Independent report

Hymenoplasty: background paper

Published 23 December 2021

Introduction

Following widespread concern that some young women and girls are being coerced and forced to have their virginity tested, and subsequently undergoing hymen repair surgery, the Department of Health and Social Care (DHSC) and the Home Office undertook an intensive review to consider if government intervention was needed.

The review also looked to understand:

• who is carrying out virginity tests and hymen repair surgery
• in what settings virginity testing and hymen repair surgery are carried out
• whether women and girls are coerced into having these tests and hymen repair surgery, and if therefore they can be considered a form of violence against women and girls (VAWG)

The review concluded that there is no reason why a virginity test should be carried out. It is not a medical procedure, and is based on repressive and inaccurate views about female virginity and the hymen. It is a form of abuse and VAWG that has detrimental physical and psychological impacts on women and girls.

The review’s findings and recommendations were published on 22 July 2021 in the Tackling violence against women and girls strategy, which announced the government’s intention to ban virginity testing when parliamentary time allowed.

The review’s conclusions for hymenoplasty were not as clear. Concerns remained that the uptake for the procedure stems from damaging and repressive attitudes towards a woman’s sexuality and virginity. The government therefore announced that it would convene an expert panel to:

• consider the clinical, legal and ethical implications of hymenoplasty
• make recommendations to the government as to whether hymenoplasty should be banned

This is the background paper for that panel. Along with setting out the findings and evidence gathered during the DHSC intensive review, this paper also outlines several other sources of evidence. This evidence includes:

• an extensive literature review
• position statements from Royal Colleges
• recent campaigns and lived experience case studies
• the conversation and positions put forward by the Moral and Ethical Advisory Group who were consulted prior to the establishment of the panel

For the purposes of this paper, the evidence has been grouped into themes and was presented to the panel to aid their discussions.

In addition, the government is aware that banning the procedure alone will not tackle the harmful misbeliefs and misconceptions surrounding virginity, and that wider societal education is required. Work has already begun with a roundtable with key stakeholders to discuss:

• how best to provide general education and information around these issues
• what targeted work with communities is needed and how this fits in with wider work on preventing and tackling honour-based abuse

Alongside this, work has begun with the Royal College of Obstetricians and Gynaecologists (RCOG) and NHS Digital to investigate the miscoding within the NHS.

Definitions

Hymen

The hymen is a thin membrane that partially covers the entrance to the vagina. During puberty, oestrogen causes the hymen to change in appearance and become very elastic. Normal variations of the post-pubertal hymen range from thin and stretchy to thick and somewhat rigid. A non-intact or stretched hymen is not necessarily an indication of past sexual activity nor is it a given that the hymen will break or bleed after first vaginal intercourse. It has relatively few blood vessels that are unlikely to cause significant bleeding.

The hymen can also stretch or tear quite easily before a woman has sex for the first time through activities such as horse riding and other sports, using tampons and masturbation. The World Health Organization is clear that the appearance of a hymen is not a reliable indication of intercourse.

Hymenoplasty

Hymenoplasty (also known as hymenorrhaphy or hymen reconstruction or hymen repair) is a surgical intervention that involves reconstructing the hymen. There are a number of different techniques to achieve this but generally it involves stitching the torn edges of the hymen together with dissolvable stitches. The aim of the procedure is to ensure that the women bleeds when she next has sexual intercourse.

Like any surgery, hymenoplasty carries risks but patients should be able to return to normal activities within 24 to 48 hours. Complete healing takes up to 3 months. Hymenoplasty does not fall within the legal or diagnostic definitions of female genital mutilation (FGM). Hymenoplasty is not the same as other procedures that could be performed on the hymen for clinical reasons (for example, surgery to remove remnant fingers of the hymen that cause discomfort, or to treat an imperforate hymen to allow menstrual blood to escape).

There is no requirement for surgeons in the private sector to record numbers of procedures performed but the extent of advertising suggests that hymenoplasty procedures are widely available.

Hymenoplasty is banned in the United Arab Emirates for non-married women.

Virginity testing

Virginity testing, also referred to as hymen, ‘two-finger’ or vaginal examination, is an inspection of the female genitalia, intended to determine whether a woman or girl has had vaginal intercourse.

The position of the World Health Organization and the RCOG is that virginity tests have no scientific merit or clinical indication as it is not possible to tell whether a woman has had intercourse through this type of examination.

Regulatory and legal landscape

Regulation

Hymenoplasty is a form of female genital cosmetic surgery. In the UK, all cosmetic surgery procedures are regulated and may only be performed by doctors registered with the General Medical Council (GMC). The GMC sets standards for doctors and provides guidance on specific interventions, such as guidance for doctors who offer cosmetic interventions, expectations for new doctors or consent.

The GMC’s decision-making and consent guidance explains how doctors should approach situations where they are concerned a patient cannot make a decision freely. It says that if, after taking steps to support the patient to make their own decision, the doctor still believes a patient is under such extreme pressure to agree to or refuse a particular intervention that they cannot exercise free will, they should seek advice through local procedures, consult their medical defence body or professional association, or seek independent legal advice. They are also expected to follow local safeguarding procedures and consider raising a concern if they think the patient’s rights have been abused or denied.

Any concerns about the practice of an individual surgeon would be a matter for the GMC. As the professional regulator, the GMC is responsible for investigating the conduct of individual doctors or surgeons and has the power to hold individuals to account where their fitness to practise is called into question.

The regulation of services differs between the home nations, who each have a different regulatory body. How these organisations operate does not differ significantly and, for the purposes of this paper, we used the Care Quality Commission (CQC) in England to illustrate how regulation works.

The CQC regulates services that provide hymen repair surgery (and female genital cosmetic surgery more broadly) where it is carried out by a healthcare professional.

Where the CQC identifies concerns or takes action that requires providers to make improvements, this information is held at a local level by our local inspection teams rather than being stored centrally. As a result, it’s not possible to provide a list for all services that offer this specific type of surgery where they may have identified concerns or taken enforcement.

Where the CQC finds evidence that standards of quality and safety are not being met in a service they regulate, then they will hold those providers to account using their enforcement powers, where necessary, to protect people. Where a service treats patients who are under the age of 18 years, the CQC expects to see evidence that appropriate child safeguarding arrangements are in place.

The CQC’s guidance on choosing cosmetic surgery reflects the current position and was updated in 2019 to reference polydioxanone (PDO) thread lifting being in scope. This guidance empowers patients by giving them the information they need, including advice on their legal rights and how to find an appropriate and safe service, thus allowing them to make informed decisions about their treatment.

The CQC also published this letter to providers and news story in 2019, which set out the CQC’s emerging concerns in this area, and called on providers to take appropriate action, where necessary, to meet the expected standards. The CQC’s concerns included the failure to ensure consent is obtained in a 2-stage process with an appropriate cooling-off period between initial consultation and surgery.

Legal

Health is devolved and, as such, the legislation between the home nations differs but not significantly. For the purposes of this paper and the work of the panel, the below legislation has been used to illustrate how surgical procedures, which include hymenoplasty, are legally regulated.

Under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, surgical procedures (including hymenoplasty) are regulated activities. Surgical procedures are defined as a procedure (including pre-operative and post-operative care) carried out by a healthcare professional for:

• the purpose of treating disease, disorder or injury
• the purpose of sterilisation or reversal of sterilisation
• cosmetic purposes, where the procedure involves the use of instruments or equipment that are inserted into the body
• the purpose of religious observance

Regulation 11 sets out the need for consent, and provides that care and treatment of service users must only be provided with the consent of the relevant person.

If a surgeon operates without consent then, aside from being in breach of the 2014 regulations, they could also be committing an offence under the Offences against the Person Act 1861.

Common law provides that a medical professional that treats a patient without consent may incur criminal liability. There are, exceptions – for example, where a patient is unable to consent to emergency treatment because of illness or injury – so there would have to be a case-by-case assessment as to whether an offence may have been committed. A failure to establish informed consent can also result in action by the GMC.

European Convention on Human Rights

Article engaged: Article 8 (Right to respect for private and family life)

Interference

The introduction of a prohibition on hymenoplasty could be argued to interfere with the right to respect for private and family life in Article 8 in that it would limit an individual woman’s ability to undergo the procedure that she might choose.

Justification

Article 8 is a qualified right. Any potential interference with Article 8 could be justified if it:

• is in accordance with the law
• meets a legitimate aim
• is necessary in a democratic society (that is, it is proportionate)

The drafting of the law creating an offence would need to be sufficiently clear and precise, and would be communicated appropriately through a planned information and education campaign. This should not present a problem and would be subject to parliamentary scrutiny.

Such an offence would meet the legitimate aim of preventing a practice that has both short and long-term negative impacts on physical and mental health, and is considered a form of VAWG, which should have no place in society even when it is consented to.

Like virginity testing, hymenoplasty is linked to:

• child marriage and forced marriage
• other forms of family coercive control, including physical and emotional control
• risk of honour-based violence, including emotional abuse and family or community disownment

Criminalising hymenoplasty is considered proportionate to this aim.

Article engaged: Article 9 (Freedom of thought, conscience and religion)

Interference

To the extent that a person’s Article 9 rights are engaged, the introduction of a prohibition on hymenoplasty has the potential to interfere with Article 9 if it infringes upon a person’s right to freedom of thought, conscience and religion.

Again, this would be linked to religious cultures where virginity is considered an important social norm that links sexual purity with the honour of an individual woman, her family and community. Evidence links hymenoplasty to Muslim, ultra-orthodox Jewish and fundamentalist Christian communities.

Article 9 protections are afforded to traditional practices that are objectively not part of the ‘core’ precepts of an individual religion but are heavily inspired by that religion and have deep cultural roots, such as the wearing of certain items of clothing. However, Article 9 protection has not been granted to other practices, such as the infliction of corporal punishment or a man’s wish to marry and have sexual relations with a girl under the legal age of sexual consent on the grounds that such a marriage was valid under Islamic law.

These examples suggest that hymenoplasty would not be a practice that finds protection on the grounds that it is the manifestation of a religion or belief.

Justification

To the extent that it could be claimed that hymenoplasty was a manifestation of religion or belief, the interference could be justified by reference to the legitimate aims of protection of health and morals, and the rights and freedoms of others.

The aims of the measures are set out above in relation to Article 8.

Article engaged: Article 14 (Freedom from discrimination) in conjunction with Article 8 or 9

Interference

Because hymenoplasty is carried out primarily among religious communities, it could be argued that there is discrimination in the protection of the rights under Articles 8 and 9 outlined above for these religious groups. And, because the practice is found in Middle Eastern and Asian communities, there could be a similar argument in relation to race.

Because the prohibition applies across the board, the argument would have to be that there is indirect discrimination against particular religious or racial groups. To make such a claim, it would be necessary to demonstrate that the situation falls within the ambit of Articles 8 and 9.

Justification

To the extent that it could be successfully argued that the hymenoplasty prohibition falls within the ambit of Articles 8 and 9, any indirect discrimination that resulted can be justified if it is “objective and reasonable”.

This is where it is shown to be in pursuit of a legitimate aim, and proportionate in the sense of striking a fair balance between the rights and freedoms of the individual and the general interest.

For the reasons set out above in relation to Article 8, this measure is considered to pursue a legitimate aim in a proportionate way.

Evidence

The evidence put forward in the following chapter stems from a mix of sources such as:

• the DHSC intensive review – findings and evidence gathered from:
  • an initial literature review (academic papers, grey literature and media coverage)
  • data from published and unpublished sources
  • evidence submitted to the VAWG strategy call for evidence by third sector organisation Karma Nirvana
  • interviews with over 25 key stakeholders from across the health and care system, including NHS clinicians, professional bodies, the Royal Colleges, and third sector organisations. Seven clinics offering hymenoplasty were approached, but the team were only able to speak to one clinician who had performed a hymenoplasty and none who had performed a virginity test
• prior to the establishment of the expert panel, the views of members of the Moral and Ethical Advisory Group. Their conversations and positions have been included in this paper and we would like to the thank those who contributed
• an extensive literature review by Professor Sir Jonathan Montgomery
• public-facing campaigns and position statements, and the amendments put forward by Richard Holden MP
• lived experience case studies – these have been provided by Karma Nirvana and the IKWRO Women’s Rights Organisation. The women and girls represented have given their agreement to share their stories, but their names and identifiable details have been anonymised. Some may find these stories distressing and there is support available. If you are affected by them in anyway, please contact the below organisations who are there to help:
  • Karma Nirvana – 0800 599 9247
  • IKWRO Women’s Rights Organisation – [email protected] or 0207 920 6460
  • Middle Eastern Women and Support Organisation (MEWSo – [email protected] or 07579 801 366

Why does hymenoplasty take place?

Hymenoplasty and virginity testing can be intertwined as women may be subjected to surgery after failing a virginity test to adhere to the cultural belief that a woman should be a virgin upon marrying.

Hymenoplasty can also be a choice. Women who have had sexual intercourse before marriage may seek surgery out of feelings of shame or from fear of punishment. There was also some evidence that women may have hymenoplasty if they are remarrying and want a ‘fresh start’.

In some cultures that place a high value on virginity and ‘purity’, displaying proof of a bride’s virginity is customary – the nuptial blood-spotted bed sheet is used as evidence – therefore hymenoplasty can save women from social embarrassment and provide the confirmation of being a virgin all over again.

Hymenoplasty is driven by a cultural expectation. It is a wider indication of a very patriarchal and culturally dominant society over women.

It is not clear whether all women who have hymenoplasty have had sexual intercourse or are having the procedure for other reasons – for example, we found some evidence to suggest that women may have a hymenoplasty if they are worried the hymen has ruptured through non-sexual activity, such as playing sport.

Early discussions in the medical and bioethics literature considered hymenoplasty as a form of gynaecological cosmetic surgery.^{[footnote 1]} This led to analyses based on informed consent.^{[footnote 2]} It was described as an example of ritualistic surgery “in fulfilment of a person’s need” and was compared to male circumcision but distinguished from FGM.^{[footnote 3]} A clinical commentary raised concerns about hypocrisy, abuse and confirming sexual inequality through surgical intervention purely on social grounds.^{[footnote 4]}

The most detailed study of women seeking hymenoplasty was carried out in the Netherlands.^{[footnote 5]} All of the 92 women applying for hymenal repair in two hospitals in Amsterdam between January 2007 and December 2009 were eligible, and 82 were recruited into the study. They were assured that their choice would be respected, provided with information and counselling before reaching a decision, and interviewed about their motivations. Approximately half were followed up for further interviews. Almost one third (n=25) of the women had lost their virginity through unwanted sex, by force or threat, but an even bigger proportion (48%) reported a history of forced intercourse. Suicide had been attempted by 7% of them as the only way out after losing their virginity.

The study asked about the expectations that the women had of the effects of reconstruction:

• blood loss on their wedding night was the sole objective for 31% of the women
• 12% had the goal of ‘feeling tight’
• 35% hoped for both these things
• 9% were seeking hymenoplasty to help them overcome traumatic sexual experiences
• 13% expected that the operation would increase their self-confidence or self-esteem

Almost all (89%) of women feared repercussions if they were perceived not to be virgins. Almost half (49%) feared that they would be expelled from their families and would have to live as an outcast. An honour killing was expected by 12%.

Some women dropped out of the study after the first (11%) or second (6%) visit without pursuing surgery. More than half (54%) decided on an alternative (such as ways to feign blood loss) to surgery or to do nothing.

After options were explored, 29% ultimately decided to go ahead with the surgery. Nineteen of those women were seen at follow-up. Only 2 of them had bled during the wedding night. Thirteen of them said that they would make the same decision again and 6 said that in retrospect they would not have chosen to have surgery.

Eleven of the women who had decided not to be operated on were interviewed at follow-up. None of them had been accused of not being a virgin, although the marriage abroad of one woman had been cancelled because a local witch doctor has declared she was not a virgin.

Where is hymenoplasty most prevalent and in which settings does it take place?

As with virginity testing, hymenoplasty is prevalent in highly conservative communities and cultures.

Hymenoplasty is carried out in private clinical settings and a procedure costs up to £3,000 – at least 22 clinics have been identified. There is some evidence of the procedure taking place on the NHS – however, there are similar procedures and this is believed a result of a misunderstanding on the procedure or coding errors. DHSC and RCOG are working with NHS Digital to investigate this further. Recent evidence has also been found that the procedure may be being carried out in community or family settings.

Hymenoplasty is most performed on unmarried women and girls. It is unclear whether both are limited to a certain age group due to the little data available, but we can derive from the anecdotal evidence that virginity tests have been performed on girls as young as 13. There are very few accounts of women in the UK who have undergone hymenoplasty speaking about their experiences, therefore it is difficult to attach the surgery to a specific age group.

It is worth drawing attention to the fact that around 9,000 people in the UK searched Google for ‘hymenoplasty’ in 2019. Although people could have researched the procedure out of curiosity, there may be a link between the number of internet searches there were for hymenoplasty and the increase in hymenoplasty requests in private clinics.

Studies of European clinicians also suggest that a majority were prepared to perform the procedure. In Switzerland, a study found that hymen reconstruction was rarely performed, but that 63.2% of clinics reported receiving requests for hymen reconstruction, of which 64.3% said they always (28.6%) or mostly (35.7%) granted the request.^{[footnote 6]}

A study of Flemish gynaecologists found that 52% of those who had received requests to perform hymen reconstructions had done so, although requests were infrequent. It was reported that, in the early 1990s, Dutch gynaecologists who performed hymen reconstructions did so between 3 a year and as frequently as 10 to 15 a month.^{[footnote 7]}

The view of the British Association of Aesthetic Plastic Surgeons (BAAPS) is that:

The BAAPS does not recognise or support hymenoplasty as a cosmetic procedure. This is not a procedure that is condoned, taught or discussed within UK plastic surgery training nor at any plastic surgery educational or scientific meetings. Furthermore, it is not part of the specialist training that a plastic surgeon on the GMC specialist register would undergo.

We recognise there may be underlying psychological, cultural and social issues that lead to hymenoplasty being sought, and which this type of procedure can perpetuate. These can detrimentally affect society and women in particular. In addition, there is a need for further social and psychological support for women affected.

Does hymenoplasty cause harm? Is it a form of violence against women and girls?

Many stakeholders supported a ban on hymenoplasty as it stems from patriarchal attitudes of coercion and control over women. Many stakeholders highlighted that the links with shame, control, coercion and honour-based abuses mean that the procedure could rarely be freely consented to.

This is about coercion and the consequences for women that don’t agree to undergo it, the consequences are high – either exclusion or harm.

We cannot conceive someone giving their consent. Irrespective of whether it is cosmetic or not, a woman is being coerced.

In terms of the psychological impact of virginity testing and hymenoplasty, many argue that anxiety, depression and post-traumatic stress disorder are commonplace – especially if performed without the patient’s consent.

Case study: LH

LH went to university. In her second year, her parents would often visit with men to meet her as potential matches for arranged marriage.

LH entered a serious relationship, which she kept hidden from her parents. She became pregnant and both she and her partner, a fellow student, wanted to keep the baby. However, LH knew that her parents would not support the relationship. LH ended up having an abortion and went back to live with her parents.

LH’s parents discovered that she had been in an intimate relationship and pressured her into having hymenoplasty and then into a marriage of their choice to an older man. LH went ahead with the hymenoplasty and the marriage. LH had children with her husband.

LH suffered extreme coercive control from her husband. Ultimately, he used this method of abuse to get full custody of their children. LH attempted suicide by jumping from the roof of their flat and broke both legs. Looking back, LH sees that the hymenoplasty played a key role in enabling the abusive forced marriage.

In addition to the risks associated with undergoing any surgical procedure, hymenoplasty can cause physical damage, including:

• sexual difficulties
• narrowing of the introitus
• acute bleeding during the procedure
• increased pain sensation

Case study: S

S was sexually abused as a child by an extended family member. S was also raped as a teenager. Her family’s only priority was their reputation – their ‘honour’ – which they believed rested upon their daughter being perceived as pure.

S’s parents spent a long time pressuring S into having hymenoplasty, because they wanted to force her into a marriage with an extended family member, who was much older and who she did not want to marry. They tried to convince her that it was in her best interests.

S was determined not to have hymenoplasty, which she felt would be intrusive, another experience of abuse and undermine her truth. To try to resolve the situation herself, she ended up marrying someone else quickly, who would not judge her for not being a virgin. She feels that, if she had not been under pressure, she may not have rushed into this marriage, which ended up being abusive.

S feels very strongly that hymenoplasty is a form of honour-based abuse and must be banned.

Case study: RR

19-year-old RR called the helpline in June 2021 and disclosed that she had been suffering from honour-based abuse and domestic abuse at the hands of her family. She explained that the trigger for this was that she has a boyfriend and had fallen pregnant.

Prior to her pregnancy being revealed, the abuse was largely verbal and emotional. However, after her family found out that she was pregnant, she was beaten, pinned down, forced into a car and taken to a hospital.

Upon arriving in the hospital, she was taken to a doctor and informed that an abortion would be taking place, as well as a procedure that would ‘reclaim her virginity’. She tried to inform the doctor that she did not want this. However, she was being held down by her family members. It was clear that RR did not want to go through with either of the procedures – however, her objections and struggles were ignored.

Somehow, RR managed to break free and ran out of the hospital. RR has since fled to safe accommodation, but is so traumatised by her experiences that she never wants to set foot in a hospital again or speak with a doctor. When we spoke, she had not even gone for her first scan and was reluctant to seek medical advice for her options regarding either keeping her baby or terminating her pregnancy.

Does hymenoplasty perpetrate harmful myths about virginity?

Many stakeholders felt strongly that hymenoplasty should be banned on the grounds that it reinforces misbeliefs about the hymen and is not clinically necessary.

Case study: N

N lives at home with her family and is in her early twenties. She was in a relationship with a man who she trusted. He took a video of them just after they had been intimate, convincing her at the time that he wanted to capture the special moment. He started to become controlling and then proposed. When his proposal was rejected, he sent some photographs to N’s family that suggested intimacy and then threatened to send the video them.

N’s aunt suggested a virginity test and that day N started searching online for hymenoplasty.

She didn’t have the money for it and was scared about the procedure as she is terrified about undergoing surgery. The only reason she looked into it was because she thought it would guarantee that she would appear a virgin if put to the test, but she did not want to do it otherwise.

She asked if IKWRO could help fund the hymenoplasty. IKWRO explained that they could not do this, but that they could support her through their advice, advocacy and counselling services. IKWRO carried out a risk assessment and needs assessment, and created a bespoke safety plan with her.

When N understood that many women never bleed at first intercourse and that hymenoplasty could not guarantee bleeding at next intercourse, she decided not to have the procedure.

Case study: A

18-year-old A called the helpline in August 2021 and disclosed that she had been suffering from honour-based abuse and sexual violence from her family. A explained that, as she is a female, she is treated differently and has different expectations placed upon her by her family. She has a lot of restrictions and is not really allowed to see her friends regularly.

A explained that she was allowed out a couple of days ago and was raped by 3 boys. She got scared that her family would find out because they regularly checked her ‘down there’ and she had been ‘fixed’ as a child. She said that her family do not believe in rape and believe that it is the woman’s fault, therefore she was terrified of making any type of disclosure.

A is due to get married in 2022 and she will not be able to hide ‘it’. A said when she was younger, in her county of origin, she knew of someone who was ‘open’ before marriage and they were killed. She remembers her family saying she deserved it. She said usually the husband ‘opens her’ on the wedding night.

She knows people who have opened by falling or something – however, it is still seen as shameful. A doesn’t agree with cutting and she does not think it should happen to girls.

A called back a couple of days later, saying that her family had conducted a virginity test on her against her will and had found out about her rape. A described being pinned down by her mother as her father and grandmother checked her.

She said that, when her father realised she had ‘been opened’ he remarked that she must want to sleep with everyone. Subsequently, her father invited all her male family members to rape her. A was gang-raped all night and then thrown out the house and told to never come back or they would kill her.

A is staying with a friend and is in a lot of pain and bleeding a lot. However, she is too scared to go and speak with a doctor as she feels it will bring too much shame.

A called back 2 weeks later. She was found by her family and returned home to them. She admitted that they held her down against her will and ‘sewed her up’ again. She said her aunties did this to her to restore her honour and virginity.

DHSC’s internal review found that there is a lack of public information and clinical leadership on hymenoplasty. Stakeholders felt that government intervention alone would not be enough to solve the root cause of the problem, and that it must go hand in hand with the provision of better information and education on both the procedure and misbeliefs about virginity. Stakeholders believed there was a lack of consensus and clinical guidance on the procedure.

The literature review found that an account of the issues from a Muslim perspective sees the surgeon faced with a dilemma between supporting deceit and saving women’s lives.^{[footnote 8]} Similar views were expressed in a study of clinicians in Tehran.^{[footnote 9]} Interviews with Egyptian doctors suggested that they made moral judgments about whether women should be considered eligible for the procedure, including whether they had repented of their sexual history, acting in the shadow of conflicting religious fatwa on its permissibility.^{[footnote 10]}

A survey of Lebanese students found that approval of the procedure was low for both women and men, and that 46% of male respondents stated that they would divorce their wife if they discovered that she had undergone hymeneal surgical restoration of virginity. Violent attitudes were also identified. Participants also reported that they would ‘hurt’ (5.3%) or kill (4%) the woman who had undergone the procedure.^{[footnote 11]}

A study of Turkish doctors identified one group who would decline to perform virginity surgery because it would involve helping a woman deceive her husband-to-be. However, this was a small group. The view that, if women wanted the procedure then it was acceptable to offer it, just like any other medical service, was more common. The researchers found that the main motive for doing so was to earn money rather than save women from harm.^{[footnote 12]}

Hymenoplasty is a form of cosmetic surgery – can we take away women’s right to choose what happens to their body?

The starting point in bioethics is that people have autonomy over their body. They get to choose what happens (or does not happen) to it through the practices of informed consent.

Some stakeholders outlined that introducing legislation in this space would take away the right for women to make decisions about procedures they wish to have and be counter to the current regulation of cosmetic surgery.

As with all forms of cosmetic surgery, hymenoplasty may not be clinically necessary but may have personal and psychological benefits for the individual. Stakeholders drew direct comparisons with other forms of cosmetic surgery – for example, if a woman can choose to have a breast augmentation, why should she be denied the right to have a hymenoplasty procedure? It was also questioned whether legislative intervention would be problematic as it may disproportionality affect women from ethnic minorities. Correlations with FGM were made.

The main ethical argument identified in favour of hymenoplasty is a patient’s right to request and receive medical procedures.^{[footnote 13]} It was noted that:

an important, and often persuasive, argument in feminist advocacy is that the decisions that competent women make regarding their own bodies and medical treatment should be respected.

The authors^{[footnote 14]} go on to state that:

Equal respect for their differences allows men to take drugs and procedures – for instance, for penis enlargement – and women to have procedures for hymen reconstruction.

The ethical literature includes comparative analyses of hymenoplasty with male circumcision, female genital cosmetic surgery, FGM and blood products for Jehovah’s witnesses. These ethical analyses generally assume that women are providing free consent to the procedure in an oppressive context. There is some support in feminist literature for the view that making hymenoplasty available can be seen as ‘pro-feminist and pro-multiculturalist’ as it enables women to choose to live by their own values.^{[footnote 15]}

A number of qualitative studies have explored decision-making. A study of women and practitioners in Tehran identifies some who rejected hymenoplasty on the basis that it would be colluding in patriarchy, while others saw it as a tool in negotiating the oppressive culture.^{[footnote 16]} A study of Tunisian practice identified the use of hymenoplasty as a pragmatic choice in the context of structural gender injustice.^{[footnote 17]} An analysis of the practice in Turkey^{[footnote 12]} suggested that women used virginity surgery:

as a strategy to combat the patriarchal expectations of the family and society without compromising their desire for a premarital sexual relationship.

These studies suggest that women make choices that are rational responses to an unreasonable and unjustifiable context.^{[footnote 18]}

It should be noted that those whom researchers can access may not be representative of the group about whom concern is most acute. The Turkish study in 1992^{[footnote 12]} suggested that women from upper classes, high status and high-income jobs did not tend to consult physicians for hymen repair, and that the ‘prototype’ of those seeking the service would be:

a metropolitan woman, in her late teens or early twenties, lower middle class, having low-status work experience and in a low-income job (clerical, sales, or nursing).

The study of Lebanese students^{[footnote 11]} found that males who answered they would hurt or kill their wife if a history of hymenoplasty was revealed were more likely to belong to a lower socioeconomic strata of society.

Little data exists on outcomes of hymenoplasty or women’s satisfaction with the results.^{[footnote 19]} One report, involving 20 patients followed up in 1993, states that all were “satisfied” with the outcome and “none had regrets”.^{[footnote 20]} However, no explanation of the definitions of these terms or methodology for follow-up was given. It was reported that half of these young women had lost their virginity as a result of forced intercourse.

Does the procedure offer protection?

In Sweden, the official policy is that hymenoplasty should not be performed. However, a study of Swedish clinicians found that 58% would be prepared to assist young females with hymenoplasty in some circumstances^{[footnote 21]}, with the main reasons for doing so recorded as being:

trust the females and take threats seriously

duty to save a patient’s life

simple way of helping patients

safe and not risky

Further exploration^{[footnote 22]} identified that:

clinicians with experience of women requesting virginity certificates or hymen reconstructions tend to be pragmatic and are not willing to alienate a young woman and cause her distress in order to maintain strongly held values or absolutistic ethics.

Swedish clinicians are concerned about the cultural context that discriminates against women, but regard hymenoplasty as protecting individual women from harm while it endures.^{[footnote 23]}

Clinicians claim they perform VT [virginity testing] and hymenoplasty for safety of the girls.

…In societies that place such importance on the concept of virginity, the wellbeing of the woman concerned is of paramount importance and, on that basis, I am willing to help the young ladies.

Would a ban indirectly increase the risk to women and girls?

A ban will not alter centuries of culture and so it is fair to argue that it will still occur in non-healthcare settings. Not only will women remain trapped in a cycle of coercion, but women will be at risk from infection and anatomical damage, and further psychological harm or stress.

In January 2020, the BBC noted:

A ban or the regulation on hymen-repair surgery could force the procedure underground which may lead to women coming to physical harm.

People will go to any lengths to ensure the hymen is repaired.

What about women that can live freely and have sex, and then have a hymenoplasty before marriage? They are internalised values, yes, but the law should not impose its values if there is no harm.

The clinician who performed hymenoplasty as part of their private practice outlined that the procedure could be a way to provide options for women who wish to have a sexually active life before marriage, or to save them from future stigma or abuse.

The dominant analysis is that hymenoplasty is a low-risk procedure that women request for social reasons and that should not normally be denied. It was acknowledged that this should be seen as a temporary solution and that work should be done to address the harmful cultural context, but this was seen as outside the scope of clinical ethics. Indeed, it was suggested^{[footnote 14]} that it was not acceptable to make women:

sacrificial instruments of eventual cultural reform by denying hymen reconstruction.

In a subsequent chapter^{[footnote 24]}, the authors argue that:

Until such modification occurs, hymen reconstruction can protect women’s human rights to life, freedom from violence and from inhuman and degrading treatment, to marry, and, for instance, to the highest attainable standard of health, in addition to the underlying right to non-discrimination.

A frequently cited editorial notes that some doctors advocate refusal of requests for hymenoplasty, but others^{[footnote 25]} argue that:

hymenal repair is performed for the interest of the young woman as it aims at protecting her from reprisals she might incur if her relatives discover that she has had premarital sex.

An influential paper argued that ethics required gynaecologists to consider the consequences of refusal^{[footnote 14]}, which were said to:

include women’s expulsion from their families and communities, terminated betrothal, divorce, personal violence and, at its most extreme, so-called ‘honor killing’, usually by close family members.

It suggested that refusal to provide the treatment was a form of conscientious objection and that clinicians therefore had a duty to refer women to other practitioners who would be prepared to perform the procedure under the FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health ethical guidelines.^{[footnote 14]}

Can there be any circumstances where a hymenoplasty should be carried out?

The literature review found that there were also discussions on how clinicians should respond if women requested hymenoplasty. An ethical commentary in the British Medical Journal argued that the main ethical issue was the doctor’s collusion in deceit.^{[footnote 26][footnote 27]}

Considering this objection to medical involvement in hymenoplasty, it was suggested that it should not prevent it being offered where virginity had been lost involuntarily (including coercion and rape)^{[footnote 14]} as:

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.

Some accounts suggest that it may be significant why virginity was lost.^{[footnote 8]} On a possible rape exemption, it has been suggested^{[footnote 27]} that:

When a woman who autonomously commits herself to satisfying the expectation of virginity is raped, the crime is particularly heinous for her, and hymenoplasty, in such a case, could be thought of as genuinely ‘truth-restoring’ because, even though the assault might have resulted in a ruptured hymen, she is still a virgin – her main concern – in the more profound and important sense of not having had voluntary sex.

The position of the RCOG and Institute of Psychosexual Medicine regarding the inclusion of rape as an exception to a legislative ban on hymenoplasty is as follows:

Hymenoplasty as a remedy or treatment for victims of rape must not be named as an exception in the proposed legislative ban on the procedure which the expert panel is currently considering.

There is no evidence that surgery to physically reconstruct a hymen that may have been damaged as a result of rape or other forms of sexual violence or sexual harassment has any benefit to supporting an individual to recover physically, emotionally or psychologically.

Undergoing hymenoplasty may actually cause flashbacks to the previous rape or sexual violence experienced by an individual, causing further psychological damage.

Hymenoplasty is very often performed on vulnerable women who are coerced into the procedure which itself may cause psychological distress without previous history of rape or assault. The probability and intensity of such psychological distress are likely increased by a history of rape or assault.

Another concern about collusion was identified: that “professionals who participate in the procedure would be complicit in holding women to higher standards of behavior (sic) and status than are required of men” and that this would be in conflict with the UN Convention on the Elimination of All Forms of Discrimination against Women.^{[footnote 14]}

A survey of midwives attending the International Confederation of Midwives in 2008 found that only 8% of respondents thought hymen operations were justifiable.^{[footnote 28]}

Support for a ban

In August 2021, RCOG published their position statement, which calls for a ban on both virginity testing and hymenoplasty. The position statement made the below recommendations:

1. A ban on the practices of virginity testing and hymenoplasty should be included in the upcoming Health and Care Bill. The government has currently committed to legislating to ban virginity testing but has not yet made this commitment on hymenoplasty. A ban on virginity testing is undermined without a ban on hymenoplasty as the 2 practices are inextricably linked. A ban solely on virginity testing is compromised unless a hymenoplasty is also prohibited.
2. NHS Digital should conduct a review of all the codes that relate to the hymen on the current NHS system, ensuring there are adequate codes available for all procedures that are clinically necessary, and no codes for procedures that allow for clinicians to undertake a hymenoplasty or ‘hymen repair’.
3. A space for comprehensive, evidence-based and high-quality information about virginity should be created on the NHS website, as well as within healthcare and other public sector settings.
4. Healthcare professionals should be supported to know what steps to take when they are requested to undertake virginity testing or hymenoplasty.

The IKWRO Women’s Rights Organisation’s Virginity Does Not Define Me campaign, launched in May 2021, calls for a ban on both virginity testing and hymenoplasty. It states that virginity testing and hymenoplasty:

are inextricably linked and the banning of virginity testing is compromised, unless hymenoplasty is also banned.

The legal continuation of both virginity testing and hymenoplasty undermines trust in the medical profession, and the absence of legislation to prohibit both undermines confidence in the government’s commitment to women's rights.

In a recent letter to the Secretary of State for Health and Social Care, the RCOG, Royal College of General Practitioners, Royal College of Midwives, Faculty of Sexual and Reproductive Health, British Society of Urogynaecology, British Society for Paediatric and Adolescent Gynaecology, British Society for Gynaecological Endoscopy, and numerous third sector organisations and campaigners requested that the government legislates for a ban via the Health and Care Bill.

Richard Holden MP has also tabled an amendment to ban the procedure in the Health and Care Bill, which has received support from 27 cross-party parliamentarians and numerous women’s rights charities.

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