Hymen

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Hymen
Hymen en.svg
Various hymen defects (the shaded areas represent the vaginal opening)
Haultain and Ferguson - external female genital organs.svg
External genitals of a human female
Details
Identifiers
Latin hymen
Greek ὑμήν
MeSH D006924
TA98 A09.1.04.008
TA2 3530
FMA 20005
Anatomical terminology

The hymen is a piece of mucosal tissue 2 millimeters in average thickness that surrounds or partially covers the vaginal introitus. A small percentage are born with hymens that are imperforate and completely obstruct the vaginal canal. It forms part of the vulva and is similar in structure to the vagina. [1] [2] The term comes straight from the Greek, for 'membrane'.

Contents

In children, a common appearance of the hymen is crescent-shaped, although many shapes are possible. Each shape in the natural range has a Latinate name. During puberty, estrogen causes the hymen to change in appearance and become very elastic. [3] [4] Normal variations of the post-pubertal hymen range from thin and stretchy to thick and somewhat rigid. [1] Very rarely, it may be completely absent. [5]

The hymen can rip or tear during first penetrative intercourse, which usually results in pain and, sometimes, mild temporary bleeding or spotting. Minor injuries to the hymen may heal on their own, and not require surgical intervention. [6] Historically, it was believed that first penetration was necessarily traumatic, but now sources differ on how common tearing or bleeding are as a result of first intercourse. [7] [8] [9] Therefore, the state of the hymen is not a reliable indicator of virginity, [2] [10] though "virginity testing" remains a common practice in some cultures, sometimes accompanied by hymen reconstruction surgery to give the appearance of virginity.

Development and histology

The genital tract develops during embryogenesis, from the third week of gestation to the second trimester, and the hymen is formed following the vagina. At week seven, the urorectal septum forms and separates the rectum from the urogenital sinus. At week nine, the Müllerian ducts move downwards to reach the urogenital sinus, forming the uterovaginal canal and inserting into the urogenital sinus. At week twelve, the Müllerian ducts fuse to create a primitive uterovaginal canal called unaleria. At month five, the vaginal canalization is complete and the fetal hymen is formed from the proliferation of the sinovaginal bulbs (where Müllerian ducts meet the urogenital sinus), and normally becomes perforate before or shortly after birth. [11]

The hymen has dense innervation. In newborn babies, still under the influence of the mother's hormones, the hymen is thick, pale pink, and redundant (folds in on itself and may protrude). For the first two to four years of life, the infant produces hormones that continue this effect. [12] Their hymenal opening tends to be annular (circumferential). [13]

Post neonatal stage, the diameter of the hymenal opening (measured within the hymenal ring) widens by approximately 1 mm for each year of age. [14] During puberty, estrogen causes the hymen to become very elastic and fimbriated. [3] [4]

The hymen can stretch or tear as a result of various behaviors, by the use of tampons [7] or menstrual cups, pelvic examinations with a speculum, or sexual intercourse. [1] Remnants of the hymen are called carunculae myrtiformes. [10]

A glass or plastic rod of 6 mm diameter having a globe on one end with varying diameter from 10 to 25 mm, called a Glaister Keen rod, is used for close examination of the hymen or the degree of its rupture. In forensic medicine, it is recommended by health authorities that a physician who must swab near this area of a prepubescent girl avoid the hymen and swab the outer vulval vestibule instead. [12] In cases of suspected rape or child sexual abuse, a detailed examination of the hymen may be performed, but the condition of the hymen alone is often inconclusive. [2]

Anatomic variations

Normal variations of the hymen range from thin and stretchy to thick and somewhat rigid. [1] [12] An imperforate hymen occurs in 1-2 out of 1,000 infants. [15] [16] The only variation that may require medical intervention is the imperforate hymen, which either completely prevents the passage of menstrual fluid or slows it significantly. In either case, surgical intervention may be needed to allow menstrual fluid to pass or intercourse to take place at all. [17]

Prepubescent hymenal openings come in many shapes, depending on hormonal and activity level, the most common being crescentic (posterior rim): no tissue at the 12 o'clock position; crescent-shaped band of tissue from 1–2 to 10–11 o'clock, at its widest around 6 o'clock. From puberty onwards, depending on estrogen and activity levels, the hymenal tissue may be thicker, and the opening is often fimbriated or erratically shaped. [13] In younger children, a torn hymen will typically heal very quickly. In adolescents, the hymenal opening can naturally extend and variation in shape and appearance increases. [1]

Variations of the female reproductive tract can result from agenesis or hypoplasia, canalization defects, lateral fusion and failure of resorption, resulting in various complications. [18]

Trauma

A hymen with a hymenal cleft visible on the left. Hymen05.jpg
A hymen with a hymenal cleft visible on the left.

Historically, it was believed that first sexual intercourse was necessarily traumatic to the hymen and always resulted in the hymen being "broken" or torn, causing bleeding. However, research on women in Western populations has found that bleeding during first intercourse does not invariably occur. [8] [9] [22] In one cross-cultural study, slightly more than half of all women self-reported bleeding during first intercourse, with significantly different levels of pain and bleeding reported depending on their region of origin. [23] [22] Not all women experience pain, and one study found a correlation between the experience of strong emotions – such as excitement, nervousness, or fear – with experiencing pain during first intercourse. [24]

In several studies of adolescent female rape victims, where patients were examined at a hospital following sexual assault, half or fewer of virgin victims had any injury to the hymen. [25] [26] [27] Tears of the hymen occurred in less than a quarter of cases. [27] However, virgins were significantly more likely to have injuries to the hymen than non-virgins. [25] [27]

In a study of adolescents who had previously had consensual sex, approximately half showed evidence of trauma to the hymen. [28] [29] Trauma to the hymen may also occur in adult non-virgins following consensual sex, although it is rare. [30] Trauma to the hymen may heal without any visible sign of injury. [25] [29] [1] An observational study of adolescent sexual assault victims found that majority of wounds to the hymen healed without any visible sign of injury having occurred. [31]

Trauma to the hymen is hypothesized to occur as a result of various other behaviors, such as tampon or menstrual cup use, pelvic examinations with a speculum, masturbation, gymnastics, or horseback riding, although the true prevalence of trauma as a result of these activities is unclear. [7] [32] [33]

Cultural and religious significance

The hymen is often attributed important cultural significance in certain communities because of its association with a woman's virginity. In those cultures, an intact hymen is highly valued at marriage in the belief that this is a proof of virginity. [7] [34] [35] Some women undergo hymenorrhaphy to restore their hymen for this reason. [35] In October 2018, the UN Human Rights Council, UN Women and the World Health Organization (WHO) stated that virginity testing must end as "it is a painful, humiliating and traumatic practice, constituting violence against women". [36]

Some traditional Christian theological interpretations state that it is intended by God for the husband to be the one to break his wife's hymen, and that the bleeding the hymen, believed occur during first intercourse (but see above), is a blood covenant that seals the bond of holy matrimony between husband and wife (cf. consummation ). [37]

Womb fury

In the 16th and 17th centuries, medical researchers mistakenly saw the presence or absence of the hymen as founding evidence of physical diseases such as "womb-fury", i.e., (female) hysteria. If not cured, womb-fury would, according to doctors practicing at the time, result in death. [38] [39]

Other animals

Due to similar reproductive system development, many mammals have hymens, including chimpanzees, elephants, manatees, whales, horses and llamas. [40] [41]

See also

Related Research Articles

<span class="mw-page-title-main">Vagina</span> Part of the female reproductive tract

In mammals and other animals, the vagina is the elastic, muscular reproductive organ of the female genital tract. In humans, it extends from the vulval vestibule to the cervix. The vaginal introitus is normally partly covered by a thin layer of mucosal tissue called the hymen. The vagina allows for copulation and birth. It also channels menstrual flow, which occurs in humans and closely related primates as part of the menstrual cycle.

<span class="mw-page-title-main">Virginity</span> State of a person who has never engaged in sexual intercourse

Virginity is the state of a person who has never engaged in sexual intercourse; it is considered a social construct, not an objective term with an operational definition. Social definitions of virginity therefore vary. Heterosexual individuals may or may not consider loss of virginity to occur only through penile-vaginal penetration, while people of other sexual orientations often include oral sex, anal sex, or manual sex in their definitions of losing one's virginity. The term virgin encompasses a range of definitions, as found in traditional, modern and ethical concepts. Religious rituals for regaining virginity exist in many cultures. Some men and women consider themselves born-again virgins.

Dyspareunia is painful sexual intercourse due to medical or psychological causes. The term dyspareunia covers both female dyspareunia and male dyspareunia, but many discussions that use the term without further specification concern the female type, which is more common than the male type. In females, the pain can primarily be on the external surface of the genitalia, or deeper in the pelvis upon deep pressure against the cervix. Medically, dyspareunia is a pelvic floor dysfunction and is frequently underdiagnosed. It can affect a small portion of the vulva or vagina or be felt all over the surface. Understanding the duration, location, and nature of the pain is important in identifying the causes of the pain.

A hymenotomy is a medical procedure involving the surgical removal or opening of the hymen. It is often performed on patients with an imperforate or septate hymen, or other situations where the hymen is unusually thick or rigid such as microperforate hymen. In the case of a female with a hymen without any opening, an opening may be created in order to facilitate menstruation. In situations where the opening is extremely small or the band(s) of a septate hymen limit access to the vaginal opening, the woman may elect for hymenotomy to allow for comfortable sexual penetration of her vagina, or to relieve pain or discomfort that occurs when inserting/removing tampons. Sexual intercourse would not normally be adversely affected by a hymenotomy.

Vaginoplasty is any surgical procedure that results in the construction or reconstruction of the vagina. It is a type of genitoplasty. Pelvic organ prolapse is often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplasty is needed following the treatment or removal of malignant growths or abscesses to restore a normal vaginal structure and function. Surgery to the vagina is done to correct congenital defects to the vagina, urethra and rectum. It may correct protrusion of the urinary bladder into the vagina (cystocele) and protrusion of the rectum (rectocele) into the vagina. Often, a vaginoplasty is performed to repair the vagina and its attached structures due to trauma or injury.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

An imperforate hymen is a congenital disorder where a hymen without an opening completely obstructs the vagina. It is caused by a failure of the hymen to perforate during fetal development. It is most often diagnosed in adolescent girls when menstrual blood accumulates in the vagina and sometimes also in the uterus. It is treated by surgical incision of the hymen.

<span class="mw-page-title-main">Vaginectomy</span> Surgical removal of the vagina

Vaginectomy is a surgery to remove all or part of the vagina. It is one form of treatment for individuals with vaginal cancer or rectal cancer that is used to remove tissue with cancerous cells. It can also be used in gender-affirming surgery. Some people born with a vagina who identify as trans men or as nonbinary may choose vaginectomy in conjunction with other surgeries to make the clitoris more penis-like (metoidioplasty), construct of a full-size penis (phalloplasty), or create a relatively smooth, featureless genital area.

Hymenorrhaphy or "hymen reconstruction surgery" is the surgical alteration of the hymen, with the goal of producing bleeding on intercourse and a tight vaginal introitus, falsely believed to indicate virginity. The term comes from the Greek words hymen meaning "membrane", and raphḗ meaning "suture". It is also known as hymenoplasty, although strictly this term would also include hymenotomy.

Hematocolpos is a medical condition in which the vagina is pooled with menstrual blood due to multiple factors leading to the blockage of menstrual blood flow. The medical definition of hematocolpos is "an accumulation of blood within the vagina". It is often caused by the combination of menstruation with an imperforate hymen. It is sometimes seen in Robinow syndrome, uterus didelphys, or other vaginal anomalies.

<span class="mw-page-title-main">Hematometra</span> Medical condition

Hematometra is a medical condition involving collection or retention of blood in the uterus. It is most commonly caused by an imperforate hymen or a transverse vaginal septum.

A virginity test is the pseudoscientific practice and process of determining whether a woman or girl is a virgin; i.e., to determine that she has never engaged in, or been subjected to, vaginal intercourse. The test typically involves a check for the presence of an intact hymen, typically on the flawed assumption that it can only be, and will always be torn as a result of vaginal intercourse. Virginity testing is most common in Asia and the Middle East, as well as Northern and Southern Africa.

A vaginal disease is a pathological condition that affects part or all of the vagina.

An artificial hymen is a type of prosthetic created for the purpose of simulating an idealized human hymen, usually to fake virginity, which some wrongly believe can be identified by the appearance, tightness, or bleeding of the hymen during vaginal penetration.

<span class="mw-page-title-main">Vulva</span> External genitalia of the female mammal

In mammals, the vulva comprises mostly external, visible structures of the female genitalia leading away from the interior parts of the female reproductive tract, starting at the vaginal opening. For humans, it includes the mons pubis, labia majora, labia minora, clitoris, vestibule, urinary meatus, vaginal introitus, hymen, and openings of the vestibular glands. The folds of the outer and inner labia provide a double layer of protection for the vagina. Pelvic floor muscles support the structures of the vulva. Other muscles of the urogenital triangle also give support.

<span class="mw-page-title-main">Postcoital bleeding</span> Non-menstrual vaginal bleeding during or after sexual intercourse

Postcoital bleeding (PCB) is non-menstrual vaginal bleeding that occurs during or after sexual intercourse. Though some causes are with associated pain, it is typically painless and frequently associated with intermenstrual bleeding.

Genital trauma is trauma to the genitalia.

<span class="mw-page-title-main">Vaginal anomalies</span> Congenital defect; abnormal or absent vagina

Vaginal anomalies are abnormal structures that are formed during the prenatal development of the female reproductive system and are rare congenital defects that result in an abnormal or absent vagina.

Vaginal trauma is injury to the vagina. It can happen during childbirth, sexual assault, and accidental occurrences.

References

  1. 1 2 3 4 5 6 Heger, Astrid H.; Emans, S. Jean, eds. (2000). Evaluation of the Sexually Abused Child: A Medical Textbook and Photographic Atlas (PDF) (2nd ed.). New York: Oxford University Press. pp. 61–65. ISBN   978-0-19-507425-3. Archived from the original (PDF) on July 8, 2018. Retrieved July 8, 2018.
  2. 1 2 3 Perlman, Sally E.; Nakajyma, Steven T.; Hertweck, S. Paige (2004). Clinical protocols in pediatric and adolescent gynecology. Parthenon. p. 131. ISBN   978-1-84214-199-1.
  3. 1 2 Lahoti, Sheela L.; McClain, Natalie; Girardet, Rebecca; McNeese, Margaret; Cheung, Kim (March 1, 2001). "Evaluating the Child for Sexual Abuse". American Family Physician. 63 (5): 883–92. ISSN   0002-838X. PMID   11261865.
  4. 1 2 Heger, Astrid H.; Emans, S. Jean, eds. (2000). Evaluation of the Sexually Abused Child: A Medical Textbook and Photographic Atlas (PDF) (2nd ed.). New York: Oxford University Press. p. 122. ISBN   978-0-19-507425-3. Archived from the original (PDF) on July 8, 2018. Retrieved July 8, 2018.
  5. ↑ Mishori, R.; Ferdowsian, H.; Naimer, K.; Volpellier, M.; McHale, T. (June 3, 2019). "The little tissue that couldn't – dispelling myths about the Hymen's role in determining sexual history and assault - Fact 1A". Reproductive Health. 16 (1): 74. doi: 10.1186/s12978-019-0731-8 . PMC   6547601 . PMID   31159818.
  6. ↑ Hegazy, Abdelmonem; Al-Rukban, Mohammed (January 1, 2012). "Hymen: Facts and conceptions". The Health. 3 (4). ISSN   2219-8083. Possible explanations for the lack of genital trauma include... acute injuries occur but heal completely.
  7. 1 2 3 4 "The Hymen". University of California, Santa Barbara . Retrieved September 19, 2020. While some females bleed the first time they have penetrative intercourse, not every female does. This depends on many factors, such as how much hymenal tissue a female has, whether her hymen has already been stretched or torn, or how thick and elastic it is.
  8. 1 2 Rogers, Deborah J; Stark, Margaret (August 8, 1998). "The hymen is not necessarily torn after sexual intercourse". BMJ: British Medical Journal. 317 (7155): 414. doi:10.1136/bmj.317.7155.414. ISSN   0959-8138. PMC   1113684 . PMID   9694770.
  9. 1 2 Emma Curtis, Camille San Lazaro (February 27, 1999). "Appearance of the hymen in adolescents is not well documented". BMJ: British Medical Journal. 318 (7183): 605. doi:10.1136/bmj.318.7183.605. PMC   1115047 . PMID   10037658. We agree with Rogers and Stark that so called rupture and bleeding of the hymen is not to be routinely expected after first sexual intercourse.
  10. 1 2 Knight, Bernard (1997). Simpson's Forensic Medicine (11th ed.). London: Arnold. p. 114. ISBN   978-0-7131-4452-9.
  11. ↑ Healey, Andrew (2012). "Embryology of the female reproductive tract". In Mann, Gurdeep S.; Blair, Joanne C.; Garden, Anne S. (eds.). Imaging of Gynecological Disorders in Infants and Children. Medical Radiology. Springer. pp. 21–30. doi:10.1007/978-3-540-85602-3. ISBN   978-3-540-85602-3.
  12. 1 2 3 McCann, J; Rosas, A. and Boos, S. (2003) "Child and adolescent sexual assaults (childhood sexual abuse)" in Payne-James, Jason; Busuttil, Anthony and Smock, William (eds). Forensic Medicine: Clinical and Pathological Aspects, Greenwich Medical Media: London, a)p.453, b)p.455 c)p.460. ISBN   978-1-84-110026-5
  13. 1 2 Heger, Astrid; Emans, S. Jean; Muram, David (2000). Evaluation of the Sexually Abused Child: A Medical Textbook and Photographic Atlas (Second ed.). Oxford University Press. p. 116. ISBN   978-0-19-507425-3.
  14. ↑ Pugno, Perry (1999). "Genital Findings in Prepubertal Girls Evaluated for Sexual Abuse". CiteSeerX   10.1.1.522.1894 .
  15. ↑ Callahan, Tamara L.; Caughey, Aaron B. (2009). Blueprints Obstetrics and Gynecology. Lippincott Williams & Wilkins. ISBN   978-0-7817-8249-4.
  16. ↑ Lardenoije, Céline; Aardenburg, Robert; Mertens, Helen (May 26, 2009). "Imperforate hymen: a cause of abdominal pain in female adolescents". BMJ Case Reports. 2009: bcr0820080722. doi:10.1136/bcr.08.2008.0722. ISSN   1757-790X. PMC   3029536 . PMID   21686660.
  17. ↑ "Imperforate hymen". medlineplus.gov. United States National Library of Medicine. 2021.
  18. ↑ "Congenital Anomalies of the Hymen". brighamandwomens.org. Brigham and Women's Hospital.
  19. ↑ "Imperforate Hymen". mountsinai.org. Mount Sinai Hospital (Brooklyn).
  20. ↑ "Cribriform Hymen". texaschildrens.org. Texas Children's Hospital.
  21. ↑ "Septate Hymen". childrenshospital.org. Boston Children's Hospital.
  22. 1 2 Loeber, Olga (2008). "Over het zwaard en de schede; bloedverlies en pijn bij de eerste coïtus Een onderzoek bij vrouwen uit diverse culturen" (PDF). Tijdschrift voor Seksuologie (in Dutch). Vol. 32. pp. 129–137. Archived from the original (PDF) on November 5, 2019. Retrieved September 7, 2018.
  23. ↑ Amy, Jean-Jacques (January 2008). "Certificates of virginity and reconstruction of the hymen". The European Journal of Contraception & Reproductive Health Care. 13 (2): 111–113. doi:10.1080/13625180802106045. ISSN   1362-5187. PMID   18465471. S2CID   37484764.
  24. ↑ Weis, David L. (1985). "The experience of pain during women's first sexual intercourse: Cultural mythology about female sexual initiation". Archives of Sexual Behavior. 14 (5): 421–438. doi:10.1007/BF01542003. PMID   4062539. S2CID   6427129.
  25. 1 2 3 White C, McLean I (May 1, 2006). "Adolescent complainants of sexual assault; injury patterns in virgin and non-virgin groups". Journal of Clinical Forensic Medicine. 13 (4): 172–180. doi:10.1016/j.jcfm.2006.02.006. ISSN   1353-1131. PMID   16564196. Hymen injury was noted in 40 (50.6%) participants of the virgin group, but only 11 (12.4%) of the non-virgin group
  26. ↑ Adams, Joyce A.; Girardin, Barbara; Faugno, Diana (May 2000). "Signs of genital trauma in adolescent rape victims examined acutely". Journal of Pediatric and Adolescent Gynecology. 13 (2): 88. doi:10.1016/S1083-3188(00)00015-2. ISSN   1083-3188. PMID   10869972.
  27. 1 2 3 Adams, Joyce A.; Girardin, Barbara; Faugno, Diana (November 1, 2001). "Adolescent Sexual Assault: Documentation of Acute Injuries Using Photo-colposcopy". Journal of Pediatric and Adolescent Gynecology. 14 (4): 175–180. doi:10.1016/S1083-3188(01)00126-7. ISSN   1083-3188. PMID   11748013. The incidence of hymenal tears in self-described virgins was higher than in nonvirgins (19% vs. 3%, P .008);
  28. ↑ Adams, Joyce A.; Botash, Ann S.; Kellogg, Nancy (March 2004). "Differences in hymenal morphology between adolescent girls with and without a history of consensual sexual intercourse". Archives of Pediatrics & Adolescent Medicine. 158 (3): 280–285. doi: 10.1001/archpedi.158.3.280 . ISSN   1072-4710. PMID   14993089. Subjects who admitted having past intercourse still had non disrupted, intact hymens in 52% of cases.
  29. 1 2 "New York Times Is Wrong about Hymens--But They Are Not Alone". Psychology Today. Retrieved September 8, 2018.
  30. ↑ Slaughter, Laura; Brown, Carl R.V.; Crowley, Sharon; Peck, Roxy (March 1997). "Patterns of genital injury in female sexual assault victims". American Journal of Obstetrics and Gynecology. 176 (3): 609–616. doi:10.1016/s0002-9378(97)70556-8. ISSN   0002-9378. PMID   9077615.
  31. ↑ Reading, Richard (December 12, 2007). "Healing of hymenal injuries in prepubertal and adolescent girls: a descriptive study". Child: Care, Health and Development. 34 (1): 137–138. doi:10.1111/j.1365-2214.2007.00818_7.x. ISSN   0305-1862. Of the girls who sustained 'superficial', 'intermediate,' or 'deep' lacerations, 15 of 18 prepubertal girls had smooth and continuous appearing hymenal rims, whereas 24 of 41 adolescents' hymens had a normal, 'scalloped' appearance and 30 of 34 had no disruption of continuity on healing. The final 'width' of a hymenal rim was dependent on the initial depth of the laceration. No scar tissue formation was observed in either group of girls.
  32. ↑ Goodyear-Smith, Felicity A.; Laidlaw, Tannis M. (June 8, 1998). "Can tampon use cause hymen changes in girls who have not had sexual intercourse? A review of the literature". Forensic Science International. 94 (1–2): 147–153. doi:10.1016/S0379-0738(98)00053-X. ISSN   0379-0738. PMID   9670493.
  33. ↑ Emans, S.Jean; Woods, Elizabeth R.; Allred, Elizabeth N.; Grace, Estherann (July 1, 1994). "Hymenal findings in adolescent women: Impact of tampon use and consensual sexual activity". The Journal of Pediatrics. 125 (1): 153–160. doi:10.1016/S0022-3476(94)70144-X. ISSN   0022-3476. PMID   8021768. Contrary to the popular belief that transections of the hymen are associated with gymnastics, horseback riding, and other vigorous sports, we found no relation between sports or gymnastics and hymenal changes. There was also no relation to prior gynecologic examination.
  34. ↑ "Muslim women in France regain virginity in clinics". Reuters. April 30, 2007. 'Many of my patients are caught between two worlds,' said Abecassis. They have had sex already but are expected to be virgins at marriage according to a custom that he called 'cultural and traditional, with enormous family pressure'.
  35. 1 2 Sciolino, Elaine; Mekhennet, Souad (June 11, 2008). "In Europe, Debate Over Islam and Virginity". The New York Times . Retrieved June 13, 2008. 'In my culture, not to be a virgin is to be dirt,' said the student, perched on a hospital bed as she awaited surgery on Thursday. 'Right now, virginity is more important to me than life.'
  36. ↑ "United Nations agencies call for ban on virginity testing". World Health Organization. October 17, 2018. Retrieved October 22, 2018.
  37. ↑ Gentry, Harold (January 21, 2021). Intimacy. WestBow Press. ISBN   978-1-6642-1232-9.
  38. ↑ Berrios, GE; Rivière, L (2006). "Madness from the womb". History of Psychiatry. 17 (66 Pt 2): 223–35. doi:10.1177/0957154x06065699. PMID   17146991. S2CID   148179899.
  39. ↑ The linkage between the hymen and social elements of control has been taken up in Marie Loughlin's book Hymeneutics: Interpreting Virginity on the Early Modern Stage published in 1997
  40. ↑ Blank, Hanne (2007). Virgin: The Untouched History. Bloomsbury Publishing. p. 23. ISBN   978-1-59691-010-2 . Retrieved November 9, 2013.
  41. ↑ Blackledge, Catherine (2004). The Story of V . Rutgers University Press. ISBN   978-0-8135-3455-8. Hymens, or vaginal closure membranes or vaginal constrictions, as they are often referred to, are found in a number of mammals, including llamas, ...
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