Guatemala: Hymen reconstruction linked to infection, haemorrhage, incontinence, fistulas, and more
The Lancet 2006; 367:1227-1228
Reconstructing virginity in GuatemalaHannah Roberts
“Intimate surgery” is being increasingly used by Guatemalan women wanting to reclaim their virginal credibility. Meanwhile, the country's President and the Catholic Church are trying to block Congressional approval for stronger reproductive health services. Hannah Roberts reports.
The premium put on female virginity in Guatemala is such that women are choosing to undergo a surgical procedure known as hymen reconstruction before marriage, to ensure they are seen as pure. Some gynaecologists estimate that as many as 2% of women in Guatemala may have needlessly, and dangerously, subjected themselves to these operations, which are frequently done in unsatisfactory conditions and without full knowledge of the risks.
Guatemala's status as one of the worst countries in Latin America for reproductive health is compounded by high rates of maternal and infant mortality and low levels of knowledge about contraception. This crisis has spurred activists to establish a powerful civil campaign advocating stronger legal regulation of reproductive-health information and services.
Widespread support for this movement has led to a new law on family planning and reproductive health being backed by a solid parliamentary majority. However, fierce opposition from President Óscar Berger, with support from the Catholic Church, is jeopardising the law's implementation. Instead, a moral and constitutional battle is being played out between the executive and parliament.
Guatemala's strong moral and social codes have helped its citizens endure decades of war, oppression, and economic hardship. Churches and religious groups have long provided comfort, guidance, and sometimes brave political activity. But when it comes to public health, the application of moral reasoning to public policies has led to a growing frustration among those who believe that health needs are being ignored.
The sanctity of female virginity is one such moral code. Women are expected to be virgins when they marry; in some communities blood evidence from the wedding night is still required for verification by the family. The profound societal significance of bridal virginity is such that women are prepared to compromise their physical health to remain socially acceptable. Rossana Cifuentes, Vice President of the Association of Women Doctors, says this culture has led to girls participating in numerous dangerous practices, such as anal sex, to avoid vaginal penetration before marriage.
But girls and women who have lost their virginity are forced to consider even more extreme measures to avoid rejection by their communities, and the economic hardship this entails. In this context, intimate surgery, which offers the appearance of virginity, seems a small price to pay. However, medical experts fiercely disagree.
Operations to reconstruct women's hymens are costly (up to US$1000), provide no health benefit, and run the risk of serious medical complications, says Miriam Bethancourt, of the Association of Guatemalan Gynaecologists and Obstetricians. She is highly critical of the “unscrupulous doctors” who, she says, are exploiting societal pressure and doing unnecessary operations.
Bethancourt believes that most of the surgeons who do these operations have not completed the full necessary medical training. And although Guatemala has a system for registration and regulation of health services, it is inadequately implemented. Monitoring of clinics is therefore inadequate and not sufficiently backed up by legal enforcement from the fledgling justice system.
Intimate surgery is advertised mainly through hand-painted announcements on walls that give mobile phone numbers. Clients are encouraged not to ask too many questions or to take notes. Women repeatedly testify that they are not informed of any of the potential risks or side-effects of the procedures. There is also frustration at the lack of follow-up services.
Gynaecologists report that women who have had hymen reconstructions come to their clinics suffering from numerous health problems, including infections, haemorrhaging, incontinence, fistulas, and extreme pain during sexual intercourse.
These problems are indicative of the typically low levels of awareness of reproductive-health issues that exist in Guatemala. The most recent official statistics, from a nationwide survey done in 2002, found that, in some parts of the country, as much as 42·1% of the population had not heard of HIV/AIDS. The survey also found that only 2·3% of the women who said they use family planning chose condoms as their preferred method of contraception. What is more, only 40·1% of women had used any form of contraception at all (modern or traditional). This figure is just 21·7% for Guatemala's majority indigenous population, with only 15·8% having used any modern method.
Unsurprisingly, there is a high population growth rate2·4% for 2005. At this level, the population could double within 25 years. However, the Guatemalan government has admitted, in response to a 2003 UN inquiry, that it considers the country's population growth rate too high.
Various surveys show there is strong public demand for enhanced family-planning services in the country. The 2002 nationwide study found that 70·9% of women wanted family planning to help them better space their children's births and to limit their family size. Various recent polls done by media outlets have produced similarly compelling findings. 96% of respondents in one survey said that the health ministry should teach and help with family planning, and 90% agreed the ministry should distribute contraceptives to space pregnancy. In another study, 80% of those interviewed agreed that schools and colleges should supply information on contraception.
A national reproductive-health programme was created on the back of the 2001 Social Development Law, but implementation is commonly regarded as inadequate and insufficienthence the ongoing reproductive health problems and unsatisfied demands for services. Furthermore, as Gloria Cospin, Executive Director of the Guatemalan Association for Sexual Education, points out, international funding for reproductive-health programmes has fallen in recent years as a consequence of the current US administration's hostility to modern family-planning methods.
For these reasons, the new family planning law has been welcomed by a wide variety of organisations from civil societyincluding professional medical bodies, traditional health groups, human-rights organisations, indigenous groups, and some Christian groupswhich have come together to campaign for better standards. They have won extensive cross-sector and cross-ethnic support for the new law, which sets obligations for the provision of reproductive-health services, including education and contraception supply. But the campaigners face considerable opposition, not just from the president, but from his influential backers, particularly the catholic church, which is an active provider of health care. Senior catholic leaders have compared contraception to bullets that create a “culture of death”.
In addition to being morally controversial, the new law has become a subject of constitutional dispute over veto powers. In November, 2005, the bill passed through Congress with an exceptionally strong cross-party majority. However, President Berger used his veto to overrule the decision. This action was then overturned by Congress in February, 2006, which decided to enact the bill unilaterally and ordered its publication in the official gazette. The government claims there have been congressional irregularities and has submitted a legal challenge to the Constitutional Court.
Guatemalan society and institutions are at a cross-roads. Campaigners argue that dismissal of the new law on family planning and reproductive health would be a rejection of democratic policy formation based on health needs. By contrast, implementation would improve mortality and morbidity rates and allow for healthier population growth. It would empower women with greater access to information and choices, which, in turn, could also help reduce the number of young women injuring their health for the sake of an appearance of virginity.