181

HUNDRED YEARS OF KORO

THE HISTORY OF A CULTURE-BOUND SYNDROME

ARABINDA N. CHOWDHURY

SUMMARY
Koro was first reported in Western medical press in 1895. The original oriental
culture-bound ’Koro’ is now referred to as ’genital retraction syndrome’ in the global
literature. During this span of a century, the primary cultural etiological focus of Koro
has also shifted towards the concept of disordered body-image perception. A
review of the world Koro literature (English language journals and books) of varied
ethnic groups, geographical regions and with different comorbidities, shows a
fascinating history of its clinical and conceptual progress over the years. This is a
brief discussion on the publication history of Koro over the last hundred years.

The credit for the very first report of Koro in a Western medical journal goes to Dr. J.C.
Blonk, the then second class health officer in Dutch-India (now Indonesia). It was he who first
introduced the term ’Koro’ and made the concept of genital retraction pathology known to the
Western world as a culture-bound illness in 1895. He learnt about the term and the concept
from a ‘‘Jal~sa&dquo; (native legal officer) who was his informant as well as a Koro sufferer. The
figure shows the first page of this historical 1895 publication.

Prior to 1895
The first official clinical reference to ’Suo Yang’ (retraction of penis), in an epidemic form, is
found in the archives of Tang district of Guangdong province, China (Jilel~9 1986). The
earliest reference to the term ’Koro’ is found in B.F. Matthes’ ’Dictionary of Buginese
Language’ (1874) of South Sulawesi. It is interesting to note that at least three publications of
the late nineteenth century, from three geographically wide-apart areas, reported genital
retraction pathology, obviously without the use of the term ‘I~®r®’, i.e. USA (Hammond,
1883); Russia (Ivanov, 1885) and England (Raven, 1886). Raven’s paper is probably the first
report of ’retraction of penis’ in the British medical press (The Lancet).

1901-1950
There are at least fifteen publications relevant to Koro available during this span of fifty years.
One is a report of ’genital shrinking’ epidemic from China (Legendre, 1908), which is the first
Koro epidemic report in a Western (French) journal, and eight are papers on different clinical
aspects of Koro. All are by Dutch physicians of the then East-Indies. The five papers of Palthe
in the 1930s are valuable basic documents of early Koro research (Palthe, 1934, 1937). Three
publications are credited for highlighting first the comprehensive clinical account (Slot,
182

1895 ~1~ ~~~ ~ff ~ ® ~ Bionk

®

Figure 1.
 183

1935); ethnomedical cultural cognition (of Sulawesi natives) (Mulder, 1935) and psycho-
analytical analysis (Kobler, 1948) of Koro. Two clinical books, one from Batavia (now
Jakarta) by Palthe (1936) and the other from London by Strong (1945) included a description
on Koro. Three publications referred the complaints of penis retraction symptom secondary
to other psychiatric morbidities, viz. I~a°aepelin (1913; as hypochondriacal delusion in
depression); Schilder (1935; as altered body-image in hypochondriasis) and Bychowski
(1943; as body-image disturbance in depression). A Koro-like phenomenon as a part of
religious experience was reported from India by Sarkar in 1943.

1951-1960
This decade is marked with the introduction of Koro in academic psychiatry. Six publications
are noteworthy which focussed primarily on the emerging diagnostic status of Koro. Yap’s s

{1951) paper is one such pioneering one where he tries to locate the nosological position of
Koro within the rubric of ‘ ‘autopathological&dquo; culturally-linked behavioural abnormality.
Koro gained more attention in text books (Linton, 1956; Arieti & Meth, 1959; Manson-Bahr,
1960). The first clinical report of ’penis shrinkage’ pathology from India was made by Pillay
in 1953.

1961-1970
This eventful decade brought Koro into prominence in the international professional
more

community. A total of nineteen reports published, of which eight were of new case
were

reportings (from Taiwan, Singapore, Hong Kong, England, France and USA); seven were
discussion papers and three were on the Singapore (1967) Koro epidemic.
Three important events need mention here: (1) The publication of Dr. Pow Ming Yap’s
valuable papers that dealt with the diagnostic status of Koro with reference to its culture-
boundness. His paper, ’Koro - a culture-bound depersonalization syndrome’ (1965) is a
superb account which has been most extensively cited to date. (2) The occurrence of a large
Koro epidemic in Singapore (536 cases: male 521, female 15) and its detailed clinical
reporting by Gwee (1968) and Ngui (1969) with special focus on the role of mass belief in
psychiatric epidemic; and (3) Reporting of more Koro cases from the Western countries. The
first Koro publication in the International Journal of Social Psychiatry is of Rin’s (1965)
paper on the Chinese cultural perspective of Koro. The reporting of Koro-like symptoms in a
schizophrenic patient from USA (Edwards, 1970) attached a new clinical dimension to Koro
in psychiatry.

1971-1980
A total of twenty reports during this decade invited further international attention to Koro.
Ten of them were of new cases (from Canada, England, USA, Israel, Indonesia and Nigeria);
four were discussion papers and four reports were on the 1976 Thailand Koro (350 cases:
male 338, female 12) epidemic (,Sunwanlert ~ Coates, 1979). Association of Koro with drug
abuse was reported from USA (Dow & Silver, 1973). &dquo;Attenuated Koro&dquo; - a variant form of
Koro has been reported from India (Rao, 1978).

1981-1990
This is the most colourful decade of Koro publications. Some eighty publications appeared
184

during this decade. Three important facts observed are: (1) reports of three large-scale Koro
epidemics (viz. Thailand, 1982; Eastern India 1982 and Guangdong, China 1985-87) and one
Koro-like epidemic from Nigeria, Africa (1988); (2) reports of Koro from many non-Chinese
subjects and (3) reports of Koro in association with diverse psychiatric and organic
morbidities. All these findings raised an intense academic debate about the cultural specificity
of Koro.

KORO EPIDEMIC

A series of research findings on different clinical and socio--cultural aspects have appeared
from the detailed studies of the Koro epidemics. Clinical data from studies of 233 cases (male
195, female 37) of Guangdong by Tseng et al. (1988) enriched our understanding of Chinese
Koro psychodynamics further. They highlighted the cultural cognition of ’fox spirit’ as a
contributory factor of Koro attack. Dutta et al. (1982) reported findings of 83 cases (male 64,
female 10) from Assam and Chowdhury et al. (1988) reported findings of 405 cases (male
357, female 48) from West Bengal. Chowdhury reported a series of findings on clinical
profile (1989 a,b); psychometric assessment of anxiety and personality pattern (1990, 1991)
and he first focussed on the abnormal penis image of male Koro cases (1989 c,d). Studies of
mass psychodynamics of Koro epidemics opened newer conceptual issues like geopolitical
stress and cultural metamorphosis (Jilek & Jilelc-Aall, 1985) and ethnic concepts and
traditional construct of sexuality.

KORO AROUND THE GLOBE

At leastthirty case reports were published during this decade from various parts of the world,
encompassing diverse ethnic backgrounds and with varieties of comorbidities. The new
geographical areas are: South Africa, New Zealand, Tanzania, Italy in addition to more cases
from USA, UK, China, Singapore and Canada. The new ethnicities reported are: Jewish,
West-Indian, Greek-Cypriot, Haitian, Ethiopian, Zulu, Scottish, Jamaican, South African
Black, Nigerian and Italian.
Association of Koro with other medical/psychiatric morbidities stressed more about the
body-dysmorphic dimension rather than its culture-relatedness. Notable among these are:
hypochondriasis (Rosenthal & Rosenthal, 1982); psychosis (Ang & Weller, 1984); psycho-
motor epilepsy (Joseph, 1986); dysfunctional autonomic control (Oyebode et al. 1986);
schizophrenia (Devan & Ong, 1987); corpus callosum tumour (Durst & Rosca-Rebaudengo,
1988) and temporoparietal stroke (Anderson, 1990).

NEW INSIGHT ON KORO

A few publications of this decade may be regarded as landmarks in the field of cultural
psychiatry, especially the culture-bound syndromes including Koro. Books of Murphy (1982)
 185

and Simons and Hughes (1985) are masterful documents and the research publications of
Sirois (1982) on epidemic hysteria; Jilek (1982) on mass psychogenic aspect of psychiatric
epidemic; Lucieer (1984-85) on stress of urbanization and sexual paranoia; Berrios and
Morley (1984) on non-Chinese presentation of Koro; Edward’s (1984) attempt of introduc-
tion of the term ‘genital retraction syndrome’ and I~ollander et al.’s (1987) report on body-
dysmorphic aspect of penile pathoperception are noteworthy.

1991 onwards
At least sixty five publications had appeared by mid-1995, indicating the increasing
professional concern about Koro. Many of these contributions took place centering around
Bernstein and fiaw’s (1990) proposition to include Koro in DSM-IV. Five unusual Koro
presentations, viz. with HIV-infection (Heyman & Fahy, 1992); with capgras syndrome
(Smyth & Dean, 1992); with drugs of abuse (Chowdhury & Bagchi, 1993; Chowdhury &
Bera, 1994; Chowdhury & Banerjee, 1996); infertility (Cohen et al. 1995) and infolie a deux
(Menezes, 1992; Wolff & Mckenzee, 1994) focussed a wider clinical perspective of Koro
further. The report of an epidemic of ’penis loss’ in Nigeria (Ilechukwu, 1992) is a finding
with far reaching transcultural significance in the field. A Koro-like symptom affecting the
tongue has been reported from Malaysia (Chin & Singh, 1995).
The discussion paper by Prince (1992) on the ethnocultural cognition of fox spirit in
Hainan island offers a new support in favour of culture-boundness of Koro and provides a
unique conceptual bridge between psychiatry and social anthropology. Kirmayer (1992)
discussed the transcultural aspect of castration theme in relation to Koro. Chowdhury (1994)
reported a detailed clinical account on female Koro and Bartholomew (1994) highlighted the
socio-pathological dynamics of Koro epidemicity. Chowdhury (1996a) in an updated analysis
critically discussed the clinical and diagnostic fallacies of Koro and stressed the need for
future research in the area of perceptual psychology (Chowdhury 1993; 1996b). Nepal
(Chowdhury & Rajbhandari, 1995) and Ireland (Sajjad & Gill, 1993) are new geographical
additions in the Koro literature and Koro from Samoan ethnicity (New Zealand) is also
reported (Chowdhury & Faulkner, 1997).

CONCLUSION

The culture-bound origin was the sole focus of literature on Koro until the late 1960s. The
concept of somatization, of Koro in Western and non-Chinese subjects and with
occurrence
other medical illness prompted a change in the preference of nomenclature from Koro to
genital retraction syndrome in the early 1980s. Advance ofpharmacotherapy, application of
psychometric and biobehavioural techniques to monitor body perception and varieties of
psychiatric and medical comorbidities of Koro from subjects of diverse ethnic, cultural and
geographical background, recently placed the Koro nosology in the realm of monosympto-
matic hypochondriacal psychosis (Fernando, 1988) or body dysmorphic disorder (Goetz &
Price, 1995) or penile dysmorphophobia (Chowdhury, 1993). The original psychoanalytical
stress on individual castration theme of Koro has also shifted more towards the social
cognition, body awareness and sexual somatization in recent years.
186

NOTE

The detailed bibliogrphy of last 100 years on Koro, viz. 226 publications including 49 of the
present author, is available on request.

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Dr. Arabinda N. Chowdhury, MD, PhD, Professor & Head, Institute of Psychiatry, 7 D.L. Khan Road, Calcutta
700 025, India