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Hymenorrhaphy: what happens behind the gynaecologist's closed door?
  1. Ihab Usta, MD
  1. Department of Obstetrics and Gynecology, American University of Beirut, Medical Center, Beirut, Lebanon

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    Premarital sex is socially and religiously unacceptable in some cultures, with grave consequences such as shame, rejection, divorce, or even death to “cleanse the shame”. Hymenorrhaphy or hymenoplasty has emerged as a procedure which attempts to restore the ability of the hymen to bleed at intercourse on the wedding night, thus protecting women from violent reprisals.

    A few articles have recently appeared in the English literature debating whether hymenoplasty is clinically indicated or ethically justified.1, 2 If we review the English literature, we find only one article addressing the success of this operation in a group of 20 patients.1 The authors claim that all 20 were satisfied with the outcome and none had regrets. Long term follow up is available on only 10 patients (50%) and they report that the procedure provided a satisfactory outcome. This single article can hardly be convincing in an era of evidence-based medicine. There is the theoretical risk of infection which might disrupt the repair, thus defeating the purpose of the operation, and there is the potential risk of bleeding with intercourse, which might be traumatic to the couple. Well controlled studies to assess success and safety are extremely difficult to perform since the procedure is illegal and religiously condemned in most of the countries where hymenoplasty is performed, and neither the patients nor the physicians are willing to be involved in medicolegal or social conflicts. Most of the time, the medical records of such procedures are destroyed and follow up of these patients risks exposing the secret they are trying so desperately to hide.

    The procedure is financially rewarding to the physicians and taxing for women. The cost of such a simple procedure might become very high, depending on the physicians' whims and their estimation of the financial resources of the patients. Physicians might attempt such an operation for the first time for financial gratification even if they have no notion about the operation, since it is not taught in medical schools and is not found in any textbook of gynaecological surgery.

    There are unperceived social and psychological risks attached to performing the operation on request. Awkward situations might arise and multiple questions should be addressed before considering the procedure as acceptable ethically, morally, or legally. What is the limit on the number of hymenoplasties women are justified in asking for? A few men are presenting to our clinics requesting a gynaecological examination of their prospective wives before marriage to ensure that such an operation has not been done. Such operations will make all women suspects in the eyes of their men even if they are conforming to cultural standards and moral values. The psychological and social implications of a forced examination on the marriage as a whole are tremendous. By performing such procedures, physicians will be protecting a few women only through harming the majority. In addition, the physician checking for virginity is usually in a predicament when a repair is discovered. Even if the doctor thinks that he or she has a duty towards the patient alone, the responsibility for the morality of the patient's relationship with her husband cannot be denied since the proposed operation is intimately concerned with that relationship. Although the operation is done for women, yet the sole purpose is to deceive men. Respect for women's autonomy directly clashes with men's autonomy.

    Finally, surgical repair of the hymen reflects social injustice and hypocrisy since it confirms social inequality. It might deter sexual abuse victims from disclosing sexual violence and questioning the offender.

    In conclusion, hymenoplasty is a simple gynaecological procedure that creates a multitude of moral, ethical, social and religious controversies. Practising gynaecologists should be aware and familiar with these implications before taking the decision for or against performing it.