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: Surgery is not what it seems Lainie Friedman Ross The decision by Dutch doctors to repair surgically the hymens of young women to mimic the virginal state is described as a case in which cultural values conflict with medical ethics. But this may not be an accurate description. Repair of the vaginal introitus is a low risk procedure that can be done as an outpatient procedure under local anaesthetic. It allows young women to bleed from intercourse on their wedding night. But it does not, as Logmans et al claim, show respect for cultural differences, nor is it proof that the immigrants cherish their traditional ideas. The surgery allows these women to appear as if they have conformed to these cultural expectations when their previous sexual experiences suggest otherwise. Despite my rejection of their cultural argument, I agree with Logmans et al that there are reasons to support the doctors' decisions to perform the surgery. The surgery may protect these women from violent reprisal. This is particularly pertinent given that at least half of the women claimed that their previous sexual intercourse was forced. However, the data may be exaggerated if these women believe that claiming forced intercourse will ensure that the doctors perform the surgery. Alternatively, the data may be an underestimation given the social taboos against the disclosure of sexual violence. In this context, the surgery may be crucial in averting further violence. Although Logmans et al are correct to differentiate between vaginoplasty and clitoridectomy, a more appropriate comparison would be that between vaginoplasty and breast implants. Both allow women to fulfil physical ideals of their respective cultures - ideals that others argue are symbols of female denigration. Obviously, there are surgeons who feel that these surgical procedures are acceptable. In this case, if a woman believes that reconstructive surgery is in her best interest, the surgeons should respect her autonomy and proceed with the repair or refer her to doctors who will do it. But it would be inadequate to stop the argument here. Respecting a patient's request for vaginoplasty must be understood in context. The surgery is only an interim solution because the true solutions are not medical but social; they are the promotion of greater gender equality in social norms and customs. MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL 60637, USA Lainie Friedman Ross, assistant director email: lross@uchicago.edu Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline