| Koro | |
|---|---|
| Classification and external resources | |
| MeSH | D016911 |
Koro is a culture-specific syndrome from Southeast Asia in which the person has an overpowering belief that his penis (or other genitalia) is shrinking and will shortly disappear. Also known as shrinking penis, the syndrome is listed in the Diagnostic and Statistical Manual of Mental Disorders. In China, it is known as shuk yang,[1][2] shook yong,[1][2] and suo yang[1][2] (simplified Chinese: 缩阳; traditional Chinese: 縮陽); jinjinia bemar[1][2] (Assam); or rok-joo[1][2] (Thai: โรคจู๋), is to describe an individual overcome with such a belief. For females, the belief focuses on the nipples retracting or shrinking.
Though the syndrome is rooted in China and found mostly in Southeast Asia, rare and isolated cases of koro are found in people of non-Chinese ethnicity worldwide. Episodes of epidemics occurred in the endemic nations. In a different cultural setting, mass hysteria of genital-shrinkage have been reported in African nations.
Contents |
In DSM-IV-TR, koro is listed as one of the entries in the Glossary of Culture-Bound Syndromes of Appendix I. The manual gives koro's definition as "a term, probably of Malaysian origin, that refers to an episode of sudden and intense anxiety that the penis (or, in females, the vulva and nipples) will recede into the body and possibly cause death."[1] Attempts by numerous authors to sub-group culture-bound syndromes place koro into different classes according to the system of classification, such as the group of "specific culture-imposed nosophobia" (classification with cardinal sign),[3] "the genital retraction taxon" (classification with common factors between syndromes),[2] and the group with "culture-related beliefs as causes for the occurrence" (classification according to how the syndromes might be affected by cultural factors).[4]
Various authors have attempted to distinguish between complete and incomplete forms of koro, as well as cultural and non-cultural forms.[5] Cultural forms are said to involve a cultural belief or myth which plays a role in the genesis and spread of the disease in the community, and are regarded as complete forms, fulfilling all the criteria of the symptom complex.[6][5] Differentiation into primary koro (as a culture-bound expression) and secondary koro (co-morbid with a CNS disorder or another psychiatric disorder; or drug-induced) has been proposed.[6]
Traditional Chinese medicine recognised koro as a sexual disease and classified it into two categories, namely "cold conglomeration in liver" and "depletion of kidney's yang".[7]
Most of the victims complain about episodes of acute attack of genital retraction or genital shrinkage, sometimes both.[8] Each episode usually lasted several hours, though the duration can be as long as two days.[9] There are cases in which koro symptoms persist for years with either chronic and continuous or recurrent history.[6] On top of retraction, other symptoms include a perception of alteration of penis shape, loss of penile muscular tone; in some cases when sufferers have no perception of retraction, they may complain of genital paraesthesia or genital shortening.[10] The cardinal breast symptom is nipple retraction, in most cases into the breast mass.[6]
Ideational components of koro anxiety neurosis include fear of impending death, penile dissolution and loss of sexual power.[6] These cognitions of impending death with retraction and perceived spermatorrhea has a strong cultural link with Chinese traditional beliefs, as demonstrated by the fact that in general, Asians with complaints of genital retraction believe that the condition is fatal, unlike most Westerners.[6][11] Other ideational themes are intra-abdominal organ shrinkage, sex change to female or eunuch, non-specific physical danger, urinary obstruction, sterility, impending madness, spirit possession and a feeling of being bewitched.[6]
Extremely anxious sufferers and their family members may resort to physical methods to prevent the believed retraction of the penis. A man may perform manual or mechanical penile traction, or "anchoring" by a loop of string or some clamping device.[12] Similarly, a woman may be seen grabbing her own breast, pulling her nipple, or even having iron pins inserted into the nipple.[11] Physical injury is inevitable, which can be considered as a complication of the syndrome.[6] These forceful attempts often lead to injuries, even to death[13]
Psychosexual conflicts, personality factors, and cultural beliefs are considered as being of etiological significance to koro.[5] Sexual adjustment histories of non-Chinese victims are often significant, such as premorbid sex inadequacy, sexual promiscuity, guilt over masturbation and impotence.[14]
Several criteria are typically used to make a diagnosis of koro: penile (or breast) retraction, anxiety related to the retraction, fear of death as a result of retraction, and use of mechanical means to prevent full retraction.[15] Cases that do not meet all the requirements are generally classified as koro-like symptoms or given a diagnosis of partial koro syndrome.[15] It has been argued that the criteria are sufficient but not necessary to make a diagnosis of koro.[6]
Genital examination reveals no actual instances of penis shrinkage or retraction. Any actual injury or damage that occurs to individuals usually arises from overly zealous attempts at preventing retraction, and treatment on the injury should be performed.
In historical culture-bound cases, reassurance and talks on sexual anatomy are given.[12] Patients are treated with psychotherapy distributed according to symptoms and to etiologically significant points in the past. Prognosis appears to be better in cases with a previously functional personality, a short history and low frequency of attacks, and a relatively uncomplicated sexual life.[9]
For sporadic Western cases, careful diagnostic workup including searching for underlying sexual conflict is recommended. The choice of psychotherapeutic treatment is based on the psychiatric pathology found.[16]
In China, traditional treatment based on the causes suggested by cultural beliefs are administrated to the patient. Praying to gods and asking Taoist priests to perform exorcism is common. If a fox spirit is believed to be involved, people may hit gongs or beat the person to drive it out. The person will receive a yang- or yin-augmenting Chinese medicine potion, usually including herbs, animal penises (of tiger, deer and fur seal), pilose antler (stag of deer) or deer tail. Other foods for therapy are pepper soup, ginger soup and liquor.[11]
Among the Chinese, koro is confined to South China and the lower Yangtze Valley.[9] A 1992 study of self-report questionnaires suggests that in the epidemic area of China, koro victims are mostly Han, male, young, single, poorly educated and fearful of supernatural forces and koro.[11] The phenomenon is also found among oversea Chinese in Southeast Asia, especially Malaysia and Indonesia, and less frequently among the Malay and Indonesian inhabitants of the countries.[9] Though there are speculations that the occurrence of koro among people in Malaysia and Indonesia was the result of Chinese migrants, this cultural diffusion view is challenged since koro epidemics have been reported in Thailand and India, involving masses of non-Chinese people.[17]
Sporadic cases of people with non-Southeast-Asian ethnicity have been reported across the globe, for example, Nepali,[18] Sudanese,[19] Jordanian,[20] Tanzanian,[21] Nigerian,[22] French,[23] British,[24][25][26] American[27][28] and Canadian.[29][30] In most of the non-Chinese cases in the Western hemisphere, genital shrinkage is reported but not all the other typical koro symptoms, such as fear of death, as in endemic countries.[31] The incomplete forms of koro are regarded as the non-cultural forms, while the complete form with acute anxiety is the classical culture-bound type.[5]
Most of the ancient literature concerning koro was related to Chinese ethnic groups. For example, koro (in its Chinese term of shuk yang) is documented in the old medical book New Collection of remedies of value (simplified Chinese: 验方新篇; traditional Chinese: 驗方新篇) which was published in Qin Dynasty. The book described the condition as "yin type of cold qi invasion" (simplified Chinese: 阴症伤寒; traditional Chinese: 陰症傷寒) which involved a sudden seizure during sexual intercourse with the penis retracting into the abdomen. It ascertains that the patient will die if not treated with "heaty" drugs on time.[12]
Local official records indicate genital retraction endemics in Hainan Island and Leizhou Peninsula in Guangdong, China, as early as the late 19th century. There were a series of epidemic outbursts in 1948, 1955, 1966, and 1974, whenever there was social tension or impending disaster, followed by the last widespread episode in 1984–1985 and a much smaller outbreak in 1987. The 1984–1985 epidemics lasted for over a year and affected over 3,000 persons in 16 cities and counties. A mental health campaign was conducted for the epidemic and since then no further episodes of the epidemic has occurred in China. Improvement in local economic conditions, associated with a better quality of life, is suggested to contribute to the fading of the episodic occurrences of koro.[11][17]
A koro epidemic struck Singapore in October 1967 for about ten days. Newspapers initially reported that some people developed koro after eating the meat of pigs inoculated with anti-swine-flu vaccine. Rumours relating eating pork and koro spread after a further report of an inoculated pig dying from penile retraction. The cases reported amounted to 97 in a single hospital unit within one day, at five days after the original news report. Government and medical officials alleviated the outbreak only by public announcements over television and in the newspapers.[32][33]
An epidemic outbreak in November 1976 in Northeast Thailand caused at least 350 cases, most of them Thai and males. Popular opinion and news media echoed the victims' projection of viewing the epidemic as caused by Vietnamese food and tobacco poisoning in a hideous assault against the Thai people.[34][35] Another large-scale epidemic in Thailand occurred in 1982.[34]
In 1982, a koro epidemic episode in Northeast India affected, in majority, poorly educated people from lower socio-economic strata. There was no evidence of significant premorbid or sexual psychopathology in most cases.[36]
Since late 1996, a small-scale epidemic of genital shrinking was reported in West African nations. Victims in the African outbreaks often interpreted the experience as genital theft, accusing someone with whom they had contact of "stealing" the organ and the spiritual essence, causing impotence. The perceived motive for theft was associated with local occult belief, the witchcraft of juju, to feed the spiritual agency or to hold the genital for ransom. Social representations about juju constitute consensual realities that propose both a means and motivation for genital-shrinking experience.[15]
The epidemic began in Nigeria and Cameroon, and spread to Ghana, Côte d'Ivoire and Senegal by 1997.[15] Cases were reported in Cotonou, Benin where mobs attacked individuals accused of the penis theft and authorities ordered security forces to curb the violence, following the deaths of five people by vigilantes.[37] Later reports of outbreak suggest a spread beyond West Africa, including the coverage of episodes in Khartoum, Sudan in September 2003;[38] Banjul, Gambia in October 2003;[15] and Kinshasa, DR Congo in 2008.[39]
Comparing West African genital-shrinking epidemics with koro in Southeast Asia, the latter has symptoms centered on genital retraction (instead of shrinkage) and fear of death (which is absent in African cases).[15] A study analyzing the West African epidemics from 1997 to 2003 concluded that rather than psychopathology, the episodes were product of normal psychological functioning in undisturbed individuals, who were influenced by the local cultural models or social representations.[15]
The Malleus Maleficarum, a 15th century European manual for witchcraft investigations, relates stories of men claiming that their genitals had disappeared, being "hidden by the devil … so that they can be neither seen nor felt." They were said to have reappeared after the men had appeased the witches responsible.[40]
At least three publications of the 1880s, from U.S., Russia and England, reported genital retraction pathology, without using the Malay or Chinese term. Koro epidemics in China were first noticed in a French report in 1908 and descriptions of koro entered clinical books of western medicine in 1936. In the 1950s, koro is noted in nosological and diagnostic psychiatry.[34]
The earliest Western reference to the term koro is found in B.F. Matthes' Dictionary of Buginese Language (1874) of South Sulawesi, Indonesia.[34] The word is also used in Makassarese language, meaning "to shrink"; the full dialect for it is garring koro.[6] In Malay, keruk is the probable linguistic link of koro which means "to shrink"[41], and koro may also be derived from some Malay terms which are associated with "head of turtle".[11] The term shuk yang, adapted from Chinese, means "the shrinkage of penis".[11]
Factors of cultural expectation in the genesis of koro can be built upon ideas of sex physiology in the traditional Chinese medicine, with free play of imagination which links fatality with genital retraction.[12]
In the ancient Chinese medical book Zhong Zang Jing (simplified Chinese: 中藏经; traditional Chinese: 中藏經), retraction of the penis with distension of the abdomen was described as a certain sign of death.[12] The yin and yang theory proposes that an unbalanced loss of the yang humour produces genital shrinkage.[9]
In Taoism and Traditional Chinese medicine, frequent ejaculation is regarded as detrimental to health, as semen is considered to be related to a man's vital energy, and hence excessive depletion of semen may lead to illness or death. Some authors believe that the idea of death caused by the semen depletion resembles the idea of death caused by genital disappearance, although such linkage between koro and Taoism, which influences Chinese medicine to some degree, is only speculative.[11]
The popularity of Chinese folklore also plays a role. The novel about ghost stories Strange Stories from a Chinese Studio describes a fox spirit which can make people weak physically and sexually and shrink their tissues. Belief in koro being caused by the fox ghost among the southern Chinese has been reported.[11]