Harms to subjects of virginity tests

The dictum ‘first do no harm’ expresses a long-standing ethical principle in the practice of medicine: non-maleficence. Since it is generally agreed that physicians are obliged not to act in ways that cause avoidable harm to their patients, I do not seek to defend the principle here. I also contend that physicians have an obligation not just to avoid inevitable actual harms, but also to act in ways that will prevent merely foreseeable potential harms, where this is possible. Again, in this article, I will assume this to be the case, and not seek to defend this claim, now. What I argue for in this section of the article is that there are actual and reasonably foreseeable harms caused by the practice of virginity testing to those who are tested, and that on the basis of the principle of non-maleficence, this imposes on physicians a duty not to perform such tests.

A distinction can be made between two categories of harm that can be experienced by those subjected to a virginity test: first there are harms that can result from the actual experience of the physical test itself; and, second, there are harms that can occur as a consequence of the results of a virginity test becoming known to parties other than the person tested. With respect to the first category, those who are subjected to a virginity test are susceptible to anxiety and emotional trauma as a result of the physical test itself. It is obvious that women who are subjected to a physical examination of their genitalia are likely to experience some emotional distress related to the invasion of their privacy and violation of their bodily integrity. WHO describes forced virginity tests as a form of sexual violence against women.10 Nadera Shalhoub-Kevorkian interviewed Palestinian women who had been subjected to virginity tests and found that her study participants expressed being ‘extremely fearful of and indeed felt terrorised by [the experience]… Their feelings of fear and invasion were manifested in a variety of ways: by their refusal to sit on the examination chair, through crying, screaming, pushing, freezing-up, being silent, fainting, etc.’11 These feelings were reported by those who were voluntarily tested and those who were forced into testing. She further claims that the experience affected the choices and lives of women long after the test and that some of the subjects became suicidal, with one going so far as to actually attempt suicide.11 These harms are hardly trivial, and since they are very likely to be experienced in some degree by those who are subjected to virginity tests,ⁱⁱⁱ on the basis of the principle of non-maleficence, physicians ought not to perform these tests.

The second category of likely harms to subjects of virginity tests involves the kinds of harm that subjects might experience as a consequence of the results of their tests becoming known to others. In most cases a virginity test is procured precisely because someone or some group of persons, other than the person tested, has an interest in knowing the result. Women are not likely to need a test to know their own virginal status, and have little need for any certification of that status for their own sakes. When it is found that a woman does not have an intact hymen, the consequences for her can be very serious. In communities where virginity is very highly valued and associated with moral purity, women who ‘fail’ a virginity test can be in danger of physical or sexual assault and even of being murdered. So called ‘honour killings’ are known to occur.12 Clearly, it is not morally justified for a physician to perform a virginity test and thereby expose the subject to the possibility of such terrible risks.

Admittedly, it is not likely that most subjects of virginity tests face the risk of such serious consequences. However, even those who do not experience physical harm are at risk of many other kinds of harm. Shaming, humiliation, stigmitisation and ostracisation are all likely consequences for those who do not pass a virginity test. Suzanne Leclerc-Madlala describes how women in the KwaZulu-Natal province of South Africa who ‘fail’ a virginity test are subjected to being called names, such as ‘rotten potatoes’, and are regarded as having tarnished their families and communities and having brought shame upon them.13 Lisa Brown contends that women identified as non-virgins in Brazil face ostracisation, and might be expelled from their family homes—a practice supported by Brazilian law until recently.14 Women who ‘fail’ virginity tests in other parts of the world are likely to experience similar harms. Furthermore, in many societies where virginity is highly prized, failing a virginity test may lead to material harms, since it may damage a woman's prospects of marrying well, if at all. Once again, on the basis of the principle of non-maleficence, physicians ought not to perform these tests, given that these sorts of harms could befall those who are not ‘certified’ as virgins.

Interestingly, it is not only those who ‘fail’ a virginity test who are at risk of harm. Leclerc-Madlala's research in South Africa has shown that those who have been identified as virgins may be at increased risk of sexual assault and even rape. Some of her respondents relayed that virgins are targeted for being arrogant or ‘haughty’ and are in danger of ‘being taught a lesson’ by local boys, sometimes encouraged by other young women who have been certified as non-virgins.15 Another significant threat is grounded in the completely unfounded view of some men in the sub-Saharan region of Africa that having sex with a virgin can cure HIV/AIDS. This places virgins at increased risk of rape.15 Furthermore, it is a truism that many men regard having sex with a virgin as a special kind of sexual ‘conquest’, such that women identified as virgins are at risk of being targets of sexual harassment, grooming, assault or rape. Once again, I contend that physicians ought not to perform virginity tests because of these foreseeable and avoidable harms that could befall all of those tested, irrespective of the specific outcome.

Thus far, in my discussion of the harms caused to those tested for virginity, I have assumed that physicians who are approached to perform these tests do so honestly, only issuing a certificate of virginity in cases where their physical examination of the patient reveals the presence of an intact hymen. In parts of the world where virginity testing is traditional and commonplace, many physicians would assume this to be their responsibility.^iv Evidence suggests that particularly in Western countries, where the practice is largely regarded as undesirable and even unethical, physicians may choose to issue a certificate of virginity regardless of what their examination reveals, or even without examination.7 When faced with a woman who is desperate and genuinely afraid of the consequences of not being able to provide a certificate to other interested parties, a physician is confronted by an unenviable moral dilemma. Dishonestly issuing a certificate may seem a lesser moral wrong than abandoning the patient to the vicissitudes of being regarded as a non-virgin in her social context. Indeed, it would be difficult to harshly judge a physician who chooses this option out of genuine concern and compassion for a patient. However, this option is fraught with ethical problems. With trust being so central to the patient-doctor relationship, it is surely very morally problematic for physicians to regularly be complicit in deceit by dishonestly issuing certificates as part of their practice as professionals. Furthermore, as I argue below, there are no scientific grounds upon which a certificate of virginity can be honestly provided. Thus, for any physician to issue a certificate constitutes less than ethically sound professional practice and veracity.

Social harms

Another reason why physicians ought not to perform virginity tests is because of the social harms associated with practice. Here I focus not on harms to the individuals who are tested themselves (although some of the harms to these individuals may harm them in terms of their social relationships), but rather on harms caused to society more broadly. One clear way in which virginity testing is socially harmful is that it unfairly targets women as being responsible for what are regarded as immoral sexual relations in some communities. It is almost always only women who are subjected to virginity tests. Even in South Africa where it is legal for males over 16 years to be tested, this rarely actually occurs.15 In most other places, virginity testing is performed on women only. The South African Human Rights Commission claims that virginity testing promotes sexism,17 and Taylor et al18 write: ‘The focus on women as opposed to acknowledging the co-responsibility of men, discriminates against women and reinforces the stereotypical perspective of female responsibility’. An entrenched characteristic of misogyny through the ages has been the inclination to regard women as tempters of men and as being responsible for leading men into sexual ‘wrongdoing’. Thus, virginity testing entails unfair gender discrimination and perpetuates a negative view of women as being primarily responsible for all acts of putative sexual misconduct. It is obvious how such an attitude to women can lead to violence and abuse against women.

Virginity testing also perpetuates patriarchy. In many patriarchal societies women are regarded as the personal property of men (their fathers or their husbands).11 Furthermore, a woman's value is a function of her ‘purity’. This seems quite literally so in many places, where the ‘bridewealth’ paid before a marriage may be reduced if a woman is certified not to be a virgin. In KwaZulu Natal in South Africa, families of young women who have ‘failed’ a virginity test are often expected to pay a fine.19 Even where the value of women is not so literally measured in monetary terms, it remains morally problematic that women are nevertheless regarded as ‘belonging’ to their husbands or fathers in some societies. This obviously reduces women to the status of things over which men have complete control. It is this sort of attitude that opens the way to ideas that men should be entitled to punish women, insist on their obedience and even, in extreme cases, to take their lives. Such notions fly in the face of established moral principles that hold that all persons should be treated with a basic dignity that respects their inherent worth as human beings. By performing virginity tests, physicians become complicit in perpetuating attitudes to women that disrespect their basic dignity and their fundamental human rights. But, it might be asked, why should this be of concern? Surely physicians do not have any special ethical obligation, just by virtue of being physicians, to confront all of society's injustices and violations of rights? The issue at stake here, however, is complicity. Physicians may not have a moral duty to champion the human rights of others, but they surely do have an obligation not to act in ways that make them complicit in the perpetuation of harmfully discriminatory attitudes.

It might be objected that I have failed to take into account the positive social goods that participating in cultural rites and fulfilling cultural expectations might provide for those who value their cultural identity very highly. I broadly support the importance of respecting other cultures and of not condemning practices simply because they are different. I have argued elsewhere that we have a moral obligation to protect the rights of communities to practice their culture, precisely because of the social goods of authenticity and identification that are the products of belonging to a culture. However, where a particular cultural practice causes significant and serious harms, it is reasonable to hold the view that the moral obligation to prevent these harms outweighs any putative ‘right’ to such a practice.^v

No scientific basis for virginity tests

Thus far, I have argued that physicians ought not to perform virginity tests on the grounds that they cause harm to the individuals tested as well as social harms. There is, however, another very important ethical principle applicable to the practice of medicine that entails that physicians ought never to perform virginity tests. I set aside considerations of non-maleficence now, and shift my focus to a basic principle of the practice of medicine, namely that it should be practised on the basis of sound science. This principle is enshrined in many ethical codes of conduct applicable to physicians. Some representative examples include: the French Code of Medical Ethics, which states that doctors should use the ‘most suitable scientific techniques’;20 the Code of Ethics of the New Zealand Medical Association which requires that physicians ‘[a]dhere to the scientific basis for medical practice’;21 the Quebec College of Physicians’ Ethics Code which states that ‘[a] physician must practice his profession in accordance with scientific principles’;22 and the Code of Ethics of the Caribbean College of Family Physicians which requires that physicians ‘[p]ractice on a scientific basis with integrity’.23

Similar provisions are found in other codes of medical ethics. This fundamental principle is not valid merely because it is supported in many professional codes of conduct. It is grounded in the notion that the practice of medicine requires practitioners to have acquired the necessary body of knowledge and skill to be able to perform their functions. It is on the basis that they are understood to be experts in the science of medicine that society allows them to practise as autonomous professionals. As Daniel Sulmasy claims, the public have no recourse but to trust in the expert knowledge of doctors, and they therefore have right to expect a special degree of trustworthiness from physicians.24 They certainly have a right to expect that they practise medicine on the basis of sound scientific principles.

When a physician is approached to perform a virginity test, he or she is essentially being asked to certify that, in his or her professional opinion, the person tested either has or has not experienced coitus. By agreeing to perform the test the physician is tacitly accepting the view that it is scientifically possible to make a judgment on the virginal status of a woman on the basis of a physical examination of the hymen alone. This view is patently false. The literature is clear on the facts: There are ways in which a hymen can be ruptured other than as a result of penetrative intercourse. Sporting activities such as horse riding, certain kinds of accidents and even the use of tampons can cause the hymen to tear.5 ,25 Furthermore, evidence suggests that it may take more than one act of coitus for an intact hymen to show signs of tearing.9 Thus, if the test for virginity is taken to be the visible or discernible presence of an intact hymen, this so called test is prone to many false positive as well as false negative results. Women who have not experienced coitus may well fail the test, and women who have experienced penetrative intercourse might nonetheless pass.4 The results of an empirical study published in The Lancet revealed that inspection of the hymen by two experienced gynaecologists confirmed virginity in only 58% of self-declared virgins, that the result was uncertain in 11% of cases and that in 31% of cases the virginal status of the participants was not confirmed by examination.25 Furthermore, another article published in the British Medical Journal reported that only 34% of women reported bleeding on first intercourse.5 The writers of The Lancet article just cited claim that ‘[c]ontrary to popular belief no definite criteria have ever been established for deciding whether a woman is a virgin or not… in [some] women the hymen is less well developed and the introitus is distensible, and it is extremely difficult for the medical examiner to state with any certainty whether the woman is, or is not, a virgin.’25 It is, of course difficult to obtain completely reliable data because such studies would have to rely on the honesty of the participants in reporting their own sexual experiences. Nonetheless, the very low level of accuracy reported in the available studies, together with the admission of physicians that it is exceptionally difficult to tell whether a hymen is ‘intact’ or not, strongly implies that inspection of the hymen is completely unreliable as a means of establishing virginal status. There is, in fact, no scientifically reliable way to test for virginity. This has the effect of rendering every virginity certificate ever issued by a physician scientifically fraudulent. Thus, for a physician to agree to perform a virginity test entails a flagrant disregard of the principle that medicine should be practised on the basis of scientific principles. The moral obligation of a physician who is approached to perform such a test is clear: the physician should inform the client that it is simply not possible to do what is being asked. Since there is no scientific basis upon which any physician can certify that a particular woman is or is not a virgin, it would be unethical for any physician to concede to such a request.

A case for declaring virginity tests professionally unethical

I have argued that physicians ought not to perform virginity tests on the basis of the principle of non-maleficence. Such tests can cause avoidable harms to those who are tested and also cause social harms. I have also argued that physicians should not perform these tests because it is scientifically known that it is not possible to reliably determine whether or not a woman is a virgin. However, it is not enough for me merely to defend the claim that it is unethical for physicians to perform virginity tests. Physicians will continue to be approached with requests for such procedures and the practice of virginity tests will continue unless the profession as a whole takes an uncompromising and unified stand against physician participation in the performance of virginity tests. Individual physicians faced with these requests ought not to be left struggling alone with how they should respond. They deserve to be able to refuse on the grounds that their professional bodies have declared such testing unethical. Furthermore, the practice of virginity testing, itself, should be challenged because of the harms it causes to the individuals tested, as well as in terms of perpetuating unfair gender discrimination, misogyny, patriarchy and other social harms. If any group of professionals is in a position to mount this challenge, it surely must be physicians, since they with their medical and scientific knowledge are aware of the complete irrationality inherent in performing ‘tests’ which are scientifically known not to be able to establish that which they are supposedly meant to establish. If the medical profession has any special moral obligation with respect to the practice of virginity testing, then it seems that it is this: as trusted medical experts, physicians ought to adopt a very clear and united stance that virginity testing is an impossibility, and therefore entirely irrational. The profession as a whole should refuse to perform such tests, and it should follow the example of the Quebec College of Physicians in denouncing virginity testing as professionally unethical. Statutory medical councils and voluntary professional associations should declare virginity testing by physicians an unethical practice.