Bookmarkers beware: Bookmarks to pages other than the home page may not work after we change our server in April Editor's Choice | This Week in BMJ | Press releases 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? Commentary: Education about the hymen is needed Sara Paterson-Brown The celebration of a bloody sheet, vividly portrayed in popular cinema, is based on strong religious and cultural beliefs. The Koran states that a bride has to be a virgin, and according to custom a woman found on her wedding night to have been "touched" brings shame to her family. Consequences include divorce through to death. (1) Young women, understandably, go to great lengths to get their hymens refashioned (hymenorraphy) before their wedding.(1) Hymenorraphy is illegal in most Arab countries, but it is performed unofficially; specialists undertake five or six procedures weekly (confidential communications). Egypt's trade in hymen repairs, reported last year, reduced "cleansing" murders by 80% over the previous 10 years.(1) The simplest technique of hymenorraphy, performed days before a wedding, uses catgut sutures to approximate hymen remnants (with or without incorporation of a gelatin capsule containing a blood-like substance which bursts on intercourse). The definitive procedure approximates undermined hymen remnants or vaginal flaps and often produces vascular bands across the introitus. These women may be told to instruct their husbands that their hymen is very vascular and that he should cut it with a "sharp instrument" before they attempt sexual intercourse. Appearances are deceptive In Western society hymenorraphy is legal and is comparable with plastic surgery in ethical terms. The concept of deception is not relevant; this operation is done for the woman; and the principle of confidentiality in medicine is as old as medicine itself. But factors such as sporting activities and use of tampons mean that bleeding with first sexual intercourse is not inevitable in the "Western" woman and is an unfair end point. I questioned 41 women colleagues about this: 14 (34%) bled on first intercourse, 26 (63%) did not, and one could not remember. Previous reports on physical examination of hymens show that the virginal state was certain in only 16 of 28 (57%) virgins,(2) and appearances relate to tampon use.(3) The report of Logmans et al on 20 cases of hymenorraphy in second generation Mediterranean and African immigrant women in the Netherlands exposes social issues that are of grave concern. Firstly, the youngest woman was 16 years old, and teenage sex in ethnic minorities is associated with a rising incidence of sexually transmitted diseases(4-7) and teenage pregnancy.(8) Secondly, 10 of 16 girls had been "forced" to have sexual intercourse. Are these girls receiving adequate sexual education, and are they more vulnerable to sexual harassment? Hymenorraphy is justifiable in certain circumstances, when the woman would otherwise suffer disgrace or worse. More importantly, however, young immigrant women require appropriate sexual education and their families need to be educated about their adherence to the "bloody sheet" theory.(8) I thank the numerous colleagues with whom I have discussed these issues. Queen Charlotte and Chelsea Hospital, London W6 0XG Sara Paterson-Brown, consultant obstetrician and gynaecologist email: s.paterson-brown@rpms.ac.uk References 1 Kandela P. Egypt's trade in hymen repair. Lancet 1996:347:1615. 2 Underhill R A, Dewhurst J. The doctor cannot always tell: medical examination of the "intact" hymen. Lancet 1978:i:375-6. 3 Emans S J, Wood E R, Allred E N, Grace E. Hymenal findings in adolescent women: impact of tampon use and consensual sexual activity. J Pediatr 1994;125:153-60. 4 Fenton K, Johnson A M, Nicoll A. Race, ethnicity, and sexual health. BMJ 1997;314:1703-4. 5 Lacey C J N, Merrick D W, Bensley V C, Fairley I. Analysis of the sociodemography of gonorrhoea in Leeds, 1989-93. BMJ 1997;314:1715-8. 6 Low N, Daker-White G, Barlow D, Pozniak AL. Gonorrhoea in inner London: results of a cross sectional study. BMJ 1997;314:1719-23. 7 De Cock K M, Low N. HIV and AIDS, other sexually transmitted diseases, and tuberculosis in ethnic minorities in United Kingdom: is surveillance serving its purpose? BMJ 1997:314:1747-51. 8 Adler M W. Sexual health - a Health of the Nation failure. BMJ 1997;314:1743-7. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline