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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.