Abstract: Koro is a culture bound syndrome in which the afflicted persons believe their genitals are retracting inwards and that this retraction is fatal. Two large-scale koro studies take different approaches in analyzing koro prevalent populations: one study based in China uses various scales to determine the ways in which a koro group differs from a clinical and control group, and the other study based in India discusses koro subjects’ perceived causes for the syndrome. Though the two populations are similar in demography, the populations significantly differ in their perceived causation of koro. This brings into question the ways in which different cultures interpret koro, as well as the nature of koro as a culture-bound syndrome. The strengths and weaknesses of the methods of both studies are critically reviewed, and suggestions for future studies are discussed.
Differing Attributions of Koro in China and India
Koro is a reactive state in which a man believes his penis, or the labia or nipples in females, is retracting inwards into the body and will eventually cause death. It is typically found in Southeast Asian countries, such as China and Thailand, as well as India and parts of Africa (Garlipp et al., 2008). There are similar syndromes in Western countries that involve the fear of genital shrinkage; however, koro primarily differs in that koro victims believe genital shrinkage is fatal. Koro typically affects people on an individual basis, though it is also known to spread like an epidemic within certain populations and affects a large number of people within a short period of time. Furthermore, though only one person may display symptoms of koro, the people surrounding the victim will often reinforce those symptoms and claim that they can also see the shrinkage of genitalia (Cheng et al., 1996). Koro primarily affects young adult males, who tend to be unmarried. Females are sometimes known to fall victim to koro, though this occurrence is more uncommon (Garlipp et al., 2008).
Koro is known by several names, such as suoyang in China and jhinjhini bimari in India (Garlipp et al., 2008). The classification of koro remains unclear to psychologists to this day. Koro has been considered a dissociative disorder (Cheng et al., 1996), as well as a panic disorder (Tseng et al., 1992), and has been related to “sexual somatization” (Chowdhury et al., 2008 p.146). Koro is difficult to classify, as much behind the causation of koro is still unknown and what little is known does not neatly fit into an existing category.
Psychologists have attempted to uncover the causation of koro through various large-scale studies. Two such studies are discussed below: Tseng et al. (1992), a prevalence study that uses various scales to determine why some people are at risk for koro whereas others in the vicinity are not, and Chowdhury et al. (2008), a study which utilizes open interviews to determine the attributions subjects make in relation to koro. The results of these studies reveal that the cultural beliefs of different populations affect the way in which victims interpret the causes of koro, and can also have an effect on which populations are at risk of a koro epidemic.
Symptom Manifestation
At the height of a koro attack, the victim will often pull on their genitalia in
an effort to reverse the retraction. The behavior of the victim at the height of the attack is said to be comparable to a panic attack. Koro victims display similar symptoms, such as palpitations and hyperventilating. However, unlike a panic disorder, koro attacks typically do not recur. Also unlike a panic disorder, koro attacks are more of a communal experience. People nearby claim that they, too, witnessed the retraction of the genitalia and will sometimes assist the victim in pulling the genitalia, believing that they are rescuing the victim. In some cases, third party members will act as instigators for a koro attack and will claim that another person’s genitals appear to be shrinking. The attack subsides within 20 to 60 minutes. Unless the victim damages themselves when pulling their genitalia, there is usually no long-term damage (Cheng et al., 1996).
Prevalence of Koro
Koro is not only bound to a handful of countries, but even within those countries, koro is typically confined to certain regions. Koro epidemics are usually precluded by periods of social unrest or conflict. Epidemics tend to reappear within the same regions; koro does not travel in waves from one region to the next. Even if a population neighbors a koro prevalent region, the physical proximity does not determine the likeliness that the neighboring population will have a koro epidemic (Tseng et al., 1992).
Tseng et al. (1992)
This study surveyed populations in Hainan Island and Leizhou Peninsula, both regions that were affected by the 1984 and 1985 koro epidemics in Guangdong, China. There were three groups surveyed: first, the koro group which consisted of 214 koro cases (173 men and 41 women); a clinical group which consisted of 56 subjects with minor psychiatric disorders (27 men and 29 women); lastly, a control group which consisted of 153 subjects who were never diagnosed for psychiatric illness and who were not affected by the koro epidemic. The distribution of subjects from Hainan and Leizhou were about equal.
The results of the symptom checklist showed that the clinical group scored significantly higher on almost all subscales in comparison to the other two groups. In comparison, the koro group scored notably higher only in the anxiety and phobic subscales in comparison to the control group. This suggests that those who are vulnerable to koro tend to be more phobic and have more anxiety than average. The personality profiles produced similar results. The scores of the clinical group associated this group with a dysfunctional personality configuration. The profiles of the koro group were similar to the control group, except that their profiles suggested they were significantly less intelligent than the subjects of the other two groups. Additionally, the koro group tended to be less educated. That the results of the koro group significantly contrasted with the results of the clinical group suggests that those with koro are mentally healthy. Thus, koro cannot be treated as a mental illness.
The Folk Belief survey revealed that, although the koro group did not significantly differ in sex-related beliefs, the koro group did score much higher in koro-related and supernatural beliefs. The section pertaining to sex-related beliefs asked if the subject believed in a connection between preservation of semen and vitality. This information contradicts the theory that koro victims link the fatality of genital shrinkage to impaired sexuality and semen loss. The results suggest that the victims’ susceptibility to koro was correlated with a belief in supernatural forces, and a belief in the existence and effects of koro.
The study concludes that populations at risk of the koro epidemic tend to be less educated males, who have strong belief in supernatural causes for disaster. The study implicates that koro victims primarily attribute their genital shrinkage to supernatural causes. This conclusion is further supported by another study conducted by Tseng et al. in Guangzhou City, near the Leizhou Peninsula. Using the Folk Belief Questionnaire, it was shown that the population did not believe in supernatural causes. Though there are many other factors that may have played a part in why that population was not susceptible to koro, these studies demonstrate that populations with a weak belief in the supernatural correlates with lessened vulnerability to koro attacks.
Perceived Attributions
Chowdhury et al. (2008)
This study surveyed a total of 101 male koro cases in the North Bengal region of India. The maximum of cases were young, umarried adults with primary education. Through in-depth interviews, Chowdhury et al. collected primarily qualitative data that asked for the subjects’ perceived causes of koro.
The breakdown of results was as follows: 54.5% attributed koro to excessive body heat, 14.9% to supernatural causes, and 7.9% to sexual causes. The responses for excessive body heat were further broken down into several ethnomedical models, though the majority prescribed to the structural and sexual energy models. The structural model follows the belief that excessive body heat destroys the outgoing nerves and vessels from the abdomen to the penis. The destruction of these vital connections pulls the penis inwards. The sexual energy model is the belief that excessive body heat drains the sexual energy stored inside the penis and scrotum, causing the shrinking of the penis. Though these are ethnomedical causations, superstitions also play a role in the subjects’ attributions: some believed excessive body heat is caused by eating certain foods or having forbidden sexual thoughts.
Those who attributed koro to supernatural causes claimed his genital shrinkage was due to black magic, malevolent forces, or was a punishment from God. This is similar to the beliefs held by the subjects of the koro group in the study by Tseng et al. Tseng et al. argued that those with koro tended to attribute koro to supernatural causes. However, the results of this study contradict this argument, as the majority of subjects in this study offered medical-based explanations when describing their perceived cause of koro. The intelligence level was similar between the subjects of both studies, which indicates that lower intelligence is not necessarily linked with strong supernatural beliefs.
Thus, a belief in supernatural causes is not a definitive characteristic of those susceptible to koro. The subjects in this study created differing attributions for the same syndrome. Though superstitious beliefs were still present in the subjects’ reasoning, this study demonstrates how the attributions of koro victims are not necessarily uniform across different populations, even when demographic makeup of the populations appear the same.
Critique of Methodology
Tseng et al. (1992)
As this was a prevalence study that utilized quantitative scales, there was no discussion of the subjects’ own attributions for koro. Though the participants believe in the supernatural, it is possible that the subjects attribute the cause of koro to something not necessarily related to the supernatural. Like the Indian subjects in the study by Chowdhury et al., Chinese people also believe in the imbalance between hot and cold states. Because culture-specific, widespread beliefs such as the hot and cold balance were not assessed, important characteristics of koro-related beliefs may be missing from this study.
Though those with koro are characterized as typically young males, females composed a significant number of the koro subjects in this study. However, the data of the female subjects appeared to be largely ignored and were used only to see if there were gender differences in the data. Because there was little mention of gender, throughout the study, it was assumed that the female koro subjects generally scored the same as the males. Yet a problem arises when analyzing the Folk Belief Questionnaire. The section that tests sex-related beliefs asked about the conservation of semen and avoiding masturbation to “protect a man’s strength.” In this section, the study specifically reported on the results of the males and made no mention of the female subjects. Though the shrinkage of women’s nipples was taken into account for the section regarding koro-related beliefs, in general, the female koro victims were given little acknowledgement.
Chowdhury et al. (2008)
The lack of quantitative data in this study lessened the usefulness of the results, as it is more difficult to directly compare the subjects of this study to the subjects of quantitative studies such as the Tseng et al. study. Though the subjects of the this study had a similar demography to the subjects of Tseng et al. (1992), the samples cannot be directly compared without extensive qualitative data for both. Without the use of recognized scales, it is impossible to know if the sample of this study differed in personality profile, mental health, or in the symptom checklist. Moreover, the sample of this study was taken from India, whereas the sample of the Tseng et al. study was taken from China. The surrounding environment and culture might have had a profound effect on the different populations’ perception of koro. Any possible differences could potentially explain why the two study samples differed in their attributions. As is, it is difficult to understand why this difference exists.
Like Tseng et al. (1992), this study marginalized the role of female koro cases. This study treated female cases of koro as outliers and excluded them from the study. Excluding subjects from the sample might limit our understanding of this syndrome and cause researchers to make incorrect assumptions about how koro affects all who are afflicted.
Future Studies
Future studies would gain more insightful data through the utilization of both the quantitative approach of Tseng et al. (1992) and the qualitative tools of Chowdhury et al. (2008). With both types of data, researchers will be able to determine not only how koro populations differ from their surrounding populations, but also how koro populations differ across countries. Qualitative data will allow researchers to better understand the cognition of the subjects and better demonstrate how cultural beliefs shape the koro syndrome.
Though females make up a minority of the population, future studies may call for more thorough attention to female subjects. Koro studies appear to treat male koro victims as the standard to which the female koro victims are compared. Though females are the minority, the characteristics and attributions of the female koro population might differ from the male population in ways that can help further our understanding of why koro occurs. Such studies could also help ascertain why there are significantly more male koro victims than females, a question that neither study takes into account.
Conclusion
As a culture-bound syndrome, koro is somewhat unusual in that it is prevalent in several countries. Though most cases are concentrated in Southeast Asia, cases have been reported in regions as far as Africa. This indicates that this disease is not strictly bound to Asian cultures, and that other factors aside from culture seem to have an influence on the prevalence of koro. Characteristics that are strongly correlated with koro, such as less education and a belief in superstitions or supernatural causes, are more a product of a person or group’s socioeconomic status rather than the country’s culture. Those with lower socioeconomic status tend to be less educated, and those who are less educated are more likely to have strong superstitious beliefs or beliefs in the supernatural. Thus, culture alone does not strictly limit the prevalence of koro.
However, culture does seem to determine whether or not a population believes genital retraction is fatal. In the introduction, it was noted that Western countries have reported cases of genital shrinkage, but that such cases differed from koro because the victims do not believe the shrinkage would cause their death. In comparison to Eastern cultures, Western cultures generally do not hold the same beliefs regarding the effect of excessive heat on genitals or of supernatural causes to disaster. Because Western culture does not provide a reason for people to fear genital shrinkage, there is no reason for Westerners to show the same level of anxiety and panic as those afflicted with koro. Culture shapes the interpretation of the symptoms. As noted previously, cultural beliefs related to heat and cold shaped the interpretations of Indian koro subjects. Culture thus affects the way people interpret and respond to genital shrinkage; the way in which these people react then determines whether or not they have koro.
References
Cheng, Sheung-Tak. A critical review of Chinese koro. Culture, Medicine and Psychiatry, 20(1): 67-82, 1996
Chowdhury, Arabinda N. Ethnomedical concept of heat and cold inKoro: study from Indian patients. Official Journal of World Association of Cultural Psychiatry, 3(3): 146-158, 2008
Garlipp, Petra. Koro--A culture-bound phenomenon: Intercultural psychiatric implications. German Journal of Psychiatry, 11: 21-28, 2008
Tseng, Wen-shing et al. Koro epidemics in Guangdong, China: A questionnaire survey. Journal of Nervous and Mental Disease, 180(2): 117-123, 1992
This is a research paper written for my Cross Cultural Psych class on a culture-bound disease. Because I figured I should at least post the stuff I'm writing for school on this dead World. ^^;
