"I feel bad for these women. They're feeling so much pressure from their male family members, and they're afraid to be rejected—or even worse, become victims of serious physical violence and even murder." Dr. Walter* hesitates. For years, the German cosmetic surgeon has been taking on patients who require hymen reconstruction. They are usually young Muslim women— virginity is an important concept in Islam, and the Quran explicitly prohibits extramarital sex in Surah 17.

According to a survey conducted by Pro Familia in 2013, roughly half of all women don't bleed during their first time. The organization says that it is a virginity myth that's been passed down to the next generation. "Doctors [who treat] cases of hymen reconstruction surgery are faced with a dilemma: They don't want women undergo unnecessary procedures, or to perpetuate myths and women-hating behavior. On the other hand, they're aware that this operation could save the women from serious consequences."

There are women who still have intact hymens even after having sex for the first time; conversely, there are women with broken or torn hymens who have never had sex. The idea that the penis must pierce through the hymen to enter the vagina is wrong, and reminiscent of a more patriarchal view of sexual intercourse. The hymen doesn't necessarily break during sex, which is why there may not be any blood even if a woman has undergone reconstructive surgery.

Hymen reconstruction surgery—or hymenoplasty, as it's known in medical jargon—can be performed in an outpatient setting and takes a little less than half an hour. If possible, the remains of the actual hymen are used for the operation.The tissue grows back fairly quickly and may even have some blood vessels that can cause bleeding during sex. But that's not guaranteed—the hymen is a thin membrane that only partially closes the opening to the vagina, and the extent to which it actually performs this function depends on the individual woman.

Obviously, Walter says, such an operation isn't really medically necessary. But the family expects there to be blood on the sheets after the wedding night. Her patients are usually about to get married, but have already had sex. The surgeon remembers a few that even arrived at her office accompanied by their boyfriends—the couples were in this together. The doctor sometimes wonders why people don't just prick their fingers with a needle. "Somehow, they want to do things 'right,'" she says.

Researchers followed 82 women as they went through the consultation process for hymen reconstruction at two clinics in Amsterdam. Their goal was to establish guidelines designed to assist doctors with the procedure. Patients and doctors are now required to meet four times before the operation can be performed, as researchers found that more than half of patients had no knowledge of the female reproductive system and harbored false assumptions about the hymen, including the widely accepted idea that it is a membrane that completely closes off the vagina. Most of them were also afraid that a man could sense whether a woman was a virgin during intercourse.

The pressure on the doctors and patients alike is huge. "The girls communicate with us via multiple secret phone numbers," Walter says. "They take the indirect route to get [in contact with] us." According to a Dutch Society of Obstetricians and Gynecologists study of women seeking hymen reconstruction, 12 percent of those surveyed said they were afraid of potential honor killings, and six percent tried to commit suicide because they were not virgins. It's also important to note that one in every three women didn't lose their virginity consensually, but through rape or coercion.

The families of the patient, however, are significantly less grateful. Walter has received death threats in the past. "Sometimes, an enraged brother or cousin calls and wants to know what's going on. We're also putting ourselves in danger."

Most patients are afraid that their families will reject them if their sexual past is somehow disclosed, Walter explains, which is why she performs these surgeries. If it protects the woman, she says, the procedure is medically justifiable. Her payment is the gratitude of her patients.

While the doctors understood that these young women needed help, the solution didn't always involve a medical procedure. In the study, women were given the option to contract their pelvic muscles to give the impression of vaginal tightness. They also received the offer of a small bottle of blood they could put on their sheets. Other options ranged from inducing bleeding by going off birth control pills, or placing an insert containing red dye into the vagina before sex.

But these options don't always work, Walter says. Some women are threatened with virginity tests to be performed by a doctor or family member in their home countries, while other families require a "virginity certificate."

"One time, a whole wedding party arrived at my hospital at night and said they wanted me to confirm, through an examination, that the bride was a virgin," recalls Dr. Michael P. Lux, a senior doctor at the Women's Hospital in Erlangen, Germany. "I invited the woman into my examination room, sent all other family members outside, and talked to her for a while. After five minutes, I pronounced her to be a virgin." The fact that a doctor can't actually tell whether a woman is a virgin was irrelevant. In that moment, Lux says, his job as a doctor was to protect the girl from danger.

Unfortunately, Walter says, the doctors who perform these surgeries need protection as well. She doesn't know how much longer she'll continue to accept patients seeking the procedure. The demand and its ensuing desperation are huge—medical forums are full of people looking for help, whether that's a discreet surgeon or a virginity certificate for their future parents-in-law. Doctors can use these forums to get in touch with patients anonymously. One of Walter's patients found her through a social worker from Somalia who had also been treated from Walter. She was a victim of of female genital mutilation in her home country and asked to have reconstructive surgery. In recent years, there's been an increasing number of refugees from African countries who ask for this procedure; Walter treats them for free.

But that's not the case for other care providers. Patients need to be careful as to not end up with the wrong doctor; Pro Familia warns that private practices, in particular, accept patients for profit, charge thousands of euros per operation, and don't even try to talk the patients out of surgery. Every medical procedure has its risks, says Lux. Scarring, decreased sensitivity and infection can all be caused by an operation gone wrong. The genitals contain more sensitive nerves than any other part of the human body. And there are no standard procedures for hymen reconstruction—so far, doctors have been teaching themselves.

Lux says patients should make sure they're seeking treatment by a medical expert or plastic surgeon with proven experience. Since the term "plastic surgeon" isn't protected in Germany, any doctor can write it on their door even if they lack any actual experience.

However, guidelines in the Netherlands advise against an operation unless it is an absolute last resort—with education, many desperate women can be persuaded that there are other options available. After all, even the first wife of the Prophet Mohammed wasn't a virgin when they married—she already had two ex-husbands and three children by the time they met.