Hymenoplasty

First, the thing that is most widely misunderstood

The second widespread belief is that there will be bleeding at first intercourse. In fact there are data showing that 40–50% of women from different cultural backgrounds have no blood loss at all at first intercourse.

The hymen can also be torn or damaged in situations other than sexual intercourse: the insertion of objects such as tampons, strenuous sporting activity, surgical procedures and falling onto a sharp object are among those listed.

What is the hymen?

It takes its name from the god of marriage in classical Greek mythology (Hymenaios). It is a membrane-like structure separating the vaginal canal from the entrance of the vagina (vestibulum). It has two edges: the attached edge and the free edge around the opening. The free edge is usually irregular, indented, or divided into several finger-like parts. The shape of the opening varies from person to person — it may be crescent, sickle, cube-shaped or septate.

Structurally it consists of connective tissue and both of its surfaces are covered by stratified squamous epithelium (the surface cell layer).

• It has a rich blood supply, and the vessels are wide and full particularly in the region near the free edge. This is the reason for the heavy bleeding that sometimes accompanies damage to it.
• It is not rich in nerves. The nerve supply is relatively rich in the attached part, is difficult to detect in the middle part, and is absent at the free edge.
• Elasticity varies from person to person. In some, elastic fibres predominate; in others, collagen fibres. For this reason it tears easily in some situations, while in others it may be elastic enough to allow intercourse without tearing.

The function of the hymen is not known. In the period before birth it separates the vaginal cavity, it opens around the time of birth, and it remains as a fold of mucosa (the thin tissue lining the inner surface) at the entrance of the vagina. If the lower end does not open, the obstruction called an imperforate hymen occurs — this is a medical condition that requires treatment.

Is it a medically necessary procedure?

The wording of the source text is clear: looked at on purely medical grounds, repair of the hymen is not medically indicated. The procedure provides no medical benefit; the balance of benefit against risk is therefore not in its favour.

On the other hand, it is noted that given the World Health Organization's definition of health as not merely the absence of disease but "a state of physical, mental and social well-being", a health benefit can be spoken of.

The position of professional bodies

In its published position statement, the Royal College of Obstetricians and Gynaecologists (RCOG) strongly opposes both virginity testing and hymenoplasty. Its reasoning is that neither is medically necessary under any circumstances, and that both reinforce social beliefs that wrongly attach a value to women on the basis of their sexual history.

RCOG also states plainly: a clinical procedure should not be performed in order to protect someone. The course to follow for people thought to be at risk of violence is referral to the relevant agencies, not surgery.

The decisive role of counselling

For most of those taking part, the information and self-confidence gained during counselling meant they were able to give up the operation they had initially seen as the only solution.

For this reason the first step on this subject is not surgery but accurate information and counselling.

Surgical approaches

The aim of the procedure is to narrow the entrance opening temporarily. There is no single standard for this — there is no accepted surgical standard aimed at restoring the bleeding property of the hymen. Hymenoplasty is one of the least well defined vulvovaginal procedures in plastic surgery.

The main described approaches:

• Narrowing the opening (luminal reduction): the most common approach. The epithelial layer at the edges of the opposing pieces of membrane is removed and the outer and inner layers are sutured so that the pieces adhere to each other.
• Removing a diamond-shaped piece of mucosa in the clefts between the remnants of the membrane, and bringing them together from left to right.
• Suturing of the three layers (STSI): this arose from the view that adhesion techniques often come apart because the blood supply of the hymen is limited. In this method the incision is made transversely and the suture placed vertically, increasing the wound area and therefore the blood supply. In a series of 125 people, uncontrolled bleeding in the early period was reported in only one person, and the healing rate was given as 91.9%.
• Vestibulo-introital tightening (VITT): a method in which a diamond-shaped incision is made in the vestibulum.

Risks and reported complications

The surgical risks of the procedure include: wound separation, infection, scarring, distortion of the shape of the vaginal entrance and over-narrowing of the entrance. Over-narrowing may lead to obstruction of the outflow of menstrual blood (haematocolpos) and to pain during intercourse (dyspareunia). The source also notes that feelings of guilt may be experienced after the procedure.

The largest known series assessed 518 people. In this series active bleeding requiring surgical intervention in the early period was seen in only 3 people (0.5%). Reported by method:

• In 227 hymenorrhaphy procedures no failure was reported.
• In 204 membrane flap procedures: 5 failures, wound separation before the wedding in 20 cases, difficult penetration requiring surgical correction in 5 cases, and bleeding due to tearing and requiring surgery in 3 cases.
• In 99 vaginal flap procedures: 1 failure (the person did not follow the post-operative care advice), a second procedure to remove tight scars in 5 cases, difficult penetration requiring surgical removal of the sutures in 10 cases, and bleeding due to a tear in 2 cases.

In the same series no complication related to childbirth was reported.