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L Seng Khoo lead article Hymenoplasty and virginity – an issue of socio-cultural morality and medical ethics pmfa news LEE SENG KHOO, IVO PITANGUY INSTITUTE, RIO DE JANEIRO, BRAZIL. VASCO SENNA-FERNANDES, IVO PITANGUY INSTITUTE, RIO DE JANEIRO, BRAZIL. This article reflects the increasing complexity of the modern world, where the rich diversity of culture, morals, the law and religion, can have profound effects on medical practice. Sometimes there is considerable debate which is not in fact appropriate. This is illustrated in the concerns about stem cell therapy and research where vocal commentators from the world of moral philosophy, the law and religion have not yet been able to distinguish between embryonic stem cell research, with the morally repugnant destruction of the fertilized embryo for the sole purpose of harnessing that life force for some other purpose, and non-embryonic stem cell research. Abortion is another contentious issue that has raised questions of morality, the law and ethics. The extreme views can lead to extreme actions and doctors in America who perform abortions, legally, may still come under threat from those who object to the law and the action. So what about virginity? Why should female virginity be prized whereas male virginity is not an issue? What are the biological imperatives in action here? It is possible to discern public health benefits from some of the traditional religious practices (e.g. avoiding pork) but what is so crucial about proof of virginity and the sanctity of marriage? The concern extends far beyond the barriers of religion and are deeply rooted in conservative societies. A gynaecologist from North West Pakistan told me recently that even medically indicated genital surgery was considered unacceptable and some mothers would rather have their daughters die than seek lifesaving treatment. The challenges do seem more extreme in the followers of Islam and an excellent paper has been published which discusses the issues in scholarly detail: ‘The Muslim Surgeon and Contemporary Ethical Dilemmas surrounding the restoration of Virginity’ (HAWWA 2007;5:324-9). This was written by Vardit Rispler-Chaim who is based in the Department of Arabic Language and Literature, The University of Haifa, Israel. The authors of this paper on hymenoplasty acknowledge the training they received from Dr Vishwa Prakesh who is based in New Delhi. In the next issue we will be publishing an update article from Dr Prakash where he describes his procedure for full-revirgination which is more than the simple hymenolasty. Whilst knowledge of techniques is essential it is also important to be aware of the state of the law. In this respect more guidance is needed with regard to what constitutes female genital mutilation in its broadest of definitions and reconstructive female genital surgery for ‘non-medical’ indications. We welcome comment and discussion on these sensitive but very important matters. H Prof Andrew Burd, Editor, PMFA News. ymenoplasty is a controversial surgical procedure that begets many ethical questions, in terms of social, cultural and medical issues. Virginity in females is a highly prized commodity in certain cultures and carries familial honour where non-virgins can face prejudice, social ostracisation and even death as they are considered to be bringing shame to the family. The notion of a ‘one size fits all’ approach in condemning or criticising hymenoplasty as a frivolous procedure that promotes deceit and encourages female oppression fails to identify socio-cultural aspects that are prevalent in the patient group seeking hymenoplasty. This paper explores the socio- cultural and religious factors involved in women seeking hymen reconstruction and the medico-legal and ethical principles that guide surgeons in offering and performing hymenoplasty. Proper training in hymen reconstruction should be offered to plastic surgeons and gynaecologists as hymenoplasty should not be trivialised as a simple, risk-free surgery. Background Hymenoplasty is defined as the surgical restoration of the structural integrity of the hymen [1]. Various techniques have been described in the literature concerning hymenoplasty [1-3]. It remains a controversial procedure that raises many ethical questions [4]. The hymen is often torn during a girl’s first experience of sexual intercourse and as such can represent the ‘loss of innocence’ and a rite of passage from girl to woman. While this is acceptable to many modern societies, loss of virginity in some cultures can bring 12 l volume 3 issue 2 V Senna- Fernandes about shame, humiliation, ostracisation and possibly even violence in the form of honour killings, resulting from husbands and families discovering from blood-free sheets that their wedding night had not been the bride’s first sexual experience [5]. In social and religious cultures that stress the importance of virginity, this could mean the difference between life and death. Brides-to-be who are unable to prove their virginity when they marry have been executed in order not to tarnish family honour [6]. Reports of these type of killings have grown exponentially in secular states in the Middle East and in Iran [6] as well as in some Western countries such as France [7]. It is important to understand that cultures differ and social norms accepted by one culture or country may not be deemed acceptable to another. People tend to identify with those who hold similar values and beliefs to themselves, sometimes vilifying those who differ. This ‘us versus them’ mentality is prevalent in many socioeconomic and cultural aspects of society. In this sense, it helps to be non-judgemental and attempt to understand that empathy is crucial in dealing with this subject matter. In Iran, engaging in premarital sex is considered a crime based on the code of ‘Crimes Against Chastity and Public Morals’ based on Islamic Shariah law [8]. In totalitarian regimes or societies in which the government imposes the law based on their religious interpretation in order to guide its citizens toward a life of acceptable morality, the lines between sin and crime are blurred. In 2008, a French Muslim couple in Lille had their marriage annulled because the wife was not a virgin. The French court