KORO Syndrome (Cultural-Based Disease)

Koro is a cultural and psychological disorder that makes an individual have an overwhelming feeling that the genitals (penis in men and nipples in women) are shrinking. It is a delusional disorder that makes one think of the shrinking as possible to cause the disappearance of the genitals (especially penis) and thus can lead to death. The person feels this way regardless of the fact that there are no substantial changes to the genitals ( Crozier, 2011) . The condition is more common in men than women, and it has that feeling that the penis can disappear inside the body with death being the final result. The women with this syndrome have a belief that their nipples are reducing into their bodies or their vulva is about to shrink and disappear, even if there are no any abnormalities in their genitals. 

The other name for koro is shrinking penis, and it is listed in the glossary of the DSM-V manual as commonly experienced in South East Asia (APA, 2013). The syndrome occurs anywhere around the world, and mass hysteria has been recorded in Europe and Africa and some cultures, it can spread from one person to another. In the English speaking nations, the disorder is referred to as genital retraction syndrome. Its diagnosis can be made through physical assessment of the genitalia to rule out any specific disease that could be causing real shrinking ( Ghanem et al., 2012) . The patients with this syndrome try to stretch and enlarge their genitals using different elements as a result of obsessive and compulsive behavior, and this could harm them. Koro is described in many names as it spans across different cultures and languages. In this paper, we will look at the origin of the word as well as the history of the syndrome. Also, the article will outline the diagnostic criteria and treatment. 

Etymology and Geographical Origin 

There is no internationally accepted description of the origin of the term koro. There are a lot of theories that try to explain the source of the term as different researchers produce varying explanations. According to some, koro may have first originated from Malay words describing the head of a turtle which retracts into the shell (Cheng, 1996). Others relate it to the Indonesian idiom, “garring koro,” that means “to shrink.” In Chinese culture, the syndrome is termed as “suoyang” in Mandarin, where suo means shrinkage and Yang refers to penis and in Cantonese, it is called “suk-yeong ( Mattelaer & Jilek, 2007) .” In India, koro is referred to as “jhinjhini bimari” which means a tingling disease. The reason is that of the belief that the first symptoms of the syndrome can be itchiness in the genitals and a tingling effect. The other names in India are “kattao” (cut off, or small tortoise), and “jinjinia bemar.” In Thailand, it is known as “Rok joo (Garlipp, 2008).” 

The first manifestations of koro-like symptoms are associated with the ancient Chinese medical records which date back to more than two thousand years ago. The documents reveal a condition that is similar to the panic disorder of today’s medicine (Garlipp, 2008). The first epidemics happened in Southern China in the Leizhou Peninsula and Hainan Island around 1865 ( Crozier, 2011) . Several occurrences have been observed after the end of World War II, and they are related to the Han Chinese like Singapore. Some have also been recorded in India and Thailand. The interesting thing about this condition happening within the Han Chinese is their culture of tabooing sexuality. 

The people in that culture developed superstitions about sex and thus making them prone to such psychological effects. The many fairy tales in the Han culture, for example the female fox, are believed to be the reason for the condition ( Sharpless, 2016) . The tale is responsible for the taking away of human sexual energy. Reports have emerged on accusations of women being possessed by the evil spirits and the result is they are brutally beaten. There are also some sporadic cases of such for instance in mainland China where two people migrated to Taiwan and presented koro in a psychotic condition (Cheng, 1996). The documents relate the etiology of this syndrome to the Chinese Yin-and-Yang philosophy and its importance to the masculinity and sexuality. This syndrome has a relatively shorter symptomology as compared to other psychological disorders. 

Koro is rarely described in the female patients and the males have the idea that the penis is retracting into the abdomen causing anxiety ( Crozier, 2011) . The fear of the thought that the genitalia will get lost into the body and resulting to death leads the symptomology of the syndrome. In the ancient medicine documents, the patients tried to stop the retraction by tying the penis or asking friends and family members to grasp the organ and prevent its shrinking. The sufferers who are extremely anxious together with their families may resort to physical means of preventing the perceived shrinkage. The men may do a manual or mechanical pulling of the penis, or anchor it using a loop of string or clamping instruments (Gwee, 1963). 

The females may resort to grabbing the breast and pulling the nipple outwards or in some cases, using pins inserted into the nipples (Gwee, 1963). These forceful attempts to prevent the retraction are crude and pose great danger to the victim. In most cases, the attempts led to severe injuries, and even death. The people who are at risk to developing this syndrome are the young, mentally uprights, and non-educated individuals who have the knowledge of existence of koro. At times, the surrounding persons can identify a victim and treat them without consent. Some reports have indicated that parents observing koro in their young ones were a common scenario in the epidemic of the syndrome. There are three cases that delude the transmission of the superstition between the patient and the wife from Great Britain citizens, and South Africa and Laos’s refugees. 

Some scholars explain that the existence of koro in China is a social illness highly attributed to the cultural myths accompanying the lack of proper information to the young people concerning their sexuality. The absence of information together with the numerous taboos makes the youth deprived of the explanation about their sexual development. In the Western cultures, single cases of koro-like symptoms have been described for decades ( Garget al., 2018) . The other terms that have been used to describe the malady in the Western countries apart from genital shrinkage syndrome, genital retraction syndrome, and koro symptom are koro syndrome, non-cultural koro, atypical koro, incomplete koro, secondary koro, and koro-like syndrome. 

The clinical image of such conditions varies from the original disorder, for instance there is no fear of death present, and the symptomology has been shown to be of acute period. It is recurrently acute and at times chronic and dwells with the individual till the end of their lives. Most of the cases have seen other mental disorders being diagnosed with a secondary koro. In some instances, however, there has been diagnosis of the syndrome without any underlying mental conditions. Some researchers have criticized the assumption that the epidemics that occurred in India, Singapore, and China under the term koro ( Garget al., 2018) . 

Classification 

Koro is listed in the DMS-V Appendix under the Glossary of Culture-Bound Syndromes. The manual describes the syndrome 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 (APA, 2013)." Several authors have made attempts to classify the syndrome into different types. Some of the classes are in groups of “culture-related beliefs as its etiological factor (Tseng, 2001),” “genital retraction taxon,” and “particular culture-imposed nosophobia.” 

Types of Koro Syndrome

Koro syndrome is classified into two categories. The first is primary koro, which can be linked to having a cultural origin and is evident in patients who do not have other mental disorders. Secondary koro is comorbid with other psychiatric disorders such as anxiety disorders, body dysmorphic disorder, or schizophrenia ( El-Badri & Leathart, 2017) . 

Characteristics of Primary Koro

This type of the condition is frequently experienced in countries like China, Japan, and India as its cause is highly linked to the cultural beliefs of that part of the world. The disorder often occurs in single men, who have limited vocation, profound values and faith in superstition like spells and witches, and little sexual knowledge. Primary koro has symptoms which are connected mostly to the heightened fear and anxiety. Besides having the excess feeling that the genitals are shrinking, the patient also feels that they can die out of the syndrome ( Atalay, 2007) . In most cases, the sufferers indicated that they experienced the shrinkage after nocturnal pollution, masturbation, or having engaged in sexual intercourse with a prostitute. The examples show the way this syndrome is closely related to the cultural belief and the lack of proper sexual education (Garlipp, 2008). 

Characteristics of Secondary Koro

The secondary koro is a type that occurs outside endemic regions, that is, countries outside South East Asia. Also known as incomplete koro, their causal agents are often thought to be other underlying mental disorders ( Atalay, 2007) . In this case, the patients believe that his or her genitals are retracting and have anxiety for it. However, they lack the belief that they could die out of it. The secondary type of Koro syndrome is not always as severe as the primary one. 

Causes  

In its natural form, the syndrome is associated with Asian socio-cultural beliefs. The etiology of koro is not defined, but the etiology is highly attributed to some psychological factors. Some of the significant etiological causes include cultural beliefs, personal factors, and psychosexual conflicts. In non-Chinese sufferers, the syndrome is associated with the sexual adjustment histories, for instance, impotence, guilt over masturbation, sexual, promiscuity, and premorbid sex inadequacy. 

Cultural Pathogenesis 

The occurrence and manifestation of culture-bound disorders are profoundly linked to the educational, psychodynamic, social, mythological, and moral background of a given group of people, and they rarely extend beyond the boundaries of the culture in question. Regarded as a culture-based psychogenic sickness, the primary center of the koro syndrome is China and other regions in South-East Asia. The exact geographical origin is hard to trace and conclude. Many questions grapple the researchers who try to determine its definite roots (Durst & Rosca-Rebaudengo, 1991). Did koro come from ancient Chinese region then spread into the neighboring Malay and other countries, or did it independently sprout in different cultures around that region? 

The Chinese form of koro, Suo yang, is deemed as an influence of the ancient Chinese education and sexual philosophy (Yap, 1965). The culture in this region is known to be respecting t older generation, and thus parental warnings on personal sexual pleasures are not lightly wished away. Masturbation in ancient China was considered to be harmful to the genitals, and hence its prohibition is profoundly rooted in the philosophy of harmony between the two essential elements of yin and yang. According to this principle, the excess of yin, or the loss of yang, wield negative pressure on the male concept ( Mattelaer & Jilek, 2007) . 

However, regular intercourse between the woman and the man helps in the manifestation of good yin and yang exchange. There was a belief that semen is a precious substance for the male and they should restrain from sexual desire. This is not only because the excess discharge would lead to the weakening of the body and mind, but it would also be the determination of death. Improper, diet, cold, masturbation, and nocturnal emissions are regarded as dangerous to the vital energy of the man as they all lead to the loss of yang. 

Epidemiology  

When occurring among the Chinese, koro syndrome is confined to the lower Yangtze Valley and in South China (Yap, 1965). In the Chinese epidemic areas, the condition is found mainly in young Han males, who are single and lacks primary education. They mostly are fearful of supernatural phenomena and koro itself. In overseas, the syndrome is confined to South East Asia especially in Indonesia and Malaysia among the Chinese living in the countries. The syndrome is, however, less frequent in the Malay and Indonesians ( Srivastava & Pandit, 2013) . There have been arguments that indicate the occurrence of koro among the people in Indonesia and Malaysia is as a result of the migration of Chinese people. The point of discussion is however faulted as there have been other cases of mass hysteria in India and Thailand that involve non-Chinese citizens. 

Also, reports are indicating the presence of this syndrome among the non-Southeast-Asian people across the world including Canadian, American, British, French, Nigerian, Tanzanian, Jordanian, Sudanese, and Nepali. In case of the occurrence of koro among the non-Chinese in the West, the secondary type is often reported as the sufferers there has no fear of imminent death, as evident in the endemic countries. The incomplete koro is regarded as non-cultural types, while the primary one associated with the acute anxiety of death is the conventional culture-bound form. 

Signs and Symptoms 

As stated earlier in this paper, the symptomology of koro is short, but the individual can lengthen it concerning their mental capacity. In most cases, the patients report acute anxiety attacks due to the perception of shrinking genitals (Durst & Rosca-Rebaudengo, 1991). This occurs without any longstanding indication actual or observable change in the genitalia. In other words, no biological change is sustained over an extended period or alterations that appear to be irreversible such as the effect of cold temperatures that cause retraction in some areas of the genitalia (Crozier, 2011). Some changes can lead to koro attack when observed, though the cold-temperature impact can be reversed after some time. 

The duration of this attack can be several hours, but the episodes may at times last up to two days. In extreme cases, koro symptoms can become chronic and persist for years. This indicates a comorbidity potential with the body dysmorphic disorder. Besides the general feeling of retraction, the victim can as well experience symptoms of perception of loss of penile muscle tone and alteration in the overall shape of the penis. In instances where the patients do not have attitudes of shrinkage, some of them report cases of genital shortening or genital paraesthesia. In female patients, the primary symptom is the perception of the nipple retreating into the breast or at times the whole breast shrinking. Although, the female symptoms are rarely reported meaning it is not common. 

In psychology, the elements of koro include the anxiety and fear of impending mortality, loss of sexual power, and penile dissolution into the body ( Mattelaer & Jilek, 2007) . The idea of awaiting death along with the demise and perception of spermatorrhea has deep roots in the beliefs of traditional Chinese. There is a more profound belief of koro being fatal in the Asian people than the patients in the West. Other superstitious themes among the Asian patients are sterility, spirit possession, impending madness, urinary obstruction, ambiguous physical danger, sex change to being a eunuch or a female, intra-abdominal organ shrinkage, and the feeling of bewitchment (Durst & Rosca-Rebaudengo, 1991). 

Diagnosis 

Different criteria can be used to diagnose koro with the primary one being the use of patient’s report. This report should be concerning the genitalia retracting despite the physical proof to demonstrate its shrinkage. A high-level diagnosis is made to examine anxiety related to the retraction, the fear of mortality from the disappearance, and the application of physical means to prevent the shrinkage ( Srivastava & Pandit, 2013) . Only the condition that meets the all the requirements is classified as koro. The others that do not satisfy these criteria are classified as koro-like syndrome or secondary koro or exposed to a diagnosis of partial koro syndrome. However, some researchers argue that the diagnostic tests are sufficient but not necessary for the determination of the condition with some classifying it as a possible cultural version of body dysmorphic disorder. DSM-IV manual, however, suggests the process of differential diagnosis of the two terms. 

Before the diagnosis, a psychiatric, psychosexual, or medical history has to be conducted by the physician. The provider should explore the client’s concerns about body image and appearance (Garlipp, 2008). It is imperative for the doctor to rule out any possibility of body dysmorphic disorder. Also, the patient should undergo screening of the overall belief, assumptions, and personal values the client is making about his or her genitals as affected by the background. Mostly, koro is an attack that has a great deal of anxiety and fear, and thus the practitioner should establish the emotional state of the patient together with the time it has taken from the onset to when the patient seeks medical attention. 

The physical diagnosis involves a checkup of the overall health along with a profound examination of the genitals. In males, the genital test should be done immediately after the penile exposure. This is done in such a way to avoid the influence that external temperature can have on the penis afterward. The primary rationale of this check is to discard any certain penile anomalies such as Peyronie’s, epispadias, and hypospadias disease ( Ghanem et al., 2012) . The practitioner should also note any presence of a substantial suprapubic fat pad as it can cause the penis to appear as retracting while the fat is the one growing. Of use can also be the measurements of stretched length, flaccid length, and flaccid girth. 

If the male client is insisting that the penis is retracting, there should be an administration of measurements after intracavernosal alprostadil to obtain the actual erect length and examine any penile anomalies when it is straight. During this physical assessment, the doctor should note any injuries inflicted to the genitals as a result of trying to stop it from retracting as additional evidence of koro. 

Treatment 

In traditional culture-based cases, the therapy comprises of talks and reassurances on sexual education and anatomy (Gwee, 1963). Psychotherapy is conducted on the patient, and the distribution is done concerning the symptoms and to the significance of the past etiological points. The prognosis improves with cases of a low frequency of attack and short koro history, a relatively uncomplicated sexual life, and previously functional personality. Sporadic cases in non-Southeast-Asian people, a profound diagnostic that includes determination of underlying sexual conflict are used. 

The psychiatric pathology established will form the basis of psychotherapeutic treatment. Indigenous Chinese medicine was based on the causes of the syndrome (Cheng, 1996). The standard intervention included praying to gods, and the Taoist priests were performing an exorcism. In case of a fox spirit involvement, the person would be beaten, or gongs hit to drive it out ( Sharpless, 2016) . A yin-and-yang augmented portion would then be offered to the person. 

Conclusion 

There is a lot of controversy in describing its clinical picture in the psychological sense and literature. However, this syndrome can be defined as a form of the panic disorder that is projected to the genitalia. The controversy is because most psychiatric diseases are classified using the Western-dominated literature. This makes the socio-cultural roots of the condition not internationally accepted. Despite the mirage that the issue causes, the knowledge of koro, its origin and etiology are essential in today’s psychiatry, medicine, and urology as there is an increased intercultural practice and immigration. 

References  

American Psychiatric Association. (2013).  Diagnostic and statistical manual of mental disorders (DSM-5®): American Psychiatric Pub. 

Atalay, H. (2007). [Two cases of koro syndrome or anxiety disorder associated with genital retraction fear]. Türk psikiyatri dergisi = Turkish journal of psychiatry. 18. 282-5. 

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Crozier, I. (2011). Making up koro: Multiplicity, psychiatry, culture, and penis-shrinking anxieties:  Journal of the history of medicine and allied sciences ,  67 (1), 36-70. 

Durst, R., & Rosca-Rebaudengo, P. (1991). The disorder named koro. Behavioural neurology, 4(1), 1-13. 

El-Badri, S., & Leathart, A. (2017). Koro-Like Symptoms Associated with Schizophrenia.  Open Journal of Psychiatry ,  7 (03), 213. 

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Ghanem, H., Glina, S., Assalian, P., & Buvat, J. (2012). Position Paper: Management of Men Complaining of a Small Penis Despite an Actually Normal Size. The Journal of Sexual Medicine 

Gwee, A. L. (1963). Koro – A Cultural Disease, Singapore Medical Journal, 4: 119–22 

Mattelaer, J. J., & Jilek, W. (2007). Sexual medicine history: Koro—the psychological disappearance of the penis:  The journal of sexual medicine ,  4 (5), 1509-1515. 

Sharpless, B. A. (Ed.). (2016). Unusual and rare psychological disorders: a handbook for clinical practice and research. Oxford University Press. 

Srivastava, M., & Pandit, B. (2013). Koro-a case report and review:  International Journal of Physiology ,  1 (1), 37. 

Tseng, W. S. (Ed.). (2001). Handbook of cultural psychiatry. Academic Press. 

Yap, P. (1965), "Koro – A Culture-Bound Depersonalization Syndrome", British Journal of Psychiatry, 111: 45–50,