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BMJ No 7129 Volume 316
Education and debate Saturday 7 February 1998
Ethical dilemma
Should doctors reconstruct the vaginal introitus of adolescent
girls to mimic the virginal state?
Who wants the procedure and why
A Logmans, A Verhoeff, R Bol Raap, F Creighton, M van Lent
| During this century many immigrants from Mediterranean and
African countries have moved to western Europe.(1) Second
and third generations often face a conflict. They may follow the
lifestyle of the new country and friends but have to remain mindful of
the original traditions and attitudes of their families.
Many immigrant groups hold strongly with the tradition that girls must
be virgins when they marry. If the bride cannot show her bloody sheet
after the wedding night, her family are shamed. Her new husband's
fa |  | |
| Many second and third generation immigrant girls remain mindful
of their cultural traditions
Photo: PETER HILTZ/HOLLANDSE HOOGTE |
Because of these far reaching consequences, many gynaecologists in the Netherlands are willing to reconstruct the hymens of adolescent girls who are no longer virgins but wish to appear so.
Reconstructing the hymen
In our hospital, the operation is carried out as an outpatient procedure. We insist that an interpreter and social worker are present during the initial consultation and that the social worker attends the surgery. The epithelial layer that has grown over the ruptured hymen is removed and the hymenal remnants are adapted by a circular running suture or by left to right approximation. Where the hymenal remnants are insufficient, a narrow strip of posterior vaginal wall is dissected for reconstruction. Three weeks later, the patient is followed up and given an opportunity to discuss any emotional issues. As is legal in the Netherlands, the patient is offered the opportunity to remove or destroy any notes on this procedure from her medical record.
We followed up the first 20 patients seen in 1993. The mean age of the girls was 19 years (range 16 to 23 years). Eight were undertaking technical and vocational training, eight were attending secondary school, and four were following courses of higher education. Ten girls claimed that they had lost their virginity as a result of forced intercourse, six were having regular intercourse, and four did not provide this information. All 20 were satisfied with the outcome of the procedure and none had any regrets. We evaluated only 10 young women long term. All 10 said the procedure provided a satisfactory outcome. All of the patients decided to have the details of the procedure removed from their medical records.
Ethics and culture
Immigration is often associated with a stepwise adaptation of the migrants to their new countries.(2) Some young women have sexual intercourse without foreseeing the consquences - that it will be impossible for them to marry in the traditional way. In the Netherlands the principal factors in ethical decisions are the patient's wishes - provided these are within the law - so medical decisions may conflict with cultural values.
We reject any suggestion that this operation is analogous to traditional clitoridectomy. There are strong arguments for rejecting a request for clitoridectomy, but equally strong ones exist for accepting hymen reconstruction. Most importantly, hymen reconstruction is not mutilating; the risk of physical, psychological, and sexual complications is far less than in clitoridectomy.(3-7) Hymen reconstruction, like male circumcision, is an example of "ritualistic surgery." Our definition of ritualistic surgery, modified from that of Bolande,(8,9) is "fulfilment of a person's need rather than a response to their medical condition." The ethics of hymen reconstruction could be compared to the ethics of cosmetic surgery, an accepted part of plastic and reconstructive surgery worldwide.
Department of Gynaecology,
Dr Daniel den Hoed
Kliniek,
3075 EA Rotterdam,
Netherlands
A Logmans,
consultant gynaecologist
A Verhoeff,
consultant gynaecologist
R Bol Raap,
senior
house officer
F Creighton,
senior house officer
M van Lent,
consultant gynaecologist
Correspondence to: Dr A Logmans,
Zuiderziekenhuis,
Gr Hilledijk
315,
3075 EA Rotterdam,
Netherlands
References
1 De Santis L, Ugarriza D N. Potential for intergenerational
conflict in Cuban and Haitian immigrant families. Arch Psychiatr
Nurs 1995;9:354-64.
2 Lipson J G, Hosseini T, Kabir S, Omidian P A, Edmonston F.
Health issues among Afghan women in California. Health Care
Women Int 1995;16:279-86.
3 Kluge E H. Female circumcision: when medical ethics confronts
cultural values. Can Med Assoc J 1993;148:288-9.
4 Meniru G I. Female genital mutilation (female circumcision).
Br J Obstet Gynaecol 1994;101:832.
5 Jordan J A. Female genital mutilation (female circumcision).
Br J Obstet Gynaecol 1994;101:94-5.
6 Baker C A, Gilson G J, Vill M D, Curet L B. Female circumcision:
obstetric issues. Am J Obstet Gynecol 1993;169:1616-8.
7 De Silva S. Obstetric sequelae of female circumcision.
Eur J Obstet Gynecol Reprod Biol 1989;32:233-40.
8 Bolande R P. Ritualistic surgery: circumcision and
tonsillectomy. N Engl J Med 1969;280:591-6.
9 Wall L L. Ritual meaning in surgery. Obstet
Gynecol 1996;88:633-7.
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