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Koro – the vanishing penis

22 Jun 2021

  • Sri Lankan case series

By Dr. Anuradha Ellepola and Ruwan Laknath Jayakody   In treating culture bound disorders, it is important to conduct clinical assessments and evaluations in order to explore the existence of premorbid personality and other conditions associated with culture bound disorders.   Introduction Culture-bound syndromes, according to R.C. Simons’s “Introduction to Culture Bound Syndromes”, are folk ailments unique to certain cultures in which alterations of behaviour are prominent. The majority of the conditions are actually not syndromes; instead, they are traditional, cultural, and local ways of responding to an assortment of misfortunes. Lanti in certain parts of the Philippines and Saladera in Peruvian Amazon are examples of conditions which are subcultural presentations as responses to life stressors. However, some culture-bound conditions are indeed syndromes. A hyper startling (extreme anxiety, excitation, hyper arousal) condition called latah found in Malaysia and Indonesia (a condition especially found in Southeast Asia where the affected person is inappropriately excited and engages in abnormal behaviour), imu in Japan (a culture-bound disorder in which the affected person is too excited and behaves abnormally with the presentation being similar to that of Latah), the jumping Frenchman of Maine (a rare condition where the patient shows uncontrollable jumping and movement of all parts of the body), and uqamairineq among Eskimos (a rare culture-bound condition) are some of the examples of such. Koro is considered a culture-bound disorder in which, according to J.J. Mattelaer and W. Jilek’s “Koro – the psychological disappearance of the penis”, the affected male believes that his penis is shrinking, retracting, or vanishing. Affected individuals in certain cultures strongly believe that their genital shrinking leads to impotence, sterility, and eventual death. Traditionally, Chinese remedies include Suo Yang (a Chinese remedy used to treat the disturbance of male energies), which is used to treat the locking up of the Yang (according to https://herbsformental health.com, it refers to the active, virile, and directed male energies) that could lead to the dangerous disruption of the life saving equilibrium between Yin (passive female principle of the universe) and Yang. Suo Yang is believed to be a tonic that builds stamina, sexual potency, and energy. Koro has originally been believed to be a Chinese culture-bound condition derived from this above mentioned concept. However, this phenomenon is also known among other cultures in Asia and Africa. The disorder is especially prevalent in cultures in which the reproductive ability is a major determinant of a young man’s worth. Some culture-bound syndromes have associations with other psychiatric disorders. The findings of N.S. Sawant and A. Nath’s “Cultural misconceptions and associated depression in Dhat syndrome” suggest a strong association between the Dhat syndrome and depression. Human sexuality-related features are prominent in some of these disorders. Dhat is such a disorder found in India and Sri Lanka where, according to P. De Silva and S.A.W. Dissanayake’s “The loss of semen syndrome in Sri Lanka: A clinical study” and A. Sumathipala, S.H. Siribaddana, and D. Bhugra’s “Culture-bound syndromes: The story of the Dhat syndrome”, the anxious patient has severe fears about seminal loss and associated problems. It is worthwhile to analyse the psycho-pathological basis of culture-bound disorders. Patients with Dhat may, according to S. Patra, A. Sidana, and N. Gupta’s “Delusion of Dhat: The quandary of the form-content dichotomy”, harbour firmly held beliefs such as delusions or overvalued ideas regarding seminal loss. Patients suffering from koro too can have comorbid psychiatric conditions and/or associated psycho-pathology. It is characterised by, according to F. Elghazouani and M. Barrimi’s “Koro syndrome: When culture interacts with psycho-pathology”, acute and severe anxiety with the strong fear of the retraction of the penis into the body and subsequent impotence, sterility, and death. Further, according to D.A. Fishbain, S. Barsky, and M. Goldberg’s “Koro (genital retraction syndrome): Psychotherapeutic interventions”, koro is known as a culture-bound syndrome characterised by symptoms such as the belief of the retraction of the penis into the abdomen and its potential lethality, intense anxiety, and the use of different means to prevent it. There are rare cases where affected females believe that her breasts and/or labia are shrinking. The feeling of sexual inadequacy, sexual myths, and sexual practices may, according to R.A. Emsley’s “Koro in a non-Chinese subject”, contribute to the disorder. Certain psycho-dynamic and anthropological precipitants such as financial problems, according to J.B. Casagrande and T. Gladwin’s “Normal and Abnormal: The Key Problem of Psychiatric Anthropology” in “Some Uses of Anthropology; Theoretical and Applied”, have been identified. The course of koro is usually brief and self-limiting. Few reported koro-like cases had been chronic, according to N. Kar’s “Chronic Koro-like symptoms: Two case reports”, and needed intense interventions. Some, according to https://www.sciencedirect.com/topics/neuroscience/koro, take remedial actions by tying the penis with strings to an object, or getting the help of others. There are possible interactions between culture and psycho-pathology. In some cases, the chronic firm belief can be attributed to a delusion, overvalued idea, or an oedipal castration anxiety, while there is a male-dominant cultural significance. However, koro is usually a state of anxiety and not delusional. The syndrome may occur in individual patients or as an epidemic. Koro epidemics have been described in cultures in Thailand (Rok-Joo – a delusional disorder in males where the patient strongly believes that his penis is retracting into the body) and India (Jinjinia bemar – a delusional disorder where the patient believes that his penis is shrinking). Features of koro have been described in western cultures (in G.E. Berrios and S.J. Morley’s “Koro-like symptom in a non-Chinese subject”; P.C. Ang and M.P. Weller’s “Koro and Psychosis”; and E.M. Kendall and P.I. Jenkins’ “Koro in an American man”) among patients with other psychiatric morbidities such as anxiety, depression, and schizophrenia. The following three case reports describe different presentations and associations of koro in the Anuradhapura District. Two of the cases involved males who believed that masculinity is strongly associated with sexual and reproductive potency.   Case one A 30-year-old, recently married three-wheeler driver from Anuradhapura presented to a psychiatric private practice with a week’s history of persistent, severe anxiety about his penis shrinking into the abdomen. He asked his wife several times to keep pulling his penis to prevent its retraction. He also experienced anticipatory anxiety prior to coitus with his wife. He suffered from insomnia, lethargy, lack of interest, and the fear of death as a consequence of the retracting penis. He married his 23-year-old wife two months ago and experienced erectile failure and premature ejaculation on a number of occasions. He was preoccupied with the distressing thoughts about sexual dysfunction, and showed features of extreme anxiety and adjustment reaction. He believed that a marriage and his maleness were useless unless he had a good erection and fertility. His anxiety about being unable to have children in the future was very marked. His premorbid personality was anxious and avoidant. He was treated with Fluoxetine (a commonly used antidepressant in the group of selective serotonin reuptake inhibitors) for premature ejaculation at the age of 22 years. There was no history of substance abuse or comorbid medical conditions. His brief belief was not delusional, and more anxiety-related. His presentation suggested an anxious personality, and the concept of sexual identity and sexual dysfunction as predispositions and precipitants to the current condition. A short course of benzodiazepines (a sedative, anxiolytic [anxiety relieving] and muscle relaxant medication) and counseling effectively treated his distressing illness.   Case two A 40-year-old, single, unemployed patient with a history of schizophrenia and on treatment for the condition presented with a firm belief that his penis was vanishing into the abdomen for one month. He attempted to prevent the disappearance of the genitalia by tying his penis with pieces of cloth. He was anxious and agitated since the onset of the unshakable belief. It was not possible to shake his belief with reassurance. His belief was systematised and associated with some logically connected beliefs. His other beliefs were related to the non-existence of the penis, infertility, erectile problems, and death as a result of the vanishing penis. His psychosis had the onset at the age of 20 years. It was genetically predisposed paranoid schizophrenia. There were four relapses over the past 20 years as his medication adherence had been erratic. The patient was on depot intramuscular (a medicine injected into a large muscle that lasts long in the body) and oral antipsychotics. His previous psychotic symptoms included auditory hallucinations, persecutory delusions, and thought interferences. He had involvement with the Police as he was caught for exhibitionism, five years ago. The current complaint was never found as a symptom in history. The relapse was possibly precipitated by the use of cannabinoids. His strong, unshakable belief was compatible with a delusion. There was nihilism since his belief was regarding the disappearance and non-existence of the genitalia. This was in the context of a psychotic relapse probably as a result of cannabis abuse. The optimisation of antipsychotics helped relieve his condition, though it took a couple of months to take effect.   Case three A 38-year-old, divorced man presented to the psychiatry outpatient clinic with severe anxiety and depressive features for one month. He had a distressing belief that his penis was disappearing at night. He believed that his genitalia were retracting into his abdomen, causing erectile impotence and the nocturnal emission of semen. He tried several mechanical means to stop the penile retraction. He had a strong fear that he would soon die as a result of this problem. He developed anxiety, panic attacks, and depression in this context. He had a past history of alcohol dependence, social anxiety, and erectile dysfunction. He had sought psychiatric help in the past with poor adherence to the management plan. His wife left him eight years ago. He managed to stop the alcohol use with medical help. His premorbid personality revealed anxiety traits from childhood. He was a backward student who was never involved in public performance. He had been bullied during childhood. He received no formal teaching about human sexuality as a student. There were several sexual myths including the belief that masturbation caused a loss of energy. Features of koro in this patient were found to be related to anxiety traits, sexual myths, and erectile dysfunction. The psycho-pathology was not substantial enough to label as a delusion or an overvalued idea. Treatment included a short course of benzodiazepines and counseling. The patient attended follow-up clinics and recovered from the condition.   Discussion Two of the three cases had associated anxiety. Both of them had anxious personality traits. Sexual dysfunction was a marked feature. Beliefs about masculinity and sexuality seem to have contributed to the disease onset. The psycho-pathology was not consistent with delusions or overvalued ideas. Both men recovered, and had no residual symptoms, within a short period of time with counseling and benzodiazepines. The other case of Koro had an underlying psychosis. It could be justified as a Koro-like condition, where the patient developed a delusion in a context of disease relapse. He had a history of cannabis use and a past history of exhibitionism. The patient took a longer time to recover from the distressing symptom. All the patients had a current or past history related to disorders of human sexuality. They all sought medical help to relieve their symptoms. All three males had classical features of Koro: Belief of penile retraction, associated anxiety and fear, and attempts to prevent the disappearance of the genitalia.   Conclusions Koro, a disease initially identified mainly in the Chinese culture, is prevalent in non-Chinese countries. Prevailing anxiety and sexuality-related conditions play an important role in the causation of the disease. Beliefs about masculinity are important predispositions. Anxiety and depression could be associated with koro due to distress. Therefore, the importance of exploring premorbid personality and other associated conditions in culture-bound disorders, must be emphasised. It is probably a brief, self-limiting condition with no residual symptoms when there is no major underlying illness.   (The principal writer, Dr. Anuradha Ellepola, is a consultant psychiatrist at the Anuradhapura Teaching Hospital)


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