The existing ideas about the hymen described as a breakable membrane that surrounds or partially covers the external vaginal opening lack scientific proof (Christianson and Eriksson, 2004; Christianson and Eriksson, 2011; Christianson and Eriksson, 2013). Smith (2012) claims that the hymen is an embryological remnant that ruptures during the later stage of embryo development, indicating that it normally does not exist after birth. Furthermore, it has been emphasised that growth makes the vaginal orifice elastic, implying that sexual intercourse seldom leaves any visible changes, and consequently it might not be possible to verify virginity (Pillai 2005; Hegazy and Al-Rukban, 2012). Therefore, it would be incorrect to link the hymen with virginity (Raveenthiran, 2009). Despite the fact that virginity is not possible to verify by an external genital examination (Van Moorst et al, 2012), these ideas about a ruptured hymen have paved the way for medical practices such as virginity examinations and hymen (re) constructions.
In some countries midwives are bystanders when physicians perform hymen examinations—virginity testing (Gürsoy and Vural, 2003). When ‘proof’ of virginity is required, a gynaecologist, a general practitioner, or a forensic physician certifies that the girl is a virgin (Alkan, 2002; Gürsoy and Vural, 2003). The phenomenon of virginity testing occurs in many countries worldwide, such as in Asia (Raveenthiran, 2009), the Middle East, and North Africa (Shalhoub-Kevorkian, 2005). Moreover, in some provinces of South Africa, older women conduct virginity tests on young girls as a strategy to prevent HIV/AIDS (George, 2008). Virginity testing was practiced in the UK in the 1980s with regards to controlling immigration (Portrait of India, 2005). Doctors in Canada say that the practice is on the rise (Krywiak, 2013), and has also been reported in European countries, such as Belgium and Sweden (Amy 2008; Essén 2010).
The fear of not being seen as a virgin on the wedding night can cause great concern for some young women—which can lead to depression, isolation, guilt, attempted suicide, and even a fear of being killed. This ‘honour’-related violence takes place in many countries worldwide. Globally, around 5000 women are murdered every year in the name of honour with an even greater number of unidentified cases estimated (The SURGIR Foundation, 2011). In Sweden, the murder of Fadime Sahindal by her father in 2002 created a public awareness of honour killings (Kurkiala, 2003).
In both economically developing and developed countries there are young women who ‘restore their virginity’ before marriage (Cook and Dickens, 2009; Eich, 2010). Gynaecologists and plastic surgeons sometimes ‘reconstruct’ the hymen of young women. This type of ‘restoration’ is called hymen repair (Eich, 2010), hymenoplasty (Van Moorst et al, 2012) or hymenorraphy (Raveenthiran, 2009), hymen revirgination (Cook and Dickens, 2009), hymen operations, hymen reconstructions, or hymen (re) construction (Christianson and Eriksson, 2011). The procedure is illegal in most Arabic countries (Alkan et al, 2002). However, in Western societies, hymen (re) construction is legal and often seen as comparable to plastic surgery (Paterson-Brown, 1998; Johnsdotter and Essén, 2010). Although it has been reported that the patient may not undergo psychological counselling and pre-operative checking, and the follow-up evaluation is often dismissed, which is controversial as regards plastic surgery in general (Raveenthiran, 2009). The surgical procedure involves cutting incisions in the introitus and sewing sutures in the opening of the vagina, making it narrower with hopes that it will cause bleeding during the ‘first’ intercourse. It is recommended that the stitches be put in place in the vagina two weeks before the wedding to increase the ‘chance’ of blood loss. It is claimed that the stitches will be more or less invisible before the vaginal intercourse takes place (Van Moorst et al, 2012).
In line with Cook and Dickens (2009), hymen revirginations are ‘generally a benign medical intervention that patients request for social reasons’. An increase in young women in Europe requesting hymen (re) constructions has been reported in mainstream media (Amy, 2008); however, there is a gap in the existing data regarding the prevalence of this (Goodman, 2011).
Consequently, these operations are done in secret and are not registered in the medical records (Raveenthiran, 2009). A few studies on health professionals' perceptions of virginity examinations and hymen (re) constructions have been conducted in Sweden (Essén et al, 2010), and in Turkey (Gürsoy and Vural, 2003). These studies report uncertainty and ambivalence among health professionals' opinions as to whether these practices are reasonable or not.
Little is known about midwives' views on these topics. Therefore, a survey was conducted with the aim of investigating the experience and attitudes of an international group of midwives regarding virginity control and hymen (re) constructions. The study also aimed to assess whether experience and attitudes differed in relation to age, area of residence, level of education and years of professional experience.
Methods
Setting and sampling procedure
The study employed a convenient sample design and a target population of midwives who attended the 28th International Confederation of Midwives (ICM) Congress in Glasgow on 1–5 June 2008. The ICM Congress delegates are not a representative sample population of all midwives; rather, they mirror a wide range of midwives in education, research, and practice. More than 3000 midwives from all over the world attended the Congress. The midwives were identified from a list of participants and electronic contact details were provided by the Congress Secretariat. At the end of June 2008, 2200 emails were sent containing information about the study along with a link to an online questionnaire. A total of 2002 emails were delivered—around 9% of the emails sent bounced-back undelivered. Two follow-up reminders were sent to every participant.
The online questionnaire
The online questionnaire was inspired our previous knowledge production about the hymen and virginity (Christianson and Eriksson, 2004; Christianson and Eriksson 2011). In addition, the preparatory work included discussions with a group of researchers at Umea University (n=20), clinical midwives (n=25), and doctoral students from various parts of the world (n=8). A pilot version of the online questionnaire was completed and responded to by a number of participants at the 28th ICM Congress (n=175). Views from the midwives participating in the pilot study served as a basis for the final online questionnaire.
The online questionnaire consisted of basic demographic data such as sex, age, country of residence, occupation, and years of professional experience. Furthermore, 16 standardised questions were asked, addressing two main areas. Section one contained seven questions and concerned biological aspects of the vaginal opening and hymen as well as rupture, bleeding, and virginity verification. Section two consisted of nine questions and concerned the participants' professional experience and attitudes towards virginity control and hymen (re) constructions. All answers were assessed in accordance with three specific response options: Yes/No/Do not know. As a follow-up to the final question, one open-ended question was also asked. All questions, except for the open-ended question (‘What is the most important thing midwives can do to work against unhealthy practices concerning the hymen?’), had to be answered in order for the respondent to be able to submit the online questionnaire. With technical assistance from Print & Media, Umea University, Sweden, all answers given in connection with the questionnaire were kept anonymous and sent to a database together with an Excel file, and forwarded to the Statistical Package for Social Sciences, SPSS, version 19.0 for Windows (SPSS, Inc, Chicago, US).
Analysis
This article will focus on the analysis of questions 8–16 (section two). The results concerning the first seven questions have been reported Christianson and Eriksson, 2013). To describe and summarise data from all participants, the answers were analysed statistically by calculating the frequency distribution. In order to determine associations between the perceptions of the participants and the basic demographic data, the dependent variables were divided into the two categories Yes and No. The answer ‘Do not know’ was not included in the comparative analysis. Univariate logistic regression, with 95% confidence intervals (95% CI) was used for the analysis, and statistical significance was defined as P<0.05. SPSS, version 19.0 for Windows was used in the analysis.
Ethical considerations
Before the online questionnaire was constructed, the topic and design were discussed with the Chair of the Regional Ethical Research Committee at Umeå University. In line with Swedish Ethical Guidelines, ethical approval was not needed (Swedish Riksdag, 2003). The research study was conducted according to general ethical guidelines, permitting voluntary participation, anonymity, and opportunities for participants to ask further questions (World Medical Association Inc, 1964).
Results
The respondents consisted of 480 conference delegates, producing a response rate of about 24%. The largest proportion comprised women (98%) while seven were men (2%). The respondents came from 39 countries representing five continents, and respondents from European countries were in the majority. There was an equal distribution of researchers/teachers and clinical midwives. The mean age of the respondents was 47.3 years and many of them had extensive professional experience amounting to around 20.1 years (Table 1). Not surprisingly, the respondents with the most professional experience were older than the mean age of the study respondents.
| Women (n=473) | Men (n=7) | |||
|---|---|---|---|---|
| n | % | n | % | |
| Age (years) | ||||
| 20–39 | 91 | 19 | 2 | 28 |
| 40–59 | 340 | 72 | 3 | 44 |
| >60 | 42 | 9 | 2 | 28 |
| Area of residence | ||||
| Nordic countries | 57 | 12 | 0 | 0 |
| The rest of Europe | 210 | 44 | 3 | 43 |
| Oceania | 118 | 25 | 0 | 0 |
| America | 58 | 12 | 3 | 43 |
| Asia | 19 | 4 | 1 | 14 |
| Africa | 11 | 3 | 0 | 0 |
| Occupation | ||||
| Researcher | 67 | 14 | 2 | 29 |
| Teacher | 149 | 32 | 3 | 43 |
| Clinical midwife | 215 | 45 | 1 | 14 |
| Student/Health professional | 42 | 9 | 1 | 14 |
| Professional experience (years) | ||||
| <10 | 111 | 23 | 2 | 29 |
| 11–20 | 122 | 26 | 3 | 43 |
| 21–30 | 171 | 36 | 1 | 14 |
| >31 | 69 | 15 | 1 | 14 |
Professional experience concerning virginity control and hymen operations
A small number of the respondents reported that they had professional experience with requests concerning virginity control (7%), virginity certificates (3%) or hymen operations (6%). A minority of the respondents thought that virginity examinations (4%) and hymen operations (8%) are justifiable (Table 2). However, a higher percentage of respondents with professional experience of requests for virginity control and/or hymen operations thought that these practices are justifiable (OR: 4.2; 95% CI 1.9–9.3).
| Question | Yes | No | Do not know | ||||
|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | ||
| 8 | Do you have professional experience of requests concerning virginity control? | 31 | 7 | 443 | 92 | 6 | 1 |
| 9 | Do you have professional experience of requests for a written statement that a young girl is a virgin? | 14 | 3 | 461 | 96 | 5 | 1 |
| 10 | Do you have professional experience of requests for hymen operations? | 27 | 6 | 449 | 93 | 4 | 1 |
| 11 | Do you think that virginity examinations are justifiable? | 18 | 4 | 430 | 89 | 32 | 7 |
| 12 | Do you think that hymen operations are justifiable? | 37 | 8 | 398 | 83 | 45 | 9 |
| 13 | Do you think that virginity examinations and hymen operations are unhealthy practises? | 403 | 84 | 29 | 6 | 48 | 10 |
| 14 | Do you think that virginity examinations and hymen operations are part of violence against women? | 414 | 86 | 24 | 5 | 42 | 9 |
| 15 | Do you think that problems related to virginity examinations and hymen operations should be addressed in midwifery education? | 386 | 81 | 45 | 9 | 49 | 10 |
| 16 | Do you think that it is the responsibility of midwives to work against virginity examination and hymen operations? | 305 | 63 | 57 | 12 | 118 | 25 |
Attitudes regarding women's health and midwifery education and practice
The majority of the respondents regarded virginity examinations and hymen operations as unhealthy practices (84%), and considered them acts of violence against women (86%). A similar proportion (81%) thought that problems related to virginity examinations and hymen operations should be addressed in midwifery education. In addition, nearly two-thirds of the respondents stated that it is the responsibility of midwives to counteract virginity examinations and hymen operations, while one-quarter were unsure concerning midwives' responsibility (Table 2).
Association between demographic data, professional experience, and attitudes towards virginity control and hymen operations
The results were also analysed to see whether there were any differences in the experience and attitudes of younger and older midwives, and if the educational level of the midwives had an impact on their experience and views. Moreover, an analysis was also carried out to discover whether the area of residence and the work experience of the midwives would have an influence on their responses. In the group with experience of the practices, a sub-group analysis was performed.
Age
In comparison to the youngest age group (20–29 years), the respondents in the oldest age group (>60 years) were significantly more likely to report professional experience with requests concerning virginity control, virginity certificates or hymen operations (OR: 4.9; 95% CI: 1.4–17.5). They were also significantly more likely to think that these practices are justifiable (OR: 4.1; 95% CI: 1.3–13.7).
Area of residence
In comparison to respondents from the Nordic countries, respondents from Africa were significantly more likely to report professional experience with requests concerning virginity control, virginity certificates and/or hymen operations (OR: 15.9; 95% CI: 3.3–75.8), while respondents from Asia were significantly more likely to think that these practices are justifiable (OR: 17.6; 95% CI: 3.9–79.5). Furthermore, respondents from Asia were significantly less likely to regard virginity examinations and hymen operations as unhealthy practices (OR: 0.2; 95% CI: 0.5–0.7). However, respondents from Oceania were significantly more likely to regard virginity examinations and hymen operations as unhealthy practices (OR: 3.6; 95% CI: 1.1–28.6) and thought that problems related to virginity examination and hymen operations should be addressed in midwifery education (OR: 3.6; 95% CI: 1.2–10.6). However, respondents from Asia were less likely to think that it is the responsibility of midwives to counteract virginity examinations and hymen operations (OR: 0.1; 95% CI: 0.03–0.43).
Sub-group analysis
In total, 49 respondents reported such experiences. In this subgroup, 4 respondents (8%) were living in the Nordic countries, 17 (35%) were living in the rest of Europe, 7 respondents (14%) in Oceania, 11 (23%) in America, 4 (8%) in Asia, and 6 (12%) in Africa. When performing a comparative analysis of the answers from the group who had professional experience with requests for virginity control and/or hymen reconstruction, 39 (80%) of the respondents in Western countries were significantly more likely to regard virginity examinations and hymen operations as unhealthy practices compared with the 10 respondents from Asia and Africa (P=0.012). However, the number of respondents from Asia and Africa was very small, and these results must be interpreted with caution.
Furthermore, respondents living in Western countries were also significantly more likely to think that problems related to virginity examination and hymen operations should be addressed in midwifery education (P=0.016).
| Demographics | Do you have professional experience of requests for virginity examination and/or hymen operations? | Do you think that virginity examinations and/or hymen operations are justifiable? | Do you think that virginity examinations and hymen operations are unhealthy practices? | Do you think that problems related to virginity examination and hymen operations should be addressed in midwifery education? | Do you think that it is the responsibility of midwives to work against virginity examination and hymen operations? | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| OR | 95% CI | P | OR | 95% CI | P | OR | 95% CI | P | OR | 95% CI | P | OR | 95% CI | P | |
| Age (years) | |||||||||||||||
| 20–39 | ref | ref | ref | ref | ref | ||||||||||
| 40–59 | 2.7 | 0.9–7.8 | 0.07 | 1.3 | 0.5–3.5 | 0.63 | 1.2 | 0.5–3.0 | 0.74 | 0.7 | 03–1.6 | 0.38 | 1.6 | 0.8–3.2 | 0.38 |
| >60 | 4.9 | 1.4–17.5 | 0.01 | 4.1 | 1.3–13.7 | 0.020 | 0.9 | 0.2–3.8 | 0.89 | 3.6 | 0.4–30.7 | 0.89 | 1.5 | 0.5–4.7 | 0.45 |
| Area of residence | |||||||||||||||
| Nordic countries | ref | ref | ref | ref | ref | ||||||||||
| The rest of Europe | 1.15 | 0.4–3.6 | 0.8 | 0.6 | 0.15–2.5 | 0.50 | 1.4 | 0.5–4.1 | 0.54 | 1.9 | 0.8–4.5 | 0.14 | 0.4 | 0.13–1.2 | 0.10 |
| Oceania | 0.8 | 0.2–3.0 | 0.8 | 1.4 | 0.4–5.4 | 0.62 | 5.4 | 1.1–28.6 | 0.049 | 3.6 | 1.2–10.6 | 0.023 | 1.3 | 0.4–4.9 | 0.70 |
| America | 3.0 | 0.9–10.2 | 0.07 | 2.8 | 0.7–11.2 | 0.15 | 5.3 | 0.6–47.0 | 0.134 | 1.7 | 0.6–5.3 | 0.33 | 0.5 | 0.15–1.95 | 0.34 |
| Asia | 2.9 | 0.7–13.0 | 0.15 | 17.6 | 3.9–79.5 | 0.000 | 0.2 | 0.5–0.7 | 0.015 | 0.9 | 0.3–3.5 | 0.93 | 0.1 | 0.26–0.4 | 0.002 |
| Africa | 15.9 | 3.3–76 | 0.000 | 2.0 | 0.2–21.2 | 0.58 | 0.4 | 0.6–2.2 | 0.27 | 0.9 | 0.2–5.1 | 0.94 | 0.3 | 0.05–2.2 | 0.25 |
| Occupation | |||||||||||||||
| Researcher | ref | ref | ref | ref | ref | ||||||||||
| Teacher | 0.75 | 0.3–1.9 | 0.54 | 1.3 | 0.5–3.9 | 0.60 | 0.9 | 0.3–3.1 | 0.91 | 0.6 | 0.17–1.7 | 0.30 | 0.9 | 034–2.3 | 0.78 |
| Clinical midwife | 0.75 | 0.3–1.8 | 0.52 | 0.9 | 0.3–2.7 | 0.90 | 1.3 | 0.4–4.2 | 0.69 | 0.6 | 0.18–1.7 | 0.30 | 0.7 | 0.30–1.8 | 0.51 |
| Student/health professional | 1.43 | 0.5–4.2 | 0.52 | 1.1 | 0.2–4.7 | 0.95 | 0.4 | 0.1–1.7 | 0.22 | 0.6 | 0.14–2.5 | 0.30 | 0.9 | 0.25–3.0 | 0.82 |
| Professional experience (years) | |||||||||||||||
| <10 | ref | ref | ref | ref | ref | ||||||||||
| 11–20 | 4.6 | 1.3–16.5 | 0.02 | 1.3 | 0.4–3.6 | 0.72 | 1.9 | 0.44–8.1 | 0.40 | 0.7 | 0.25–2.0 | 0.55 | 1.5 | 0.56–4.0 | 0.42 |
| 21–30 | 5.94 | 1.7–20.2 | 0.004 | 1.2 | 0.4–3.6 | 0.72 | 0.6 | 0.2–1.8 | 0.38 | 0.7 | 0.3–1.9 | 0.52 | 0.9 | 0.43–2.1 | 0.96 |
| >31 | 4.73 | 1.2–18.5 | 0.03 | 2.3 | 0.8–6.8 | 0.13 | 0.8 | 0.2–2.6 | 0.67 | 0.5 | 0.2–1.3 | 0.16 | 0.8 | 0.34–1.9 | 0.59 |
Occupation
In comparison to researchers, neither experience nor attitudes concerning virginity examinations and hymen operations appeared to differ significantly between the groups of clinical midwives, teachers, and students/health professionals.
Years of professional experience
All respondents who had more professional experience were significantly more likely to report that they had experience of requests concerning virginity control, virginity certificates, and/or hymen operations than those whose professional experience was ≤10 years). Respondents with more professional experience were often older than the mean age of the study respondents.
Discussion
Ten percent of the respondents reported experience of request(s) for virginity examinations and/or hymen (re)constructions. These respondents were more likely to report that these practices are justifiable than did those without such experience. The majority of the midwives in this study stated that virginity examinations and hymen (re) constructions are unjustifiable and considered them acts of violence toward women. Additionally, almost two-thirds of the participants stated that it is the responsibility of midwives to counteract these practices, and that health problems related to virginity examinations and hymen (re) constructions should be addressed in midwifery education.
The results of this online survey indicate that most of the responding midwives had little experience with requests for virginity examinations, virginity certificates, and hymen (re) constructions, even though there are studies that claim that the phenomenon has increased over the past few decades (Amy, 2008; Van Moorst et al, 2012). One explanation for this lack of experience might be that midwives generally do not come across these practices in their work. Traditionally, midwives most often work with women during pregnancy and childbirth, and the fabrication of virgin certificates is not an area in which midwives participate—partially because women do not need a virginity certificate during pregnancy and birth. Usually, this complex issue has been assigned to physicians, including the decision to fake a diagnosis (Helgesson and Lynöe, 2008), and ‘verify virginity’ (Smith, 2012), or to (re) construct a hymen.
The pros and cons of hymen (re) constructions and the ethics that surround this practice are discussed by Risper-Chaim (2007). The paper discusses whether restoration of virginity is a way to deceive husbands or not, as well as whether the practice contributes to sexual liberation for women. It is not a matter of female emancipation, nor of misleading men, but rather a serious sexual and reproductive health problem that reproduce the myths and misconceptions about women's genitals (Christianson and Eriksson, 2013).
According to Awwad (2011), the physicians who examine women's ‘state of virginity’ and restore the hymen through hymen (re) construction, are contributing to the view that women are subordinates in society, and these physicians help uphold a patriarchal gender order in which violence against women and misogyny are part of this view. Despite age, area of residence, level of education and years of professional experience, the majority of the midwives in our study agreed that virginity control and hymen (re) construction are acts of violence against women. Forced virginity examinations and hymen (re) constructions are unscientific and can cause great harm to the women (Wells, 2006). The terms ‘Virgo intacta’, ‘virginal status’, or ‘ruptured hymen’ are misleading, as it is not possible to verify if a girl has had vaginal sex or not (Smith, 2012). Furthermore, discriminatory attitudes about women's sexuality are detrimental to women's health and deny them the right to a satisfying sex life (Shalev, 2000). Women and girls rarely consent to such examinations without coercion by third parties (families, partner, and society); virginity examinations may violate ethical principles of autonomy, privacy, and cause psychological harm. From our point of view this is gender-based violence that is abusive, cruel, and insulting.
The debate that surrounds hymen (re) constructions has a patriarchal tone implying a risk that old-fashioned ideas will be preserved (Eich, 2010). However, from some feminist or multicultural standpoints women are viewed as agents who should decide what is best for them (Saharso, 2003). Some feminist scholars suggest that hymen (re) constructions may be justifiable if they spare the woman a great deal of suffering (Saharso, 2003). This author concludes that allowing hymen repair surgery to be available is both pro-feminist and pro-multiculturalist. The opinions of the majority of the participating midwives are that hymen (re) constructions are unjustifiable and unhealthy, and amount to acts of violence against women. Berer (2007) argues that female genital mutilation (FGM), cosmetic genitoplasty, and hymen (re) constructions are just different sides of the same coin. They are performed to make young women eligible for marriage. However, the population surveyed for this paper appears generally to have little or no experience with these issues, and may therefore have little understanding of the huge cultural and personal issues faced by women in countries were these practices are more common. A minority of the midwives in both developing and developed countries responded that both hymen (re) construction and virginity control can be acceptable. This may be reasonable—for instance, when honour-related violence is a risk and the woman fears her life is in jeopardy if she fails to bleed during her wedding night.
Approximately two-thirds of the midwives stated that it is the responsibility of midwives to counter virginity examinations and hymen operations, and 81% stated that problems related to virginity examinations and hymen (re) constructions should be addressed in midwifery education. One-quarter of the midwives were unsure; therefore, more education on this subject is needed. A study performed in Kenya and Zambia showed that there was an increase in open attitudes towards adolescents' sexuality and reproduction among a select group of nurse-midwives after they received more education on the topic (Warenius et al, 2006). A study performed among midwives in Vietnam had similar findings (Klingberg-Allvin et al, 2007). The authors concluded that the topic of gender inequality in sexual and reproductive health and the ethical dilemmas surrounding this subject need to be addressed more in midwifery education. The word midwife means ‘with woman’ (World Health Organization, 2011), midwives globally provide care to pregnant women and during birth, and are often at the forefront in promoting women's health (Fullerton et al, 2003). Therefore, midwives' work plays a significant role in improving the sexual and reproductive health of women. A first step would be to implement and develop gender theory in midwifery education, which may be a significant challenge.
Methodological considerations
In order to capture data from midwives without the constraints of geographical location an online questionnaire was practical and economical option. An online questionnaire is inexpensive, fast, and easy to use (Kwak and Radler, 2002; Denscombe, 2006), although they are rarely used in midwifery research. However, there may be some problems with the design and technical distribution. According to Kwak and Radler (2002), web surveys tend to appeal to young men, devoted Internet users, and those with greater technological knowledge. However, now women use the internet in equal numbers to men (Gosling et al, 2004). A response rate of approximately 24% is lower in comparison with traditional questionnaire studies, but is comparable to other online surveys (Fraze, 2003; Truell, 2003; Gosling et al, 2004; Denscombe, 2006).
In accordance with Galesic (2006), there are at least two aspects—one positive and one negative—that will affect the response rate and the drop-out rate: interest and burden. Our prior understanding was that the topic would appeal to midwives globally. The design, length, and style of the questionnaire should have affected people's motivation to respond or not (Vicente and Reis, 2010). The questionnaire was neat, short, and easy to fill in. The fairly low response rate could be due to too little interest in the topic, lack of familiarity with the topic, the email containing the link to the questionnaire having been overlooked (Cantrell and Lupinacci, 2007), or the topic being perceived as too offensive or thought-provoking. For the respondent to be able to press the send button, all questions had to be answered, which also may have been a barrier to participation. The questionnaire was written in English, which was not the native language of all of the midwives. This could also have been an obstacle for some of the midwives, although the main language at the ICM Congress was English. Not all midwives have access to the internet. Slow internet connections or other problems with downloading the file or fear of a virus may also have been obstacles to participation for some midwives (Galesic, 2006).
The majority of respondents came from Western countries, particularly Europe, which may confound the findings or increase the risk of Eurocentrism (Krumer-Nevo and Sidi, 2012). Therefore, the reader is advised to keep these contextual features in mind when evaluating the generalisation of the results. Despite this, the results may contribute to the debate and to raise awareness among midwives about this issue.
Conclusion
The suppression and control of women's sexuality can take many different routes. Worldwide, the control of women's genitals and the faking of ‘virginity’ by means of questionable medical practices such as virginity examinations and hymen (re)constructions have become increasingly common. The majority of the midwives in this study had no professional experience with the issue; nevertheless, they stressed that virginity examinations and hymen (re) constructions are unjustifiable and unhealthy, and amount to acts of violence against women. The majority of the respondents thought that the various problems related to virginity control and hymen (re) construction should be addressed in midwifery education, pointing to a need for improved knowledge among midwives.
Approximately two-thirds of the study group believed that it is the responsibility of midwives to reject these practices, indicating that midwives refuse to accept misogynistic practices that devalue women. A first step could be to implement and develop gender theory in midwifery education, while addressing the fact that virginity control and hymen (re)construction are unscientific and may cause great harm to women worldwide, and that the faking of ‘virginity’ in medicine and health care do not favour the emancipation of women. To perform ‘virginity check-ups’ and hymen (re) constructions would be to allow the continuation of counter factual ideas about women's genital anatomy. It also constitutes inhumane and degrading treatment and is a form of gender discrimination that flies in the face of human rights principles for women.