Shrink rap: A beginner’s guide to Koro in females

In a previous blog, I examined Koro (the so-called genital retraction syndrome). This is a culture-bound syndromes found primarily in Asian regions (e.g., China, Singapore, Thailand, India). Koro refers to a kind of “genital hysteria” with “terror stricken” individuals (typically male) believing that that their genitals are shriveling, shrinking up, retracting into the abdomen and/or disappearing, and that this ultimately leads to death. Writing in a 1997 issue of the Journal of Psychology and Human Sexuality, Dr. J.T. Cheng noted of Koro that it:

“Is best perceived as a social malady supported by cultural myths which tend to affect young people who are deprived of proper sex information to explain their physical development”.

Koro is rarely described in women but published case studies in the academic literature do exist. All of these female cases report that the affected women reported the shrinking of the vulval labia, nipples, and/or the breasts. The interesting thing about Koro is that all the body parts affected (penis in males; breasts, nipples and labia in women) are those that naturally swell and shrink in response not only in relation to sexual arousal but also in response to temperature and climate changes, depression, anxiety, stress, fear, illness, and/or psychoactive drug ingestion.

Most Koro epidemics while primarily comprising males always appear to involve a small minority of females. For instance, Dr. Robert Bartholomew’s book Exotic Deviance reports the Koro epidemic that occurred in northeast Thailand at the end of 1976 that affected approximately 2,000 people (primarily rural Thai residents in the border provinces of Maha Sarakham, Nakhon Phanom, Nong Khai and Udon Thani). As with most Koro epidemics, the symptoms included the perception of genital shrinkage and impotence among males, whereas females typically reported sexual frigidity, with breast and vulva shrinkage. The origins of the epidemics can vary and include the supernatural. For instance, in a 1986 issue of the journal Curare, Dr. W.G. Jilek described an atmosphere of collective fear of ghosts during a Koro epidemic in Zhanjiang town (Guangdong in China). Those affected believed that ghosts would make the genitals of men and breast of women shrink and disappear into the abdomen and chest. To end the Koro epidemic, the villagers’ drove the ghosts out of their village used drum-beating, bell ringing and bursting of firecrackers.

In 2005, Vivian Dzokoto and Glenn Adams published a paper in Culture, Medicine and Psychiatry examining genital shrinking epidemics in West Africa. More specifically, they examined all media reports of genital shrinking in six West African nations between January 1997 and October 2003 (comprising a total of 56 media reports). Most of the reports were of males but Dzokoto and Adams noted that three Ghanaian news reports included females. All three women reported experiencing shrinking breasts and/or changes to their genitalia. They also noted that:

“One report described a woman whose ‘private parts sealed.’ Another report described a woman who reported that her genital organ (unspecified) was vanishing. Again, it is unclear whether references to sealing and vanishing of female genitalia represent different ways of describing the same experience or represent qualitatively distinct forms of subjective experience.In all reported cases, experience of symptoms tended to be brief and acute. There were no reported cases of recurrence”.

The earliest report of Koro in a female was arguably be in a 1936 book chapter entitled ‘Psychiatry and Neurology in the Tropics’ by Wulfften Palthe. Since then there have been sporadic reports of female Koro in the literature. One of the more notable cases reported was by Kovács and Osváth in a 1998 issue of the journal Psychpathology. This case was unusual because it was a case of genital retraction syndrome in Hungary (although the woman reported was a Korean woman by background).

In a 1982 issue of the Indian Journal of Psychiatry, Dr. D. Dutta and colleagues reported on the (then) recent epidemic of Koro that occurred in four districts of Assam (June 1982 to September, 1982). The 83 cases they reported included 19 females. Interestingly, all the female Koro cases in this particular sample believed it was their breasts that were affected in some way. More specifically, Dr. Dutta and his team reported that:

“9 out of 19 female cases (47.3%) suffered from genital symptoms in form of shrinkage or pull of the breast. Not a single female complained of labial shrinkage. 12 out of 19 cases (69.1%) reported retrosternal pain and other anxiety symptoms subsequently leading to dissociation of varying degree and duration”.

In 1994, Dr. Arabinda Chowdhury (who has written lots of papers on the topic of Koro) published a paper in the journal Transcultural Psychiatry comprising an analysis of 48 cases of female Koro (based on a population of women that claimed to have Koro in an Indian epidemic in the North Bengal region). In females, Dr. Chowdhury noted that “the cardinal symptom is the perception of retraction or shrinkage of nipple or breast mass into the chest cavity or of labia into the abdomen with acute fear of either imminent death or sexual invalidism”. This was the first paper in the world literature to explore the detailed clinical characteristics of Koro in females. Before examining the individual cases, Dr. Chowdhury examined the gender distribution in seven Koro epidemics. The following statistics were reported: Singapore (1969; 469 cases, 15 female), Thailand (1978; 350 cases, 12 female), Indonesia (1978; 13 cases, 2 female), India (1982; 83 cases, 19 female), India (1985; 31 cases, 13 female), India (1988; 405 cases, 48 female) and China (1988; 232 cases, 37 female).

Dr. Chowdhury reported that of the 48 female cases (aged 8 to 54 years), the mean age was nearly 24 years. In relation to Koro, 56% reported retracting nipples (both breasts in all but two cases), 13% reported a flattening of their breasts, 8% reported a retraction in both breasts, 8% reported a pricking sensation in both breasts, 8% reported retraction of the labia, and 5% reported vaginal pain.

It appears that in the same that penis size seems to be a near-universal concern and/or obsession of men, women also share a similar fear, but with different sexual body parts (i.e., vulvas, breasts, and nipples). All of these body parts in males and females (i.e., penis, scrotum, breasts, nipples) are physiologically capable of changing size not only in relation to sexual arousal but also from other non-sexual factors (temperature and climate change, anxiety, depression, stress, fear, illness, and/or psychoactive drug ingestion/intoxication).

One literature review of 84 case reports of Koro (and Koro-like disorders) published in a 2008 issue of the German Journal of Psychiatry by Dr. Petra Garlipp (Hannover Medical School Germany) concluded that there were two unifying features of the case reports cited in the clinical literature. These were (i) the diversity in relation to the clinical picture, the underlying mental disorder, the treatment approach and their classification and nomenclature chosen, and (ii) the symptom of fear.

In response to Dr. Garlipp’s paper, Dr. Arabinda Chowdhury noted that by only using published case studies, female Koro was hardly discussed (because most data about female Koro comes from data collected during Koro epidemics rather than case study interview data). why the review had been so biased towards males. Based on his own research, Dr. Chowdhury wrote that there were at least 146 female Koro case reports from seven epidemics in the years 1969 to 1988. He believed the large number of cases involving women offered many interesting clinical issues in the female expression of Koro, which should have been included in Garlipp’s review. His view was that the differences between male and female Koro in relation to psychodynamics, presentation and associated clinical features of Koro would have made Garlipp’s paper “more interesting”. However, Dr. Chowdhury’s paper didn’t mention what these differences were. Maybe there is not the data to do this. Although it is known that episodes of female Koro can endure for weeks or months, the origin of female anxiety over the absorption of their sex organs is at present unclear.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bartholomew, R. (2000). Exotic Deviance: Medicalizing Cultural Idioms from Strangeness to Illness. Boulder: University of Colorado Press.

Bartholomew, R. (2008). Penis panics. In R. Heiner (Ed.), Deviance across cultures (pp. 79–85). New York: Oxford University Press.

Chowdhury, A.N. (1994). Koro in females: An analysis of 48 cases. Transcultural Psychiatry, 31, 369-380.

Chowdhury, A.N. (2008). Ethnomedical concept of heat and cold in Koro: study from Indian patients. World Cultural Psychiatry Research Review, July, 146-158.

Chowdhury, A.N. (2008). Cultural Koro and Koro-Like Symptom (KLS). German Journal of Psychiatry, 11, 81-82

Cheng, S.T. (1997). Epidemic Genital Retraction Syndrome: Environmental and personal risk factors in Southern China. Journal of Psychology and Human Sexuality, 9, 57-70.

Dutta, D., Phookan, H.R. & Das, P.D. (1982). The Koro epidemic in Lower Assam. Indian Journal of Psychiatry, 24, 370-374.

Dzokoto, V.A. & Adams, G. (2005). Understanding genital-shrinking epidemics in West Africa: Koro, Juju, or mass psychogenic illness? Culture, Medicine and Psychiatry, 29,53-78.

Garlipp, P. (2008). Koro – A culture-bound phenomenon intercultural psychiatric implications. German Journal of Psychiatry, 11, 21-28.

Jilek, W.G. (1986). Epidemic of “Genital Shrinking” (Koro): Historical review and report of a recent outbreak in south China. Curare, 9, 269-282.

Kar, N. (2005). Chronic koro-like symptoms – two case reports. BMC Psychiatry, 5, 34 (doi:10.1186/1471-244X-5-34).

Kovács, A. & Osváth P. (1988). Genital retraction syndrome in a Korean woman. A case of Koro in Hungary. Psychopathology, 31, 220-224.

Lehman, H. E. (1980). Unusual Psychiatric disorders. In: A.M. Freedman, H.I. Kaplan & B.J. Sadock (Eds.). Comprehensive Textbook of Psychiatry (Third Edition, Vol. II). Baltimore: Williams and Wilkins.

Palthe, P.M. (1936). Psychiatry and Neurology in the Tropics. In: C.D. de Langen and A. Lichtenstein (Eds.), A Clinical Textbook of Tropical Medicine (pp. 525-547). Batavia: G. Kolff and Company.

Phillips, K. (2004). Body dysmorphic disorder: recognizing and treating imagined ugliness. World Psychiatry, 3, 12-17.

Genital on my mind: A beginner’s guide to Koro

Koro is a culture-bound syndrome found primarily in Asian regions (e.g., China, Singapore, Thailand, India) and has been documented for thousands of years in those particular cultures. In essence, Koro refers to a kind of “genital hysteria” with “terror stricken” males believing that that their genitals are shriveling, shrinking up, retracting into the abdomen and/or disappearing, and that this ultimately leads to death (a so-called ‘genital retraction syndrome). The word ‘Koro’ is of Malayan-Indonesian origin and means ‘tortoise’ (presumably used to highlight the similarity between the retracting head and wrinkled neck of a tortoise and the belief that the male penis is retracting inside the body). Writing in a 1997 issue of the Journal of Psychology and Human Sexuality, Dr. J.T. Cheng noted of Koro that it:

“Is best perceived as a social malady supported by cultural myths which tend to affect young people who are deprived of proper sex information to explain their physical development”.

Various academic papers and book chapters (such as one by Dr. R. Bartholomew in 2008) claim that affected individuals take extreme measures to suspend the condition (e.g., placing clamps, clothes pegs, rubber bands, and/or tying string around their penis to stop it retracting. In some cases, men had family members physically hold onto their penis until they receive “treatment” from local healers). According to Dr. Bartholomew episodes of Koro can last for weeks or months and affect thousands of men. The condition has been recorded in Chinese academic texts going back to the 1800s. There also appear to be different cultural variants of Koro-like syndromes. For instance, in West Africa, some Nigerian men actually believe that their penises have been stolen.

Sometimes the condition occurs en masse such as the “penis panics” that have been documented in countries such as China, India and Singapore. For instance, a well documented Koro panic occurred in Singapore during the Autumn of 1967. The regional hospitals were inundated with hundreds of men demanding penile treatment (and thinking they would die without treatment). During this particular Koro epidemic, it was thought that the cause was eating pork (from pigs that had been inoculated for swine fever).

In Northeast Thailand in November/December 1976, around 2,000 men thought that their penises were shrinking. Another ‘penis panic’ was reported more recently in the Guangdong province of China. For over a year in 1984-1985 around 5,000 people living in the region believed they had Koro. Other Chinese Koro epidemics have occurred frequently on Hainan Island in the China Sea and also in the nearby Leizhou Peninsula in Southern China. These Koro epidemics suggest that various socio-cultural factors are influencing people’s beliefs about the condition. However, on a socio-demographic level, the psychological literature on Koro suggests that individuals that are most likely to be affected are those living in rural regions where there is poor education.

Most Koro epidemics are among adult males but isolated “collective occurrences” of Koro among children have also been reported in the Chinese Sichuang Province in a 1993 issue of the Chinese Journal of Mental Health. More recently, in a December 2010 issue of World Cultural Psychiatry Research Review, Dr. Li Jie (Guangzhou Psychiatric Hospital, China) reported a Koro endemic among 64 schoolboys in the Fuhu village of Guangdong. The contributing factors for the mass occurrence were reported as being (i) the familiarity with koro in the community, (ii) stress due to their studies, and (iii) a misleading warning and instruction from the school principal.

The interesting thing about Koro is that the penis is a body part that naturally swells and shrinks in response not only in relation to sexual arousal but also in response to temperature and climate changes, depression, anxiety, stress, fear, illness, and/or psychoactive drug ingestion. These real reasons for penile shrinkage when combined within cultures that accept and to some extent ‘authenticate’ the existence of Koro, can lead (in some instances and circumstances) to the psychosocial panics documented in particular regions or countries. Koro has also been is associated with various and specific cultural beliefs. One such set of beliefs is that unhealthy or abnormal sexual behaviours (e.g., masturbation, wet dreams, sex with prostitutes, etc.) disturb the “yin/yang equilibrium” that allegedly exists within a husband and wife’s sex life and causes Koro.

Some psychologists have also speculated that Koro may be psychologically related to body dysmorphic disorder. However, Dr Katharine Phillips (Warren Alpert Medical School of Brown University, USA), an expert in BDD and writing in a 2004 issue of World Psychiatry notes that although Koro has similarities to BDD, Koro differs from BDD by (i) its normally brief duration of a few weeks or months rather than years, (ii) different associated features (e.g., the belief by the sufferer that they are going to die), (iii) response to reassurance, and (iv) occasional epidemic occurrences (something that never happens with more traditional BDD occurrences).

However, there were a couple of case reports published by Dr. Nilamadhab Kar (Wolverhampton Primary Care Trust, UK) in BMC Psychiatry arguing that Koro is not always an acute, brief lasting illness. Dr. Kar’s paper reported two cases of males with with koro-like symptoms from East India (characterized by excessive anxiety and a belief that their genitals were shrinking) had lasted over ten years and concluded that in some cases, there is the possibility of a chronic form of Koro syndrome.

One literature review of 84 case reports of Koro (and Koro-like disorders) published in a 2008 issue of the German Journal of Psychiatry by Dr. Petra Garlipp (Hannover Medical School Germany) concluded that there were two unifying features of the case reports cited in the clinical literature. These were (i) the diversity in relation to the clinical picture, the underlying mental disorder, the treatment approach and their classification and nomenclature chosen, and (ii) the symptom of fear. Based on her comprehensive review, Dr. Garlipp collated all known etiological and predisposing factors. The two main sets of factors implicated in Koro and Koro-like disorders were (i) psychosexual conflicts, (ii) personality factors, (iii) cultural beliefs, (iv) sexual conflicts, and (v) guilt feelings, often caused by religious background. She also reported that factors implicated with commonly shared beliefs included (i) geographic seclusion, (ii) mostly young poorly educated men susceptible to superstitious beliefs, (iii) suggestion, (iv) belief in the concept of Koro, (v) immature personality and lack of sexual confidence, (vi) previous knowledge of Koro, (vii) poor body image, (viii) history of venereal disease, and (ix) preoccupation with genitals.

Dr Garlipp also concluded that treatment with antidepressants and antipsychotics has – in the main – been successful. She also concluded that:

“Koro in its original sense is an Asian socio-cultural phenomenon. Its clinical picture has been controversially discussed in psychiatric literature but could be best described as a kind of panic disorder with the leading symptom of fear projected to the genitals. Yet, it is questionable whether this phenomenon can be put into a Western dominated classification of psychiatric diseases, as the socio-cultural roots are not adequately appreciated…All clinical phenomena presenting themselves in a wider sense as genital retraction syndromes with the leading symptom of fear should be named as such: genital retraction syndromes. All other nomenclatures, especially Koro- like syndrome, secondary Koro etc., should be dismissed as misleading”.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Adeniran, R.A. & Jones, J.R. (1994). Koro: Culture-bound disorder or universal symptom? British Journal of Psychiatry, 164, 559- 561.

Bartholomew, R. (2008). Penis panics. In R. Heiner (Ed.), Deviance across cultures (pp. 79–85). New York: Oxford University Press.

Cheng, S.T. (1997). Epidemic Genital Retraction Syndrome: Environmental and personal risk factors in Southern China. Journal of Psychology and Human Sexuality, 9, 57-70.

Garlipp, P. (2008). Koro – A culture-bound phenomenon intercultural psychiatric implications. German Journal of Psychiatry, 11, 21-28.

Jie, L. (2010). Koro endemic among school children in Guangdong, China. World Cultural Psychiatry Research Review, December, 102-105.

Kar, N. (2005). Chronic koro-like symptoms – two case reports. BMC Psychiatry, 5, 34 (doi:10.1186/1471-244X-5-34).

Phillips, K. (2004). Body dysmorphic disorder: recognizing and treating imagined ugliness. World Psychiatry, 3, 12-17.

Tseng, W.S., Kan-Ming, M., Hsu, J., Li-Shuen, L., Li-Wah. O., Guo-Qian, C., & Da-Wie J. (1988). A sociocultural study of Koro epidemics in Guangdong, China. American Journal of Psychiatry, 145, 1538-1543.

Tseng, W.S., Kan-Ming, M., Li-Shuen, L., Guo-Qian, C., Li- Wah, O., & Hong-Bo, Z. (1992). Koro epidemics in Guangdong, China. A questionnaire survey. Journal of Nervous and Mental Diseases, 180, 117-123.

Zhang, J.K. & Zhu, M.X. (1993). Three cases report of children Koro. [Chinese] Chinese Journal of Mental Health, 7, 40-41.