Illness is a tricky phenomena. As biological creatures, we are subject to a host of potential issues that can harm us or make us feel sick. How an illness manifests, is diagnosed and treated relies on time and place. Curing a cold varies greatly among cultures and the time period in which it occurs.

Culturally-bound diseases include anorexia which is on the rise in third worlds proportional to increased exposure to media. Many years ago, someone might suffer from the vapors or a nervous break down, but those diseases no longer exist. My little brother was diagnosed with hyper-activity in the seventies which didn’t exist when I was growing up. Hyper-activity is seldom diagnosed in comparison with attention deficit disorder in more recent years. I admit, this is a simplified version of the aforementioned diseases, but it does not change the obvious point; ailments which humans experience are shaped by commonly shared cultural beliefs.

I travel a lot. My dear friend was amazed to discover I never experienced jet lag. I didn’t experience it, because for me, being tired the next day, adjusting sleeping hours, etc. was not placed in the framework of jet lag. In other words, I experienced the symptoms, but did not fully understand or accept the culturally constructed paradigm. Now that I do, I reluctantly admit I suffer jet lag. Once accepted, there is an entire construct (medical system) to cure and minimize my symptoms, as well as a community with shared understandings of the ailment.

“Medical systems emerge from attempts to survive disease and surmount death, and from social and cultural responses to illness and the sick role", stated medical anthropologist, Dr. Lola Ross.

My following paper discusses a disease that reached epidemic proportions as late as 1987. This disease seems ridiculous to imagine within the paradigm of current beliefs, but was quite real to the afflicted and their communities. Consider current diseases, the roles of people involved, the paradigm of which we diagnose, treat and respond to diseases and how they might be shaped directly by vested parties such as drug companies.

M - August 22, 2016

 

Suo Yang, a culturally-bound disease
Suo yang, more commonly known by the Malaysian and ethnographic term “koro", means shrinking or retracting (suo) penis (yang). Koro is a disease in which the afflicted believes his or her genitalia are shrinking or retracting into the abdomen. The disease has been classified into several different and conflicting syndromes. Most commonly, koro is referred to as a culture-bound syndrome. A culture-bound syndrome is a condition "from which people suffer because they believe certain things about health-predisposition, external agents and so forth" (Topley, 1978: 424).

Koro has also been classified as a genital retraction syndrome (GRS) (Simons & Hughes, 1984: 152), Freudian castration complex has also been applied to koro cases in hopes of a better understanding. Western models, however tend to universalize signs and ignore cultural influences. This paper will explore some of the current theories of koro and why it affects certain groups in geographic regions, while excluding others, thus demonstrating how medical generalizations are incomplete understandings of this disease.

The following scenario of a koro episode reflects a general pattern of the disease in China. Although exceptions exist, they will be addressed in later text. The first symptom of koro in males is a belief that the individual's genitalia is shrinking or retracting, medically referred to as hyperinvolution. Recognition of shrinking genitalia often occurs after either a cool bath, urination out of doors when the penis is exposed to cold, or when an insect bite is discovered in the genital area. An overwhelming panic overcomes the afflicted: he believes his penis will continue to retract into the abdomen and he will die. He grabs his penis to prevent further retraction, while yelling for help.

Family and neighbors are compelled to assist, as they also believe koro can result in death. Assistance by the opposite sex is prohibited and is believed to cause death. Those who do offer aid vigorously massage, clamp, tie with strings or yam stems, hold with chopsticks, manually grab and pull the penis to prevent it from shrinking into the abdomen. Injury to the genitalia during the rescue attempt is almost inevitable. After the victim is revived (usually at the point the helpers are tired) he is given a potion to drink. Anything associated with yang elements, such as shoots of the male palmyra is administered through the potion (Tseng, 1988; 1542).

Females afflicted with koro perceive their nipples are retracting into their chests or their labia are shrinking. A woman will grab her nipples or enlist neighbors and friends to insert metal pins through her nipples to prevent retraction. Rare instances of shrinkage of the tongue, nose or ear by pre-adolescents have also been reported (Tseng, 1988: 1540). The victim may turn pale, appear panicked and start to shiver, hyperventilate, sweat and have palpitations. Sometimes these symptoms can be misconstrued as a case of koro. On one bride's wedding day, her "paleness" and "weakness" led family members to believe she was suffering from a suoyang attack. An attempted effort to prevent her nipples from retracting continued until she finally yelled out that her breasts were indeed not shrinking (Cheng, 1996: 71).

Typically, koro is a male disease. in the Singapore epidemic of 1967, only eight of the two hundred cases reported in two local hospitals involved females (Kleinman, 1981: 255). Results from P.M. Yap's study of nineteen cases of koro in Hong Kong indicate the "syndrome is usually to be found among young men of poor education and immature, dependent personality who lack confidence in their own virility and and are in conflict over the presence of genital impulses, although some may show hypersexual tendencies" (1965: 50). Failure to honor certain avoidances can result in a koro attack. For example, several prohibitions involve tortoises: one cannot step over a tortoise stool or horse hair; walking in front of a tortoise must also be avoided; if the tortoise retracts his head in one's presence, it is a bad omen; however, if he is facing away from you and retracts his head, it is a positive sign. The retraction of a turtle's head into its shell is an overt symbol of the penis retracting into the abdomen. Other prohibitions include certain foods such as; legumes (kentjoer) which means to retract; or giant scallops, because they profoundly shrink when cooked.

With a few exceptions, koro is geographically confined. Most incidents occur in South China, especially in island villages and in the lower Yang-tse valley, South East Asia, Thailand, Singapore, Malaysia and Indonesia. Cases in the United States, Great Britain, France, Canada and India with no geographic patterning have also been reported. One of the marked differences, however, between cases restricted to Indonesia and China and those found in the United States, is that koro in Chinese and Indonesians is not necessarily accompanied by other psychological or physical illness and the patient seldom believes retraction of the genitalia into the abdomen will result in death. Among Chinese, once the koro episode subsides, it is unlikely to recur. G.E. Berrios and Si. Morley documented fifteen incidents among non-Chinese who experienced koro-like states. All incidents involved males between the ages nineteen and fifty-five. All suffered additionally from an effective disorder (anxiety, depression) and schizophrenia, drug abuse or brain lesions. For many patients, this was a recurring disease; one case spanned twenty years. Seven of the patients in the study believed their penes were actually shrinking into their abdomens. Thirteen of patients believed their symptoms would not result in death. Four of the patients used physical force to prevent their penes from retracting. The most frequent feature of the sample is a feeling of premorbid sexual inadequacy among patients (1984: 332, 333). The study concludes;

Koro-like symptoms in non-Chinese subjects might constitute behavioral phenotypes without underlying cultural genesis. Descriptively they are over-valued ideas, (sometimes reaching delusional proportion) related to a variety of primary psychiatric conditions. The symptom usually improves once the underlying disorder has been treated.  The diagnosis of Koro is of value only in specific cultural niches because it enables the psychiatrist to activate psychotherapeutic routines which are socially meaningful (1984: 333).

Attempts to define and consequently treat koro in its cultural context have resulted in a predominate theory basing the illness in the prevalent Chinese belief of yin and yang. Yin and yang are harmonic, complementary opposites. Within each there is an element of the other. In the symbol of yin and yang, a small dot within each element's representation reflects an embryonic element of the other. This represents a division of each element into greater and lesser categories. As part of the i-ching, yin and yang are incorporated with another belief system called the theory of the five elements (wu hsing). The greater yang is correlated with fire; the lesser with wood. The greater yin is correlated. with water: the lesser with cold. Yin and yang are equally divided in the remaining element, the earth. The sexes are also divided between male and female, respectively as yin and yang. Seminal fluid is part of the essence of yang and ancient Chinese believed it to be of limited quantity, in contrast to women's inexhaustible receptacle of yin essence. A Taoist medical philosophy stresses that during intercourse, males can absorb yin essence and thus strengthen vitality and sexual energy (yang). Every emission of semen represents a loss of-vital essence, unless it is compensated with equivalent amounts of yin essence from the woman. A balance is very important. Lack of (yang causes death (Rawson, 1973 q. Chowdhuiy, 1996 : 52). If the male can refrain from ejaculation, and consequent emission of yang essence, he could gain the most benefit. The expenditure of a limited resource of sperm is then reserved for times his partner is most likely to conceive. Conception is of utmost importance as it is the descendants' role to fulfill the ancestral duties and sacrifices that ensure the well-being of the dead (Gulik, 1961: 40-46).

The great importance placed on supplying descendants, combined with an ideological framework such as the yin and yang and the five elements, find recurrent expression in Chinese literature in both old and new writings. The literature stresses two points. First, the most prized possession of a man is semen. His good health and, ultimately, his very life (as well as his
ancestor's) is reliant on maintaining this vital force. Second, the male should reserve ejaculations for certain specified occasions, yet give his female partner satisfaction every time they have intercourse (Gulik, 1961: 47). In 1922, Zhange Dianjie wrote a sex handbook for distribution in Hong Kong called, Eiventiais of hygienelbryouth. He claimed the body contained two types of fluid, one of which was seminal. Seminal fluid, according to Zhang, is finite and should be cherished as if it were sacred:

semen is the lifeline of mankind. It normally condenses in the kidney, which is why physicians call the kidney the gateway of vitality. The fife expectancy of mankind depends entirely on the use and fall of semen. Semen is to the life of man what oil is to the lamp and what water is to the fish: the lamp will lade when the oil runs out; the fish will die without water; life can obviously not be preserved if the semen is dissipated (1922: 10-47).

Concern over the loss of sperm and, thus yang essence, is evident in a proposed anti-masturbation movement in Republican China. Sociologist Yi Jiayue, who proposed the movement, proclaimed, "To predict the rise and fall of the nation, one should look at the physique of the race; to assess the future of the state, it is enough to examine the bedclothes of our youth" ( Yi, q, Dikotter, 1995: 165).

Seminal emission is differentiated in Chinese terminology. Improper emission during involuntary stimulation is called "hack and cut" (zhnola); "masturbation" (shouyin); involuntary ejaculation during sleep is "loose and leak" (yixie); or "emission during a dream" (inenyi), and "losing essence" (yijing). Regardless of the terminology, seminal discharge represented a lack of one's control of his body through the mind according to late imperial medical texts. The mind's power over bodily fluids was thought to be indicative of individual responsibility and resulted in an inability of the medical experts to distinguish between physiological gonorrhea and voluntary emissions. By the 1920's, fear of pathological emissions or spermatorrhoea (yijini,7) pervaded medical literature on sex in Republican China (Dikkoter, 1995: 167).

Effects of masturbation included fatigue, palpitations, irregular blood circulation, indigestion, insanity, hypochondria, restlessness, irrational terror, unhappiness, worsening of eye¬sight, infertility, atrophy of the sex glands and ultimately, death. Nearly every possible malady could be attributed to this activity. Means to prohibit masturbation included tying a towel around one's waist during sleep, covering the genitalia with a leather loin cloth, hands kept on the desk tops at school, ingestion of potassium bromide and avoiding activities or situations that increased "heat." Many of these recommendations for dissuading this act are not unique to China. Nineteenth century European literature also detailed negative medical consequences of masturbation with a similar response of panic-driven means to prevent such activity (Dikotter, 1995:169-173). What is unique, however, in the instance of China is the concern over discharge of seminal fluid in connection to long-held, still current beliefs regarding the five elements and yin and yang.

In Yap's study, all nineteen of the patients were deeply concerned with what they imagined in varying ways to be sexual excess. All patients had also resorted to masturbation as a coping mechanism for an assortment of problems including fear of disease, wife's frigidity, impotence and lack of partner (1965: 45). The results of Yap's study substantiate the theory of yin and yang and indicate a strong relationship with the manner and form the disease is manifested. Although it may seemingly give an explanation to why people in China experience koro, it fails to explain why large sectors of the Chinese population, especially in the north, never suffer from the illness.

In Chinese medicine, when there is an inability to cure through the five elements and yin and yang models, the next step is to determine if there is a problem with spirits. This is the same course of action attempted by scholars to determine why koro is found almost exclusively in southern China although ideological frameworks are the same. A belief in the fox spirit has been correlated with southern coastal cases of koro (Mo, 1987; Tseng, 1988: q. Chong, 1996:76). As early as the Chou dynasty, foxes had been associated with large amounts of vital essence and supernatural properties. A number of stories such by the Tang dynasty that deal with fox-lore. The Ilvitan-chung-chi, a small book from the T'ang period of unknown authorship, described the fox spirit as follows:

When a fox is fifty years old, it acquires the ability to change itself into a woman. At one hundred it can assume the shape of a beautiful girl, or that of a sorcerer, or also that of an adult man who has sexual intercourse with women. At that age the fox knows what is happening at a distance of a thousand miles, it can derange the human mind and reduce a person to an imbecile. When the fox is a thousand years old, it is in communication with Heaven, and is then called Heavenly Fox, t`ien-hu (Gulik, 1961: 210).

Other T'ang dynasty stories included themes in which foxes turned into men or beautiful women who were the source of disease. Foxes dwelled in graves where a young girl was buried. The fox would revive the corpse by entering it and proceed to play tricks on a man (Gulik, 1961: 211). Although the belief of the fox spirit is acting as incubi, debauching both men and women and is currently wide-spread in North China (Gulik, 1961: 211), Tseng found in a study of one hundred people in a non-epidemic city, Guanzhou, that the sample was much less convinced about the supernatural influences of the fox spirit and of koro than in Hainan Island where a karo epidemic had occurred. People within epidemic areas evidence their belief in the fox spirit through their remedies for koro; treatment then becomes a combination of exorcism and yang medicine, Taoist priests are asked to perform exorcisms, gods are prayed to, and loud noises are made with gongs to drive the spirit away. The victim of koro may actually be beaten in order to drive out the fox spirit that has possessed him in addition to the previously described techniques for preventing genitalia hyperinvolution (Cheng, 1996: 76, 77).

Supernatural beliefs and sexual oppression may make people in certain regions more susceptible to kora, but do not necessarily provide the catalyst for epidemics. Aside from large-scale epidemics of kora, meager numbers of cases are reported, For example, Yap only found nineteen cases in his fifteen year study in Hong Kong and less than one percent of the population was affected by koro. Large-scale epidemics, however, have occurred in 1948, 1955, 1966, 1974, 1984-85, 1987. The epidemic of 1984-85 originated in the Lingao County of Hainan Island and eventually spread through the rest of the island. Upon the news of the Hainan epidemic, reported several months later in Haikang County in Leizhou Peninsula, an epidemic outbreak of koro began in Leizhou. The wave of kora spread up and down the Peninsula until it reached the northern end of the Peninsula and ended in Zhanjian City. The epidemic, by this point, had lasted nearly a year and affected over 3,000 people in sixteen cities. Clearly, large numbers of people are affected in a relatively short period of time. The only groups of people to remain unaffected in the Hainan epidemic were Li and Miao minority groups who live in the Hainan mountains. Li and Miao groups did not share the same cultural myths regarding the fox spirit and their attitudes toward toward sex are liberal. Dating and premarital sex are sanctioned among the Li and Miao people, which may also diminish the underlying factors that increase one's susceptibility to koro (Cheng, 1996: 78). Having a propensity for a disease does not necessarily mean that the disease will be manifested. Since koro is a disease that affects not only the afflicted, but those around him, it becomes a community phenomenon. The catalyst for koro's manifestation is a shared belief within the community of impending epidemic.

The epidemic of 1984 was precipitated by a fortune-teller who warned that the last half of 1984 would be disastrous with many reports of koro. The community expected koro, thus fulfilling the fortune-teller's prophecy. Other than an isolated case in Russia (Edwards, in .Simon and Hughes, 1984: 182), no one had actually ever reported total retraction. When new cases of had moved on after his failure and panic would subside. The 1967 Singapore koro epidemic spread after a report that an inoculation given to pigs to prevent swine fever caused koro in those who ate them. A rumor that the Vietcong were poisoning food supplies in order to cause impotency in Thai males precipitated the 1976 epidemic in Thailand (Cooper, 1993: 898). In epidemics outside of China, Chinese are disproportionately affected. Of the hundreds of patients seen daily during the Singapore epidemic, 97.8% were Chinese, although they only represented 74.4% of the local population. The presence of Chinese immigrants, many among whom believe genital retraction and consequent death is possible, may raise the incidence of the illness among the non-Chinese indigenous population (Edwards, 1984; in Simon & Hughes, 1984: 179).

Other attempts to explain the occurrence of koro in other cultural contexts focus on Western psychological theories. Freudian castration complex theory seems an obvious choice. Wulfften Palthe concluded, upon commencement of his Chinese research koro, "We have here before us, therefore, a living example of Freud's castration complex" (1936: 55). Wulfilen's claim was rebutted by Nobler and Edwards: "The syndrome lacks an attempt to disguise the castration fear with another fear, nor is the penis displaced with another object" (Simon & Hughes, 1985: 179). Edwards does credit the application of the Freudian complex with recognizing the presence of castration anxiety, evident in the child-rearing practices that reinforce a fear of castration, illness and death as a punishment for masturbation, but he claims this is only part of the picture. Epidemics generated by reports of fortune-tellers and rumored food contamination all point to a larger social context in which to find meaning for the disease (Simons & Hughes, 1985:179,180), leading back to yin and yang and the belief in the fox spirit.

Biomedical causes have also been reported by Devereaux:

Yet, at. a glance any good textbook of urology will indicate that the luxating penis can, for all practical purposes, retract into the abdominal wall or into the tissue. The fact. that none of our authorities makes any reference to this condition once more underscores the well known fact that no amount of technical knowledge can cancel the forces of repression." (1954: 488, )

It is in fact highly possible that koro symptoms of retraction or shrinking do occur when the victim becomes frightened and numerous people begin to pull and tie strings around his penis during an episode. Though there is strong possibility of a sense of hyperinvolution when taking a cold bath or urinating outside in the cold air, there is no chance that the afflicted will die from shrinkage or retraction. While a biomedical explanation may be a piece of the puzzle, it in no way illuminates the total picture. A total picture can only be achieved by examining a broadly defined ecological framework, which includes cultural beliefs and practices, psychocultural functioning, and environmental and biomedical influences. Edwards also cautions against formulating one concept of a disease and universally applying it to other situations (Simon & Hughes, 1985: 184). Universal application of a culture-specific disease has rendered no insight to the disease as it exists in any society. Reported cases of koro among non-Chinese, specifically western cultures, shows very little similarity, and the diagnosis of koro may actually hinder proper diagnosis. Proper diagnosis of koro is of value, however, in specific cultural niches, because it enables the practitioner to provide care that is socially meaningful (Berrios & Morley, 1984: 333). The prognosis of koro, when correctly applied is very good. Patients seldom have recurrences of the disease and a remedy may be as minimal as proper sex education (Chen 1996: 79). This prescription is congruent with the fact that Chinese afflicted with koro have no particularly odd or bizarre behavior beyond the belief in the disease and its ramifications (Chowdhury, 1996:45).

Koro is often defined as a culture-bound disease or syndrome that predominately affects males who are poorly educated, immature, lack proper sex information and hold a strong belief in the actualization of koro. Belief in the disease is geographically limited and while cases of people with similar symptoms globally surface, they lack the belief in a cultural framework that facilitates faro's full expression. Koro is actually a Malaysian term applied to the Chinese disease suo yang that has a similar meaning of "shrinking penis." Koro and suo yang have come to be nearly indistinguishable, but for their geographical boundaries. The belief of koro comes from a long history of concern for preservation of semen and the consequent prohibitions against and concern over masturbation or sexual excess in which sperm would be expended. A genuine belief that koro will result in death is one of its most distinguishing factors from non-indigenous cases. Non-indigenous cases also are accompanied by other physical or psychological pathologies, unlike the Chinese koro patient. A cultural framework for the manifestation of koro includes the belief in yin and yang and the five elements. Spirit beliefs may also influence the occurrence of koro, as in the 1984 epidemic. By looking at the disease within the cultural context, it is possible to best serve those afflicted. If one region believes the catalyst for a koro epidemic is a fox- spirit, it requires different processes to promote a cure than in a region where the catalyst is contaminated pork. Universal application of an "exotic" or culture-specific disease may actually hinder a proper diagnosis. That is not to say a disease will always exist in a cultural vacuum. Evidence of cultural diffusion is shown in the presence of koro among non-Chinese in areas where there are large numbers of Chinese immigrants, but understanding how disease is spread through cultural contact should not preclude a thorough concept of the disease in its indigenous state.

 

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