Gender and cultural understandings in medical nonindicated interventions: A critical discussion of attitudes toward nontherapeutic male circumcision and hymen (re)construction

Introduction

Hymen (re)construction—also described as hymenoplasty, hymenorrhaphy, hymen repair, or revirgination—and male circumcision—typically the removal of part or all of the penile foreskin—are medical surgeries that give rise to specific ethical concerns. Both surgeries are usually performed for cultural and religious reasons, although in rare cases circumcision can also be medically indicated.^1,2 While hymenoplasty is usually requested by the patient herself, male circumcision is mainly performed on infants and boys upon parental request. While the latter is an irreversible intervention, hymenoplasty has no lasting bodily effects. Yet, nontherapeutic circumcision is widely performed and accepted, while hymenoplasty is a much more controversial technique and medical professionals in Europe are mostly against it.^3–5

This raises critical questions about why these two surgeries are regarded so differently. Scholars in medical ethics, medical professionals, and associations largely agree that decisions in medicine should be guided by the principles of autonomy, beneficence, nonmaleficence, and justice, as devised in the classical work of Beauchamp and Childress. ⁶ Yet, as we aim to demonstrate, assessing both surgeries within this framework displays some puzzling inconsistencies.

This article first outlines the main ethical issues that arise in scholarly debates on hymen (re)construction and male circumcision. As these are not only discussed in medical ethics, we reviewed publications that were selected from medical (PubMed and Medline Database), sociologically, culturally, and philosophically oriented databases, including the Social Sciences Citation Index, Academic Search Elite (EBSCOhost), Sociological Abstracts (Illumina), and Philpapers. ⁷ Next, we explore how standard ethical principles apply to both surgeries and conclude that the divergent attitudes toward both surgeries also rely on gendered socio-cultural understandings and the different symbolic meanings that are attributed to both surgeries.

This article does not discuss the foundations or usefulness of a principled ethical framework, nor does it engage with debates on whether such frameworks are cross-culturally applicable or theoretical issues about moral universalism and the foundations of normative ethics. It is assumed that such frameworks are largely accepted to guide clinical practice. Yet, by pointing out how socio-cultural understandings impact on ethical decisions, it aims to stimulate a more critical understanding of ethical decision-making in clinical practice.

Hymen(re)construction: Sexual autonomy and double standards

In many countries around the world, and contrary to Western popular belief not only in Muslim cultures, the norm is that women abstain from premarital sex.^8–11 An intact hymen and loss of blood during sexual intercourse in the wedding night is traditionally considered as proof of virginity. Yet, many women do not bleed when they have intercourse for the first time ¹² and the hymen is not, as is often believed, a membrane separating the vagina from the outside world, but “a thin, bloodless, elastic mucosa surrounding the opening of the vaginal introitus.” ¹¹ This piece of mucosa can also be ruptured by doing sport, or by inserting a tampon, and, because of its elasticity does not have to show signs of defloration after penetration. Therefore, it is a myth that doctors can establish whether a young woman is still a virgin.^13,14 Although there is technically not necessarily a perforated membrane to restore, physicians get requests to perform a surgery to restore the hymen. In communities in which premarital virginity is expected, the consequences when a young woman is suspected of having lost her virginity can be severe, both for herself and for her family. In Turkey, the most frequent cause of attempted suicide among young women is hymen examination ¹⁵ and hymen (re)constructions are said to have reduced the number of honor killings in Egypt. ¹⁶

Throughout Europe hymen (re)constructions are performed in hospitals and private clinics, usually after (more or less extensive) counselling.^3,5,14,17,18 The most common methods of surgery described in the literature are temporary hymen suture and hymenoplasty.^11,18 The first method comes down to applying a few stitches in the remnants of the hymen, resulting in a small opening. As the stitches hold their tensile strength for only about a week, this method is only suited for women who intend to have the wedding within that week. The second method is more lasting and requires real wound healing of the hymen. Both methods are done under local anesthesia and patients are discharged on the day of the surgery.

In some countries, medical associations have developed guidelines on hymen surgery. According to the Dutch Society of Obstetrics and Gynecology, hymen(re)construction should not be performed, unless it appears, after counseling, that no other option offers a solution. Detailed instructions are given about what the counseling should entail. In case the request for help is inconsistent with the physician’s personal views, the patient should be referred to someone else. ¹⁹

Some surveys further show that the surgery is a very contested practice among medical professionals. In Sweden, almost half (46.9%) of the consulted GPs and gynecologists fully agreed with the statement that under no circumstance physicians should write a virginity certificate and similarly 42% agreed that they never should perform a hymen restoration. The others agreed that under certain conditions, they would be prepared to assist with this. The researchers conclude that the main value conflict experienced by the respondents is “on the one hand helping patients in distress (or saving lives) and on the other hand the importance of standing up against suppressive and patriarchal norms.” ²⁰ Another Swedish survey that included not only gynecologists and midwives, but also youth welfare and social officers suggests that this value conflict is experienced more generally among Swedish health practitioners. ³ In the Netherlands 73% of the surveyed gynecologists said they would never perform a hymen (re)construction. ²¹ In Switzerland, a questionnaire was sent to 100 clinics for gynecology in public hospitals. While a minority (16.7%) refused to perform a hymen (re)construction, more than half of the clinics (64.3%) reported that they always (28.6%) or mostly (35.7%) granted the request. ⁵ In a study that surveyed the views on hymen (re)construction from midwives, predominantly from Europe, the majority of the respondents (86%) agreed with the statement that virginity examinations and hymen operations are part of violence against women and only 8% believed hymen (re)construction is justifiable. ²² A survey among gynecologists in Flanders (Belgium) showed that they were very divided about whether hymen (re)construction violated the right to physical integrity of the woman; roughly a third agreed, a third was neutral, and a third disagreed. ¹⁸ The study also asked whether physicians had actually received a request for hymen (re)construction. Of those who had, half of them (52.5%) had performed the procedure. The most frequently mentioned arguments to comply with the woman’s request were respecting her autonomy (65.3%) and the risky situation in which she was involved (44.9%). For those who decided not to perform the surgery their main reasons were that it was not a medically indicated procedure (41.5%), because it would keep up the virginity myth (45.3%) and also the double sexual standards (49.1%). Almost half of them (49.1%) considered the procedure a violation of the patient’s bodily integrity.

The referred to guidelines and surveys indicate that, generally, medical professionals condemn the virginity rule as infringing on the sexual autonomy of women and as representing double sexual standards. Therefore, and also because the procedure is not medically indicated, they believe hymen (re)construction should not be performed. Some see the surgery as also infringing on the patient’s bodily integrity. If nevertheless some physicians are in favor of operating, this is because they wish to respect the woman’s autonomy and take into account the reprisals they expect the woman has to face. Even the Dutch guidelines that go furthest in meeting the woman’s needs, with their many provisos and the extensive counseling that is required, make clear that the Dutch professionals only grudgingly agree to perform the surgery.

Common ethical arguments contra hymen (re)construction are that there is no medical indication, that performing the operation is becoming an accomplish in deceit, that the operation contributes to keeping up the myth that all women have a hymen that bleeds with the first coitus, that it perpetuates gender inequality, that it amounts to discrimination of women and violates women’s right of autonomy and their right to bodily integrity. Monika Christianson and Carola Eriksson ²² for instance argue that “virginity control and hymen ‘reconstructions’ are elements of patriarchy, whereby violence and control are employed to subordinate women.” They recognize that if the woman’s life is at stake hymen (re)constructions may be justifiable, but generally they consider hymen (re)construction as an instrument in the control of women’s sexuality and therefore an “inhumane and degrading treatment and (…) a form of gender discrimination that flies in the face of human rights principles for women.” ²² The proper way of action, therefore, is to empower women so that they are better able to resist virginity control and hymen (re)constructions. Others do not dispute that requests for hymen (re)constructions follow from patriarchal norms that discriminate against females but give priority to the well-being of the individual patient and her autonomy^16,23–25 or have other principled arguments pro operating that outweigh arguments contra. Regarding hymen (re)construction as deceit, Pablo de Lora ²⁶ discusses a common objection against the deception argument: if hymen (re)construction is wrong, because it is deceit, then all cosmetic surgery is unethical. De Lora, however, thinks hymen (re)construction is not like any other form of cosmetic surgery. Normally, the plastic surgeon actually does change the appearance of a nose, breast, or belly. In that sense, it is no deceit, but a transformation; the deceit is in not telling that this new appearance is not given by nature. Hymen (re)construction, however, does not restore chastity. The surgery helps the woman to convince someone else that she is still a virgin. Therefore, hymen (re)construction is according to De Lora a form of deceitful cosmetic surgery, which makes the physician an accomplish in an act that is wrong. Yet, there may be other things to consider that justify performing the surgery. ²⁶ Alain Vande Putte ²⁷ refers to these “other things” when arguing that showing respect for the autonomy and bodily integrity of the patient “may override considerations of truthfulness towards third parties interested in controlling these aspects of the patient’s life.” Another overriding concern is formulated by Lee Seng Khoo and Vasco Senna-Fernandes, ²⁸ who believe that physicians should refrain from moral judgment:

We have to understand the human need to belong, to be accepted and loved by their subcultural group with their own values and beliefs. We cannot attack others’ religious beliefs even if they conflict with our own and cannot violate basic human rights by withholding medical or surgical treatment.

Nontherapeutic male circumcision: Genital autonomy and gender injustice

Historically, circumcision—the surgical removal of some, or all, of the foreskin—is found among different religious, cultural, and geographical communities.^30,31 Although the practice dates back to Ancient history, it became rapidly medicalized during the 19th and 20th century, especially in Anglo-Saxon countries, where it was initially recommended to prevent masturbation and sexually transmitted diseases such as syphilis. ³² In countries like the US, where neonatal circumcision became routinely performed, anticircumcision activists challenged the surgery as medically unnecessary and potentially harmful.^33,34 While the American Academy of Pediatrics (AAP) no longer recommends routine neonatal circumcision, it considers the surgery to be a low risk procedure that helps to prevent urinary tract infections, acquisition of HIV, and transmissions of some STIs and penile cancer—a rare, but deadly disease. Because circumcision in infancy is associated with fewer complications, the AAP recommends that the surgery should be available upon parental request. ³⁵ In response to the AAP statement, physicians from different European countries, however, declared that the assessment of evidence and the policy statement of the AAP had a cultural bias: if infant circumcision would not have been such a widely accepted practice in the US, benefits and harms would have been assessed in a very different way. ³⁶ These critiques do not dispute that circumcision confers certain health benefits, but question whether these can possibly justify infant circumcision or instead would, from a medical standpoint, require the boy’s consent. As Frisch and Earp ³⁷ explain:

(…) the question is not whether certain health benefits may in fact ensue from the sheer surgical removal of the foreskin, but whether, in light of alternative, less invasive, means of achieving the same desired health outcomes, the benefits are sufficient to outweigh the costs, harms, and other disadvantages (i.e. ‘risks’), some of which may be subjective in nature and therefore difficult to quantify.

In contrast to an earlier wave of bioethical debates that mainly focused on neonatal circumcision in countries like the US, male circumcision is now also increasingly debated in Europe, in the context of politicized debates on multiculturalism and religious accommodation. ⁴⁴ In 2001, following a case where six asylum-seeking Bosnian boys were circumcised in a reception center and became badly infected, Sweden was the first to adopt a legislation that restricted the legality of circumcisions of minors to those who were performed by a licensed doctor. ⁴⁵ In 2010, the Dutch Federation of Physicians declared that the circumcision of boys was in conflict with the rights of the child, and recommended that surgeries should only be allowed when performed by a medical doctor. ⁴⁶ In 2012, in considering the case of a four-your-old Muslim boy whose circumcision had resulted in complications, a German district court in Cologne declared that nontherapeutic circumcision of minors was unlawful offence. The ruling initiated fierce protests, especially from Jewish and Muslim communities. Some spokesmen denounced the court’s ruling as an act of anti-Semitism ⁴⁷ and Germany responded to the protests by adopting a law that explicitly allows for religious circumcision on parental request, including its performance by nonmedical practitioners. ⁴⁸ Yet, also in 2013, the Parliamentary Assembly of the Council of Europe adopted a resolution concerning “Children’s Right to Physical Integrity” in which circumcision of young boys is considered as a violation of the physical integrity of children, comparable to female genital mutilation and early childhood medical interventions on intersex children. ⁴⁹ The statement evoked fierce criticisms from minority groups and, in a later resolution, the Assembly stresses that there is no consensus among Member States on circumcision and recommends not to allow ritual circumcision of children unless it is practiced by trained and skilled persons, in appropriate medical and health conditions. ⁵⁰ In 2017, the Belgian Advisory Committee on Bioethics issued an advice to no longer refund the surgery by public social security. ⁵¹ In 2018, a bill is proposed in Iceland to ban male circumcision. ⁵²

In political discourses and scholarly debates, male circumcision is frequently compared with female genital cutting/mutilation (FGC/M).^53,54 The international community considers FGM/C as a violation of human rights, gender-based violence, and a form of child abuse. According to the WHO, all surgeries that involve the partial or complete removal of external female genitalia as well as other injuries (like pricking, piercing, incising, scraping, and cauterization) are harmful to the health of women and a form of gender-based violence. ⁵⁵ The WHO considers male circumcision and FGM as substantially different: while FGM is seen as a manifestation of deep-rooted gender inequality and linked to a reduction in women’s sexual desire and an irreversible loss of their capability for sexual functioning, male circumcision, on the other hand, is mainly associated with health benefits and considered as a gender neutral and nondiscriminatory practice. ³⁸ Nevertheless, as a number of studies point out, there is often a symbolic overlap in meanings and rationalizations of female and male genital cutting. ⁵⁶ Although it is difficult to generalize about the meanings of male circumcision, it cannot be ignored that it is not a gender neutral practice, but one that often serves to establish manhood and male power and thus maintains patriarchal relations, oppressive gender norms, and hierarchies.^57,58 With regard to harmfulness, some types of FGM/C—particularly those that are considered under type 4—are also less physically harmful than male circumcision. Yet the former are criminalized, while the latter are unregulated. ⁵⁹ In identifying harmful cultural practices as practices that only negatively affect girls and women (predominantly in the South), human rights discourses have largely neglected that boys and other genders could also be harmed by cultural practices. Some authors therefore claim that the unequal human rights and legal recognition of physical and sexual integrity of girls and boys constitute in itself a form of gender injustice.^53,60 Yet, some draw attention to similar harms and meanings of female and male genital cutting in in order to advocate a more repressive approach of male circumcision ⁵³ while others use the comparison to endorse a more tolerating approach of—less harmful—forms of FGM/C. ⁶¹

Concerns about the protection of the genital integrity of children have also been fed by a growing opposition to so-called normalization surgeries performed on intersex children. While such surgeries are medically nonindicated, they are medically performed to make intersex children fit into the strict gender binary.^56,62 Whereas female, male, and intersexed genital alterations are increasingly problematized from a children’s rights perspective, ⁶³ circumcision of male adults or minors that are able to consent is largely perceived as unproblematic and is even recommended as a valuable alternative. ⁶⁴

Discussion: Autonomy, beneficence, nonmaleficence, and justice

In the debates on hymen (re)construction that were previously revised, two, or three, positions can be distinguished. While all agree that the request for a hymen (re)construction is inspired by a patriarchal norm, some believe that hymen (re)construction should therefore not be performed, whereas others believe that it may be performed, because the woman’s well-being and autonomy are paramount. This, however, should always be combined with counseling to make women aware of this patriarchal norm.^14,24 Furthermore, some believe that at the same time public measures should be taken aimed at cultural reform of the minority groups in question.^4,23 Yet, a common argument that is raised is that requests for hymen (re)construction are inspired by a patriarchal norm that infringes on women’s autonomy. Request by women to restore their hymen is perceived as not truly autonomous and counseling is therefore recommended. The counseling practices that were reported in the literature, however, far extend the usual conditions of informed consent. In the Netherlands, the guideline of the Dutch Society of Obstetrics and Gynecology gives detailed instructions about what the counseling should entail: informing the patient about her body; if necessary with the use of a mirror, find out about the meaning of virginity for her, her partner, and their families; if possible draw the partner into the counseling, and check on risky sexual behavior, incest, and trauma that may be covered up or aggravated by the procedure. Although counseling can be perceived as enhancing the autonomy of the patient, it can also be used to influence patient’s decisions imposing upon them other values and norms. ⁶⁵ In debates on abortion, counseling requirements were often opposed by feminist as they were perceived to aim at changing women’s minds, create feelings of guilt, and undermining women’s right to decide. ⁶⁶ We notice, further, that in the debates on hymen (re)construction the surgery is not compared to arguably harmful cultural practices in the West, like cosmetic surgery, which pose comparable questions around autonomy and choice.^67–69

Furthermore, in debates on hymen (re)construction, harm comes to mean social and physical reprisals, like being expelled from home or being murdered, and well-being the absence thereof. Hymen (re)construction to enhance self-worth is only discussed in the case of rape victims. The idea that other motives but fear, like a desire to be part of a community or to express a cultural identity might inspire the requests, is virtually absent. This is also reflected in the common argument that there is no medical indication for hymen (re)construction. Medical need is then reduced to illness, injury, or physical impairment, hence, resting on a biological understanding of health.

In contrast, the reasons to request for a nontherapeutic male circumcision, whether by parents or the persons themselves, are generally not questioned. Ethical issues mainly arise on the conditions of proxy consent: as young children cannot decide for themselves, parents or legal guardians are supposed to act in the best interests of the child and to give their consent to medical treatment, yet their decisions may not put the physical health, well-being, or life of the child in danger. Since health benefits only become relevant later in life while the surgery entails pain, discomfort, risks for complications for the child and is irreversible, nontherapeutic infant circumcision is not justifiable for mere health preventive reasons. Yet, children’s well-being does not only involve physical concerns. To be part of a community, to be able to express a religious or cultural identity, and to experience social acceptance and positive self-worth are also important and are largely accepted to justify other medically nonindicated surgeries on children. Cosmetic and corrective surgeries are seen as justifiable if they are in the child’s best, immediate or future, interest. However, as is for instance argued in the case of “normalizing” surgeries of intersexed children, what is considered to be in the child’s best interests can also rely on oppressive gendered norms. ⁵⁶

In the case of hymen (re)construction, it is often argued that the operation should only be performed if the women fear violence and physical sanctions, such as honor killings. However, hymen “repair” can spare the young woman in question a lot of psychological and social suffering, like shame or not being able to marry. While male circumcision may not have the same effect in terms of becoming exposed to physical violence or honor killing, there is also a huge social pressure to perform the surgery. Furthermore, there is hardly any evidence on medical complications to temporary hymen suture, and while hymenoplasty is a more invasive technique, medical complications are rare. Yet, harms and risks of male circumcision have remained unrecognized for a long time, because of the cultural acceptance of the practice and its gendered meanings, including the endurance of pain as a sign of physical strength and manhood.^57,58

Conclusion

Autonomy and bodily integrity are values that are protected by law, human rights instruments, and medical ethical standards. Therapeutic interventions require informed consent, where possible, by the person herself. In the case of adult persons, autonomy is seen as a standard condition, which implies that persons should be regarded as capable of making autonomous decisions, unless a person is severely mentally handicapped or suffers from a psychiatric disease that deteriorates this capacity. Where minors are concerned, there is also a growing tendency to respect their capacities for autonomous decision-making. In the case of very young children, parents or legal guardians are supposed to decide in the best interests of the child. Opinions on what is in the best interests of the child diverge, as these are based on socio-cultural values and meanings. With regard to nontherapeutic surgeries, difficult questions therefore not only arise on how to balance harms and benefits, but also on what counts as relevant to assess harm and well-being. What counts as bodily harm and well-being cannot be disconnected from personal values, social meanings, and cultural identities.

Yet, this recognition is also behind the demand for informed consent and patients’ rights to decide for themselves. However, when young and adult women ask for a hymen (re)construction, this is often refused or only performed after extensive counselling. By contrast, requests for male circumcision by adults or minors who have the maturity to understand the implications of a procedure are not problematized. Thus, medical paternalism apparently only comes up with regard to women’s requests, and more particularly those of migrant women.

As both concern genital surgeries, they bring gendered and cultural assumptions about the sexual body to the foreground. Male circumcision is more culturally acceptable in western countries whereas hymen repair is almost exclusively conceived as an issue of immigrant minorities, and Muslims in particular. Hymen (re)construction is problematized from a women’s rights perspective and condemned as stemming from patriarchal norms. Male circumcision is seldom discussed from a gender perspective, and although increasingly problematized from a children’s rights perspective, circumcision of adults and older boys is also increasingly suggested as an acceptable alternative. It thus seems that autonomy and bodily integrity are regarded as sufficiently protected by the informed consent of the patient in the case of circumcision, but not in the case of hymen (re)construction.