Koro: culture-bound disorder or universal symptom?

Classical Koro and Koro-Like Symptoms: Illustration from Canada

Koro syndrome has been colorfully described as a pathological distortion of one’s body image of the genital organ. In Koro, body image dysphoria is characterized by severe anxiety related to the delusional idea that one’s genitals will shrink and retract into one’s abdomen, eventually leading to death. This syndrome was first reported in South East Asia, where endemics have been described, but it has also sporadically occurred globally. We present a systematic literature review on Koro syndrome and report 7 cases from Canada. A search review with PubMed and Google Scholar resulted in 504 entries. Sixty-seven manuscripts were eventually selected following a thorough elimination process. The resultant literature underscored the cultural diversity that underlay the reported cases. Various aspects of Koro have been examined (eg, etiological, clinical, diagnostic, and cultural aspects). It has stimulated substantial scholarly debate, discussions, correspondences, and arguments from anthropological, psychiatric, psychological, and biological perspectives. In our series, it seems that Koro could have been misattributed here. The primary concern was not with penile retraction of the cases. To our knowledge, this is the first time that a series of cases is documented from North America where the syndrome is often ignored. We highlight the potential differences between the classical Koro syndrome and a collection of beliefs related to the perception or delusion of penile retraction in other codable psychiatric disorders, Koro-like syndrome. Understanding Koro syndrome beyond geographic boundaries is in line with our collected case reports of Koro from outside Asia.

Clinical course and treatment outcome of Koro: A follow up study from a Koro epidemic reported from West Bengal, India

BACKGROUND

Koro, as a culture bound syndrome is predominantly reported from Asian countries. There is dearth of well-designed research focussing on course and outcome of Koro.

METHOD

In the index study, 64 consecutive consenting patients with symptoms of Koro reported in different disciplines of a tertiary care Government Hospital of West Bengal were recruited over a period of 3 months. They were treated by standard treatment protocol and followed up for next 3 months. Data was collected on clinical course and treatment outcome by a pretested semi-structured proforma, specially developed for this study.

RESULTS

A typical subject was a young single male, educated up to primary standard, agricultural worker by occupation and belonged to Hindu rural joint family. Among the whole sample 23% were female. Majority were referred from either private doctors or hospitals or government hospitals and reported first at non-psychiatric OPD. Dropout and recovery rates were 28% (male 33%, female 13%) and 89% (male 89%, female 92%) respectively. 20%, 75%, 9%, 31%, 19% of patients needed indoor admission, oral anxiolytics, injectable tranquilizers, specific pharmacological and psychosocial treatment, supportive medical treatment respectively. There was a subtle difference in course and treatment outcome noted between the genders. A new modality of psycho-sexual intervention 'sex education in vivo' was applied on patients of Koro with favourable result.

CONCLUSION

Female counterpart represented a significant proportion. Overall improved trend of utilizing medical care facilities was observed. But sceptical attitude towards Psychiatric treatment is prevailing. An overall good treatment outcome was noted among the Koro victims.

Ethical and Sociocultural Aspects of Sexual Function and Dysfunction in Both Sexes

AIMS

This study aimed to highlight the salient sociocultural factors contributing to sexual health and dysfunction and to offer recommendations for culturally sensitive clinical management and research as well for an ethically sound sexual health care, counseling and medical decision-making.

BACKGROUND

There are limited data on the impact of sociocultural factors on male and female sexual function as well as on ethical principles to follow when clinical care falls outside of traditional realms of medically indicated interventions.

METHODS

This study reviewed the current literature on sociocultural and ethical considerations with regard to male and female sexual dysfunction as well as cultural and cosmetic female and male genital modification procedures.

RESULTS

It is recommended that clinicians evaluate their patients and their partners in the context of culture and assess distressing sexual symptoms regardless of whether they are a recognized dysfunction. Both clinicians and researchers should develop culturally sensitive assessment skills and instruments. There are a number of practices with complex ethical issues (eg, female genital cutting, female and male cosmetic genital surgery). Future International Committee of Sexual Medicine meetings should seek to develop guidelines and associated recommendations for a separate, broader chapter on ethics.

Concurrent Koro and Cotard syndromes in a Spanish male patient with a psychotic depression and cerebrovascular disease

Koro and Cotard syndromes are uncommon conditions described in a variety of psychiatric and medical disorders. The authors report the third case of a simultaneous presentation of both syndromes, in a 62-year-old inpatient Spanish male with major depressive disorder with psychotic features, parkinsonism and cognitive impairment. A discussion of the literature and the possible relationship between both syndromes and other neuropsychiatric disorders are presented.

Ramadan fasting triggering koro-like symptoms during acute alcohol withdrawal: a case report from Oman

This article describes a case of koro-like symptoms from Oman associated with alcohol withdrawal and illustrates how the socio-cultural practices of Ramadan-fasting affected the patterning and timing of presentation of severe alcohol withdrawal symptoms. The patient was severely distressed by the delusion that his penis had been amputated. The acute anxiety involving this delusion appears to be conceptually and phenomenologically similar to koro.

SEXUAL MEDICINE HISTORY: Koro—The Psychological Disappearance of the Penis

The aim of this article is to present a summarizing overview on ethnomedical aspects of koro (in Chinese called suo-yang), the panic anxiety state in which affected males believe that the penis is shrinking and/or retracting, and perhaps disappearing. While reduction of penile volume occurs physiologically due to vasoconstriction in cold temperature and intense anxiety, it is believed in certain cultures that genital shrinking leads to impotence and sterility, and eventually to death. Traditional Chinese medicine treats suo-yang, the reduction of the male principle yang, as a dangerous disturbance of the life-sustaining yin-yang equilibrium of the organism. Koro has therefore been held to be a Chinese "culture-bound" condition. However , the koro phenomenon is also known among diverse ethnic and religious groups in Asia and Africa, typically in cultures in which reproductive ability is a major determinant of a young person's worth. Koro epidemics of panic anxiety due to widespread fears of losing one's genitals, procreative ability, and even one's life, are triggered by rumors of genital disappearance supposedly caused in China by female fox spirits, in Singapore and Thailand by mass poisoning, and in Africa by sorcery, usually in the context of socioeconomic or political tension. Today, in contemporary Western societies, ideas of genital disappearance are not culturally endorsed. But historically, it should be remembered that in the late Middle Ages in Europe, a man could lose his membrum virile through magical attacks by witches. The conclusion is that the psychological disappearance of the penis is a universal syndrome that was described recently in Asia and Africa and already in Medieval Europe.

A conceptual history of Koro

Koro is a culture-bound syndrome characterized by a fear that the genitals or breasts will retract into the body and cause death. Here we consider the history of ideas about Koro, from early concepts in traditional Chinese medicine (TCM) to contemporary ideas from medicine and sociology. This conceptual history reveals important issues about the classification (nosology) of Koro. In doing so, it demonstrates the need to integrate standardized phenomenological criteria with etiological models in order to capture the important features of complex behavioral disorders in the cross-cultural setting.

[The syndrome of genital retraction from a transcultural psychiatric point of view. Chinese suo yang, Indonesian koro and non-Asian forms (koro-like symptoms)]

The present article reviews the syndrome of genital retraction (SGR) from the perspective of transcultural psychiatry. It is best known as a culture-bound syndrome in Asia, e. g. koro in Indonesia or suo yang in Southern China, where it can be also observed in so-called epidemics. The syndrome is characterised by the sensation that the genitals are shrinking and being pulled back into the abdomen; this perception is associated with fear of death, because the subjects expect to die as soon as the genital has disappeared completely. Particularly in the case of suo yang, the involvement of local traditional concepts of illness can be established. In the Western world, however, SGR is observed only in single cases. The symptoms are less dramatic and do not show a particular cultural context. This form of SGR is called "koro-like" (koro-like symptoms, KLS). In contrast to the Asian form, KLS are not observed in healthy subjects, but as an unspecific syndrome related to other neuropsychiatric illnesses. In this review, we compare both forms of the SGR in terms of symptoms, cultural aspects and therapeutic strategies.

[Koro-like symptoms in a recurrent depressive disorder]

We report the case of a German male with a major depressive episode who also suffered from the terrifying perception that his penis was shrinking. These so-called koro-like symptoms (KLS) had also been present in earlier depressive episodes and subsided in the symptom-free interval of the recurrent depressive disorder. Under sufficient antidepressant medication with venlafaxine and lithium not only KLS but also the depressive symptoms remitted. The course of illness provides further evidence that KLS are not a distinct clinical entity in Western countries, but represent a concomitant syndrome that requires treatment of the underlying illness.

Koro: a case in an Eastern European asylum seeker in Ireland

Koro is characterised as a perception that one's genital organs are shrinking and will eventually recede into the abdomen. It was initially described in South East Asia as a culture bound syndrome but this syndrome has recently been recognised in a non-culture bound context A case is described of a depressed Eastern European asylum seeker with koro like symptoms. All symptoms resolved completely with fluoxetine treatment The relevant literature to the case is reviewed, in relation to onset, symptoms and treatment of this rare syndrome. In addition comparison is made with previous reports of the non-culture bound variant.

Koro associated with phobia for AIDS

Koro, in its complete, classic form has been described as a culture bound syndrome. It usually occurs in otherwise healthy individuals in the context of acute, severe anxiety. The incomplete form of Koro is said to occur as part of a recognizable primary psychiatric disorder. A case report is presented for the first time of Koro in association with phobia for AIDS. A cognitive-behavioral approach was utilized in the management of the AIDS phobia and symptoms of Koro.

Genital pain associated with genital retraction: a case of Koro syndrome

Koro is a unique psychiatric disorder in which acute anxiety accompanies the perception of genital retraction. This case report describes a case of Koro syndrome associated with penile and scrotal pain. A review of the literature has not shown any previous report of Koro associated with genital pain.