Is my daughter still a virgin? Can you, please, check it, doctor?

Abstract

Gender-based violence is a pervasive public health problem, let alone a violation of human rights. The World Health Organization (WHO) has estimated that, overall, 35% of women worldwide have experienced physical and/or sexual intimate partner violence or nonpartner sexual violence. In 2016, the author had the privilege to work with an outstanding group of people that helps sexual and gender-based violence (SGBV) survivors in Port-au-Prince, Haiti. The clinic, run by an international nongovernmental organizations, open walk-in to anyone in need, is functioning to the present day. In its 1^st year along, the clinic helped almost 1000 survivors, mainly underaged girls. At the clinic, a highly qualified staff of local doctors and nurses, psychologists, and social workers is available, free of charge, 24 h a day, 7 days a week, and accessible to SGBV survivors in absolute confidentiality. Survivors are offered all the support they might need as per the WHO guidelines, from medical assistance (treating of physical injuries, testing and preventing sexually transmitted diseases such as HIV or hepatitis B, and also gynecological and obstetric care) to psychological counseling, as well as specific referrals to shelters, legal aid, or secondary care as needed. Virginity still is highly valued in Haiti, and the father, mother, the beau-mare, or aunt of the survivor will often approach the doctor and anxiously whisper the question: “Is my daughter (goddaughter, niece) still a virgin?”, “Can you, please, check it, Doctor?” This article presents the perspective of SGBV survivors clinic in Port-au-Prince, Haiti.

Gender-Based Violence: A Public Health Problem

Gender-based violence is a pervasive public health problem, let alone a violation of human rights.[1,2,3,4,5,6] The World Health Organization (WHO) has estimated that, overall, 35% of women worldwide have experienced physical and/or sexual intimate partner violence or nonpartner sexual violence.[1] Impressive figures, especially when considering that other forms of gender violence such as psychological or financial, are more difficult to assess as there is no consensus on standard measures and thresholds.[1] In fact, a survey from the European Agency for Fundamental Rights revealed that 43% of European women (28 EU) have experienced psychological violence from an intimate partner in their lifetime,[7] compared to the WHO estimation of one in four (25%) women in Europe having experienced sexual or physical violence in their lifespan.[1]

Sexual and gender-based violence (SGBV) undermines health and also carries many other different implications legally, morally, and socially for all the actors involved - starting from survivors and their families to perpetrators themselves, as well as local communities and society as a whole.[1,8] With regard to intimate partner violence, literature shows that abused women are remarkably more likely to encounter serious health problems as compared to women who do not experience such violence. Having a low weight-at-birth baby is 16% times more likely for women who experience IPV, the risk of depression, alcohol disorders, and/or abortion doubles among abused women, while in certain regions of the world, they are 1.5 times more likely to contract HIV compared to women who have not experienced partner violence.[1]

Health Outcomes of Sexual and Gender-Based Violence

Based on the prognosis, health outcomes of SGBV can be divided into fatal and nonfatal, which can also be grouped into acute and chronic. Death can be the result of a fatal injury in the course of the assault - up to 38% of all murders of women are committed by an intimate partner[1] - or secondary to sexual violence, HIV infection/AIDS, or “honor” killing.[1,2,9] Death can also be self-inflicted, as a result of mental health problems or social pressure (stigmatization) secondary to the attack.[1,2,3,5] Nonfatal health consequences are many and impact different aspects of survivors' lives, ranging from alcohol/drug abuse, overeating, and other harmful behaviors to mental health conditions (low self-esteem, anxiety, depression, posttraumatic stress disorder, eating disorder, and sexual dysfunctions), as well as reproductive and gynecological complications (unwanted pregnancy, sexually transmitted infections (STI)/HIV, miscarriage, and pregnancy complications) and chronic conditions (chronic pain, persistent headache gastrointestinal disorder, and fibromyalgia).[1,2,3,10,11]

SGBV can, in fact, result in a wide spectrum of clinical conditions that may require immediate medical attention, as well as referrals to different consultants and counselors from surgeons and orthopedics for lacerations or fractures, to obstetricians and gynecologists for pelvic inflammatory disease, pregnancy complication, and consequences of unsafe abortions, as well as mental health specialists.[1,2,3,10,11]

Sexual and Gender-Based Violence and Virginity Testing

Besides the devastating health outcomes, SGBV also presents social consequences. Globally, regardless of the geographical area, gender violence is constantly complicated by blame and stigmatization.[2,4,9,10] In some countries, social norms specifically related to family's “honor” are strictly tied to an unmarried girl's virginity before marriage. In such societies, rape survivors can face a multiplication of violence: secondary to the sexual assault, girls may be blamed for the attack, disowned by their families, and rejected by the local community, beaten, or in worst cases, killed (“honor-” based violence).[2,4,12] In the face of such negative consequences is not surprising that the demand for hymen repair has recently increase in some regions of the world, raising a whole new set of questions and debate.[12]

At the loss of dignity, self-esteem and control over their own body, sexual violence survivors have to add the shaming and terrifying thought of having lost their virginity, and its social consequences. To add more shame and suffering to the sexual violence, survivors will undergo an examination, often forcibly - the so called virginity test - for forensic purposes - looking for proof of the survivor assertion and allegations - or simply for social reasons.[4,9,13] According to the Independent Forensic Expert Group, virginity testing, also known as virginity or vaginal examination, or the two-finger test, is defined as “a gynecological examination that is intended to correlate the status and appearance of the hymen with previous sexual contact to determine whether a female has had or is habituated to sexual intercourse.”[14]

Gender-Based Violence and Virginity Testing: an Haitian Experience

At the Portu-au-Prince clinic, a highly qualified staff of local doctors and nurses, psychologists, and social workers is available, free of charge, 24 h a day, 7 days a week, and accessible to SGBV survivors in absolute confidentiality. Survivors are offered all the support they might need as per the WHO guidelines, from medical assistance (treating of physical injuries, testing and preventing sexually transmitted diseases such as HIV or hepatitis B, and also gynecological and obstetric care) to psychological counseling, as well as specific referrals to shelters, legal aid, or secondary care as needed.[10,15] The walk-in clinic, run by an international NGO, is open to anyone in need and is operating to the present day. In its first year along, the clinic assisted almost one thousand survivors, mainly underaged girls.[15]

At the clinic in Port-au-Prince, every member of the team is essential to a successful journey back to a normal life for SGBV survivors. A comprehensive response to sexual and gender violence is multidisciplinary work; a collaboration among different professionals is essential while maintaining complete respect of the survivor's autonomy and dignity.[8,10,11] Such healing process can only begin when survivors ask for help, a real leap of faith from people who have been robbed of trust in mankind as a whole. Moreover in order to mend the visible and invisible wounds, restore dignity and rebuild confidence an effective medical response to (S)GBV requires compassion, validation, empathy and lack of judgment from providers.[3,8,10] A long and complex journey Haitian survivors often have to undertake alone, in secrecy, because of the stigmatization and victimization they would suffer within their communities, and sometimes, even within their own family, if they shared the abuse they suffered.

Is My Daughter Still a Virgin?

In Port-au–Prince, the medical staff has never faced a judicial request of virginity examination from a court of law or local authorities; however, parents and relatives of survivors often do ask. Virginity still is highly valued the father, mother, the beau-mare, or aunt of the survivor will often approach the doctor and anxiously whisper the question: “Is my daughter (goddaughter, niece) still a virgin?”, “Can you, please, check it, Doctor?”

The short answer is no - at the SGBV clinic in Port-au–Prince, we cannot and do not perform virginity tests. A firm answer that calls for a very sensible and clear explanation: health professionals do not perform virginity tests because it is a violation of human rights, a form of gender violence, and most importantly because virginity testing has no scientific foundation and is medically unreliable.[10,11,16,17,18]

This being the case, the entire staff at the SGBV clinic is faced with a difficult task: how do you deny what seems to be a vital information for survivors and their families? It's a matter of debunking the myths of virginity that crushes the lives of women globally, and especially for sexual violence survivors who will be shamed and blamed for what another person did to her. The aftermath of sexual violence is already devastating as it is and rather inevitable; while the humiliation, the physical and mental pain of a gynecological examination, often forcibly conducted is cruel, useless, and unethical, therefore it can and should be avoided.[10,12,14,16,18]

Virginity Testing: Facts versus Myths

In fact, besides the lack of medical or scientific value, studies show that virginity testing is harmful: it is physically painful and mentally distressing. The vaginal examination appears to be linked to unusual sexual behavior and higher risk of STI infections, despite the fact that in certain areas in Africa, virginity testing aims to reduce the spread such contagious diseases.[12,13,14] At a psychological level, research reveals that virginity testing can easily result in diminished self-esteem, anxiety, depression, and even suicide or attempted suicide, especially in case of forced examination.[4,14]

To help our patients and tackle such embedded myths, at the gender violence clinic in Port-au-Prince, we decided to put our efforts and knowledge together and create a leaflet to inform and explain to patients and their families about virginity: anatomical myths, and scientific facts. A leaflet to be used as a technical support during consultations, as well as educational material in the waiting room or informative sessions. “So, doctor, can you check my daughter's virginity? can you tell me if she is still a virgin?” No, we cannot. There is no physical sign that indicates the virginity of a woman: in fact, no physical examination will be able to evaluate the virginity of a human being, man or woman. “What about the Hymen, doctor?” the hymen is an anatomical part, an elastic membrane in the vaginal canal. It is not a valuable nor scientific sign of virginity: It is sufficiently elastic to be penetrated without breaking, but fragile to be lacerated by activities other than sexual interactions.

Anatomically, the hymen is a membrane composed of solely connective tissue (mainly elastic and collagenous fibers) that hormonal levels are able to modify, so it can increase in elasticity or turn into a cornified thin string. The hymen also presents a range of morphological variations from congenital absence to microperforations and septa. Moreover, in the case of a laceration or notch, it is impossible to identify the cause of the damage. Thus, according to existing evidence, many experts believe the appearance of hymen is not a reliable indicator of virginity or vaginal sex.[14,16,18]

In spite of the total lack of any scientific value and the physical and psychological consequences, virginity tests are still performed and imposed on girls all over the world for different reasons – from reducing premarital sex and HIV infection in some parts of Africa, as part of a recruitment and job requirements to join the Indonesian police force, for forensic evidence collection after a sexual assault as well as for assessment of premarital virginity or lack of wedding night bleeding.[6,13,16] Moreover, due to globalization, in recent years, request and performance of virginity testing have been appearing in countries, new to this practice, such as Canada and Europe,[13,14,18] which should raise concerns and encourage national medical boards to reflect on the medical ethics of performing such a humiliating, painful, and scientifically unreliable practice, regardless of the reason they are requested.[18]

Despite the fact that experts and literature find virginity testing scientifically unreliable and that the WHO has prescribed and discredited the practice,[10,12,14,15,16,18] debunking historical myths about virginity remains a challenge, especially as false beliefs such as intact hymen and wedding night bleeding are embedded in the mainstream culture even among the more educated population and health professionals.[12]

Journey Ahead

Cultural change is a long process, but every journey starts with a first step, and this is ours at SGBV clinic in Port-au-Prince, Haiti: dismantling myths about women's virginity. We are informing people and hopefully empowering them. We do it for our patients and their families and also for all the women around the world, hoping to raise awareness on virginity testing as an unethical, shaming, medically harmful, and scientifically unreliable practice no health professional should agree on performing.

Conflict of Interest

The author declares a conflict of interest as she has been involved in the establishment and management of the SGBV Pran Men'M Klink and has collaborated to the project on debunking virginity myths that is presented in the article.