls and young women combined one of the methods for mimicking blood loss with “their newly-learned ability to voluntarily contract the pelvic floor at intromission” to create a sensation of “tightness”. In another study, some women reported that, in spite of not bleeding on their wedding night, they were believed to be virgins because they were so “tight”, suggesting that the pelvic floor exercises may be one of the most effective tools with which girls and young women can convince their husbands of their virginity (Loeber 2014a).

Virginity certificates

Some girls obtain a virginity certificate from a health care professional (Bekker et al 1996). However, this may not yield the desired results. First, there is no reliable way to establish the virginal status of a woman by means of a physical examination, and the health care professional may refuse to provide a document which states unequivocally that the girl is still a virgin. Second, even if the document only states that that there are no visible signs of

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previous intercourse (Helgesson & Lynöe 2008; Loeber 2014a), the health care professional may not want to be complicit in the intended deceit which requires such “careful” wording. Third, if the girl procures a virginity certificate herself, unprompted by her future husband or extended family, she may raise suspicion regarding her virginal status rather than lower it. Finally, virginity certificates from Western doctors may not be trusted and may not alleviate the pressure to provide proof of virginity that is considered more convincing. Therefore, virginity certificates may not prevent the girl or young woman’s virginal status from being questioned.

Conclusion regarding multi-disciplinary approaches

In spite of understanding and accepting factual evidence regarding female anatomy and the hymen, most girls and young women know that they will still be expected to bleed and feel “tight” (van Moorst et al 2012a). Nevertheless, results from various studies (van Moorst et al 2012a; Loeber 2014a) suggest that a multidisciplinary approach aimed at providing women with the opportunity to reframe their problem and consider the various possibilities open to them, can give most women the “increased knowledge and self-confidence”(van Moorst et al 2012a) to let go of the idea that HP is the only solution. The most successful model so far seems to be the one developed by Van Moorst et al (van Moorst et al 2012a), with a 100% satisfaction rate, a 71% opt-out-of-surgery rate, and a 79% follow-up rate. However, I would agree that, if a woman is given all the counselling, information and instruction that forms a part of this method, is capable of informed consent, and still feels that “reconstructive surgery is in her best interest”, health care professionals should “respect her autonomy and proceed with the repair or refer her to doctors who will do it” (Webb 1998).

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Chapter 7: Conclusion

Given the oppressive social background in which the virginity rule is enforced, and the consequences that girls and young women, and not boys and young men may face if they do not adhere to it, it is understandable that many health care professionals have raised objections against performing an operation that may make them complicit in these discriminatory practices. Furthermore, the medical facts regarding the anatomy of the hymen and the HP procedure show that there is no reliable way to determine whether a girl or young woman is a virgin or not, and the belief that all women bleed upon “defloration” is based on myth rather than fact. As educational means are unlikely to be successful the concern voiced by health care professionals that by performing HP they may perpetuate these myths is equally understandable. However, the analysis of the consequentialist objections that health care professionals have raised against HP, and the analogies I have drawn with mFGC and cLP, show that these objections do not provide sufficient grounds to refuse the operation, and other operations that are carried out routinely and without censure may be more vulnerable to these objections than HP. Health care professionals may have raised these consequentialist objections predominantly because they have deontological objections against the virginity rule. The virginity rule serves as a mechanism of gender inequality and is indeed ethically untenable. However, the virginity rule cannot be equated with HP, and health care professionals do not condone it by performing this operation. Furthermore, the analysis of the deontological objections against HP and the analogies I have drawn with mFGC and cLP show that these objections do not provide sufficient grounds to refuse the operation. Quite to the contrary, HP may protect girls and young women from the violation of their right to freedom from discrimination, the right to bodily integrity, and the right to autonomy and self- determination by the practices surrounding the virginity rule. Health care professionals may have raised the above objections due to their cultural situatedness. Multidisciplinary intake models that consist of multiple visits, and inform, examine and counsel girls and young women regarding the facts surrounding the virginity myth and the options that are open to them, may provide a less-culturally situated approach. Such an approach may also help avoid a passive acceptance of the virginity rule, as it allows girls and young women to reframe their problem, and may give them enough knowledge and self-confidence to no longer see HP as the only solution to their problem.

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Addendum Anatomy of the Hymen

Fig. 1 (Hegazy & Al-Rukban 2012)

Female Genital Anatomy

The external female genitalia are called the vulva, and consist of the mons pubis, the labia majora or outer labia, and the labia minora or inner labia. The labia minora split to enclose the clitoris and the vestibule, the area containing the urethral and vaginal orifices (Hegazy & Al-Rukban 2012). The hymen is not a “lid-like membrane ” (Cinthio 2014) closing off the vagina “from the outside world” (Bekker et al 1996), as popular belief would have it:

The (hymen) is located 1-2 cm inside the vaginal opening, not deep inside the vagina. Every woman’s (hymen) looks different - just like ear lobes, noses and labia - and differs in size, colour and shape. It consists of folds of mucous tissue, which may be tightly or more loosely folded. It is slightly pink, almost transparent, but if it’s thicker it may look a little paler or whitish. It may resemble the petals of a rose or other flower, it may be carnation-shaped, or it may look like a jigsaw piece or a half-moon. In the vast majority of cases, it is elastic and stretchy (Knöfel Magnusson 2009)

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Hymen Shape

The hymen is perforated, which allows blood and mucous tissue to pass through it during menstruation. Its shape “differs dramatically from one female to another” (Hegazy & Al- Rukban 2012), and can be annular (round), crescentic (semilunar, concave towards the mons pubis), septate (one or more residual bands extending across the opening), cribriform (containing multiple small openings) or fimbriated (redundant, folding in on itself and/or protruding) (fig. 1).

Hymen Size

The aperture of the hymen ranges in diameter from a pinpoint to an opening that “admits the tip of one or even two fingers” (Hegazy & Al-Rukban 2012). Attempts to determine the normal size of the hymen, in order to establish a threshold that, if crossed, could be used as an indicator of sexual abuse, have been largely unsuccessful. Neither the diameter of the hymenal opening nor the size of the hymenal tissue proved to be a reliable criterion, as a high degree of overlapping was found between abused and non-abused girls, and as there are other factors that affect these values such as age, hymen shape, examination method and state of relaxation of the patient (Hegazy & Al-Rukban 2012).

Histological Structure

The hymen consists mainly of elastic and collagenous tissue, covered on its surface by stratified epithelium. There are few nerve cells, and no glandular or muscle element present. The hymen is a relatively avascular membrane, and as a consequence, is unlikely to bleed significantly even if torn (Hegazy & Al-Rukban 2012).

Development

At seven weeks of embryonic development, the utero-vaginal canal leading to the uterus ends at the back wall of the urogenital sinus, which leads to the vestibule. At this point, the two structures are separate and distinct. However, where they touch, a proliferation of epithelial cells takes place, and together they form the vaginal plate (Schöni-Affolter et al., retrieved 8 December 2014). In the third month, genetically determined self-destruction of

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the cells of the vaginal plate leads to its canalisation (Fahmy 2015), a process which is completed in the fifth month, and by which the utero-vaginal canal “opens itself towards the outside” (Schöni-Affolter et al., retrieved 8 December 2014). However, the utero-vaginal canal remains separated from the urogenital sinus by the hymen. At this stage, the hymen effectively consists of a cranial or top layer that is derived from the utero-vaginal canal, and a bottom layer that is derived from the urogenital sinus (Fahmy 2015). At or around birth, the hymen ruptures and “remains as a thin fold of mucous membrane just within the vaginal orifice” (Hegazy & Al-Rukban 2012).

(Cours d'embryologie en ligne à l'usage des étudiants et étudiantes en médecine, retrieved 8 December 2014)

Abnormalities of the Hymen

Congenital abnormalities of the hymen include hymenal polyps and tags (common after birth, most resolve spontaneously by age 3), hymenal ridges and bands (in 86% of new-borns, 93% resolve spontaneously by age 3), and hymenal notches (in 35% of new-borns, unspecified decrease in frequency as the hymen becomes less redundant). A more rare congenital abnormality is a microperforate hymen, a condition that at least in one case has

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persisted after sexual intercourse, even though the hymeneal orifice is so small that it is difficult to perceive (Hegazy & Al-Rukban 2012).

Imperforate Hymen

In rare cases, if the central epithelial cells of the hymen do not degenerate, the vagina may remain closed off completely. This is usually the result of the urogenital sinus not canalising (Fahmy 2015). In order to form an outflow tract, the traditional treatment is hymenectomy: the removal of the hymenal tissue (Hegazy & Al-Rukban 2012). However, in Muslim countries, where the hymen has a great social value, other techniques (Hegazy & Al-Rukban 2012) may be used to perforate the hymen, whilst taking great care to make the opening “annular”, thereby making it seem “intact” (Abder-Rahman 2009).

Age-related Changes

During a woman’s lifetime, the hymen undergoes significant changes related to her oestrogen levels. At prepuberty, the hymenal tissue is thin and brittle, whereas at puberty, it becomes thick and redundant, with a tendency of folding out. During adolescence, the elasticity of the hymen increases, and a sexually active adolescent may have a hymen that shows no signs of trauma. At pregnancy the epithelium of the hymen becomes very thick and rich in glycogen, and after (natural) childbirth nothing is left of it but a few tags. At menopause, oestrogen deprivation causes the epithelium to become thin again (Hegazy & Al- Rukban 2012).

Function

Although various hypotheses have been suggested for the existence of the hymen (Morgan 1972; Smith 1984; Hobday et al 1997), most of them are highly speculative and rather implausible. Most authors agree that the hymen has no known biological function (Cook & Dickens 2009; Knöfel Magnusson 2009; Kyrillou et al 2009; Hegazy & Al-Rukban 2012; Fahmy 2015), and that its rupture is of no medical consequence (Cook & Dickens 2009; Hegazy & Al-Rukban 2012), although it may, at the early stages of life, play a role in the protection of the vaginal mucosa from contamination by faecal matter and other pollutants (Fahmy 2015).

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Ruptured Hymen

Ruptures to the hymen due to sexual intercourse can appear as irregular hymenal edges and narrow rims at the point of injury, or in the case of deeper penetrating injuries, as defects in the integrity of the hymen. In many cases penetration does not result in visible tissue damage, or acute injuries occur but heal completely (Finkel 1989; McCann et al 2007). Other causes of rupture include use of tampons, vigorous sporting activities, surgical procedures, and falling on sharp objects (Paterson-Brown 1998; O'Connor 2008; Raveenthiran 2009; Cook & Dickens 2009; Kyrillou et al 2009; Hegazy & Al-Rukban 2012).

Hymenoplasty Techniques

Although a lot of literature exists on the ethical questions surrounding HP, few papers give an adequate or indeed any kind of description of the actual procedure. However, I would argue that the invasive nature of the procedure is of ethical consequence, and that a thorough description of the various techniques health care professionals use, and of what is known of the costs and benefits of the operation, is therefore essential.

General Technique

When a hymen is ruptured, remnants of it usually remain present. The standard HP procedure entails the approximation and stitching together of two or three of the largest of these remnants. The operation can be carried out under local or general anaesthetic (Prakash 2009). The patient is placed in the lithotomy position, which means she is lying down on her back, with her thighs parted 90 degrees and raised 30 degrees, her knees flexed 90 degrees, and her lower legs supported by surgical stirrups (Lithotomy Position – www.urology- textbook.com, retrieved 3 February 2015). The vaginal area is prepared for surgery and, under magnification, two or three remnants, which usually have an inverted ‘V’ shape, are selected (fig. 1). The skin and scar tissue from the sides of these remnants are removed for secondary closure. These sides are then stitched together in two layers, first the inner and then the outer layer of the remnants (fig. 2 and 3). This produces a fold-like structure similar to the hymen and doesn’t leave any scars. Some small remnant may be left unstitched.

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Ointment is applied to the sutures, and the patient is advised to post-operatively clean the area with warm water and apply further ointment. The patient is also prescribed antibiotics to prevent infection, and analgesic tablets to deal with the pain, which is thought to be minimal (Prakash 2009).

Temporary Hymen Suture (THS) versus Hymen Restoration (HR)

Recently, two alternative methods of hymenoplasty have been offered. Temporary Hymen Suture (THS) uses fast-absorbing suture, which is designed to lose 50% of its strength within a week. The aim is not to form a lasting bond between the hymenal remnants, but instead to have the stitches tear upon penetration. Due to the temporary nature of the stitches, the operation has to be carried out shortly before the wedding date, which in some circumstances, such as a wedding abroad, may prohibit the use of this technique. However, preliminary reports suggest that this technique may be more successful in producing blood

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loss on the wedding night. In the one available study to date, out of 17 patients who underwent THS, 13 reported blood loss on the wedding night (76%). Concerns that the future husband may look for and see the sutures have never been confirmed (Loeber 2014a).

Hymen Reconstruction (HR), on the other hand, needs to be carried out at least six weeks before the wedding, to allow time for the sutures to disappear. It is often the method of choice when no wedding is planned in the near future, or if it will take place abroad. As there may be less of a possibility for follow-up to take place, it may be more difficult to evaluate how successful the procedure is in producing blood loss (Loeber 2014a). However, the few findings that do exist suggest that HR may be less successful at producing blood loss, with positive results ranging from 6 out of 11 (55%) (Loeber 2014a) to a meagre 2 out of 19 (11%) (van Moorst et al 2012a). It should be clear from the sparsity of the number of patients who have been followed up, that any conclusions regarding the effectiveness of either method are preliminary, and that more research is needed to determine the effectiveness of these methods. However, a more complete assessment of the results of the procedures is hindered by the secrecy surrounding the interventions and the frequent lack of feedback from women undergoing them (Loeber 2014a). The procedure should take place no sooner than 14 days preceding the wedding, to increase blood loss chances, and not much later, to avoid that the sutures can be seen (van Moorst et al 2012a).

The Cerclage Method

One author has described a cerclage method, whereby the sides of the hymenal remnants are cleaned of skin and scar tissue, and stitched together. Instead, the suture is introduced at the 6 o’clock position about 2 to 3 mm into the edge of the hymenal remnants, run clockwise into the submucosa to the 12 o’clock position, and back down along the other side. The ends of the sutures are then tied around a 12 mm dilator to form an annular hymen. The method is said to produce a more even result that the approximation methods: an “intact annular hymen with a trans-hymenal diameter of about 1 cm” (Ou et al 2008). However, as it is not mentioned whether or not this technique leads to blood loss at the following coitus (Kara\csahin et al 2009), and this is the main reason why women request a HP operation, it is not clear how the cerclage method holds up against the approximation method in aspects other than the aesthetic appearance of the hymen.

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Alternative methods

If no hymenal remnants are present, or they prove to be of insufficient size or shape to perform the operation, a narrow strip of posterior vaginal wall, “complete with its blood supply” (Cinthio 2014), is dissected for reconstruction (Logmans et al 1998a), and approximated to the anterior vaginal wall as a band across the hymenal ring (Renganathan et al 2009). Alternatively, an incision can be made in the vaginal membrane where both sides are pulled and stitched together (Cinthio 2014). To date, there seems to be no data available regarding the efficacy of these techniques in producing blood loss. Additionally, some clinics offer the insertion of Alloplant, a tear-through biological material used for transplantation (Cinthio 2014). Finally, there have been reports of the incorporation of a gelatine capsule containing a blood-like substance, that breaks upon penetration to simulate hymenal bleeding (Paterson-Brown 1998; Renganathan et al 2009).

Female genital cutting techniques

(The Political Domain, retrieved 27 April 2015)

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Four different types of female genital cutting have been identified. Type 1 involves partial or total removal of the clitoris and/or the prepuce, and is also referred to as clitoridectomy. Type 2 involves partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora, and is also referred to as excision. Type 3 involves narrowing of the vaginal opening, through the creation of a covering seal formed by cutting and repositioning the labia minora and/or labia majora, with or without removal of the clitoris (World Health Organization, retrieved 27 April 2015). Only a minimal opening is left passing urine and menstrual blood, which must be opened again for intercourse and childbirth (Shell- Duncan 2001). This is also referred to as infibulation or Pharaonic circumcision. Type 4 includes all other harmful procedures to the female genitalia for non-medical purposes (World Health Organization, retrieved 27 April 2015), such as “pricking, piercing, or incision of the clitoris and or labia; stretching of the clitoris and/or labia; cauterisation by burning of the clitoris and surrounding tissues; scraping (angurya cuts) of the vaginal orifice or cutting (gishiri cuts) of the vagina; introduction of corrosive substances into the vagina to cause bleeding, or of herbs into the vagina with the aim of tightening or narrowing the vagina” (Cook et al 2002) .

Labiaplasty Techniques

Several techniques for performing labiaplasty exist, most of which are aimed at producing neatly aligned, symmetrical labia majora and non-protruding labia minora. Most common amongst these techniques are elliptical linear resection and wedge resection. Elliptical linear resection, also known as the “amputation technique”, is a trimming technique that involves the removal of protuberant tissue from the labia minora, after which the edges are over-sewn. However, this technique fails to preserve the corrugated free edges of the labia, and risks over-correction or complete amputation, as well as excessive tightening. Wedge resection may prevent some of these problems by cutting out a V- or W-shaped centre portion of the labia minora and approximating the edges to preserve the labial edge and colour. Often a 90- degree Z-plasty is performed to spread the tension over the suture line. Many other modifications of the original procedure exist, including de-epithelialisation whereby a wedge of skin is removed, but deeper tissues are preserved. The procedure can be performed under local anaesthetic, conscious sedation, or general anaesthetic (Liao et al 2010; Iglesia et al 2013).

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