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Hymenal Ethics: An Evaluation of the Hymen Reconstructive Surgery in The Netherlands

 

Young and in love, 18 year old Naima decides to take an unconventional step to prepare for her wedding night. She walks into a Rutgers Stichting clinic, a Dutch family planning clinic known for its liberal approach towards sexuality and inquires about hymenorraphy. Hymenorraphy, also known as hymenoplasty and hymen reconstruction surgery, is a relatively simple surgical procedure that can be performed under local anesthesia. 

At the tender age of 7, Naima, a Dutch-Moroccan, was repeatedly sexually abused by an older cousin and lost her virginity. Now she believes she can regain her virginity through reconstruction of her hymen. Like many girls in her position, Naima kept the story of her abuse secret and only shared it with a close friend. Despite being the victim of a tragedy, Naima feels guilty and is still haunted by her past. 

Naima has now been engaged for two months and while she would like to be honest with her fiancé and her family about her past, she does not want to cause a scandal in the family. Her abuser still plays a large role in her family and Naima does not want to tear the family apart. When referred to a psychotherapist, Naima showed little willingness to discuss her past and wanted to focus only on her future and her reputation which she thought could only be salvaged by the surgery. For her, the idea of the surgery meant that she could ‘regain’ her virginity in more than just the physical sense.  

Naima’s understanding of virginity and her association of the loss of virginity with guilt is neither unique nor rare amongst Dutch-Muslims. According to Islam, ‘chastity’ is an essential aspect of pre-marital life. The Qur’an calls for both men and women to remain ‘pure’ and preserve their ‘chastity’. In practice however, it is mostly women who have been pressured to adhere to the strict interpretation of this ancient command that takes ‘chastity’ to mean ‘virginity. Women are expected to remain virgins until their wedding night, which has evolved into a ritual of deflowering. This ritual, however, is not historically a Muslim ritual; it has been practiced in different parts around the Mediterranean – by Christians and Muslims alike. 

A woman’s chastity is closely associated with her family’s honor. If a girl is seen as sexually promiscuous, she is said to bring shame to the family and disgrace the family honor. In some extreme cases a girl could be accused of being sexually promiscuous simply for talking to a strange man. In other and more common cases, girls are accused of dishonoring the family when they engage in sexual activities before they are married. Worried about their family’s honor, an increasing number of Dutch-Moroccan and Dutch-Turkish girls in the Netherlands are opting for hymen reconstruction surgery as a recovery of their virginity. Due to the sensitivity of the topic and the secretiveness in which doctors and patients go about it there are not exact figures indicating the frequency of the operation in The Netherlands. Dr. Weis Obdeijn, a sexologist at the Rutgers Stichting clinic in The Hague, says that they gets approximately 50 queries a year but only half that number opt to undergo the surgery. 

Dr. Obdeijn has worked at the Rutgers Stichting clinic for over 15 years and has a great deal of experience in working with girls that are tangled in compromising and potentially dangerous situations due to their sexual history. In talking about the type of girls that come to the clinic with queries about virginity and the surgery, Dr. Obdeijn makes a distinction between her Dutch-Moroccan and Dutch-Turkish patients in saying that although there is a much larger number of Dutch-Moroccan girls inquiring about the surgery, Dutch-Turkish girls are often in much more serious and life-threatening situations. A similar observation was made by Dr. Edien Bartels, an Anthropology and Ethnic Studies professor in the Amsterdam Vrije University, where extensively researched Islam and female circumcision in The Netherlands.

The secrecy in which this topic is handled in the medical arena and amongst Dutch-Muslims made it extremely hard to reach doctors that perform the surgery and are willing to take a strong stance on the topic. According to Dr. H.D Boyraz-Ikriz, a general practitioner in a multi-ethnic neighborhood in Amsterdam, only 2 out of 10 hospitals in Amsterdam are willing to perform this surgery. At the sound of the words hymen reconstruction, many people tend to cringe and toss around the accusation that it is against medical ethics and that it is a human rights violation. In order to better understand these accusations, we decided to explore the issues around the surgery from 3 main perspectives: medical, anthropological and theological. 

Medical Ethics and the Role of Doctors as Social Regulators

“It is against my principles,” said Dr. H.D Boyraz-Ikiz. “If a person is not in medical need of a surgery, then I don’t recommend it.” Despite that, Dr. Boyraz-Ikiz has made the decision to learn how to perform this outpatient surgery since she believes that in some extreme cases such as rape, the operation can be justified. As a Dutch-Turk, Dr. Boyraz-Ikiz is familiar with the traditions that pressure women to remain virgins until they are married, as well as the grave consequences of ‘disgracing’ the family honor. Dr. Boyraz-Ikiz plans to start performing the surgery in her clinic in Bos en Lommer, a district of Amsterdam with a large Dutch-Muslim population. “I understand that this is a sensitive issue and I would like to offer these girls a safe and familiar environment where they can feel a bit more comfortable,” she explains. Dr Boyraz-Ikiz’ approach to the topic is practical and realistic. Despite her ethical hesitations regarding the surgery, she does her best to help the girls that come to her for advice. On the other hand, when we asked Dr. Boyraz-Ikiz whether she will advertise the fact that she is going to learn how to perform the surgery, she emphasized that she wouldn’t since she doesn’t want to encourage girls to undergo the surgery or choose it as an alternative to dealing with the repercussions of their own actions.  

Once Dr. Boyraz-Ikiz begins to perform the surgery, she will be part of an unknown number of doctors who practice hymenorraphy and do not talk openly about it or publicize it. One of the reasons behind this phenomenon of silence is that many doctors find it difficult to separate the political questions around the treatment of women in Muslim societies from the ethical questions around the surgery. This phenomenon raises several interesting questions on the role of doctors as social regulators. While many doctors refuse to conduct the surgery as a form of protest against what they see as the commodification of women in patriarchal Muslim societies, others such as Dr. Obdeijn are more concerned with the difficulties individual patients face. Dr. Obdeijn sees the deceptive aspects of the surgery and the problems around the treatment of women as commodities but urges others to withhold  judgments and assumptions about Islam and feminism and approach the surgery from a strictly professional perspective that keeps the patient’s best interest in mind. 

For ideal results, the surgery is usually performed a few days before a girls wedding night. In most cases, the girls are 18 or older when they undergo the surgery. Legally and socially they are consenting adults. In a world where cosmetic surgery is becoming increasingly popular and more women choose to modify their bodies while chasing a distorted image of the ‘ideal’ woman (which only exists in magazines and advertisements), why should we draw the line at hymenorraphy? Why is one form of deceptive surgery accepted while the other one is frowned upon? This question becomes increasingly relevant considering the fact that hymenorraphy is a simple and harmless procedure which can have a real impact for many women and may provide them with a haven from social out casting and life threatening situations. 

The question of hymenorraphy in The Netherlands and Western Europe highlights existing forms of xenophobia and points to how easily people tend to notice differences and ignore similarities. For instance, from a medical perspective some would argue that hymenorraphy is ethically more justifiable than male circumcision – practiced freely and with little societal objections in the Netherlands despite the fact that male circumcision is generally performed on baby boys that are not able to give their consent. Male circumcision, often practiced without anesthesia, can be a painful and traumatic experience for baby boys as they are pinned down while a part of their penis is clamped and amputated. Where should doctors draw the line when it comes to traditional rites involving blood—or should they even be the ones to draw a line? Furthermore, should cultural relativism be taken into account when considering the legitimacy of a traditional rite?

Understanding Cultural Rituals

According to Dr. E. Bartels, the discussion around hymenorraphy in The Netherlands is unique. It has been colored by the discussion on symbolic female circumcision, an idea introduced by K. Bartels in the beginning of the 90’s that suggested that doctors should consider offering a symbolic and less painful form of female circumcision in The Netherlands. While K. Bartels was simply offering a pragmatic and realistic solution to a growing problem, the idea was rejected and frowned on by Dutch academia. The rejection of her suggestion did not take into consideration the opinions of those which would have been affected by it the most – those who practice female circumcision in the Netherlands. By rejecting K. Bartels’ suggestion and now allowing any discussion around it, female circumcision continues to be a problem in The Netherlands. This sheds an interesting light on hymen reconstructive surgery, demonstrating that a problem deeply embedded in a culture cannot be solved by simply dismissing it as primitive or unethical. While hymenorraphy itself is not a cultural rite, it is a modern catalyst allowing women who are no longer virgins to participate in an ancient rite that Dr. E. Bartels calls ‘the rite of deflowering’. 

To better understand a phenomenon such hymenorraphy, it is important to look at it from an anthropological perspective and understand the underlying reasons and the social behavior inducing girls to take part. Instead of simply examining the theoretical and medical aspects of the surgery, we must make an effort to contextualize the operation and understand why girls are put in a position where they feel that their worth depends on their virginity. “You must keep in mind that rituals don’t randomly emerge, they are symbolic actions that express a message,” Dr E. Bartels stresses. “To understand a ritual you must first ask yourself what is the message and what it is trying to express.” The rite of deflowering celebrates a range of values such as purity, chastity, beauty, honor and masculinity in Islamic tradition. To approach the problem of why some girls are deemed worthless or seen as a disgrace if they engage in pre-marital sex, we have to look closely not at the rite of deflowering but at the cultural interpretations of the values of purity, chastity, beauty and honor and masculinity. It is important to bear in mind that this rite does not only have possible negative implications for the women but also for the men who are expected to prove their masculinity during this rite. 

Treating hymenorraphy as a problem without considering the underlying cultural issues is unconstructive and does not allow us to reach the root of the problem— communities assessing the value of their daughters by the ‘intactness’ of their hymen (especially since between 60-80% of girls do not bleed during their first vaginal intercourse). In communities where family plays a large role in shaping the decisions that girls make in their youth, the relationship between chastity and honor puts a huge pressure on girls to act in a ‘decent and respectable’ way. “I want to do this for my family’s reputation, for my parents’ peace of mind and for my sisters,” said a young and distressed Dutch-Moroccan girl to Dr. Obdeijn while inquiring about the surgery. Dr. Obdeijn and Dr. E. Bartels both observed that significance of chastity as a mark of family honor is stronger amongst lower class families. “The more money you have and the higher the status you possess, the less contingent the family honor becomes on the chastity of your daughter,” Dr. E. Bartels notes. The relationship between a family’s socio-economic status and the reliance of their family honor on the daughter’s chastity suggests that through improving the socio-economic condition of these migrant communities (specifically the one of Dutch-Moroccans and Dutch-Turks) it can be possible to partially relief the distress that leads to honor related violence. 

Meanwhile, considering the fact that the existing issues around the ‘rite of deflowering’ and hymenorraphy are not issues that can be cured instantly, it is important to acknowledge them as part of the Dutch society and move on from that point. While initially, these problems appeared to us as being a result of the clash between Islam and the West— in terms of sexuality and gender inequality— it soon became apparent to us this was not the case. When we asked Dr. E. Bartels whether these issues are related to problems of integration and whether she saw hymenorraphy as a way in which girls can integrate into Dutch society more easily, she strongly disagreed. “The problems that we are now faced around the topic of hymenorraphy are not unique to The Netherlands or to the West. It is not a question of how these cultures should assimilate into Dutch culture but it is a matter of accepting that we are now living in a multi-cultural society and as such it is important to adopt the problems of everyone in that society and take responsibility for their different problems as our own,” she explains. Therefore, the different groups in a society need specialized attention from a social perspective and in medical care. “Alcoholics, drug addicts and the elderly are all in need of specialized attention and the state makes it available for them,” she notes. If there are problems that are more common amongst the Dutch-Moroccan and Dutch-Turkish communities then there needs to be a channel in which these problems can be dealt with appropriately. At this point in time, there is a demand in these communities for hymenorraphy. Whether the surgery is ethical or unethical and whether doctors should practice it is a question to be determined without discrimination against those who are in need. Political debates on what is the norm and what is ‘too foreign’ should be left out of medical care so that every person is able to get the specialized attention they need. 

Two Dutch-Muslim Perspectives 

While it is important for medical care to assimilate according to the needs of the society, it is essential that communities become introspective and critical of their own actions in order to inspire positive change. Ceylan Pektas-Weber, chairwoman of Al-Nisa Foundation of Muslim Women, sees hymenorraphy as a superficial and temporary solution of a deeper problem. As a Muslim woman, Pektas-Weber understands the situations that girls often find themselves in and doesn’t condemn the surgery as a whole. She views the surgery as more of a last minute resort, to be utilized only in extreme cases where it may save a girl’s physical or mental well-being. From an Islamic perspective Pektas-Weber points out that while lying is condemned by the Qur’an there are Hadiths that offer extenuating circumstances where lying can be excused. One of these cases, she specifies, is to keep a husband and wife together. Furthermore, Pektas-Weber stresses that Islam values dignity of life and humanity more than anything and when it comes to issues of life and death there are always extenuating circumstances. “While Islam prohibits the consumption of pork and non-Halal meat, it excuses eating it if nothing else is available,” she notes. 

A more extreme position on this topic was taken by Maimunah van der Heide, the founder of Stichting Vangnet, an organization for Muslims girls (Huiskamerproject voor Moslim meiden). When asked about the position of Stichting Vangnet on hymenorraphy, Van der Heide’s response was strict and straightforward. “I do not support the surgery. It is a lie and I would never support anyone that chooses to lie,” she asserts, “I agree that girls are often the victims of cultural traditions but I do not believe that hymenorraphy is any kind of solution to the real problems that they face. It does not prevent or stop honor killings since honor related violence can be based on rumors and will happen regardless of the availability of the surgery.” While the two Muslim women take different stances on the issue of the surgery, they both agree that the problem is complex and deeply-rooted; a problem of gender inequality and the perpetuation of double standards for men and women, especially concerning sexuality. 

Final Words

Every angle of examining this issue has presented us with more questions than answers, demonstrating the complexity of the question of hymenorraphy in The Netherlands. It is a question of ethics, cultural and religious relativism and a question of integration of medical care. The circumstances that create the need for hymenorraphy in The Netherlands are based on conservative cultural interpretations of ancient values, an issue that cannot be solved with temporary solutions like the availability or lack of availability of hymenorraphy. However, the existing need for the surgery calls for an open-minded medical, anthropological and theological acceptance and initiation of discussion around this topic. A short examination of the topic has shown us the judgments and accusations made against hymenorraphy are myopic and do not consider the complex circumstances surrounding this issue. Instead, they contribute to the process of marginalization and othering. 

 

 

References

Interviews:

•Dr. H.D Boyraz-Ikriz, general practitioner in Bos & Lommer Amsterdam (June 21, 2007)

•Dr. E.A.C. Bartels, associate professor Anthropology and Ethnic Studies at the Vrije University Amsterdam (June 27, 2007)

•Mrs. C. Pektas-Weber, chairwoman of Al Nisa Muslim Women Organization (June 27, 2007)

•Dr. W. Obdeijn-Van Welij, doctor and sexologist at Rutgers Stichting The Hague (June 27, 2007)

•Miss. Maimunah van der Heide, founder of Stichting Vangnet, (June 26, 2007)

Articles:

•Bartels, E., ‘Maagdelijkheid en maagdenvliesherstel tussen ethiek en beleid: een reactie’ [Virginity and hymen construction between ethics and policy: a reaction], in: Migrantenstudies, 2000; 16, p. 45-53. 

•Bartels, E., ‘Medical ethics and rites involving blood’, in: Anthropology & Medicine, 2003; 10 (1), p. 105-114.

•Bekker, M. et al, ‘Reconstructing hymens or constructing sexual inequality? Service Provision to Islamic young women coping with the demand to be a virgin’, in: Journal of Community & Applied Social Psychology, 1996; vol. 6, p. 329-334.

•Hendrickx, K. et al, ‘Seksueel gedrag bij Marokkaanse immigranten van de tweede generatie, balancerend tussen traditionele houdingen en veilig vrijen’[Sexual behaviour of Moroccan second generation immigrants, balancing between traditions and safe sex], research paper University of Antwerpen, 1997/1998, Article 2002.

•Logmans, A. et al., ‘Ethical dilemma: Should doctors reconstruct the vaginal introitus of adolescent girls to mimic the virginal state? Who wants the surgery and why.’, in: British Medcal Journal, 1998; 316, p. 459-460.

•Obdeijn, W. & Wils, J-P, ‘Herstel van het maagdenvlies’[Reconstruction of the hymen], in: Tijdschrift voor Geneeskunde en Ethiek, 2001; 11 (1), p. 20-23. 

•Rademakers, J., Mouthaan, I. and De Neef, M., ‘Diversity in sexual health: Problems and dilemmas’, in: The European Journal of Contraception and Reproductive Health Care, 2005; 10 (4), p. 207-211. 

•Tuori, S., ‘Gender equality and multiculturalism as nation-buildiging discourses’, in:  European Journal of Women’s Studies, 2007; 14 (21), p. 21-35.

•Paterson-Brown, S., ‘Commentary: education about the hymen is needed- ethical dilemma: should doctors reconstruct the vaginal introïtus of adolescent girls to mimic the virginal state?, in: British Medcal Journal, 1998; 316, p. –

Websites:

•http://www.alnisa.nl, Muslim Women Organization (last visit: June 28, 2007)

•http://elnaar.blogspot.com/search/label/Womens%20Rights, blogspot El Naar Haninah, blog on:  Veils and Virginity. Muslim women in France regain virginity in clinics, by Alexandra Steigrad (last visit: June 28, 2007) 

•http://www.iiav.nl/, International Informationcentre and Archief for the Womenmovement (last visit: June 28, 2007)

•http://omroep.nl/nps/mix/welcome.html?../meidenvanhalal/mainframe_meidenvanhalal.html~main, television program of three Muslims girls (last visit: June 28, 2007)

•http://www.nvog-documenten.nl/, Nederlandse Vereniging voor Obstetrie en Gynaecologie, guidelines on hymenreconstruction (last visit: June 28, 2007)

•http://www.stichtingvangnet.nl, livingroomproject for Muslim girls (last visit: June 28, 2007)

Documentary:

•Episode 3, 2005: ‘Maagdelijkheid’ [Virginity] of Meiden van Halal [Girls of Halal], NPS 

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Netherlands Netherlands 2007

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