Hymen reconstruction surgery (HR), while ethically controversial, is now available in many countries. Little clinical evidence and hardly any surgical standards support the intervention. Nearly as scarce is social science research exploring women's motivations for the intervention, and health care professionals' justifications for its provision. In order to better understand decision-making processes, we conducted semi-structured interviews in metropolitan Tunis, in 2009, with six women seeking the procedure, four friends who supported such women, four physicians who perform the operation, and one midwife. Health care professionals and patient companions expressed moral ambivalence about HR: although they could comprehend the individual situation of the women, they expressed concern that availability of the procedure might further entrench the patriarchal norms that compel the motivation for seeking HR in the first place. Some women seeking HR shared this concern, but felt it was not outweighed by their personal aims, which were to marry and become mothers, or to overcome past violent sexual experiences. The women felt HR to be uniquely helpful in achieving these aims; all made pragmatic decisions about their 1 bodies in a social environment dominated by patriarchal norms. The link between HR and pervasive gender injustice, including the credible threat of serious social and physical harm to women perceived to have failed to uphold the norm of virginity before marriage, raises questions about health care professionals' responsibility while facing requests for HR. Meaningful regulatory guidance must acknowledge that these genuine harms are at stake; it must do so, however, without resorting to moral double standards. We recommend a reframing of HR as a temporary resource for some women making pragmatic choices in a context of structural gender injustice. We reconfirm the importance of factual sexual and reproductive education, most importantly to counter distorted beliefs that conflate an "intact hymen" with virginity.

The "reconstruction of the hymen"consists in a surgical suture of the seam of a hymen that has been fissured due to vaginal intercourse or other causes. This intervention aims at triggering bleeding on the occasion of the next intercourse, a phenomenon often required as proof of virginity within certain traditions. Valid data regarding this ethically and medically controversial and predominantly tabooissue is scarce. In an effort to further explore this practice, we have collected information about hymenorrhaphy from the databases of two anonymous, medical, online counselling services provided by the University Hospital Zürich, and explicitly for teenagers by the Children's Hospital Zürich. We found a sample of 22 questions from women seeking advice, and the results vividly illustrate the psycho-social dilemma these women face, prompting us to suggest that further ethical discussion, collection of empirical data and broad public education on issues related to sexuality are necessary.

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