title: Hymen reconstruction as pragmatic empowerment? Results of a qualitative study from Tunisia.
abstract: Hymen reconstruction surgery (HR), while ethically controversial, is now available in many countries. Little clinical evidence and hardly any surgical standards support the intervention. Nearly as scarce is social science research exploring women's motivations for the intervention, and health care professionals' justifications for its provision. In order to better understand decision-making processes, we conducted semi-structured interviews in metropolitan Tunis, in 2009, with six women seeking the procedure, four friends who supported such women, four physicians who perform the operation, and one midwife. Health care professionals and patient companions expressed moral ambivalence about HR: although they could comprehend the individual situation of the women, they expressed concern that availability of the procedure might further entrench the patriarchal norms that compel the motivation for seeking HR in the first place. Some women seeking HR shared this concern, but felt it was not outweighed by their personal aims, which were to marry and become mothers, or to overcome past violent sexual experiences. The women felt HR to be uniquely helpful in achieving these aims; all made pragmatic decisions about their bodies in a social environment dominated by patriarchal norms. The link between HR and pervasive gender injustice, including the credible threat of serious social and physical harm to women perceived to have failed to uphold the norm of virginity before marriage, raises questions about health care professionals' responsibility while facing requests for HR. Meaningful regulatory guidance must acknowledge that these genuine harms are at stake; it must do so, however, without resorting to moral double standards. We recommend a reframing of HR as a temporary resource for some women making pragmatic choices in a context of structural gender injustice. We reconfirm the importance of factual sexual and reproductive education, most importantly to counter distorted beliefs that conflate an "intact hymen" with virginity.
authors.affiliation: University of Zurich, Switzerland; Ludwig-Maximilians-University, Munich, Germany. Electronic address: wild@ethik.uzh.ch.
authors.forename: Verina
authors.initials: V
authors.lastname: Wild
authors.affiliation: EHESS, Paris, France.
authors.forename: Hinda
authors.initials: H
authors.lastname: Poulin
authors.affiliation: University of Toronto, Canada.
authors.forename: Christopher W
authors.initials: CW
authors.lastname: McDougall
authors.affiliation: University of East Anglia, Norwich, Great Britain, United Kingdom.
authors.forename: Andrea
authors.initials: A
authors.lastname: Stöckl
authors.affiliation: University of Zurich, Switzerland.
authors.forename: Nikola
authors.initials: N
authors.lastname: Biller-Andorno
mesh_terms: D001294:Attitude to Health; D005260:Female; D013509:Gynecologic Surgical Procedures; D006282:Health Personnel; D006801:Humans; D006924:Hymen / Q000601:surgery*; D007407:Interviews as Topic; D008297:Male; D008393:Marriage; D036301:Qualitative Research; D019651:Plastic Surgery Procedures / Q000523:psychology; D012746:Sexual Abstinence / Q000523:psychology; D012725:Sexual Behavior; D014416:Tunisia; D014933:Women's Rights
keywords: Ethics; Gender inequality; Hymen reconstruction; Hymen repair; Hymenorrhaphy; Qualitative study; Tunisia; Virginity